Joshua S. Hill

Perioperative Mortality for Pancreatectomy: A National Perspective

Objective:To analyze in-hospital mortality after pancreatectomy using a large national database. Summary and Background Data:Pancreatic resections, including pancreaticoduodenectomy, distal pancreatectomy, and total pancreatectomy, remain the only potentially curative interventions for pancreatic cancer. The goal of this study was to define factors affecting outcomes after pancreatectomy for neoplasm. Methods:A retrospective analysis was performed using all patients undergoing pancreatic resections for neoplastic disease identified from the Nationwide Inpatient Sample from 1998 to 2003. Crude in-hospital mortality was analyzed by χ2. A multivariable model was constructed to adjust for age, sex, hospital teaching status, hospital surgical volume, year of resection, payer status, and selected comorbid conditions. Results:In all, 279,445 patient discharges were identified with a primary diagnosis of pancreatic neoplasm. A total of 39,463 (14%) patients underwent resection during that hospitalization. In-hospital mortality was 5.9% with a significant decrease from 7.8% to 4.6% from 1998 to 2003 by trend analysis (P < 0.0001). Resections done at low (<5 procedures/year)- and medium (5–18/year)-volume centers had higher mortality compared with those at high (>18/year)-volume centers (low-volume odds ratio = 3.3; 95% confidence interval, 2.3–4.; medium-volume, odds ratio = 2.1; 95% confidence interval, 1.5–3.0). The proportion of procedures performed at high volume centers increased from 30% to 39% over the 6-year time period (P < 0.0001) by trend test. Conclusions:This large observational study demonstrates an improvement in operative mortality for patients undergoing pancreatectomy for neoplastic disease from 1998 to 2003. In addition, a greater proportion of pancreatectomies were performed at high-volume centers in 2003. The regionalization of pancreatic surgery may have partially contributed to the observed decrease in mortality rates.

Pancreatic neuroendocrine tumors: the impact of surgical resection on survival

Although surgical resection is generally recommended for patients with localized pancreatic neuroendocrine tumors (PNETs), the impact of resection on overall survival is unknown. The authors investigated the survival advantage of pancreatic resection using a national database.

Regionalization of abdominal aortic aneurysm repair: Evidence of a shift to high-volume centers in the endovascular era

INTRODUCTION Since the early 1990s, many studies have shown lower mortality for abdominal aortic aneurysm (AAA) repair at high-volume centers compared with low-volume centers. The introduction of endovascular AAA repair (EVAR) also has changed the practice of AAA repair. The goal of this study was to determine if regionalization of AAA repair occurred in the United States. Etiologic factors were examined in addition to any reduction in operative mortality rates. METHODS Patient discharges of nonruptured AAA repair were identified from the Nationwide Inpatient Sample between 1998 and 2004. Hospitals were stratified by yearly AAA surgical volume of low (< or =17 cases), medium (18 to 50), and high (>50). RESULTS A total of 46,901 patients underwent AAA repair (72.7% open vs 27.3% endovascular). The percentage of AAA repairs performed at both low-volume (36.2% to 24.3%) and medium-volume (51.0% to 44.8%) centers fell; whereas, the percentage performed at high-volume centers nearly tripled (12.9% vs 30.9%). In 1998 there were 10 high-volume centers; by 2004 this had increased to 26. The number of low-volume centers decreased, from 412 to 328. EVAR was more rapidly adopted by high-volume centers compared with low-volume centers. By 2004, 64.3% of AAA repairs at high-volume centers were done with endovascular techniques compared with 31.8% in low-volume centers. A concurrent reduction occurred in patient mortality, from 4.4% in 1998 to 2.5% in 2004 (P < .0001). CONCLUSION Between 1998 and 2004, a trend towards the regionalization of AAA repair to high-volume centers occurred. Nearly one-third of all AAA repairs were performed at high-volume centers. There was a concurrent increase in the frequency of endovascular AAA repair, especially at high-volume centers. During this period of regionalization of AAA repair to high-volume centers, patient mortality after AAA repair decreased by 23%. Thus, the observed regionalization of AAA repair and the reduction in short-term patient mortality for this operation may be explained by increased utilization of endovascular technologies at high-volume centers.

Pancreatic resection: a key component to reducing racial disparities in pancreatic adenocarcinoma

Blacks are affected disproportionately by pancreatic adenocarcinoma and have been linked with poor survival. Surgical resection remains the only potential curative option. If surgical disparities exist, then they may provide insight into outcome discrepancies.

Complications After Pancreatectomy for Neuroendocrine Tumors: A National Study

BACKGROUND Although resection of pancreatic neuroendocrine tumors (PNETs) has a demonstrated survival advantage, further evaluation of the overall morbidity of these procedures is needed. Our objective was to examine a composite outcome of major postoperative complications, including in-hospital mortality. MATERIALS AND METHODS The Nationwide Inpatient Sample (NIS), 1998-2006, was used to identify all patients with a diagnosis of PNET who had undergone pancreatectomy. Candidate predictors consisted of patient and hospital characteristics. Univariate analyses included chi(2) tests. Multivariate analyses were performed with logistic regression to determine which predictors were independently associated with the composite outcome. RESULTS A total of 463 (2274 nationally weighted) patients were identified. Overall composite postoperative complication rate was 29.6%. The majority of complications involved infections (11.1%), digestive complications (8.8%), or pulmonary compromise (7.3%). In-hospital mortality rate was 1.7%. High Charlson comorbidity score, procedure type of Whipple or total pancreatectomy, and urban hospital location were all associated with significantly increased complication rate. Logistic regression analysis demonstrated: Charlson score of > or =3 versus score of 0 (adjusted odds ratio (OR) 4.1, 95% confidence interval (CI) 2.1-8.3), surgery type of Whipple or total pancreatectomy versus partial pancreatectomy (adjusted OR 2.7, 95% CI 1.8-4.1), and hospital location of urban versus rural (adjusted OR 4.5, 95% CI 3.0-6.9). CONCLUSIONS While in-hospital mortality rates are low for surgical resection of PNETs, there is a considerable overall postoperative complication rate associated with these procedures. Careful patient and surgery selection may be the key to a surgical treatment approach for PNETs that may optimize outcomes.

Perioperative mortality for management of hepatic neoplasm: a simple risk score

Objectives:To develop a population-based risk score for stratifying patients by risk of in-hospital mortality following procedural intervention for hepatic neoplasm. Background:There has been growing support for the value of surgical management of hepatic neoplastic disease, both primary and metastatic. Advances in surgical and ablative technologies have contributed to a decrease in the mortality associated with these procedures. However, multiple patient-, disease- and treatment-related factors can contribute to perioperative morbidity and mortality. Methods:Using the Nationwide Inpatient Sample from 1998 to 2005, a retrospective cohort of patient-discharges for hepatic procedures with a concurrent diagnosis of hepatic primary or metastatic neoplasm to the liver was assembled. Procedures were categorized as lobectomy, wedge resection, or enucleation/ablation. Logistic regression and bootstrap methods were used to create an integer score for estimating the risk of in-hospital mortality using patient demographics, comorbidities, procedure type, tumor type, and hospital characteristics. A randomly selected sample of 80% of the cohort was used to create the risk score. Testing was conducted in the remaining 20% validation-set. Results:In total, 12,969 patient-discharges were identified. Overall in-hospital mortality was 3.45%. Predictive characteristics incorporated into the model included: age, sex, Charlson comorbidity score, procedure type, hospital type, and type of neoplasm. Integer values were assigned to these, and used to calculate an additive score. Five clinically relevant groups were assembled to stratify risk, with a 36-fold gradient in mortality. Rates in the groups were as follows: 0.9%, 2.5%, 6.8%, 17.6%, and 35.9%. In the derivation set, as well as in the validation set, the simple score discriminated well, with c-statistics of 0.76 and 0.70, respectively. Conclusions:An integer-based risk score can be used to predict in-hospital mortality after hepatic procedure for neoplasm, and may be useful for preoperative risk stratification and patient counseling.

In-Hospital Mortality for Liver Resection for Metastases: A Simple Risk Score

BACKGROUND Surgical management of liver metastases from various primaries is increasingly common. The mortality of such procedures is not well-defined. Accurate predictions for perioperative risk could augment decision-making. MATERIALS AND METHODS The Nationwide Inpatient Sample was queried (1998-2005) for patient-discharges for hepatic procedures for metastases. Logistic regression and bootstrap methods were used to create an integer score for estimating the risk of in-hospital mortality using patient demographics, comorbidities, procedure, and hospital type. A randomly selected sample of 80% of the cohort was used to create the risk score, with validation of the score in the remaining 20%. RESULTS For the total 50,537 patient-discharges, overall in-hospital mortality was 2.6%. Factors included in the model were age, sex, Charlson comorbidity score, procedure type, and teaching hospital status. Integer values were assigned for calculating an additive score. Four score groups were assembled to stratify risk, with a 15-fold gradient of mortality ranging from 0.9% to 14.7% (P<0.0001). In the derivation and the validation set, the score discriminated well, with a c-statistic of 0.72 and 0.72, respectively. CONCLUSION An integer-based risk score can be used to predict in-hospital mortality after hepatic procedure for metastases, and may be useful for preoperative patient counseling.

Total pancreatectomy: a national study

BACKGROUND Total pancreatectomy (TP) is performed for various indications. Historically, morbidity and mortality have been high. Recent series reporting improved peri-operative mortality have renewed interest in TP. We performed a national review of TP including indication, patient/hospital characteristics, complications and peri-operative mortality. METHODS The Nationwide Inpatient Sample (NIS) was queried to identify TPs performed during 1998 to 2006. Univariate analyses were used to compare patient/hospital characteristics. Multivariable logistic regression was performed to identify predictors of in-hospital mortality. Post-operative complications/disposition were assessed. RESULTS From 1998 to 2006, 4013 weighted patient-discharges occurred for TP. Fifty-three per cent were male; mean age 58 years. INDICATION neoplastic disease 67.8%. Post-operative complications occurred in 28%. Univariate analyses: TPs increased significantly (1998, n = 384 vs. 2006 n = 494, P < 0.01). 77.1% of TPs occurred in teaching hospitals (P < 0.0001), 86.4% in hospitals performing <five pancreatectomies/year (P < 0.0001). In-patient mortality was 8.5% with a significant decrease (12.4% 1998-2000 vs. 5.9% 2002-2006, P < 0.01). Multivariable analyses: advanced age [referent < or = 50 years; > or = 70 Adjusted odds ratio (AOR) 3.4, 95% confidence interval (CI) 1.33-8.67], select patient comorbidities and year (referent = 2004-2006; 1998-2000 AOR 2.70; 95% CI 1.41-5.14) independently predicted in-patient mortality whereas hospital surgical volume did not. DISCUSSION TP is increasingly performed nationwide with a concomitant decrease in peri-operative mortality. Patient characteristics, rather than hospital volume, predicted increased mortality.

In-Hospital Mortality after Pancreatic Resection for Chronic Pancreatitis: Population-Based Estimates from the Nationwide Inpatient Sample

BACKGROUND Pancreatic resection can be performed to ameliorate the sequelae of chronic pancreatitis in selected patients. The perceived risk of pancreatectomy may limit its use. Using a national database, this study compared mortality after pancreatic resections for chronic pancreatitis with those performed for neoplasm. STUDY DESIGN Patient discharges with chronic pancreatitis or pancreatic neoplasm were queried from the Nationwide Inpatient Sample, 1998 to 2006. To account for the Nationwide Inpatient Sample weighting schema, design-adjusted analyses were used. RESULTS There were 11,048 pancreatic resections. Malignant neoplasms represented 64.2% of the sample; benign neoplasms and pancreatitis comprised 17.1% and 18.7%, respectively. In-hospital mortality rates were 2.2% and 1.7% for the pancreatitis and benign tumor cohorts, respectively, compared with 5.9% for the malignancy cohort (overall p < 0.01). A multivariable logistic regression examined differences in mortality among diagnoses while adjusting for patient and hospital characteristics; covariates included patient gender, race, age, comorbidities, type of pancreatectomy, payor, hospital teaching status, hospital size, and hospital volume. After adjustment, patients undergoing resection for pancreatitis were at a significantly lower risk of in-hospital mortality when compared with those with malignant neoplasm (odds ratio, 0.43; 95% CI, 0.28 to 0.67). CONCLUSIONS Pancreatectomies for chronic pancreatitis have lower in-hospital mortality than those performed for malignancy and similar rates as resection for benign tumors. Pancreatic resection, which can improve quality of life in chronic pancreatitis patients, can be performed with moderate mortality rates and should be considered in appropriate patients.

A national propensity-adjusted analysis of adjuvant radiotherapy in the treatment of resected pancreatic adenocarcinoma

The benefit of adjuvant radiotherapy (RT) for resected pancreatic adenocarcinoma remains controversial after randomized clinical trials. In this national‐level US study, a propensity score (conditional probability of receiving RT) was used to adjust for potential confounding in nonrandomized designs from treatment group differences.