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Variation in Hospital Utilization of Minimally Invasive Distal Pancreatectomy for Localized Pancreatic Neoplasms

  • Ryan J. Ellis
  • Lindsey M. Zhang
  • Clifford Y. Ko
  • Mark E. Cohen
  • David J. Bentrem
  • Karl Y. Bilimoria
  • Anthony D. Yang
  • Mark S. Talamonti
  • Ryan P. MerkowEmail author
Original Article
  • 18 Downloads

Abstract

Background

Minimally invasive distal pancreatectomy (MIDP) for localized neoplasms has been demonstrated to be feasible and safe. However, national adoption of the technique is poorly understood. Objectives of this study were to identify factors associated with use of minimally invasive distal pancreatectomy for localized neoplasms and assess hospital variation in MIDP utilization.

Methods

Retrospective cohort study of patients with pancreatic cysts, stage I pancreatic ductal adenocarcinoma, and stage I pancreatic neuroendocrine tumors undergoing distal pancreatectomy from the ACS NSQIP Pancreas Targeted Dataset. Factors associated with use of MIDP were identified using multivariable logistic regression and hospital-level variation was assessed.

Results

Analysis included 3,059 patients at 139 hospitals. Overall, 64.5% of patients underwent minimally invasive distal pancreatectomy. Patients were more likely to undergo MIDP if they had lower ASA classification (P = 0.004) or BMI ≥ 30 (P < 0.001) and less likely if they had pancreatic adenocarcinoma (P < 0.001). There was notable hospital variability in utilization (range 0 to 100% of cases). Hospital-level utilization of minimally invasive distal pancreatectomy did not appear to be driven by patient selection, as hierarchical analysis demonstrated that only 1.8% of observed hospital variation was attributable to measured patient selection factors.

Conclusion

Utilization of MIDP for localized pancreatic neoplasms is highly variable. While some patient-level factors are associated with MIDP use, hospital adoption of MIDP appears to be the primary driver of utilization. Monitoring hospital-level use of MIDP may be a useful quality measure to monitor uptake of emerging techniques in pancreatic surgery.

Keywords

Health services research Surgical quality Pancreatic surgery Distal pancreatectomy 

Abbreviations

ACS

American College of Surgeons

DSM

Death or serious morbidity

MIDP

Minimally invasive distal pancreatectomy

NSQIP

National Surgical Quality Improvement Program

ODP

Open distal pancreatectomy

PDAC

Pancreatic ductal adenocarcinoma

PNET

Pancreatic neuroendocrine tumor

Notes

Funding Information

RJE is supported by a postdoctoral research fellowship (Agency for Healthcare Research and Quality [AHRQ] 5T32HS000078). ADY is supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (K08HL145139). RPM is supported by the Agency for Healthcare Quality (K12HS026385) and an Institutional Research Grant from the American Cancer Society (IRG-18-163-24).

Compliance with Ethical Standards

Disclaimer

The American College of Surgeons as an organization had no role in the design and conduct of the study; analysis and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Views expressed in this work represent those of the authors only.

References

  1. 1.
    Lillemoe, K.D., et al., Distal pancreatectomy: indications and outcomes in 235 patients. Ann Surg, 1999. 229(5): p. 693-8; discussion 698-700.CrossRefGoogle Scholar
  2. 2.
    Soreide, K., et al., A nationwide cohort study of resection rates and short-term outcomes in open and laparoscopic distal pancreatectomy. HPB (Oxford), 2018.Google Scholar
  3. 3.
    Cuschieri, A., Laparoscopic surgery of the pancreas. J R Coll Surg Edinb, 1994. 39(3): p. 178-84.PubMedGoogle Scholar
  4. 4.
    Nigri, G.R., et al., Metaanalysis of trials comparing minimally invasive and open distal pancreatectomies. Surg Endosc, 2011. 25(5): p. 1642-51.CrossRefGoogle Scholar
  5. 5.
    Jusoh, A.C. and B.J. Ammori, Laparoscopic versus open distal pancreatectomy: a systematic review of comparative studies. Surg Endosc, 2012. 26(4): p. 904-13.CrossRefGoogle Scholar
  6. 6.
    Jin, T., et al., A systematic review and meta-analysis of studies comparing laparoscopic and open distal pancreatectomy. HPB (Oxford), 2012. 14(11): p. 711-24.CrossRefGoogle Scholar
  7. 7.
    de Rooij, T., et al., Minimally invasive versus open distal pancreatectomy (LEOPARD): a multicenter patient-blinded randomized controlled trial. Ann Surg, 2018.Google Scholar
  8. 8.
    Gavriilidis, P., K.J. Roberts, and R.P. Sutcliffe, Laparoscopic versus open distal pancreatectomy for pancreatic adenocarcinoma: a systematic review and meta-analysis. Acta Chir Belg, 2018. 118(5): p. 278-286.CrossRefGoogle Scholar
  9. 9.
    van Hilst, J., et al., Minimally invasive versus open distal pancreatectomy for ductal adenocarcinoma (DIPLOMA): a pan-European propensity score matched study. Ann Surg, 2019. 269(1): p. 10-17.CrossRefGoogle Scholar
  10. 10.
    Hawkins, A.T., et al., Barriers to laparoscopic colon resection for cancer: a national analysis. Surg Endosc, 2018. 32(2): p. 1035-1042.CrossRefGoogle Scholar
  11. 11.
    Cohen, M.E., et al., Optimizing ACS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and surgical focus. J Am Coll Surg, 2013. 217(2): p. 336-46 e1.CrossRefGoogle Scholar
  12. 12.
    User Guide for the 2016 ACS NSQIP Participant Use Data File (PUF). https://www.facs.org/~/media/files/quality%20programs/nsqip/nsqip_puf_userguide_2016.ashx October 2017.
  13. 13.
    Allison, P.D., Handling missing data by maximum likelihood. SAS Global Forum 2012: Statistics and Data Analysis, 2012.Google Scholar
  14. 14.
    Paruch, J.L., et al., Impact of hepatectomy surgical complexity on outcomes and hospital quality rankings. Ann Surg Oncol, 2014. 21(6): p. 1773-80.CrossRefGoogle Scholar
  15. 15.
    Merkow, R.P., et al., Validity and feasibility of the american college of surgeons colectomy composite outcome quality measure. Ann Surg, 2013. 257(3): p. 483-9.CrossRefGoogle Scholar
  16. 16.
    Guidelines (2013) for managing overweight and obesity in adults. Preface to the Expert Panel Report (comprehensive version which includes systematic evidence review, evidence statements, and recommendations). Obesity (Silver Spring), 2014. 22 Suppl 2: p. S40.Google Scholar
  17. 17.
    Stefanou, A.J., et al., Laparoscopic colectomy significantly decreases length of stay compared with open operation. Surg Endosc, 2012. 26(1): p. 144-8.CrossRefGoogle Scholar
  18. 18.
    Makino, T., et al., The impact of obesity on perioperative outcomes after laparoscopic colorectal resection. Ann Surg, 2012. 255(2): p. 228-36.CrossRefGoogle Scholar
  19. 19.
    Afaneh, C., et al., Obesity does not increase morbidity of laparoscopic cholecystectomy. J Surg Res, 2014. 190(2): p. 491-7.CrossRefGoogle Scholar
  20. 20.
    Klompmaker, S., et al., Nationwide evaluation of patient selection for minimally invasive distal pancreatectomy using American College of Surgeons’ National Quality Improvement Program. Ann Surg, 2017. 266(6): p. 1055-1061.CrossRefGoogle Scholar
  21. 21.
    Maggino, L., et al., Impact of operative time on outcomes after pancreatic resection: a risk-adjusted analysis using the American College of Surgeons NSQIP Database. J Am Coll Surg, 2018. 226(5): p. 844-857 e3.CrossRefGoogle Scholar
  22. 22.
    Plotkin, A., et al., Reduced morbidity with minimally invasive distal pancreatectomy for pancreatic adenocarcinoma. HPB (Oxford), 2017. 19(3): p. 279-285.CrossRefGoogle Scholar
  23. 23.
    Sharpe, S.M., et al., The laparoscopic approach to distal pancreatectomy for ductal adenocarcinoma results in shorter lengths of stay without compromising oncologic outcomes. Am J Surg, 2015. 209(3): p. 557-63.CrossRefGoogle Scholar
  24. 24.
    Baker, M.S., et al., Defining quality for distal pancreatectomy: does the laparoscopic approach protect patients from poor quality outcomes? J Gastrointest Surg, 2013. 17(2): p. 273-80.CrossRefGoogle Scholar
  25. 25.
    Kantor, O., et al., Laparoscopic distal pancreatectomy for cancer provides oncologic outcomes and overall survival identical to open distal pancreatectomy. J Gastrointest Surg, 2017. 21(10): p. 1620-1625.CrossRefGoogle Scholar
  26. 26.
    Shakir, M., et al., The learning curve for robotic distal pancreatectomy: an analysis of outcomes of the first 100 consecutive cases at a high-volume pancreatic centre. HPB (Oxford), 2015. 17(7): p. 580-6.CrossRefGoogle Scholar
  27. 27.
    de Rooij, T., et al., Single-surgeon learning curve in 111 laparoscopic distal pancreatectomies: does operative time tell the whole story? J Am Coll Surg, 2017. 224(5): p. 826-832 e1.CrossRefGoogle Scholar
  28. 28.
    Cancer, A.C.o.S.C.o. Commission on Cancer Programs Practice Profile Reports: colon measure specifications. 2018 [cited 2018 12/21]; Available from: https://www.facs.org/~/media/files/quality%20programs/cancer/ncdb/measure%20specs%20colon.ashx.
  29. 29.
    Jaffe, T.A., et al., Safety considerations in learning new procedures: a survey of surgeons. J Surg Res, 2017. 218: p. 361-366.CrossRefGoogle Scholar
  30. 30.
    Jaffe, T.A., et al., Strategies for new skill acquisition by practicing surgeons. J Surg Educ, 2018. 75(4): p. 928-934.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  • Ryan J. Ellis
    • 1
    • 2
    • 3
  • Lindsey M. Zhang
    • 1
    • 2
    • 4
  • Clifford Y. Ko
    • 1
    • 5
    • 6
  • Mark E. Cohen
    • 1
  • David J. Bentrem
    • 2
    • 3
  • Karl Y. Bilimoria
    • 1
    • 2
    • 3
  • Anthony D. Yang
    • 2
    • 3
  • Mark S. Talamonti
    • 7
    • 8
  • Ryan P. Merkow
    • 1
    • 2
    • 3
    Email author
  1. 1.Division of Research and Optimal Patient CareAmerican College of SurgeonsChicagoUSA
  2. 2.Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  3. 3.Northwestern Institute for Comparative Effectiveness Research in Oncology, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  4. 4.Department of SurgeryUniversity of Chicago MedicineChicagoUSA
  5. 5.Department of Surgery, David Geffen School of MedicineUniversity of CaliforniaLos AngelesUSA
  6. 6.VA Greater Los Angeles Healthcare SystemLos AngelesUSA
  7. 7.Department of SurgeryNorthShore University HealthSystemEvanstonUSA
  8. 8.Pritzker School of MedicineUniversity of ChicagoChicagoUSA

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