In‐hospital survival after pancreatoduodenectomy is greater in high‐volume hospitals versus lower‐volume hospitals: a meta‐analysis

• Published in: ANZ journal of surgery Vol. 92; no. 1-2; pp. 77 - 85
• Main Authors: Kovoor, Joshua G., Ma, Ning, Tivey, David R., Vandepeer, Meegan, Jacobsen, Jonathan Henry W., Scarfe, Anje, Vreugdenburg, Thomas D., Stretton, Brandon, Edwards, Suzanne, Babidge, Wendy J., Anthony, Adrian A., Padbury, Robert T. A., Maddern, Guy J.
• Format: Journal Article
• Language: English
• Published: Melbourne John Wiley & Sons Australia, Ltd 01.01.2022; Blackwell Publishing Ltd
• Subjects: centralisation; Hospital Mortality; Hospitals; Hospitals, High-Volume; Humans; Meta-analysis; Mortality; Pancreaticoduodenectomy; pancreatoduodenectomy; postoperative mortality; Statistical analysis; Subgroups; Survival; Thresholds; volume‐outcome relationships; Whipple procedure; United States > US; centralisation; pancreatoduodenectomy; volume-outcome relationships; postoperative mortality; Whipple procedure
• ISSN: 1445-1433; 1445-2197
• DOI: 10.1111/ans.17293

Background Variation in cut‐off values for what is considered a high volume (HV) hospital has made assessments of volume‐outcome relationships for pancreaticoduodenectomy (PD) challenging. Accordingly, we performed a systematic review and meta‐analysis comparing in‐hospital mortality after PD in hospitals above and below HV thresholds of various cut‐off values. Method PubMed/MEDLINE, Embase and Cochrane Library were searched to 4 January 2021 for studies comparing in‐hospital mortality after PD in hospitals above and below defined HV thresholds. After data extraction, risk of bias was assessed using the Downs and Black checklist. A random‐effects model was used for meta‐analysis, including meta‐regressions. Registration: PROSPERO, CRD42021224432. Results From 1855 records, 17 observational studies of moderate quality were included. Median HV cut‐off was 25 PDs/year (IQR: 20–32). Overall relative risk of in‐hospital mortality was 0.37 (95% CI: 0.30, 0.45), that is, 63% less in HV hospitals. All subgroup analyses found an in‐hospital survival benefit in performing PDs at HV hospitals. Meta‐regressions from included studies found no statistically significant associations between relative risk of in‐hospital mortality and region (USA vs. non‐USA; p = 0.396); or 25th percentile (p = 0.231), median (p = 0.822) or 75th percentile (p = 0.469) HV cut‐off values. Significant inverse relationships were found between PD hospital volume and other outcomes. Conclusion In‐hospital survival was significantly greater for patients undergoing PDs at HV hospitals, regardless of HV cut‐off value or region. Future research is required to investigate regions where low‐volume centres have specialized PD infrastructure and the potential impact on mortality. This systematic review and meta‐analysis objectively demonstrates that in‐hospital survival after pancreaticoduodenectomy (PD) is greater in hospitals performing an annual volume of PDs above a defined high volume (HV) cut‐off threshold compared with hospitals below such a threshold. At HV hospitals the relative risk of in‐hospital survival is more than double that of hospitals below the HV threshold. As both HV cut‐off value and region had no significant association with relative risk of in‐hospital mortality, this in‐hospital survival benefit may apply universally regardless of region or defined HV cut‐off value.