Adjuvant radiotherapy in combination with 5-fluorouracil is safe and well tolerated. However, the benefit in this study was small; routine use of adjuvant chemoradiotherapy is not warranted as standard treatment in cancer of the head of the pancreas or periampullary region.

ObjectiveTo perform a two-part study of pancreaticoduodenectomy in the Netherlands, focusing on the effects of risk factors on outcomes in a single high-volume hospital and the effect of hospital volume on outcomes. Summary Background DataHospital volume and surgeon caseload can be related to the rates of complications and death, and the influence of risk factors can be volume-dependent. Provision of regionalized care should take this into account. MethodsIn part A, a single-institution database on 300 consecutive patients undergoing pancreaticoduodenectomy was divided into two periods with similar numbers of patients. Overall complications, deaths, hospital stay, and risk factors were analyzed in the two periods and compared with an historical reference group. In part B, Netherlands medical registry data on age and postoperative death of patients who underwent partial pancreaticoduodenectomy from 1994 to 1998 were analyzed for the influence of hospital volume on death. ResultsBetween the time periods, the institutional death rate decreased from 4.9% to 0.7%, the complication rate from 60% to 41%. Median hospital stay decreased from 24 to 15 days. The death rate was not related to patient age and did not differ between surgeons. Serum creatinine levels, need for blood transfusion, and period of resection were independent risk factors for complications.The death rate after pancreaticoduodenectomy in the Netherlands was 12.6% in 1994 and 10.1% in 1998; it was greater in patients older than age 65. During the 5-year period, 40% of the procedures were performed in hospitals performing fewer than five resections per year, and the death rate was greater than in hospitals performing more than 25 resections per year. ConclusionsThe overall death rate after pancreaticoduodenectomy did not decrease significantly during the period, and it was greater in low-volume hospitals and older patients. The lower death and complication rates in high-volume hospitals, including the singlecenter outcomes, were similar to those reported in other countries and may be due to better prevention and management of complications. Pancreaticoduodenectomy should be performed in centers with sufficient experience and resources for support.In the past, pancreaticoduodenectomy has been associated with a high rate of complications (40 -60%) and a high death rate (up to 20%). Combined with a dismal prognosis, in particular for patients with pancreatic carcinoma, this led to a nihilistic approach by some clinicians.1 In experienced centers, death rates have decreased dramatically, 2-6 which has encouraged other surgeons to perform pancreatic resections in nonspecialized units. The complication and death rates of surgery depend on many variables, including the presence of malignancy, the severity of jaundice, nutritional status, infection, and impaired renal function. 7,8 These factors have allowed better patient selection. In parallel, several reports since 1995 have highlighted the influence of hospital volume on hospital death.

Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: http://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. One group comprised patients undergoing percutaneous or surgical drainage procedures; the other had patients undergoing resection of the pancreatic remnant. RESULTS:Twenty-nine patients (11%) had clinical manifestations of pancreatic leakage, and the mortality in these patients was 28% (overall mortality: 3.7%). Leakage occurred after a median of 5 days (range 1-20). Age, preoperative bilirubin level, and albumin counts were not risk factors for pancreatic leakage. Small pancreatic duct size (Ͻ2mm) (pϽ0.01) and ampullary carcinoma as histopathologic diagnosis (pϽ0.05) were risk factors. The median number of relaparotomies was two (range 0-4) in the drainage group (nϭ21), versus 1.5 (range 1-5) in patients who underwent resection (nϭ8). The median hospital stay was 74 days (range 36-219), versus 55 days (range 22-107) for the drainage and resection groups, respectively (pϽ0.05). Mortality was lower in patients who underwent resection, 38 versus 0% (pϽ0.05). CONCLUSIONS: Leakage of the pancreatic anastomosis is a severe complication after pancreaticoduodenectomy and carries a high mortality rate (28%). Completion pancreatectomy could be performed without additional mortality. In patients with severe and persistent leakage of the anastomosis, early completion pancreatectomy is the treatment of choice. (J Am

ObjectiveTo determine the feasibility and desirability of laparoscopic cholecystectomy (LC) in day-care versus LC with clinical observation. Summary Background DataLaparoscopic cholecystectomy has been performed regularly as outpatient surgery in patients with uncomplicated gallstone disease in the United States, but this has not been generally accepted in Europe. The main objections are the risk of early severe complications (bleeding) or other reasons for readmission, and the argument that patients might feel safer when observed for one night. Quality-of-life differences hitherto have not been investigated. MethodsEighty patients (American Society of Anesthesiology [ASA] 1/11) with symptomatic gallstones were randomized to receive LC either in day-care or with clinical observation. Complications, (re)admissions, consultations of general practitioners or the day-care center within 4 days after surgery, use of pain medication, quality of life, convalescence period, time off from professional activities, and treatment preference were assessed. The respective costs of day-care and clinical observation were determined. ResultsOf the 37 patients assigned to the day-care group who underwent elective surgery, 92% were discharged successfully after an observation period of 5.7 ± 0.2 hours. The remainder of the patients in this group were admitted to the hospital and clinically observed for 24 hours.For the 37 patients in the clinical observation group who underwent elective surgery, the observation time after surgery was 31 ± 3 hours.Three patients in the day-care group and one patient in the clinical observation group had complications after surgery. None of the patients in either group consulted a general practitioner or the hospital during the first week after surgery.Use of pain medication was comparable in both groups over the first 48 hours after surgery. There were no differences in pain and other quality-of-life indicators between the groups during the 6 weeks of follow-up.Of the patients in the day-care group, 92% preferred daycare to clinical observation. The same percentage of patients in the clinical observation group preferred at least 24 hours of observation to day-care.Costs for the day-care patients were substantially lower (approximately $750/patient) than for the clinical observation patients.