A “Hub and Spoke” Model for Pancreaticoduodenectomy across the Indonesian Archipelago

Abstract

Background: Pancreaticoduodenectomy (PD) is associated with major morbidity and mortality especially in low volume centers. A centralized model is not suitable for Indonesia, due to its geographical characteristics and the underlying structure of its health funding. As an alternative, an outreach program was developed and delivered by a dedicated hepatopancreatobiliary (HPB) team. The aim of this study was to describe the outcomes of such approach. Methods: A retrospective study of all patients undergoing Pancreaticoduodenectomy or total pancreatectomy by a single HPB team was performed. A “hub and spoke” model /decentralization strategy was used to deliver the care between a tertiary center and eight peripheral centers. Patient demographics, system measures, and outcomes were collected. Results: A total of 213 patients were identified as undergoing a resection within the period of 1993–2017. A total of 47 resections (22%) were performed at a peripheral center. The median age was 51 years and 91(46%) of patients had ampullary carcinoma. The perioperative mortality was 17% but improved over time. Only 19/198 (9.5%) patients with the malignant disease received adjuvant therapy. The median (95%CI) survival for patients with pancreatic and ampullary cancer was 12 (9-15) and 24 (14-34) months respectively. Conclusions: A hub and spoke model as a decentralization strategy for managing patients with peri-ampullary tumors can lead to an improvement in access and outcomes. However further work is required if they are to achieve outcomes achieved by international high-volume centers within centralization programs.

Keep It or Leave It? Comparison of Preoperative Scoring as Mortality Predictor Post-Pancreaticoduodenectomy

“…Intraoperative factors such as the duration of the surgery, the amount of bleeding, fluid resuscitation, blood transfusion should be included in the scoring system. They can contribute to increasing the accuracy of postoperative mortality prediction (Romano et al, 2015;Lalisang et al, 2019;Mirrielees et al, 2020). We need to explore other factors of the patient with similar scores but with different outcomes.…”