Association of Textbook Outcome and Surgical Case Volume with Long-Term Survival in Patients Undergoing Surgical Resection for Pancreatic Cancer

Abstract

BACKGROUND: Current literature has identified textbook outcome (TO) as a quality metric after cancer surgery. We studied whether TO after pancreatic resection has a stronger association with long-term survival than individual hospital case volume. STUDY DESIGN: Patients undergoing surgery for pancreatic adenocarcinoma from 2010 to 2015 were identified from the National Cancer Database. Hospitals were stratified by volume (low less than 6, medium 6 to 19, and high 20 cases or more per year), and overall survival data were abstracted. We defined TO as adequate lymph node count, negative margins, length of stay less than the 75th percentile, appropriate systemic therapy, timely systemic therapy, and without a mortality event or readmission within 30 days. The association of TO and case volume was assessed using a multivariable Cox regression model for survival. RESULTS: Overall, 7270 patients underwent surgery, with 30.7%, 48.7%, and 20.6% performed at low-, medium-, and high-volume hospitals, respectively. Patients treated at low-volume hospitals were more likely to be Black, be uninsured or on Medicaid, have higher Charlson comorbidity scores, and be less likely to achieve TO (23.4% TO achievement vs 37.5% achievement at high-volume hospitals). However, high hospital volume was no longer associated with overall survival once TO was added to the multivariable model stratified by volume status. Achievement of TO corresponded to a 31% decrease in mortality (hazard ratio 0.69; p < 0.001), independent of hospital volume. CONCLUSIONS: Improved long-term survival after pancreatic resection was associated with TO rather than high hospital volume. Quality improvement efforts focused on TO criteria have the potential to improve outcomes irrespective of case volume.

Ideal Outcome After Pancreatoduodenectomy

“…37 Multiple other studies investigating "oncological textbook outcome," showed a clear association of higher surgical case volume and better outcomes. 38 The results of this study should be interpreted in light of several limitations. First, the results of this study can be influenced by the difference in the structure of the registries, most importantly voluntary and multicenter (North America and Germany) versus mandatory and national (The Netherlands and Sweden), the frequency of auditing, and the duration of follow-up.…”

“…A study including 20,902 patients after pancreatic resection derived from Medicare insurance files showed that patients after pancreatic resection by a top-quartile volume surgeon were more likely to achieve textbook outcome (70% vs 63%), whereas a resection by a low-quartile volume surgeon caused a 46% rate of textbook outcome 37 . Multiple other studies investigating “oncological textbook outcome,” showed a clear association of higher surgical case volume and better outcomes 38 …”

Achieving Textbook Outcomes in Colorectal Cancer Surgery Is Associated with Improved Long-Term Survival: Results of the Multicenter Prospective Cohort Study

“…However, the association between long-term outcomes of cancer patients and surgical volume is conflicting to this day. The impact of surgical case volume on long-term survival has been extensively analyzed in hepatopancreatic and gastric cancer surgery [ 28 , 29 , 30 , 31 ]. However, the relationship between caseload and textbook outcome is still conflicting.…”

Robotic versus laparoscopic liver resection in various settings: an international multicenter propensity score-matched study of 10,075 patients

“…35 In recent years, textbook outcome measures are gaining traction across various surgical specialties, and the achievement of textbook outcome has been linked to increased survival in esophagogastric and pancreatic surgery. 36,37 Gorgec et al defined, based on an international survey among hepatobiliary surgeons, and validated TOLS, thus providing a potent outcome assessment tool in this domain. 31 Of note, the addition of the variable 'absence of a prolonged length of stay' (named TOLS +) did not reach the 80% consensus threshold in this definition, which therefore requires a more nuanced interpretation.…”