Useful benchmarks to evaluate outcomes after esophagectomy and pancreaticoduodenectomy.
BACKGROUND
Multiple publications have suggested that outcomes after complex operations are better at high-volume centers. However, of all the potential "outcomes" to measure, only mortality has been studied extensively. The broadest difference in mortality between low- and high-volume centers has been measured after esophagectomy (EG) and pancreaticoduodenectomy (PD). If a low-volume center recorded high mortality, then a broader set of outcomes beyond mortality would be useful for self-assessment.


METHODS
Two single-surgeon prospective databases for outcomes of EG and PD were reviewed in a multispecialty clinic within a tertiary-referral, resident-training hospital. Between January 1996 and December 2002, 174 consecutive patients underwent EG performed by 1 surgeon (25 cases/y), and 232 consecutive patients underwent PD performed by another surgeon (34 cases/y). We measured hospital and 30-day mortality rate, mean operation time (OR time), mean estimated intraoperative blood loss (EBL), mean length of stay (LOS), and the anastomotic leak rate. These outcomes were compared with those of recently published cases for EG and PD.


RESULTS
Mortality for both operations was zero. After EG, OR time was 394 minutes (literature = 336), EBL was 204 mL (literature = 964), transfusion rate was 3.5% (literature = 34%), LOS was 11.1 days (literature = 16.6), leak was 2.9% (literature = 9.1%), and reoperation was 1.7% (literature = not stated). After PD, OR time was 450 minutes (literature = 431), EBL was 382 mL (literature = 1,183), transfusion rate was 7.3% (literature = not stated), LOS was 11.2 days (literature = 17.8), leak was 6.5% (literature = 9.9%), and reoperation was 0.4% (literature = 3.8%).


CONCLUSIONS
These 2 single-surgeon series provide benchmarks to help better define acceptable outcomes after EG and PD. This assessment demonstrated lower mortality and LOS in a high-volume surgical practice. These outcomes are not associated with OR time but with lower EBL, less need for transfusion, and lower need for reoperation. Anastomotic leaks occurred in both series; however, this was not associated with mortality because of early recognition and the use of nonsurgical minimally invasive techniques. If mortality is high at a low-volume center, then the additional benchmarks of this study, in addition to mortality and LOS, could be used to lower mortality through self-assessment by identifying specific outcomes that need improvement.
Traverso
L William
LW
Department of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave., PO Box 900, Seattle, WA 98111-0900, USA. gtslwt@vmmc.org
Shinchi
Hiroyuki
H
Low
Donald E
DE
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019985:Benchmarking / Q000379:methods* / Q000592:standards; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D001803:Blood Transfusion / Q000706:statistics & numerical data; D002983:Clinical Competence / Q000592:standards; D004322:Drainage / Q000706:statistics & numerical data; D016629:Esophagectomy / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data; D005260:Female; D005769:Gastrointestinal Motility; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods* / Q000592:standards; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data; D011182:Postoperative Care / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011446:Prospective Studies; D012086:Reoperation / Q000706:statistics & numerical data; D013997:Time Factors; D014861:Washington / Q000453:epidemiology