title: Major pancreatic resections for suspected cancer in a community-based teaching hospital: lessons learned.
abstract: BACKGROUND
  The literature reports 4-10% mortality rate, 30-60% morbidity rate, and 9-29% anastomotic leak rate after pancreaticoduodenectomy (PD) performed for periampullary tumors. These data demonstrate a linear relationship between surgical volume and outcome.
  
  
  METHODS
  The objective of this study was to evaluate the experience of a high-volume hospital with low-volume pancreatoduodenectomy for suspected cancer. The study was designed as a retrospective review of medical records of all patients who underwent pancreatoduodenal resection or total pancreatectomy for a suspected periampullary carcinoma between January 1994 and December 2003. The setting of the study was a community-based teaching hospital with a general surgery residency training program.
  
  
  RESULTS
  A total of 63 patients underwent pancreatoduodenal resection or total pancreatectomy. All procedures were performed by a total of 15 different surgeons; however, 27 operations were performed by one surgeon. Pre-operative diagnosis in most cases was either a known malignancy-27 cases (43%) or a tumor of the head of the pancreas, suspicious for malignancy-36 cases (57%). One patient underwent a total pancreatectomy. In 62 patients a pancreatoduodenal resection (Whipple procedure) was performed. Post-operative 30-day mortality was 4.7% (three patients). Overall in-hospital mortality was 9.5% (six patients). Ten (16.1%) had a leak of the pancreato-jejunal anastomosis, six of which resolved with non-operative management. Of the remaining four patients, three died from peritonitis or consequences of erosive hemorrhage.
  
  
  CONCLUSIONS
  Post-operative leak of the pancreatic anastomosis represents a technical challenge. Although most of the leaks can be treated non-operatively, those that lead to peritonitis or erosive hemorrhage warrant operative intervention. Major pancreatic resections can be performed safely with low rates of morbidity and operative mortality with careful selection of patients at a low-volume community-based teaching hospital.
authors.affiliation: Department of Surgery Christiana Care Health Services, Helen F. Graham Cancer Center, Newark, Delaware, USA.
authors.forename: Ramaz E
authors.initials: RE
authors.lastname: Metreveli
authors.forename: Katherine
authors.initials: K
authors.lastname: Sahm
authors.forename: Raafat
authors.initials: R
authors.lastname: Abdel-Misih
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Petrelli
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater; D001706:Biopsy / Q000379:methods; D002277:Carcinoma / Q000401:mortality / Q000601:surgery*; D003691:Delaware; D005260:Female; D017052:Hospital Mortality; D006764:Hospitals, Community; D006784:Hospitals, Teaching; D006801:Humans; D008197:Lymph Node Excision; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010179:Pancreas / Q000473:pathology; D010180:Pancreatectomy / Q000706:statistics & numerical data; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000706:statistics & numerical data; D011183:Postoperative Complications; D012189:Retrospective Studies