title: Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience.
abstract: OBJECTIVE
  To determine the importance of hospital volume, surgeon experience, and surgeon volume in performing pancreaticoduodenectomy (PD).
  
  
  METHODS
  From 1980 through 2007, 1003 patients underwent PD by 19 surgeons at a university hospital.
  
  
  METHODS
  Patient morbidity and mortality, quality of resection, and learning curve were examined according to hospital volume (period 1: 1980-2003 vs period 2: 2004-2007), surgeon experience (total number of PDs), and surgeon volume (number of PDs per year).
  
  
  RESULTS
  Perioperative morbidity and mortality for all 1003 PDs were 41% and 3%, respectively. Differences existed between period 1 and period 2 in percentage of PDs performed in elderly patients (7% vs 17%), mortality (4% vs 2%), estimated blood loss (1817 mL vs 780 mL), length of stay (18 days vs 12 days), and proportion of International Study Group on Pancreatic Fistula grade C pancreatic fistulae (29% vs 12%). Surgeons with less experience (<50 PDs) performed PD with higher morbidity (53% vs 39%), pancreatic fistula rate (20% vs 10%), estimated blood loss (1918 mL vs 1101 mL), and operative time (458 minutes vs 335 minutes) compared with surgeons with more experience (> or =50 PDs). Experienced surgeons had comparable outcomes irrespective of annual volume. Mortality, margins, and number of lymph nodes resected were not affected by surgeon experience or surgeon volume. Learning curves projected that less experienced surgeons would achieve morbidity and mortality rates equivalent to those of experienced surgeons when they reached 20 and 60 PDs, respectively.
  
  
  CONCLUSIONS
  Improvement in PD outcomes, including mortality, occurred with increased PD volume at a pancreatic center. Surgeon experience remained an important determinant of overall morbidity. Experienced surgeons, however, had comparable outcomes irrespective of annual volume.
authors.affiliation: Department of Surgery, Indiana University School of Medicine, 980 W Walnut Street, Indianapolis, IN 46202, USA. maxschmi@iupui.edu
authors.forename: C Max
authors.initials: CM
authors.lastname: Schmidt
authors.forename: Olivier
authors.initials: O
authors.lastname: Turrini
authors.forename: Purvi
authors.initials: P
authors.lastname: Parikh
authors.forename: Michael G
authors.initials: MG
authors.lastname: House
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Zyromski
authors.forename: Atilla
authors.initials: A
authors.lastname: Nakeeb
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Howard
authors.forename: Henry A
authors.initials: HA
authors.lastname: Pitt
authors.forename: Keith D
authors.initials: KD
authors.lastname: Lillemoe
mesh_terms: D000328:Adult; D000368:Aged; D019985:Benchmarking / Q000379:methods; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D002983:Clinical Competence / Q000706:statistics & numerical data*; D005260:Female; D006785:Hospitals, University / Q000706:statistics & numerical data*; D006801:Humans; D007196:Indiana; D007858:Learning; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010185:Pancreatic Fistula / Q000209:etiology; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000401:mortality / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012107:Research Design; D012189:Retrospective Studies