title: Pancreatoduodenectomy--current status of surgical and perioperative techniques in Germany.
abstract: BACKGROUND
  Pancreatoduodenectomy in Germany is performed by a broad range of hospitals. A diversity of operative techniques is employed as no guidelines exist for intra- and perioperative management. We carried out a national survey to determine the de facto German standards for pancreatoduodenectomy, assess quality assurance measures, and identify relevant issues for further investigation.
  
  
  METHODS
  A questionnaire evaluating major outcome variables, case load, preferred surgical procedures, and perioperative management during pancreatoduodenectomy was developed and sent to 211 German hospitals performing >12 pancreatoduodenectomies per year (requirement for certification as a pancreas center). Statistical analysis was carried out using the Fisher Exact, Mann-Whitney U, and Spearman tests.
  
  
  RESULTS
  The final response rate was 86 % (182/211). The preferred technique and de facto German standard for pancreatoduodenectomy was pylorus-preserving pancreatoduodenectomy with pancreatojejunostomy carried out via duct-to-mucosa anastomosis with interrupted sutures using PDS 4.0. The minority of German pancreas centers were certified (18-48 %). The certification rate increased with higher capacity levels and case load (P < 0.05); however, significant correlations between the fistula rate and hospital case load, hospital capacity level, or hospital certification status were not seen.
  
  
  CONCLUSIONS
  This study revealed a distinct variety of management strategies for pancreatic surgery and available evidence-based data was not necessarily translated into clinical practice. The limited certification rate represented a shortcoming of quality assurance. The data emphasize the need for further trials to answer the questions whether hospital certifications and omission of drains improve outcome after pancreatoduodenectomy and for the establishment of guidelines for pancreatoduodenectomy.
authors.affiliation: Department of General and Visceral Surgery, University Hospital Muenster, Waldeyerstr.1, 48149, Muenster, Germany.
authors.forename: Christina
authors.initials: C
authors.lastname: Haane
authors.forename: Wolf Arif
authors.initials: WA
authors.lastname: Mardin
authors.forename: Britta
authors.initials: B
authors.lastname: Schmitz
authors.forename: Sameer
authors.initials: S
authors.lastname: Dhayat
authors.forename: Richard
authors.initials: R
authors.lastname: Hummel
authors.forename: Norbert
authors.initials: N
authors.lastname: Senninger
authors.forename: Christina
authors.initials: C
authors.lastname: Schleicher
authors.forename: Soeren Torge
authors.initials: ST
authors.lastname: Mees
mesh_terms: D002568:Certification; D005858:Germany / Q000453:epidemiology; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D010185:Pancreatic Fistula / Q000453:epidemiology; D016577:Pancreaticoduodenectomy / Q000592:standards* / Q000706:statistics & numerical data*; D010193:Pancreaticojejunostomy / Q000592:standards / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D016526:Workload / Q000706:statistics & numerical data