title: Pancreaticoduodenectomy: outcomes in a low-volume, specialised Hepato Pancreato Biliary unit.
abstract: BACKGROUND
  This study was designed to evaluate the outcomes of pancreaticoduodenectomy (PD) at a low-volume specialised Hepato Pancreato Biliary (HPB) unit. Volume outcome analyses show significantly better results for patients undergoing PD at high-volume centres (Begg et al. JAMA 280:1747-1751, 1998; Finlayson et al. Arch Surg 138:721-725, 2003; Birkmeyer et al. N Engl J Med 346:1128-1137, 2002; Gouma et al. Ann Surg 232:786-795, 2000). Centralisation of PD seems to be the logical conclusion to be drawn from these results. In countries like Australia with a small and widely dispersed population, centralisation may not be always feasible. Alternative strategy would be to have similar systems in place to those in high-volume centres to achieve similar results at low-volume centres. Many Australian tertiary care centres perform low to medium volumes of PD (Chen et al. HPB 12:101-108, 2010; Kwok et al. ANZ J Surg 80:605-608, 2010; Barnett and Collier ANZ J Surg 76:563-568, 2006; Samra et al. Hepatobiliary Pancreat Dis Int 10:415-421, 2011). Most of these have a specialised HPB unit, accredited by the Australia and New Zealand Hepatic pancreatic and biliary association (ANZHPBA), as training units for post fellowship training in HPB surgery. It is imperative to perform outcome-based analyses in these units to ensure safety and high quality of care.
  
  
  METHODS
  Retrospective analysis of database for periampullary carcinoma (1998 till date) was performed in an ANZHPBA accredited HPB unit based at a tertiary care teaching hospital in South Australia. Because age older than 74 years is shown to be a predictive marker of increased morbidity and mortality after a PD, we analysed the outcomes in this subset of patients separately.
  
  
  RESULTS
  Fifty-three patients underwent PD in 14 years. Overall mortality was 3.8 %. The last in hospital mortality was in 1999. The morbidity rates and the oncologic outcomes were similar to those in high-volume units.
  
  
  CONCLUSIONS
  PD can be safely performed in a low-volume specialised unit at centres where the amenities and processes at high-volume centres can be replicated.
authors.affiliation: Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA, 5011, Australia, kanhere.harsh@health.sa.gov.au.
authors.forename: H A
authors.initials: HA
authors.lastname: Kanhere
authors.forename: M I
authors.initials: MI
authors.lastname: Trochsler
authors.forename: M H
authors.initials: MH
authors.lastname: Kanhere
authors.forename: A N
authors.initials: AN
authors.lastname: Lord
authors.forename: G J
authors.initials: GJ
authors.lastname: Maddern
mesh_terms: D000367:Age Factors; D000368:Aged; D000818:Animals; D001315:Australia; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality*; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D012189:Retrospective Studies; D018570:Risk Assessment; D012737:Sex Factors; D013503:Surgery Department, Hospital / Q000706:statistics & numerical data*; D013997:Time Factors; D016896:Treatment Outcome; D016526:Workload