title: Pancreaticoduodenal resection for malignancy in a low-volume center: long-term outcomes from a developing country.
abstract: BACKGROUND
  The technical complexity of pancreatic resection has made it a specialized procedure performed in high-volume centers. It has been shown that patients operated on in high-volume pancreatobiliary centers have fewer complications and better survival. The purpose of this study was to share our experience with and report long-term outcomes of pancreaticoduodenal resections performed in a low-volume center in Pakistan.
  
  
  METHODS
  Data of patients who underwent pancreaticoduodenal resection for adenocarcinoma at our institute from 1999 to 2012 were reviewed. A total of 39 patients were included in the study. Variables included patients' clinical and histopathological characteristics. Outcome was determined based on complication rate, 30- and 90-day mortality, disease-free survival, and overall survival. For survival analysis, Kaplan-Meier curves were used and significance was determined using a log rank test. Univariate Cox analysis was performed to determine significant factors for multivariate analysis.
  
  
  RESULTS
  The majority of tumors [20 (51 %)] were moderate grade, T1/T2 [20 (51 %)], ampullary adenocarcinomas [18 (46 %)]. Mean hospital stay was 14 ± 8 days. The mean number of nodes removed was 13.9 ± 6.9, while mean number of positive nodes was 1 ± 1.7. Expected 5-year overall survival and relapse-free survival were 38 and 48 %, respectively. Overall 5-year survival was significantly different with respect to nodal involvement, i.e., 47 vs. 28 % (P = 0.018). On univariate analysis, nodal involvement was the only factor associated with an increased risk of death (P = 0.02, hazard ratio [HR] 2.9, confidence interval [CI] 1.1-7.8).
  
  
  CONCLUSIONS
  Low-volume centers are an acceptable alternate to high-volume centers for performing pancreaticoduodenal resection in carefully selected patients. Efforts should be directed at developing specialized hepatobiliary centers in developing countries.
authors.affiliation: Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, Abubakar.hafeez@yahoo.com.
authors.forename: Abu Bakar Hafeez
authors.initials: AB
authors.lastname: Bhatti
authors.forename: Mohammad Aasim
authors.initials: MA
authors.lastname: Yusuf
authors.forename: Syed Ather Saeed
authors.initials: SA
authors.lastname: Kazmi
authors.forename: Aamir Ali
authors.initials: AA
authors.lastname: Syed
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D000328:Adult; D000368:Aged; D014670:Ampulla of Vater; D003138:Common Bile Duct Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D003906:Developing Countries; D018572:Disease-Free Survival; D004379:Duodenal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D005260:Female; D061846:Hospitals, Low-Volume; D006801:Humans; D053208:Kaplan-Meier Estimate; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D010154:Pakistan; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors