Hospital Surgical Volume Shown to Impact Survival of Pancreatic Cancer Patients Whose Minimally Invasive Surgery Is Converted to Open

Anthony Villano, MD, a surgical oncologist at Fox Chase and first author on the study published in The American Journal of Surgery.
Anthony Villano, MD, a surgical oncologist and first author on a study published in The American Journal of Surgery.

PHILADELPHIA (February 23, 2023)—Pancreatic ductal adenocarcinoma is the most common type of pancreatic cancer, and, as the seventh leading cause of cancer death in the world, it is both aggressive and lethal.

Treatment typically requires pancreatoduodenectomy, also known as a Whipple procedure, a complex surgery in which the head of the pancreas, the gallbladder, the bile duct, part of the small intestine, and sometimes a portion of the stomach are removed.

In a recently published study, researchers at Fox Chase Cancer Center determined that patients’ whose pancreatoduodenectomy had to be converted to an open procedure (CTO) from a minimally invasive procedure due to complications fared better at institutions that performed more minimally invasive pancreatic cancer surgeries annually.

In an effort to improve patient outcomes, clinicians have moved toward using minimally invasive laparoscopic or robotic methods of surgery when performing these procedures. However, past research has shown that when complications force a surgical team to stop the minimally invasive procedure and move to a CTO procedure, those patients have worse postoperative outcomes than if they had an open surgery from the start.

“The repercussions of getting converted to open surgery are highest at lower-volume centers with less experience, and these downstream effects are mitigated quite a bit if you go to a hospital that does a high volume of these procedures,” said Anthony Villano, MD, a surgical oncologist at Fox Chase and first author on the study. “Outcomes tend to be best at places that have more experience with this procedure.”

Using eight years of data from the National Cancer Database, Villano, Sanjay S. Reddy, MD, FACS, co-director of the Marvin & Concetta Greenberg Pancreatic Cancer Institute, and their coauthors looked at survival rates of nonmetastatic pancreatic cancer patients following pancreatoduodenectomy.

They divided the subjects by surgery type—open surgery, successfully completed minimally invasive surgery, and minimally invasive surgery that was CTO—and confirmed prior research findings that CTO patients had worse short-term morbidity and mortality than patients in the other two groups. In a novel finding, long-term survival was also worse in patients who underwent CTO as compared to those who underwent successfully completed minimally invasive surgery or an open operation from the start.

The researchers then compared these patients’ outcomes based on the hospitals where they were treated: hospitals that performed more than 10 minimally invasive pancreatoduodenectomies each year were deemed high volume, and hospitals that performed fewer were deemed low volume.

What they found was surprising. When patients’ CTO surgery occurred at a low-volume center, they continued to have significantly worse short- and long-term mortality than patients who underwent successfully completed minimally invasive surgery. However, at high-volume hospitals, this effect was mitigated and survival rates were more similar across the three surgery groups.

Villano said that to improve outcomes for patients, the next step is to identify the factors contributing to this disparity.

“What’s the ‘secret sauce’ at the higher-volume centers? What are they doing differently that the low-volume centers are not?” he said. “Experience is one factor, but I think there are many more, and we don’t know them all.”

The paper, “Discrepancies in Survival After Conversion to Open in Minimally Invasive Pancreatoduodenectomy,” was published in The American Journal of Surgery.

Fox Chase Cancer Center (Fox Chase), which includes the Institute for Cancer Research and the American Oncologic Hospital and is a part of Temple Health, is one of the leading comprehensive cancer centers in the United States. Founded in 1904 in Philadelphia as one of the nation’s first cancer hospitals, Fox Chase was also among the first institutions to be designated a National Cancer Institute Comprehensive Cancer Center in 1974. Fox Chase is also one of just 10 members of the Alliance of Dedicated Cancer Centers. Fox Chase researchers have won the highest awards in their fields, including two Nobel Prizes. Fox Chase physicians are also routinely recognized in national rankings, and the Center’s nursing program has received the Magnet recognition for excellence six consecutive times. Today, Fox Chase conducts a broad array of nationally competitive basic, translational, and clinical research, with special programs in cancer prevention, detection, survivorship, and community outreach. It is the policy of Fox Chase Cancer Center that there shall be no exclusion from, or participation in, and no one denied the benefits of, the delivery of quality medical care on the basis of race, ethnicity, religion, sexual orientation, gender, gender identity/expression, disability, age, ancestry, color, national origin, physical ability, level of education, or source of payment.

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