The effect of hospital volume on mortality, morbidity and dissected lymph nodes in pancreaticoduodenectomy for periampullary region tumors



Periampullary tumor, Hospital volume, Pancreaticoduodenectomy


Background/Aim: Since the first pancreaticoduodenectomy (PD) surgeries, mortality, morbidity and length of hospital stay decreased, in return, the number of uncomplicated cases and dissected lymph nodes increased over the years. The aim of our study was to determine the effect of hospital volume on survival, postoperative hospital stay, fistula rate, morbidity rate and the number of lymph nodes dissected. Methods: In this retrospective cohort study, 213 patients who were operated with the diagnosis of periampullary tumor between January 2008 and January 2016 were included in the study. The patients were divided into four groups according to the years of surgery: Group A (n=31, 2008-2009), Group B (n=46, 2010-2011), Group C (n=50, 2012-2013) and Group D (n=86, 2014-2016). The groups were compared with each other in terms of the following factors; Pancreatic fistula rates, postoperative hospital stay, mortality rates, morbidity rates, number of dissected lymph nodes. Results: It has been observed that there is a relation between pancreatic tissue quality and duct size with fistulas (P=0.0016 and P=0.017, respectively). It is seen that as the amount of number lymph nodules increases, the quality of staging improves (P=0.009). Rates of mortality and morbidity are decreased, as the hospital volume increased (P=0.037), The same effect of hospital volume is observed in length of hospital stay and fistula rates, both improved (P=0.017 and P<0.001, respectively). Conclusion: It is easy to state that the increase in hospital volume and surgeon’s experience is directly related with patient outcomes. As the understanding of anatomy increases, quality of the surgery is assumed to be increased as well as the reduction in length of hospital stay, mortality and morbidity rates, and the increase in quantity of dissected lymph nodules.


Download data is not yet available.


Perek S. İ.Ü. Cerrahpaşa Tıp Fakültesi Sürekli Tıp Eğitimi Etkinlikleri, Hepato-Bilier Sistem ve Pankreas Hastalıkları Sempozyum Dizisi. Pankreas kanseri. 2002;28:217-8.

Sakin A, Sahin S, Sakin A, Atci M, Geredeli Ç, Cihan Ş. Effect of type 2 diabetes mellitus on survival in metastatic pancreatic cancer. J Surg Med. 2021;5(1):17-21.

Cameron JL, Riall TS, Coleman J, Belcher KA. One thousand consecutive pancreaticoduodenectomies. Ann Surg. 2006;244(1):10-5.

Crist DW, Sitzmann JV, Cameron JL. Improved hospital morbidity, mortality, and survival after the Whipple procedure. Ann Surg. 1987;206(3):358-65.

Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg. 1997;226(3):248-60.

Kuhlmann KFD, De Castro SMM, Wesseling, Ten Kate FJW, Offerhaus GJA, Busch ORC, et al. Surgical treatment of pancreatic adenocarcinoma: actual survival and prognostic factors in 343 patients. Eur j cancer, 2004;40(4):549-58.

Makary MA, Winter JM, Cameron JL, Campbell KA, Chang D, Cunningham SC, et al. Pancreaticoduodenectomy in the very elderly. J Gastrointest Surg. 2006;10:347–56.

Mukaiya M, Hirata K, Satoh T, Kimura M, Yamashiro K, Ura H et al. Lack of Survival Benefit of Extended Lymph Node Dissection for Ductal Adenocarcinoma of the Head of the Pancreas: Retrospective Multi-institutional Analysis in Japan. World J Surg. 1998;22:248–53.

Nagai H, Kuroda A, Morioka Y. Lymphatic and local spread of T1 and T2 pancreatic cancer. A study of autopsy material. Ann Surg. 1986;204(1):65-71.

Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205-13.

Bassi C. International Study Group on Pancreatic Fistula Definition; Postoperative pancreatic fistula; an international study group (ISGPF) definition. Surgery. 2005;138:8-13.

Tabachnick BG, Fidell LS. Using multivariate statistics. Boston: Allyn& Bacon; 2007.

Silen V SM. Pancreas. In : Schwartz SI, Shires GT, Spencer FC, eds. Principles of Surgery 5. ed. McGraw- Hill; 1998. pp. 1413-1440.

Jones L, Russell C, Mosca F, Boggi U, Sutton R, Slavin J, et al. Standard Kausch-Whipple Pancreatoduodenectomy. Dig Surg. 1999;16:297-304.

Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med. 1979;301(25):1364-69.

van Heek NT, Kuhlmann KF, Scholten RJ, de Castro SM, Busch OR, van Gulik TM, et al. Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in the Netherlands. Ann Surg. 2005;242(6):781-90.

Finlayson EVA, Goodney PP, Birkmeyer JD. Hospital Volume and Operative Mortality in Cancer Surgery: A National Study. Arch Surg. 2003;138(7):721–5.

Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA. 1998;280:1747-51.

Birkmeyer JD, Stukel TA, Siewers A, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;22:2117-27.

Eppsteiner RW, Csikesz NG, McPhee JT, Tseng JF, Shah SA. Surgeon volume impacts hospital mortality for pancreatic resection. Ann Surg. 2009;249:635–40.

Nordback I, Parviainen M, Raty S, Kuivanen H, Sand J. Resection of the head of the pancreas in Finland: effects of hospital and surgeon on short-term and long-term results. Scand J Gastroenterol. 2002;37:1454–60.

Bachmann MO, Alderson D, Peters TJ, Bedford C, Edwards D, Wotton S, et al. Influence of specialization on the management and outcome of patients with pancreatic cancer. Br J Surg. 2003;90:171–7.

Nathan H, Cameron JL, Choti MA, Schulick RD, Pawlik TM. The volume–outcomes effect in hepato-pancreato-biliary surgery: hospital versus surgeon contributions and specificity of the relationship. J Am Coll Surg. 2009;208:528–38.

Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients. Ann Surg. 2009;250:1029–34.

Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361:1368–75.

Tran K, Van Eijck C, Di Carlo V, Hop WC, Zerbi A, Balzano G, et al. Occlusion of the pancreatic duct versus pancreaticojejunostomy: a prospective randomized trial. Ann Surg. 2002;236:422–8.

Conlon KC, Labow D, Leung D, Smith A, Jarnagin W, Coit DG, et al. Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Ann Surg. 2001;234:487–93.

Pratt WB, Mark P. Callery M. Risk prediction for development of pancreatic fistula using the ISGPF classification scheme. World J Surg. 2008;32(3)419-28.

Kollmar O, Moussavian MR, Bolli M, Richter S, Schilling MK. Pancreatojejunal leakage after pancreas head resection: anatomic and surgeon-related factors. J Gastrointest Surg. 2007;11:1699-703.

Lin JW, Cameron JL, Yeo CJ, Riall TS, Lillemoe K. Risk factors and outcomes in post pancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg . 2004;8:951–9.

Marcus SG, Cohen H, Ranson JH. Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg. 1995;221:635–48.

Van Berge Henegouwen MI, De Wit LT, Van Gulik TM, Obertop H, Gouma DJ. Incidence, risk factors, and treatment of pancreatic leakage after pancreaticoduodenectomy: drainage versus resection of the pancreatic remnant. J Am Coll Surg. 1997;185:18–24.

Yang YM, Tian XD, Zhuan Y, Wang WM, Wan YL, Huang YT. Risk factors of pancreatic leakage after pancreaticoduodenectomy. World J Gastroenterol. 2005;11:2456–61.

House MG, Gönen M, Jarnagin WR, D’Angelica M, DeMatteo RP, Fong Y, et al. Prognostic significance of pathologic nodal status in patients with resected pancreatic cancer. J Gastrointest Surg. 2007;11:1549–55.

Pedrazzoli S, DiCarlo V, Dionigi R, Mosca F, Pederzoli P, Pasquali C, et al. Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group. Ann Surg. 1998;228:508–17.

Capussotti L, Massucco P, Ribero D, Vigano L, Muratore A, Calgaro M. Extended lymphadenectomy and vein resection for pancreatic head cancer: outcomes and implications for therapy. Arch Surg. 2003;138:1316–22.

Pawlik TM, Gleisner AL, Cameron JL, Winter JM, Assumpcao L, Lillemoe KD, et al. Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer. Surgery 2007;141:610–618.

Tomlinson JS, Jain S, Bentrem DJ, Sekeris EG, Maggard MA, Hines OJ, et al. Accuracy of staging node-negative pancreas cancer: a potential quality measure. Arch Surg. 2007;142:767–73.

Gutierrez JC, Franceschi D, Koniaris LG. How many lymph nodes properly stage a periampullary malignancy? J Gastrointest Surg. 2008;12:77– 85.

Schwarz RE, Smith DD. Extent of lymph node retrieval and pancreatic cancer survival: information from a large US population database. Ann Surg Oncol. 2006;13:1189–200.






Research Article

How to Cite

Turhan VB, Dikmen K, Kerem M. The effect of hospital volume on mortality, morbidity and dissected lymph nodes in pancreaticoduodenectomy for periampullary region tumors. J Surg Med [Internet]. 2022 Mar. 1 [cited 2024 May 25];6(3):263-7. Available from: