THE oncological SURGERY of the pancreas? It is not for everyone. The goal must be centralization towards a limited number of hospitals with experience in the execution of what is the most complex surgical procedure at the abdominal level. And not to penalize the surgeons of the smaller hospitals. But to know that, with the same diagnosis, all patients will have equal chances of treatment, regardless of the center to which they will be entrusted. A challenge that, as far as Italy is concerned, is all uphill. But which – on the basis of scientific evidence – now appears unpostponable.
Pancreatic surgery: the choice of the center makes the difference
The latest confirmation that surgical treatment in the case of a pancreatic cancer cannot be carried out wherever it comes from one i study spanish published in the journal Surgery. The authors prospectively assessed the conditions of 877 patients operated on in 74 different hospitals. All were affected by a periampullary neoplasm, that is to say in the abdominal region that encloses the bile duct (which carries bile from the gallbladder to the intestine), the pancreatic duct (covered by enzymes that reach the intestine from the pancreas) and epithelium of the duodenum. A small area, but with a very complex architecture. And, as such, not easy to remove surgically. By observing their post-operative course and relying on data from the interventions carried out in each center, the researchers measured the impact of the experience on patient outcomes. The minimum number of interventions to be performed each year was thus determined at 31 “to reduce the risk of postoperative complications”. On the other hand, it is necessary to go up to at least 37 to “contract hospitalization times”, which normally are never less than two weeks. Much lower is the number of interventions (6) sufficient for each center to reduce mortality. This latter fact could lead to considering any hospital capable of offering a highly complex surgical procedure. But the exact opposite is true.
The number of interventions is not everything
“To assess the quality of pancreatic surgery it is no longer sufficient to measure only the mortality or the serious complications that may emerge later”, put pen to paper the surgeons of the University Hospital of Valencia, including the Italian Dimitri Dorcaratto: “Our study shows that at least nine indicators are affected by the experience of a hospital.” Technical aspects, but not only. In the middle there is the life of patients, whose fate hangs in the outcome of these interventions. ” work of colleagues confirms the importance of volumes: pancreatic surgery must be rationalized and managed by a small number of centers located throughout the country “, clarifies Massimo Falconi, director of the pancreatic surgery unit of the Irccs San Raffaele Hospital in Milan: “The merit of this study is to have established what should be the minimum number of operations to be performed each year on the basis of the measured results. arbitrary manner, as up to now we have tried to do in Italy. Having said this, however, it is also right to reiterate that the volumes of operators are important, but by themselves they are not enough to recognize the quality of a center. these patients have specific training in pancreatic surgery and have the essential services to manage frequent post-operative complications ”.
In Italy at least 130 avoidable deaths every year
An issue that also emerged on the basis of Italian data, published less than a year ago on the British Journal of Surgery. Drawing on data from the Ministry of Health, the researchers from San Raffaele and the Verona university hospital (numbers in hand, the first two centers in Italy for the treatment of pancreatic neoplasms) were able to confirm what the scientific community claims from time. When treating pancreatic cancer, the fewer the number of surgical procedures completed, the less likely you are to survive the disease. And in Italy, in 300 of the 395 hospitals surveyed, between 2014 and 2016 only three pancreatic operations were performed on average per year. It is no coincidence, according to the white coats, that in these centers the operative mortality recorded was higher than 10%. With peaks of up to 20-25%. This means that 1 in 4 or 5 patients who enter the operating room in these facilities not only do not recover from the disease, but lose their life in the weeks following the surgery. “Every year in Italy at least 130 deaths could be avoided following an operation for the removal of a pancreatic tumor”, the researchers warn: “A model that can be implemented immediately to improve the care of these patients is what it envisages. the centralization of interventions in those centers that combine a sufficient number of surgical interventions with a mortality rate of less than 5% ”. The way forward, according to experts, is that of “pay by results”. By tying reimbursements to the outcome of the treatments, as is already done in the case of some drug therapies, a double benefit could be obtained. On the one hand, the proportion of centers that perform few interventions and expose to significant risks for patients would gradually erode. On the other hand, it would allow hospitals with the most robust cases to increase investments and, consequently, to be able to cope with a growing need for health. In five years, in Italy, the new annual cases of pancreatic cancer have in fact increased from 12,700 (2014) to over 14 thousand (2020). With a fifth of these patients who can benefit from surgery.
Pancreas Units are needed to improve care
The objective to aim for must therefore be to have – in the centers identified for the treatment of pancreatic tumors – multidisciplinary groups such as those found in breast units for the treatment of different forms of breast cancer. “These are multidisciplinary structures that must provide for the co-presence of surgeons, oncologists, gastroenterologists, pathologists, nutritionists, radiologists and radiotherapists”, explains Falconi, who is also president of the Italian Association for the Study of the Pancreas. A reality that, in full measure, is present in no more than 6-8 hospitals in Italy. Moreover, all concentrated from Rome upwards: with some structures in Veneto and Lombardy in which 4 out of 10 new accesses concern southern patients. “The centers of reference for the treatment of pancreatic neoplasms must put themselves at the service of the country, also carrying out training activities – continues the expert -. But to offer a quality service a few kilometers from home to patients in the South, an awareness is also needed on the part of the Regions, beyond any parochialism. There is no need for a center in each of these, but a few hospitals that acquire all the necessary skills and meet the demands of those arriving from neighboring regions as well ”.
Pancreatic surgery: it is still early for laparoscopy
Skills called to also look at innovation. As has already happened in other areas of surgery, interest in laparoscopy and robotics is also growing in the case of that of the pancreas. At the moment, however, the data do not show significant benefits. According to a study just published in The Lancetin fact, patients operated on with laparoscopy benefit on average from only one day less hospitalization than those treated in the traditional way. A result that – in the face of identical mortality rates at 90 days and similar postoperative complications – does not allow to celebrate any milestone. “The difficulty of this intervention is not given by the surgical technique that is chosen, but by the anatomy and functioning of the organ – says Falconi -. Laparoscopy can bring an advantage in the medium and long term. At the moment, however, it represents a choice with no real benefits in terms of mortality and morbidity and which requires even more experience on the part of those who perform it ”.
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