Implementation of a strategic preoperative surgical meeting to improve the level of care at a high-volume pancreatic center: a before-after analysis of 1000 consecutive cases

The indication, planning, and risk analysis of a pancreatic surgical procedure have recently become increasingly complex. In December 2015, the "Pancreas Round" (PR) meeting was established at our institution to preoperatively review all scheduled cases with a specific focus on surgical indications and technical issues. The present study aims to determine the impact of the PR on the clinical practice in terms of avoiding unrequested laparotomies and anticipating intraoperative pitfalls. A "before-after" study was conducted by retrospectively comparing a pre-intervention period (9/2014-11/2015) to a prospectively assessed post-intervention one (12/2015-3/2017). Outcomes considered were explorative laparotomy (EL) occurrence and a "mismatch" between what was preoperatively expected by the PR and what was intraoperatively found. Of the 1057 patients included in the present study, 531 underwent surgery in the pre- and 526 in the post-intervention period, respectively. The EL rate was comparable between the two periods (15.4% vs. 12.2%, p = 0.123), despite the significant increase of surgical explorations after neoadjuvant chemotherapy during the post-intervention period (27% vs. 18%, p < 0.001). The "mismatch" rate between preoperative planning and intraoperative findings was significantly reduced in the post-intervention period (12.2% vs. 8.4%, p = 0.038) compared to the pre-PR period. In the setting of a high-volume center, a preoperative surgical meeting designed to review all cases scheduled for surgical exploration can enhance the level of care by addressing intraoperative pitfalls

Cost-effectiveness and quality of life analysis of laparoscopic and robotic distal pancreatectomy: a propensity score-matched study

Background: This study analyzed the Quality of Life (QoL) and cost-effectiveness of laparoscopic (LDP) versus robotic distal pancreatectomy (RDP). Method: All patients who underwent LDP or RDP from 2011 to 2017 and with a minimum postoperative follow-up of 12&nbsp;months were included in the study. To minimize bias, a propensity score-matched analysis (1:2) was performed. Two different questionnaires (EORTC QLQ-C30 and EQ-5D) were completed by the patients. The mean differential cost and mean differential Quality Adjusted Life Years (QALY) were calculated and plotted on a cost-utility plane. Results: The study population consisted of 152 patients. After having applied the propensity score matching, the final population included 103 patients divided into RDP group (n = 37, 36%) and LDP (n = 66, 64%). No differences were found between groups regarding the baseline, intraoperative, postoperative, and pathological variables (p &gt; 0.05). The QoL analysis showed a significant improvement in the RDP group on the postoperative social function, nausea, vomiting, and financial status (p = 0.010, p = 0.050, and p = 0.030, respectively). As expected, the crude costs analysis confirmed that RDP was more expensive than LDP (12,053 Euros vs. 5519 Euros, p &lt; 0.001). However, the robotic approach had a higher probability of being more cost-effective than the laparoscopic procedure when a willingness to pay of more than 4800 Euros/QALY was accepted. Conclusion: RDP was associated with QoL improvement in specific domains. Crude costs were higher relative to LDP. Cost-effectiveness threshold resulted to be 4800 euros/QALY. The increasing worldwide diffusion of the robotic technology, with easier access and possible cost reduction, could increase the sustainability of this procedure

Supplementary Material for: Long-term follow-up after surgery for chronic pancreatitis – a bicentric retrospective experience.

Introduction The impact of surgery on nutritional status, pancreatic function and symptoms of patients affected by chronic pancreatitis (CP) has not been unequivocally determined. This study aims to evaluate clinical follow-up after surgery for CP in an Italian-Austrian population. Materials and Methods Patients operated for CP at two high-volume centers between 2000 and 2018 were analysed. The following parameters were compared between the pre- and post-operative period: nutritional status, endocrine and exocrine pancreatic functions and chronic pain. Results Overall, 186 patients underwent surgery for CP. Among these, 68 (40%) answered a specific follow-up questionnaire. The body mass index showed a significant increase between pre-and post-operative assessments (21.1 vs 22.5 p = 0.003). Furthermore, a 60% decrease in the prevalence of chronic pain (81 vs 21%, p < 0.001) was observed. On the contrary, both exocrine and endocrine pancreatic functions pointed towards a worsening after surgery, with consistent higher rates of patients presenting with diabetes mellitus, as well as patients requiring insulin therapy and oral intake of pancreatic enzymes. The analysis of body composition performed on 40 (24%) patients with a complete imaging pack revealed no significant change in the nutritional status after surgery. Discussion/Conclusion Despite the good results observed in terms of pain relief, the surgical approach led to a consistent worsening of the global pancreatic function. No significant influence of surgery on the nutritional status of patients was detected