Pancreaticoduodenectomy (PD) is a complex and high-risk surgical procedure utilized for treating tumors in the pancreatic head or periampullary region. The procedure entails a considerable risk of adverse outcomes, including death. In the era before the 1980s, PD was associated with high morbidity rates (40%-60%) and mortality rates (20%).
However, advancements in surgical techniques, critical care facilities, and the establishment of specialized centers of excellence at regional levels have led to a remarkable decrease in post-operative morbidity and mortality rates over the years. Patients treated at high-volume centers have experienced improvements in post-operative survival and overall life expectancy, marking a global shift in the situation.
The Sher-i-Kashmir Institute of Medical Sciences (SKIMS), located in Srinagar, Kashmir, stands among the leading medical institutes in North India, catering to a population of 13.6 million across 20 districts. My professional journey began in the Surgical division of Gastroenterology at SKIMS, where I initially received advice to focus solely on abdominal issues. However, I found myself drawn to pancreatic-related problems. When a separate department of Surgical Gastroenterology was established at SKIMS, I became part of the team entrusted with creating and organizing the performance profile of the future department.
Our approach shifted from caution to a commitment to providing high-quality tertiary care for a referral stream of patients, making PD a routine surgical procedure. Collaborating with my colleagues, we developed the “Superior Approach Technique” (SAT) for PD, offering several advantages over the traditional Whipple’s Technique (Hepatobiliary Pancreatic Disease International 12,196-203, 2013). The adoption of SAT allowed SKIMS to provide a secure and comfortable process for patients in need of PD, contributing to the skilful and dexterous management of cases. This transformation played a pivotal role in establishing SKIMS as a reputable high-volume center for PD operations globally.
The effectiveness of the SAT technique was evident in the improved postoperative results, showcasing the dedication and commitment of the surgical and support team. The department responded to global advancements by developing a patient management protocol, adapting to expanding subspecialty-based surgical practice, regionalizing apical surgical care, and establishing high-volume centers in response to a rise in patient volume. As a result, SAT contributed to a decrease in inoperative blood loss, a reduction in the need for blood transfusions, and a shorter operative time. The contribution of non-technical personnel further played a crucial role in reducing poor operational outcomes attributed mostly to a lack of teamwork, poor decision-making, and inappropriate behavior patterns.
High-volume centers, equipped with skilled and technically competent surgeons utilizing cutting-edge technologies, have been associated with excellent patient care in the pre-operative, intra-operative, and post-operative settings. Recent analyses of the volume-outcome relationship highlight that surgeon characteristics and system resources are crucial factors determining outcomes, more likely to be present at high-volume centers. The synergistic relationship between human and material resources, surgical frequency, and competence leads to positive outcomes, including shorter lengths of stay, reduced rates of morbidity and mortality, and decreased hospital expenditure.
Our department, guided by a focused team of professionals, was committed to the dexterous treatment of patients based on standardized diagnostic procedures and effective management of post-operative complications. Information on provider capabilities distributed at local, regional, and national levels resulted in a voluminous stream of referral cases, contributing to the regionalization of PD service. In the first phase of our study (January 2002 to September 2006), the average number of PD cases was 4, increasing to 14 cases each year in the next three and a half years, reaching a peak of 34 cases per year in the final phase.
This significant increase in the volume of PD surgeries correlated with a decrease in operative parameters, complications, and mortality rates.
The sub-specialization of surgical services and regionalization of complex surgical operations at our center played a crucial role in decreasing morbidity and mortality rates associated with PDs while improving their prognosis. These centers exhibited a spirit of teamwork in managing intensive care and providing interventional radiological support, selectively applying surgical dexterity to deserving patients, especially those with pancreatic cancer. In-hospital mortality rates substantially decreased in high-volume tertiary care centers, reporting a mortality rate of 4% or less, signifying a significant decline.
In the national context, India, with around 36 cancer centers and one National Cancer Institute, faces unique challenges in cancer treatment, particularly with a predominantly rural population (nearly 70%) having limited or no access to specialized healthcare. Patients in need of specialized cancer treatment often struggle with financing their costs through borrowing money, selling assets, or relying on contributions from friends and family.
Unfortunately, a major portion of India’s health budget is directed toward managing infectious diseases, antepartum healthcare, vaccination, and other primary preventive programs. Given the resource limitations and socio-economic constraints of the country, there is a need to emphasize government insurance schemes covering the poor and ensure accessibility to well-equipped cancer hospitals in tier Ⅱ and Ⅲ cities. Collaboration between these hospitals and centers of excellence in the region is crucial to ensuring the delivery of high-quality cancer care, incorporating vigilant frameworks and frequent quality and outcome checks.
Multiple studies have reported positive outcomes after PD from low to medium-volume tertiary care centers. An alternative solution could be the establishment of a National Cancer Grid, akin to expanding super-specialty surgical programs available in some centers. Attention should be paid to the hub and spoke model-based growth of healthcare delivery, facilitating the development of an adequate number of referral and high-volume centers for performing PDs. Implementing such measures would likely lead to decreased morbidity and mortality rates, accompanied by appreciable economic and clinical benefits. Early discharge from hospitals could enable patients to receive timely mandatory adjuvant treatment, thereby improving overall survival rates.
The development of centers of excellence for PD can benefit both surgeons and primary care physicians, allowing them to invest their time and efforts in achieving greater proficiency and a better understanding of problems along with their solutions. Creating a dedicated referral system in each state and accrediting cancer centers capable of performing PD and other major surgical procedures is a critical challenge that must be addressed at both governmental and societal levels.
Until the referral system is adequately prepared, a good outreach program from a centralized service for PD is crucial. Achieving optimal management of complex and expensive cancer care involves centralizing it, establishing an adequate number of referrals and high-volume centers for performing PDs that should be functional and regularly audited to ensure sustained, high-quality care. One of the most significant global health challenges is to provide affordable cancer control and care in emerging economies, given the substantial costs associated with cancer, involving complex systems, pathways, and technologies. This makes cancer a major challenge for healthcare systems in developing countries.
Despite the benefits of the Hub and Spoke network, effectively fulfilling patient care needs by strategically centralizing advanced medical services at a single site and distributing basic services via a secondary site, certain risks exist. These risks include congestion at the hub, overextension of spokes, staff dissatisfaction at spokes, and transportation disruptions. Efforts should be directed towards eliminating these occurrences.
Despite the benefits of centralization, logistic problems include the need for patients to travel long distances to reach the centralized cancer center, uncertainty regarding the unfamiliar place for the patient, loss of work hours for the patient and their accompanying family members, and additional expenses incurred on travel, accommodation, boarding, and other related needs.
The socio-political system of a country, particularly India, holds the responsibility of providing necessary facilities to patients in need of appropriate surgical treatment, hospital care, and socio-economic support, with a prioritization of patients suffering from pancreatic cancer.
In India, volume-outcome studies have been conducted to evaluate hospital performance based on their annual caseload, with encouraging results. However, there is still much work to be done in bringing down postoperative morbidity, which remains a challenge even after centralization.
With the increase in the number of medical colleges within the Jammu and Kashmir (Union Territory), there should be an emphasis on increasing expert manpower, expanding infrastructure, equipment, and other logistic supplies needed to ensure quality services. Simultaneously, an outreach program from centers of excellence needs to be introduced for performing advanced surgical procedures. Furthermore, a proper referral and cross-referral system needs to be in place.
These medical colleges should collaborate with the centers of excellence in the region to ensure the delivery of high-quality cancer care within a framework that encompasses frequent quality and outcome checks.
Thus, rural patients in need of high-quality advanced surgery should be able to make informed choices about having their surgery locally, and all citizens must have access to a good standard of surgical care, irrespective of geography and economic status. Importantly, in an ideal world, surgeons in low-volume institutions, lacking sufficient resources to rescue patients once they have a serious complication, should reconsider doing pancreatic resections.
This necessitates acknowledgment by politicians and healthcare planners of the overwhelming evidence on the volume-outcome relationship for complex and risky operations like pancreatic resections.
Dr Omar Javed Shah, Former Director/Dean and Head department of Surgical Gastroenterology SKIMS