Wuthering heights: Outcomes from pancreatic surgery and trends in treatment of pancreatic ductal adenocarcinoma in Norway in a post-centralization era

Abstract

<p><i>Aim:</i> The main aim of this thesis was to explore the contemporary outcomes of pancreatic surgery and treatment of pancreatic ductal adenocarcinoma in Norway seen in light of the centralization process and the volume-outcome relationship. <p><i>Methods:</i> We analysed three complete national patient cohorts using prospectively gathered data from national medical quality registries. The inclusion criteria were either having a pancreatoduodenectomy (Paper I and II) or being diagnosed with pancreatic ductal adenocarcinoma (Paper III). The main studied outcomes were short-term morbidity and mortality, and for paper III provision of tumour-directed treatment and survival. <p><i>Results:</i> In paper I we found that the national in-hospital mortality and 90-day mortality after pancreatoduodenectomy were 2% and 4%, respectively, and 14% of patients had a relaparotomy within 30 days. High age, male gender and relaparotomy were independent predictors of 90-day mortality, whereas Regional Health Authority where treated was not. In paper II we showed that patients who had a pancreatoduodenectomy at the medium/low-volume units had similar short-term outcomes to patients treated at the sole high-volume unit (>40 PDs a year). For patients diagnosed with pancreatic ductal adenocarcinoma between 2004-2018 (paper III), resection rates (p<0.001) and use of perioperative chemotherapy (p<0.001) increased over time, and survival after resection improved with a HR (95% CI) for death of 0.65 (0.57-0.76) between late and early study period. For non-resected patients, provision of palliative chemotherapy increased over time (p<0.001). Still, four in ten patients did not receive any tumour-directed treatment. <p><i>Conclusions:</i> The postoperative outcomes after pancreatoduodenectomy in Norway are beneficial and the current level of centralization of surgery seems just. Although more patients with pancreatic ductal adenocarcinoma currently reach resection and the survival prospects for this subgroup are slightly improving, no sizeable improvement was seen for this patient group when viewed as a whole.