Patients undergoing pancreaticoduodenectomy (PD) may face greater risks of complications in settings involving lower PD-specific surgeon volumes, regardless of nurse-to-patient ratios, according to a study recently published in the Journal of Gastrointestinal Surgery.

“Pancreaticoduodenectomy, in part owing to the technical skill required, has been characterized as one of the most complex operations with significant morbidity and mortality,” explained the researchers in their report.

In this study, the researchers examined records of Medicare beneficiaries (N=6,668) who had undergone PD. Outcomes of these surgeries were analyzed with respect to nurse-to-patient ratios and PD-specific surgeon volumes, with both variables stratified into 4 levels each. Nurse-to-patient ratios were based on total nurse hours per adjusted patient days in a year, and PD-specific surgeon volumes were based on the numbers of these procedures performed by surgeons per year.

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Patients had a median age of 73 years, and 55.1% had a Charlson comorbidity score of 3 or higher. Postoperative complications occurred in 28.3% of patients.

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Median PD-specific surgeon volumes were 24 (interquartile range [IQR], 21-29) in the tier with the greatest volume and 2 (IQR, 1-3) in the lowest-volume tier (P <.001). Most (71.0%) PDs involved surgeons who fell within the bottom 2 tiers by volume.

Complications occurred with 26% higher odds for PDs performed in facilities within the lowest nurse-to-patient ratio tier compared with facilities from the highest nurse-to-patient ratio tier. Complications were even more common for patients treated by surgeons within the lowest tier by PD volume, with 43% higher odds than for those treated by surgeons in the highest-volume tier. Nurse-to-patient ratio did not significantly influence the odds of complications in analyses within tiers of PD-specific surgeon volume.

The researchers concluded that PD-specific surgeon volume is a critical factor in outcomes for patients undergoing this procedure.


Paredes AZ, Hyer JM, Tsilimigras DI, Sahara K, White S, Pawlik TM. Interaction of surgeon volume and nurse-to-patient ratio on post-operative outcomes of Medicare beneficiaries following pancreaticoduodenectomy [published online November 19, 2019]. J GastrointestSurg. doi: 10.1007/s11605-019-04449-w