Balancing surgical innovation with cost and efficiency

Shiva Jayaraman, MD, MESc From the University of Toronto, St. Joseph's Health Centre, Toronto, Ont. See the related research paper by Wang and colleagues on p. 263. Accepted for publication May 20, 2014 Correspondence to: S. Jayaraman University of Toronto St. Joseph's Health Centre 30 The Queensway, Suite 240 SSW Toronto ON M6R 1B5 [email protected]

DOI: 10.1503/cjs.006114

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The standard approach to neoplasia of the pancreatic head is pancreatico­ duodenectomy, otherwise known as the Whipple procedure. Traditionally, this operation is performed through an open laparotomy incision. In highvolume centres, and when performed by appropriately qualified surgeons, the Whipple procedure is safe and effective management for diseases of the pancreatic head. Still, this operation remains one of the most complex abdominal procedures. With the proliferation of minimally invasive sur­ gery, more complex operations are being performed using laparoscopy and other minimal access techniques. A group from McGill University and the Montreal Jewish General Hospital have prospectively evaluated their experience with minimally invasive pancreaticoduodenectomy and have compared this experience to the open approach. This is the first compara­ tive series of its kind from Canada.

he world’s first minimally invasive pancreaticoduodenectomy was reported by Canadian surgeons in 1994.1 Since then, several smaller reports have followed that suggest that many of the traditional advan­ tages of minimally invasive surgery may be possible in select patients under­ going surgery for neoplasms of the pancreatic head.2 In this edition of the Canadian Journal of Surgery (CJS), W ang and colleagues3 report Canada’s first comparative series between minimally invasive pancreaticoduodenectomy using a hybrid approach and open pancreaticoduodenectomy. In their series, they demonstrate a shorter length of stay in hospital for the minimally inva­ sive group, with similar perioperative outcomes and complication rates between the minimally invasive and open surgery groups. They also report a trend toward lengthier operations in the minimally invasive group. This experience highlights one of the conflicts we face in our health care system. As health care budgets shrink, there are increased fiscal pressures on hospitals and, by extension, operating room resources. Likewise, a key metric for quality in Canadian surgery is waiting times. These realities may challenge the technical progress suggested by W ang and colleagues. If advanced approaches are more broadly applied and if the observation of increased duration of surgery and the possibility of greater resource utilization persist, widespread uptake of this novel approach may have to be limited. On the other hand, if it can be demonstrated that improved perioperative out­ comes are reproducible with minimally invasive pancreaticoduodenectomy and that once a suitable learning curve is overcome good outcomes can be provided to patients in a timely and efficient manner, then more widespread, systematic uptake may be possible. Likewise, new technology may permit greater effi­ ciency in such complex minimally invasive procedures, facilitating an improve­ ment in important perioperative parameters and thereby decreasing costs. As mentioned in a previous CJS editorial, surgeons need to find solutions to the fiscal and societal restraints currently in place for our health care sys­ tem.4 With new technology and novel approaches to surgical diseases, we are

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challenged to balance our desire to improve patient out­ comes and incorporate new approaches while maintaining a fiscally sound and efficient system. If more surgeons embrace minimally invasive pancreaticoduodenectomy in Canada, it will be important to better understand whether the potentially increased costs of this approach are justified by superior outcomes, new efficiencies and improved qual­ ity of life for patients.

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Competing interests: None declared.

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Gagner M, Pomp P. Laparoscopic pylorus-preserving pancreatico­ duodenectomy. Surg Endosc 1994;8:408-10. Gumbs AA, Rodriguez Rivera AM, Milone L, et al. Laparoscopic pancreatoduodenectomy: a review of 28S published cases. Ann Surg Oncol 2011;18:13 35-41. W ang Y, Bergman S, Piedimonte S, et al. Bridging the gap between open and minimally invasive pancreaticoduodenectomy: the hybrid approach. Can J Surg 2014;57:263-70. Harvey EJ. Process improvement in surgery. Can J Surg 2014;57:4.

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Mark your calendar and plan to attend the 2014 Canadian Surgery Forum! September 17-21, 2014 Vancouver Convention Centre & Fairmont Waterfront Hotel The Forum is intended fo r com m unity and academic surgeons, residents in training, researchers, surgical and operating room nurses, Fellows and medical students. The 2014 Forum will offer outstanding opportunities for continuing professional development, dialogue on educational and research issues, and networking. For more inform ation, please visit www.cags-accg.ca and www.canadiansurgeryforum.com. See y o u in V a n c o u v e r!

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Balancing surgical innovation with cost and efficiency.

The standard approach to neoplasia of the pancreatic head is pancreaticoduodenectomy, otherwise known as the Whipple procedure. Traditionally, this op...
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