Does a Multidisciplinary Approach Have a “Compensatory Effect” on Surgeon Experience in Pacreaticoduodenectomy?

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To the Editor:
Mathur et al1 have recently published in your journal an article titled “Pancreatico-duodenectomy at High-volume Centers: Surgeon Volume Goes Beyond the Leapfrog Criteria.” We found it of major interest because this is a very topical issue and has been a subject often discussed within the scientific community.
In Italy, as in other countries, the centralization of pancreatic surgery has been proposed as a practice within high-volume hospitals due to the fact that the surgical treatment of pancreatic diseases, particularly cancer, is highly demanding, and involves a significant learning curve. Therefore, considering the low epidemiological incidence of such a disease, a single surgeon coming from a low-volume, nonreferral center would never achieve an extensive experience to complete his learning curve. It is, in fact, of common knowledge that the surgeon's experience is crucial in decreasing the mortality rate. However, it could be argued whether a single surgeon's capability is sufficient to provide the best treatment for pancreatic cancer or whether the presence of other specialists (eg, anesthesiologists, general and interventional radiologists, endoscopists, etc.) should be operational as well, to guarantee a multidisciplinary approach of possible surgical complications. Lastly, the issue on which is the best parameter to be considered, whether the single surgeon experience or a hospital's multidisciplinary support, is a highly debated topic.
Seeking to provide an answer to these questions, we do agree with authors that low-volume surgeons in low-volume hospitals should no longer perform this type of surgery, because the outcome is clearly frustrating. Perhaps, a slight difference in the outlook of the problem in our case consists in the role of the hospital's multidisciplinary competence. Indeed, according to Mathur et al,1 the hospital volume would not seem to be so crucial, and seems it decreases only the length of the hospital stay and hospital charges, whereas surgeon volume is strictly related to in-hospital mortality.
According to our experience,2 this parameter would seem to be more important also in reducing the complication and reoperation rate and consequently, the general postoperative mortality and morbidity. Moreover, the presence of other specialists in pancreatic patient conditions would compensate the average level of expertise of the surgical team, allowing more operators to approach such tumors. This option would thus allow to cater more patients for the treatment of this life-threatening condition.
Pancreatic surgery has a significant learning curve, as suggested by Tseng et al,3 and it is technically demanding, but is it the case that only surgical experience can reduce mortality or bring it to acceptably low levels?
If the hospital effect is limited in reducing only the length of hospital stay and charges, and would not be beneficial for low-volume surgeons, could the multidisciplinary approach play a major role and have a compensatory effect on surgeon volume? Kanhere et al,4 in their study, in fact, suggest that pancreaticoduodenectomy can be safely performed in low-volume specialized units where the services and processes of high-volume centers can be replicated.
By way of conclusion, we sincerely wish to commend the authors for their analysis, and we would like to urge researchers to focus on the topic of the influence of a multidisciplinary support in the outcome of pancreatic surgery, to allow more surgeons to be involved in pancreatic operations seeking to have more successfully treated pancreatic patients.
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