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Effects of volume on outcome in hepatobiliary surgery: a review with guidelines proposal
Eloisa Franchi1, Matteo Donadon1,2, Guido Torzilli1,2
1Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy.
Insights
Centralizing complex hepatobiliary surgery improves outcomes, but clear criteria for centralization are lacking. This review proposes guidelines based on clinical practice to address this complexity.
Area of Science:
- Hepatobiliary Surgery
- Surgical Outcomes
- Healthcare Policy
Background:
- A well-established link exists between surgical procedure volume and patient outcomes in hepatobiliary surgery.
- Higher procedure volumes are consistently associated with improved short- and long-term results for complex surgical interventions.
Purpose of the Study:
- To explore the rationale and challenges of centralizing complex hepatobiliary procedures.
- To identify the need for precise criteria regarding what, where, and who should perform these procedures.
- To propose guidelines for centralization in hepatobiliary surgery, acknowledging current literature limitations.
Main Methods:
- Literature review on the centralization of hepatobiliary surgery.
- Analysis of determinants influencing centralization processes.
- Consideration of diverse stakeholder needs within different healthcare systems.
Main Results:
- While consensus supports centralization for improved quality of care, specific criteria are absent.
- Numerous uncontrolled factors complicate the centralization process.
- Divergent needs exist among stakeholders like politicians, patients, surgeons, and institutions.
Conclusions:
- Despite the consensus on centralization, precise criteria for its implementation in hepatobiliary surgery are missing.
- Guidelines are proposed based on good clinical practice due to limited data-driven evidence.
- Addressing stakeholder needs is crucial for effective centralization strategies.
Abstract:
The positive relationship between volume and outcome in hepatobiliary surgery has been demonstrated for many years. As for other complex surgical procedures, both improved short- and long-term outcomes have been associated with a higher volume of procedures. However, whether the centralization of complex hepatobiliary procedures makes full sense because it should be associated with higher quality of care, as reported in the literature, precise criteria on what to centralize, where to centralize, and who should be entitled to perform complex procedures are still missing. Indeed, despite the generalized consensus on centralization in hepatobiliary surgery, this topic remains very complex because many determinants are involved in such a centralization process, of which some of them cannot be easily controlled. In the context of different health systems worldwide, such as national health systems and private insurance, there are different stakeholders that demand different needs: politicians, patients, surgeons, institutions and medical associations do not always have the same needs. Starting from a review of the literature on centralization in hepatobiliary surgery, we will propose some guidelines that, while not data-driven due to low evidence in the literature, will be based on good clinical practice.
