BACKGROUND:Left-sided pancreatectomies are increasingly done by minimally invasive surgery (MIS), but variation persists in clinical practice. The implementation of MIS at a population level may identify areas for improvement. The aim of this study was to investigate the implementation of minimally invasive left-sided pancreatic resections at a national level, using population-adjusted resection rates and impact on a composite ideal outcome. STUDY DESIGN:All open and laparoscopic left-sided pancreatectomies as recorded in a national quality register, as a nationwide IDEAL stage IV cohort study from 2016 to 2023. Population-adjusted resection rates over time were calculated. Rates of ideal outcome were calculated and risk was expressed as odds ratio with 95% CI. RESULTS:The study period included 817 left-sided pancreatectomies, of which 519 (63.5%) were by minimally invasive access. The temporal age- and sex-adjusted resection rates for open and laparoscopic procedures were stable, but with regional variation in MIS. MIS was associated with shorter hospital stays and increased discharge-to-home rates. Patients selected for laparoscopy were younger, had better performance status and American Society for Anesthesiology risk score, and achieved higher ideal outcomes. In multivariable analysis, achieving an ideal outcome was associated with MIS in nonobese patients with good performance status in the recent time period and with health region. CONCLUSIONS:A temporal stability in resection rates and access type within regions demonstrated significant differences in the use of MIS. Although MIS was associated with the selection of younger, nonobese patients and lower rates of malignant lesions, it was also associated with 2-fold higher rates of ideal outcomes.

BACKGROUND:An ideal outcome represents a favorable postoperative journey defined by a composite endpoint. Sex disparities and type of surgery may influence the chance to achieve an ideal outcome. We aimed to investigate factors associated with achieving an ideal outcome after pancreatectomy in a national cohort. STUDY DESIGN:This study examined a complete nationwide cohort of all pancreatoduodenectomies or left-sided pancreatectomies across a universal healthcare system. Uni- and multivariable logistic regression models were performed related to procedure- and sex-related outcomes. RESULTS:Of 2,057 patients, 1,950 (95%) were included and 1,130 (57.9%) achieved an ideal outcome, with significant sex disparities (62.3% vs 54.1% for women and men, respectively, p < 0.001). Women experienced fewer severe complications (22.6% vs 30.1%, p < 0.001), had fewer reoperations (5.5% vs 10.1%, p < 0.001), and lower 30-day mortality (0.8% vs 1.9%, p = 0.026) compared with men. Women also had lower rates of extended length of stay (22.1% vs 26.1%, p = 0.038) and lower 30-day readmission rates (18.1% vs 23.4%, p = 0.004). Female sex was a strong predictor of achieving an ideal outcome (odds ratio 1.39, 95% CI 1.15 to 1.69, p < 0.001), as was distal pancreatectomy compared with pancreatoduodenectomy (adjusted odds ratio 2.09, 95% CI 1.69 to 2.59, p < 0.001). Sex distribution of procedures (pancreatectomy vs left-sided resections) was similar. Women were slightly older (24.0% vs 20.3%, older than 75 years of age, respectively; p = 0.049) and lower rates of diabetes (12.8% vs 21.2%, respectively; p < 0.001). CONCLUSIONS:Women more often achieved an ideal outcome and had better outcomes across all domains. Observed sex disparities in outcomes warrant investigation into putative biological mechanisms that may underlie these observed clinical differences.

Background In patients undergoing resection for pancreatic cancer, adjuvant modified fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) improves overall survival compared with alternative chemotherapy regimens. We aimed to compare the efficacy and safety of neoadjuvant FOLFIRINOX with the standard strategy of upfront surgery in patients with resectable pancreatic ductal adenocarcinoma. Methods NORPACT-1 was a multicentre, randomised, phase 2 trial done in 12 hospitals in Denmark, Finland, Norway, and Sweden. Eligible patients were aged 18 years or older, with a WHO performance status of 0 or 1, and had a resectable tumour of the pancreatic head radiologically strongly suspected to be pancreatic adenocarcinoma. Participants were randomly assigned (3:2 before October, 2018, and 1:1 after) to the neoadjuvant FOLFIRINOX group or upfront surgery group. Patients in the neoadjuvant FOLFIRINOX group received four neoadjuvant cycles of FOLFIRINOX (oxaliplatin 85 mg/m(2), irinotecan 180 mg/m(2), leucovorin 400 mg/m(2), and fluorouracil 400 mg/m(2) bolus then 2400 mg/m(2) over 46 h on day 1 of each 14-day cycle), followed by surgery and adjuvant chemotherapy. Patients in the upfront surgery group underwent surgery and then received adjuvant chemotherapy. Initially, adjuvant chemotherapy was gemcitabine plus capecitabine (gemcitabine 1000 mg/m(2) over 30 min on days 1, 8, and 15 of each 28-day cycle and capecitabine 830 mg/m(2) twice daily for 3 weeks with 1 week of rest in each 28-day cycle; four cycles in the neoadjuvant FOLFIRINOX group, six cycles in the upfront surgery group). A protocol amendment was subsequently made to permit use of adjuvant modified FOLFIRINOX (oxaliplatin 85 mg/m(2), irinotecan 150 mg/m(2), leucovorin 400 mg/m(2), and fluorouracil 2400 mg/m(2) over 46 h on day 1 of each 14-day cycle; eight cycles in the neoadjuvant FOLFIRINOX group, 12 cycles in the upfront surgery group). Randomisation was performed with a computerised algorithm that stratified for each participating centre and used a concealed block size of two to six. Patients, investigators, and study team members were not masked to treatment allocation. The primary endpoint was overall survival at 18 months. Analyses were done in the intention-to-treat (ITT) and per-protocol populations. Safety was assessed in all patients who were randomly assigned and received at least one cycle of neoadjuvant or adjuvant therapy. This trial is registered with ClinicalTrials.gov, NCT02919787, and EudraCT, 2015-001635-21, and is ongoing. Findings Between Feb 8, 2017, and April 21, 2021, 77 patients were randomly assigned to receive neoadjuvant FOLFIRINOX and 63 to undergo upfront surgery. All patients were included in the ITT analysis. For the per-protocol analysis, 17 (22%) patients were excluded from the neoadjuvant FOLFIRINOX group (ten did not receive neoadjuvant therapy, four did not have pancreatic ductal adenocarcinoma, and three received another neoadjuvant regimen), and eight (13%) were excluded from the upfront surgery group (seven did not have pancreatic ductal adenocarcinoma and one did not undergo surgical exploration). 61 (79%) of 77 patients in the neoadjuvant FOLFIRINOX group received neoadjuvant therapy. The proportion of patients alive at 18 months by ITT was 60% (95% CI 49-71) in the neoadjuvant FOLFIRINOX group versus 73% (62-84) in the upfront surgery group (p=0 center dot 032), and median overall survival by ITT was 25 center dot 1 months (95% CI 17 center dot 2-34 center dot 9) versus 38 center dot 5 months (27 center dot 6-not reached; hazard ratio [HR] 1 center dot 52 [95% CI 1 center dot 00-2 center dot 33], log-rank p=0 center dot 050). The proportion of patients alive at 18 months in per-protocol analysis was 57% (95% CI 46-67) in the neoadjuvant FOLFIRINOX group versus 70% (55-83) in the upfront surgery group (p=0 center dot 14), and median overall survival in per-protocol population was 23 center dot 0 months (95% CI 16 center dot 2-34 center dot 9) versus 34 center dot 4 months (19 center dot 4-not reached; HR 1 center dot 46 [95% CI 0 center dot 99-2 center dot 17], log-rank p=0 center dot 058). In the safety population, 42 (58%) of 73 patients in the neoadjuvant FOLFIRINOX group and 19 (40%) of 47 patients in the upfront surgery group had at least one grade 3 or worse adverse event. 63 (82%) of 77 patients in the neoadjuvant group and 56 (89%) of 63 patients in the upfront surgery group had resection (p=0 center dot 24). One sudden death of unknown cause and one COVID-19-related death occurred after the first cycle of neoadjuvant FOLFIRINOX. Adjuvant chemotherapy was initiated in 51 (86%) of 59 patients with resected pancreatic ductal adenocarcinoma in the neoadjuvant FOLFIRINOX group and 44 (90%) of 49 patients with resected pancreatic ductal adenocarcinoma in the upfront surgery group (p=0 center dot 56). Adjuvant modified FOLFIRINOX was given to 13 (25%) patients in the neoadjuvant FOLFIRINOX group and 19 (43%) patients in the upfront surgery group. During adjuvant chemotherapy, neutropenia (11 [22%] patients in the neoadjuvant FOLFIRINOX group and five [11%] in the upfront surgery group) was the most common grade 3 or worse adverse event. Interpretation This phase 2 trial did not show a survival benefit from neoadjuvant FOLFIRINOX in resectable pancreatic ductal adenocarcinoma compared with upfront surgery. Implementation of neoadjuvant FOLFIRINOX was challenging. Future trials on treatment sequencing in resectable pancreatic ductal adenocarcinoma should be biomarker driven. Copyright (c) 2024 Elsevier Ltd. All rights reserved.

Objectives: Most patients with pancreatic cancer who have undergone surgical resection eventually develop disease recurrence. This study aimed to investigate whether there is evidence to support routine surveillance after pancreatic cancer surgery, with a secondary aim of analyzing the implementation of surveillance strategies in the Nordic countries. Materials and Methods: A scoping review was conducted to identify clinical practice guidelines globally and research studies relating to surveillance after pancreatic cancer resection. This was followed by a survey among 20 pancreatic units from four Nordic countries to assess their current practice of follow-up for operated patients. Results: Altogether 16 clinical practice guidelines and 17 research studies were included. The guidelines provided inconsistent recommendations regarding postoperative surveillance of pancreatic cancer. The clinical research data were mainly based on retrospective cohort studies with low level of evidence and lead-time bias was not addressed. Active surveillance was recommended in Sweden and Denmark, but not in Norway beyond the post-operative/adjuvant period. Finland had no national recommendations for surveillance. The Nordic survey revealed a wide variation in reported practice among the different units. About 75% (15 of 20 units) performed routine postoperative surveillance. Routine CA 19-9 testing was used by 80% and routine CT by 67% as part of surveillance. About 73% of centers continued follow-up until 5 years postoperatively. Conclusion: Evidence for routine long-term (i.e. 5 years) surveillance after pancreatic cancer surgery remains limited. Most pancreatic units in the Nordic countries conduct regular follow-up, but protocols vary.

LBA4005 Background: Fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) has shown improved survival in metastatic pancreatic cancer, and promising results as downstaging chemotherapy in locally advanced pancreatic cancer. The efficacy of neoadjuvant FOLFIRINOX in patients with resectable pancreatic cancer is unknown. Methods: This is a randomized phase II trial with patients included from 12 Nordic centers in the period 2017-2021. Patients with resectable pancreatic head cancer were randomly assigned to receive either four neoadjuvant cycles of FOLFIRINOX followed by surgery and eight adjuvant cycles mFOLFIRINOX, or upfront surgery and adjuvant mFOLFIRINOX (12 cycles). The primary endpoint was overall survival at 18 months after date of randomization (intention-to-treat [ITT]). Overall survival was estimated with the Kaplan-Meier method, and differences between the respective treatment arms were analyzed with log rank tests. Results: In NORPACT-1, 140 patients were randomly assigned (neoadjuvant chemotherapy, n=77;upfront surgery, n=63). Median age was 66.5 years (IQR 59, 72), while 115 (82.1%) and 25 (17.9%) patients were ECOG 0 and 1, respectively. Median OS by ITT was 25.1 months [95% CI 17.2-34.9] with neoadjuvant chemotherapy and 38.5 months [95% CI 27.6-not reached] with upfront surgery (p=0.096). The proportion of patients alive at 18 months by ITT was 59.7 % [95% CI 48.9-70.7] and 73.0 % [95% CI 62.0-84.0], respectively (p=0.100). Resection rates were 81.8% (63/77) in the neoadjuvant group and 88.9% (56/63) in the upfront surgery group (p=0.342). In the neoadjuvant group 61 (79.2%) patients initiated neoadjuvant FOLFIRINOX. Completion of the four planned cycles was 60%, with dose reductions and delays in 70% and 28.3%. Per-protocol (PP) analysis of 60 patients with pancreatic ductal adenocarcinoma (PDAC) who received minimum one cycle neoadjuvant FOLFIRINOX compared with 55 patients in the upfront surgery arm who were explored showed median OS of 23.0 months [95% CI 16.2-34.9] and 34.4 months [95% CI 19.4-not reached] (p=0.158). Adjuvant chemotherapy initiation rate was 66.2% and 74.6% (p=0.282) by ITT. In resected PDAC patients the rate was 86.4% and 89.8% (p=0.593). Of 120 patients receiving at least one dose of neoadjuvant and/or adjuvant chemotherapy (safety population), 57.5% (42/73) in the neoadjuvant group and 40.4% (19/47) in the upfront surgery group experienced at least one grade ≥3 adverse event (p=0.067). In PP analysis neoadjuvant FOLFIRINOX was associated with significantly higher rate of N0 (p=0.002) and R0 resection (p=0.011). Conclusions: Neoadjuvant FOLFIRINOX did not improve OS compared with upfront surgery in resectable pancreatic head cancer. Our results do not support neoadjuvant chemotherapy as standard of care for these patients. Future trials should incorporate a biomarker-based design. Clinical trial information: NCT02919787 .

Background and purpose Preoperative inflammatory markers, such as Glasgow prognostic score, modified Glasgow prognostic score and C-reactive protein to albumin ratio, were shown to be associated with prognosis in patients undergoing pancreatectomy for cancer. However, little is known about their predictive role in a Western population. Methods The Norwegian National Registry for Gastrointestinal Surgery (NORGAST) was used to capture all pancreatectomies performed within the study period (November 2015—April 2021). The association between the preoperative inflammatory markers and postoperative outcomes was studied. Their impact on survival was examined in patients operated for pancreatic ductal adenocarcinoma. Results A total of 1554 patients underwent pancreatectomy in this period. Glasgow prognostic score, modified Glasgow prognostic score and C-reactive protein to albumin ratio were associated with severe complications (Accordion grade ≥ III) in the univariable but not in the multivariable analysis. C-reactive protein to albumin ratio, but not Glasgow prognostic score and modified Glasgow prognostic score, was linked to survival following pancreatectomy for ductal adenocarcinoma. In the multivariable model, age, neoadjuvant chemotherapy, ECOG score, C-reactive protein to albumin ratio and total pancreatectomy correlated with survival. Also, preoperative C-reactive protein to albumin ratio was significantly associated with survival after pancreatoduodenectomy. Conclusions Preoperative Glasgow prognostic score, modified Glasgow prognostic score and C-reactive protein to albumin ratio have no role in predicting the complications after pancreatectomy. C-reactive protein to albumin ratio is a significant predictor for survival in ductal adenocarcinoma, yet its clinical relevance should be explored in conjunction with the pathology parameters and adjuvant therapy.

BACKGROUND:As patient-centered care gains more attention, assessing the patient's perspective on their recovery has become increasingly important. In response to the need for a reliable and valid patient reported outcome measurement tool for major surgical resections in Norway. The Norwegian Registry for Gastrointestinal Surgery (NORGAST) initiated a project to translate and evaluate QoR-15's psychometric properties for patients going through general, gastrointestinal (GI), and hepato-pancreato-biliary (HPB) resectional surgery. METHODS:After a translation and adaption of the original version of QoR-15 into Norwegian, the QoR-15NO was psychometrically evaluated including a confirmatory factor analysis to test for unidimensionality, as well as tests for content validity, internal consistency, measurement error, construct validity, feasibility, and responsiveness. This process included cognitive interviews using a structured interview guide. Further, patients who underwent various types of GI/HPB surgery at five hospitals in different parts of Norway completed the QoR-15NO before surgery and on the first or second day after surgery. The impact of surgery was classified according to Surgical Outcome Risk Tool v2 (SORT), in extra major/complex, major, intermediate, and minor. RESULTS:This study included 324 patients with 83% return rate with both pre- and postoperative forms. There were negative correlations between duration of surgery and postoperative QoR-15 score and the difference between post- and preoperative score (change score). Individuals who had gone through surgery with major impact had a lower postoperative mean QoR-15 score (97) than their counterparts who had experienced either medium (QoR-15: 110) or minor (QoR15: 119) impact surgery. Cronbach's alpha (0.88) and Omega Alpha Total (ωt = 0.90) indicate that the scale has good to very good internal consistency. Test-retest reliability was measured by Intra-class Correlation Coefficient to ICC = 0.70. Confirmatory factor analyses supported that a one-factor model with correlated residuals had a good fit to data. CONCLUSION:This study supports QoR-15NO as a valid, essentially unidimensional, feasible, and responsive instrument among patients undergoing general, GI, and HPB resectional surgery in Norway. The total QoR-15NO score provides important information that can be used in an everyday clinical setting and integrated into NORGAST.

Preoperative inflammatory markers were shown to be associated with prognosis following surgery for hepato-pancreato-biliary cancer. Yet little evidence exists about their role in patients with colorectal liver metastases (CRLM). This study aimed to examine the association between selected preoperative inflammatory markers and outcomes of liver resection for CRLM. Data from the Norwegian National Registry for Gastrointestinal Surgery (NORGAST) was used to capture all liver resections performed in Norway within the study period (November 2015–April 2021). Preoperative inflammatory markers were Glasgow prognostic score (GPS), modified Glasgow prognostic score (mGPS) and C-reactive protein to albumin ratio (CAR). The impact of these on postoperative outcomes, as well as on survival were studied. Liver resections for CRLM were performed in 1442 patients. Preoperative GPS ≥ 1 and mGPS ≥ 1 were present in 170 (11.8

Purpose Although widely applied, the results following laparoscopic rectal resection (LRR) compared to open rectal resection (ORR) are still debated. The aim of this study was to assess clinical short- and long-term results as well as oncological resection quality following LRR or ORR for cancer in a 5-year national cohort. Methods Data from the Norwegian Registry for Gastrointestinal Surgery and the Norwegian Colorectal Cancer Registry were retrieved from January 2014 to December 2018 for patients who underwent elective resection for rectal cancer. Primary end point was 5-year overall survival. Secondary end points were local recurrence rates within 5 years, oncological resection quality, and short-term outcome measures. Results A total of 1796 patients were included, of whom 1284 had undergone LRR and 512 ORR. There was no difference in 5-year survival rates between the groups after adjusting for relevant covariates with Cox regression analyses. Crude 5-year survival was 77.1% following LRR compared to 74.8% following ORR ( p = 0.015). The 5-year local recurrence rates were 3.1% following LRR and 4.1% following ORR ( p = 0.249). Length of hospital stay was median 8.0 days (quartiles 7.0–13.0) after ORR compared to 6.0 (quartiles 4.0–8.0) days after LRR. After adjusting for relevant covariates, estimated additional length of stay after ORR was 3.1 days ( p < 0.001, 95% CI 2.3–3.9). Rates of positive resection margins and number of harvested lymph nodes were similar. There were no other significant differences in short-term outcomes between the groups. Conclusion LRR was performed with clinical and oncological outcomes similar to ORR, but with shorter hospital stay.

PURPOSE:A diverting stoma is commonly formed to reduce the rate of anastomotic leak following anterior resection with anastomosis, although some studies question this strategy. The aim of this study was to assess the leak rates and overall complication burden after anterior resection with and without a diverting stoma. METHODS:A 5-year national cohort with prospectively registered data of patients who underwent elective anterior resection for rectal cancer located < 15 cm from the anal verge. Data were retrieved from the Norwegian Registry for Gastrointestinal Surgery and the Norwegian Colorectal Cancer Registry. Primary end point was relaparotomy or relaparoscopy for anastomotic leak within 30 days from index surgery. Secondary endpoints were postoperative complications including reoperation for any cause. RESULTS:Some 1018 patients were included of whom 567 had a diverting stoma and 451 had not. Rate of reoperation for anastomotic leak was 13 out of 567 (2.3%) for patients with diverting stoma and 35 out of 451 (7.8%) (p > 0.001) for patients without. In multivariable analyses not having a diverting stoma (aOR 3.77, c.i 1.97-7.24, p < 0.001) was associated with increased risk for anastomotic leak. However, there were no differences in overall reoperation rates following anterior resection with or without diverting stoma (9.3% vs 10.9%, p = 0.423), and overall complication rates were similar. Reoperation was associated with increased mortality irrespective of the main intraoperative finding. CONCLUSION:Diverting stoma formation after anterior resection is protective against reoperation for anastomotic leak but does not affect overall rates of reoperation or complications within 30 days.

Background Improvement in survival from pancreatic ductal adenocarcinoma (PDAC) has been reported in trial settings but is less explored in unselected cohorts. The aim of this study was to assess trends in provision of treatments and survival in Norway over a 15-year period following the implementation of hepato-pancreato-biliary (HPB) multidisciplinary teams, centralization of surgery, and implementation of modern chemotherapy (CTx) regimens. Methods A population-based observational study was conducted by analysing all patients diagnosed with PDAC between 2004 and 2018 using coupled data from the Cancer Registry of Norway and the National Patient Registry. Results A total of 10 630 patients were identified, of whom 1492 (14.0 per cent) underwent surgical resection. The resection rate, median age of those resected, and provision of perioperative CTx all increased over time. Median overall survival after resection improved from 16.0 months in the period 2004 to 2008 to 25.1 months in the period 2014 to 2018 (P < 0.001). For non-resected patients there was a rise in the provision of palliative chemotherapy, but little survival gain over time (median overall survival for 2004 to 2008 was 3.2 months versus 4.2 months for 2014 to 2018; P < 0.001). The rate of patients who did not receive any tumour-directed treatment (neither CTx nor surgery) was 44.3 per cent (2481 of 5603 patients) and decreased from 52.9 per cent in 2010 to 37.9 per cent in 2018 (P < 0.001). The median overall survival for all patients with PDAC increased from 3.7 months for 2004 to 2008 to 5.8 months for 2014 to 2018 (P < 0.001). Conclusion Survival after resection increased substantially, as did national resection rates. Little development in the provision of CTx or survival was observed for non-resected patients. A complete 15-year (2004-2018) national cohort of patients with pancreatic ductal adenocarcinoma was analyzed for trends in tumour-directed treatment and survival. The resection rates, age among resected and survival after resection increased and more patients received perioperative chemotherapy. For non-resected patients there was little change in provision of chemotherapy and survival, and still 4 in 10 patients receive no tumor-directed treatment.

Background Conversion from laparoscopic to open access colorectal surgery is associated with a poorer postoperative outcome. The aim of this study was to assess conversion rates and outcomes after standard laparoscopic rectal resection (LR) and robotic laparoscopic rectal resection (RR). Methods A national 5-year cohort study utilizing prospectively recorded data on patients who underwent elective major laparoscopic resection for rectal cancer. Data were retrieved from the Norwegian Registry for Gastrointestinal Surgery and from the Norwegian Colorectal Cancer Registry. Primary end point was conversion rate. Secondary end points were postoperative complications within 30 days and histopathological results. Chi-square test, two-sided T test, and Mann-Whitney U test were used for univariable analyses. Both univariable and multivariable logistic regression analyses were used to analyze the relations between different predictors and outcomes, and propensity score matching was performed to address potential treatment assignment bias. Results A total of 1284 patients were included, of whom 375 underwent RR and 909 LR. Conversion rate was 8 out of 375 (2.1%) for RR compared with 87 out of 909 (9.6%) for LR (p < 0.001). RR was associated with reduced risk for conversion compared with LR (aOR 0.22, 95% CI 0.10-0.46). There were no other outcome differences between RR and LR. Factors associated with increased risk for conversion were male gender, severe cardiac disease and BMI > 30. Conversion was associated with higher rates of major complications (20 out of 95 (21.2%) vs 135 out of 1189 (11.4%) p = 0.005), reoperations (13 out of 95 (13.7%) vs 93 out of 1189 (7.1%) p = 0.020), and longer hospital stay (median 8 days vs 6 days, p = 0.001). Conclusion Conversion rate was lower with robotic assisted rectal resections compared with conventional laparoscopy. Conversions were associated with higher rates of postoperative complications.

The timing of surgical resection of synchronous liver metastases from colorectal cancer has been debated for decades. Several strategies have been proposed, but high-level evidence remains scarce. Simultaneous resection of the primary tumour and liver metastases has been described in numerous retrospective audits and meta-analyses. The potential benefits of simultaneous resections are the eradication of the tumour burden in one procedure, overall shorter procedure time, reduced hospital stay with the likely benefits on quality of life and an expected reduction in the use of health care services compared to staged procedures. However, concerns about accumulating complications and oncological outcomes remain and the optimal selection criteria for whom simultaneous resections are beneficial remains undetermined. Based on the current level of evidence, simultaneous resection should be restricted to patients with a limited liver tumour burden. More high-level evidence studies are needed to evaluate the quality of life, complication burden, oncological outcomes, as well as overall health care implications for simultaneous resections.

BACKGROUND:Centralization of pancreatic surgery is currently called for owing to superior outcomes in higher-volume centres. Conversely, organizational and patient concerns speak for a moderation in centralization. Consensus on the optimal balance has not yet been reached. This observational study presents a volume-outcome analysis of a complete national cohort in a health system with long-standing centralization.METHODS:Data for all pancreatoduodenectomies in Norway in 2015 and 2016 were identified through a national quality registry and completed through electronic patient journals. Hospitals were dichotomized (high-volume (40 or more procedures/year) or medium-low-volume).RESULTS:Some 394 procedures were performed (201 in high-volume and 193 in medium-low-volume units). Major postoperative complications occurred in 125 patients (31·7 per cent). A clinically relevant postoperative pancreatic fistula occurred in 66 patients (16·8 per cent). Some 17 patients (4·3 per cent) died within 90 days, and the failure-to-rescue rate was 13·6 per cent (17 of 125 patients). In multivariable comparison with the high-volume centre, medium-low-volume units had similar overall complication rates, lower 90-day mortality (odds ratio 0·24, 95 per cent c.i. 0·07 to 0·82) and no tendency for a higher failure-to-rescue rate.CONCLUSION:Centralization beyond medium volume will probably not improve on 90-day mortality or failure-to-rescue rates after pancreatoduodenectomy.

Background: Universal health care (UHC) should ensure equal access to and use of surgery, but few studies have explored variation in UHC systems. The objective was to describe practice of distal pancreatectomy in Norway covered exclusively by an UHC. Methods: Data on all patients undergoing distal pancreatectomy from the Norwegian Patient Register over a 5-year period. Age-and gender-adjusted population-based resection rates (adj. per million/yr) for distal pancreatectomy were analysed across 4 regions and outcomes related to splenic salvage rate, hospital stay, reoperation, readmissions and 90-day mortality risk between regions. Risk is reported as odds ratio (OR) with 95% confidence interval (c.i.). Results: Regional difference exist in terms of absolute numbers, with the majority of procedures done in one region (n = 331; 59.7%). Regional variation persisted for age- and gender-adjusted population-rates, with highest rate at 23.8/million/yr and lowest rate at 13.5/mill/yr (for a 176% relative difference; or an absolute difference of +10.3 resections/million/yr). Overall, a lapDP instead of an open DP was 3.5 times more likely in SouthEast compared to all other regions combined (lapDP rate: 83% vrs 24%, respectively; OR 15.4, 95% c.i. 10.1-23.5; P < 0.001). The splenic salvage rate was lower in SouthEast (19.9%) compared to all other regions (average 26.5%; highest in Central-region at 37.0%; P = 0.010 for trend). Controlled for other factors in multivariate regression, 'region' of surgery remained significantly associated with laparoscopic access. Conclusion: Despite a universal health care system, considerable variation exists in resection rates, use of laparoscopy and splenic salvage rates across regions. (C) 2019 IAP and EPC. Published by Elsevier B.V. All rights reserved.

Background: Distal pancreatectomy (DP) is increasingly done by laparoscopy but data from routine practise are scarce. We describe practise in a national cohort. Methods: Data from the Norwegian Patient Register of all patients undergoing DP from 2012 to 2016. National resection rates were analysed. Short-term outcomes include length of stay, reoperation, readmissions and 90-day mortality. Risk is reported as odds ratio (OR) with 95% confidence interval (c.i.). Results: Of 554 procedures, 327 (59%) were laparoscopic. Median age was 66 years (iqr 55-72) and 52% were women. Resection rates increased during the period for all DP (from 1.76 to 2.39 per 100.000/ yr), and significantly for laparoscopic DP (adjusted R-square 0.858; P = 0.015). Elderly patients had more resection (r(2) = 0.11; P = 0.019). Splenectomy (n = 427; 77%) was less likely with laparoscopy (laparoscopy 72% vs open 84%, respectively; OR 0.64, 95% c.i. 0.42-0.97; P = 0.035). Multivisceral resections occurred more often in open DP (5.3% vs 1.2% for laparoscopy, OR 4.51, 1.44-14.2; P = 0.008). Reoperation occurred in 34 (6%), readmission in 109 (20%), and mortality in 8 (1.4%). Hospital stay was shorter for laparoscopic DP. Conclusion: Use of DP increases in the population, particularly in the elderly, with use of laparoscopic access and an association with a reduced hospital stay.

Background: Centralization of pancreatic resections is advocated due to a volume-outcome association. Pancreatic surgery is in Norway currently performed only in five teaching hospitals. The aim was to describe the short-term outcomes after pancreatoduodenectomy (PD) within the current organizational model and to assess for regional disparities. Methods: All patients who underwent PD in Norway between 2012 and 2016 were identified. Mortality (90 days) and relaparotomy (30 days) were assessed for predictors including demographic data and multi-visceral or vascular resection. Aggregated length-of-stay and national and regional incidences of the procedure were also analysed. Results: A total of 930 patients underwent PD during the study period. In-hospital mortality occurred in 20 patients (2%) and 34 patients (4%) died within 90 days. Male gender, age, multi-visceral resection and relaparotomy were independent predictors of 90-day mortality. Some 131 patients (14%) had a relaparotomy, with male gender and multi-visceral resection as independent predictors. There was no difference between regions in procedure incidence or 90-day mortality. There was a disparity within the regions in the use of vascular resection (p = 0.021). Conclusion: The short-term outcomes after PD in Norway are acceptable and the 90-day mortality rate is low. The outcomes may reflect centralization of pancreatic surgery.

Background & aims: Although malnutrition is thought to be common among patients with intraabdominal diseases and is recognized as a risk factor for postoperative complications, diagnostic criteria for malnutrition have not been consistent. Thus, the Global Leadership Initiative in Malnutrition (GLIM) has recently published new criteria for malnutrition. The aims of this study were to investigate the prevalence of malnutrition according to weight loss and BMI criteria in GLIM's second step for the diagnosis and their association with severe postoperative complications in patients undergoing gastrointestinal resections. Method: The current study includes adult patients who were prospectively included in the Norwegian Registry for Gastrointestinal Surgery in the period between 2015 and 2018. Exclusion criteria were acute surgery and lack of information regarding preoperative weight and/or postoperative complications. Severe surgical complications were classified according to the Revised Accordion Classification system and malnutrition with the GLIM criteria. Associations were assessed by logistic regression analyses, and the adjusted odds ratio included age (continuous), gender (male/female) and scores from the American Society of Anesthesiologists Physical Status Classification System and the Eastern Cooperative Oncology Group. Results: Out of 6110 patients, 2161 (35.4%) were classified as with malnutrition, 1206 (19.7%) with moderate and 955 (15.6%) with severe malnutrition. Malnourished patients were 1.29 (95% CI: 1.13-1.47) times more likely to develop severe surgical complications, and 2.15 (95% CI: 1.27-3.65) times more likely to die within 30 days, as compared to those who were not. Conclusion: Preoperative malnutrition is common among patients having gastrointestinal resections and is associated with an increased risk of severe surgical complications. (C) 2019 The Authors. Published by Elsevier Ltd.