LAUSR

Editor I have read with great interest the article by Balzano et al1. This is an inspiring piece of work, although I am afraid it will remain an academic attempt to improve patient care and the results unimplemented by the healthcare regulators. I propose some additional considerations. The first is training. It has been reported that surgeons with extensive previous experience who subsequently have low surgical volume achieve comparable results with regard to morbidity and mortality as surgeons with a similar level of experience who maintain a high volume2. Likewise, the outcomes of pancreatic resections performed in high volume hospitals and low volume hospitals, lead by surgeons who shared the same mentor, were similar3. The second element is patient selection. Their results showed a skewed proportion of elderly patients (age> 70 years) who underwent pancreatic resection against very high volume centres. Moreover, in the multivariate analysis, a Charlson co-morbidity index ≥2, increased the odds of mortality by almost 4-fold. Patient selection is challenging. Treatment decisions based on individual judgement are subject to bias, and may result in inappropriate surgery and consequent adverse outcomes. On the other hand, in the general population, there is a growing demand for cure, with often unrealistic expectations. Whether a patient is salvaged after a complication is a function of the care delivered by the hospital, but mostly of patient frailty4. Conversely, failure to offer surgery to patients who are judged unfit based on generic and imprecise risk variables is unacceptable. Pancreatic surgery might have been offered more frequently to old and frail patients in low volume centres for lack of risk assessment and for the surgeon rewarding of performing challenging operations. At this aim, why not collecting data from the very high volume institutions on the ratio between observed and operated patients as benchmark of overused surgery?5.