Seoul Metropolitan Government - Seoul National University Boramae Medical Center is a public municipal hospital covering the southwestern area of Seoul, Korea, which is subsidized by the Seoul Metropolitan Government and is managed by Seoul University Hospital. From March 2003 to November 2015, 183 patients underwent PD in this hospital. Clinicopathological data were retrospectively collected from medical records until 2014 and then prospectively collected from January 2015. Clinical data including age, sex, underlying disease, operation data, and relevant clinical outcomes were analyzed. The status of a patient's medical insurance was defined by the policy of the Korean National Health Insurance Service (NHIS). This study was approved by the Institutional Review Board of Seoul Metropolitan Government - Seoul National University Boramae Medical Center (IRB No. 16-2015-176).

We followed the definition of Kim et al. [1], who graded “hospital volume” according to the number of annual PD cases: very low (<10), low (10–18), medium (19–35), high (54–111), and very high (215).

The Clavien-Dindo classification was used for grading postoperative complications. Postoperative surgical complications were considered to have occurred in cases that were classified above grade II [2]. Postoperative pancreatic fistula (POPF) was defined and graded according to the criteria of the International Study Group of Pancreatic Fistula [3]. Only clinically relevant POPF (grade B or C) was regarded as a postoperative complication. Delayed gastric emptying (DGE) was also graded according to the definition of the International Study Group of Pancreatic Surgery [4]. Intra-abdominal fluid collection was defined as complicated fluid detected in the operative field on CT on the 7th postoperative day, regardless of the existence of POPF. In-hospital mortality was defined as patient death within a 30-day postoperative hospital stay during the index admission, regardless of its cause. For comparison of clinical outcomes, an article [1] that has analyzed nationwide PD data was used as a reference. To evaluation of long term outcome, survival analysis was performed in pancreatic head cancer.

Three surgeons performed the surgical procedures. All PD surgeries were performed in laparotomy fashion. Pylorus-preserving PD (PPPD) was preferred to conventional PD in the interest of organ preservation. Pancreaticoenteric anastomoses were performed in pancreaticojejunostomy (PJ) fashion using the duct-to-mucosa method. Although the use of pancreatic stents was left to the surgeon's discretion, external pancreatic stenting was usually performed when the pancreatic texture was soft and the diameter of the main pancreatic duct was less than 3 mm, and internal pancreatic stents were inserted when the diameter of the main pancreatic duct was greater than 5 mm and the pancreas had a hard texture. Prophylactic intravenous antibiotics were administered only on the day of surgery. Octreotide was not routinely administered. The nasogastric tube was removed on the 1st postoperative day. Small sips of water were allowed from the second postoperative day, and a blended diet was attempted after gas was passed. Amylase levels in abdominal drainage fluid were checked on the postoperative third, fifth, and seventh days. Abdominal CT was routinely performed on the seventh day after surgery to rule out arterial pseudoaneurysm and to examine fluid collections.

In cases in which arterial pseudoaneurysm was suspected or postpancreatic hemorrhage was evident, angiography in the interventional radiology suite was preferred to relaparotomy. Intra-abdominal drains were removed when no fluid collection was evident on CT scan and clinically relevant POPF had not occurred.

The social security system of South Korea is composed of 3 fields including social insurance, public assistance, and social welfare service. As a compulsory social insurance program, the Korean health insurance system covers the entire population living in the country. Therefore, if all residents pay their medical insurance premium according to their income, the finances of the health care system are secured. The NHIS is the governmental agency that deals with medical tax revenue, then comprehensively manages it for all medical insurance services. The operational system of national health insurance in South Korea is shown in Fig. 1 (http://www.nhis.or.kr). In brief, total medical costs for a certain health care service consist of (1) NHIS payment: sum of payment for healthcare services from NHIS with a certain rate of copayment by the insured; and (2) Non-NHIS payment: cost for various health care services which do not meet the criteria for NHIS payment (e.g., ultrasonography, magnetic resonance imaging, robotic surgery). These costs are unpayable by the NHIS but should be paid by the patients themselves, with prices reasonably determined by the health care providers.

Health care providers can ask for reimbursement from the NHIS for the health care services provided to the patients, for which the ratio of actual NHIS payment to copayment by the patient is determined by the patient's economic status. For the beneficiaries of national basic livelihood, in other words the patients with low economic status, the proportion of NHIS payment will be increased. Particularly in the case of the destitute poor, the charge to the patients goes to nearly zero. The Health Insurance Review and Assessment Service (HIRA) audits and reviews the bills from health care providers, then announces the review results to the NHIS and gives feedback to health care providers. In the current study, we divided the patients into 2 groups based on the proportion of the payment from the NHIS: (1) Health insurance group: the NHIS paid about 80% of all medical costs as social insurance; and (2) Medical aid (beneficiaries) group: the NHIS covered 95%–100% of all medical costs for the basic livelihood group as public assistance. In particular, since cancer patients were preferentially allowed to pay only 5% of health care service costs, they were also included in the medical aid group in this study to equally compare the costs with those of other hospitals.

The hospital costs for PD patients in the 3 previous years (from January 2013 to November 2015) were analyzed. To specifically compare the hospital costs of PD with those of other hospitals, the overall costs for the patients with pancreatic head cancer were selectively analyzed using the data extracted from the database of the NHIS (http://www.nhis.or.kr) and the open database at the website of HIRA (http://www.hira.or.kr).

Kim et al. [1] analyzed and reported Korean data regarding PD. The authors used this article as a clinical reference regarding PD in Korea.

All statistical analyses were performed with IBM SPSS Statistics ver. 22.0 (IBM Co., Armonk, NY, USA). Nominal data were compared with the chi-square test and Fisher exact test and continuous data with the Kruskal-Wallis test. Kaplan-Meier survival analysis was performed to evaluation of long term outcome. P-values less than 0.05 were considered statistically significant.

The median age of the patients was 67 years (range, 14–89) and the male:female ratio was 99:84 (54.1%:45.9%). The number of patients with Charlson comorbidity index scores of greater than 3 was 122 (66.7%). The proportion of patients in the health insurance group was 80.9% and the proportion in the medical aid beneficiaries group was 19.1%. Preoperative biliary drainage was performed in 137 patients (74.8%), endoscopic retrograde biliary drainage (ERBD) in 64 (35.0%), percutaneous transhepatic biliary drainage (PTBD) in 59 (32.3%), and endoscopic nasobiliary drainage (ENBD) in 14 (7.7%). PPPD accounted for 76% of all PD cases. One hundred thirty-nine cases of PJ were externally diverted through a pancreatic stent, while 34 cases were internally drained. Ten patients had no stent. Sixteen cases were diagnosed as benign disease (8.7%) while the other 167 cases were diagnosed as malignant disease (91.3%) The most common diagnosis was distal common bile duct cancer (65 cases, 35.5%).

The median operation time was 350 minutes (range, 169–600 minutes). Packed red blood cells were transfused in 88 cases (48.1%). Eighty-eight patients (48.1%) experienced more than one postoperative complication. POPF occurred in 113 patients (61.7%), but clinically relevant POPF developed in only 45 patients (24.6%; grade B, 43; grade C, 2). Twenty-one patients had intra-abdominal fluid collection and 18 patients experienced DGE. Fifteen patients developed postoperative pneumonia, and the number of patients who experienced wound complications was 15. Among the nine patients who developed postoperative bleeding, 7 patients bled from arterial pseudoaneurysm, one from arterial erosive bleeding from the dorsal pancreatic artery, and the other due to unknown causes. Six out of the 7 cases of pseudoaneurysmal bleeding originated from the gastroduodenal artery stump and the remaining one originated from the proximal right hepatic artery. All of the 7 cases were embolized with coils in the interventional radiology suite and were successfully controlled, but 1 patient eventually died from pneumonia with pulmonary edema. The case of arterial erosive bleeding from the dorsal pancreatic artery was also well controlled with coil embolization, and the patient who experienced bleeding due to an unknown cause underwent relaparotomy twice, on the second and third postoperative days. However, these 2 patients eventually died due to pulmonary edema and pneumonia. In-hospital mortality was 3.8% (n = 7). Pulmonary problems were the main cause of death (n = 4), followed by sepsis (n = 1), renal failure (n = 1), and cerebral infarction (n = 1). The median length of stay in the hospital after surgery was 20 days (range, 6–137 days). The 5-year survival rate of 36 pancreatic head cancer patients was 15.0% (Fig. 3)

When the total number of cases was sequentially divided into 3 groups, 61 cases could be evenly allocated to the first (March 2003 to April 2009, 6 years), the second (May 2009 to April 2013, 4 years), and the third period (May 2013 to November 2015, 2.5 years), respectively. The overall complication rate was similar among the 3 periods (41.0% vs. 41.0% vs. 50.8%, P = 0.451) but the overall POPF rate was observed to have improved significantly (P = 0.015). The rate of clinically relevant POPF gradually decreased without statistical significance from the first period to the third (27.9% vs. 24.6% vs. 11.5%, P = 0.065). The mean operation time and the length of hospital stay were found to have diminished significantly (P = 0.007, P = 0.008, respectively).

Among the patients, 148 were partially supported by the health insurance system while the other 35 patients, accounting for 19.1% of the total patient population, were fully subsidized as medical aid beneficiaries (Fig. 4). In comparison with the reported data for South Korea [1], the proportion of medical aid beneficiaries in the study hospital was significantly higher than that of other hospitals in the country (P = 0.002).

Fig. 5 shows the composition of the average medical cost for the patients who underwent PD in the study hospital. The mean total cost was 16,583,755 Korean won (KRW) (13,819 USD). The total NHIS payment of 13,243,315 KRW (11,036 USD), which constituted 79.8% of the total cost, was made up of both payment from the NHIS (12,409,315 KRW [10,341 USD], 74.8%) and patient copayments (834,000 KRW [695 USD], 5%). The actual burden to the patients included both the patient copayment portions of the NHIS payment (834,007 KRW [695 USD], 5%) and non-NHIS payments (3,339,629 KRW [2,783 USD], 20.1%), reaching a total of 4,173,636 KRW (3,478 USD) (25.1%).

Particularly useful data from HIRA reported that a total of 70 hospitals in Korea performed PD for pancreatic head cancer from January 2014 to December 2014, and the average NHIS payment per patient was 12,160,000 KRW (10,133 USD). During the same period, 6 PD operations were performed for pancreatic head cancer in the study hospital, and the mean total NHIS payment was 11,619,493 KRW (9,682 USD).