Department of Surgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy.
J Gastrointest Surg. 2012 Mar;16(3):518-23. doi: 10.1007/s11605-011-1777-2. Epub 2011 Nov 15.
Despite the close relationship between hospital volume and mortality after pancreaticoduodenectomy (PD), the role of surgeon volume still remains an open issue. Retrospective multi-institutional reviews considered only in-hospital mortality, whereas no data about major complications are available so far. The aim of this study is to assess the independent impact of surgeon volume on outcome after PD in a single high-volume institution.
Demographics and clinical and surgical variables were prospectively collected on 610 patients who underwent PD from August 2001 to August 2009. The cutoff value to categorize high- and low-volume surgeons (HVS and LVS, respectively) was 12 PD/year. The primary endpoint was operative mortality (death within 30-day post-discharge). Secondary endpoints were morbidity, pancreatic fistula (PF), and length of hospital stay (LOS).
In the whole series, mortality was 4.1%, overall morbidity was 61.3%, and PF rate was 27.5%. Two HVS performed 358 PD (58.6%), while six LVS performed 252 PD (41.4%). Mortality was 3.9% for HVS and 4.3% for LVS (p=0.84). The major complication rate was similar for HVS and LVS (14.5% vs. 16.2%). The PF rate was higher for LVS (32.4% vs. 24.1%, p=0.03). The mean LOS was 15.5 days for HVS vs. 16.9 days for LVS (p=0.11). At multivariate analysis, risk factors for PF occurrence were LVS, soft pancreatic stump, small duct diameter, and longer operative time.
Low-volume surgeons had a higher PF rate. However, this did not increase mortality and major morbidity rates probably because of the protective effect of high-volume hospital in improving patient rescue from life-threatening complications.
尽管胰十二指肠切除术（PD）后的医院容量与死亡率之间存在密切关系，但外科医生的容量仍然是一个悬而未决的问题。回顾性多机构审查仅考虑院内死亡率，而迄今为止尚无主要并发症的数据。本研究的目的是在单一高容量机构中评估外科医生容量对 PD 后结果的独立影响。
前瞻性收集了 610 例于 2001 年 8 月至 2009 年 8 月接受 PD 的患者的人口统计学和临床及手术变量。将高容量外科医生（HVS）和低容量外科医生（LVS）分类的截止值为 12 PD/年。主要终点是手术死亡率（出院后 30 天内死亡）。次要终点是发病率、胰瘘（PF）和住院时间（LOS）。
在整个系列中，死亡率为 4.1%，总发病率为 61.3%，PF 发生率为 27.5%。两名 HVS 完成了 358 例 PD（58.6%），六名 LVS 完成了 252 例 PD（41.4%）。HVS 的死亡率为 3.9%，LVS 的死亡率为 4.3%（p=0.84）。HVS 和 LVS 的主要并发症发生率相似（14.5% vs. 16.2%）。LVS 的 PF 发生率较高（32.4% vs. 24.1%，p=0.03）。HVS 的平均 LOS 为 15.5 天，LVS 的 LOS 为 16.9 天（p=0.11）。多变量分析显示，PF 发生的危险因素为 LVS、软胰腺残端、小胰管直径和较长的手术时间。
低容量外科医生的 PF 发生率较高。然而，这并没有增加死亡率和主要发病率，这可能是因为高容量医院在改善患者从危及生命的并发症中抢救的作用。
