Department of General Surgery, Mayo Clinic Florida, Jacksonville, FL 32225, United States.
World J Gastroenterol. 2012 Aug 28;18(32):4342-9. doi: 10.3748/wjg.v18.i32.4342.
To investigate national trends in distal pancreatectomy (DP) through query of three national patient care databases.
From the Nationwide Inpatient Sample (NIS, 2003-2009), the National Surgical Quality Improvement Project (NSQIP, 2005-2010), and the Surveillance Epidemiology and End Results (SEER, 2003-2009) databases using appropriate diagnostic and procedural codes we identified all patients with a diagnosis of a benign or malignant lesion of the body and/or tail of the pancreas that had undergone a partial or distal pancreatectomy. Utilization of laparoscopy was defined in NIS by the International Classification of Diseases, Ninth Revision correspondent procedure code; and in NSQIP by the exploratory laparoscopy or unlisted procedure current procedural terminology codes. In SEER, patients were identified by the International Classification of Diseases for Oncology, Third Edition diagnosis codes and the SEER Program Code Manual, third edition procedure codes. We analyzed the databases with respect to trends of inpatient outcome metrics, oncologic outcomes, and hospital volumes in patients with lesions of the neck and body of the pancreas that underwent operative resection.
NIS, NSQIP and SEER identified 4242, 2681 and 11,082 DP resections, respectively. Overall, laparoscopy was utilized in 15% (NIS) and 27% (NSQIP). No significant increase was seen over the course of the study. Resection was performed for malignancy in 59% (NIS) and 66% (NSQIP). Neither patient Body mass index nor comorbidities were associated with operative approach (P = 0.95 and P = 0.96, respectively). Mortality (3% vs 2%, P = 0.05) and reoperation (4% vs 4%, P = 1.0) was not different between laparoscopy and open groups. Overall complications (10% vs 15%, P < 0.001), hospital costs [44,741 dollars, interquartile range (IQR) 28 347-74 114 dollars vs 49 792 dollars, IQR 13 299-73 463, P = 0.02] and hospital length of stay (7 d, IQR 4-11 d vs 7 d, IQR 6-10, P < 0.001) were less when laparoscopy was utilized. One and two year survival after resection for malignancy were unchanged over the course of the study (ductal adenocarinoma 1-year 63.6% and 2-year 35.1%, P = 0.53; intraductal papillary mucinous neoplasm and nueroendocrine 1-year 90% and 2-year 84%, P = 0.25). The majority of resections were performed in teaching hospitals (77% NIS and 85% NSQIP), but minimally invasive surgery (MIS) was not more likely to be used in teaching hospitals (15% vs 14%, P = 0.26). Hospitals in the top decile for volume were more likely to be teaching hospitals than lower volume deciles (88% vs 43%, P < 0.001), but were no more likely to utilize MIS at resection. Complication rate in teaching and the top decile hospitals was not significantly decreased when compared to non-teaching (15% vs 14%, P = 0.72) and lower volume hospitals (14% vs 15%, P = 0.99). No difference was seen in the median number of lymph nodes and lymph node ratio in N1 disease when compared by year (P = 0.17 and P = 0.96, respectively).
There appears to be an overall underutilization of laparoscopy for DP. Centralization does not appear to be occurring. Survival and lymph node harvest have not changed.
通过查询三个国家的患者护理数据库，研究远端胰腺切除术（DP）的国家趋势。
从全国住院患者样本（NIS，2003-2009 年）、国家手术质量改进计划（NSQIP，2005-2010 年）和监测、流行病学和最终结果（SEER，2003-2009 年）数据库中，使用适当的诊断和程序代码，我们确定了所有患有良性或恶性体尾部胰腺病变并接受部分或远端胰腺切除术的患者。NIS 中腹腔镜的使用通过国际疾病分类，第九版相应的程序代码定义；NSQIP 通过探查性腹腔镜或未列出的程序当前程序术语代码定义。在 SEER 中，患者通过国际肿瘤学疾病分类，第三版诊断代码和 SEER 程序代码手册，第三版程序代码确定。我们分析了数据库中与颈部和体部胰腺病变患者住院结果指标、肿瘤学结果和医院容量的趋势。
NIS、NSQIP 和 SEER 分别确定了 4242、2681 和 11082 例 DP 切除术。总体而言，腹腔镜的使用率为 15%（NIS）和 27%（NSQIP）。在研究过程中没有明显增加。59%（NIS）和 66%（NSQIP）的患者因恶性肿瘤进行了切除术。患者的身体质量指数或合并症与手术方法均无相关性（P=0.95 和 P=0.96）。死亡率（3%比 2%，P=0.05）和再次手术（4%比 4%，P=1.0）在腹腔镜和开放组之间无差异。总体并发症（10%比 15%，P<0.001）、医院费用[44741 美元，四分位距（IQR）28347-74114 美元比 49792 美元，IQR 13299-73463 美元，P=0.02]和住院时间（7 天，IQR 4-11 天比 7 天，IQR 6-10 天，P<0.001）在腹腔镜使用时较低。恶性肿瘤切除后 1 年和 2 年的生存率在研究过程中没有变化（导管腺癌 1 年生存率为 63.6%，2 年生存率为 35.1%，P=0.53；导管内乳头状黏液性肿瘤和神经内分泌肿瘤 1 年生存率为 90%，2 年生存率为 84%，P=0.25）。大多数切除术在教学医院进行（NIS 为 77%，NSQIP 为 85%），但微创手术（MIS）在教学医院中并不常见（15%比 14%，P=0.26）。手术量最高的十分位数的医院比手术量较低的十分位数的医院更有可能是教学医院（88%比 43%，P<0.001），但在切除时更不可能使用 MIS。与非教学医院（15%比 14%，P=0.72）和手术量较低的医院（14%比 15%，P=0.99）相比，教学医院和手术量最高的十分位数医院的并发症发生率并没有显著降低。在 N1 疾病中，与年份相比，淋巴结中位数和淋巴结比率没有显著差异（P=0.17 和 P=0.96）。
DP 中腹腔镜的总体使用率似乎较低。集中化似乎没有发生。生存和淋巴结采集没有变化。
