Riediger Hartwig, Adam Ulrich, Utzolino Stefan, Neeff Hannes P, Hopt Ulrich T, Makowiec Frank
Department of Surgery, Humboldt-Klinikum, Berlin, Germany.
J Gastrointest Surg. 2014 Aug;18(8):1434-40. doi: 10.1007/s11605-014-2555-8. Epub 2014 Jun 5.
Hospital and surgeon volume are potential factors influencing postoperative mortality and morbidity after pancreatic resection. Data on perioperative outcome of individual surgeons in different institutions, however, are scarce. We evaluated the perioperative outcome after pancreatic head resections (PHR) performed by a high-volume pancreatic surgeon in a high-volume university department and (later) in a community hospital with low prior experience in major pancreatic surgery.
We compared the results after PHR were performed by a single experienced surgeon between 2001 and October 2006 in a specialized unit of a German university hospital (n = 83; group A) with the results after PHR were performed in a community hospital between November 2006 and 2011 (n = 145; group B). Before the study period (-2001), the surgeon already had a personal caseload of >200 PHR. In addition to the 228 PHR analyzed here, the surgeon also had taught further >150 PHR to residents and consulting surgeons. Comparable surgical and perioperative techniques were applied in both series (e.g., types of resection and reconstruction, abdominal drains, early enteral feeding). The data of both series were prospectively recorded in SPSS databases.
The median age of the patients was lower in group A (58 vs. 66 years in B; p < 0.01). Indications for PHR were pancreatic cancer (A 39 % vs. B 45 %), other periampullary cancer (A 18 % vs. B 12 %), chronic pancreatitis (A 33 % vs. B 28 %), and others (A 10 % vs. B 15 %). Most PHR were pylorus preserving (64 vs. 75 %), with oncologically indicated portal vein resections in 24 % (A) or 33 % (B). The percentage of duodenum-preserving PHR was lower in group B (14 vs. 26 % in A). Mortality of PHR was 3.6 % in group A and 2.8 % in B (p = 0.72). Overall morbidity rate was 49 % (A) or 57 % (B; p = 0.25). Using the expanded Accordion classification, complications classified as grade 4 or higher occurred in 9 % (A) and 11 % (B; p = 0.74). Postoperative pancreatic leak (any grade) was documented in 26 % (A) and 25 % (B; p = 0.87).
Surgeon volume and a high individual experience, respectively, contribute to acceptable complication rates and low mortality rates after pancreatic head resection. An experienced surgeon can provide a good perioperative outcome after pancreatic resection even after a change of hospital or medical staff.
医院规模和外科医生手术量是影响胰腺切除术后死亡率和发病率的潜在因素。然而，关于不同机构中个体外科医生围手术期结果的数据却很匮乏。我们评估了一位高手术量胰腺外科医生在一所高手术量大学附属医院（以及后来在一所此前缺乏大型胰腺手术经验的社区医院）进行胰头切除术（PHR）后的围手术期结果。
我们比较了一位经验丰富的外科医生于2001年至2006年10月在德国大学医院的一个专科科室进行的PHR结果（n = 83；A组）与2006年11月至2011年在一家社区医院进行的PHR结果（n = 145；B组）。在研究期之前（-2001年），这位外科医生个人的PHR手术量已超过200例。除了这里分析的228例PHR外，这位外科医生还向住院医师和会诊外科医生传授了另外150多例PHR手术。两个系列均采用了可比的手术和围手术期技术（例如，切除和重建类型、腹腔引流、早期肠内喂养）。两个系列的数据均前瞻性记录于SPSS数据库中。
A组患者的中位年龄较低（A组为58岁，B组为66岁；p < 0.01）。PHR的适应证为胰腺癌（A组39% vs. B组45%）、其他壶腹周围癌（A组18% vs. B组12%）、慢性胰腺炎（A组33% vs. B组28%）以及其他情况（A组10% vs. B组15%）。大多数PHR为保留幽门手术（分别为64%和75%），因肿瘤原因行门静脉切除的比例在A组为24%，在B组为33%。B组保留十二指肠的PHR比例较低（A组为26%，B组为14%）。PHR的死亡率在A组为3.6%，在B组为2.8%（p = 0.72）。总体发病率在A组为49%，在B组为57%（p = 0.25）。采用扩展的手风琴分类法，4级及以上并发症在A组为9%，在B组为11%（p = 0.74）。术后胰瘘（任何级别）的记录在A组为26%，在B组为25%（p = 0.87）。
外科医生的手术量以及丰富的个人经验分别有助于在胰头切除术后实现可接受的并发症发生率和低死亡率。即使更换医院或医疗团队，经验丰富的外科医生在胰腺切除术后仍可提供良好的围手术期结果。
