McMillan Matthew T, Soi Sameer, Asbun Horacio J, Ball Chad G, Bassi Claudio, Beane Joal D, Behrman Stephen W, Berger Adam C, Bloomston Mark, Callery Mark P, Christein John D, Dixon Elijah, Drebin Jeffrey A, Castillo Carlos Fernandez-Del, Fisher William E, Fong Zhi Ven, House Michael G, Hughes Steven J, Kent Tara S, Kunstman John W, Malleo Giuseppe, Miller Benjamin C, Salem Ronald R, Soares Kevin, Valero Vicente, Wolfgang Christopher L, Vollmer Charles M
*Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania†Department of Surgery, Mayo Clinic, Jacksonville, Florida‡Department of Surgery, University of Calgary, Calgary, Canada§Department of Surgery, University of Verona, Verona, Italy¶Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana||Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee**Department of Surgery, Jefferson Medical College, Philadelphia, Pennsylvania††Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio‡‡Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts§§Department of Surgery, University of Alabama School of Medicine, Birmingham, Alabama¶¶Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts||||Department of Surgery, Baylor College of Medicine, Houston, Texas***Department of Surgery, University of Florida College of Medicine, Gainesville, Florida†††Department of Surgery, Yale School of Medicine, New Haven, Connecticut‡‡‡Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.
Ann Surg. 2016 Aug;264(2):344-52. doi: 10.1097/SLA.0000000000001537.
To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator.
Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of interest and (2) a comprehensive risk-adjustment process to control for differences in patient risk.
This multinational, retrospective study of 4301 pancreatoduodenectomies involved 55 surgeons at 15 institutions. Risk for CR-POPF was assessed using the previously validated Fistula Risk Score, and pancreatic fistulas were stratified by International Study Group criteria. CR-POPF variability was evaluated and hierarchical regression analysis assessed individual surgeon and institutional performance.
There was considerable variability in both CR-POPF risk and occurrence. Factors increasing the risk for CR-POPF development included increasing Fistula Risk Score (odds ratio 1.49 per point, P < 0.00001) and octreotide (odds ratio 3.30, P < 0.00001). When adjusting for risk, performance outliers were identified at the surgeon and institutional levels. Of the top 10 surgeons (≥15 cases) for nonrisk-adjusted performance, only 6 remained in this high-performing category following risk adjustment.
This analysis of pancreatic fistulas following pancreatoduodenectomy demonstrates considerable variability in both the risk and occurrence of CR-POPF among surgeons and institutions. Disparities in patient risk between providers reinforce the need for comprehensive, risk-adjusted modeling when assessing performance based on procedure-specific complications. Furthermore, beyond inherent patient risk factors, surgical decision-making influences fistula outcomes.
以临床相关术后胰瘘（CR-POPF）的发生情况作为质量指标，评估胰十二指肠切除术的手术效果。
准确评估外科医生和机构的手术效果需要（1）对感兴趣的结局有标准化定义，以及（2）一个全面的风险调整过程来控制患者风险的差异。
这项对4301例胰十二指肠切除术的多国回顾性研究涉及15家机构的55名外科医生。使用先前验证的胰瘘风险评分评估CR-POPF的风险，并根据国际研究组标准对胰瘘进行分层。评估CR-POPF的变异性，并通过分层回归分析评估个体外科医生和机构的手术效果。
CR-POPF的风险和发生率均存在相当大的变异性。增加CR-POPF发生风险的因素包括胰瘘风险评分增加（每增加1分，比值比为1.49，P<0.00001）和使用奥曲肽（比值比为3.30，P<0.00001）。在调整风险后，在外科医生和机构层面识别出了手术效果异常者。在未进行风险调整的手术效果排名前10位的外科医生（≥15例手术）中，风险调整后只有6位仍处于这一高手术效果类别。
这项对胰十二指肠切除术后胰瘘的分析表明，外科医生和机构之间CR-POPF的风险和发生率均存在相当大的变异性。提供者之间患者风险的差异强化了在基于特定手术并发症评估手术效果时进行全面的风险调整建模的必要性。此外，除了固有的患者风险因素外，手术决策也会影响胰瘘结局。
