*Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA †Division of Biostatistics, Department of Surgery, University of Pittsburgh, Pittsburgh, PA ‡Chongqing Medical University Affiliated First Hospital, Chongqing, China §Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
Ann Surg. 2016 Sep;264(3):482-91. doi: 10.1097/SLA.0000000000001862.
To evaluate and quantify surgical skill by grading surgical performance of the pancreaticojejunostomy from robotic pancreaticoduodenectomies (RPDs). We hypothesized that video grading of surgical performance would contribute to estimating risk of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy.
POPF majorly contributes to pancreaticoduodenectomy morbidity. Risk scores [Fistula Risk Score (FRS) and Braga] derived from patient variables are validated for predicting POPF. Birkmeyer et al showed assessment of surgical proficiency is an important component of outcomes.
POPF was diagnosed using International Study Group definition. Technical performance of robotic pancreaticojejunostomy video was graded by 2 blinded surgeons using: (1) pancreaticojejunostomy step-by-step variables [PJ-specific variables (PJVs); max = 115]; and (2) the Objective Structured Assessment of Technical Skills (OSATS) score.
One hundred thirty-three pancreaticojejunostomies were analyzed. POPF was 18%. Higher FRS (P = 0.011) and Braga (P = 0.041) scores predicted POPF. Graders' subjective prediction did not correlate with FRS/Braga scores. Grader 1 scores (P = 0.043), but not grader 2 (P = 0.44), predicted POPF. PJV scores >105 were predictive of POPF (P = 0.039). Scoring only PJV duct-to-mucosa stitches (max = 50) was highly predictive of POPF (P = 0.0053). Higher OSATS scores were associated with a decreased rate of POPF (P = 0.022). On multivariate analysis, adding technical scoring to statistically significant patient variables (ie, gland texture) improves the model and can independently predict POPF. The strongest predictive model for POPF consisted of soft gland (odds ratio = 18.28, 95% confidence interval = 2.19-152.57) and low OSATS (odds ratio = 0.82, 95% confidence interval = 0.70-0.96). OSATS, modeled with FRS or Braga scores, independently predicted POPF.
This is the first study to demonstrate that technical scoring of a surgeon's performance independently predicts patient outcomes in pancreatic surgery. Future studies should consider how to validate and incorporate technical metrics.
通过评估机器人胰十二指肠切除术（RPD）中的胰肠吻合术的手术表现来评估和量化手术技能。我们假设手术表现的视频分级将有助于估计胰十二指肠切除术后胰瘘（POPF）的风险。
POPF 主要导致胰十二指肠切除术的发病率。基于患者变量的风险评分[瘘管风险评分（FRS）和 Braga]已被验证可用于预测 POPF。Birkmeyer 等人表明，评估手术熟练程度是结局的重要组成部分。
使用国际研究组的定义诊断 POPF。由 2 名盲法外科医生使用以下方法对机器人胰肠吻合术视频的技术性能进行分级：（1）胰肠吻合术分步变量[胰肠吻合术特定变量（PJVs）；最大值= 115]；和（2）客观结构化评估技术技能（OSATS）评分。
共分析了 133 例胰肠吻合术。POPF 发生率为 18%。更高的 FRS（P=0.011）和 Braga（P=0.041）评分预测了 POPF。评分者的主观预测与 FRS/Braga 评分不相关。评分者 1 的评分（P=0.043），但评分者 2 的评分（P=0.44），预测了 POPF。PJVs 评分>105 与 POPF 相关（P=0.039）。仅评分胰管对黏膜吻合钉数（最大值=50）对预测 POPF 具有高度预测性（P=0.0053）。更高的 OSATS 评分与 POPF 发生率降低相关（P=0.022）。在多变量分析中，将技术评分添加到统计学上显著的患者变量（即腺体质地）可以改善模型，并可独立预测 POPF。POPF 的最强预测模型由软腺体组成（比值比=18.28，95%置信区间=2.19-152.57）和低 OSATS（比值比=0.82，95%置信区间=0.70-0.96）。OSATS 与 FRS 或 Braga 评分相结合，可独立预测 POPF。
这是第一项证明外科医生手术表现的技术评分可独立预测胰腺手术患者结局的研究。未来的研究应考虑如何验证和纳入技术指标。
