Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, the Pancreas Institute, University of Verona Hospital Trust, Italy.
Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; Department of Surgery, University of Chicago Hospitals, Chicago, IL.
J Am Coll Surg. 2018 May;226(5):844-857.e3. doi: 10.1016/j.jamcollsurg.2018.01.004. Epub 2018 Mar 1.
Longer operative time (OT) has been associated with negative outcomes in various surgical procedures, but its role in pancreatic resection, a complex, high-acuity endeavor, is not yet well defined. The aim of this study was to analyze the relationship between OT and pancreatectomy outcomes in a risk-adjusted fashion.
This retrospective cohort study analyzed patients undergoing pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) between 2014 and 2015 using the procedure-targeted pancreatectomy database of the American College of Surgeons NSQIP. Univariable analyses and multiple backward stepwise conditional logistic regression models were used to assess the impact of OT on postoperative occurrences.
Among 10,157 patients, 6,844 PDs and 3,313 DPs were performed. Median operative time was 358 minutes (interquartile range 282 to 444 minutes) for PD and 213 minutes (interquartile range 157 to 285 minutes) for DP. Male sex, younger age, obesity, neoadjuvant treatment, minimally invasive approaches, and vascular/concurrent organ resections were associated with longer OT for both procedures. Morbidity increased in a stepwise manner with increasing OT. After risk adjustment, increasing OT was negatively associated with overall morbidity, major complications, pancreatectomy-specific complications, infectious complications, and prolonged hospital stay. These associations were independent from patients' preoperative characteristics, operative approach, vascular or concurrent organ resection, and postoperative diagnosis. These findings held true for both PD and DP. Conversely, the association between OT and mortality was mainly driven by the excessive operative durations for PDs, and was not significant for DPs.
Longer OT is independently associated with worse perioperative outcomes after pancreatic resection, and should be considered a relevant parameter in risk-adjustment processes for outcomes evaluation. These findings suggest possible areas of quality improvement through individual and system-level initiatives.
在各种外科手术中，较长的手术时间（OT）与不良结局相关，但在胰腺切除术这一复杂、高风险的手术中，其作用尚未明确。本研究旨在分析 OT 与胰腺切除术结局之间的关系，并进行风险调整。
本回顾性队列研究使用美国外科医师学会 NSQIP 的胰腺切除术靶向数据库，分析了 2014 年至 2015 年期间行胰十二指肠切除术（PD）或胰体尾切除术（DP）的患者。采用单变量分析和多步向后条件逻辑回归模型，评估 OT 对术后并发症发生的影响。
在 10157 例患者中，行 PD 6844 例，行 DP 3313 例。PD 的中位手术时间为 358 分钟（四分位距 282 至 444 分钟），DP 为 213 分钟（四分位距 157 至 285 分钟）。男性、年龄较小、肥胖、新辅助治疗、微创入路以及血管/同时合并器官切除与两种术式的 OT 延长相关。OT 逐渐增加与发病率呈阶梯式上升。风险调整后，OT 增加与总并发症、主要并发症、胰腺切除相关并发症、感染并发症和住院时间延长呈负相关。这些关联独立于患者术前特征、手术入路、血管或同时合并器官切除以及术后诊断。这些发现适用于 PD 和 DP。相反，OT 与死亡率的关联主要归因于 PD 过长的手术时间，而 DP 则不显著。
OT 延长与胰腺切除术后围手术期结局恶化独立相关，应作为风险调整过程中评估结局的相关参数。这些发现表明通过个体和系统层面的措施，可能有改善质量的空间。
