微创与开腹胰十二指肠切除术的结果：泛欧倾向评分匹配研究。
Outcomes After Minimally-invasive Versus Open Pancreatoduodenectomy: A Pan-European Propensity Score Matched Study.
机构信息
Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, the Netherlands.
Department of Surgery, UKSH Campus Lübeck, Lübeck, Germany.
出版信息
Ann Surg. 2020 Feb;271(2):356-363. doi: 10.1097/SLA.0000000000002850.
OBJECTIVE
To assess short-term outcomes after minimally invasive (laparoscopic, robot-assisted, and hybrid) pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) among European centers.
BACKGROUND
Current evidence on MIPD is based on national registries or single expert centers. International, matched studies comparing outcomes for MIPD and OPD are lacking.
METHODS
Retrospective propensity score matched study comparing MIPD in 14 centers (7 countries) performing ≥10 MIPDs annually (2012-2017) versus OPD in 53 German/Dutch surgical registry centers performing ≥10 OPDs annually (2014-2017). Primary outcome was 30-day major morbidity (Clavien-Dindo ≥3).
RESULTS
Of 4220 patients, 729/730 MIPDs (412 laparoscopic, 184 robot-assisted, and 130 hybrid) were matched to 729 OPDs. Median annual case-volume was 19 MIPDs (interquartile range, IQR 13-22), including the first MIPDs performed in 10/14 centers, and 31 OPDs (IQR 21-38). Major morbidity (28% vs 30%, P = 0.526), mortality (4.0% vs 3.3%, P = 0.576), percutaneous drainage (12% vs 12%, P = 0.809), reoperation (11% vs 13%, P = 0.329), and hospital stay (mean 17 vs 17 days, P > 0.99) were comparable between MIPD and OPD. Grade-B/C postoperative pancreatic fistula (POPF) (23% vs 13%, P < 0.001) occurred more frequently after MIPD. Single-row pancreatojejunostomy was associated with POPF in MIPD (odds ratio, OR 2.95, P < 0.001), but not in OPD. Laparoscopic, robot-assisted, and hybrid MIPD had comparable major morbidity (27% vs 27% vs 35%), POPF (24% vs 19% vs 25%), and mortality (2.9% vs 5.2% vs 5.4%), with a fewer conversions in robot-assisted- versus laparoscopic MIPD (5% vs 26%, P < 0.001).
CONCLUSIONS
In the early experience of 14 European centers performing ≥10 MIPDs annually, no differences were found in major morbidity, mortality, and hospital stay between MIPD and OPD. The high rates of POPF and conversion, and the lack of superior outcomes (ie, hospital stay, morbidity) could indicate that more experience and higher annual MIPD volumes are needed.
目的
评估微创（腹腔镜、机器人辅助和杂交）胰十二指肠切除术（MIPD）与开放胰十二指肠切除术（OPD）在欧洲中心的短期结果。
背景
目前关于 MIPD 的证据基于国家登记处或单一专家中心。缺乏比较 MIPD 和 OPD 结果的国际、匹配研究。
方法
回顾性倾向评分匹配研究比较了每年进行≥10 例 MIPD 的 14 个中心（7 个国家）（2012-2017 年）的 MIPD 与每年进行≥10 例 OPD 的 53 个德国/荷兰外科登记中心的 OPD（2014-2017 年）。主要结局是 30 天主要发病率（Clavien-Dindo ≥3）。
结果
在 4220 名患者中，729/730 例 MIPD（412 例腹腔镜、184 例机器人辅助和 130 例杂交）与 729 例 OPD 相匹配。每年的中位病例量为 19 例 MIPD（四分位距，IQR 13-22），包括 10/14 个中心首次进行的 MIPD，以及 31 例 OPD（IQR 21-38）。主要发病率（28% vs 30%，P=0.526）、死亡率（4.0% vs 3.3%，P=0.576）、经皮引流（12% vs 12%，P=0.809）、再次手术（11% vs 13%，P=0.329）和住院时间（平均 17 天 vs 17 天，P>0.99）在 MIPD 和 OPD 之间无差异。MIPD 后更常发生 B/C 级术后胰瘘（POPF）（23% vs 13%，P<0.001）。MIPD 中单排胰肠吻合与 POPF 相关（优势比，OR 2.95，P<0.001），但在 OPD 中无相关性。腹腔镜、机器人辅助和杂交 MIPD 的主要发病率（27% vs 27% vs 35%）、POPF（24% vs 19% vs 25%）和死亡率（2.9% vs 5.2% vs 5.4%）无差异，机器人辅助-MIPD 的转化率较低（5% vs 26%，P<0.001）。
结论
在每年进行≥10 例 MIPD 的 14 个欧洲中心的早期经验中，MIPD 和 OPD 在主要发病率、死亡率和住院时间方面无差异。高 POPF 和转化率发生率以及缺乏优越的结果（即住院时间、发病率）可能表明需要更多的经验和更高的年度 MIPD 量。
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