腹腔镜胰体尾切除术的实施和结果的多中心观察性队列研究。

Multicentre observational cohort study of implementation and outcomes of laparoscopic distal pancreatectomy.

机构信息

Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK.

Department of Surgery, Morriston Hospital, Swansea, UK.

出版信息

Br J Surg. 2019 Nov;106(12):1657-1665. doi: 10.1002/bjs.11292. Epub 2019 Aug 27.

DOI:10.1002/bjs.11292

PMID:31454072

Abstract

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is increasingly being performed as an alternative to open surgery. Whether the implementation and corresponding learning curve of LDP have an impact on patient outcome is unknown. The aim was to investigate the temporal trends in practice across UK centres.

METHODS

This was a retrospective multicentre observational cohort study of LDP in 11 tertiary referral centres in the UK between 2006 and 2016. The learning curve was analysed by pooling data for the first 15 consecutive patients who had LDP and examining trends in surgical outcomes in subsequent patients.

RESULTS

In total, 570 patients underwent LDP, whereas 888 underwent open resection. For LDP the median duration of operation was 240 min, with 200 ml blood loss. The conversion rate was 12·1 per cent. Neuroendocrine tumours (26·7 per cent) and mucinous cystic neoplasms (19·7 per cent) were commonest indications. The proportion of LDPs increased from 24·4 per cent in 2006-2009 (P1) to 46·0 per cent in 2014-2016 (P3) (P < 0·001). LDP was increasingly performed for patients aged 70 years or more (16 per cent in P1 versus 34·4 per cent in P3; P = 0·002), pancreatic ductal adenocarcinoma (6 versus 19·1 per cent; P = 0·005) and advanced malignant tumours (27 versus 52 per cent; P = 0·016). With increasing experience, there was a trend for a decrease in blood transfusion rate (14·1 per cent for procedures 1-15 to 3·5 per cent for procedures 46-75; P = 0·008), ICU admissions (32·7 to 19·2 per cent; P = 0·021) and median duration of hospital stay (7 (i.q.r. 5-9) to 6 (4-7) days; P = 0·002). After 30 procedures, a decrease was noted in rates of both overall morbidity (57·7 versus 42·2 per cent for procedures 16-30 versus 46-75 respectively; P = 0·009) and severe morbidity (18·8 versus 9·7 per cent; P = 0·031).

CONCLUSION

LDP has increased as a treatment option for lesions of the distal pancreas as indications for the procedure have expanded. Perioperative outcomes improved with the number of procedures performed.

摘要

背景

腹腔镜胰体尾切除术（LDP）作为一种替代开腹手术的方法，应用日益广泛。LDP 的实施和相应的学习曲线是否会影响患者的预后尚不清楚。本研究旨在调查英国各中心的实践变化趋势。

方法

这是一项回顾性多中心观察队列研究，纳入了 2006 年至 2016 年间英国 11 家三级转诊中心的 11 例行 LDP 的患者。通过分析前 15 例行 LDP 的连续患者的手术数据，研究学习曲线，并观察后续患者的手术结果变化趋势。

结果

共有 570 例行 LDP，888 例行开腹手术。LDP 的中位手术时间为 240 分钟，失血量为 200ml。中转开腹率为 12.1%。神经内分泌肿瘤（26.7%）和黏液性囊性肿瘤（19.7%）是最常见的手术指征。LDP 的比例从 2006-2009 年的 24.4%（P1）增加到 2014-2016 年的 46.0%（P3）（P<0.001）。LDP 越来越多地用于 70 岁或以上的患者（P1 中为 16%，P3 中为 34.4%；P=0.002）、胰腺导管腺癌（P1 中为 6%，P3 中为 19.1%；P=0.005）和晚期恶性肿瘤（P1 中为 27%，P3 中为 52%；P=0.016）。随着经验的增加，输血率（从第 1-15 例的 14.1%降至第 46-75 例的 3.5%；P=0.008）、ICU 入院率（从 32.7%降至 19.2%；P=0.021）和中位住院时间（从 7（IQR 5-9）天降至 6（4-7）天；P=0.002）呈下降趋势。第 30 例以后，总并发症发生率（第 16-30 例为 57.7%，第 46-75 例为 42.2%；P=0.009）和严重并发症发生率（第 16-30 例为 18.8%，第 46-75 例为 9.7%；P=0.031）均有所下降。