Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy.
Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Surgery. 2021 Apr;169(4):708-720. doi: 10.1016/j.surg.2020.11.022. Epub 2020 Dec 30.
Pancreatoduodenectomies at high risk for clinically relevant pancreatic fistula are uncommon, yet intimidating, situations. In such scenarios, the impact of individual surgeon experience on outcomes is poorly understood.
The fistula risk score was applied to identify high-risk patients (fistula risk score 7-10) from 7,706 pancreatoduodenectomies performed at 18 international institutions (2003-2020). For each case, surgeon pancreatoduodenectomy career volume and years of practice were linked to intraoperative fistula mitigation strategy adoption and outcomes. Consequently, best operative approaches for clinically relevant pancreatic fistula prevention and best performer profiles were identified through multivariable analysis models.
Eight hundred and thirty high-risk pancreatoduodenectomies, performed by 64 surgeons, displayed an overall clinically relevant pancreatic fistula rate of 33.7%. Clinically relevant pancreatic fistula rates decreased with escalating surgeon career pancreatoduodenectomy (-49.7%) and career length (-41.2%; both P < .001), as did transfusion and reoperation rates, postoperative morbidity index, and duration of stay. Great experience (≥400 pancreatoduodenectomies performed or ≥21-year-long career) was a significant predictor of clinically relevant pancreatic fistula prevention (odds ratio 0.52, 95% confidence interval 0.35-0.76) and was more often associated with pancreatojejunostomy reconstruction and prophylactic octreotide omission, which were both independently associated with clinically relevant pancreatic fistula reduction. A risk-adjusted performance analysis also correlated with experience. Moreover, minimizing blood loss (≤400 mL) significantly contributed to clinically relevant pancreatic fistula prevention (odds ratio 0.40, 95% confidence interval 0.22-0.74).
Surgeon experience is a key contributor to achieve better outcomes after high-risk pancreatoduodenectomy. Surgeons can improve their performance in these challenging situations by employing pancreatojejunostomy reconstruction, omitting prophylactic octreotide, and minimizing blood loss.
临床上有意义的胰瘘高风险胰十二指肠切除术并不常见，但却令人望而生畏。在这种情况下，个体外科医生经验对结果的影响知之甚少。
应用瘘管风险评分从 18 个国际机构（2003-2020 年）的 7706 例胰十二指肠切除术中识别高危患者（瘘管风险评分 7-10）。对于每个病例，将外科医生胰十二指肠切除术的职业生涯量和实践年限与术中瘘管缓解策略的采用和结果联系起来。因此，通过多变量分析模型确定了预防临床上有意义的胰瘘的最佳手术方法和最佳执行者特征。
830 例高危胰十二指肠切除术由 64 名外科医生完成，总的临床上有意义的胰瘘发生率为 33.7%。随着外科医生职业生涯胰十二指肠切除术（-49.7%；均 P <.001）和职业生涯年限（-41.2%；均 P <.001）的增加，临床上有意义的胰瘘发生率下降，输血和再次手术率、术后发病率指数和住院时间也下降。丰富的经验（完成≥400 例胰十二指肠切除术或≥21 年的职业生涯）是预防临床上有意义的胰瘘的显著预测因素（比值比 0.52，95%置信区间 0.35-0.76），并且更常与胰肠吻合术重建和预防性奥曲肽省略相关，这两者均与临床上有意义的胰瘘减少独立相关。风险调整后的绩效分析也与经验相关。此外，最大限度地减少出血量（≤400 mL）显著有助于预防临床上有意义的胰瘘（比值比 0.40，95%置信区间 0.22-0.74）。
外科医生经验是实现高危胰十二指肠切除术后更好结果的关键因素。外科医生可以通过采用胰肠吻合术重建、省略预防性奥曲肽和最大限度地减少出血量来提高他们在这些具有挑战性的情况下的表现。
