腹腔镜胰十二指肠切除术的结果可以通过患者选择和学习曲线得到改善。
The outcome of laparoscopic pancreatoduodenectomy is improved with patient selection and the learning curve.
机构信息
Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France.
Department of Anesthesiology and Intensive Care Medicine, Military Hospital of Tunis, Tunis, Tunisia.
出版信息
Surg Endosc. 2022 Mar;36(3):2070-2080. doi: 10.1007/s00464-021-08493-z. Epub 2021 Apr 21.
BACKGROUND
In our first experience, laparoscopic pancreatoduodenectomy (LPD) was associated with higher morbidity than open PD. Since, the surgical technique has been improved and LPD was avoided in some patients at very high risk of postoperative pancreatic fistula (POPF). We provide our most recent results.
METHOD
Between 2011 and 2018, 130 LPD were performed and divided into 3 consecutive periods based on CUSUM analysis and compared: first period (n = 43), second period (n = 43), and third period (n = 44).
RESULTS
In the third period of this study, LPD was more frequently performed in women (46%, 39%, 59%, p = 0.21) on dilated Wirsung duct > 3 mm (40%, 44%, 57%; p = 0.54). Intraductal papillary mucinous neoplasm (IPMN) became the primary indication (12%, 39%, 34%; p = 0.037) compared to pancreatic adenocarcinoma (35%, 16%, 16%; p = 0.004). Malignant ampulloma re-increased during the third period (30%, 9%, 20%; p = 0.052) with the amelioration of surgical technique. The operative time increased during the second period and decreased during the third period (330, 345, 270; p < 0.001) with less blood loss (300, 200, 125; p < 0.001). All complications decreased, including POPF grades B/C (44%, 28%, 20%; p = 0.017), bleeding (28%, 21%, 14%; p = 0.26), Clavien-Dindo III-IV (40%, 33%, 16%; p = 0.013), re-interventions (19%, 14%, 9%; p = 0.43), and the hospital stay (26, 19, 18; p = 0.045). Less patients with similar-sized adenocarcinoma were operated during the second period (70%, 33%, 59%; p = 0.002) with more harvested lymph nodes in the third period (21,19, 25; p = 0.031) and higher R0 resection (70%, 79%, 84%; p = 0.5). On multivariate analysis the protective factors against POPF of grades B/C were pancreatic adenocarcinoma and invasive IPMN, BMI < 22.5 kg/m, and patients operated in the third period.
CONCLUSION
This study showed that the outcome of LPD significantly improves with the learning curve and patient selection. For safe implementation and during the early learning period, LPD should be indicated in patients at lower risk of POPF.
背景
在我们的首次经验中，腹腔镜胰十二指肠切除术（LPD）的发病率高于开腹 PD。自那以后，手术技术得到了改进，并且在一些术后胰瘘（POPF）风险非常高的患者中避免了 LPD。我们提供了最新的结果。
方法
在 2011 年至 2018 年期间，进行了 130 例 LPD，并根据累积和分析分为 3 个连续时期进行比较：第一期（n=43）、第二期（n=43）和第三期（n=44）。
结果
在这项研究的第三期，LPD 更频繁地在女性中进行（46%、39%、59%，p=0.21），在扩张的 Wirsung 导管上>3mm（40%、44%、57%；p=0.54）。与胰腺腺癌（35%、16%、16%；p=0.004）相比，胰管内乳头状黏液性肿瘤（IPMN）成为主要指征（12%、39%、34%；p=0.037）。恶性壶腹腺瘤在第三期再次增加（30%、9%、20%；p=0.052），同时手术技术得到了改善。第二期手术时间延长，第三期手术时间缩短（330、345、270；p<0.001），失血量减少（300、200、125；p<0.001）。所有并发症均减少，包括 POPF 分级 B/C（44%、28%、20%；p=0.017）、出血（28%、21%、14%；p=0.26）、Clavien-Dindo III-IV（40%、33%、16%；p=0.013）、再次干预（19%、14%、9%；p=0.43）和住院时间（26、19、18；p=0.045）。第二期手术的类似大小的腺癌患者减少（70%、33%、59%；p=0.002），第三期手术的淋巴结清扫更多（21、19、25；p=0.031），R0 切除率更高（70%、79%、84%；p=0.5）。多因素分析显示，POPF 分级 B/C 的保护因素是胰腺腺癌和侵袭性 IPMN、BMI<22.5kg/m2 和第三期手术的患者。
结论
本研究表明，随着学习曲线和患者选择的变化，LPD 的结果显著改善。为了安全实施和在早期学习阶段，LPD 应在 POPF 风险较低的患者中进行。
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