Torphy Robert J, Friedman Chloe, Halpern Alison L, Ahrendt Steven A, McCarter Martin D, Del Chiaro Marco, Schulick Richard D, Gleisner Ana
Department of Surgery, University of Colorado, Aurora, Colorado.
Department of Surgery, University of Colorado, Aurora, Colorado.
J Surg Res. 2021 Dec;268:720-728. doi: 10.1016/j.jss.2021.06.086. Epub 2021 Sep 3.
There is a need to better define the safety of implementing the use of minimally invasive pancreaticoduodenectomy (MIPD) in order to provide evidence for safe application. The objective of this study was to evaluate the mortality associated with the implementation of MIPD across low and high-volume facilities using the National Cancer Database (NCDB).
Patients in the NCDB with pancreatic cancer diagnosed from 2010-2016 undergoing MIPD were selected. Cumulative MIPD volume for each facility was calculated from the number of MIPD cases performed each year prior to and including the year of a patient's operation. A random effects logistic regression model was used to examine the adjusted association between log-transformed cumulative MIPD volume and 90-day mortality.
After controlling for patient, tumor and facility-related variables, there was decreased 90-day mortality as the cumulative MIPD volume increased (OR 0.81; 95% CI 0.69-0.95; P = 0.009). Average annual open pancreaticoduodenectomy (PD) volume was independently protective throughout the implementation phase (OR 0.98; 95% CI 0.97-0.99; P = 0.049). This equates to an average predicted probability of 90-day mortality for the first 5 cumulative MIPD cases of 7.51% at a low-volume facility (5 open PDs per year) versus 4.39% at a high-volume facility (50 open PDs per year).
Using the NCDB, 90-day mortality following MIPD decreased with higher cumulative facility MIPD case volume. Although higher cumulative MIPD case volume was associated with reduced 90-day mortality at both low and high-volume facilities, the higher mortality during the implementation of MIPD is magnified at low-volume facilities. This retrospective analysis demonstrates that MIPD can be safely implemented with low mortality at facilities with high-volume open PD programs.
为给微创胰十二指肠切除术（MIPD）的安全应用提供依据，有必要更好地明确其实施安全性。本研究的目的是利用美国国家癌症数据库（NCDB）评估高水平和低水平手术量机构施行MIPD的死亡率。
选取2010年至2016年在NCDB中诊断为胰腺癌并接受MIPD的患者。根据患者手术年份及之前每年施行的MIPD病例数计算每个机构的累计MIPD手术量。采用随机效应逻辑回归模型检验经对数转换的累计MIPD手术量与90天死亡率之间的校正关联。
在控制了患者、肿瘤和机构相关变量后，随着累计MIPD手术量增加，90天死亡率降低（比值比[OR]0.81；95%置信区间[CI]0.69 - 0.95；P = 0.009）。在整个实施阶段，年均开放性胰十二指肠切除术（PD）手术量具有独立的保护作用（OR 0.98；95% CI 0.97 - 0.99；P = 0.049）。这相当于低水平手术量机构（每年5例开放性PD）前5例累计MIPD病例的90天死亡率平均预测概率为7.51%，而高水平手术量机构（每年50例开放性PD）为4.39%。
利用NCDB数据，MIPD术后90天死亡率随机构累计MIPD病例数增加而降低。虽然在高水平和低水平手术量机构中，较高的累计MIPD病例数都与降低的90天死亡率相关，但在低水平手术量机构中，MIPD实施期间较高的死亡率更为突出。这项回顾性分析表明，在开展大量开放性PD手术的机构中，MIPD可以安全实施且死亡率较低。
