Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK.
Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK.
Surgery. 2022 Jul;172(1):319-328. doi: 10.1016/j.surg.2021.12.033. Epub 2022 Feb 25.
The complexity of pancreaticoduodenectomy and fear of morbidity, particularly postoperative pancreatic fistula, can be a barrier to surgical trainees gaining operative experience. This meta-analysis sought to compare the postoperative pancreatic fistula rate after pancreatoenteric anastomosis by trainees or established surgeons.
A systematic review of the literature was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with differences in postoperative pancreatic fistula rates after pancreatoenteric anastomosis between trainee-led versus consultant/attending surgeons pooled using meta-analysis. Variation in rates of postoperative pancreatic fistula was further explored using risk-adjusted outcomes using published risk scores and cumulative sum control chart analysis in a retrospective cohort.
Across 14 cohorts included in the meta-analysis, trainees tended toward a lower but nonsignificant rate of all postoperative pancreatic fistula (odds ratio: 0.77, P = .45) and clinically relevant postoperative pancreatic fistula (odds ratio: 0.69, P = .37). However, there was evidence of case selection, with trainees being less likely to operate on patients with a pancreatic duct width <3 mm (odds ratio: 0.45, P = .05). Similarly, analysis of a retrospective cohort (N = 756 cases) found patients operated by trainees to have significantly lower predicted all postoperative pancreatic fistula (median: 20 vs 26%, P < .001) and clinically relevant postoperative pancreatic fistula (7 vs 9%, P = .020) rates than consultant/attending surgeons, based on preoperative risk scores. After adjusting for this on multivariable analysis, the risks of all postoperative pancreatic fistula (odds ratio: 1.18, P = .604) and clinically relevant postoperative pancreatic fistula (odds ratio: 0.85, P = .693) remained similar after pancreatoenteric anastomosis by trainees or consultant/attending surgeons.
Pancreatoenteric anastomosis, when performed by trainees, is associated with acceptable outcomes. There is evidence of case selection among patients undergoing surgery by trainees; hence, risk adjustment provides a critical tool for the objective evaluation of performance.
胰腺十二指肠切除术较为复杂，且人们担心术后出现并发症，尤其是胰瘘，这可能会成为外科培训生获得手术经验的障碍。本项荟萃分析旨在比较培训生和资深外科医生进行胰肠吻合术后胰瘘的发生率。
按照系统评价和荟萃分析首选报告条目进行文献系统评价，使用荟萃分析汇总培训生和顾问/主治医生进行胰肠吻合术后胰瘘的发生率差异。通过使用发表的风险评分进行风险调整的结果，并在回顾性队列中使用累积和控制图分析进一步探讨胰瘘发生率的变化。
荟萃分析共纳入 14 项研究，培训生的所有术后胰瘘（比值比：0.77，P=0.45）和临床相关术后胰瘘（比值比：0.69，P=0.37）发生率虽较低，但无统计学意义。然而，存在病例选择的证据，培训生更不可能为胰管直径<3mm 的患者进行手术（比值比：0.45，P=0.05）。同样，对回顾性队列（N=756 例）的分析发现，与顾问/主治医生相比，培训生操作的患者术后所有预测性胰瘘（中位数：20%比 26%，P<0.001）和临床相关胰瘘（7%比 9%，P=0.020）的发生率明显较低，这是基于术前风险评分。在多变量分析中调整这一因素后，培训生或顾问/主治医生进行胰肠吻合术后，所有预测性胰瘘（比值比：1.18，P=0.604）和临床相关胰瘘（比值比：0.85，P=0.693）的风险仍然相似。
培训生进行胰肠吻合术的结果是可以接受的。在接受培训生手术的患者中存在病例选择的证据；因此，风险调整为客观评估绩效提供了一个重要工具。
