Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.
Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
Ann Surg. 2023 Nov 1;278(5):e1048-e1054. doi: 10.1097/SLA.0000000000005796. Epub 2023 Jan 20.
To assess the learning curve of pancreaticojejunostomy during robotic pancreatoduodenectomy (RPD) and to predict the risk of postoperative pancreatic fistula (POPF) by using the objective structured assessment of technical skills (OSATS), taking the fistula risk into account.
RPD is a challenging procedure that requires extensive training and confirmation of adequate surgical performance. Video grading, modified for RPD, of the pancreatic anastomosis could assess the learning curve of RPD and predict the risk of POPF.
Post hoc assessment of patients prospectively included in 4 Dutch centers in a nationwide LAELAPS-3 training program for RPD. Video grading of the pancreaticojejunostomy was performed by 2 graders using OSATS (attainable score: 12-60). The main outcomes were the combined OSATS of the 2 graders and POPF (grade B/C). Cumulative sum analyzed a turning point in the learning curve for surgical skill. Logistic regression determined the cutoff for OSATS. Patients were categorized for POPF risk (ie, low, intermediate, and high) based on the updated alternative fistula risk scores.
Videos from 153 pancreatic anastomoses were included. Median OSATS score was 48 (interquartile range: 41-52) points and with a turning point at 33 procedures. POPF occurred in 39 patients (25.5%). An OSATS score below 49, present in 77 patients (50.3%), was associated with an increased risk of POPF (odds ratio: 4.01, P =0.004). The POPF rate was 43.6% with OSATS < 49 versus 15.8% with OSATS ≥49. The updated alternative fistula risk scores category "soft pancreatic texture" was the second strongest prognostic factor of POPF (odds ratio: 3.37, P =0.040). Median cumulative surgical experience was 17 years (interquartile range: 8-21).
Video grading of the pancreatic anastomosis in RPD using OSATS identified a learning curve and a reduced risk of POPF in case of better surgical performance. Video grading may provide a valid method to surgical training, quality control, and improvement.
通过考虑瘘管风险，使用客观结构化手术技能评估（OSATS）评估机器人胰十二指肠切除术（RPD）中胰肠吻合术的学习曲线，并预测术后胰瘘（POPF）的风险。
RPD 是一项具有挑战性的手术，需要广泛的培训和确认足够的手术表现。针对 RPD 进行视频分级，对胰腺吻合术进行评估，可评估 RPD 的学习曲线，并预测 POPF 的风险。
对全国范围内 LAELAPS-3 机器人胰十二指肠切除术培训计划中 4 个荷兰中心前瞻性纳入的患者进行事后评估。使用 OSATS（可获得的分数：12-60）由 2 位评分者对胰肠吻合术进行视频分级。主要结果是 2 位评分者的综合 OSATS 和 POPF（B/C 级）。累积和分析手术技能学习曲线的转折点。逻辑回归确定 OSATS 的截止值。根据更新的替代瘘管风险评分，患者被分为 POPF 风险（低、中、高）。
共纳入 153 例胰肠吻合术视频。中位 OSATS 评分为 48 分（四分位间距：41-52），转折点为 33 例。39 例患者（25.5%）发生 POPF。77 例（50.3%）患者 OSATS 评分低于 49，与 POPF 风险增加相关（优势比：4.01，P=0.004）。OSATS<49 的 POPF 发生率为 43.6%，OSATS≥49 的 POPF 发生率为 15.8%。更新的替代瘘管风险评分类别“软胰腺质地”是 POPF 的第二大预测因素（优势比：3.37，P=0.040）。中位累积手术经验为 17 年（四分位间距：8-21）。
使用 OSATS 对 RPD 中胰腺吻合术进行视频分级可确定学习曲线，并在手术表现更好的情况下降低 POPF 的风险。视频分级可能为手术培训、质量控制和改进提供有效的方法。
