Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy.
Ann Surg. 2024 Jun 1;279(6):1036-1045. doi: 10.1097/SLA.0000000000006060. Epub 2023 Jul 31.
To analyze the association of a surgeon's experience with postoperative outcomes of pancreatoduodenectomies (PDs) when stratified by Fistula Risk Score (FRS).
Centralization is now well-established for pancreatic surgery. Nevertheless, the benefits of individual surgeon's experience in high-volume settings remain undefined.
Pancreatoduodenectomies performed by 82 surgeons across 18 international specialty institutions (median: 140 PD/year) were analyzed. Surgeon cumulative PD volume was linked with postoperative outcomes through multivariable models, adjusted for patient/operative characteristics and the FRS. Then, surgeon experience was also stratified by the 10, previously defined, most clinically impactful scenarios for clinically relevant pancreatic fistula (CR-POPF) development.
Of 8189 PDs, 18.7% suffered severe complications (Accordion≥3), 4.8% were reoperated upon and 2.2% expired. Although the most experienced surgeons (top-quartile; >525 career PDs) more often operated on riskier cases, their experience was significantly associated with declines in CR-POPF ( P <0.001), severe complications ( P =0.008), reoperations ( P <0.001), and length of stay (LOS) ( P <0.001)-accentuated even more in the most impactful FRS scenarios (2830 patients). Risk-adjusted models indicate male sex, increasing age, ASA class, and FRS, but not surgeon experience, as being associated with severe complications, failure-to-rescue, and mortality. Instead, upper-echelon experience demonstrates significant reductions in CR-POPF (OR 0.66), reoperations (OR 0.64), and LOS (OR 0.65) in moderate-to-high fistula risk circumstances (FRS≥3, 68% of cases).
At specialty institutions, major morbidity, mortality, and failure-to-rescue are primarily associated with baseline patient characteristics, while cumulative surgical experience impacts pancreatic fistula occurrence and its attendant effects for most higher-risk pancreatoduodenectomies. These data also suggest an extended proficiency curve exists for this operation.
分析在按瘘管风险评分（Fistula Risk Score，FRS）分层的情况下，外科医生经验与胰十二指肠切除术（pancreatoduodenectomy，PD）术后结果的相关性。
胰腺手术的集中化现已得到充分证实。然而，在高容量环境下，个体外科医生经验的益处仍未得到明确界定。
分析了 18 家国际专业机构的 82 名外科医生进行的 8189 例 PD 手术。通过多变量模型，将外科医生的累积 PD 量与术后结果联系起来，这些模型经过了患者/手术特征和 FRS 的调整。然后，根据之前定义的 10 个最具临床影响的与临床相关胰瘘（clinically relevant pancreatic fistula，CR-POPF）发生相关的场景，对医生经验进行了分层。
在 8189 例 PD 中，18.7%发生严重并发症（Accordion≥3），4.8%再次手术，2.2%死亡。尽管经验最丰富的外科医生（四分位最高；>525 例 PD 手术）更倾向于治疗高风险病例，但他们的经验与 CR-POPF（ P <0.001）、严重并发症（ P =0.008）、再次手术（ P <0.001）和住院时间（length of stay， LOS）（ P <0.001）的减少显著相关，在最具影响力的 FRS 场景中（2830 例患者）更为明显。风险调整模型表明，男性、年龄增长、ASA 分级和 FRS 与严重并发症、治疗失败和死亡率相关，而外科医生经验与这些结果不相关。相反，在中高危瘘管风险（FRS≥3，占病例的 68%）情况下，上层经验显著降低了 CR-POPF（OR 0.66）、再次手术（OR 0.64）和 LOS（OR 0.65）的发生。
在专业机构中，主要的发病率、死亡率和治疗失败主要与基线患者特征相关，而累积手术经验则影响大多数高风险 PD 术后胰瘘的发生及其相关影响。这些数据还表明，该手术存在扩展的熟练曲线。
