Zhang Xiao-Jie, Fei He, Guo Chun-Guang, Sun Chong-Yuan, Li Ze-Feng, Li Zheng, Chen Ying-Tai, Che Xu, Zhao Dong-Bing
Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China.
World J Gastrointest Surg. 2023 Oct 27;15(10):2259-2271. doi: 10.4240/wjgs.v15.i10.2259.
Textbook outcomes (TOs) have been used to assess the quality of surgical treatment for many digestive tumours but not ampullary carcinoma (AC).
To discuss the factors associated with achieving a TO and further explore the prognostic value of a TO for AC patients undergoing curative pancreaticoduodenectomy (PD).
Patients who underwent PD at the China National Cancer Center between 1998 and 2020 were identified. A TO was defined by R0 resection, examination of ≥ 12 Lymph nodes, no prolonged hospitalization, no intensive care unit treatment, no postoperative complications, and no 30-day readmission or mortality. Cox regression analysis was used to identify the prognostic value of a TO for overall survival (OS) and recurrence-free survival (RFS). Logistic regression was used to identify predictors of a TO. The rate of a TO and of each indicator were compared in patients who underwent surgery before and after 2010.
Ultimately, only 24.3% of 272 AC patients achieved a TO. A TO was independently associated with improved OS [hazard ratio (HR): 0.443, 95% confidence interval (95%CI): 0.276-0.711, = 0.001] and RFS (HR: 0.379, 95%CI: 0.228-0.629, < 0.001) in the Cox regression analysis. Factors independently associated with a TO included a year of surgery between 2010 and 2020 (OR: 4.549, 95%CI: 2.064-10.028, < 0.001) and N1 stage disease (OR: 2.251, 95%CI: 1.023-4.954, = 0.044). In addition, the TO rate was significantly higher in patients who underwent surgery after 2010 ( < 0.001) than in those who underwent surgery before 2010.
Only approximately a quarter (24.3%) of AC patients achieved a TO following PD. A TO was independently related to favourable oncological outcomes in AC and should be considered as an outcome measure for the quality of surgery. Further multicentre research is warranted to better elucidate its impact.
教科书式结局（TOs）已被用于评估多种消化肿瘤的手术治疗质量，但未用于壶腹癌（AC）。
探讨与实现TO相关的因素，并进一步探讨TO对接受根治性胰十二指肠切除术（PD）的AC患者的预后价值。
确定1998年至2020年在中国国家癌症中心接受PD的患者。TO的定义为R0切除、检查≥12个淋巴结、无延长住院时间、无重症监护病房治疗、无术后并发症以及无30天再入院或死亡。采用Cox回归分析确定TO对总生存（OS）和无复发生存（RFS）的预后价值。采用逻辑回归确定TO的预测因素。比较2010年前后接受手术的患者的TO率和各指标率。
最终，272例AC患者中只有24.3%实现了TO。在Cox回归分析中，TO与改善的OS[风险比（HR）：0.443，95%置信区间（95%CI）：0.276 - 0.711，P = 0.001]和RFS（HR：0.379，95%CI：0.228 - 0.629，P < 0.001）独立相关。与TO独立相关的因素包括2010年至2020年的手术年份（OR：4.549，95%CI：2.064 - 10.028，P < 0.001）和N1期疾病（OR：2.251，95%CI：1.023 - 4.954，P = 0.044）。此外，2010年后接受手术的患者的TO率显著高于2010年前接受手术的患者（P < 0.001）。
PD术后只有约四分之一（24.3%）的AC患者实现了TO。TO与AC良好的肿瘤学结局独立相关，应被视为手术质量的结局指标。有必要进行进一步的多中心研究以更好地阐明其影响。
