Surgeon experience contributes to improved outcomes in pancreatoduodenectomies at high risk for fistula development.
Aged
Clinical Competence
Female
Humans
Male
Middle Aged
Outcome Assessment, Health Care
Pancreatic Fistula
/ diagnosis
Pancreaticoduodenectomy
/ adverse effects
Postoperative Complications
/ epidemiology
Quality Improvement
Quality of Health Care
/ statistics & numerical data
Risk Assessment
Risk Factors
Surgeons
Journal
Surgery
ISSN: 1532-7361
Titre abrégé: Surgery
Pays: United States
ID NLM: 0417347
Informations de publication
Date de publication:
04 2021
04 2021
Historique:
received:
19
09
2020
revised:
12
11
2020
accepted:
17
11
2020
pubmed:
3
1
2021
medline:
1
5
2021
entrez:
2
1
2021
Statut:
ppublish
Résumé
Pancreatoduodenectomies at high risk for clinically relevant pancreatic fistula are uncommon, yet intimidating, situations. In such scenarios, the impact of individual surgeon experience on outcomes is poorly understood. The fistula risk score was applied to identify high-risk patients (fistula risk score 7-10) from 7,706 pancreatoduodenectomies performed at 18 international institutions (2003-2020). For each case, surgeon pancreatoduodenectomy career volume and years of practice were linked to intraoperative fistula mitigation strategy adoption and outcomes. Consequently, best operative approaches for clinically relevant pancreatic fistula prevention and best performer profiles were identified through multivariable analysis models. Eight hundred and thirty high-risk pancreatoduodenectomies, performed by 64 surgeons, displayed an overall clinically relevant pancreatic fistula rate of 33.7%. Clinically relevant pancreatic fistula rates decreased with escalating surgeon career pancreatoduodenectomy (-49.7%) and career length (-41.2%; both P < .001), as did transfusion and reoperation rates, postoperative morbidity index, and duration of stay. Great experience (≥400 pancreatoduodenectomies performed or ≥21-year-long career) was a significant predictor of clinically relevant pancreatic fistula prevention (odds ratio 0.52, 95% confidence interval 0.35-0.76) and was more often associated with pancreatojejunostomy reconstruction and prophylactic octreotide omission, which were both independently associated with clinically relevant pancreatic fistula reduction. A risk-adjusted performance analysis also correlated with experience. Moreover, minimizing blood loss (≤400 mL) significantly contributed to clinically relevant pancreatic fistula prevention (odds ratio 0.40, 95% confidence interval 0.22-0.74). Surgeon experience is a key contributor to achieve better outcomes after high-risk pancreatoduodenectomy. Surgeons can improve their performance in these challenging situations by employing pancreatojejunostomy reconstruction, omitting prophylactic octreotide, and minimizing blood loss.
Sections du résumé
BACKGROUND
Pancreatoduodenectomies at high risk for clinically relevant pancreatic fistula are uncommon, yet intimidating, situations. In such scenarios, the impact of individual surgeon experience on outcomes is poorly understood.
METHODS
The fistula risk score was applied to identify high-risk patients (fistula risk score 7-10) from 7,706 pancreatoduodenectomies performed at 18 international institutions (2003-2020). For each case, surgeon pancreatoduodenectomy career volume and years of practice were linked to intraoperative fistula mitigation strategy adoption and outcomes. Consequently, best operative approaches for clinically relevant pancreatic fistula prevention and best performer profiles were identified through multivariable analysis models.
RESULTS
Eight hundred and thirty high-risk pancreatoduodenectomies, performed by 64 surgeons, displayed an overall clinically relevant pancreatic fistula rate of 33.7%. Clinically relevant pancreatic fistula rates decreased with escalating surgeon career pancreatoduodenectomy (-49.7%) and career length (-41.2%; both P < .001), as did transfusion and reoperation rates, postoperative morbidity index, and duration of stay. Great experience (≥400 pancreatoduodenectomies performed or ≥21-year-long career) was a significant predictor of clinically relevant pancreatic fistula prevention (odds ratio 0.52, 95% confidence interval 0.35-0.76) and was more often associated with pancreatojejunostomy reconstruction and prophylactic octreotide omission, which were both independently associated with clinically relevant pancreatic fistula reduction. A risk-adjusted performance analysis also correlated with experience. Moreover, minimizing blood loss (≤400 mL) significantly contributed to clinically relevant pancreatic fistula prevention (odds ratio 0.40, 95% confidence interval 0.22-0.74).
CONCLUSION
Surgeon experience is a key contributor to achieve better outcomes after high-risk pancreatoduodenectomy. Surgeons can improve their performance in these challenging situations by employing pancreatojejunostomy reconstruction, omitting prophylactic octreotide, and minimizing blood loss.
Identifiants
pubmed: 33386129
pii: S0039-6060(20)30807-2
doi: 10.1016/j.surg.2020.11.022
pii:
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
708-720Investigateurs
William E Fisher
(WE)
George Van Buren
(G)
Mark P Callery
(MP)
Tara S Kent
(TS)
Wande B Pratt
(WB)
Charles M Vollmer
(CM)
Ammara A Watkins
(AA)
Michael G House
(MG)
Joal D Beane
(JD)
Adam C Berger
(AC)
Christopher L Wolfgang
(CL)
Ammar A Javed
(AA)
Katherine E Poruk
(KE)
Kevin C Soares
(KC)
Vicente Valero
(V)
Carlos Fernandez-Del Castillo
(C)
Zhi V Fong
(ZV)
Horacio J Asbun
(HJ)
John A Stauffer
(JA)
Mark P Bloomston
(MP)
Mary E Dilhoff
(ME)
Ericka N Haverick
(EN)
Carl R Schmidt
(CR)
John D Christein
(JD)
Robert H Hollis
(RH)
Chad G Ball
(CG)
Elijah Dixon
(E)
Steven J Hughes
(SJ)
Charles M Vollmer
(CM)
Jeffrey A Drebin
(JA)
Brett Ecker
(B)
Russell Lewis
(R)
Matthew McMillan
(M)
Benjamin Miller
(B)
Priya Puri
(P)
Thomas Seykora
(T)
Michael J Sprys
(MJ)
Amer H Zureikat
(AH)
Stacy J Kowalsky
(SJ)
Stephen W Behrman
(SW)
Claudio Bassi
(C)
Fabio Casciani
(F)
Laura Maggino
(L)
Giuseppe Malleo
(G)
Roberto Salvia
(R)
Giulia Savegnago
(G)
Lorenzo Cinelli
(L)
Massimo Falconi
(M)
Stefano Partelli
(S)
Euan J Dickson
(EJ)
Nigel B Jamieson
(NB)
Lavanniya K P Velu
(LKP)
Ronald R Salem
(RR)
John W Kunstman
(JW)
Commentaires et corrections
Type : CommentIn
Informations de copyright
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