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Surgeon experience contributes to improved outcomes in pancreatoduodenectomies at high risk for fistula development

Published:December 29, 2020DOI:https://doi.org/10.1016/j.surg.2020.11.022

      Abstract

      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.
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      Linked Article

      • Why is a 0-fistula rate in pancreaticojejunostomy impossible?
        SurgeryVol. 169Issue 4
        • Preview
          In the last 20 years, over 4,000 manuscripts on the subject of the pancreatic anastomosis have been published and listed in PubMed. The Achilles heel of the pancreaticoduodenectomy is the pancreatic anastomosis (although PubMed identifies only 9 manuscripts that mention Achilles heel and the subject of the pancreatic anastomosis). The normal pancreas is an organ that is nearly devoid of connective tissue. Hence, the use of this collagen-poor organ in anastomotic construction has been likened to sewing moonbeams to flatus.
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