Abstract
Pancreatoduodenectomy (PD) has become a routine procedure. Recent series report perioperative mortality rates of 5% or less, moderate morbidity, and even improved long-term survival. Nevertheless, being one of the most complex abdominal operations, a certain number of surgical procedures (i.e., personal caseload) seems essential for acceptable results. The objectives of this retrospective study were to evaluate whether PD can be safely performed as a teaching operation, and if the personal caseload of the senior surgeon affects morbidity and mortality. A series of 128 consecutive PDs carried out at a large academic teaching hospital were analyzed. The 49 operations performed by 11 residents of the surgical department as teaching operations under supervision of an experienced (senior) surgeon (ES) were compared with operations performed by an ES (group 2, n=79). Three patients died from non-procedure-related causes (two in group 1). Eleven patients of group 2 had to be reoperated, in contrast to three in group 1 (NS). The total number of complications and number of pancreatic fistulas were comparable in the two groups. Surgeons performing less than one PD per year had significantly more complications. Under direct supervision of an experienced surgeon PD can be performed safely as a teaching operation. A caseload of at least one resection per year seems necessary for consistently good results.
Résumé
La duodénopancréatectomie céphalique (DPC) est devenue une intervention de pratique courante. Les séries récentes rapportent une mortalité péri-opératoire de 5% ou moins, une morbidité modérée, ainsi qu’une survie à long terme améliorée. Néanmoins, comme il s’agit d’une des opérations abdominales les plus complexes, une pratique régulière (nombre de cas réalisés personnellement) semble essentielle pour avoir de bons résultants. Les objectifs de cette étude rétrospective ont été d’évaluer si la DPC peut être réalisée avec sécurité lorsqu’on l’apprend à un autre chirurgien et si le nombre de cas réalisés par le chirurgien senior influence la morbidité et la mortalité. On a analysé les résultats de 128 DPC consécutives, réalisées dans un grand hôpital universitaire recevant des résidents. Quarante-neuf interventions ont été réalisées par 11 résidents (R) du département de chirurgie sous la supervision d’un chirurgien expérimenté (senior) (ES) (groupe 1) et les résultats ont ensuite été comparés aux résultats des interventions réalisées par le chirurgien ES seul (groupe 2, n=79). Trois patients sont décédés de causes sans rapport avec l’intervention (2 dans groupe 1). Onze patients du groupe 2 ont nécessité une réintervention comparés à trois dans le groupe 1 (NS). Le nombre total des complications ainsi que le nombre de fistules étaient comparables dans les deux groupes. Les chirurgiens réalisant moins d’une DPC par an avaient significativement plus de complications. Sous la supervision directe d’un chirurgien expérimenté, la DPC peut être réalisée avec sécurité en tant qu’intervention d’apprentissage. Réaliser une intervention par an est un strict minimum pour obtenir de bons résultats.
Resumen
La pancreatoduodenectomia (PD) se ha convertido en un procedimiento rutinario. Las series informadas más recientemente señalan tasas de mortalidad perioperatoria de 5% o menos, morbilidad moderada y mejor supervivencia a largo plazo. Sin embargo, puesto que se trata de una de las más complejas operaciones abdominales, parece esencial poseer una determinada experiencia personal para lograr resultados aceptables. El propósito de este estudio retrospectivo fue determinar si la PD puede ser realizada como una operación de enseñanza y si la experiencia personal, en términos del número de casos operados ‘por el cirujano senior afecta la morbilidad y la mortalidad. Se revisaron las historias de 128 pacientes sometidos a PD consecutivas en un hospital universitario; 49 operaciones fueron practicadas por once residentes (R) de cirugía como operaciones de enseñanza bajo la supervisión de un cirujano experto (CE), las que fueron comparadas con las operaciones realizadas por el mismo CE (grupo 2, n=79). Tres pacientes murieron por causas no relacionadas con el procedimiento (2 en el grupo 1). Once del grupo 2 tuvieron que ser reoperados, contra 3 en el grupo 1 (NS). El número total de complicaciones, lo mismo que el grupo de fístulas pancreáticas, fue comparable en los dos grupos. Los cirujanos que practican menos de una PD anual registraron significativamente más complicaciones. En conclusión, la PD puede ser practicada en forma segura como operación de enseñanza bajo la supervisión de un cirujano experto. Se requiere por lo menos la experiencia de una PD anual para lograr buenos resultados en forma consistente.
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References
Howard JM. Development and progress in resective surgery for pancreatic cancer. World J. Surg. 1999;23:901
Whipple AO, Parsons WB, Mullins CR. Treatment of carcinoma of the ampulla of Vater. Ann. Surg. 1935;102:763
Crist DW, Sitzmann JV, Cameron JL. Improved hospital morbidity, mortality and survival after the Whipple procedure. Ann. Surg. 1987;206:358
Connolly MM, Dawson PJ, Michelassi F, et al. Survival in 1001 patients with carcinoma of the pancreas. Ann. Surg. 1987;206:366
Nakase A, Matsumoto Y, Uchida K, et al. Surgical treatment of cancer of the pancreas and the periampullary region: cumulative results in 57 institutions in Japan. Ann. Surg. 1977;185:52
Gudjonsson B. Cancer of the pancreas: 50 vears of surgery. Cancer 1987;60:2284
Shapiro TM. Adenocarcinoma of the pancreas: a statistical analysis of bypass vs. Whipple resections in good risk patients. Ann. Surg. 1975;182:715
Klinkenbijl JHG, van der Schelling GP, Hop WCJ, et al. The advantages of pylorus preserving pancreaticoduodenectomy in malignant disease of the pancreas and periampullary region. Ann. Surs. 1992;216:142
Lillemoe KD. Current management of pancreatic carcinoma. Ann. Surg. 1995;221:133
Neoptolemos JP, Rüssel RCG, Bramhall S, et al. Low mortality following resection for pancreatic and periampullary tumours in 1062 patients: UK survey of specialist pancreatic units. Br. J. Surg. 1997;84:1370
Trede M, Schwall G, Saeger HD. Survival after pancreaticoduodenectomy: 118 resections without an operative mortality. Ann. Surg. 1990;211:447
Allema JH, Reinders ME, van Gulik TM, et al. Prognostic factors for survival after pancreaticoduodenectomy for patients with carcinoma of the pancreatic head region. Cancer 1995;75:2069
Klempnauer J, Ridder GJ, Bektas H, et al. Surgery for exocrine pancreatic cancer: who are the 5- and 10-year survivors? Oncology 1995;52:353
Klempnauer J, Ridder GJ, Pichlmayr R. Prognostic factors after resection of ampullary carcinoma: multivariate survival analysis in comparison with ductal cancer of the pancreatic head. Br. J. Surg. 1995;82:1686
Funovics JM, Zoech G, Wenzl E, et al. Progress in reconstruction after resection of the head of the pancreas. Surg. Gynecol. Obstet. 1987;164:545
Grace PA, Pitt HA, Longmire WP. Pylorus preserving pancreaticoduodenectomy: an overview. Br. J. Surg. 1990;77:968
Braasch JW, Deziel DJ, Rossi RL, et al. Pyloric and gastric preserving pancreatic resection: experience with 87 patients. Ann. Surg. 1986;204:411
Barens SA, Lillemoe KD, Kaufman HS, et al. Pancreaticoduodenectomy for benign disease. Am. J. Surg. 1996;17:131
Lillemoe KD, Cameron JL, Yeo CJ, et al. Pancreaticoduodenectomy: does it have a role in the palliation of pancreatic cancer? Ann. Surs. 1996;223:718
Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcome. Ann. Surg. 1997;226:248
Friess H, Beger HG, Sulkowski U, et al. Randomized controlled multicentre study of the prevention of complications by octreotide in patients undergoing surgerv for chronic pancreatitis. Br. J. Sura. 1995;82:1270
Buechler M, Friess H, Klempa I, et al. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am. J. Surg. 1992;163:125
Crucitti F, Doglietto GB, Viola G, et al. Assessment of risk factors for pancreatic resection for cancer. World J. Surg. 1998;22:241
Roder JD, Schneider PM, Stein HJ, et al. Number of lymph node metastases is significantly associated with survival in patients with radically resected carcinoma of the ampulla of Vater. Br. J. Surg. 1995;82:1693
Roder JD, Stein HJ, Huttl W, et al. Pylorus preserving versus standard pancreático duodenectomy: an analysis of 110 pancreatic and periampullary carcinomas. Br. J. Surg. 1992;79:152
Singh SM, Longmire WP, Reber HA. Surgical palliation for pancreatic cancer: the UCLA experience. Ann. Surg. 1990;212:132
Baumel H, Huguier M, Manderscheid JC, et al. Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery. Br. J. Surg. 1994;81:102
Bramhall SR, Allum WH, Jones AG, et al. Treatment and survival in 13560 patients with pancreatic cancer, and incidence of the disease in the West Midlands: an epidemiological study. Br. J. Surg. 1995;82:111
Wade TP, el Ghazzawy AG, Virgo KS, et al. The Whipple resection for cancer in U.S. Department of Veterans Affairs hospitals. Ann. Surg. 1995;221:241
Glasgow RE, Mulvihill SJ. Hospital volume influences outcome in patients undergoing pancreatic resection for cancer. West. J. Med. 1996;165:294
Edge SB, Schmieg RE Jr, Rosenlof LK, et al. Pancreas cancer resection outcome in American University centers in 1989–1990. Cancer 1993;71:3502
Gouma DJ, Obertop H. Centralization of surgery for periampullary malignancy. Br. J. Surg. 1999;86:1361
Airan MC, Ko ST. Effectiveness of strict credentialing and proctoring guidelines on outcomes of laparoscopic cholecystectomy in a community hospital. Surg. Endose. 1994;8:396
Hodgson WJ, Byrne DW, Savino JA, et al. Laparoscopic cholecystectomy: the early experience of surgical attendings compared with that of residents trained by apprenticeship. Surg. Endose. 1994;8:1058
McMahon DJ, Chen S, MacLellan DG. Formal teaching of basic surgical skills. Aust. N.Z.J. Surg. 1995;65:607
Sequeira R, Weinbaum F, Satterfield J, et al. Credentialing physicians for new technology: the physician’s learning curve must not harm the patient. Am. Surg. 1994;60:821
Phillips RK, Hittinger R, Blesovsky L, et al. Local recurrence following “curative” surgery for large bowel cancer. I. The overall picture. Br. J. Surg. 1984;71:12
Putnam JB Jr, Suell DM, McMurtrey MJ, et al. Comparison of three techniques of esophagectomy within a residency training program. Ann. Thorac. Surg. 1994;57:319
Parikh D, Johnson M, Chagla L, et al. D2 gastrectomy: lessons from a prospective audit of the learning curve. Br. J. Surg. 1996;83:1595
Watson DI, Baigrie RJ, Jamieson GG. A learning curve for laparoscopic fundoplication: definable, avoidable, or a waste of time? Ann. Surg. 1995;224:198
Matthews HR, Powell DJ, McConkey CC. Effect of surgical experience on the results of resection for oesophageal carcinoma. Br. J. Surg. 1986;73:621
Porter GA, Sosklone CL, Yakimets WW, et al. Surgeon related factors and outcome in rectal cancer. Ann. Surg. 1998;227:157
Singh KK, Aitken RJ. Outcome in patients with colorectal cancer managed by surgical trainees. Br. J. Surg. 1999;86:1332
Nitecki SS, Sarr MG, Colby TV, et al. Long term survival after resection for ductal adenocarcinoma of the pancreas: is it really improving? Ann. Surg. 1995;221:59
Yeo CJ, Cameron JL, Malier MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann. Surg. 1995;222:580
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Published Online: September 26, 2002
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Wamser, P., Stift, A., Passler, C. et al. How to pass on expertise: Pancreatoduodenectomy at a teaching hospital. World J. Surg. 26, 1458–1462 (2002). https://doi.org/10.1007/s00268-002-5958-8
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DOI: https://doi.org/10.1007/s00268-002-5958-8