Nationwide Evaluation of Patient Selection for Minimally Invasive Distal Pancreatectomy Using American College of Surgeons' National Quality Improvement Program
Nationwide Evaluation of Patient Selection for Minimally Invasive Distal Pancreatectomy Using American College of Surgeons' National Quality Improvement Program
复制标题
DOI：
10.1097/sla.0000000000001982
复制
发表时间：
2017-12-01
影响因子：
9
通讯作者：
Moser, A. James
中科院分区：
文献类型：
--
作者：
Klompmaker, Sjors;van Zoggel, Desley;Moser, A. James
目的：评估目前全国范围内微创远端胰腺切除术 (MIDP) 的病例选择因素，并确定与开腹远端胰腺切除术 (ODP) 相比不良结果的实际危险因素。背景：预测 MIDP 术后结果的患者选择标准仍不清楚。因此，这种手术技术的广泛采用可能被推迟，其潜在益处可能没有得到充分利用。 方法：2014 年，使用针对胰腺的美国外科医生学会国家质量改进计划 (ACS-NSQIP) 数据库，在 106 个中心进行了选择性 ODP 和 MIDP 的回顾性队列研究。排除标准是新辅助治疗或胰腺炎作为唯一诊断。主要结局包括综合主要发病率指标，反映包括死亡率和再手术在内的不良事件。使用多变量模型来检测当前的选择因素并确定复合主要发病率的实际危险因素。结果：共有 928 名患者使用腹腔镜或机器人辅助方法接受了 ODP (n = 472) 或 MIDP (n = 456)，其中 24% 为胰腺导管腺癌 (PDAC)。目前 MIDP 的选择因素是良性疾病（比值比：OR：1.56，CI：1.10-2.21）和体重指数（BMI）3040（OR：1.41，CI：1.04-1.91）。目前 ODP 的选择因素包括 PDAC（OR：0.45，CI：0.31-0.64）、良性肿瘤大小 > 5 厘米（OR：0.40，CI：0.23-0.67）和多脏器手术（OR：0.39，CI：0.26-0.59）。 ODP 和 MIDP 之间复合主要发病率的危险因素没有差异。与 ODP 相比，MIDP 和较低的复合主要发病风险之间存在趋势（OR：0.43，CI：0.17-1.07）。 结论：目前 ODP 或 MIDP 的选择因素（良性疾病、肿瘤大小和 BMI）并不能降低主要发病风险。我们没有发现任何证据表明应根据肿瘤病因或大小、BMI 或患者身体状况避免 MIDP。
Objective: To assess current nationwide case selection factors for minimally invasive distal pancreatectomy (MIDP) and identify actual risk factors for adverse outcomes compared with open distal pancreatectomy (ODP).Background: Patient selection criteria that predict outcomes after MIDP remain unknown. As a result, widespread adoption of this surgical technique may have been delayed and its potential benefits possibly under-exploited.Methods: Retrospective cohort study of elective ODP and MIDP performed at 106 centers in 2014, using the pancreas-targeted American College of Surgeons' National Quality Improvement Program (ACS-NSQIP) database. Exclusion criteria were neoadjuvant treatment or pancreatitis as only diagnosis. Primary outcome includes a composite major morbidity metric, reflecting adverse events including mortality and reoperation. Multivariable modeling was used to detect current selection factors and to identify actual risk factors of composite major morbidity.Results: A total of 928 patients underwent ODP (n = 472) or MIDP (n = 456) using a laparoscopic or robot-assisted approach, 24% for pancreatic ductal adenocarcinoma (PDAC). Current selection factors for MIDP were benign disease (odds ratio: OR: 1.56, CI: 1.10-2.21) and body mass index (BMI) 3040 (OR: 1.41, CI: 1.04-1.91). Current selection factors for ODP were PDAC (OR: 0.45, CI: 0.31-0.64), benign tumor size > 5 centimeters (OR: 0.40, CI: 0.23-0.67), and multivisceral procedures (OR: 0.39, CI: 0.26-0.59). Risk factors for composite major morbidity did not differ between ODP and MIDP. A trend was observed between MIDP and a lower risk of composite major morbidity compared with ODP (OR: 0.43, CI: 0.17-1.07).Conclusions: Current selection factors for ODP or MIDP (benign disease, tumor size, and BMI) do not mitigate the risk of major morbidity. We found no evidence that MIDP should be avoided based on tumor etiology or size, BMI, or patient physical status.