How to pass on expertise: Pancreatoduodenectomy at a teaching hospital

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.

Calculating the risk of a pancreatic fistula after a pancreaticoduodenectomy: a systematic review

“…Risk stratification of a POPF may have a role in facilitating training opportunities. A PD is considered one of the most technically demanding surgical procedures and is a challenging operation for both trainers to teach and trainees to learn . Recognizing patients at a lower risk of POPF may permit the trainee to perform the pancreatoenteric anastomosis, and conversely an experienced pancreatic surgeon may choose to construct this anastomosis in a high‐risk patient.…”

A questionnaire on the educational system for pancreatoduodenectomy performed in 1,134 patients in 71 institutions as members of the Japanese Society of Pancreatic Surgery

“…Hepato-pancreato-biliary surgeons are needed in many surgical patients' experience [5]. Previous studies have shown the necessity for training in highvolume centers [4,18], under team medicine [24], or under the supervision of an experienced senior surgeon [25]. These suggestions are correct.…”

Pancreatic carcinoma

“…Mortality is caused predominantly by abdominal sepsis including sequelae like hemorrhage. Non-surgical, especially cardiopulmonary complications had been shown to add significantly to postoperative mortality and morbidity [15,17,18]. Percutaneous drainage is used to treat intraabdominal complications like fluid retention and abscesses due to pancreatic fistula, reoperation reserved for those situations, that cannot be controlled percutaneously.…”

“…Wamser et al were able to demonstrate that proctoring this complex procedure is possible in experienced centers without increased complication rates [15]. Some papers reported on the laparoscopic approach to pancreatic surgery and cancer.…”