title: Division of surgeon workload in pancreaticoduodenectomy: striving to decrease post-operative pancreatic fistula.
abstract: BACKGROUND
  Many studies have reported factors affecting pancreatic leakage after pancreaticoduodenectomy (PD), but there have been few reports on surgeon workload and post-operative pancreatic fistula (POPF). This study was conducted to explore whether a surgeon's workload during PD impacts the occurrence of POPF.
  
  
  METHODS
  We retrospectively analysed 270 consecutive patients who underwent PD between January 2008 and June 2013 by a single experienced surgeon. These patients were divided into those who underwent PD entirely by a single operator (group 1) and those who received reconstructions by other operators (group 2). Duct-to-mucosa pancreaticojejunostomy was performed on all patients. The International Study Group on Pancreatic Fistula criteria were used to define POPF.
  
  
  RESULTS
  There were 157 patients (58.1%) in group 1 and 113 patients (41.9%) in group 2. The post-operative morbidity rate was comparable between the two groups (55.4% versus 52.2%; P = 0.603), but the clinical pancreatic fistula (grade B/C) rate was significantly different (10.8% versus 2.7%; P = 0.011). The overall post-operative mortality was one patient (0.4%). Significant associations were found between clinical pancreatic fistulas and soft pancreas texture (P = 0.021), preoperative serum albumin level ≤3.5 g/dL (P = 0.012), other pathology besides pancreatic cancer (P = 0.027) and a single-operator procedure (P = 0.019). A multivariate logistic regression analysis revealed that a single operator (odds ratio: 4.2, P = 0.029) was a significant predictive risk factor for clinically relevant POPF.
  
  
  CONCLUSIONS
  Dividing the surgeon's workload in PD is associated with lower rates of POPF.
authors.affiliation: Department of Surgery, Dankook University Hospital, Cheonan, Korea.
authors.forename: Dong Hun
authors.initials: DH
authors.lastname: Kim
authors.affiliation: Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
authors.forename: Seong Ho
authors.initials: SH
authors.lastname: Choi
authors.affiliation: Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
authors.forename: Dong Wook
authors.initials: DW
authors.lastname: Choi
authors.affiliation: Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
authors.forename: Jin Seok
authors.initials: JS
authors.lastname: Heo
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000517:prevention & control*; D016577:Pancreaticoduodenectomy / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000517:prevention & control*; D012189:Retrospective Studies; D016526:Workload
keywords: division; pancreatic fistula; pancreaticoduodenectomy; predictive risk factor; workload