Investigation on the psychological impact of grade B or C pancreatic fistula of post pancreatoduodenectomy (PD) on surgeon-in-chief and its related factors

doi:10.21203/rs.3.rs-2364078/v1

Background

Postoperative pancreatic fistula (POPF) is the most common complication of pancreatoduodenectomy (PD), and it is the main cause of mortality. A survey was conducted among hepatobiliary pancreatic surgeons to understand the experience of the surgeon-in-chief in PD and POPF, focusing on the psychological impact of POPF on the surgeon-in-chief, related factors, and factors to alleviate psychological pressure.

Methods

A 21-question questionnaire was conducted among hepatobiliary and pancreatic surgeons, adopting the method of a retrospective cross-sectional survey. The questionnaire was distributed through Wechat, and the software platform was questionnaire star. Count data were expressed in absolute values or percentages, and the x² test was used in univariate analysis.

Results

A total of 97 hepatobiliary and pancreatic surgeons completed the questionnaire. Eighty-six out of the ninety-seven (88.66%) participants were from third-level first-class hospitals, and participants from hospitals below third-level first-class made up 11/97 (11.34%). Ninety-two out of ninety-seven (94.85%) participants felt uneasy, nervous, or anxious after their patients suffered from grade B or C POPF. Participants making 67/97 (69.07%) suffered from sleeplessness, and 56/97(57.73%) participants' decision-making ability for treatment was affected. Participants making a total of 73/97(75.26%) were worried about grade B or C POPF when performing PD again, becoming overly alert.

Conclusions

Whether hepatobiliary and pancreatic surgeons in hospitals of Third-Level First Class or below, whether they have PD experience, and whether they have experienced grade B or C POPF will have a psychological impact on the surgeon-in-chief.

Biological sciences/Psychology

Health sciences/Medical research

Pancreatoduodenectomy

physical impact

grade B or C pancreatic fistula

investigation

related factors.

Pancreatoduodenectomy (PD) is a complex surgical procedure, mainly used for precancerous and malignant tumors in the area around the pancreatic head and ampulla. PD has traditionally been performed by open methods. However, in recent years, several large observational studies from high-volume centers have shown potential advantages laparoscopic methods have over open PD [1]. The increase of postoperative pancreatic fistula (POPF), and postoperative bleeding of laparoscopic PD, especially in centers with relatively small operation volume, has attracted public attention [2, 3]. POPF is one of the most severe and inevitable complications that occur after pancreatic surgeries. Complications directly affect patients, having a long-term psychosocial impact on the quality of life [4]. According to previous studies, the incidence of POPF in patients undergoing PD differs in each operation center, but the overall range is 13–35% [5–11]. Severe POPF may lead to post pancreatectomy hemorrhage and even death [12]. In 2005, International Study Group of Pancreatic Surgery (ISGPS) developed a definition and grading standard of POPF. This standard was updated in 2016, including biochemical leak, grade B and C POPF [13]. POPF also has a negative impact on the surgeon-in-chief, and it may have further negative consequences on patients.

A large cross-sectional survey of 7905 members of the American College of surgery showed that there was a statistically significant adverse relationship among major medical error reports and quality of life, job burnout and depressive symptoms [14]. A UK-based qualitative study has highlighted complications after surgery significantly affect the mood and behavior of surgeons [15]. PD is a very complex and difficult operation. The surgeon-in-chief usually has to make major decisions that determine the fate of the operation and the patient, in a high-pressure environment. Unfortunately, after this surgery, there is still need to face troublesome complications such as POPF, which has also become the fuse for the psychological pressure on surgeon-in-chief.

This survey was conducted among hepatobiliary and pancreatic surgeons to understand the experience of surgeon-in-chief in PD and POPF, focusing on the psychological impact of POPF on the surgeon-in-chief, related factors, and factors to alleviate the psychological pressures involved.

A retrospective web-based cross-sectional survey was conducted to determine the extent of psychological impact grade B or C POPF has on surgeon-in-chief and its related factors. The target population was hepatobiliary pancreatic surgeons, who have done the PD operation and experienced grade B or C POPF (Table 2). The questionnaire was administered online on the questionnaire star platform and was distributed through Wechat. Participation was voluntary, there was no incentive given after completion, and participants remained anonymous. The survey was open for a week. The questionnaire was based on relevant literature and three scales; including post-traumatic stress disorder self-assessment scale (PCL-C), generalized anxiety disorder scale (GAD-7), and patient health questionnaire and depression scale (PHQ-9). The questionnaire consisted of 18 single choice questions, 1 multiple choice question, 1 scoring question, and 1 free response question. This questionnaire focused on the psychological impact of patients with grade B or C POPF on surgeons, the impact on the surgeon's decision-making ability, and factors to alleviate psychological pressure. All questions were mandatory to complete the questionnaire.

The PCL-C, GAD-7, and PHQ-9 scales served as the reference for analysis of the traumatic stress disorder, depression, and anxiety of the respondents according to questions 5-16 of the questionnaire.

The questionnaire survey was then analyzed by the SPSS 25.0 statistical software. The counting data were expressed in absolute numbers or percentages. The X² test was used in univariate analysis, and the difference was statistically significant (P < 0.05).

A total of 97 participants completed the questionnaire. Participants from third-level first-class hospitals made up 86/97 (88.66%) of the cohort. A fraction of 26/97 (26.8%) of the participants performed 0-10 PD surgeries, 20/97 (20.62%) participants performed 11-30 PD surgeries, and 51/97 (52.58%) participants performed more than 30 PD surgeries. Participants making 50/97 (51.55%) of the cohort performed 0-10 PD surgeries per year, 28/97 (28.87%) participants performed 11-30 PD surgeries per year, and 19/97 (19.59%) participants performed more than 30 PD surgeries per year.

Data obtained from this study showed that most of the participants had certain psychological effects when their patients suffered complications of POPF (Fig. 1). When patients suffer grade B or C POPF, 92/97 (94.85%) participants felt uneasy, nervous or anxious, 67/97 (69.07%) participants endured sleeplessness and uneasy sleep, 49/97 (50.52%) participants had difficulty relaxing after the patients' POPF was relieved, and 34/97 (35.05%) participants dreamt about such cases. When 32/97 (32.99%) participants thought of previously experienced cases of grade B or C POPF during a PD procedure, they had physical reactions such as sweating and palpitation. Participants making up 73/97 (75.26%) of the cohort worried about the recurrence of grade B or C POPF, becoming overly alert when performing PD again. A fraction of 61/97 (62.89%) of the cohort felt flustered and annoyed once the patients had grade B or C POPF after surgery.

Patients with grade B or grade C POPF also have a certain impact on the work efficiency of surgeon-in-chief (Fig. 2). In a general assessment by participants on their concentration on work, 2/97 (2.06%) felt very unfocused, 4/97 (4.12%) felt unfocused, 15/97 (15.46%) generally focused, 25/97 (25.77%) relatively focused, 26/97 (26.8%) focused, and 25/97 (25.77%) very focused. The influence of patients complicated with POPF on the decision-making ability of surgeon-in-chief is shown in Figure 3. The decision-making ability of 56/97 (57.73%) of the participants on the treatment plan was affected, 57/97 (58.76%) of the participants' ability to choose surgical methods was affected, and 68/97 (70.1%) participants indicated that familiarity with the surgical team affected the secondary surgery (Figure 4), such as reconstruction of pancreatic jejunostomy and pancreaticogastric anastomosis.

The factors that relieved the psychological pressure of the participants include peer communication (85.57%), department level protection (72.16%), hospital level protection (47.42%), auxiliary department support (56.7%). A fraction of 70/97 (72.16%) of the participants received help from senior surgeons.

For Grade B POPF, most participants encountered less than 10 cases, and a few participants encountered 30-50 cases; for Grade C POPF, most participants encountered less than 5 cases, and a few participants encountered 5-10 cases. The possible factors that may cause psychological influence to surgeon-in-chief due to patients suffering POPF are shown in Fig. 5. Most participants may have psychological stress after experiencing POPF, and the severity is related to whether the patient is grade B or grade C POPF. Most of the participants can relieve their psychological pressure through peer communication, department level protection, and auxiliary department support. Table 1 shows the specific contents of the questionnaire administered.

Results from the univariate analysis showed that from the perspective of post-traumatic stress disorder, there were statistically significant differences between the participants with an annual operation volume of more than 30, and participants with less than 30 in the following situations: surgeon-in-chief had sleeplessness (X² =15.55, P < 0.01), cases of POPF often appeared in dreams (X² =6.243, P =0.012), and the participants became overly alert (X²=11.82, P < 0.01) due to worry about possible complications of grade B or C POPF during PD surgery again. Table 3 shows more details. In terms of depression and anxiety, there were statistically significant differences in the following situation: surgeon-in-chief having sleeplessness (X² =15.55, P < 0.01). Once patients had grade B or C POPF, participants felt flustered and annoyed (X²=13.54, P < 0.01) (Table 4). From the perspective of decision-making ability, there are statistically significant differences in the following situations: the decision-making ability of the surgeon-in-chief on the treatment plan was affected (X²= 13.03, P < 0.01), and the ability of the surgeon-in-chief to select suitable operation modes were also affected (X² =18.01, P < 0.01). The specific contents can be found in Table 5.

PD surgery usually leads to POPF, a complication that can lead to delayed bleeding and even death in severe cases. It is a complication doctors and patients find difficulty accepting [12]. Results from this survey show that the psychological impact on the surgeons who have performed the PD surgery a total of 0–10 times and an average of 0–10 times per year was relatively small. The psychological impact on the participants who have performed PD surgery more than 30 times and an average of 11–30 times per year was relatively large. There was relatively small psychological impact on participants who have experienced POPF fewer times, which may be due to their relatively insufficient experience in dealing with the complication. The psychological impact on the participants who performed PD more than 30 times and more than 30 times a year is small. This may be based on the fact that such participants work in large-volume surgery facilities, having experienced many cases of POPF and accumulated a lot of clinical experience. Therefore, they can handle POPF relatively calmly. One may think that the impact of grade B or C POPF on the surgeon-in-chief is related to the number of surgeries performed by the surgeon-in-chief during his medical career, constantly improving surgical techniques, and accumulated experience in taking effective measures according to different conditions after the occurrence of POPF. However, if the surgeon-in-chief performs a large number of operations, but rarely experiences POPF from patients, it will also have a psychological impact on the surgeon, affecting his decision-making ability in making further treatment plans.

Results from this study show that when participants have post-traumatic stress disorder, depression, and anxiety, peers communicate with each other to find solutions, and get the protection and support of their departments and hospitals. This relieved the psychological pressure on surgeon-in-chief. Some participants also said that they could recover through further treating patients with POPF, as this relieves pressure on them. When the decision-making ability is affected, most surgeon-in-chief got help from senior doctors. Among the 97 participants, 25 had experienced medical disputes. Medical liability insurance is not very popular in China. If medical disputes arise involving economic compensation, most doctors only make personal compensation. In this survey, only 23 participants had medical liability insurance compensation. It is therefore suggested that the state vigorously promotes medical liability insurance, to give corresponding protection to surgeon-in-chief, so as to alleviate their psychological pressure.

Results also shoe that although the self-evaluation of the work concentration of surgeon-in-chief after encountering the patient's POPF had a certain relationship with operation experience and experience in dealing with POPF, these are not the only determinants, but also related to surgeon-in-chief’ own psychological quality. Not all surgeon-in-chief who performed a large number of operations have a high concentration, and this may be related to the severity of each POPF case and the psychological tolerance of each surgeon-in-chief.

This study evaluated the extent of the psychological impact of POPF on the surgeon-in-chief and its influencing factors. Data obtained show that the POPF of the patients has a psychological impact on most of the surgeon-in-chief, and the severity of impact is mainly related to the amount of surgery performed and the experience in dealing with POPF. When surgeon-in-chief are in a state of depression and anxiety, peer communication, department and hospital level protection and auxiliary department support all reduce psychological pressure, thus alleviating theirs depression and anxiety. Again, vigorously promoting medical liability insurance guarantees the career of surgeon-in-chief. The questionnaire was distributed through Wechat and unfortunately, could not cover all hepatobiliary and pancreatic surgeons, and this was a limitation. This study was a retrospective survey and may have recall bias. The conclusions drawn from this study need to be verified by larger samples and more comprehensive investigations.

Funding

This work was supported by the Yun nan Fundamental Research Projects (Grant No. 202101AT070239) and the Investigator Initiated Trail Projects of the Second Afliated Hospital of Kunming Medical University (Grant No. 2020ynlc004) and the Medical Reserve Talents project of Yunnan Provincial Health Commission (H-2018065).

Acknowledgements

The authors are grateful to the 97 surgeons who accepted our request to respond to this survey.

Authors’ contributions

Manqin Hu designed the study, Dingwei Xu supervised the data collection, Xincheng Li and Ao Li analyzed the data, Yan Zhang prepared the manuscript for publication, Jie Huang reviewed the draft of the manuscript. All authors have read and approved the manuscript.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Ethical approval statements

All methods were carried out in accordance with relevant guidelines and regulations. All experimental protocols were approved by the Medical Ethics committee of the Second Affiliated Hospital of Kunming Medical University. Informed consent was obtained from all subjects and/or their legal guardian(s).

No conflict of interest exists in submitting this manuscript, and all authors approve the manuscript for publication.

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Table1 Contents of questionnaire

Survey questions

Number of PD performed per year?

0-10

11-30

More than 30

Total number of PD performed?

0-10

11-30

More than 30

Hospital level of surgeon-in-chief?

Third-level first-class Class

Lower than third-level first-class

The patient has grade B or C POPF, and the surgeon feels uneasy, nervous or anxious?

Yes

No

The patient has grade B or C POPF, and the surgeon-in-chief has sleeplessness and uneasy sleep?

Yes

No

When the patient has grade B or C POPF, the surgeon-in-chief scores the attention and concentration of the work by himself?

1(very inattentive)

2(inattentive)

3(generally focused)

4(relatively focused)

5(focused)

6(very focused)

The patient has grade B or C POPF, and the surgeon-in-chief has the help of senior doctors?

Yes

No

Even if the patient has grade B or C POPF remission , it is difficult for the surgeon-in-chief to relax?

Yes

No

The patient has grade B or C POPF, which affects the decision-making ability of the surgeon-in-chief for the treatment?

Yes

No

After the patient has grade B or C POPF, the ability of the surgeon-in-chief to consider the choice of surgical method is affected?

Yes

No

After the patient has grade B or C POPF, the surgeon's familiarity with the operation team will affect the secondary operation?

Yes

No

Patients with grade B or C POPF often appear in the surgeon's dream?

Yes

No

When the surgeon-in-chief contacts PD again, he will think of the previous cases of grade B or C POPF, resulting in physical reactions such as sweating and palpitation?

Yes

No

The surgeon-in-chief was worried about grade B or C POPF when performing PD again, becoming overly alert?

Yes

No

In PD surgery performed by the surgeon-in-chief, once the patient has grade B or C POPF, he will feel flustered and annoyed?

Yes

No

There were several cases of grade B POPF and several cases of grade C POPF in the surgeon-in-chief 's medical career?

The factors of relieving the psychological pressure of the surgeon-in-chief after grade B or C POPF?

Peer exchange

Department level protection

Hospital level protection

Support of auxiliary departments

Others

The patient died during the perioperative period?

Yes

No

Doctor-patient dispute?

Yes

No

Medical liability insurance compensation?

Yes

No

Table 2 The number of case of grade B or C POPF experienced by each participant

The number of case of grade B POPF

The number of case of grade C POPF

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

3

0

5

1

10

0

10

1

8

2

5

2

0

unclear

0

3

0

5

6

5

1

0

unclear

10

3

5

unclear

1

2

3

6

8

4

2

unclear

5

30-40

0

2

unclear

2

3

1

3

5

10

1

4

5

10

4

8

2

50

unclear

10

4

5

8

2

1

10

1

3

2

1

unclear

5

20

6-8

8

12

10

unclear

0

30-50

2

1

3

2

unclear

3

unclear

2

5

10

30

5

2

unclear

30

unclear

1

0

1

2

0

1

2

unclear

0

1

unclear

0

2

0

1

0

2

1

2

unclear

0

3

0

7

2

0

unclear

0

1

10

0

unclear

0

6

0

1

0

2

5

1

2

0

9

unclear

3

1

0

3

0

3

1

0

5

0

unclear

1

0

1

8

0

unclear

2

0

2

1

0

2

unclear

3

10

0

1

3

4

5

2

1

unclear

0

Table 3 Questions and statistical results related to PCL-C

question	assignment	The annual number of cases below 30	The annual number of cases above 30	X²value	P value
The patient has grade B or C POPF, and the chief surgeon has sleeplessness and uneasy sleep
Yes	1	61	6	15.548	0.000
No	0	17	13	15.548	0.000
Patients with grade B or C POPF often appear in the surgeon's dream
Yes	1	32	2	6.243	0.012
No	0	46	17	6.243	0.012
When the chief surgeon contacts PD again, he will think of the previous cases of grade B or C POPF, resulting in physical reactions such as sweating and palpitation
Yes	1	29	3	3.162	0.075
No	0	49	16	3.162	0.075
The chief surgeon was worried about grade B or C POPF when performing PD again, becoming overly alert
Yes	1	65	8	11.820	0.001
No	0	13	11	11.820	0.001

Table 4 Questions and statistical results related to GAD7

question	assignment	The annual number of cases below 30	The annual number of cases above 30	X²value	P value
The patient has grade B or C POPF, and the surgeon feels uneasy, nervous or anxious
Yes	1	75	17		0.252
No	0	3	2		0.252
The patient has grade B or C POPF, and the chief surgeon has sleeplessness and uneasy sleep
Yes	1	61	6	15.548	0.000
No	0	17	13	15.548	0.000
Even if the patient has grade B or C POPF remission , it is difficult for the chief surgeon to relax
Yes	1	43	6	3.390	0.066
No	0	35	13	3.390	0.066
In PD surgery performed by the chief surgeon, once the patient has grade B or C POPF, he will feel flustered and annoyed
Yes	1	56	5	13.540	0.000
No	0	22	14	13.540	0.000

Table 5 Effects of POPF on treatment regimens

question	assignment	The annual number of cases below 30	The annual number of cases above 30	X²value	P value
The patient has grade B or C POPF, which affects the decision-making ability of the chief surgeon for the treatment
Yes	1	52	4	13.027	0.000
No	0	26	15	13.027	0.000
After the patient has grade B or C POPF, the ability of the chief surgeon to consider the choice of surgical method is affected
Yes	1	54	3	18.007	0.000
No	0	24	16	18.007	0.000

No competing interests reported.

Investigation on the psychological impact of grade B or C pancreatic fistula of post pancreatoduodenectomy (PD) on surgeon-in-chief and its related factors

Status:

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Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Materials And Methods

Results

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Status:

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