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

Background Postoperative pancreatic �stula (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 x 2 test was used in univariate analysis.


Introduction
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 highvolume centers have shown potential advantages laparoscopic methods have over open PD [1].The increase of postoperative pancreatic stula (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][6][7][8][9][10][11]. Severe POPF may lead to post pancreatectomy hemorrhage and even death [12].In 2005, International Study Group of Pancreatic Surgery (ISGPS) developed a de nition 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 signi cant 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 signi cantly affect the mood and behavior of surgeons [15].PD is a very complex and di cult 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-inchief, related factors, and factors to alleviate the psychological pressures involved.

Materials And Methods
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 X 2 test was used in univariate analysis, and the difference was statistically signi cant (P < 0.05).
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 di culty 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 ustered 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 e ciency of surgeon-inchief (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 in uence 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 in uence 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 speci c contents of the questionnaire administered.
Results from the univariate analysis showed that from the perspective of post-traumatic stress disorder, there were statistically signi cant 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 (X 2 =15.55,P < 0.01), cases of POPF often appeared in dreams (X 2 =6.243,P =0.012), and the participants became overly alert (X 2 =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 signi cant differences in the following situation: surgeon-in-chief having sleeplessness (X 2 =15.55,P < 0.01).Once patients had grade B or C POPF, participants felt ustered and annoyed (X 2 =13.54,P < 0.01) (Table 4).From the perspective of decision-making ability, there are statistically signi cant differences in the following situations: the decision-making ability of the surgeonin-chief on the treatment plan was affected (X 2 = 13.03,P < 0.01), and the ability of the surgeon-in-chief to select suitable operation modes were also affected (X 2 =18.01,P < 0.01).The speci c contents can be found in Table 5.

Discussion
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 nd di culty 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 insu cient 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 nd 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.

Conclusion
This study evaluated the extent of the psychological impact of POPF on the surgeon-in-chief and its in uencing 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 veri ed by larger samples and more comprehensive investigations.Effect of postoperative pancreatic stula on the decision-making ability of chief surgeon

Funding 2
This work was supported by the Yun nan Fundamental Research Projects (Grant No. 202101AT070239) and the Investigator Initiated Trail Projects of the Second A iated Hospital of Kunming Medical University (Grant No. 2020ynlc004) and the Medical Reserve Talents project of Yunnan Provincial Health Commission (H-2018065).level of surgeon-in-chief?Third-level rst-class Class Lower than third-level rst-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?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 di cult 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 ustered 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?The number of case of grade B or C POPF by each participant The number of case of grade B POPF The number of case of grade C

Figure 2 Self
Figure 2

Table 3
Questions and statistical results related to PCL-C

Table 4
Questions and statistical results related to GAD7