Eckstein H-H, Bruckner T, Heider P, Wolf O, Hanke M, Niedermeier H-P, Noppeney T, Umscheid T, Wenk H
Department for Vascular Surgery, Klinikum rechts der Isar, Technical University, Munich, Germany.
Eur J Vasc Endovasc Surg. 2007 Sep;34(3):260-6. doi: 10.1016/j.ejvs.2007.05.006. Epub 2007 Jun 29.
Several studies indicate that high-volume hospitals have better results in open repair of unruptured abdominal aortic aneurysms (AAA). Up to now no studies had addressed this question in German hospitals.
Post-hoc-analysis from a prospective physician-led registry.
Since 1999, the German Society for Vascular Surgery has conducted a prospective registry for open and endovascular repair of AAAs. This study includes 131 hospitals who conducted n=10163 elective open repairs for unruptured AAA between 1999 to 2004. All perioperative variables including annual volume as a continuous variable were analysed in a step-wise logistic regression model. In order to define a threshold annual volume an additional logistic regression analysis was performed by use of annual volume groups (0-9, 10-19, 20-29, 30-39, 40-49, 50 or more). The relationship between annual volume and further outcome parameters (length of procedure, blood transfusion, length of stay) were also analyzed.
The overall mortality rate was 3.2%. The stepwise logistic regression model identified the following predictors of an increased perioperative mortality: age (OR 1.084, 95% CI 1.066-1.102), AAA diameter (OR 1.008, 95% CI 1.001-1.016), length of procedure (OR 1.008, 95% CI 1.006-1.009), ASA-Score (OR 2.636, 95% CI 2.129-3.264), suprarenal clamping (OR 1.447, 95% CI 1.008-2,078), blood transfusion (OR 1.786, 95% CI 1.268-2.514). Annual volume was moderately predictive (OR 1.003, 95% CI 1-1.006) but failed to reach statistical significance (p=0.07). The analysis of volume groups identified a significantly higher risk for hospitals with an annual volume of 1-9 AAA-repairs by comparison to hospitals with an annual volume of 50 or more AAA-repairs (OR 1.903, 95% CI 1.124-3.222). Operations at low volume hospitals were also longer (p<0.001), with an extended postoperative stay (p<0.001) and a higher transfusion rate (p<0.001).
Patient's age, ASA classification, AAA diameter, length of procedure, suprarenal clamping and blood transfusion are predictive variables for an increased perioperative mortality in elective open AAA repair. Mortality is also increased by a low annual volume. Further studies are needed to examine whether these data are applicable to all German hospitals.
多项研究表明，高手术量的医院在未破裂腹主动脉瘤（AAA）开放修复方面有更好的结果。截至目前，尚无研究探讨德国医院的这一问题。
来自一项由医生主导的前瞻性登记研究的事后分析。
自1999年以来，德国血管外科学会对AAA的开放和血管内修复进行了一项前瞻性登记研究。本研究纳入了131家医院，这些医院在1999年至2004年间对n = 10163例未破裂AAA进行了择期开放修复。在逐步逻辑回归模型中分析了所有围手术期变量，包括将年手术量作为连续变量进行分析。为了确定年手术量阈值，通过使用年手术量分组（0 - 9、10 - 19、20 - 29、30 - 39、40 - 49、50及以上）进行了额外的逻辑回归分析。还分析了年手术量与其他结局参数（手术时长、输血、住院时长）之间的关系。
总体死亡率为3.2%。逐步逻辑回归模型确定了以下围手术期死亡率增加的预测因素：年龄（OR 1.084，95% CI 1.066 - 1.102）、AAA直径（OR 1.008，95% CI 1.001 - 1.016）、手术时长（OR 1.008，95% CI 1.006 - 1.009）、美国麻醉医师协会（ASA）评分（OR 2.636，95% CI 2.129 - 3.264）、肾上腹主动脉阻断（OR 1.447，95% CI 1.008 - 2.078）、输血（OR 1.786，95% CI 1.268 - 2.514）。年手术量具有中等预测性（OR 1.003，95% CI 1 - 1.006），但未达到统计学显著性（p = 0.07）。对手术量分组的分析发现，与年手术量为50例及以上AAA修复的医院相比，年手术量为1 - 9例AAA修复的医院风险显著更高（OR 1.903，95% CI 1.124 - 3.222）。低手术量医院的手术时间也更长（p < 0.001），术后住院时间延长（p < 0.001）且输血率更高（p < 0.001）。
患者年龄、ASA分级、AAA直径、手术时长、肾上腹主动脉阻断和输血是择期开放AAA修复围手术期死亡率增加的预测变量。年手术量低也会增加死亡率。需要进一步研究来检验这些数据是否适用于所有德国医院。
