Tilney Henry S, Heriot Alexander G, Purkayastha Sanjay, Antoniou Anthony, Aylin Paul, Darzi Ara W, Tekkis Paris P
Department of Biosurgery and Surgical Technology, Imperial College London, St. Mary's Hospital, London, England.
Ann Surg. 2008 Jan;247(1):77-84. doi: 10.1097/SLA.0b013e31816076c3.
To assess rates of abdominoperineal excision of the rectum (APER) for rectal cancer between centers and over time, and to evaluate the influence of patient characteristics, including social deprivation, on APER rate.
Data on patients undergoing APER or anterior resection (AR) in England were extracted from a national administrative database for the years 1996 to 2004. The primary outcome was the proportion of patients presenting with rectal cancer undergoing APER. Hierarchical logistic regression was used to identify independent factors associated with a nonrestorative resection.
Data on 52,643 patients were analyzed, 13,109(24.9%) of whom underwent APER. The APER rate significantly reduced over the study period from 29.4% to 21.2% (P < 0.001). Operative mortality following AR decreased significantly during the period of study (5.1% to 4.2%, P = 0.002), while that following APER did not (P = 0.075). Male patients were more likely to undergo APER (P < 0.001), whereas those with an emergency presentation more commonly underwent AR (P < 0.001). Independent predictors of increased APER rate were male gender (odds ratio [OR] = 1.239, P < 0.001) and social deprivation (most vs. least deprived; OR = 1.589, P < 0.001), whereas increasing patient age (OR = 0.977, P = 0.027 per 10-year increase), year of study (2003/4 vs. 1996/7; OR = 0.646, P < 0.001) and initial presentation as an emergency (OR = 0.713, P < 0.001) were associated with lower APER rates. After accounting for case-mix, there was significant between-center variability in APER rates.
Socially deprived patients were more likely to undergo abdominoperineal resection. Significant improvements in rates of nonrestorative resection were seen over time but although short-term outcomes following AR have improved, those following APER have not. Permanent stoma rates following rectal cancer surgery may be considered a surrogate marker of surgical quality.
评估不同中心及不同时间段直肠癌腹会阴联合切除术（APER）的发生率，并评估包括社会剥夺状况在内的患者特征对APER发生率的影响。
从一个国家行政数据库中提取1996年至2004年在英格兰接受APER或前切除术（AR）患者的数据。主要结局是直肠癌患者接受APER的比例。采用分层逻辑回归来确定与非保留性切除术相关的独立因素。
分析了52643例患者的数据，其中13109例（24.9%）接受了APER。在研究期间，APER发生率从29.4%显著降至21.2%（P<0.001）。研究期间，AR术后手术死亡率显著下降（从5.1%降至4.2%，P = 0.002），而APER术后手术死亡率未下降（P = 0.075）。男性患者更有可能接受APER（P<0.001），而急诊患者更常接受AR（P<0.001）。APER发生率增加的独立预测因素是男性（比值比[OR]=1.239，P<0.001）和社会剥夺（最贫困与最不贫困；OR = 1.589，P<0.001），而患者年龄增加（每增加10岁，OR = 0.977，P = 0.027）、研究年份（2003/4年与1996/7年；OR = 0.646，P<0.001）以及初诊为急诊（OR = 0.713，P<0.001）与较低的APER发生率相关。在考虑病例组合后，各中心之间的APER发生率存在显著差异。
社会剥夺患者更有可能接受腹会阴切除术。随着时间的推移，非保留性切除术的发生率有显著改善，但尽管AR术后短期结局有所改善，APER术后结局并未改善。直肠癌手术后永久性造口率可被视为手术质量的替代指标。
