Pieracci Fredric M, Fahey Thomas J
Department of Surgery, Weill Medical College of Cornell University, 411 East 69th Street, KB-220, New York, NY 10021, USA.
World J Surg. 2008 May;32(5):740-6. doi: 10.1007/s00268-007-9347-1.
Substernal thyroidectomy (ST), as compared to conventional, cervical thyroidectomy, is a technically demanding procedure that is associated with increased morbidity and mortality. We tested the hypothesis that outcomes following ST are improved at centers that perform a high volume of thyroidectomies.
Patients who underwent ST from 1998 to 2004 were extracted from the New York State Statewide Planning and Research Cooperative System database. Hospital volume of thyroidectomies was divided into low (<33 per year), middle (33-99 per year), and high (>or=100 per year) volumes. Outcome variables included hospital length of stay (LOS), recurrent laryngeal nerve (RLN) injury, hypoparathyroidism, postoperative bleeding, respiratory failure, blood transfusion, and mortality.
A total of 1153 STs were analyzed; 372 (32.2%) were performed at low-volume centers, 388 (33.7%) at middle-volume centers, and 393 (34.0%) at high-volume centers. Linear associations were observed between increasing hospital volume of thyroidectomies and decreasing age (p=0.003), increasing co-morbidity (p<0.0001), increased likelihood of total versus subtotal thyroidectomy (p<0.0001), and increased likelihood of thyroid malignancy (p<0.0001). Despite this, increasing hospital volume of thyroidectomies predicted a decreased likelihood of overall complications (p=0.005), postoperative bleeding (p=0.01), blood transfusion (p=0.04), respiratory failure (p=0.04) and mortality (p=0.004), as well as a trend toward a decreased LOS (p=0.06). The overall complication rate and the mortality rate remained significantly associated with volume group by multivariate analysis.
Despite more extensive surgery on patients with greater co-morbidity, LOS, morbidity, and mortality were all decreased when ST occurred at hospitals that perform a high volume of thyroidectomies.
与传统的颈部甲状腺切除术相比，胸骨后甲状腺切除术（ST）是一项技术要求较高的手术，其发病率和死亡率也更高。我们检验了这样一个假设，即在进行大量甲状腺切除术的中心，ST术后的结果会得到改善。
从纽约州全州规划与研究合作系统数据库中提取1998年至2004年接受ST手术的患者。甲状腺切除术的医院手术量分为低（每年<33例）、中（每年33 - 99例）、高（每年≥100例）三个等级。结果变量包括住院时间（LOS）、喉返神经（RLN）损伤、甲状旁腺功能减退、术后出血、呼吸衰竭、输血和死亡率。
共分析了1153例ST手术；372例（32.2%）在低手术量中心进行，388例（33.7%）在中等手术量中心进行，393例（34.0%）在高手术量中心进行。甲状腺切除术医院手术量增加与年龄降低（p = 0.003）、合并症增加（p < 0.0001）、甲状腺全切除术与次全切除术可能性增加（p < 0.0001）以及甲状腺恶性肿瘤可能性增加（p < 0.0001）之间存在线性关联。尽管如此，甲状腺切除术医院手术量增加预示着总体并发症（p = 0.005）、术后出血（p = 0.01）、输血（p = 0.04）、呼吸衰竭（p = 0.04）和死亡率（p = 0.004）的可能性降低，以及住院时间有缩短趋势（p = 0.06）。通过多变量分析，总体并发症发生率和死亡率仍与手术量组显著相关。
尽管对合并症更多的患者进行了更广泛的手术，但在进行大量甲状腺切除术的医院进行ST手术时，住院时间、发病率和死亡率均有所降低。
