结直肠手术中的可改变风险因素：外科医生手术量的核心作用。

Pata Giacomo, Casella Claudio, Nascimbeni Riccardo, Cirillo Laura, Salerni Bruno

Cattedra di Chirurgia Generale, University of Brescia School of Medicine, Brescia, Italy.

Ann Ital Chir. 2008 Nov-Dec;79(6):427-32; discussion 432-3.

BACKGROUND

Our objective was to inform the ongoing debate regarding selective referral of colorectal cancer patients to high-volume surgeons in order to improve outcomes.

PATIENTS AND METHOD

We evaluated data on patients treated by colorectal-dedicated surgeons (first study-group) and non specialized surgeons (second study-group). Particular attention has been paid to patients selection in order to collect two study-groups with similar demographic and clinical characteristics, differing only as regards providers' surgical experience in the colorectal field. We focused on postoperative mortality and 5-year overall and cancer-specific survival. We also analyzed resection rates of the primary tumor and colostomy rates for patients with stage I to III rectal cancer, and use of (neo)adjuvant (chemo)radiation therapy for patients with stage II-III rectal cancer by surgeon's volume.

RESULTS

The analysis of these 2 study-groups shows better results for patients treated by colorectal-trained surgeons (high-volume surgeons) for each parameter taken into account: lower postoperative mortality (OR 0.32; 95% CI:0.7-0.1; p = 0.04), increased 5-year overall and cancer specific survival (rising from 41.2% and 46.4% to 56% and 61.2% respectively; OR 1.8; 95% CI: 1.3-2.6; p < 0.005). Patient treated by non specialized surgeons are more likely to receive a permanent colostomy (abdominoperineal resection: APR) (OR 5.9; 95% CI: 3.3-10.7) and to undergo a non-resective procedure (OR 4.8; 95% CI: 1.9-12)(p < 0.005). No difference was found between the 2 study-groups in the use of (neo)adjuvant (chemo)radiation therapy for patients with stage II-III rectal cancer.

CONCLUSIONS

Our analysis suggests that surgeon's volume does impact on outcomes for patients undergoing surgery due to colorectal cancer.

背景

我们的目的是为正在进行的关于将结直肠癌患者选择性转诊至高手术量外科医生以改善治疗结果的辩论提供信息。

患者与方法

我们评估了由结直肠专科外科医生治疗的患者（第一研究组）和非专科外科医生治疗的患者（第二研究组）的数据。特别关注了患者的选择，以便收集两个具有相似人口统计学和临床特征的研究组，仅在结直肠领域的提供者手术经验方面有所不同。我们重点关注术后死亡率、5年总生存率和癌症特异性生存率。我们还分析了I至III期直肠癌患者的原发肿瘤切除率和结肠造口术率，以及II - III期直肠癌患者根据外科医生手术量使用（新）辅助（化疗）放疗的情况。

结果

对这两个研究组的分析表明，对于所考虑的每个参数，接受结直肠培训的外科医生（高手术量外科医生）治疗的患者结果更好：术后死亡率更低（OR 0.32；95% CI：0.7 - 0.1；p = 0.04），5年总生存率和癌症特异性生存率提高（分别从41.2%和46.4%升至56%和61.2%；OR 1.8；95% CI：1.3 - 2.6；p < 0.005）。非专科外科医生治疗的患者更有可能接受永久性结肠造口术（腹会阴切除术：APR）（OR 5.9；95% CI：3.3 - 10.7）并接受非切除性手术（OR 4.8；95% CI：1.9 - 12）（p < 0.005）。在II - III期直肠癌患者使用（新）辅助（化疗）放疗方面，两个研究组之间未发现差异。