Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN 55905, USA.
Gynecol Oncol. 2011 Oct;123(1):58-64. doi: 10.1016/j.ygyno.2011.06.018. Epub 2011 Jul 13.
To determine the impact of surgical guidelines and transparent periodic assessment of surgical quality on endometrial cancer (EC) staging by gynecologic oncologists in a single institution and to identify process-of-care, patient-specific, and disease-specific risk factors that influence surgical quality.
In January 2004, a prospective treatment algorithm was implemented for EC at our institution. The number of nodes harvested was a surrogate, and staging quality from 2004 to 2008 (quality assessment [QA] interval) was compared with the previous 5 years (pre-QA interval). Since 2004, low-risk cases based on frozen section examination had not undergone lymphadenectomy and were excluded. Independent patient-specific, disease-specific, and surgery-related risk factors influencing lymphadenectomy quality during both intervals were identified with multivariable logistic regression analysis.
Pelvic and para-aortic lymph node dissection (LND) in surgical EC management before QA (n=420) were 77.9% and 48.8% vs 89.3% and 83.4% during the QA (n=561) (P<.001). The median number of pelvic and para-aortic nodes harvested in LND was 29 and 10 before QA vs 34 and 16 during the QA interval (P<.001). With acceptance of stringent criteria for defining systematic LND (mean node count-1 SD) during the QA, systematic pelvic (≥22 nodes) and para-aortic (≥10 nodes) LNDs occurred in 57.4% and 25.7% of cases before QA vs 77.9% and 70.7% during the QA interval (P<.001). In patients with LND, rates of systematic pelvic and para-aortic LND were 73.7% and 53.0% before vs 87.2% and 84.8% after QA (P<.001). Multivariable logistic regression analysis showed independent factors influencing systematic pelvic and para-aortic LND (P<.01): surgeon and stage during the pre-QA interval vs surgical approach; intraoperative ascites; body mass index; surgeon; patient age; and myometrial invasion after QA implementation.
Inclusion of detailed surgical guidelines and transparent periodic assessment of surgical quality translated to dramatic improvement in quality of surgical EC staging. This implementation was associated with a transition to more patient-specific risk factors influencing systematic LND. Although surgical quality metrics were markedly enhanced during QA, persistent variability observed among surgeons and the change in surgical approach render continuous QA and improvement obligatory.
确定手术指南和对妇科肿瘤医生进行透明的周期性手术质量评估对单一机构中子宫内膜癌（EC）分期的影响，并确定影响手术质量的手术过程、患者特异性和疾病特异性的风险因素。
2004 年 1 月，在我院实施了子宫内膜癌的前瞻性治疗方案。采集的淋巴结数量是一个替代指标，比较了 2004 年至 2008 年（质量评估[QA]间隔）和之前 5 年（预 QA 间隔）的分期质量。自 2004 年以来，根据冷冻切片检查为低风险的病例未行淋巴结切除术，已被排除在外。使用多变量逻辑回归分析确定了两个间隔期间影响淋巴结切除术质量的独立患者特异性、疾病特异性和手术相关风险因素。
QA 前（n=420）手术 EC 管理中的盆腔和腹主动脉旁淋巴结清扫术（LND）分别为 77.9%和 48.8%，QA 期间（n=561）分别为 89.3%和 83.4%（P<.001）。QA 前 LND 中盆腔和腹主动脉旁采集的中位数淋巴结数分别为 29 个和 10 个，QA 期间分别为 34 个和 16 个（P<.001）。在 QA 期间接受了定义系统 LND（平均淋巴结计数-1 SD）严格标准后，QA 前系统盆腔（≥22 个淋巴结）和腹主动脉旁（≥10 个淋巴结）LND 的发生率分别为 57.4%和 25.7%，QA 期间分别为 77.9%和 70.7%（P<.001）。在接受 LND 的患者中，QA 前系统盆腔和腹主动脉旁 LND 的发生率分别为 73.7%和 53.0%，QA 后分别为 87.2%和 84.8%（P<.001）。多变量逻辑回归分析显示，影响系统盆腔和腹主动脉旁 LND 的独立因素（P<.01）：QA 前的外科医生和分期 vs 手术方式；术中腹水；体重指数；外科医生；患者年龄；以及 QA 实施后的肌层浸润。
详细的手术指南和透明的周期性手术质量评估的纳入显著提高了手术 EC 分期的质量。这一实施与更多影响系统 LND 的患者特异性风险因素的转变有关。尽管 QA 期间的手术质量指标有了明显提高，但外科医生之间仍然存在明显的变异性，手术方式的改变也要求持续进行 QA 和改进。
