Bliss Lindsay A, Yang Catherine J, Chau Zeling, Ng Sing Chau, McFadden David W, Kent Tara S, Moser A James, Callery Mark P, Tseng Jennifer F
Surgical Outcomes Analysis & Research and Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Surgery, University of Connecticut Health Center, University of Connecticut School of Medicine, Farmington, CT, USA.
HPB (Oxford). 2014 Oct;16(10):899-906. doi: 10.1111/hpb.12283. Epub 2014 Jun 6.
The volume effect in pancreatic surgery is well established. Regionalization to high-volume centres has been proposed. The effect of this proposal on practice patterns is unknown.
Retrospective review of pancreatectomy patients in the Nationwide Inpatient Sample 2004-2011. Inpatient mortality and complication rates were calculated. Patients were stratified by annual centre pancreatic resection volume (low <5, medium 5-18, high >18). Multivariable regression model evaluated predictors of resection at a high-volume centre.
In total, 129,609 patients underwent a pancreatectomy. The crude inpatient mortality rate was 4.3%. 36.0% experienced complications. 66.5% underwent a resection at high-volume centres. In 2004, low-, medium- and high-volume centres resected 16.3%, 24.5% and 59.2% of patients, compared with 7.6%, 19.3% and 73.1% in 2011. High-volume centres had lower mortality (P < 0.001), fewer complications (P < 0.001) and a shorter median length of stay (P < 0.001). Patients at non-high-volume centres had more comorbidities (P = 0.001), lower rates of private insurance (P < 0.001) and more non-elective admissions (P < 0.001).
In spite of a shift to high-volume hospitals, a substantial cohort still receives a resection outside of these centres. Patients receiving non-high-volume care demonstrate less favourable comorbidities, insurance and urgency of operation. The implications are twofold: already disadvantaged patients may not benefit from the high-volume effect; and patients predisposed to do well may contribute to observed superior outcomes at high-volume centres.
胰腺手术中的容量效应已得到充分证实。有人提议将手术集中到高容量中心进行。但这一提议对实际手术模式的影响尚不清楚。
回顾性分析2004 - 2011年全国住院患者样本中的胰腺切除术患者。计算住院死亡率和并发症发生率。根据各中心每年的胰腺切除量将患者分层（低容量中心<5例，中等容量中心5 - 18例，高容量中心>18例）。多变量回归模型评估在高容量中心进行手术的预测因素。
共有129,609例患者接受了胰腺切除术。粗住院死亡率为4.3%。36.0%的患者出现并发症。66.5%的患者在高容量中心接受了手术。2004年，低容量、中等容量和高容量中心分别切除了16.3%、24.5%和59.2%的患者，而2011年这一比例分别为7.6%、19.3%和73.1%。高容量中心的死亡率更低（P < 0.001），并发症更少（P < 0.001），中位住院时间更短（P < 0.001）。非高容量中心的患者合并症更多（P = 0.001），私人保险覆盖率更低（P < 0.001），非择期入院率更高（P < 0.001）。
尽管手术有向高容量医院转移的趋势，但仍有相当一部分患者在这些中心以外接受手术。接受非高容量治疗的患者在合并症、保险情况和手术紧迫性方面表现较差。这有两方面的影响：本就处于不利地位的患者可能无法从高容量效应中获益；而原本预后良好的患者可能导致高容量中心出现更好的手术结果。
