Henneman Daniel, Dikken Johan L, Putter Hein, Lemmens Valery E P P, Van der Geest Lydia G M, van Hillegersberg Richard, Verheij Marcel, van de Velde Cornelis J H, Wouters Michel W J M
Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands,
Ann Surg Oncol. 2014 Dec;21(13):4068-74. doi: 10.1245/s10434-014-3873-5. Epub 2014 Jul 9.
This study was designed to define a statistically sound and clinically meaningful cutoff point for annual hospital volume for esophagectomy. Higher hospital volumes are associated with improved outcomes after esophagectomy. However, reported optimal volumes in literature vary, and minimal volume standards in different countries show considerable variation. So far, there has been no research on the noncategorical, nonlinear, volume-outcome relationship in esophagectomy.
Data were derived from the Netherlands Cancer Registry. Restricted cubic splines were used to investigate the nonlinear effects of annual hospital volume on 6 month and 2 year mortality rates. Outcomes were adjusted for year of diagnosis, case-mix, and (neo)adjuvant treatment.
Between 1989 and 2009, 10,025 patients underwent esophagectomy for cancer in the Netherlands. Annual hospital volumes varied between 1 and 83 year, increasing over time. Increasing annual hospital volume showed a continuous, nonlinear decrease in hazard ratio (HR) for mortality along the curve. Increasing hospital volume from 20 year (baseline, HR = 1.00) to 40 and 60 year was associated with decreasing 6 month mortality, with a HR of 0.73 (95 % confidence interval (0.65-0.83) and 0.67 (0.58-0.77) respectively. Beyond 60 year, no further decrease was detected. Higher hospital volume also was associated with decreasing 2 year mortality until 50 esophagectomies year with a HR of 0.86 (0.79-0.93).
Centralization of esophagectomy to a minimum of 20 resections/year has been effectively introduced in the Netherlands. Increasing annual hospital volume was associated with a nonlinear decrease in mortality up to 40-60 esophagectomies/year, after which a plateau was reached. This finding may guide quality improvement efforts worldwide.
本研究旨在确定食管癌切除术年度医院手术量的统计学合理且具有临床意义的临界值。更高的医院手术量与食管癌切除术后更好的预后相关。然而，文献报道的最佳手术量各不相同，不同国家的最低手术量标准也存在显著差异。到目前为止，尚未有关于食管癌切除术非分类、非线性的手术量 - 预后关系的研究。
数据来源于荷兰癌症登记处。使用受限立方样条来研究年度医院手术量对6个月和2年死亡率的非线性影响。对诊断年份、病例组合和（新）辅助治疗进行了结果调整。
1989年至2009年期间，荷兰有10,025例患者因癌症接受了食管癌切除术。年度医院手术量在每年1至83例之间变化，且随时间增加。年度医院手术量的增加显示死亡率的风险比（HR）沿曲线呈连续、非线性下降。将医院手术量从每年20例（基线，HR = 1.00）增加到40例和60例与6个月死亡率降低相关，HR分别为0.73（95%置信区间（0.65 - 0.83））和0.67（0.58 - 0.77）。超过60例后，未检测到进一步下降。更高的医院手术量也与2年死亡率降低相关，直至每年50例食管癌切除术，HR为0.86（0.79 - 0.93）。
荷兰已有效推行将食管癌切除术集中至每年至少20例切除。年度医院手术量的增加与死亡率的非线性下降相关，直至每年40 - 60例食管癌切除术，此后达到平稳状态。这一发现可能会指导全球范围内的质量改进工作。
