Odagiri Hiroyuki, Yasunaga Hideo, Matsui Hiroki, Fushimi Kiyohide, Iizuka Toshiro, Kaise Mitsuru
1 Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan 2 Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan 3 Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan.
Dis Colon Rectum. 2015 Jun;58(6):597-603. doi: 10.1097/DCR.0000000000000335.
Colorectal endoscopic submucosal dissection has gained popularity as a minimally invasive technique for the treatment of colorectal neoplasms in many countries, including Japan. However, most previous studies of endoscopic submucosal dissection had relatively small sample sizes and only included patients treated at specialized centers. Associations between hospital volume and complication rates after colorectal endoscopic submucosal dissection are still poorly understood.
Our aim was to clarify the relationships between hospital volume and the occurrence rates of bleeding and perforation after colorectal endoscopic submucosal dissection.
This was a retrospective cohort study. Hospital volume was defined as the number of colorectal endoscopic submucosal dissections performed at each hospital between April 2012 and March 2013 and was categorized into the following quartiles: 1) very low-volume (18 or less patients during the year), 2) low-volume (19-35 patients), 3) high-volume (36-58 patients), and 4) very high-volume (59 or more).
This study was based on a national inpatient data from the Japanese Diagnosis Procedure Combination database.
A total of 7567 patients with colorectal endoscopic submucosal dissection were included.
Severe postoperative bleeding requiring endoscopic hemostasis or blood transfusion within 1 week after endoscopic submucosal dissection and perforation requiring open surgery were the main outcomes measured.
Severe postoperative bleeding and perforation occurred in 331 (4.4%) and 13 patients (0.2%). Multivariable logistic regression analysis showed that the very high hospital volume group had a significantly lower proportion of severe postoperative bleeding than the very low hospital volume group (OR = 0.48 [95 % CI, 0.27-0.83]; p = 0.009).
This study lacked some information on clinicopathologic features including en bloc resection, curative resection, and relapse. Individual endoscopist experience could not be analyzed.
The present study clearly showed a significant association between higher hospital volume and lower occurrence of severe postoperative bleeding.
在包括日本在内的许多国家，大肠内镜黏膜下剥离术已成为一种治疗大肠肿瘤的微创技术并受到广泛欢迎。然而，此前大多数关于内镜黏膜下剥离术的研究样本量相对较小，且仅纳入了在专科中心接受治疗的患者。目前对于医院手术量与大肠内镜黏膜下剥离术后并发症发生率之间的关联仍知之甚少。
我们的目的是阐明医院手术量与大肠内镜黏膜下剥离术后出血和穿孔发生率之间的关系。
这是一项回顾性队列研究。医院手术量定义为每家医院在2012年4月至2013年3月期间进行的大肠内镜黏膜下剥离术的数量，并分为以下四分位数：1）极低手术量（每年18例或更少患者），2）低手术量（19 - 35例患者），3）高手术量（36 - 58例患者），4）极高手术量（59例或更多）。
本研究基于日本诊断程序组合数据库的全国住院患者数据。
总共纳入了7567例行大肠内镜黏膜下剥离术的患者。
主要观察指标为内镜黏膜下剥离术后1周内需要内镜止血或输血的严重术后出血以及需要进行开放手术的穿孔。
严重术后出血和穿孔分别发生在331例（4.4%）和13例（0.2%）患者中。多变量逻辑回归分析显示，极高医院手术量组的严重术后出血比例显著低于极低医院手术量组（比值比 = 0.48 [95%置信区间，0.27 - 0.83]；p = 0.009）。
本研究缺乏一些关于临床病理特征的信息，包括整块切除、根治性切除和复发情况。无法分析个体内镜医师的经验。
本研究清楚地表明，较高的医院手术量与较低的严重术后出血发生率之间存在显著关联。
