Adam Mohamed Abdelgadir, Thomas Samantha, Youngwirth Linda, Pappas Theodore, Roman Sanziana A, Sosa Julie A
Department of Surgery, Duke University Medical Center, Durham, North Carolina.
Department of Biostatistics, Duke University, Durham, North Carolina.
JAMA Surg. 2017 Apr 1;152(4):336-342. doi: 10.1001/jamasurg.2016.4753.
There is increasing interest in expanding use of minimally invasive pancreaticoduodenectomy (MIPD). This procedure is complex, with data suggesting a significant association between hospital volume and outcomes.
To determine whether there is an MIPD hospital volume threshold for which patient outcomes could be optimized.
DESIGN, SETTING, AND PARTICIPANTS: Adult patients undergoing MIPD were identified from the Healthcare Cost and Utilization Project National Inpatient Sample from 2000 to 2012. Multivariable models with restricted cubic splines were used to identify a hospital volume threshold by plotting annual hospital volume against the adjusted odds of postoperative complications. The current analysis was conducted on August 16, 2016.
Incidence of any complication.
Of the 865 patients who underwent MIPD, 474 (55%) were male and the median patient age was 67 years (interquartile range, 59-74 years). Among the patients, 747 (86%) had cancer and 91 (11%) had benign conditions/pancreatitis. Overall, 410 patients (47%) had postoperative complications and 31 (4%) died in-hospital. After adjustment for demographic and clinical characteristics, increasing hospital volume was associated with reduced complications (overall association P < .001); the likelihood of experiencing a complication declined as hospital volume increased up to 22 cases per year (95% CI, 21-23). Median hospital volume was 6 cases per year (range, 1-60). Most patients (n = 717; 83%) underwent the procedure at low-volume (≤22 cases per year) hospitals. After adjustment for patient mix, undergoing MIPD at low- vs high-volume hospitals was significantly associated with increased odds for postoperative complications (odds ratio, 1.74; 95% CI, 1.03-2.94; P = .04).
Hospital volume is significantly associated with improved outcomes from MIPD, with a threshold of 22 cases per year. Most patients undergo MIPD at low-volume hospitals. Protocols outlining minimum procedural volume thresholds should be considered to facilitate safer dissemination of MIPD.
扩大微创胰十二指肠切除术（MIPD）的应用越来越受到关注。该手术复杂，数据表明医院手术量与手术结果之间存在显著关联。
确定是否存在一个能使患者手术结果达到最佳的MIPD医院手术量阈值。
设计、设置和参与者：从2000年至2012年的医疗成本和利用项目国家住院样本中识别接受MIPD的成年患者。使用带有受限立方样条的多变量模型，通过绘制年度医院手术量与术后并发症调整后的比值比来确定医院手术量阈值。当前分析于2016年8月16日进行。
任何并发症的发生率。
在865例行MIPD的患者中，474例（55%）为男性，患者年龄中位数为67岁（四分位间距，59 - 74岁）。患者中，747例（86%）患有癌症，91例（11%）患有良性疾病/胰腺炎。总体而言，410例患者（47%）出现术后并发症，31例（4%）在住院期间死亡。在对人口统计学和临床特征进行调整后，医院手术量增加与并发症减少相关（总体关联P <.001）；随着医院手术量增加至每年22例，发生并发症的可能性下降（95%CI，21 - 23）。医院手术量中位数为每年6例（范围，1 - 60）。大多数患者（n = 717；83%）在低手术量（每年≤22例）医院接受该手术。在对患者构成进行调整后，在低手术量医院与高手术量医院接受MIPD与术后并发症发生几率增加显著相关（比值比，1.74；95%CI，1.03 - 2.94；P =.04）。
医院手术量与MIPD术后结果改善显著相关，阈值为每年22例。大多数患者在低手术量医院接受MIPD。应考虑制定概述最低手术量阈值的方案，以促进MIPD更安全地推广。
