Kagedan Daniel J, Goyert Nik, Li Qing, Paszat Lawrence, Kiss Alexander, Earle Craig C, Karanicolas Paul J, Wei Alice C, Mittmann Nicole, Coburn Natalie G
Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
J Gastrointest Surg. 2017 Mar;21(3):506-515. doi: 10.1007/s11605-016-3346-1. Epub 2017 Jan 5.
Performance of pancreaticoduodenectomy (PD) in high-volume centers has been posited to improve postoperative morbidity and mortality, consistent with the volume-outcomes hypothesis. We sought to evaluate the impact of hospital volume on 90-day PD outcomes at hepatopancreatobiliary (HPB) centers within a regionalized system.
A retrospective population-based observational cohort study was performed, using administrative records of patients undergoing PD between 2005 and 2013 in Ontario, Canada. Postoperative administrative codes were used to define complications. Patients' 90-day postoperative outcomes were compared between center-volume categories using chi-square tests and multivariable regression. Volume cutoffs were defined using minimal regional standards (20PD/year), with assessment of the impact of further volume increases.
Of 2660 patients, 2563 underwent PD at HPB centers. Of these, 38.9% underwent surgery at higher-volume centers (>40 PD/year), 36.9% at medium-volume centers (20-39 PD/year), and 24.1% at lower-volume centers (10-19 PD/year). Mortality (30- and 90-day) was lowest at higher-volume hospitals (1.5%, 2.7%, respectively) compared to medium-volume (3.9%, 6.3%) and lower-volume hospitals (2.9%, 5.2%) (p < 0.01). Patients treated at higher- and medium-volume centers had lower reoperation rates (10.3%, 10.7% vs. 16.7%, p = 0.0002) and less prolonged length of stay (23.2%, 22.0% vs. 31.6%, p < 0.0001) compared to lower-volume centers.
Progressive increases in hospital volume correspond to improved 90-day outcomes following PD.
根据手术量-预后假说，在高手术量中心开展胰十二指肠切除术（PD）被认为可降低术后发病率和死亡率。我们旨在评估医院手术量对区域化系统内肝胆胰（HPB）中心90天PD预后的影响。
进行一项基于人群的回顾性观察队列研究，使用2005年至2013年在加拿大安大略省接受PD患者的行政记录。术后行政编码用于定义并发症。使用卡方检验和多变量回归比较不同中心手术量类别的患者90天术后预后。手术量临界值根据最低区域标准（每年20例PD）确定，并评估手术量进一步增加的影响。
2660例患者中，2563例在HPB中心接受了PD。其中，38.9%在高手术量中心（每年>40例PD）接受手术，36.9%在中等手术量中心（每年20 - 39例PD），24.1%在低手术量中心（每年10 - 19例PD）。与中等手术量医院（3.9%，6.3%）和低手术量医院（2.9%，5.2%）相比，高手术量医院的死亡率（30天和90天）最低（分别为1.5%，2.7%）（p < 0.01）。与低手术量中心相比，在高手术量和中等手术量中心接受治疗的患者再次手术率较低（10.3%，10.7%对16.7%，p = 0.0002），住院时间延长的比例也较低（23.2%，22.0%对31.6%，p < 0.0001）。
医院手术量的逐步增加与PD术后90天预后改善相关。
