结直肠癌手术中医院及外科医生手术量与治疗结果关系的系统评价与Meta分析
Systematic review and a meta-analysis of hospital and surgeon volume/outcome relationships in colorectal cancer surgery.
作者信息
Huo Ya Ruth, Phan Kevin, Morris David L, Liauw Winston
机构信息
Hepatobiliary and Surgical Oncology Unit, UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia.
Faculty of Medicine, St George Clinical School, UNSW Australia, Kensington, NSW, Australia.
出版信息
J Gastrointest Oncol. 2017 Jun;8(3):534-546. doi: 10.21037/jgo.2017.01.25.
BACKGROUND
Numerous hospitals worldwide are considering setting minimum volume standards for colorectal surgery. This study aims to examine the association between hospital and surgeon volume on outcomes for colorectal surgery.
METHODS
Two investigators independently reviewed six databases from inception to May 2016 for articles that reported outcomes according to hospital and/or surgeon volume. Eligible studies included those in which assessed the association hospital or surgeon volume with outcomes for the surgical treatment of colon and/or rectal cancer. Random effects models were used to pool the hazard ratios (HRs) for the association between hospital/surgeon volume with outcomes.
RESULTS
There were 47 articles pooled (1,122,303 patients, 9,877 hospitals and 9,649 surgeons). The meta-analysis demonstrated that there is a volume-outcome relationship that favours high volume facilities and high volume surgeons. Higher hospital and surgeon volume resulted in reduced 30-day mortality (HR: 0.83; 95% CI: 0.78-0.87, P<0.001 & HR: 0.84; 95% CI: 0.80-0.89, P<0.001 respectively) and intra-operative mortality (HR: 0.82; 95% CI: 0.76-0.86, P<0.001 & HR: 0.50; 95% CI: 0.40-0.62, P<0.001 respectively). Post-operative complication rates depended on hospital volume (HR: 0.89; 95% CI: 0.81-0.98, P<0.05), but not surgeon volume except with respect to anastomotic leak (HR: 0.59; 95% CI: 0.37-0.94, P<0.01). High volume surgeons are associated with greater 5-year survival and greater lymph node retrieval, whilst reducing recurrence rates, operative time, length of stay and cost. The best outcomes occur in high volume hospitals with high volume surgeons, followed by low volume hospitals with high volume surgeons.
CONCLUSIONS
High volume by surgeon and high volume by hospital are associated with better outcomes for colorectal cancer surgery. However, this relationship is non-linear with no clear threshold of effect being identified and an apparent ceiling of effect.
背景
全球众多医院正在考虑制定结直肠手术的最低手术量标准。本研究旨在探讨医院手术量和外科医生手术量与结直肠手术结局之间的关联。
方法
两名研究者独立检索了6个数据库，检索时间从建库至2016年5月，查找报告了根据医院和/或外科医生手术量得出的结局的文章。符合条件的研究包括那些评估医院或外科医生手术量与结肠癌和/或直肠癌手术治疗结局之间关联的研究。采用随机效应模型汇总医院/外科医生手术量与结局之间关联的风险比（HRs）。
结果
共纳入47篇文章（1,122,303例患者、9,877家医院和9,649名外科医生）。荟萃分析表明，存在一种手术量-结局关系，即高手术量的机构和高手术量的外科医生更具优势。更高的医院手术量和外科医生手术量可降低30天死亡率（HR分别为：0.83；95%CI：0.78 - 0.87，P<0.001和HR：0.84；95%CI：0.80 - 0.89，P<0.001）以及术中死亡率（HR分别为：0.82；95%CI：0.76 - 0.86，P<0.001和HR：0.50；95%CI：0.40 - 0.62，P<0.001）。术后并发症发生率取决于医院手术量（HR：0.89；95%CI：0.81 - 0.98，P<0.05），但除吻合口漏外不取决于外科医生手术量（HR：0.59；95%CI：0.37 - 0.94，P<0.01）。高手术量的外科医生与更高的5年生存率、更多的淋巴结清扫相关，同时降低复发率、手术时间、住院时间和费用。最佳结局出现在有高手术量外科医生的高手术量医院，其次是有高手术量外科医生的低手术量医院。
结论
外科医生高手术量和医院高手术量与结直肠癌手术更好的结局相关。然而，这种关系是非线性的，未发现明确的效应阈值，且存在明显的效应上限。
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