Gani Faiz, Cerullo Marcelo, Zhang XuFeng, Canner Joseph K, Conca-Cheng Alison, Hartzman Alan E, Husain Syed G, Cirocco William C, Traugott Amber L, Arnold Mark W, Johnston Fabian M, Pawlik Timothy M
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
Surgery. 2017 Oct;162(4):880-890. doi: 10.1016/j.surg.2017.06.018. Epub 2017 Aug 10.
Although the relationship between laparoscopic surgery and improved clinical outcomes has been well established across a variety of procedures, the effect of operative experience with laparoscopic surgery remains less defined. The present study sought to assess the comparative benefit of laparoscopic colorectal surgery relative to surgeon volume.
Commercially insured patients aged 18 to 64 years undergoing a colorectal resection were identified using the MarketScan Database from 2010-2014. Multivariable logistic regression analysis was used to calculate and compare postoperative mortality/morbidity by operative approach relative to surgeon volume.
A total of 21,827 patients were identified who met inclusion criteria. The median age among patients was 53 years (interquartile range: 46-59) with a slight majority of patients being female (n = 11,248, 51.5%). Laparoscopic operations were performed in 49.2% of patients (n = 10,756), whereas 50.7% (n = 11,071) underwent an open colorectal resection. On multivariable analysis, laparoscopic surgery was associated with 64% decreased odds of developing a postoperative complication or mortality (odds ratio = 0.36, 95% confidence interval, 0.32-0.41, P < .001). Patients who underwent colectomy performed by a higher operative volume surgeon (high versus low: odds ratio = 0.68, 95% confidence interval, 0.61-0.77, P < .001) demonstrated decreased odds of developing a postoperative complication/mortality. Interestingly the potential decrease in risk-adjusted morbidity/mortality between laparoscopic and open surgery was somewhat greater among high-operative-volume surgeons (odds ratio = 0.29, 95% confidence interval, 0.25-0.34, P < .001) and intermediate-operative-volume surgeons (odds ratio = 0.30, 95% confidence interval, 0.25-0.36, P < .001) compared with low-operative-volume surgeons (odds ratio = 0.36, 95% confidence interval, 0.32-0.41, P < .001).
Although laparoscopic surgery was associated with improved postoperative clinical outcomes, the effect of laparoscopic surgery varied somewhat according to surgeon volume.
尽管腹腔镜手术与多种手术方式中改善的临床结局之间的关系已得到充分证实，但腹腔镜手术的手术经验的影响仍不太明确。本研究旨在评估腹腔镜结直肠手术相对于外科医生手术量的比较效益。
使用2010 - 2014年的MarketScan数据库识别年龄在18至64岁之间接受结直肠切除术的商业保险患者。采用多变量逻辑回归分析，计算并比较相对于外科医生手术量的手术方式的术后死亡率/发病率。
共识别出21,827例符合纳入标准的患者。患者的中位年龄为53岁（四分位间距：46 - 59岁），女性患者略占多数（n = 11,248，51.5%）。49.2%的患者（n = 10,756）接受了腹腔镜手术，而50.7%（n = 11,071）接受了开放性结直肠切除术。在多变量分析中，腹腔镜手术与术后发生并发症或死亡的几率降低64%相关（优势比 = 0.36，95%置信区间，0.32 - 0.41，P <.001）。由手术量较高的外科医生进行结肠切除术的患者（高手术量与低手术量：优势比 = 0.68，95%置信区间, 0.61 - 0.77，P <.001）发生术后并发症/死亡的几率降低。有趣的是，与低手术量外科医生（优势比 = 0.36，95%置信区间，0.32 - 0.41，P <.001）相比，高手术量外科医生（优势比 = 0.29，95%置信区间，0.25 - 0.34，P <.001）和中等手术量外科医生（优势比 = 0.30，95%置信区间，0.25 - 0.36，P <.001）在腹腔镜手术和开放手术之间经风险调整后的发病率/死亡率的潜在降低幅度更大。
尽管腹腔镜手术与术后临床结局改善相关，但腹腔镜手术效果根据外科医生手术量有所不同。
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