Section of Colon and Rectal Surgery, Division of General Surgery, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA.
Departments of Anesthesiology and Biomedical Informatics, Vanderbilt University, Nashville, TN, USA.
Surg Endosc. 2018 Feb;32(2):1035-1042. doi: 10.1007/s00464-017-5782-8. Epub 2017 Aug 24.
Level one evidence has shown that minimally invasive surgery (MIS) for colon cancer improves short-term outcomes with equivalent long-term oncologic results when compared to open surgery. However, the adoption of MIS for patients with colon cancer has not been universal. The goal of this study is to identify barriers to the use of MIS surgery in colon cancer resection across the United States.
The National Cancer Database was queried for all cases of colonic adenocarcinoma resection from 2010 to 2012. Patients undergoing an MIS approach were compared with those undergoing open surgery (OS). MIS was defined as either robotic or laparoscopic surgery. Patients with metastatic disease, surgery for palliation, or tumors >8 cm were excluded. Multivariable modeling was used to identify variables associated with the use of open surgery.
After applying exclusion criteria, 124,205 cases were identified. An MIS approach was used in only 54,621 (44%) patients. In a multivariable model adjusting for stage and tumor size, a number of important factors were associated with decreased odds of a MIS approach including black race (OR .91; p < .0001), lack of insurance (OR .51; p < .0001), lower education (OR .88; p < .0001), lower income (OR .83; p < .0001), treatment at a community program (OR .86; p < .0001), and treatment at a low-volume center (OR .79; p < .0001). Utilization of MIS increased over the study period (2010: 38.7%, 2011: 44.0%, 2012: 49.1%; p < .0001).
MIS approach is utilized in less than half of all colon resections in this national database, which accounts for over 70% of all diagnosed cancers in the US. Significant variability exists among age, race, insurance status, socioeconomic status, region, and facility type. In light of the recognized benefits of the MIS approach, local and national policy should focus on narrowing these disparities and continuing the upward trend of MIS utilization.
一级证据表明，与开放性手术相比，微创外科（MIS）治疗结肠癌可改善短期预后，同时获得同等的长期肿瘤学结果。然而，MIS 并未被普遍应用于结肠癌患者。本研究旨在确定美国结肠癌切除术使用 MIS 手术的障碍。
从 2010 年至 2012 年，国家癌症数据库对所有结肠腺癌切除术病例进行了查询。接受 MIS 方法的患者与接受开放性手术（OS）的患者进行了比较。MIS 定义为机器人或腹腔镜手术。排除转移性疾病、姑息性手术或肿瘤>8cm 的患者。多变量模型用于确定与开放性手术使用相关的变量。
在应用排除标准后，共确定了 124205 例病例。仅 54621（44%）例患者采用 MIS 方法。在调整分期和肿瘤大小的多变量模型中，许多重要因素与降低 MIS 方法的可能性相关，包括黑种人（OR.91；p<.0001）、无保险（OR.51；p<.0001）、教育程度较低（OR.88；p<.0001）、收入较低（OR.83；p<.0001）、在社区项目治疗（OR.86；p<.0001）和在低容量中心治疗（OR.79；p<.0001）。在研究期间，MIS 的使用率增加（2010 年：38.7%，2011 年：44.0%，2012 年：49.1%；p<.0001）。
在这个国家数据库中，MIS 方法仅用于不到一半的所有结肠切除术，占美国所有诊断癌症的 70%以上。年龄、种族、保险状况、社会经济地位、地区和医疗机构类型之间存在显著差异。鉴于 MIS 方法的公认益处，地方和国家政策应侧重于缩小这些差距，并继续提高 MIS 的使用率。
