Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY.
Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY; Division of Colorectal Surgery, University of Rochester Medical Center, Rochester, NY.
Surgery. 2018 Feb;163(2):305-310. doi: 10.1016/j.surg.2017.07.024. Epub 2017 Oct 13.
This study identified variation and factors associated with ileal pouch-anal anastomosis after total colectomy for ulcerative colitis.
The Statewide Planning & Research Cooperative System was used to identify patients with ulcerative colitis who underwent total colectomy in New York state from 2000-2013. Bivariate and mixed-effects multivariable analyses were performed to assess patient, surgeon, and hospital-level factors as well as surgeon and hospital-level variation associated with ileal pouch-anal anastomosis after total colectomy.
Across 2,203 patients, the rate of ileal pouch-anal anastomosis was 34%. Overall, 465 surgeons and 148 hospitals performed at least one total colectomy for ulcerative colitis from 2000-2013, and 178 surgeons and 80 hospitals performed at least one ileal pouch-anal anastomosis for ulcerative colitis during the study period. The median rate of ileal pouch-anal anastomosis creation was 14% (range = 6% to 69%) across surgeons and 14% (range = 7% to 63%) across hospitals. Patient-level factors independently associated with ileal pouch-anal anastomosis were younger age, lower comorbidity burden, and elective total colectomy. Surgeon and hospital-level factors independently associated with ileal pouch-anal anastomosis were colorectal surgery board-certification, surgeon ileal pouch-anal anastomosis volume, and hospital ileal pouch-anal anastomosis volume. Patient-level factors explained 43% of the surgeon and 47% of the hospital variation in ileal pouch-anal anastomosis creation while surgeon-level factors explained 26% of the surgeon and 21% of the hospital variation.
These findings suggest that variation in ileal pouch-anal anastomosis creation for ulcerative colitis is influenced largely by provider practices/preferences or lack of referral of patients after colectomy to surgeons and centers that perform ileal pouch-anal anastomosis. Providers and hospitals that do not routinely perform ileal pouch-anal anastomosis should refer patients to centers with ileal pouch-anal anastomosis expertise after total colectomy.
本研究旨在确定全结肠切除术后行回肠贮袋肛管吻合术的变化情况及相关因素，以评估溃疡性结肠炎患者的治疗效果。
利用全州规划和研究合作系统，对 2000 年至 2013 年间纽约州行全结肠切除术的溃疡性结肠炎患者进行回顾性分析。采用二变量和混合效应多变量分析，评估患者、外科医生和医院层面的因素，以及与全结肠切除术后行回肠贮袋肛管吻合术相关的外科医生和医院层面的变异性。
在 2203 例患者中，行回肠贮袋肛管吻合术的比例为 34%。总体而言，2000 年至 2013 年间，共有 465 名外科医生和 148 家医院至少进行了一次全结肠切除术治疗溃疡性结肠炎，在此期间，有 178 名外科医生和 80 家医院至少进行了一次回肠贮袋肛管吻合术治疗溃疡性结肠炎。外科医生层面的中位回肠贮袋肛管吻合术创建率为 14%（范围为 6%至 69%），医院层面的中位创建率为 14%（范围为 7%至 63%）。患者年龄较小、合并症负担较低以及择期行全结肠切除术等患者层面的因素与行回肠贮袋肛管吻合术独立相关。外科医生和医院层面的独立相关因素为结直肠外科委员会认证、外科医生行回肠贮袋肛管吻合术的例数以及医院行回肠贮袋肛管吻合术的例数。患者层面的因素可解释外科医生和医院层面在创建回肠贮袋肛管吻合术方面变异的 43%和 47%，而外科医生层面的因素可解释外科医生和医院层面变异的 26%和 21%。
这些发现表明，溃疡性结肠炎患者行回肠贮袋肛管吻合术的变化在很大程度上受到提供者实践/偏好或缺乏对行全结肠切除术后的患者进行转介的影响，以转至行回肠贮袋肛管吻合术的外科医生和中心。不常规行回肠贮袋肛管吻合术的外科医生和医院应在全结肠切除术后将患者转介至具有回肠贮袋肛管吻合术专长的中心。
