Divisions of Gynecologic Surgery, Health Care Policy and Research, and Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; the Department of Medical and Surgical Gynecology, Mayo Clinic Hospital, Phoenix, Arizona; and the Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy.
Obstet Gynecol. 2018 Feb;131(2):304-311. doi: 10.1097/AOG.0000000000002428.
To assess how the widespread adoption of minimally invasive surgery in the United States is associated with changes in 30-day morbidity and mortality in endometrial cancer treatment.
In this retrospective cohort study, the American College of Surgeons' National Surgical Quality Improvement Project database for 2008-2014 was reviewed for patients who had undergone surgery for endometrial cancer according to their primary Current Procedural Terminology (CPT) codes. Women with CPT codes for advanced cancer or with disseminated disease were excluded. A trend analysis across the time period by surgical approach (open surgery through laparotomy, vaginal surgery, and minimally invasive surgery) was performed using a Cochran-Armitage test for trend. Thirty-day surgical outcomes were compared between patients who had minimally invasive surgery and open surgery. Inverse probability of treatment weighting models were used to investigate the independent effect of minimally invasive surgery on 30-day outcomes.
Overall, 12,283 patients met the inclusion criteria. A significant implementation of minimally invasive surgery (24.2-71.4%) and a concomitant decrease in open surgery through laparotomy (71.1-26.4%) were observed from 2008 to 2014 (both P<.001). Rate of vaginal surgery did not change over time (1.5-2.2%, P=.06). After adjusting for possible confounders, open surgery (compared with minimally invasive surgery) was independently associated with increased odds of major complications (n=347 versus n=274, adjusted odds ratio [OR] 2.4, 95% CI 2.0-2.8), readmission (n=269 versus n=238, adjusted OR 2.2, 95% CI 1.8-2.6), reoperation (n=80 versus n=93, adjusted OR 1.5, 95% CI 1.2-2.1), superficial surgical site infection (n=190 versus n=55, adjusted OR 6.8, 95% CI 5.0-9.2), perioperative transfusion (n=430 versus n=149, adjusted OR 5.9, 95% CI 4.8-7.1), and death (n=41 vs, n=20, adjusted OR 3.8, 95% CI 2.2-6.6). A comprehensive decrease in 30-day morbidity for the treatment of endometrial cancer overall was observed from 2008 to 2014 (P<.001), whereas 30-day mortality remained stable (P=.24).
The widespread adoption of minimally invasive surgery is associated with substantial decreases in 30-day morbidity, readmission, and reoperation for women treated for endometrial cancer in the United States.
评估美国广泛采用微创手术与子宫内膜癌治疗中 30 天发病率和死亡率变化的关系。
本回顾性队列研究分析了 2008 年至 2014 年美国外科医师学院国家手术质量改进计划数据库中接受子宫内膜癌手术的患者，这些患者根据其主要的现行操作术语（Current Procedural Terminology，CPT）代码进行分类。排除了 CPT 代码为晚期癌症或疾病扩散的患者。通过 Cochran-Armitage 趋势检验对手术方法（剖腹手术、阴道手术和微创手术）的时间趋势进行分析。比较接受微创手术和开放手术患者的 30 天手术结果。采用逆概率处理权重模型探讨微创手术对 30 天结局的独立影响。
总体而言，共有 12283 名患者符合纳入标准。从 2008 年到 2014 年，微创手术的实施显著增加（24.2%至 71.4%），同时剖腹手术的比例相应下降（71.1%至 26.4%）（均 P<.001）。阴道手术的比例在这段时间内没有变化（1.5%至 2.2%，P=.06）。在调整了可能的混杂因素后，与微创手术相比，开放手术（n=347 与 n=274）的主要并发症（调整比值比[OR] 2.4，95%置信区间[CI] 2.0-2.8）、再入院（n=269 与 n=238，调整 OR 2.2，95% CI 1.8-2.6）、再次手术（n=80 与 n=93，调整 OR 1.5，95% CI 1.2-2.1）、浅表手术部位感染（n=190 与 n=55，调整 OR 6.8，95% CI 5.0-9.2）、围手术期输血（n=430 与 n=149，调整 OR 5.9，95% CI 4.8-7.1）和死亡（n=41 与 n=20，调整 OR 3.8，95% CI 2.2-6.6）的风险更高。2008 年至 2014 年，子宫内膜癌整体 30 天发病率呈显著下降趋势（P<.001），而 30 天死亡率保持稳定（P=.24）。
美国广泛采用微创手术与子宫内膜癌治疗中 30 天发病率、再入院率和再次手术率的大幅下降有关。
