Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
J Am Coll Surg. 2021 Jun;232(6):864-871. doi: 10.1016/j.jamcollsurg.2021.01.017. Epub 2021 Feb 25.
The relationship between hospital volume and surgical outcomes is well-established; however, considerable socioeconomic and geographic barriers to high-volume care persist. This study assesses how the overall volume of hepatopancreaticobiliary (HPB) cancer operations impacts outcomes of liver resections (LRs).
The National Cancer Database (2004-2014) was queried for patients who underwent LR for hepatocellular carcinoma. Hospital volume was determined separately for all HPB operations and LRs. Centers were dichotomized as low and high volume based on the median number of operations. The following study cohorts were created: low-volume hospitals (LVHs) for both LRs and HPB operations, mixed-volume hospitals (MVHs) with low-volume LRs but high-volume HPB operations, and high-volume LR hospitals (HVHs) for both LRs and HPB operations.
Of 7,265 patients identified, 37.5%, 8.8%, and 53.7% were treated at LVHs, MVHs, and HVHs, respectively. On multivariable analysis, patients treated at LVHs had higher 30-day mortality compared with patients treated at HVHs (odds ratio 1.736; p < 0.001). However, patients treated at MVHs experienced 30-day mortality comparable with patients treated at HVHs (odds ratio 0.789; p = 0.318). Similar results were found for positive margin status, prolonged hospital stay, and overall survival.
LR outcomes at low-volume LR centers that have substantial experience with HPB cancer operations are similar to those at high-volume LR centers. Our results demonstrate that the volume to outcomes curve for HPB operations should be assessed more holistically and that patients can safely undergo liver operations at low-volume LR centers if HPB volume criteria are met.
医院容量与手术结果之间的关系已得到充分证实；然而，高容量护理仍然存在相当大的社会经济和地理障碍。本研究评估了肝胰胆 (HPB) 癌症手术的总体数量如何影响肝切除术 (LR) 的结果。
国家癌症数据库 (2004-2014 年) 对接受肝细胞癌 LR 的患者进行了查询。分别确定所有 HPB 手术和 LR 的医院容量。根据手术数量的中位数，将中心分为低容量 (LVH) 和高容量 (HVH)。创建了以下研究队列：LR 和 HPB 手术均为低容量医院 (LVH)、LR 低容量但 HPB 手术高容量的混合容量医院 (MVH) 以及 LR 和 HPB 手术均为高容量医院 (HVH)。
在确定的 7265 名患者中，分别有 37.5%、8.8%和 53.7%在 LVH、MVH 和 HVH 接受治疗。多变量分析显示，与 HVH 治疗的患者相比，LVH 治疗的患者 30 天死亡率更高 (比值比 1.736；p < 0.001)。然而，MVH 治疗的患者 30 天死亡率与 HVH 治疗的患者相似 (比值比 0.789；p = 0.318)。阳性切缘状态、住院时间延长和总生存情况也得到了类似的结果。
在具有大量 HPB 癌症手术经验的低容量 LR 中心进行 LR 的结果与高容量 LR 中心相似。我们的结果表明，应该更全面地评估 HPB 手术的容量与结果曲线，如果符合 HPB 容量标准，患者可以在低容量 LR 中心安全地进行肝脏手术。
