MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Georgetown University School of Medicine, Washington, DC.
MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Hyattsville, MD.
Surgery. 2022 Feb;171(2):293-298. doi: 10.1016/j.surg.2021.06.031. Epub 2021 Aug 22.
Laparoscopic colectomy is considered the standard of care in colon cancer treatment when appropriate expertise is available. However, guidelines do not delineate what experience is required to implement this approach safely and effectively. This study aimed to establish a data-derived, hospital-level annual volume threshold for laparoscopic colectomy at which patient outcomes are optimized.
This evaluation included 44,157 stage I to III adenocarcinoma patients aged ≥40 years who underwent laparoscopic colon resection between 2010 and 2015 within the National Cancer Database. The primary outcome was overall survival, with 30- and 90-day mortality, duration of stay, days to receipt of chemotherapy, and number of lymph nodes examined as secondary. Segmented logistic and Cox regression models were used to identify volume thresholds which optimized these outcomes.
In hospitals performing ≥30 laparoscopic colectomies per year there were incremental improvements in overall survival for each additional resection beyond 30. Hospitals performing ≥30 procedures/year demonstrated improved 30-day mortality (1.3% vs 1.7%, P < .001), 90-day mortality (2.3% vs 2.9%, P < .001), and overall survival (84.3% vs 82.3%, P < .001). Those hospitals performing <30 procedures/year had no significant benefit in overall survival. Thresholds were not identified for any other outcomes. Results were comparable in colon cancer patients with stage IV or multiple cancers.
A high-volume hospital threshold of ≥30 cases/year for laparoscopic colectomies is associated with improved patient survival and outcomes. A minimum volume standard may help providers determine which approach is most suitable for their hospital's practice as open procedures may yield better oncologic results in low volume settings.
腹腔镜结直肠切除术在有适当专业知识的情况下被认为是结肠癌治疗的标准治疗方法。然而，指南并没有规定实施这种方法的经验要求，以确保其安全有效。本研究旨在建立一个数据衍生的、基于医院水平的年度腹腔镜结直肠切除术量阈值，使患者的治疗效果达到最佳。
本评估纳入了 2010 年至 2015 年间在国家癌症数据库中接受腹腔镜结肠切除术的 44157 名年龄≥40 岁的 I 期至 III 期腺癌患者。主要结局是总生存率，次要结局包括 30 天和 90 天死亡率、住院时间、接受化疗的时间以及检查的淋巴结数量。使用分段逻辑回归和 Cox 回归模型来确定优化这些结局的容量阈值。
在每年进行≥30 例腹腔镜结直肠切除术的医院中，每年每增加 30 例以上的手术，总生存率都会有所提高。每年进行≥30 例手术的医院 30 天死亡率（1.3%比 1.7%，P<0.001）、90 天死亡率（2.3%比 2.9%，P<0.001）和总生存率（84.3%比 82.3%，P<0.001）均得到改善。而每年进行<30 例手术的医院在总生存率方面没有显著获益。其他结局也没有确定阈值。在患有 IV 期或多种癌症的结肠癌患者中，结果是可比的。
腹腔镜结直肠切除术的高容量医院阈值≥30 例与患者生存和结局的改善相关。最低容量标准可能有助于提供者确定哪种方法最适合其医院的实践，因为在低容量环境下，开放手术可能会产生更好的肿瘤学结果。
