Rajan Sendhil, Gracie Dale, Aspinall Sebastian
General and Endocrine Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, AB25 2ZN, UK.
Paediatric Surgery, Royal Hospital of Children and Young People, Edinburgh, UK.
World J Surg. 2023 May;47(5):1221-1230. doi: 10.1007/s00268-022-06863-9. Epub 2023 Jan 2.
Outcomes in endocrine surgery have been shown to improve with surgeon volume. We aimed to study the effect of surgeon volume on morbidity following parathyroidectomy.
UKRETS data from 2004 to 2019 was studied. Parathyroidectomies for primary hyperparathyroidism with complete data were included. Exclusion criteria were age <18 or >80 years; surgeons contributing <10 cases overall; and length of stay >28 days. Multivariable analysis was performed. Primary outcome was persistent hypercalcaemia; secondary outcomes were haemorrhage, length of stay, need for re-admission, post-operative hypocalcaemia, and need for calcium/vitamin D supplements to maintain eucalcaemia at 6 months.
153 surgeons undertook mean 22.5 (median 17, range 2-115) parathyroidectomies/year. Persistent hypercalcaemia affected 4.8% (776/16140) overall; 5.7% (71/1242) in surgeons undertaking < 10 cases/year; 5.1% (3339/6617) for 10-30 cases/year; 5.0% (270/5397) for 30-50 cases; and 3.3% (96/2884) for >50 cases/year. High-volume (>50 parathyroidectomies/year) surgeons operated 23.4% (809/3464) of negative localisation cases compared to 16.4% (2074/12676) of positive localisation cases. Persistent hypercalcaemia was almost twice as common in image negative (7.9%) compared to image-positive (4%) cases. Persistent hypercalcaemia was significantly more likely to occur in the low volume (<10 parathyroidectomies/year) group than high volume (>50 parathyroidectomies/year), regardless of image positivity (p = 0.0006). Surgeon volume significantly reduced persistent hypercalcaemia on multivariable analysis (OR = 0.878, 95%CI 0.842-0.914, p < 0.001), along with age, sex, and positive localisation. BNE and re-operation significantly increased persistent hypercalcaemia. Post-operative hypocalcaemia occurred in 3.2% (509/16040) and was reduced with increasing surgeon volume (OR = 0.951, 95%CI 0.910-0.993, p < 0.001). Haemorrhage and length of stay were not significantly associated with surgeon volume.
The incidence of persistent hypercalcaemia, post-operative hypocalcaemia, and persistent hypoparathyroidism decreased with increasing surgeon volume. The relative reduction in persistent hypercalcaemia with surgeon volume was similar in image negative and positive groups, but the absolute reduction was higher in image negative cases. Restricting image negative parathyroidectomy to high-volume surgeons could be considered.
内分泌手术的预后已显示会随着外科医生的手术量增加而改善。我们旨在研究外科医生手术量对甲状旁腺切除术后发病率的影响。
研究了2004年至2019年英国甲状腺和内分泌外科学会（UKRETS）的数据。纳入了有完整数据的原发性甲状旁腺功能亢进症的甲状旁腺切除术。排除标准为年龄<18岁或>80岁；总体手术量<10例的外科医生；以及住院时间>28天。进行了多变量分析。主要结局是持续性高钙血症；次要结局是出血、住院时间、再次入院需求、术后低钙血症以及6个月时维持血钙正常所需的钙/维生素D补充剂。
153名外科医生每年平均进行22.5例（中位数17例，范围2 - 115例）甲状旁腺切除术。总体上，持续性高钙血症影响4.8%（776/16140）；每年手术量<10例的外科医生中为5.7%（71/1242）；每年手术量10 - 30例的为5.1%（3339/6617）；30 - 50例的为5.0%（270/5397）；每年手术量>50例的为3.3%（96/2884）。高手术量（每年>50例甲状旁腺切除术）的外科医生进行了23.4%（809/3464）的阴性定位病例手术，而阳性定位病例为16.4%（2074/12676）。与影像阳性（4%）病例相比，影像阴性（7.9%）病例中持续性高钙血症几乎是其两倍。无论影像是否阳性，低手术量（每年<10例甲状旁腺切除术）组中持续性高钙血症发生的可能性显著高于高手术量（每年>50例甲状旁腺切除术）组（p = 0.0006）。多变量分析显示，外科医生手术量显著降低了持续性高钙血症（比值比[OR]=0.878，95%置信区间[CI]0.842 - 0.914，p<0.001），同时还有年龄、性别和阳性定位。双侧颈部探查（BNE）和再次手术显著增加了持续性高钙血症。术后低钙血症发生率为3.2%（509/16040），并随着外科医生手术量增加而降低（OR = 0.951，95%CI 0.910 - 0.993，p<0.001）。出血和住院时间与外科医生手术量无显著关联。
随着外科医生手术量增加，持续性高钙血症、术后低钙血症和持续性甲状旁腺功能减退症的发生率降低。影像阴性和阳性组中，随着外科医生手术量增加，持续性高钙血症相对降低程度相似，但影像阴性病例中绝对降低幅度更高。可考虑将影像阴性甲状旁腺切除术限制在高手术量的外科医生中进行。
