Department of Thoracic Surgery, Division of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy.
Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
Updates Surg. 2024 Aug;76(4):1475-1482. doi: 10.1007/s13304-023-01723-0. Epub 2023 Dec 16.
Improving the quality of lung cancer care at a cost that can be sustained is a hotly debated issue. High-risk, low-volume procedures (such as lung resections) are believed to improve significantly when centralised in high-volume centres. However, limited evidence exists to support volume requirements in lung cancer surgery. On the other hand, there was no evidence that the number of lung resections affected either the short-term perioperative results or the long-term cost. Using data from an extensive nationwide registry, this study investigated the correlations between surgical volumes and selected perioperative outcomes. A retrospective analysis of a prospectively filled national registry that follows stringent quality assurance and security procedures was conducted to ensure data accuracy and security. Patients who underwent VATS lobectomy from 2014 to 2019 at the participating centres were included. Selected perioperative outcomes were reported. Total direct hospital cost is measured at discharge for hospitalisations with a primary diagnosis of lung cancer, hospital stay costs, and postoperative length of hospital stay after lobectomy. After the propensity score matched, centres were divided into three groups according to the surgical volume of the unit where VATS lobectomies were performed (high-volume centre: > 500 lobectomies; medium-volume centre: 200-500 lobectomies; low-volume centre: < 200 lobectomies). 11,347 patients were included and matched (low-volume center = 2890; medium-volume center = 3147; high-volume center = 2907). The mean operative time density plot (Fig. 1A) showed no statistically significant difference (p = 0.67). In contrast, the density plot of the harvested lymph nodes (Fig. 1B) showed significantly higher values in the high-volume centres (p = 0.045), albeit without being clinically significant. The adjusted rates of any and significant complications were higher in the low-volume centre (p = 0.034) without significantly affecting the length of hospital stay (p = 0.57). VATS lobectomies for lung cancer in higher-volume centres seem associated with a statistically significantly higher number of harvested lymph nodes and lower perioperative complications, yet without any significant impact in terms of costs and resource consumption. These findings may advise the investigation of the learning curve effect in a complete economic evaluation of VATS lobectomy in lung cancer. Fig. 1 The mean operative time density plot showed no statistically significant difference (p = 0.67).
提高肺癌治疗质量且控制成本是一个备受争议的问题。人们认为，在高容量中心集中进行高风险、低容量的手术（如肺切除术）可以显著改善。然而，目前尚无证据支持肺癌手术的容量要求。另一方面，没有证据表明肺切除术的数量会影响短期围手术期结果或长期成本。本研究使用来自广泛的全国性登记处的数据，调查了手术量与选定的围手术期结果之间的相关性。对一个严格遵循严格质量保证和安全程序的前瞻性全国登记处进行回顾性分析，以确保数据的准确性和安全性。纳入 2014 年至 2019 年在参与中心接受胸腔镜肺叶切除术的患者。报告选定的围手术期结果。总直接住院费用是针对以肺癌为主要诊断的住院患者出院时的住院费用、住院费用和肺叶切除术后的住院时间。在倾向评分匹配后，根据实施胸腔镜肺叶切除术的单位的手术量（高容量中心：>500 例肺叶切除术；中容量中心：200-500 例肺叶切除术；低容量中心：<200 例肺叶切除术）将中心分为三组。共纳入并匹配了 11347 例患者（低容量中心=2890 例；中容量中心=3147 例；高容量中心=2907 例）。手术时间密度图（图 1A）显示无统计学差异（p=0.67）。相反，淋巴结采集的密度图（图 1B）显示高容量中心的数值明显更高（p=0.045），尽管没有临床意义。低容量中心的任何并发症和显著并发症的调整发生率更高（p=0.034），但对住院时间没有显著影响（p=0.57）。高容量中心的肺癌胸腔镜肺叶切除术似乎与统计学上明显更多的淋巴结采集和较低的围手术期并发症相关，但在成本和资源消耗方面没有任何显著影响。这些发现可能建议在肺癌胸腔镜肺叶切除术的完整经济评估中研究学习曲线效应。图 1 手术时间密度图显示无统计学差异（p=0.67）。
