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计算机综述手术报告与高级卵巢癌手术医生口述报告的比较。

A computer synoptic operative report versus a report dictated by a surgeon in advanced ovarian cancer.

机构信息

Department of Surgery, Paoli-Calmettes Institute, Marseille, Provence-Alpes-Côte d'Azu, France.

Department of Surgery, Paoli-Calmettes Institute, Marseille, Provence-Alpes-Côte d'Azu, France

出版信息

Int J Gynecol Cancer. 2024 Apr 1;34(4):581-585. doi: 10.1136/ijgc-2023-004947.

Abstract

OBJECTIVE

To evaluate the role of a computer synoptic operative report in enhancing the quality and completeness of surgical reporting for advanced ovarian cancer surgeries.

METHODS

The study was conducted at a tertiary cancer center between January 2016 and September 2021, and the computer synoptic operative report was implemented in May 2019. The study compared two cohorts: the first consisted of the 'before computer synoptic operative report (P1)' period, during which the operative reports were dictated freely by the surgeons, and the second consisted of the 'after computer synoptic operative report (P2)' period, during which all surgeons used the computer synoptic operative report.

RESULTS

The study analyzed 227 operative reports, with 104 during period 1 (P1) and 123 during period 2 (P2). . Although interval debulking surgery after fewer than six chemotherapy cycles was more frequent in P2, the rate of primary debulking surgery was similar between the groups. The median intra-operative peritoneal carcinomatosis index was higher in P2 (2 in P1 vs 4 in P2, p<0.001), and mean blood loss was higher in P1 (308 mL vs 151 mL, p<0.001). The rate of complete cytoreduction was similar between P1 and P2 (97% vs 87%, respectively, p=0.6). The median length of hospital stay was 12 days in the P1 group and 16 days in the P2 group (p=0.5). Compliance with all eight significant items was higher in the P2 group, with all items present in 66% of the operative reports in the P2 group compared with none of the reports in the P1 group. Compliance for the following items was: International Federation of Obstetrics and Gynecology stage (24% vs 100%), histology (76% vs 97%), CA125 (63% vs 89%), type of surgery (38% vs 100%), peritoneal carcinomatosis index (21% vs 100%), complete cytoreduction score 36% vs 99%), Aletti score (0% vs 89%), and blood loss (32% vs 98%) for P1 and P2; respectively.

CONCLUSION

The use of the computer synoptic operative report improved the completeness and quality of the surgical information documented in advanced ovarian cancer surgeries.

摘要

目的

评估计算机手术总结报告在提高高级卵巢癌手术报告的质量和完整性方面的作用。

方法

本研究于 2016 年 1 月至 2021 年 9 月在一家三级癌症中心进行,计算机手术总结报告于 2019 年 5 月实施。该研究比较了两个队列:第一个队列为“使用计算机手术总结报告前(P1)”时期,在此期间,外科医生自由口述手术报告;第二个队列为“使用计算机手术总结报告后(P2)”时期,在此期间,所有外科医生均使用计算机手术总结报告。

结果

该研究共分析了 227 份手术报告,其中 P1 组 104 份,P2 组 123 份。虽然 P2 组中少于 6 个化疗周期后进行间隔性肿瘤细胞减灭术更为频繁,但两组的初次肿瘤细胞减灭术率相似。P2 组的术中腹膜癌病指数中位数更高(P1 组为 2,P2 组为 4,p<0.001),P1 组术中出血量更高(308mL 比 151mL,p<0.001)。P1 和 P2 组的完全肿瘤细胞减灭术率相似(分别为 97%和 87%,p=0.6)。P1 组的中位住院时间为 12 天,P2 组为 16 天(p=0.5)。P2 组的所有 8 项重要项目的符合率均较高,P2 组的手术报告中均包含 66%的项目,而 P1 组的报告中没有任何项目符合要求。符合率较高的项目包括:国际妇产科联合会(FIGO)分期(24%比 100%)、组织学(76%比 97%)、CA125(63%比 89%)、手术类型(38%比 100%)、腹膜癌病指数(21%比 100%)、完全肿瘤细胞减灭术评分(36%比 99%)、Aletti 评分(0%比 89%)和出血量(32%比 98%)。

结论

使用计算机手术总结报告提高了高级卵巢癌手术中记录的手术信息的完整性和质量。

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