Covens A, Rosen B, Gibbons A, Osborne R, Murphy J, DePetrillo A, Lickrish G, Shaw P, Colgan T
Department of Obstetrics and Gynecology, University of Toronto.
Gynecol Oncol. 1993 Oct;51(1):39-45. doi: 10.1006/gyno.1993.1243.
A multivariate analysis was performed on 405 patients who underwent radical hysterectomy and pelvic lymphadenectomy by eight surgeons for stage IB cervical carcinoma, to determine the influence of primary surgeon on morbidity. Patient characteristics analyzed (mean/proportion) were age (41 years), quetelet index (25.4), American Society of Anesthesiologists classification of physical status (0.5% > 2), previous laparotomies (23%), previous radiation (0.7%), prophylactic antibiotics (95%), prophylactic heparin (67%), tumor size (1.0 cm), histology (68% SCC), grade (68% grades 2 or 3), vascular space involvement (45%), pelvic lymph node metastases (6%), and depth of invasion (6.6 mm). Morbidity characteristics analyzed (mean/proportion) were blood loss (910 ml), operative time (3.0 hr), intra-op complications (5%), post-op infectious (21%) and non-infectious complications (7%), transfusions (35%), post-op hospital stay (9.9 days), time to normal urine residual (9.0 days), and bladder dysfunction at 3 months post-op (21%). Mean tumor size was the only preoperative characteristic that was significantly different among surgeons (P < 0.001). Of the factors evaluated for morbidity, mean blood loss (P < 0.0001), operative time (P < 0.001), and postoperative hospital stay (P < 0.001) varied among physicians as did the incidence of blood transfusion (P < 0.0001) and bladder dysfunction at 3 months postoperatively (P < 0.0001). On multivariate analysis, surgeon was independently significant for blood loss (P < 0.0001), operative time (P < 0.0001), postoperative hospital stay (P < 0.001), incidence of blood transfusion (P < 0.0001), and bladder dysfunction at 3 months postoperatively (P < 0.0001). Despite differences in tumor size, patients appeared similar among the surgeons. Differences in patient morbidity among surgeons do exist and are of significant magnitude. Since the design of surgical trials to assess the therapeutic ratio should include not only measures of efficacy, but also measures of morbidity to be meaningful, intersurgical morbidity between centers/surgeons must continue to be quantified.
对8位外科医生为IB期宫颈癌患者实施根治性子宫切除术和盆腔淋巴结清扫术的405例患者进行了多因素分析，以确定主刀医生对发病率的影响。分析的患者特征（均值/比例）包括年龄（41岁）、体重指数（25.4）、美国麻醉医师协会身体状况分级（>2级占0.5%）、既往开腹手术史（23%）、既往放疗史（0.7%）、预防性使用抗生素（95%）、预防性使用肝素（67%）、肿瘤大小（1.0 cm）、组织学类型（68%为鳞状细胞癌）、分级（68%为2级或3级）、脉管间隙受累情况（45%）、盆腔淋巴结转移情况（6%）以及浸润深度（6.6 mm）。分析的发病特征（均值/比例）包括失血量（910 ml）、手术时间（3.0小时）、术中并发症（5%）、术后感染性（21%）和非感染性并发症（7%）、输血情况（35%）、术后住院时间（9.9天）、恢复正常残余尿量的时间（9.0天）以及术后3个月时的膀胱功能障碍（21%）。平均肿瘤大小是外科医生之间唯一有显著差异的术前特征（P<0.001）。在评估的发病相关因素中，平均失血量（P<0.0001）、手术时间（P<0.001）和术后住院时间（P<0.001）在医生之间存在差异，输血发生率（P<0.0001）和术后3个月时的膀胱功能障碍发生率（P<0.0001）也存在差异。多因素分析显示，外科医生对失血量（P<0.0001）、手术时间（P<0.0001）、术后住院时间（P<0.001）、输血发生率（P<0.0001）和术后3个月时的膀胱功能障碍发生率（P<0.0001）具有独立的显著影响。尽管肿瘤大小存在差异，但各外科医生的患者情况看起来相似。外科医生之间患者发病率确实存在差异，且差异幅度较大。由于评估治疗比的外科试验设计不仅应包括疗效指标，还应包括有意义的发病率指标，因此各中心/外科医生之间的手术发病率必须继续进行量化。
