Evidence of the effect of 'specialization' on the management, surgical outcome and survival from colorectal cancer in Wessex
Evidence of the effect of 'specialization' on the management, surgical outcome and survival from colorectal cancer in Wessex
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DOI：
10.1002/bjs.4085
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发表时间：
2003-05-01
影响因子：
9.6
通讯作者：
Thompson, MR
中科院分区：
文献类型：
--
作者：
Smith, JAE;King, PM;Thompson, MR
背景：在前韦塞克斯地区（人口300万），建立了一项结肠直肠癌管理的前瞻性审计，以调查与生存变化相关的因素。方法：对1991 ~ 1994年诊断为结直肠癌的5173例（手术治疗的4562例）进行5年随访。收集转诊、诊断、手术治疗、术后并发症和结果的详细信息。探讨了手术结果与生存率、病例量和专业化（定义为包括大不列颠和爱尔兰结肠直肠学协会的成员资格）之间的关系，并考虑了具有预后意义的变量。结果：高容量手术（每年超过50例手术）与专业化之间存在统计学上显著的关联。与非专科医生相比，专科医生的最大获益体现在较低的术后死亡率(优势比0.67（95%可信区间（ci . 0.53至0.84））、较低的吻合口漏率（优势比0.46 (ci . 0.31至0.66)）、较高的局部无复发生存率（风险比0.56(0.44至0.71)）和较好的长期生存率（风险比0.76 (ci . 0.71至0.83)）。结论：与大量病例量相比，结肠直肠外科专业化与有益预后之间存在更强的关联。这不能完全由病例组合或患者人群来解释，并且在结肠和直肠手术后以及疾病晚期的患者中可以看到。
Background: A prospective audit of the management of colorectal cancer was established to investigate factors associated with variation in survival observed within the former Wessex region (population three million).Methods: Some 5173 patients (4562 surgically treated) with colorectal cancer diagnosed between 1991 and 1994 were followed for 5 years. Details of referral, diagnosis, surgical treatment, postoperative complications and outcomes were collected. The association between surgical outcomes and survival and both case volume and specialization (defined to include membership of the Association of Coloproctology of Great Britain and Ireland) was explored, accounting for variables with prognostic significance.Results: There was a statistically significant association between high-volume operators (more than 50 operations per year) and specialization. The greatest benefit was observed with respect to specialists versus non-specialists, in terms of a lower postoperative mortality rate (odds ratio 0.67 (95 per cent confidence interval (c.i. 0.53 to 0.84))), lower anastomotic leak rates (odds ratio 0.46 (c.i. 0.31 to 0.66)), higher local recurrence-free survival (hazard ratio 0.56 (0.44 to 0.71)) and better long-term survival (hazard ratio 0.76 (c.i. 0.71 to 0.83)).Conclusion: There is a stronger association between surgical specialization in coloproctology and beneficial outcome than with high-volume caseloads. This is not entirely accounted for by case-mix or patient population, and is seen following colonic and rectal surgery and among patients with advanced disease.