Objective

To investigate whether there is a correlation between institutional or surgeon case volume and outcomes in patients with ruptured abdominal aortic aneurysm (rAAA).

Data Sources

The Healthcare Database Advanced Search interface developed by the National Institute of Health and Care Excellence was used to search MEDLINE, Embase, CINAHL, and CENTRAL.

Review Methods

The systematic review complied with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines with the protocol registered in PROSPERO (CRD42020213121). Prognostic studies were considered comparing outcomes of patients with rAAA undergoing repair in high and low volume institutions or by high and low volume surgeons. Pooled estimates for peri-operative mortality were calculated using the odds ratio (OR) and 95% confidence intervals (CI), applying the Mantel-Haenszel method. Analysis of adjusted outcome estimates was performed with the generic inverse variance method.

Results

Thirteen studies reporting a total of 120 116 patients were included. Patients treated in low volume centres had a statistically significantly higher peri-operative mortality than those treated in high volume centres (OR 1.39; 95% CI 1.22 – 1.59). Subgroup analysis showed a mortality difference in favour of high volume centres for both endovascular aneurysm repair (EVAR; OR 1.61, 95% CI 1.11 – 2.35) and open repair (OR 1.50, 95% CI 1.25 – 1.81). Adjusted analysis showed a benefit of treatment in high volume centres for open repair (OR 1.68, 95% CI 1.21 – 2.33) but not for EVAR (OR 1.42, 95% CI 0.84 – 2.41). Differences in peri-operative mortality between low and high volume surgeons were not statistically significant for either EVAR (OR 1.06, 95% CI 0.59 – 1.89) or open surgical repair (OR 1.18, 95% CI 0.87 – 1.63).

Conclusion

A high institutional volume may result in a reduction of peri-operative mortality following surgery for rAAA. This peri-operative survival advantage is more pronounced for open surgery than EVAR. Individual surgeon caseload was not found to have a significant impact on outcomes.

中文翻译：

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编辑推荐 - 机构和外科医生手术量对腹主动脉瘤破裂修复术后结果影响的系统评价和荟萃分析

客观的

调查机构或外科医生的病例数量与腹主动脉瘤 (rAAA) 破裂患者的结果之间是否存在相关性。

数据源

由美国国家健康与护理卓越研究所开发的医疗保健数据库高级搜索界面用于搜索 MEDLINE、Embase、CINAHL 和 CENTRAL。

复习方法

系统评价符合系统评价和元分析首选报告项目 (PRISMA) 指南和 PROSPERO 中注册的方案 (CRD42020213121)。预后研究被考虑比较 rAAA 患者在高容量和低容量机构或由高容量和低容量外科医生进行修复的结果。使用比值比 (OR) 和 95% 置信区间 (CI)，应用 Mantel-Haenszel 方法计算围手术期死亡率的汇总估计值。使用通用逆方差方法对调整后的结果估计进行分析。

结果

共纳入了 13 项研究，共报告了 120 116 名患者。在低容量中心接受治疗的患者的围手术期死亡率显着高于在高容量中心接受治疗的患者（OR 1.39；95% CI 1.22 – 1.59）。亚组分析显示，血管内动脉瘤修复（EVAR；OR 1.61，95% CI 1.11 – 2.35）和开放修复（OR 1.50，95% CI 1.25 – 1.81）的死亡率差异有利于大容量中心。调整后的分析显示，在大手术量中心进行开放修复治疗有益（OR 1.68，95% CI 1.21 – 2.33），但对 EVAR 无效（OR 1.42，95% CI 0.84 – 2.41）。对于 EVAR (OR 1.06, 95% CI 0.59 – 1.89) 或开放手术修复 (OR 1.18, 95% CI 0.87 – 1.63)，小手术量和大手术量外科医生围手术期死亡率的差异无统计学意义。

结论

较高的机构容量可能会降低 rAAA 手术后的围手术期死亡率。与 EVAR 相比，开放手术的这种围手术期生存优势更为明显。未发现个体外科医生的病例量对结果有显着影响。