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Abstract：
OBJECTIVE: To investigate whether there is a correlation between institutional or surgeon case volume and outcomes in patients with ruptured abdominal aortic aneurysm (rAAA).
METHODS: 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.
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).
CONCLUSIONS: 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.
METHODS: 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.
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).
CONCLUSIONS: 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.
摘要：
目的：探讨腹主动脉瘤破裂（rAAA）患者的机构或外科病例量与预后是否相关。
方法：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,中央。
方法：系统评价符合系统评价和荟萃分析（PRISMA）指南的首选报告项目，方案在PROSPERO（CRD42020213121）中注册。预后研究考虑比较rAAA患者在高容量和低容量机构或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）计算围手术期死亡率的汇总估计值。应用Mantel-Haenszel方法。使用通用逆方差方法对调整后的结果估计值进行分析。
结果：共纳入13项研究，共报告120116例患者。在低容量中心治疗的患者的围手术期死亡率显著高于在高容量中心治疗的患者(OR1.39;95%CI1.22-1.59)。亚组分析显示，对于血管内动脉瘤修复（EVAR；OR1.61，95％CI1.11-2.35）和开放修复（OR1.50，95％CI1.25-1.81），死亡率差异有利于高容量中心。调整后的分析显示，在开放修复的高容量中心治疗有益（OR1.68，95％CI1.21-2.33），但对EVAR无效（OR1.42，95％CI0.84-2.41）。对于EVAR（OR1.06，95％CI0.59-1.89）或开放手术修复（OR1.18，95％CI0.87-1.63），低容量和高容量外科医生的围手术期死亡率差异无统计学意义。
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，开放手术的围手术期生存优势更为明显。未发现个别外科医生的病例量对结果有重大影响。
方法：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,中央。
方法：系统评价符合系统评价和荟萃分析（PRISMA）指南的首选报告项目，方案在PROSPERO（CRD42020213121）中注册。预后研究考虑比较rAAA患者在高容量和低容量机构或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）计算围手术期死亡率的汇总估计值。应用Mantel-Haenszel方法。使用通用逆方差方法对调整后的结果估计值进行分析。
结果：共纳入13项研究，共报告120116例患者。在低容量中心治疗的患者的围手术期死亡率显著高于在高容量中心治疗的患者(OR1.39;95%CI1.22-1.59)。亚组分析显示，对于血管内动脉瘤修复（EVAR；OR1.61，95％CI1.11-2.35）和开放修复（OR1.50，95％CI1.25-1.81），死亡率差异有利于高容量中心。调整后的分析显示，在开放修复的高容量中心治疗有益（OR1.68，95％CI1.21-2.33），但对EVAR无效（OR1.42，95％CI0.84-2.41）。对于EVAR（OR1.06，95％CI0.59-1.89）或开放手术修复（OR1.18，95％CI0.87-1.63），低容量和高容量外科医生的围手术期死亡率差异无统计学意义。
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，开放手术的围手术期生存优势更为明显。未发现个别外科医生的病例量对结果有重大影响。
