老人大腸癌患者接受腹腔鏡大腸切除手術和傳統大腸切除手術臨床結果及醫療資源利用比較

Comparisons of clinical outcomes and resource utilization between laparoscopic colectomy and open colectomy for colon cancer in the elderly population of Taiwan

陸懷恩(Huai-En Lu)

指導教授 ： 楊哲銘

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2013年)

https://doi.org/10.6831/TMU.2013.00041

摘要

研究動機與目的：隨著人口壽命延長，大腸癌發生率逐年增加，文獻回顧顯示腹腔鏡大腸切除手術可以安全及有效的應用於老人大腸癌患者，腹腔鏡大腸切除手術已成為大腸癌患者另一合適治療選擇。此手術在醫療資源利用及臨床結果與傳統大腸切除手術比較不盡相同，國內目前只有少數個案討論，並無使用全民健保資料庫分析此相關議題，值得本研究進一步探討利用全民健保資料庫，分析台灣老人大腸癌患者接受腹腔鏡大腸切除手術和傳統大腸切除手術臨床結果及醫療資源利用情形。
研究方法：本研究為橫斷式設計(cross-sectional study)，以臺灣國家衛生研究院提供的健保資料庫2005年百萬抽樣歸人檔為研究材料(LHID2005)，以回溯性方式分析全民健保資料庫2001年至2010年65歲以上(含)大腸癌患者接受腹腔鏡大腸切除手術和傳統大腸切除手術案例，收集資料內容包括年齡、性別、合併症、手術切除型式、轉換至傳統手術方式、醫院層級、住院併發症、出院狀況、住院日數、住院總費用。使用SPSS 17.0版套裝軟體(SPSS Inc. Chicago, IL, USA)進行資料處理與統計分析。連續變項以獨立樣本t檢定及變異數分析、類別變項以卡方檢定檢視各自變項與依變項關係。最後使用多項式羅吉斯迴歸及複迴歸分析依變項與自變項間關係，P值小於0.05表示有意義。
研究結果：本研究期間收集老人大腸癌患者接受大腸切除手術共672位，其中604位(90%)接受傳統大腸切除手術，68位(10%)接受腹腔鏡大腸切除手術。在傳統大腸切除手術組，性別比(M / F : 55.6 / 44.4)，平均年齡為74.41歲，死亡人數為7人，右側大腸切除為最多手術型式 (47.2%)。在腹腔鏡大腸切除手術組，性別比(M/F:48.5/51.5)，平均年齡為74.10歲，無死亡人數，手術轉換率為零(轉換為傳統大腸切除手術)，乙狀結腸切除為最多手術型式(42.7%)。兩組手術經t test、卡方及變異數分析比較結果顯示：在性別、年齡、手術切除型式、合併症、手術轉換率、出院狀況、住院併發症等變項無顯著差異，在醫院層級方面大腸切除手術不論是傳統或腹腔鏡方式大多於醫學中心執行(P = 0.021)，在住院日方面腹腔鏡大腸切除手術組有較短住院日(14.51±9.51 vs. 16.94±9.19, P=0.04)，在醫療費用方面腹腔鏡大腸切除手術組使用較少住院總費用(121,710.31±35,529.31 vs. 135,059.10±82,870.70,P = 0.016)。經迴歸分析顯示在住院併發症方面兩組手術類別比較並無顯著差異，但研究對象其年齡愈大其出院狀況當以改為門診治療為參考組時，較易為死亡(OR:1.14,95% CI:1.01-1.28)，另研究對象其年齡愈大及合併症較多者住院總醫療費用較多；而研究對象其年齡愈大及合併症較多者住院日數較長。
結論：腹腔鏡大腸切除手術於老人大腸癌患者是安全且經濟有效，不論是傳統大腸切除或腹腔鏡大腸切除患者，年齡及合併症嚴重度是決定出院狀況、住院日數及住院總醫療費用的重要變項。

關鍵字

腹腔鏡大腸切除手術、大腸癌、老年人、全民健保資料庫

並列摘要

Background and purpose: With longer life expectancy, the incidence of colon cancer increases with age. A review of the literature shows that laparoscopic colectomy is safe and effective for the treatment of colon cancer in elderly patients. Laparoscopic colectomy has emerged as a preferred approach for colon cancer. The aims of this study were to compare the clinical outcome and resources utilization of laparoscopic colectomy (LC) with open colectomy (OC）for cancer in patients 65 years of age or older from a large nationwide database.
Methods: Cross-sectional studies were designed from 2001 to 2010, using a million-sampled, longitudinal dataset (LHID2005) published by National Health Research Institute. Data was extracted from a retrospective collected database for all patients undergoing a colon resection from 2001 through 2010.Data collected included age, sex, comorbidities, type of resection, conversion rate, type of hospital, in-hospital complication, discharge status, length of stay, total hospital cost. Continuous variables were analyzed by independent t test and ANOVA. Categorical variables were compared by χ2 test. Multinomial logistic regression and multiple regression were used to assessed the variables between the type of surgery, in-hospital complication, discharge status, length of stay, total hospital cost, with P values <0.05 considered significant.
Results: A total of six hundred seventy-two elderly patients who underwent colectomy for colon cancer were included in the analysis. 604 (90%) had open colectomy and 68(10%) had laparoscopic colectomy during the study period. Median ages were 74.41 years and 74.10 years in the open and laparoscopic groups respectively. Age, type of resection, comorbidities, conversion rate, discharge status, in-hospital complications were similar in the two groups. Conversion rate is zero. No patient died in the laparoscopic group and seven died in the open group. Right colectomy (47.2%) is the most common resection in open colectomy patients. Sigmoid colon resection (42.7%) is the most common surgery in laparoscopic colectomy patients. Colectomy was preferred to perform in medical center (P=0.021).Patients undergoing laparoscopic colectomy had a short length of stay (14.51±9.51 vs. 16.94±9.19, P=0.04) and low hospital cost (121,760.31±35,529.31 vs.135,059±82,870.70, P=0.016) when compared with open colectomy. Regression analysis revealed no difference in in-hospital complications between two groups, advanced age patients have high mortality (OR:1.14, 95%, CI: 1.01-1.28),longer length of stay was observed on advanced age (P=0.026) and high comorbidity patients(P=0.004)；high total hospital cost was also in advanced age (P=0.002) and high comorbidity patients(P<0.001).
Conclusions: Laparoscopic colectomy for colon cancer in elderly patients is safe and beneficial including shorter length of stay and low total hospital cost. Age and comorbidity were associated with length of stay and total hospital cost regardless of laparoscopic or open colectomy in elderly patients with colon cancer.

並列關鍵字

Laparoscopic colectomy, Colon cancer, Elderly, National Health Insurance

參考文獻

朱育增、吳肖琪(2010)。回顧與探討次級資料適用之共病測量方法。台灣衛誌， 29(1), 8-21。

朱育增、吳肖琪、李玉春、賴美淑、譚醒朝(2010)。探討共病測量方法於健保次級資料之應用。台灣衛誌，29(3),191-200。

羅永男、蔡孟叡、陳宏昇、鄭企峰、李孟達(2009)。區域醫院發展腹腔大腸直腸癌切除術之初期經驗。臺灣外科醫學會雜誌，42(3),146-153。

賴鵬升、侯奕仲、張東晟、洪基翔、林宏茂、梁金銅(2010)。地區醫院的腹腔鏡大腸直腸手術之學習曲線。中華民國大腸直腸外科醫學會雜誌，21(1),1-8。

Sing-Chuen Ting, H.-H. C., Dong-Jung Liang,Tian-Yuh Liou. (2005). Comparison of Laparoscopic Colectomy and Conventional Open Colecomy in Elderly patients. Journal Society of Colon and Rectal Surgeon, 16, 39-46.