当科における腹腔鏡下大腸癌手術クリニカルパスの有用性とその評価

Evaluation of our clinical pathway for laparoscopy-assisted colorectal surgery

◆要旨：当科では2005年から，退院を5病日に設定した腹腔鏡下大腸癌手術（以下，LAC）のクリニカルパス（以下，新CP）を使用している．今回，この新CPの妥当性，有用性を検証した．2004年以前の9病日退院のCP（以下，旧CP）を比較対照とした．新CPを適応した117例中99例（84.6％）は5病日までに退院基準を満たし，32例（27.4％）が実際に5病日までに退院した．負のバリアンスは80歳以上の高齢者と直腸癌症例に多く発生した．新CPは旧CPと比較して，合併症の発生率に差はなく（16/117＝13.7％vs 6/31＝19.4％, P＝0.429），術後在院日数は短縮し（7.7日vs 11.5日, P<0.001），入院医療費の1日単価は高かった（9,178点vs 6,373点, P<0.001）．現行のCPは妥当かつ有用であるが，今後はアンケート調査などに基づき，患者側に立ったCPの個別化が必要である．

　This study is aimed to assess the validity and the usefulness of our original clinical pathway（CP）for laparoscopy-assisted colectomy（LAC）. We set up the discharge day on the 5 th post operative day（POD）since 2005（new CP, n＝117）. Discharge day was set on the 9 th POD prior to 2005（old CP, n＝31）and this was used as a comparison control. Ninety nine LAC patients（99/117＝84.6%）attained the discharge standard of 5 th POD, and 32 patients（27.4%）were actually discharged by 5 th POD. The incidence of variance was high in patients of 80 years or older and for those with rectal cancer. Short-term results were compared between patients who underwent new CP and those for old CP. There was no difference in the incidence of complications between the two groups（16/117＝13.7%vs 6/31＝19.4%, P＝0.429）. The average postoperative hospital stay for patients in new CP（7.7 days）was significantly shorter than those in old CP（11.5 days）（P<0001）. The hospitalization health care cost per day was significantly higher in new CP（9178 points）than in old CP（6373 points）（P<0.001）. In conclusion, new CP is appropriate and useful. In the future, individualization of the CP would be necessary to achieve patients'satisfaction.