超越手术室？门诊与手术室EBUS-TBNA路径的细胞学产量与资源利用比较

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中文摘要

背景/目的： 支气管内超声引导下经支气管针吸活检（EBUS-TBNA）可通过在麻醉、场所、气道管理、监测、恢复和住院方面不同的路径进行。我们比较了采用镇静和自主呼吸的门诊内镜套房路径与采用全身麻醉和喉罩通气的的手术室路径，评估基于细胞学的产量、样本充分性、工作流程和成本。方法：这项单中心观察性研究连续纳入EBUS-TBNA操作。分配为非随机，反映了工作流程、手术室可用性、复杂性、气道/麻醉考虑和判断。主要终点是诊断队列中基于细胞学的诊断产量；分期结局包括细胞学分布、样本充分性和充分样本中的阳性率。整个队列没有系统性的诊断验证；然而，在分期队列中，当有术后淋巴结病理时进行了回顾性检索。由于验证仍不完整且选择性可用，未估计敏感性、特异性、阴性预测值和总体诊断准确性。结果：临床结局分析包括447例操作（319例诊断和128例分期），而行政成本数据集包括533例完成的操作。诊断产量在路径之间相似（108/229，47.2% vs. 45/90，50.0%；p = 0.740）。在分期队列中，样本充分性相当（83/85，97.6% vs. 39/42，92.9%；p = 0.331），充分样本中的阳性率无差异（21.7% vs. 20.5%；p = 1.000）。探索性术后病理淋巴结分期数据可用于60/128例分期操作；在58例具有可解释EBUS-TBNA结果的病例中，患者水平N分期一致性为44/58（75.9%），术后淋巴结升期发生在11/58（19.0%）。未记录到预先指定的术中复合不良事件。手术室病例的持续时间似乎更短，但由于差异记录不完整，仅为描述性。手术室路径的住院时间和成本显著更高。结论：两种路径显示出相似的基于细胞学的结局，但住院率和成本不同。非随机分配和路径异质性排除了作为镇静与全身麻醉比较的因果解释。有必要进行前瞻性研究，采用标准化分配、诊断验证、系统捕获不良事件和随访。

英文摘要

Background/Objectives: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can be performed via pathways that differ in anesthesia, setting, airway management, monitoring, recovery, and hospitalization. We compared an outpatient endoscopy suite pathway with sedation and spontaneous breathing, and an operating room pathway with general anesthesia and laryngeal mask ventilation, assessing cytology-based yield, sample adequacy, workflow, and costs. Methods: This single-center observational study included consecutive EBUS-TBNA procedures. Allocation was nonrandom and reflected workflow, operating room availability, complexity, airway/anesthetic considerations, and judgment. The primary endpoint was cytology-based diagnostic yield in the diagnostic cohort; staging outcomes included cytology distribution, sample adequacy, and positivity among adequate samples. Systematic diagnostic verification was not available for the entire cohort; however, postoperative nodal pathology was retrospectively retrieved when available in the staging cohort. Because verification remained incomplete and selectively available, sensitivity, specificity, negative predictive value, and overall diagnostic accuracy were not estimated. Results: Clinical outcome analyses included 447 procedures (319 diagnostic and 128 staging), while the administrative cost dataset included 533 completed procedures. Diagnostic yield was similar between pathways (108/229, 47.2% vs. 45/90, 50.0%; p = 0.740). In the staging cohort, sample adequacy was comparable (83/85, 97.6% vs. 39/42, 92.9%; p = 0.331), and positivity among adequate samples did not differ (21.7% vs. 20.5%; p = 1.000). Exploratory postoperative pathological nodal-stage data were available for 60/128 staging procedures; among 58 cases with interpretable EBUS-TBNA results, patient-level N-stage concordance was 44/58 (75.9%), and postoperative nodal upstaging occurred in 11/58 (19.0%). No prespecified intraprocedural composite adverse events were documented. Duration appeared shorter in operating room cases but, owing to incomplete differential recording, was descriptive only. Length of stay and costs were markedly higher in the operating room pathway. Conclusions: The pathways showed similar cytology-based outcomes but differed in hospitalization rates and costs. Nonrandom allocation and pathway heterogeneity preclude causal interpretation as a sedation-versus-general-anesthesia comparison. Prospective studies with standardized allocation, diagnostic verification, systematic capture of adverse events, and follow-up are warranted.