Flum David R, Cheadle Allen, Prela Cecilia, Dellinger E Patchen, Chan Leighton
Department of Surgery, University of Washington, Seattle, Washington 98195-6410, USA.
JAMA. 2003 Oct 22;290(16):2168-73. doi: 10.1001/jama.290.16.2168.
Common bile duct (CBD) injury during cholecystectomy is a significant source of patient morbidity, but its impact on survival is unclear.
To demonstrate the relation between CBD injury and survival and to identify the factors associated with improved survival among Medicare beneficiaries.
DESIGN, SETTING, AND PATIENTS: Retrospective study using Medicare National Claims History Part B data (January 1, 1992, through December 31, 1999) linked to death records and to the American Medical Association's (AMA's) Physician Masterfile. Records with a procedure code for cholecystectomy were reviewed and those with an additional procedure code for repair of the CBD within 365 days were defined as having a CBD injury.
Survival after cholecystectomy, controlling for patient (sex, age, comorbidity index, disease severity) and surgeon (procedure year, case order, surgeon specialty) characteristics.
Of the 1 570 361 patients identified as having had a cholecystectomy (62.9% women), 7911 patients (0.5%) had CBD injuries. The entire population had a mean (SD) age of 71.4 (10.2) years. Thirty-three percent of all patients died within the 9.2-year follow-up period (median survival, 5.6 years; interquartile range, 3.2-7.4 years), with 55.2% of patients without and 19.5% with a CBD injury remained alive. The adjusted hazard ratio (HR) for death during the follow-up period was significantly higher (2.79; 95% confidence interval [CI]; 2.71-2.88) for patients with a CBD injury than those without CBD injury. The hazard significantly increased with advancing age and comorbidities and decreased with the experience of the repairing surgeon. The adjusted hazard of death during the follow-up period was 11% greater (HR, 1.11; 95% CI, 1.02-1.20) if the repairing surgeon was the same as the injuring surgeon.
The association between CBD injury during cholecystectomy and survival among Medicare beneficiaries is stronger than suggested by previous reports. Referring patients with CBD injuries to surgeons or institutions with greater experience in CBD repair may represent a system-level opportunity to improve outcome.
胆囊切除术中胆总管（CBD）损伤是患者发病的重要原因，但其对生存的影响尚不清楚。
证明CBD损伤与生存之间的关系，并确定医疗保险受益人中与生存改善相关的因素。
设计、设置和患者：使用医疗保险国家索赔历史B部分数据（1992年1月1日至1999年12月31日）进行回顾性研究，该数据与死亡记录和美国医学协会（AMA）的医师主文件相关联。审查了有胆囊切除术程序代码的记录，那些在365天内有额外的CBD修复程序代码的记录被定义为有CBD损伤。
胆囊切除术后的生存情况，控制患者（性别、年龄、合并症指数、疾病严重程度）和外科医生（手术年份、病例顺序、外科医生专业）特征。
在1570361例被确定为进行了胆囊切除术的患者中（62.9%为女性），7911例患者（0.5%）有CBD损伤。所有患者的平均（标准差）年龄为71.4（10.2）岁。在9.2年的随访期内，所有患者中有33%死亡（中位生存期为5.6年；四分位间距为3.2 - 7.4年），无CBD损伤的患者中有55.2%存活，有CBD损伤的患者中有19.5%存活。与无CBD损伤的患者相比，有CBD损伤的患者在随访期内死亡的调整后风险比（HR）显著更高（2.79；95%置信区间[CI]：2.71 - 2.88）。风险随着年龄增长和合并症而显著增加，随着修复外科医生的经验增加而降低。如果修复外科医生与造成损伤的外科医生相同，随访期内死亡的调整后风险高11%（HR，1.11；95% CI，1.02 - 1.20）。
胆囊切除术中CBD损伤与医疗保险受益人生存之间的关联比以前的报告所表明的更强。将有CBD损伤的患者转诊给在CBD修复方面经验更丰富的外科医生或机构可能是改善结局的系统层面的机会。
