Cruz Carlos P, Eidt John F, Capps Christy, Kirtley Leah, Moursi Mohammed M
Department of Surgery, Division of Vascular Surgery, Central Arkansas Veterans Healthcare System, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot 520-2, Little Rock, AR 72205, USA.
Am J Surg. 2003 Nov;186(5):449-54. doi: 10.1016/j.amjsurg.2003.07.027.
This study was made to evaluate the experience at a Department of Veterans Affairs (VA) hospital with consecutive major lower extremity amputations over a period of 7 years.
The records of 229 patients (221 male and 8 female) who underwent 296 consecutive major lower extremity amputations (119 above-knee amputations [AKA] and 177 below-knee amputations [BKA]) over a period of 86 months (September 1994 to October 2001) were retrospectively analyzed. All amputations were performed by members of the vascular surgery department.
Forty of the 229 patients (17%) eventually required a contralateral amputation, 27 patients (12%) had BKAs that eventually necessitated conversion to AKA, and 44 amputations (15%) required an initial guillotine amputation. The 30-day mortalities for BKA, AKA, and BKA to AKA operations were 12%, 17%, and 7%, respectively. Eighty-eight of the amputations (30%) developed wound complications, and required 137 revisions. Seventy-seven of the amputations (26%) had undergone prior revascularization, of which 31 (48%) had an early failed bypass. The average preoperative ankle/brachial index (ABI) was 0.57. Of the patients undergoing amputation, 97 (42%) complained of rest pain, 91 (40%) complained of claudication, and 158 (69%) had tissue loss or gangrene at the time of their operation. One hundred and forty-six patients (64%) were diabetic. Twenty-two patients (9%) were dialysis dependent and 81 patients (35%) admitted to smoking. Of the known causes of death, 21 resulted from myocardial infarction, 22 from congestive heart failure, 14 from respiratory failure, 13 from disseminated cancer, 10 from sepsis, 7 from stroke, and 6 from renal failure. Preoperative functional status determinations revealed that of 272 patients with enough information to assess functional status, 43 were totally dependent, 97 were partially independent, and 132 were independent. Of the 229 patients, 168 (73%) were ambulatory prior to their amputation, and at the completion of this review only 53 patients (23%) were ambulatory.
Most patients undergoing major lower extremity amputations have many comorbidities; hence morbidity and mortality rates are high, with the most common causes of death being cardiac and respiratory in nature. These data suggest that major lower extremity amputations highlight a very high-risk population with only 39% survival at 7 years, as well as a costly subset secondary to prolonged hospitalization times (average 15 days, range 3 to 105), in addition to the extraordinary cost associated with diminished functional status.
本研究旨在评估一家退伍军人事务部（VA）医院在7年期间连续进行下肢大截肢手术的经验。
回顾性分析了1994年9月至2001年10月期间86个月内229例患者（221例男性和8例女性）连续进行的296例下肢大截肢手术记录（119例膝上截肢[AKA]和177例膝下截肢[BKA]）。所有截肢手术均由血管外科医生进行。
229例患者中有40例（17%）最终需要对侧截肢，27例患者（12%）的膝下截肢最终需要转换为膝上截肢，44例截肢手术（15%）需要进行初次断头截肢。膝下截肢、膝上截肢以及膝下截肢转换为膝上截肢手术的30天死亡率分别为12%、17%和7%。88例截肢手术（30%）出现伤口并发症，需要进行137次修复。77例截肢手术（26%）此前接受过血管重建，其中31例（48%）早期搭桥失败。术前平均踝肱指数（ABI）为0.57。接受截肢手术的患者中，97例（42%）主诉静息痛，91例（40%）主诉间歇性跛行，158例（69%）在手术时出现组织缺损或坏疽。146例患者（64%）患有糖尿病。22例患者（9%）依赖透析，81例患者（35%）承认吸烟。在已知的死亡原因中，21例死于心肌梗死，22例死于充血性心力衰竭，14例死于呼吸衰竭，13例死于播散性癌症，10例死于败血症，7例死于中风，6例死于肾衰竭。术前功能状态评估显示，在272例有足够信息评估功能状态的患者中，4例完全依赖，97例部分独立，132例独立。229例患者中，168例（73%）在截肢前能够行走，而在本次研究结束时，只有53例患者（23%）能够行走。
大多数接受下肢大截肢手术的患者有多种合并症；因此发病率和死亡率很高，最常见的死亡原因是心脏和呼吸系统疾病。这些数据表明，下肢大截肢突出了一个高危人群，7年生存率仅为39%，此外，由于住院时间延长（平均15天，范围3至105天）以及功能状态下降带来的巨大成本，这是一个成本高昂的亚组。
