Kologlu Murat, Tutuncu Tanju, Yuksek Yunus Nadi, Gozalan Ugur, Daglar Gul, Kama Nuri Aydin
4th Department of Surgery, Ankara Numune Hospital, Ankara, Turkey.
Surgery. 2004 Mar;135(3):282-7. doi: 10.1016/s0039-6060(03)00395-7.
We previously developed a risk score for conversion from laparoscopic to open cholecystectomy (RSCLO). The aim of this study is to validate this scoring system in a new patient population and test its use in case selection for resident training.
The data of 1,000 laparoscopic cholecystectomies (LC) that had been performed in our clinic between 1992 and 1999 were analyzed retrospectively, and RSCLO was developed. Scores take values between -20 and 41; values below -3 represent low risk, and values over -3 represent high risk. Analyses in this group of patients showed that at least 15 cases have to be performed for adequate LC training. The current study is a clinical prospective study based on data of the previous study and evaluates RSCLO in a new patient population of 400 LCs. All patients were scored preoperatively; surgeons who had performed 15 or fewer LCs previously operated only patients with a score below -3. Patients with high scores (>values of -3) were operated only by surgeons who had performed at least 16 LCs. Results of the first 1,000 cases and later 400 cases (new patient population of the current study) were compared in terms of conversion to open cholecystectomy, complications, and operation times.
Both in the first 1,000 patients and later in 400 patients, increasing scores resulted with higher conversion rates and complication rates and longer operation times (P<.05). In the later 400 patients, conversion rate (4.8% vs 3.0%, P=.08), complication rate (5.5% vs 3.5%, P=.07), and mean operation time (56.8 min vs 52.5 min, P=.004) were decreased when compared with the first 1,000 patients. In resident training cases, conversion and complication rates decreased to 0%, and mean operation time was shortened by nearly 10 minutes. In high-score difficult cases, conversion and complication rates decreased, and mean operation time was shortened by nearly 20 minutes.
This risk score can predict the difficulty of LC cases reliably. Scoring patients preoperatively can decrease the problems in training cases, and management of difficult cases may be left to experienced surgeons.
我们之前开发了一种用于预测腹腔镜胆囊切除术转为开腹胆囊切除术的风险评分系统（RSCLO）。本研究的目的是在新的患者群体中验证该评分系统，并测试其在住院医师培训病例选择中的应用。
回顾性分析了1992年至1999年间在我们诊所进行的1000例腹腔镜胆囊切除术（LC）的数据，并开发了RSCLO。评分范围为-20至41；低于-3分表示低风险，高于-3分表示高风险。对该组患者的分析表明，为了进行充分的LC培训，至少需要进行15例手术。本研究是一项基于先前研究数据的临床前瞻性研究，在400例新的LC患者群体中评估RSCLO。所有患者在术前进行评分；之前进行过15例或更少LC手术的外科医生仅为评分低于-3分的患者进行手术。高分（>-3分）患者仅由之前进行过至少16例LC手术的外科医生进行手术。比较了前1000例病例和后来400例病例（本研究的新患者群体）在转为开腹胆囊切除术、并发症和手术时间方面的结果。
在前1000例患者和后来的400例患者中，评分越高，转化率、并发症发生率越高，手术时间越长（P<0.05）。与前1000例患者相比，后来400例患者的转化率（4.8%对3.0%，P=0.08）、并发症发生率（5.5%对3.5%，P=0.07）和平均手术时间（56.8分钟对52.5分钟，P=0.004）均有所降低。在住院医师培训病例中，转化率和并发症发生率降至0%，平均手术时间缩短了近10分钟。在高分困难病例中，转化率和并发症发生率降低，平均手术时间缩短了近20分钟。
该风险评分能够可靠地预测LC病例的难度。术前对患者进行评分可以减少培训病例中的问题，困难病例的管理可留给经验丰富的外科医生。
