Tekkis Paris P, Kinsman Robin, Thompson Michael R, Stamatakis Jeffrey D
Department of Surgery, St Mark's Hospital, Harrow, UK.
Ann Surg. 2004 Jul;240(1):76-81. doi: 10.1097/01.sla.0000130723.81866.75.
This study was designed to investigate the early outcomes after surgical treatment of malignant large bowel obstruction (MBO) and to identify risk factors affecting operative mortality.
Data were prospectively collected from 1046 patients with MBO by 294 surgeons in 148 UK hospitals during a 12-month period from April 1998. A predictive model of in-hospital mortality was developed using a 3-level Bayesian logistic regression analysis.
The median age of patients was 73 years (interquartile range 64-80). Of the 989 patients having surgery, 91.7% underwent bowel resection with an overall mortality of 15.7%. The multilevel model used the following independent risk factors to predict mortality: age (odds ratio [OR] 1.85 per 10 year increase), American Society of Anesthesiologists grade (OR for American Society of Anesthesiologists grade I versus II,III,IV-V = 3.3,11.7,22.2), Dukes' staging (OR for Dukes' A versus B,C,D = 2.0, 2.1, 6.0), and mode of surgery (OR for scheduled versus urgent, emergency = 1.6, 2.3). A significant interhospital variability in operative mortality was evident with increasing age (variance = 0.004, SE = 0.001, P < 0.001). No detectable caseload effect was demonstrated between specialist colorectal and other general surgeons.
Using prognostic models, it was possible to develop a risk-stratification index that accurately predicted survival in patients presenting with malignant large bowel obstruction. The methodology and model for risk adjusted survival can set the reference point for more accurate and reliable comparative analysis and be used as an adjunct to the process of informed consent.
本研究旨在调查恶性大肠梗阻（MBO）手术治疗后的早期结果，并确定影响手术死亡率的危险因素。
在1998年4月起的12个月期间，英国148家医院的294名外科医生前瞻性收集了1046例MBO患者的数据。使用三级贝叶斯逻辑回归分析建立了院内死亡率预测模型。
患者的中位年龄为73岁（四分位间距64 - 80岁）。在989例接受手术的患者中，91.7%接受了肠切除术，总体死亡率为15.7%。多水平模型使用以下独立危险因素预测死亡率：年龄（每增加10岁优势比[OR]为1.85）、美国麻醉医师协会分级（美国麻醉医师协会I级与II、III、IV - V级相比的OR分别为3.3、11.7、22.2）、Dukes分期（Dukes A期与B、C、D期相比的OR分别为2.0、2.1、6.0）以及手术方式（择期与急诊、紧急手术相比的OR分别为1.6、2.3）。随着年龄增长，手术死亡率存在显著的医院间差异（方差 = 0.004，标准误 = 0.001，P < 0.001）。在结直肠专科医生和其他普通外科医生之间未显示出可检测到的病例数量效应。
使用预后模型，有可能开发出一种风险分层指数，准确预测恶性大肠梗阻患者的生存情况。风险调整生存的方法学和模型可为更准确可靠的比较分析设定参考点，并用作知情同意过程的辅助工具。
