Savage A P, Malt R A
Surgical Service, Massachusetts General Hospital, Boston.
Ann Surg. 1991 Dec;214(6):689-95. doi: 10.1097/00000658-199112000-00008.
To determine the reasons for improved mortality and morbidity rates after major hepatic resection, five variables were analyzed retrospectively in 300 patients operated on over a 27-year period: (1) the indication for surgery, (2) the surgical approach, (3) the urgency with which surgery was performed, (4) the nature of the surgical procedure, and (5) the experience of the surgeon. The operative mortality rate decreased from 19% between 1962 and 1979 to 9.7% between 1980 and 1988 (p less than 0.05). The operative mortality rates for patients undergoing resection for benign hepatic neoplasms was 3.4%; for metastatic tumors, 6.3%; for primary hepatic malignancies, 19%; and for trauma, 33%. Fifty-seven percent of operations before 1980 were performed through a thoracoabdominal exposure as compared with 19% after 1980. Overall a thoracoabdominal exposure of the liver was associated with a 20% mortality rate as compared with 8.6% for operations with abdominal exposure of the liver (p less than 0.02). Elective operations accounted for 65% of hepatic resections before 1980, as compared with 90% after 1980, and were associated with an 8.8% mortality rate as compared with 30.7% for urgent and emergency operations (p less than 0.001). Segmental and wedge resections were associated with a 5.3% mortality rate as compared with 14.7% for major hepatic resections (p less than 0.05), but this difference did not affect overall operative mortality rates because there was no change in the proportion of major hepatic resections after 1980. Surgical experience was not a determinant of operative mortality or morbidity rates in elective operations. Although there was no reduction in the complication rate after 1980, there was a reduction in postoperative stay from 26 days before 1980 to 16 days after 1980 (p less than 0.001). A reduction in the incidence of postoperative sepsis and a change in its management was associated with improved operative mortality rates.
为了确定肝大部切除术后死亡率和发病率改善的原因，我们对27年间接受手术的300例患者的五个变量进行了回顾性分析：（1）手术指征；（2）手术入路；（3）手术的紧迫性；（4）手术方式的性质；（5）外科医生的经验。手术死亡率从1962年至1979年间的19%降至1980年至1988年间的9.7%（p<0.05）。肝良性肿瘤切除患者的手术死亡率为3.4%；转移性肿瘤患者为6.3%；原发性肝癌患者为19%；创伤患者为33%。1980年前57%的手术通过胸腹联合切口进行，而1980年后这一比例为19%。总体而言，肝脏的胸腹联合暴露与20%的死亡率相关，而肝脏腹部暴露手术的死亡率为8.6%（p<0.02）。1980年前择期手术占肝切除术的65%，而1980年后为90%，择期手术的死亡率为8.8%，而急诊和紧急手术的死亡率为30.7%（p<0.001）。节段性和楔形切除术的死亡率为5.3%，而肝大部切除术的死亡率为14.7%（p<0.05），但这一差异并未影响总体手术死亡率，因为1980年后肝大部切除术的比例没有变化。手术经验不是择期手术中手术死亡率或发病率的决定因素。虽然1980年后并发症发生率没有降低，但术后住院时间从1980年前的26天减少到1980年后的16天（p<0.001）。术后脓毒症发生率的降低及其管理的改变与手术死亡率的改善相关。
