Bowles Thomas A, Sanders Kerrie M, Colson Mark, Watters David A
Department of Clinical and Biomedical Sciences (Surgery), Barwon Health, University of Melbourne, Geelong, Australia.
ANZ J Surg. 2008 Jan-Feb;78(1-2):24-7. doi: 10.1111/j.1445-2197.2007.04351.x.
Audit is a compulsory part of practice and all outcomes are now scrutinized. Raw results may be used to compare performance but these may not accurately reflect case and patient mix. Risk stratification tools, such as American Society of Anaesthesiologists (ASA) and Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM), have been shown to predict morbidity and mortality at the expense of extra data collection. The Special Cooperative Audit of Rural Surgeons reported that two comorbidities increased mortality from 4% to 16, but this finding has not been confirmed. Our aim was to compare risk stratification tools and confirm or refute if comorbidities are accurate predictors of morbidity and mortality.
We made use of an existing colorectal audit, which includes ASA, POSSUM, comorbidities and surgical outcomes. Our anaesthetic department provided data from preoperative cardiopulmonary exercise tests. A poor surgical outcome was defined as death, anastomotic leak and a complication requiring significant intervention.
Data collection was complete for comorbidities, but only 79% cases had ASA scores, 72% completed POSSUM sets and 39% anaerobic threshold. POSSUM >30, ASA III and two comorbidities were all predictors of mortality and grade 3 complications. Anaerobic threshold <11 mL/min/kg did not predict poor surgical outcome. Anastomotic leak was not predicted by any of the scoring systems.
ASA, POSSUM and the presence of two comorbidities were significant predictors of mortality and morbidity, excluding anastomotic leaks. Comorbidities are simple to collect and their correlation with outcome compares favourably with POSSUM. Comorbidities are a simple and quick method of risk stratification for colorectal surgery.
审计是医疗实践的一个强制性部分，现在所有结果都要接受审查。原始结果可用于比较医疗表现，但这些结果可能无法准确反映病例和患者情况。风险分层工具，如美国麻醉医师协会（ASA）分级和用于计算死亡率和发病率的生理与手术严重程度评分（POSSUM），已被证明可预测发病率和死亡率，但需要额外收集数据。农村外科医生特别合作审计报告称，两种合并症会使死亡率从4%升至16%，但这一发现尚未得到证实。我们的目的是比较风险分层工具，并确认或反驳合并症是否是发病率和死亡率的准确预测指标。
我们利用了一项现有的结直肠审计，其中包括ASA分级、POSSUM评分、合并症和手术结果。我们的麻醉科提供了术前心肺运动试验的数据。不良手术结果定义为死亡、吻合口漏和需要重大干预的并发症。
合并症的数据收集完整，但只有79%的病例有ASA评分，72%完成了POSSUM评分，39%有无氧阈值数据。POSSUM>30、ASA III级和两种合并症都是死亡率和3级并发症的预测指标。无氧阈值<11 mL/min/kg不能预测不良手术结果。任何评分系统都无法预测吻合口漏。
ASA分级、POSSUM评分和两种合并症的存在是死亡率和发病率（不包括吻合口漏）的重要预测指标。合并症易于收集，其与结果的相关性与POSSUM评分相比更具优势。合并症是结直肠手术风险分层的一种简单快速的方法。
