预测肝切除术后不良结局：NSQIP 数据库中 2313 例肝切除术分析。
Predicting poor outcome following hepatectomy: analysis of 2313 hepatectomies in the NSQIP database.
机构信息
Department of Surgery, Weill Cornell Medical College, The Methodist Hospital, Houston, TX 77030, USA.
出版信息
HPB (Oxford). 2009 Sep;11(6):510-5. doi: 10.1111/j.1477-2574.2009.00095.x.
BACKGROUND
For the past two decades multiple series have documented that liver resection has become safer. The purpose of this study was to determine the current status of hepatic resection in the USA by analysing the multi-institutional experience within the National Surgical Quality Improvement Program (NSQIP) dataset.
METHODS
Of the 363,897 cases in the 2005-2007 NSQIP Participant Use File, 2313 elective open hepatectomy cases were identified (1344 partial, 230 left, 510 right and 229 extended hepatectomies). A total of 57 perioperative risk factors and 28 postoperative complications were compared. To determine the applicability of NSQIP general risk models to hepatic surgery, the prognostic value of standard multivariate analysis was compared with the NSQIP general surgery aggregate risk indices (expected probability of morbidity [morbprob], expected probability of mortality [mortprob]).
RESULTS
The median age of patients listed in the database was 60 years; sex distributions were equivalent; 78% were White; 65% of patients had an ASA score of 3 or 4, and the most prevalent co-morbidity was hypertension (46%). A total of 41% of patients had disseminated cancer, 19% of whom had received chemotherapy within 30 days of surgery. The overall 30-day mortality rate was 2.5% (57/2313) and the 30-day major morbidity rate was 19.6% (453/2313). Multivariate analysis identified nine risk factors associated with major morbidity and two risk factors associated with mortality. In contrast, the morbprob and mortprob statistics did not predict outcomes accurately. For those patients who developed major morbidity, the median length of stay was longer (10 vs. 6 days; P = 0.001) and the mortality rate was higher (11.3% vs. 0.3%; P = 0.001).
CONCLUSIONS
Analysis of the NSQIP experience with hepatectomy indicates that the current mortality and major morbidity rate benchmarks are 2.5% and 19.6%, respectively. Poor outcomes were associated with nutritional status, liver function and the extent of hepatectomy. The NSQIP general surgery morbprob and mortprob values were relatively poor predictors of post-hepatectomy observed morbidity, indicating the need for specialty-specific NSQIP modelling.
背景
在过去的二十年中，多项研究系列记录表明肝切除术已变得更加安全。本研究旨在通过分析国家外科质量改进计划（NSQIP）数据集内的多机构经验，确定美国肝切除术的现状。
方法
在 2005-2007 年 NSQIP 参与者使用文件的 363897 例中，确定了 2313 例择期开腹肝切除术病例（1344 例部分肝切除术、230 例左肝切除术、510 例右肝切除术和 229 例扩大肝切除术）。比较了 57 种围手术期危险因素和 28 种术后并发症。为了确定 NSQIP 一般风险模型是否适用于肝外科，比较了标准多变量分析的预后价值与 NSQIP 普通外科综合风险指数（预计发病率 [morbprob]、预计死亡率 [mortprob]）。
结果
数据库中列出的患者的中位年龄为 60 岁；性别分布均衡；78%为白人；65%的患者 ASA 评分为 3 或 4 级，最常见的合并症是高血压（46%）。共有 41%的患者患有播散性癌症，其中 19%的患者在手术前 30 天内接受过化疗。总的 30 天死亡率为 2.5%（57/2313），30 天主要发病率为 19.6%（453/2313）。多变量分析确定了 9 个与主要发病率相关的风险因素和 2 个与死亡率相关的风险因素。相比之下，morbprob 和 mortprob 统计数据不能准确预测结果。对于发生主要发病率的患者，中位住院时间更长（10 天 vs. 6 天；P = 0.001），死亡率更高（11.3% vs. 0.3%；P = 0.001）。
结论
对 NSQIP 肝切除术经验的分析表明，目前的死亡率和主要发病率基准分别为 2.5%和 19.6%。不良预后与营养状况、肝功能和肝切除术范围有关。NSQIP 普通外科 morbprob 和 mortprob 值相对较差地预测了肝切除术后观察到的发病率，表明需要针对特定专业进行 NSQIP 建模。
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