Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.
Ann Surg. 2010 Aug;252(2):345-50. doi: 10.1097/SLA.0b013e3181e982d6.
We sought to use a multi-institutional, prospective, clinical database to better understand adverse outcomes in chronic liver disease (CLD) patients undergoing colorectal surgery.
CLD confers significant perioperative risk. However, there are little population-based data available for prognostication and risk stratification in these patients.
We used data from the 2005-2007 American College of Surgeons National Surgical Quality Improvement Project to study 30,927 patients undergoing colorectal resections. We first identified patients with CLD (n = 1565) with any of the following clinical characteristics: ascites, esophageal varices, or total bilirubin greater than 2 mg/dL. Postoperative complications and mortality rates were then compared between CLD and non-CLD patients.
CLD patients have a nearly 6.5-fold increased risk of mortality following colorectal operations (Relative Risk [RR], 6.53; 3.2% in non-CLD group versus 21.5% in CLD group). Patients with CLD also had significantly higher major complication rates (RR, 2.72; 15.4% vs. 41.9%, respectively). The failure to rescue rate (ie, proportion of deaths following major complications) was also markedly higher in patients with CLD (RR, 2.27; 15.1% vs. 34.2%, respectively). Furthermore, stratification of CLD patients by Model for End-stage Liver Disease (MELD) score demonstrated significantly higher rates of complications (RR, 2.41; 2.31-2.51), failure to rescue (RR, 2.62; 2.35-2.90), and mortality (RR, 8.92; 8.11-9.78) in CLD patients with MELD > or =15 compared with CLD patients with MELD <15.
Colorectal surgery in CLD patients is associated with significant morbidity and mortality. Furthermore, those who develop major complications have a significantly higher risk of death compared to non-CLD. These very high risks should be discussed at length with patients prior to undertaking major surgical procedures.
我们旨在利用多机构、前瞻性临床数据库，更好地了解慢性肝脏疾病（CLD）患者行结直肠手术后的不良结局。
CLD 会增加围手术期的风险。然而，目前针对此类患者，预测预后和风险分层的人群数据十分有限。
我们使用了 2005-2007 年美国外科医师学会国家外科质量改进计划的数据，研究了 30927 例行结直肠切除术的患者。我们首先确定了有以下任何一种临床特征的 CLD 患者（n=1565）：腹水、食管静脉曲张或总胆红素>2mg/dL。然后比较 CLD 患者和非 CLD 患者的术后并发症和死亡率。
CLD 患者结直肠手术后的死亡率增加近 6.5 倍（相对风险[RR]，6.53；非 CLD 组为 3.2%，CLD 组为 21.5%）。CLD 患者的主要并发症发生率也显著升高（RR，2.72；分别为 15.4%和 41.9%）。CLD 患者的救援失败率（即主要并发症后死亡的比例）也明显更高（RR，2.27；分别为 15.1%和 34.2%）。此外，根据终末期肝病模型（MELD）评分对 CLD 患者进行分层，显示 MELD>或=15 的 CLD 患者并发症发生率（RR，2.41；2.31-2.51）、救援失败率（RR，2.62；2.35-2.90）和死亡率（RR，8.92；8.11-9.78）均显著高于 MELD<15 的 CLD 患者。
CLD 患者行结直肠手术与显著的发病率和死亡率相关。此外，发生重大并发症的患者与非 CLD 患者相比，死亡风险显著增加。在进行重大手术之前，应与患者充分讨论这些极高的风险。
