Lovegrove Richard E, Tilney Henry S, Remzi Feza H, Nicholls R John, Fazio Victor W, Tekkis Paris P
St Mark’s Hospital, Middlesex, UK.
Arch Surg. 2011 Jan;146(1):82-8. doi: 10.1001/archsurg.2010.304.
A model could be developed to identify patients who can safely undergo restorative proctocolectomy (RPC) without proximal diversion.
Logistic regression analysis was used to identify independent factors favoring omission of ileostomy at the time of RPC. A propensity nomogram was developed and validated using measures of calibration, discrimination, and subgroup analysis.
Two tertiary referral centers.
A total of 4013 patients undergoing RPC between January 1977 and December 2005 were included in the study sample.
The decision to omit loop ileostomy at the time of RPC.
After study group exclusions, proximal diversion was performed in 3196 of 3733 patients (85.6%) undergoing RPC; 45.4% of 3733 patients were women. The mean (SD) age at surgery was 37.4 (12.8) years. Ulcerative colitis was the indication for RPC in 2304 patients (61.7%) and familial adenomatous polyposis in 364 patients (9.8%), and a J pouch was performed in 2657 patients (71.2%). The following were found to be associated with ileostomy omission: stapled anastomosis (odds ratio [OR], 6.4), no preoperative corticosteroid use (OR, 3.2), familial adenomatous polyposis diagnosis (OR, 2.6), cancer diagnosis (OR, 3.4), female sex (OR, 1.6), and age at surgery younger than 26 years (OR, 2.1) (P < .01 for all). The model discriminated well (area under the receiver operating characteristic curve, 74.9%), with no significant differences between observed and expected outcomes (P = .49). Omission of proximal diversion demonstrated no significant effect on postoperative adverse events, although it was associated with a 2-day increase in the median length of hospital stay (P < .01).
Incorporation of a 5-point nomogram in the preoperative assessment of patients undergoing RPC may aid clinicians in identifying a select group of patients who may be candidates for ileostomy omission during RPC.
可以开发一种模型来识别能够安全地接受保留性直肠结肠切除术（RPC）且无需近端转流的患者。
采用逻辑回归分析来确定在RPC时有利于不进行回肠造口术的独立因素。使用校准、区分度和亚组分析的方法开发并验证了倾向评分列线图。
两个三级转诊中心。
1977年1月至2005年12月期间接受RPC的4013例患者被纳入研究样本。
RPC时决定不进行袢式回肠造口术。
在排除研究组患者后，3733例接受RPC的患者中有3196例（85.6%）进行了近端转流；3733例患者中45.4%为女性。手术时的平均（标准差）年龄为37.4（12.8）岁。2304例患者（61.7%）因溃疡性结肠炎接受RPC，364例患者（9.8%）因家族性腺瘤性息肉病接受RPC，2657例患者（71.2%）进行了J袋手术。发现以下因素与不进行回肠造口术相关：吻合器吻合（比值比[OR]，6.4）、术前未使用皮质类固醇（OR，3.2）、家族性腺瘤性息肉病诊断（OR，2.6）、癌症诊断（OR，3.4）、女性（OR，1.6）以及手术年龄小于26岁（OR，2.1）（所有P<0.01）。该模型区分度良好（受试者操作特征曲线下面积，74.9%），观察结果与预期结果之间无显著差异（P = 0.49）。尽管不进行近端转流与住院中位时间增加2天相关（P<0.01），但对术后不良事件无显著影响。
在接受RPC患者的术前评估中纳入一个5分的列线图，可能有助于临床医生识别出一组在RPC期间可能适合不进行回肠造口术的患者。
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