Cho Sung W, Bhayani Neil, Newell Pippa, Cassera Maria A, Hammill Chet W, Wolf Ronald F, Hansen Paul D
Hepatobiliary and Pancreatic Surgery Program, Providence Portland Medical Center, Portland, OR 97213, USA.
Arch Surg. 2012 Sep;147(9):864-9. doi: 10.1001/archsurg.2012.1663.
To compare the outcomes of umbilical hernia repair in patients with and without signs of portal hypertension, such as esophageal varices or ascites; to assess the effect of emergency surgery on complication rates; and to identify predictors of postoperative mortality.
Database search from January 1, 2005, through December 31, 2009.
North American hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program initiative.
We studied patients who underwent umbilical hernia repair. Those with congestive heart failure, disseminated malignant tumor, or chronic renal failure while undergoing dialysis were excluded.
Preoperative variables and perioperative course were analyzed. Main outcome measures were morbidity and mortality after umbilical hernia repair.
A total of 390 patients with ascites and/or esophageal varices formed the study group, and the remaining 22 952 patients formed the control group. The overall morbidity and mortality rates for the study group were 13.1% and 5.1%, whereas these rates were 3.9% and 0.1% for the control group, respectively (P < .001). For the study group, the mortality after elective repair among patients with a model for end-stage liver disease (MELD) score greater than 15 was 11.1% compared with 1.3% in patients with a MELD score of 15 or less. The patients with ascites and/or esophageal varices underwent emergency surgery more frequently than the control group (37.7% vs 4.9%; P < .001). Emergency surgery for the study group was associated with a higher morbidity than elective surgery (20.8% vs 8.3%; P < .001) but not a significantly higher mortality (7.4% vs 3.7%; P = .11). However, logistic regression analysis showed that age older than 65 years, MELD score higher than 15, albumin level less than 3.0 g/dL (to convert to grams per liter, multiply by 10), and sepsis at presentation were more predictive of postoperative mortality.
Umbilical hernia repair in the presence of ascites and/or esophageal varices is associated with significant postoperative complication rates. Emergency surgery is associated with higher morbidity rates but not significantly higher mortality rates. Elective repair of umbilical hernia should be avoided for those with adverse predictors, such as age older than 65 years, MELD score higher than 15, and albumin level less than 3.0 g/dL.
比较有门静脉高压体征（如食管静脉曲张或腹水）与无门静脉高压体征患者的脐疝修补术结果；评估急诊手术对并发症发生率的影响；并确定术后死亡率的预测因素。
检索2005年1月1日至2009年12月31日的数据库。
参与美国外科医师学会国家外科质量改进计划倡议的北美医院。
我们研究了接受脐疝修补术的患者。排除了在手术时患有充血性心力衰竭、弥漫性恶性肿瘤或正在接受透析的慢性肾衰竭患者。
分析术前变量和围手术期过程。主要观察指标是脐疝修补术后的发病率和死亡率。
共有390例有腹水和/或食管静脉曲张的患者组成研究组，其余22952例患者组成对照组。研究组的总体发病率和死亡率分别为13.1%和5.1%，而对照组的这些比率分别为3.9%和0.1%（P <.001）。对于研究组，终末期肝病模型（MELD）评分大于15的患者择期修补术后死亡率为11.1%，而MELD评分小于或等于15的患者为1.3%。有腹水和/或食管静脉曲张的患者比对照组更频繁地接受急诊手术（37.7%对4.9%；P <.001）。研究组的急诊手术与择期手术相比，发病率更高（20.8%对8.3%；P <.001），但死亡率没有显著更高（7.4%对3.7%；P = 0.11）。然而，逻辑回归分析显示，年龄大于65岁、MELD评分高于15、白蛋白水平低于3.0 g/dL（换算为克每升需乘以10）以及就诊时存在脓毒症更能预测术后死亡率。
存在腹水和/或食管静脉曲张时进行脐疝修补术会导致显著的术后并发症发生率。急诊手术与更高的发病率相关，但死亡率没有显著更高。对于有不良预测因素（如年龄大于65岁、MELD评分高于15和白蛋白水平低于3.0 g/dL）的患者，应避免择期脐疝修补术。
