Elnahas Ahmad, Nguyen Geoffrey C, Okrainec Allan, Quereshy Fayez, Jackson Timothy D
Division of General Surgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada,
Surg Endosc. 2014 Sep;28(9):2708-12. doi: 10.1007/s00464-014-3532-8. Epub 2014 Apr 16.
Morbid obesity is strongly associated with nonalcoholic fatty liver disease. However, the effect of underlying liver disease on clinical outcomes following bariatric surgery has not been well studied. This study aims to determine the effect of underlying liver disease on short-term outcomes in bariatric patients using the model of end-stage liver disease (MELD) scoring system as a practical measure of hepatic dysfunction.
A retrospective cohort analysis was performed using data from the American College of Surgeons' National surgery quality improvement program participant use files. The study population consisted of patients that underwent elective laparoscopic-stapled bariatric surgery for morbid obesity between 2005 and 2012. Patients were excluded if they had a bleeding disorder or renal failure requiring dialysis. The optimal MELD cut-off score to predict 30-day adverse events was determined and used to stratify patients into two groups. The primary outcome was 30-day adverse events, defined as a postoperative complication or reoperation. The secondary outcome was 30-day mortality. A multiple logistic regression was performed to adjust the odds ratio (OR) estimate for 30-day adverse events based on the MELD cut-off score.
38,875 patients were included in the study population. A MELD score of 7.9 was determined to be the optimal cut-off to predict 30-day adverse events based on the maximized linear combination of specificity and sensitivity. After adjusting for confounding, the OR estimates for 30-day adverse events and mortality using the cut-off score as the key predictor were 1.22 [95 % CI 1.06-1.41] and 2.33 [95 % CI 1.19-4.56], respectively.
Using this large national surgical registry, bariatric patients with MELD scores ≥7.9 had a significant but marginal risk of 30-day adverse events and mortality. This suggests that severity of liver disease may affect bariatric surgery outcomes and should be considered during preoperative evaluations.
病态肥胖与非酒精性脂肪性肝病密切相关。然而，基础肝病对减肥手术后临床结局的影响尚未得到充分研究。本研究旨在使用终末期肝病模型（MELD）评分系统作为肝功能障碍的一种实用衡量指标，确定基础肝病对减肥手术患者短期结局的影响。
采用美国外科医师学会国家手术质量改进项目参与者使用文件中的数据进行回顾性队列分析。研究人群包括2005年至2012年间因病态肥胖接受择期腹腔镜吻合器减肥手术的患者。有出血性疾病或需要透析的肾衰竭患者被排除。确定预测30天不良事件的最佳MELD临界值，并用于将患者分为两组。主要结局是30天不良事件，定义为术后并发症或再次手术。次要结局是30天死亡率。进行多元逻辑回归以根据MELD临界值调整30天不良事件的比值比（OR）估计值。
38875名患者纳入研究人群。基于特异性和敏感性的最大化线性组合，确定MELD评分为7.9是预测30天不良事件的最佳临界值。在调整混杂因素后，以临界值作为关键预测指标时，30天不良事件和死亡率的OR估计值分别为1.22 [95%CI 1.06 - 1.41]和2.33 [95%CI 1.19 - 4.56]。
使用这个大型国家手术登记数据库，MELD评分≥7.9的减肥手术患者发生30天不良事件和死亡的风险显著但较小。这表明肝病严重程度可能影响减肥手术结局，术前评估时应予以考虑。
