Goodenough Christopher J, Ko Tien C, Kao Lillian S, Nguyen Mylan T, Holihan Julie L, Alawadi Zeinab, Nguyen Duyen H, Flores Juan R, Arita Nestor T, Roth J Scott, Liang Mike K
Department of Surgery, University of Texas Health Science Center, Houston, TX.
Department of Surgery, Baylor College of Medicine, Houston, TX.
J Am Coll Surg. 2015 Apr;220(4):405-13. doi: 10.1016/j.jamcollsurg.2014.12.027. Epub 2015 Jan 2.
Ventral incisional hernias (VIH) develop in up to 20% of patients after abdominal surgery. No widely applicable preoperative risk-assessment tool exists. We aimed to develop and validate a risk-assessment tool to predict VIH after abdominal surgery.
A prospective study of all patients undergoing abdominal surgery was conducted at a single institution from 2008 to 2010. Variables were defined in accordance with the National Surgical Quality Improvement Project, and VIH was determined through clinical and radiographic evaluation. A multivariate Cox proportional hazard model was built from a development cohort (2008 to 2009) to identify predictors of VIH. The HERNIAscore was created by converting the hazards ratios (HR) to points. The predictive accuracy was assessed on the validation cohort (2010) using a receiver operator characteristic curve and calculating the area under the curve (AUC).
Of 625 patients followed for a median of 41 months (range 0.3 to 64 months), 93 (13.9%) developed a VIH. The training cohort (n = 428, VIH = 70, 16.4%) identified 4 independent predictors: laparotomy (HR 4.77, 95% CI 2.61 to 8.70) or hand-assisted laparoscopy (HAL, HR 4.00, 95% CI 2.08 to 7.70), COPD (HR 2.35; 95% CI 1.44 to 3.83), and BMI ≥ 25 kg/m(2) (HR1.74; 95% CI 1.04 to 2.91). Factors that were not predictive included age, sex, American Society of Anesthesiologists (ASA) score, albumin, immunosuppression, previous surgery, and suture material or technique. The predictive score had an AUC = 0.77 (95% CI 0.68 to 0.86) using the validation cohort (n = 197, VIH = 23, 11.6%). Using the HERNIAscore: HERNIAscore = 4(∗)Laparotomy+3(∗)HAL+1(∗)COPD+1(∗) BMI ≥ 25, 3 classes stratified the risk of VIH: class I (0 to 3 points),5.2%; class II (4 to 5 points),19.6%; and class III (6 points), 55.0%.
The HERNIAscore accurately identifies patients at increased risk for VIH. Although external validation is needed, this provides a starting point to counsel patients and guide clinical decisions. Increasing the use of laparoscopy, weight-loss programs, community smoking prevention programs, and incisional reinforcement may help reduce rates of VIH.
腹部手术后高达20%的患者会发生腹直肌切口疝（VIH）。目前尚无广泛适用的术前风险评估工具。我们旨在开发并验证一种风险评估工具，以预测腹部手术后的VIH。
2008年至2010年在一家机构对所有接受腹部手术的患者进行了一项前瞻性研究。根据国家外科质量改进项目定义变量，并通过临床和影像学评估确定VIH。从一个开发队列（2008年至2009年）构建多变量Cox比例风险模型，以识别VIH的预测因素。通过将风险比（HR）转换为分数来创建HERNIA评分。使用受试者工作特征曲线并计算曲线下面积（AUC），在验证队列（2010年）中评估预测准确性。
在625例患者中，中位随访41个月（范围0.3至64个月），93例（13.9%）发生了VIH。训练队列（n = 428，VIH = 70，16.4%）确定了4个独立预测因素：开腹手术（HR 4.77，95% CI 2.61至8.70）或手辅助腹腔镜手术（HAL，HR 4.00，95% CI 2.08至7.70）、慢性阻塞性肺疾病（COPD，HR 2.35；95% CI 1.44至3.83）以及体重指数（BMI）≥25 kg/m²（HR 1.74；95% CI 1.04至2.91）。无预测作用的因素包括年龄、性别、美国麻醉医师协会（ASA）评分、白蛋白、免疫抑制、既往手术以及缝合材料或技术。使用验证队列（n = 197，VIH = 23，11.6%）时，预测评分的AUC = 0.77（95% CI 0.68至0.86）。使用HERNIA评分：HERNIA评分 = 4×开腹手术 + 3×HAL + 1×COPD + 1×BMI≥25，3个类别对VIH风险进行了分层：I类（0至3分），5.2%；II类（4至5分），19.6%；III类（6分），55.0%。
HERNIA评分能准确识别VIH风险增加的患者。尽管需要外部验证，但这为向患者提供咨询和指导临床决策提供了一个起点。增加腹腔镜手术的使用、开展减肥项目、社区吸烟预防项目以及切口加强措施可能有助于降低VIH的发生率。
