Bohnen Jordan D, Ramly Elie P, Sangji Naveen F, de Moya Marc, Yeh D Dante, Lee Jarone, Velmahos George C, Chang David C, Kaafarani Haytham M A
From the Division of Trauma (J.D.B., N.F.S., M.D.M., D.D.Y., J.L., G.C.V., H.M.A.K.), Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Surgery (E.P.R.), Oregon Health & Science University, Portland, Oregon; and Codman Center for Clinical Effectiveness in Surgery (N.F.S., L.L., D.C.C., H.M.A.K.), Massachusetts General Hospital, Boston, Massachusetts.
J Trauma Acute Care Surg. 2016 Jul;81(1):122-30. doi: 10.1097/TA.0000000000001015.
Emergency surgery (ES) is acknowledged to be riskier than nonemergency surgery (NES). Yet, little is known about the relative impact of individual perioperative risk factors on 30-day outcomes in ES versus NES.
Using the 2011-2012 American College of Surgeons National Surgical Quality Improvement Program nationwide database, the 20 most common ES procedures were identified by Current Procedural Terminology code. Current Procedural Terminology codes with less than 300 observations in either ES or NES were excluded. Emergency surgery cases were defined as "emergent" and "nonelective" per American College of Surgeons National Surgical Quality Improvement Program criteria. Multivariable regression models were constructed to identify predictors of 30-day major morbidity and mortality (MMM) in each group, controlling for demographics, American Society of Anesthesiologists class, comorbidities, preoperative laboratory values, and procedure type. The odds ratios of independent predictors of MMM in ES and NES were derived then individually compared between the two groups; "effect modification" of procedure status (ES vs. NES) on each risk factor was subsequently calculated.
Of 986,034 patients, 170,131 met inclusion criteria (59,949 ES; 110,182 NES). The overall risk of MMM was significantly higher in ES versus NES (16.75% vs. 9.73%, p < 0.001; odds ratio, 1.18; 95% confidence interval, 1.12-1.24; p < 0.001). Of 40 ES- and 38 NES-identified independent risk factors, preoperative transfusion and white blood cell count of 4.5 × 10/μL or less carried significantly higher relative risk of MMM in ES versus NES. Conversely, ascites, preoperative anemia, and white blood cell count of 11 × 10/μL to 25 × 10/μL carried greater relative risk for MMM in NES. Four procedures (laparoscopic cholecystectomy, laparotomy, and umbilical and incisional herniorrhaphy) were inherently riskier in ES versus NES. The effect modification of ES (vs. NES) ranged between 0.68 (0.52-0.88) for ascites and 2.56 (1.67-3.92) for umbilical hernia repair.
Perioperative risk factors and procedure type impact postoperative morbidity and mortality differently in ES versus NES. Instead of using the same risk-adjustment model for both ES and NES, as currently practiced, our findings strongly suggest the need to benchmark emergent and elective surgeries separately.
Prognostic/epidemiologic study, level III.
急诊手术（ES）被认为比非急诊手术（NES）风险更高。然而，关于围手术期个体风险因素对急诊手术与非急诊手术30天结局的相对影响，人们了解甚少。
利用2011 - 2012年美国外科医师学会全国外科质量改进计划的全国性数据库，通过当前手术操作术语编码确定20种最常见的急诊手术。排除在急诊手术或非急诊手术中观察例数少于300的当前手术操作术语编码。根据美国外科医师学会全国外科质量改进计划标准，将急诊手术病例定义为“紧急”和“非选择性”。构建多变量回归模型以确定每组中30天严重并发症和死亡率（MMM）的预测因素，同时控制人口统计学、美国麻醉医师协会分级、合并症、术前实验室值和手术类型。得出急诊手术和非急诊手术中MMM独立预测因素的比值比，然后在两组之间进行单独比较；随后计算手术状态（急诊手术与非急诊手术）对每个风险因素的“效应修正”。
在986,034例患者中，170,131例符合纳入标准（59,949例急诊手术；110,182例非急诊手术）。急诊手术中MMM的总体风险显著高于非急诊手术（16.75%对9.73%，p < 0.001；比值比，1.18；95%置信区间，1.12 - 1.24；p < 0.001）。在40个急诊手术和38个非急诊手术确定的独立风险因素中，术前输血以及白细胞计数为4.5×10⁹/μL或更低，在急诊手术中导致MMM的相对风险显著高于非急诊手术。相反，腹水、术前贫血以及白细胞计数为11×10⁹/μL至25×10⁹/μL在非急诊手术中导致MMM的相对风险更高。四种手术（腹腔镜胆囊切除术、剖腹术以及脐疝和切口疝修补术）在急诊手术中本质上比非急诊手术风险更高。急诊手术（与非急诊手术相比）的效应修正范围在腹水的0.68（0.52 - 0.88）至脐疝修补术的2.56（1.67 - 3.92）之间。
围手术期风险因素和手术类型对急诊手术与非急诊手术术后并发症和死亡率的影响不同。我们的研究结果强烈表明，不应像目前这样对急诊手术和非急诊手术使用相同的风险调整模型，而需要分别对急诊手术和择期手术进行基准评估。
预后/流行病学研究，III级。
