Sirany Anne-Marie E, Chow Christopher J, Kunitake Hiroko, Madoff Robert D, Rothenberger David A, Kwaan Mary R
1 Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota 2 Department of Surgery, University of Minnesota, Minneapolis, Minnesota 3 Department of Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
Dis Colon Rectum. 2016 Jul;59(7):662-9. doi: 10.1097/DCR.0000000000000609.
More than 450,000 US patients with end-stage renal disease currently dialyze. The risk of morbidity and mortality for these patients after colorectal surgery has been incompletely described.
We analyzed the 30-day morbidity and mortality rates of chronic dialysis patients who underwent colorectal surgery.
This was a retrospective analysis.
Hospitals that participate in the American College of Surgeons National Surgical Quality Improvement Program were included.
The study included adult patients who underwent emergency or elective colon or rectal resection between 2009 and 2014.
Baseline characteristics were compared by dialysis status. The impact of chronic dialysis on 30-day mortality and serious postoperative morbidity was examined using multivariate logistic regression.
We identified 128,757 patients who underwent colorectal surgery in the American College of Surgeons National Surgical Quality Improvement Program database. Chronic dialysis patients accounted for 1% (n = 1285) and were more likely to be older (65.4 vs 63.2 years; p < 0.0001), black (27.2% vs 8.7%; p < 0.0001), preoperatively septic (22.1% vs 7.1%; p < 0.0001), require emergency surgery (52.0% vs 14.7%; p < 0.0001), have ischemic bowel (15.7% vs 1.6%; p < 0.0001), or have perforation/peritonitis (15.5% vs 4.2%; p < 0.0001). Chronic dialysis patients were also less likely to have a laparoscopic procedure (17.3% vs 45.0%; p < 0.0001). Chronic dialysis patients had higher unadjusted mortality (22.4% vs 3.3%; p < 0.0001), serious postoperative morbidity (47.9% vs 18.8%; p < 0.0001), and median length of stay (9 vs 6 days; p < 0.0001). In emergent cases (n = 19,375), multivariate logistic regression models demonstrated a higher risk of mortality for dialysis patients (OR = 1.73 (95% CI, 1.38-2.16)) but not for serious morbidity. Models for elective surgery demonstrated a similar effect on mortality (OR = 2.47 (95% CI, 1.75-3.50)) but also demonstrated a higher risk of serious morbidity (OR = 1.28 (95% CI, 1.04-1.56)).
The postoperative 30-day window may underestimate the true incidence of serious morbidity and mortality.
Chronic dialysis patients undergoing elective or emergent colorectal procedures have a higher risk-adjusted mortality.
目前美国有超过45万终末期肾病患者接受透析治疗。这些患者结直肠手术后的发病和死亡风险尚未得到充分描述。
我们分析了接受结直肠手术的慢性透析患者的30天发病率和死亡率。
这是一项回顾性分析。
纳入了参与美国外科医师学会国家外科质量改进计划的医院。
该研究纳入了2009年至2014年间接受急诊或择期结肠或直肠切除术的成年患者。
根据透析状态比较基线特征。使用多因素逻辑回归分析慢性透析对30天死亡率和严重术后发病率的影响。
我们在美国外科医师学会国家外科质量改进计划数据库中识别出128,757例接受结直肠手术的患者。慢性透析患者占1%（n = 1285），且更可能年龄较大（65.4岁对63.2岁；p < 0.0001）、为黑人（27.2%对8.7%；p < 0.0001）、术前感染（22.1%对7.1%；p < 0.0001）、需要急诊手术（52.0%对14.7%；p < 0.0001）、患有缺血性肠病（15.7%对1.6%；p < 0.0001）或穿孔/腹膜炎（15.5%对4.2%；p < 0.0001）。慢性透析患者接受腹腔镜手术的可能性也较小（17.3%对45.0%；p < 0.0001）。慢性透析患者未经调整的死亡率较高（22.4%对3.3%；p < 0.0001）、严重术后发病率较高（47.9%对18.8%；p < 0.0001），中位住院时间较长（9天对6天；p < 0.0001）。在急诊病例（n = 19,375）中，多因素逻辑回归模型显示透析患者的死亡风险较高（OR = 1.73（95%CI，1.38 - 2.16）），但严重发病率风险无差异。择期手术模型对死亡率有类似影响（OR = 2.47（95%CI，1.75 - 3.50）），但也显示严重发病率风险较高（OR = 1.28（95%CI，1.04 - 1.56））。
术后30天的观察期可能低估了严重发病率和死亡率的真实发生率。
接受择期或急诊结直肠手术的慢性透析患者经风险调整后的死亡率较高。
