Rencuzogullari Ahmet, Benlice Cigdem, Valente Michael, Abbas Maher A, Remzi Feza H, Gorgun Emre
Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.
Dis Colon Rectum. 2017 May;60(5):527-536. doi: 10.1097/DCR.0000000000000789.
Elderly patients undergoing colorectal surgery have increasingly become under scrutiny by accounting for the largest fraction of geriatric postoperative deaths and a significant proportion of all postoperative complications, including anastomotic leak.
This study aimed to determine predictors of anastomotic leak in elderly patients undergoing colectomy by creating a novel nomogram for simplistic prediction of anastomotic leak risk in a given patient.
This study was a retrospective review.
The database review of the American College of Surgeons National Surgical Quality Improvement Program was conducted at a single institution.
Patients aged ≥65 years who underwent elective segmental colectomy with an anastomosis at different levels (abdominal or low pelvic) in 2012-2013 were identified from the multi-institutional procedure-targeted database.
We constructed a stepwise multiple logistic regression model for anastomotic leak as an outcome; predictors were selected in a stepwise fashion using the Akaike information criterion. The validity of the nomogram was externally tested on elderly patients (≥65 years of age) from the 2014 American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database.
A total of 10,392 patients were analyzed, and anastomotic leak occurred in 332 (3.2%). Of the patients who developed anastomotic leak, 192 (57.8%) were men (p < 0.001). Based on unadjusted analysis, factors associated with an increased risk of anastomotic leak were ASA score III and IV (p < 0.001), chronic obstructive pulmonary disease (p = 0.004), diabetes mellitus (p = 0.003), smoking history (p = 0.014), weight loss (p = 0.013), previously infected wound (p = 0.005), omitting mechanical bowel preparation (p = 0.005) and/or preoperative oral antibiotic use (p < 0.001), and wounds classified as contaminated or dirty/infected (p = 0.008). Patients who developed anastomotic leak had a longer length of hospital stay (17 vs 7 d; p < 0.001) and operative time (191 vs 162 min; p < 0.001). A multivariate model and nomogram were created.
This study was limited by its retrospective nature and short-term follow-up (30 d).
An accurate prediction of anastomotic leak affecting morbidity and mortality after colorectal surgery using the proposed nomogram may facilitate decision making in elderly patients for healthcare providers.
接受结直肠手术的老年患者越来越受到关注，因为他们在老年术后死亡中占比最大，且在包括吻合口漏在内的所有术后并发症中占相当大的比例。
本研究旨在通过创建一种新颖的列线图来简单预测特定患者吻合口漏的风险，从而确定接受结肠切除术的老年患者吻合口漏的预测因素。
本研究为回顾性研究。
在美国外科医师学会国家外科质量改进计划的数据库回顾中，研究在单一机构进行。
从多机构手术目标数据库中识别出2012 - 2013年接受择期节段性结肠切除术且在不同水平（腹部或低位盆腔）进行吻合的≥65岁患者。
我们构建了一个以吻合口漏为结果的逐步多元逻辑回归模型；使用赤池信息准则以逐步方式选择预测因素。该列线图的有效性在2014年美国外科医师学会国家外科质量改进计划结肠切除术目标数据库中的老年患者（≥65岁）中进行了外部测试。
共分析了10392例患者，其中332例（3.2%）发生吻合口漏。发生吻合口漏的患者中，192例（57.8%）为男性（p < 0.001）。基于未调整分析，与吻合口漏风险增加相关的因素包括美国麻醉医师协会（ASA）评分III和IV（p < 0.001）、慢性阻塞性肺疾病（p = 0.004）、糖尿病（p = 0.003）、吸烟史（p = 0.014）、体重减轻（p = 0.013）、既往伤口感染（p = 0.005）、未进行机械肠道准备（p = 0.005）和/或术前使用口服抗生素（p < 0.001），以及分类为污染或脏污/感染的伤口（p = 0.008）。发生吻合口漏的患者住院时间更长（17天对7天；p < 0.001），手术时间更长（191分钟对162分钟；p < 0.001）。创建了一个多变量模型和列线图。
本研究受其回顾性性质和短期随访（30天）的限制。
使用所提出的列线图准确预测影响结直肠手术后发病率和死亡率的吻合口漏，可能有助于医疗服务提供者为老年患者做出决策。
