Pei Kevin Y, Zhang Yawei, Sarac Timur, Davis Kimberly A
Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT.
Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, New Haven, CT; Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT.
Ann Vasc Surg. 2018 Jul;50:259-268. doi: 10.1016/j.avsg.2017.11.073. Epub 2018 Mar 6.
There is evidence to suggest outcomes may be related to surgeon experience or skill level. Lower extremity amputations are performed by both general surgeons (GSs) and vascular surgeons (VSs); however, the effect of specialty on postoperative outcome in below-knee amputation is not known. This retrospective study compares outcomes in below-knee amputations (BKA) between VS and GS.
Patients who underwent below-knee amputations between 2005 and 2014 were identified from the American College of Surgeons National Surgical Quality Improvement Project database. Data collected included patient demographics, comorbid conditions, and indication for procedures. Univariate and multivariate unconditional logistic regression models and linear regression models were employed to evaluate the associations between various outcomes and indications for surgery, emergency and teaching status, and surgical specialty.
Amputations performed by GSs experienced an increased risk of developing pneumonia (odds ratio [OR] = 1.49, 95% confidence interval [CI]: 1.19-1.86), pulmonary embolism (OR = 2.10, 95% CI: 1.10-4.01), and sepsis (OR = 1.29, 95% CI: 1.05-1.59). When stratified by indications for BKA, similar outcomes were noted between GS and VS if indication for surgery was diabetes or peripheral vascular disease; however, there was increased risk of pneumonia (OR = 1.86, 95% CI: 1.26-2.74), sepsis (OR = 1.96, 95% CI: 1.39-2.75), and death (OR = 1.47, 95% CI: 1.04-2.07, P = 0.027) when GS performed BKA for infectious indications. Overall complications were higher when GS performed BKA emergently (OR = 1.17, 95% CI: 1.01-1.36).
There are less postoperative complications when VSs performed BKA for infectious indications, during emergencies, and at nonteaching hospitals. Clinicians should consider vascular consultation for these specific scenarios.
有证据表明，手术结果可能与外科医生的经验或技术水平有关。普通外科医生（GSs）和血管外科医生（VSs）都会进行下肢截肢手术；然而，专业对膝下截肢术后结果的影响尚不清楚。这项回顾性研究比较了血管外科医生和普通外科医生在膝下截肢（BKA）方面的手术结果。
从美国外科医师学会国家外科质量改进项目数据库中识别出2005年至2014年间接受膝下截肢手术的患者。收集的数据包括患者人口统计学信息、合并症以及手术指征。采用单因素和多因素无条件逻辑回归模型以及线性回归模型来评估各种手术结果与手术指征、急诊和教学状况以及外科专业之间的关联。
普通外科医生进行的截肢手术发生肺炎（比值比[OR]=1.49，95%置信区间[CI]：1.19-1.86）、肺栓塞（OR=2.10，95%CI：1.10-4.01）和败血症（OR=1.29，95%CI：1.05-1.59）的风险增加。当按膝下截肢指征分层时，如果手术指征为糖尿病或外周血管疾病，普通外科医生和血管外科医生的手术结果相似；然而，当普通外科医生因感染指征进行膝下截肢手术时，发生肺炎（OR=1.86，95%CI：1.26-2.74）、败血症（OR=1.96，95%CI：1.39-2.75）和死亡（OR=1.47，95%CI：1.04-2.07，P=0.027）的风险增加。普通外科医生急诊进行膝下截肢手术时总体并发症更高（OR=1.17，95%CI：1.01-1.36）。
血管外科医生在因感染指征、急诊情况下以及在非教学医院进行膝下截肢手术时，术后并发症较少。临床医生在这些特定情况下应考虑进行血管会诊。
