Division of Cardiac Surgery, David Geffen School of Medicine at the University of California, Los Angeles.
David Geffen School of Medicine, University of California, Los Angeles.
Surgery. 2018 Sep;164(3):539-545. doi: 10.1016/j.surg.2018.04.030. Epub 2018 Jun 19.
Cardiovascular complications are the leading cause of death after noncardiac surgery. Major abdominal operations represent the largest category of procedures considered to have an increased risk of cardiovascular complications. The current aim was to examine trends in the incidence of mortality, perioperative myocardial infarction, and cardiac arrest to determine the presence of potential volume-outcome relationships.
We performed a retrospective analysis of the Nationwide Inpatient Sample for patients undergoing elective, open abdominal esophagectomy, gastrectomy, pancreatectomy, nephrectomy, hepatectomy, splenectomy, and colectomy (major abdominal surgery) during 2008-2014. Univariate and multivariate analyses were performed to determine the impact of operative volume on rates of myocardial infarction, cardiac arrest, and mortality.
Of the 962,754 elective admissions for major abdominal surgery, 1.4% experienced in-hospital mortality, 0.7% myocardial infarction, and 0.35% cardiac arrest. Myocardial infarction and cardiac arrest were associated with a 24-fold increase in risk of perioperative mortality. Compared with institutions that have a very low volume of operations, those hospitals with larger volumes of operations had a decreased risk of cardiac arrest and incident mortality after cardiovascular complications, but the odds of myocardial infarction were greatest at higher operative-volume hospitals. The annual all-cause mortality and myocardial infarction rates decreased over time, but the incidence of cardiac arrest increased.
Myocardial infarction or cardiac arrest after major abdominal surgery increased the odds of mortality with superior rescue after cardiovascular complications at higher volume institutions. Across all US hospitals performing major abdominal surgery, the rate of cardiac arrest increased without a concomitant increase in myocardial infarction or mortality. Novel targets for risk modification of myocardial infarction and cardiac arrest as well as investigation of processes that facilitate rescue after these complications at higher operative-volume hospitals are needed to delineate quality improvement opportunities.
心血管并发症是非心脏手术后死亡的主要原因。大腹部手术是被认为具有更高心血管并发症风险的最大手术类别之一。本研究旨在检查死亡率、围手术期心肌梗死和心脏骤停的发生率趋势，以确定是否存在潜在的量效关系。
我们对 2008 年至 2014 年期间在全国住院患者样本中接受择期开放腹部食管切除术、胃切除术、胰腺切除术、肾切除术、肝切除术、脾切除术和结肠切除术（大腹部手术）的患者进行了回顾性分析。进行了单变量和多变量分析，以确定手术量对心肌梗死、心脏骤停和死亡率的影响。
在 962754 例择期大腹部手术的住院患者中，有 1.4%发生院内死亡率，0.7%发生心肌梗死，0.35%发生心脏骤停。心肌梗死和心脏骤停与围手术期死亡率增加 24 倍相关。与手术量非常低的机构相比，手术量较大的医院在发生心血管并发症后心脏骤停和事件死亡率的风险降低，但在手术量较高的医院，心肌梗死的几率最大。全因死亡率和心肌梗死发生率随时间降低，但心脏骤停的发生率增加。
大腹部手术后发生心肌梗死或心脏骤停会增加死亡率的几率，但在更高容量的机构中，心血管并发症后的抢救效果更好。在美国所有进行大腹部手术的医院中，心脏骤停的发生率增加，而心肌梗死或死亡率没有增加。需要确定心肌梗死和心脏骤停的风险修正新目标，并研究在手术量较高的医院中这些并发症后促进抢救的过程，以确定质量改进的机会。
