Coakley Kathleen M, Sarasani Sneha, Prasad Tanu, Steele Scott R, Paquette Ian, Heniford Brant T, Davis Bradley R
Carolinas Medical Center, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina.
Division of Colon and Rectal Surgery, Cleveland Clinic Main Campus, Cleveland, Ohio.
J Surg Res. 2018 Dec;232:43-48. doi: 10.1016/j.jss.2018.04.012. Epub 2018 Jul 2.
For cirrhotic patients awaiting liver transplantation, the Model for End-Stage Liver Disease Sodium (MELD-Na) model is extensively studied. Because of the simplicity of the scoring system, there has been interest in applying MELD-Na to predict patient outcomes in the noncirrhotic surgical patient, and MELD-Na has been shown to predict postoperative morbidity and mortality after elective colectomy. Our aim was to identify the utility of MELD-Na to predict anastomotic leak in elective colorectal cases.
The American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database was queried (2012-2014) for all elective colorectal procedures in patients without ascites. Leak rates were compared by MELD-Na score using chi-square tests and multivariate logistic regression analysis.
We identified 44,540 elective colorectal cases (mean age, 60.5 y ± 14.4, mean body mass index 28.8 ± 6.6 kg/m, 52% female), of which 70% were colon resections and 30% involved partial rectal resections (low anterior resections). Laparoscopic approach accounted for 64.72% while 35.3% were open. The overall complication and mortality rates were 21% and 0.7%, respectively, with a total anastomotic leak rate of 3.4%. Overall, 98% had a preoperative MELD-Na score between 10 and 20. Incremental increases in MELD-Na score (10-14, 15-19, and ≥20) were associated with an increased leak rate, specifically in partial rectal resections (3.9% versus 5.1% versus 10.7% P <0.028). MELD-Na score ≥20 had an increased leak rate when compared with those with MELD-Na 10-14 (odds ratio [OR] 1.627; 95% confidence interval [CI] [1.015, 2.607]). An MELD-Na score increase from 10-14 to 15-19 increases overall mortality (OR 5.22; 95% CI [3.55, 7.671]). In all elective colorectal procedures, for every one-point increase in MELD-Na score, anastomotic leak (OR 1.04 95% CI [1.006, 1.07]), mortality (OR 1.24; 95% CI, [1.20, 1.27]), and overall complications (OR 1.10; 95% CI [1.09, 1.12]) increased. MELD-Na was an independent predictor of anastomotic leak in partial rectal resections, when controlling for gender, steroid use, smoking, approach, operative time, preoperative chemotherapy, and Crohn's disease (OR 1.06, 95% CI [1.002, 1.122]).
MELD-Na is an independent predictor of anastomotic leak in partial rectal resections. Anastomotic leak risk increases with increasing MELD-Na in elective colorectal resections, as does 30-d mortality and overall complication rate. As MELD-Na score increases to more than 20, restorative partial rectal resection has a 10% rate of anastomotic leak.
对于等待肝移植的肝硬化患者，终末期肝病钠模型（MELD-Na）已得到广泛研究。由于该评分系统简单易行，人们对将MELD-Na应用于预测非肝硬化手术患者的预后产生了兴趣，并且MELD-Na已被证明可预测择期结肠切除术后的并发症发生率和死亡率。我们的目的是确定MELD-Na在预测择期结直肠手术吻合口漏方面的实用性。
查询美国外科医师学会国家外科质量改进计划的目标结肠切除数据库（2012 - 2014年），获取所有无腹水患者的择期结直肠手术信息。使用卡方检验和多因素逻辑回归分析，按MELD-Na评分比较漏出率。
我们共识别出44540例择期结直肠手术病例（平均年龄60.5岁±14.4岁，平均体重指数28.8±6.6kg/m²，52%为女性），其中70%为结肠切除术，30%为部分直肠切除术（低位前切除术）。腹腔镜手术占64.72%，开放手术占35.3%。总体并发症发生率和死亡率分别为21%和0.7%，总吻合口漏出率为3.4%。总体而言，98%的患者术前MELD-Na评分为10至20分。MELD-Na评分的逐步升高（10 - 14分、15 - 19分和≥20分）与漏出率增加相关，特别是在部分直肠切除术中（分别为3.9%、5.1%和10.7%，P<0.028）。与MELD-Na评分为10 - 14分的患者相比，MELD-Na评分≥20分的患者漏出率增加（比值比[OR]1.627；95%置信区间[CI][1.015, 2.607]）。MELD-Na评分从10 - 14分增加到15 - 19分，总体死亡率增加（OR 5.22；95% CI[3.55, 7.671]）。在所有择期结直肠手术中，MELD-Na评分每增加1分，吻合口漏（OR 1.04，95% CI[1.006, 1.07]）、死亡率（OR 1.24；95% CI，[1.20, 1.27]）和总体并发症（OR 1.10；95% CI[1.09, 1.12]）均增加。在控制性别、类固醇使用、吸烟、手术方式、手术时间、术前化疗和克罗恩病等因素后，MELD-Na是部分直肠切除术中吻合口漏的独立预测因素（OR 1.06，95% CI[1.002, 1.122]）。
MELD-Na是部分直肠切除术中吻合口漏的独立预测因素。在择期结直肠切除术中，吻合口漏的风险随着MELD-Na的升高而增加，30天死亡率和总体并发症发生率也是如此。当MELD-Na评分增加到超过20分时，保留性部分直肠切除术的吻合口漏出率为10%。
