Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, CA-034, Boston, MA, 02115, USA.
Harvard Medical School, Boston, MA, USA.
J Gastrointest Surg. 2019 Apr;23(4):643-650. doi: 10.1007/s11605-018-04081-0. Epub 2019 Jan 18.
Surgery in neutropenic patients is challenging due to both atypical manifestations of common conditions and higher perioperative risk. We sought to describe the outcomes of neutropenic patients undergoing abdominal surgery and to identify factors contributing to morbidity and mortality.
A retrospective chart review was performed for all patients neutropenic in the 24-hours prior to an abdominal operation at our institution between 1998 and 2017. The primary and secondary outcomes were 30-day mortality and morbidity, respectively. The chi-square test and two-tailed Student's t test were used for univariable comparisons (non-parametric tests used when appropriate). To determine the optimal threshold of absolute neutrophil count (ANC) to discriminate 30-day mortality, we maximized the Youden index (J).
Amongst 237 patients, mortality was 11.8% (28/237) and morbidity 54.5% (130/237). Absolute neutrophil count < 500 cells/μL (50% vs. 20.6%, P < 0.01) and perforated viscus (35.7% vs. 14.8%, P = 0.01) were associated with mortality. Perforated viscus (25.4% vs. 7.5%) was also associated with morbidity. Urgent operations were associated with higher morbidity (63.6% vs 34.7%, P < 0.001) and mortality (16.4% vs 1.4%, P = 0.002) when compared to elective operations. Transfer from an outside hospital (22.3% vs. 11.2%, P = 0.02) and longer median time from admission to operation (2 days (IQR 0-6) vs. 1 day (IQR 0-3), P < 0.01) were associated with morbidity. An ANC threshold of 350 provided the best discrimination for mortality.
Elective surgery in the appropriately chosen neutropenic patient is relatively safe. For patients with obvious surgical pathology, we advocate for earlier operation and a lower threshold for surgical consultation in an effort expedite the diagnosis and necessary treatment.
由于常见病症的表现不典型和围手术期风险较高，中性粒细胞减少症患者的手术具有挑战性。我们旨在描述中性粒细胞减少症患者行腹部手术后的结局，并确定导致发病率和死亡率的因素。
我们对 1998 年至 2017 年期间在我院接受腹部手术前 24 小时内中性粒细胞减少症的所有患者进行了回顾性病历分析。主要和次要结局分别为 30 天死亡率和发病率。使用卡方检验和双侧学生 t 检验进行单变量比较（适用时使用非参数检验）。为了确定区分 30 天死亡率的最佳绝对中性粒细胞计数（ANC）阈值，我们最大化了约登指数（J）。
在 237 例患者中，死亡率为 11.8%（28/237），发病率为 54.5%（130/237）。ANC<500 个细胞/μL（50% vs. 20.6%，P<0.01）和穿孔性内脏（35.7% vs. 14.8%，P=0.01）与死亡率相关。穿孔性内脏（25.4% vs. 7.5%）也与发病率相关。与择期手术相比，紧急手术与更高的发病率（63.6% vs. 34.7%，P<0.001）和死亡率（16.4% vs. 1.4%，P=0.002）相关。与从外院转入（22.3% vs. 11.2%，P=0.02）和从入院到手术的中位时间延长（2 天（IQR 0-6）vs. 1 天（IQR 0-3），P<0.01）相关。ANC 阈值为 350 时，对死亡率的区分度最佳。
在适当选择的中性粒细胞减少症患者中，择期手术相对安全。对于有明显手术病理的患者，我们主张更早地进行手术，并降低手术咨询的阈值，以加快诊断和必要的治疗。
