多中心验证美国创伤外科学会急性胆囊炎分级量表。
Multicenter validation of the American Association for the Surgery of Trauma grading scale for acute cholecystitis.
机构信息
From the Department of Surgery (K.M.S., R.O.), Yale School of Medicine, New Haven, CT; Department of Surgery (M. Cripps, K.K., L.T.), University of Texas Southwestern School of Medicine, Dallas, TX; Department of Surgery (H.M.K., M.E.), Massachusetts General Hospital, Boston, MA; Department of Surgery (R.P., M. Crandall, J.M.), College of Medicine - Jacksonville, University of Florida, Jacksonville, FL; Department of Surgery (T.J.S., J.R.), UC Health, Colorado Springs, CO; Department of Surgery (D.C.C., L.M.C.), Marshfield Clinic, Marshfield, WI; Department of Surgery (T.M.E.), School of Medicine, University of Utah, Salt Lake City, UT; and Department of Surgery (R.S., B.Z.), Cooper Medical School of Rowan University, Camden, NJ.
出版信息
J Trauma Acute Care Surg. 2021 Jan 1;90(1):87-96. doi: 10.1097/TA.0000000000002901.
BACKGROUND
The American Association for the Surgery of Trauma (AAST) patient assessment committee has created grading systems for emergency general surgery diseases to assist with clinical decision making and risk adjustment during research. Single-institution studies have validated the cholecystitis grading system as associated with patient outcomes. Our aim was to validate the grading system in a multi-institutional fashion and compare it with the Parkland grade and Tokyo Guidelines for acute cholecystitis.
METHODS
Patients presenting with acute cholecystitis to 1 of 8 institutions were enrolled. Discrete data to assign the AAST grade were collected. The Parkland grade was collected prospectively from the operative surgeon from four institutions. Parkland grade, Tokyo Guidelines, AAST grade, and the AAST preoperative grade (clinical and imaging subscales) were compared using linear and logistic regression to the need for surgical "bailout" (subtotal or fenestrated cholecystectomy, or cholecystostomy), conversion to open, surgical complications (bile leak, surgical site infection, bile duct injury), all complications, and operative time.
RESULTS
Of 861 patients, 781 underwent cholecystectomy. Mean (SD) age was 51.1 (18.6), and 62.7% were female. There were six deaths. Median AAST grade was 2 (interquartile range [IQR], 1-2), and median Parkland grade was 3 (interquartile range [IQR], 2-4). Median AAST clinical and imaging grades were 2 (IQR, 2-2) and 1 (IQR, 0-1), respectively. Higher grades were associated with longer operative times, and worse outcomes although few were significant. The Parkland grade outperformed the AAST grade based on area under the receiver operating characteristic curve.
CONCLUSION
The AAST cholecystitis grading schema has modest discriminatory power similar to the Tokyo Guidelines, but generally lower than the Parkland grade, and should be modified before widespread use.
LEVEL OF EVIDENCE
Diagnostic study, level IV.
背景
美国创伤外科学会（AAST）患者评估委员会已经为急症普通外科疾病创建了分级系统，以协助临床决策和研究中的风险调整。单机构研究已经验证了胆囊炎分级系统与患者结局相关。我们的目的是采用多机构的方式验证该分级系统，并将其与 Parkland 分级和东京指南进行比较，以评估其对急性胆囊炎的适用性。
方法
将就诊于 8 家机构之一的急性胆囊炎患者纳入研究。收集用于分配 AAST 分级的离散数据。前瞻性地从 4 家机构的手术医师处收集 Parkland 分级。采用线性和逻辑回归比较 Parkland 分级、东京指南、AAST 分级和 AAST 术前分级（临床和影像学亚量表）与手术“抢救”（胆囊次全切除术或胆囊造口术，或胆囊造瘘术）、转为开放性手术、手术并发症（胆漏、手术部位感染、胆管损伤）、所有并发症和手术时间的相关性。
结果
861 例患者中，781 例行胆囊切除术。患者的平均（SD）年龄为 51.1（18.6）岁，62.7%为女性。有 6 例死亡。AAST 分级中位数为 2 级（四分位距[IQR]，1-2 级），Parkland 分级中位数为 3 级（IQR，2-4 级）。AAST 临床和影像学分级的中位数分别为 2 级（IQR，2-2 级）和 1 级（IQR，0-1 级）。较高的分级与较长的手术时间和较差的结局相关，但大多无统计学意义。基于受试者工作特征曲线下面积，Parkland 分级优于 AAST 分级。
结论
AAST 胆囊炎分级方案具有与东京指南相似的适度判别能力，但一般低于 Parkland 分级，在广泛应用前需要进行修改。
证据等级
诊断研究，IV 级。
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