急性胆囊炎AAST分级量表的修订及其与严重程度生理指标的比较。
Revision of the AAST grading scale for acute cholecystitis with comparison to physiologic measures of severity.
作者信息
Schuster Kevin M, O'Connor Rick, Cripps Michael, Kuhlenschmidt Kali, Taveras Luis, Kaafarani Haytham M, El Hechi Majed, Puri Ruchir, Schroeppel Thomas J, Enniss Toby M, Cullinane Daniel C, Cullinane Laura M, Agarwal Suresh, Kaups Krista, Crandall Marie, Tominaga Gail
机构信息
From the Department of Surgery (K.M.S., R.O.), Yale School of Medicine New Haven, Connecticut; Department of Surgery (M.C., K.K., L.T.), University of Texas Southwestern School of Medicine, Dallas, Texas; Department of Surgery (H.M.K., M.E.H.), Massachusetts General Hospital Boston, Massachusetts; Department of Surgery (R.P., M.C.), University of Florida College of Medicine Jacksonville, Jacksonville, Florida; Department of Surgery (T.J.S.), UC Health, Colorado Springs, Colorado; Department of Surgery (T.M.E.), University of Utah, School of Medicine, Salt Lake City, Utah; Department of Surgery (D.C.C., L.M.C.), Marshfield Clinic Marshfield, Wisconsin; Department of Surgery (S.A.J.), Duke University Medical Center Durham, North Carolina; Department of Surgery (K.K.), University of California San Francisco, Fresno, Fresno; and Department of Surgery (G.T.), Scripps Memorial Hospital La Jolla, California.
出版信息
J Trauma Acute Care Surg. 2022 Apr 1;92(4):664-674. doi: 10.1097/TA.0000000000003507.
BACKGROUND
Grading systems for acute cholecystitis are essential to compare outcomes, improve quality, and advance research. The American Association for the Surgery of Trauma (AAST) grading system for acute cholecystitis was only moderately discriminant when predicting multiple outcomes and underperformed the Tokyo guidelines and Parkland grade. We hypothesized that through additional expert consensus, the predictive capacity of the AAST anatomic grading system could be improved.
METHODS
A modified Delphi approach was used to revise the AAST grading system. Changes were made to improve distribution of patients across grades, and additional key clinical variables were introduced. The revised version was assessed using prospectively collected data from an AAST multicenter study. Patient distribution across grades was assessed, and the revised grading system was evaluated based on predictive capacity using area under receiver operating characteristic curves for conversion from laparoscopic to an open procedure, use of a surgical "bail-out" procedure, bile leak, major complications, and discharge home. A preoperative AAST grade was defined based on preoperative, clinical, and radiologic data, and the Parkland grade was also substituted for the operative component of the AAST grade.
RESULTS
Using prospectively collected data on 861 patients with acute cholecystitis the revised version of the AAST grade has an improved distribution across all grades, both the overall grade and across each subscale. A higher AAST grade predicted each of the outcomes assessed (all p ≤ 0.01). The revised AAST grade outperformed the original AAST grade for predicting operative outcomes and discharge disposition. Despite this improvement, the AAST grade did not outperform the Parkland grade or the Emergency Surgery Score.
CONCLUSION
The revised AAST grade and the preoperative AAST grade demonstrated improved discrimination; however, a purely anatomic grade based on chart review is unlikely to predict outcomes without addition of physiologic variables. Follow-up validation will be necessary.
LEVEL OF EVIDENCE
Diagnostic Test or Criteria, Level IV.
背景
急性胆囊炎的分级系统对于比较治疗结果、提高医疗质量以及推动研究至关重要。美国创伤外科学会（AAST）的急性胆囊炎分级系统在预测多种结果时，其区分能力仅为中等，且表现不如东京指南和帕克兰分级。我们推测，通过更多专家达成共识，AAST解剖学分级系统的预测能力可以得到提高。
方法
采用改良的德尔菲法对AAST分级系统进行修订。做出改变以改善各等级间患者的分布情况，并引入了其他关键临床变量。使用从AAST多中心研究中前瞻性收集的数据对修订版进行评估。评估各等级间的患者分布情况，并基于预测能力对修订后的分级系统进行评估，采用受试者操作特征曲线下面积来评估从腹腔镜手术转为开放手术、采用手术“补救”程序、胆漏、主要并发症以及出院回家等情况。术前AAST分级基于术前、临床和放射学数据来定义，并且帕克兰分级也被用于替代AAST分级的手术部分。
结果
利用对861例急性胆囊炎患者前瞻性收集的数据，AAST分级的修订版在所有等级、整体等级以及各子量表中的分布都有所改善。较高的AAST分级可预测所评估的各项结果（所有p≤0.01）。修订后的AAST分级在预测手术结果和出院处置方面优于原始的AAST分级。尽管有此改进，但AAST分级仍未超过帕克兰分级或急诊手术评分。
结论
修订后的AAST分级和术前AAST分级显示出更好的区分能力；然而，仅基于病历审查的纯解剖学分级在不增加生理变量的情况下不太可能预测结果。有必要进行后续验证。
证据级别
诊断试验或标准，IV级。
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