From the Plastic Surgery Department, Brown University, Providence, RI.
Plastic Surgery Division, University of Pennsylvania, Philadelphia, PA.
Ann Plast Surg. 2022 May 1;88(3 Suppl 3):S219-S223. doi: 10.1097/SAP.0000000000003189.
Preoperative surgical risk assessment is a major component of clinical decision making. The ability to provide accurate, individualized risk estimates has become critical because of growing emphasis on quality metrics benchmarks. The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) Surgical Risk Calculator (SRC) was designed to quantify patient-specific risk across various surgeries. Its applicability to plastic surgery is unclear, however, with multiple studies reporting inaccuracies among certain patient populations. This study uses meta-analysis to evaluate the NSQIP SRC's ability to predict complications among patients having plastic surgery.
OVID MEDLINE and PubMed were searched for all studies evaluating the predictive accuracy of the NSQIP SRC in plastic surgery, including oncologic reconstruction, ventral hernia repair, and body contouring. Only studies directly comparing SCR predicted to observed complication rates were included. The primary measure of SRC prediction accuracy, area under the curve (AUC), was assessed for each complication via DerSimonian and Laird random-effects analytic model. The I2 statistic, indicating heterogeneity, was judged low (I2 < 50%) or borderline/unacceptably high (I2 > 50%). All analyses were conducted in StataSE 16.1 (StataCorp LP, College Station, Tex).
Ten of the 296 studies screened met criteria for inclusion (2416 patients). Studies were classified as follows: (head and neck: n = 5, breast: n = 1, extremity: n = 1), open ventral hernia repair (n = 2), and panniculectomy (n = 1). Predictive accuracy was poor for medical and surgical complications (medical: pulmonary AUC = 0.67 [0.48-0.87], cardiac AUC = 0.66 [0.20-0.99], venous thromboembolism AUC = 0.55 [0.47-0.63]), (surgical: surgical site infection AUC = 0.55 [0.46-0.63], reoperation AUC = 0.54 [0.49-0.58], serious complication AUC = 0.58 [0.43-0.73], and any complication AUC = 0.60 [0.57-0.64]). Although mortality was accurately predicted in 2 studies (AUC = 0.87 [0.54-0.99]), heterogeneity was high with I2 = 68%. Otherwise, heterogeneity was minimal (I2 = 0%) or acceptably low (I2 < 50%) for all other outcomes.
The NSQIP Universal SRC, aimed at offering individualized quantifiable risk estimates for surgical complications, consistently demonstrated poor risk discrimination in this plastic surgery-focused meta-analysis. The limitations of the SRC are perhaps most pronounced where complex, multidisciplinary reconstructions are needed. Future efforts should identify targets for improving SRC reliability to better counsel patients in the perioperative setting and guide appropriate healthcare resource allocation.
术前手术风险评估是临床决策的重要组成部分。由于越来越强调质量指标基准，提供准确、个体化的风险估计变得至关重要。美国外科医师学院国家外科质量改进计划（NSQIP）手术风险计算器（SRC）旨在量化各种手术中患者的特定风险。然而，它在整形手术中的适用性尚不清楚，因为多项研究报告了某些患者群体的准确性存在差异。本研究使用荟萃分析评估 NSQIP SRC 预测整形手术患者并发症的能力。
在 OVID MEDLINE 和 PubMed 上搜索了所有评估 NSQIP SRC 在整形手术（包括肿瘤重建、腹疝修复和身体轮廓）中的预测准确性的研究，包括肿瘤重建、腹疝修复和身体轮廓。仅包括直接比较 SRC 预测与观察到的并发症发生率的研究。通过 DerSimonian 和 Laird 随机效应分析模型评估 SRC 预测准确性的主要指标曲线下面积（AUC）。指示异质性的 I2 统计量判断为低（I2 < 50%）或边界/不可接受高（I2 > 50%）。所有分析均在 StataSE 16.1（StataCorp LP，德克萨斯州学院站）中进行。
筛选出的 296 项研究中有 10 项符合纳入标准（2416 名患者）。研究分为以下几类：（头颈部：n = 5，乳房：n = 1，四肢：n = 1），开放性腹疝修复（n = 2）和脐成形术（n = 1）。医疗和手术并发症的预测准确性较差（医疗：肺部 AUC = 0.67 [0.48-0.87]，心脏 AUC = 0.66 [0.20-0.99]，静脉血栓栓塞 AUC = 0.55 [0.47-0.63]），（手术：手术部位感染 AUC = 0.55 [0.46-0.63]，再次手术 AUC = 0.54 [0.49-0.58]，严重并发症 AUC = 0.58 [0.43-0.73]，任何并发症 AUC = 0.60 [0.57-0.64]）。尽管有 2 项研究准确预测了死亡率（AUC = 0.87 [0.54-0.99]），但异质性很高，I2 = 68%。否则，所有其他结局的异质性均较小（I2 = 0%）或可接受（I2 < 50%）。
旨在提供手术并发症个体化量化风险估计的 NSQIP 通用 SRC 在本整形手术重点荟萃分析中始终表现出较差的风险区分能力。SRC 的局限性在需要复杂的多学科重建时可能最为明显。未来的努力应确定改进 SRC 可靠性的目标，以便更好地为围手术期患者提供咨询，并指导适当的医疗资源分配。
