Department of Surgery, Anne Arundel Medical Center, Annapolis, Maryland.
Georgetown Transplant Institute, Department of Surgery, Georgetown University Hospital, Washington, District of Columbia.
J Surg Res. 2022 Nov;279:127-134. doi: 10.1016/j.jss.2022.05.021. Epub 2022 Jun 24.
Interfacility transfer to a referral center is often considered for patients with liver disease undergoing nonelective cholecystectomy given management complexities and perioperative risk. We sought to determine the association between the Model for End Stage Liver Disease (MELD) score, transfer frequency, and outcomes in those patients using a national database.
The ACS-NSQIP participant use files were queried for nonelective open or laparoscopic cholecystectomy from 2016 to 2018. Patients were grouped according to low (6-11), intermediate (12-18), or high (>18) MELD. In the high MELD group, patient characteristics and outcomes were compared between transferred and nontransferred patients and multivariate regression was performed to evaluate independent predictors of outcomes. Outcomes included in-hospital mortality, complications, length-of-stay (LOS), and 30-d reoperation and readmission.
30,171 subjects were included. Transfer was more likely as MELD increased (19.5% high versus 12.1% low, P < 0.001). High MELD patients had increased LOS, reoperation, readmission, and mortality rates compared to low MELD. In high MELD patients (n = 1016), those transferred were more likely older, white, obese, and septic. Transferred patients had increased mortality (7.6% versus 4.2%, P = 0.044), LOS, reoperation, and complications. After controlling for differences between transferred and nontransferred patients, transfer status was not independently associated with mortality (OR = 1.593, P = 0.177), postoperative complications or LOS, but was associated with increased risk for reoperation. Sepsis and laparoscopic surgery were independently associated with higher and lower mortality, respectively.
Transfer status is not independently associated with mortality, postoperative complications, or prolonged LOS, suggesting patients with advanced liver disease undergoing acute cholecystectomy may not benefit from interfacility transfer.
由于管理复杂性和围手术期风险，对于接受非择期胆囊切除术的肝病患者，通常会考虑将其转至转诊中心。我们试图使用国家数据库确定终末期肝病模型（MELD）评分、转院频率与这些患者结局之间的关联。
从 2016 年至 2018 年，ACS-NSQIP 参与者使用文件查询了非择期开腹或腹腔镜胆囊切除术。根据 MELD 评分（6-11 分为低分组，12-18 分为中分组，>18 分为高分组）将患者分为低、中、高 MELD 三组。在高 MELD 组中，比较了转院和未转院患者的患者特征和结局，并进行了多变量回归以评估结局的独立预测因素。结局包括院内死亡率、并发症、住院时间（LOS）、30 天再手术和再入院。
共纳入 30171 例患者。随着 MELD 的升高，转院的可能性更大（高 MELD 组为 19.5%，低 MELD 组为 12.1%，P<0.001）。与低 MELD 患者相比，高 MELD 患者的 LOS、再手术、再入院和死亡率更高。在高 MELD 患者（n=1016）中，转院患者更可能年龄较大、为白人、肥胖和脓毒症。转院患者的死亡率（7.6%比 4.2%，P=0.044）、LOS、再手术和并发症发生率更高。在控制了转院和未转院患者之间的差异后，转院状态与死亡率（OR=1.593，P=0.177）、术后并发症或 LOS 均无独立相关性，但与再手术风险增加相关。脓毒症和腹腔镜手术与死亡率升高和降低独立相关。
转院状态与死亡率、术后并发症或 LOS 延长无关，提示接受急性胆囊切除术的晚期肝病患者可能无法从院际转院中获益。
