Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Center for Surgery and Health Economics, University of Pennsylvania Perelman School of Medicine, The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA.
Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Ann Surg. 2023 Jul 1;278(1):72-78. doi: 10.1097/SLA.0000000000005519. Epub 2022 Jul 4.
To determine the effect of operative versus nonoperative management of emergency general surgery conditions on short-term and long-term outcomes.
Many emergency general surgery conditions can be managed either operatively or nonoperatively, but high-quality evidence to guide management decisions is scarce.
We included 507,677 Medicare patients treated for an emergency general surgery condition between July 1, 2015, and June 30, 2018. Operative management was compared with nonoperative management using a preference-based instrumental variable analysis and near-far matching to minimize selection bias and unmeasured confounding. Outcomes were mortality, complications, and readmissions.
For hepatopancreaticobiliary conditions, operative management was associated with lower risk of mortality at 30 days [-2.6% (95% confidence interval: -4.0, -1.3)], 90 days [-4.7% (-6.50, -2.8)], and 180 days [-6.4% (-8.5, -4.2)]. Among 56,582 intestinal obstruction patients, operative management was associated with a higher risk of inpatient mortality [2.8% (0.7, 4.9)] but no significant difference thereafter. For upper gastrointestinal conditions, operative management was associated with a 9.7% higher risk of in-hospital mortality (6.4, 13.1), which increased over time. There was a 6.9% higher risk of inpatient mortality (3.6, 10.2) with operative management for colorectal conditions, which increased over time. For general abdominal conditions, operative management was associated with 12.2% increased risk of inpatient mortality (8.7, 15.8). This effect was attenuated at 30 days [8.5% (3.8, 13.2)] and nonsignificant thereafter.
The effect of operative emergency general surgery management varied across conditions and over time. For colorectal and upper gastrointestinal conditions, outcomes are superior with nonoperative management, whereas surgery is favored for patients with hepatopancreaticobiliary conditions. For obstructions and general abdominal conditions, results were equivalent overall. These findings may support patients, clinicians, and families making these challenging decisions.
确定手术与非手术治疗急症普通外科疾病对短期和长期结局的影响。
许多急症普通外科疾病可以通过手术或非手术治疗，但缺乏高质量的证据来指导治疗决策。
我们纳入了 2015 年 7 月 1 日至 2018 年 6 月 30 日期间接受急症普通外科疾病治疗的 507677 名 Medicare 患者。使用基于偏好的工具变量分析和近-远匹配比较手术治疗与非手术治疗，以尽量减少选择偏差和未测量的混杂因素。结局为死亡率、并发症和再入院率。
对于肝胆胰疾病，手术治疗与 30 天[-2.6%（95%置信区间：-4.0，-1.3）]、90 天[-4.7%（-6.50，-2.8）]和 180 天[-6.4%（-8.5，-4.2）]的死亡率降低相关。在 56582 例肠梗阻患者中，手术治疗与住院期间死亡率升高相关[2.8%（0.7，4.9）]，但此后无显著差异。对于上消化道疾病，手术治疗与住院期间死亡率升高相关[9.7%（6.4，13.1）]，且随时间推移而增加。对于结直肠疾病，手术治疗与住院期间死亡率升高相关[6.9%（3.6，10.2）]，且随时间推移而增加。对于一般腹部疾病，手术治疗与住院期间死亡率升高相关[12.2%（8.7，15.8）]。这种效应在 30 天内减弱[8.5%（3.8，13.2）]，此后不再显著。
手术治疗急症普通外科疾病的效果因疾病和时间而异。对于结直肠和上消化道疾病，非手术治疗的结局更优，而对于肝胆胰疾病，手术治疗更有利。对于肠梗阻和一般腹部疾病，总体结果相当。这些发现可能支持患者、临床医生和家属做出这些具有挑战性的决策。
