Clavien P A, Camargo C A, Croxford R, Langer B, Levy G A, Greig P D
Multiorgan Transplantation Program, University of Toronto, Ontario, Canada.
Ann Surg. 1994 Aug;220(2):109-20. doi: 10.1097/00000658-199408000-00002.
This study defined negative outcomes of solid organ transplantation, proposed a new classification of complications by severity, and applied the classification to evaluate the results of orthotopic liver transplantation (OLT).
The lack of uniform reporting of negative outcomes has made reports of transplantation procedures difficult to interpret and compare. In fact, only mortality is well reported; morbidity rates and severity of complications have been poorly described.
Based on previous definition and classification of complications for general surgery, a new classification for transplantation in four grades is proposed. Results including risk factors of the first 215 OLTs performed at the University of Toronto have been evaluated using the classification.
All but two patients (99%) had at least one complication of any kind, 92% of patients surviving more than 3 months had grade 1 (minor) complications, 74% had grade 2 (life-threatening) complications, and 30% had grade 3 (residual disability or cancer) complications. Twenty-nine per cent of patients had grade 4 complications (retransplantation or death). The most common grade 1 complications were steroid responsive rejection (69% of patients) and infection that did not require antibiotics or invasive procedures (23%). Grade 2 complications primarily were infection requiring antibiotics or invasive procedures (64%), postoperative bleeding requiring > 3 units of packed red cells (35%), primary dysfunction (26%), and biliary disease treated with antibiotics or requiring invasive procedures (18%). The most frequent grade 3 complication was renal failure, which is defined as a permanent rise in serum creatinine levels > or = twice the pretransplantation values (11%). Grade 4 complications (retransplantation or death) mainly were infection (14%) and primary dysfunction (11%). Comparison between the first and last 50 OLTs of the series indicates a significant decrease in the mean number of grade 1 and 2 complications. This was partially a result of better medical status of patients at the time of transplantation. Using univariate and multivariate analyses of risk factors, the best predictor of grade 1 complications was donor obesity; for grade 2 complications, the best predictor was a donor liver rewarming time of > 90 minutes, and for grade 3 and 4 complications, the best predictor was the APACHE II scoring system and donor cardiac arrest.
Standardized definitions and classifications of complications of transplantation will allow us to better evaluate and compare results of transplantation among centers and over time, and better compare effectiveness of new therapies. Orthotopic liver transplantation still is a procedure with high morbidity that requires careful analysis of risk factors to optimize selection of patients and organ sharing.
本研究定义了实体器官移植的不良结局，提出了一种按严重程度对并发症进行的新分类，并应用该分类评估原位肝移植（OLT）的结果。
缺乏对不良结局的统一报告使得移植手术的报告难以解读和比较。事实上，只有死亡率得到了充分报告；发病率和并发症的严重程度描述甚少。
基于先前普通外科并发症的定义和分类，提出了一种分为四个等级的移植新分类。使用该分类对多伦多大学进行的前215例OLT的结果（包括危险因素）进行了评估。
除两名患者（99%）外，所有患者至少有一种并发症，存活超过3个月的患者中，92%有1级（轻微）并发症，74%有2级（危及生命）并发症，30%有3级（残留残疾或癌症）并发症。29%的患者有4级并发症（再次移植或死亡）。最常见的1级并发症是类固醇反应性排斥反应（69%的患者）和无需使用抗生素或侵入性操作的感染（23%）。2级并发症主要是需要抗生素或侵入性操作的感染（64%）、术后出血需要超过3单位浓缩红细胞（35%）、原发性功能障碍（26%）以及用抗生素治疗或需要侵入性操作的胆道疾病（18%）。最常见的3级并发症是肾衰竭，定义为血清肌酐水平永久性升高≥移植前值的两倍（11%）。4级并发症（再次移植或死亡）主要是感染（14%）和原发性功能障碍（11%）。该系列中前50例和后50例OLT的比较表明，1级和2级并发症的平均数量显著减少。这部分是由于移植时患者的医疗状况改善。通过对危险因素的单因素和多因素分析，1级并发症的最佳预测因素是供体肥胖；对于2级并发症，最佳预测因素是供体肝脏复温时间>90分钟，对于3级和4级并发症，最佳预测因素是急性生理与慢性健康状况评分系统（APACHE II）和供体心脏骤停。
移植并发症的标准化定义和分类将使我们能够更好地评估和比较不同中心以及不同时间的移植结果，并更好地比较新疗法的有效性。原位肝移植仍然是一种发病率高的手术，需要仔细分析危险因素以优化患者选择和器官分配。
