低BMI与术后30天死亡率较高有关


  【24drs.com】根据在线发表于11月21日外科学志(Archives of Surgery)的研究,身体质量指数(BMI)较低的病患在一般手术与血管手术后30天内的死亡率比体重较重者高,校正其它与体重无关的病患本身或手术相关死亡率风险因素之后,此关联依旧成立。
  
  在以前,未曾于临床针对BMI对术后死亡率影响的资料进行评估,此次分析发现,189,533名病患的研究样本中,根据BMI分成5组,BMI最小(<23.1 kg/m2)的这组,死亡机率比BMI值为中间的参考组(26.3 - <29.7 kg/m2)者高40% (校正胜算比[AOR]为1.40,P < .001),校正变项包括主要的手术方式,以及美国外科医学会全国手术质量改善计划所拟定的死亡可能性风险因素。
  
  再者,根据维吉尼亚大学外科系的Florence Turrentine博士等研究者指出,体重最轻组的死亡率为2.8%,比体重最重组(≧35.3 kg/m2)的1.0%死亡率高出2倍之多。
  
  因为肥胖比率自1990年后上升超过100%,且肥胖相关死亡率也上升,研究者希望以更精准的内容评估BMI和近期手术死亡率的关联。他们表示,之前有许多研究认为肥胖与各类手术前后的死亡率无显著关联。
  
  不过,这些研究中,少数有校正分析BMI对死亡率的影响,但是同时考量了其它两个独立因素:每个病患的现有整体死亡率风险,以及依据手术类型的死亡率风险。
  
  这次分析的资料为2005和2006年、美国外科学会全国手术质量改善计划(NSQIP)所属的183个地点、一般手术和血管手术的数据,共有189,533名病患接受评估,3,245人(1.7%)在术后30天内死亡。
  
  测量病患BMI后依据NSQIP特定的分组方式分成5组,藉由NSQIP的30天死亡率风险分数(得自30个以上的人口统计学变项、共病症因素以及术前实验室数据),评估每个病患在研究开始时的现有死亡率风险差异,此外,评估资料以计算45种主要手术类别对病患的独立死亡率风险因素。
  
  手术类别对病患之独立死亡率风险因素的分析发现,和术后30天死亡率较高(与腹腔镜手术相比,腹腔镜手术死亡率2%定义为对照值)有关的前3种手术类别为剖腹检查手术(13.9%的病患死亡)、下肢截肢(8.1%)与小肠切除术(7.9%);至于比较安全的手术类型,19种手术类型的病患死亡率小于等于1%。
  
  作者们也发现,BMI和一些手术类型有值得注意的相互影响,也就是说,这些类型手术的BMI和死亡率之关联与接受腹腔镜手术者相比有统计上的差异;这些结果认为,BMI和死亡率之间的相互影响对某些相较于腹腔镜手术属于高风险或低风险手术之类型相当重要。
  
  与对照组(腹腔镜手术)相比,死亡率风险差异达统计上显著意义(P < .05)的手术类型有:结肠造口术(AOR,1.09;P = .009)、伤口清创术(AOR,1.68;P = .002)、回肠造口术(AOR,1.56;P = .008)、肌肉骨骼手术(AOR,0.49;P = .03)、头颈部血管内膜切除术(AOR,0.55;P = .002)、上胃肠道手术(AOR,0.42;P < .001)、胆囊切除术(AOR,0.27;P = .04)以及乳房切除术 (AOR,0.05;P = .001)。
  
  作者们解释,越来越多证据和文献支持肥胖会影响美国及全球的手术实务,迄今的报告显示,最起码,并发症比率和住院资源都与肥胖病患的手术有所影响。这篇研究用的美国外科学会NSQIP资料库,足以评估相当多数的病患,并检视更多的手术类型。研究者结论指出,BMI是术后30天内相当重要的死亡率预测因子,校正手术类型和病患本身的死亡率风险因素之后也是如此,BMI小于23.1之病患的死亡率风险显著增加。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=6659&x_classno=0&x_chkdelpoint=Y
  

Low BMI Associated With High 30-Day Postsurgical Mortality

By Rod Franklin
Medscape Medical News

November 21, 2011 — Patients with a lower body mass index (BMI) are more likely to die within 30 days of general and vascular surgery than heavier individuals, even after adjustment for additional patient- and procedure-based mortality risk calculations independent of weight, according to research published online November 21 in the Archives of Surgery.

Data assessing the contribution of BMI to postsurgical mortality at a level of clinical specificity previously not examined showed that within the lightest quintile of BMI measurements (<23.1 kg/m2) in a 189,533-patient study group, there was a 40% greater chance for death compared with patients in the middle (reference group) BMI quintile of 26.3 to <29.7 kg/m2 (adjusted odds ratio [AOR], 1.40, P < .001), adjusted for the type of principal operating procedure and patient differences in baseline mortality risk, determined from American College of Surgeons National Surgical Quality Improvement Program probability of death.

Moreover, the lightest patients demonstrated a 2.8% mortality rate, which was more than twice the 1.0% mortality rate exhibited in the heaviest (?35.3 kg/m2) quintile of patients, according to the researchers, led by Florence Turrentine, PhD, RN, from the Department of Surgery at the University of Virginia in Charlottesville.

With obesity increasing more than 100% since 1990 and obesity-related disease on the rise, investigators wanted to assess the relationship between BMI and near-term surgical mortality within a more specifically adjudicated context. They acknowledged that numerous prior studies had documented no significant association between obesity and perioperative mortality for various categories of surgery.

Few of these studies, however, were adjusted to assess BMI effect on mortality with consideration given to concurrent levels of risk contributed by 2 additional, independently calculated factors: overall existing per patient risk for mortality, and risk for mortality according to the type of surgery.

Data reported for the years 2005 and 2006 were analyzed from 183 sites included in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database of general and vascular surgery. Of the189,533 patients reviewed in the evaluation, 3245 (1.7%) died within 30 days of surgery.

Measures of patient BMI were divided into nonstandard quintiles specific to the NSQIP study population. Baseline differences in overall existing mortality risk were evaluated for each patient, using the NSQIP probability of 30-day mortality risk score, which draws on more than 30 demographic variables as well as comorbidity factors and preoperative lab values. In addition, data were assessed to calculate the effect on patient mortality risk contributed by each of 45 independently evaluated categories of principal operating procedure.

The latter analysis found that the top 3 procedural categories associated with high 30-day mortality (compared with laparoscopy as a middle-range reference procedure responsible for 2% of the patient deaths) were exploratory laparotomy (13.9% of patient deaths), lower-extremity amputations (8.1%), and small bowel resection (7.9%). On the safer end of the procedural scale, 19 types of surgery each were associated with 1% or fewer of the patient deaths.

The authors also found notable interactions between BMI and some procedural categories, indicating that the link between BMI and mortality was statistically different for those categories than for patients who underwent laparoscopy. These findings suggest that the interaction between BMI and mortality plays a role within certain categories of surgery that may be classified as high risk or low risk, relative to laparoscopy.

Compared with the reference procedure, statistically significant (P < .05) differences in mortality odds were found for colostomies (AOR, 1.09; P = .009), wound debridement (AOR, 1.68; P = .002), ileostomy (AOR, 1.56; P = .008), musculoskeletal procedures (AOR, 0.49; P = .03), endarterectomy of head/neck vasculature (AOR, 0.55; P = .002), upper gastrointestinal procedures (AOR, 0.42; P < .001), cholecystectomy (AOR, 0.27; P = .04), and mastectomy (AOR, 0.05; P = .001).

"There is increasing evidence and supportive literature that obesity affects the practice of surgery in the United States and worldwide," explain the authors. "Reports to date have shown that, at the very least, complication rates and hospital resources have been affected by procedures on obese patients." The American College of Surgeons NSQIP database, used in the current study, "allows for the evaluation of a larger number of patients and for the examination of more specific types of procedures." The researchers conclude that "BMI is a significant predictor of mortality within 30 days of surgery, even after adjusting for the contribution to mortality risk made by type of surgery and for a specific patient's overall expected risk of death. Patients with a BMI of less than 23.1 demonstrated a significant increased risk of death."

The authors have disclosed no relevant financial relationships.

Arch Surg. Published online November 21, 2011.

    
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