간담췌 정규 수술을 받은 후 예기치 않게 중환자실에 입실한 환자들의 불량한 예후에 영향을 미치는 위험인자

Abstract

간담췌 수술은 술 후 합병증 발생률과 사망률이 높은 것으로 알려져 있다. 고위험 수술로 인하여 일부 환자들은 예기치 않게 중환자실 치료가 필요하며, 이 환자들의 상태나 예후를 예측하는 것은 임상적으로 중요하다. 최근에는 간담췌 수술 후 정례적인 중환자실 입실은 드물며, 합병증 발생 등으로 갑자기 중환자실 치료가 필요 경우가 대부분이다. 이 환자들의 특성을 파악하여 임상경과를 예측하고 치료하는 것은 매우 중요하다고 할 수 있다. 본 연구는 단일기관 후향적 연구로 2014년 1월 1일부터 2020년 12월 31일까지 7년간 서울아산병원 간담췌 외과에서 수술을 받은 23,041의 환자 중 응급수술, 간담췌 이외 질환의 동반 수술, 감시관찰만을 위한 입실, 수술 전부터 중환자실에서 치료 중이었던 환자를 제외하고, 간담췌 수술 후 합병증 발생으로 예기치 않게 중환자실에 입실한 165명의 환자를 대상으로 unfavorable outcome(사망 혹은 7일 이상의 중환자실 재원)에 영향을 미치는 인자들을 분석했다. Favorable outcome을 보인 군(73명)과 unfavorable outcome을 보인 군(92명)으로 나누어 비교했을 때는 나이, Age-adjusted Charlson comorbidity index(ACCI) score, ASA PS(The American Society of Anesthesiologists physical status) classification, 간절제술 + 간외 담도절제술 혹은 간췌십이지장절제술, 수술일로부터 중환자실 입실일까지 소요일, 중환자실 입실 원인, APACHE IV score에서 양 군간 유의한 차이가 있었다. 이 중 다변량 로지스틱 회귀분석에서 unfavorable outcome을 유발하는 독립 인자는 간절제술 + 담도절제술 혹은 간췌십이지장절제술, 75점 이상의 APACHE(Acute Physiology and Chronic Health Evaluation) IV score, 패혈증으로 중환자실에 입실 한 경우 및 높은 ACCI score 였다. 결론적으로 간담췌 수술 후 예기치 않게 중환자실에 입실한 환자에서 많은 동반질환, 복잡한 간담췌 수술과 중환자실 입실 당시의 환자 상태의 심각성 및 패혈증을 동반한 합병증은 불량한 예후인자라고 할 수 있으므로 각별한 주의와 집중관찰 및 치료가 필요할 것으로 사료된다. |Background: Hepatobiliary & pancreas (HBP) surgery is related to high rate of severe complication or perioperative mortality. Recently, fewer patients are admitted in the intensive care unit (ICU) routinely immediately after undergoing a major HBP surgery. Hence, it is necessary to have a comprehensive understanding of the patients who experienced unplanned ICU admission (UIA) due to severe postoperative complications. We aimed to identify the prognostic factors of these patients to predict their clinical course and to treat them accordingly. Methods: This single-center retrospective cohort study was conducted in Seoul Asan Medical Center. We enrolled patients who required UIA following an HBP surgery from January 1, 2014 to December 31, 2020. Those who underwent emergency surgery, were co-operated in another department, were readmitted in the hospital, underwent routine ICU admission <48 h after surgery, and were admitted in the ICU before surgery were excluded. Results: In total, 165 patients met the inclusion criteria, with a mean age of 66.6 years; of them, 76.4% were men. The mean age-adjusted Charlson comorbidity index (ACCI) score was 5.11, and the mean body mass index was 23.6 kg/m2. Pancreaticoduodenectomy was the most common type of surgery (35.2%, 58/165). The mean duration of surgery was 304 min; the mean Acute Physiology and Chronic Health Evaluation (APACHE) IV score was 80.9. The mean length from index surgery to initial ICU admission was 6.9 days; the mean length of stay (LOS) in the ICU was 14.3 days; the mean length of hospital stay was 40.4 days; and the mortality rate was 29.1%. Compared with the favorable outcome group (n=73), the unfavorable outcome (mortality+LOS in ICU ≥7 days) group was older (age 69.6 vs 62.8 years, p<.001) and had a higher ACCI score (5.6 vs 4.5, p<.001). They had higher rates of obtaining an American Society of Anesthesiologists physical status score of 3 (35.6% vs 12.3%, p=0.038), undergoing hepatectomy + extrahepatic bile duct resection or hepatopancreatoduodenectomy (40.2% vs 19.2%, p=0.004), and developing sepsis as reasons for ICU admission (43.5% vs 17.8%, p=0.003). In addition, the index surgery to ICU admission was longer (8.7 vs 4.7, p=0.020) and the APACHE IV score was higher by 20 points (90.3 vs 69.8, p<.001). Among these, the higher ACCI score, surgery type, sepsis at UIA, and an APACHE IV score of >75 were independently significant prognostic factors. Conclusion: For UIA patients following elective HBP surgery with higher ACCI score, complex operation type, severe condition (APACHE IV score > 75) or sepsis at UIA are likely to fall in unfavorable outcome, therefore, they should be monitored closely and treated accordingly