基于德尔菲法构建胸外科手术难度评价量表

Establishment of Thoracic Surgical Difficulty Assessment Scale based on Delphi method

目的:手术难度关系到手术安全,但长期以来仅作为一种主观感受被描述。目前,对胸外科手术难度进行量化评价的研究较少。本研究旨在使用会议调查结合德尔菲法构建胸外科手术难度量表,并应用于胸部肿瘤手术中以评价其信度和效度。方法:在2次全国性胸外科会议期间,以半开放性问卷的方式向与会胸外科医生代表调查可能影响手术难度的因素,建立胸外科手术难度评价条目池。利用2轮德尔菲专家咨询法对条目池中各指标的重要性进行评分。计算各指标的平均分、满分率和变异系数,采用综合指数法决定是否删除该指标,构建胸外科手术难度评价量表。收集胸部肿瘤患者的手术资料,应用该量表评价胸外科肺部、食管和纵膈肿瘤手术的难度。以目前常用的难度评价指标:手术时间、术中估计失血量、视觉模拟评分(Visual Analogue Scale,VAS)、副损伤率、输血率作为标准,评价量表的信度和效度。结果:2轮会议调查一共发放问卷230份,排除重复问卷后回收有效问卷149份。通过20位专家的2轮德尔菲法咨询对各难度评价指标进行评分及筛选,由此形成的胸外科手术难度评价量表包括5项主要指标(手术决策、操作空间、分离界面、重建方法和手术材料)和16项次要指标[美国麻醉医师协会(American Society of Anesthesiologists,ASA)分级、手术创伤、术者经验、空间大小、空间深度、空间来源、空间毗邻、界面内容、解剖间隙、视野、界面大小、重建复杂度、重建范围、自体材料、人工生物材料及器械]。赋予权重后,胸外科手术难度评价量表的总评分为1~3。1分表示极简单,3分表示极困难。进一步收集127例胸部肿瘤手术资料。肺部肿瘤、食管肿瘤及纵隔肿瘤手术的难度评分分别为1.69±0.26、1.86±0.18及1.56±0.31,胸外科手术难度评价量表在3种手术中应用的Cronbach’sα系数分别为0.993、0.974及0.989,Spearman-Brown系数分别为0.996、0.984及0.996。肺部肿瘤手术和纵膈肿瘤手术中手术难度评分与手术时间、术中估计失血量及VAS的Spearman相关系数分别为0.360和0.634、0.632和0.578,以及0.696和0.875(均P<0.05)。困难手术组(手术难度评分>1.85)的术后并发症发生率显著高于非困难手术组(P=0.02)。结论:成功构建了可量化的胸外科手术难度评价量表,并在胸部肿瘤手术中显示出较好的信、效度。胸外科手术难度评价量表在降低手术难度、控制手术并发症和培训外科医生方面具有广阔的应用前景。

Objective:The difficulty of surgery,which is related to surgical safety,has only been mentioned as a subjective perception for a long time.There are few studies to quantitatively and systematically evaluate the difficulty of thoracic surgery.This study aims to establish a quantitative evaluation index system for thoracic surgical difficulty,and to evaluate its reliability and validity.Methods:During the 2 national thoracic surgery academic conferences,the factors that may affect the difficulty of thoracic surgery were evaluated by the thoracic surgeons via semi open questionnaires,and then the evaluation item pool of thoracic surgery difficulty was established.The importance of each indicator in the evaluation item pool was graded by 2 rounds of Delphi method.The average score,full score rate and coefficient of variation of each index were calculated,and the composite index method was used to decide whether to delete the indicator.Finally,the difficulty evaluation scale of thoracic surgery was constructed.The surgical data of patients with thoracic tumors were collected.The scale was used to evaluate the difficulty of thoracic surgery for lung,esophageal,and mediastinal tumors.The reliability and validity of the scale were evaluated by the commonly used difficulty evaluation indexes:Operation time,intraoperative estimated blood loss,Visual Analog Scale(VAS),side injury rate,and blood transfusion rate as standards.Results:A total of 230 questionnaires were distributed in the 2 rounds of survey,and 149 valid questionnaires were collected after eliminating duplicate questionnaires.Through 2 rounds of Delphi consultation with 20 experts,the difficulty evaluation indexes were scored and screened,and the difficulty evaluation scale of thoracic surgery was established.It included 5 main indexes(surgical decision-making,operation space,separation interface,reconstruction method,and surgical materials)and 16 secondary indexes[American Society of Anesthesiologists(ASA)classification,surgical trauma,operator experience,space size,space depth,space source,space adjacent,interface content,anatomical gap,visual field,interface size,reconstruction complexity,reconstruction scope,autologous materials,artificial biomaterials and instruments].After weighting,the total score of Thoracic Surgery Difficulty Evaluation Scale was from 1 to 3.A Score at 1 standed for simplicity,and score at 3 standed for difficulty.Further data were collected for 127 cases of thoracic tumor surgery.The difficulty scores of surgery for lung,esophageal,and mediastinal tumor were 1.69±0.26,1.86±0.18,and 1.56±0.31,respectively,and the Cronbach’sαcoefficients of the scale in 3 tumor surgeries were 0.993,0.974,and 0.989,repectively,and the Spearman Brown coefficients were 0.996,0.984,and 0.996,respectively.The Spearman correlation coefficients of operation difficulty score with operation time,estimated blood loss,and VAS were 0.360 and 0.634,0.632 and 0.578,0.696 and 0.875,respectively(all P<0.05).The incidence of postoperative complications in the difficult operation group(difficulty score>1.85)was higher than that in the non difficult operation group(P=0.02).Conclusion:The quantitative Thoracic Surgical Difficulty Assessment Scale has been successfully established,which shows good reliability and validity in thoracic tumor surgery.The Thoracic Surgical Difficulty Assessment Scale has broad application prospects in reducing the difficulty of the surgery,controlling surgical complications,and training surgeons.