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《中华消化外科杂志》2018年2月第17卷第2期论著

腹腔镜辅助远端胃癌根治术后并发症发生的危险因素分析

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引用本文:
郗洪庆,蓝炘,张珂诚,等.腹腔镜辅助远端胃癌根治术后并发症发生的危险因素分析[J].中华消化外科杂志,2018,17(2):182-187.DOI:10.3760/cma.j.issn.1673-9752.2018.02.012.
【摘要】

目的:探讨腹腔镜辅助远端胃癌根治术(LADG)后并发症发生的危险因素。
方法:采用回顾性病例对照研究方法。收集2010年1月至2016年5月解放军总医院收治的488例行LADG患者的临床病理资料。根据日本胃癌治疗指南行LADG。观察指标:(1)手术及术后情况。(2)术后并发症发生的危险因素分析。(3)随访和生存情况。采用门诊和电话方式进行随访,了解患者术后生存及肿瘤复发、转移情况,随访时间截至2017年10月。正态分布的计量资料以±s表示,偏态分布的计量资料以M(四分位距)表示。单因素分析采用X2检验(计数资料)、t检验(方差齐的正态分布计量资料)或t′检验(方差不齐的 正态分布计量资料)、非参数检验(偏态分布的计量资料)。多因素分析采用Logistic回归模型。
结果:
(1)手术及术后情况:488例患者均成功完成手术,其中7例因术中出血、手术困难等原因行中转开腹手术,481例行LADG。488例患者手术时间为(233±71)min,术中出血量为100 mL(100 mL)。488例患者中, 99例发生术后并发症,部分患者同时合并多种并发症,其中ClavienDindo Ⅰ、Ⅱ、Ⅲa、Ⅲb、Ⅳa、Ⅳb、Ⅴ级分别为39、26、26、6、0、0、2例;发生例数最多的3种术后并发症分别为胃排空障碍(18例)、肠梗阻(14例)和吻合口瘘(14例),ClavienDindo分级<Ⅲa级例数分别为12、12、6例,≥Ⅲa级例数分别为6、2、8例。99例发生术后并发症患者中,97例经对症处理后好转,2例死亡。488例患者术后住院时间为(13±12)d。(2)术后并发症发生的危险因素分析:单因素分析结果显示:术前存在伴发疾病、消化道重建方式是影响行LADG患者术后并发症发生的相关因素(X2=11.225,6.581,P<0.05)。多因素分析结果显示:术前存在伴发疾病、消化道重建方式为Billroth Ⅱ式吻合术是影响行LADG患者术后并发症发生的独立危险因素 [优势比(OR)=2.336,2.630,95%可信区间:1.475~3.687,1.369~5.053,P<0.05]。(3)随访和生存情况:486例出院患者中,380例获得术后随访,随访时间为2~89个月,中位随访时间为42个月。随访期间, 289例患者无瘤生存,35例出现肿瘤复发和(或)转移,48例为肿瘤相关性死亡,8例为非肿瘤相关性死亡。
结论:吻合口瘘是LADG术后常见且严重的并发症,术前存在伴发疾病、消化道重建方式为Billroth Ⅱ式吻合术是影响行LADG患者术后并发症发生的独立危险因素。

【Abstract】

Objective:To explore the risk factors of complications after laparoscopyassisted distal gastrectomy (LADG) for gastric cancer (GC).
Methods:The retrospective casecontrol study was conducted. The clinicopathological data of 488 GC patients who underwent LADG in the General Hospital of the Chinese People′s Liberation Army between January 2010 and May 2016 were collected. Observation indicators: (1) surgical and postoperative situations; (2) risk factors analysis of postoperative complications; (3) followup and survival situations. Followup using outpatient examination and telephone interview was performed to detect the postoperative survival of patients up to October, 2017. Measurement data with normal distribution were represented as ±s, and measurement data with skewed distribution were described as M (interquartile range).The univariate analysis was done using the chisquare test (count data), t test (measurement data with normal distrubution and homogeneity of variance) or t′ test (measurement data with normal distribution and heterogeneity of variance) and nonparametric test (measurement data with skewed distrubution). The multivariate analysis was done using the Logistic regression model.
Results:(1) Surgical and postoperative situations: all the 488 patients underwent successful surgery, including 7 with conversion to open surgery due to intraoperative bleeding and difficult surgery and 481 with LADG. The operation time and volume of intraoperative blood loss of 488 patients were (233± 71)minutes and 100 mL (100 mL). The postoperative complications occurred in 99 of 488 patients, some patients merged simultaneously multiple complications. The ClavienDindoⅠ, Ⅱ, Ⅲa, Ⅲb, Ⅳa, Ⅳb and Ⅴ complications were detected in 39, 26, 26, 6, 0, 0 and 2 patients, respectively. The top 3 postoperative complications were delayed gastric emptying (18 patients), intestinal obstruction (14 patients) and anastomotic fistula (14 patients). Cases with delayed gastric emptying, intestinal obstruction and anastomotic fistula were respectively 12, 12, 6 with the ClavienDindo classification <Ⅲa and 6, 2, 8 with the ClavienDindo classification≥Ⅲa. Of 99 patients with postoperative complications, 97 were improved by symptomatic treatment and 2 died. Duration of postoperative hospital stay was (13±12)days. (2) Risk factors analysis of postoperative complications: the results of univariate analysis showed that preoperative concomitant diseases and digestive tract reconstruction were the related factors affecting postoperative complications of patients undergoing LADG (X2=11.225, 6.581, P<0.05). The results of multivariate analysis showed that preoperative concomitant diseases and Billroth Ⅱ anastomosis were the independent risk factors affecting postoperative complications of patients undergoing LADG (Odds ratio=2.336, 2.630, 95% confidence interval: 1.475-3.687, 1.369-5.053, P<0.05). (3) Followup and survival situations: of 486 discharged patients, 380 were followed up for 2-89 months, with a median time of 42 months. During the followup, 289, 35, 48 and 8 patients had respectively tumorfree survival, tumor recurrence and/or metastasis, tumorrelated death and nontumorrelated death.
Conclusion:The anastomotic fistula is one of the common and severe complications after LADG, and preoperative concomitant diseases and Billroth Ⅱ anastomosis are the independent risk factors affecting postoperative complications of patients undergoing LADG.

DOI:10.3760/cma.j.issn.1673-9752.2018.02.012
基金项目:国家自然科学基金(81272698、81672319、81602507、81773135、81572465);北京市科技计划项目(Z161100000516237);北京市科技新星计划(xx2018114);解放军总医院医疗大数据研发项目(2016MBD-012)
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