腹腔镜消化性溃疡穿孔修补术中中转开腹的危险因素分析

Risk factors associated with conversion to open surgery of laparoscopic repair for perforated peptic ulcer

目的分析影响腹腔镜消化性溃疡穿孔修补术中中转开腹的危险因素。方法回顾性分析成都市第五人民医院2009年1月至2014年12月期间诊断为胃溃疡或十二指肠球部溃疡穿孔并行腹腔镜手术的成年患者的临床资料,根据是否中转开腹分为腹腔镜组及中转开腹组,对2组患者的一般临床资料、临床结局及预后因素进行分析。结果本研究纳入符合条件的患者235例,其中有207例在腹腔镜组,28例在中转开腹组。2组患者的年龄,性别,体质量指数,术前合并症、溃疡史、使用药物史、吸烟史、嗜酒史,入院时美国麻醉师协会分级、白细胞计数、C反应蛋白,手术医生,缝合方式,穿孔部位比较差异均无统计学意义(P>0.05)。入院时中转开腹组患者的降钙素原水平明显高于腹腔镜组(P=0.040),穿孔距离手术时间也较腹腔镜组长(P<0.001),穿孔直径也明显大于腹腔镜组(P<0.001)。中转开腹组与腹腔镜组相比,30 d死亡、再穿孔、腹腔脓肿及伤口感染率比较差异均无统计学意义(P>0.05),中转开腹组的并发症Clavien-Dindo分级Ⅰ+Ⅱ级患者所占比例明显高于腹腔镜组(P<0.001),总住院时间(P=0.002)、术后排气时间(P=0.003)、术后止痛药使用时间(P<0.001)及术后下床活动时间(P=0.001)均明显长于腹腔镜组。将可能影响中转开腹的因素进行logistic回归分析,结果显示,溃疡穿孔距离手术时间〔OR为2.104,95%CI为(1.124,3.012),P=0.020〕及溃疡穿孔直径〔OR为2.475,95%CI为(1.341,6.396),P=0.013〕是影响中转开腹的危险因素。使用受试者操作特征曲线分析溃疡穿孔直径及穿孔距离手术时间预测中转开腹的临界值结果发现,当溃疡穿孔直径为8 mm时,预测中转开腹的敏感性为76%,特异性为93%,受试者操作特征曲线下面积(AUC)为0.912;当溃疡穿孔距离手术时间为14 h时,预测中转开腹的敏感性为86%,特异性为71%,AUC为0.909。结论从本研究的结果来看,溃疡穿孔直径≥8 mm及穿孔时间≥14 h可能成为腹腔镜消化性溃疡穿孔修补术中中转开腹的预测因子,而降钙素原可以作为一种辅助的预测因子考虑。

Objectives To analyze risk factors associated with conversion to open surgery of laparoscopic repair for perforated peptic ulcer. Methods From January 2009 to December 2014, 235 patients underwent laparoscopic repair for perforated peptic ulcer in the Chengdu 5th Hospital, were enrolled in this study. These patients were divided into laparoscopic repair group （n=207） and conversion to open surgery group （n=28）. The characteristics, clinical outcomes, and prognosis factors were compared between these two groups. The receiver operating characteristic （ROC） curve was used to determine the critical cutoff value for diameter and duration of perforation for predicting conversion to open surgery. Results There were no significant differences of the age, gender, body mass index, comorbidity, history of ulcer,smoking history, history of nonsteroidal antiinflammatory drugs or steroids use, history of alcohol use, American Society of Anesthesiologists classification on admission, white blood cell count on admission, C reaction protein on admission,surgeons, suture method, and location of perforation between these two groups （P〉0.05）. The patients in the conversion to open surgery group had a higher procalcitonin （PCT） level on admission （P=0.040）, longer duration of peroration （P〈0.001）, larger diameter of peroration （P〈0.001）, longer hospital stay （P=0.002）, higher proportion of patients with Clavien-Dindo classification Ⅰ and Ⅱ（P〈0.001）, longer gastrointestinal function recovery time （P=0.003）, longer analgesics use time （P〈0.001）, and longer off-bed time （P=0.001） as compared with the laparoscopic repair group. The results of logistic regression analysis showed that the peroration duration on admission （ OR： 2.104, 95% CI （1.124, 3.012）, P=0.020] and peroration diameter on admission （ OR： 2.475, 95% CI （1.341, 6.396）, P=0.013 1 were two predictors of conversion to open surgery. For the diameter of perforation, 8.0 mm was the critical cutoff value for predicting conversion to open surgery by ROC curve analysis, the sensitivity was 76%, the specificity was 93%, and the area under the curve （A UC） was 0.912. For the duration of perforation, 14 h was the critical cutoff value to predict conversion to open surgery,the sensitivity was 86%, the specificity was 71%, and the A UC was 0.909. Conclusions The preliminary results in this study show that diameter of perforation of 8 mm and duration of perforation of 14 h are two reliable risk factors associated with conversion to open surgery for perforated peptic ulcer. Also, PCT level would mightbe considered as a helpful risk factor for it.