减重代谢手术后30d内再入院的临床特征及危险因素分析

Clinical features and risk factors analysis of 30-day readmission after bariatric and metabolic surgery

目的探讨减重代谢手术后30d内患者再入院的发生率、临床表现、原因、治疗方法及危险因素。方法采用回顾性病例对照研究方法。收集2010年5月至2016年5月南京医科大学第一附属医院收治的631例行减重代谢手术肥胖症患者的临床资料。631例患者行腹腔镜胃袖状切除术（LSG）或腹腔镜胃旁路术（LRYGB）。患者出院后采用门诊和电话方式随访1个月，了解患者再入院情况。随访时间截至2016年6月。观察指标：（1）减重代谢术后30d内再人院情况：再人院例数、再人院时间、再入院临床表现及原因、治疗。（2）影响减重代谢术后30d内再入院的危险因素分析。偏态分布的计量资料采用肼（范围）表示。单因素分析采用爿。检验，多因素分析采用Logisic回归模型。结果（1）减重代谢术后30d内再人院情况：631例患者术后均随访1个月，2l例发生30d内再人院，发生率为3．33％（21／631）；其中男13例，女8例；行LSG10例，行RYGB11例。21例患者中位术后再入院时间为12d（4～30d）。21例患者中，11例临床表现为恶心、呕吐及脱水，6例表现为消化道出血，2例表现为高热，1例表现为肠梗阻，1例表现为腹痛。21例患者中，8例因术后不当饮食再入院，包括过早进食固体5例、过早进食半流质食物1例、进食刺激性食物1例、整片吞服药片1例；3例术后过度焦虑；1例Petersen裂孔疝；1例吻合口溃疡；1例吻合口水肿；1例腹腔脓肿；6例未明确导致临床表现的原因，其中4例表现为消化道出血，但未能进一步行内镜检查，1例术后出现不明原因腹痛，但实验室、影像学及胃镜检查未见明确异常，1例高热，但影像学检查未见明显异常。21例患者中，19例经保守治疗（补液、抑酸等）后好转出院，无再入院；1例腹腔脓肿患者经急诊清创引流后治愈；1例Petersen裂孔疝患者经急诊手术后痊愈。21例患者再入院后中位住院时间为7d（3～40d）。（2）影响减重代谢手术后30d内再入院的危险因素分析：单因素分析结果显示：患者性别、术前嗜食习惯及术后住院时间是影响减重代谢手术后30d内再人院的相关因素（疋。5．330，6．498，4．574。P〈0．05）。多因素分析结果显示：男性及具有术前嗜食习惯是影响减重代谢手术后30d内再入院的独立危险因素（OR=2．489，2．912，95％可信区间：1．006～6．161，1．196～7．088，P〈0．05）。结论恶心、呕吐及脱水是减重代谢手术后30d内再入院的最常见临床表现，且多与患者不当饮食有关。男性及具有术前嗜食习惯是影响减重代谢手术后30d内再人院的独立危险因素。

Objective To explore the incidence, clinical features, causes, treatment method and risk factors of 30-day readmission after bariatric and metabolic surgery. Methods The retrospective case-control study was conducted. The clinical data of 631 obese patients who underwent bariatric and metabolic surgery in the First Affiliated Hospital of Nanjing Medical University from May 2010 to May 2016 were collected. All the 631 patients underwent laparoscopic sleeve gastreetomy （LSG） or laparoscopic Roux-en-Y gastric bypass （LRYGB）. Patients were followed up by outpatient examination and telephone interview for 1 month to detect readmission of patients up to June 2016. Observation indicators： （1） 30-day readmission situations after bariatric and metabolic surgery： cases with readmission, readmission time, clinical features, causes and treatment of readmission ; （2） risk factors analysis affecting 30-day readmission after bariatric and metabolic surgery. Measurement data with skewed distribution were described as M （range）. The univariate analysis and multivariate analysis were respectively doneusing the chi-square test and Logistic regression model. Results （ 1 ） Thirty-day readmission situations after bariatric and metabolic surgery： among 631 patients receiving postoperative 1-months follow-up, 21 had 30-day readmission, with an incidence of 3.33%（21/631 ） , including 13 males and 8 females; 10 received LSG and 11 received LRYGB. The median readmission time of 21 patients was 12 days （ range, 4-30 days）. Of 21 patients, nausea, vomiting and dehydration of the main manifestations were detected in 11 patients, gastrointestinal bleeding in 6 patients, high fever in 2 patients, bowel obstruction in 1 patient and abdominal pain in 1 patient. The causes of the readmission of 21 patients： 8 had improper food intake including 5 with premature solid food intake, 1 with premature semi-fluid food intake, 1 with irritating food intake and 1 with swallowing whole tablets; 3 had postoperative over-anxiety; 1 had Pete1~en hiatal hernia; I had anastomotie ulcer; 1 had anastomotic edema; 1 had abdominal abscess. Of 6 patients with uncertain causes, 4 had gastrointestinal bleeding and didn＇t receive endoscopy; 1 had postoperative unexplained abdominal pain and underwent laboratory and imaging examinations and gastroscopy, showing no trouble finding; 1 had high i^ver, and no abnormality was detected by imaging examination. Of 21 patients, 19 underwent conservative treatment （rehydration and acid suppression） and then discharged from hospital after improvement, without readmission; 1 with abdominal abscess was cured after emergency debridement and drainage; 1 with Petersen hiatal hernia was cured by emergency surgery. The median duration of hospital stay in 21 patients with readmission was 7 days （range, 3-40 clays）. （2） Risk factors analysis affecting 30-day readmission after bariatric and metabolic surgery： the results of univariate analysis showed that gemter, preoperative adephagia habit and duration of postoperative hospital stay were related factors affecting 30- day readmission after bariatric and metabolic surgery （X2 = 5. 330, 6. 498, 4. 574, P〈 0.05）. The results of muhivariate analysis showed that male and preoperative adephagia habit were independent risk factors affecting 30- day readnfission after bariatric and metabolic surgery （OR= 2.489, 2.912, 95% cotdence interval： 1.006-6.161, 1.196-7.088, P〈0.05）. Conclusions Nausea, vomiting and dehydration are common manifestations of patients with 30-day readmission after bariatric and metabolic surgery, and it might be associated with improper food intake. Male and preoperative adephagia habit are independent risk factors affecting 30-day readmission after bariatric and metabolic surgery.