胃癌患者发生延迟性术后肠麻痹的危险因素分析

Analysis of risk factors of prolonged postoperative ileus after gastric cancer surgery

目的探讨胃癌患者发生延迟性术后肠麻痹（PPOI）的危险因素。方法前瞻性纳入2016年8—10月期间经术前胃镜病理明确胃癌并于解放军总医院普通外科接受手术治疗的83例胃癌患者，统计PPOI发生情况并采用单因素和logistic回归模型进行多因素分析诱发PPOI的危险因素。PPOI定义为腹部手术后96 h胃肠功能尚未恢复。其诊断标准为术后第97 h或以后满足以下2项或以上条件：（1）过去12 h内出现中、重度恶心[10分量表：轻度（1～3分）、中度（4～7分）、重度（8～10分）]或呕吐；（2）过去2餐内不能耐受固体食物，患者自我报告食量〈25%；（3）过去24 h内未排气、排粪；（4）临床医师通过敲击腹部，判断为中、重度腹胀；（5）过去24 h内影像学检查（腹部X线平片或CT），符合以下2或3项，证实肠梗阻：胃扩张、出现液气平面、小肠或结直肠袢扩张。结果83例胃癌患者中，男62例，女21例，男女比约3∶1；年龄（60.1 ± 11.0）（39～89）岁。术后病理分期为Ⅲ～Ⅳ期41例，Ⅰ～Ⅱ期42例。根据诊断标准，术后22例（26.5%）出现PPOI，其中96 h内未排气排粪合并中重度恶心、呕吐3例，96 h内未排气排粪合并中重度腹胀15例，96 h内未排气排粪合并中重度恶心、呕吐及中重度腹胀4例。22例PPOI患者经过保守治疗，临床症状均得到改善。单因素分析显示，年龄≥65岁[13/26（50.0%）比9/57（15.8%），χ2=10.727，P=0.001]、术后体温≥38.0℃[8/17（47.1%）比14/66（21.2%），χ2= 4.636，P= 0.031]、术后血清K＋水平[20/81（24.7%）比2/2，χ2=5.682，P= 0.017]、术后是否使用地佐辛镇痛[15/38（39.5%）比7/45（15.6%），χ2=6.050，P= 0.014]与发生PPOI有关。多因素分析显示，年龄≥65岁（OR=17.415，95% CI：17.151～17.750，P= 0.015）、术后体温≥38℃（OR=15.855，95%CI：15.422～16.214，P= 0.013）和术后使用地佐辛镇痛（OR= 21.379，95%CI：20.814～21.654，P= 0.010）是胃癌患者发生PPOI的独立危险因素。结论年龄较大、术后体温升高和术后使用地佐辛镇痛的胃癌患者发生PPOI风险更高，需要特别加强围手术期管理和干预。

Objective To investigate the risk factors of prolonged postoperative ileus （PPOI） after gastric cancer surgery. Methods Definition of PPOI was that gastrointestinal function did not return to normal within 96 hours after operation. Diagnostic criteria of PPOI were as follows： according with over 2 below conditions at postoperative 97-hour： （1） moderate to severe sick （mild： 1-3 points, moderate： 4-7 points, severe： 8-10 points） or vomiting occurred in past 12 hours. （2） patient wasintolerable of solid food in the last 2 meals and reported the food-intake as less than 25%. （3） no flatus and defecation occurred in past 24 hours. （4） moderate to severe abdominal distension was diagnosed by doctor with knocking abdomen. （5） iconography examination （abdominal X-ray or CT） in past 24 hours revealed gastrectasis, gas-fluid plane, intestinal or coloreetal loop extension, indicating the ileus. A total of 83 patients with gastric carcinoma confirmed by preoperative gastroscopic pathology undergoing operation at the Department of General Surgery, Chinese PLA General Hospital from August 2016 to October 2016 were prospectively enrolled in the study. The incidence and risk factors of PPOI after gastric cancer surgery were calculated and analyzed with univariate and logistic regression multivariate analyses. Results Of 83 gastric cancer patients, 62 were male and 21 were female with an average age of （60.1 ± 11.0）（39-89） years. Postoperative pathology showed 41 cases with m-IV stage, 42 eases withⅠ~Ⅱ stage. According to the above diaguostic criteria, 22 （26.5%） patients were diagnosed as PPOI postoperatively. Among 22 eases, 3 eases had no flatus and defecation with moderate-severe sick and vomiting within postoperative 96 hours; 15 eases had no flatus and defecation with moderate-severe abdominal extension within postoperative 96 hours; 4 eases had no flatus and defeeation with moderate- severe sick, vomiting and moderate-severe abdominal extension within postoperative 96 hours. Clinical symptoms of all the POOI patients were improved following conservative treatment. Univariate analysis showed that age≥65 years [13/26 （50.0%） vs. 9/57 （15.8%）, X2=10.727, P=0.00I], postoperative body temperature ≥38.0℃ [8/17 （47.1%） vs. 14/66 （21.2%）, X2=4.636, P=0.031], postoperative serum potassium level [20/81 （24.7%） vs. 2/2, X2=5.682, P=0.017], and use of opioid agent Dezocine [ 15/38 （39.5%） vs. 7/45 （15.6%）, X2=6.050, P = 0.014] were associated with POOI. Logistic regression analysis showed that age≥ 65 years （OR =17.415,95% CI： 17.151 -17.750, P = 0.015）, postoperative body temperature≥38% （0R=15.855, 95 %CI：15.422-16.214, P = 0.013）, use of Dezoeine after surgery （0R=21.379, 95%CI：20.814-21.654, P=0.010） were the independent risk factors of PPOI after gastric cancer surgery. Conclusion Gastric patients with older age, increased body temperature and the use of Dezocine after surgery have higher risk of POOI and need special perioperative management and treatment.