术中气道峰压监测对经口内镜下肌切开术气体相关并发症的预测价值

Predictive value of intraoperative airway peak pressure monitoring for gas-related complications of peroral endoscopic myotomy

目的探讨经口内镜下肌切开术(POEM)术中气道峰压变化对气体相关并发症的预测价值,为气体相关并发症的早期诊断提供参考依据。方法回顾性研究2014年1月-2019年4月该院行POEM治疗的38例贲门失弛缓症(AC)的临床资料。根据有无气体相关并发症及其严重程度进行分组,A组无气体相关并发症,B组轻度气体相关并发症(纵隔气肿或/和皮下气肿),C组中度气体相关并发症(纵隔、皮下气肿合并气腹),D组重度气体相关并发症(合并气胸)。并记录每例患者麻醉插管成功后1 min(T1)、隧道建立10 min(T2)、隧道建立完成(T3)、肌层切开10 min(T4)、肌层切开完成(T5)相应时间点的气道峰压值(Ppeak)。同时以Ppeak在1 min内升高≥30%设定为显著升高。首先对气体相关并发症的影响因素进行分析,并对各组患者术中不同时间点的Ppeak进行比较,同时计算Ppeak发生显著升高对预测气体相关并发症的灵敏度、特异度、阳性预测值和阴性预测值。结果发现有无气体相关并发症的两组患者,在既往治疗史、是否为S形食管、隧道入口建立方式、手术时间上差异具有统计学意义(P<0.05),且手术时间为气体相关并发症的独立危险因素;4组患者的Ppeak在T1~T3、T4~T5时间段内均呈上升趋势,T3~T4时间段内均呈下降趋势,并且C组与D组在T2~T3时间段内的升高幅度明显高于A组与B组,C、D两组在T3、T4和T5时明显高于A、B两组(P<0.05),T5时B组高于A组,D组高于C组,差异均有统计学意义(P<0.05);术中Ppeak显著升高预测气体相关并发症的灵敏度78.57%(22/28)、特异度80.00%(8/10)、阳性预测值91.67%(22/24)和阴性预测值57.14%(8/14)。结论术中Ppeak监测在预测气体相关并发症方面具有较高的临床价值,通过早期预防及干预可降低围手术期风险。

Objective To investigate the predictive value of the change of airway peak pressure(Ppeak) for gas-related complications of peroral endoscopic myotomy(POEM), and provide reference for early diagnosis of gas-related complications. Methods A retrospective study was performed on the clinical data of 38 achalasia(AC) patients receiving POEM from January 2014 to April 2019. We divided all the patients into groups according to the presence or absence of gas-related complications and their severity. Group A: no gas-related complications, Group B: mild gas-related complications(mediastinal emphysema or/and Subcutaneous emphysema), Group C: moderate(mediastinal and subcutaneous emphysema combined with pneumoperitoneum), Group D: severe(combined with pneumothorax). The Ppeak was recorded at 1 min after successful anesthesia intubation(T1), 10 min after the tunnel was dissected(T2), tunnel dissection was completed(T3), 10 min after myotomy(T4) and myotomy was completed(T5) for each patient. Meanwhile, the rise of Ppeak within 1 min was more than thirty percent, which was set as a significant increase. Firstly, the influencing factors of gas-related complications were analyzed. The Ppeak at different time points during the operation of each group of patients was compared. At the same time, the sensitivity, specificity, positive and negative predictive value for predicting gas-related complications caused by significant increase of Ppeak were calculated. Results The differences between the two groups that had or not had gas-related complications were statistically significant(P < 0.05) in the past treatment history, whether it was an S-shaped esophagus, the establishment method of tunnel entrance and the operation time. And the independent risk factor is operative time. In the four groups of patients, Ppeak appeared an upward trend in T1~ T3 and T4~ T5 and a downward trend in T3~T4. Moreover, the increase degrees of Ppeak of group C and group D in T2~ T3 period were significantly higher than that of group A and group B. Ppeaks of Group C and group D were significantly higher than group A and group B at T3, T4 and T5(P < 0.05). Group B was higher than group A and group D was higher than group C at T5. The difference was statistically significant(P < 0.05). During the operation, the sensitivity was(78.57%, 22/28), specificity was(80.00%, 8/10), positive predictive value was(91.67%, 22/24) and negative predictive value was(57.14%, 8/14) for predicting gas-related relative complications caused by significant increase of Ppeak. Conclusion Intraoperatively Ppeak monitoring has high clinical value in terms of predicting gas-related complications and perioperative risks can be decreased by prevention and intervention in early stage.