十二指肠侧壁瘘临床特征及预后风险因素分析

Analysis of clinical features and prognostic risk factors of duodenal lateral fistula

目的:了解十二指肠侧壁瘘的临床特征与预后情况,探讨影响其预后的高危因素,以改善其治疗结局。方法:采用回顾性研究方法,通过检索中国肠瘘与腹腔感染注册系统数据库,提取数据库中于2018年1月1日至12月31日期间住院治疗,并具有完整临床资料的十二指肠侧壁瘘患者作为研究对象。患者临床资料包括患者性别、年龄、住院时间、住院费用、重症监护室(ICU)入住情况、原发疾病、肠外瘘数目、并发症、治疗措施与疾病转归情况。结果:共纳入142例十二指肠侧壁瘘患者,其中男97例,女45例;中位年龄54(19~88)岁。十二指肠侧壁瘘的原发疾病位列前三的分别是消化道溃疡/穿孔33例(23.2%)、胆道疾病27例(19.0%)、创伤24例(16.9%)。单发十二指肠侧壁瘘117例(82.4%),同时合并其他部位瘘25例(17.6%)。142例患者中治愈127例(89.4%),其中手术治愈49例,保守治愈78例,死亡15例(10.6%)。在实施感染源控制方法上14例(9.9%)患者采取穿刺引流,18例(12.7%)患者采取剖腹引流。单因素分析结果显示,年龄≥60岁(χ^2=6.891,P=0.009)、原发疾病为消化道溃疡/穿孔(χ^2=8.515,P=0.004)、合并其他部位瘘(χ^2=5.798,P=0.016)、合并营养不良(χ^2=5.595,P=0.018)、肺部感染(χ^2=12.449,P<0.001)、出血(χ^2=6.466,P=0.011)、多器官功能障碍综合征(MODS)(χ^2=37.258,P<0.001),感染源控制时采用剖腹引流(χ^2=6.466,P=0.011)的患者死亡率较高。多因素logistic回归分析结果显示,年龄≥60岁(OR=44.375,95%CI:2.676~735.822,P=0.008)、合并其他部位瘘(OR=16.54,95%CI:1.744~156.913,P=0.015)和MODS(OR=238.447,95%CI:9.496~5987.78,P=0.001)是十二指肠侧壁瘘患者死亡的独立危险因素。结论:十二指肠侧壁瘘总体死亡率仍较高,医源性十二指肠损伤(外科手术、内镜治疗)是其主要直接致瘘原因,高龄(≥60岁)、合并其他部位瘘和MODS显著增加患者死亡风险。

Objective To investigate the clinical features and prognosis of duodenal lateral fistula(DLF),and to explore the high-risk factors affecting its prognosis,so as to improve its treatment outcome.Methods The regression study was conducted based on the database of the Registration System of Chinese Gastrointestinal Fistula and Intra-Abdominal Infections.DLF patients who were hospitalized from January 1,2018 to December 31,2018 and had complete clinical data in the database were selected as the research object.The clinical data included patient gender,age,length of hospital stay,hospitalization costs,intensive care unit(ICU)admission,underlying diseases,primary diseases,direct causes of DLF,complications,treatment and outcomes.Results A total of 142 patients with DLF were enrolled,including 97 males and 45 females,with a median age of 54 years.The top three primary diseases of DLF were gastrointestinal ulcers and perforations in 33 cases(23.2%),biliary tract disease in 27 cases(19.0%),and trauma in 24 cases(16.9%).There were 117 cases(82.4%)with single DLF,and 25 cases(17.6%)were combined with other fistula.Among the 142 patients,127 were healed(49 by surgery and 78 self-healing)and 15(10.6%)died.14 cases(9.9%)underwent percutaneous catheter drainage,and 18 cases underwent laparotomy drainage.Univariate prognostic analysis showed that advanced age(≥60 years old)(χ^2=6.891,P=0.009),primary diseases as gastrointestinal ulcers/perforations(χ^2=8.515,P=0.004),combined with other fistula(χ^2=5.798,P=0.016),malnutrition(χ^2=5.595,P=0.018),pulmonary infection(χ^2=12.449,P<0.001),hemorrhage(χ^2=6.466,P=0.011),multiple organ dysfunction syndrome(MODS)(χ^2=37.258,P<0.001),underwent laparotomy drainage(χ^2=6.466,P=0.011)were associated with mortality.Multivariate prognostic analysis confirmed that age≥60 years old(OR=44.375,95%CI:2.676-735.822,P=0.008),combined with other fistula(OR=16.54,95%CI:1.744-156.913,P=0.015)and MODS(OR=238.447,95%CI:9.496-5987.78,P=0.001)were independent risk factors of the death for DLF patients.Conclusions The mortality rate of DLF is still relatively high.Iatrogenic duodenal injury(surgical operation,endoscopic treatment)is the main direct cause of fistula.Advanced age,combined with other fistula and MODS significantly increases the risk of death of patients.