克罗恩病患者发生延迟性术后肠麻痹的围手术期影响因素分析

Analysis of the perioperative factors influencing the occurrence of prolonged postoperative ileus in patients with Crohn′s disease

目的分析克罗恩病(CD)患者发生延迟性术后肠麻痹(PPOI)的围手术期影响因素。方法采用回顾性病例对照研究的方法。收集2019年6月至2021年1月在南京大学医学院附属金陵医院行部分肠管切除术的CD患者的临床资料。根据是否发生PPOI将患者分为PPOI组和非PPOI组,采用单因素分析比较两组围手术期指标的差异。采用Spearman秩相关检验排除相关性较强的变量。取单因素分析中P<0.05且有临床意义的变量,通过受试者工作特征(ROC)曲线确定变量的截断值,将其转换成二分类定性资料,再行多因素Logistic回归分析确定PPOI的独立危险因素。结果共纳入314例患者,男性202例,女性112例;年龄(39±14)岁。89例(28.3%)患者发生PPOI,设为PPOI组;没有发生PPOI者225例(71.7%),设为非PPOI组。与非PPOI组比较,PPOI组患者手术时间更长[128(99,166)min比110(85,141)min,P=0.006],术中使用的阿片类药物总量更多[2.9(2.4,3.3)MME/kg比2.7(2.4,3.1)MME/kg,P=0.011,MME为吗啡毫克当量],术中输液量更多(P=0.009),晶体液用量更多(P=0.007),术中单位体质量液体平衡(IOB/BW)更高[18.8(14.1,25.5)ml/kg比16.4(12.5,20.7)ml/kg,P=0.005],术后3 d内白蛋白最低值更低(P=0.019),术后白蛋白最大变化量更高(P=0.024),术后3 d内血钾最低值更低(P=0.007),术后第1天补液量更多(P<0.001),术后住院时间更长(P<0.001)。相关性分析中,术中输液量和IOB/BW(r=0.689,P<0.001)、术中输液量和晶体液用量(r=0.986,P<0.001)之间相关性较强,因此术中输液量和晶体液用量未纳入多因素分析。ROC曲线的截断值:手术时间为123.5 min,阿片类药物总量为2.84 MME/kg,IOB/BW为21.08 ml/kg,术后3 d内白蛋白、血钾最低值分别为29.15 g/L、3.75 mmol/L,术后白蛋白最大变化量为7.25 g/L,术后第1天补液量2751.5 ml。多因素Logistic回归分析中,手术时间≥123.5 min(OR=2.162,95%CI:1.260~3.710,P=0.005)、IOB/BW≥21.08 ml/kg(OR=3.184,95%CI:1.817~5.581,P<0.001)、术后白蛋白最大变化量≥7.25 g/L(OR=1.948,95%CI:1.110~3.419,P=0.02)和术后第1天补液量≥2751.5 ml(OR=2.845,95%CI:1.630~4.966,P<0.001)是PPOI的独立危险因素。结论CD患者若存在手术时间长、IOB/BW高、术后白蛋白变化大和术后第1天补液量多等因素较易发生PPOI,控制IOB/BW和术后第1天补液量是降低PPOI发生率的重要措施。

Objective To explore the perioperative factors which influence the occurrence of prolonged postoperative ileus(PPOI)in patients with Crohn′s disease(CD).Methods A retrospective case-control study was conducted.Clinical data of CD patients who underwent partial intestinal resection at Jinling Hospital of Medical School of Nanjing University from June 2019 to January 2021 were analyzed retrospectively.The patients were divided into PPOI group and non-PPOI group according to whether the PPOI happened or not.The differences in perioperative indexes between PPOI and non-PPOI groups were assessed by univariate analysis.Spearman rank correlation test was used to exclude variables with strong correlations.The receiver operating characteristic(ROC)curve was performed to determine the cut-off values of the variables with P<0.05 in univariate analysis and clinical significance,and the variables were converted into binary qualitative data.And then the data were analyzed by multivariate Logistic regression to determine the independent risk factors of PPOI.Results A total of 314 patients were included,including 202 males and 112 females with the age of(39±14)years old.Eighty-nine(28.3%)patients with PPOI were set as PPOI group,and 225(71.7%)patients without PPOI were set as non-PPOI group.Compared with non-PPOI group,patients in PPOI group had longer surgery duration[128(99,166)min vs.110(85,141)min,P=0.006],more total opioids[2.9(2.4,3.3)MME/kg vs.2.7(2.4,3.1)MME/kg,P=0.011,MME:morphine milligram equivalent],more intraoperative infusion volume(P=0.009),more crystal solution volume(P=0.007),higher intraoperative in-out balance per body weight(IOB/BW)[18.8(14.1,25.5)ml/kg vs.16.4(12.5,20.7)ml/kg,P=0.005],lower minimum level of albumin within 3 days after surgery(P=0.019),higher maximum change of albumin level after surgery(P=0.024),lower minimum concentration of serum potassium within 3 days after surgery(P=0.007),and more infusion supplement on the first day after surgery(P<0.001),and longer postoperative hospital stay(P<0.001).In the correlation analysis,there were strong correlations between intraoperative infusion volume and IOB/BW(r=0.689,P<0.001),and intraoperative infusion volume and crystal fluid volume(r=0.986,P<0.001)respectively.Therefore,intraoperative infusion volume and crystal fluid volume were excluded from the multivariate analysis.The cut-off value of the surgery duration was 123.5 min by ROC curve,the total opioids was 2.84 MME/kg,IOB/BW was 21.08 ml/kg,the minimum level of albumin and the minimum concentration of serum potassium within 3 days after surgery were 29.15 g/L and 3.75 mmol/L respectively,the maximum change of albumin level after surgery was 7.25 g/L,and the fluid supplement on the first day after surgery was 2751.5 ml.In multivariate Logistic regression analysis,surgery duration≥123.5 min(OR=2.162,95%CI:1.260-3.710,P=0.005),IOB/BW≥21.08 ml/kg(OR=3.184,95%CI:1.817-5.581,P<0.001),maximum change of albumin level≥7.25 g/L after surgery(OR=1.948,95%CI:1.110-3.419,P=0.02)and fluid supplement≥2751.5 ml on the first day after surgery(OR=2.845,95%CI:1.630-4.966,P<0.001)were the independent risk factors for PPOI.Conclusions CD patients who have the factors of long surgery duration,high IOB/BW,big change of albumin level after surgery and much fluid supplement on the first day after surgery are prone to PPOI.Therefore,controlling IOB/BW and fluid supplement on the first day after surgery are important measures to reduce the incidence of PPOI.