加速康复外科背景下根治性胃癌手术患者发生超长住院时间的影响因素分析

Factors influencing super-long hospital stays in patients undergoing radical gastrectomy in the age of enhanced recovery after surgery

目的通过分析加速康复背景下胃癌手术患者超长住院时间的影响因素,为优化胃癌围手术期管理,降低平均住院时间,提高医疗资源利用率提供参考依据和指导建议。方法本研究采用回顾性病例对照研究方法。纳入标准:(1)病理诊断为胃腺癌;(2)进行了胃癌根治性手术;(3)临床病理资料完整。排除标准:(1)既往有上腹部手术史;(2)胃癌远处转移或者同期合并其他正在治疗的肿瘤性疾病;(3)同期进行了放化疗等治疗;(4)术前有梗阻、穿孔等胃癌相关并发症。根据上述标准,纳入285例住院时间≥30 d的病例(超长住院时间组)。以年龄、性别、医疗费别、肿瘤pTNM分期和手术切除范围作为匹配因素,通过倾向性评分匹配按照1∶1进行筛选,筛选出同期住院时间<30 d的285例病例作为对照组(非超长住院时间组)。主要观察指标包括两组病例术前、术中、术后等与超长住院时间潜在相关的因素。术后并发症分级采用Clavien-Dindo系统。结果单因素分析显示,合并基础疾病数量多、术前会诊次数多、术前会诊时间≥3 d、转科、手术时间长、开放手术、术中出血量≥200 ml、在重症监护室(ICU)时间长、有手术或非手术相关并发症、术后并发症Clavien-Dindo分级高以及进行二次手术与住院时间超长有关(均P<0.05)。转科(OR=4.876,95%CI:1.500~16.731,P<0.001)、术前会诊时间≥3 d(OR=1.758,95%CI:1.036~2.733,P=0.034)、术后出现手术相关并发症(OR=6.618,95%CI:2.141~20.459,P=0.01)以及并发症等级更高(Clavien-DindoⅠ级:OR=7.176,95%CI:1.785~28.884,P<0.001;Clavien-DindoⅡ级:OR=18.984,95%CI:6.286~57.312,P<0.001;Clavien-DindoⅢ~Ⅳ级:OR=7.546,95%CI:1.495~37.952,P=0.014)均是住院时间超长的独立危险因素。结论通过减少转科、缩短术前会诊时间、提高手术质量和减少术后并发症发生率,可降低平均住院时间延长的风险。

Objective To obtain experience and generate suggestions for reducing average hospital stays,optimizing perioperative management of patients with gastric cancer and improving utilization of medical resources by analyzing the factors influencing super-long hospital stays in patients undergoing radical gastrectomy in the age of enhanced recovery after surgery(ERAS).Methods This was a case-control study.Inclusion criteria:(1)pathologically diagnosed gastric adenocarcinoma;(2)radical surgery for gastric cancer;and(3)complete clinicopathologic data.Exclusion criteria:(1)history of upper abdominal surgery;(2)presence of distant metastasis of gastric cancer or other ongoing neoplastic diseases;(3)concurrent chemoradiotherapy;and(4)preoperative gastric cancer-related complications such as obstruction or perforation.The study cohort comprised 285 eligible patients with hospital stays of≥30 days(super-long hospital stay group).Using propensity score matching in a 1:1 ratio,age,sex,medical insurance,pTNM stage,and extent of surgical resection as matching factors,285 patients with hospital stays of<30 days during the same period were selected as the control group(non-long hospital stay group).The primary endpoint was relationship between pre-,intra-,and post-operative characteristics and super-long hospital stays.Clavien-Dindo grade was used to classify complications.Results Univariate analysis showed that number of comorbidities,number of preoperative consultations,preoperative consultation,inter-departmental transference,operation time,open surgery,blood loss,intensive care unit time,presence of surgical or non-surgical complications,Clavien-Dindo grade of postoperative complications,and reoperation were associated with super-long hospital stays(all P<0.05).Inter-departmental transference(OR=4.876,95%CI:1.500-16.731,P<0.001),preoperative consultation time≥3 d(OR=1.758,95%CI:1.036–2.733,P=0.034),postoperative surgery-related complications(OR=6.618,95%CI:2.141-20.459,P=0.01),and higher grade of complications(Clavien-Dindo Grade I:OR=7.176,95%CI:1.785-28.884,P<0.001;Clavien-Dindo Grade II:OR=18.984,95%CI:6.286-57.312,P<0.001;Clavien-Dindo Grade III-IV:OR=7.546,95%CI:1.495-37.952,P=0.014)were independent risk factors for super-long hospital stays.Conclusion Optimizing preoperative management,enhancing perioperative management,and surgical quality control can reduce the risk of prolonging average hospital stay.