腹腔镜手术在老年上消化道溃疡穿孔中的临床效果及安全性研究

The Clinical Effect and Safety of Laparoscopic Surgery in Elderly Patients with Upper Gastrointestinal Ulcer Perforation

目的 探讨在治疗老年上消化道溃疡穿孔患者时采取腹腔镜手术的临床效果以及预后。方法 回顾性分析2015年1月—2020年12月在福建医科大学附属闽东医院胃肠外科治疗的141例老年上消化道溃疡穿孔患者的临床资料,对照组(70例)采取传统开腹穿孔修补术进行治疗,观察组(71例)采取腹腔镜穿孔修补术进行治疗,对比两组各项手术及恢复指标、并发症、疼痛程度、炎性因子、免疫功能及白细胞计数。结果 观察组术中出血量(39.61±5.94)mL,术后恢复肠鸣音时间(4.73±1.21)h,排气时间(21.52±4.67)h,镇痛时间(11.24±3.56)h,住院时间(6.25±1.46)d,明显优于对照组,差异有统计学意义(t=38.727、9.899、40.877、28.999、16.325,P<0.05)。观察组切口感染、腹腔脓肿、肠道粘连、肠梗阻的总并发症发生率为2.82%,显著低于对照组,差异有统计学意义(χ^(2)=8.089,P<0.05)。观察组术后1、2、3 d的VAS疼痛评分为(3.57±1.03)分、(2.54±0.83)分、(1.15±0.47)分,明显低于对照组,差异有统计学意义(t=11.873、13.614、22.124,P<0.05)。观察组术后1、2 d的IL-1为(11.75±4.58)ng/L、(8.03±2.98)ng/L,明显低于对照组,差异有统计学意义(t=2.311、5.715,P<0.05);观察组术后1、2 d的IL-6为(13.38±3.91)ng/L、(9.72±3.59)ng/L,明显低于对照组,差异有统计学意义(t=3.913、4.714,P<0.05);观察组术后1、2 d的TNF-α为(43.46±12.63)ng/L、(30.91±10.78)ng/L,明显低于对照组,差异有统计学意义(t=2.948、3.675,P<0.05)。观察组术后1、2 d的CD4^(+)为(33.96±6.42)%、(44.03±7.51)%,CD4^(+)/CD8^(+)为(1.17±0.08)、(1.91±0.10),均高于对照组,差异有统计学意义(P<0.05);观察组术后1、2 d的CD8^(+)为(28.92±5.84)%、(23.05±5.26)%,明显低于对照组,差异有统计学意义(P<0.05)。观察组术后4、24、48 h的WBC水平为(22.31±1.76)×10~9/L、(14.28±1.52)×10~9/L、(11.58±1.66)×10~9/L,明显低于对照组,差异有统计学意义(P<0.05)。结论 老年上消化道溃疡穿孔实施腹腔镜手术的临床效果显著,创伤小,术后恢复快,疼痛轻,炎症反应程度低,对免疫功能的影响小。

Objective To explore the clinical effect and prognosis of laparoscopic surgery in the treatment of elderly patients with upper gastrointestinal ulcer perforation.Methods The clinical data of 141 elderly patients with perforated upper digestive tract ulcer treated in Department of Gastroenterology,Mindong Hospital Affiliated to Fujian Medical University from January 2015 to December 2020 were retrospectively analyzed.The control group(70 cases)received traditional open perforation repair,the observation group(71 cases)underwent laparoscopic perforation repair.The two groups were compared in terms of operation and recovery indexes,complications,pain,inflammatory factors,immune function and white blood cell count.Results The intraoperative bleeding volume of the observation group was(39.61±5.94)mL,the postoperative recovery time of bowel sounds was(4.73±1.21)h,the exhaust time was(21.52±4.67)h,the analgesia time was(11.24±3.56)h,and the hospitalization time was(6.25±1.46)d,which was significantly better than that of the control group,and the difference was statistically significant(t=38.727,9.899,40.877,28.999,16.325,P<0.05).The incidence of complications such as incision infection,abdominal abscess,intestinal adhesion and intestinal obstruction in the observation group was 2.82%,which was significantly lower than that in the control group,the difference was statistically significant(χ^(2)=8.089,P<0.05).The VAS pain scores of the observation group were(3.57±1.03)points,(2.54±0.83)points and(1.15±0.47)points on the 1 d,2 d and 3 d after operation,which were significantly lower than those of the control group,the difference was statistically significant(t=11.873,13.614,22.124,P<0.05).The IL-1 levels in the observation group were(11.75±4.58)ng/L and(8.03±2.98)ng/L on the 1 d and 2 d after operation,which were significantly lower than those in the control group,the difference was statistically significant(t=2.311,5.715,P<0.05);the IL-6 levels in the observation group were(13.38±3.91)ng/L and(9.72±3.59)ng/L on the 1 d and 2 d after operation,which were significantly lower than those in the control group,the difference was statistically significant(t=3.913,4.714,P<0.05);the TNF-αof the observation group was(43.46±12.63)ng/L and(30.91±10.78)ng/L on the 1 d and 2 d after operation,which was significantly lower than that of the control group,the difference was statistically significant(t=2.948,3.675,P<0.05).The CD4+and CD4+/CD8+in the observation group were(33.96±6.42)%,(44.03±7.51)%,(1.17±0.08)and(1.91±0.10)respectively,higher than those in the control group on the 1 d and 2 d after operation,the difference was statistically significant(P<0.05);the CD8+of the observation group was(28.92±5.84)%and(23.05±5.26)%on the 1 d and 2 d after operation,which was significantly lower than that of the control group,the difference was statistically significant(P<0.05).The WBC level in the observation group was(22.31±1.76)×109/L,(14.28±1.52)×109/L,(11.58±1.66)×109/L at 4,24 and 48 hours after operation,significantly lower than the control group,the difference was statistically significant(P<0.05).Conclusion Laparoscopic surgery for perforation of upper digestive tract ulcer in the elderly has significant clinical effect,small trauma,rapid recovery,mild pain,low inflammatory reaction and little impact on immune function.