腹腔镜技术在老年急性肠梗阻患者治疗中的应用——一项前瞻性双中心单臂临床研究

Application of laparoscopic technology on elderly patients with acute intestinal obstruction:a prospective two-center single-arm clinical study

目的分析腹腔镜技术治疗老年急性肠梗阻患者的安全性与可行性。方法采用前瞻性双中心单臂临床研究方法。选择2017年10月至2021年10月在龙游县人民医院和青海大学附属医院普通外科接受治疗且符合纳入标准的441例急性肠梗阻患者作为研究对象。10例患者伴慢性阻塞性肺疾病(COPD),术后给予机械通气、无创呼吸、持续性低流量吸氧,雾化吸入、扩张支气管治疗。12例患者伴慢性肾脏疾病(CKD),术后给予血液透析治疗。441例患者接受腹腔镜探查、小肠减压术、确定性手术,术后采用静脉营养、使用抗菌药物、皮下注射低分子肝素(10 U/kg)。观察术前、术后、出院时患者血气分析(伴COPD)、肾功能(伴CKD)、体质量和体质量指数(BMI)、并发症及预后情况。结果441例老年性肠梗阻患者中男性240例,女性201例;病程(74.2±6.4)h,BMI为(25.4±6.7)kg/m^(2)。束带黏连280例行肠黏连松解术;小肠坏死87例,小肠脂肪血管瘤19例,行小肠切除吻合术;闭孔疝21例,行疝修补术;小肠柿石34例,行小肠切开取柿石术。10例COPD患者,术后血气明显改善,动脉血氧分压(PaO_(2))较术前明显升高〔mmHg(1 mmHg≈0.133 kPa):80.3±3.3比72.6±2.7,P<0.01〕,动脉血二氧化碳分压(PaCO_(2))较术前明显降低(mmHg:35.7±3.6比47.6±1.3,P<0.01),4例死于Ⅱ型呼吸衰竭,6例患者出院时PaO_(2)〔(77.4±6.7)mmHg〕较术后明显降低(P<0.01),PaCO_(2)〔(42.1±5.2)mmHg〕较术后明显升高(P<0.01)。12例伴CKD患者,术后尿素氮(BUN)和血肌酐(SCr)均较术前明显升高〔BUN(μmol/L):79.5±8.5比18.8±4.7,SCr(μmol/L):312.7±12.1比138.4±9.7,均P<0.01〕,2例死于肾衰竭,8例出院时BUN〔(9.2±0.7)μmol/L〕和SCr〔(112.5±3.8)μmol/L〕均较术后明显降低(均P<0.01)。术前、术后与出院时BMI和体质量比较差异均无统计学意义〔BMI(kg/m^(2)):25.4±6.7、24.9±3.9比23.9±3.5,体质量(kg):74.2±6.8、73.7±3.3比72.8±4.6,均P>0.05〕。435例患者痊愈出院,均无下肢静脉血栓形成、肠漏、切口裂开、切口感染。结论采用腔镜探查、肠道减压、确定性手术、治疗基础疾病以及低分子肝素皮下注射等策略,治疗老年急性肠梗阻患者,是安全且可行的。

Objective To analyse the safety and feasibility of laparoscopic techniques in the treatment of elderly patients with acute intestinal obstruction.Methods A prospective two-center single-arm clinical study was conducted.A total of 441 patients with acute intestinal obstruction treated at the department of general surgery of Longyou County People's Hospital and Hospital Affiliated to Qinghai University from October 2017 to October 2021 and met the inclusion criteria were selected as study subjects.Among them,10 patients had chronic obstructive pulmonary disease(COPD)and were given mechanical ventilation,noninvasive ventilation,continuous low-flow oxygen inhalation,nebulization inhalation,and bronchodilator treatment after surgery.Twelve patients had chronic kidney disease(CKD)and were given hemodialysis treatment after surgery.All 441 patients underwent laparoscopic exploration,small intestine decompression,and definitive surgery.After surgery,they received intravenous nutrition,antibiotics,and subcutaneous injection of low-molecular-weight heparin(10 U/kg).The blood gas analysis(for patients with COPD),renal function(for patients with CKD),weight,body mass index(BMI),complications,and prognosis were observed before surgery,after surgery,and at discharge.Results There were 441 elderly patients with intestinal obstruction in the study,including 240 males and 201 females.The mean duration of the disease was(74.2±6.4)hours,and the BMI was(25.4±6.7)kg/m^(2).A total of 280 patients with adhesions underwent adhesion lysis surgery,while 87 patients with small bowel necrosis and 19 patients with small bowel lipoangiomatosis underwent small bowel resection and anastomosis.Additionally,21 patients with obturator hernia underwent hernia repair surgery,and 34 patients with small bowel persimmon stones underwent small bowel incision and stone removal surgery.For the 10 patients with COPD,there was a significant increase in arterial partial pressure of oxygen[PaO_(2) mmHg(1 mmHg≈0.133 kPa):80.3±3.3 vs.72.6±2.7,P<0.01],and a significant decrease in arterial partial pressure of carbon dioxide(PaCO_(2))compared to preoperative levels(mmHg:35.7±3.6 vs.47.6±1.3,P<0.01).Four patients died of typeⅡrespiratory failure,and 6 patients had a significant decrease in PaO_(2)[(77.4±6.7)mmHg]and a significant increase in PaCO_(2)[(42.1±5.2)mmHg]at discharge compared to postoperative levels(both P<0.01).Among the 12 patients with CKD,both blood urea nitrogen(BUN)and serum creatinine(SCr)increased significantly after surgery compared to preoperative levels[BUN(μmol/L):79.5±8.5 vs.18.8±4.7,SCr(μmol/L):312.7±12.1 vs.138.4±9.7,both P<0.01].Two patients died of renal failure,and 8 patients had a significant decrease in BUN[(9.2±0.7)μmol/L]and SCr[(112.5±3.8)μmol/L]at discharge compared to postoperative levels(both P<0.01).There were no significant differences in BMI and weight between preoperative,postoperative,and discharge times[BMI(kg/m^(2)):25.4±6.7,24.9±3.9 vs.23.9±3.5;weight(kg):74.2±6.8,73.7±3.3 vs.72.8±4.6;all P>0.05].A total of 435 patients recovered from acute intestinal obstruction with no complications such as lower extremity venous thrombosis,intestinal fistula,wound dehiscence,or wound infection.Conclusion The strategy of treating elderly patients with acute intestinal obstruction by laparoscopic exploration,intestinal decompression,definitive surgery,treatment of underlying diseases,and subcutaneous injection of low-molecular-weight heparin is safe and feasible.