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《中华消化外科杂志》2018年9月第17卷第9期论著

影响克罗恩病肠切除术后切口感染的危险因素分析

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引用本文:
刘华山,张珑娟,梁振兴,等.影响克罗恩病肠切除术后切口感染的危险因素分析[J].中华消化外科杂志,2018,17(9):935-942.DOI:10.3760/cma.j.issn.1673-9752.2018.09.012.
【摘要】

目的:分析影响克罗恩病肠切除术后切口感染的危险因素。
方法:采用回顾性病例对照研究方法。收集2007年1月至2016年12月中山大学附属第六医院收治的239例克罗恩病行肠切除术患者的临床病理资料。患者均行肠切除术。观察指标:(1)手术情况。(2)随访情况。(3)影响术后切口感染的危险因素分析。(4)影响患者术前贫血的临床因素。采用门诊或病房接诊方式进行随访,随访内容为术后30 d内切口感染情况。随访时间截至2017年1月。采用Shapiro-Wilk进行正态性检验。正态分布的计量资料以±s表示,组间比较采用t检验;偏态分布的计量资料以M(范围)表示,组间比较采用Wilcoxon秩和检验。单因素和多因素分析采用Logistic回归模型,将单因素分析中P<0.05的指标纳入多因素分析中以逐步向前法进行分析。
结果:(1)手术情况:239例患者中,11例行急诊手术、228例行择期手术;65例行腹腔镜手术、174例行开腹手术;手术方式均为肠切除术,肠切除术后179例行消化道重建吻合,81例行肠造口术(21例联合行肠吻合和造口术)。239例患者术中发现纤维性狭窄137例、肠瘘113例、小肠梗阻101例、脓肿58例、蜂窝组织炎54例、肠穿孔11例(部分患者合并多种症状)。(2)随访情况:239例患者术后30 d均获得随访,随访期间48例发生切口感染,均经对症支持治疗后好转。(3)影响术后切口感染的危险因素分析:①单因素分析结果显示:疾病行为、红细胞沉降率>20 mm/h、术前贫血、术前合并慢性肠瘘、开腹手术、术中发现纤维性狭窄、术中发现肠瘘是影响克罗恩病患者术后切口感染发生的危险因素(比值比=2.530,2.579,4.233,2.988,2.554,0.503,3.052,95%可信区间:1.218~2.259,1.141~5.833,1.598~11.210,1.522~5.864,1.082~6.029,0.265~0.954,1.555~5.993,P<0.05)。②多因素分析结果显示:术前贫血和术中发现肠瘘是影响克罗恩病患者术后切口感染发生的独立危险因素(比值比=3.881,2.837,95%可信区间:1.449~10.396,1.429~5.634,P<0.05)。(4)影响患者术前贫血的临床因素:术前贫血患者的性别(男性)、体质量指数、红细胞沉降率>20 mm/h、血小板>300×109/L、C反应蛋白升高、白蛋白<35 g/L例数分别为120例、(17.4±2.9)kg/m2、130、75、139、65例;术前不贫血患者分别为65例、(18.3±2.9)kg/m2、36、12、39、10例,两者上述指标比较,差异均有统计学意义(x2=17.966,t=2.210, x2=12.219,14.440,14.661,12.272,P<0.05)。
结论:术前贫血及术中发现肠瘘是克罗恩病患者肠切除术后切口感染的独立危险因素,术前贫血与围术期炎症状态具有相关性。

【Abstract】

Objective:To analyze the risk factors affecting postoperative incisional infection in Crohn′s disease (CD) patients after bowel resection.
Methods:The retrospective case-control study was conducted. The clinicopathological data of 239 CD patients who underwent bowel resection in the Sixth Affiliated Hospital of Sun Yat-sen University between January 2007 and December 2016 were collected. All patients underwent bowel resection. Observation indicators: (1) surgical situations; (2) follow-up; (3) risk factors analysis affecting postoperative incisional infection; (4) clinical factors affecting preoperative anemia. The follow-up using outpatient examination or ward diagnosis was performed to detect incisional infection within 30 days postoperatively up to January 2017. The normality test was done by Shapiro-Wilk. Measurement data with normal distribution were represented as ±s, and comparison between groups was evaluated with the t test. Measurement data with skewed distribution were described as M (range), and comparison between groups was analyzed using the Wilcoxon rank-sum test. The univariate analysis and multivariate analysis were done using the Logistic regression model. The P<0.05 in univariate analysis was incorporated into multivariate analysis for analysis in the forward wald.
Results: (1) Surgical situations: of 239 patients, 11 underwent emergency surgery and 228 underwent elective surgery; 65 and 174 underwent respectively laparoscopic surgery and open surgery; 179 received digestive tract reconstruction and anastomosis and 81 received enterostomy (21 combined with anastomosis and enterostomy). Among 239 patients, 137, 113, 101, 58, 54 and 11 were complicated respectively with fiber stenosis, intestinal fistula, obstruction of small intestine, abscess, cellulitis and enterobrosis (some patients combined with multiple signs). (2) Follow-up: 239 patients were followed up at 30 days postoperatively. During the follow-up, 48 with incisional infection were improved by symptomatic treatment. (3) Risk factors analysis affecting postoperative incisional infection: ① Results of univariate analysis showed that illness behavior, sedimentation rate of RBC > 20 mm/h, preoperative anemia, preoperative chronic intestinal fistula, open surgery, intraoperative fiber stenosis and intraoperative intestinal fistula were risk factors affecting occurrence of postoperative incisional infection [odds ratio (OR)=2.530, 2.579, 4.233, 2.988, 2.554, 0.503, 3.052, 95% confidence interval (CI): 1.218-2.259, 1.141-5.833, 1.598-11.210, 1.522-5.864, 1.082-6.029, 0.265-0.954, 1.555-5.993, P<0.05]. ② Results of multivariate analysis showed that preoperative anemia and intraoperative intestinal fistula were independent risk factors affecting occurrence of postoperative incisional infection (OR=3.881, 2.837, 95%CI: 1.449-10.396, 1.429-5.634, P<0.05). (4) Clinical factors affecting preoperative anemia: cases (male) with preoperative anemia, body mass index (BMI), cases with sedimentation rate of RBC > 20 mm/h, platelet (PLT) > 300×109/L, elevated C-reactive protein, albumin (Alb) <35 g/L were respectively 120, (17.4±2.9)kg/m2, 130, 75, 139, 65 in patients with preoperative anemia and 65, (18.3±2.9)kg/m2, 36, 12, 39, 10 in patients without preoperative anemia, with statistically significant differences (χ2=17.966, t=2.210, χ2=12.219, 14.440, 14.661, 12.272, P<0.05).
Conclusion:The preoperative anemia and intraoperative intestinal fistula are independent risk factors affecting occurrence of postoperative incisional infection, and preoperative anemia is associated with perioperative inflammatory conditions.

DOI:10.3760/cma.j.issn.1673-9752.2018.09.012
基金项目:国家自然科学基金(81870383);广东省科技计划项目(2015B020229001);广东省自然科学基金(2017A030313785);广州市科技计划项目(201804010014)
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