胆系疾病开腹手术术后感染危险因素分析及防治

发布时间：2018-05-02 13:04

本文选题：开腹胆道手术 + 术后感染　；参考：《浙江大学》2015年博士论文

【摘要】：背景和目的：胆道手术是外科领域中重要的手术之一,由于其解剖复杂精细,手术难度较高。尽管随着腹腔镜手术的兴起和发展,使诸如胆囊切除之类的手术可以在腹腔镜下进行,术后感染相关并发症也随之降低,但大部分胆系手术仍然在开腹下进行。开腹手术术后感染是最常见的胆道手术术后并发症,且发生率较高,延长住院时间,增加医疗费用,严重影响病患预后。为此,减少胆道手术术后感染的发生具有重要的临床意义。然而,目前尚无简单有效的方案来降低胆道术后感染的发生率,但可以通过分析潜在影响因子找到术后感染的危险因素。与国外研究相比,国内分析开腹胆道手术术后感染危险因素的文献较少,且多以单因素分析为主。与单因素分析相比,多因素分析考虑了因素之间的相互作用和多指标之间的内在联系,结论更为可靠。本研究旨在通过对临床大数据的回顾性分析,以Logistic回归法筛选开放胆道手术术后感染的相关因素,探讨影响胆系手术术后感染相关性并发症的主要危险因子,建立术后感染的风险预测模型,帮助早期发现高风险患者,用于指导临床工作,尽可能减少术后感染相关并发症的发生。方法：本研究为回顾性研究,采用病例对照设计由果及因的研究方法,对浙江大学医学院附属第二医院肝胆胰外科(外五病区)2012年1月至2014年10月期间所有行开放胆道手术的患者进行回顾性分析,查阅患者的临床病历资料,收集患者的一般情况、既往病史、围手术期相关临床资料以及术后感染发生情况及种类,结合权威外科学教材《克氏外科学》第20版及相关文献,将可能影响胆道手术术后感染发生的31相关项临床指标纳入研究。应用SPSS13.0软件,先对这些临床参数进行单因素logistic分析,以p=0.05为检验水准,将有统计学意义(p0.05)的因素进行多因素Logistic逐步回归分析。筛选影响胆道疾病术后感染的危险因素,建立logistic回归方程。计算各因素的相对危险度,并检测该模型评价新入院病人样本术后感染相关并发症的灵敏度、特异度和准确度。术后感染的诊断标准参照原卫生部2001年颁发的《医院感染诊断标准(试行)》,中南大学湘雅医院等发布的《医院感染监测规范》及胆道感染的行业标准,并结合临床实际情况决定。结果：研究共纳入符合要求的病例576例,术后发生感染162例,术后总感染发生率为28.12%。其中腹腔感染和胆道感染仍占较高的比例,分别为11.50%和10.80%。单因素Logistic回归分析发现影响胆系手术术后感染发生率显著相关的因素包括性别、肥胖、既往腹部手术次数、术前白蛋白、PT、发热、白细胞异常、CRP异常、术前合并感染、术前应用抗生素、ASA分级、手术时间、术中失血量、术中输血、术后气管插管、术后入ICU和术后发热；对有统计学意义的17项指标做进一步的多因素Logistic回归分析后得出肥胖、术中输血和麻醉分级3个相关因素进入Logistic回归方程,作用强度依次为术中输血(OR=5.342,P=0.000)、肥胖(OR=3.291,P=0.000)和麻醉分级(OR=1.508,P=0.013)。以概率值0.5作为交界点,将后续120例新入院病人数据代入方程,得出的预测值与实际数据比较,结果显示,此概率模型判断胆系疾病开腹手术术后感染并发症的准确度为80%(96/120)、灵敏度为65.63%(21/32)、特异度为85.23%(75/88),模型的曲线下面积为0.837(95%置信区间为0.801～0.873)。结论：胆系疾病开腹手术术后感染发生率依然较高,与众多因素相关,本研究认为肥胖、术中输血和麻醉分级3个相关因素是影响开腹胆道手术术后感染发生的独立危险因素,应引起临床医生的重视。
[Abstract]:Background and objective: biliary surgery is one of the most important surgery in the field of surgery. Because of its complex anatomy, the operation is difficult. Although with the rise and development of laparoscopic surgery, surgery such as cholecystectomy can be performed under laparoscopy, and postoperative infection related complications are reduced, but most of the biliary surgery remains. After laparotomy, infection is the most common postoperative complication of biliary tract operation, and the incidence is high, the time of hospitalization is prolonged, the cost of medical treatment is increased, and the prognosis of the patients is seriously affected. Therefore, it has important clinical significance to reduce the incidence of infection after biliary operation. However, there is no simple and effective scheme to reduce the bile. The incidence of postoperative infection can be found, but the risk factors for postoperative infection can be found by analyzing the potential factors. Compared with foreign studies, there are fewer literature on the risk factors for infection after the operation of the biliary tract surgery, and mainly by single factor analysis. Compared with the single factor analysis, the multifactor analysis takes into account the interaction between factors. The purpose of this study is to screen the related factors of infection after open biliary surgery by Logistic regression analysis, and to explore the main risk factors affecting the infection related complications after biliary operation and to establish the risk prediction model for postoperative infection. It helps early detection of high-risk patients to guide clinical work and minimize postoperative infection related complications.
Methods: in this study, a retrospective study was conducted, and a case control design was used to study all the patients undergoing open biliary surgery from January 2012 to October 2014 in the Second Affiliated Hospital of Zhejiang University Medical College (five ward), and to check the patient's clinical records and collect the patients. General conditions, past medical history, related clinical data of perioperative period, and the incidence and types of postoperative infection, combined with the twentieth edition of the Kirschner's surgery, and the related literature, combined with the authoritative external science textbook, and related literature, the clinical indicators that may affect the incidence of infection after biliary operation are included in the study. SPSS13.0 software is applied to these clinical parameters first. Single factor Logistic analysis, with p=0.05 as the test level, the factors of statistical significance (P0.05) were analyzed by multiple factor Logistic stepwise regression analysis. The risk factors affecting postoperative infection of biliary tract diseases were screened and logistic regression equation was established. The relative risk degree of each factor was calculated, and the model was tested to evaluate the postoperative infection of new hospitalized patients. The sensitivity, specificity and accuracy of the related complications. The diagnostic criteria for postoperative infection refer to the standard of hospital infection diagnosis issued by the Ministry of health in 2001, the standard of hospital infection monitoring and the industry standards of biliary tract infection issued by Xiangya Hospital of the Central South University and so on.
Results: 576 cases were included in the study and 162 cases were infected after operation. The incidence of total infection after operation was 28.12%.. The proportion of abdominal infection and biliary tract infection was still high. The single factor Logistic regression analysis of 11.50% and 10.80%. found that the factors affecting the incidence of infection after biliary operation include sex, Obesity, the number of previous abdominal operations, preoperative albumin, PT, fever, leukocyte abnormality, CRP abnormalities, combined infection, preoperative application of antibiotics, ASA classification, operation time, intraoperative blood loss, intraoperative blood transfusion, postoperative endotracheal intubation, postoperative ICU and postoperative fever; further multivariate Logistic regression for statistically significant 17 indicators After the analysis, 3 factors related to obesity, intraoperative blood transfusion and anesthesia classification entered the Logistic regression equation. The effect intensity was in order of intraoperative blood transfusion (OR=5.342, P=0.000), obesity (OR=3.291, P=0.000) and anesthesia classification (OR=1.508, P=0.013). The probability value of 0.5 was used as the junction point, and the data of the subsequent 120 new hospitalized patients were replaced by the equation, and the prediction was obtained. Compared with the actual data, the results showed that the accuracy of the infection complications after laparotomy was 80% (96/120), the sensitivity was 65.63% (21/32), the specificity was 85.23% (75/88), and the area under the curve of the model was 0.837 (95% confidence interval 0.801 to 0.873).
Conclusion: the incidence of infection after laparotomy for biliary diseases is still high, and it is related to many factors. This study suggests that obesity, intraoperative blood transfusion and anesthesia classification are 3 independent factors affecting the incidence of infection after the operation of open biliary tract surgery, which should be paid attention to by clinicians.

【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R657.4

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