腹腔镜直肠切除术中转开腹评分系统建立及临床应用

发布时间：2018-07-08 20:31

本文选题：腹腔镜直肠切除术 + 中转开腹　；参考：《山东大学》2016年博士论文

【摘要】：目的：回顾性研究602例腹腔镜直肠切除术临床数据,确定腹腔镜直肠切除术中转开腹术前风险因素,建立腹腔镜直肠切除术中转开腹评分系统。最后对腹腔镜直肠切除术中转开腹评分系统的效能、稳定性、发展性进行评价。方法：首先汇总国内外腹腔镜结、直肠手术临床资料6248例,分析导致腹腔镜结、直肠切除术中转开腹原因。综合国内外关于腹腔镜直肠切除术中转开腹的相关文献以及上述中转开腹原因确定可能的腹腔镜直肠切除术中转开腹风险因素。然后,采用SPSS19.0数据软件,对青岛大学医学院附属医院2001年1月-2013年12月,完成的602例腹腔镜直肠切除术临床资料,进行单因素分析(卡方检验)及Logistic多因素回归分析,最终确定导致腹腔镜直肠切除术中转开腹的术前风险因素为：手术者手术经验(手术例数≤25例)、有腹部手术史、男性、肥胖(BMI≥28)、肿瘤直径≥6cm、肿瘤浸润或(和)转移。对数据进行logistic多因素分析,并建立腹腔镜直肠中转开腹的数学函数模型。根据腹腔镜直肠切除术中转开腹数学函数模型中各个自变量系数(即优势比0R值)的意义以及Logistics多因素分析特点可建立腹腔镜直肠切除术中转开腹评分系统。最后对建立的评分系统的效能(灵敏度及特异度检验)、临床使用效果、评分系统的稳定性及发展性进行综合评价。结果：首先汇总分析了国内外6248例腹腔镜结、直肠手术临床资料,中转开腹551例,中转率为8.82%。具体中转开腹原因如下：粘连100例(18.15%),周围浸润92例(16.70%),肿瘤巨大90例(16.33%),出血51例(9.26%),暴露困难43例(7.80%),转移30例(5.44%),肥胖24例(4.36%),器械意外22例(3.99%),肠道损伤14例(2.54%),骨盆狭窄13例(2.36%),膀胱输尿管损伤12例(2.18%),手术者经验10例(1.81%),周围炎症10例(1.81%),吻合问题9例(1.63%),未发现肿瘤8例(1.45%),肠梗阻6例(1.09%),无法耐受麻醉5例(0.91%),内脏损伤4例(0.73%),结肠扩张3例(0.54%)。综合国内外关于腹腔镜直肠切除术中转开腹的相关文献及上述中转开腹原因,首先确定可能导致腹腔镜直肠切除术中转开腹的术前风险因素包括男性、高龄(年龄≥65岁)、肥胖(BMI≥28)、有腹部手术史、肿瘤直径≥6cm、肿瘤有周围浸润或(和)转移、手术者经验(手术例数≤25例)、手术方式、合并高血压、合并冠心病、合并糖尿病、麻醉ASA评分≥III级等。对2001年1月一2013年12月青岛大学医学院附属医院完成的602例腹腔镜直肠切除术临床资料进行回顾性分析,其中男性320例,女性282例,Dixon术395例,Miles术207例,平均年龄56.33岁,中转开腹84例,中转开腹率13.95%。数据采用SPSS19.0进行统计分析,首先进行单因素分析(卡方检验)显示手术者经验(手术例数≤25例)、有腹部手术史、男性、肥胖(BM1≥28)、肿瘤直径≥6cm、肿瘤浸润或(和)转移为中转开腹术前风险因素。由于导致腹腔镜直肠切除术中转是多种因素共同影响的结果,所以还需要对数据进行Logistic多因素分析,结果显示导致腹腔镜直肠切除术中转开腹的风险因素包括手术者经验(手术例数≤25例)、有腹部手术史、男性、肥胖(BM1≥28)、肿瘤直径≥6cm、肿瘤浸润或(和)转移。通过对数据进行1ogistic分析,建立腹腔镜直肠中转开腹可能性的数学函数模型如下：根据Logistic多元回归的特点及自变量系数即优势比(0R值)的特点可对各腹腔镜直肠切除术术前中转开腹风险因素进行赋值：手术者经验(手术例数≤25例)为4分,有腹部手术史为5分,男性为6分,肥胖(BMI ≥28)为10分,肿瘤直径≥6cm为15分,肿瘤转移或(和)浸润为21分。根据各风险因素赋值计算出602例患者每位患者的实际风险赋值总得分,再根据患者赋值总得分及是否中转开腹,画ROC曲线计算出不同得分组的特异度和灵敏度。ROC曲线下面积为0.876,相应的标准误为0.021。得分为14.5时,其ROC曲线的敏感度为0.786和特异度为0.861为最佳。当得分低于14.5分时其中转开腹率为3.88%(18/464),当得分高于14.5分时中转开腹率为47.83%(66/138),有显著统计学差异(P0.001)。最后建立腹腔镜直肠切除术中转开腹术前预测评分系统,所建立的中转开腹术前评分包含手术者经验(手术例数≤25例)、有腹部手术史、男性、肥胖(BM1≥28)、肿瘤直径≥6cm、肿瘤浸润或(和)转移等6个变量,其赋值分别为4分、5分、6分、10分、15分、21分。如总得分高于14.5分,不建议患者实行腹腔镜直肠手术,如总得分低于14.5分,推荐患者实行腹腔镜直肠手术。对滕州市中心人民医院实施的100例腹腔镜直肠切除术患者,术前计算评分,检测评分系统的临床使用效果。100例患者均实施腹腔镜直肠切除手术,其中中转14例,中转率为14%。得分低于14.5分患者88人,中转4人,中转率4.55%,得分高于14.5分患者12人,中转10人,中转率为83.33%,两组中转开腹率有统计学差异(P0.05)。结论：1、手术经验(手术例数≤25例)、腹部手术史、男性、肥胖(BMI≥28)、肿瘤直径≥6cm、肿瘤浸润或(和)转移是腹腔镜直肠切除术中转开腹的术前风险因素。2、临床上应用本文建立的腹腔镜直肠切除中转开腹评分(LRTO-2014)可以有效地降低中转开腹机率,避免不必要的中转开腹。3、随着新技术的应用、新器械的发明、新理念的发展,腹部手术史、肿瘤直径≥6cm、肿瘤浸润或(和)转移等术前风险因素对中转开腹的影响逐渐降低,而当手术者在经历了腹腔镜直肠切除的学习曲线并获得了相对丰富的手术经验后,其手术经验对中转开腹的影响保持相对稳定。
[Abstract]:Objective: To review the clinical data of 602 cases of laparoscopic rectal excision, to determine the risk factors of laparotomy before laparoscopy and to establish a laparotomy scoring system for laparoscopic rectal excision. Finally, the effectiveness, stability and development of the laparotomy scoring system were evaluated. A total of 6248 cases of laparoscopic and rectal surgery were collected, and the causes of laparotomy were analyzed. The relevant literature on the conversion of laparotomy at home and abroad and the possible causes of laparotomy risk factors were determined. Then, S A single factor analysis (chi square test) and Logistic multiple regression analysis were performed on 602 cases of laparoscopic rectal excision in the Affiliated Hospital of Qiingdao University Medical School Affiliated Hospital January 2001 -2013 December. The risk factors leading to the operation of laparotomy were determined by surgical operation. Experience (operation number or less than 25 cases), with a history of abdominal surgery, male, obese (BMI > 28), tumor diameter more than 6cm, tumor infiltration or (and) metastasis. The data were analyzed by logistic multiple factors and the mathematical function model of laparotomy for laparotomy was established. According to the coefficient of variables in the mathematical function model transferred to the laparotomy laparotomy, the coefficient of variable coefficients The significance of the advantage than the 0R value and the characteristics of Logistics multifactor analysis can be used to establish a laparotomy scoring system for laparoscopic rectal excision. Finally, a comprehensive evaluation of the effectiveness of the established scoring system (sensitivity and specificity test), clinical use effect, the stability and development of the scoring system. Results: first, a summary and analysis of the country is made. 6248 cases of internal and external laparoscopic surgery, rectal surgery clinical data, 551 cases of conversion to open abdomen, the transfer rate of 8.82%. specific transfer to open the abdomen as follows: adhesion 100 cases (18.15%), peripheral infiltration 92 cases (16.70%), tumor 90 cases (16.33%), hemorrhage 51 cases (9.26%), 43 exposure (7.80%), metastasis 30 cases (5.44%), obesity cases ) 14 cases of intestinal injury (2.54%), 13 cases of pelvic stenosis (2.36%), 12 cases of bladder ureter injury (2.18%), 10 cases (1.81%), 10 cases of peripheral inflammation (1.81%), 9 cases of anastomosis (1.63%), no tumor 8 cases (1.81%), intestinal obstruction cases, visceral injury cases, colon dilatation cases. The internal and external literature related to laparotomy in laparoscopic rectal resection and the reasons for the transfer of laparotomy first determine that the risk factors that may lead to laparotomy may include male, elderly (age 65), obesity (BMI > 28), abdominal hand history, tumor diameter more than 6cm, tumor surrounding infiltration or (and) metastasis, The operative experience (the number of cases or less than 25 cases), the mode of operation, the combination of hypertension, the combination of coronary heart disease, the combined diabetes, the ASA score of III and so on. The clinical data of 602 cases of laparoscopic rectal excision, which were completed in the Affiliated Hospital of Qiingdao University Medical College in December 2013 January 2001, were retrospectively analyzed, of which 320 cases were male, 282 cases of women, Dixon 395 cases, 207 cases of Miles operation, average age 56.33 years, 84 cases of open laparotomy, and conversion of open rate 13.95%. data using SPSS19.0 statistical analysis. First of all, single factor analysis (chi square test) showed the operation experience (the number of surgical cases less than 25 cases), the history of abdominal surgery, male sex, obesity (BM1 > 28), tumor diameter more than 6cm, tumor infiltration or metastasis Logistic multifactor analysis of the data is needed because of the common effects of a variety of factors that lead to laparoscopic recorectomy. The results show that the risk factors that lead to laparotomy in the laparoscopic rectectomy include the experience of the surgeon (the number of surgical cases is less than 25 cases), and the history of abdominal surgery, Men, obesity (BM1 > 28), tumor diameter more than 6cm, tumor infiltration or (and) metastasis. By 1ogistic analysis of the data, a mathematical function model for the possibility of laparotomy in the laparoscopic rectum is established as follows: according to the characteristics of multiple regression of Logistic and the characteristics of the coefficient of self variable (0R), it can be used before the laparoscopic resection of the rectum. Risk factors for transabdominal surgery were assigned: the operative experience (operative number or less than 25 cases) was 4, the history of abdominal surgery was 5, the male was 6, the obesity (BMI > 28) was 10, the tumor diameter was more than 6cm 15, the tumor metastasis or (and) infiltration was 21. According to the risk factors, the actual risk assignment of each patient was calculated and the total value of each patient was calculated. According to the total score of the patient's assignment and the conversion of the laparotomy, the ROC curve was drawn to calculate the area of the specificity and sensitivity of the different group and the sensitivity.ROC curve of 0.876. When the corresponding standard was 14.5 for 0.021., the sensitivity of the ROC curve was 0.786 and the specificity was 0.861. When the score was below 14.5 points, the open abdominal rate was 3.8. 8% (18/464), when the transfer rate was 47.83% (66/138) when the score was higher than 14.5 (P0.001), there was a significant statistical difference (P0.001). Finally, the pre operation prediction scoring system for laparotomy was established, and the pre operation score of the laparotomy included the operative experience (the number of surgical cases in 25 cases), the history of abdominal surgery, men, and obesity (BM1 > 28). 6 variables, such as tumor diameter more than 6cm, tumor infiltration or (and) metastasis, were assigned to 4 points, 5 points, 6 points, 10 points, 15 points, 21 points. If the total score was higher than 14.5, the patients were not recommended for laparoscopic rectal surgery, such as the total score of less than 14.5, and 100 cases of laparoscopic surgery for Tengzhou Central People's Hospital were recommended. Patients with rectal excision, preoperative calculation score and clinical use effect of scoring system were performed by laparoscopic rectal excision, of which 14 cases were transferred, 14 cases were transferred, the transfer rate was lower than 14.5 in 88, 4, 4.55%, 12, 10, 83.33%, and two groups. The abdominal rate was statistically different (P0.05). Conclusions: 1, surgical experience (number of cases or less than 25 cases), history of abdominal surgery, male, obesity (BMI > 28), tumor diameter more than 6cm, tumor infiltration or (and) metastasis are the risk factors for the preoperative transabdominal surgery in laparoscopic rectal excision (.2), clinical application of laparoscopic rectal excision and laparotomy score (LRT O-2014) can effectively reduce the rate of transabdominal surgery and avoid unnecessary transabdominal.3. With the application of new technology, the invention of the new apparatus, the development of the new concept, the history of abdominal surgery, the diameter of the tumor more than 6cm, the preoperative risk factors of tumor infiltration or (and) metastasis have gradually reduced the effect of the laparotomy, while the surgeon experienced the laparoscopy. After the rectum resection learning curve and gained relatively rich surgical experience, the influence of surgical experience on conversion to laparotomy remained relatively stable.
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R657.1

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