腹腔镜胆囊切除术患者的临床路径变异分析

发布时间：2018-09-13 16:40

【摘要】：[目的]通过回顾性研究腹腔镜胆囊切除术患者行临床路径情况,分析临床路径变异原因,减少临床路径中途退径病例,完善腹腔镜胆囊切除术的临床路径。[方法]回顾分析了 2015年1月-2016年12月在昆明医科大学附属甘美医院行腹腔镜胆囊切除术的临床路径患者的临床资料。纳入标准:行LC的所有临床路径病例,排除标准:未行临床路径的LC病例。分为临床路径完成组(A组)和临床路径中途退径组(B组),其中B组分为行手术治疗组(B1组)和未手术治疗组(B2组)。分析A组和B组的年龄、性别、术前及术后的血常规、肝肾功能、超敏C反应蛋白、术前及术后腹部超声检查、总住院时间、住院费用。还有B组中途退径的原因分析,总结并改善临床路径的完成率。统计学分析采用SPSS20.0软件,计量资料的差异采用非参数Mann-Whitney检验;计数资料采用x2检验(或Fisher精确检验)进行差异性分析。P0.05认为结果具有统计学意义。[结果]1.符合纳入标准的病例共231例,其中顺利完成临床路径的有182例(A组),占78.79%,年龄18-82岁,平均年龄约46.54±0.90岁,男性64例,女性118例,男女性别比为1:1.84。未完成临床路径的病例有49例(B组),占21.21%,年龄24-85岁,平均年龄约50.73±1.99岁,男性28例,女性21例,男女性别比为1.33:1。2.A组住院天数要明显少于B组,5.79±0.15天VS.11.53±0.73天,差异有统计学意义(P0.0001);且A组住院费用明显低于B组,7931±159.9元VS.12120±705.7元,差异有统计学意义(P0.0001)。3.A组手术率100%,治愈率100%,B组手术率53.06%,手术治愈率100%。所有手术后无并发症,如胆漏、出血、感染等。临床路径退出组(B组)术前ALT、AST、术后CRP高于临床路径完成组,且超出正常范围(96.24IU/L vs.44.97IU/L,P=0.0054;44.24IU/L vs.29.52IU/L;P=0.023;57.54mg/Lvs.34.06mg/L,P=0.010),差异有统计学意义。其他临床指标如TBIL、ALB等两组间未见明显差异。4.本研究中临床路径完成组(A组)共182人,退出组(B组)49人,平均年龄分别为:46.54岁±0.90 VS.50.73岁±1.99,P0.05,其中老年患者(65岁)比例分别为:4.40%(8/182)VS.12.24%(6/49),B组老年患者比例要高于A组,但差异无统计学意义(P=0.051);临床路径退出组中男性患者比例要明显高于临床路径完成组:35.2%(64/182)VS.57.1%(28/49),差异有统计学意义(P=0.005)。临床路径退出组(B组),有26例病例(B1组)行手术治疗,23病例(B2组)未行手术,手术率为53.06%。B1组分为4类,第一类(B1a)完成LC,术后出现与手术无关的症状中转退出5例,第二类(B1b)直接行开腹胆囊切除术和/或胆道探查术6例,第三类(B1c)先行LC后中转开腹8例,第四类(B1d)术前行相关检查或女性月经来潮延期LC手术7例。B2组也分为四类,第一类(B2a)因手术风险大,未行手术3例,第二类(B2b)因无手术指征未行手术3例,第三类(B2c)拒绝手术治疗8例,第四类(B2d)术前发现其他疾病完善检查未予手术9例。可控变异病例有21例,包括部分B1b组、B1d组、B2a组和B2c组,占42.85%,非可控变异病例有28例,是LC临床路径变异的主要原因。[结论]1.腹腔镜胆囊切除术行临床路径能缩短住院时间和减少住院费用。2.男性患者发生临床路径变异的可能性更高。3.非可控因素是腹腔镜胆囊切除术临床路径变异的主要原因。4.通过优化术前评估和管理,可进一步降低可控因素导致的腹腔镜胆囊切除术临床路径变异。
[Abstract]:[Objective] To retrospectively study the clinical pathway of laparoscopic cholecystectomy (LC) patients, analyze the causes of variation of clinical pathway, reduce the cases of retrogression of clinical pathway, and improve the clinical pathway of LC. [Methods] Laparoscopic cholecystectomy was performed in Ganmei Hospital Affiliated to Kunming Medical University from January 2015 to December 2016. Inclusion criteria: All clinical pathway cases of LC, exclusion criteria: LC cases without clinical pathway were divided into clinical pathway completion group (group A) and clinical pathway midway retreat group (group B), of which group B was divided into surgical treatment group (group B1) and non-surgical treatment group (group B2). Age, sex, preoperative and postoperative blood routine, liver and kidney function, high-sensitivity C-reactive protein, preoperative and postoperative abdominal ultrasonography, total length of hospital stay, hospitalization costs. There were also reasons for group B midway retreat to summarize and improve the completion rate of clinical pathway. Statistical analysis using SPSS20.0 software, non-parametric Mann-Whitne measurement data differences. P 0.05 showed that the results were statistically significant. [Results] 1. A total of 231 cases met the inclusion criteria, of which 182 cases (group A) successfully completed the clinical pathway, accounting for 78.79%, 18-82 years old, with an average age of 46.54 (+ 0.90), 64 males, 118 females, and 118 males. The female sex ratio was 1:1.84. There were 49 cases (group B), accounting for 21.21%, aged 24-85 years, with an average age of 50.73 + 1.99 years. There were 28 males and 21 females. The male-female sex ratio was 1.33:1.2. The operation rate was 100%, the cure rate was 100%, the operation rate was 53.06% and the cure rate was 100%. There were no postoperative complications, such as bile leakage, bleeding, infection and so on. ALT, AST and CRP in group B were higher than those in group B before operation and after operation. Normal range (96.24 IU/L vs. 44.97 IU/L, P = 0.0054; 44.24 IU/L vs. 29.52 IU/L; P = 0.023; 57.54 mg/L vs. 34.06 mg/L, P = 0.010), the difference was statistically significant. Other clinical indicators such as TBIL, ALB were not significantly different between the two groups. S.50.73 years old (+ 1.99), P 0.05, in which the proportion of elderly patients (65 years old) were 4.40% (8/182) VS.12.24% (6/49), the proportion of elderly patients in group B was higher than that in group A, but the difference was not statistically significant (P = 0.051); the proportion of male patients in the withdrawal group of clinical pathway was significantly higher than that in the completion of clinical pathway group (35.2% (64/182) VS.57.1% (28/49), the difference was statistically significant (P In group B, 26 cases (group B1) were operated on, 23 cases (group B2) were not operated on, and the operation rate was 53.06%. Group B1 was classified into 4 groups, the first group (B1a) completed LC, 5 cases were withdrawn from the operation, the second group (B1b) underwent open cholecystectomy and / or bile duct exploration, the third group (B1c) underwent open cholecystectomy directly. Eight patients underwent LC before laparotomy, seven patients underwent pre-operative examination or delayed menstrual surgery in the fourth group (B1d). Group B2 was also divided into four groups. The first group (B2a) did not undergo surgery because of the high risk of surgery, the second group (B2b) did not undergo surgery because of no surgical indications, the third group (B2c) refused surgery in 8 cases, and the fourth group (B2d) found other diseases before surgery. There were 21 controllable variant cases, including some B1b group, B1d group, B2a group and B2c group, accounting for 42.85%. 28 uncontrollable variant cases were the main reason for the variation of LC clinical pathway. [Conclusion] 1. Laparoscopic cholecystectomy with clinical pathway can shorten the length of hospital stay and reduce the cost of hospitalization. 2. Male patients with clinical pathway. Uncontrollable factors are the main reason for the variation of clinical pathways in laparoscopic cholecystectomy. 4. By optimizing preoperative evaluation and management, the variation of clinical pathways in laparoscopic cholecystectomy caused by controllable factors can be further reduced.
【学位授予单位】：昆明医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R657.4

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