基于升阶梯治疗原则分析重症急性胰腺炎患者行开腹坏死物清除术的危险因素

段玉灵; 冯赞杰; 范国鑫; 王磊; 刘康伟; 彭慈军

doi:10.3969/j.issn.1001-5256.2021.04.033

基于升阶梯治疗原则分析重症急性胰腺炎患者行开腹坏死物清除术的危险因素

DOI: 10.3969/j.issn.1001-5256.2021.04.033

1.
遵义医科大学附属医院肝胆外科，贵州遵义 563000
2.
遵义医科大学生物化学与分子生物学教研室，贵州遵义 563000

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。

作者贡献声明：段玉灵、彭慈军负责课题设计，资料分析，撰写论文；刘康伟、王磊参与收集数据，修改论文；冯赞杰、范国鑫负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

作者简介:
段玉灵(1994—)，女，主要从事胆道恶性梗阻疾病的外科手术治疗研究

通信作者:
彭慈军，doctorpengcijun@163.com

中图分类号: R576
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出版历程
- 收稿日期: 2020-09-12
- 录用日期: 2020-12-08
- 出版日期: 2021-04-20

Risk factors for open pancreatic necrosectomy in patients with severe acute pancreatitis: An analysis based on the surgical step-up approach

1.
Department of Hepatobiliary Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou 563000, China
2.
Department of Biochemistry and Molecular Biology, Zunyi Medical University, Zunyi, Guizhou 563000, China

摘要

摘要: 目的开腹坏死物清除术(OPN)是单纯经皮穿刺置管引流(PCD)失败后治疗重症急性胰腺炎(SAP)的有效方式，探讨导致患者需要继续行OPN的危险因素。方法选取2010年1月1日—2018年6月30日于遵义医科大学附属医院行基于“step-up”原则外科干预方式的SAP患者156例，根据后期是否行OPN分为PCD组(n=126)和PCD+OPN组(n=30)。收集患者年龄、性别、病因、入院血钙、入院白细胞、CTSI评分>7分、APACHE-Ⅱ评分、Ronson评分、是否合并胰周液体积聚、是否合并感染、是否合并多器官功能衰竭(MOF)、PCD干预时间是否超过入院后1周等临床资料。计量资料两组间比较采用t检验；计数资料两组间比较采用χ²检验。采用多因素logistic回归分析确定后期行OPN的独立预测因子。结果 SAP患者后期需要行OPN的概率为19.2%。PCD组与PCD+OPN组相比，入院时合并MOF所占比例更少[34(27.0%) vs 21(70.0%)，χ²=19.642, P < 0.01]；PCD干预时间 < 1周所占比例更高[78(61.9%) vs 6(20.0%)，χ²=17.121, P < 0.01]。入院时合并MOF、入院后首次PCD干预时间>1周、入院时合并感染[OR(95%CI)分别为5.343(1.832~15.583)、5.518(1.742~17.477)、5.016(1.322~19.378)，P值均 < 0.05]是SAP患者后期需要行OPN的独立危险因素。结论 SAP入院时合并MOF、入院后初次PCD干预时间>1周和入院时合并感染是基于“step-up”原则下的SAP患者早期行PCD治疗后需要继续行OPN的独立危险因素，在临床实践中及时识别相关危险因素有利于把握OPN的时机以改善SAP患者的临床预后。
- 胰腺炎 /
- 危险因素 /
- 升阶梯治疗原则
Abstract: Objective To investigate the risk factors for open pancreatic necrosectomy (OPN), an effective treatment method for severe acute pancreatitis (SAP) after the failure of percutaneous catheter drainage (PCD), in patients with SAP. Methods A retrospective analysis was performed for 156 patients with SAP who underwent surgical intervention based on the step-up approach in The Affiliated Hospital of Zunyi Medical University from January 1, 2010 to June 30, 2018, and according to whether OPN was performed, the patients were divided into PCD group with 126 patients and PCD+OPN group with 30 patients. Related clinical data were collected, including age, sex, etiology, blood calcium on admission, white blood cell count on admission, whether CTSI score was >7, APACHE-Ⅱ score, Ranson score, presence or absence of peripancreatic fluid accumulation, presence or absence of infection, presence or absence of multiple organ failure (MOF), and whether PCD was performed at more than 1 week after admission. The t-test was used for comparison of continuous data between groups, and the chi-square test was used for comparison of categorical data between groups; a multivariate logistic regression analysis was used to determine the independent predictive factors for OPN. Results The probability of OPN was 19.2% for SAP patients in the later stage. Compared with the PCD+OPN group, the PCD group had a significantly lower proportion of patients with MOF on admission [27.0% (34/126) vs 70.0% (21/30), χ²=19.642, P < 0.01] and a significantly higher proportion of patients undergoing PCD at less than 1 week after admission [61.9% (78/126) vs 20.0% (6/30), χ²=17.121, P < 0.01]. MOF on admission (odds ratio [OR]=5.343, 95% confidence interval [CI]: 1.832-15.583, P < 0.05), initial PCD performed at more than 1 week after admission (OR= 5.518, 95% CI: 1.742-17.477, P < 0.05), and infection on admission (OR=5.016, 95% CI: 1.322-19.378, P < 0.05) were independent risk factors for subsequent OPN in SAP patients. Conclusion SAP with MOF on admission, initial PCD performed at more than 1 week after admission, and SAP with infection on admission are independent risk factors for subsequent OPN in SAP patients undergoing PCD in the early stage based on the step-up approach. Timely identification of related risk factors helps to grasp the timing of OPN in clinical practice and improve the clinical prognosis of SAP patients.
- Pancreatitis /
- Risk Factors /
- Step-up Surgery

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图 1 临床资料处理流程图

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表 1 SAP行OPN单因素分析

因素	单纯PCD组(n=126)	PCD+OPN组(n=30)	统计值	P值
年龄(岁)	47±14	45±18	t=-0.074	0.941
性别[例(%)]
男	75(59.5)	15(50.0)	χ²=0.900	0.343
女	51(40.5)	15(50.0)
病因[例(%)]			χ²=0.535	0.911
胆源性	32(25.4)	6(20.0)
高脂性	48(38.1)	12(40.0)
酒精性	14(11.1)	3(10.0)
其他	32(25.4)	9(30.0)
入院合并MOF[例(%)]	34(27.0)	21(70.0)	χ²=19.642	0.001
CTSI评分≥7分[例(%)]	47(37.3)	17(56.7)	χ²=3.756	0.053
入院血钙(mmol/L)	1.93±0.33	1.82±0.26	t=-1.930	0.054
入院白细胞(×10⁹/L)	13.06±6.42	13.19±5.48	t=-0.418	0.674
APACHE-Ⅱ评分(分)	10.85±1.92	11.00±1.46	t=-0.677	0.498
Ronson评分(分)	4.18±0.85	4.10±0.80	t=-0.299	0.765
胰周液体积聚[例(%)]	86(68.3)	24(80.0)	χ²=1.608	0.205
合并感染[例(%)]	16(12.7)	7(23.3)	χ²=2.180	0.140
入院1周内行PCD[例(%)]	78(61.9)	6(20.0)	χ²=17.121	0.001

下载: 导出CSV

表 2 SAP行OPN多因素logistic回归分析

变量	B值	SE	Wald	df	P值	OR	95%CI
外科干预前合并MOF	1.676	0.546	9.418	1	0.002	5.343	1.832~15.583
入院超过1周行PCD	1.708	0.588	8.433	1	0.004	5.518	1.742~17.477
合并感染	1.622	0.685	5.603	1	0.018	5.061	1.322~19.378

下载: 导出CSV

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