本文選題：開腹膽道手術 + 術后感染�。� 參考：《浙江大學》2015年博士論文

【摘要】：背景和目的：膽道手術是外科領域中重要的手術之一,由于其解剖復雜精細,手術難度較高。盡管隨著腹腔鏡手術的興起和發(fā)展,使諸如膽囊切除之類的手術可以在腹腔鏡下進行,術后感染相關并發(fā)癥也隨之降低,但大部分膽系手術仍然在開腹下進行。開腹手術術后感染是最常見的膽道手術術后并發(fā)癥,且發(fā)生率較高,延長住院時間,增加醫(yī)療費用,嚴重影響病患預后。為此,減少膽道手術術后感染的發(fā)生具有重要的臨床意義。然而,目前尚無簡單有效的方案來降低膽道術后感染的發(fā)生率,但可以通過分析潛在影響因子找到術后感染的危險因素。與國外研究相比,國內分析開腹膽道手術術后感染危險因素的文獻較少,且多以單因素分析為主。與單因素分析相比,多因素分析考慮了因素之間的相互作用和多指標之間的內在聯(lián)系,結論更為可靠。本研究旨在通過對臨床大數據的回顧性分析,以Logistic回歸法篩選開放膽道手術術后感染的相關因素,探討影響膽系手術術后感染相關性并發(fā)癥的主要危險因子,建立術后感染的風險預測模型,幫助早期發(fā)現(xiàn)高風險患者,用于指導臨床工作,盡可能減少術后感染相關并發(fā)癥的發(fā)生。 方法：本研究為回顧性研究,采用病例對照設計由果及因的研究方法,對浙江大學醫(yī)學院附屬第二醫(yī)院肝膽胰外科(外五病區(qū))2012年1月至2014年10月期間所有行開放膽道手術的患者進行回顧性分析,查閱患者的臨床病歷資料,收集患者的一般情況、既往病史、圍手術期相關臨床資料以及術后感染發(fā)生情況及種類,結合權威外科學教材《克氏外科學》第20版及相關文獻,將可能影響膽道手術術后感染發(fā)生的31相關項臨床指標納入研究。應用SPSS13.0軟件,先對這些臨床參數進行單因素logistic分析,以p=0.05為檢驗水準,將有統(tǒng)計學意義(p0.05)的因素進行多因素Logistic逐步回歸分析。篩選影響膽道疾病術后感染的危險因素,建立logistic回歸方程。計算各因素的相對危險度,并檢測該模型評價新入院病人樣本術后感染相關并發(fā)癥的靈敏度、特異度和準確度。術后感染的診斷標準參照原衛(wèi)生部2001年頒發(fā)的《醫(yī)院感染診斷標準(試行)》,中南大學湘雅醫(yī)院等發(fā)布的《醫(yī)院感染監(jiān)測規(guī)范》及膽道感染的行業(yè)標準,并結合臨床實際情況決定。 結果：研究共納入符合要求的病例576例,術后發(fā)生感染162例,術后總感染發(fā)生率為28.12%。其中腹腔感染和膽道感染仍占較高的比例,分別為11.50%和10.80%。單因素Logistic回歸分析發(fā)現(xiàn)影響膽系手術術后感染發(fā)生率顯著相關的因素包括性別、肥胖、既往腹部手術次數、術前白蛋白、PT、發(fā)熱、白細胞異常、CRP異常、術前合并感染、術前應用抗生素、ASA分級、手術時間、術中失血量、術中輸血、術后氣管插管、術后入ICU和術后發(fā)熱；對有統(tǒng)計學意義的17項指標做進一步的多因素Logistic回歸分析后得出肥胖、術中輸血和麻醉分級3個相關因素進入Logistic回歸方程,作用強度依次為術中輸血(OR=5.342,P=0.000)、肥胖(OR=3.291,P=0.000)和麻醉分級(OR=1.508,P=0.013)。以概率值0.5作為交界點,將后續(xù)120例新入院病人數據代入方程,得出的預測值與實際數據比較,結果顯示,此概率模型判斷膽系疾病開腹手術術后感染并發(fā)癥的準確度為80%(96/120)、靈敏度為65.63%(21/32)、特異度為85.23%(75/88),模型的曲線下面積為0.837(95%置信區(qū)間為0.801～0.873)。 結論：膽系疾病開腹手術術后感染發(fā)生率依然較高,與眾多因素相關,本研究認為肥胖、術中輸血和麻醉分級3個相關因素是影響開腹膽道手術術后感染發(fā)生的獨立危險因素,應引起臨床醫(yī)生的重視。
[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.

【學位授予單位】：浙江大學
【學位級別】：博士
【學位授予年份】：2015
【分類號】：R657.4

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