腹腔鏡膽囊切除術患者的臨床路徑變異分析
發(fā)布時間：2018-09-13 16:40
【摘要】：[目的]通過回顧性研究腹腔鏡膽囊切除術患者行臨床路徑情況,分析臨床路徑變異原因,減少臨床路徑中途退徑病例,完善腹腔鏡膽囊切除術的臨床路徑。[方法]回顧分析了 2015年1月-2016年12月在昆明醫(yī)科大學附屬甘美醫(yī)院行腹腔鏡膽囊切除術的臨床路徑患者的臨床資料。納入標準:行LC的所有臨床路徑病例,排除標準:未行臨床路徑的LC病例。分為臨床路徑完成組(A組)和臨床路徑中途退徑組(B組),其中B組分為行手術治療組(B1組)和未手術治療組(B2組)。分析A組和B組的年齡、性別、術前及術后的血常規(guī)、肝腎功能、超敏C反應蛋白、術前及術后腹部超聲檢查、總住院時間、住院費用。還有B組中途退徑的原因分析,總結并改善臨床路徑的完成率。統(tǒng)計學分析采用SPSS20.0軟件,計量資料的差異采用非參數(shù)Mann-Whitney檢驗;計數(shù)資料采用x2檢驗(或Fisher精確檢驗)進行差異性分析。P0.05認為結果具有統(tǒng)計學意義。[結果]1.符合納入標準的病例共231例,其中順利完成臨床路徑的有182例(A組),占78.79%,年齡18-82歲,平均年齡約46.54±0.90歲,男性64例,女性118例,男女性別比為1:1.84。未完成臨床路徑的病例有49例(B組),占21.21%,年齡24-85歲,平均年齡約50.73±1.99歲,男性28例,女性21例,男女性別比為1.33:1。2.A組住院天數(shù)要明顯少于B組,5.79±0.15天VS.11.53±0.73天,差異有統(tǒng)計學意義(P0.0001);且A組住院費用明顯低于B組,7931±159.9元VS.12120±705.7元,差異有統(tǒng)計學意義(P0.0001)。3.A組手術率100%,治愈率100%,B組手術率53.06%,手術治愈率100%。所有手術后無并發(fā)癥,如膽漏、出血、感染等。臨床路徑退出組(B組)術前ALT、AST、術后CRP高于臨床路徑完成組,且超出正常范圍(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),差異有統(tǒng)計學意義。其他臨床指標如TBIL、ALB等兩組間未見明顯差異。4.本研究中臨床路徑完成組(A組)共182人,退出組(B組)49人,平均年齡分別為:46.54歲±0.90 VS.50.73歲±1.99,P0.05,其中老年患者(65歲)比例分別為:4.40%(8/182)VS.12.24%(6/49),B組老年患者比例要高于A組,但差異無統(tǒng)計學意義(P=0.051);臨床路徑退出組中男性患者比例要明顯高于臨床路徑完成組:35.2%(64/182)VS.57.1%(28/49),差異有統(tǒng)計學意義(P=0.005)。臨床路徑退出組(B組),有26例病例(B1組)行手術治療,23病例(B2組)未行手術,手術率為53.06%。B1組分為4類,第一類(B1a)完成LC,術后出現(xiàn)與手術無關的癥狀中轉退出5例,第二類(B1b)直接行開腹膽囊切除術和/或膽道探查術6例,第三類(B1c)先行LC后中轉開腹8例,第四類(B1d)術前行相關檢查或女性月經來潮延期LC手術7例。B2組也分為四類,第一類(B2a)因手術風險大,未行手術3例,第二類(B2b)因無手術指征未行手術3例,第三類(B2c)拒絕手術治療8例,第四類(B2d)術前發(fā)現(xiàn)其他疾病完善檢查未予手術9例�？煽刈儺惒±�21例,包括部分B1b組、B1d組、B2a組和B2c組,占42.85%,非可控變異病例有28例,是LC臨床路徑變異的主要原因。[結論]1.腹腔鏡膽囊切除術行臨床路徑能縮短住院時間和減少住院費用。2.男性患者發(fā)生臨床路徑變異的可能性更高。3.非可控因素是腹腔鏡膽囊切除術臨床路徑變異的主要原因。4.通過優(yōu)化術前評估和管理,可進一步降低可控因素導致的腹腔鏡膽囊切除術臨床路徑變異。
[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.
【學位授予單位】：昆明醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R657.4
本文編號：2241738
[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.
【學位授予單位】：昆明醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R657.4
【參考文獻】
相關期刊論文 前10條
1 徐曉平;許健波;胡俊青;;肝功能指標對膽囊結石繼發(fā)無癥狀膽總管結石的預判價值[J];世界華人消化雜志;2016年31期
2 楊海軍;趙海濱;杜峰華;高迎軍;劉兵;劉健康;;肝功能檢測在膽囊結石合并無癥狀膽總管結石診斷中的意義[J];中國現(xiàn)代普通外科進展;2016年09期
3 許柳琴;陳瑜;郭秋蘭;羅漢媚;鐘建美;;快速康復外科護理與傳統(tǒng)護理在腹腔鏡膽囊切除術圍手術期的應用研究[J];護士進修雜志;2016年11期
4 劉玲;戴燕;;護理臨床路徑改進在日間腹腔鏡膽囊切除術中的應用[J];華西醫(yī)學;2016年04期
5 俞德梁;寧鵬濤;王娟;劉小南;;關于日間手術定義與首批推薦適宜手術的思考[J];醫(yī)學與哲學(B);2015年12期
6 周濤;;16排CT和1.5T磁共振胰膽管成像用于臨床分組診斷膽囊結石合并肝外膽總管結石的隨機對照分析[J];中國CT和MRI雜志;2015年10期
7 李志超;王煜;王小成;劉洋;馬洪升;;基于快速康復外科理念的疼痛管理模式在日間腹腔鏡膽囊切除術的應用[J];華西醫(yī)學;2015年05期
8 趙麗敏;;7685例職工健康體檢腹部超聲結果分析[J];河南醫(yī)學研究;2015年02期
9 蔣龔彥;朱建平;林聰平;吳仲秋;王露;;膽囊結石患者超聲診斷結果漏診及誤診分析[J];現(xiàn)代生物醫(yī)學進展;2014年36期
10 楊真真;劉大毛;肖衛(wèi)東;李勇;;膽囊結石患病率的性別差異分析[J];現(xiàn)代中西醫(yī)結合雜志;2014年18期
，本文編號：2241738
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