结直肠癌患者手术部位切口感染的危险因素分析

2020-07-27 15:53刘铭张露余伟儇李洪王力斌
中国医学创新 2020年19期
关键词:皮下肠梗阻腹腔

刘铭 张露 余伟儇 李洪 王力斌

【摘要】 目的:探讨结直肠癌患者发生术后手术部位切口感染(SSI)的危险因素,提出减少术后SSI风险的策略。方法:回顾性分析本院2008年12月-2018年12月行结直肠癌外科手术的721患者的临床资料,采用Logistic回归模型分析术后SSI的独立危险因素。结果:721例结直肠癌患者术后SSI发生率为8.46%(61/721),单因素分析结果显示术后SSI与BMI指数、贫血、低蛋白血症、结肠梗阻、糖尿病、腹腔感染、皮下引流有关(P<0.05)。Logistic多因素分析结果显示,BMI指数>25 kg/m2、Hb<90 g/L、

合并结肠梗阻、合并糖尿病、合并腹腔感染为结直肠癌患者术后SSI的独立危险因素(P<0.05),皮下引流是术后SSI的保护因素。结论:BMI指数>25 kg/m2、Hb<90 g/L、合并结肠梗阻、合并糖尿病、合并腹腔感染为结直肠癌术后SSI的独立危险因素,采取皮下引流能减少术后SSI風险。

【关键词】 结直肠癌 手术切口感染危险因素 Logistic回归分析

[Abstract] Objective: To put forward the strategies of reducing for lowering risk of surgical site infections in colorectal cancer patients by investigating and analyzing the potential risk factors. Method: The clinical data of 721 patients with colorectal cancer treated in our hospital from December 2008 to December 2018 were analyzed. Result: The overall infection rate was 8.46% (61/721). Monofactor analysis showed that BMI index, anemia, hypoproteinemia, colorectal obstruction, diabetes, abdominal infection, subcutaneous drainage were significantly associated with incision infection (P<0.05). Multivariate logistic analysis showed that BMI index, anemia, colorectal obstruction, diabetes, abdominal infection were the independent risk factors for incision infection in colorectal cancer (P<0.05). Conclusion: BMI index, anemia, colorectal obstruction, diabetes and abdominal infection are the independent risk factors of incision infection in patients with colorectal cancer after surgery, subcutaneous drainage can decrease the incidence of surgical site infections.

[Key words] Colorectal cancer Surgical site infections Risk factors Logistic regression analysis

First-authors address: Donghua Hospital Affiliate to Sun Yat-sen University, Dongguan 523808, China

doi:10.3969/j.issn.1674-4985.2020.19.040

手术部位切口感染(Surgical site infections,SSI)是结直肠癌手术后的常见并发症,报道发生率为3.0%~16.3%[1-2]。一旦发生,往往明显增加住院时间及患者费用,还可能推迟辅助化疗开始的时间。有报道显示,结直肠癌术后SSI与年龄、肥胖或营养不良、糖尿病、吸烟、肿瘤分期、切口类型和长度、手术时间、术前放化疗及联合器官切除、既往手术史、慢性肝病、伴造口等因素相关[3-4]。为进一步探讨结直肠癌手术后SSI的危险因素,本文收集了在本院外科进行手术治疗的721例结直肠癌患者的临床资料,进行回顾性分析,现报道如下。

1 资料与方法

1.1 一般资料 2008年12月-2018年12月本院共收治721例接受外科手术的结直肠癌患者,其中男女比率为1.32/1(411/310),中位年龄为56.65岁(19~91岁)。所有病例均病理确诊为结肠或直肠癌。本研究经东莞东华医院伦理委员会批准,所有患者均签署知情同意书。纳入标准:接受外科手术治疗的结直肠癌患者;手术治疗的术式包含腹会阴联合切除、直肠前切除术、乙状结肠切除术、左半结肠切除术、横结肠切除术+大肠次全切除术等。排除标准:仅行探查者;仅行造瘘者;经肛门的直肠癌手术患者;经肛门取标本的患者;临床资料不全者;术后30 d内死亡者。

1.2 方法 回顾性分析选取患者的性别、年龄、BMI指数、术前合并症(糖尿病、低蛋白血症、贫血、结肠梗阻)、腹腔感染、手术方式(腹腔镜手术或开放手术)、皮下引流情况。

1.3 判断标准 肥胖定义为BMI>25 kg/m2,低蛋白血症定义为ALB<30 g/L,贫血定义为Hb<90 g/L。结肠梗阻通过CT或术中探查诊断,腹腔感染包括吻合口瘘及CT诊断的腹腔感染。术后SSI的诊断标准:表浅SSI一般发生在术后30 d内,仅限于切口涉及的皮肤和皮下组织,发生于术后30 d内,符合以下条件之一:(1)化脓性液体排出;(2)表浅切口有疼痛,局部肿胀,发红或发热;(3)被主治医生诊断为手术部位SSI。切口缝合针眼处有轻微炎症和少许分泌物不属于SSI,单纯切口脂肪液化,不属于SSI。

1.4 统计学处理 采用SPSS 22.0统计软件进行分析,计量资料用(x±s)表示,比较采用t检验,计数资料用率(%)表示,分类变量的比较采用字2检验,以术后切口是否感染为因变量,其他临床因素为自变量,采取Logistic回归分析对数据进行多因素分析,以P<0.05为差异有统计学意义。

2 结果

行结直肠癌手术的721例患者中有61例发生术后SSI,发生率为8.460%。SSI危险因素的单因素分析结果显示,术后发生SSI与BMI指数、贫血、低蛋白血症、结肠梗阻、糖尿病、腹腔感染、皮下引流有关(P<0.05)。见表1。SSI危险因素的多因素分析以SSI作为因变量(Y),以性别、年龄等11个相关因素作为自变量(X),把因变量(Y)和自变量(X)引入非条件Logistic回归分析模型,进行危险因素多元分析。因变量(Y)中,SSI=1,未发生SSI=0。关于自变量(X),性别(X1)中,男性=1,女性=0;年龄(X2)中,>60岁=1,≤60岁=0,BMI指数(X3)中,BMI>25 kg/m2=1,<25 kg/m2=0;合并糖尿病(X4)中,是=1,否=0;合并低蛋白血症(X5)中,ALB<30 g/L=1,>30=0、合并贫血(X6)中,Hb<90 g/L=1,>90 g/L=0、合并结肠梗阻(X7)中,是=1,否=0;合并腹部感染(X8)中,是=1,否=0;手术方式(X9)中,腹腔镜手术=1,开放手术(含腹腔镜中转)=0;皮下引流(X10)中,是=1,否=0。结果显示BMI指数>25 kg/m2、Hb<90 g/L、合并结肠梗阻、合并糖尿病、合并腹腔感染为结直肠癌术后SSI的独立危险因素。皮下引流是术后SSI的保护因素。见表2。

3 讨论

结直肠癌术后SSI的发生中高BMI指数或皮下脂肪厚度高被认为是一个重要的危险因素[5]。原因是缝合时脂肪组织间易留有腔隙,容易造成组织液积聚。打结过紧可导致脂肪组织血供缺乏,切开皮下组织时过多使用电凝可能引起皮下组织坏死。结直肠癌肿瘤原发部位也与术后SSI风险相关,有报道显示,直肠癌术后SSI风险比右半结肠切除高,原因可能是直肠癌手术时间较长[6]。另外肥胖患者组织中抗生素浓度下降也是术后易发生SSI的原因,对于肥胖患者可考虑适当提高抗生素用量。有研究证实采取腹腔镜下手术能减少结直肠癌术后SSI风险,特别是肥胖患者[7]。另外有报道使用抗菌缝线缝合能降低消化道手术SSI率[8]。改良格拉斯预后评分(Modified Glasgow prognostic score,mGPS)通过C反应蛋白和ALB评估患者的营养状况,mGPS评分高是结直肠癌术后SSI的危险因素[9]。肿瘤恶病质患者术前的营养治疗十分重要,肠内免疫营养治疗能够减少结直肠癌术后SSI[10]。贫血的结直肠患者术后SSI发生率高于没有贫血的患者,在择期手术前应纠正贫血,而输注浓缩红细胞不会增加SSI风险[11]。糖尿病也是术后SSI的危险因素[3],糖尿病患者机体免疫力降低,高血糖环境易引起组织水肿,利于细菌生长,影响切口愈合,术前需控制患者血糖在理想水平。结肠癌手术中低血压是术后SSI的危险因素之一,原因可能与切口周围组织灌注不良有关。术前WBC比率升高也是术后SSI的危险因素[5]。术前口服抗生素能降低结直肠癌术后SSI发生率,而肠道准备能否减少SSI风险仍存在争议[12-13]。

结直肠癌合并腹腔感染往往意味着肿瘤分期晚和手术创伤大,Ⅱ/Ⅲ期结肠癌术后发生SSI患者往往预后欠佳[14]。结直肠手术多为Ⅱ类或Ⅲ类切口,术中胃肠道内容物或腹腔脓性渗出液很容易污染切口,需做好切口保护,而应用双环切口保护套能降低结直肠癌术后SSI风险[15]。结直肠癌伴结肠梗阻的比率报道在8%~29%[16-17],本研究中合并结肠梗阻的患者占15.5%(112/721)。结肠梗阻使正常的生理功能紊乱,内源性菌群和数量以及肠道自身免疫功能均遭到破坏,肠道菌群的改变使感染并发症明显升高。Mabardy等[18]研究表明,术前接收结肠支架植入的患者术后总体并发症发生率较低(10.5% vs 21.7%,P=0.01),未行术前支架植入的患者结肠造口率高出2倍以上(42.5% vs 19.5%,P=0.01)。提示结直肠癌伴结肠梗阻的患者可考虑先行结直肠支架植入解除梗阻,减少SSI等感染并发症的发生。

皮下引流与SSI的关系仍有争议,有报道认为腹部切口皮下引流并不能降低SSI风险。这点与本文研究结果不一致,可能与患者基本情况不同等有关[19]。本研究显示,皮下引流是結直肠癌手术术后SSI的独立保护性预后因素,皮肤下方可能积聚渗出液或血液,而脂肪层可以提供细菌生长的环境,增加SSI的风险。切口皮下引流的目的是引流渗出液或积血,减少SSI的风险。Numata等[20]发现结直肠癌手术的患者皮下引流组SSI率小于未引流组(3.2% vs 9.8%,P=0.041)。Yoshimatsu等[21]研究纳入72例结肠造口的患者,其中23例发生了SSI,而使用皮下引流和吸收线缝合皮下能明显降低SSI的发生。Watanbe等[22]RCT研究也证实皮下引流是结直肠癌手术后SSI的独立预后因素,能预防SSI。

综上所述,BMI指数>25 kg/m2、Hb<90 g/L、合并结肠梗阻、合并糖尿病、合并腹腔感染为结直肠癌术后SSI的独立危险因素。然而结直肠癌患者术后发生SSI危险因素很多,应针对危险因素采取有效的控制和干预手段,加强切口缝合技巧的锻炼,注重保护皮下组织的血运和使用切口皮下引流能够有效减少结直肠癌术后SSI的发生。本研究为回顾性研究和单中心研究,还需要更大样本前瞻性研究进一步证实。

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(收稿日期:2019-10-10) (本文編辑:周亚杰)

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