摘要
目的探讨非糖尿病消化道瘘患者接受择期确定性胃肠道重建手术的围手术期间血糖升高的不良影响。方法选择南京军区南京总医院肠瘘治疗中心2012年9月至2015年12月期间行确定性胃肠道重建手术治疗的消化道瘘患者中年龄18～70岁、术前无弥漫性腹膜炎及全身感染等现象者，回顾分析其临床资料和手术前后血糖检测水平，按照术后48h内所检测获得的最高血糖值，将患者分为正常血糖组（血糖〈6．9mmol／L）、轻中度高血糖组（血糖6．9-11．4mmol／L）和重度高血糖组（血糖≥11．7mmol／L），比较3组患者临床特征的差异，分析术后高血糖对包括术后发生手术部位感染和吻合口瘘、术后肠内营养恢复时间和住院天数以及住院费用等指标的影响。结果314例患者入组，术后出现胃瘘6例，小肠瘘95例，回结肠吻合口瘘116例，结直肠瘘97例。术后血糖升高（〉6．9mmol／L）193例（61．5％），其中轻中度高血糖组148例，重度高血糖组45例；正常血糖组121例。3组患者的性别、体质指数、有无吸烟史、是否饮酒及原发病类型比较．差异没有统计学意义（均P〉0．05）；但高血糖组患者年龄及ASA评分显著高于正常血糖组（均P=0．000）；高血糖组患者术后发生回结肠吻合口瘘的比例（轻中度高血糖：40．5％，60／148：重度高血糖：44．4％，20／45）高于正常血糖组（29．8％，36／121）。术后血糖升高的两组患者术中接受输血人数相比正常血糖组更多（P=0．001）、手术时间更长（P=0．026）、吻合口数量≥2个者更多（P=0．001），接受腹腔镜辅助手术比例更低（P=0．005），术后发生手术部位感染的比例（P=0．006）、吻合口瘘发生率（P=0．004）和再次接受手术比例高（P=0．004）；肠内营养恢复时间（P=0．001）、ICU住院时间（P=0．001）及总住院时间更长（P=0．000）；住院期间的治疗费用更高（P=0．000）。多元回归分析结果显示，轻中度和重度高血糖是预测手术部位感染（OR=1．99，95％CI：1．12～3．54，P=0．019；OR：3．02，95％CI：1．36—6．70，P=0．007）和吻合口瘘（OR=7．59，95％CI：1．68～34．34，P=0．009；OR=13．4，95％CI：2．50。71．65，P=0．002）的独立危险因素。多元线性回归分析提示，正常血糖组相对于轻中度血糖组肠内营养恢复时间提前2d，相对于重度高血糖组提前近3d；轻中度血糖组住院时间相对于正常血糖组延迟2d，重度高血糖组则相对于正常血糖组延迟近10d。结论消化道瘘患者接受择期确定性胃肠道重建手术围手术期间血糖升高者比例较高，血糖升高易导致手术部位感染或出现吻合口瘘，并影响术后恢复。故对于术后发生高血糖的患者，建议必要时予以降糖干预。
Objective To investigate the effect of hyperglycemia within postoperative 48 hours on gastrointestinal （GI） fistula patients without preoperative diagnosis of diabetes undergoing selective GI reconstruction. Methods Clinical data of GI fistula patients with age of 18 to 70 years and without diffuse peritonitis and systemic infection undergoing definitive GI reconstruction at Intestinal Fistula Center of Jinling Hospital from September 2012 to December 2015 were retrospectively analyzed. According to the highest blood glucose （BG） value detected within postoperative 48 hours, patients were divided into normoglycemia （BG 〈 6.9 retool/L）, mild hyperglycemia （6.9 to 11.4 mmol/L） and severe hyperglycemia （BG ≥11.5 mmol/L） groups. Clinical manifestations were compared among three groups. Effects of postoperative hyperglycemia on associated parameters, including postoperative surgical site infection, anastomotic leakage, intestinal nutrition recovery, hospital stay and hospitalization cost were investigated. Results A total of 314 patients were enrolled, of whom postoperative gastric fistula occurred in 6 cases, small intestinal fistula in 95 cases, ileocolonic anastomotic fistula in 116, and colorectal fistula in 97 cases. One hundred and ninety-three （61.5%） patients experienced hyperglycemia, including 148 cases of mild hyperglycemia group and 45 cases of severe hyperglycemia group, the other 121 cases were of normoglycemia group. There were no significant differences in gender, BMI, ratio of smoking, ratio of alcohol user and primary diseases among 3 groups （all P 〉 0.05）. Older patients were vulnerable to postoperative hyperglycemia and patients who developed hyperglycemia were also prone to have increased ASA score （all P = 0.000）. Hyperglycemia patients had significantly higher ratio of postoperative ileocolonic anastomotic fistula （mild hyperglycemia group： 40.5%, 60/148; severe hyperglycemia group： 44.4%, 20/45） than normoglycemia cases （29.8%, 36/121 ）. Compared to normoglycemia group, ratio of intra-operative transfusion case was higher （P = 0.001）, operative time was longer （P = 0.026）, ratio of number of anastomosis 〉 2 was higher （P = 0.001 ）, ratio of receiving laparoscopic-assisted operation was lower （P = 0.005）, ratio of postoperative surgical site infection was higher （P = 0.006）, incidence of anastomotie leakage was higher （P= 0.004）, ratio of re-operation was higher （P = 0.004）, intestinal nutrition recovery time was longer （P = 0.001 ）, ICU stay was longer （P = 0.001 ）, total hospitalization time was longer （P = 0.000） and hospitalization cost was more expensive （P = 0.000） in both two hyperglycemia groups. Multivariate regression analysis showed that mild hyperglycemia and severe hyperglycemia were independent risk factors to predict surgical site infection （OR = 1.99, 95%CI： 1.12 to 3.54, P = 0.019; OR = 3.02, 95%CI： 1.36 to 6.70, P = 0.007） and anastomotie leakage （OR = 7.59, 95%CI： 1.68 to 34.34, P = 0.009; OR = 13.4, 95%CI： 2.50 to 71.65, P= 0.002）. Multivariate linear regression analysis indicated that intestinal recovery time of normoglycemia group was 2 days shorter and 3 days shorter, and hospitalization time of normoglycemia group was 2 days shorter and 10 days shorter as compared with mild hyperglycemia and severe hyperglycemia group, respectively. Conclusions Elevated postoperative BG is common in GI fistula patients receiving selective GI reconstruction. Postoperative hyperglycemia is significantly associated with surgical site infection, anastomotic leakage and prolonged intestinal recovery. BG control treatment should be recommended for those patients with postoperative hyperglycemia.
作者
胡琼源
任建安
汤文浩
黎介寿
Hu Oiongyuan Ren Jian＇ au Tang Wenhao Li Jieshou(Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Naujing 210002, China)
出处
《中华胃肠外科杂志》
CAS
CSCD
北大核心
2017年第10期1156-1161,共6页
Chinese Journal of Gastrointestinal Surgery
基金
国家自然科学基金（81571881）
关键词
消化道瘘
高血糖
手术部位感染
吻合口瘘
Gastrointestinal fistula
Hyperglycemia
Surgical site infection
Anastomotic leakage
