高盛貴
[摘要] 目的 分析胃大部分切除術(shù)與單純修補(bǔ)術(shù)治療急性胃穿孔的臨床療效。 方法 選擇2015年8月~2016年8月間80例急性胃穿孔患者進(jìn)行回顧性分析,并根據(jù)手術(shù)方法分組,各40例。A組采取胃大部分切除術(shù),B組則采取單純修補(bǔ)術(shù)方案。比較兩組急性胃穿孔病情改善率;病灶切除或穿孔縫合耗時、術(shù)后腸鳴音恢復(fù)時間、手術(shù)后康復(fù)出院時間;分析住院期間出現(xiàn)的并發(fā)癥現(xiàn)象,出院后隨訪1年對比兩組急性胃穿孔復(fù)發(fā)情況。 結(jié)果 兩組患者療效總有效率比較差異無統(tǒng)計學(xué)意義(P>0.05);B組病灶切除或穿孔縫合耗時、術(shù)后腸鳴音恢復(fù)時間、手術(shù)后康復(fù)出院時間短于A組(P<0.05);出院后隨訪1年對比兩組急性胃穿孔復(fù)發(fā)情況顯示B組復(fù)發(fā)率更低(P<0.05);住院期間出現(xiàn)并發(fā)癥方面,B組顯著低于A組(P<0.05)。 結(jié)論 胃大部分切除術(shù)與單純修補(bǔ)術(shù)治療急性胃穿孔的臨床療效相當(dāng),其中胃大部分切除術(shù)可徹底切除病灶,降低復(fù)發(fā)率,但損傷較大,術(shù)后并發(fā)癥多,住院時間和康復(fù)時間長,而單純修補(bǔ)術(shù)則和胃大部分切除術(shù)相反,損傷較小、康復(fù)較快、并發(fā)癥少,但因單純修補(bǔ)無法徹底清除病灶復(fù)發(fā)率較高。
[關(guān)鍵詞] 胃大部分切除術(shù);單純修補(bǔ)術(shù);急性胃穿孔;復(fù)發(fā);并發(fā)癥
[中圖分類號] R656.6 [文獻(xiàn)標(biāo)識碼] B [文章編號] 1673-9701(2017)34-0049-03
Clinical effect of subtotal gastrectomy and simple repair on acute gastric perforation
GAO Shenggui
Department of General Surgery,F(xiàn)oshan City Nanhai District Fifth People's Hospital in Guangdong Province, Foshan 528231,China
[Abstract] Objective To analyze the clinical effect of subtotal gastrectomy and simple repair on acute gastric perforation. Methods 80 patients with acute gastric perforation from August 2015 to August 2016 were selected and retrospectively analyzed,which were divided into groups according to the operation method, with 40 cases in each group. Group A underwent subtotal gastrectomy. Group B underwent simple repair program. The rate of improvement of acute gastric perforation, the time of lesions removal or perforation suture, the recovery time of postoperative bowel sounds and the rehabilitation discharge time after surgery were compared between the two groups. The complication symptoms during hospitalization were analyzed. Within follow-up for 1 year after discharge, the recurrence of acute gastric perforation between the two groups was compared. Results There was no statistically significant difference in the rate of total effective between the two groups(P>0.05). The time of lesions removal or perforation suture, the recovery time of postoperative bowel sounds and the rehabilitation discharge time after surgery in group B were shorter than those of the group A(P<0.05). During follow-up for 1 year after discharge, the recurrence of acute gastric perforation between the two groups was compared. The results showed that the recurrence rate of acute gastric perforation was lower in group B(P<0.05). Complications in group B during hospitalization were significantly lower than those in group A(P<0.05). Conclusion The subtotal gastrectomy and simple repair have the same effect in the treatment of acute gastric perforation. The subtotal gastrectomy can completely remove the lesion, reduce the recurrence rate, but has great damage, more postoperative complications and long hospitalization and rehabilitation time. While simple repair is contrary to subtotal gastrectomy, and has less damage, faster recovery and fewer complications, but has high recurrence rate because that simple repair can not completely remove the lesion.endprint
[Key words] Subtotal gastrectomy; Simple repair; Acute gastric perforation; Recurrence; Complication
胃穿孔最常見的原因是在胃潰瘍的基礎(chǔ)上暴飲暴食所致,暴飲暴食能引起胃酸和胃蛋白酶增加、胃容積增大,很容易誘發(fā)胃穿孔?;颊咄蝗话l(fā)生劇烈腹痛,疼痛最初開始于上腹部或穿孔的部位,常呈刀割或燒灼樣痛,一般為持續(xù)性,疼痛很快擴(kuò)散至全腹部。急性胃穿孔是常見消化系統(tǒng)疾病,是消化性潰瘍嚴(yán)重并發(fā)癥,可威脅患者生命安全。目前治療急性胃穿孔的手術(shù)方式較多,其中以胃大部分切除術(shù)與單純修補(bǔ)術(shù)為常見[1-2]。本研究探討了胃大部分切除術(shù)與單純修補(bǔ)術(shù)治療急性胃穿孔的臨床療效,現(xiàn)報道如下。
1 資料與方法
1.1 一般資料
選擇2015年8月~2016年8月間80例急性胃穿孔患者進(jìn)行回顧性分析,并根據(jù)手術(shù)方法分組,各40例。A組男24例,女16例;年齡21~73歲,平均(45.19±2.24)歲。發(fā)病時間2~45 h,平均(22.21±0.25)h。B組男23例,女17例;年齡21~72歲,平均(45.67±2.87)歲。發(fā)病時間2~45 h,平均(22.24±0.29)h。兩組一般資料比較差異無統(tǒng)計學(xué)意義(P>0.05)。具有可比性。
納入標(biāo)準(zhǔn):(1)符合急性胃穿孔標(biāo)準(zhǔn);(2)知情同意本次研究,簽署同意書;(3)對手術(shù)無禁忌;(4)可接受1年隨訪。排除標(biāo)準(zhǔn):(1)不同意進(jìn)行手術(shù)治療,存在手術(shù)禁忌;(2)無法接受隨訪;(3)惡性腫瘤、心肝腎功能不全、凝血功能障礙者。
1.2 方法
A組采取胃大部分切除術(shù),氣管插管全身麻醉,之后探查病灶處,用生理鹽水清洗腹腔,將胃部殘留液體排空,并在胃組織遠(yuǎn)端切除,之后給予胃空腸吻合術(shù)。
B組則采取單純修補(bǔ)術(shù)方案。氣管插管全身麻醉,常規(guī)消毒和常規(guī)鋪巾,手術(shù)切口選擇患者正中上腹部切口,對胃穿孔病灶進(jìn)行探查,用生理鹽水清洗腹腔,將胃部殘留液體排空之后縫合病灶,在穿孔灶外用大網(wǎng)膜覆蓋和結(jié)扎。
1.3 觀察指標(biāo)
比較兩組急性胃穿孔病情改善率;病灶切除或穿孔縫合耗時、術(shù)后腸鳴音恢復(fù)時間、手術(shù)后康復(fù)出院時間;分析住院期間出現(xiàn)的并發(fā)癥現(xiàn)象,出院后隨訪1年對比兩組急性胃穿孔復(fù)發(fā)情況。
1.4 療效判定標(biāo)準(zhǔn)
顯效:疼痛、發(fā)熱等癥狀消失;有效:疼痛、發(fā)熱等癥狀好轉(zhuǎn);無效:不滿足有效標(biāo)準(zhǔn)。急性胃穿孔病情改善率=顯效率+有效率[3]。
1.5 統(tǒng)計學(xué)方法
采用SPSS18.0軟件統(tǒng)計數(shù)據(jù),計量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,采用t檢驗;計數(shù)資料采用[n(%)]表示,行χ2檢驗,P<0.05為差異有統(tǒng)計學(xué)意義。
2 結(jié)果
2.1 兩組患者療效比較
兩組患者總有效率比較差異無統(tǒng)計學(xué)意義(P>0.05)。見表1。
2.2兩組病灶切除或穿孔縫合耗時、術(shù)后腸鳴音恢復(fù)時間、手術(shù)后康復(fù)出院時間比較
B組病灶切除或穿孔縫合耗時、術(shù)后腸鳴音恢復(fù)時間、手術(shù)后康復(fù)出院時間短于A組(P<0.05),見表2。
2.3兩組并發(fā)癥、復(fù)發(fā)率比較
出院后隨訪1年對比兩組急性胃穿孔復(fù)發(fā)情況顯示B組復(fù)發(fā)率更低(P<0.05);住院期間出現(xiàn)并發(fā)癥方面,B組顯著低于A組(P<0.05)。見表3。
3討論
急性胃穿孔為胃潰瘍進(jìn)一步進(jìn)展所形成的消化道疾病,其發(fā)生和胃酸過多分泌、胃黏膜保護(hù)作用減弱相關(guān)[4]。在出現(xiàn)急性胃穿孔之后,腹腔內(nèi)大量胃液積聚,可對腹膜產(chǎn)生刺激作用,并導(dǎo)致患者出現(xiàn)疼痛感。對于急性胃穿孔若控制不及時,容易引發(fā)休克,需及時采取有效措施控制病情,改善患者預(yù)后[5-6]。
目前,隨著醫(yī)學(xué)技術(shù)不斷發(fā)展,治療急性胃穿孔的術(shù)式也增多,其中單純修補(bǔ)術(shù)操作比較簡單,手術(shù)時間較短,安全性高,可減少術(shù)后并發(fā)癥,但多適用于急性胃穿孔發(fā)病24 h內(nèi),但術(shù)后容易復(fù)發(fā),難以徹底治愈[7-9]。胃大部分切除術(shù)可直接解決病灶問題,將胃部病灶切除,可降低主細(xì)胞和壁細(xì)胞數(shù)量,降低胃酸分泌和胃蛋白酶水平,減輕患者痛苦[10-12]。研究顯示對于合并幽門梗阻和活動性出血患者采取胃大部分切除術(shù)可獲得較為理想的效果,但胃大部分切除術(shù)創(chuàng)傷大,出血量大,術(shù)后并發(fā)癥多[13-15]。
本研究中,A組采取胃大部分切除術(shù),B組則采取單純修補(bǔ)術(shù)方案。結(jié)果顯示,兩組急性胃穿孔病情改善率之間無顯著差異,說明胃大部分切除術(shù)與單純修補(bǔ)術(shù)治療急性胃穿孔的臨床療效相當(dāng),前者可通過切除病灶消除患者臨床癥狀,后者可通過將穿孔修補(bǔ)達(dá)到治療作用。
B組病灶切除或穿孔縫合耗時、術(shù)后腸鳴音恢復(fù)時間、手術(shù)后康復(fù)出院時間短于A組,說明單純修補(bǔ)術(shù)手術(shù)操作更為簡單,且術(shù)后康復(fù)更快。出院后隨訪1年對比兩組急性胃穿孔復(fù)發(fā)情況顯示,B組復(fù)發(fā)率更低(P<0.05);住院期間出現(xiàn)的并發(fā)癥方面,B組顯著低于A組(P<0.05),說明單純修補(bǔ)術(shù)的創(chuàng)傷和并發(fā)癥更少,安全性更高,但療效不徹底,而胃大部分切除術(shù)則效果更徹底,可有效預(yù)防復(fù)發(fā)。
綜上所述,胃大部分切除術(shù)與單純修補(bǔ)術(shù)治療急性胃穿孔的臨床療效相當(dāng),其中胃大部分切除術(shù)可徹底切除病灶,降低復(fù)發(fā)率,但損傷較大,術(shù)后并發(fā)癥多,住院時間和康復(fù)時間長,而單純修補(bǔ)術(shù)則和胃大部分切除術(shù)相反,損傷較小,康復(fù)較快,并發(fā)癥少,但因單純修補(bǔ)無法徹底清除病灶復(fù)發(fā)率較高。
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(收稿日期:2017-09-18)endprint