来自大型全州范围数据库的粘连性小肠梗阻的结局：非手术治疗后的预期结果。

Outcomes in adhesive small bowel obstruction from a large statewide database: What to expect after nonoperative management.

机构信息

From the Trauma Service (L.E.W., R.Y.C., C.E.D., J.M.B., W.J.B., V.B., C.B.S., M.J.S.), Scripps Mercy Hospital, San Diego, California.

出版信息

J Trauma Acute Care Surg. 2019 Apr;86(4):651-657. doi: 10.1097/TA.0000000000002196.

DOI:10.1097/TA.0000000000002196

PMID:30907786

Abstract

BACKGROUND

Although adhesive small-bowel obstruction (ASBO) is frequently managed nonoperatively, little is known regarding outcomes on readmission following this approach. Using a large population-based dataset, we evaluated risk factors for operative intervention and mortality at readmission in patients with ASBO who were initially managed nonoperatively.

METHODS

The ASBO patients were identified in the California Office of Statewide Health Planning and Development 2007 to 2014 patient discharge database. Patients who were managed operatively at index admission or had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for nonadhesive obstructive small bowel disease were excluded. Associations between risk factors and both operative intervention and death following readmission were evaluated using survival analysis.

RESULTS

Among 15,963 ASBO patients, 3,103 (19.4%) had at least one readmission. The 1,069 (34.5%) who received an operation during their first readmission presented sooner (175 days vs. 316 days, p < 0.001) and were more likely to die during that readmission (5.2% vs. 0.7%, p < 0.001). Operative management at first readmission was associated with younger age, fewer comorbidities, and shorter times to readmission. Patients operatively managed at first readmission had longer times to second readmission compared with nonoperative patients. Stratified analyses using nonoperative patients as the reference over the study period revealed that patients who underwent lysis of adhesions and bowel resection were 5.04 times (95% confidence interval [CI], 2.82-9.00) as likely to die while those who underwent lysis only were 2.09 times (95% CI, 1.14-3.85) as likely to die. Patients with bowel resection only were at an increased risk for subsequent interventions beyond the first readmission (hazard ratio, 1.79; 95% CI, 1.11-2.87).

CONCLUSION

In a large cohort readmitted for ASBO and initially managed nonoperatively, subsequent operative intervention conferred a greater risk of death and a longer time to readmission among survivors. Prospective research is needed to further delineate outcomes associated with initial nonoperative management of ASBO.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

摘要

背景

尽管粘连性小肠梗阻（ASBO）常采用非手术方法治疗，但对于此类患者在非手术治疗后再次入院时的手术干预和死亡率的相关信息知之甚少。本研究使用大型基于人群的数据集，评估了在初始非手术治疗的 ASBO 患者中，再次入院时发生手术干预和死亡的风险因素。

方法

在加利福尼亚州全州卫生规划和发展办公室 2007 年至 2014 年的患者出院数据库中确定 ASBO 患者。排除在指数入院时接受手术治疗或具有非粘连性阻塞性小肠疾病的国际疾病分类，第 9 修订版，临床修正诊断代码的患者。使用生存分析评估风险因素与再次入院后的手术干预和死亡之间的关联。

结果

在 15963 例 ASBO 患者中，有 3103 例（19.4%）至少有一次再次入院。在首次再次入院期间接受手术的 1069 例（34.5%）患者更早就诊（175 天比 316 天，p < 0.001），且在该次再次入院期间更有可能死亡（5.2%比 0.7%，p < 0.001）。首次再次入院时的手术治疗与更年轻的年龄、更少的合并症和更短的再次入院时间相关。与非手术患者相比，首次再次入院时接受手术治疗的患者的第二次再次入院时间更长。在整个研究期间，以非手术患者为参照的分层分析显示，接受粘连松解和肠切除术的患者死亡的可能性是接受单纯粘连松解术的患者的 5.04 倍（95%置信区间[CI]，2.82-9.00），而仅接受粘连松解术的患者死亡的可能性是单纯粘连松解术的患者的 2.09 倍（95%CI，1.14-3.85）。仅行肠切除术的患者再次入院后接受进一步干预的风险增加（危险比，1.79；95%CI，1.11-2.87）。