开腹术治疗继发性腹膜炎患者中内脏保护预防肠-腔瘘的意义：倾向评分匹配病例对照分析。

The Significance of Visceral Protection in Preventing Enteroatmospheric Fistulae During Open Abdomen Treatment in Patients With Secondary Peritonitis: A Propensity Score-matched Case-control Analysis.

机构信息

Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital, Koblenz, Germany.

Department of Surgery, University Hospital of Bonn, Bonn, Germany.

出版信息

Ann Surg. 2021 Jun 1;273(6):1182-1188. doi: 10.1097/SLA.0000000000003440.

DOI:10.1097/SLA.0000000000003440

PMID:31318792

Abstract

OBJECTIVE

To evaluate the influence of a visceral protective layer (VPL) on the formation of enteroatmospheric fistulae (EAF) in open abdomen treatment (OAT) for peritonitis.

BACKGROUND

EAF formation is a severe complication of OAT. Despite the widespread use of OAT, there are no robust evidence-based recommendations for preventing EAF.

METHODS

A total of 120 peritonitis patients with secondary peritonitis as a result of a perforation of a hollow viscus or anastomotic insufficiency who had undergone OAT were included, and 14 clinical parameters were recorded in prospective OAT databases at 2 tertiary referral centers. For this analysis, patients with a VPL were assigned to the treatment group and those without a VPL to the control group. Propensity Score (PS) matching was performed. Known risk factors in OAT such as malignant disease, mortality, emergency operation, OAT duration, and fascial closure were matching variables. The influence of VPL on EAF formation was statistically evaluated using logistic regression analysis.

RESULTS

With 34 patients in each group, no notable differences were identified with regard to age, sex, underlying disease, mortality, emergency operation, fascial closure, and OAT duration. Overall, a mortality rate of 22.1% for OAT due to peritonitis was observed. Mean OAT duration was approximately 9 days, and secondary fascial closure was achieved in more than two-thirds of all patients. Fascial traction was used in more than 75% of cases. EAF formation was significantly more frequent in the control group (EAF formation: VPL group 2.9% vs control 26.5%; P = 0.00). In the final regression analysis, the use of VPL resulted in a significant reduction in the risk of EAF formation (odds ratio 0.08; 95% confidence interval 0.01-0.71, P = 0.02), which translates to a relative risk reduction of 89.1%.

CONCLUSION

VPL effectively prevents EAF formation during OAT in patients with peritonitis. We recommend the consistent use of VPL as part of a standardized OAT treatment algorithm.

摘要

目的

评估内脏保护层（VPL）对腹膜炎开放式腹部治疗（OAT）中肠-气瘘（EAF）形成的影响。

背景

EAF 的形成是 OAT 的严重并发症。尽管 OAT 被广泛应用，但对于预防 EAF 尚无强有力的循证推荐。

方法

共纳入 120 例因空腔脏器穿孔或吻合口不足导致继发性腹膜炎的腹膜炎患者，在 2 家三级转诊中心的前瞻性 OAT 数据库中记录了 14 项临床参数。在这项分析中，有 VPL 的患者被分配到治疗组，没有 VPL 的患者被分配到对照组。采用倾向评分（PS）匹配。OAT 中的已知危险因素，如恶性疾病、死亡率、急诊手术、OAT 持续时间和筋膜闭合，作为匹配变量。采用 logistic 回归分析统计评估 VPL 对 EAF 形成的影响。

结果

每组 34 例患者，年龄、性别、基础疾病、死亡率、急诊手术、筋膜闭合和 OAT 持续时间无显著差异。总的来说，腹膜炎 OAT 的死亡率为 22.1%。OAT 平均持续时间约为 9 天，超过三分之二的患者实现了二次筋膜闭合。超过 75%的患者使用了筋膜牵引。对照组 EAF 形成的发生率明显更高（EAF 形成：VPL 组 2.9%，对照组 26.5%；P=0.00）。在最终的回归分析中，VPL 的使用显著降低了 EAF 形成的风险（比值比 0.08；95%置信区间 0.01-0.71，P=0.02），这意味着相对风险降低了 89.1%。