本文選題：腹腔鏡直腸切除術(shù) + 中轉(zhuǎn)開(kāi)腹��； 參考：《山東大學(xué)》2016年博士論文

【摘要】：目的：回顧性研究602例腹腔鏡直腸切除術(shù)臨床數(shù)據(jù),確定腹腔鏡直腸切除術(shù)中轉(zhuǎn)開(kāi)腹術(shù)前風(fēng)險(xiǎn)因素,建立腹腔鏡直腸切除術(shù)中轉(zhuǎn)開(kāi)腹評(píng)分系統(tǒng)。最后對(duì)腹腔鏡直腸切除術(shù)中轉(zhuǎn)開(kāi)腹評(píng)分系統(tǒng)的效能、穩(wěn)定性、發(fā)展性進(jìn)行評(píng)價(jià)。方法：首先匯總國(guó)內(nèi)外腹腔鏡結(jié)、直腸手術(shù)臨床資料6248例,分析導(dǎo)致腹腔鏡結(jié)、直腸切除術(shù)中轉(zhuǎn)開(kāi)腹原因。綜合國(guó)內(nèi)外關(guān)于腹腔鏡直腸切除術(shù)中轉(zhuǎn)開(kāi)腹的相關(guān)文獻(xiàn)以及上述中轉(zhuǎn)開(kāi)腹原因確定可能的腹腔鏡直腸切除術(shù)中轉(zhuǎn)開(kāi)腹風(fēng)險(xiǎn)因素。然后,采用SPSS19.0數(shù)據(jù)軟件,對(duì)青島大學(xué)醫(yī)學(xué)院附屬醫(yī)院2001年1月-2013年12月,完成的602例腹腔鏡直腸切除術(shù)臨床資料,進(jìn)行單因素分析(卡方檢驗(yàn))及Logistic多因素回歸分析,最終確定導(dǎo)致腹腔鏡直腸切除術(shù)中轉(zhuǎn)開(kāi)腹的術(shù)前風(fēng)險(xiǎn)因素為：手術(shù)者手術(shù)經(jīng)驗(yàn)(手術(shù)例數(shù)≤25例)、有腹部手術(shù)史、男性、肥胖(BMI≥28)、腫瘤直徑≥6cm、腫瘤浸潤(rùn)或(和)轉(zhuǎn)移。對(duì)數(shù)據(jù)進(jìn)行l(wèi)ogistic多因素分析,并建立腹腔鏡直腸中轉(zhuǎn)開(kāi)腹的數(shù)學(xué)函數(shù)模型。根據(jù)腹腔鏡直腸切除術(shù)中轉(zhuǎn)開(kāi)腹數(shù)學(xué)函數(shù)模型中各個(gè)自變量系數(shù)(即優(yōu)勢(shì)比0R值)的意義以及Logistics多因素分析特點(diǎn)可建立腹腔鏡直腸切除術(shù)中轉(zhuǎn)開(kāi)腹評(píng)分系統(tǒng)。最后對(duì)建立的評(píng)分系統(tǒng)的效能(靈敏度及特異度檢驗(yàn))、臨床使用效果、評(píng)分系統(tǒng)的穩(wěn)定性及發(fā)展性進(jìn)行綜合評(píng)價(jià)。結(jié)果：首先匯總分析了國(guó)內(nèi)外6248例腹腔鏡結(jié)、直腸手術(shù)臨床資料,中轉(zhuǎn)開(kāi)腹551例,中轉(zhuǎn)率為8.82%。具體中轉(zhuǎn)開(kāi)腹原因如下：粘連100例(18.15%),周圍浸潤(rùn)92例(16.70%),腫瘤巨大90例(16.33%),出血51例(9.26%),暴露困難43例(7.80%),轉(zhuǎn)移30例(5.44%),肥胖24例(4.36%),器械意外22例(3.99%),腸道損傷14例(2.54%),骨盆狹窄13例(2.36%),膀胱輸尿管損傷12例(2.18%),手術(shù)者經(jīng)驗(yàn)10例(1.81%),周圍炎癥10例(1.81%),吻合問(wèn)題9例(1.63%),未發(fā)現(xiàn)腫瘤8例(1.45%),腸梗阻6例(1.09%),無(wú)法耐受麻醉5例(0.91%),內(nèi)臟損傷4例(0.73%),結(jié)腸擴(kuò)張3例(0.54%)。綜合國(guó)內(nèi)外關(guān)于腹腔鏡直腸切除術(shù)中轉(zhuǎn)開(kāi)腹的相關(guān)文獻(xiàn)及上述中轉(zhuǎn)開(kāi)腹原因,首先確定可能導(dǎo)致腹腔鏡直腸切除術(shù)中轉(zhuǎn)開(kāi)腹的術(shù)前風(fēng)險(xiǎn)因素包括男性、高齡(年齡≥65歲)、肥胖(BMI≥28)、有腹部手術(shù)史、腫瘤直徑≥6cm、腫瘤有周圍浸潤(rùn)或(和)轉(zhuǎn)移、手術(shù)者經(jīng)驗(yàn)(手術(shù)例數(shù)≤25例)、手術(shù)方式、合并高血壓、合并冠心病、合并糖尿病、麻醉ASA評(píng)分≥III級(jí)等。對(duì)2001年1月一2013年12月青島大學(xué)醫(yī)學(xué)院附屬醫(yī)院完成的602例腹腔鏡直腸切除術(shù)臨床資料進(jìn)行回顧性分析,其中男性320例,女性282例,Dixon術(shù)395例,Miles術(shù)207例,平均年齡56.33歲,中轉(zhuǎn)開(kāi)腹84例,中轉(zhuǎn)開(kāi)腹率13.95%。數(shù)據(jù)采用SPSS19.0進(jìn)行統(tǒng)計(jì)分析,首先進(jìn)行單因素分析(卡方檢驗(yàn))顯示手術(shù)者經(jīng)驗(yàn)(手術(shù)例數(shù)≤25例)、有腹部手術(shù)史、男性、肥胖(BM1≥28)、腫瘤直徑≥6cm、腫瘤浸潤(rùn)或(和)轉(zhuǎn)移為中轉(zhuǎn)開(kāi)腹術(shù)前風(fēng)險(xiǎn)因素。由于導(dǎo)致腹腔鏡直腸切除術(shù)中轉(zhuǎn)是多種因素共同影響的結(jié)果,所以還需要對(duì)數(shù)據(jù)進(jìn)行Logistic多因素分析,結(jié)果顯示導(dǎo)致腹腔鏡直腸切除術(shù)中轉(zhuǎn)開(kāi)腹的風(fēng)險(xiǎn)因素包括手術(shù)者經(jīng)驗(yàn)(手術(shù)例數(shù)≤25例)、有腹部手術(shù)史、男性、肥胖(BM1≥28)、腫瘤直徑≥6cm、腫瘤浸潤(rùn)或(和)轉(zhuǎn)移。通過(guò)對(duì)數(shù)據(jù)進(jìn)行1ogistic分析,建立腹腔鏡直腸中轉(zhuǎn)開(kāi)腹可能性的數(shù)學(xué)函數(shù)模型如下：根據(jù)Logistic多元回歸的特點(diǎn)及自變量系數(shù)即優(yōu)勢(shì)比(0R值)的特點(diǎn)可對(duì)各腹腔鏡直腸切除術(shù)術(shù)前中轉(zhuǎn)開(kāi)腹風(fēng)險(xiǎn)因素進(jìn)行賦值：手術(shù)者經(jīng)驗(yàn)(手術(shù)例數(shù)≤25例)為4分,有腹部手術(shù)史為5分,男性為6分,肥胖(BMI ≥28)為10分,腫瘤直徑≥6cm為15分,腫瘤轉(zhuǎn)移或(和)浸潤(rùn)為21分。根據(jù)各風(fēng)險(xiǎn)因素賦值計(jì)算出602例患者每位患者的實(shí)際風(fēng)險(xiǎn)賦值總得分,再根據(jù)患者賦值總得分及是否中轉(zhuǎn)開(kāi)腹,畫ROC曲線計(jì)算出不同得分組的特異度和靈敏度。ROC曲線下面積為0.876,相應(yīng)的標(biāo)準(zhǔn)誤為0.021。得分為14.5時(shí),其ROC曲線的敏感度為0.786和特異度為0.861為最佳。當(dāng)?shù)梅值陀?4.5分時(shí)其中轉(zhuǎn)開(kāi)腹率為3.88%(18/464),當(dāng)?shù)梅指哂?4.5分時(shí)中轉(zhuǎn)開(kāi)腹率為47.83%(66/138),有顯著統(tǒng)計(jì)學(xué)差異(P0.001)。最后建立腹腔鏡直腸切除術(shù)中轉(zhuǎn)開(kāi)腹術(shù)前預(yù)測(cè)評(píng)分系統(tǒng),所建立的中轉(zhuǎn)開(kāi)腹術(shù)前評(píng)分包含手術(shù)者經(jīng)驗(yàn)(手術(shù)例數(shù)≤25例)、有腹部手術(shù)史、男性、肥胖(BM1≥28)、腫瘤直徑≥6cm、腫瘤浸潤(rùn)或(和)轉(zhuǎn)移等6個(gè)變量,其賦值分別為4分、5分、6分、10分、15分、21分。如總得分高于14.5分,不建議患者實(shí)行腹腔鏡直腸手術(shù),如總得分低于14.5分,推薦患者實(shí)行腹腔鏡直腸手術(shù)。對(duì)滕州市中心人民醫(yī)院實(shí)施的100例腹腔鏡直腸切除術(shù)患者,術(shù)前計(jì)算評(píng)分,檢測(cè)評(píng)分系統(tǒng)的臨床使用效果。100例患者均實(shí)施腹腔鏡直腸切除手術(shù),其中中轉(zhuǎn)14例,中轉(zhuǎn)率為14%。得分低于14.5分患者88人,中轉(zhuǎn)4人,中轉(zhuǎn)率4.55%,得分高于14.5分患者12人,中轉(zhuǎn)10人,中轉(zhuǎn)率為83.33%,兩組中轉(zhuǎn)開(kāi)腹率有統(tǒng)計(jì)學(xué)差異(P0.05)。結(jié)論：1、手術(shù)經(jīng)驗(yàn)(手術(shù)例數(shù)≤25例)、腹部手術(shù)史、男性、肥胖(BMI≥28)、腫瘤直徑≥6cm、腫瘤浸潤(rùn)或(和)轉(zhuǎn)移是腹腔鏡直腸切除術(shù)中轉(zhuǎn)開(kāi)腹的術(shù)前風(fēng)險(xiǎn)因素。2、臨床上應(yīng)用本文建立的腹腔鏡直腸切除中轉(zhuǎn)開(kāi)腹評(píng)分(LRTO-2014)可以有效地降低中轉(zhuǎn)開(kāi)腹機(jī)率,避免不必要的中轉(zhuǎn)開(kāi)腹。3、隨著新技術(shù)的應(yīng)用、新器械的發(fā)明、新理念的發(fā)展,腹部手術(shù)史、腫瘤直徑≥6cm、腫瘤浸潤(rùn)或(和)轉(zhuǎn)移等術(shù)前風(fēng)險(xiǎn)因素對(duì)中轉(zhuǎn)開(kāi)腹的影響逐漸降低,而當(dāng)手術(shù)者在經(jīng)歷了腹腔鏡直腸切除的學(xué)習(xí)曲線并獲得了相對(duì)豐富的手術(shù)經(jīng)驗(yàn)后,其手術(shù)經(jīng)驗(yàn)對(duì)中轉(zhuǎn)開(kāi)腹的影響保持相對(duì)穩(wěn)定。
[Abstract]:Objective: To review the clinical data of 602 cases of laparoscopic rectal excision, to determine the risk factors of laparotomy before laparoscopy and to establish a laparotomy scoring system for laparoscopic rectal excision. Finally, the effectiveness, stability and development of the laparotomy scoring system were evaluated. A total of 6248 cases of laparoscopic and rectal surgery were collected, and the causes of laparotomy were analyzed. The relevant literature on the conversion of laparotomy at home and abroad and the possible causes of laparotomy risk factors were determined. Then, S A single factor analysis (chi square test) and Logistic multiple regression analysis were performed on 602 cases of laparoscopic rectal excision in the Affiliated Hospital of Qiingdao University Medical School Affiliated Hospital January 2001 -2013 December. The risk factors leading to the operation of laparotomy were determined by surgical operation. Experience (operation number or less than 25 cases), with a history of abdominal surgery, male, obese (BMI > 28), tumor diameter more than 6cm, tumor infiltration or (and) metastasis. The data were analyzed by logistic multiple factors and the mathematical function model of laparotomy for laparotomy was established. According to the coefficient of variables in the mathematical function model transferred to the laparotomy laparotomy, the coefficient of variable coefficients The significance of the advantage than the 0R value and the characteristics of Logistics multifactor analysis can be used to establish a laparotomy scoring system for laparoscopic rectal excision. Finally, a comprehensive evaluation of the effectiveness of the established scoring system (sensitivity and specificity test), clinical use effect, the stability and development of the scoring system. Results: first, a summary and analysis of the country is made. 6248 cases of internal and external laparoscopic surgery, rectal surgery clinical data, 551 cases of conversion to open abdomen, the transfer rate of 8.82%. specific transfer to open the abdomen as follows: adhesion 100 cases (18.15%), peripheral infiltration 92 cases (16.70%), tumor 90 cases (16.33%), hemorrhage 51 cases (9.26%), 43 exposure (7.80%), metastasis 30 cases (5.44%), obesity cases ) 14 cases of intestinal injury (2.54%), 13 cases of pelvic stenosis (2.36%), 12 cases of bladder ureter injury (2.18%), 10 cases (1.81%), 10 cases of peripheral inflammation (1.81%), 9 cases of anastomosis (1.63%), no tumor 8 cases (1.81%), intestinal obstruction cases, visceral injury cases, colon dilatation cases. The internal and external literature related to laparotomy in laparoscopic rectal resection and the reasons for the transfer of laparotomy first determine that the risk factors that may lead to laparotomy may include male, elderly (age 65), obesity (BMI > 28), abdominal hand history, tumor diameter more than 6cm, tumor surrounding infiltration or (and) metastasis, The operative experience (the number of cases or less than 25 cases), the mode of operation, the combination of hypertension, the combination of coronary heart disease, the combined diabetes, the ASA score of III and so on. The clinical data of 602 cases of laparoscopic rectal excision, which were completed in the Affiliated Hospital of Qiingdao University Medical College in December 2013 January 2001, were retrospectively analyzed, of which 320 cases were male, 282 cases of women, Dixon 395 cases, 207 cases of Miles operation, average age 56.33 years, 84 cases of open laparotomy, and conversion of open rate 13.95%. data using SPSS19.0 statistical analysis. First of all, single factor analysis (chi square test) showed the operation experience (the number of surgical cases less than 25 cases), the history of abdominal surgery, male sex, obesity (BM1 > 28), tumor diameter more than 6cm, tumor infiltration or metastasis Logistic multifactor analysis of the data is needed because of the common effects of a variety of factors that lead to laparoscopic recorectomy. The results show that the risk factors that lead to laparotomy in the laparoscopic rectectomy include the experience of the surgeon (the number of surgical cases is less than 25 cases), and the history of abdominal surgery, Men, obesity (BM1 > 28), tumor diameter more than 6cm, tumor infiltration or (and) metastasis. By 1ogistic analysis of the data, a mathematical function model for the possibility of laparotomy in the laparoscopic rectum is established as follows: according to the characteristics of multiple regression of Logistic and the characteristics of the coefficient of self variable (0R), it can be used before the laparoscopic resection of the rectum. Risk factors for transabdominal surgery were assigned: the operative experience (operative number or less than 25 cases) was 4, the history of abdominal surgery was 5, the male was 6, the obesity (BMI > 28) was 10, the tumor diameter was more than 6cm 15, the tumor metastasis or (and) infiltration was 21. According to the risk factors, the actual risk assignment of each patient was calculated and the total value of each patient was calculated. According to the total score of the patient's assignment and the conversion of the laparotomy, the ROC curve was drawn to calculate the area of the specificity and sensitivity of the different group and the sensitivity.ROC curve of 0.876. When the corresponding standard was 14.5 for 0.021., the sensitivity of the ROC curve was 0.786 and the specificity was 0.861. When the score was below 14.5 points, the open abdominal rate was 3.8. 8% (18/464), when the transfer rate was 47.83% (66/138) when the score was higher than 14.5 (P0.001), there was a significant statistical difference (P0.001). Finally, the pre operation prediction scoring system for laparotomy was established, and the pre operation score of the laparotomy included the operative experience (the number of surgical cases in 25 cases), the history of abdominal surgery, men, and obesity (BM1 > 28). 6 variables, such as tumor diameter more than 6cm, tumor infiltration or (and) metastasis, were assigned to 4 points, 5 points, 6 points, 10 points, 15 points, 21 points. If the total score was higher than 14.5, the patients were not recommended for laparoscopic rectal surgery, such as the total score of less than 14.5, and 100 cases of laparoscopic surgery for Tengzhou Central People's Hospital were recommended. Patients with rectal excision, preoperative calculation score and clinical use effect of scoring system were performed by laparoscopic rectal excision, of which 14 cases were transferred, 14 cases were transferred, the transfer rate was lower than 14.5 in 88, 4, 4.55%, 12, 10, 83.33%, and two groups. The abdominal rate was statistically different (P0.05). Conclusions: 1, surgical experience (number of cases or less than 25 cases), history of abdominal surgery, male, obesity (BMI > 28), tumor diameter more than 6cm, tumor infiltration or (and) metastasis are the risk factors for the preoperative transabdominal surgery in laparoscopic rectal excision (.2), clinical application of laparoscopic rectal excision and laparotomy score (LRT O-2014) can effectively reduce the rate of transabdominal surgery and avoid unnecessary transabdominal.3. With the application of new technology, the invention of the new apparatus, the development of the new concept, the history of abdominal surgery, the diameter of the tumor more than 6cm, the preoperative risk factors of tumor infiltration or (and) metastasis have gradually reduced the effect of the laparotomy, while the surgeon experienced the laparoscopy. After the rectum resection learning curve and gained relatively rich surgical experience, the influence of surgical experience on conversion to laparotomy remained relatively stable.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R657.1

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10 張U，

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