【摘要】：[目的]通過(guò)回顧性研究腹腔鏡膽囊切除術(shù)患者行臨床路徑情況,分析臨床路徑變異原因,減少臨床路徑中途退徑病例,完善腹腔鏡膽囊切除術(shù)的臨床路徑。[方法]回顧分析了 2015年1月-2016年12月在昆明醫(yī)科大學(xué)附屬甘美醫(yī)院行腹腔鏡膽囊切除術(shù)的臨床路徑患者的臨床資料。納入標(biāo)準(zhǔn):行LC的所有臨床路徑病例,排除標(biāo)準(zhǔn):未行臨床路徑的LC病例。分為臨床路徑完成組(A組)和臨床路徑中途退徑組(B組),其中B組分為行手術(shù)治療組(B1組)和未手術(shù)治療組(B2組)。分析A組和B組的年齡、性別、術(shù)前及術(shù)后的血常規(guī)、肝腎功能、超敏C反應(yīng)蛋白、術(shù)前及術(shù)后腹部超聲檢查、總住院時(shí)間、住院費(fèi)用。還有B組中途退徑的原因分析,總結(jié)并改善臨床路徑的完成率。統(tǒng)計(jì)學(xué)分析采用SPSS20.0軟件,計(jì)量資料的差異采用非參數(shù)Mann-Whitney檢驗(yàn);計(jì)數(shù)資料采用x2檢驗(yàn)(或Fisher精確檢驗(yàn))進(jìn)行差異性分析。P0.05認(rèn)為結(jié)果具有統(tǒng)計(jì)學(xué)意義。[結(jié)果]1.符合納入標(biāo)準(zhǔn)的病例共231例,其中順利完成臨床路徑的有182例(A組),占78.79%,年齡18-82歲,平均年齡約46.54±0.90歲,男性64例,女性118例,男女性別比為1:1.84。未完成臨床路徑的病例有49例(B組),占21.21%,年齡24-85歲,平均年齡約50.73±1.99歲,男性28例,女性21例,男女性別比為1.33:1。2.A組住院天數(shù)要明顯少于B組,5.79±0.15天VS.11.53±0.73天,差異有統(tǒng)計(jì)學(xué)意義(P0.0001);且A組住院費(fèi)用明顯低于B組,7931±159.9元VS.12120±705.7元,差異有統(tǒng)計(jì)學(xué)意義(P0.0001)。3.A組手術(shù)率100%,治愈率100%,B組手術(shù)率53.06%,手術(shù)治愈率100%。所有手術(shù)后無(wú)并發(fā)癥,如膽漏、出血、感染等。臨床路徑退出組(B組)術(shù)前ALT、AST、術(shù)后CRP高于臨床路徑完成組,且超出正常范圍(96.24IU/L vs.44.97IU/L,P=0.0054;44.24IU/L vs.29.52IU/L;P=0.023;57.54mg/Lvs.34.06mg/L,P=0.010),差異有統(tǒng)計(jì)學(xué)意義。其他臨床指標(biāo)如TBIL、ALB等兩組間未見(jiàn)明顯差異。4.本研究中臨床路徑完成組(A組)共182人,退出組(B組)49人,平均年齡分別為:46.54歲±0.90 VS.50.73歲±1.99,P0.05,其中老年患者(65歲)比例分別為:4.40%(8/182)VS.12.24%(6/49),B組老年患者比例要高于A組,但差異無(wú)統(tǒng)計(jì)學(xué)意義(P=0.051);臨床路徑退出組中男性患者比例要明顯高于臨床路徑完成組:35.2%(64/182)VS.57.1%(28/49),差異有統(tǒng)計(jì)學(xué)意義(P=0.005)。臨床路徑退出組(B組),有26例病例(B1組)行手術(shù)治療,23病例(B2組)未行手術(shù),手術(shù)率為53.06%。B1組分為4類(lèi),第一類(lèi)(B1a)完成LC,術(shù)后出現(xiàn)與手術(shù)無(wú)關(guān)的癥狀中轉(zhuǎn)退出5例,第二類(lèi)(B1b)直接行開(kāi)腹膽囊切除術(shù)和/或膽道探查術(shù)6例,第三類(lèi)(B1c)先行LC后中轉(zhuǎn)開(kāi)腹8例,第四類(lèi)(B1d)術(shù)前行相關(guān)檢查或女性月經(jīng)來(lái)潮延期LC手術(shù)7例。B2組也分為四類(lèi),第一類(lèi)(B2a)因手術(shù)風(fēng)險(xiǎn)大,未行手術(shù)3例,第二類(lèi)(B2b)因無(wú)手術(shù)指征未行手術(shù)3例,第三類(lèi)(B2c)拒絕手術(shù)治療8例,第四類(lèi)(B2d)術(shù)前發(fā)現(xiàn)其他疾病完善檢查未予手術(shù)9例�？煽刈儺惒±�21例,包括部分B1b組、B1d組、B2a組和B2c組,占42.85%,非可控變異病例有28例,是LC臨床路徑變異的主要原因。[結(jié)論]1.腹腔鏡膽囊切除術(shù)行臨床路徑能縮短住院時(shí)間和減少住院費(fèi)用。2.男性患者發(fā)生臨床路徑變異的可能性更高。3.非可控因素是腹腔鏡膽囊切除術(shù)臨床路徑變異的主要原因。4.通過(guò)優(yōu)化術(shù)前評(píng)估和管理,可進(jìn)一步降低可控因素導(dǎo)致的腹腔鏡膽囊切除術(shù)臨床路徑變異。
[Abstract]:[Objective] To retrospectively study the clinical pathway of laparoscopic cholecystectomy (LC) patients, analyze the causes of variation of clinical pathway, reduce the cases of retrogression of clinical pathway, and improve the clinical pathway of LC. [Methods] Laparoscopic cholecystectomy was performed in Ganmei Hospital Affiliated to Kunming Medical University from January 2015 to December 2016. Inclusion criteria: All clinical pathway cases of LC, exclusion criteria: LC cases without clinical pathway were divided into clinical pathway completion group (group A) and clinical pathway midway retreat group (group B), of which group B was divided into surgical treatment group (group B1) and non-surgical treatment group (group B2). Age, sex, preoperative and postoperative blood routine, liver and kidney function, high-sensitivity C-reactive protein, preoperative and postoperative abdominal ultrasonography, total length of hospital stay, hospitalization costs. There were also reasons for group B midway retreat to summarize and improve the completion rate of clinical pathway. Statistical analysis using SPSS20.0 software, non-parametric Mann-Whitne measurement data differences. P 0.05 showed that the results were statistically significant. [Results] 1. A total of 231 cases met the inclusion criteria, of which 182 cases (group A) successfully completed the clinical pathway, accounting for 78.79%, 18-82 years old, with an average age of 46.54 (+ 0.90), 64 males, 118 females, and 118 males. The female sex ratio was 1:1.84. There were 49 cases (group B), accounting for 21.21%, aged 24-85 years, with an average age of 50.73 + 1.99 years. There were 28 males and 21 females. The male-female sex ratio was 1.33:1.2. The operation rate was 100%, the cure rate was 100%, the operation rate was 53.06% and the cure rate was 100%. There were no postoperative complications, such as bile leakage, bleeding, infection and so on. ALT, AST and CRP in group B were higher than those in group B before operation and after operation. Normal range (96.24 IU/L vs. 44.97 IU/L, P = 0.0054; 44.24 IU/L vs. 29.52 IU/L; P = 0.023; 57.54 mg/L vs. 34.06 mg/L, P = 0.010), the difference was statistically significant. Other clinical indicators such as TBIL, ALB were not significantly different between the two groups. S.50.73 years old (+ 1.99), P 0.05, in which the proportion of elderly patients (65 years old) were 4.40% (8/182) VS.12.24% (6/49), the proportion of elderly patients in group B was higher than that in group A, but the difference was not statistically significant (P = 0.051); the proportion of male patients in the withdrawal group of clinical pathway was significantly higher than that in the completion of clinical pathway group (35.2% (64/182) VS.57.1% (28/49), the difference was statistically significant (P In group B, 26 cases (group B1) were operated on, 23 cases (group B2) were not operated on, and the operation rate was 53.06%. Group B1 was classified into 4 groups, the first group (B1a) completed LC, 5 cases were withdrawn from the operation, the second group (B1b) underwent open cholecystectomy and / or bile duct exploration, the third group (B1c) underwent open cholecystectomy directly. Eight patients underwent LC before laparotomy, seven patients underwent pre-operative examination or delayed menstrual surgery in the fourth group (B1d). Group B2 was also divided into four groups. The first group (B2a) did not undergo surgery because of the high risk of surgery, the second group (B2b) did not undergo surgery because of no surgical indications, the third group (B2c) refused surgery in 8 cases, and the fourth group (B2d) found other diseases before surgery. There were 21 controllable variant cases, including some B1b group, B1d group, B2a group and B2c group, accounting for 42.85%. 28 uncontrollable variant cases were the main reason for the variation of LC clinical pathway. [Conclusion] 1. Laparoscopic cholecystectomy with clinical pathway can shorten the length of hospital stay and reduce the cost of hospitalization. 2. Male patients with clinical pathway. Uncontrollable factors are the main reason for the variation of clinical pathways in laparoscopic cholecystectomy. 4. By optimizing preoperative evaluation and management, the variation of clinical pathways in laparoscopic cholecystectomy caused by controllable factors can be further reduced.
【學(xué)位授予單位】：昆明醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R657.4

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