粘连性腹内疝手术并发症危险因素分析

Risk Factors for Surgical Complications in Patients with Adhesive Internal Hernia

摘要: 目的：分析粘连性腹内疝患者术中及术后总体并发症的发生情况及危险因素，重点探讨发病至手术时间对并发症的影响，为临床手术时机选择提供参考。方法：回顾性收集本院经手术证实的粘连性腹内疝患者临床资料，共64例。根据自觉症状出现至手术时间将患者分为3组：a组(≤1 d，20例)、b组(1 d < 时间 ≤ 3 d，13例)、c组(>3 d，31例)。将术中肠缺血、肠穿孔、肠切除以及术后3个月内并发症(如切口感染、腹腔感染、梗阻复发等)合并定义为“总体并发症”，比较不同发病时间组间并发症发生情况及相关临床特征。以总体并发症为因变量，纳入年龄、体重指数(body mass index, BMI)、白细胞计数(white blood cell, WBC)、C反应蛋白(C-reactive protein, CRP)、白蛋白(albumin, ALB)、肌酐(creatinine, CR)、术前影像学特征(闭袢征象、肠壁水肿、腹水)、既往腹部手术史、既往小肠梗阻史、合并基础疾病及发病时间分组等具有临床意义且单因素分析P < 0.10的变量，采用多因素Logistic回归模型分析总体并发症的独立危险因素。结果：64例患者中，总体并发症发生32例(50.0%)。a、b、c组三组总体并发症发生率分别为30.0% (6/20)、69.2% (9/13)、54.8% (17/31)，差异有统计学意义(χ² = 6.62, P = 0.036)。其中肠缺血26例(40.6%)、肠切除26例(40.6%)、肠穿孔2例(3.1%)，术后3个月内并发症8例(12.5%)。多因素Logistic回归分析结果显示，在校正年龄、BMI、WBC、CRP、ALB、CR、术前影像学特征、既往腹部手术史、既往小肠梗阻史及合并基础疾病后，与发病时间 ≤ 1 d的a组相比，b组(1~3 d)总体并发症风险显著增加(OR = 11.58, 95%CI 1.56~86.00, P = 0.017)，c组(>3 d)总体并发症风险亦显著升高(OR = 5.56, 95%CI 1.01~30.54, P = 0.048)；既往小肠梗阻史(OR = 7.73, 95%CI 0.71~83.83, P = 0.093)及合并基础疾病(OR=5.26, 95%CI 0.86~32.02, P = 0.072)与总体并发症呈正相关趋势，但差异未达统计学意义。结论：粘连性腹内疝患者总体并发症发生率较高，手术时机延长是影响手术并发症的独立危险因素，发病时间超过24 h明显增加术中及术后总体并发症风险。对于临床高度怀疑粘连性腹内疝且存在肠缺血高危因素的患者，应在积极短期非手术治疗评估基础上尽早手术干预，避免发病时间延长，可能有助于降低并发症发生率和改善预后。

Abstract: Objective: This paper aims to analyze the incidence and risk factors of overall intraoperative and postoperative complications in patients with adhesive internal hernia, with a particular focus on the impact of the interval from symptom onset to surgery, so as to provide evidence for optimization of surgical timing. Methods: Clinical data of 64 patients with adhesive internal hernia confirmed by surgery in our hospital were retrospectively collected. According to the time from symptom onset to operation, patients were divided into three groups: group a (≤1 day, n = 20), group b (1 < time ≤ 3 days, n = 13), and group c (>3 days, n = 31). Intraoperative bowel ischemia, bowel perforation, bowel resection, and postoperative complications within 3 months (including wound infection, intra-abdominal infection, and recurrent obstruction) were combined and defined as “overall complications”. The incidence of overall complications and related clinical characteristics were compared among the three groups. Overall complications were used as the dependent variable. Age, body mass index (BMI), white blood cell count (WBC), C-reactive protein (CRP), albumin (ALB), creatinine (CR), preoperative imaging features (closed-loop sign, bowel wall edema, ascites), history of abdominal surgery, history of small bowel obstruction, underlying diseases, and onset-to-surgery groups, which were clinically relevant and had P < 0.10 in univariate analyses, were entered into a multivariate logistic regression model to identify independent risk factors. Results: Overall complications occurred in 32 of the 64 patients (50.0%). The incidence of overall complications in groups a, b, and c was 30.0% (6/20), 69.2% (9/13), and 54.8% (17/31), respectively (χ² = 6.62, P = 0.036). Bowel ischemia and bowel resection were observed in 26 patients each (40.6%), bowel perforation in 2 (3.1%), and postoperative complications within 3 months in 8 (12.5%). Multivariate logistic regression showed that, after adjustment for age, BMI, WBC, CRP, ALB, CR, preoperative imaging features, previous abdominal surgery, history of small bowel obstruction, and underlying diseases, patients in group b (1 < time ≤ 3 days) had a significantly higher risk of overall complications than those in group a (≤1 day) (OR = 11.58, 95%CI: 1.56–86.00, P = 0.017), and patients in group c (>3 days) also had an increased risk (OR = 5.56, 95%CI: 1.01–30.54, P = 0.048). A history of small bowel obstruction (OR = 7.73, 95%CI: 0.71~83.83, P = 0.093) and underlying diseases (OR = 5.26, 95%CI: 0.86~32.02, P = 0.072) showed a positive association with overall complications but did not reach statistical significance. Conclusions: Patients with adhesive internal hernia have a high incidence of overall complications, and delayed surgical timing is an independent risk factor for perioperative complications. A symptom onset-to-surgery interval exceeding 24 hours markedly increases the risk of overall intraoperative and postoperative complications. For patients with a strong clinical suspicion of adhesive internal hernia and high-risk features for bowel ischemia, early surgical intervention after a short period of careful non-operative assessment is recommended to avoid prolonged symptom duration, which may help reduce the incidence of complications and improve prognosis.