急性肠系膜静脉血栓形成致透壁性肠坏死的临床危险因素分析  

Clinical risk factors for transmural intestinal necrosis in acute mesenteric venous thrombosis

作　　者：黄应雄[1] 叶子[1] 蒋鹏[1] 詹红[1] 姚陈[2] 崔冀[3] Huang Yingxiong;Ye Zi;Jiang Peng;Zhan Hong;Yao Chen;Cui Ji(Department of Emergency,the First Affiliated Hospital of Sun Yat-sen University,Guangzhou 510080,China;Department of Vascular Surgery,the First Affiliated Hospital of Sun Yat-sen University,Guangzhou 510080,China;Department of Gastrointestinal Surgery,the First Affiliated Hospital of Sun Yat-sen University,Guangzhou 510080,China)

机构地区：[1]中山大学附属第一医院急诊科,广州510080 [2]中山大学附属第一医院血管外科,广州510080 [3]中山大学附属第一医院胃肠外科,广州510080

出　　处：《中华普通外科学文献（电子版）》2023年第6期413-421,共9页Chinese Archives of General Surgery(Electronic Edition)

基　　金：广东省医学科学技术研究基金项目(A2023101);广东省自然科学基金面上项目(2022A1515012457)。

摘　　要：目的探讨急性肠系膜静脉血栓形成(MVT)致透壁性肠坏死(TIN)的临床危险因素,并建立预测模型。方法回顾性分析2010年1月至2017年12月中山大学附属第一医院经急诊收治最终诊断为急性MVT的患者102例。根据肠切除术后的病理观察及随访结果,将患者分为TIN组(35例)和非TIN组(67例)。收集并比较两组患者的临床症状、生命体征、腹部体征、急诊首次实验室检查及CT等临床资料,采用多因素Logistic回归分析急性MVT致TIN的临床危险因素,应用受试者工作特征(ROC)曲线评价危险因素预测TIN的价值。结果102例急性MVT患者中,男性77例(75.5%),年龄(42.9±14.9)岁,中位随访时间40(3~84)个月。41例于首次入院后行剖腹探查,其中40例(39.21%)行肠切除术,术后病理分析31例发生TIN,9例为小肠黏膜及黏膜下坏死;剩余61例于首次入院后行非手术治疗,其中2例因广泛肠坏死无法行肠切除病死,2例在3个月的随访期内因发生肠坏死行肠切除术。62例(60.8%)存在MVT的继发性病因。多因素Logistic回归分析显示,血白细胞(WBC)计数>14.87×10^(9)/L(OR=10.574,95%CI:1.762~63.468;P=0.010)、凝血酶时间(TT)≤15.9 s(OR=7.880,95%CI:1.302~47.696;P=0.025)、CT显示中量腹腔积液(OR=11.730,95%CI:1.747~78.753;P=0.011)为急性MVT致TIN的独立危险因素。存在0、1、2和3个独立危险因素的急性MVT患者发生TIN的风险分别为0、4.76%、54.55%和100.00%,依据危险因素建立预测模型,其对急性MVT致TIN的预测性能较高,ROC曲线下面积为0.928(95%CI:0.848~0.974)。结论WBC>14.87×10^(9)/L、TT≤15.9 s和CT显示中量腹腔积液,是急性MVT患者发生TIN的独立危险因素。密切监测这些危险因素可以避免不必要的手术和肠切除,减少TIN进行手术治疗的延误。Objective To investigate clinical risk factors for transmural intestinal necrosis(TIN)in acute mesenteric venous thrombosis(MVT)and establish a predictive model for TIN.Methods A retrospective analysis was carried out in 102 consecutive patients admitted to Department of Emergency in the First Affiliated Hospital of Sun Yat-sen University with diagnosis of acute MVT during January 2010 and December 2017.These patients were divided into TIN group(35 cases)and non-TIN group(67 cases)based on histopathologic examination of the resected bowel intraoperatively and clinical follow-up.Clinical data including symptoms,vital signs,abdominal physical examination,laboratory results and CT investigations at admission were collected.Multivariable logistic regression analysis was conducted to identify risk factors for TIN of acute MVT,and the receiver operating characteristics(ROC)curve was used to assess the prediction value of the risk factors for TIN.Results Of the 102 patients with acute MVT,there were 77 males(75.5%),with a age of(42.9±14.9)years old,and the median follow-up period was 40 months(ranging from 3 to 84 months).A total of 41 patients experienced exploratory laparotomy during first hospitalization and 40(39.21%)of them underwent intestinal resection,whereas only 31 patients were diagnosed with TIN by histopathologic examination of the resected bowel,and the rest 9 patients were identified to have mucosal necrosis without TIN.61 patients received conservative treatment during first hospitalization,2 of whom were unable to undergo surgery as the extensive intestinal necrosis and died soon,whereas 2 patients failed to respond to anticoagulation therapy and underwent intestinal resection within 3 months of follow-up period.A total of 62 patients(60.8%)were found to have secondary etiologies.Multivariable analysis using binary Logistic regression analysis showed that the significant independent predictors for TIN in patients with acute MVT were WBC count>14.87×10^(9)/L(OR=10.574,95%CI:1.762-63.468;P=0.010),TT≤1

关 键 词：肠系膜静脉血栓形成 透壁性肠坏死 危险因素 肠切除 

分 类 号：R65[医药卫生—外科学]