胰十二指肠切除术后复杂腹腔感染的危险因素分析及病原菌构成

目的通过探讨胰十二指肠切除术（PD）后发生复杂腹腔感染（cIAI）的相关影响因素及病原菌构成,为PD后cIAI的预防提供一定的依据。 方法回顾性分析2010年1月至2020年1月于宁夏医科大学总医院行PD患者病例资料,按照纳入标准收集发生cIAI 89例为感染组;从360余例未发生cIAI患者中按照约1∶1的比例等距随机抽样91例为对照组。收集感染组术后引流液的细菌培养情况,统计描述病原菌构成;单因素和多因素Logistic回归分析PD后发生cIAI的危险因素。 结果术前减黄（OR=6.569,95% CI：1.178~14.630）、手术时间≥6 h（OR=6.872,95% CI：2.258~20.913）和术后胰瘘（OR=3.426,95% CI：1.219~9.631）是PD后发生cIAI的危险因素（均P<0.05）。培养菌株28种,革兰阴性菌以大肠埃希菌、阴沟肠杆菌、肺炎克雷伯菌居多（总构成比为50.00%）,革兰阳性菌以屎肠球菌居多（构成比为52.17%）,真菌中以白色念珠菌居多（构成比为92.86%）。 结论PD后发生cIAI病情危重,合理的术前减黄及缩短手术时间对于cIAI的预防尤为重要,应及时合理应用抗生素进行综合治疗。     

Risk factors and management of intra-abdominal infection after extended radical gastrectomy

Background

This study elucidated risk factors and management for intra-abdominal infection after extended radical gastrectomy.

Methods

From 1988 to 2004, 2,076 patients with gastric cancer underwent extended radical gastrectomy at Taipei Veterans General Hospital. Risk factors for intra-abdominal infection were determined by analyzing clinicopathological factors, operative procedure, combined organ resection, operative time, blood loss, and associated disease(s). Management modalities were summarized.

Results

The overall complication rate was 18.7%. Eighty (3.9%) patients were found to have intra-abdominal infections. Age, prolonged operation time, and combined organ resection were the precipitating factors. These patients were categorized into 3 groups: intra-abdominal abscess with adequate drainage, intra-abdominal abscess without anastomotic leakage, and intra-abdominal abscess because of leakage. Adequate drainage was the primary treatment. Mortality rate was 22.5% (18), and the most common cause of mortality was intra-abdominal abscess caused by leakage.

Conclusions

Although expert surgical skills can minimize the incidence of intra-abdominal infection, management also requires experience and training.     

肝移植后受者真菌感染的易感因素分析

肝移植为治疗终末期肝病的有效手段.肝移植受者术后常继发真菌感染,其发生率为4%～48%,而病死率则高达50%～80%[1].探讨其易感因素,对真菌感染的预防及早期诊断,对提高疗效具有重要意义.     

腹腔镜阑尾切除术后腹腔脓肿的危险因素研究

目的:探讨腹腔镜阑尾切除术(laparoscopic appendectomy,LA)后发生腹腔脓肿的危险因素,为制定预防治疗措施提供依据。方法:回顾研究2013年1月至2015年6月561例行LA患者的临床资料,按性别、阑尾病理分型、有无糖尿病、是否腹腔冲洗及腹腔引流分组,比较术后腹腔脓肿的发生率。对发生腹腔脓肿者采用单因素分析及多因素分析进一步明确术后腹腔脓肿的危险因素。结果:561例患者中508例纳入本研究,其中14例(2.76%)术后发生腹腔脓肿,腹腔冲洗组术后脓肿发生率显著高于未冲洗组(9.02%vs.0.53%,P=0.001)。单因素分析结果显示,术后腹腔脓肿的危险因素包括年龄(P=0.001)、手术时间(P=0.031)、术后抗生素使用时间(P=0.000)、术中腹腔冲洗等。多因素分析结果显示,术中腹腔冲洗是引起LA术后腹腔脓肿的唯一危险因素(P=0.001),发生腹腔脓肿者术后抗生素使用时间显著延长。结论:术中腹腔冲洗是LA术后发生腹腔脓肿的独立危险因素,避免不必要的术中腹腔冲洗有助于预防LA术后腹腔脓肿的形成。     

Risk factors for mortality and intra-abdominal morbidity after distal pancreatectomy

BACKGROUND: The purpose of this study was to analyze the short-term outcome and to determine risk factors after distal pancreatectomy (DP). METHODS: This prospective single-center study included 61 patients undergoing DP with splenic preservation in 6 (10%). The diagnoses included pancreatic adenocarcinoma (n = 9), neuroendocrine neoplasms (n = 17), benign neoplasm (n = 26), pseudocyst (n = 4), chronic pancreatitis (n = 2), and other diagnoses (n = 3). Twelve clinical factors were studied. The chi-square test was used for univariate analysis. RESULTS: The median duration of the postoperative hospital stay was 10 days (range, 5-155 days). Two patients (3%) died postoperatively; 12 patients (20%) had one or more intra-abdominal complications with reoperation necessary in 3 patients (5%): 6 pancreatic fistula (10%), 11 intra-abdominal collections (18%), 1 postoperative hemorrhage (2%). Univariate analysis showed that a body mass index >25 kg/m 2 was the only risk factor for intra-abdominal complication ( P = .003). CONCLUSIONS: DP is associated with an intra-abdominal morbidity rate of 20%, which is increased for patients with a body mass index >25 kg/m 2 .     

肾移植术后深部真菌感染的危险因素评估

目的 探讨肾移植术后深部真菌感染的危险因素及其对预后的影响。 方法 对我院1994年1月至2008年5月2573例肾移植患者进行回顾性分析。根据术后是否有深部真菌感染将患者分为病例组和对照组,比较两组年龄、术前情况、术后并发症、引流管留置时间以及应用广谱抗生素和抗排斥药物的差异,找出引起术后深部真菌感染的危险因素。分析危险因素数目对深部真菌感染发病率和病死率,以及患者病死率和移植肾丧失功能率的影响。 结果 与对照组相比,病例组中高龄患者（≥60岁）较多（P < 0.05）;移植肾功能恢复延迟（DGF）、急性排斥、巨细胞病毒感染、肝功能异常、伤口愈合延迟、骨髓抑制等并发症的发生率较高（P < 0.05）;术后引流管留置时间>1周、应用广谱抗生素>1周以及使用抗胸腺细胞球蛋白、抗淋巴细胞球蛋白或抗CD3单克隆抗体抗排斥的患者比例较高（P < 0.01）。Logistic多因素回归分析表明高龄患者（≥60岁）、DGF、伤口愈合延迟、WBC<4.0×109和术后使用广谱抗生素>1周是诱发深部真菌感染的独立危险因素（P < 0.05）。随着危险因素数目的增加,深部真菌感染的发病率和病死率显著升高（χ2值分别为91.2和18.1,P < 0.01）,移植肾丧失功能率也显著增加（χ2 = 93.0,P < 0.01）。 结论 评估肾移植术后真菌感染危险因素,积极预防深部真菌感染,对改善肾移植预后有重要价值。     

Risk factors for cytomegalovirus infection and disease after kidney transplantation: A meta-analysis

ObjectiveTo investigate the risk factors for cytomegalovirus (CMV) infection and disease in kidney transplantation recipient, and provide references for the prevention and control of CMV infection and disease in kidney transplantation patients.MethodsChinese and international literature related to risk factors for CMV infection and disease in renal transplant recipients was searched using databases, including China National Knowledge Infrastructure; WanFang Data; Wiper; Chinese Biomedical Literature database; PubMed; Embase; Web of Science, and the Cochrane Register of Controlled Trials. Two researchers independently screened the literature, extracted the data, and evaluated the quality of the literature according to published standards. A meta-analysis was performed using RevMan 5.4 software to extract the risk factors for CMV infection and disease in renal transplant recipients.ResultsA total of 59,847 subjects were included in 24 studies. The risk factors for CMV infection were ATG [OR = 2.76, 95% CI (2.10, 3.63), P < 0.00001], Donor (D) CMV-IgG(+) Receptor (R)(−): (D+/R-) [OR = 2.97, 95% CI (1.63, 5.44), P = 0.004 < 0.05], recipient age [OR = 1.96, 95% CI (1.50, 2.54), P < 0.00001], lymphocytopenia [OR = 3.26, 95% CI (1.46, 7.31), P < 0.00001], and mycophenolate [OR = 3.22, 95% CI (2.02, 5.46), P < 0.00001]. The protective factor for CMV infection was glomerular filtration rate (GFR) [OR = 0.98, 95% CI (0.97, 0.99), P < 0.00001], and the uncertain factors were the use of tacrolimus [OR = 0.91, 95% CI (0.64, 1.28), P = 0.58 > 0.05], rejection [OR = 1.32, 95% CI (0.49, 3.53), P = 0.58 > 0.05], donor age [OR = 1.00, 95% CI (0.99, 1.01), P = 0.67 > 0.5], and preemptive therapy [OR = 0.51, 95% CI (0.11, 2.36), P = 0.86 > 0.05]. The risk factors for CMV disease were D+/R- [OR = 4.78, 95% CI (3.76, 6.07), P < 0.00001], ATG [OR = 1.83, 95% CI (1.25, 2.67), P < 0.00001], rejection [OR = 1.42, 95% CI (1.26, 1.59), P < 0.00001], mycophenolate [OR = 1.67, 95% CI (1.38, 2.02), P < 0.00001], recipient age [OR = 1.03, 95% CI (1.02, 1.03), P < 0.00001], donor age [OR = 1.01, 95% CI (1.00, 1.01), P = 0.001 < 0.05], Donor (D) CMV-IgG(+) Receptor(R)(+): (D+/R+) [OR = 1.92, 95% CI (1.49, 2.46), P < 0.00001], the use of prednisolone [OR = 1.59, 95% CI (1.32, 1.92), P < 0.00001], and diabetes mellitus[OR = 1.18, 95% CI (1.01, 1.37), P = 0.03 < 0.05], and the uncertain factors were donor type [OR = 4.10, 95% CI (0.28, 59.79), P = 0.30 > 0.05], time of transplantation [OR = 0.95, 95% CI (0.78, 1.16), P = 0.64 > 0.05], and the use of cyclosporine [OR = 1.50, 95% CI (0.62, 3.64), P = 0.37 > 0.05].ConclusionThere are many factors influencing CMV infection and disease in kidney transplant patients. Risk factors should be carefully monitored, protective factors strengthened, and more attention paid to uncertain factors.     

肝移植术后早期感染危险因素分析及预测

目的探讨肝移植术后早期(≤1个月)感染发生的危险因素并建立列线图预测模型。 方法回顾性分析2016年1月至2020年12月宁波大学附属李惠利医院肝移植中心200例同种异体肝移植受者临床资料。根据纳入和排除标准共收集181例受者的人口学数据、临床资料和病原菌检测结果,根据术后早期是否发生感染分为感染组(n＝96)和非感染组(n＝85)。分析受者术后早期感染菌群分布特点和相关危险因素,构建列线图并评价其拟合度、区分度和临床实用性。正态分布计量资料采用独立样本t检验比较,不符合正态分布计量资料采用Mann-Whitney U检验比较。分类变量采用χ²检验或Fisher确切概率法。采用Logistic回归分析进行多因素分析。采用R语言(4.1.2)软件rms包构建列线图模型,并通过Bootstrap自抽样法对模型进行内部验证;采用Hosmer-Lemeshow检验、校准曲线、受试者工作特征(ROC)曲线下面积、一致性指数(C指数)及临床决策曲线分析来评价列线图的校准度、区分度及临床实用性。P<0.05为差异有统计学意义。 结果纳入研究的181例受者中,肝移植术后早期感染发生率为53.0%(96/181),96例感染组受者共检出病原菌132株,以革兰阴性菌最为常见(42.4%)。受者术后2周内感染发生率最高(70.8%,68/96),感染常见部位为肺部和血行感染。多因素Logistic回归分析结果显示,受者女性(OR＝4.235,95%CI：1.577～11.370)、MELD评分≥20(OR＝3.742,95%CI：1.296～10.805)、Chlid-Pugh分级C级(OR＝3.346,95%CI：1.263～8.862)、术后呼吸机使用时间(OR＝1.036,95%CI：1.009～1.063)是肝移植术后早期感染的独立危险因素。根据上述独立危险因素建立列线图预测模型,经Bootstrap法进行内部验证,Hosmer-Lemeshow检验无统计学意义(χ²＝7.236,P>0.05),校正曲线贴近于理想曲线,预测模型与观测值具有较好的拟合度。C指数和ROC曲线下面积均为0.800(95%CI：0.735～0.865),模型具有良好的区分度。模型临床决策曲线在较广的阈值概率范围内(0.2～1.0),高于采用单一危险因素预测,显示该模型具有临床实用性。 结论肝移植受者性别、MELD评分、Child-Pugh分级和术后呼吸机使用时间是移植术后早期感染的独立危险因素,列线图对移植术后早期感染的预测效果良好。     

肝移植手术后肺部感染的危险因素分析

目的 探讨肝移植手术患者术后肺部感染的危险因素。
方法 回顾性分析2005年6月至2013年6月于三家临床医疗中心首次行原位肝移植手术的1 358例患者的临床资料。根据患者术后30 d内是否发生肺部感染将患者分成两组：感染组和非感染组。收集术前资料、术中资料及术后资料，采用单因素分析及二元Logistic回归分析肝移植术后肺部感染的危险因素。
结果 肝移植手术后有316例（23.3%）发生肺部感染，其中有21例（6.7%）死亡。与非感染组比较，感染组术前诊断为慢性重型肝炎、肝癌、丙型肝炎肝硬化、先天性肝脏疾病及肝衰竭、术前合并肝肾综合征、肝昏迷、糖尿病的比例、术前肌酐浓度明显升高（P<0.05），术前总蛋白、白蛋白浓度明显降低（P<0.05），无肝期时间、术后苏醒时间及术后拔管时间明显延长（P<0.05），术中失血量明显增加（P<0.05），术中尿量明显减少（P<0.05），术中使用去氧肾上腺素、阿托品、利多卡因及呋塞米的比例明显降低（P<0.05），术后死亡率明显升高（P<0.05）。二元Logistic回归分析显示：慢性重型肝炎、丙型肝炎肝硬化、肝衰竭、术前合并糖尿病、术中失血量>1 900 ml、术后苏醒时间>7.3 h是肝移植患者术后肺部感染的危险因素；手术方式（经典非转流原位肝移植）、术中使用利多卡因、术前总蛋白>64.6 g/L、术中尿量>1 800 ml是肝移植手术患者术后肺部感染的保护因素。
结论 术前诊断慢性重型肝炎、丙型肝炎肝硬化、肝衰竭、术前合并糖尿病、术中失血量>1 900 ml、术后苏醒时间>7.3 h是肝移植手术后肺部感染的危险因素。     

Risk factors for post-appendicectomy intra-abdominal abscess.

BACKGROUND: Appendicectomy is a common emergency operation, after which major complications are uncommon, however when they do occur they are a major cause of concern to patient and surgeon. This study aims to determine the incidence and risk factors for post-appendicectomy intra-abdominal abscess formation. METHOD: A retrospective review was undertaken of all appendicectomies undertaken in Christchurch Hospital between 1 January and 31 December 1995. Appendicectomies were identified from a database of histology. The patients' notes were reviewed and the surgical approach, histological diagnosis and postoperative complications identified. RESULTS: A total of 417 appendicectomies was identified of which 331 were open, 66 laparoscopic, and 20 undertaken at laparotomy. Mean day stays for each group were 4.4, 4.2 and 11.5 days, respectively. The percentages of patients with acute appendicitis in each group were 87, 58 and 35%. Histologically the appendix was inflamed in 80% (334) of patients (acute 232, chronic 15, perforated 56 and gangrenous 24). There were six postoperative intra-abdominal abscesses (1.4%), all occurring in the open appendicectomy group when the histology was either perforated or gangrenous appendicitis (P < 0.001). There were no cases of postoperative abscess formation following laparoscopic appendicectomy. All cases of postoperative intra-abdominal abscess were associated with perforated and/or gangrenous appendicitis (P < 0.001). The incidence of intra-abdominal abscesses was 7.5% with a perforated and/or gangrenous appendix. There were two cases of iatrogenic perforation following laparoscopic appendicectomy. CONCLUSION: The incidence of intra-abdominal abscess is 1.4% of all appendicectomies. The only identified risk factor for development of post-appendicectomy intra-abdominal abscess was the underlying pathology of gangrenous or perforated appendicitis.     

Risk factors for smoking abuse after heart transplantation

Patients (n = 103) were studied before heart transplantation with regard to smoking habits by means of a clinical interview, and 81 were submitted to Minnesota Multiphasic Personality Inventory (MMPI). After a mean time of 50.8 +/- 24.2 months from transplant, they were once again interviewed to ascertain their smoking habits after intervention. Nonsmokers (35 of 103) were still nonabusers. Of the remaining 68 patients who ceased smoking before heart transplant, 12 (17.6%) had returned to tobacco abuse. Dividing these 68 patients into two groups based upon the length of smoking cessation before heart transplant (less than 1 year: short term [ST] more than 1 year: long term [LT]), we noticed that the ST group showed a much greater rate of reabuse (8 of 20, 40%) than the LT group (4 of 48, 8.3%, P =.006). Analyzing six scales of MMPI, we found a statistically different score for self-control ability (scale K) in ST and LT smokers compared to nonsmokers (45.5 and 45.5 vs 51.2, P =.026), and for difficult adaptation (scale Ma) in ST compared both to LT smokers and nonsmokers (ST 57, LT 50.5, NS 47.6; P =.042 LT vs ST, P =.0005 ST vs NS). We concluded that patients who have recently decided to stop smoking and show after MMPI compilation a score of >50 for K and <50 for Ma scale have a higher risk of reabuse and need a greater effort by the transplant team to reinforce their will to stop smoking.     

Risk factors for biliary complications after liver transplantation

HYPOTHESIS: Biliary complications after liver transplantation can be predicted from perioperative factors. DESIGN: Retrospective analysis of data collected prospectively. SETTING: Tertiary referral center. PATIENTS: From October 5, 1991, through June 22, 2002, 230 patients received 241 consecutive orthotopic liver transplants. Patients were divided into those with (group 1) and those without (group 2) biliary complications. MAIN OUTCOME MEASURES: Postoperative outcomes, biliary leakage, and anastomotic stricture. RESULTS: The overall biliary complication rate was 20.7%, including bile leakage rate of 7.1% and anastomotic stricture rate of 16.2%. By means of univariate analysis, risk factors associated with biliary complications were preoperative serum bilirubin level (P = .003), international normalized ratio (P = .04), the use of stent or T-tube splinting of the anastomosis (P = .02), and the use of live-donor liver graft (P = .03). Stepwise logistic regression analysis demonstrated that the preoperative serum bilirubin level (relative risk [RR], 1.00), use of stent or T-tube splinting of the anastomosis (RR, 2.10), and use of live-donor liver graft (RR, 2.01) were independent risk factors predicting biliary complications after liver transplantation. Graft survival rates at 1, 3, and 5 years were 89.5%, 84.7%, and 79.7%, respectively, in group 1 and 84.7%, 78.4%, and 75.1%, respectively, in group 2 (P>.05). Patient survival rates at 1, 3, and 5 years were 89.1%, 86.5%, and 86.5%, respectively, in group 1, and 86.1%, 82.8%, and 81.0%, respectively, in group 2 (P>.05). CONCLUSIONS: Preoperative serum bilirubin level and the use of stent or T-tube splinting of the anastomosis and live-donor liver grafts were independent risk factors for biliary complications after liver transplantation. We postulated that high preoperative serum bilirubin level reflected severe liver disease and difficult hemostasis, leading to inadvertent injury to the anastomosis during graft rotation or manipulation for hemostasis. The use of a stent or a T tube predisposes to more complications. Further technical refinement is necessary for biliary reconstruction in live-donor liver transplantation.     

Risk factors for cardiovascular disease after renal transplantation

Cardiovascular diseases (CVD) have become the leading cause of mortality in renal transplant recipients. Well-known cardiovascular (CV) risk factors and graft dysfunction both play an important role in the development of the posttransplantation CV events. We studied 233 stable kidney transplant patients to establish the prevalence of CVD and to assess CV risk factors that can be evaluated (and modified) in daily clinical practice. While 6.2% of the patients had coronary heart disease (CHD) before the transplantation, 16% displayed at least 1 CV event posttransplantation. The most significant factors associated with CV events were as follows: gender, length of smoking, diabetes mellitus, hepatitis C virus antibodies (HCV), dyslipidemia, proteinuria, and serum creatinine levels.     

胃癌切除术后腹腔感染的影响因素

目的探讨胃癌切除术后腹腔感染的影响因素。方法采用病例对照研究的方法,对1728例胃癌患者的术前状态、肿瘤病理学因素和手术方法等指标进行Logistic回归分析。结果单因素分析发现,年龄、营养不良、慢性阻塞性肺病、糖尿病、心脏病、凝血酶原时间、淋巴细胞计数、肿瘤长径、腹水、侵及周围脏器、TNM分期、胃切除方式、术中失血量、手术时间、术中输血和淋巴结清扫范围等16个因素与胃癌术后腹腔感染的发生有关;多因素分析显示,有7个独立危险因素与胃癌术后腹腔感染的发生有关,其作用由强到弱依次为：淋巴结清扫范围（N2^＋-N3和N2）、肿瘤侵及周围脏器、糖尿病、手术时间、年龄、淋巴细胞计数。结论应针对胃癌术后IAI发生的上述主要影响因素进行必要的干预。     

胰十二指肠切除术后腹腔感染细菌学和耐药性及其危险因素分析

目的总结胰十二指肠切除术后腹腔内感染的规律,探讨其主要危险因素,为防治感染提供依据。方法回顾性分析165例胰十二指肠切除术后腹腔感染患者细菌学及耐药性资料,比较研究围手术期因素和感染发生的相关性。结果65例患者腹腔引流液标本培养阳性,35例患者符合腹腔内感染诊断标准。共分离出118株菌珠,其中革兰阴性杆菌64株,占54.2%,革兰阳性球菌43株,占36.4%。前5位病原菌依次为金黄色葡萄球菌20例、铜绿假单胞菌19例、大肠埃希菌9例、肺炎克雷伯菌9例和粪肠球菌9例。72%的致病菌发生于术后2周内。病原菌大多为多重耐药。甲氧西林耐药金黄色葡萄球菌的检出率占金黄色葡萄球菌感染的40%,多重耐药性肠球菌较以往增加,未发现对万古霉素耐药的革兰阳性球菌。铜绿假单胞菌对亚胺培南的耐药率达68%。超广谱β-内酰胺酶的检出率在大肠埃希菌和肺炎克雷伯菌中分别为22%和33%,产超广谱β-内酰胺酶菌珠对大多数β内酰胺类抗生素高度耐药。感染相关的因素包括术前放化疗、胰漏(瘘)和肺部感染。结论胰十二指肠切除术后腹腔感染的病原菌以革兰阴性菌为主。大多数细菌具有多重耐药性。当术前行放化疗,术后合并胰漏(瘘)和肺部感染时,腹腔感染发病率显著增高。