胆道手术的风险预测

目的寻找影响肝内外胆管手术预后的因素。方法对本院实施的肝内外胆管手术进行回顾性分析，遴选出31个可能导致术后并发症和死亡的临床及实验室参数，先对其进行单因素筛选，将有统计学意义的因素再进行Logistic逐步回归分析。结果457例（次）病人发生并发症74例（16．16％），死亡18例（3．94％）。与死亡有关的并发症包括：腹腔感染，肺部感染，急性肾衰竭，肝衰竭，多器官功能衰竭。Logistic逐步回归分析得出7个影响术后并发症和死亡的因素：①男性；②恶性病；③手术时间〉4h；④年龄〉60岁；⑤低蛋白血症；⑥低钠血症；⑦高胆红素血症。当影响因素≤2个时（低危病人），并发症率为13．02％，病死率为0．55％；当影响因素〉2个时（高危病人），并发症率为28．13％，病死率为16．67％；低危病人与高危病人之间比较并发症率、病死率均有统计学意义（P〈0．0001）。结论高危病人术后并发症率和病死率明显升高，且随影响因素个数的增多而升高。感染性并发症、梗阻性黄疸术后急性肾衰竭发生率较高。提示加强围手术期的抗感染、营养支持治疗，合理纠正低钠血症，积极防治急性肾衰竭可能是减少手术并发症和死亡的主要手段。

Risk prediction for biliary tract surgery

Objective To investigate the risk factors affecting prognosis after intra-or extrahepatic biliary tract surgery. Methods Retrospective analysis was performed in a consecutive series of 457 patients undergoing biliary tract surgery. Multiple preoperative and intraoperative variables were examined. Pearson chi-square analysis or Fisher's exact test, when appropriate, was used for univari-ate comparison of all the variables. Logistic stepwise regression was taken for multivariate analysis. Results Single analysis showed that 16 parameters had a significant correlation with hospital mortality. Stepwise logistic regression revealed that 7 parameters including male, age over 60 years, malignancy, operation duration longer than 4 h, hypoalbuminemia, hyponatremia and hyperbilirubinemia were independent in predicting postoperative mortality and morbidity. Risk factors over 2 were found to be associated with increased postoperative morbidity (28. 13%) and mortality (16. 67%) as compared with those less than 2 (P<0. 0001). The mortality and morbidity were proportionally increased in the patients with 3 or more than 3 risk factors. Conclusions The postoperative morbidity and mortality increase along with the increase in number of factors. Preoperative correction of hyponatremia and hypoalbuminemia, adequate nutritional support in perioperative period and wise choice of proper surgical procedure might be useful in decreasing morbidity and mortality in biliary tract surgery. Meanwhile, the prevention of renal failure in patients with biliary obstruction is important.