背景:术后肠梗阻(POI)是腹部大手术后的常见并发症。关于腹部手术后POI的大部分可用数据来自胃肠道和泌尿外科文献。这些数据已经被推断为血管手术,特别是关于开放式腹主动脉瘤(AAA)手术的强化康复计划。然而,血管患者是一个独特的患者群体,对胃肠道和泌尿系统数据进行外推可能不一定合适.因此,本研究的目的是描述开放性AAA手术患者POI的患病率和危险因素.
方法:这是一个回顾性研究,2016年1月至2023年7月接受开放式AAA手术患者的单机构研究.如果患者接受了非选择性修复或在索引手术后72小时内过期,则将其排除在外。主要结果是POI率,定义为术后第三天后出现以下两种或两种以上症状:恶心和/或呕吐,不能耐受口服食物摄入,没有肠胃气,腹胀,或者肠梗阻的放射学证据.
结果:共有123例患者符合研究标准,总体POI率为8.9%(n=11)。发生POI的患者的BMI明显较低(24.3kg/m2对27.1kg/m2,P=.003),更有可能接受经腹膜入路(81.8%对42.0%,P=.022),中线剖腹手术(81.8%对37.5%,P=.008),更长的总夹紧时间(151.6分钟对97.7分钟,P=.018),术中晶体液输注量较多(3495mL对2628mL,P=.029),更有可能回到手术室(27.3%对3.6%,P=.016)。近端钳夹部位与POI无关(P=0.463)。POI患者术后血管加压药使用率也较高(100%vs61.1%,P=.014),术后前3天口服吗啡当量较多(488.0mg216.0对203.8mg29.6P=.016)。发生POI的患者有更长的住院时间(12.5天对7.6天,P<.001),NGT减压持续时间更长(5.9天比2.2天,P<.001),和更长的饮食耐受时间(9.1天对3.7天,P<.001)。在那些开发POI的人中(n=11),4人(36.4%)在入院期间需要父母的总营养。
结论:POI是接受择期开放AAA手术的患者的一种病态并发症,可显著延长住院时间。有发展POI风险的患者是BMI较低的患者,通过腹膜入路进行了手术修复,中线剖腹手术,更长的夹紧时间,术中输注大量晶体,回到手术室,术后血管加压药的使用,和更高的口服吗啡当量。这些数据突出了降低POI患病率的重要围手术期机会。
BACKGROUND: Postoperative ileus (POI) is a common complication following major abdominal surgery. The majority of the data available regarding POI following abdominal surgery is from the
gastrointestinal and urologic literature. These data have been extrapolated to vascular surgery, especially with regards to enhanced recovery programs for open abdominal aortic aneurysm (AAA) surgery. However, vascular patients are a unique patient population and extrapolation of
gastrointestinal and urological data may not necessarily be appropriate. Therefore, the purpose of this study was to delineate the prevalence and risk factors of POI in patients undergoing open AAA surgery.
METHODS: This was a retrospective, single-institution study of patients who underwent open AAA surgery from January 2016 to July 2023. Patients were excluded if they had undergone non-elective repairs or had expired within 72 hours of their index operation. The primary outcome was rates of POI, which was defined as the presence of two or more of the following after the third postoperative day: nausea and/or vomiting, inability to tolerate oral food intake, absence of flatus, abdominal distension, or radiological evidence of ileus.
RESULTS: A total of 123 patients met study criteria with an overall POI rate of 8.9% (n=11). Patients who developed a POI had significantly lower BMIs (24.3 kg/m2 versus 27.1 kg/m2, P=.003), were more likely to undergo a transperitoneal approach (81.8% versus 42.0%, P=.022), midline laparotomy (81.8% versus 37.5%, P=.008), longer total clamp times (151.6 minutes versus 97.7 minutes, P=.018), larger amounts of intraoperative crystalloid infusion (3495 mL versus 2628 mL, P=.029), and were more likely to return to the operating room (27.3% versus 3.6%, P=.016). Proximal clamp site was not associated with POI (P=.463). POI patients also had higher rates of post-operative vasopressor use (100% versus 61.1%, P=.014) and larger amounts of oral morphine equivalents in the first 3 post-operative days (488.0 mg + 216.0 versus 203.8 mg + 29.6 P=.016). Patients who developed POI had longer lengths of stay (12.5 days versus 7.6 days, P<.001), longer duration of NGT decompression (5.9 days versus 2.2 days, P<.001), and a longer period of time before diet tolerance (9.1 days versus 3.7 days, P<.001). Of those that developed a POI (n=11), 4 (36.4%) required total parental nutrition during the admission.
CONCLUSIONS: POI is a morbid complication amongst patients undergoing elective open AAA surgery that significantly prolongs hospital stay. Patients at risk for developing a POI are those with lower BMIs, had an operative repair via a transperitoneal approach, midline laparotomy, longer clamp times, larger amounts of intraoperative crystalloid infusion, a return to the operating room, post-operative vasopressor use, and higher amounts of oral morphine equivalents. These data highlight important peri-operative opportunities to reduce the prevalence of POI.