胃十二指腸潰瘍穿孔的手術治療: 是否越簡單越好?

SURGICAL MANAGEMENT OF PERFORATED GASTRODUODENAL ULCERS: IS THE LESS THE BETTER?

背景與目的：既使目前許多藥物能有效治療上消化道潰瘍，然而「潰瘍穿孔」的病人仍是一個困難的臨床問題，持續挑戰著外科醫師。本研究探討潰瘍穿孔之手術處理的初期死亡和併發症之危險因子，以及如何有效改善臨床結果。

研究方法：我們依照回顧性的方式收集所有自1997年一月一日至2002年十二月31日到中部某家醫學中心接受消化性潰瘍穿孔手術治療的外科病人，對其背景資料、急診處置、手術種類、術中的發現，以及併發症與死亡率作分析與比較。統計學上有意義的標準則訂在p<0.05。

研究結果：在回溯研究的六年內，一共有444名病人接受手術治療潰瘍穿孔。病人平均年齡為54.5  19.3歲。男性與女性的分佈為344:100。整體的死亡率與重要併發症的比率各為12.6% 與 24.8%。根據多元邏輯迴歸分析統計分析，我們發現四個重要危險因子包括：年齡大於70歲，就診時的收縮血壓小於90mmHg，潰瘍穿孔時間大於24小時，以及是否有共病。手術的死亡率和併發症發生率與危險因子的數目成正向關係。腹痛與到達急診就醫的時段，以及外科會診時間前的急診處置時間，在發生手術併發症的病人族群都明顯增長(p<0.005)。在各種手術方法中，迷走神經切斷合併胃竇切除術的病人有較高的死亡率與併發症，但這些差別僅在有上述任何危險因子的病人身上才發現。

結論：根據本研究的初步結果發現，為了提升外科手術處置潰瘍穿孔的臨床結果，急診處置的時間必須縮短，且及時的外科會診有其必要。外科醫師在決定選擇手術種類時，必須考慮病人是否有危險因子的存在。

 

Introduction: The perforated gastroduodenal ulcer remains a challenge for surgeons even in the era of effective anti-ulcer medications. This study was performed to identify risk factors associated with early surgical morbidity and mortality of patients with perforated ulcers and how to improve the clinical outcomes.

Methods: We retrospectively reviewed 444 patients who underwent operations for the perforated ulcers in a tertiary medical center located in central Taiwan between January 1, 1997 and December 31, 2002. Demographic data, intraoperative findings, surgical procedures, complications, and outcomes were analyzed. Statistical significance was attributed to p<0.05.

Results: The mean age was 54.5  19.3 years. Male to female ratio was 344:100. Overall surgical mortality and morbidity rates were 12.6% and 24.8%, respectively. Four risk factors were identified by multiple logistic regression analyses including age  70 years old, Bp < 90 mmHg on presentation, duration of perforation  24 hours, and medical comorbidity. Operative morbidity and mortality correlated with the number of risk factors. The duration of time from the onset of pain to the presentation to the ER and workup time at ER before surgical consultation was significantly longer among patients who died or developed postoperative complications (p<0.005). Vagotomy and antrectomy were associated with higher mortality and with more major complications than other procedures in patients with risk factors.

Conclusions: In order to improve the outcome of patients with ulcer perforation, delay in treatment should be minimized and early surgical consult is important. Appropriate selection of surgical techniques is crucial especially among patients with risk factors.