海军军医大学学报  2022, Vol. 43 Issue (12): 1471-1474   PDF    
引用本文
朱中飞, 胡昊, 何天霖. 腹腔镜胆囊切除术后胃肠道症状改善及影响因素分析[J]. 海军军医大学学报, 2022, 43(12): 1471-1474  
ZHU Zhong-fei, HU Hao, HE Tian-lin. Improvement of gastrointestinal symptoms and its influencing factors in patients after laparoscopic cholecystectomy[J]. Academic Journal of Naval Medical University, 2022, 43(12): 1471-1474 (in Chinese with English abstract)  
腹腔镜胆囊切除术后胃肠道症状改善及影响因素分析
朱中飞, 胡昊, 何天霖     
海军军医大学(第二军医大学)第一附属医院肝胆胰腺外科，上海 200433
收稿日期: 2022-04-28    接受日期: 2022-09-07
作者简介: 朱中飞，硕士，主治医师.E-mail: 18116315433@163.com.
通信作者(Corresponding author): 何天霖, Tel: 021-31161628, E-mail: tlhe@smmu.edu.cn.
摘要: 目的 探讨腹腔镜胆囊切除术(LC)后患者胃肠道症状改善情况，并分析其影响因素。方法 回顾性分析2020年1月至2021年12月于海军军医大学(第二军医大学)第一附属医院肝胆胰腺外科接受LC治疗的患者资料。患者年龄＞18岁，排除恶性肿瘤。统计患者一般资料，包括病程、基础疾病、既往腹部手术史、术前检查结果; 手术相关资料，包括中转开腹、胆道损伤、是否放置腹腔引流管; 术后并发症，包括胆漏、出血、腹腔感染、切口感染、副损伤等。随访6个月，采用胃肠道症状评定量表(GSRS)对患者进行问卷调查。结果 173例患者中男84例(48.55%)、女89例(51.45%)，平均年龄为(54.12±13.38)岁，发病的中位时间为6.00(1.75，24.00)个月。术后GSRS的中位总评分为0(0，1)分，较术前中位总评分[3(0，5)分]明显降低(P＜0.01)。患者腹痛症状术前出现110例(63.85%)，术后16例(9.25%，P＜0.01); 烧心和反酸术前12例(6.94%)，术后6例(3.47%，P＜0.05); 恶心呕吐术前38例(21.97%)，术后2例(1.16%，P＜0.01); 上腹部紧抽感术前35例(20.23%)，术后1例(0.58%，P＜0.01); 腹胀术前41例(23.70%)，术后11例(6.36%，P＜0.01); 腹泻术后发生26例(15.03%)，较术前增加14例(P＜0.01)。结论 LC术后患者胃肠道症状明显改善，通过GSRS评分可以全面且直观地分析患者上述症状在手术前后的变化。对于术后腹痛未全部缓解、腹泻症状病例增加的原因需进一步扩大样本进行分析。
关键词: 腹腔镜胆囊切除术    胃肠道症状评定量表    腹泻    影响因素    
Improvement of gastrointestinal symptoms and its influencing factors in patients after laparoscopic cholecystectomy
ZHU Zhong-fei, HU Hao, HE Tian-lin     
Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Naval Medical University (Second Military Medical University), Shanghai 200433, China
Abstract: Objective To investigate the improvement of gastrointestinal symptoms in patients after laparoscopic cholecystectomy (LC), and analyze the influencing factors. Methods The clinical data of LC patients in Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Naval Medical University (Second Military Medical University) from Jan. 2020 to Dec. 2021 were analyzed retrospectively. The patients were older than 18 years, and those with malignant tumors were excluded. The general information (including course of disease, underlying diseases, previous surgical history, and preoperative examination), surgical-related data (including conversion to laparotomy, biliary tract injury, and whether to place an abdominal drain), and postoperative complications (including bile leakage, hemorrhage, abdominal infection, incision infection, and side injury) of patients were collected. All the patients were followed up for 6 months and investigated with the gastrointestinal symptom rating scale (GSRS). Results Among the 173 patients, 84 (48.55%) were males and 89 (51.45%) were females, with an average age of (54.12±13.38) years. The median time of onset was 6.00 (1.75, 24.00) months. The median total score of GSRS after operation was 0 (0, 1), which was significantly lower than that before operation (3 [0, 5]) (P < 0.01). One hundred and ten (63.85%) cases complained of abdominal pain before operation and it decreased to 16 (9.25%) cases after operation (P < 0.01). Twelve (6.94%) cases presented heartburn and acid regurgitation before operation and 6 (3.47%) cases after operation (P < 0.05). There were 38 (21.97%) cases of nausea and vomiting before operation and 2 (1.16%) cases after operation (P < 0.01). Upper abdominal discomfort occurred in 35 (20.23%) cases before operation and 1 (0.58%) case after operation (P < 0.01). Abdominal distension was found in 41 (23.70%) cases before operation and 11 (6.36%) cases after operation (P < 0.01). Postoperative diarrhea occurred in 26 (15.03%) cases, with an increase of 14 cases (P < 0.01). Conclusion The gastrointestinal symptoms of patients after LC are significantly improved. The GSRS score can be used to comprehensively and intuitively analyze the changes of the above symptoms before and after the operation. The reasons for the persistent abdominal pain and diarrhea of patients after surgery need to be further analyzed with a large sample.
Key words: laparoscopic cholecystectomy    gastrointestinal symptom rating scale    diarrhea    influencing factors    

腹腔镜胆囊切除术(laparoscopic cholecystectomy，LC)于1985年由德国科学家首次报道[1]，之后LC的应用越来越广泛，目前已成为胆囊良性疾病治疗的金标准[2]。虽然LC的并发症发生率和死亡率均很低[3]，但胆囊切除术后患者可能出现腹痛、腹胀、腹泻及其他胃肠道症状，称为胆囊切除术后综合征(postcholecystectomy syndrome，PCS)。目前有关PCS的发生率及病因的报道较多，但对其发生程度的研究较少[4]。本研究回顾性分析了2020年1月至2021年12月于海军军医大学(第二军医大学)第一附属医院肝胆胰腺外科接受LC治疗的患者资料，利用胃肠道症状评定量表(gastrointestinal symptom rating scale，GSRS)量化术后胃肠道症状程度，分析患者术后胃肠道症状改善状况，并探讨其影响因素。

1 资料和方法 1.1 一般资料

回顾分析2020年1月至2021年12月于海军军医大学(第二军医大学)第一附属医院肝胆胰腺外科接受LC治疗的患者资料。所有患者年龄＞18岁，经门诊诊断为急性或慢性胆囊炎(胆囊壁增厚≥3 mm)、胆囊结石、胆囊息肉(息肉直径≥1 cm)等，入院后完善术前检查，排除胆囊恶性肿瘤患者，符合LC手术指征[5]，所有手术均由经验丰富的肝胆外科医师完成。统计患者一般资料(病程、基础疾病、既往腹部手术史、术前检查结果)、手术相关资料(中转开腹、胆道损伤、是否放置腹腔引流管等)及术后并发症(胆漏、出血、腹腔感染、切口感染、副损伤等)。

1.2 GSRS评分

通过电话回访进行GSRS问卷调查。GSRS包含15个项目：腹痛、烧心、反酸、上腹部不适、恶心呕吐、腹鸣、腹胀、嗳气、排气增多、排便减少、排便增多、腹泻、便秘、排便紧迫感、排便不尽感。随访患者术前及术后6个月内是否存在上述症状，根据程度、频率、持续时间、缓解因素和社会活动受影响等分为4个等级：无或轻微、中度、重度、严重影响生活质量，分别记为0~3分，合计得分即为症状评分，评分越高症状越严重[6]。

1.3 GSRS影响因素分析

对老年(≥60岁)患者、性别、合并症、既往腹部手术史、术前心电图异常、急性胆囊炎、术中放置腹腔引流管、术后并发症等相关资料进行分析。

1.4 统计学处理

应用SPSS 24.0软件进行数据分析。符合正态分布的计量资料以x±s表示; 不符合正态分布的计量资料以中位数(下四分位数，上四分位数)表示，采用Wilcoxon符号秩检验。计数资料以例数和百分数表示，采用χ2检验。检验水准(α)为0.05。

2 结果

共184例患者完成LC，排除2例术后病理提示胆囊恶性肿瘤和9例失访，最终有173例患者纳入本研究。成功回访的173例患者中，男84例(48.55%)、女89例(51.45%); 年龄22~83岁，平均年龄为(54.12±13.38)岁，≥60岁有76例(43.93%)、＜60岁97例(56.07%); 发病的中位时间为6.00(1.75，24.00)个月。术前心电图异常61例(35.26%)，急性胆囊炎8例(4.62%)，既往腹部手术史62例(35.84%)，术中放置腹腔引流管67例(38.73%)，平均失血量为(61.03±26.40)mL。术后5例(2.89%)患者发生切口脂肪液化，无胆管损伤及胆漏发生，无患者中转开腹，平均住院时间(5.35±3.00)d。

173例患者中，术前腹痛110例(63.58%)、烧心和反酸12例(6.94%)、恶心呕吐38例(21.97%)、上腹部紧抽感35例(20.23%)、腹胀41例(23.70%)、腹泻12例(6.94%)、便秘8例(4.62%)，术后腹痛16例(9.25%)、烧心和反酸6例(3.47%)、恶心呕吐2例(1.16%)、上腹部紧抽感1例(0.58%)、腹胀11例(6.36%)、腹泻26例(15.03%)、便秘1例(0.58%)，术后腹痛、烧心和反酸、恶心呕吐、上腹部紧抽感、腹胀症状较术前明显缓解(P均＜0.05)，但腹泻症状较术前加重(P＜0.01)。见表 1。

表 1 173例接受LC患者胃肠道症状发生情况及GSRS评分 

术后腹泻的26例患者中＜60岁19例(19.59%，19/97)、≥60岁7例(9.21%，7/76)。患者否认肠鸣音亢进或减弱、嗳气、排便紧迫感。术后GSRS的中位总评分为0(0，1)分，较术前中位总评分[3(0，5)分]明显降低(P＜0.01)。

单因素分析发现，性别、年龄、术前心电图正常与否、有无合并症、有无急性胆囊炎、有无腹部手术史、术中放置腹腔引流管与否、有无术后并发症等因素均未对患者术后GSRS评分产生影响(P均＞0.05，表 2)。

表 2 173例LC患者术后GSRS评分影响因素分析

3 讨论

LC属于择期手术，目的是消除患者症状，改善患者生活质量。在美国，每年约有75万人接受LC[7]。目前的研究对LC术后患者的胃肠道症状关注较少。

GSRS由瑞典科学家提出，从5个维度(腹痛症状、反流症状、消化不良症状、腹泻症状、便秘症状)对患者胃肠道症状进行测量，每个症状的严重程度采用利克4级评分法[6]。GSRS最早被应用于肠易激综合征症状评分，显示出良好的一致性和信效度，研究证实该量表能有效评价消化道症状及其严重程度，对评价腹部手术后胃肠道症状的改善情况具有重要意义[8-11]。

患者选择LC时主要关注腹部症状是否会缓解，本研究结果显示，LC术后患者腹痛、腹胀、烧心和反酸、恶心呕吐及上腹部紧抽感较术前明显缓解(P均＜0.05)。采用GSRS定量分析手术前后症状的变化能够客观地提供相关预后数据，同时还能给患者提供术后症状恢复预期。本研究中患者术后GSRS总评分下降，与术前比较差异有统计学意义[0(0，1)分vs 3(0，5)分，P＜0.01]，提示胃肠道症状明显改善，进一步证实LC治疗胆囊疾病的有效性，与既往报道[12]一致。Han等[13]发现女性患者LC术后1个月胃肠道症状较前加重，认为性别是LC后胃肠道症状的独立影响因素; 随访1年后发现影响因素为既往腹部手术史。本研究通过单因素分析探讨了患者性别、年龄、合并症、既往腹部手术史、术前心电图异常、急性胆囊炎、术中放置腹部引流管、术后并发症等多种因素与LC后胃肠道症状的关系，但未发现影响术后胃肠道症状变化的原因。

胆囊炎最常见的症状是腹痛，以右上腹为主。本研究结果显示，LC术后9.25%(16/173)的患者仍表现出腹痛。有研究认为即使限制LC准入条件也不能降低患者术后疼痛的发生比例[14]。Zhang等[15]也发现约10%的胆囊切除术患者术后存在上腹痛，女性、入院前24 h急性发作及持续时间＞30 min可能为术后上腹痛的影响因素。

LC术后患者可能还会出现新发症状，本研究表明LC术后腹泻发生率为15.30%(26/173)，与术前相比新增14例。Feng等[16]认为胆囊切除术后的腹泻发生率为5%~12%，且部分患者术后不缓解或成为新发症状，原因尚不明确，可能与年龄、肠道菌群失调有关[17-18]。

LC术后腹痛和腹泻对患者生活质量造成了一定影响，需引起重视。对于术后腹痛未全部缓解、腹泻症状病例增加的原因需进一步扩大样本进行分析。

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