- 學位論文
使用較安全的縫合技巧來關閉胃潰瘍穿孔：兩種修補方式的比較
Safer Suture Techniques for Repair of Perforated Gastric Ulcer: Cellan-Jones Repair versus Primary Closure with Omentoplasty
若您是本文的作者，可授權文章由華藝線上圖書館中協助推廣。
摘要
研究背景 : 消化性潰瘍不論在台灣或者對世界而言，並非是一個少見的疾病。它一年約略影響全球四百萬的人口。其中，消化性潰瘍進展成潰瘍穿孔的比例，依照文獻的不同，大約占了2-14%左右。對於消化性潰瘍穿孔的治療是以手術為主，保守治療為輔。目前在全球而言，外科醫師處理消化性潰瘍穿孔的手術方式大多數是做潰瘍穿孔修補術，使用胃相關切除術來對付潰瘍穿孔的適應症與比例已經減少。在台大醫院總院的外科醫師，施展潰瘍穿孔修補術的主要方式是先用縫合線把潰瘍穿孔給閉合起來，然後再覆蓋腹腔內的大網膜於潰瘍穿孔縫合處，並給予這處大網膜綁線固定之後，而結束這潰瘍穿孔修補術。這樣的術式一般稱之為primary closure with omentoplasty。然而外科教科書<< Fischer's Mastery of Surgery.第六版>>，其內文所介紹潰瘍穿孔修補術的方式，則是先不用把潰瘍穿孔給閉合，而是直接把腹腔內的大網膜覆蓋在潰瘍穿孔處，再給予這處大網膜綁線固定綁合，然後完成這潰瘍穿孔修補術。這樣的術式是由C.J. Cellan-Jones醫師在西元1929年所發表的縫合潰瘍穿孔的方式，文獻稱之為Cellan-Jones repair。目前世界沒有相關的文獻是在討論比較這兩種潰瘍穿孔修補方式的治療預後孰優孰劣。 研究目的 : 本研究目的是利用台灣單一區域醫院的案例進行回溯性分析，來分析診斷為胃前壁潰瘍穿孔的患者，分別接受primary closure with omentoplasty以及Cellan-Jones repair的術後再次滲漏率有無顯著差異以及其他短期預後比較。 研究方法 : 本研究使用台大醫院新竹分院的病歷與手術系統 (Portal系統)，收集從2015年01月01日到2019年09月30日止，消化性潰瘍穿孔的病人在急診、手術前、手術中、和手術後住院的相關治療數據，來分析研究患者在接受不同的胃前壁潰瘍穿孔縫合方式之後，觀察置放腹腔內引流管來追蹤穿孔處是否有再次消化道內容物滲漏。利用統計軟體SAS (Statistical Analysis System) Enterprise Guide 7.1卡方檢驗分析接受兩種不同的胃前壁穿孔縫合方式的患者，其住加護病房天數、總住院天數、穿孔處再次滲漏和是否死亡的情形，兩組是否有統計上的差異。 研究結果 : 統計台大醫院新竹分院將近五年的消化性潰瘍穿孔病人數據。其中在診斷消化性潰瘍穿孔後有接受手術治療的患者，其病人總數為124人，包含了在手術中確診的胃潰瘍穿孔人數74人、十二指腸潰瘍穿孔人數47人以及伴隨胃癌診斷的患者人數為3人。 然而在胃潰瘍穿孔的74人當中，有41人(55.4%)接受了primary closure with omentoplasty；另外31人(41.9%)接受Cellan-Jones repair；剩下的2人(2.7%)則是接受了遠端胃切除術。比較primary closure with omentoplasty和Cellan-Jones repair兩組，其患者基礎數據包含性別、年齡、身體質量指數、脈搏速率、指測血氧濃度、收縮壓小於90mmHg、抽血數據(白血球、血紅素、肌酐酸)、Boey系統指數、胃潰瘍穿孔大小、與預後包含併發症率、住加護病房天數、住院總天數、術後死亡等項目在統計上無明顯差異。但是預後的術後滿3日未腸道營養、胃潰瘍穿孔處再次滲漏兩個項目有達到統計上的差異。 胃潰瘍穿孔患者接受primary closure with omentoplasty的41人這組的穿孔再次滲漏的患者有5人(12.2%)，這5人全體(100%)的總住院天數超過21日(超長住院)，這5人全體(100%)手術後超過3日才給予穩定的經口進食。另外，若將組內再以穿孔大小分為兩組，一組穿孔直徑≤10mm與另一組穿孔直徑介於10到20mm之間。分析後發現穿孔直徑≤10mm組發生滲漏有2人(6.06%)與介於10到20mm之間發生滲漏有3人(37.50%)，p = 0.0148。 胃潰瘍穿孔患者接受Cellan-Jones repair這組的穿孔再次滲漏的患者有0人(0%)；手術後超過3日才給予穩定腸道營養總共人0人(0%)。 結論 : 胃前壁潰瘍穿孔的患者在接受Cellan-Jones repair的修補方式後，相較於另一組primary closure with omentoplasty的患者，其胃前壁潰瘍穿孔有顯著較低的再次滲漏率。尤其是針對穿孔大小介於1到2公分的患者，primary closure with omentoplasty有更高的滲漏率。而當接受primary closure with omentoplasty的患者若產生胃前壁潰瘍穿孔再次滲漏的情形，其住院總天數將會延長，以及手術後進食的日期也會延後。
並列摘要
Background : Perforated gastric ulcers are potentially complicated surgical emergencies and appropriate early management is essential in order to avoid subsequent problems including potential septic shock and multiple organ failure. A variety of techniques for closure of perforated gastric ulcer have been described: suture closure with or without omentoplasty, or bolstered by a patch of pediculized omentum (Cellan-Jones repair) or free omentum. There is no official recommendation regarding the type of suture repair. Aim : The purpose of this study is to compare two suture technique, primary closure with omentoplasty and Cellan-Jones repair, during emergency abdominal operation for these patients with perforated gastric ulcer , and to confirm which suture technique is superior in leakage rate? Methods : Patients undergoing perforated peptic ulcer repair at NTUH, Hsin-chu branch was identified from NTUH portal system database near five-year period 2015/01-2019.10. Additional data were obtained by retrospective review of electronic records and case notes. We tried to compare the outcome between primary closure with omentoplasty (n = 41) and Cellan-Jones repair (n = 31) by Chi-square analysis. The results were considered statistically significant if p < 0.05. Results : Three patients died (7.32%), and five incurred re-leakage (12.2%) in the group of primary closure with omentoplasty. The primary closure with omentoplasty and Cellan-Jones repair groups are comparable in gender, body mass index, pulse rate, SpO2, Lab data, Boey score and size of ulcer perforation. The mobidity rate, ICU days, hospital days, and mortality are also similar. There were statistically significant differences in outcome of days in early feeding and re-leakage (p <.0001 p = 0.0438). Comparison of the re-leakage of perforated size ≤ 10 mm and > 10 mm groups in primary closure with omentoplasty patients revealed that the > 10 mm group showed higher leakage rate (6.06%：37.50%, p = 0.0148). Conclusion : Compared to primary closure with omentoplasty, Cellan-Jones repair is a safe procedure with lower leakage rate.
參考文獻
1. Zelickson MS, Bronder CM, Johnson BL, Camunas JA, Smith DE, Rawlinson D, Von S, Stone HH, Taylor SM. Helicobacter pylori is not the predominant etiology for peptic ulcers requiring operation. American Surgeon. 2011;77(8):1054-1060.
2. Bertleff MJ, Lange JF. Perforated peptic ulcer disease: a review of history and treatment. Digestive Surgery. 2010;27(3):161-169.
3. Lau JY, Sung J, Hill C, Henderson C, Howden CW, Metz DC. Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion. 2011;84(2):102-113.
4. Kin Tong Chung, Vishalkumar G Shelat. Perforated peptic ulcer - an update. World Journal of Gastrointestinal Surgery. 2017;9(1):1-12.
5. Boey J, Choi SK, Poon A, Alagaratnam TT. Risk stratification in perforated duodenal ulcers. A prospective validation of predictive factors. Annals of surgery. 1987;205(1):22-26.