胃癌根治术后小肠梗阻伴发腹水的临床特征及血性腹水的诊断指标分析

Clinical characteristics of small bowel obstruction with ascites after radical gastrectomy for gastric cancer and diagnostic markers for bloody ascites

摘要:

背景与目的 肠梗阻作为临床常见急腹症，其早期诊断与手术时机的选择直接影响患者预后。胃癌根治术后因消化道重建异常、肠系膜间隙形成及腹膜损伤等因素，肠梗阻发生率较高，且常伴随不同性状腹水。血性腹水多提示肠壁缺血性坏死，但现有指标对血性腹水的早期识别效能有限。本研究探讨胃癌根治术后小肠梗阻伴发不同性状腹水患者的临床特征，并重点分析对血性腹水有诊断价值的指标。方法 回顾性分析2010年1月—2021年12月江苏省江阴市人民医院胃肠外科收治的65例胃癌根治术后肠梗阻伴腹水患者的临床资料。按腹水性状分为浆液性腹水组（n=42）、乳糜性腹水组（n=9）和血性腹水组（n=14）。比较三组患者相关临床指标以及术前白细胞（WBC）、中性粒细胞（NEU）、淋巴细胞和中性粒细胞/淋巴细胞比值（NLR）的差异，并通过受试者工作特征（ROC）曲线分析炎症指标对小肠梗阻伴发血性腹水的临床诊断价值。结果 浆液性腹水组发病至入院时间明显高于乳糜性腹水组和血性腹水组（P<0.05）；血性腹水组患者术后住院时间明显长于浆液性腹水组和乳糜性腹水组（P<0.05）；血性腹水组中小肠切除的比例（6/14）明显高于乳糜性腹水组（0/9）和浆液性腹水组（7/42）（P<0.05）；血性腹水组中复发比例（3/14）高于乳糜性腹水组（1/9）和浆液性腹水组（2/42），但差异无统计学意义（P>0.05）。在浆液性腹水组、乳糜性腹水组和血性腹水组中，WBC、NEU、NLR水平依次升高，差异有统计学意义（P<0.05）。ROC曲线结果显示，与WBC和NEU比较，NLR预测肠梗阻伴血性腹水能力更高（曲线下面积：0.84；敏感度：75%；特异度：85%）。结论 NLR水平与胃癌根治术后肠梗阻伴发腹水的性状密切相关，尤其在血性腹水患者中显著升高。相比传统炎症指标WBC和NEU，NLR在识别血性腹水方面具有更高的敏感度和特异度，可作为预测肠壁缺血性坏死的有效辅助诊断指标，为临床决策提供重要参考。此外，血性腹水患者小肠切除率高、住院时间延长，提示其临床预后较差。

Abstract:

Background and Aims Intestinal obstruction is a common acute abdominal condition, and early diagnosis and timely surgical intervention are critical to patient prognosis. After radical gastrectomy for gastric cancer, due to abnormal digestive tract reconstruction, mesenteric space formation, and peritoneal injury, the incidence of intestinal obstruction is relatively high, often accompanied by ascites of varying characteristics. Bloody ascites usually suggest intestinal wall ischemia and necrosis; however, current clinical indicators have limited effectiveness in the early identification of this condition. This study was performed to investigate the clinical characteristics of postoperative small bowel obstruction with different types, with a particular focus on identifying markers with diagnostic values for bloody ascites.Methods The clinical data of 65 patients with small bowel obstruction and ascites after radical gastrectomy for gastric cancer admitted to the Department of Gastrointestinal Surgery of Jiangyin People's Hospital between January 2010 and December 2021 were retrospectively analyzed. Based on the ascites characteristics, patients were divided into serous ascites group (n=42), chylous ascites group (n=9), and bloody ascites group (n=14). Clinical parameters and preoperative white blood cell count (WBC), neutrophil count (NEU), lymphocyte count, and neutrophil-to-lymphocyte ratio (NLR) were compared among the groups. Receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic value of inflammatory markers for bloody ascites.Results The time from onset to hospital admission was significantly longer in the serous ascites group compared to the chylous and bloody ascites groups (P<0.05). Postoperative hospital stay was significantly prolonged in the bloody ascites group compared to the other two groups (P<0.05). The rate of small bowel resection in the bloody ascites group (6/14) was significantly higher than that in the chylous ascites group (0/9) or serous ascites group (7/42) (P<0.05). Although the recurrence rate in the bloody ascites group (3/14) was higher than in the chylous ascites group (1/9) or serous (2/42) ascites group, the difference was not statistically significant (P>0.05). WBC, NEU, and NLR levels increased progressively from the serous to chylous to bloody ascites groups, with statistically significant differences (P<0.05). ROC curve analysis showed that NLR had superior diagnostic performance in predicting bloody ascites (AUC: 0.84; sensitivity: 75%; specificity: 85%) compared to WBC and NEU.Conclusion NLR is closely associated with the characteristics of ascites in patients with small bowel obstruction after radical gastrectomy and is significantly elevated in those with bloody ascites. Compared to traditional inflammatory markers WBC and NEU, NLR demonstrates higher sensitivity and specificity for identifying bloody ascites, making it a valuable adjunct diagnostic tool for predicting intestinal wall ischemia and necrosis. Furthermore, patients with bloody ascites showed higher rates of bowel resection and more extended hospital stays, suggesting a poorer clinical prognosis.