عوامل خطر و پيگيري نتايج درمان جراحي در سالمندان بالاي 65 سال در مركز آموزشي درماني لقمان حكيم طي سال هاي 1375 تا 1385

Evaluation of the Risk Factors and Post Operation Follow-up of the Elderly (>65 Years Old) in a Ten Year (1996-2006) at Loqman Hospital

ﺯﻣﻴﻨﻪ ﻭ ﻫﺪﻑ: ﺟﺮﺍﺣﻲ ﺩﺭ ﺳﺎﻟﻤﻨﺪﺍﻥ ﻳﻜﻲ ﺍﺯ ﺑﺨﺶ ﻫﺎﻱ ﻣﻬﻢ ﺩﺭ ﺟﺮﺍﺣﻲ ﺍﺳﺖ. ﺩﺭ 2 ﺩﻫﻪ ﮔﺬﺷﺘﻪ ﻣﻴﺰﺍﻥ ﺟﺮﺍﺣﻲ ﺩﺭ ﺍﻓﺮﺍﺩ ﺑﺎﻻﻱ 65 ﺳﺎﻝ ﺍﺯ 19 ﮐﻞ ﺟﺮﺍﺣﻲ ﻫﺎ ﺍﻓﺰﺍﻳﺶ ﻳﺎﻓﺘﻪ ﺍﺳﺖ. ﺍﻧﺘﻈﺎﺭ ﻣﻲ ﺭﻭﺩ ﺟﻤﻌﻴﺖ ﺍﻓﺮﺍﺩ ﺑﺎﻻﻱ 65 ﺳﺎﻝ ﺍﺯ 12/7 ﺩﺭ ﺳﺎﻝ 2030 ﺑﺮﺳﺪ، ﮐﻪ ﺑﻴﺸﺘﺮﻳﻦ ﺭﺷﺪ ﺩﺭ ﺍﻓﺮﺍﺩ ﺑﺎﻻﻱ 85 ﺳﺎﻝ ﺧﻮﺍﻫﺪ ﺑﻮﺩ. ﺍﮔﺮ ﻓﺎﻛﺘﻮﺭﻫﺎﻱ ﺧﻄﺮ، ﻣﻴﺰﺍﻥ ﻭ ﺭﺍﺑﻄﻪ ﺁﻧﻬﺎ ﺭﺍ ﺑﺎ ﻋﻮﺍﺭﺽ ﺑﻌﺪ ﺍﺯ ﺟﺮﺍﺣﻲ ﺑﺮﺭﺳﻲ ﻛﻨﻴﻢ، ﻣﻲ ﺗﻮﺍﻧﻴﻢ ﺑﺎ ﻛﻨﺘﺮﻝ ﻣﻬﻤﺘﺮﻳﻦ ﺁﻧﻬﺎ، ﻋﻮﺍﺭﺽ ﺭﺍ ﻛﺎﻫﺶ ﺩﻫﻴﻢ. ﻣﻮﺍﺩ ﻭ ﺭﻭﺵ ﻫﺎ: ﺩﺭ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﮐﻪ ﺑﻪ ﺻﻮﺭﺕ ﻣﻄﺎﻟﻌﻪ ﺗﻮﺻﻴﻔﻲ ﮔﺬﺷﺘﻪ ﻧﮕﺮ ﺍﻧﺠﺎﻡ ﮔﺮﺩﻳﺪ، ﺟﺎﻣﻌﻪ ﻣﻮﺭﺩ ﻧﻈﺮ ﺍﻓﺮﺍﺩ ﺳﺎﻟﻤﻨﺪ ﺑﺎﻻﻱ 65 ﺳﺎﻝ ﺑﻮﺩﻧﺪ ﮐﻪ ﺩﺭ ﻣﺮﮐﺰ ﺁﻣﻮﺯﺷﻲ ﺩﺭﻣﺎﻧﻲ ﻟﻘﻤﺎﻥ ﺩﺭ ﻃﻲ ﺳﺎﻝ ﻫﺎﻱ 1375 ﺗﺎ 1385 ﺑﻪ ﺻﻮﺭﺕ ﺍﻭﺭﮊﺍﻧﺲ ﻭ ﺍﻟﮑﺘﻴﻮ ﺗﺤﺖ ﺟﺮﺍﺣﻲ ﻻﭘﺎﺭﺍﺗﻮﻣﻲ ﺯﻳﺮ ﺑﻴﻬﻮﺷﻲ ﻋﻤﻮﻣﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺑﻮﺩﻧﺪ. ﺑﻴﻤﺎﺭﺍﻥ ﺑﻪ ﺳﻪ ﮔﺮﻭﻩ ﺗﻘﺴﻴﻢ ﺷﺪﻧﺪ، ﺳﻪ ﮔﺮﻭﻩ ﺷﺎﻣﻞ ﺑﻴﻤﺎﺭﺍﻥ 65 ﺗﺎ 75 ﺳﺎﻝ، 75 ﺗﺎ 85 ﺳﺎﻝ ﻭ ﺑﺎﻻﻱ 85 ﺳﺎﻝ ﻣﻲ ﺑﺎﺷﺪ. ﺳﭙﺲ ﻣﺪﺕ ﺑﺴﺘﺮﻱ ﺩﺭ ﺑﻴﻤﺎﺭﺳﺘﺎﻥ ﻭ ﻋﻮﺍﺭﺽ ﻧﺎﺷﻲ ﺍﺯ ﺟﺮﺍﺣﻲ ﻭ ﻣﻮﺭﺗﺎﻟﻴﺘﻲ ﺑﻴﻤﺎﺭﺍﻥ ﺍﺯ ﭘﺮﻭﻧﺪﻩ ﻫﺎ ﺛﺒﺖ ﮔﺮﺩﻳﺪ ﻭ ﺭﺍﺑﻄﻪ ﺁﻧﻬﺎ ﺑﺎ ﻋﻮﺍﻣﻞ ﺧﻄﺮ ﻣﺸﺨﺺ ﺷﺪ. ﻳﺎﻓﺘﻪ ﻫﺎ: ﺩﺭ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺍﺯ ﻧﻈﺮ ﺗﻮﺯﻳﻊ ﺳﻨﻲ، ﻣﺮﺩﺍﻥ ﺑﻴﺸﺘﺮ ﺍﺯ ﺯﻧﺎﻥ ﺑﻮﺩﻧﺪ، ﺑﻪ ﻃﻮﺭﻱ ﮐﻪ ﺍﺯ 1000 ﺑﻴﻤﺎﺭ ﻣﻮﺭﺩ ﻣﻄﺎﻟﻌﻪ 624 ﺑﻴﻤﺎﺭ ﻣﺮﺩ ﻭ 376 ﺑﻴﻤﺎﺭ ﺯﻥ ﺑﻮﺩﻧﺪ. ﺩﺭ ﻣﺠﻤﻮﻉ ﺟﺮﺍﺣﻲ ﻫﺎﻱ ﺍﻧﺠﺎﻡ ﺷﺪﻩ 600 ﻣﻮﺭﺩ ﺍﻭﺭﮊﺍﻧﺴﻲ ﻭ 400 ﻣﻮﺭﺩ ﺍﻟﮑﺘﻴﻮ ﺑﻮﺩﻩ ﺍﺳﺖ. ﺗﻌﺪﺍﺩ ﺑﻴﻤﺎﺭﺍﻧﻲ ﮐﻪ ﺩﺍﺭﺍﻱ ﺳﺎﺑﻘﺔ ﺑﻴﻤﺎﺭﻱ ﺍﻳﺴﮑﻤﻴﮏ ﺑﻮﺩﻧﺪ، ﺩﺭ ﺳﻪ ﮔﺮﻭﻩ ﺳﻨﻲ ﻭ ﺑﺮ ﺍﺳﺎﺱ ﺟﻨﺲ ﻣﻮﺭﺩ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻨﺪ. ﺑﻪ ﻃﻮﺭ ﮐﻠﻲ 60/1 ﺑﻴﻤﺎﺭﺍﻥ ﺑﺪﻭﻥ ﺳﺎﺑﻘﺔ ﺑﻴﻤﺎﺭﻱ ﺍﻳﺴﮑﻤﻴﮏ ﻭ 39/9 ﺩﺍﺭﺍﻱ ﺳﺎﺑﻘﺔ ﺑﻴﻤﺎﺭﻱ ﺑﻮﺩﻧﺪ. ﻣﻮﺭﺗﺎﻟﻴﺘﻪ ﺑﻴﻤﺎﺭﺍﻧﻲ ﮐﻪ ﺩﺍﺭﺍﻱ ﺑﻴﻤﺎﺭﻱ ﺍﻳﺴﮑﻤﻴﮏ ﺑﻮﺩﻧﺪ، ﺑﻪ ﻃﻮﺭ ﻗﺎﺑﻞ ﺗﻮﺟﻬﻲ ﺍﺯ ﮔﺮﻭﻩ ﺑﺪﻭﻥ ﺳﺎﺑﻘﻪ ﺑﻴﺸﺘﺮ ﺑﻮﺩ، ﺑﻪ ﻃﻮﺭﻱ ﮐﻪ ﺩﺭ ﺳﻪ ﮔﺮﻭﻩ ﻣﻮﺭﺗﺎﻟﻴﺘﻲ ﺑﻪ ﺗﺮﺗﻴﺐ ﺷﺎﻣﻞ 4/5 ﺩﺭ ﻣﻘﺎﺑﻞ 1/5%، 6 ﺑﻮﺩﻩ ﺍﺳﺖ. ﻫﻤﭽﻨﻴﻦ ﻣﺪﺕ ﺑﺴﺘﺮﻱ ﺩﺭ ﺑﻴﻤﺎﺭﺍﻥ ﺩﺍﺭﺍﻱ ﺑﻴﻤﺎﺭﻱ ﺍﻳﺴﮑﻤﻴﮏ ﺑﺎ ﺍﻓﺰﺍﻳﺶ ﺳﻦ ﺍﻓﺰﺍﻳﺶ ﻳﺎﻓﺘﻪ ﺍﺳﺖ ﻭ ﺑﻪ ﺗﺮﺗﻴﺐ ﺩﺭ ﺳﻪ ﮔﺮﻭﻩ ﺳﻨﻲ 14 ﺭﻭﺯ ﺩﺭ ﺑﺮﺍﺑﺮ 7 ﺭﻭﺯ، 20 ﺭﻭﺯ ﺩﺭ ﺑﺮﺍﺑﺮ 11 ﺭﻭﺯ ﻭ 28 ﺭﻭﺯ ﺩﺭ ﺑﺮﺍﺑﺮ 18 ﺭﻭﺯ ﺑﻮﺩﻩ ﺍﺳﺖ. ﻧﺘﻴﺠﻪ ﮔﻴـﺮﻱ: ﺑﻴﻤﺎﺭﻱ ﻫﺎﻱ ﻫﻤﺰﻣﺎﻥ ﺯﻳﺎﺩﻱ ﺩﺭ ﺳﺎﻟﻤﻨﺪﺍﻥ ﺑﺎﻻﻱ 65 ﺳﺎﻝ ﻣﻮﺭﺩ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻨﺪ. ﺩﺭ ﺑﻴﻦ ﺍﻳﻦ ﻣﻮﺍﺭﺩ ﺑﻴﻤﺎﺭﻱ ﻫﺎﻱ ﺍﻳﺴﮑﻤﻴﮏ ﻗﻠﺒﻲ ﺍﺯ ﻟﺤﺎﻅ ﺁﻣﺎﺭ ﺑﻴﺸﺘﺮﻳﻦ ﺑﻴﻤﺎﺭﻱ ﻫﻤﺮﺍﻩ ﺑﻮﺩﻩ ﺍﺳﺖ ﻭ ﺑﻴﺸﺘﺮﻳﻦ ﺭﺍﺑﻄﻪ ﺭﺍ ﺩﺭ ﻣﻮﺭﺩ ﺍﻓﺰﺍﻳﺶ ﺭﻭﺯﻫﺎﻱ ﺑﺴﺘﺮﻱ ﺩﺭ ﺑﻴﻤﺎﺭﺳﺘﺎﻥ ﺩﺭ ﻣﻘﺎﻳﺴﻪ ﺑﺎ ﺁﻧﻬﺎﻳﻲ ﮐﻪ ﺍﻳﻦ ﺑﻴﻤﺎﺭﻱ ﻫﻤﺮﺍﻩ ﺭﺍ ﻧﺪﺍﺷﺘﻨﺪ، ﺩﺍﺷﺘﻪ ﺍﺳﺖ. ﻣﻲ ﺗﻮﺍﻥ ﺑﺎ ﮐﻨﺘﺮﻝ ﺷﺎﻳﻌﺘﺮﻳﻦ ﻭ ﺑﺎﺭﺯﺗﺮﻳﻦ ﺑﻴﻤﺎﺭﻱ ﻫﻤﺮﺍﻩ ﮐﻪ ﺑﺎ ﺍﻓﺰﺍﻳﺶ ﻣﻮﺭﺑﻴﺪﻳﺘﻲ ﻭ ﻣﻮﺭﺗﺎﻟﻴﺘﻲ ﻫﻤﺮﺍﻩ ﺍﺳﺖ، ﺁﻣﺎﺭ ﻋﻮﺍﺭﺽ ﺑﻌﺪ ﺍﺯ ﺟﺮﺍﺣﻲ ﻭ ﻫﻤﭽﻨﻴﻦ ﺑﺎﺭ ﺍﻗﺘﺼﺎﺩﻱ ﺟﺮﺍﺣﻲ ﺩﺭ ﺳﺎﻟﻤﻨﺪﺍﻥ ﺭﺍ ﮐﺎﻫﺶ ﺩﺍﺩ.

Introduction & Objective: Surgery in the elderly is an important part of surgery. In the last two decades, the number of surgeries in persons >65 years old has increased from 19% to 37% of all of surgeries. It is expected that the population of over 65 years old will increase from 12.7% to 20% by 2030. If we evaluate the risk factors and relationships between them and post operative morbidity and mortality, then we can decrease post operative complications by controlling the most common and the most important risk factors. Materials & Methods: From 1996 to 2006, 1000 patients with the age of >65 years old were operated (only laparatomy) under general anesthesia at Loghman Medical Center. The randomly selected patients were separated into three groups: 65 to 75, 75 to 85 and >85 years old. The duration of hospitalization and post operative complications and mortality of these patients were recorded and their relation with risk factors were evaluated. Results: This study included 624 men and 376 women. They were divided into three age groups among which 60.1% of the patients had no history of comorbidity and 39.9% had this history. Mortality in patients that had IHD was much more than those that did not have risk factors significantly. In three groups the mortality rate consisted of: 4.5% vs 1.5%, 6% vs 1% and 8.5% vs 2%. Duration of hospitalization in three groups were: 14 days vs 7, 20 days vs 11 and 28 days vs 18. Conclusions: In this study various kinds of comorbidity in patients were evaluated. Among these, IHD was the most common comorbidity that was associated with morbidity and mortality. This relationship was increased from >65 to >85 years old patients. On the other hand, we can decrease morbidity and mortality in the elderly through controls and aggressive treatment of cardiovascular system diseases and evaluations and controls of risk factors.