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大規模診療報酬情報データベースを用いた複雑性腹腔内感染症の診療指針の検討

土谷, 飛鳥 東京大学 DOI:10.15083/0002006131

2023.03.20

概要

【別紙 2】

審査の結果の要旨
氏名 土谷 飛鳥

本研究は、複雑性腹腔内感染症に関する診断・治療の有効性に関して、大規模入院
診療報酬情報データベースを用いて2つの研究;(i)腹腔内培養検査実施の有無と死亡
との関連、(ii)大腸直腸穿孔に対する 2 つの手術方法のアウトカム比較、を行い検証し
たものであり、以下の結果を得ている。
研究1;41,495 人の患者のうち 16,303 人に腹腔内培養検査が行われた。培養検査実施
群は非実施群に比べて死亡割合が有意に低かった(調整済みオッズ比 0.85; 95%信頼区
間 0.77, 0.95)。サブグループ解析では、下部消化管穿孔、胆道系感染(穿孔)、医療関
連感染、高リスク市中感染のあるサブグループにおいて、腹腔内培養検査の有無で死
亡割合に統計学的有意差が認められた。
研究 2; Hartmann 手術群 5,455 人、一期的吻合術群 3,045 人の対象患者を同定した。
傾向スコアマッチング法では、30 日死亡割合は Hartmann 手術群が有意に低下してい
た(リスク差 1.9%; 95%信頼区間 0.5, 3.4)。逆確率重み付法でも同様の結果であった
(リスク差 1.9%; 95%信頼区間 1.0, 2.8)。操作変数法では、点推定値は傾向スコア分析
と同じ方向であった(リスク差 4.4%; 95%信頼区間 -3.3, 12.1)。一期的吻合術群で
は、合併症による二次手術の発生割合が有意に高く(リスク差 3.8%; 95%信頼区間 2.5,
4.1)、術後集中治療介入期間が長かった。

以上、本論文は複雑性腹腔内感染症患者における腹腔内培養検査の施行が死亡割合低
下と有意に関連することを示し、下部消化管穿孔、胆道系感染(穿孔)、医療関連感
染、高リスク市中感染などの特定の疾患・状態においては、腹腔内培養検査を施行す
る方が良いかもしれないことを明らかにした。また、大腸直腸穿孔の患者において、
Hartmann 手術の術式が死亡割合の低下と関連することを示し、ショック状態、免疫抑
制状態、高齢者である場合には、特に Hartmann 手術の術式を選択する方が良いかもし
れないことを明らかにした。本研究はこれまで根拠の少なかった複雑性腹腔内感染症

の診療指針の一分野において、新たなエビデンスに基づきその推奨事項の妥当性を明
らかにしたものであり、複雑性腹腔内感染症の診療に重要な貢献をなすと考えられ
る。
よって本論文は博士( 医学 )の学位請求論文として合格と認められる。

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