濕熱法與可控式燒灼扁桃腺切除會增加出血風險


  Aug. 20, 2004 - 根據來自英國國家前瞻性扁桃腺切除稽核(NPTA)團隊發表於8月21日Lancet的期中分析結果顯示,濕熱法與可控式扁桃腺切除術造成術後出血的風險,至少是傳統冷鐵式切除法的3倍。
  
  英格蘭皇家手術學院倫敦公共衛生醫學院臨床效率小組Jan van der Meulen醫師與其同事指出,「熱的」扁桃腺切除術(例如濕熱法與可控式燒灼)的技術已臻完善,但是部分證據顯示,這些技術比傳統僅僅以縫合及填塞來止血的傳統「冷鐵」切除方式好。
  
  為了確認術後發生出血的危險因子,NTPA團隊於2003年7月為252家英國與北愛爾蘭醫院的11,796接受不同手術方式的病患做期中(6個月)分析。
  
  術後28日內總合出血率為3.3%(389位病患),原本就出血的病患,發生繼發性出血的機率顯著地較高(2.9%〔337位)相較於0.5%〔59位〕)。
  
  接受冷鐵切割術而沒有接受濕熱法或可控式燒灼的病患,發生繼發性出血機率最低(0.75%);相反的,接受雙極濕熱式扁桃腺切除術患者發生繼發性出血的相對風險為3.1(95%信賴區間,1.9—5.0﹔P<.001)而接受可控式燒灼的是3.4(95%信賴區間,1.9—6.2﹔P<.001);至於使用冷鐵切割配合溼熱法止血的相對風險則為2.2(95%信賴區間,1.3—3.7﹕P<.002)。
  
  研究人員指出,雖然我們的發現傾向使用冷鐵式而不是濕熱式,但基於目前的證據,我們並不認為應該停止使用這種技術;我們建議謹慎地使用濕熱法,並且要由受過訓練的醫師操作,且仍需要更進一步的臨床試驗來支持這項試驗結果。
  
  這項試驗由英國衛生部門與北愛爾蘭社會服務與公共安全部門贊助。
  
  在該項研究伴隨的評論中,英國皇家Devon與Exeter醫院Malcom Hilton評論指出,雖然試驗結果支持使用濕熱法的扁桃腺切除術會增加繼發性出血的理論,但是之間的因果關係並沒有被證實。
  
  Hilton醫師結論指出,將稽核自然地延伸,將會是一種扁桃腺切除術諮詢導向的全國前瞻性隨機分派試驗,它可將其他因子的影響減少到最小;不過,要獲得進一步有關扁桃腺切除技術安全性的結論,必須基於最佳品質的臨床證據。

Diathermy and Coblation Tonsil

By Yael Waknine
Medscape Medical News

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Aug. 20, 2004 — Diathermy and coblation tonsillectomy have a postoperative hemorrhage rate at least three times that of cold steel tonsillectomy without use of "hot" techniques, according to interim results from the UK National Prospective Tonsillectomy Audit (NPTA) published in the Aug. 21 issue of The Lancet.

" 'Hot' tonsillectomy techniques (eg. diathermy and coblation) have become well established, but there is little evidence to suggest that they are better than traditional 'cold steel' dissection with only packs or ties for haemostasis," write Jan van der Meulen, MD, from the Clinical Effectiveness Unit at the Royal College of Surgeons of England – London School of Hygiene and Tropical Medicine, and colleagues.

To determine risk factors for hemorrhage after tonsillectomy, the NPTA investigators produced an interim (six-month) analysis of 11,796 tonsillectomies performed with varying techniques in 252 hospitals in England and Northern Ireland during July 2003.

The overall rate of hemorrhage within 28 days of surgery was 3.3% (n = 389). Secondary hemorrhage occurred at a significantly higher rate compared with primary hemorrhage (2.9% [n = 337] vs. 0.5% [n = 59]).

The rate of secondary hemorrhage was lowest in patients undergoing cold-steel dissection without diathermy or coblation (0.75%). In comparison, the relative risk of secondary hemorrhage was 3.1 with bipolar diathermy tonsillectomy (95% confidence interval [CI], 1.9 - 5.0; P < .001) and 3.4 with coblation tonsillectomy (95% CI, 1.9 - 6.2; P < .001). With use of diathermy only for hemostasis and cold steel for dissection, the relative risk was 2.2 (95% CI, 1.3 - 3.7; P = .002).

"[A]lthough our findings favour cold steel without diathermy, we do not think that hot techniques should be stopped on the basis of the current evidence," the authors write, advising that diathermy be used with appropriate caution, and only after proper training. "[F]urther clinical research is necessary to support the results of our study."

The study was funded by the Department of Health in England, and the Department of Health, Social Services and Public Safety in Northern Ireland.

"Correlation is never proof of causation, though the results...support the hypothesis that use of diathermy in tonsillectomy increases the secondary hemorrhage rate," comments Malcom Hilton, from the Royal Devon & Exeter Hospital, U.K., in an accompanying editorial.

"A natural extension of the audit would be a consultant-led national prospective randomized trial of common tonsillectomy techniques, so that other confounding factors can be minimized," Dr. Hilton concludes, adding that further conclusions on the safety of tonsillectomy techniques should be based on the best-quality clinical evidence.

Lancet. 2004;364:642-643, 697-702

Reviewed by Gary D. Vogin, MD

    
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