腹腔鏡手術可以減少住院感染率


  April 25, 2008 — 根據發表於美國腸胃道與內視鏡外科醫師學會2008年會並登載於4月號Surgical Endoscopy期刊的一篇回溯分析,相較於開放手術,腹腔鏡手術可以減少50%的住院感染率和65%的再住院率;這項分析的病患是接受膽囊切除術、闌尾切除術、子宮切除術。
  
  擔任發表人的主要作者Andrew I. Brill醫師向Medscape General Surgery表示,這些結果以及此一領域之前的研究,強力支持腹腔鏡手術的好處,可以運用到研究中三項手術以外的其他手術,估計每年可減少美國170萬件住院感染導致的100,000例死亡;Brill醫師是舊金山加州太平洋醫學中心的婦科微創主任。
  
  此外,Brill醫師表示,該研究是首度檢視在這些手術出院後30天內的感染;研究發現,40%的感染發生在出院後30天內;之前有關出院後感染的研究有限 ,主要是比較腹腔鏡手術和開放手術的不確定風險。
  
  研究者回溯分析22間醫院、11,662名手術住院病患的資料,使用院內感染標記( nosocomial infection marker,NIM)辨識住院和出院後發生的院內感染。
  
  NIM是一種電腦演算系統,可以確認微生物的院內感染存在,分辨病源和污染、辨識獨立的複製品、暫時確認院內或社區感染病源;之前的多醫院研究顯示,NIM電腦演算偵測院內感染有86%的敏感性和98.5%的專一性。
  
  目前的研究中,腹腔鏡或開放式膽囊切除術的病患佔32.7%、闌尾切除術佔24.0%、子宮切除術佔 43.3%;利用感染源分析資料,包括泌尿道、傷口、呼吸道、血液以及其他;其他共變項,如性別、年紀、保險類型、住院複雜度、急診住院、病例組合指標(case mix index)住院,均以單一變項和多變項邏輯迴歸分析。
  
  開放式手術的整體感染率是4.09%,腹腔鏡手術是 2.11%;根據337名病患的399件NIMs資料,相較於開放手術,腹腔鏡膽囊切除術和子宮切除術均可減少超過50%的院內感染整體風險(腹腔鏡比開放式膽囊切除術減少66%;腹腔鏡比開放式子宮切除術減少 52%:兩者的P < .01);至於腹腔鏡和開放式闌尾切除術,在院內感染率風險則沒有明顯差異。
  
  交叉比較子宮切除術、膽囊切除術、闌尾切除術,與開放式手術相比,腹腔鏡手術可以減少各類型的院內感染整體的風險比 (OR):呼吸道感染減少 80%、血液感染減少 69%、傷口感染減少 59%、泌尿道感染39%、其他類型的院內感染減少48%。
  
  奧蘭多市佛羅里達紀念醫院骨盆健康中心主任、婦科外科主任Steven D. McCarus醫師表示,必須呼籲的是減少開放式子宮切除術,因為增加了院內感染風險;McCarus醫師並未參加此研究,由Medscape General Surgery邀請提出建議。
  
  McCarus醫師表示,婦科和一般外科需持續微創方式,以改善病患的結果;這篇報告特別註明並強調女性病患的微創手術好處。
  
  雖然有27%的病患在出院之後發現有院內感染而再度住院,但相較於開放式手術,腹腔鏡膽囊切除和子宮切除術可以減少65%的再度住院(P < .01)。
  
  Brill醫師表示,藉由減少感染率,腹腔鏡手術可以相當程度地減少健康照護體系用於院內感染的費用達數十億美金;該研究也顯示,相較於開放式手術,當病患接受腹腔鏡膽囊移除和子宮切除術時,可以減少65%因院內感染的再住院率,這表示可以節省住院花費。
  
  本研究的限制包括,缺少一些潛在影響結果的資料,例如抗生素的使用、麻醉分數、傷口類型、身體質量指數、之前的住院史、心血管疾病或糖尿病以及免疫不全等共病症。
  
  Brill 醫師表示,這個模式中有一些明確的變項未被考量,包括校正共病症狀況、疾病嚴重度、以及診斷相關的內因性限制;不過,此分析中的統計干擾因為樣本數夠大而消弭,研究期間使用的資料沒有任何排除,單一變項和多變項分析的結果都一致。
  
  若論及研究的弱點,McCarus醫師表示,因為缺乏一些資料以及沒有校正病患的共病症而受到限制;不過,研究的強項在於從22間醫院超過11,000名以上的住院病患資料進行分析。
  
  McCarus醫師表示,資料分析適當的進行,比較腹腔鏡與開放式膽囊切除術和子宮切除術的結論是明顯的;這篇報告有其重要性,因為院內感染問題是全面性的;這鼓勵我們這些醫師繼續研究以表達感染率和風險。
  
  除了降低院內感染,腹腔鏡手術還有其他好處;不過,在選擇這兩種手術時要衡量潛在的傷害。
  
  Brill 醫師表示,雖然腹腔鏡手術可能會有傷害腹內臟器與構造的風險,但相較於開腹手術,腹腔鏡手術可以提供比較好的美觀效果、比較迅速的恢復、比較少的術後疼痛,以及適合門診手術。
  
  McCarus醫師表示,若未經訓練,腹腔鏡手術有其風險;腹腔鏡手術須由有適當訓練的醫師執行才有好處,醫師持續學習微創手術技術改善或改變,是達到最終目標的重要環節— 目標就是迅速恢復、減少住院天數、術後恢復較快速。
  
  至於其他研究,Brill醫師建議將這項研究擴展到其他現在以開腹和腹腔鏡方式進行的手術類型,例如結腸切除術;他也建議比較這兩類型手術的花費,記住,院內感染會造成較高的花費。
  
  Brill醫師結論表示,這類的回溯研究利用挖掘資料以提供比其他研究更多的資訊,使得這些研究可以整合新治療方式的實際影響,幫助確認需要手術之病患的最佳與最有效率的照護。
  
  Johnson & Johnson集團旗下的 Ethicon Endo-Surgery公司發展及行銷微創手術與開放手術的進階裝置,並贊助此項研究;Brill醫師和 McCarus醫師都是Ethicon Endo-Surgery公司的諮詢顧問。
  
  美國腸胃道與內視鏡外科醫師學會2008年會暨畢業後課程。發表於2008年4月12日。

Laparoscopic Surgery May Reduc

By Laurie Barclay, MD
Medscape Medical News

April 25, 2008 — Laparoscopic surgery was linked to a 50% reduction in hospital-acquired infection rates and a 65% reduction in hospital readmissions vs open surgery, according to the results of a retrospective analysis presented recently at the Society of American Gastrointestinal and Endoscopic Surgeons 2008 Annual Scientific Session and published in the April issue of Surgical Endoscopy. This analysis was limited to patients undergoing cholecystectomy, appendectomy, or hysterectomy.

"These results, combined with previous research into this area, strongly suggest [that] the benefits of laparoscopic surgery may apply to procedures beyond the 3 types included in this particular study to reduce the estimated 100,000 deaths associated with the 1.7 million hospital-acquired infections that occur annually in the [United States]," presenter and lead author Andrew I. Brill told Medscape General Surgery. Dr. Brill is director of minimally invasive gynecology at the California Pacific Medical Center in San Francisco.

"Additionally, this study is the first to examine infections specific to these procedures 30 days postdischarge," Dr. Brill said. "The study discovered that 40% of the infections identified occurred within 30 days after hospital discharge. Previous studies on postdischarge infections have been very limited, and it is likely that comparisons of laparoscopic and open surgeries have underestimated risks."

The investigators retrospectively analyzed data from 11,662 surgical admissions to 22 hospitals that used the nosocomial infection marker (NIM) to identify nosocomial infections occurring during hospitalization and postdischarge.

NIM is a computer algorithm that identifies the existence of nosocomial infections at the microbiological level, distinguishing likely pathogens from contaminants, identifying duplicate isolates, and temporally determining hospital- vs community-acquired pathogen acquisition. A previous multihospital study showed 86% sensitivity and 98.5% specificity of the NIM algorithm for detecting nosocomial infections.

In the present study, admission was for laparoscopic or open cholecystectomy in 32.7% of patients, for appendectomy in 24.0%, and for hysterectomy in 43.3%. Data were analyzed by source of infection, including urinary tract, wounds, respiratory tract, bloodstream, and others. The effect of certain potentially confounding variables, such as sex, age, insurance type, complexity of admission, admission through the emergency department, and hospital case mix index, was examined with single and multivariable logistic regression analyses.

Overall infection rates were 4.09% for open surgery and 2.11% for laparoscopic procedures. In analyses based on 399 NIMs identified in 337 patients, laparoscopic cholecystectomy and hysterectomy were each associated with a greater than 50% reduction in the overall odds of acquiring nosocomial infections compared with open surgery (66% reduction for laparoscopic vs open cholecystectomy; 52% reduction for laparoscopic vs open hysterectomy; P < .01 for each).

Laparoscopic and open appendectomy were not significantly different in terms of the odds of acquiring nosocomial infections.

Across hysterectomies, cholecystectomies, and appendectomies, laparoscopic surgery vs open surgery was associated with a reduction in the overall odds ratio (OR) for each type of nosocomial infection: an 80% reduction in the OR for respiratory tract infection, a 69% reduction in the OR for bloodstream infection, a 59% reduction in the OR for wound infection, a 39% reduction in the OR for urinary tract infection, and a 48% reduction in the OR for other types of nosocomial infections.

"A call to action must be heard to decrease open hysterectomy techniques, which have an increased nosocomial infection risk," said Steven D. McCarus, MD, chief of gynecological surgery and director of the Center for Pelvic Health at Florida Hospital Celebration in Orlando. Dr. McCarus was not involved with this study but was asked to provide independent commentary for Medscape General Surgery.

"Gynecologists and general surgeons will continue minimally invasive approaches to improve patient outcomes," Dr. McCarus said. "This paper especially endorses and emphasizes the benefits of minimally invasive surgery in the female patient."

Although 27% of patients found to have a nosocomial infection after discharge were readmitted to the hospital, laparoscopic cholecystectomy and hysterectomy were associated with a 65% reduction in readmissions for infections compared with open surgery (P < .01).

"By reducing the rate of infection, laparoscopic surgery has the potential to dramatically cut into the billions of dollars [in costs] incurred by the healthcare system due to hospital-acquired infections," Dr. Brill said. "The study also showed a 65% reduction in hospital readmissions for hospital-acquired infections when a patient underwent laparoscopic gallbladder removal and hysterectomy when compared to open surgery. This translates into cost savings for hospitals and payors."

Limitations of this study include absence of certain data that could potentially confound the results, such as antibiotic use, anesthesia scores, wound class, body mass index, prior hospitalization, and comorbidities of cardiovascular disease, diabetes mellitus, and immunodeficiency.

"There were definitely variables that were not considered in the model, including no adjustments for comorbid conditions, the severity of disease, and the intrinsic limits of present [diagnosis-related groups]," Dr. Brill said. "However, the statistical noise in this analysis is well balanced by the very large sample size, the use of all data during the time frame without any exclusions, and the fact that univariate and multivariate findings were consistent."

In terms of study weaknesses, Dr. McCarus agreed that the controls were limited by the absence of certain data and that there was no adjustment for patient comorbidities. However, a major strength was analysis of more than 11,000 admissions to 22 hospitals.

"Analysis of data was appropriately done, and conclusions were significant in comparing laparoscopic cholecystectomy and hysterectomy to their open counterparts," Dr. McCarus said. "Certainly this paper is an important one because of the associated nosocomial infection problem that is global. This encourages us as surgeons to continue additional research where we can address infection rates and risks."

In addition to potential reduction in nosocomial infections, laparoscopic surgery may confer other benefits over open surgery. However, potential harms should also be considered when choosing between these approaches.

"Whereas laparoscopic surgery carries the irreducible but small risk of injury to intraabdominal visceral and vascular structures, compared to laparotomy it provides superior cosmesis, more rapid recovery, less postoperative pain, and the option for outpatient surgery," Dr. Brill said.

"In untrained hands, laparoscopy has associated risks," Dr. McCarus agreed. "Laparoscopic surgery has benefits when performed by properly trained surgeons. A commitment on the part of the surgeon to learn and relearn minimally invasive techniques as technologies improve or change is paramount in reaching our endpoint — the endpoint being quicker recovery, decreased hospital stays, and faster [postoperative] recovery."

In terms of additional research, Dr. Brill recommends extending this research to other types of surgical procedures now routinely performed by both laparotomic and laparoscopic methods, such as colectomy. He also suggests investigating the comparative cost components of conventional vs laparoscopic surgery, keeping in mind the high costs related to nosocom

    
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