腹腔鏡闌尾切除術比較適合肥胖病患


  【24drs.com】根據美國外科醫學會國家外科手術品質改善計畫(ACS NSQIP)2005-2009年闌尾切除術病患資料進行的兩篇分析,與開放式闌尾切除術患者相比,以腹腔鏡方式進行闌尾切除術的肥胖病患併發症較少且住院期間較短。
  
  Keck醫學院外科副教授Rodney J. Mason醫師等人將研究結果發表於6月美國外科醫學會期刊。
  
  病患分類為肥胖(身體質量指數[BMI]大於等於30 kg/m2)、病態肥胖(BMI大於等於40 kg/m2)、超級病態肥胖(BMI大於等於50 kg/m2),主要結果是30天整體發病率、嚴重發病率與死亡率。
  
  第一篇分析比較了資料庫中所有肥胖病患進行開放式或腹腔鏡闌尾切除術後的結果,共有13,330名病患為肥胖,其中,2,921人(22%)進行過開放式闌尾切除術,10,409人(78%)進行的是腹腔鏡闌尾切除術;對這兩組進行單一變項分析,41種ACS NSQIP術前風險因素中有29種具有顯著差異。這個世代中,938名(7%)肥胖病患發生某種病態,504人(4%)發生嚴重病態,28人(0.2%)死亡。
  
  無併發症的闌尾炎病患,兩組的死亡率是相同的,但是,有併發症的闌尾炎病患中,接受開放式手術者的比率高於腹腔鏡手術者;病態肥胖和超級病態肥胖病患之間並無差異。
  
  開放式手術組的整體發病率比較高。表面手術部位感染(SSI)、深處切口SSI、器官空間SSI、切口裂開、肺炎、意外氣管插管、使用呼吸器超過48小時、心臟停止、深部靜脈血栓/血栓性靜脈炎、敗血症、敗血性休克、重返手術室等,都是開放式手術組高於腹腔鏡手術組。
  
  整體而言,開放式手術組與傷口無關的併發症發生率為8%(228/2921名病患)、腹腔鏡手術組為4%(389/10,409);差異達顯著程度(P < .001);非感染相關併發症發生率則是開放式手術組2% (63/2921)、腹腔鏡手術組0.6% (67/10,409);差異也達顯著(P < .001)。
  
  整體住院天數方面,開放式手術組比腹腔鏡手術組多2.3天(平均差異2.3天;95%信心區間2.11 - 2.49)。
  
  越重的病患,差異越明顯;與開放式手術組相比,腹腔鏡手術組中,肥胖病患的住院天數少2.2天、病態肥胖組少2.6天、超級病態肥胖組病患少2.8天。
  
  Mason醫師等人使用擴大實際配對方式為2,228名病患配對,以減少因為非隨機分配手術方法引起的偏差;配對之後,選樣偏差顯著降低。
  
  配對世代中,只有表面SSI和深部切口SSI、敗血症、返回手術室等,仍然是開放式闌尾切除術組顯著較高;其他方面則無差異。整體而言,與傷口無關的併發症發生率,則是開放式手術組(4%;48/1114)和腹腔鏡手術組(3%;35/1114;P = .146)相似。
  
  整體而言,與感染無關的併發症發生率也是兩組相當(開放式手術組0.7% [8/1114] vs.腹腔鏡手術組0.3% [3/1114];P = .131)。
  
  腹腔鏡手術組的整體發病率顯著較低,開放式手術組中,BMI增加與發病率顯著較高有關。
  
  整體住院天數方面,腹腔鏡手術組比開放式手術組少1.2天(平均差異1.2天;95%信心區間0.98 - 1.42)。
  
  作者們寫道,在配對和未配對的肥胖病患中,腹腔鏡方式都有明顯的優勢。此外,使用多變項風險校正分析,在未配對世代中,腹腔鏡技術依舊較佳,校正風險因素之後,與整體發病率降低57%有關,配對世代的風險則是降低53% 。
  
  作者們結論表示,多數發病是因為傷口相關問題,開放式手術組中,隨著肥胖程度而增加。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6876&x_classno=0&x_chkdelpoint=Y
  

Laparoscopic Appendectomy Better for Obese Patients

By Troy Brown
Medscape Medical News

July 2, 2012 — Obese patients who have appendectomies performed laparoscopically experience fewer complications and have shorter hospital stays than obese patients who have open appendectomies, according to 2 analyses of data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database of patients who had appendectomies between 2005 and 2009.

Rodney J. Mason, MBBCh, associate professor of surgery at Keck School of Medicine in Los Angeles, California, and colleagues published their findings in the July issue of the Journal of the American College of Surgeons.

Patients were classified as obese if they had a body mass index (BMI) of 30 kg/m2 or higher, morbidly obese if their BMI was 40 kg/m2 or higher, and super morbidly obese if their BMI was 50 kg/m2 or higher. The primary outcomes measured were 30-day overall morbidity, serious morbidity, and mortality.

Aggregate Cohort

The first analysis compared outcomes of all obese patients in the database after having an open or laparoscopic appendectomy. A total of 13,330 patients were obese; of these, 2921 (22%) had an open appendectomy and 10,409 (78%) had a laparoscopic appendectomy. There were significant differences in 29 of 41 ACS NSQIP preoperative risk factors between the 2 groups on univariate analysis.

In the cohort, 938 (7%) of the obese patients experienced some kind of morbidity, 504 (4%) suffered a serious morbidity, and 28 (0.2%) died.

Mortality was the same for both groups of patients who had uncomplicated appendicitis, but it was higher for patients with complicated appendicitis who had the open procedure than for patients with complicated appendicitis who had the laparoscopic surgery. There were no differences between morbidly obese and super morbidly obese patients.

Overall morbidity was considerably higher in the open appendectomy group. Superficial surgical site infection (SSI), deep incisional SSI, organ space SSI, wound disruption, pneumonia, unplanned intubation, being on a ventilator longer than 48 hours, cardiac arrest, deep-vein thrombosis/thrombophlebitis, sepsis, septic shock, and return to the operating room were all significantly higher in the open surgery group than the laparoscopic group.

Overall, the incidence of non–wound-related complications in the open surgery group was 8% (228/2921 patients) and 4% (389/10,409) in the laparoscopic group; the difference was significant (P < .001). The overall incidence of non-infectious-related complications was 2% (63/2921 patients) in the open group and 0.6% (67/10,409) in the laparoscopic group; this difference also was significant (P < .001).

Overall hospital length of stay was 2.3 days longer for patients who had open surgery compared with patients who had laparoscopic surgery (mean difference, 2.3 days; 95% confidence interval, 2.11 - 2.49).

Differences were more pronounced in heavier patients. In the laparoscopic group, hospital stays were 2.2 days shorter in obese patients, 2.6 days shorter in morbidly obese patients, and 2.8 days shorter in super morbidly obese patients.

Matched Cohort

Dr. Mason and colleagues matched a total of 2228 patients using a coarsened exact matching procedure to reduce bias that could have occurred because of the nonrandom assignment of surgical method. After matching, selection bias was significantly reduced.

In the matched cohort, only superficial SSI and deep incisional SSI, sepsis, and return to the operating room remained significantly higher in the open appendectomy group; there were no differences in the remaining outcomes. Overall, the incidence of non–wound-related complications was similar in the open surgery group (4%; 48/1114 patients) and the laparoscopic surgery group (3%; 35/1114; P = .146).

Overall, the incidence of non–infection-related complications was equivalent in both groups (0.7% [8/1114 patients] for the open group vs 0.3% [3/1114] for the laparoscopic group; P = .131).

Overall morbidity was significantly lower in the laparoscopic surgery group, and increasing BMI was associated with significantly higher morbidity in the open surgery group.

Overall hospital LOS was 1.2 days shorter for the laparoscopic group compared with the open group (mean difference, 1.2 days; 95% confidence interval, 0.98 - 1.42).

Obesity Increases Risk

"The considerable difference favoring the laparoscopic approach was seen for both the matched and unmatched obese patients. In addition, the laparoscopic technique was still considerably better in the unmatched cohort using the multivariable risk-adjusted analysis and was associated with a 57% reduction in overall morbidity in all the obese patients after risk adjustment, which was similar to the 53% reduction in risk in the matched cohort," the authors write.

"Most of the morbidity is due to wound-related issues that become more prevalent in the open approach with increasing obesity," the authors conclude.

The authors have disclosed no relevant financial relationships.

J Am Coll Surg. 2012;215:88-100.

    
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