腹腔镜减少小肠阻塞风险


  【24drs.com】根据刊载于4月号外科学志人口基础回溯登记研究结果,进行开放式腹部手术的病患,发生小肠阻塞(SBO)的机会是进行腹腔镜腹部手术患者的至少4倍。
  
  利用瑞典全国健康福祉委员会住院病患登记库之108,141名患者的资料,研究者发现,术后发生SBO的比率介于0.4%-13.9%,依手术类型而异;多变项分析发现,年纪、之前的腹部手术、共病症、手术技术都是SBO的风险因素,大部分的手术中,进行腹腔镜手术病患的SBO风险最低。
  
  瑞典Scandinavian手术结果研究组Eva Angenete博士等人写道,小肠阻塞确实是健康照护的挑战,正确辨识风险因素可以改善降低腹部手术后之SBO风险的工具;这篇研究显示,除了年纪、之前的腹部手术、共病症等重要因素之外,手术技术也是与SBO有关的重要因素。
  
  研究者分析了2002年1月1日至2004年12月31日间、进行腹腔镜胆囊切除术、子宫切除术、输卵管卵巢切除术、肠切除,前位切除术、腹会阴联合切除、直肠固定术、阑尾切除术、减肥手术等手术的病患资料,评估了年纪、性别、共病症情况、手术技术(开放式或腹腔镜),有SBO病史的病患则排除在外。
  
  主要结果是,在前述之手术后5年内评估发生SBO的情况。
  
  研究者发现,减重手术是腹腔镜手术组中,唯一SBO风险较高者,但差异未达统计上的显著程度(胜算比[OR]为0.7 [95%信心区间(CI)为 0.4 - 1.2];P > .05);输卵管卵巢切除术是开放式腹部手术组中SBO风险最高的(OR,7.6 [95% CI,4.4 - 13.1];P < .001)。
  
  有关研究限制的讨论方面,作者们指出,因为未回顾病患个人的病历纪录,病患可能有其它肠阻塞风险影响,不过,他们认为这个风险在各组是相当的。此外,各适应症之间可能有所影响,因为胆囊切除术、肠切除、阑尾切除术等手术之SBO发生率和共病症有关,也和进行开放式或腹腔镜手术有关。作者们试图在手术类别中阐述这点,但也指出需要后续研究。
  
  Angenete博士等人写道,事实是,这是篇人口基础研究,样本数够大、表示我们的研究结果确实代表手术技术会导致实际差异;腹腔镜手术的短期效益和安全性,为了进一步减少手术并发症,腹腔镜应作为首选的技术是可行的。
  
  麻州波士顿哈佛医学院、布莱根妇女医院一般外科Luke M. Funk医师和Stanley W. Ashley医师受邀发表评论时写道,这结果为腹腔镜手术减少与再度住院有关之沾黏的发生率提供新证据,对手术照护质量和费用都有重要影响。
  
  Funk医师和Ashley医师指出,对于保险人和健康照护政策领袖,如果多以腹腔镜手术取代开放式手术,费用可明显节省,美国每年花在沾黏相关并发症的住院病患费用超过20亿美元,节省下来相当可观。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=6789&x_classno=0&x_chkdelpoint=Y
  

Laparoscopy Reduces Risk for Small Bowel Obstruction

By Jennifer Garcia
Medscape Medical News

April 16, 2012 — Patients who undergo an open abdominal surgery are at least 4 times more likely to develop small bowel obstruction (SBO) compared with patients who undergo laparoscopic surgery for most abdominal procedures. These are the findings of a population-based retrospective register study published in the April issue of the Archives of Surgery.

Using data from 108,141 patients in the Inpatient Register held by the Swedish National Board of Health and Welfare, the researchers found that the incidence of SBO after surgery ranged from 0.4% to 13.9%, depending on the type of surgery. A multivariate analysis revealed that age, previous abdominal surgery, comorbidity, and surgical technique were risk factors for SBO. Patients who underwent laparoscopic surgeries had the lowest SBO risk among most surgical procedures.

"Small-bowel obstruction is a substantial health care challenge, and correctly identified risk factors can provide improved tools to reduce the risk of SBO after an abdominal surgical procedure," write Eva Angenete, MD, PhD, from the Scandinavian Surgical Outcomes Research Group, Gothenburg, Sweden, and colleagues. "This study shows that, beyond important factors such as age, previous abdominal surgery, and comorbidity, the surgical technique is the most important factor related to SBO," note the authors.

The researchers analyzed surgical records for patients who underwent cholecystectomy, hysterectomy, salpingo-oophorectomy, bowel resection, anterior resection, abdominoperineal resection, rectopexy, appendectomy, and bariatric surgery between January 1, 2002, through December 31, 2004. Age, sex, comorbid conditions, and surgical technique (open vs laparoscopic) were evaluated. Patients with a history of surgery for SBO were excluded from the study.

The main outcome assessed was the development of SBO within 5 years after the index surgery.

The researchers found that bariatric surgery was the only procedure in which the risk for SBO was higher in the laparoscopy group, although the difference was not statistically significant (odds ratio [OR], 0.7 [95% confidence interval (CI), 0.4 - 1.2]; P > .05). Salpingo-oophorectomy was the procedure with the highest risk for SBO after open abdominal surgery (OR, 7.6 [95% CI, 4.4 - 13.1]; P < .001).

Discussing some of the study limitations, the authors note that because the patients' individual medical records were not reviewed, there is a risk that patients with other types of bowel obstruction were included. However, they considered the risk to be equally distributed in all groups. In addition, possible confounding by indication may have occurred because the analyses included comorbidity related to the incidence of SBO in cholecystectomy, bowel resection, and appendectomy but was also related to whether open or laparoscopic surgery was performed. The authors attempted to address this in their categorization of the procedures but note that this will require further study.

"The fact that this study is population based and that the group size is sufficiently large indicate that our results represent an actual difference due to surgical technique," write Dr. Angenete and colleagues. "The safety and the short-term benefits of laparoscopy are already known, and it is possible that laparoscopy should be regarded as the preferred technique in an attempt to further reduce the complications of surgery," conclude the authors.

In an invited commentary, Luke M. Funk, MD, MPH, and Stanley W. Ashley, MD, from the Department of General Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, write: "This finding adds to the body of literature suggesting that laparoscopy decreases the incidence of adhesion related readmissions and has important implications for both the quality and cost of surgical care."

"For payers and health care policy leaders, it suggests that substantial cost savings could be achieved if open surgery were replaced with laparoscopic surgery more often. Given that inpatient expenditures on adhesiolysis-related complications exceed $2 billion annually in the United States, these savings could be substantial," add Dr. Funk and Dr. Ashley.

The study was funded by grants from the Swedish Cancer Foundation, the Swedish Medical Association, the Gothenburg Medical Association, the Assar Gabrielsson Foundation, the Magn Berwall's Foundation, and the Swedish Research Council. The authors and editorialists have disclosed no relevant financial relationships.

Arch Surg. 2012;147:359-365.

    
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