腹腔镜阑尾切除术比较适合肥胖病患


  【24drs.com】根据美国外科医学会国家外科手术质量改善计画(ACS NSQIP)2005-2009年阑尾切除术病患资料进行的两篇分析,与开放式阑尾切除术患者相比,以腹腔镜方式进行阑尾切除术的肥胖病患并发症较少且住院期间较短。
  
  Keck医学院外科副教授Rodney J. Mason医师等人将研究结果发表于6月美国外科医学会期刊。
  
  病患分类为肥胖(身体质量指数[BMI]大于等于30 kg/m2)、病态肥胖(BMI大于等于40 kg/m2)、超级病态肥胖(BMI大于等于50 kg/m2),主要结果是30天整体发病率、严重发病率与死亡率。
  
  第一篇分析比较了资料库中所有肥胖病患进行开放式或腹腔镜阑尾切除术后的结果,共有13,330名病患为肥胖,其中,2,921人(22%)进行过开放式阑尾切除术,10,409人(78%)进行的是腹腔镜阑尾切除术;对这两组进行单一变项分析,41种ACS NSQIP术前风险因素中有29种具有显著差异。这个世代中,938名(7%)肥胖病患发生某种病态,504人(4%)发生严重病态,28人(0.2%)死亡。
  
  无并发症的阑尾炎病患,两组的死亡率是相同的,但是,有并发症的阑尾炎病患中,接受开放式手术者的比率高于腹腔镜手术者;病态肥胖和超级病态肥胖病患之间并无差异。
  
  开放式手术组的整体发病率比较高。表面手术部位感染(SSI)、深处切口SSI、器官空间SSI、切口裂开、肺炎、意外气管插管、使用呼吸器超过48小时、心脏停止、深部静脉血栓/血栓性静脉炎、败血症、败血性休克、重返手术室等,都是开放式手术组高于腹腔镜手术组。
  
  整体而言,开放式手术组与伤口无关的并发症发生率为8%(228/2921名病患)、腹腔镜手术组为4%(389/10,409);差异达显著程度(P < .001);非感染相关并发症发生率则是开放式手术组2% (63/2921)、腹腔镜手术组0.6% (67/10,409);差异也达显著(P < .001)。
  
  整体住院天数方面,开放式手术组比腹腔镜手术组多2.3天(平均差异2.3天;95%信心区间2.11 - 2.49)。
  
  越重的病患,差异越明显;与开放式手术组相比,腹腔镜手术组中,肥胖病患的住院天数少2.2天、病态肥胖组少2.6天、超级病态肥胖组病患少2.8天。
  
  Mason医师等人使用扩大实际配对方式为2,228名病患配对,以减少因为非随机分配手术方法引起的偏差;配对之后,选样偏差显著降低。
  
  配对世代中,只有表面SSI和深部切口SSI、败血症、返回手术室等,仍然是开放式阑尾切除术组显著较高;其它方面则无差异。整体而言,与伤口无关的并发症发生率,则是开放式手术组(4%;48/1114)和腹腔镜手术组(3%;35/1114;P = .146)相似。
  
  整体而言,与感染无关的并发症发生率也是两组相当(开放式手术组0.7% [8/1114] vs.腹腔镜手术组0.3% [3/1114];P = .131)。
  
  腹腔镜手术组的整体发病率显著较低,开放式手术组中,BMI增加与发病率显著较高有关。
  
  整体住院天数方面,腹腔镜手术组比开放式手术组少1.2天(平均差异1.2天;95%信心区间0.98 - 1.42)。
  
  作者们写道,在配对和未配对的肥胖病患中,腹腔镜方式都有明显的优势。此外,使用多变项风险校正分析,在未配对世代中,腹腔镜技术依旧较佳,校正风险因素之后,与整体发病率降低57%有关,配对世代的风险则是降低53% 。
  
  作者们结论表示,多数发病是因为伤口相关问题,开放式手术组中,随著肥胖程度而增加。
  
  资料来源: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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