男性、年长等因素增加胆囊并发症风险


  【24drs.com】针对一间非教学医院单一手术小组进行的腹腔镜胆囊切除术(LCs),一项10年回溯评估提供了实际状况的一些写照。
  
  作者们在文章中指出,这篇报告是来自单一非教学医院的最大型研究,刊载于7/8月版的Journal of Laparoendoscopic and Advanced Surgical Techniques。
  
  土耳其伊斯坦堡Umraniye教育与研究医院一般外科Mustafa Hasbahceci医师等人写道,腹腔镜胆囊切除术被视为胆结石治疗的黄金标准,但因多数临床回顾合并了不同医院的手术团队以及外科医师,或单一机构的多名外科医师或团队的结果,以致于难以获得手术结果的实际面貌;而且,在教学医院和非教学医院的比较方面,也不清楚并发症比率,特别是胆管损伤。
  
  为了厘清这些议题,作者们回顾了2000年1月至2010年10月间,在土耳其伊斯坦堡29 May医院、土耳其宗教基金会进行的所有腹腔镜胆囊切除术病例;结果测量包括:转为开腹手术、手术时间、住院天数与住院期间到出院3个月后发生的并发症,全部病患在术后追踪至少3个月。
  
  研究分析1,557名病患,包括1,222名女性和335名男性,平均年纪54.1 ± 12.3岁,76%病患的身体质量指数(BMI)介于25 kg/m2和34.99 kg/m2;大多数手术(1401例[90%])是选择性进行,191例(12%)患者曾发生过急性胆囊炎(AC),34人(2%)曾发生过急性胆源性胰腺炎。
  
  手术时间范围为10-200分钟,平均43.4分钟,85.8%案例的手术时间小于60分钟;住院天数平均为1.2天(范围1 – 19天),93.1%的病患在手术后1天内出院,94.8%的病患在2天内出院。
  
  有39例需要转为开腹手术,转换率为2.5%。最常见的转换原因,是有许多和目前或以前的急性胆囊炎发作有关的发炎,分别有17例(43.5%)和15例(38.5%),转换术式的其它原因包括:胆管损伤(n = 3人)、之前手术导致的致密沾黏(n = 2人)以及设备故障(n = 2人)。
  
  作者们写道,总计51名病患发生57例(3.7%)并发症,最常见的并发症为感染相关(11名病患)、胆汁漏出(n = 10人)、出血(n = 7人)、总胆管残余结石(n = 6人)、术后麻痹性肠梗塞(n = 6人)以及术后腹水(n = 4人)。
  
  作者们报告指出,与转换为开腹手术机率较高的相关因素包括:男性(胜算比[OR]4.473;P < .001)、55岁以上(OR,2.478;P < .01)、因为急性胆囊炎导致急诊住院(OR = 558.263;P < .001)、曾发生过急性胆囊炎(OR,4.766;P < .001)。和发病率有关的风险因素包括:男性(OR,1.813;P < .046)、美国麻醉科医师协会分数3分(OR,3.706;P < .005)、因为急性胆囊炎急诊住院(OR,7.034;P < .001)、曾发生过急性胆囊炎(OR,3.378;P < .001)。
  
  作者们指出,其它作者曾报告过的并发症比率范围从1.5%到高达17%皆有,根据的因素包括:出现复杂性胆结石疾病、男性、年长、需转为开腹手术、手术时间大于2小时、是否在教学医院进行。与之前文献的并发症比率相比,其研究发现的3.7%并发症比率或许可视为可接受的结果。
  
  可能的研究限制包括,回溯型研究设计,在这段期间于该机构实际进行腹腔镜胆囊切除术的1,676名病患中有119人的资料不完整,导致需将这些病患排除于分析。
  
  研究者结论表示,他们的结果或许可作为未来在单一非教学医院进行腹腔镜胆囊切除术之研究的比较基础。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=6908&x_classno=0&x_chkdelpoint=Y
  

Male Sex, Older Age Raise Risk for Gallbladder Complications

By Norra MacReady
Medscape Medical News

August 10, 2012 — A 10-year retrospective review of laparoscopic cholecystectomies (LCs) performed by a single surgical group at a non–teaching hospital provides a snapshot of that surgery under real-life conditions.

This report is one of the largest to come from a single non–teaching hospital, the authors explain in their article, which was published in the July/August issue of the Journal of Laparoendoscopic and Advanced Surgical Techniques.

LC is considered the gold standard for gallstone treatment, but it is hard to obtain a true picture of outcomes because most clinical reviews combine the findings either of multiple studies of different surgeons and surgical groups at several hospitals or of multiple surgeons and groups at a single institution over time, lead author Mustafa Hasbahceci, MD, from the Department of General Surgery, Umraniye Education and Research Hospital, Umraniye, Istanbul, Turkey, and colleagues write. It is also unclear how the rate of complications, particularly bile duct injury, at teaching hospitals compares with that seen at non–teaching hospitals.

In an effort to clarify these issues, the authors reviewed all LC procedures performed between January 2000 and October 2010 at the Religious Foundation of Turkey, 29 May Hospital, in Istanbul. Outcome measures included conversion to open surgery, surgery duration, length of hospital stay, and complications that occurred during hospital admission and up to 3 months out. All patients were followed-up for at least 3 months postoperatively.

The analysis included 1557 patients: 1222 women and 335 men, with an average age of 54.1 ± 12.3 years. Seventy-six percent of the patients had a body mass index (BMI) of between 25 kg/m2 and 34.99 kg/m2. Most of the procedures (1401 [90%]) were performed electively. One hundred and ninety one (12%) of the patients had had a previous attack of acute cholecystitis (AC), and 34 (2%) had a history of acute biliary pancreatitis.

The duration of surgery ranged from 10 to 200 minutes, with a mean of 43.4 minutes. Surgery lasted less than 60 minutes in 85.8% of the cases. The mean length of hospital stay was 1.2 days (range, 1 - 19 days), with 93.1% of patients discharged within 1 day of surgery and 94.8% of patients discharged within 2 days.

Open surgery was required in 39 cases, for a conversion rate of 2.5%. Severe inflammation related to current or previous AC attacks was the most common reason for conversion, seen in 17 (43.5%) and 15 (38.5%) patients respectively. Bile duct injury (n = 3), dense adhesions resulting from previous surgery (n = 2), and equipment failure (n = 2) were other reasons for conversion.

"In total, 57 (3.7%) complications occurred in 51 patients," the authors write. The most common complications were those related to infection (seen in 11 patients), biliary leakage (n = 10), bleeding (n = 7), retained stones in the common bile duct (n = 6), postoperative paralytic ileus (n = 6), and postoperative ascites (n = 4).

Factors associated with a higher probability of conversion to open surgery were male sex (odds ratio [OR], 4.473; P < .001), age older than 55 years (OR, 2.478; P < .01), emergency admission resulting from AC (OR = 558.263; P < .001), and a history of previous AC attacks (OR, 4.766; P < .001), the authors report. Risk factors associated with morbidity included male sex (OR, 1.813; P < .046), an American Society of Anesthesiologists score of 3 (OR, 3.706; P < .005), emergency admission because of AC (OR, 7.034; P < .001), and a history of previous AC attacks (OR, 3.378; P < .001).

Other authors have reported complication rates ranging from 1.5% to as high as 17%, depending on factors such as the presence of complicated gallstone disease, male sex, advanced patient age, need for conversion to open surgery, duration of surgery more than 2 hours, and whether the procedure was performed at a teaching hospital, the authors add. "Our 3.7% complication rate may be considered a favorable result compared with the...complication rate found in the past literature."

Possible limitations of this study include the retrospective design and incomplete data on 119 of the 1676 patients who actually underwent LC at this institution during the time in question, leading to the exclusion of those patients from the analysis.

"Our results may serve as a baseline for comparison with future studies done at single, non-teaching hospitals where surgical teams perform laparoscopic cholecystectomies over a long period of time," the investigators conclude.

The authors have disclosed no relevant financial relationships.

J Laparoendosc Adv Surg Tech. 2012;22:527-532.

    
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