荷兰拉德博德大学医学中心Richard P G ten Broek研究组近日取得一项新成果。他们比较了开放和腹腔镜手术后的粘连相关再入院的发生率。相关论文2020年1月4日发表于《柳叶刀》。

粘连是腹部手术后长期发病的主要原因。尽管腹腔镜能够减少粘连形成，但微创手术后长期粘连相关的发病率尚未清楚。

研究组对采用腹腔镜或开放术对腹部或盆腔进行手术的全年龄患者进行了一项回顾性队列研究，采用苏格兰国家卫生局的验证人群数据。2009年6月1日至2011年6月30日，共有72270例患者接受了腹部或盆腔手术，其中29.8%行腹腔镜手术，70.2%行开放手术。术后5年，有3.5%的患者因粘连直接相关疾病而再次住院，17.6%的患者因粘连可能相关疾病而再次住院，13.1%的患者因潜在的复杂粘连而再次手术。

在接受腹腔镜手术的21519名患者中，1.7%因粘连直接相关疾病而再次住院，开放手术组中有4.3%；腹腔镜手术组中16.0%的患者因粘连可能相关疾病而再次住院，开放手术组中有18.2%。在多变量分析中，腹腔镜与开放手术相比，粘连直接相关再入院的风险降低了32%，粘连可能相关再入院的风险降低了11%。手术类型、恶性肿瘤、性别和年龄也与粘连相关再入院的风险独立相关。

总之，腹腔镜手术减少了粘连相关疾病再入院的发生率。然而，粘连相关再入院的总负担依然很大。随着腹腔镜手术的推广，可能会改善很多人的预后，但仍有必要采取进一步措施，以减少粘连相关术后并发症的发生率。

附：英文原文

Title: Adhesion-related readmissions after open and laparoscopic surgery: a retrospective cohort study (SCAR update)

Author: Pepijn Krielen, Martijn W J Stommel, Pille Pargmae, Nicole D Bouvy, Erica A Bakkum, Harold Ellis, Michael C Parker, Ewen A Griffiths, Harry van Goor, Richard P G ten Broek

Issue&Volume: 2020/01/04

Abstract: 

Background

Adhesions are the most common driver of long-term morbidity after abdominal surgery. Although laparoscopy can reduce adhesion formation, the effect of minimally invasive surgery on long-term adhesion-related morbidity remains unknown. We aimed to assess the impact of laparoscopy on adhesion-related readmissions in a population-based cohort.

Methods

We did a retrospective cohort study of patients of any age who had abdominal or pelvic surgery done using laparoscopic or open approaches between June 1, 2009, and June 30, 2011, using validated population data from the Scottish National Health Service. All patients who had surgery were followed up until Dec 31, 2017. The primary outcome measure was the incidence of hospital readmissions directly related to adhesions in the laparoscopic and open surgery cohorts at 5 years. Readmissions were categorised as directly related to adhesions, possibly related to adhesions, and readmissions for an operation that was potentially complicated by adhesions. We did subgroup analyses of readmissions by anatomical site of surgery and used Kaplan-Meier analyses to assess differences in survival across subgroups. We used multivariable Cox-regression analysis to determine whether surgical approach was an independent and significant risk factor for adhesion-related readmissions.

Findings

Between June 1, 2009, and June 30, 2011, 72?270 patients had an index abdominal or pelvic surgery, of whom 21?519 (29·8%) had laparoscopic index surgery and 50?751 (70·2%) had open surgery. Of the 72?270 patients who had surgery, 2527 patients (3·5%) were readmitted within 5 years of surgery for disorders directly related to adhesions, 12?687 (17·6%) for disorders possibly related to adhesions, and 9436 (13·1%) for operations potentially complicated by adhesions. Of the 21?519 patients who had laparoscopic surgery, 359 (1·7% [95% CI 1·5–1·9]) were readmitted for disorders directly related to adhesions compared with 2168 (4·3% [4·1–4·5]) of 50?751 patients in the open surgery cohort (p<0·0001). 3443 (16·0% [15·6–16·4]) of 21?519 patients in the laparoscopic surgery cohort were readmitted for disorders possibly related to adhesions compared with 9244 (18·2% [17·8–18·6]) of 50?751 patients in the open surgery cohort (p<0·005). In multivariate analyses, laparoscopy reduced the risk of directly related readmissions by 32% (hazard ratio [HR] 0·68, 95% CI 0·60–0·77), and of possibly related readmissions by 11% (HR 0·89, 0·85–0·94) compared with open surgery. Procedure type, malignancy, sex, and age were also independently associated with risk of adhesion-related readmissions.

Interpretation

Laparoscopic surgery reduces the incidence of adhesion-related readmissions. However, the overall burden of readmissions associated with adhesions remains high. With further increases in the use of laparoscopic surgery expected in the future, the effect at the population level might become larger. Further steps remain necessary to reduce the incidence of adhesion-related postsurgical complications.

DOI: 10.1016/S0140-6736(19)32636-4

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32636-4/fulltext