Campbell Brendan T, McLean Kelly, Barnhart Douglas C, Drongowski Robert A, Hirschl Ronald B
Robert Wood Johnson Clinical Scholars Program and C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA.
J Pediatr Surg. 2002 Jul;37(7):1068-71; discussion 1068-71. doi: 10.1053/jpsu.2002.33846.
BACKGROUND/PURPOSE: An increasing number of pediatric surgeons are using the laparoscopic approach to treat pyloric stenosis. The advantage of laparoscopic pyloromyotomy is uncertain and has not been evaluated in the setting of a pediatric surgery fellowship program.
The authors retrospectively reviewed the medical records of all patients who underwent pyloromyotomy for congenital hypertrophic pyloric stenosis at their institution from January 1, 1997 through December 31, 2000 (n = 117). Information obtained included age, sex, weight, admission laboratory values, attending surgeon, resident surgeon and their level of training, operating time, intraoperative and postoperative complications, time to full feedings, incidence of postoperative emesis, duration of postoperative emesis, length of stay, and total hospital charges. These variables then were compared between the open (OPEN) and laparoscopic (LAP) groups.
From January 1, 1997 through December 31, 2000, 65 LAP and 52 OPEN pyloromyotomies were performed. Characteristics of patients in the OPEN and LAP groups were similar. The mean operating time was 33 +/- 2 minutes for OPEN versus 38 +/- 2 minutes for LAP (P =.07). The incidence of postoperative emesis (LAP, 68%, OPEN, 65%), duration of postoperative emesis (LAP, 7.3 +/- 1.2 hours; OPEN, 8.1 +/- 1.8 hours), and time to full feedings (LAP, 19.5 +/- 1.6 hours; OPEN, 19.5 +/- 1.3 hours) did not differ significantly between groups (P >.05). Mean postoperative length of stay in both groups was similar (LAP, 31 +/- 5; OPEN, 28 +/- 2 hours; P =.64). Mucosal perforation occurred in 5 patients (8%) in the Lap and 2 patients (4%) in the OPEN group (P =.39). Postoperative complications occurred in 12 LAP (18%) and 6 OPEN patients (12%, P =.31). Five LAP cases were converted to OPEN. In the LAP group there was one unrecognized mucosal perforation and one incomplete pyloromyotomy both of which required reoperation. As the laparoscopic approach was adopted, general surgery resident participation as operating surgeon in these cases decreased from 81% in 1997 to 19% in 2000. Hospital charges were higher in the LAP group, but not significantly (LAP, $6,676 +/- 1,005; OPEN, $5,292 +/- 306; P = 27).
Laparoscopic pyloromyotomy has progressively become the dominant surgical approach to pyloromyotomy at our institution. The LAP and OPEN approaches have similar outcomes. However, the Lap approach may be associated with increased complication rates, a reduction in general surgery resident operative experience, and higher hospital charges.
背景/目的：越来越多的小儿外科医生采用腹腔镜手术治疗幽门狭窄。腹腔镜幽门肌切开术的优势尚不确定，且未在小儿外科住院医师培训项目中得到评估。
作者回顾性分析了1997年1月1日至2000年12月31日期间在其机构因先天性肥厚性幽门狭窄接受幽门肌切开术的所有患者的病历（n = 117）。获取的信息包括年龄、性别、体重、入院实验室检查值、主治医生、住院医生及其培训水平、手术时间、术中及术后并发症、完全恢复经口喂养的时间、术后呕吐发生率、术后呕吐持续时间、住院时间和总住院费用。然后对开放手术（OPEN）组和腹腔镜手术（LAP）组的这些变量进行比较。
1997年1月1日至2000年12月31日期间，共进行了65例腹腔镜幽门肌切开术和52例开放手术。开放手术组和腹腔镜手术组患者的特征相似。开放手术组的平均手术时间为33±2分钟，而腹腔镜手术组为38±2分钟（P = 0.07）。两组术后呕吐发生率（腹腔镜手术组为68%，开放手术组为65%）、术后呕吐持续时间（腹腔镜手术组为7.3±1.2小时；开放手术组为8.1±1.8小时）以及完全恢复经口喂养的时间（腹腔镜手术组为19.5±1.6小时；开放手术组为19.5±1.3小时）差异均无统计学意义（P>0.05）。两组的平均术后住院时间相似（腹腔镜手术组为31±5小时；开放手术组为28±2小时；P = 0.64）。腹腔镜手术组有5例（8%）发生黏膜穿孔，开放手术组有2例（4%）发生黏膜穿孔（P = 0.39）。腹腔镜手术组有12例（18%）发生术后并发症，开放手术组有6例（12%）发生术后并发症（P = 0.31）。5例腹腔镜手术转为开放手术。在腹腔镜手术组中有1例未被识别的黏膜穿孔和1例不完全幽门肌切开术，均需再次手术。随着腹腔镜手术方法的采用，这些病例中普通外科住院医生作为手术医生的参与率从1997年时的81%降至2000年时的19%。腹腔镜手术组的住院费用较高，但差异无统计学意义（腹腔镜手术组为6676±1005美元；开放手术组为5292±306美元；P = 0.27）。
在我们机构，腹腔镜幽门肌切开术已逐渐成为幽门肌切开术的主要手术方式。腹腔镜手术和开放手术的结果相似。然而，腹腔镜手术方式可能与并发症发生率增加、普通外科住院医生手术经验减少以及住院费用较高有关。
