临床医生指导：腹股沟疝观察等待管理中患者的选择。

A clinician's guide to patient selection for watchful waiting management of inguinal hernia.

机构信息

Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.

出版信息

Ann Surg. 2011 Mar;253(3):605-10. doi: 10.1097/SLA.0b013e31820b04e9.

DOI:10.1097/SLA.0b013e31820b04e9

PMID:21239979

Abstract

OBJECTIVE

The goal of this study was to assist surgeons in managing patients with minimally symptomatic inguinal hernia by identifying characteristics that predict crossover to surgery or worsening of hernia symptoms.

BACKGROUND

Randomized trials have suggested that watchful waiting management of minimally symptomatic inguinal hernia is an acceptable alternative to surgical repair. However, these trials found that roughly a quarter of patients would elect for repair in the first 2 years, suggesting that not all patients are good candidates for watchful waiting.

METHODS

The 336 patients randomized to watchful waiting in the American College of Surgeons Watchful Waiting Hernia Trial constituted the study population. Preoperative patient characteristics were used to predict 2 outcomes, either crossover to surgery or the development of hernia pain limiting activities and/or crossover to surgery. Patients in our study were part of a previously registered randomized trial: NCT00263250.

RESULTS

At 2 years, 72 patients crossed over to surgery, with pain with strenuous activities [odds ratio (OR), 1.3 per 10-mm visual analog scale pain scale], chronic constipation (OR, 4.9), prostatism (OR, 2.9), being married (OR, 2.3), and good health [OR, 3.0 American Society of Anesthesiologists Class (ASA) 1 vs 2], predicting crossover. An additional 28 patients developed pain, limiting their activities, with pain during strenuous activities (OR, 1.3 per 10-mm visual analog scale) and chronic constipation (OR, 4.5), predicting the combined outcome of pain limiting activities and/or crossover to surgery. Higher levels of activity reduced the risk (OR, 0.95) of this combined outcome.

CONCLUSIONS

Readily identifiable patient characteristics can predict those patients with minimally symptomatic inguinal hernia who are likely to "fail" watchful waiting hernia management. Consideration of these factors will allow surgeons to optimally tailor hernia management.

摘要

目的

本研究旨在帮助外科医生管理症状轻微的腹股沟疝患者，通过识别预测交叉至手术或疝症状恶化的特征。

背景

随机试验表明，对症状轻微的腹股沟疝进行密切观察等待管理是手术修复的一种可接受的替代方案。然而，这些试验发现，大约四分之一的患者会在头两年内选择手术修复，这表明并非所有患者都适合密切观察等待。

方法

在接受美国外科医师学会密切观察等待疝试验的 336 名随机分组接受密切观察等待的患者中，构成了研究人群。使用术前患者特征来预测 2 个结果，要么交叉至手术，要么出现疝痛限制活动和/或交叉至手术。我们研究中的患者是先前注册的随机试验的一部分：NCT00263250。

结果

在 2 年时，有 72 例患者交叉至手术，其中剧烈活动时疼痛（比值比 [OR]，每 10mm 视觉模拟量表疼痛评分增加 1.3）、慢性便秘（OR，4.9）、前列腺问题（OR，2.9）、已婚（OR，2.3）和健康状况良好（OR，美国麻醉医师学会 [ASA] 1 级比 2 级增加 3.0），这些都预测了交叉。另有 28 例患者出现疼痛，限制了他们的活动，其中剧烈活动时疼痛（OR，每 10mm 视觉模拟量表疼痛评分增加 1.3）和慢性便秘（OR，4.5）预测了疼痛限制活动和/或交叉至手术的联合结果。更高水平的活动降低了这一联合结果的风险（OR，0.95）。