Gysin Claudine, Dulguerov Pavel
Division of Pediatric Otolaryngology, University Children's Hospital, Zurich, Switzerland.
ORL J Otorhinolaryngol Relat Spec. 2013;75(3):123-32. doi: 10.1159/000342314. Epub 2013 Aug 22.
A thorough review of the publications on surgical techniques used for tonsillectomy is provided, emphasizing randomized studies and meta-analysis. In the assessment of the data it is important to clearly define and categorize the types of posttonsillectomy bleeding (PTB), as well as the various factors that have been associated with increased PTB. In recent audits of a large number of tonsillectomies, the PTB rates seem to concur: 1% early and 2.5% delayed PTB; 10% anamnestic, 2% objective, and 2% re-operation PTB. Objective PTB rates beyond 10% should require an audit. The bipolar technique seems associated with the least early PTB, while the cold technique is associated with the least delayed PTB. Because of the lack of large well-conducted randomized trials, it is difficult to conclude which technique is the best. With electrocautery techniques, the current power should be adjusted to the minimal level providing hemostasis. Surgical techniques for tonsillectomy that should probably be abandoned include monopolar electrocautery, Coblation, various lasers, and the harmonic scalpel. Vessel-sealing systems might hold promise and deserve further evaluation. Tonsillotomy might be associated with less postoperative pain, but the hemorrhagic advantage in randomized studies is not obvious. Tonsil regrowth rates and efficacy to treat obstruction need also further evaluation.
本文对扁桃体切除术的手术技术相关文献进行了全面综述，重点关注随机研究和荟萃分析。在评估数据时，明确界定和分类扁桃体切除术后出血（PTB）的类型以及与PTB增加相关的各种因素非常重要。在最近对大量扁桃体切除术的审计中，PTB发生率似乎一致：早期为1%，延迟性PTB为2.5%；记忆性出血为10%，客观性出血为2%，再次手术性PTB为2%。客观性PTB发生率超过10%时应进行审计。双极技术似乎与最少的早期PTB相关，而冷技术与最少的延迟性PTB相关。由于缺乏大规模的高质量随机试验，很难得出哪种技术是最佳的结论。对于电灼技术，应将电流功率调整到实现止血的最低水平。可能应摒弃的扁桃体切除手术技术包括单极电灼、低温等离子消融、各种激光以及超声刀。血管封闭系统可能有前景，值得进一步评估。扁桃体部分切除术可能与术后疼痛较轻相关，但在随机研究中的出血优势并不明显。扁桃体再生率和治疗阻塞的疗效也需要进一步评估。
