Department of Surgery, Duke University Medical Center, Durham, NC.
Department of Surgery, Duke University Medical Center, Durham, NC.
Surgery. 2014 Aug;156(2):371-8. doi: 10.1016/j.surg.2014.03.003. Epub 2014 Mar 14.
Over the past 2 decades, laparoscopy has been established as a superior technique in many general surgery procedures. Few studies, however, have examined the impact of the use of a laparoscopic approach in patients with symptomatic congestive heart failure (CHF). Because pneumoperitoneum has known effects on cardiopulmonary physiology, patients with CHF may be at increased risk. This study examines current trends in approaches to patients with CHF and effects on perioperative outcomes.
The 2005-2011 National Surgical Quality Improvement Program Participant User File was used to identify patients who underwent the following general surgery procedures: Appendectomy, segmental colectomy, small bowel resection, ventral hernia repair, and splenectomy. Included for analysis were those with newly diagnosed CHF or chronic CHF with new signs or symptoms. Trends of use of laparoscopy were assessed across procedure types. The primary endpoint was 30-day mortality. The independent effect of laparoscopy in CHF was estimated with a multiple logistic regression model.
A total of 265,198 patients were included for analysis, of whom 2,219 were identified as having new or recently worsened CHF. Of these patients, there were 1,300 (58.6%) colectomies, 486 (21.9%) small bowel resections, 216 (9.7%) ventral hernia repairs, 141 (6.4%) appendectomies, and 76 (3.4%) splenectomies. Laparoscopy was used less frequently in patients with CHF compared with their non-CHF counterparts, particularly for nonelective procedures. Baseline characteristics were similar for laparoscopy versus open procedures with the notable exception of urgent/emergent case status (36.4% vs 71.3%; P < .001). After multivariable adjustment, laparoscopy seemed to have a protective effect against mortality (adjusted odds ratio, 0.45; P = .04), but no differences in other secondary endpoints.
For patients with CHF, an open operative approach seems to be utilized more frequently in general surgery procedures, particularly in urgent/emergent cases. Despite these patterns and apparent preferences, laparoscopy seems to offer a safe alternative in appropriately selected patients. Because morbidity and mortality were considerable regardless of approach, further understanding of appropriate management in this population is necessary.
在过去的 20 年中，腹腔镜技术已在许多普通外科手术中确立为一种优越的技术。然而，很少有研究检查在有症状充血性心力衰竭（CHF）患者中使用腹腔镜方法的影响。由于气腹对心肺生理学有已知的影响，CHF 患者的风险可能会增加。本研究检查了当前针对 CHF 患者的方法趋势及其对围手术期结果的影响。
使用 2005-2011 年国家手术质量改进计划参与者用户文件确定接受以下普通外科手术的患者：阑尾切除术，节段性结肠切除术，小肠切除术，腹疝修补术和脾切除术。分析包括新诊断为 CHF 或慢性 CHF 伴有新体征或症状的患者。评估了各种手术类型中腹腔镜使用的趋势。主要终点是 30 天死亡率。使用多变量逻辑回归模型估计腹腔镜在 CHF 中的独立作用。
共分析了 265198 例患者，其中 2219 例被确定为新发或近期恶化的 CHF。这些患者中，有 1300 例（58.6％）行结肠切除术，486 例（21.9％）小肠切除术，216 例（9.7％）腹疝修补术，141 例（6.4％）阑尾切除术和 76 例（3.4％）脾切除术。与非 CHF 患者相比，患有 CHF 的患者接受腹腔镜手术的频率较低，尤其是在非择期手术中。与开腹手术相比，腹腔镜手术与开腹手术的基线特征相似，但紧急/紧急病例状态（36.4％比 71.3％；P <.001）除外。经过多变量调整后，腹腔镜似乎对死亡率具有保护作用（调整后的优势比，0.45；P =.04），但在其他次要终点上没有差异。
对于 CHF 患者，在普通外科手术中似乎更常使用开腹手术方法，尤其是在紧急/紧急情况下。尽管存在这些模式和明显的偏好，但在适当选择的患者中，腹腔镜似乎是一种安全的替代方法。由于无论采用哪种方法，发病率和死亡率都相当可观，因此需要进一步了解该人群的适当治疗方法。
