腹疝管理：基于系统评价的专家共识

Ventral Hernia Management: Expert Consensus Guided by Systematic Review.

作者信息

Liang Mike K, Holihan Julie L, Itani Kamal, Alawadi Zeinab M, Gonzalez Juan R Flores, Askenasy Erik P, Ballecer Conrad, Chong Hui Sen, Goldblatt Matthew I, Greenberg Jacob A, Harvin John A, Keith Jerrod N, Martindale Robert G, Orenstein Sean, Richmond Bryan, Roth John Scott, Szotek Paul, Towfigh Shirin, Tsuda Shawn, Vaziri Khashayar, Berger David H

机构信息

*University of Texas Health Science Center at Houston, Houston, TX †Veterans Affairs Boston Healthcare System, Boston University and Harvard Medical School, Boston, MA ‡Baylor College of Medicine, Texas Medical Center, Houston, TX §Center for Minimally Invasive and Robotic Surgery, Peoria, AZ ¶University of Iowa, Iowa City, IA ||Medical College of Wisconsin, Milwaukee, WI **University of Wisconsin, Madison, WI ††Oregon Health and Science University, Portland, OR ‡‡West Virginia University, Morgantown, WV §§University of Kentucky, Lexington, KY ¶¶Indiana University Health, Indianapolis, IN ||||Beverly Hills Hernia Center, Beverly Hills, CA ***University of Nevada School of Medicine, Las Vegas, NV †††George Washington University, Washington, DC.

出版信息

Ann Surg. 2017 Jan;265(1):80-89. doi: 10.1097/SLA.0000000000001701.

DOI:10.1097/SLA.0000000000001701

PMID:28009730

Abstract

OBJECTIVE

To achieve consensus on the best practices in the management of ventral hernias (VH).

BACKGROUND

Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence.

METHODS

A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy.

RESULTS

Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients.

CONCLUSIONS

Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

摘要

目的

就腹疝（VH）管理的最佳实践达成共识。

背景

VH的管理模式多种多样，通常缺乏有力的证据支持，或与现有证据缺乏相关性。

方法

进行系统综述以确定每个主题可获得的最高级别证据。组建了一个疝外科专家小组。开展了电子邮件问卷调查、证据审查、小组讨论和反复投票。当所有专家就一种管理策略达成一致时，即为达成共识。

结果

专家们一致认为，肥胖患者（A级）、当前吸烟者（A级）以及糖化血红蛋白（HbA1C）≥6.5%的患者（B级）进行VH修复（VHR）时并发症会增加。对于BMI≥50kg/m²的患者（C级）、当前吸烟者（A级）或HbA1C≥8.0%的患者（B级），不建议进行择期VHR。BMI为30-50kg/m²或HbA1C为6.5-8.0%的患者需要个体化干预以降低手术风险（C级，B级）。非手术治疗被认为短期发病风险较低（C级）。对于疝≥2cm的修复，建议使用补片加强（A级）。在几个领域，高质量数据有限，无法达成共识，包括补片类型、组织分离技术和复杂患者的管理。