Department of Surgery, University of California, Irvine , 333 City Blvd. W. Ste. 850, Orange, CA, 92868, USA.
Surg Endosc. 2018 Mar;32(3):1280-1285. doi: 10.1007/s00464-017-5805-5. Epub 2017 Aug 15.
Patients with severe chronic obstructive pulmonary disease (COPD) are at a higher risk for postoperative respiratory complications. Despite the benefits of a minimally invasive approach, laparoscopic pneumoperitoneum can substantially reduce functional residual capacity and raise alveolar dead space, potentially increasing the risk of respiratory failure which may be poorly tolerated by COPD patients. This raises controversy as to whether open techniques should be preferentially employed in this population.
The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2011 to 2014 was used to examine the clinical data from patients with COPD who electively underwent laparoscopic and open colectomy. Patients defined as having COPD demonstrated either functional disability, chronic use of bronchodilators, prior COPD-related hospitalization, or reduced forced expiratory reserve volumes on lung testing (FEV1 <75%). Demographic data and preoperative characteristics were compared. Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes.
Of the 4397 patients with COPD, 53.8% underwent laparoscopic colectomy (LC) while 46.2% underwent open colectomy (OC). The LC and OC groups were similar with respect to demographic data and preoperative comorbidities. Equivalent frequencies of exertional dyspnea (LC 35.4 vs OC 37.7%, P = 0.11) were noted. After multivariate risk adjustment, OC demonstrated an increased rate of overall respiratory complications including pneumonia, reintubation, and prolonged ventilator dependency when compared to LC (OR 1.60, 95% CI 1.30-1.98, P < 0.01). OC was associated with longer length of stay (10 ± 8 vs. 6.7 ± 7 days, P < 0.01) and higher readmission (OR 1.36, 95% CI 1.09-1.68, P < 0.01) compared to LC.
Despite the potential risks of laparoscopic pneumoperitoneum in the susceptible COPD population, a minimally invasive approach was associated with lower risk of postoperative respiratory complications, shorter length of stay, and decrease in postoperative morbidity.
患有严重慢性阻塞性肺疾病（COPD）的患者术后发生呼吸系统并发症的风险较高。尽管微创方法具有优势，但腹腔镜气腹会显著降低功能残气量并增加肺泡死腔，从而增加呼吸衰竭的风险，而 COPD 患者可能难以耐受这种风险。这引发了争议，即此类人群是否应优先采用开放技术。
利用 2011 年至 2014 年美国外科医师学会国家外科质量改进计划（NSQIP）数据库，对选择性接受腹腔镜和开腹结肠切除术的 COPD 患者的临床数据进行了检查。患有 COPD 的患者表现为功能障碍、慢性使用支气管扩张剂、既往 COPD 相关住院治疗或肺功能测试中用力呼气储备量减少（FEV1<75%）。比较了人口统计学数据和术前特征。利用线性和逻辑回归进行多变量分析并确定风险调整后的结果。
在 4397 例 COPD 患者中，53.8%接受了腹腔镜结肠切除术（LC），46.2%接受了开腹结肠切除术（OC）。LC 和 OC 组在人口统计学数据和术前合并症方面相似。两组患者的体力活动后呼吸困难发生率相当（LC 组 35.4%，OC 组 37.7%，P=0.11）。经过多变量风险调整后，OC 组在包括肺炎、再插管和延长呼吸机依赖在内的总体呼吸系统并发症发生率方面高于 LC 组（OR 1.60，95%CI 1.30-1.98，P<0.01）。OC 组的住院时间（10±8 天与 6.7±7 天，P<0.01）和再入院率（OR 1.36，95%CI 1.09-1.68，P<0.01）均高于 LC 组。
尽管腹腔镜气腹在易感 COPD 人群中存在潜在风险，但微创方法与较低的术后呼吸系统并发症风险、较短的住院时间和降低术后发病率相关。
