腹腔镜与开腹手术治疗急性穿孔性胃十二指肠溃疡的围手术期结局的荟萃分析。
Meta-analysis of perioperative outcomes of acute laparoscopic versus open repair of perforated gastroduodenal ulcers.
机构信息
From the Department of General and Oncologic Surgery, University of Perugia, Terni, Italy (R.C, E.R.); University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK (K.S.); Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Trauma Center, Bologna, Italy (S.D.S.); Department of Surgical Sciences (A.A.), University of Turin, Turin, Italy; Department of General Surgery (M.Z.), Policlinico San Pietro, Ponte San Pietro, Italy; Health Planning Service, Regional Health Authority of Umbria, Perugia, Italy (I.A.); Department of Surgery (N.V.), Montichiari Hospital, ASST Spedali Civili Brescia, Brescia, Italy; Emergency Surgery Unit, Cisanello Hospital, University of Pisa, Pisa, Italy (M.C.); Department of Gastrointestinal Surgery (K.S.), Stavanger University Hospital, Stavanger, Norway; and Department of Clinical Medicine (K.S.), University of Bergen, Bergen, Norway.
出版信息
J Trauma Acute Care Surg. 2018 Aug;85(2):417-425. doi: 10.1097/TA.0000000000001925.
BACKGROUND
Surgery is the treatment of choice for perforated peptic ulcer disease. The aim of the present review was to compare the perioperative outcomes of acute laparoscopic versus open repair for peptic ulcer disease.
METHODS
A systematic literature search was performed for randomized controlled trials (RCTs) published in PubMed, SCOPUS, and Web of Science.
RESULTS
The search included eight RCTs: 615 patients comparing laparoscopic (307 patients) versus open peptic perforated ulcer repair (308 patients). Only few studies reported the Boey score, the Acute Physiologic Assessment and Chronic Health Evaluation score, and the Mannheim Peritonitis Index. In the RCTs, there is a significant heterogeneity about the gastric or duodenal location of peptic ulcer and perforation size. All trials were with high risk of bias. This meta-analysis reported a significant advantage of laparoscopic repair only for postoperative pain in first 24 hours (-2.08; 95% confidence interval, -2.79 to -1.37) and for postoperative wound infection (risk ratio, 0.39; 95% confidence interval, 0.23-0.66). An equivalence of the other clinical outcomes (postoperative mortality rate, overall reoperation rate, overall leaks of the suture repair, intra-abdominal abscess rate, operative time of postoperative hospital stay, nasogastric aspiration time, and time to return to oral diet) was reported.
CONCLUSION
In this meta-analysis, there were no significant differences in most of the clinical outcomes between the two groups; there was less early postoperative pain and fewer wound infections after laparoscopic repair. The reported equivalence of clinical outcomes is an important finding. These results parallel the results of several other comparisons of open versus laparoscopic general surgery operations-equally efficacious with lower rates of wound infection and improvement in some measures of enhanced speed or comfort in recovery. Notably, the trials included have been published throughout a considerable time span during which several changes have occurred in most health care systems, not least a widespread use of laparoscopy and increase in the laparoscopic skills.
LEVEL OF EVIDENCE
Systematic review and meta-analysis, level III.
背景
手术是治疗穿孔性消化性溃疡病的首选方法。本综述的目的是比较急性腹腔镜与开放性修复消化性溃疡穿孔的围手术期结果。
方法
在 PubMed、SCOPUS 和 Web of Science 中进行了系统的文献检索，以寻找随机对照试验 (RCT)。
结果
搜索包括 8 项 RCT：615 例患者比较腹腔镜（307 例）与开放性消化性溃疡穿孔修复（308 例）。只有少数研究报告了 Boey 评分、急性生理评估和慢性健康评估评分以及曼海姆腹膜炎指数。在 RCT 中，消化性溃疡和穿孔大小的胃或十二指肠位置存在显著的异质性。所有试验均存在高偏倚风险。这项荟萃分析仅报告腹腔镜修复在术后 24 小时内的术后疼痛（-2.08；95%置信区间，-2.79 至-1.37）和术后伤口感染（风险比，0.39；95%置信区间，0.23-0.66）方面具有显著优势。还报告了其他临床结局（术后死亡率、总再手术率、缝线修复的总漏口、腹腔脓肿发生率、术后住院时间、鼻胃管抽吸时间和恢复口服饮食时间）的等效性。
结论
在这项荟萃分析中，两组之间大多数临床结局没有显著差异；腹腔镜修复后早期术后疼痛减轻，伤口感染减少。报告的临床结局等效性是一个重要发现。这些结果与其他几项关于开放性与腹腔镜普通外科手术的比较结果相似，同样有效，伤口感染率较低，在某些加速或提高舒适度的恢复措施方面有所改善。值得注意的是，所包括的试验在相当长的一段时间内发表，在此期间，大多数医疗保健系统发生了许多变化，尤其是腹腔镜的广泛应用和腹腔镜技能的提高。
证据等级
系统评价和荟萃分析，III 级。
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