Kauffman Jeremy D, Snyder Christopher W, Danielson Paul D, Chandler Nicole M
Division of Pediatric Surgery, Johns Hopkins All Children's Hospital , St. Petersburg, Florida.
J Laparoendosc Adv Surg Tech A. 2019 Mar;29(3):402-408. doi: 10.1089/lap.2018.0576. Epub 2018 Nov 27.
Studies comparing pediatric laparoscopic and open total proctocolectomy with ileoanal anastomosis (TPC-IAA) are limited in size and number. This study utilized the adult and pediatric databases of the National Surgical Quality Improvement Project (NSQIP) to evaluate 30-day outcomes of these two techniques.
Patients younger than 21 years who underwent TPC-IAA from 2012 to 2016 were identified in both NSQIP databases. Simple and multivariate logistic regression was used to compare risk of reoperation, readmission, and postoperative occurrences between laparoscopic and open groups. Cox regression was used to evaluate length of stay (LOS).
A total of 440 cases were identified, of which 421 (95.7%) were elective. Median age in the elective group was 15.8 years (interquartile range 13-18). Diagnoses included inflammatory bowel disease (47%), benign neoplasm (42%), and Hirschsprung disease (6%). The laparoscopic group (67.5%, n = 139) had shorter median postoperative LOS (6 versus 8 days, P < .001) and decreased incidence of pulmonary complications (risk ratio [RR] 0.09; CI: 0.01-0.80, P = .031) and superficial surgical site infections (SSI) (RR 0.30; 95% CI: 0.10-0.88, P = .028). Median operative time was shorter (4.6 versus 5.1 hours, P = .013) and risk of organ space SSI was lower (RR = 0.11, 95% CI: 0.01-0.80, P = .037) in the open group (n = 282). Rates of 30-day readmission and reoperation were similar between groups.
In the first study to utilize data from both the pediatric and adult NSQIP databases, resulting in the largest pediatric sample of TPC-IAA to date, we found that 67.5% of elective cases were performed laparoscopically, the highest reported in a multi-institutional pediatric study, indicating increasing comfort with advanced laparoscopic techniques among pediatric surgeons. The laparoscopic approach resulted in shorter postoperative LOS and decreased risk of superficial SSI, whereas the open approach was associated with shorter operative time and lower risk of organ space SSI.
比较小儿腹腔镜与开放全直肠系膜切除回肠肛管吻合术（TPC - IAA）的研究在规模和数量上都很有限。本研究利用国家外科质量改进项目（NSQIP）的成人和小儿数据库来评估这两种技术的30天结局。
在两个NSQIP数据库中识别出2012年至2016年接受TPC - IAA的21岁以下患者。采用单因素和多因素逻辑回归比较腹腔镜组和开放手术组再次手术、再次入院及术后并发症发生的风险。采用Cox回归评估住院时间（LOS）。
共识别出440例病例，其中421例（95.7%）为择期手术。择期手术组的中位年龄为15.8岁（四分位间距13 - 18岁）。诊断包括炎症性肠病（47%）、良性肿瘤（42%）和先天性巨结肠（6%）。腹腔镜组（67.5%，n = 139）术后中位住院时间较短（6天对8天，P <.001），肺部并发症发生率降低（风险比[RR] 0.09；CI：0.01 - 0.80，P = 0.031），浅表手术部位感染（SSI）发生率降低（RR 0.30；95% CI：0.10 - 0.88，P = 0.028）。开放手术组（n = 282）的中位手术时间较短（4.6小时对5.1小时，P = 0.013），器官间隙SSI风险较低（RR = 0.11，95% CI：0.01 - 0.80，P = 0.037）。两组30天再次入院率和再次手术率相似。
在第一项利用小儿和成人NSQIP数据库数据的研究中，获得了迄今为止最大的小儿TPC - IAA样本，我们发现67.5%的择期病例采用腹腔镜手术，这是多机构小儿研究中报道的最高比例，表明小儿外科医生对先进腹腔镜技术的接受度不断提高。腹腔镜手术方式导致术后住院时间缩短，浅表SSI风险降低，而开放手术方式与较短的手术时间和较低的器官间隙SSI风险相关。
