拉氏手术的结果：手术方法重要吗？
Outcomes for Ladd's procedure: Does approach matter?
机构信息
DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
出版信息
J Pediatr Surg. 2022 Jan;57(1):141-146. doi: 10.1016/j.jpedsurg.2021.09.016. Epub 2021 Sep 20.
BACKGROUND
Laparoscopic Ladd's procedure has been proven safe and effective for the treatment of malrotation. However, the nationwide utilization and outcomes of elective Ladd's procedure are largely unknown.
METHODS
The Nationwide Readmissions Database from 2010 to 2014 was used to identify patients 0-18 years (excluding newborns) with malrotation who underwent elective Ladd's procedure. Demographics, hospital factors, and outcomes were compared by approach (laparoscopic vs. open) using standard statistical tests and propensity score (PS) matched analysis. Results were weighted for national estimates.
RESULTS
1343 patients (44% male) underwent elective Ladd's procedure via laparoscopic (22%) or open (78%) approach. Laparoscopic approach was more common in large hospitals (26% vs. 16%), patients >13 years (30% vs. 20%), and those with higher income (29% vs. 16%), all p < 0.001. Following PS matching, compared to the laparoscopic approach, open Ladd's was associated with index hospital length of stay > 7 days (20% vs. 8%), more post-operative gastrointestinal dysfunction (12% vs. < 1%), and more nausea, vomiting, and/or diarrhea (16% vs. 6%), all p < 0.001. The overall readmission rates within 30 days and the year of index operation were 8% and 15%, respectively. In the matched cohort, those undergoing laparoscopic Ladd's were less likely to be readmitted than those with the open approach (7% vs. 16%, p < 0.001) and experienced less gastrointestinal issues on readmission (5% vs. 15%, p = 0.002). There were similar rates of post-operative small bowel obstruction (< 3% vs. < 3%, p = 0.840) and volvulus (0% vs. < 1%, p = 0.136). Redo Ladd's procedure was performed in less than 4% of readmissions and all occurred within 5 days of initial hospital discharge.
CONCLUSION
The majority of Ladd's procedures in the U.S. are being performed open, despite comparable outcomes following a laparoscopic approach. Readmission rates are similar with either approach, and the rate of redo Ladd's procedure is lower than previously reported.
LEVEL OF EVIDENCE
Level III.
背景
腹腔镜 Ladd 手术已被证明可安全有效地治疗旋转不良。然而，择期 Ladd 手术的全国应用和结果在很大程度上尚不清楚。
方法
使用 2010 年至 2014 年的全国再入院数据库，确定 0-18 岁（不包括新生儿）经择期 Ladd 手术治疗的旋转不良患者。使用标准统计检验和倾向评分（PS）匹配分析比较腹腔镜（22%）和开放（78%）两种手术方式的患者特征、医院因素和结局。结果按全国估计进行加权。
结果
1343 例患者（44%为男性）经腹腔镜（22%）或开放（78%）手术方式行择期 Ladd 手术。与开放手术相比，腹腔镜手术更常见于大医院（26% vs. 16%）、年龄大于 13 岁的患者（30% vs. 20%）和收入较高的患者（29% vs. 16%），所有 p 值均<0.001。经 PS 匹配后，与腹腔镜手术相比，开放 Ladd 手术与索引住院时间>7 天（20% vs. 8%）、术后胃肠功能障碍（12% vs. <1%）以及恶心、呕吐和/或腹泻（16% vs. 6%）的发生率更高，所有 p 值均<0.001。术后 30 天和索引手术年度的总再入院率分别为 8%和 15%。在匹配队列中，与开放手术相比，接受腹腔镜 Ladd 手术的患者再入院率较低（7% vs. 16%，p<0.001），且再入院时胃肠道问题发生率较低（5% vs. 15%，p=0.002）。术后小肠梗阻（<3% vs. <3%，p=0.840）和扭转（0% vs. <1%，p=0.136）的发生率相似。再行 Ladd 手术的比例不足 4%，且所有手术均在初次出院后 5 天内进行。
结论
尽管腹腔镜手术的结果相似，但美国大多数 Ladd 手术仍采用开放手术方式进行，尽管腹腔镜手术方式的结果相似，但再入院率相似，且再次行 Ladd 手术的比例低于之前的报告。
证据等级
III 级。
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