Securing the appendiceal stump without clip is safe 腹腔鏡腹腔內縫線結扎闌尾斷端 之回顧性研究 7分鐘 討論3分鐘 中文口頭報告 佛教花蓮慈濟醫院 外科部 鍾秉儒 李明哲 吳柏鋼 葉倫斌 凌慶賢 陳言丞 何靜淳 陳華宗 陳宗明 施廷翰 楊穎勤
Acute appendicitis Incidence: 1 per 1000 per year 25% surgical emergency admissions 40% ER laparotomies 所以大略從統計數據看起來，這是一個相當常見的疾病 Surg Laparosc Endosc Percutan Tech. 2012 Jun;22(3):226-31. World J Emerg Surg. 2015 Sep 17;10:42.
Laparoscopic appendectomy 1983 Kurt Semm: Endoscopic Appendectomy Better cosmesis Shorter hospital stays Less pain Faster return to normal activities Good diagnostic tool in suspected cases 在1983年 LA 就變成治療aa 的主流 better cosmesis, shorter hospital stays, less pain, Faster return to normal activities In women: better diagnostic tool
Complication of appendectomy Most common: infection Secure closure of the appendiceal stump 如何去必免術後的infection 主要是因為確實這樣才能必避 Prevention & management of laparoendoscopic surgical complications, 3rd edition
Closure of the appendiceal stump 隨著時代的進步，以即新器械的發展 harmonic
Closure of the appendiceal stump 除了上述的工具之外，在laparoscopic 的手術中，用手術線材來進行closure，也是一個常見的方法
Closure of the appendiceal stump
Aim 不同closure of appendiceal stump對預後的影 響。
Patients and Methods 回溯性的觀察型研究 花蓮慈濟醫院近十年來進行laparoscopic appendectomy的病人。 透過醫囑系統，利用手術健保碼來做資料的搜尋。 收取單一主治醫師病人。 分析術中不同closure of the appendiceal stump對預後的影響。
2007~2015/12 醫囑系統 手術碼：74004B 腹腔鏡闌尾切除術 收取單一主治醫師病人(n=63) 進行資料的分析
OP management Item N = 63 % 3 ports 63 100 Stump Silk ligation 50 80.6 Clip 21 33.9 Mesoappen. EC 22 35.5 Ligature 24 38.7 12 19 Drain No drain tube 55 87.3 Penrose 2 3.2 JP 6 9.5 Comorbidity: HTN, DM, CAD, old CVA, ESRD
少一個人是因為有一個op note沒寫 (N=41) (N=21)
Patient Characteristics Non-clip group (N=41) Clip group (N=21) P valve Gender Male 21 (51%) 14 (70%) 0.25 Female 20 (49%) 7 (30%) Age 45.4 ± 20.4 25.0 ± 11.8 0.003 BMI 23.3 ± 3.6 22.9 ± 5.3 0.09 Time to OP 1.5 ± 1.1 1.5 ± 0.7 0.74 Previous abdomen surgery 3 (7.3%) 0 (0%) 0.21
OP finding Non-clip group (N=41) Clip group (N=21) P valve Ascites No 22 (53.7%) 6 (28.6%) 0.17 Clear 5 (12.2%) 4 (19.0%) Dirty 14 (34.1) 11 (52.4%) Adhesion 23 (56.1%) 7 (33.3%) 0.09 Abscess 3 (7.3%) 0 (0%) 0.20 Rupture 8 (19.5%) 3 (14.3%) 0.61
OP management Non-clip group (N=41) Clip group (N=21) P valve Mesoappen. EC 19 (46.3%) 3 (15.0%) <0.05 Ligasure 21 (51.2%) Clip 1 (2.4%) 11 (55.0%) Drain No 35 (85.4%) 20 (95.2) 0.45 Penrose 4 (9.8%) 1 (4.8%) JP 2 (4.9%) 0 (0%)
Outcome Non-clip group (N=41) Clip group (N=21) P valve OP time (mins) 68 ± 26 81 ± 24 0.07 Time to eat (days) 1.3 ± 0.6 1.2 ± 0.5 0.63 Antibiotic use 8.7 ± 5.2 4.3 ± 4.2 0.00 Length of stay 4.7 ± 3.2 3.1 ± 1.4 0.02 OPD f/u (wks) 1.7 ± 1.5 1.2 ± 0.9 0.13 Complication rate 20 (48.8%) 6 (28.6%) Superficial SSI 7 (17.1%) 3 (14.3%) 0.78
OP time (regression) Item β CI P valve Clip Yes No -9.34 No -9.34 (-34.15, 15.35) 0.45 Mesoappen Electro. 10.66 (-15.13, 36.45) 0.41 Suture 8.79 (-16.16, 33.73) 0.48 Adhesion -5.52 (-20.03, 8.99) Age 0.186 (-0.27, 0.65) 0.42 BMI 0.37 (-1.51, 2.24) 0.70 Ordinal No. of surgery -0.61 (-1.14, -0.09) 0.02 Generalized Linear Model
Antibiotic use (regression) Item β CI P valve Clip Yes No 0.08 (-4.14, 5.73) 0.32 Mesoappen Electro. 2.98 (-2.17, 8.13) 0.25 Suture 1.80 (-3.10, 6.71) 0.47 Adhesion 0.28 0.20 Age 0.01 (-0.82, 0.94) 0.89 BMI 0.23 (-0.14, 0.61) 0.22 Ordinal No. (-0.27, 0.18) 0.14
Length of stay (regression) Item β CI P valve Clip Yes No 2.44 (-0.10, 4.99) 0.06 Mesoappen Electro. -0.40 (-3.05, 2.25) 0.76 Suture -0.52 (--3.08, 2.05) 0.69 Adhesion -1.47 (--2.93, -0.004) 0.05 Age -0.03 (-0.72, 0.02) 0.24 BMI 0.07 (-0.12, 0.27) 0.44 Ordinal No. -0.01 (-0.07, 0.04) Beta值 標準化係數
In summary No statistic different between non-clip and clip group on OP duration Antibiotic use Complication rate Superficial SSI Longer LOS in non-clip group (trend)