小肠梗阻早期行粘连松解术更有益

圣迭戈——一项全国数据分析的结果显示，与急性小肠梗阻入院24 h之后接受粘连松解术的患者相比， 入院24 h内接受粘连松解术患者的30天严重并发症发生率和死亡率显著降低，且住院时间也显著缩短。


Kristin N. Kelly医生

外科健康结局与研究单位(SHORE)、罗彻斯特大学医疗中心外科的Kristin N. Kelly医生在美国外科医师/国家外科质量提高项目全国会议上指出：“外科医生历来接受的指导是，对于完全性小肠梗阻应尽快手术，绝不可以等待一昼夜以上。这样做的原因是担心发生肠缺血、穿孔和腹膜炎等后果。有意思的是，在20多年后，实践模式发生了变化。”例如，2009年全国住院患者研究的近期数据显示，仅有18%的小肠梗阻患者接受手术干预，其他患者均接受保守治疗，包括静脉补液和鼻胃管减压(J. Trauma Acute Care Surg. 2013;74:181-7)。此外，近期发布的指南(World J. Emerg. Surg. 2011;6:5)写道：“如无腹膜体征或肠缺血证据，在建议对比研究或手术之前，非手术治疗可推迟3~5天。”

“目前，仍存在手术可能困难、危险或促进更多粘连形成的顾虑。但另一方面，延迟手术治疗可能增加病死率。当前的疑惑是，我们是否过分强调保守治疗？因此，有必要探讨提前手术治疗是否存在益处。”为此，Kelly医生及其同事搜索了2005~2010年美国外科医师学会/国家外科质量提高项目数据库中诊断为粘连性小肠梗阻的患者。分析对象局限于在入院后1周之内接受手术的患者。将入院至手术时间定义为早期（24 h之内）和晚期（24 h之后）。使用单变量和多变量分析对治疗组进行比较，评估与多种患者和手术因素之间的相关性。

在符合入选标准的8,912例患者中，3,240例 (36%)接受了早期粘连松解术，其余5,692例 (64%)接受了晚期手术。平均至手术时间为1.7天，但晚期手术组有大约3/4的患者在入院后1~3天接受手术。“早期手术组患者年龄较轻，合并疾病较少，功能状态较好。但两组术前脓毒血症和全身炎症反应综合征发生率相似。”

结果显示，与晚期手术组相比，早期手术组急诊手术比例较高（分别为45%和60%；P＜0.0001），更多接受腹腔镜手术（分别为13%和19%，P<0.0001），但两组的手术时间（分别平均为89和93分钟）和小肠切除发生率相似（分别为28%和27%）。早期手术组平均术后住院时间缩短约2天（分别为9.5天和7.4天；P＜0.0001）。多变量分析显示，与晚期手术组相比，早期手术组30天时严重并发症减少17%［比值比(OR)为0.83；P=0.005］，死亡率降低26%（OR为0.74；P=0.041）。三种最常见的并发症为呼吸并发症(28%)、脓毒血症/感染中毒性休克(25%)和非预期再次手术(18%)。

Kelly医生披露无相关利益冲突。

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By: DOUG BRUNK, Internal Medicine News Digital Network

SAN DIEGO – Patients who underwent adhesiolysis within 24 hours of hospital admission for acute small bowel obstruction had a significant reduction in 30-day major morbidity, mortality, and hospital length of stay, compared with those who underwent adhesiolysis after 24 hours, results from an analysis of national data showed.

"Historically, the teaching was that surgeons should never let the sun rise and set on a complete small bowel obstruction," Dr. Kristin N. Kelly said at the national conference of the American College of Surgeons/National Surgical Quality Improvement Program. "The consequences of bowel ischemia, perforation, and peritonitis were feared. Interestingly, over the past 2 decades, practice patterns have shifted."
 
For example, she said, a recent study of data from the 2009 Nationwide Inpatient Sample researchers found that only 18% of patients with small bowel obstruction received surgical intervention and the rest were managed with conservative measures including intravenous fluid and nasogastric decompression (J. Trauma Acute Care Surg. 2013;74:181-7).

In addition, recently released guidelines (World J. Emerg. Surg. 2011;6:5) "have suggested that without peritoneal signs or evidence of bowel ischemia, nonoperative management can be extended for 3-5 days before contrast studies or surgery [is] recommended," said Dr. Kelly of the Surgical Health Outcomes and Research Enterprise (SHORE) and the department of surgery at the University of Rochester (N.Y.) Medical Center. "The concern remains that surgery may be difficult or dangerous or promote additional adhesion formation. Alternatively, delaying surgical treatment may increase morbidity and mortality. We wondered if perhaps we’ve moved too far toward conservative management. We sought to address if there is a benefit to a prompt surgical approach. Our aim was to examine whether adhesiolysis within 24 hours of admission for acute small bowel obstruction is associated with improved 30-day morbidity and mortality compared with those undergoing later adhesiolysis."

She and her associates searched the 2005-2010 American College of Surgeons/National Surgical Quality Improvement Program database for patients who had a diagnosis of adhesive small bowel obstruction. They limited their analysis to patients who were operated on within 1 week of admission. The time from admission to operation was classified as early (within 24 hours) or late (after 24 hours). The groups were compared using univariate and multivariate analysis to examine the association between numerous patient and operative factors.

Of the 8,912 patients who met inclusion criteria, 3,240 (36%) underwent early adhesiolysis while the remaining 5,692 (64%) underwent the procedure late. The mean time to surgery was 1.7 days, while about three-quarters of patients in the late group had surgery between 1 and 3 days after admission.

Compared with patients in the late adhesiolysis group, those in the early adhesiolysis group had higher rates of emergency operations (60% vs. 45%, respectively; P less than .0001), and more laparoscopic operations (19% vs. 13%; P less than .0001), but both groups had similar operative times (a mean of 93 vs. 89 minutes) and similar rates of small bowel resection (27% vs. 28%). The mean postoperative length of stay was about 2 days shorter in the early group (7.4 days vs. 9.5 days; P less than .0001).

"Patients in the early group were slightly younger, had fewer comorbodities, and better functional status," Dr. Kelly added. "But the rates of preoperative sepsis and systemic inflammatory response syndrome were similar."

On multivariate analysis patients in the early adhesiolysis group had 17% fewer major complications (odds ratio, 0.83; P = .005) and a 26% lower mortality rate (OR, 0.74; P = .041) at 30 days, compared with their counterparts in the late adhesiolysis group. The three most common complications were respiratory complications (28%), sepsis/septic shock (25%), and unexpected return to the operating room (18%).

Dr. Kelly acknowledged certain limitations of the study, including the potential for selection bias and that "perhaps surgeons postpone operating on patients with many comorbodities and poorer functional status, or perhaps it takes several days for a surgical referral," she said. "We are also limited because we do not have information regarding all of the clinical, personal, and administrative factors that may go into any individual surgeon’s decision to take a patient to the OR. Finally, we don’t have data on the case difficulty or any intraoperative occurrences. These would be useful in evaluating whether the timing really affected how challenging the case might be." Nevertheless, the findings "support early surgeon involvement and an expeditious approach to small bowel obstruction," she concluded.

Dr. Kelly said she had no relevant financial disclosures.