趙相坤 朱杰 魏嵐
[摘要] 目的 比較腹腔鏡闌尾切除術(shù)(LA)與開(kāi)腹闌尾切除(OA)治療闌尾炎的效果和成本,分析兩者的差異原因。 方法 回顧性分析2014年1月~2016年11月期間的首都醫(yī)科大學(xué)宣武醫(yī)院門(mén)診和急診的495例闌尾炎患者的資料,根據(jù)治療方式不同,將患者分為L(zhǎng)A組(實(shí)驗(yàn)組,n = 441)和OA組(對(duì)照組,n = 54)。比較兩組患者年齡、性別、麻醉分級(jí)(ASA)、手術(shù)時(shí)間、住院時(shí)間、抗生素使用時(shí)間和總費(fèi)用等。 結(jié)果 實(shí)驗(yàn)組術(shù)后住院時(shí)間短于對(duì)照組,差異有高度統(tǒng)計(jì)學(xué)意義(P < 0.01);實(shí)驗(yàn)組手術(shù)時(shí)間短于對(duì)照組,差異有高度統(tǒng)計(jì)學(xué)意義(P < 0.01)??股厥褂脮r(shí)間實(shí)驗(yàn)組短于對(duì)照組,差異有高度統(tǒng)計(jì)學(xué)意義(P < 0.01)。實(shí)驗(yàn)組術(shù)中出血量少于對(duì)照組出血量時(shí)間,差異有高度統(tǒng)計(jì)學(xué)意義(P < 0.01)。兩組總費(fèi)用比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P > 0.05)。 結(jié)論 LA是一種安全、有效的闌尾切除術(shù)手術(shù)方法,與OA比較,縮短了住院時(shí)間、手術(shù)時(shí)間和抗生素使用時(shí)間,出血量少,可作為闌尾炎和腹痛患者的標(biāo)準(zhǔn)治療方法。
[關(guān)鍵詞] 腹腔鏡闌尾切除術(shù);開(kāi)腹闌尾切除術(shù);住院費(fèi)用;手術(shù)時(shí)間;住院時(shí)間;抗生素使用時(shí)間
[中圖分類(lèi)號(hào)] R656.8? ? ? ? ? [文獻(xiàn)標(biāo)識(shí)碼] A? ? ? ? ? [文章編號(hào)] 1673-7210(2019)07(a)-0098-04
Outcomes and cost comparison of laparoscopic appendectomy versus open appendectomy
ZHAO Xiangkun1? ?ZHU Jie2? ?Wei Lan3
1.Department of Biomedical Informatics, School of Biomedical Engineering, Capital Medical University, Beijing? ?100069, China; 2.Department of Information Management, the National Police University for Criminal Justice, Hebei Province, Baoding? ?071000, China; 3.Department of Information Center, Xuanwu Hospital, Capital Medical University, Beijing? ?100053, China
[Abstract] Objective To compare the effects and costs of laparoscopic appendectomy (LA) and open appendectomy (OA) in treating appendicitis, and analyze the reasons for the differences. Methods The data of 495 cases of appendicitis in the Outpatient and Emergency Department of Xuanwu Hospital of Capital Medical University from January 2014 to November 2016 were retrospectively analyzed, according to different treatment methods, patients were divided into LA group (experimental group, n = 441) and OA group (control group, n = 54). Age, sex, anesthesia classification (ASA), operation time, hospitalization time, antibiotic use time and total cost were compared between the two groups. Results The length of stay in the LA group was shorter than the control group, and the difference was highly statistically significant (P < 0.01). The operation time of experimental group was significantly shorter than that of control group, and the difference was highly statistically significant (P < 0.01). The time of antibiotic treatment in experimental group was shorter than that in control group, and the difference was highly statistically significant (P < 0.01). The intraoperative blood loss in experimental group was less than that in control group, the difference was highly statistically significant (P < 0.01). There was no statistically significant difference in total cost between the two groups (P > 0.05). Conclusion LA is a safe and effective surgical method for appendectomy. Compared with OA, LA shortens hospital stay, operation time and antibiotic use time, and reduces blood loss. LA may be the standard treatment for patients with appendicitis and abdominal pain.
[Key words] Laparoscopic appendectomy; Open appendectomy; Hospital costs; Operation time; Length of stay; Time of antibiotic treatment
闌尾炎是最常見(jiàn)的腹內(nèi)急診疾病,主要的治療手段包括腹腔鏡闌尾切除術(shù)(laparoscopic appendectomy,LA)與開(kāi)腹闌尾切除術(shù)(open appendectomy,OA)。雖然LA方法已經(jīng)過(guò)去了30多年,LA方法一直沒(méi)有成為治療闌尾炎的“金標(biāo)準(zhǔn)”,兩種方法在醫(yī)院一直同時(shí)存在。目前,關(guān)于LA和OA療效的對(duì)比分析呈現(xiàn)不同的觀點(diǎn)。有研究[1-2]認(rèn)為L(zhǎng)A是治療腹部急癥的一種很有希望的工具,可以降低成本和侵襲性,最大限度地增加預(yù)后和患者的舒適度。研究[3-10]表明LA是安全的,并導(dǎo)致更快的恢復(fù)正常活動(dòng),較少的傷口并發(fā)癥。這些發(fā)現(xiàn)受到了其他研究者[9,11-14]的質(zhì)疑,他們觀察到這兩種手術(shù)的結(jié)果沒(méi)有明顯的差異,而且注意到LA費(fèi)用較高,術(shù)后并發(fā)癥發(fā)生率高。本研究主要是比較LA與OA在手術(shù)時(shí)間、住院時(shí)間、抗生素使用天數(shù)、手術(shù)效果及住院費(fèi)用等指標(biāo)的差異,分析導(dǎo)致結(jié)果不一致的原因,為臨床實(shí)踐提供幫助。
1 資料與方法
1.1 一般資料
回顧性分析2014年1月~2016年11月首都醫(yī)科大學(xué)宣武醫(yī)院門(mén)診和急診的495例闌尾炎患者的臨床資料。其中,接受開(kāi)腹闌尾切除術(shù)的患者54例(對(duì)照組)和經(jīng)腹腔鏡治療的患者441例(實(shí)驗(yàn)組),本研究經(jīng)首都醫(yī)科大學(xué)醫(yī)學(xué)倫理學(xué)審查批準(zhǔn)。
1.2 方法
對(duì)照組采用開(kāi)腹闌尾切除術(shù),實(shí)驗(yàn)組采用腹腔鏡闌尾切除術(shù),收集每組患者的人口學(xué)數(shù)據(jù)、術(shù)前數(shù)據(jù)以及住院手術(shù)數(shù)據(jù)等。對(duì)數(shù)據(jù)進(jìn)行篩選,剔除指標(biāo)項(xiàng)缺失較多病例;對(duì)所有患者數(shù)據(jù)進(jìn)行規(guī)范化處理,保持?jǐn)?shù)據(jù)的一致性。最后得到患者的人口學(xué)特征、手術(shù)時(shí)間、住院時(shí)間、抗生素使用時(shí)間、手術(shù)效果和費(fèi)用等數(shù)據(jù)信息。
1.3 統(tǒng)計(jì)學(xué)方法
采用SPSS 22.0對(duì)所得數(shù)據(jù)進(jìn)行統(tǒng)計(jì)學(xué)分析,計(jì)數(shù)資料以頻率和百分比表示,采用χ2檢驗(yàn)與Fisher精確檢驗(yàn)進(jìn)行比較。連續(xù)型數(shù)值型數(shù)據(jù),經(jīng)正態(tài)檢驗(yàn)后,幾乎均不滿(mǎn)足正態(tài)性,只有極個(gè)別滿(mǎn)足正態(tài)分布(對(duì)照組西藥費(fèi)分布滿(mǎn)足正態(tài)),為保持結(jié)果一致性,采用中位數(shù)(M)和四分位間距(inter quartile range,IQR)表示,組間比較采用非參數(shù)獨(dú)立樣本的Mann-Whitney U檢驗(yàn)。以P < 0.05為差異有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
2.1 兩組人口學(xué)及術(shù)前數(shù)據(jù)比較
兩組患者年齡、性別、術(shù)前預(yù)防用抗菌藥標(biāo)志、患者來(lái)源、ASA分級(jí)比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P > 0.05)。見(jiàn)表1。
2.2 兩組住院時(shí)間及手術(shù)情況比較
實(shí)驗(yàn)組住院天數(shù)及術(shù)后住院時(shí)間少于對(duì)照組,差異均有高度統(tǒng)計(jì)學(xué)意義(P < 0.01)。實(shí)驗(yàn)組術(shù)后抗菌藥使用天數(shù)、抗生素使用時(shí)間少于對(duì)照組,差異均有高度統(tǒng)計(jì)學(xué)意義(P < 0.01);實(shí)驗(yàn)組手術(shù)時(shí)間明顯短于對(duì)照組,術(shù)中出血量低于對(duì)照組,差異均有高度統(tǒng)計(jì)學(xué)意義(P < 0.01)。見(jiàn)表2。
2.3 兩組手術(shù)效果比較
兩種轉(zhuǎn)歸情況、切口愈合等級(jí)比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P > 0.05)。見(jiàn)表3。
2.4 兩組住院費(fèi)用比較
兩組手術(shù)用一次性材料費(fèi)、手術(shù)費(fèi)、護(hù)理治療費(fèi)、護(hù)理費(fèi)、檢查費(fèi)用、床位費(fèi)和康復(fù)治療費(fèi)比較,差異有高度統(tǒng)計(jì)學(xué)意義(P < 0.01);實(shí)驗(yàn)組手術(shù)用一次性材料費(fèi)和手術(shù)費(fèi)高于對(duì)照組,其余各項(xiàng)均低于對(duì)照組。兩組抗菌藥費(fèi)用、治療用一次性材料費(fèi)、一般治療費(fèi)、監(jiān)護(hù)及輔助呼吸設(shè)備費(fèi)、輸氧費(fèi)、化驗(yàn)費(fèi)比較,差異有統(tǒng)計(jì)學(xué)意義(P < 0.05);而兩組總費(fèi)用、病理費(fèi)和西藥費(fèi)比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P > 0.05)。見(jiàn)表4。
3 討論
腹腔鏡手術(shù)與開(kāi)放手術(shù)比較,普遍認(rèn)為可以縮短住院時(shí)間,減少術(shù)后并發(fā)癥。盡管擁有上述明顯的優(yōu)點(diǎn),但由于擔(dān)心手術(shù)時(shí)間可能更長(zhǎng),術(shù)后腹腔膿腫的發(fā)生率更高,以及成本較高, LA的優(yōu)勢(shì)仍然是一個(gè)爭(zhēng)論的問(wèn)題,OA似乎仍然被廣泛應(yīng)用于臨床實(shí)踐。
文獻(xiàn)[3-10,15-16]指出用腹腔鏡手術(shù)治療闌尾炎可明顯提高手術(shù)效果,減少術(shù)后并發(fā)癥發(fā)生,手術(shù)更安全、有效,值得臨床推廣使用。薛兆強(qiáng)等[17]分析了腹腔鏡手術(shù)在小兒急性闌尾炎的臨床療效,指出手術(shù)時(shí)間、出血量、術(shù)后切口感染發(fā)生率、住院時(shí)間、住院費(fèi)用等,差異均有統(tǒng)計(jì)學(xué)意義。有研究[18-19]針對(duì)成人急性闌尾炎,認(rèn)為腹腔鏡手術(shù)與開(kāi)腹相比,手術(shù)時(shí)間、肛門(mén)排氣、住院時(shí)間差異顯著。郭婧等[20]指出腹腔鏡闌尾切除術(shù)能降低手術(shù)切口相關(guān)并發(fā)癥發(fā)生,對(duì)肥胖患者更具優(yōu)勢(shì)。曾達(dá)[21]指出腹腔鏡闌尾手術(shù)術(shù)后恢復(fù)快,感染率低,住院周期短,愈后好。但也有一些研究[9,11-14]指出這兩種手術(shù)的結(jié)果沒(méi)有明顯的差異,而且注意到LA費(fèi)用較高,術(shù)后并發(fā)癥發(fā)生率高。
本研究中,兩種手術(shù)方法,患者試驗(yàn)組住院時(shí)間少于對(duì)照組,手術(shù)時(shí)間少于對(duì)照組,差異均有高度統(tǒng)計(jì)學(xué)意義(P < 0.01),與文獻(xiàn)[17-19]一致。更為重要的是術(shù)后住院時(shí)間,實(shí)驗(yàn)組少于對(duì)照組,差異有高度統(tǒng)計(jì)學(xué)意義(P < 0.01),說(shuō)明LA可以使得患者早日恢復(fù),改善患者生活質(zhì)量。實(shí)驗(yàn)組抗生素使用時(shí)間短于對(duì)照組,差異有高度統(tǒng)計(jì)學(xué)意義(P < 0.01)。
總費(fèi)用支出方面,兩種方法比較差異無(wú)統(tǒng)計(jì)學(xué)意義,這與文獻(xiàn)[11-12,17]不一致。在所有費(fèi)用明細(xì)中實(shí)驗(yàn)組手術(shù)用一次性材料費(fèi)高出對(duì)照組2005元,高出部分約占總費(fèi)用的12%,手術(shù)費(fèi)高出1000元,約占總費(fèi)用的6%,這是由腹腔鏡手術(shù)自身的特點(diǎn)決定的,而其他各項(xiàng)支出,實(shí)驗(yàn)組均小于對(duì)照組,間接解釋了差異無(wú)統(tǒng)計(jì)學(xué)意義的原因。實(shí)際上,LA只有手術(shù)用一次性材料費(fèi)和手術(shù)費(fèi)高于OA,這是由于LA手術(shù)的自身特點(diǎn)和時(shí)間學(xué)習(xí)曲線決定的,相信隨著LA手術(shù)材料價(jià)格的不斷降低和醫(yī)生技術(shù)嫻熟度的提高,這兩項(xiàng)費(fèi)用也會(huì)不斷降低。特別是與術(shù)后恢復(fù)直接相關(guān)的兩項(xiàng)費(fèi)用護(hù)理治療費(fèi)和護(hù)理費(fèi),實(shí)驗(yàn)組少于對(duì)照組,差異有高度統(tǒng)計(jì)學(xué)意義(P < 0.01),說(shuō)明LA手術(shù)方法所需的護(hù)理資源小于OA的護(hù)理資源。
手術(shù)過(guò)程中,實(shí)驗(yàn)組術(shù)中出血量少于對(duì)照組,術(shù)后轉(zhuǎn)歸和傷口愈合等級(jí)差異無(wú)統(tǒng)計(jì)學(xué)意義(P > 0.05),顯示手術(shù)效果無(wú)差別。
綜上所述,腹腔鏡手術(shù)與開(kāi)腹闌尾切除術(shù)比較,治療效果上是相同的。但是LA方法具有術(shù)后住院時(shí)間短、手術(shù)時(shí)間短、出血量少、術(shù)后抗菌藥天數(shù)和抗生素使用天數(shù)少的優(yōu)點(diǎn)。LA可作為闌尾炎和腹痛患者的標(biāo)準(zhǔn)治療方法。
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中國(guó)醫(yī)藥導(dǎo)報(bào)2019年19期