从预防SSI的角度，哪些阑尾炎手术不宜选择腔镜手术方式？一项大样本研究

楚楚

[size=0.84em]J Am Coll Surg. 2012 Oct 11. pii: S1072-7515(12)01133-7. doi: 10.1016/j.jamcollsurg.2012.08.035. [Epub ahead of print]
Tailoring the Operative Approach for Appendicitis to the Patient: A Prediction Model from National Surgical Quality Improvement Program Data.[size=0.92em]Senekjian L, Nirula R.
[size=0.84em]Source

Division of General Surgery, University of Utah School of Medicine, Salt Lake City, UT. Electronic address: lara.senekjian@hsc.utah.edu.

AbstractBACKGROUND:

Laparoscopic appendectomy (LA) is increasingly being performed in the United States, despite controversy about differences in infectious complication rates compared with open appendectomy (OA). Subpopulations exist in which infectious complication rates, both surgical site and organ space, differ with respect to LA compared with OA.

STUDY DESIGN:

All appendectomies in the National Surgical Quality Improvement Program database were analyzed with respect to surgical site infection (SSI) and organ space infection (OSI). Multivariate logistic regression analysis identified independent predictors of SSI or OSI. Probabilities of SSI or OSI were determined for subpopulations to identify when LA was superior to OA.

RESULTS:

From 2005 to 2009, there were 61,830 appendectomies performed (77.5% LA), of which 9,998 (16.2%) were complicated (58.7% LA). The risk of SSI was considerably lower for LA in both noncomplicated and complicated appendicitis. Across all ages, body mass index, renal function, and WBCs, LA was associated with a lower probability of SSI. The risk of OSI was considerably greater for LA in both noncomplicated and complicated appendicitis. In complicated appendicitis, OA was associated with a lower probability of OSI in patients with WBC >12 cells × 10(3)/μL. In noncomplicated appendicitis, OA was associated with a lower probability of OSI in patients with a body mass index <37.5 when compared with LA.

CONCLUSIONS:

Subpopulations exist in which OA is superior to LA in terms of OSI, however, SSI is consistently lower in LA patients.

这是一项来自美国外科质量改进计划数据库的预测模型研究。该研究包括了2005-2009年的61,830台阑尾炎手术，其中16.2%有合并症。总体来说，腔镜阑尾炎手术在有合并症和没有合并症的患者中发生SSI的风险均低一些。Across（在此如何翻译比较合适呢？） 在所有年龄、身体质量指数、肾功能和白细胞，腔镜阑尾炎手术发生SSI的风险更抵。但器官/腔隙感染腔镜阑尾炎手术更高一些。在有合并症的阑尾炎中，对于WBC大于1万2，开放阑尾手术发生SSI的风险低一些。在没有合并症的阑尾炎中，身体质量指数小于37.5的患者，选择开放阑尾手术，发生器官/腔隙感染的可能性要低一些。

楚楚

顺便再熟悉一下什么是身体质量指数：

身体质量指数(BMI)，即BMI（Body Mass Index）指数也叫做身体质量指数，是目前国际上常用的衡量人体胖瘦程度以及是否健康的标准，比单纯的以体重认定更具准确性。BMI适用于18岁至65岁的人士，不适用儿童、青少年、孕妇、乳母、老人及运动员等。

BMI 分类	中国参考标准
体重过低	<18.5
正常范围	18.5～23.9
肥胖前期	24.0～26.9
I度肥胖	27～29.9
II度肥胖	≥30
Ⅲ度肥胖	≥40

这篇文章中，对于身体质量指数小于37.5的阑尾患者，选用开放手术方式发生器官腔隙感染的可能性低一些。对此有二点疑问：第一，SSI患者相关危险因素之一是肥胖，应该说BMI越小，发生SSI的可能性越小，是不是选择腔镜手术方式发生SSI的风险也越小呢？第二，注意以上列表信息，是“中国参考标准”，那么美国的参考标准是什么？是不是阅读不同国家的有关BMI文献均要查查该国的参考标准呢？哪位朋友可以提供一下美国的BMI参考标准？37.5这个节点代表了什么意义？

鱼儿飞

个人觉得不同国家的人体质不一样，比如中国人就普遍比美国人偏瘦小一些，所以不同国家对肥胖的定义不一样。BMI>37.5应该是说比较肥胖了，开放性手术发生脂肪液化的可能性较大，伤口不易愈合，易造成手术部位感染