扁桃腺切除術的併發症機率不一

作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　June 1, 2010 — 根據發表在2010年6月號耳鼻喉科－頭頸部癌症手術的一項病例控制與病歷回溯研究結果，扁桃腺切除術的併發症機率不一。
　　
　　資深作者Craig S. Derkay醫師在一項新聞稿中表示，有關於哪個術式最好，目前仍有爭議。然而，一個重點是，在這項研究中，無論你使用哪種外科技術移除扁桃腺，我們的研究結果顯示，不同術式之間的安全性是可接受的。
　　
　　這項研究的目的在於比較一大群兒童接受三種不同扁桃腺切除術的重大併發症機率。這些術式為微清創囊內扁桃腺切除，以一種螺旋切除工具來刮除組織；低溫消融，一種使用放射射頻能量，控制的、非加溫過程；或是電燒，以電加溫金屬探頭透過熱傳導破壞組織的技術。
　　
　　重大併發症以術後出血需要回到開刀房處理或是在急診室進行燒灼，或是脫水需要靜脈輸液或是再入院定義。
　　
　　在一家區域兒童醫院，研究者們回溯4776位1至18歲兒童，在36個月內接受微清創囊內扁桃腺切除、低溫消融、或Bovie術式，進行腺樣體切除術、扁桃腺切除術、或是腺樣體扁桃腺切除術。為了協助確認重大術後併發症危險因子，每位有此併發症的患者都與2位病例對照控制組受試者做比較。
　　
　　接受腺樣體扁桃腺切除術整體的併發症機率為1.7% ± 0.4%（80/4776），扁桃腺切除術則是2.3% ± 0.5%（80/3362）。不同的移除扁桃腺技術與不同的重大併發症機率有關（低溫消融為34/1235[2.8% ± 0.9%]、電燒為40/1289[3.1% ± 0.9%]以及微清創囊內扁桃腺切除6/824[0.7% ± 0.7%]，P值<0.001）。
　　
　　雖然年齡並非術後脫水相關因子（5.33相較於5.49歲），但術後出血發生在年齡較大的兒童（8.5歲相較於5.5歲；P<0.001）。在病例控制部份研究，並未確切地找出腺樣體扁桃腺切除術發生併發症高風險群患者。也並未發現外科醫師或外科住院醫師是影響預後的獨立共變項。
　　
　　作者們寫到，在這個現實生活的教學醫院外科場所，這三種不同的扁桃腺切除術常規地由住院醫師或主治外科醫師執行，當與低溫消融及電燒完全扁桃腺切除技術比較時，微清創囊內扁桃腺切除與較低的扁桃腺切除術後出血及脫水機率有關。
　　
　　這項研究的限制包括回溯性研究設計、觀察性設計；電子病歷編碼正確性可靠度；以及發生併發症但未回診處理併發症患者的可能性。
　　
　　研究作者們的結論是，在我們的機構中，不論你使用哪種術式移除扁桃腺，我們的結果顯示，安全性是可接受的。
　　
　　這項研究並未接受外在贊助。試驗作者們表示沒有相關資金上的往來。


Tonsillectomy Techniques Differ in Complication Rates

By Laurie Barclay, MD
Medscape Medical News

June 1, 2010 — Tonsillectomy techniques differ in complication rates, according to the results of a case-control study and chart review reported in the June 2010 issue of Otolaryngology–Head and Neck Surgery.

"Questions will remain regarding what is the best procedure," said senior author Craig S. Derkay, MD, FAAP, in a news release. "However, an important point is that that no matter which surgical technique was used for removal of the tonsils in the study, our results demonstrate an acceptable level of safety across all procedures."

The goal of the study was to compare major complication rates in a large cohort of children undergoing adenotonsillectomy by 3 different techniques. These were microdebrider intracapsular tonsillectomy, in which a rotary cutting tool is used to shave tissue; coblation, a controlled, non–heat-driven process using radiofrequency energy; or electrocautery, in which tissue is destroyed by heat conduction from an electrically heated metal probe.

Major complications were defined as postoperative hemorrhage necessitating return to the operating room, or cauterization in the emergency department and dehydration necessitating intravenous fluids or readmission.

At a regional children's hospital, the investigators reviewed records of 4776 patients aged 1 to 18 years who underwent adenoidectomy, tonsillectomy, or adenotonsillectomy by microdebrider, coblator, or Bovie during a 36-month period. To help identify risk factors for major postoperative complications, patients with such complications were each compared vs 2 case-matched control subjects.

Complication rate was 1.7% ± 0.4% (80/4776) overall and 2.3% ± 0.5% for adenotonsillectomy or tonsillectomy alone (80/3362). Different techniques of tonsil removal were associated with varying rates of major complications (34/1235 [2.8% ± 0.9%] for coblation, 40/1289 [3.1% ± 0.9%] for electrocautery, and 6/824 [0.7% ± 0.7%] for microdebrider [P < .001]).

Although age was not a factor associated with postsurgical dehydration (5.33 vs 5.49 years), postoperative hemorrhage occurred in older children (8.5 vs 5.5 years; P < .001). Patients at risk for complications during adenotonsillectomy were not reliably identified by the case-control portion of the study. Neither identity of the surgeon nor participation by resident surgeons was a confounding independent variable.

"In this 'real life' teaching hospital surgical setting in which [3] different techniques of tonsillectomy are routinely performed by a variety of resident and attending surgeons, microdebrider intracapsular tonsillectomy is associated with lower rates of post-tonsillectomy hemorrhage and dehydration when compared to coblation and electrocautery complete tonsillectomy technique," the study authors write.

Limitations of this study include retrospective, observational design; reliance on the accuracy of electronic medical record coding; and the possibility that patients with complications did not return to the study institution for management of their complications.

"No matter which surgical technique was used for removal of the tonsils at our institution, our results demonstrate an acceptable level of safety," the study authors conclude.

This study received no external funding. The study authors have disclosed no relevant financial relationships.

Otolaryngol Head Neck Surg. 2010;142:886-892.