轉帖一篇美國胃腸內鏡外科醫生雜誌的一篇文章-常規引流闌尾穿孔的內鏡手術可減少盆腔膿腫的形成

Routine Pelvic Drainage Reduces Pelvic Abscess Formation After Laparoscopic Appendectomy for Gangrenous or Perforated Appendicitis

Andrea Pakula, MD MPH, Amber Jones, MSIV, Ray Chung, MD FACS. Kern Medical Center

Background: Laparoscopic appendectomy has become the treatment of choice for acute appendicitis with equal or better outcomes than traditional open appendectomy. Laparoscopic appendectomy in patients with gangrenous or perforated appendicitis carries an increased rate of pelvic abscess formation, requiring reoperation or percutaneous (IR) drainage when compared to open appendectomy. We hypothesized that routine placement of pelvic Jackson-Pratt drains in gangrenous or perforated appendicitis, and limited intra-abdominal irrigation, decreases pelvic abscess formation after laparoscopic appendectomy in these patients.

Methods: Following IRB approval, charts of 283 patients undergoing laparoscopic appendectomy between 01/07 and 02/10 were reviewed. Only patients with findings of a perforated or gangrenous appendix were included. Patients were separated into two groups, Group 1: JP drain(s) placed with limited localized irrigation; Group 2: no JP drain, irrigated ad lib by the operating surgeons. Data collected included intra-abdominal or pelvic abscess postoperatively, IR drainage of the abscess, hospital length of stay, and the use of antibiotics. Clinic follow-up notes were reviewed to evaluate length of drainage and effectiveness of treatment.

Results: A total of 121 patients underwent laparoscopic appendectomy with findings of a perforated or gangrenous appendix from January 2007 to February 2010. 29 patients had placement of JP drains (Group 1) and 92 patients did not have a Jackson Pratt drain placed (Group 2). 18/92 (20%) of the Group 2 patients developed pelvic abscesses requiring IR drainage. 0/29 (0%) of Group 1 patients developed pelvic abscess. However, one patient in Group 1 developed a subphrenic abscess requiring IR drainage. Since the JP drain was not intended to prevent subphrenic abscesses, this patient was not included in our analysis. The Fisher’s Exact Test was used for our statistical analysis and we found the two-tailed probability to be 0.01. This is statistically significant when a p-value of <0.05 was used.

Conclusions: Use of Jackson Pratt drainage in patients with perforated or gangrenous appendicitis, who undergo laparoscopic appendectomy have a decreased rate of pelvic abscess/infection. Limited and localized intra-abdominal irrigation may limit dissemination of contamination and further decrease pelvic abscess formation. The need for treatment with IR drainage is decreased. The hospital length of stay is also decreased in the patients who have JP drains placed at time of operation. We therefore recommend the routine use of JP drainage of the pelvis after laparoscopic appendectomy for gangrenous or perforated appendicitis.


Session: Resident/Fellow
Program Number: S121

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這片文章已經回答了爭論的要點。。。 -禦用文人- 給 禦用文人 發送悄悄話 (0 bytes) () 07/07/2016 postreply 11:22:41

醫學基本理論都解釋的清清楚楚的東西,再好的抗生素也不能替代良好的引流。根本就不用爭論的。 -薛成- 給 薛成 發送悄悄話 薛成 的博客首頁 (0 bytes) () 07/07/2016 postreply 11:39:42

老薛,您這說得千真萬確,但是關鍵是不一定適用於那個具體病情。 -惡俗老狼- 給 惡俗老狼 發送悄悄話 惡俗老狼 的博客首頁 (1478 bytes) () 07/07/2016 postreply 12:40:29

你看帖不仔細。手術前診斷為闌尾炎穿孔,手術醫生也證實,有一個孔漏了。 -薛成- 給 薛成 發送悄悄話 薛成 的博客首頁 (472 bytes) () 07/07/2016 postreply 12:42:38

no no no, no popped, but leaky。我剛才特意仔細回去看了原帖。 -惡俗老狼- 給 惡俗老狼 發送悄悄話 惡俗老狼 的博客首頁 (67 bytes) () 07/07/2016 postreply 12:43:49

還是那句話,這裏麵的很多信息並不是非常明確,很多都是按照我們自己的理解而瞎猜。 -惡俗老狼- 給 惡俗老狼 發送悄悄話 惡俗老狼 的博客首頁 (122 bytes) () 07/07/2016 postreply 12:45:56

由此案聯想到普遍情形。 -TBz- 給 TBz 發送悄悄話 TBz 的博客首頁 (644 bytes) () 07/07/2016 postreply 13:09:10

邏輯呢?沒有邏輯思維當不了好醫生。 -薛成- 給 薛成 發送悄悄話 薛成 的博客首頁 (325 bytes) () 07/07/2016 postreply 13:14:57

化膿性闌尾炎,闌尾裏麵是高壓,一旦漏了,哪會是一點點漏?那是噴啊!至於口語用詞可能不規範而已。 -薛成- 給 薛成 發送悄悄話 薛成 的博客首頁 (0 bytes) () 07/07/2016 postreply 12:46:49

我們這裏醫生和家屬交代,是否rupture,有時就會用burst或者pop這些常用“俗”語。方便病人理解。 -惡俗老狼- 給 惡俗老狼 發送悄悄話 惡俗老狼 的博客首頁 (0 bytes) () 07/07/2016 postreply 12:51:53

來來來,給你看一個幾壇網友的帖子,很好的病例。要是我可能也會誤診,所以收集了。正好可以給你看看。 -薛成- 給 薛成 發送悄悄話 薛成 的博客首頁 (5432 bytes) () 07/07/2016 postreply 12:55:17

還是那句話,不了解當時的具體病情,隻能茶館閑聊,不能具體指導診療。如果 -惡俗老狼- 給 惡俗老狼 發送悄悄話 惡俗老狼 的博客首頁 (409 bytes) () 07/07/2016 postreply 13:02:18

而這個孩子手術證明穿孔了。手術後5天腹痛,高燒不退,再後來不得不再住院,發現有糞石,切口感染。 -薛成- 給 薛成 發送悄悄話 薛成 的博客首頁 (158 bytes) () 07/07/2016 postreply 13:08:07

好好好,不爭了。 -惡俗老狼- 給 惡俗老狼 發送悄悄話 惡俗老狼 的博客首頁 (0 bytes) () 07/07/2016 postreply 13:09:17

診斷為raptured.說是leaked, not poped -huela- 給 huela 發送悄悄話 huela 的博客首頁 (26 bytes) () 07/07/2016 postreply 13:21:47

醫生做完手術告訴我們是raptured -huela- 給 huela 發送悄悄話 huela 的博客首頁 (187 bytes) () 07/07/2016 postreply 13:35:59

thank you for your clarification. -惡俗老狼- 給 惡俗老狼 發送悄悄話 惡俗老狼 的博客首頁 (33 bytes) () 07/07/2016 postreply 13:37:40

其實到這裏混,經常還需要查查資料,也漲不少知識,蠻有意思的。 -惡俗老狼- 給 惡俗老狼 發送悄悄話 惡俗老狼 的博客首頁 (0 bytes) () 07/07/2016 postreply 14:34:25

按你的邏輯,老T根本就沒資格在這混,不是正規軍,連遊擊隊都沒幹過。嗬嗬嗬。。。。。。。 -薛成- 給 薛成 發送悄悄話 薛成 的博客首頁 (0 bytes) () 07/07/2016 postreply 14:40:02

好像基本上沒有看到老T給什麽醫學建議。 -惡俗老狼- 給 惡俗老狼 發送悄悄話 惡俗老狼 的博客首頁 (663 bytes) () 07/07/2016 postreply 14:46:53

可是他還是喜歡仲裁一下的:))) -薛成- 給 薛成 發送悄悄話 薛成 的博客首頁 (0 bytes) () 07/07/2016 postreply 14:50:12

我可是有理有據啊。哪裏胡攪蠻纏?你的流程圖也證明我的判斷及推理正確。 -薛成- 給 薛成 發送悄悄話 薛成 的博客首頁 (0 bytes) () 07/07/2016 postreply 16:58:50

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