本帖最後由 lsc0019 於 2009-7-21 23:23 編輯
作者：Louise Gagnon
出處：WebMD醫學新聞
July 6, 2009 (德州達拉斯) — 一篇發表於美國代謝與減重手術協會第26屆年會的研究顯示，將適合減重手術的病患根據他們術前的共病症狀況進行分類，可以獲得較少的術後併發症與降低健康照護資源的使用。
主要研究者、亞利桑那大學醫學院臨床副教授、Scottsdale減重中心減重外科Robin Blackstone醫師表示，我們認為，如果我們確認肥胖的代謝問題，如高血壓、糖尿病與睡眠呼吸中止，並將其納入考量，將可以改善整個醫療過程與術後的結果。
根據Blackstone醫師表示，研究者發展一種「代謝敏銳性評分(MAS)」方式，連同身體質量指數，而可以有更個人化的病患術前評估。
MAS是一種4分評分系統，1分表示最不嚴重、4分表示最嚴重。此系統將年紀、身體質量指數、體重、深部靜脈栓塞/肺栓塞病史、睡眠呼吸中止、糖尿病、高血壓、無法行動、心臟病與心理分類等變項納入考量。
Blackstone醫師解釋，20歲左右、體重超過理想體重100磅的年輕人，沒有胰島素阻抗性糖尿病且還沒有高血壓者，評為1分，這些都在2001至2008年進行減重手術。病態肥胖、且大約55歲、且有阻塞性睡眠呼吸中止合併氣喘和胰島素依賴型糖尿病者，評為4分。
研究者前溯納入1,072名病患，其中597名病患接受胃繞道手術，475名病患接受胃束帶手術，他們在術前都進行MAS評分。
MAS組的病患彼此比較，且和在2006年8月前進行減重手術的1,344名病患比較，此一時間點為研究者開始將病患納入MAS組的時間。這1,344名病患被視為控制組。
運用MAS前後，共有1,821名病患接受Roux-en-Y胃繞道手術，595人接受腹腔鏡可調式胃束帶手術。
研究者發現，運用評分系統後，30天內再住院率顯著下降。接受胃繞道手術的病患中，運用MAS前的再住院率為8.5%，運用MAS之後為1.7%(P < .001)。接受腹腔鏡可調式胃束帶手術的病患中，運用MAS前後的30天內再住院率相同。
接受胃繞道手術的病患中，運用此評分系統後，術後感染率降低，從運用MAS前的3.5%降低到運用MAS之後的0.7% (P < .001)。接受胃繞道手術的病患運用MAS後，術後體內疝氣、阻塞、腹內膿瘍與肺炎也都減少。
接受腹腔鏡可調式胃束帶手術的病患中，運用MAS前後的術後感染率沒有顯著差異，運用MAS前為0.8%，運用MAS之後為1.1%。
腹腔鏡可調式胃束帶手術運用MAS後的整體結果有改善，有較少的束帶滑動(運用MAS前為6.7%，運用MAS之後為0.6%；P < .001)。此外，運用MAS後，胃束帶手術病患的住院天數減少，運用MAS前為1.3天，運用MAS之後為0.8 天(P = .01)。
所有病患的再度手術率，在運用MAS之後降低了57%，從運用MAS前的2.1%降低到運用MAS之後的0.9%，這是顯著的差異。
雖然使用此一評分系統對於減重手術病患並沒有明顯的因果關係，資料顯示，使用評分系統之病患的結果優於那些沒有使用此系統者。
北卡羅來納杜克大學外科副主任、美國代謝與減重手術協會執行委員Eric DeMaria醫師表示，當醫師發展出更佳的病患風險評估系統，即可改善結果。有許多研究顯示如此。
他指出，釐清並多加注意有多種風險的病患的確有其道理。術前血壓控制不佳之病患需要更積極的醫療處置也有其道理。
Blackstone醫師報告擔任Ethicon Endo-Surgery公司的顧問，EnteroMedics Inc公司的研究員，Surgical Review Corporation公司的董事會成員。DeMaria醫師宣告沒有相關財務關係。
美國代謝與減重手術協會2009年會：摘要PL-309。發表於2009年6月26日。
ASMBS 2009: Scoring System Helps Reduce Risk for Complications After Bariatric Procedures
By Louise Gagnon
Medscape Medical News
July 6, 2009 (Dallas, Texas) — Stratifying patients who are candidates for bariatric procedures according to their preoperative comorbidities results in fewer postoperative complications and decreases the use of healthcare resources, a study presented here at the 26th annual meeting of the American Society for Metabolic and Bariatric Surgery shows.
"We thought if we recognize and take into account the metabolic components of obesity — things like hypertension, diabetes, and sleep apnea — that we would be able to improve outcomes by recognizing and managing those things throughout the whole hospital course and postoperatively," said Robin Blackstone, MD, FACS, principal investigator of the study, bariatric surgeon at Scottsdale Bariatric Center in Arizona, and an associate clinical professor at the University of Arizona School of Medicine.
Researchers developed a Metabolic Acuity Score (MAS) to accompany the body mass index and permit a more personalized preoperative assessment of patients, according to Dr. Blackstone.
The MAS is a 4-point scoring system, with a score of 1 being the least severe and a score of 4 being the most severe. The system takes into account variables such as age, body mass index, weight, history of deep vein thrombosis/pulmonary embolism, sleep apnea, diabetes, hypertension, immobility, heart disease, and psychological classification.
"A young patient in his or her twenties and being 100 pounds over his or her ideal weight, who would not have insulin-resistant diabetes and does not yet have hypertension, would be assigned a score of 1," explained Dr. Blackstone, who performed all of the bariatric procedures between 2001 and 2008. "A patient who is morbidly obese and is about 55 [years of age and] has obstructive sleep apnea combined with asthma and insulin-dependent diabetes would be assigned a score of 4."
The investigators prospectively enrolled 1072 patients, with 597 patients receiving gastric bypass surgery and 475 patients receiving gastric banding, and assigned them a MAS score before the procedure.
The MAS groups were compared with each other and were compared with 1344 patients who had received bariatric procedures before August 2006, the time at which point the institution began dividing patients into MAS groups. This group served as controls.
There were 1821 patients who underwent Roux-en-Y gastric bypass surgery and 595 who received laparoscopic adjustable gastric band procedures before and after MAS was implemented.
Investigators found a dramatic drop in readmission rates within 30 days after the scoring system was put in place. The readmission rate was 8.5% before MAS and 1.7% after MAS (P < .001) for patients who received gastric bypass surgery. The readmission rate within 30 days was the same both before the use of MAS and after its use among laparoscopic adjustable gastric band patients.
Infection rates after surgery were lower after implementing the scoring system in gastric bypass patients at 3.5% before MAS and 0.7% after MAS (P < .001). There were also reductions in postoperative internal hernias, obstructions, intraabdominal abscesses, and pneumonia once MAS was implemented in gastric bypass patients.
There was no statistically significant difference in postprocedure infection rates among laparoscopic adjustable gastric band patients, with the rate being 0.8% before MAS and 1.1% after MAS.
Overall outcomes after laparoscopic adjustable gastric banding were improved with the implementation of the MAS system, with fewer band slips (6.7% before MAS and 0.6% after MAS; P < .001). In addition, gastric banding patients had a shortened hospital stay with the implementation of MAS, with a length of stay of 1.3 days before MAS and 0.8 days afterward (P = .01).
The reoperation rate for all patients decreased by 57% after MAS was implemented, from 2.1% before MAS to 0.9% after MAS, which was significant.
Although there does not appear to be a clear cause and effect from using a scoring system for bariatric surgery patients, the data suggest that patient outcomes with a scoring system in place seem to be superior compared to those without such a system.
"As surgeons develop better systems to evaluate their patients for risk, the outcomes approve," said Eric DeMaria, MD, FACS, FASMBS, member of the executive council of the American Society for Metabolic and Bariatric Surgery and vice-chairman of the Department of Surgery at Duke University in Durham, North Carolina. "There is a lot of work that is demonstrating that."
"It appears to make sense to identify and target patients who have numerous risk factors for much more attention and care," he added. "It makes sense to have more aggressive medical management of patients who have out-of-control blood pressure before surgery."
Dr. Blackstone has reported being a consultant for Ethicon Endo-Surgery Inc, an investigator for EnteroMedics Inc, and a member of the board of directors of the Surgical Review Corporation. Dr. DeMaria has disclosed no relevant financial relationships.
American Society for Metabolic and Bariatric Surgery 2009 Annual Meeting: Abstract PL-309. Presented June 26, 2009. |
|
