腹腔镜与开腹胃十二指肠溃疡穿孔修补术的前瞻性随机对照研究

Comparison of Laparoscopic Versus Open Repair of Acute Peptic Ulcer Perforation: a Prospective Randomized Controlled Trial

目的：探讨腹腔镜与开腹行胃十二指肠溃疡穿孔修补术的优缺点。方法2011年4月-2013年6月，将133例胃十二指肠溃疡急性穿孔患者采用抽取信封法随机分为腹腔镜组（68例）和开腹组（65例），2组年龄、性别、穿孔大小、部位和麻醉学评分等方面无显著差异（P＞0．05）。对比2组手术时间、术中出血量、术后肠鸣音恢复时间、术后第1天及第3天疼痛评分及镇痛次数、术后并发症发生率和术后住院时间等指标。结果与开腹组相比，腹腔镜组术中出血少[（10．2±2．2）ml vs．（23．7±4．6）ml，t＝-21．742，P＝0．000]，术后肠鸣音恢复早[（26．2±6．1）h vs．（39．4±8．5）h，t＝-10．324，P＝0．000]，术后疼痛轻[第1天疼痛评分（4．1±1．1）vs．（7．6±1．7），t＝-14．159，P＝0．000，第3天疼痛评分（1．7±0．9）vs．（3.6±1．2），t＝-10．360，P＝0．000]，镇痛次数少[中位数1（0-9） vs．3（0-12），Z＝-7．208，P＝0．000]，术后切口感染发生率低[0（0％） vs．6（9．2％），P＝0．012]，术后住院时间短[（6．3±1．3）d vs．（8．2±2．7）d，t＝-5．206，P＝0．000]。2组手术时间差异无显著性（ P＞0.05）。随访3-6个月，2组均无再次穿孔及死亡。结论腹腔镜手术修补胃十二指肠溃疡急性穿孔安全可靠，具有疼痛轻、切口感染少、康复快、术后住院时间短等优点，是治疗良性胃十二指肠溃疡急性穿孔的理想术式。

Objective To compare the differences of the results between the laparoscopic and open repair in the treatment of acute peptic ulcer perforation . Methods From April 2011 to June 2013, 133 patients with a clinical diagnosis of perforated peptic ulcer were randomly assigned to either laparoscopic （n=68） or open （n=65） repairs.The two groups were comparable in age , sex, size and site of perforations, and American Society of Anesthesiology （ASA） classification （P〉0.05）.The data of the operation time, operative bleeding, postoperative bowel sound recovery time , pain scores, sedative usage, incidence of complications, and length of postoperative hospital stay were compared between the two groups . Results All the laparoscopic or open repairs were completed successfully under general anesthesia .The operative bleeding and postoperative bowel sound recovery time in laparoscopic group were significantly less than those in the open group [（10.2 ±2.2） ml vs.（23.7 ±4.6） ml, t=-21.742, P=0.000 and （26.2 ±6.1） h vs.（39.4 ±8.5） h, t =-10.324, P=0.000].After surgery, patients in the laparoscopic group required significantly less parenteral analgesics than those who underwent open repair [median, 1 dose（0-9） vs.3 doses（0-12）, Z=-7.208, P=0.000）. The visual analog pain scores （ VAS ） in day 1 and day 3 after surgery were significantly lower in the laparoscopic group as well [（4.1 ±1.1） vs.（7.6 ±1.7）, t=-14.159, P=0.000 and （1.7 ±0.9） vs.（3.6 ±1.2）, t=-10.360, P=0.000].There were fewer incision infections in the laparoscopic group than those in the open group （0 vs.6 cases, P =0.012）.The mean postoperative hospital stay was （6.3 ±1.3） days in the laparoscopic group versus （8.2 ±2.7） days in the open group （t=-5.206, P=0.000）.Laparoscopic repair of perforated peptic ulcer took similar time with open repair （P〉0.05）.The patients were followedup for 3 -6 months , during which there was no patient undergoing re-perforation or fatal complications in both groups . Conclusions Laparoscopic repair of perforated peptic ulcer is a safe and reliable procedure .It is associated with less damage , less postoperative pain , less incision infections , quicker recovery , shorter postoperative hospital stay , and earlier return to normal daily activities than the conventional open repair , being an ideal treatment for most acute peptic ulcer perforation .