Журнал "Медицина невідкладних станів" Том 20, №4, 2024
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Лапароскопічна холецистектомія з дренуванням і без нього: систематичний огляд і метааналіз
Автори: Чуклін С.С., Чуклін С.М.
Медичний центр Святої Параскеви, м. Львів, Україна
Рубрики: Медицина невідкладних станів
Розділи: Клінічні дослідження
Версія для друку
Актуальність. Абдомінальний дренаж з профілактичною метою десятиліттями використовувався хірургами через можливість раннього виявлення ознак післяопераційних ускладнень. Проте справжня цінність звичайного дренування після абдомінальної операції все ще дискутується. Існують контрасти між дослідженнями, які підтримують встановлення дренажу виключно у пацієнтів з інтраопераційними ускладненнями, і працями, які демонструють сприятливий вплив профілактичного дренування на післяопераційний біль, нудоту та блювання. Проте все ще бракує доказів щодо використання рутинного дренування черевної порожнини після лапароскопічної холецистектомії та його клінічної цінності. Поточні настанови не згадують про роль дренажу після лапароскопічної холецистектомії. Мета: оцінити, чи є звичайний післяопераційний дренаж ефективнішим, ніж його відсутність, у пацієнтів з неускладненим доброякісним захворюванням жовчного міхура після лапароскопічної холецистектомії. Матеріали та методи. Пошук в електронних базах даних MedLine, Scopus, бібліотеці Cochrane було проведено для рандомізованих контрольованих досліджень, у яких повідомлялося про результати лапароскопічної холецистектомії з абдомінальним дренажем і без нього, до січня 2024 року. Систематичний огляд проводився відповідно до рекомендацій PRISMA, а метааналіз — за допомогою моделей фіксованих і випадкових ефектів. Розраховували відношення шансів (OR) з довірчим інтервалом (ДІ) для якісних змінних і середню різницю (MD) з ДІ для безперервних змінних за допомогою IBM SPSS Statistic 29.0.2.0. Результати. У метааналіз було включено 44 РКД за участю 5185 пацієнтів (2592 з дренажами проти 2593 без них). Не було статистично значущих відмінностей у показниках частоти накопичення внутрішньочеревної рідини (OR = 0,87; 95% ДІ: 0,64–1,19; p = 0,39) між двома групами. Абдомінальні дренажі не зменшили загальну частоту нудоти та блювання (OR = 1,51; 95% ДІ: 0,85–2,70; p = 0 ,16) або болю в плечі (OR = 0,90; 95% ДІ: 0,58–1,41; p = 0,65). Група абдомінального дренування показала значно вищі показники болю (MD = 0,67; 95% ДІ: 0,37–0,98; p < 0,001), ніж пацієнти без дренажу. Дренування черевної порожнини подовжило тривалість операції (MD = 3,82; 95% ДІ: 1,93–5,70; p < 0,001), але не тривалість перебування в лікарні після операції (MD = 0,42; 95% ДІ: –0,02–0,85; p = 0,06). Було виявлено, що ранова інфекція (OR = 3,26; 95% ДІ: 2,35–4,51; p < 0,001), лихоманка (OR = 4,40; 95% ДІ: 2,57–7,8554; p < 0,001) і пневмонія (OR = 4,74; 95% ДІ: 2,25–9,97; p < 0,001) пов’язані з використанням абдомінальних дренажів. Висновки. На сьогодні немає жодних доказів на підтримку використання планового дренування після лапароскопічної холецистектомії при неускладненому доброякісному захворюванні жовчного міхура. Відсутність дренування після лапароскопічної холецистектомії безпечна та пов’язана з меншою кількістю ускладнень. Післяопераційне відновлення поліпшується, якщо немає дренажу. Для підтвердження цих висновків потрібні подальші добре сплановані рандомізовані клінічні дослідження.
Background. The abdominal drainage with a prophylactic purpose was used by surgeons for decades because of the possibility to detect early signs of postoperative complications. However, the real value of routine drainage after abdominal surgery is still debated. There are discrepancies between studies supporting the drain placement only in patients with intraoperative complications and works showing a beneficial effect of prophylactic abdominal drainage on postoperative pain, nausea, and vomiting. However, there is still a lack of evidence on the use of routine abdominal drainage following laparoscopic cholecystectomy and its clinical value. Current guidelines do not mention the role of drainage after laparoscopic cholecystectomy. Objective: to evaluate whether conventional postoperative drainage is more effective than no drainage in patients with non-complicated benign gallbladder disease after laparoscopic cholecystectomy. Materials and methods. A search in the electronic databases MEDLINE, Scopus, Cochrane Library was conducted for randomized controlled trials reporting outcomes of laparoscopic cholecystectomy with and without an abdominal drainage until January 2024. The systematic review was conducted in accordance with the PRISMA guidelines and meta-analysis — using fixed and random effects models. Odds ratio (OR) with confidence interval (CI) for qualitative variables and mean difference (MD) with CI for continuous variables were calculated using IBM SPSS Statistics 29.0.2.0. Results. Forty-four randomized controlled trials involving 5,185 patients (2,592 with drains vs 2,593 without them) were included in the meta-analysis. There were no statistically significant differences in the incidence of intra-abdominal fluid accumulation (OR = 0.87; 95% CI: 0.64–1.19; p = 0.39) between two groups. Abdominal drains did not reduce the overall incidence of nausea and vomiting (OR = 1.51; 95% CI: 0.85–2.70; p = 0 .16) or shoulder pain (OR = 0.90; 95% CI: 0.58–1.41; p = 0.65). The abdominal drain group reported significantly higher pain scores (MD = 0.67; 95% CI: 0.37–0.98; p < 0.001) than patients without drains. Abdominal drainage increased operative time (MD = 3.82; 95% CI: 1.93–5.70; p < 0.001) but not the length of hospital stay after surgery (MD = 0.42; 95% CI: –0.02–0.85; p = 0.06). Wound infection (OR = 3.26; 95% CI: 2.35–4.51; p < 0.001), fever (OR = 4.40; 95% CI: 2.57–7.8554; p < 0.001) and pneumonia (OR = 4.74; 95% CI: 2.25–9.97; p < 0.001) were found to be associated with the use of abdominal drains. Conclusions. Currently, there is no evidence to support the use of routine drainage after laparoscopic cholecystectomy in non-complicated benign gallbladder disease. No drainage after laparoscopic cholecystectomy is safe and associated with fewer complications. Postoperative recovery is improved if drain is not used. Further well-designed randomized clinical trials are required to confirm this finding.
лапароскопічна холецистектомія; дренування; ускладнення; огляд; метааналіз
laparoscopic cholecystectomy; drainage; complications; review; meta-analysis
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