大肠直肠癌联合会议课件

EBM Journal Club,2012-08-28 GS 謝閔傑,題目,張先生今年42歲,他接受健康檢查時,腹部超音波發現有脂肪肝以及膽囊內有兩顆結石約1.5公分,他被轉介到外科門診諮詢,一般外科陳醫師向他說明了一些膽結石可能會碰到的併發症,包括急性膽囊炎,膽管炎和胰臟炎,甚至少數可能轉變成為膽囊癌,所以建議他在年輕力壯,身體健康良好的時候接受腹腔鏡膽囊切除手術,但是張先生聽了之後覺得很猶豫不決,因為他平時並沒有任何進食後上腹部不適或是消化不良的症狀出現,但是他又很害怕會不會如陳醫師所言,以後出現嚴重的併發症而導致不可收拾?他想上網找一些實證醫學資料作為參考,您可以提供他一些有用的意見(到底要不要接受膽囊切除手術的決定)嗎 ?,實證醫學的 5 個步驟,步驟1: 形成臨床問題 步驟2: 尋找証據 步驟3: 嚴謹評估証據 步驟4: 臨床應用 步驟5: 評估效果,步驟1: 形成臨床問題,Type of Questions (1) Background questions (2) Foreground questions,Background questions,Gallstone disease Complication of gallstone? Acute cholecystitis Choledocholithiasis Acute pancreatitis 發生率? Asymptomatic or silence gallstone or incidental gallstone,Background Knowledge ( From Up to date database),The routine use of ultrasonography for the evaluation of abdominal pain, pelvic disease, and abnormal liver function tests has led to the identification of incidental gallstones in many patients The majority of these patients have no symptoms attributable to the gallstones approximately 20 percent will become symptomatic during up to 15 years of follow-up. The likelihood of continued symptoms or the development of other complications of gallstone disease (such as cholecystitis, pancreatitis, and choledocholithiasis) is substantially higher in patients who have developed symptomatic gallstones.,In a landmark study, for example, the entire population of a town in Italy (Sirmione) was screened by ultrasound for the presence of gallstones or gallstone related disease. Of 132 subjects with gallstones who were identified, the following observations were made: The overall prevalence of gallstones was 7 percent, was higher in women than men (9 versus 5 percent), and increased with advancing age. Patients with gallstones were significantly more likely to suffer from biliary pain compared with patients without gallstones (22 versus 2 percent). Eighty-two percent of patients found to have gallstones were not aware of having gallstones prior to the study; 16 percent of these patients developed symptoms during 10 years of follow-up.,In a study from Norway, 1371 randomly selected patients who had not had a cholecystectomy underwent an ultrasound examination. Incidental gallstones were discovered in 285 (21 percent) . Twenty-four years later, a follow-up study was performed that included 134 of the patients who had gallstones. The patients underwent either a clinical examination (89 patients) or answered a mail or telephone questionnaire (45 patients). Gallstones were present on ultrasound in 25 of 89 patients (28 percent overall, 31 percent of women and 25 percent of men). The mean age of the 89 patients at the time of the initial examination was 44 years for women and 45 years for men. There was no association between the number or size of gallstones at the original examination and the demonstration of gallstones at follow-up. Nine of 134 patients (7 percent) had undergone cholecystectomy, as had 5 of 91 patients who had died prior to follow-up (6 percent). During follow-up, 44 percent developed abdominal pain, and 29 percent had what were deemed to be functional abdominal complaints.,Foreground Questions,A question root “is”, “do” or “does” PICO P代表 patient 或者 problem I 代表 intervention 通常為診斷 (diagnostic) 或者是治療 (treatment) C代表 comparisons (comparative intervention) O代表 outcome,步驟1: 形成臨床問題,建議以 PICO 的方式形成問題 P: Patient I: Intervention C: Comparison O: Outcome,步驟1: 形成臨床問題,Silence gallstone or asymptomatic gallstone是否需要外科手術治療? P: Patient asymptomatic gallstone 病患 I: Intervention 接受外科手術治療 (prophylactic cholecystectomy) C: Comparison 不接受外科手術治療(觀察或是保守治療medical treatment) O: Outcome 併發症或是死亡率,步驟2: 尋找證據,醫學資料庫檢索,步驟2: 尋找證據,以 Medline 為例 以 Key word, Text word 查尋 Map to medical subject headings (MeSH) And, Or, And Not 功能: 可交集或聯集 Key word 限制功能: Limited to (年代,英文,Randomized controlled trial),Cochrane library,Pubmed search,The Evidence Pyramid,步驟4: 臨床應用,應用於臨床病患 應以effective, efficiency, equality 的理念應用於病人 最終結果想法(the end result idea)的理想 制定醫療政策 Agent for Healthcare Research and Quality (AHRQ) in USA,結論,ROLE OF PROPHYLACTIC CHOLECYSTECTOMY There are no prospective trials of therapy, either surgical or medical, for asymptomatic gallstones. However, decision analysis models have shown no benefit of a prophylactic cholecystectomy. In one study, for example, decision analysis was used to compare the consequences of prophylactic cholecystectomy with expectant management in patients with asymptomatic gallstones . Prophylactic cholecystectomy slightly decreased survival and was not associated with an appreciable gain in discounted life years gained. Although this model was constructed prior to the development of laparoscopic cholecystectomy, it is unlikely that the laparoscopic approach would significantly alter the results based upon sensitivity analysis included in the study.,結論,Prophylactic cholecystectomy is not indicated in most patients with asymptomatic gallstones. Possible exceptions include patients who are at increased risk for gallbladder carcinoma or gallstone complications, in whom prophylactic cholecystectomy or incidental cholecystectomy at the time of another abd