文献摘要

成人經管壁上或管壁下乳突切除術後之疾病復發率
The Disease Recurrence Rate After the Canal Wall Up or Canal Wall Down Technique in Adult

Volume 1, Issue 1

關鍵字 :
Cholesteatoma, recurrence, residual disease, canal wall up, canal wall down, hearing outcome, hearing loss. 膽脂瘤、復發、殘留、管壁上、管壁下、聽力結果、聽力損失

作者 :
Kelly G. P. Kerckhoffs, BSc; Maarten B.J. Kommer, BSc; Thom H. L. van Strien, BSc; Simeon J. A. Visscher, BSc; Hanneke Bruijnzeel, MD; Adriana L. Smit, MD; Wilko Grolman, MD, PhD

譯者 :
基隆長庚紀念醫院 趙偉傑醫師

摘要:


Objectives/Hypothesis:  To review which type of cholesteatoma surgery, canal wall up (CWU) or canal wall down (CWD), provides the lowest risk for residual and/or recurrent disease in adults with primary acquired cholesteatoma.


Data Sources: PubMed, Embase, CINAHL, the Cochrane Library, Scopus and Web of Science.


Study Design:  We selected articles comparing CWU with CWD, reporting on disease recidivism (combined residual and recurrent disease) or independent residual or disease recurrence rates. We included studies with a moderate to high relevance.


Results:  Our search yielded 2,060 articles. We selected seven studies that carried a moderate risk of bias. Six studies described higher disease recidivism after the CWU procedure [16.7–61.0%] compared to the CWD technique [0–13.2%]. Four studies showed statistical significant difference (P < .05). One study showed opposite results: recidivism was found in 7.8% CWU and in 22.1% CWD cases (P < .001). Studies showed CWU recidivism more likely to be residual disease, whereas CWD recidivism tended to be recurrent disease.


Conclusion: The majority of included studies showed CWU to result in more disease recidivism compared to the CWD technique in adult patients with a primary acquired cholesteatoma. If recidivism risk is the most important factor to consider a certain surgical technique, we recommend application of the CWD procedure. However, many additional factors in patient care will define the best treatment decision, such as residual hearing and access to health care. Our recommendations are based on Level II evidence, which underlines the need for future high-level evidence studies.

專家評論:


成人經管壁上或管壁下乳突切除術後之疾病復發率

基隆長庚紀念醫院   趙偉傑醫師


膽脂瘤為中耳或乳突腔內囊狀的角質化鱗狀上皮組織,從起源上可以分為先天性與後天性。後天性膽脂瘤不論原發性獲續發性,處理原則皆為手術的移除,最主要的手術方式分為canal wall up (CWU) mastoidectomy與canal wall down(CWD),CWD 移除了後耳道壁而CWU則保留,CWD的缺點在於乳突與外耳道形成的開放空腔需要定期回診局部治療,而CWU防止了這些麻煩但是保留的耳道壁在手術中可能遮蔽了部分視野而導致無法完全清除病灶提高了殘存的機會。此外因為原始解剖構造依然保留,原本造成疾病的原因如中耳通氣不良依然存在而復發的機會因而提升。本篇系統性回顧目的為歸納各家論文成人膽脂瘤病患接受CWD及 CWU 之後殘存率(residual rate)與復發率(recurrence rate )從2060篇將符合搜尋條件:成人膽脂瘤、比較canal wall down 與canal wall up mastoidectomy 之結果、探討recidivism(殘存率併復發率)或獨立的殘存率與復發率,本文有別於meta-analysis之系統性分析論文,作者將文獻收集的文章初步以其設定的收納條件剔除之後建立了一套評分系統critical appraisal tool( CAT) 來進一步分析與評比剩下的論文的重要性(relevance) 與有效性(validity),主要評分項目為:1. 病患的年齡,2. 術後追蹤的時間長短,3 是否有區分殘留率與復發率年齡小於九歲文獻中再發率顯著增加,術後追蹤時間長短區分了殘留與復發。而區分了殘留與復發後確定了疾病的發作原因。會使用這樣的評分系統可能是因為分析膽脂瘤手術的相關論文不容易使用meta-analysis來進行系統性回顧分析,而如此將作者從文獻回顧中認為重要的因子列入評分項目進行論文評比而得出相對重要且有效的論文回顧進而做出有證據力的結論。如此的分析方式可以使用在相對較多臨床經驗論述的主題來進行系統性回顧,值得學習。

經過統計將重要度較高的7篇論文選出。其中六篇論文指出相較於CWD[0–13.2%],CWU[16.7–61.0%]術後有較高的復發殘存率,其中四篇統計學上有顯著意義,而另外一篇則顯示相反之結果:CWU(7.8%) VS CWD(22.1%)。總體而言CWU 的相對殘存率高而CWD若有則多是復發比率較高。

膽脂瘤手術需要考慮的重要術後因子還有殘存聽力的多少以及術後局部清理所產生的醫療成本,此時CWU可以提供較好的聽力保存以及減少術後經常性局部治療的必要,雖有較高的殘存復發率但配合數月後第二次探查手術,仍可再降低復發率。此外因為這種臨床手術結果比較的論文多以回朔性分析,疾病的嚴重度已經影響了手術醫師術式上的選擇,較嚴重散佈性的膽脂瘤案例選擇CWD而本質上聽力結果已經注定不佳,復發率較高。這些都是這篇論文回顧中無法有足夠證據去證實與可能產生的盲點。

結論上若是手術的結果最重要的指標是殘存合併復發率的話則手術的選擇建議為CWD,當合併考慮殘存聽力以及後續之健康照顧時本文不足以提出有效的建議而需要更多高品質實證醫學論文以為佐證。




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