膽囊微創手術生活品質之分析

研究目的膽囊切除為目前很普遍的手術分為三種：開腹式膽囊切除術(Open Cholecystectomy, OC)、腹腔鏡膽囊切除術(Laparoscopic Cholecystectomy, LC)及機器人系統輔助膽囊切除術(Robotic-assist Cholecystectomy, RAC)。國外有研究比較腹腔鏡與多孔機器手臂醫療處理，且結果顯示機器人手臂會有較好的生活品質，但國內鮮少有研究針對腹腔鏡與單孔機器手臂兩者長期的術後療效，因此本研究透過長期追蹤，探討膽囊切除病人術後之改善趨勢，評估病人在GIQLI及SF-36各構面之變化及影響健康相關生活品質(HRQoL)之重要因素。研究方法本研究為前瞻及縱貫性研究，以問卷方式進行資料蒐集，於2015年11月至2017年3月間，選取台灣南部某教學醫院接受膽囊切除之患者做為研究樣本。分別使用GIQLI及SF-36健康生活品質問卷作為測量，追蹤術前、術後3個月、術後6個月、術後1 年及術後2年，共為五個時間點。本研究利用廣義估計方程式(GEE)進行趨勢分析，探討不同時間點膽囊切除手術後健康相關生活品質。研究結果本研究條件共有601位微創膽囊切除術個案，機器人輔助方式有75位(12.5%)，腹腔鏡有526位(87.5%)，以女性占大多數(56.6%)，平均年齡層為54.4歲，平均住院天數為4.13天。研究結果顯示GIQLI：RC及LC病人在術後三個月、六個月有明顯改善趨勢，但在一年及兩年就沒有明顯的改變；SF-36問卷：RC及LC病人在術後各構面皆有明顯改善，尤其是在活力健康構面有明顯的改善，表示術後病人疼痛減少活動力較好，但生理健康層面與心理健康層面沒有太大的改變。以GEE分析重要影響因子，發現術前功能分數有顯著(P<0.05)，表示術後的恢復狀況越好，有膽結石的患者，若即早治療，預後效果較好。結論與建議使用不同微創手術不管對病人或是手術特性都是好的，尤其可以縮短住院天數、減少疼痛，術後恢復快，更能減少醫療資源的耗用。整體生活品質在術後三、六個月有明顯改善，但六個月後到兩年改變的幅度不大，病人做完手術後皆恢復成健康狀態。本研究收集RC病人並不多，未來可以添增個案數，亦能再深入探討醫療資源耗用及醫療成效上的變化，可提供醫院決策者評估未來購買重大儀器之參考。

關鍵字

腹腔鏡膽囊切除手術；機器手臂膽囊切除手術； GIQLI ； SF-36 ； HRQoL

並列摘要

Purpose Cholecystectomy is a common procedure for the treatment of gallstones, including three types: open cholecystectomy (OC), laparoscopic cholecystectomy (LC) and robotic-assisted cholecystectomy (RAC). The study purposed to evaluate trends of the patients' health-related quality of life (HRQoL) and to explore the major predictors of HRQoL during the study period. Methods In this prospective and longitudinal study, we conducted questionnaire survey as the research method. From November 2015 to March 2017, patients receiving cholecystectomy in a teaching hospital in southern Taiwan were recruited as subjects of this study. We explored the degree of improvement in different dimensions of assessment tools such as Gastrointestinal Quality-of-Life Index (GIQLI) and Global Taiwan SF-36 Questionnaires. All participants completed both questionnaires at the time points of immediately before surgeries, 3rd month, 6th month, 1st year, and 2nd year postoperatively. We used Generalized Estimation Equation (GEE) and STATA statistical software to analyze the data. Results A total of 601 cases of minimally invasive cholecystectomy were found in this study. There were 75 (12.5%) of the RC and 526 (87.5%) of LC. It showed that 56.6% of the population was female, the average age was 54.4 years, and the average length of stay was 4.13 days. The results also showed that, in GIQLI, patients receiving RC and LC had significant improvement at the 3rd month and the 6th month after the surgery, but there was no significant difference at the first year and the 2nd year after the surgery. In SF-36, patients receiving RC and LC had significant improvement in all facets, especially in the facet of dynamic health, indicating that the patients had less postoperative pain and more ambulatory after the surgery. However there is no significant difference in the facets of physical and mental health (P <0.05). The GEE model found that the prognosis is better in patients with gallstones if they receive early treatment. Conclusions Implementing different types of minimally invasive surgeries is beneficial, regardless of the patient or surgical characteristics. In particular, it would have reduced length of hospital stay, reduced pain, more rapid recovery, and reduced medical resources utilization. The HRQoL at the 3rd to 6th month after surgery improved significantly, but there is no significant difference during the 6th month to the 2nd year after the surgery. The patients had full recovery of health status after the surgery. The restrict of the study is that there are not enough RC patients collected in this study. The number of participants can be increased in the future, and the changes in medical resource consumption and medical performance can be further explored. It can provide reference for hospital decision makers to evaluate future purchases of major instruments.