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1 Evidence-Based Medicine 觀摩會蔡坤璋 2008/07/15

2 Clinical scenario 28 歲的女性病患, 因 Acute appendicitis 接受 Appendectomy, 一週後返回門診拆線, 醫師在拆掉傷口上的 Nylon 3-0 縫線後病患看著傷口, 縐著眉頭說 : 傷口好醜喔, 醫生, 為什麼不能像我姊姊上次開脂肪瘤一樣, 用不必拆線的那種針? 醫生回答 : 因為闌尾炎手術是屬於污染性傷口, 用那種皮下可吸收線會增加傷口污染的機會, 只能用這種不可吸收線, 我們的老師都是這樣教, 書上也是這樣寫的. 病患 : 是這樣嗎??? 滿臉疑惑又有點不爽地離開診間.

3 Clinical scenario 病患離開後, 這位醫師心裡想 : 我剛才對病患說的話, 是真的嗎? 有什麼證據?

4 實證醫學五步驟步驟一 : 形成出一個可以回答的臨床問題步驟二 : 搜尋最佳證據步驟三 : 嚴格評讀證據步驟四 : 將臨床專業與病人價值觀相結合步驟五 : 評估執行效果及效用

5 問題用 subcuticular absorbable suture 的縫合方式會增加 Appendectomy 傷口感染的機會嗎?

6 PICO Patients/Population: patients undergoing appendectomy. Rupture or not, young or elderly. Intervention: subcuticular absorbable suture. Comparison: Non-absorbable suture. Outcome: wound infection rate.

7 實證醫學五步驟步驟一 : 形成出一個可以回答的臨床問題步驟二 : 搜尋最佳證據步驟三 : 嚴格評讀證據步驟四 : 將臨床專業與病人價值觀相結合步驟五 : 評估執行效果及效用

8 Medical Database Prefiltered ( secondary) database: ACPJC, Cochorane Library, clinical evidence, UpToDate 等等 Unfliltered (primary) database: Ovid Medline 或 Pubmed 等等搜尋介面

9 Searching Keywords: appendectomy, appendicectomy, subcuticular, suture, wound infection

14 Subcuticular suturing after appendicectomy Lancet, 1977 The results of using interrupted nylon skin suture or subcuticular polyglycolic acid sutures after appendicectomy were compared in a prospective controlled trial in 127 patients. Wound infections were significantly more common when subcuticular skin closure was used.

15 Skin closure during appendicectomy: a controlled trial of subcuticular and interrupted transdermal suture techniques Department of surgery, University of Benin Teaching Hospital, Nigeria J R Coll Surg Edinb, 1990

16 Over an 18-month period, 100 consecutive patients who underwent appendicectomy were randomly allocated to have skin closure either by interrupted transdermal or subcuticular techniques. Ninety cases were performed as emergencies within 6 h of admission. Only cases of acute uncomplicated appendicitis were included. Complications arising from the method of wound closure used were assessed. It was noted that the mean wound closure time and cost of material were significantly reduced in the group using the subcuticular technique (P less than 0.025). The wound infection rate was the same in both groups, but when all wound complications were taken together, there was a significantly higher incidence with the interrupted method. The results from this trial indicate that subcuticular wound closure during appendicectomy-- an operation with a high risk of infection--is not associated with an increase in the incidence of wound complications and offers a cost and time-saving advantage.

17 Subcuticular skin closure as a standard approach to emergency appendectomy in children: prospective clinical trail Department of pediatric surgery, Assaf Harofeh medical center, Israel World Journal of Surgery, 1996

18 We evaluated the morbidity associated with primary closure by interrupted subcuticular absorbable sutures following emergency appendectomy. In a prospective clinical trial over a 12-month period, 216 children who underwent emergency appendectomy had skin closure using subcuticular interrupted absorbable polyglactin 4-0 sutures. Preoperative prophylactic antibiotics consisting of metronidazole alone or in combination with gentamicin were used in patients with suspected phlegmonous appendicitis; a combination of metronidazole, gentamicin, and ampicillin was used when perforation of the appendix was suspected. Postoperatively, in patients with phlegmonous appendicitis metronidazole was given for 24 hours, whereas in those with peritonitis the triple antibiotics were continued for 7 to 10 days. All patients were assessed for complications resulting from the technique of wound closure. No intraabdominal abscesses or serious complications were recorded. The overall incidence of wound infection was 1.8%. Among children with a perforated appendix the rate of superficial wound infection was 5.7%. There was no difference in the rate of wound infection between patients who received metronidazole alone or metronidazole plus gentamicin preoperatively. All the patients and their families were satisfied with the cosmetic results and with the fact that removal of skin sutures was unnecessary. We conclude that the use of prophylactic antibiotics permits standard skin closure by interrupted absorbable subcuticular suture.

19 實證醫學五步驟步驟一 : 形成出一個可以回答的臨床問題步驟二 : 搜尋最佳證據步驟三 : 嚴格評讀證據步驟四 : 將臨床專業與病人價值觀相結合步驟五 : 評估執行效果及效用

20 實證醫學五步驟步驟一 : 形成出一個可以回答的臨床問題步驟二 : 搜尋最佳證據步驟三 : 嚴格評讀證據步驟四 : 將臨床專業與病人價值觀相結合步驟五 : 評估執行效果及效用

21 Evidence Patient Doctor

22 Conclusion In non-perforated appendicitis, nonimmuno-compromised patients, treated with appropriate antibiotics, skin closure with subcuticular absorbable suture is feasible.

23 實證醫學五步驟步驟一 : 形成出一個可以回答的臨床問題步驟二 : 搜尋最佳證據步驟三 : 嚴格評讀證據步驟四 : 將臨床專業與病人價值觀相結合步驟五 : 評估執行效果及效用

24 Thank You for Your Attention!

211 better than those in the control group, with significant difference between two groups (P < 0.05). The ocular hypertension of patients in the cont

211 better than those in the control group, with significant difference between two groups (P < 0.05). The ocular hypertension of patients in the cont 210 毛果芸香碱联合拉坦前列素治疗原发性急性闭角型青光眼的疗效观察符元党 1, 郑振优 2, 林再雄 2, 周吉良 1. 昌江黎族自治县中西医结合医院, 海南昌江 572700 2. 海南医学院附属医院眼科, 海南海口 570100 1 摘要 : 目的探讨