Bickell Nina A, Aufses Arthur H, Rojas Mary, Bodian Carol
Department of Health Policy, Mount Sinai School of Medicine, New York, NY 10029, USA.
J Am Coll Surg. 2006 Mar;202(3):401-6. doi: 10.1016/j.jamcollsurg.2005.11.016. Epub 2006 Jan 18.
Increasing time between symptom onset and treatment may be a risk factor for a ruptured appendix, but little is known about how the risk changes with passing time. This study aimed to determine the changes in risk of rupture in patients with appendicitis with increasing time from symptom onset to treatment to help guide the swiftness of surgical intervention.
We conducted a retrospective chart review of physician office, clinic, emergency room, and inpatient records of a random sample of 219 of 731 appendicitis patients operated on between 1996 and 1998 at 2 inner-city tertiary referral and municipal hospitals. Conditional risks of rupture were calculated using life table methods. Logistic regression was used to assess factors associated with rupture, and linear regression was used to assess factors affecting time from first examination to treatment.
Rupture risk was < or = 2% in patients with less than 36 hours of untreated symptoms. For patients with untreated symptoms beyond 36 hours, the risk of rupture rose to and remained steady at 5% for each ensuing 12-hour period. Rupture was greater in patients with 36 hours or more of untreated symptoms (estimated relative risk [RR]=6.6; 95% CI: 1.9 to 8.3), age 65 years and older (RR=4.2; 95% CI: 1.9 to 6.1), fever > 38.9 degrees C (RR=3.6; 95% CI: 1.2 to 5.7), and tachycardia (heart rate > or = 100 beats/minute; RR=3.4; 95% CI: 1.8 to 5.4). Time between first physician examination and treatment was shorter among patients presenting to the emergency department (median, 7.1 hours versus 10.9 hours; p<0.0001), and those for whom a physician's leading diagnostic impression was appendicitis (6.3 hours versus 11.3 hours; p<0.0001). Patients sent for CT scan experienced longer times to operation (18.6 hours versus 7.1 hours; p<0.0001).
Risk of rupture in ensuing 12-hour periods rises to 5% after 36 hours of untreated symptoms. Physicians should be cautious about delaying surgery beyond 36 hours from symptom onset in patients with appendicitis.
症状出现至治疗之间的时间延长可能是阑尾破裂的一个危险因素，但对于该风险如何随时间变化却知之甚少。本研究旨在确定阑尾炎患者从症状出现至治疗的时间增加时破裂风险的变化，以帮助指导手术干预的及时性。
我们对1996年至1998年间在两家市中心三级转诊医院和市立医院接受手术的731例阑尾炎患者中的219例进行随机抽样，对其医生办公室、诊所、急诊室和住院记录进行回顾性图表审查。使用生命表方法计算破裂的条件风险。采用逻辑回归评估与破裂相关的因素，采用线性回归评估影响从首次检查到治疗时间的因素。
症状未治疗时间少于36小时的患者破裂风险≤2%。对于症状未治疗超过36小时的患者，每随后12小时破裂风险升至5%并保持稳定。症状未治疗36小时或更长时间的患者破裂风险更高（估计相对风险[RR]=6.6；95%可信区间：1.9至8.3），65岁及以上患者（RR=4.2；95%可信区间：1.9至6.1），发热>38.9℃（RR=3.6；95%可信区间：1.2至5.7），以及心动过速（心率≥100次/分钟；RR=3.4；95%可信区间：1.8至5.4）。到急诊科就诊的患者从首次医生检查到治疗的时间较短（中位数，7.1小时对10.9小时；p<0.0001），医生主要诊断印象为阑尾炎的患者时间较短（6.3小时对11.3小时；p<0.0001）。接受CT扫描的患者手术时间较长（18.6小时对7.1小时；p<0.0001）。
症状未治疗36小时后，随后12小时内的破裂风险升至5%。对于阑尾炎患者，医生应谨慎避免在症状出现后36小时以上延迟手术。
