Tan E C T H, Severijnen R S V M, Rosman C, van der Wilt G J, van Goor H
Department of General Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, P.O. Box 9101, 690, 6500, 6500 HB, The Netherlands.
World J Surg. 2006 Apr;30(4):512-8; discussion 519. doi: 10.1007/s00268-005-0350-0.
Considerable variability exists in the surgical approach to acute appendicitis in children, affecting both quality and costs of care. A national survey provides insight into daily surgical practice and enables comparison of practice with the available evidence.
A national survey was conducted in all 121 Dutch hospitals asking detailed information concerning diagnosis and treatment of children suspected of acute appendicitis. An evidence-based practice (EBP) score was developed on the basis of a critical appraisal of the literature, allowing for classification of reported practices with regard to the level of evidence and identification of hospitals working in accordance with the best available evidence.
The overall response rate was 93%. For the diagnosis of acute appendicitis, respondents relied predominantly on patient history (29%) and clinical examination (31%), followed by laboratory results (22%). Only 20% of the departments routinely measured total white blood cell count (WBC), C-reactive protein (CRP) and leukocyte differential count (proportion of polymorphonuclear cells), being part of the triad that provides diagnostic evidence. Although strong evidence exists in favour of routine prophylaxis for suspected appendicitis, only two thirds of surgical departments reported this as part of their routine practice. For a number of issues, reasonably consistent evidence is available (e.g. primarily versus delayed closure, drainage versus lavage, routine peritoneal culturing). Thirty-eight percent of the departments routinely cultured abdominal fluid despite various reports that it provides no therapeutic advantage. Not more than 22% of the departments closed the skin in perforated appendicitis in spite of clear supportive evidence. Considerable variation exists in cleaning the abdomen in perforated appendicitis, despite evidence favouring lavage. Comparing departments in terms of compliance with available evidence revealed that most paediatric surgery departments worked according to evidence-based medicine.
Available evidence on diagnosis and treatment of acute appendicitis in children is only partly applied in a small proportion of hospitals in the Netherlands. It is recommended that national guidelines be published, which could decrease health care costs and increase more uniform policy, improve quality of care for this group of patients and improve training of residents in general surgery in the Netherlands.
儿童急性阑尾炎的手术方法存在很大差异，这影响了医疗质量和成本。一项全国性调查有助于深入了解日常手术实践，并能将实践与现有证据进行比较。
对荷兰所有121家医院进行了一项全国性调查，询问有关疑似急性阑尾炎儿童的诊断和治疗的详细信息。在对文献进行批判性评估的基础上制定了基于证据的实践（EBP）评分，从而能够根据证据水平对报告的实践进行分类，并识别出按照最佳现有证据开展工作的医院。
总体回复率为93%。对于急性阑尾炎的诊断，受访者主要依赖患者病史（29%）和临床检查（31%），其次是实验室检查结果（22%）。只有20%的科室常规检测全血细胞计数（WBC）、C反应蛋白（CRP）和白细胞分类计数（多形核细胞比例），这三项是提供诊断依据的三联检查项目。尽管有强有力的证据支持对疑似阑尾炎进行常规预防，但只有三分之二的外科科室报告将其作为常规操作的一部分。对于一些问题，有合理一致的证据（例如一期缝合与延迟缝合、引流与灌洗、常规腹腔培养）。尽管有各种报告表明腹腔积液培养并无治疗优势，但仍有38%的科室常规进行腹腔积液培养。尽管有明确的支持证据，但穿孔性阑尾炎患者中，只有不超过22%的科室缝合皮肤。穿孔性阑尾炎的腹腔清理存在很大差异，尽管有证据支持灌洗。根据对现有证据的依从性对各科室进行比较发现，大多数小儿外科科室是按照循证医学开展工作的。
关于儿童急性阑尾炎诊断和治疗的现有证据在荷兰只有一小部分医院得到了部分应用。建议发布国家指南，这可以降低医疗成本，使政策更加统一，提高这类患者的医疗质量，并改善荷兰普通外科住院医师的培训。
