Ditillo Michael F, Dziura James D, Rabinovici Reuven
Department of Surgery, Yale University School of Medicine, New Haven, CT 06520, USA.
Ann Surg. 2006 Nov;244(5):656-60. doi: 10.1097/01.sla.0000231726.53487.dd.
To examine whether delayed surgical intervention in adult patients with acute appendicitis is safe by correlating the interval from onset of symptoms to operation (total interval) with the degree of pathology and incidence of postoperative complications.
Prompt appendectomy has long been the standard of care for acute appendicitis because of the risk of progression to advanced pathology. This time-honored practice has been recently challenged by studies in pediatric patients, which suggested that acute appendicitis can be managed in an elective manner once antibiotic therapy is initiated. No such data are available in adult patients with acute appendicitis.
A retrospective review of 1081 patients who underwent an appendectomy for acute appendicitis between 1998 and 2004 was conducted. The following parameters were monitored and correlated: demographics, time from onset of symptoms to arrival at the emergency room (patient interval) and from arrival to the emergency room to the operating room (hospital interval), physical, computed tomography (CT scan) and pathologic findings, complications, length of stay, and length of antibiotic treatment. Pathologic state was graded 1 (G1) for acute appendicitis, 2 (G2) for gangrenous acute appendicitis, 3 (G3) for perforation or phlegmon, and 4 (G4) for a periappendicular abscess.
The risk of advanced pathology, defined as a higher pathology grade, increased with the total interval. When this interval was <12 hours, the risk of developing G1, G2, G3, and G4, was 94%, 0%, 3%, and 3%, respectively. These values changed to 60%, 7%, 27%, and 6%, respectively, when the total interval was 48 to 71 hours and to 54%, 7%, 26%, and 13% for longer than 71 hours. The odds for progressive pathology was 13 times higher for the total interval >71 hours group compared with total interval<12 hours (95% confidence interval = 4.7-37.1). Although both prolonged patient and hospital intervals were associated with advanced pathology, prehospital delays were more profoundly related to worsening pathology compared with in-hospital delays (P < 0.001). Advanced pathology was associated with tenderness to palpation beyond the right lower quadrant (P < 0.001), guarding (P < 0.001), rebound (P < 0.001), and CT scan findings of peritoneal fluid (P = 0.01), fecalith (P = 0.01), dilation of the appendix (P < 0.001), and perforation (P < 0.001). Increased length of hospital stay (P < 0.001) and antibiotic treatment (P < 0.001) as well as postoperative complications (P < 0.001) also correlated with progressive pathology.
In adult patients with acute appendicitis, the risk of developing advanced pathology and postoperative complications increases with time; therefore, delayed appendectomy is unsafe. As delays in seeking medical help are difficult to control, prompt appendectomy is mandatory. Because these conclusions are derived from retrospective data, a prospective study is required to confirm their validity.
通过将症状出现至手术的间隔时间（总间隔时间）与病理程度及术后并发症发生率相关联，探讨成年急性阑尾炎患者延迟手术干预是否安全。
由于存在进展为严重病理状态的风险，及时行阑尾切除术长期以来一直是急性阑尾炎的标准治疗方法。这种由来已久的做法最近受到了儿科患者研究的挑战，这些研究表明，一旦开始抗生素治疗，急性阑尾炎可以择期处理。成年急性阑尾炎患者尚无此类数据。
对1998年至2004年间因急性阑尾炎接受阑尾切除术的1081例患者进行回顾性研究。监测并关联以下参数：人口统计学资料、症状出现至抵达急诊室的时间（患者间隔时间）以及从抵达急诊室至手术室的时间（医院间隔时间）、体格检查、计算机断层扫描（CT扫描）及病理结果、并发症、住院时间及抗生素治疗时间。病理状态分为：急性阑尾炎为1级（G1），坏疽性急性阑尾炎为2级（G2），穿孔或蜂窝织炎为3级（G3），阑尾周围脓肿为4级（G4）。
病理分级越高，即进展为严重病理状态的风险随总间隔时间增加。当该间隔时间<12小时时，发生G1、G2、G3和G4的风险分别为94%、0%、3%和3%。当总间隔时间为48至71小时时，这些值分别变为60%、7%、27%和6%；间隔时间超过71小时时，分别变为54%、7%、26%和13%。总间隔时间>71小时组进展为严重病理状态的几率是总间隔时间<12小时组的13倍（95%置信区间=4.7-37.1）。虽然患者间隔时间和医院间隔时间延长均与严重病理状态相关，但与住院延迟相比，院前延迟与病理恶化的相关性更强（P<0.001）。严重病理状态与右下腹以外触痛（P<0.001）、肌紧张（P<0.001）、反跳痛（P<0.001）以及CT扫描显示的腹腔积液（P=0.01）、粪石（P=0.01）、阑尾扩张（P<0.001）和穿孔（P<0.001）相关。住院时间延长（P<0.001）、抗生素治疗时间延长（P<0.001）以及术后并发症（P<0.001）也与进展为严重病理状态相关。
成年急性阑尾炎患者发生严重病理状态及术后并发症的风险随时间增加；因此，延迟阑尾切除术不安全。由于寻求医疗帮助的延迟难以控制，必须及时行阑尾切除术。鉴于这些结论来自回顾性数据，需要进行前瞻性研究以证实其有效性。
