St Peter Shawn D, Sharp Susan W, Holcomb George W, Ostlie Daniel J
Department of Surgery, The Children's Mercy Hospital, Kansas City, MO 64108, USA.
J Pediatr Surg. 2008 Dec;43(12):2242-5. doi: 10.1016/j.jpedsurg.2008.08.051.
Appendicitis is the most common urgent condition in general surgery, and yet there is no evidence-based definition for perforation. Therefore, all retrospective data published on perforated appendicitis are unreliable because of an ill-defined denominator. For approximately 2 years beginning in April 2005, we performed a prospective randomized trial investigating 2 different antibiotic regimens for perforated appendicitis. During this study, we strictly defined perforation as a hole in the appendix or a fecalith in the abdomen. Before this prospective study, perforation was staff surgeon opinion. We investigated the abscess rates in both the perforated and nonperforated appendicitis populations before and during the study to determine if our definition was safe and that there was not an increased risk of abscess formation in patients treated as nonperforated.
Records of all patients undergoing laparoscopic appendectomy for appendicitis during the immediate 2 years before using the definition were compared to those treated in the 2 years after the definition was implemented. Interval and incidental appendectomies were ruled out. The postoperative abscess rate (when perforation was not defined) was compared to the abscess rate of those for whom perforation was strictly defined.
There were 292 patients treated for acute nonperforated appendicitis in the 2 years before the definition and 388 patients after the definition. There were 131 patients treated for perforated appendicitis before the definition and 161 after the definition was implemented. The abscess rate in those with perforated appendicitis increased from 14% to 18% after the definition was used. However, after the definition began to be used, the abscess rate for those patients treated as nonperforated decreased from 1.7% to 0.8%.
Defining perforation as a hole in the appendix or a fecalith in the abdomen is effective in identifying the patients at risk for postoperative abscess formation. Application of these criteria would allow substantial reduction in therapy for patients with purulent or gangrenous appendicitis who do not possess the same abscess risk. These data outline the first evidence-based definition of perforation.
阑尾炎是普通外科最常见的急症，然而对于穿孔却没有基于证据的定义。因此，由于分母定义不明确，所有已发表的关于穿孔性阑尾炎的回顾性数据都是不可靠的。从2005年4月开始的大约两年时间里，我们进行了一项前瞻性随机试验，研究两种不同的抗生素方案用于治疗穿孔性阑尾炎。在这项研究中，我们严格将穿孔定义为阑尾上的一个洞或腹腔内的粪石。在这项前瞻性研究之前，穿孔是由外科医生判断的。我们调查了研究前和研究期间穿孔性阑尾炎和非穿孔性阑尾炎患者的脓肿发生率，以确定我们的定义是否安全，以及被当作非穿孔性治疗的患者发生脓肿形成的风险是否没有增加。
将使用该定义之前紧接着的两年内所有因阑尾炎接受腹腔镜阑尾切除术的患者记录，与实施该定义后的两年内接受治疗的患者记录进行比较。排除间隔期和偶然的阑尾切除术。将术后脓肿发生率（穿孔未定义时）与穿孔被严格定义的患者的脓肿发生率进行比较。
在定义之前的两年里，有292例患者接受了急性非穿孔性阑尾炎的治疗，定义之后有388例。在定义之前有131例患者接受了穿孔性阑尾炎的治疗，定义实施后有161例。使用该定义后，穿孔性阑尾炎患者的脓肿发生率从14%上升到了18%。然而，在开始使用该定义后，被当作非穿孔性治疗的患者的脓肿发生率从1.7%下降到了0.8%。
将穿孔定义为阑尾上的一个洞或腹腔内的粪石，对于识别有术后脓肿形成风险的患者是有效的。应用这些标准将能大幅减少对那些没有相同脓肿风险的化脓性或坏疽性阑尾炎患者的治疗。这些数据概述了首个基于证据的穿孔定义。
