Department of Surgery, The Children's Mercy Hospital, Kansas City, MO 64108, USA.
J Pediatr Surg. 2010 Jan;45(1):231-4; discussion 234-4. doi: 10.1016/j.jpedsurg.2009.10.040.
Some surgeons use nonoperative management with or without interval appendectomy for patients who present with perforated appendicitis. These strategies depend on accurately delineating perforation by computed tomography (CT). Since 2005, our institution has used an evidence-based definition for perforation as a hole in the appendix or fecalith in the abdomen. This has been shown to clearly separate those with a high risk of abscess from those without. To quantify the ability of CT to identify which patients would meet these criteria for perforation, we tested 6 surgeons and 2 radiologists who evaluated blinded CT scans.
A junior and senior surgical residents, 2 staff interventional radiologists, and 4 attending pediatric surgeons with 3 to 30 years of experience reviewed 200 CT scans of pediatric patients who had undergone a laparoscopic appendectomy. All CT scans were reviewed electronically, and the reviewers were blinded to the results, outcome, and intraoperative findings. None of the patients had a well-formed abscess on CT. The reviewers were asked to decide only on perforated or nonperforated appendicitis according to our intraoperative definition. Clinical admission data were reviewed and compared between groups.
In total, the reviewers were correct 72% of the time with an overall sensitivity of 62% and a specificity of 81%. The overall positive predictive value was 67%, and the negative predictive value was 77%.
This study shows that in the absence of a well-formed abscess, the triage of patient care based on a preoperative diagnosis of perforation from CT may be imprudent and subject a portion of the population to an unnecessarily prolonged course of care.
一些外科医生对表现出穿孔性阑尾炎的患者采用非手术治疗（伴或不伴间隔阑尾切除术）。这些策略取决于通过计算机断层扫描（CT）准确划定穿孔的范围。自 2005 年以来，我们机构一直使用穿孔的循证定义，即阑尾有孔或腹部有粪石。这一方法可以明确区分高危脓肿和非高危脓肿患者。为了量化 CT 识别符合穿孔标准的患者的能力，我们对 6 名外科医生和 2 名放射科医生进行了测试，他们评估了盲法 CT 扫描。
一名初级和一名高级外科住院医师、2 名介入放射科工作人员和 4 名具有 3 至 30 年经验的主治儿科外科医生对 200 名接受腹腔镜阑尾切除术的儿科患者的 CT 扫描进行了评估。所有 CT 扫描均通过电子方式进行评估，评估人员对结果、结果和术中发现均不知情。所有患者的 CT 均未见形成良好的脓肿。评估人员仅根据我们的术中定义，决定是穿孔性还是非穿孔性阑尾炎。查阅了临床入院数据并在组间进行了比较。
评估者的正确率为 72%，总敏感度为 62%，特异性为 81%。总的阳性预测值为 67%，阴性预测值为 77%。
本研究表明，在没有形成良好脓肿的情况下，根据 CT 术前诊断穿孔来分诊患者的治疗可能是不明智的，这会导致一部分患者接受不必要的延长治疗。
