Department of Surgery, University of California, San Diego, CA.
Department of Surgery, University of California, San Diego, CA.
J Am Coll Surg. 2014 May;218(5):905-13. doi: 10.1016/j.jamcollsurg.2014.01.003. Epub 2014 Jan 18.
Emerging literature has supported the safety of nonoperative management of uncomplicated appendicitis.
Patients with emergent, uncomplicated appendicitis were identified by appropriate ICD-9 diagnosis codes in the California Office of Statewide Health Planning and Development database from 1997 to 2008. Rates of treatment failure, recurrence, and perforation after nonsurgical management were calculated. Factors associated with treatment failure, recurrence, and perforation were identified using multivariable logistic regression. Mortality, length of stay, and total charges were compared between treatment cohorts using matched propensity score analysis.
Of 231,678 patients with uncomplicated appendicitis, the majority (98.5%) were managed operatively. Of the 3,236 nonsurgically managed patients who survived to discharge without an interval appendectomy, 5.9% and 4.4% experienced treatment failure or recurrence, respectively, during a median follow-up of more than 7 years. There were no mortalities associated with treatment failure or recurrence. The risk of perforation after discharge was approximately 3%. Using multivariable analysis, race and age were significantly associated with the odds of treatment failure. Sex, age, and hospital teaching status were significantly associated with the odds of recurrence. Age and hospital teaching status were significantly associated with the odds of perforation. Matched propensity score analysis indicated that after risk adjustment, mortality rates (0.1% vs 0.3%; p = 0.65) and total charges ($23,243 vs $24,793; p = 0.70) were not statistically different between operative and nonoperative patients; however, length of stay was significantly longer in the nonoperative treatment group (2.1 days vs 3.2 days; p < 0.001).
This study suggests that nonoperative management of uncomplicated appendicitis can be safe and prompts additional investigations. Comparative effectiveness research using prospective randomized studies can be particularly useful.
新兴文献支持对单纯性阑尾炎采用非手术治疗。
通过加州全州卫生规划与发展数据库中的适当 ICD-9 诊断代码，从 1997 年至 2008 年确定患有急诊单纯性阑尾炎的患者。计算非手术治疗后治疗失败、复发和穿孔的发生率。使用多变量逻辑回归确定与治疗失败、复发和穿孔相关的因素。使用匹配倾向评分分析比较治疗组之间的死亡率、住院时间和总费用。
在 231678 例单纯性阑尾炎患者中，大多数（98.5%）接受了手术治疗。在 3236 例幸存至出院且无间隔阑尾切除术的非手术治疗患者中，5.9%和 4.4%分别在超过 7 年的中位随访期间经历了治疗失败或复发。治疗失败或复发无死亡病例。出院后穿孔的风险约为 3%。使用多变量分析，种族和年龄与治疗失败的几率显著相关。性别、年龄和医院教学地位与复发几率显著相关。年龄和医院教学地位与穿孔几率显著相关。匹配倾向评分分析表明，在风险调整后，手术和非手术患者的死亡率（0.1% vs 0.3%；p = 0.65）和总费用（$23243 vs $24793；p = 0.70）没有统计学差异；然而，非手术治疗组的住院时间明显更长（2.1 天 vs 3.2 天；p < 0.001）。
本研究表明，单纯性阑尾炎的非手术治疗可能是安全的，并提示需要进一步研究。使用前瞻性随机研究的比较效果研究可能特别有用。
