Kelly Kristin N, Fleming Fergal J, Aquina Christopher T, Probst Christian P, Noyes Katia, Pegoli Walter, Monson John R T
*Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY; and †Department of Pediatric Surgery, University of Rochester Medical Center, Rochester, NY.
Ann Surg. 2014 Sep;260(3):466-71; discussion 472-3. doi: 10.1097/SLA.0000000000000874.
This study examines patient and operative factors associated with organ space infection (OSI) in children after appendectomy, specifically focusing on the role of operative approach.
Although controversy exists regarding the risk of increased postoperative intra-abdominal infections after laparoscopic appendectomy, this approach has been largely adopted in the treatment of pediatric acute appendicitis.
Children aged 2 to 18 years undergoing open or laparoscopic appendectomy for acute appendicitis were selected from the 2012 American College of Surgeons Pediatric National Surgical Quality Improvement Program database. Univariate analysis compared patient and operative characteristics with 30-day OSI and incisional complication rates. Factors with a P value of less than 0.1 and clinical importance were included in the multivariable logistic regression models. A P value less than 0.05 was considered significant.
For 5097 children undergoing appendectomy, 4514 surgical procedures (88.6%) were performed laparoscopically. OSI occurred in 155 children (3%), with half of these infections developing postdischarge. Significant predictors for OSI included complicated appendicitis, preoperative sepsis, wound class III/IV, and longer operative time. Although 5.2% of patients undergoing open surgery developed OSI (odds ratio = 1.82; 95% confidence interval, 1.21-2.76; P = 0.004), operative approach was not associated with increased relative odds of OSI (odds ratio = 0.99; confidence interval, 0.64-1.55; P = 0.970) after adjustment for other risk factors. Overall, the model had excellent predictive ability (c-statistic = 0.837).
This model suggests that disease severity, not operative approach, as previously suggested, drives OSI development in children. Although 88% of appendectomies in this population were performed laparoscopically, these findings support utilization of the surgeon's preferred surgical technique and may help guide postoperative counsel in high-risk children.
本研究探讨阑尾切除术后儿童器官间隙感染（OSI）相关的患者及手术因素，特别关注手术方式的作用。
尽管对于腹腔镜阑尾切除术后腹腔内感染风险增加存在争议，但这种手术方式已在小儿急性阑尾炎的治疗中广泛应用。
从2012年美国外科医师学会儿科国家外科质量改进计划数据库中选取2至18岁因急性阑尾炎接受开腹或腹腔镜阑尾切除术的儿童。单因素分析比较患者及手术特征与30天OSI及切口并发症发生率。P值小于0.1且具有临床重要性的因素纳入多变量逻辑回归模型。P值小于0.05被认为具有统计学意义。
在5097例接受阑尾切除术的儿童中，4514例手术（88.6%）为腹腔镜手术。155例儿童发生OSI（3%），其中一半感染在出院后出现。OSI的显著预测因素包括复杂性阑尾炎、术前脓毒症、伤口分类III/IV级以及手术时间较长。尽管5.2%的开腹手术患者发生OSI（比值比=1.82；95%置信区间，1.21 - 2.76；P = 0.004），但在调整其他危险因素后，手术方式与OSI相对比值增加无关（比值比=0.99；置信区间，0.64 - 1.55；P = 0.970）。总体而言，该模型具有出色的预测能力（c统计量=0.837）。
该模型表明，如之前所认为的那样，并非手术方式，而是疾病严重程度驱动儿童OSI的发生。尽管该人群中88%的阑尾切除术为腹腔镜手术，但这些发现支持采用外科医生首选的手术技术，并可能有助于指导高危儿童的术后咨询。
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