Popa Dorin, Soltes Marek, Uranues Selman, Fingerhut Abe
1 University of Medicine and Pharmacy "Carol Davila" Bucharest, University Emergency Hospital , Bucharest, Romania .
2 I. Chirurgicka Klinika, University of Pavol Jozef Safarik , Kosice, Slovak Republic.
J Laparoendosc Adv Surg Tech A. 2015 Nov;25(11):897-902. doi: 10.1089/lap.2014.0624.
Laparoscopic appendectomy (LA) has proven to be a feasible alternative to open appendectomy (OA). However, as some of the purported advantages of LA (versus OA) are marginal, evidence is accumulating that appendectomy may not be necessary for uncomplicated appendicitis and there is concern about using laparoscopy for all patients with suspected acute appendicitis. In spite of widespread popularity and use, the literature reporting the indications is sparse and sometimes misleading (i.e., containing distorted deductions or conclusions, also called "spin"). This study aimed to determine subsets of patients for whom LA may present real advantages over OA and to analyze the validity of specific indications for LA (instead of OA).
A systematic review and critical analysis of the literature were conducted.
We analyzed 90 retrospective reviews, prospective studies, meta-analyses, and cohort and prospective randomized studies, presenting a total of approximately 390,000 patients, concerning potentially specific advantages of LA in the elderly, the obese, during pregnancy, and complicated appendicitis, including diffuse peritonitis and ectopic appendices. Overall, LA was associated with (1) lower overall complication rates (and notably less decompensated comorbidities), mortality, and costs, as well as shorter duration of hospital stay, in the elderly, (2) decreased morbidity (notably parietal) in the obese, and (3) potential (diagnostic) advantages in pregnancy (even though LA is associated with a higher rate of fetal loss than in OA). In complicated or ectopic appendicitis, LA is feasible and safe and, if performed without conversion, should lead to less short- and long-term parietal morbidity. However, published data are very heterogeneous, there are few sound controlled trials, and conclusions found in the literature are often based on misleading deductions or a very low level of evidence.
LA is a safe and effective method to treat acute appendicitis in specific settings such as the elderly and the obese, as well as in ectopic appendices, with potentially specific parietal advantages in these subsets of patients. Further randomized studies and robust meta-analyses are necessary before recommending LA for complicated appendicitis and peritonitis, as well as in pregnancy.
腹腔镜阑尾切除术（LA）已被证明是开腹阑尾切除术（OA）的一种可行替代方法。然而，由于LA（与OA相比）的一些所谓优势并不明显，越来越多的证据表明，对于单纯性阑尾炎，阑尾切除术可能并非必要，并且人们对所有疑似急性阑尾炎患者都使用腹腔镜检查存在担忧。尽管LA广受欢迎且应用广泛，但报道其适应证的文献却很稀少，有时还会产生误导（即包含扭曲的推论或结论，也称为“歪曲”）。本研究旨在确定LA可能比OA具有真正优势的患者亚组，并分析LA（而非OA）特定适应证的有效性。
对文献进行了系统综述和批判性分析。
我们分析了90篇回顾性综述、前瞻性研究、荟萃分析以及队列研究和前瞻性随机对照研究，这些研究共涉及约390,000例患者，探讨了LA在老年人、肥胖者、妊娠期以及复杂性阑尾炎（包括弥漫性腹膜炎和异位阑尾）中的潜在特定优势。总体而言，LA与以下情况相关：（1）在老年人中，总体并发症发生率较低（尤其是失代偿性合并症较少）、死亡率较低、成本较低，以及住院时间较短；（2）在肥胖者中，发病率降低（尤其是腹壁发病率）；（3）在妊娠期具有潜在（诊断）优势（尽管LA与胎儿丢失率高于OA相关）。在复杂性或异位阑尾炎中，LA是可行且安全的，并且如果不转为开腹手术，应导致较少的短期和长期腹壁发病率。然而，已发表的数据非常异质，可靠的对照试验很少，文献中的结论往往基于误导性的推论或证据水平极低。
LA是治疗特定情况下急性阑尾炎的安全有效方法，如老年人、肥胖者以及异位阑尾患者，在这些患者亚组中具有潜在的特定腹壁优势。在推荐LA用于复杂性阑尾炎、腹膜炎以及妊娠期之前，还需要进一步的随机研究和有力的荟萃分析。
