手术与抗生素——“阑尾炎难题”仍在继续：一项荟萃分析。
Operation versus antibiotics--The "appendicitis conundrum" continues: A meta-analysis.
作者信息
Sakran Joseph V, Mylonas Konstantinos S, Gryparis Alexandros, Stawicki Stanislaw P, Burns Christopher J, Matar Maher M, Economopoulos Konstantinos P
机构信息
From the Department of Surgery (J.V.S.), Johns Hopkins University, Baltimore, Maryland; Surgery Working Group (K.S.M., K.P.E.), Society of Junior Doctors, Athens, Greece; Division of Pediatric Surgery, Department of Surgery (K.S.M.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Institute of Preventive Medicine, Environmental & Occupational Health (A.G.), Prolepsis, Athens, Greece; Department of Hygiene, Epidemiology and Medical Statistics (A.G.), Medical School, National and Kapodistrian University of Athens, Athens, Greece; Department of Research & Innovation (S.P.S.), St Luke's University Health Network, Bethlehem, Pennsylvania; Department of Surgery (C.J.B.), Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery (M.M.M.), Medical University of South Carolina, Charleston, South Carolina; and Department of Surgery (K.P.E.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
出版信息
J Trauma Acute Care Surg. 2017 Jun;82(6):1129-1137. doi: 10.1097/TA.0000000000001450.
BACKGROUND
Acute appendicitis continues to constitute a diagnostic and therapeutic challenge. The aim of this study was to synthesize evidence from randomized controlled trials (RCTs) comparing nonoperative versus surgical management of uncomplicated acute appendicitis in adult patients.
METHODS
A systematic literature search of the PubMed, Cochrane, and Scopus databases was performed with respect to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement (end-of-search date: January 29, 2017). Data on the study design, interventions, participants, and outcomes were extracted by two independent reviewers. The random-effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when substantial heterogeneity was encountered; otherwise, the fixed-effects (Mantel-Haenszel) model was implemented. Quality assessment of included RCTs was performed using the modified Jadad scale.
RESULTS
Five RCTs were included in this review. Overall, 1,430 adult patients with uncomplicated acute appendicitis underwent either nonoperative (n = 727) or operative management (n = 703). Treatment efficacy at 1-year follow-up was significantly lower (63.8%) for antibiotics compared with the surgery group (93%) (risk ratio [RR], 0.68; 95% confidence interval [CI], 0.60-0.77; p < 0.001). Overall complications were significantly higher in the surgery group (166/703 [23.6%]) compared with the antibiotics group (56/727 [7.7%]) (RR, 0.32; 95% CI, 0.24-0.43; p < 0.001). No difference was found between the two treatment modalities in terms of perforated appendicitis rates (RR, 0.52; 95% CI, 0.14-1.92), length of hospital stay (weighted mean difference [WMD], 0.20; 95% CI, -0.16 to 0.56), duration of pain (WMD, 0.22; 95% CI, -5.30 to -5.73), and sick leave (WMD, -2; 95% CI, -5.2 to 1.1).
CONCLUSIONS
Conservative management of uncomplicated appendicitis in adults warrants further study. Addressing patients' expectations via a shared decision-making process is a crucial step in optimizing nonoperative outcomes.
LEVEL OF EVIDENCE
Systematic review, level II.
背景
急性阑尾炎仍然是一个诊断和治疗方面的挑战。本研究的目的是综合来自随机对照试验（RCT）的证据，比较成年患者单纯性急性阑尾炎的非手术治疗与手术治疗。
方法
根据PRISMA（系统评价和Meta分析的首选报告项目）声明（检索截止日期：2017年1月29日），对PubMed、Cochrane和Scopus数据库进行系统的文献检索。由两名独立的审阅者提取关于研究设计、干预措施、参与者和结果的数据。当遇到实质性异质性时，使用随机效应模型（DerSimonian-Laird）计算合并效应估计值；否则，采用固定效应（Mantel-Haenszel）模型。使用改良的Jadad量表对纳入的RCT进行质量评估。
结果
本综述纳入了5项RCT。总体而言，1430例成年单纯性急性阑尾炎患者接受了非手术治疗（n = 727）或手术治疗（n = 703）。与手术组（93%）相比，抗生素治疗1年随访时的治疗有效率显著较低（63.8%）（风险比[RR]，0.68；95%置信区间[CI]，0.60 - 0.77；p < 0.001）。手术组的总体并发症发生率（166/703 [23.6%]）显著高于抗生素组（56/727 [7.7%]）（RR，0.32；95% CI，0.24 - 0.43；p < 0.001）。两种治疗方式在穿孔性阑尾炎发生率（RR，0.52；95% CI，0.14 - 1.92）、住院时间（加权平均差[WMD]，0.20；95% CI， - 0.16至0.56）、疼痛持续时间（WMD，0.22；95% CI， - 5.30至 - 5.73）和病假（WMD， - 2；95% CI， - 5.2至1.1）方面未发现差异。
结论
成人单纯性阑尾炎的保守治疗值得进一步研究。通过共同决策过程满足患者的期望是优化非手术治疗结果的关键步骤。
证据级别
系统评价，二级。
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