University of Texas Southwestern Medical Center, Department of Surgery, Dallas, TX.
University of Texas Southwestern Medical Center, Department of Surgery, Dallas, TX; VA North Texas Health Care System, Department of Surgery, Dallas, TX.
Surgery. 2018 Sep;164(3):460-465. doi: 10.1016/j.surg.2018.04.027. Epub 2018 Jun 18.
Some studies indicate that noncomplicated acute appendicitis might be treated exclusively with antibiotics instead of an appendectomy. This study was undertaken to assess outcomes in elderly veterans and to determine if operative intervention would lead to substantial complications such that a nonoperative strategy should be investigated.
A retrospective, single-institution analysis was conducted of patients who underwent an appendectomy at the VA North Texas Health Care System over a period of 12 years (from July 2005 to June 2017). Patients who underwent an appendectomy for cancer, interval appendectomy, exploratory laparotomy for perforated appendicitis, or appendectomy as part of another major operation were excluded from the study. Patients were then grouped as elderly (≥60 years old) and young (<60 years old), and differences in outcome were assessed. Univariate and multivariate analyses were also performed to determine if age and comorbid conditions were independent predictors of complications in both cohorts.
Of patients who underwent an appendectomy for acute appendicitis (n = 257, male = 90.7%, age = 45.4 ± standard deviation 15.6 years, body mass index = 30.3 ± 6.3 kg/m), 195 were young (38.7 ± 11.2 years old) and 62 elderly (66 ± 5 years old). More patients were male in the elderly cohort (98.4% vs 88%; P = .01). The incidence of gangrenous and perforated appendicitis was greater in elderly patients (11.3% and 14.4% vs 24 % and 40%, P < .01 each). Diabetes and hypertension, as well as a history of cardiac, pulmonary, and renal diseases, were more than 2-fold greater in older patients. Complications and 30-day readmission rates were similar in both groups (young vs elderly: 7.2% and 9% vs 9.7% and 11%, P > .5 each). Logistic regression analysis showed that age and American Society of Anesthesia level were not independent predictors of complications. A history of cardiac disease and open operation independently predicted complications regardless of age. Unexpected malignancy was 3% in the elderly and 1.5% in the young cohort (P = .6) CONCLUSION: Complicated appendicitis is more common in elderly patients. Appendectomy in elderly veteran patients has a low rate of complications similar to younger patients and the private sector. Operative intervention in this group of patients is not prohibitive. Further studies are needed to determine if nonoperative intervention is noninferior to an appendectomy in this high-risk patient population.
一些研究表明，非复杂性急性阑尾炎可能仅通过抗生素治疗即可，而无需进行阑尾切除术。本研究旨在评估老年退伍军人的治疗结果，并确定手术干预是否会导致严重并发症，从而需要探索非手术策略。
对在 VA 北德克萨斯医疗保健系统接受阑尾切除术的患者进行了回顾性、单机构分析，研究期间为 12 年（2005 年 7 月至 2017 年 6 月）。排除因癌症、间隔期阑尾切除术、穿孔性阑尾炎剖腹探查术或阑尾切除术作为其他主要手术一部分而接受阑尾切除术的患者。然后将患者分为老年（≥60 岁）和年轻（<60 岁）组，并评估其结果差异。还进行了单变量和多变量分析，以确定年龄和合并症是否是两个队列中并发症的独立预测因素。
在接受阑尾切除术治疗急性阑尾炎的患者中（n=257，男性占 90.7%，年龄=45.4±15.6 岁，体重指数=30.3±6.3kg/m），195 例为年轻患者（38.7±11.2 岁），62 例为老年患者（66±5 岁）。老年组中男性比例更高（98.4%比 88%；P=.01）。老年患者坏疽性和穿孔性阑尾炎的发生率更高（分别为 11.3%和 14.4%比 24%和 40%；P<.01 各）。糖尿病和高血压以及心脏病、肺部和肾脏疾病的病史在老年患者中也超过两倍。两组的并发症和 30 天再入院率相似（年轻组与老年组分别为 7.2%和 9%比 9.7%和 11%；P>.5 各）。Logistic 回归分析显示，年龄和美国麻醉医师协会分级不是并发症的独立预测因素。无论年龄大小，心脏病病史和开放性手术均独立预测并发症。老年患者的意外恶性肿瘤发生率为 3%，年轻患者为 1.5%（P=.6）。
老年患者中更常见复杂阑尾炎。老年退伍军人患者行阑尾切除术的并发症发生率与年轻患者和私营部门相似。该组患者的手术干预并非不可行。需要进一步的研究来确定在这一高危患者人群中，非手术干预是否不劣于阑尾切除术。
