Jaschinski Thomas, Mosch Christoph G, Eikermann Michaela, Neugebauer Edmund Am, Sauerland Stefan
Institute for Research in Operative Medicine (IFOM) - Department for Evidence-based Health Services Research, University Witten/Herdecke, Ostmerheimer Str. 200 (Building 38), Cologne, Germany, 51109.
Cochrane Database Syst Rev. 2018 Nov 28;11(11):CD001546. doi: 10.1002/14651858.CD001546.pub4.
The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment of choice for acute appendicitis. However, in consequence of the evolution of endoscopic surgery, the operation can also be performed with minimally invasive surgery. Due to smaller incisions, the laparoscopic approach may be associated with reduced postoperative pain, reduced wound infection rate, and shorter time until return to normal activity.This is an update of the review published in 2010.
To compare the effects of laparoscopic appendectomy (LA) and open appendectomy (OA) with regard to benefits and harms.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE and Embase (9 February 2018). We identified proposed and ongoing studies from World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and EU Clinical Trials Register (9 February 2018). We handsearched reference lists of identified studies and the congress proceedings of endoscopic surgical societies.
We included randomised controlled trials (RCTs) comparing LA versus OA in adults or children.
Two review authors independently selected studies, assessed the risk of bias, and extracted data. We performed the meta-analyses using Review Manager 5. We calculated the Peto odds ratio (OR) for very rare outcomes, and the mean difference (MD) for continuous outcomes (or standardised mean differences (SMD) if researchers used different scales such as quality of life) with 95% confidence intervals (CI). We used GRADE to rate the quality of the evidence.
We identified 85 studies involving 9765 participants. Seventy-five trials included 8520 adults and 10 trials included 1245 children. Most studies had risk of bias issues, with attrition bias being the largest source across studies due to incomplete outcome data.In adults, pain intensity on day one was reduced by 0.75 cm on a 10 cm VAS after LA (MD -0.75, 95% CI -1.04 to -0.45; 20 RCTs; 2421 participants; low-quality evidence). Wound infections were less likely after LA (Peto OR 0.42, 95% CI 0.35 to 0.51; 63 RCTs; 7612 participants; moderate-quality evidence), but the incidence of intra-abdominal abscesses was increased following LA (Peto OR 1.65, 95% CI 1.12 to 2.43; 53 RCTs; 6677 participants; moderate-quality evidence).The length of hospital stay was shortened by one day after LA (MD -0.96, 95% CI -1.23 to -0.70; 46 RCTs; 5127 participant; low-quality evidence). The time until return to normal activity occurred five days earlier after LA than after OA (MD -4.97, 95% CI -6.77 to -3.16; 17 RCTs; 1653 participants; low-quality evidence). Two studies showed better quality of life scores following LA, but used different scales, and therefore no pooled estimates were presented. One used the SF-36 questionnaire two weeks after surgery and the other used the Gastro-intestinal Quality of Life Index six weeks and six months after surgery (both low-quality evidence).In children, we found no differences in pain intensity on day one (MD -0.80, 95% CI -1.65 to 0.05; 1 RCT; 61 participants; low-quality evidence), intra-abdominal abscesses after LA (Peto OR 0.54, 95% CI 0.24 to 1.22; 9 RCTs; 1185 participants; low-quality evidence) or time until return to normal activity (MD -0.50, 95% CI -1.30 to 0.30; 1 RCT; 383 participants; moderate-quality evidence). However, wound infections were less likely after LA (Peto OR 0.25, 95% CI 0.15 to 0.42; 10 RCTs; 1245 participants; moderate-quality evidence) and the length of hospital stay was shortened by 0.8 days after LA (MD -0.81, 95% CI -1.01 to -0.62; 6 RCTs; 316 participants; low-quality evidence). Quality of life was not reported in any of the included studies.
AUTHORS' CONCLUSIONS: Except for a higher rate of intra-abdominal abscesses after LA in adults, LA showed advantages over OA in pain intensity on day one, wound infections, length of hospital stay and time until return to normal activity in adults. In contrast, LA showed advantages over OA in wound infections and length of hospital stay in children. Two studies reported better quality of life scores in adults. No study reported this outcome in children. However, the quality of evidence ranged from very low to moderate and some of the clinical effects of LA were small and of limited clinical relevance. Future studies with low risk of bias should investigate, in particular, the quality of life in children.
急性阑尾炎切除术是最常开展的外科手术之一。与治疗效果相关的开放手术一直是急性阑尾炎的首选治疗方法。然而，随着内镜手术的发展，该手术也可通过微创手术进行。由于切口较小，腹腔镜手术可能会减轻术后疼痛、降低伤口感染率，并缩短恢复正常活动的时间。这是对2010年发表的综述的更新。
比较腹腔镜阑尾切除术（LA）和开腹阑尾切除术（OA）的利弊。
我们检索了Cochrane对照试验中心注册库（CENTRAL）、Ovid MEDLINE和Embase（2018年2月9日）。我们从世界卫生组织（WHO）国际临床试验注册平台（ICTRP）、ClinicalTrials.gov和欧盟临床试验注册库中识别了拟开展和正在进行的研究（2018年2月9日）。我们手工检索了已识别研究的参考文献列表以及内镜外科学会的会议论文集。
我们纳入了比较成人或儿童LA与OA的随机对照试验（RCT）。
两位综述作者独立选择研究、评估偏倚风险并提取数据。我们使用Review Manager 5进行荟萃分析。对于非常罕见的结局，我们计算Peto比值比（OR），对于连续结局（如果研究人员使用不同的量表，如生活质量量表，则计算标准化均数差（SMD）），我们计算均数差（MD）并给出95%置信区间（CI）。我们使用GRADE对证据质量进行评级。
我们识别出85项研究，涉及9765名参与者。75项试验纳入了8520名成人，10项试验纳入了1245名儿童。大多数研究存在偏倚风险问题，由于结局数据不完整，失访偏倚是各研究中最大的偏倚来源。
在成人中，LA术后第1天的疼痛强度在10 cm视觉模拟量表（VAS）上降低了0.75 cm（MD -0.75，95%CI -1.04至-0.45；20项RCT；2421名参与者；低质量证据）。LA术后伤口感染的可能性较小（Peto OR 0.42，95%CI 0.35至0.51；63项RCT；761名参与者；中等质量证据），但LA术后腹腔内脓肿的发生率增加（Peto OR 1.65，95%CI 1.12至2.43；53项RCT；6677名参与者；中等质量证据）。LA术后住院时间缩短了1天（MD -0.96，95%CI -1.23至-0.70；46项RCT；5127名参与者；低质量证据）。LA术后恢复正常活动的时间比OA提前5天（MD -4.97，95%CI -6.77至-3.16；17项RCT；1653名参与者；低质量证据）。两项研究显示LA术后生活质量评分更高，但使用了不同的量表，因此未给出合并估计值。一项在术后两周使用SF-36问卷，另一项在术后6周和6个月使用胃肠道生活质量指数（均为低质量证据）。
在儿童中，我们发现术后第1天的疼痛强度无差异（MD -0.80，95%CI -1.65至0.05；1项RCT；61名参与者；低质量证据），LA术后腹腔内脓肿的发生率无差异（Peto OR 0.54，95%CI 0.24至1.22；9项RCT；1185名参与者；低质量证据），恢复正常活动的时间无差异（MD -0.50，95%CI -1.30至0.30；1项RCT；383名参与者；中等质量证据）。然而，LA术后伤口感染的可能性较小（Peto OR 0.25，95%CI 0.15至0.42；10项RCT；1245名参与者；中等质量证据），LA术后住院时间缩短了0.8天（MD -0.81，95%CI -1.01至-0.62；6项RCT；316名参与者；低质量证据）。纳入的研究均未报告生活质量情况。
除成人LA术后腹腔内脓肿发生率较高外，LA在术后第1天的疼痛强度、伤口感染、住院时间和恢复正常活动的时间方面比OA更具优势。相比之下，LA在儿童伤口感染和住院时间方面比OA更具优势。两项研究报告成人LA术后生活质量评分更高。没有研究报告儿童的这一结局。然而，证据质量从极低到中等不等，LA的一些临床效果较小且临床相关性有限。未来偏倚风险较低的研究应特别调查儿童的生活质量。
