General and Emergency Surgery dept, Bufalini Hospital, Cesena, Italy.
General and Emergency Surgery dept, Bufalini Hospital, Cesena, Italy.
J Pediatr Surg. 2019 Nov;54(11):2234-2241. doi: 10.1016/j.jpedsurg.2019.01.065. Epub 2019 Feb 25.
No consensus exists among surgeons regarding the optimal treatment of complicated acute appendicitis in children (CAA). Existing studies present heterogeneity of data and only few studies analyzed free perforated appendicitis (FPA) separately from appendicular abscess (AAb) and appendicular phlegmon (AP).
Studies which have been judged eligible for this systematic review and consequent meta-analysis are those comparing non-operative management (NOM) with operative management (OM) in children with CAA. Studies were subgrouped between those analyzing mixed patients with CAA, those focusing on patients with AAb/AP and those focusing on patients with FPA.
Fourteen studies fulfilled the inclusion criteria and were included in the meta-analysis with a total of 1288 patients. In the fixed-effects model the complication rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.07, 95%CI = 0.02-0.27) and to the OM arm for the FPA subgroup (RR = 1.86, 95%CI = 1.20-2.87); the re-admission rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.35, 95%CI = 0.13-0.93) and to the OM arm for the FPA subgroup (RR = 1.49, 95%CI = 1.49-7.44). There was no statistical heterogeneity for the two subgroups of patients. The costs weren't significantly different between NOM and OM. The length of stay was favorable to OM. The pooled proportion rate of NOM success was 90%, the pooled relapse rate of appendicitis was 15.4%.
Children with AAb/AP reported better results in terms of complication rate and re-admission rate if treated with NOM. Conversely children with FPA showed lower complication rate and re-admission rate if treated with OM.
II.
对于儿童复杂性急性阑尾炎（CAA）的最佳治疗方案，外科医生之间尚未达成共识。现有的研究数据存在异质性，只有少数研究分别分析了自由穿孔性阑尾炎（FPA）与阑尾脓肿（AAb）和阑尾蜂窝织炎（AP）。
本系统评价和随后的荟萃分析中，纳入了将非手术治疗（NOM）与手术治疗（OM）用于 CAA 儿童的比较研究。这些研究被分为混合 CAA 患者分析亚组、仅关注 AAb/AP 患者的亚组和仅关注 FPA 患者的亚组。
14 项研究符合纳入标准，并纳入了共 1288 例患者的荟萃分析。在固定效应模型中，对于 AAb/AP 亚组，初始 NOM 组的并发症发生率明显优于 NOM 组（RR=0.07，95%CI=0.02-0.27），对于 FPA 亚组，OM 组的并发症发生率明显优于 OM 组（RR=1.86，95%CI=1.20-2.87）；对于 AAb/AP 亚组，初始 NOM 组的再入院率明显优于 NOM 组（RR=0.35，95%CI=0.13-0.93），对于 FPA 亚组，OM 组的再入院率明显优于 OM 组（RR=1.49，95%CI=1.49-7.44）。这两个患者亚组之间没有统计学异质性。NOM 和 OM 之间的成本没有显著差异。住院时间有利于 OM。NOM 成功率的汇总比例为 90%，阑尾炎复发率为 15.4%。
如果采用 NOM 治疗，AAb/AP 患者的并发症发生率和再入院率更好。相反，如果采用 OM 治疗，FPA 患儿的并发症发生率和再入院率更低。
II 级。
