腹腔镜阑尾切除术优于开腹手术治疗复杂阑尾炎。
Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis.
机构信息
The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Penrith, NSW, Australia.
Discipline of Surgery, The University of Sydney, Nepean Hospital, Level 5, South Block, P.O. Box 63, Penrith, NSW, 2751, Australia.
出版信息
Surg Endosc. 2019 Jul;33(7):2072-2082. doi: 10.1007/s00464-019-06746-6. Epub 2019 Mar 13.
BACKGROUND
Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis.
METHODS
A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case-control studies (CCS) that compared LA with OA for complicated appendicitis.
RESULTS
Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71-1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31-0.59, p < 0.0001), wound infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19-0.36, p < 0.001), respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13-0.49, p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%; OR = 0.65, 95% CI: 0.42-1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%; OR = 0.15, 95% CI: 0.04-0.61, p = 0.008). LA has a significantly shorter hospital stay (6.4 days vs. 8.9 days, p = 0.02) and earlier resumption of solid food (2.7 days vs. 3.7 days, p = 0.03).
CONCLUSION
These results clearly demonstrate that LA for complicated appendicitis has the same incidence of IAA but a significantly reduced morbidity, mortality and length of hospital stay compared with OA. The finding of complicated appendicitis at laparoscopy is not an indication for conversion to open surgery. LA should be the preferred treatment for patients with complicated appendicitis.
背景
在过去的三十年中，腹腔镜阑尾切除术（LA）已成为治疗单纯性急性阑尾炎的常规方法。由于担心与开腹阑尾切除术（OA）相比，LA 术后腹腔内脓肿（IAA）的发生率增加，腹腔镜手术治疗复杂性阑尾炎（坏疽和/或穿孔）的作用仍存在争议。本研究旨在比较 LA 与 OA 治疗复杂性阑尾炎的结果。
方法
按照 PRISMA 指南，使用 MEDLINE、EMBASE、PubMed 和 Cochrane 数据库对随机对照试验（RCT）和病例对照研究（CCS）进行了系统文献检索，这些研究比较了 LA 与 OA 治疗复杂性阑尾炎。
结果
共纳入了三项 RCT 和 30 项 CCS 的 6428 名患者（OA 组 3254 名，LA 组 3174 名）的数据。IAA 的发生率无显著差异（LA=6.1% vs. OA=4.6%；OR=1.02，95%CI=0.71-1.47，p=0.91）。LA 治疗复杂性阑尾炎的总体术后发病率较低（LA=15.5% vs. OA=22.7%；OR=0.43，95%CI：0.31-0.59，p<0.0001），包括伤口感染（LA=4.7% vs. OA=12.8%；OR=0.26，95%CI：0.19-0.36，p<0.001）、呼吸并发症（LA=1.8% vs. OA=6.4%；OR=0.25，95%CI：0.13-0.49，p<0.001）、术后肠梗阻/小肠梗阻（LA=3.1% vs. OA=3.6%；OR=0.65，95%CI：0.42-1.0，p=0.048）和死亡率（LA=0% vs. OA=0.4%；OR=0.15，95%CI：0.04-0.61，p=0.008）。LA 的住院时间明显更短（6.4 天 vs. 8.9 天，p=0.02），固体食物恢复时间更早（2.7 天 vs. 3.7 天，p=0.03）。
结论
这些结果清楚地表明，与 OA 相比，LA 治疗复杂性阑尾炎的 IAA 发生率相同，但发病率、死亡率和住院时间明显降低。腹腔镜检查发现复杂性阑尾炎并不是转为开腹手术的指征。LA 应成为治疗复杂性阑尾炎患者的首选方法。
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