Barie Philip S
Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, and Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York, USA.
Surg Infect (Larchmt). 2021 Dec;22(10):991-1003. doi: 10.1089/sur.2021.059. Epub 2021 Sep 20.
The medical fascination with the appendix vermiformis dates from the clandestine prosectors of the fifteenth century. The surgical management of appendiceal inflammation dates from 1735, but acceptance that acute appendicitis (AA) should be treated primarily by resection with or without drainage would not follow for 150 years. Recent publication of several randomized clinical trials (RCTs) of non-operative management (NOM) of AA affords the opportunity to review the historical record, describe the evolution of AA management toward NOM, and assess what is in the best interest of the patient. Review and synthesis of historical and contemporary English, French, German, and Italian literature with expert opinion. Modern understanding of AA dates to the landmark 1886 clinico-pathologic correlative study by Reginald Fitz, which coined the term appendicitis and coincided with recognition by surgeons that AA could be diagnosed pre-operatively and managed surgically, with mortality rates of approximately 10%. Not until 1901 did Albert Ochsner advocate NOM, paradoxically for severe cases unlikely to survive operation. Markedly decreased mortality coincided with the introduction of sulfanilamide in 1935 and penicillin and curare in 1942. The first large series of patients with AA treated primarily with NOM was published in 1956 by Eric Coldrey. Modern management evolved rapidly in the late twentieth century, including effective anti-anaerobic antibiotic agents (1970s), laparoscopic appendectomy (LA; 1980), and pelvis computed tomography with rectal contrast (1998) all representing important contributions. Randomized controlled trials of NOM of AA date to 1995, with one large trial (2015) showing that open appendectomy was not non-inferior to NOM, and another (2020) demonstrating non-inferiority between (mostly) LA and NOM. However, one-year failure rates are high (∼30%) and appear to increase further with longer follow-up. Laparoscopic appendectomy is curative and cost-effective management for AA, with low morbidity. Results of recent RCTs of NOM of AA indicate that LA remains the treatment of choice, particularly if a fecalith is present. However, patient preferences must be taken into account; some may prefer NOM for the 60%-70% chance that surgery may be avoided, which should be considered when providing informed consent. Non-operative management should be undertaken in the outpatient setting if possible. Antibiotic management-whether or not for NOM-should adhere to the principles of stewardship.
医学对阑尾的痴迷可以追溯到15世纪那些秘密解剖学家。阑尾炎症的外科治疗可追溯到1735年，但急性阑尾炎（AA）应主要通过切除并视情况引流来治疗这一观点在150年后才被接受。近期发表的几项关于AA非手术治疗（NOM）的随机临床试验（RCT）为回顾历史记录、描述AA治疗向NOM的演变以及评估什么最符合患者利益提供了契机。通过专家意见对历史和当代的英文、法文、德文和意大利文文献进行回顾与综合。现代对AA的理解可追溯到1886年Reginald Fitz具有里程碑意义的临床病理相关性研究，该研究创造了阑尾炎这个术语，同时外科医生认识到AA可在术前诊断并通过手术治疗，死亡率约为10%。直到1901年Albert Ochsner才提倡NOM，矛盾的是针对不太可能在手术中存活的严重病例。1935年引入磺胺类药物以及1942年引入青霉素和箭毒后死亡率显著下降。1956年Eric Coldrey发表了首个主要采用NOM治疗的大量AA患者系列研究。现代治疗在20世纪后期迅速发展，包括有效的抗厌氧菌抗生素（20世纪70年代）、腹腔镜阑尾切除术（LA；1980年）以及盆腔计算机断层扫描联合直肠造影（1998年），这些都代表了重要贡献。AA的NOM随机对照试验可追溯到1995年，一项大型试验（2015年）表明开放阑尾切除术并不劣于NOM，另一项试验（2020年）表明（大部分为）LA和NOM之间无劣效性。然而，一年的失败率很高（约30%），且似乎随着随访时间延长进一步增加。腹腔镜阑尾切除术是治疗AA的有效且具有成本效益的方法，发病率低。近期AA的NOM RCT结果表明LA仍然是首选治疗方法，如果存在粪石则尤其如此。然而，必须考虑患者的偏好；一些患者可能因有60%-70%的机会避免手术而更喜欢NOM，在提供知情同意时应予以考虑。如果可能，非手术治疗应在门诊进行。抗生素治疗——无论是否用于NOM——都应遵循管理原则。
