阑尾切除术与单纯阑尾炎非手术治疗的比较：使用等级有序量表对东部创伤外科学会多中心研究的事后分析。

Appendectomy versus nonoperative management of simple appendicitis: A post hoc analysis of an Eastern Association for the Surgery of Trauma multicenter study using a hierarchical ordinal scale.

机构信息

From the Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, Miami, FL (D.D.Y., G.V., S.Q., K.A.J., R.R., G.D.P., N.N.), University of Miami Miller School of Medicine; Biostatistics, Miami, FL (H.Z.), University of Miami; Medical College of Wisconsin, Milwaukee, WI (C.D.); and Denver Health, Denver, CO (R.L.).

出版信息

J Trauma Acute Care Surg. 2022 Jun 1;92(6):1031-1038. doi: 10.1097/TA.0000000000003581. Epub 2022 Feb 22.

DOI:10.1097/TA.0000000000003581

PMID:35195095

Abstract

BACKGROUND

Controversy exists about the preferred initial treatment of appendicitis. We sought to compare the two treatments for initial management of simple appendicitis.

METHODS

In this post hoc analysis of the Multicenter Study for the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, subjects were divided into appendectomy or nonoperative management (NOM; antibiotics only or percutaneous drainage) cohorts. A novel topic-specific hierarchical ordinal scale was created with eight mutually exclusive categories: mortality, reoperation, other secondary interventions, readmission, emergency department visit, wound complication, surgical site infection, and no complication. Pairwise comparisons of American Association for the Surgery of Trauma Imaging Severity Grade 1 (simple appendicitis) patients were compared using win-lose-tie scoring and the sums of appendectomy/NOM groups were compared.

RESULTS

A total 3,591 subjects were included: 3,262 appendectomy and 329 NOM, with significant differences in baseline characteristics between groups. Across 28 sites, the rate of NOM ranged from 0% to 48%, and the loss to follow-up rate was significantly higher for NOM compared with appendectomy (16.5% vs. 8.7%, p = 0.024). In the simple appendicitis hierarchical ordinal scale analysis, 2,319 subjects resulted in 8,714,304 pairwise comparisons; 75% of comparisons resulted in ties. The median (interquartile range) sums for the two groups are as follows: surgical, 400 (400-400), and NOM, 400 (-2,427 to 400) (p < 0.001). A larger proportion of appendectomy subjects (88.1%) had an outcome that was equivalent (or better) than at least half of the subjects compared with NOM subjects (NOM, 70.5%; OR [95% confidence interval], 0.3 [0.2-0.4]).

CONCLUSION

In contemporary American practice, appendectomy (compared with NOM) for simple appendicitis is associated with lower odds of developing clinically important unfavorable outcomes in the first year after illness.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

摘要

背景

关于阑尾炎的首选初始治疗存在争议。我们旨在比较两种方法治疗单纯性阑尾炎的初始管理。

方法

在《美国急性阑尾炎多中心治疗研究：穿孔和坏疽》数据库的事后分析中，将受试者分为阑尾切除术或非手术治疗（仅使用抗生素或经皮引流）队列。创建了一个新的特定主题层次有序量表，共有 8 个互斥类别：死亡率、再次手术、其他次要干预、再入院、急诊就诊、伤口并发症、手术部位感染和无并发症。使用赢-输-平计分法比较美国外科创伤协会影像学严重程度等级 1（单纯性阑尾炎）患者的配对比较，并比较阑尾切除术/非手术治疗组的总和。

结果

共纳入 3591 例患者：3262 例阑尾切除术和 329 例非手术治疗，两组基线特征存在显著差异。在 28 个地点，非手术治疗率从 0%到 48%不等，与阑尾切除术相比，非手术治疗的失访率明显更高（16.5%比 8.7%，p=0.024）。在单纯性阑尾炎层次有序量表分析中，2319 例患者产生 8714304 对比较；75%的比较结果为平局。两组的中位数（四分位距）总和如下：手术组为 400（400-400），非手术组为 400（-2，427 至 400）（p<0.001）。与非手术治疗组相比（非手术治疗组，88.1%的患者结局至少与一半患者相当（或更好），而非手术治疗组为 70.5%（比值比[95%置信区间]，0.3[0.2-0.4]）。