Lastunen Kirsi S, Leppäniemi Ari K, Mentula Panu J
Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
Br J Surg. 2022 Jun 14;109(7):588-594. doi: 10.1093/bjs/znac120.
Mild appendicitis may resolve spontaneously. The use of CT may lead to an overdiagnosis of uncomplicated appendicitis. The aims of this study were to examine whether early imaging results in more patients being diagnosed with acute appendicitis than initial observation, and to study the safety and feasibility of score-based observation compared with imaging in patients with equivocal signs of appendicitis.
Patients with suspected appendicitis with symptoms for fewer than 24 h and an Adult Appendicitis Score of 11-15 were eligible for this trial. After exclusions, patients were randomized openly into two equal-sized groups: imaging and observation. Patients in the imaging group had ultrasound imaging followed by CT when necessary, whereas those in the observation group were reassessed after 6-8 h with repeated scoring and managed accordingly. The primary outcome was the number of patients requiring treatment for acute appendicitis within 30 days.
Ninety-three patients were randomized to imaging and 92 to observation; after exclusions, 93 and 88 patients respectively were analysed. In the imaging group, more patients underwent treatment for acute appendicitis than in the observation group: 72 versus 57 per cent (difference 15 (95 per cent c.i. 1 to 29) per cent). This suggests that patients with spontaneously resolving appendicitis were not diagnosed or treated in the observation group. Some 55 per cent of patients in the observation group did not need diagnostic imaging within 30 days after randomization. There was no difference in the number of patients diagnosed with complicated appendicitis (4 versus 2 per cent) or negative appendicectomies (1 versus 1 per cent) in the imaging and observation groups.
Score-based observation of patients with early equivocal appendicitis results in fewer patients requiring treatment for appendicitis. Registration number: NCT02742402 (http://www.clinicaltrials.gov).
轻度阑尾炎可能会自行缓解。使用CT可能会导致对非复杂性阑尾炎的过度诊断。本研究的目的是探讨早期影像学检查是否比初始观察能使更多患者被诊断为急性阑尾炎，并研究在阑尾炎体征不明确的患者中，基于评分的观察与影像学检查相比的安全性和可行性。
症状出现少于24小时且成人阑尾炎评分为11 - 15分的疑似阑尾炎患者符合本试验条件。排除后，患者被公开随机分为两组，每组人数相等：影像学检查组和观察组。影像学检查组患者先进行超声检查，必要时再进行CT检查，而观察组患者在6 - 8小时后重新评估，重复评分并据此进行处理。主要结局是30天内需要接受急性阑尾炎治疗的患者数量。
93例患者被随机分配至影像学检查组，92例至观察组；排除后，分别对93例和88例患者进行分析。影像学检查组中接受急性阑尾炎治疗的患者比观察组更多：分别为72%和57%（差异为15%（95%置信区间为1%至29%））。这表明观察组中阑尾炎自行缓解的患者未被诊断或治疗。观察组中约55%的患者在随机分组后30天内无需进行诊断性影像学检查。影像学检查组和观察组中被诊断为复杂性阑尾炎的患者数量（分别为4%和2%）或阴性阑尾切除术的患者数量（分别为1%和1%）没有差异。
对早期阑尾炎体征不明确的患者进行基于评分的观察，可使需要接受阑尾炎治疗的患者减少。注册号：NCT02742402（http://www.clinicaltrials.gov）。
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