Colon and Rectal Surgery Department, Massachusetts General Hospital, Boston.
Gastrointestinal Surgery Department, Gastromed Institute, Sao Paulo, Brazil.
JAMA Surg. 2022 Sep 1;157(9):828-834. doi: 10.1001/jamasurg.2022.2937.
Appendectomy remains the standard of care for uncomplicated acute appendicitis despite several randomized clinical trials pointing to the safety and efficacy of nonoperative management of this disease. A meta-analysis of randomized clinical trials may contribute to the body of evidence and help surgeons select which patients may benefit from surgical and nonsurgical treatment.
To assess the efficacy and safety of nonoperative management vs appendectomy for acute uncomplicated appendicitis.
A systematic review was conducted using indexed sources (Embase and PubMed) to search for published randomized clinical trials in English comparing nonoperative management with appendectomy in adult patients presenting with uncomplicated acute appendicitis. To increase sensitivity, no limits were set for outcomes reported, sex, or year of publication. All nonrandomized or quasi-randomized trials were excluded, and validated primers were used.
Among 1504 studies imported for screening, 805 were duplicates, and 595 were excluded for irrelevancy. A further 96 were excluded after full-text review, mainly owing to wrong study design or inclusion of pediatric populations. Eight studies met the inclusion criteria and were selected for the meta-analysis.
Meta-extraction was conducted with independent extraction by multiple reviewers using the Covidence platform for systematic reviews and in accordance with PRISMA guidelines. Data were pooled by a random-effects model.
Treatment success and major adverse effects at 30 days' follow-up.
The main outcome (treatment success proportion at 30 days of follow-up) was not significantly different in the operative and nonoperative management cohorts (risk ratio [RR], 0.85; 95% CI, 0.66-1.11). Likewise, the percentage of major adverse effects was similar in both cohorts (RR, 0.72; 95% CI, 0.29-1.79). However, in the nonoperative management group, length of stay was significantly longer (RR, 1.48; 95% CI, 1.26-1.70), and a median cumulative incidence of 18% of recurrent appendicitis was observed.
These results point to the general safety and efficacy of nonoperative management of uncomplicated acute appendicitis. However, this strategy may be associated with an increase in duration of hospital stay and a higher rate of recurrent appendicitis. This meta-analysis may help inform decision-making in nonoperative management of uncomplicated acute appendicitis.
尽管有几项随机临床试验指出非手术治疗这种疾病的安全性和有效性，但阑尾切除术仍然是治疗单纯性急性阑尾炎的标准治疗方法。对随机临床试验的荟萃分析可能有助于积累证据，并帮助外科医生选择哪些患者可能受益于手术和非手术治疗。
评估非手术治疗与阑尾切除术治疗单纯性急性阑尾炎的疗效和安全性。
使用索引来源（Embase 和 PubMed）进行系统评价，以搜索比较成人单纯性急性阑尾炎患者非手术治疗与阑尾切除术的已发表随机临床试验。为了提高敏感性，对报告的结局、性别或出版年份没有设置任何限制。所有非随机或准随机试验均被排除，并且使用了经过验证的引物。
在导入筛选的 1504 项研究中，805 项是重复的，595 项因不相关而被排除。进一步在全文审查后排除了 96 项，主要是由于错误的研究设计或纳入儿科人群。符合纳入标准的 8 项研究被纳入荟萃分析。
使用 Covidence 平台对系统评价进行独立的多审评论文数据提取，并符合 PRISMA 指南。使用随机效应模型对数据进行汇总。
30 天随访时的治疗成功率和主要不良影响。
主要结局（30 天随访时的治疗成功率）在手术和非手术治疗组之间没有显著差异（风险比 [RR]，0.85；95% CI，0.66-1.11）。同样，两组的主要不良影响比例也相似（RR，0.72；95% CI，0.29-1.79）。然而，在非手术治疗组中，住院时间明显延长（RR，1.48；95% CI，1.26-1.70），并且观察到 18%的复发性阑尾炎的累积发生率中位数。
这些结果表明单纯性急性阑尾炎非手术治疗的总体安全性和有效性。然而，这种策略可能与住院时间延长和更高的复发性阑尾炎率相关。这项荟萃分析可能有助于为单纯性急性阑尾炎的非手术治疗决策提供信息。
