背景:这是对2017年首次发布的Cochrane评论的更新。急性阑尾炎(阑尾炎症)可以是简单或复杂的。阑尾痰和阑尾脓肿是复杂阑尾炎的例子。阑尾痰是阑尾右下方的弥漫性炎症,而阑尾脓肿是腹部离散的发炎肿块,含有脓液。阑尾痰和脓肿占急性阑尾炎的2%至10%。阑尾痰或脓肿患者通常需要阑尾切除术以缓解症状(例如腹痛,食欲不振,恶心,和呕吐)并避免并发症(例如腹膜炎(腹部衬里感染)。阑尾痰或脓肿患者的手术可能较早(入院后或入院后几天内),或延迟(几周后在随后的住院中)。阑尾痰或脓肿的阑尾切除术的最佳时机存在争议。
目的:评估早期阑尾切除术与延迟阑尾切除术对阑尾痰或脓肿患者总发病率和死亡率的影响。
方法:我们搜索了CENTRAL,MEDLINE,Embase,另外两个数据库,5项试验于2023年6月11日登记,同时进行参考检查以确定更多研究.
方法:我们纳入了所有个体和集群随机对照试验(RCT),不论语言,发布状态,或参与者的年龄,比较阑尾痰或脓肿患者的早期和延迟阑尾切除术。
方法:我们使用了Cochrane预期的标准方法学程序。
结果:我们纳入了8个RCTs,将828名参与者随机分配到因阑尾痰病(7项试验)或阑尾脓肿(1项试验)的早期或延迟阑尾切除术。这些研究是在美国进行的,印度,尼泊尔,和巴基斯坦。由于缺乏盲法和缺乏已发表的方案,所有RCT都有很高的偏倚风险。他们还不清楚随机化方法和随访时间。1.早期与延迟开放或腹腔镜阑尾切除术治疗阑尾痰我们纳入了7项试验,涉及788名患有阑尾痰的儿科和成人参与者:394名参与者被随机分配到早期阑尾切除术组(开放或腹腔镜阑尾切除术,一旦阑尾肿块在同一入院内消退)。和394人被随机分配到延迟阑尾切除术组(最初的保守治疗,随后几周后延迟开腹或腹腔镜阑尾切除术).两组均无死亡。关于早期阑尾切除术对总体发病率的影响的证据非常不确定(风险比(RR)0.74,95%置信区间(CI)0.19至2.86;3项试验,146名参与者;非常低的确定性证据),出现伤口感染的参与者比例(RR0.99,95%CI0.48至2.02;7项试验,788名参与者),以及发生粪便瘘的参与者比例(RR1.75,95%CI0.36~8.49;5项试验,388名参与者)。早期阑尾切除术可降低腹部脓肿发生率(RR0.26,95%CI0.08至0.80;4项试验,626名参与者;非常低的确定性证据),住院总时间减少约两天(平均差(MD)-2.02天,95%CI-3.13至-0.91;5项试验,680名参与者),并将离开正常活动的时间增加约五天(MD5.00天;95%CI1.52至8.48;1项试验,40名参与者),但是证据非常不确定。2.早期与延迟腹腔镜阑尾切除术治疗阑尾脓肿我们纳入了一项涉及40名阑尾脓肿儿科参与者的试验:20人被随机分配到早期阑尾切除术组(急诊腹腔镜阑尾切除术)。20例患者被随机分配到延迟性阑尾切除术组(初始保守治疗,10周后延迟腹腔镜阑尾切除术).两组均无死亡。该试验没有报告总体发病率,各种并发症,或远离正常活动的时间。关于早期阑尾切除术对住院总长的影响的证据非常不确定(MD-0.20天,95%CI-3.54至3.14;非常低的确定性证据)。
结论:对于患有阑尾痰的儿科和成人参与者,早期与延迟开放或腹腔镜阑尾切除术的比较,非常低的确定性证据表明,早期阑尾切除术可以降低腹部脓肿的发生率。证据非常不确定早期阑尾切除术是否可以预防整体发病率或其他并发症。早期阑尾切除术可能会减少住院总时间,增加远离正常活动的时间,但是证据非常不确定。为了比较患有阑尾脓肿的儿科参与者的早期和延迟腹腔镜阑尾切除术,数据是稀疏的,我们不能排除早期阑尾切除术与延迟阑尾切除术的显著益处或危害.迫切需要对这一主题进行进一步的试验,并且应指定一组使用抗生素的标准,手术前经皮引流阑尾脓肿,和阑尾痰或脓肿的解决。未来的试验应包括结果,如远离正常活动的时间和住院时间。
This is an update of a Cochrane review first published in 2017. Acute appendicitis (inflammation of the appendix) can be simple or complicated. Appendiceal phlegmon and appendiceal
abscess are examples of complicated appendicitis. Appendiceal phlegmon is a diffuse inflammation in the bottom right of the appendix, while appendiceal abscess is a discrete inflamed mass in the abdomen that contains pus. Appendiceal phlegmon and
abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or
abscess usually need an appendicectomy to relieve their symptoms (e.g. abdominal pain, loss of appetite, nausea, and vomiting) and avoid complications (e.g. peritonitis (infection of abdominal lining)). Surgery for people with appendiceal phlegmon or abscess may be early (immediately after hospital admission or within a few days of admission), or delayed (several weeks later in a subsequent hospital admission). The optimal timing of appendicectomy for appendiceal phlegmon or
abscess is debated.
To assess the effects of early appendicectomy compared to delayed appendicectomy on overall morbidity and mortality in people with appendiceal phlegmon or abscess.
We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers on 11 June 2023, together with reference checking to identify additional studies.
We included all individual and cluster-randomised controlled trials (RCTs), irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess.
We used standard methodological procedures expected by Cochrane.
We included eight RCTs that randomised 828 participants to early or delayed appendicectomy for appendiceal phlegmon (7 trials) or appendiceal abscess (1 trial). The studies were conducted in the USA, India, Nepal, and Pakistan. All RCTs were at high risk of bias because of lack of blinding and lack of published protocols. They were also unclear about methods of randomisation and length of follow-up. 1. Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon We included seven trials involving 788 paediatric and adult participants with appendiceal phlegmon: 394 of the participants were randomised to the early appendicectomy group (open or laparoscopic appendicectomy as soon as the appendiceal mass resolved within the same admission), and 394 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed open or laparoscopic appendicectomy several weeks later). There was no mortality in either group. The evidence is very uncertain about the effect of early appendicectomy on overall morbidity (risk ratio (RR) 0.74, 95% confidence interval (CI) 0.19 to 2.86; 3 trials, 146 participants; very low-certainty evidence), the proportion of participants who developed wound infections (RR 0.99, 95% CI 0.48 to 2.02; 7 trials, 788 participants), and the proportion of participants who developed faecal fistulas (RR 1.75, 95% CI 0.36 to 8.49; 5 trials, 388 participants). Early appendicectomy may reduce the abdominal abscess rate (RR 0.26, 95% CI 0.08 to 0.80; 4 trials, 626 participants; very low-certainty evidence), reduce the total length of hospital stay by about two days (mean difference (MD) -2.02 days, 95% CI -3.13 to -0.91; 5 trials, 680 participants), and increase the time away from normal activities by about five days (MD 5.00 days; 95% CI 1.52 to 8.48; 1 trial, 40 participants), but the evidence is very uncertain. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscess We included one trial involving 40 paediatric participants with appendiceal abscess: 20 were randomised to the early appendicectomy group (emergent laparoscopic appendicectomy), and 20 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed laparoscopic appendicectomy 10 weeks later). There was no mortality in either group. The trial did not report on overall morbidity, various complications, or time away from normal activities. The evidence is very uncertain about the effect of early appendicectomy on the total length of hospital stay (MD -0.20 days, 95% CI -3.54 to 3.14; very low-certainty evidence).
For the comparison of early versus delayed open or laparoscopic appendicectomy for paediatric and adult participants with appendiceal phlegmon, very low-certainty evidence suggests that early appendicectomy may reduce the abdominal abscess rate. The evidence is very uncertain whether early appendicectomy prevents overall morbidity or other complications. Early appendicectomy may reduce the total length of hospital stay and increase the time away from normal activities, but the evidence is very uncertain. For the comparison of early versus delayed laparoscopic appendicectomy for paediatric participants with appendiceal abscess, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy. Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery, and resolution of the appendiceal phlegmon or
abscess. Future trials should include outcomes such as time away from normal activities and length of hospital stay.