无并发症阑尾炎的孩童可以不用手术


  【24drs.com】根据在线发表于12月16日JAMA外科学期刊的一篇前瞻式病患选择世代研究,无并发症阑尾炎的大部份孩童,如果他们与他们的家人一开始选择以非手术方式处理,在一年时,可以避免手术。
  
  俄亥俄州哥伦布市全国儿童医院外科、全国儿童医院研究中心、手术结果研究中心Peter C. Minneci医师在新闻稿中表示,家属选择用抗生素治疗孩子的阑尾炎,即便后来如果抗生素无效还是要进行阑尾切除术,他们认为尝试使用抗生素而避免手术是值得的。
  
  他表示,这些病患避免了手术与麻醉的风险,且快速地恢复原来的活动。
  
  这篇研究包括了102名年龄7-17岁,在2012年10月1日至2013年3月6日间诊断有急性阑尾炎者,其中,37人选择使用非手术方式治疗阑尾炎,65人选择进行手术。
  
  研究的主要结果是,一年时的非手术处置成功率,成功的定义为一年时不用进行阑尾切除术;次级结果包括比较有并发症之阑尾炎发生率、孩童的失能天数、家长的失能比率、一年时的健康照护费用。
  
  研究者定义有并发症之阑尾炎为,病理分析显示破裂、穿孔或坏疽性阑尾炎。
  
  非手术处置的成功率,在出院、30天、1年时分别为:94.6% (95%信赖区间[CI]、81.8% - 99.3%;37名中有33人)、 89.2% (95% CI, 74.6% - 97.0%;37名中有33人)、75.7% (95% CI, 58.9% - 88.2%;37名中有28人)。
  
  在中位数21个月的追踪期,非手术处置的整体成功率为75.7%(35名中有28人)。
  
  非手术组的住院期间比手术组长(中位数37小时 [四分位距(IQR), 29 - 41] vs 20 [四分位距(IQR) 15 - 30]小时,P < .001),非手术组有2名病患因为30天内复发阑尾炎而再度住院,并接受了腹腔镜阑尾切除术。
  
  在一年时,两组有并发症的阑尾炎比率没有显著差异,非手术组为2.7% (37名中有1人) 、手术组为12.3% (65名中有8人) (P = .15)。
  
  在一年时, 手术组病患的术后并发症比率为7.7% (65名中有5人),其中2例为严重并发症(1例再度住院、1例再度手术),后来进行阑尾切除术的非手术组病患,没有发生术后并发症。
  
  两组在一年时的健康照护相关生活质量是类似的,相较于手术组,非手术处理与一年时的失能天数显著较少有关(中位数,8天[IQR, 5 - 18] vs 21天[IQR, 15 - 25];P < .001)。
  
  相较于手术组,非手术处理与一年时的阑尾炎照护相关总费用较低有关(中位数,$4,219 [IQR, $2,514 - $7,795] vs $5,029 [IQR, $4,596 - $5,482];P = .01)。
  
  成本敏感性分析显示,相较于手术组,非手术处理组在一年时的阑尾炎照护相关总费用依旧显著较低(中位数,$4,219 [IQR, $2,691 - $6,536] vs $4,992 [IQR, $4,688 - $5,636];P = .01)。
  
  加州大学戴维斯医学院、加州大学戴维斯儿童医院的Diana Lee Farmer医师与Rebecca Anne Stark医师,在受邀发表评论时时写道,可以确认的是,病患的选择对病患有利,且改善了整体的病患满意度,问题是,病患在何时可以做选择?
  
  这两位评论作者指出,病患选择的概念在病患照护的诸多利基中获得青睐。
  
  他们解释,在确认是否提供安全的选择时,第一步是,只出不同的治疗选项有相当程度的结果,不过,在医师和病患的偏见之间取得平衡是困难的,特别是因为医师的偏见是根据个人的经验与舒适度,因此,可能比病患的偏见更有价值。
  
  他们结论指出,在我们完全放弃指导病患的决策责任之前,还需要更深入的研究;许多病患依旧希望我们是医师,而非另类的Google查找器。
  
  资料来源:http://www.24drs.com/
  
  Native link:Many Kids With Uncomplicated Appendicitis Can Skip Surgery

Many Kids With Uncomplicated Appendicitis Can Skip Surgery

By Troy Brown, RN
Medscape Medical News

Most children with uncomplicated appendicitis avoided surgery at 1 year when they and their families initially chose to manage the condition nonoperatively, according to a prospective patient choice cohort study published online December 16 in JAMA Surgery.

"Families who choose to treat their child's appendicitis with antibiotics, even those who ended up with an appendectomy because the antibiotics didn't work, have expressed that for them it was worth it to try antibiotics to avoid surgery," Peter C. Minneci, MD, from the Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, and the Department of Surgery, Nationwide Children’s Hospital, Columbus, Ohio, said in a news release.

"These patients avoided the risks of surgery and anesthesia, and they quickly went back to their activities," he said.

The study included 102 patients aged 7 to 17 years diagnosed with acute uncomplicated appendicitis from October 1, 2012, through March 6, 2013. Of those, 37 chose to manage the appendicitis nonoperatively and 65 chose to undergo surgery.

The study's primary outcome was the success rate of nonoperative management at 1 year, where success was defined as "not having undergone an appendectomy at 1 year." Secondary outcomes included comparisons of the rates of complicated appendicitis, disability days for the child, disability rates for the parent, and healthcare costs at 1 year.

The researchers defined complicated appendicitis as having pathological analysis showing ruptured, perforated, or gangrenous appendicitis.

The success rate of nonoperative management was 94.6% (95% confidence interval [CI], 81.8% - 99.3%; 35 of 37 children), 89.2% (95% CI, 74.6% - 97.0%; 33 of 37 children), and 75.7% (95% CI, 58.9% - 88.2%; 28 of 37 children) at hospital discharge, 30 days, and 1 year, respectively.

The overall success rate of nonoperative management was 75.7% (28 of 35 children) at a median follow-up of 21 months.

The nonoperative group had longer hospitalizations compared with the surgery group (median, 37 [interquartile range (IQR), 29 - 41] vs 20 [interquartile range (IQR) 15 - 30] hours, respectively; P < .001). Two patients in the nonsurgical group had readmissions for recurrent appendicitis within 30 days and underwent laparoscopic appendectomy.

The rates of complicated appendicitis at 1 year were not significantly different between the two groups, at 2.7% (1 of 37 children) for the nonoperative management group and 12.3% (8 of 65 children) for the surgery group (P = .15).

At 1 year, the postoperative complication rate in those who chose surgery was 7.7% (five of 65 patients), with two major complications (one readmission, one reoperation). No postoperative complications occurred among the nonoperative patients who underwent appendectomy later.

Healthcare-related quality-of-life scores were similar for the two groups at 1 year. Nonoperative management was associated with significantly fewer disability days at 1 year compared with surgery (median, 8 [IQR, 5 - 18] vs 21 [IQR, 15 - 25] days, respectively; P < .001).

And nonoperative management was associated with lower total appendicitis-related healthcare costs at 1 year compared with surgery (median, $4219 [IQR, $2514 - $7795] vs $5029 [IQR, $4596 - $5482], respectively; P = .01).

The cost sensitivity analysis showed that total appendicitis-related healthcare costs at 1 year remained significantly lower in the nonoperative group compared with in the surgery group (median, $4219 [IQR, $2691 - $6536] vs $4992 [IQR, $4688 - $5636], respectively; P = .01).

"When Should Patients Have the Choice?"

"The idea that patient choice both empowers the patient and improves overall patient satisfaction is well established. The question is, when should patients have the choice?" write Diana Lee Farmer, MD, and Rebecca Anne Stark, MD, from the University of California Davis School of Medicine and the University of California Davis Children’s Hospital, in an invited commentary.

The commentators note that the concept of patient choice has gained favor in "several niches of patient care."

"Demonstrating that different treatment options have equivalent outcomes is the first step in determining whether offering a choice is safe," they explain. "However, balancing the biases of both the physician and the patient is difficult, especially because physician bias is based on personal experience and comfort level and thus may be of more value than the bias of the patient."

They conclude, "Further study is needed in this arena before we completely abdicate the responsibility for guiding our patient's decision making. Many patients still want us to be 'doctors,' not Google impersonators."

The authors and commentators have disclosed no relevant financial relationships.

JAMA Surgery. Published online December 16, 2015.

    
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