阑尾炎一定要用手术治疗吗?


  【24drs.com】根据一篇新研究,以计算机断层(CT)证实,无并发症的阑尾炎,使用抗生素治疗和阑尾切除术一样有效。在一年的追踪期间,随机分组接受抗生素治疗的大多数患者并不需要阑尾切除术,而那些接受阑尾切除术者也没有显著并发症。尽管如此,当以非劣性试验比较这两种治疗时,研究者发现,抗生素治疗并没有达到预先设定的非劣性标准。
  
  芬兰Turku大学医院Paulina Salminen博士等人在6月16日的JAMA期刊发表了「Appendicitis Acuta (APPAC)」多中心试验的结果。
  
  研究者随机指派病患到手术组接受阑尾切除术或者到抗生素组接受广效抗生素(ertapenem、levofloxin和metronidazole)治疗,研究者指出,许多病患选择接受手术,研究者难以招募有意愿被指定到抗生素组的病患,接受阑尾切除术者中,15人(5.5%)接受的是腹腔镜阑尾切除术。
  
  作者们写道,就我们所知,APPAC试验是迄今有关抗生素治疗阑尾炎的最大型多中心、开放卷标、非劣性[随机控制试验]。进行研究设计时,我们假设避免手术会有充分的好处,抗生素组的可接受失败率为24%。然而,我们发现失败率是27.3% (95%信赖区间为22.0%-33.2%)而无法建立抗生素治疗阑尾炎的非劣性论述。
  
  研究者也发现,72.7%(95%信赖区间为66.8% - 78.0%)的病患是无并发症的急性阑尾炎,只接受抗生素治疗后即恢复。随机指派到抗生素组的8名病患被误认为是有并发症的阑尾炎而进行了不必要的阑尾切除术,这8个病患的资料可能会干扰了这篇研究结果。
  
  抗生素组病患的平均住院天数比手术组患者长,不过,研究者指出,抗生素组患者的最短住院天数是由治疗规范指定,未来可能可以缩短。
  
  以前的试验曾经提出抗生素治疗在阑尾炎治疗中的角色,不过,这些试验的信赖度受限于仅有急性阑尾炎诊断、抗生素治疗时间、主要终点的确认不佳,也因此,之前这些试验的结果各异就不意外了。
  
  阑尾炎可能是没有并发症与急性的,也可能并发穿孔、腹内脓疡和/或粪石。例如,之前一篇研究发现,粪石患者比较可能发生有并发症的急性阑尾炎,而无法使用抗生素治疗。
  
  目前这篇研究试图避免这个问题,所以只纳入由计算机断层确认诊断为无并发症急性阑尾炎的患者,例如,他们排除了粪石患者。
  
  计算机影像让筛选病患成为可行的,作者们解释计算机断层的好处指出,我们研究的另一个特点是,藉由计算机断层而使阴性阑尾切除术比率降低,使用计算机断层也使我们可以辨识无并发症的急性阑尾炎,我们在这篇研究中成功地以抗生素治疗了大部分患者。
  
  目前这篇研究的另一个强度是研究者选用的抗生素,他们在文章中强调,成功地以抗生素治疗阑尾炎需要选择广效性抗生素,以治疗引起阑尾炎的许多病原菌。
  
  作者们建议,计算机断层证实无并发症之急性阑尾炎患者,应告知患者,使其有机会在抗生素治疗与阑尾切除术之间有所选择。
  
  伊利诺州芝加哥西北大学Feinberg医学院的Edward Livingston医师、马里兰州巴尔的摩约翰霍普金斯医学院的Corrine Vons博士同意,并执笔编辑评论指出,无并发症阑尾炎患者放弃进行阑尾切除术的时机已来临,这个手术已经用于患者超过100年,随著像计算机断层这种精密诊断工具的发展以及有效的广效抗生素治疗,目前用于多数急性阑尾炎病例的阑尾切除术,对于无并发症的阑尾炎就是不必要的了。
  
  不过,德州休士顿贝勒医学院外科医师、未参与本篇研究的Monica E. Lopez医师仍未被说服,整体而言,她不认为这篇研究的结果会改变实务。
  
  资料来源:http://www.24drs.com/
  
  Native link:Does Appendicitis Have to Be Treated With Surgery?

Does Appendicitis Have to Be Treated With Surgery?

By Lara C. Pullen, PhD
Medscape Medical News

Antibiotic treatment of patients with computed tomography (CT)-proven, uncomplicated appendicitis may be as effective as appendectomy, according to a new study. The majority of patients randomly assigned to receive antibiotic treatment did not require an appendectomy during 1 year of follow-up, and those who did receive an appendectomy did not have significant complications. Despite this, when the two treatments were compared in a noninferiority trial, the investigators found that antibiotic treatment did not meet the prespecified criterion for noninferiority.

Paulina Salminen, MD, PhD, from the Turku University Hospital in Finland, and colleagues published the results of the Appendicitis Acuta (APPAC) multicenter trial in the June 16 issue of JAMA.

The researchers randomly assigned patients to either a surgery group to receive an appendectomy performed using the standard open technique or to an antibiotic group to receive broad-spectrum antibiotics (ertapenem, levofloxin, and metronidazole). The investigators note that many patients elected to receive surgery, and the investigators had difficulty recruiting patients willing to be assigned to the antibiotic group. Of those who underwent appendectomy, 15 (5.5%) patients underwent laparoscopic appendectomy.

"To our knowledge, the APPAC trial is the largest multicenter, open-label, noninferiority [randomized controlled trial] of antibiotic treatment for appendicitis conducted to date. When the trial was designed, we assumed that there would be sufficient benefits from avoiding surgery and that a 24% failure rate in the antibiotic group would be acceptable. Instead, we found a failure rate of 27.3% (95% confidence interval, 22.0%-33.2%) and were not able to establish the noninferiority of antibiotic treatment for appendicitis," the authors write.

The investigators did find that 72.7% (95% confidence interval, 66.8% - 78.0%) of patients with uncomplicated acute appendicitis recovered after receiving only antibiotic therapy. Eight patients randomly assigned to the antibiotic group were mistakenly identified as having complicated appendicitis and received an appendectomy that may not have been required. These eight patients may have confounded the results of the study.

Patients in the antibiotic group had a longer median length of hospital stay than patients in the surgery group. The investigators note, however, that the minimal length of hospital stay for patients in the antibiotic group was specified in the treatment protocol and could likely be shortened in the future.

Previous trials have addressed the role of antibiotic therapy as a treatment for appendicitis. These trials were limited, however, by their reliance on clinical diagnosis of acute appendicitis, duration of antibiotic treatment, and poor determination of the primary endpoint. Not surprisingly, the results from these previous trials have been mixed.

Appendicitis may present as uncomplicated and acute, or it may be complicated by a perforation, intraabdominal abscess, and/or appendicoliths. A previous study, for example, found that patients with appendicoliths were more likely to have complicated acute appendicitis and to fail antibiotic treatment.

The current study attempted to avoid this problem by enrolling only patients with a CT-confirmed diagnosis of uncomplicated acute appendicitis. They excluded, for example, patients with appendicoliths.

CT imaging made such patient selection feasible. The authors explained the benefits of CT imaging: "Another feature of our study was the low negative appendectomy rate attributable to CT imaging. Use of CT also enabled us to identify uncomplicated acute appendicitis that was successfully treated with antibiotics alone in the majority of patients enrolled in our study," the authors write.

Another strength of the current study was the investigators' choice of antibiotics. They emphasized in their article that successful antibiotic treatment of appendicitis requires the selection of an antibiotic that provides broad-spectrum coverage of the many pathogens that might cause appendicitis.

The authors suggest that patients diagnosed with CT-proven uncomplicated acute appendicitis be given the opportunity to make an informed decision between antibiotic treatment and appendectomy.

Edward Livingston, MD, from Northwestern University Feinberg School of Medicine in Chicago, Illinois, and Corrine Vons, MD, PhD, from Johns Hopkins School of Medicine in Baltimore, Maryland, agree and penned an accompanying editorial to that effect. They write that, "[t]he time has come to consider abandoning routine appendectomy for patients with uncomplicated appendicitis. The operation served patients well for more than 100 years. With development of more precise diagnostic capabilities like CT and effective broad-spectrum antibiotics, appendectomy may be unnecessary for uncomplicated appendicitis, which now occurs in the majority of acute appendicitis cases."

Monica E. Lopez, MD, a surgeon at Baylor College of Medicine in Houston, Texas, who was not involved in the study, remains, however, unconvinced: "Overall, I don't think the findings of the study warrant a change in practice," she explained in an email to Medscape Medical News.

Dr Salminen reported receiving personal fees for lectures from Merck and Roche. The other authors, the editorialists, and Dr Lopez have disclosed no relevant financial relationships.

JAMA. 2015;313:2340-2348.

    
相关报导
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2016/10/24 下午 05:46:10
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