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抗生素非手术治疗儿童单纯性阑尾炎优于手术治疗
作者:小柯机器人 发布时间:2020/7/28 14:54:29

美国全国儿童医院阿比盖尔·韦克斯纳研究所Peter C. Minneci团队比较了使用抗生素非手术治疗和腹腔镜阑尾切除术对儿童单纯性阑尾炎的疗效。2020年7月27日,《美国医学会杂志》发表了这项成果。

单独使用抗生素可非手术治疗单纯性儿童阑尾炎,其失能天数少于手术治疗。

为了确定非手术治疗儿童单纯性阑尾炎的成功率,并比较非手术治疗与手术治疗的致残率、满意度、健康相关生活质量和并发症的差异, 2015年5月至2018年10月,研究组进行了一项多机构、非随机、对照、干预研究,在美国7个州的10家三级儿童医院招募了1068名7-17岁的单纯性阑尾炎儿童,平均年龄为12.4岁,女孩占38%。根据患者和家属选择,370例单独使用抗生素治疗,698例在入院12小时内紧急行腹腔镜阑尾切除术。

共有806例(75%)患者接受了完整的随访,其中非手术组284例(77%),手术组522例(75%)。与手术组相比,非手术组的患者更年幼(中位年龄分别为12.3岁和12.5岁),黑人占比高(9.6%和4.9%),其他种族占比高(14.6%和8.7%),看护人具有学士学位的占比高(29.8%和23.5%),接受超声诊断的占比高(79.7%和74.5%)。

在治疗逆概率加权(IPTW)后,一年内非手术治疗的成功率为67.1%。非手术组患者一年内的平均失能天数(定义为因阑尾炎相关护理而无法参加所有正常活动的天数)为6.6天,显著少于手术组(10.9天)。在其他16个预先指定的次要指标中,有10个没有显著差异。

总之,对于患单纯性阑尾炎的儿童,仅使用抗生素的初始非手术治疗策略的成功率为67.1%,且1年时的失能天数显著少于紧急手术治疗。

附:英文原文

Title: Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis

Author: Peter C. Minneci, Erinn M. Hade, Amy E. Lawrence, Yuri V. Sebastio, Jacqueline M. Saito, Grace Z. Mak, Christa Fox, Ronald B. Hirschl, Samir Gadepalli, Michael A. Helmrath, Jonathan E. Kohler, Charles M. Leys, Thomas T. Sato, Dave R. Lal, Matthew P. Landman, Rashmi Kabre, Mary E. Fallat, Jennifer N. Cooper, Katherine J. Deans

Issue&Volume: 2020-07-27

Abstract: Importance  Nonoperative management with antibiotics alone has the potential to treat uncomplicated pediatric appendicitis with fewer disability days than surgery.

Objective  To determine the success rate of nonoperative management and compare differences in treatment-related disability, satisfaction, health-related quality of life, and complications between nonoperative management and surgery in children with uncomplicated appendicitis.

Design, Setting, and Participants  Multi-institutional nonrandomized controlled intervention study of 1068 children aged 7 through 17 years with uncomplicated appendicitis treated at 10 tertiary children’s hospitals across 7 US states between May 2015 and October 2018 with 1-year follow-up through October 2019. Of the 1209 eligible patients approached, 1068 enrolled in the study.

Interventions  Patient and family selection of nonoperative management with antibiotics alone (nonoperative group, n=370) or urgent (≤12 hours of admission) laparoscopic appendectomy (surgery group, n=698).

Main Outcomes and Measures  The 2 primary outcomes assessed at 1 year were disability days, defined as the total number of days the child was not able to participate in all of his/her normal activities secondary to appendicitis-related care (expected difference, 5 days), and success rate of nonoperative management, defined as the proportion of patients initially managed nonoperatively who did not undergo appendectomy by 1 year (lowest acceptable success rate, ≥70%). Inverse probability of treatment weighting (IPTW) was used to adjust for differences between treatment groups for all outcome assessments.

Results  Among 1068 patients who were enrolled (median age, 12.4 years; 38% girls), 370 (35%) chose nonoperative management and 698 (65%) chose surgery. A total of 806 (75%) had complete follow-up: 284 (77%) in the nonoperative group; 522 (75%) in the surgery group. Patients in the nonoperative group were more often younger (median age, 12.3 years vs 12.5 years), Black (9.6% vs 4.9%) or other race (14.6% vs 8.7%), had caregivers with a bachelor’s degree (29.8% vs 23.5%), and underwent diagnostic ultrasound (79.7% vs 74.5%). After IPTW, the success rate of nonoperative management at 1 year was 67.1% (96% CI, 61.5%-72.31%; P=.86). Nonoperative management was associated with significantly fewer patient disability days at 1 year than did surgery (adjusted mean, 6.6 vs 10.9 days; mean difference, 4.3 days (99% CI, 6.17 to 2.43; P<.001). Of 16 other prespecified secondary end points, 10 showed no significant difference.

Conclusion and Relevance  Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year. However, there was substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not met.

DOI: 10.1001/jama.2020.10888

Source: https://jamanetwork.com/journals/jama/fullarticle/2768929

期刊信息

JAMA-Journal of The American Medical Association:《美国医学会杂志》,创刊于1883年。隶属于美国医学协会,最新IF:51.273
官方网址:https://jamanetwork.com/
投稿链接:http://manuscripts.jama.com/cgi-bin/main.plex