穿孔性阑尾炎手术切除后是否腹腔引流的近期预后分析的随机对照试验

Prognosis of peritoneal drainage after perforated appendicitis:a randomized controlled study

目的腹腔脓肿是穿孔性阑尾炎(PAP)最常见的并发症,阑尾切除术后是否行腹腔引流取决于阑尾炎症严重程度,但是很大程度上还是取决于术者的专业知识和个人习惯,国际上并未就穿孔性阑尾炎术后是否常规行腹腔引流达成共识。本试验评估阑尾炎伴穿孔患者术后是否腹腔引流的近期预后并比较预后的差异,同时比较腹腔镜阑尾切除术(LA)及开腹阑尾切除术(OA)预后的差异。方法本试验为随机对照试验(RCT),纳入自2012年3月收入我科术中诊断为穿孔性阑尾炎患者540例,采取简单随机分组方法将患者分为试验组(腹腔引流)和对照组(不行腹腔引流),采用χ2检验和t检验对相关资料进行分析。结果 2012年3月2日至2015年4月30日,本试验共纳入540例穿孔性阑尾炎患者并完成阑尾切除术。试验组与对照组术后总并发症发生率分别为11.5%(31/270)和35.2%(95/270),术后腹腔脓肿发生率分别为5.2%和14.8%,术后腹痛发生率分别为0%和13.7%,组间差异有统计学意义(P均<0.05),而切口感染率(5.6%vs.6.3%,P=0.175)以及术后残端瘘(0.7%vs.0.4%,P=0.563)组间差异无统计学意义;两组患者术后再次干预发生率(14.1%vs.32.6%)、经皮/直肠腹腔穿刺引流发生率(0.7%vs.7.8%)以及术后抗生素使用(13.0%vs.23.0%),差异有统计学意义(P均<0.05);术后再次手术和术后住院时间两组患者差异无统计学意义(P=0.102,P=0.094)。LA与OA预后指标比较,两组患者术后并发症发生率分别为35.1%(87/248)和14.6%(34/233),差异有统计学意义(P<0.000 1),术后再次干预发生率分别为19.3%(45/233)和30.2%(75/248),差异有统计学意义(P=0.006),两组患者术后住院时间差异无统计学意义(4.4 d vs.4.2 d,P=0.117)。结论穿孔性阑尾炎术后行腹腔引流可有效降低术后并发症以及术后再次干预发生率,显著提高近期疗效。LA近期疗效优于OA。

Objective The intra-abdominal abscess（IAA） is the most common complication of perforated appendicitis（PAP）. It is critic that whether performing peritoneal drainage（PD） or not after appendectomy depending on the severity of appendicitis, but a large extent depends on the professional knowledge and personal habits. In this study, we evaluated the prognosis of patients with appendicitis with perforation or not after operation. Additionally, we assessed the differences of prognosis between LA and OA. Methods This was a randomized controlled trial（RCT）. Since March 2012, 540 patients with perforated appendicitis were included in our study. The patients were divided into experimental group（PD group） and control group（No PD）. The data were analyzed by using χ2 test and t test. Results During March 2, 2012 and April 30, 2015, 540 patients with PAP were enrolled and received appendectomy. For PD group and control group, the postoperative complications were 11.5%（31/270） and 35.2%（95/270）; postoperative IAA incidence rate was 5.2% and 13.7%, respectively; the incidence rate of postoperative pain were 0% and 14.8%, respectively. The incidence of incision infection（5.6% vs. 0.4%, P=0.175） and stump leakage（0.7% vs. 0.4%, P=0.563） were similar. Postoperative re-intervention of two groups was different significantly（14.1% vs. 32.6%, P〈0.000 1）. The percentage of percutaneous/transrectal drainage of two groups were 0.7% and 7.8%, and the incidence of prolonged intravenous antibiotics were 13.0% and 23.0%（P〈0.05, respectively）. There was no significant difference of re-operation and hospital stay in two groups. Compared with OA, LA resulted in a lower complications and re-intervention（14.6% vs. 35.1%, P〈0.000 1; 19.3% vs. 30.2%, P=0.006, respectively）. There was no significant difference of hospital stay between the two groups（4.2 d vs. 4.4 d, P=0.117）. Conclusion PD after PAP can effectively reduce postoperative complications and significantly improve the short-term prognosis. Laparoscopic appendectomy is more suitable than open surgery.