左侧阑尾炎的临床分析(附2例报道及212例文献复习)

Clinical analysis of left-sided appendicitis: report of 2 cases and review of 212 published cases

目的总结左侧阑尾炎(left-sided appendicitis,LSA)的临床特点及诊治方法。方法计算机检索Pubmed、Google Scholar、万方、中国知网、维普及Sino Med数据库中的LSA相关文献(检索时间为1981年1月至2017年6月),结合重庆市北碚区中医院收治的2例LSA病例,总结LAS的临床特征及其诊治策略。结果共检索到92篇文献,共计212例LSA患者,联合笔者收治的2例,共计214例LAS患者纳入分析。疼痛固定部位:左下腹139例(65.0%),右下腹30例(14.0%),中下腹及左上腹各15例(7.0%),脐周8例(3.7%),右上腹3例(1.4%),中上腹及盆腔各2例(0.9%)。解剖结构异常分类:全内脏反位(situs inversus totalis,SIT)131例(61.2%),肠旋转不良(midgut malrotation,MM)53例(24.8%),盲肠游离21例(9.8%),阑尾过长4例(1.9%),升结肠游离2例(0.9%),其他3例(1.4%)。术前正确诊断LSA 114例(53.3%),其中术前正确诊断为SIT型LSA 98例(74.8%,98/131),正确诊断为MM型LSA 12例(22.6%,12/53)。3例(1.4%)行保守治疗,211例(98.6%)行手术治疗,术式:腹腔镜切除25例(11.7%),开腹手术145例(67.8%),不详41例(19.1%);开腹手术切口:腹直肌旁切口74例(51.0%),腹正中线切口16例(11.0%),左侧反麦氏点切口43例(29.7%),右侧麦氏点切口12例(8.3%)。结论 LSA的解剖异常主要以SIT和MM为主,异常的解剖结构及不准确的疼痛定位使LSA的诊断存在一定的困难,容易导致延迟诊断或误诊。腹腔镜手术或剖腹探查手术是LSA较为适用的手术方式。

Objective To investigate the clinical features, diagnosis, and surgical methods of left-sided appendicitis （LSA）. Methods We retrieved LSA-related literatures through Pubmed, Google Scholar English databases, Wanfang, CNKI, VIP, and SinoMed databases （published from January 1981 to June 2017）, as well as 2 cases of LSA who treated in Beibei Traditional Chinese Medical Hospital, to analyze the clinical characteristics of LSA and its diagnosis and treatment methods. Results There were 92 articles in a total of 212 LSA patients were retrieved, and 2 cases treated in Beibei Traditional Chinese Medical Hospital, a total of 214 LSA patients were included in the analysis. Pain fixed position of LSA： 139 cases （65.0%） located in left-lower quadrant, 30 cases （14.0%） located in right-lower quadrant, 8 cases （3.7%） located in peri-umbilical, 15 cases （7.0%） located in mid-lower abdomen, 15 cases （7.0%） located in left-upper quadrant, 3 cases （1.4%） located in right-upper abdomen, 2 cases （0.9%） located in mid-upper abdomen, 2 cases （0.9%） located in pelvic cavity, respectively. LSA had occurred in association with several types of abnormal anomalies： 131 cases （61.2%） suffered from situs inversus totalis （SIT）, 53 cases （24.8%） suffered from midgut malrotation （MM）, 21 cases （9.8%） suffered from cecal malrotation, 4 cases （1.9%） suffered from long appendix, 2 cases （0.9%） suffered from free ascending colon, and 3 cases （1.4%） were unclear. The diagnosis of 114 LSA cases （53.3%） before operation was correct, in which the correct diagnosis rates of SIT-LSA and MNI-LSA were 74.8% （98/131） and 22.6% （12/53）, respectively. Three patients （1.4%） underwent conservative treatment, and 211 patients （98.6%） underwent surgical treatment, including 25 cases （11.7%） of laparoscopic surgery, 145 cases （67.8%） of open abdominal surgery, and unknown of 41 cases （19.1%）. Laparotomy incision： abdominal incision in 74 cases （51.0%）, ventral midline incision in 16 cases （11.0%）, the left side of the anti McBurney incision in 43 cases （29.7%）, right McBurney incision in 12 cases （8.3%）. Conclusions LSA mainly occurs in association with 2 types of congenital anomalies： SIT and MM. There is some difficult to make diagnosis for abnormal anatomy and inaccurate pain location of LSA, so it is easy to cause the delay in diagnosis or misdiagnosis. For LSA, the choices oflaparoscopy or laparotomy operation methods are applicable.