無併發症闌尾炎的孩童可以不用手術


  【24drs.com】根據線上發表於12月16日JAMA外科學期刊的一篇前瞻式病患選擇世代研究,無併發症闌尾炎的大部份孩童,如果他們與他們的家人一開始選擇以非手術方式處理,在一年時,可以避免手術。
  
  俄亥俄州哥倫布市全國兒童醫院外科、全國兒童醫院研究中心、手術結果研究中心Peter C. Minneci醫師在新聞稿中表示,家屬選擇用抗生素治療孩子的闌尾炎,即便後來如果抗生素無效還是要進行闌尾切除術,他們認為嘗試使用抗生素而避免手術是值得的。
  
  他表示,這些病患避免了手術與麻醉的風險,且快速地恢復原來的活動。
  
  這篇研究包括了102名年齡7-17歲,在2012年10月1日至2013年3月6日間診斷有急性闌尾炎者,其中,37人選擇使用非手術方式治療闌尾炎,65人選擇進行手術。
  
  研究的主要結果是,一年時的非手術處置成功率,成功的定義為一年時不用進行闌尾切除術;次級結果包括比較有併發症之闌尾炎發生率、孩童的失能天數、家長的失能比率、一年時的健康照護費用。
  
  研究者定義有併發症之闌尾炎為,病理分析顯示破裂、穿孔或壞疽性闌尾炎。
  
  非手術處置的成功率,在出院、30天、1年時分別為:94.6% (95%信賴區間[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)。
  
  在中位數21個月的追蹤期,非手術處置的整體成功率為75.7%(35名中有28人)。
  
  非手術組的住院期間比手術組長(中位數37小時 [四分位距(IQR), 29 - 41] vs 20 [四分位距(IQR) 15 - 30]小時,P < .001),非手術組有2名病患因為30天內復發闌尾炎而再度住院,並接受了腹腔鏡闌尾切除術。
  
  在一年時,兩組有併發症的闌尾炎比率沒有顯著差異,非手術組為2.7% (37名中有1人) 、手術組為12.3% (65名中有8人) (P = .15)。
  
  在一年時, 手術組病患的術後併發症比率為7.7% (65名中有5人),其中2例為嚴重併發症(1例再度住院、1例再度手術),後來進行闌尾切除術的非手術組病患,沒有發生術後併發症。
  
  兩組在一年時的健康照護相關生活品質是類似的,相較於手術組,非手術處理與一年時的失能天數顯著較少有關(中位數,8天[IQR, 5 - 18] vs 21天[IQR, 15 - 25];P < .001)。
  
  相較於手術組,非手術處理與一年時的闌尾炎照護相關總費用較低有關(中位數,$4,219 [IQR, $2,514 - $7,795] vs $5,029 [IQR, $4,596 - $5,482];P = .01)。
  
  成本敏感性分析顯示,相較於手術組,非手術處理組在一年時的闌尾炎照護相關總費用依舊顯著較低(中位數,$4,219 [IQR, $2,691 - $6,536] vs $4,992 [IQR, $4,688 - $5,636];P = .01)。
  
  加州大學戴維斯醫學院、加州大學戴維斯兒童醫院的Diana Lee Farmer醫師與Rebecca Anne Stark醫師,在受邀發表評論時時寫道,可以確認的是,病患的選擇對病患有利,且改善了整體的病患滿意度,問題是,病患在何時可以做選擇?
  
  這兩位評論作者指出,病患選擇的概念在病患照護的諸多利基中獲得青睞。
  
  他們解釋,在確認是否提供安全的選擇時,第一步是,只出不同的治療選項有相當程度的結果,不過,在醫師和病患的偏見之間取得平衡是困難的,特別是因為醫師的偏見是根據個人的經驗與舒適度,因此,可能比病患的偏見更有價值。
  
  他們結論指出,在我們完全放棄指導病患的決策責任之前,還需要更深入的研究;許多病患依舊希望我們是醫師,而非另類的Google搜尋器。
  
  資料來源: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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