腹腔镜阑尾切除术治疗急性阑尾炎：如何阻止外科医生使用不充分的治疗方法

概要
急性阑尾炎（AA）以渐进和不可逆的方式发展，即使AA的临床过程可以通过有意的药物暂时改变。可以基于白细胞计数和增强的计算机断层扫描的发现来进行AA的可靠和实时诊断。急诊腹腔镜阑尾切除术（LA）被认为是AA的首选治疗选择。在疾病发作后6-12周的间隔/延迟阑尾切除术被认为是不安全的，在等待时间内具有高复发率。然而，该技术可以具有一些优点，以避免患有阑尾肿块的患者不必要的延长切除。 AA的非手术管理只能在儿童中容忍。术后并发症根据患者的因素而增加，急诊全身麻醉的时间避免可能对高危患者有益。外科医生的技能和合作对于成功的洛杉矶来说非常重要。从诊断开始延迟阑尾切除术不到24小时是安全的。另外，根据患者，医生和机构的因素，半选择性方式（即症状发作后24小时内的LA）可能是矛盾的。 AA是强制性的LA。幸运的是，日本政府使用覆盖洛杉矶的全民健康保险制度。

关键词：腹腔镜阑尾切除术，急性阑尾炎，间隔阑尾切除术，手术，延迟阑尾切除术
核心提示：急性阑尾炎以渐进和不可逆的方式发展，急诊腹腔镜阑尾切除术（LA）是强制性的。日本政府使用全民医疗保险制度。根据医学伦理，任何医生和机构都可以在日本常规执行昂贵的急诊LA。不安全但具有成本效益的治疗方法，例如间隔/延迟阑尾切除术和保守治疗仅在日本不适用。在日本应该尊重历史悠久的做法（即新兴的LA）。

介绍
急性阑尾炎（AA）是一种临床诊断[1,2]。第一次阑尾切除术于1886年在纽约进行[1]，此后，阑尾切除术被认为是最常见的急诊手术[2-4]。由于进展为晚期病理生理学的风险，即时阑尾切除术一直是AA的标准治疗方法[3]。

目前，腹腔镜阑尾切除术（LA）可作为AA的首选治疗选择[1,3]。然而，患者入院时随叫随到的外科医生是确定患者是否可以接受有利的LA或常规开放手术的重要因素[5]。此外，对于急诊腹腔镜手术不利组合的医院临床病程较差是一个关键问题[3,6]。简而言之，医院和医生的因素会影响AA的严重程度[3,5-7]。

二级/三级医院的24小时手术转移给外科医生带来了压力[8]。在加班和休息期间的紧急手术导致更高的发病率和死亡率[9,10]。然而，AA表示手术紧急情况。

一旦开始抗生素治疗，AA可以以选择性方式进行管理[2,11-14]。对AA进行间歇性和/或延迟性阑尾切除术的初始非手术治疗受到了挑战，特别是在儿科患者中[3]。然而，间隔/延迟阑尾切除术的必要性和有效性在成人患者中仍存在争议[2,3,11-18]，尽管一些研究人员认为间隔/延迟阑尾切除术仅对治疗阑尾肿块有一定的优势[12,14]。 ]。

作者根据之前的研究回顾了AA管理中的主要争议，并讨论了哪些实践是AA患者的最佳选择。

病理生理
AA的确切机制仍不清楚，但据信是多因素的。可能涉及膳食纤维，家族因素和来自粪便嵌塞或淋巴样增生的管腔阻塞以及其他过程（例如寄生虫感染）不足[19-22]。外部（即淋巴组织增生）或内部（即，浓缩的粪便物质和附睾）压迫引起的腔内阻塞起着重要的病理生理作用[3]。这随后导致粘液产生增加，细菌过度生长，病毒感染和淤滞，这增加了阑尾壁张力[3,19-24]。因此，血液和淋巴液流量减少，坏死和穿孔随之而来[3]。由于这些事件会随着时间的推移而发生，因此只有早期手术方法才能预防疾病进展[3,4]。回盲部周围的免疫管发育良好且复杂，阑尾具有自身的免疫学特征[25-28]。已经鉴定了许多主要的免疫和细胞功能相关基因组，其涉及AA的保护作用，随后在实验性结肠炎中进行阑尾切除术[25]。

一旦疾病被触发，AA就会以渐进和不可逆转的方式发展[3,4,29]。即使是组织学上正常的阑尾也清楚地显示了针对AA的炎症反应的证据，如细胞因子产生/表达所示[29]。

阑尾肿块（穿孔AA后肿瘤形成）是围住阑尾穿孔的最终结果[2,16]。在病理学上，这种肿块可能从痰到脓肿[16]。含有脓的肿块是炎性肿瘤，由发炎的阑尾，邻近的内脏和较大的网膜组成[16]。

在AA中，肿瘤坏死因子-α位于通路的顶端[29,30]，干扰素-γ和白细胞介素-6起重要作用[30,31]。 Fas介导的细胞凋亡诱导是淋巴细胞选择和免疫过程下调的主要因素，内皮细胞Fas配体表达在AA中升高[26]。 AA在渐进和不可逆的途径中发展[2,16]，即使AA的临床过程可以通过有意的药物暂时改变[32]。

诊断价值
AA的物理发现已经确立[33]。许多研究人员，如Charles McBurney，Niels Thorkild Rovsing，Jacob Moritz Blumberg，Otto Lanz，Frederic Treves等人参与了AA的初步研究[1,34]。大多数患者在疾病过程早期出现[2]，尽管在2％-6％的患者中，在术前成像时发现阑尾肿块时进行诊断[16,35]。年轻女性患者被错误诊断为AA的风险最高，因此进行了不必要的手术[36]。

计算机断层扫描（CT）对于诊断比超声检查更可靠[37,38]，对于疑似阑尾炎应常规进行CT检查[39]。增强CT扫描已成为AA患者的主要诊断工具，具有高灵敏度和特异性[39]。简而言之，增强CT是严格诊断和评估炎症程度的有力工具[15,36,37,39-42]，增强CT优于医生的临床检查[36,37,39,40] 。螺旋CT图像研究应该进行对比增强，即使剂量较低[37,43]。针对疑似阑尾炎的常规CT可改善患者的护理，缩短手术时间，减少医院资源的使用和总体入院费用[39]。

实验室数据显示白细胞（WBC），C反应蛋白（CRP）和白细胞介素-6的血清水平与AA有关[44-46]。最可靠的标记既不是中性粒细胞计数也不是CRP，而是WBC计数[1,44]。

白细胞计数和CT检查结果同样为外科医生提供补充信息，以识别紧急手术的必要性[36,44,47]。随着WBC测量和增强CT成像的发展，阴性阑尾切除率已降至<5％[1,36,40,48]。

LA的历史
LA于1983年报道[49]。此后，与传统的开放式手术相比，LA的一些优点，如疼痛减轻，化妆品更少，住院时间更短，伤口恢复更快，成本更低，显示出来自20世纪90年代[50-63]。 LA的术后并发症也低于常规开放手术[56,64-66]。因此，LA已成为全球标准手术[1,15,50,62,65-67]。尽管手术时间（包括埋置缝合线）在LA [50-52,55]可能更长，但开腹和腹腔镜阑尾切除术之间的严重发病率/死亡率没有显著差异[68]。目前，自然孔口经腔内窥镜手术也被认为是安全可行的[69,70]。

手术期限
许多医生对从症状发作到手术的持续时间感兴趣。在AA成人患者中，发生晚期病理生理学和术后并发症的风险随着时间而增加[3,4]。然而，少数人认为从手术入院到麻醉诱导的持续时间在总体发病率或严重发病率/死亡率的回归模型中无法预测[71]。

间期/延迟阑尾切除术被认为是不安全的[3]，虽然术语“间隔阑尾切除术”只能用于阑尾肿块并且在疾病开始后6-12周进行[1,12,14]。寻求医疗帮助的任何延误导致难以控制AA，并且必须立即进行阑尾切除术[3,4]。间期/延迟阑尾切除术可能不会增加穿孔和中度/重度并发症的风险[1,71,72]，但与非穿孔性阑尾炎患者手术部位感染（SSI）风险增加和住院时间延长显著相关[71,73]。有必要及时进行外科手术，以避免在这一人群中出现额外的发病率[73]。

转移患者不太可能破裂，主要是因为他们早期出现[72]。阑尾切除术延迟24小时的患者发病率并未增加[1]。从诊断开始延迟阑尾切除术超过6小时但不到24小时是安全的，并且不会导致更差的结果[74]。这有助于限制对外科医生和手术室时间表的干扰[74]。矛盾的是，根据医生和医院的因素，以半选择的方式接近的AA（即症状出现后24小时内的LA）可能是可接受的[1,3,5-7,74]。

医生延迟避免阴性阑尾切除术并不影响疾病的阶段[7]。外科医生决定在医院观察患者以明确诊断是合理的[7]，因为它不会对结果产生不利影响[7]。

外科手术
LA的实际程序在图1,1,12和3.3中详细示出。仅在手术期间放置胃和膀胱导管进行减压以避免意外伤害[1]。


图1
端口放置和腹腔镜视图。 A-C：如果左侧横向端口设置为腹腔镜，则可以制作更宽角度的工作钳。 然而，仍然可见5毫米的刺伤疤痕; D-F：显示使用具有最佳美容效果的内窥镜的LA的端口放置。 LA：腹腔镜阑尾切除术。


图2
腹腔镜阑尾切除术的主要技术。 A：用于柔性腹腔镜的耻骨上端口（5 mm）放置在阴毛区域（蓝色虚线）以隐藏术后刺伤疤痕。 左侧侧口（3 mm）尽可能低，以便为工作钳提供足够的角度，并通过内衣隐藏术后刺伤疤痕; B：应该识别膀胱壁（红色箭头），膀胱圆顶（蓝色虚线）和中央脐带皱褶。 虽然耻骨上腹膜容易在端口插入期间延伸，但应放置耻骨上端口而不会造成膀胱损伤; C：应避免对左下腹部血管造成任何损伤; D：应该在不妨碍腹壁的情况下进行阑尾系膜（红色箭头）的反作用。 3毫米镊子的抓握力和旋转力就足够了。 可以以卷入方式（蓝色箭头）缩短阑尾，以避免腹壁受到任何干扰。


图3
腹腔镜阑尾切除术的关键技术。A：阑尾血管应清楚地解剖，并在没有夹子的情况下密封，以便随后使用内窥镜; B：应完全切除阑尾根（红色实心箭头）。灵活的内窥镜具有延长切除盲肠的优点（红色虚线箭头）; C：在放置内置物之前应识别回盲瓣（红色箭头）。应避免任何涉及此阀门的情况; D：应仔细检查外部倒置的吻合钉线。如果对残端有任何疑虑，可以添加几条间断的血管肌缝线。应移除不相关和溢出的吻合钉（蓝色箭头）。

残端阑尾炎是不完全手术的关键结果[75]，并且在LA期间对阑尾基部的管理很重要。外科医生需要决定对阑尾基部的最佳管理;选择包括剪辑，结扎。对于日间手术和延长切除盲肠的应用，柔性内镜具有一些优势[76-79]。然而，endostaple（Tri-camele camel 45 mm和iDrive; Medtronic，Minneapolis，MN，United States）的质量可能过高，并且成本高于结扎工具（Endoloop; Ethicon，Cincinnati，OH，United States）或夹闭合[80]。如果对残端有任何担忧，可以添加几条间断的血管肌缝线，尽管缝合技术在技术上要求很高[80]。

腹膜穿孔AA
外科医生应该意识到LA后腹腔脓肿形成的发生率可能更高[68,81,82]。使用endobags（RüschMemoBag; Teleflex，Wayne，PA，美国），阑尾残端的倒置，以及在仰卧位小心地进行腹部局部冲洗可以减少脓肿形成的发生率[81]。手术期间腹腔灌洗是治疗全身性腹膜炎的有效，安全，简单的方法[83]。应该用超过10L的生理盐水冲洗腹腔[84,85]，并且在手术后防止腹腔脓肿形成的生理盐水量的截止水平是12L [83]。不要犹豫，放一个引流管。在右腹部充分地形成穿过腹壁的排出通道，以防止排出脱位。

美容术
目前已接受初次闭合，即使是腹部脏伤的复杂性阑尾炎[86-88]。然而，手术后数天可能出现延迟闭合，可导致SSI降低，住院时间缩短，成本降低[89,90]。即使在复杂的阑尾炎中，LA也具有降低SSI率的优势[82,91-93]。

LA住院医生的稳定性
视频，如Nintendo Wii（Nintendo Co.，Ltd.，Kyoto，Japan）和Playstation 2（索尼互动娱乐公司，日本东京）[94-101]，以及腹腔镜表现技巧都很好地联系在一起。因此，年轻一代可能适合进行腹腔镜手术[94-101]。住院医生在外科医生的指导下进行的LA是安全可行的[102,103]。随着住院医生经验的增加，手术时间和术后并发症可以减少[104]。传统开放手术中的偶然阑尾切除术对于教育年轻外科医生也很重要[105]。

在等待时间内间隔/延迟的附件和复发
一些医生认为AA的管理仍存在争议[2,42]。阑尾肿块是穿孔AA的痛苦形式[2,16]。阑尾肿块的初始保守治疗首先在1901年被提倡作为一种解决方案[106]。在最初的非手术治疗[2,11-14]之后，选择性地进行间隔/延迟阑尾切除术，但是越来越多的证据[2,11-18,107,108]对其进行了质疑。

间隔/延迟阑尾切除术等待时间AA复发率为6％-37％[13-15,109-114]，复发AA手术并发症发生率也不低（3％-23％）[11,107,109,115] -117。间期/延迟阑尾切除术的倡导者认为，在等待期间，即使实际率很高，AA的复发率也很低[3,13-15,109-114]。间隔/延迟阑尾切除术通常在6-12周进行，主要是因为害怕复发性阑尾炎或担心存在恶性肿瘤[12,14,118,119]。

特别是在阑尾肿块中，间隔/延迟阑尾切除术可能具有一些优点。这些优点包括提供明确的诊断，排除任何潜在的伪装恶性肿瘤，并避免不必要的扩大切除[12,14,108,118-121]。

术后并发症
该综述表明成人AA患者的病理生理严重程度和并发症发生率具有时间依赖性[3]，因此推测阑尾切除术延迟是不安全的[3,4]。

AA导致的死亡率难以观察[3,76]，阑尾切除术后的死亡率几乎为零[76]。然而，老年患者，男性患者，使用类固醇，基线疾病，活动性肺炎和出血倾向的患者的发病率和死亡率明显增加[3,56,122]。应考虑围手术期注射抗生素以减少并发症，包括SSI [1,123,124]。 LA的术后并发症也低于常规开放手术[56,64,65]。

单独保守治疗
值得注意的是，在初步成功的保守治疗后，非手术治疗比常规间隔/延迟阑尾切除术具有成本优势[2]。从保守治疗阑尾肿块中恢复的患者应进行结肠镜检查或钡灌肠以检测任何潜在的疾病，并排除共存的结直肠癌[12,14,108,118-121]。

经验丰富的外科医生进行腹腔镜手术是治疗阑尾脓肿的安全可行的一线治疗方法[32,67]。此外，与可比的住院治疗相比，腹腔镜手术与再次入院次数减少和额外干预措施相比更少[67]。然而，非手术治疗在选定人群中具有良好的耐受性和有效性，特别是在儿童中[125-127]。一些最初接受保守治疗的患者不需要手术治疗[13,17,107,120,128]，AA不应再被视为间隔/延迟阑尾切除术的适应症[13,17,107,120,128,129]。常规间隔/延迟阑尾切除术使患者受益不到20％[14]。大多数复发发生在前6个月[14,109-112]，但在1年时降低到约2％[107,112,118]。重要的是，AA在渐进和不可逆的途径中发展[2,16]，即使AA的临床过程可以通过有意的抗生素临时修改[32]。在抗生素治疗期间，住院时间和术后并发症随着病理进展而增加[3]。

在阑尾脓肿和肿块的非手术治疗中逐步适应抗生素治疗是有效的[130]。一线抗生素的失败没有相关的预测因素[130]。使用第二代广谱头孢菌素（例如头孢替坦）进行单药治疗，每天两次，是一种经济有效的辅助治疗方案[38]。可以使用第三代头孢菌素[15]，但尚未推荐[131]。

具体情况
某些患者的情况特别列在手术适应症中，如老年人，妊娠和阴性阑尾切除术[1,48,129]。虽然已经报道了孕妇的LA，但应该避免胎儿丢失和阴性阑尾切除术[132,133]。现有的低级证据表明，孕妇的LA与胎儿丢失的风险增加有关[132,134]。阑尾切除术和早期阑尾炎与妊娠率增加有关[135]。患有早期阑尾炎的年轻女性的妊娠率高于晚期阑尾炎。提倡早期转诊进行腹腔镜检查和阑尾切除术[135]。可能偶然检测到阑尾肿瘤[136,137]。

合理的成本
据报道，LA的成本效益[57]。没有LA的非手术治疗成本最低[138]。在初步成功的保守治疗后，非手术治疗比常规间隔阑尾切除术具有成本优势[2]。

尽管自由使用一次性设备，LA仍然可以在国家关税范围内进行[139]。该程序的成本存在相当大的差异，并且可以通过更严格地使用一次性设备和标准化恢复协议来降低成本[139]。

讨论
临床上，许多外科医生认为洛杉矶是一种合适的治疗方法[76]。然而，LA需要全身麻醉，尽管目前正在尝试联合脊髓硬膜外麻醉或局部麻醉的LA [140,141]。 LA以半选择的方式（在症状出现后24小时内）可能有助于避免麻醉诱导的不舒服情况，例如饱腹和脱水[142,143]。然而，即使在高容量的中心，不利的组合，例如夜间手术室的低活动性，也会影响AA的临床过程[6]。总体而言，LA可能是半选择性的。

每个国家都有自己的健康保险制度。日本政府使用全民医疗保险制度。因此，在日本可以很容易地进行昂贵的成像研究和紧急手术。然而，在美国和欧洲，昂贵的研究和治疗选择可能不确定[144,145]。日本的新程序在被政府理事会列入健康保险制度列表之前不予批准[146]。矛盾的是，如果手术一旦被列入日本的医疗保险制度，任何医生和机构都可以根据医学道德规范地进行手术，甚至是昂贵的急诊手术。在日本，作者必须考虑如何单独拆除间隔/延迟阑尾切除术和抗生素。

诊断方法和随后的管理途径已经建立[147]。经验丰富的外科医生掌握或指导的洛杉矶是安全的，具有很多有益的优势[148,149]。大批量中心应常规进行紧急腹腔镜手术，包括LA [148]。医生和外科医生有一个很大的有趣前沿。

结论
AA是病理生理学上的进展性的。随着时间的推移，AA很难控制。 AA的强制要求二级/三级医院的LA，这种历史悠久的做法应该得到尊重。间隔/延迟阑尾切除术和保守治疗在日本是不合适的。可以问这样一个问题：“未来十年，急诊医师或普通外科医生应该去哪里？”作者认为重点是稳定世界各地的AA快速升级。

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