European Journal of Trauma and Emergency Surgery ( IF 1.9 ) Pub Date : 2023-01-24 , DOI: 10.1007/s00068-022-02191-8 Gary Alan Bass 1, 2, 3, 4 , Lewis J Kaplan 1, 5 , Maximilian Peter Forssten 2 , Thomas N Walsh 6 , Yang Cao 7 , Shahin Mohseni 2 ,
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Introduction
Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications.
Material and methods
We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy (ClinicalTrials.gov Registration: NCT04365491). We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. Outcome measures of interest were the incidence of complications, unplanned reoperation, readmission, admission to the ICU, death, hospital length of stay, and procedure duration. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs).
Results
Three-thousand seven hundred sixty-eight consecutive adult patients, included from 71 centers in 14 countries, were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1379(37.0%), with a stapler in 1421(38.1%) and between clips in 929(24.9%). The technique for securely dividing the appendix at its base in acutely inflamed (AAST Grade 1) appendicitis was equally divided between division between looped ligatures, clips and stapled transection. However, the technique used differed in complicated appendicitis (AAST Grade 2 +) compared with uncomplicated (Grade 1), with a shift toward transection of the appendix base by stapler (58% vs. 38%; p < 0.001). While no statistical difference in outcomes could be detected between different techniques for division of appendix base, decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41–0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11–0.96), p = 0.045] complications could be detected when using energy devices.
Conclusions
Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Technique selection for both mesoappendix transection and appendix resection correlates with AAST grade. Higher grade led to more ultrasonic tissue transection and stapled appendix resection. Higher AAST appendicitis grade also correlated with infection-related complication occurrence. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intraoperative surgical technique toward advanced adjuncts.
中文翻译：
阑尾系膜横切和阑尾切除技术：来自 ESTES SnapAppy 研究的见解
介绍
手术治疗的阑尾炎在阑尾系膜横切和阑尾基部截肢技术方面表现出很大的异质性。目前尚不清楚特定的手术技术是否提供了结果益处或减少了并发症。
材料与方法
我们对所有在 SnapAppy 期间入院时接受腹腔镜阑尾切除术的患者进行了预先指定的亚组分析（ClinicalTrials.gov 注册号：NCT04365491）。我们收集了关于手术技术、患者人口统计和疾病严重程度指数的常规匿名观察数据，没有改变临床护理途径或通常的外科医生偏好。感兴趣的结果指标是并发症的发生率、计划外再次手术、再入院、入住 ICU、死亡、住院时间和手术持续时间。我们使用具有稳健标准误差的泊松回归模型来计算事件率比率 (IRR) 和 95% 置信区间 (CI)。
结果
来自 14 个国家 71 个中心的 3768 名连续成年患者从入院之日起接受了为期 90 天的随访。1564 例 (69.4%) 和 688 例 (30.5%) 使用电烙术止血切开阑尾系膜。阑尾在 1379 例 (37.0%) 中通过环状结扎线、1421 例 (38.1%) 中的订书机和 929 例 (24.9%) 中的夹子之间的基部被截断。在急性发炎（AAST 1 级）阑尾炎中，在底部安全地分割阑尾的技术在环状结扎、夹子和钉合横断之间进行均等划分。然而，复杂性阑尾炎（AAST 2 级以上）与无并发症性阑尾炎（1 级）所使用的技术不同，转向通过吻合器横切阑尾基部（58% 对 38%；p < 0.001）。虽然在不同的阑尾基部划分技术之间没有检测到结果的统计差异，但任何 [调整后的 IRR (95% CI)：0.58 (0.41–0.82)，p = 0.002] 和严重 [调整后的 IRR ( 95 % CI): 0.33 (0.11–0.96), p = 0.045] 使用能量设备时可以检测到并发症。
结论
安全的阑尾系膜横切和阑尾切除术是使用异构技术完成的。阑尾系膜横切术和阑尾切除术的技术选择与 AAST 等级相关。更高的等级导致更多的超声组织横断和缝合阑尾切除术。较高的 AAST 阑尾炎分级也与感染相关并发症的发生相关。尽管急性阑尾炎方法的总体耐受性良好，但疾病敏锐度或复杂性的增加似乎鼓励术中手术技术对高级辅助手术的同质性。
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