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基于国外指南解读老年急性阑尾炎诊治要点
Key points in the diagnosis and treatment of acute appendicitis in the elderly: An interpretation based on international guidelines
急性阑尾炎（AA）是外科常见的急腹症。与年轻病人相比，老年急性阑尾炎病人呈现出独特的流行病学特征和预后，其死亡率、穿孔率、术后并发症发生率以及并发结肠癌和阑尾癌的风险均较高，而诊断准确率较低。目前，针对老年急性阑尾炎的诊治，国际上主要有两版指南可供参考，分别是2019年版的《SIFIPAC/WSES/SICG/SIMEU指南：老年急性阑尾炎的诊断和治疗》与《EAES快速指南：老年阑尾炎》。由于老年病人临床症状不典型，常规的临床评分系统[如阑尾炎炎性反应评分（AIR）及成人阑尾炎评分（AAS）]应用受限。指南建议对Alvarado评分≥5分的老年病人进行CT扫描以明确诊断，特别是增强CT，有助于鉴别是否存在阑尾穿孔。治疗策略的核心在于区分单纯性与复杂性阑尾炎。对于CT确诊的老年单纯性阑尾炎病人，若其不愿接受手术且能接受复发风险，非手术治疗（抗生素治疗）是一种可行选择，其成功率可>70%。对于伴有脓肿的复杂性阑尾炎，推荐在非手术治疗的基础上联合经皮穿刺引流术。而腹腔镜阑尾切除术因其创伤小、并发症少、住院时间短等优势，被推荐为老年急性阑尾炎的首选手术方式。此外，考虑到老年AA病人结肠癌发病率显著增高，指南强烈建议所有老年AA病人均应进行结肠镜筛查。
Acute appendicitis (AA) is a common surgical acute abdomen. Compared with younger patients, elderly patients with AA present unique epidemiological characteristics and prognoses, including higher rates of mortality, perforation, and postoperative complications, as well as an increased risk of concurrent colorectal and appendiceal cancer, but lower diagnostic accuracy. Currently, two main international guidelines are available for the diagnosis and management of AA in the elderly: The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition) and the EAES rapid guideline: appendicitis in the elderly. Due to atypical clinical symptoms in elderly patients, the application of conventional clinical scoring systems such as the Alvarado score, Appendicitis Inflammatory Response (AIR) score, and Adult Appendicitis Score (AAS) is limited. The guidelines recommend computed tomography (CT) scan for elderly patients with an Alvarado score ≥5 to confirm the diagnosis; contrast-enhanced CT is particularly helpful in identifying appendiceal perforation. The core of the treatment strategy is to differentiate between uncomplicated and complicated appendicitis. For elderly patients with CT-confirmed uncomplicated appendicitis who are unwilling to undergo surgery and can accept the risk of recurrence, non-operative management with antibiotics is a feasible option, with a success rate of >70%. For complicated appendicitis with an abscess, percutaneous drainage combined with non-operative management is recommended. Laparoscopic appendectomy is recommended as the preferred surgical approach for elderly patients with AA owing to its advantages of minimal trauma, fewer complications, and shorter hospital stay. Furthermore, considering the significantly increased incidence of colorectal cancer in elderly patients with AA, the guidelines strongly recommend that all elderly patients with AA should undergo colonoscopic screening.
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Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6),management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.
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There is a lack of trustworthy evidence-informed guidelines on the diagnosis and management of acute appendicitis in elderly patients.We developed a rapid guideline in accordance with GRADE and AGREE II standards. The steering group consisted of general surgeons, members of the EAES Research Committee/Guidelines Subcommittee with expertise and experience in guideline development, advanced medical statistics and evidence synthesis, biostatisticians, and a guideline methodologist. The guideline panel consisted of three general surgeons, an intensive care physician, a geriatrician and a patient advocate. We conducted systematic reviews and the results of evidence synthesis were summarized in evidence tables. Recommendations were authored and published through an online authoring and publication platform (MAGICapp), with the guideline panel making use of an evidence-to-decision framework and a Delphi process to arrive at consensus.This rapid guideline provides a weak recommendation against the use of clinical scoring systems to replace cross-sectional imaging in the diagnostic approach of suspected appendicitis in elderly patients. It provides a weak recommendation against the use of antibiotics alone over surgical treatment in patients who are deemed fit for surgery, and a weak recommendation for laparoscopic over open surgery. Furthermore, it provides a summary of surgery-associated risks in elderly patients. The guidelines, with recommendations, evidence summaries and decision aids in user-friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/4494.This rapid guideline provides evidence-informed trustworthy recommendations on the diagnosis and management of acute appendicitis in elderly patients.
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To investigate the epidemiology, treatment and outcomes of acute appendicitis (AA) in a large population study.This is a retrospective cohort study derived from the administrative dataset of the Bergamo district healthcare system (more than 1 million inhabitants) from 1997 to 2013. Data about treatment, surgery, length of stay were collected. Moreover for each patients were registered data about relapse of appendicitis and hospital admission due to intestinal obstruction.From 1997 to 2013 in the Bergamo district we collected 16544 cases of AA, with a crude incidence rate of 89/100000 inhabitants per year; mean age was 24.51 ± 16.17, 54.7% were male and the mean Charlson's comorbidity index was 0.32 ± 0.92. Mortality was < 0.0001%. Appendectomy was performed in 94.7% of the patients and the mean length of stay was 5.08 ± 2.88 d; the cumulative hospital stay was 5.19 ± 3.36 d and 1.2% of patients had at least one further hospitalization due intestinal occlusion. Laparoscopic appendectomy was performed in 48% of cases. Percent of 5.34 the patients were treated conservatively with a mean length of stay of 3.98 ± 3.96 d; the relapse rate was 23.1% and the cumulative hospital stay during the study period was 5.46 ± 6.05 d.The treatment of acute appendicitis in Northern Italy is slowly changing, with the large diffusion of laparoscopic approach; conservative treatment of non-complicated appendicitis is still a neglected option, but rich of promising results.
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To define the mortality rate of appendectomy patients and appendectomy-related risk factors.Appendectomy has been considered as a safe operation and negative appendectomies acceptable in order to avoid perforations. There are few publications on appendectomy-related mortality. Removal of a normal appendix has been suggested to be related to a higher mortality rate versus removal of an inflamed appendix.Data on all appendectomy patients between 1990 and 2010 in Finland were retrieved from the Discharge Register of the National Institute for Health and Welfare and combined with data from the Death Certificate Register of Statistics Finland. Thirty-day mortality was identified and compared with overall mortality. Detailed information from death certificates of patients dying within 30-day post-surgery was collected and analyzed.Over the study period, the thirty-day post-appendectomy mortality rate was 2.1/1000. Increased mortality was found in patients over 60 years of age. Negative appendectomy and complicated appendicitis were related to mortality. The negative appendectomy rate was higher in patients older than 40 years of age. During the study period, both mortality and the rate of negative appendectomies decreased, while the rate of laparoscopic appendectomies increased.Post-appendectomy mortality is related to both negative appendectomies and complicated appendicitis. Diagnostic accuracy is fundamental in the care of patients with acute appendicitis, especially in the elderly. Improved diagnostic accuracy may have reduced mortality over the last two decades in Finland.
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急性阑尾炎是最常见的外科急症之一，阑尾切除术是最常实施的外科手术之一。通过诊断性影像技术，如超声、CT和MRI，并结合临床表现与实验室指标，可以做出准确的诊断并评估其病理学类型，以避免延误诊治；并且据此分层或辨别出复杂性急性阑尾炎，以决策手术治疗还是保守治疗。阑尾脓肿、孕期阑尾炎和复发性阑尾炎等须根据病人特殊情况予以诊治。急性阑尾炎诊治目的在于提供符合以病人为中心的治疗决策，以减轻病人的痛苦、节省医疗资源以及减少并发症。
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徐德全, 侯利民. 老年急腹症外科诊治中值得关注的若干问题[J]. 中国普通外科基础与临床杂志, 2022, 29(8): 1078-1082. DOI:10.7507/1007-9424.202206030.
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Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.
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国家卫生和计划生育委员会, 国家中医药管理局, 中国人民解放军总后勤部卫生部. 抗菌药物临床应用指导原则(2015年版)[M]. 北京: 人民卫生出版社, 2015.
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陈志亮, 丁嘉宁, 陶凯雄, 等. 美国胃肠内镜外科医师学会《阑尾炎诊断与治疗指南(2024)》解读[J]. 中国实用外科杂志, 2024, 44(12): 1343-1346. DOI: 10.19538/j.cjps.issn1005-2208.2024.12.04.
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徐德全, 周昊昕, 侯利民. 老年消化道穿孔多学科病例讨论[J]. 中国临床研究, 2023, 3(9): 1423-1426. DOI:10.13429/j.cnki.cjcr.2023.09.030.
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The objective of this study was to employ artificial intelligence (AI) technology for the development of a model that can accurately forecast the outcome of emergency general surgery (EGS) in elderly patients. Additionally, an innovative visual scoring system called geriatric emergency perioperative risk index (GEPR) was devised based on this model.A retrospective database of geriatric patients who had undergone EGS was used for the development of the AI model and GEPR. The study employed a specialized algorithm, comprising of four sequential steps namely scale prototype selection, clinical data collection and collation, AI model development, and GEPR development.In total, 1500 patients with the mean age of 69.8 ys were enrolled in the study. RandomForestClassifier algorithm outperformed the other AI models. Based on the feature importance, GEPR was derived, with a total score range of 0-26. The C-statistic of GEPR for in-hospital mortality was 0.872 (95% confidence interval, 0.840-0.905). The observed probability of in-hospital mortality gradually increased from 0% at a score of 0 to 63.3% at a score of 12 and 100% at a score of 15.Using patient-related and technical parameters, a GEPR model derived from AI algorithms for prediction of surgical complications in geriatric EGS was developed. The GEPR model reliably predicts postoperative in-hospital mortality in geriatric EGS patients. Clinical studies are currently being conducted to validate the stability and precision of the GEPR model utilizing the MIMIC-IV database. Further prospective multicenter trials are needed to externally validate the developed model.Copyright © 2025 Elsevier Inc. All rights reserved.
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