運用實證探討兒童急性單純性闌尾炎抗生素治療相較於手術治療效果

Effect of Antibiotic Therapy Compared with Surgery in Children with Acute Uncomplicated Appendicitis an Evidence-Based Appraisal

形成臨床提問：性闌尾炎目前首選治療方式為手術切除，兒童手術需全身麻醉，文獻指出兒童闌尾炎術後約10%於30天內會發生手術或麻醉併發症，兒童住院壓力主要為身體傷害與疼痛，手術後常因傷口疼痛而出現恐懼害怕行為，臥床不敢動且不願下床，導致復原時間延長及增加家屬焦慮。近年來有證據顯示，抗生素對急性單純性闌尾炎治療有好的效果，故擬以實證方法探討抗生素對此疾病的成效，做為臨床與家屬討論及選擇的佐證依據。文獻搜尋的方法與分析：本文設定Pediatric、Child、Appendicitis、Anti-Bacterial Agents、General Surgery、Appendectomy、Treatment Outcome、兒童、急性單純性闌尾炎、抗生素治療、手術治療、治療效果等中英文關鍵字，過程經由PubMed MeSH Database搜尋資料庫包括：PubMed、CINAHL、Cochrane Library、華藝線上圖書館、全國碩博士論文等資料庫，本議題為治療類型，搜尋時間為2016年至2021年7月，研究設計限制為隨機控制研究與統合分析。最初文獻搜尋共找到25篇，排除重覆及不相關文獻，得到22篇，首先檢查文獻標題及摘要，刪除與主題不符文獻17篇，剩餘3篇逐一閱讀全文，最終納入隨機控制研究1篇及統合分析2篇進行評讀及探討。文獻的品質評讀：本文採用2018年NHS之Critical Appraisal Skills Program（CASP）進行嚴格文獻評讀，1篇隨機控制研究針對「5-15歲」歐洲的急性闌尾炎，以「抗生素治療」及「手術治療」比較50位個案再次手術機率，抗生素組有11位後續需闌尾切除手術，手術組未再次手術，但無提供95%CI和p值，此研究有提及費用，相較於台灣有健保制度，價位仍有差異。2篇統合分析文獻中Hung et al.（2017）為亞、歐及美洲的5-18歲急性非複雜性闌尾炎病童針對「抗生素治療」及「手術治療」進行比較404位個案，顯示手術的失敗率低（95% CI, 2.67%-29.79%，I^2=0%，p=<.001），具顯著差異，但信賴區間大，為低精準度，有出版偏差現象，所以此研究納入完整性被質疑，雖有提及費用，但台灣有健保，所以價位有差異。另一篇Georgiou et al.（2017）只搜尋英文文獻的「抗生素治療」及「手術治療」，共比較（716名）亞、歐、美洲及中東的<18歲病童，顯示抗生素治療成功率97%（95% CI, 95.5%-98.7%，I^2=0%，p=.7），為高精準度，但統計無顯著差異，未提治療費用。結論與建議：綜合3篇文獻，急性單純性闌尾炎使用抗生素治療成功率為90.5-97%，但2個月至5年內，約14-46%的人要求或再度復發須執行闌尾切除手術，後續無穿孔性或壞死性闌尾炎發生。建議當病童罹患急性單純性闌尾炎，可採取醫病共享決策方式，讓病童、家屬與醫療團隊充分討論，讓其了解抗生素與手術治療的優缺點，共同達成最佳可行的治療選項，以病人為中心的醫療決策。抗生素治療也建議將來可再進一步研究驗證成效，期望做為醫護人員臨床處置參考。

Ask an answerable question (PICO): Surgical resection is currently the preferred treatment for acute appendicitis, and general anesthesia is required for children's surgery. Literature indicates that about 10% of children with appendicitis will experience complications of surgery or anesthesia within 30 days after appendicitis. Children's hospitalization stress is mainly physical injury and pain, Fearful behaviors often due to wound pain after surgery, Bedridden and afraid to move and unwilling to get out of bed, Lead to prolonged recovery time and increased family anxiety. In recent years, evidence has shown that antibiotics have a good effect on the treatment of acute simple appendicitis. Therefore, it is proposed to explore the efficacy of antibiotics in this disease by empirical methods, as a supporting basis for clinical discussion and selection with family members. The Method and Analysis of Literature Review: Key words search are pediatric, child, appendicitis, anti-Bacterial agents, general Surgery, appendectomy, treatment outcome, children, acute uncomplicated appendicitis, antibiotic, surgical, treatment effect, etc. through PubMed MeSH Database using ⸢OR⸥ and ⸢AND⸥. Database Including: PubMed, CINAHL, Cochrane Library, Huayi Online Library, National Master and Doctoral Dissertation and other databases, this topic is the type of treatment, the search time is from 2016 to July 2021, and the research design is limited to randomized controlled studies and integration analyze. In the initial literature search, a total of 25 articles were found. Duplicate and irrelevant articles were excluded, and 22 articles were obtained. First, the titles and abstracts of the articles were checked, 17articles that were inconsistent with the topic were deleted, and the remaining 3articles were read one by one. Finally, 1 article and Integrate analysis of 2 articles for review and discussion. Critical Appraisal: This article uses the 2018 NHS Critical Appraisal Skills Program (CASP) to conduct a rigorous literature review, a randomized controlled study of '5-15 years old' acute appendicitis in Europe, comparing 50 cases with 'antibiotic treatment' and 'surgery treatment' The probability of reoperation, 11 patients in the antibiotic group required subsequent appendectomy, and the operation group did not undergo reoperation, but the 95% CI and p value were not provided. This study mentioned the cost. Compared with Taiwan's health insurance system, the price is still different. In 2 meta-analyses, Hung et al (2017) compared 404 cases of 'antibiotic treatment' and 'surgical treatment' in children aged 5-18 years with acute uncomplicated appendicitis in Asia, Europe and the Americas, showing the failure of surgery The rate is low (95% CI, 2.67%-29.79%, I 2=0%, p=<.001), with significant difference, but the confidence interval is large, which is low precision and has publication bias, so this study included complete Sex is questioned. Although the cost is mentioned, considering Taiwan has health insurance, the price should be different. Another article, Georgiou et al. (2017), searched only English literature for 'antibiotic treatment' and 'surgical treatment', and compared a total of 716 sick children <18 years old in Asia, Europe, America and the Middle East, showing that antibiotic treatment was successful The rate was 97% (95% CI, 95.5%-98.7%, I 2=0%, p=.7),which was high precision, but there was no statistically significant difference, and no treatment cost was mentioned. Conclusions and Recommendations: Based on 3 literatures, the success rate of antibiotic treatment for acute uncomplicated appendicitis is 90.5-97%, but within 2 months to 5 years, about 14-46% of people require or relapse to perform appendectomy and no perforation or necrotizing appendicitis. It is suggested that when a sick child suffers from acute uncomplicated appendicitis, a shared decision-making method between doctors and patients can be adopted, so that patient, family members and medical team can fully discuss, let them underst and the advantages and disadvantages of antibiotics and surgical treatment, and jointly reach the best feasible treatment options. Patient-Centered Medical Decision Making. Antibiotic treatment also suggests that further research can be conducted to verify the effect in the future, and it is expected to be used as a reference for clinical treatment of medical staff.