Laparoscopic interval appendectomy適応のためのスコアリングシステムの構築

• Published in: Nihon Fukubu Kyukyu Igakkai Zasshi (Journal of Abdominal Emergency Medicine) Vol. 36; no. 6; pp. 1013 - 1019
• Main Authors: 柳橋 浩男, 小杉 千弘, 首藤 潔彦, 森 幹人, 平野 敦史, 佐塚 哲太郎, 菊地 祐太郎, 廣島 幸彦, 松尾 憲一, 田中 邦哉, 宮澤 幸正, 幸田 圭史
• Format: Journal Article
• Language: Japanese
• Published: 日本腹部救急医学会 2016; Japanese Society for Abdominal Emergency Medicine
• Subjects: laparoscopic interval appendectomy; スコア; 急性虫垂炎
• ISSN: 1340-2242; 1882-4781
• DOI: 10.11231/jaem.36.1013

The concept of interval appendectomy (IA) has become popular as an elective surgical strategy for acute appendicitis, because it is less invasive, is associated with fewer postoperative complications, and is cosmetically advantageous. Although IA is performed after the inflammation has subsided with conservative initial treatment in the acute stage, it is still under debate as to which approach, emergent or interval appendectomy, is the better treatment strategy for patients with acute appendicitis. The aim of this study was to conduct a retrospective comparison of the clinical data of patients who had undergone laparoscopic IA (LIA, n=37) and those who had undergone laparoscopic emergency appendectomy (LEA, n=13), and to establish a new scoring system IA scoring system to predict the potential success of LIA. The WBC count and serum CRP were significantly lower in the LIA group (P=0.004 and 0.020), whereas the pelvic abscess cavity size, intestinal ectasia and ascites were significantly more severe in the LEA group (P=0.007, 0.023 and 0.022). Logistic regression analysis was performed using the above five factors, and a scoring system to predict the potential success of LIA was established using each regression coefficient with approximate proportion (WBC count: 0 or 2 points; serum CRP and intestinal ectasia: 0-1 point; abscess cavity: 0-2 points; and ascites: 0-3 points). An IA score of ≤4 was associated with a 91.9% of sensitivity, 90.9% of specificity and 91.7% of accuracy for potentially successful LIA. 保存的治療後のinterval appendectomyの概念が広がりつつあるが，その手術適応やタイミングについては主観的判断の要素も含まれ議論の余地は多い。当科での待機的腹腔鏡下虫垂切除術（laparoscopic interval appendectomy: LIA）の臨床所見と周術期成績を準緊急的腹腔鏡下虫垂切除術（laparoscopic emergency appendectomy: LEA）と後方視的に比較した。その上でLIA選択のための客観的判断基準として，入院翌日の白血球数，CRP値，CT所見での膿瘍の程度，小腸拡張の有無，腹水の程度を用いた重症度スコア（IAスコア）を構築した。IAスコアを用いたLIAとLEAの分別能は感度91.9％，特異度90.9％であり，4点以下は保存加療が可能でLIA適応あり，5点以上はLEAを念頭に置いた入院管理を行う必要がある。