Research question : Morbidity of appendectomy ?? ??????? appendicitis ???????????????? ?????????? ????????????????????????????????????????? ???????????????????????

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Research question Morbidity of appendectomy
?? ??????? appendicitis ?????????????????????????
? ?????????????????????????????????????????
???????????????????????

• ???.??????? ???????? 42460055
• ???.?????? ???????? 42460154
• ???.?????? ????? 42460576

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??????????

• ?????????????????????????? 30
  ??????????????????????????? 1 ??
  ??????????????????????????????????????????????????
  ?????? ???????????????????????????????????????????
  ????????????? ????????????????????????????????????
  ?????????????????????????????????
  ??????????????????? ??????????????????????????
  ???????????????????????????????????????? 8 ????
  ??????????????????????????????????????????????????
  ??????????????????????????????????????????????????
  ????????????? ?????????????????????????????????
  ?????????????????????????????????????????????????

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??????? ??????

• Appendectomy ??????????????????????
  ????????????????????????????? ????????????????????
  ???????????????????????????????
  ???????????????????????????? ???
  ?????????????????(surgical wound infection) ????
  ?????????????????? (intra-abdominal abscess)
  ??????????????????????????????????????????????????
  ???????????????????????????? ?????????????????????
  ??????????????????????????????????????????????????
  ??????????????????????????????????????????????????
  ?? ???????????????????????????????????????????????
  ???

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1.Reviews and Research questions

• 1.1 Consult with expert
• 1.2 Review of literature
• -Mortality after appendectomy in
  Sweden,1987-1996.
• Paul G. Blomqvist et al,2001/Annal of Surgery
• -Standardized patient care guidelines reduce
  infectious morbidity in appendectomy patients.
• Kenneth S. Helmer et al./The American Journal of
  Surgery 183(2002)

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• Mortality after appendectomy in
  Sweden,1987-1996.
• Paul G. Blomqvist et al,2001/Annal of Surgery
• ????? mortality after appendectomy ???????
  cohort study(prospective) ??????????? follow up
  ?????????? 30 ??? ??????? admit ?? case
  ??????????????????? ?????????????
  ????,???,discharge diagnosis,underlying cause of
  death,and the time of death after admission ????
  case??????????????????????????? ???? , ???
  ,underlying cause of abdominal pain
• ??????????? 2.44/1000 ?? ??????????????????
  ?????? 0-9 ?? ??????? 0.31,20-29 ?? ???????
  0.07,nonagenarians 164 ???????????????????????????
  ??????????????????????????????????????????????????
  ? 0.8/1000 ?? ??????????????????????????
  5.1/1000?? ???????????????????????????????????????
  ???????????????????1.9/1000 ?? ??? 10/1000 ??
  ?????????????????????????????

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• Standardized patient care guidelines reduce
  infectious morbidity in appendectomy patients.
• Kenneth S. Helmer et al,2002/The American Journal
  of Surgery 183
• -at the Lyndon Baines Johnson County Hospital in
  Houston,Texas.
• -retrospective Jan 1,1998 - Dec 31,1998
• -prospective Jan 1,1999 - Dec 31,1999
• -no exclusion criteria
• -?????????????????????????????????????????????,??
  ?,?????????????????????????????????????????????,??
  ??????????????,???????????????????????????????,???
  ??????????????????????, intraoperative and
  pathologic finding,????????????????????-??????????
  ,????????????????????????????????,?????????????,??
  ???????????????????????????????

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• -?? simple appendicitis nonprotocol ??
  infectious complication 2
• protocol ?? infectious complication
  2
• -?? perforated or gangrenous appendix
• nonprotocol ?? infectious complication 33
• protocol ?? infectious complication
  13

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Results of the review

• Research question
• ????????? Morbidity of appendectomy ?? acute
  appendicitis ??????????????????????????
  ?????????????????????????????????????????
  ???????????????????????
• ???????? ???????????????????
  ??????????????????????????????????????????????????
  ????????????? ??????? appendicitis ??????????????

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2.Objective

• 1. ???????????????????????????????????????????????
  ?????????????????????????????? ????????
  ?????????????????????????????????
• 2. ??????????????????????????????????
  appendicitis ????????????????????? ????????
  ????????????????????????????????????????????
• 3. ???????????????????????????????????????????????
  ?????????? ??????????????????????????

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3.Expected outcome

• 1. ???????????????????????????????????????????
  ???????????????????????????????????????????????
  ????????????????????????
• 2. ???????????????????????????????????????????????
  ??????????????????????????????????????????????????
  ?????????? acute appendicitis

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4. Study design

• Observation
• Analytical (comparative)
• Retrospective

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4.1 ???????????????(target population)

• Inclusion criteria
• ????????????????????????? appendectomy
  ????????????????????? ????????????????????????????
  ????????????? ??????????????? 1 ?.?.44 - 30
  ?.?.45

• Exclusion criteria
• ?????????????????????? 5 ??
• ???????????????????????????????????????????? ????
  ?????????????

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4.2 ????????????????????(study population)????????
?????????????????(sampling technique)

• Non-probability sampling (????????????????????????
  ???????
• ?????????????)

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4.3 ???????????? (sample size)

• Two independent group
• N/group Za/2 /p2(1-p2) ZB
  /p1(1-p1)p2(1-p2)2
• Za Z-statistics for confidence interval
• P Prevalence

(p1-p2)2
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• Za/2 1.96 , ZB 1.28
• sample size P Prevalence P1 ?????????
  morbidity ??????? treatment 0.13
  P2 ????????? morbidity ??????? control 0.33
• ??????????? N 104.04 (???????????????????
  ??? perforated appendix)
• ?????????????????????????????????????????
  perforated appendix ?????????? 19.4 ??????????
  appendicitis ???????
• ????????????????????????????????????? sample size
  ??????? 100 104.04 536. 2886
  19.4

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5.????????????????????????????????

• 5.1 ??????(variables)
• Dependent variable wound infection
  ,intraabdominal abscess
• Independent variable simple appendicitis
• perforated or gangrenous appendix
• surgery time
• antibiotic
• surgical equipment
• Confounding variable experience of surgeon

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• 5.2 ??????????(precision)
• 5.2.1 Operational definitions
• Morbidity ????????????????????
  ???????????(surgical wound infection)
  ,??????????????????(intra-abdominal abscess)
  ,????????????????????
• surgical wound infection ????????????????????
  ????????(purulent drainage) ,?????????????(celluli
  tis)??????????????????????? ,?????????????????????
  ???????????
• intra-abdominal abscess ??????????????????????
  ?????????? ?????????????????
• perforated appendix ??????????????????????????
  ?????????(hole in the appendix)
  ,?????????????????????????????( free fluid in the
  abdomen or an abscess cavity)
• .

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• gangrenous appendix ??????????????????????????
  ???????????????????????(the gross appearance of
  necrosis involving the appendix)
• 5.2.2 Inter and intra-observer variations
• 5.3 Accuracy ( ??????????? )
• ??????????????????????????????? ????????nurse
  note ???progress note , order sheets ???????????
  medical record

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6.Quality assurance ( ??????????????? )

• Data supervision data editing

7. Data analysis ( ?????????????????? )

• Chi-square test

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Result
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Preoperative patient characteristics
mean age (years)
P 0.53
P 0.95
P 0.15
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Preoperative patient characteristics
duration of symptoms (hours)
P 0.14
P 0.96
P 0.27
28
P 0.68
29
???????????????????????????????????
P 0.46
P 0.39
30
Length of stay(mean) simple appendicitis
P 0.54
P 0.40
P 0.78
31
Length of stay(mean) perforated,phregmon or
gangrenous appendix
P 0.75
P 0.35
P 0.58
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?????????????????????????????? Surgeon ???
Complication
P 0.78
P 0.40
P 0.38
33
??????????????????????????????preoperative
antibiotic ??? complication
P 1.00
P 0.48
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Conclusion

• ??????????????????? ???????? ????????????????????
  ????????????? ????????????????????????????????????
  ??????????????????????????? ??????????????????????
  ?

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Discussion

• Selection bias study design
• choice of
  sampling frame
• loss to follow
  up
• Information bias incorrect diagnostic criteria
• Confounding bias age
• 
  underlying disease

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Suggestion

• ???????????????????????????????????????????
  Prospective ??????????????????????????????????????
  ???????????? ?????????????? ? ???
• ???????????????????????????????????
  ????????????????? ???????????????????????
  ????????????????????????

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?????????????

• ???????? ???????????? . Appendix . ??
  ???????? ???????????? , ???? ????????? ,
  ?????????? . ?????????????? ( ????????????? 6 ).
  ???????? ????????????????????????????? , 2544
  647 58
• ?????? ????????????? . ???????????????????????
  ???? 2 ,2545
• Rosemary A., Kozar and Joel J. Roslyn . The
  Appendix. In Schwartz SI ,Shires GT , Spencer
  FC , Husser WC, editors . Principles of
  Surgery .7th edition. New York McGraw Hill ,
  1999 1383 94
• Kenneth S. Helmer and the others. Standardized
  patient care guidelines reduce infectious
  morbidity in appendectomy patients The American
  Journal of Surgery vol.83,2002 608-613
• Paul G. Blomqvist,PhD and others. Mortality after
  appendectomy in Sweden,1987-1996 Annal of
  Surgery,2001 465-470

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