Prospective Observational Study on acute Appendicitis Worldwide (POSAW)

The Impact of Imaging on Negative Appendectomies for Early Appendicitis in Children

OBJECTIVES

The rate of negative appendectomy in children is 7%. The value of imaging depends on the institution. In addition, imaging errors can lead to an appendectomy in children who do not have appendicitis. It is the hypothesis that children with short onset of symptoms who undergo negative appendectomy often have erroneous imaging findings.

METHODS

A retrospective study of patients' records over a 30-month period was carried out. A search by histologic diagnosis in the department of pathology was used to identify the cases of all patients who did not have a diseased appendix with the preoperative diagnosis of appendicitis. In addition, the imaging report was reviewed for the radiologic diagnosis of each patient, and the operative note was reviewed to document the clinical indication for surgery.

RESULTS

A total of 1377 patients who underwent appendectomy with the preoperative diagnosis of appendicitis were reviewed. Sixty-eight of these children did not have an abnormal pathologic diagnosis; hence, there was a negative appendectomy rate of 4.8%. All 68 had imaging before surgery consistent with appendicitis. Thirty-six of these patients had symptoms less than 3 days. In 30 (84%) of these 36 patients, the note identifies imaging as the indication for surgery.

CONCLUSIONS

Children who had an appendectomy and found to have a normal appendix shared 2 characteristics. (1) Their symptoms were less than 3 days, and (2) the imaging was considered the indication by the surgical team. In the situation of an unclear diagnosis and a short onset of symptoms, observation or further evaluation should be considered.

Did the COVID-19 Pandemic Prolong the Time Till Diagnosis and Worsen Outcomes for Children with Acute Appendicitis?

Background and Objectives: Our aim was to see if the COVID-19 pandemic led to an increase of time until diagnosis, operation, and time spent in Emergency room (ER), and if it resulted in more cases of complicated appendicitis and complication rates in children. Materials and Methods: We conducted a retrospective analysis of patients admitted to the Pediatric Surgery Department with acute appendicitis during a 4-month period of the first COVID-19 pandemic and compared it to the previous year data—the same 4-month period in 2019. Results: During the pandemic, the time spent in the ER until arriving at the department increased significantly 2.85 vs. 0.98 h p < 0.001, and the time spent in the department until the operation 5.31 vs. 2.66 h, p = 0.03. However, the time from the beginning of symptoms till ER, operation time and the length of stay at the hospital, as well as the overall time until operation did not differ and did not result in an increase of complicated appendicitis cases or postoperative complications. Conclusions: The COVID-19-implemented quarantine led to an increase of the time from the emergency room to the operating room by 4 h. This delay did not result in a higher rate of complicated appendicitis and complication rates, allowing for surgery to be postponed to daytime hours if needed.

Current Practice of Acute Appendicitis Diagnosis and Management in China (PANDA-C): A National Cross-Sectional Survey

Background: The aim of this study was to describe and analyze the current status of the diagnosis and management of acute appendicitis in China. Patients and Methods: An online record system was used to collect data retrospectively from 52 medical centers in mainland China. All patients with acute appendicitis who were first treated at the hospital in 2017 were included and followed up for one year. Propensity score matching (PSM) was used to exclude the potential confounders and analyze the difference in outcomes between the non-operative management (NOM) and surgical groups. Results: A total of 10,187 patients were enrolled, of whom 5,517 (54.2%) were males. A total of 2,056 (20.2%) cases received NOM. The one-year recurrence rate of appendicitis in the NOM group was 19.3%. On PSM analysis, we found that the NOM group had a lower complication rate (2% vs. 4.2%; p = 0.001) and an acceptable success rate (96.8% vs. 100%; p < 0.001) compared with the operative group in patients with non-complicated acute appendicitis. However, in the complicated acute appendicitis population, the in-hospital complication rate in the NOM group was higher (10.8% vs. 5.8%; p = 0.048) and the success rate was lower (95.4% vs. 100%; p < 0.001) than the operative group. The recurrence rate was lower in patients with non-complicated acute appendicitis than in those with complicated acute appendicitis (17.3% vs. 30.8%; p = 0.010). In the operative group, pre-operative antimicrobial prophylaxis-covered anaerobes could reduce the surgical site infection (SSI) rate compared with that in the non-covered anaerobes group in non-complicated patients (0.9% vs. 1.9%; p = 0.020). Conclusions: Appendectomy is currently the most effective treatment for acute appendicitis. However, NOM is an alternative treatment for non-complicated acute appendicitis but not for complicated acute appendicitis because of the lower complication rate, considerable success rate, and recurrence rate.

Management of acute appendicitis during the COVID-19 pandemic: Views of two Brazilian surgical societies

Acute appendicitis (AA) is a frequent cause of abdominal pain requiring surgical treatment. During the COVID-19 pandemic, surgical societies considered other therapeutic options due to uncertainties in the evolution of the disease. The purpose of this study is to assess the treatment of AA by members of two Brazilian surgical societies in this period. A common questionnaire was sent in 2020. There were 382 responses. Most surgeons had more than 15 years of profession (68.3%) and treated more than five cases per month (44.8%). About 72.5% would indicate chest CT to investigate COVID-19 in patients with AA. For those patients sustaining uncomplicated AA, without COVID-19, 60.2% would indicate laparoscopic appendectomy (VLA), followed by open appendectomy (OA) (31.7%) and non-operative management (NOM) (1.3%). For those with mild COVID-19, OA was suggested by 51.0%, followed by VLA (29.6%) and NOM (6.0%). For those with severe COVID-19, OA was proposed by 35.3%, followed by NOM (19.9%) and VLA (18.6%). For patients with periappendiceal abscesses, without COVID-19, VLA was suggested by 54.2%, followed by OA (33.2%) and NOM (4.4%). For those with mild COVID-19, OA was proposed in 49.5%, followed by VLA (29.3%) and NOM (8.9%). In those with severe COVID-19, OA was proposed in 36.6%, followed by NOM (25.1%) and VLA (17.3%). This information, based on two recognized Brazilian surgical societies, can help the surgeon to select the best approach individually.

Tubal abortion masquerading as an acute appendicitis with a negative urine pregnancy test: A case report

Introduction and importance

Spontaneous expulsion of product of conception through the fimbrial end to the peritoneal cavity is a rare mode of progression of tubal pregnancy. Thus, ectopic pregnancy can present with right-sided iliac fossa pain which can be preoperatively misdiagnosed as acute appendicitis.

Case history

A 30-year regularly menstruating woman presented with right iliac fossa pain which was diagnosed as acute appendicitis preoperatively with an ultrasound. However, intraoperatively, a product of conception-like material measuring 3 ∗ 3 cm was seen hanging from the right fimbrial end of the fallopian tube with a normal appendix. With an intraoperative diagnosis of spontaneous tubal abortion, histopathology of the resected mass showed chorionic villi lined by trophoblastic cells along with decidualized tissue, fibrinoid material, and blood clot.

Discussion

Ectopic pregnancy presenting as a right iliac fossa pain can mimic acute appendicitis. An abnormal β-hCG pattern/level which doesn't correspond to the gestational age suggests the likely diagnosis of ectopic gestation. Transvaginal ultrasound is the preferred imaging modality for the evaluation of patients with suspected ectopic gestation. A urine pregnancy kit cannot always exclude an underlying ectopic pregnancy because of the associated false-negative results.

Conclusion

Urgent laparotomy to prevent detrimental complications associated with ectopic gestation should be done. Surgeons should be aware of this suspicion as a false negative UPT can happen and misguide clinicians about the possible occurrence of ectopic pregnancy.

•

Ectopic pregnancy can present as acute appendicitis in females of reproductive age group.

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A urine pregnancy test cannot always exclude ectopic pregnancy owing to its associate false negative results.

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High degree of clinical suspicion is required to omit life threatening consequences.

Efficacy of Preoperative Imaging Features and Blood Tests in Predicting the Increased Risk of Conversion in Laparoscopic Appendectomy Surgery

Background

In this study, we identified preoperative risk factors, including imaging features and blood tests, to predict conversion from laparoscopic appendectomy to open appendectomy. Thus, we aimed to prevent patients from being exposed to the risks of laparoscopy by choosing patients for whom proceeding directly to an open surgery as an initial approach was appropriate.

Patients and methods

The cohort of 632 patients who underwent laparoscopic appendectomy due to acute appendicitis in our center between January 2017 and March 2021 were analyzed, and 521 of these patients comprised the study population. Baseline characteristics, medical history, preoperative laboratory tests, imaging features, and postoperative pathologic findings of all patients according to groups who underwent laparoscopic appendectomy or conversion to open appendectomy were examined.

Results

Among 521 patients, the appendectomy procedure was completed laparoscopically in 498 (95.6%) patients, and conversion to open appendectomy was occurred in 23 (4.4%) patients. 223 (42.8%) patients were female, and 298 (57.2%) patients were male. The mean age of all patients was 35.17±12.61 years (range, 16-80 years). Preoperative ultrasonography feature associated with a higher rate of conversion was free fluid collection (p=0.001). The levels of C-reactive protein, neutrophil, and neutrophil/lymphocyte ratio on admission were found to be significantly higher in the conversion group compared to the laparoscopy group (p=0.001, p=0.027, p=0.02, respectively). 

Conclusions

Free fluid collection detected by ultrasonography, and elevation of C-reactive protein, neutrophil, and neutrophil/lymphocyte ratio may be useful in the prediction of a high risk of conversion appendectomy. Despite the unquestionable advantages of laparoscopic surgery, there are still substantial conversion rates. Within this framework, our study will help the surgeons to choose the most appropriate surgical methods for patients by evaluating them individually, and to inform them of the possibility of conversion to the open approach, and other risks before surgery. 

Aspiration versus peritoneal lavage in appendicitis: a meta-analysis

BACKGROUND

Acute appendicitis is one of the most frequent abdominal surgical emergencies. Intra-abdominal abscess is a frequent post-operative complication. The aim of this meta-analysis was to compare peritoneal irrigation and suction versus suction only when performing appendectomy for complicated appendicitis.

METHODS

According to PRISMA guidelines, a systematic review was conducted and registered into the Prospero register (CRD42020186848). The risk of bias was defined to be from low to moderate.

RESULTS

Seventeen studies (9 RCTs and 8 CCTs) were selected, including 5315 patients. There was no statistical significance in post-operative intra-abdominal abscess in open (RR 1.27, 95% CI 0.75-2.15; I2 = 74%) and laparoscopic group (RR 1.51, 95% CI 0.73-3.13; I2 = 83%). No statistical significance in reoperation rate in open (RR 1.27, 95% CI 0.04-2.49; I2 = 18%) and laparoscopic group (RR 1.42, 95% CI 0.64-2.49; I2 = 18%). In both open and laparoscopic groups, operative time was lower in the suction group (RR 7.13, 95% CI 3.14-11.12); no statistical significance was found for hospital stay (MD - 0.39, 95% CI - 1.07 to 0.30; I2 = 91%) and the rate of wound infection (MD 1.16, 95% CI 0.56-2.38; I2 = 71%).

CONCLUSIONS

This systematic review has failed to demonstrate the statistical superiority of employing intra-operative peritoneal irrigation and suction over suction-only to reduce the rate of post-operative complications after appendectomy, but all the articles report clinical superiority in terms of post-operative abscess, wound infection and operative times in suction-only group.

Diverticular Disease of the Appendix Is Associated with Complicated Appendicitis

INTRODUCTION

Diverticular disease of the vermiform appendix (DDA) has an incidence of 0.004 to 2.1% in appendicectomy specimens. DDA is variably associated with perforation and malignancy. We report a single-center experience of DDA. The primary aim is to validate the association of DDA with complicated appendicitis or malignancy, and the secondary aim is to validate systemic inflammatory response syndrome (SIRS) criteria and quick Sepsis-related Organ Failure Assessment (qSOFA) scores.

METHODS

The histopathology reports of 2,305 appendicectomy specimens from January 2011 to December 2015 were reviewed. Acute appendicitis was found in 2,164 (93.9%) specimens. Histology of the remaining 141 (6.1%) patients revealed: normal appendix (n = 110), DDA (n = 22), endometriosis of appendix (n = 6), and an absent appendix (n = 3). Patient demographics, clinical profile, operative data, and perioperative outcomes of DDA patients are studied. Modified Alvarado score, Andersson score, SIRS criteria, and qSOFA scores were retrospectively calculated.

RESULTS

The incidence of DDA was 0.95%. Ten patients (45.5%) had diverticulitis. The mean age of DDA patients was 39.5 years (range 23-87), with male preponderance (n = 12, 54.5%). The median Modified Alvarado score was 8 (range 4-9), and the median Andersson score was 5 (range 2-8). Fourteen patients (63.6%) had SIRS, and none had a high qSOFA score. Eight patients (36.4%) had complicated appendicitis (perforation [n = 2] or abscess [n = 6]). Eleven (50%) patients underwent laparoscopic appendicectomy. There were three 30-day readmissions and no mortality.

CONCLUSION

DDA is a distinct clinical pathology associated with complicated appendicitis.

Cost-effectiveness analysis of nonoperative management versus open and laparoscopic surgery for uncomplicated acute appendicitis in Colombia

BACKGROUND

Traditionally, uncomplicated acute appendicitis (AA) has been treated with appendectomy. However, the surgical alternatives might carry out significant complications, impaired quality of life, and higher costs than nonoperative treatment. Consequently, it is necessary to evaluate the different therapeutic alternatives' cost-effectiveness in patients diagnosed with uncomplicated appendicitis.

METHODS

We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18-60 years with a diagnosis of uncomplicated AA from the payer´s perspective at the secondary and tertiary health care level. The time horizon was 5 years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed.

METHODS

We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18-60 years with a diagnosis of uncomplicated AA from the payer's perspective at the secondary and tertiary health care level. The time horizon was five years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed.

RESULTS

LA presents a lower cost ($363 ± 35) than OA ($384 ± 41) and NOM ($392 ± 44). NOM exhibited higher QALYs (3.3332 ± 0.0276) in contrast with LA (3.3310 ± 0.057) and OA (3.3261 ± 0.0707). LA dominated the OA. The ICER between LA and NOM was $24,000/QALY. LA has a 52% probability of generating the highest NMB versus its counterparts, followed by NOM (30%) and OA (18%). There is a probability of 0.69 that laparoscopy generates more significant benefit than medical management. The mean value of that incremental NMB would be $93.7 per patient.

CONCLUSIONS

LA is a cost-effectiveness alternative in the management of patients with uncomplicated AA. Besides, LA has a high probability of producing more significant monetary benefits than NOM and OA from the payer's perspective in the Colombian health system.

Conditional CT Strategy-An Effective Tool to Reduce Negative Appendectomy Rate and the Overuse of the CT

(1) Background: Diagnosis of acute appendicitis (AA) remains challenging; either computed tomography (CT) is universally used or negative appendectomy rates of up to 30% are reported. Transabdominal ultrasound (TUS) as the first-choice imaging modality might be useful in adult patients to reduce the need for CT scans while maintaining low negative appendectomy (NA) rates. The aim of this study was to report the results of the conditional CT strategy for the diagnosis of acute appendicitis. (2) Methods: All patients suspected of acute appendicitis were prospectively registered from 1 January 2016 to 31 December 2018. Data on their clinical, radiological and surgical outcomes are presented. (3) Results: A total of 1855 patients were enrolled in our study: 1206 (65.0%) were women, 649 (35.0%) were men, and the median age was 34 years (IQR, 24.5–51). TUS was performed in 1851 (99.8%) patients, and CT in 463 (25.0%) patients. Appendices were not visualized on TUS in 1320 patients (71.3%). Furthermore, 172 (37.1%) of 463 CTs were diagnosed with AA, 42 (9.1%) CTs revealed alternative emergency diagnosis and 249 (53.8%) CTs were normal. Overall, 519 (28.0%) patients were diagnosed with AA: 464 appendectomies and 27 diagnostic laparoscopies were performed. The NA rate was 4.2%. The sensitivity and specificity for TUS and CT are as follows: 71.4% and 96.2%; 93.8% and 93.6%. (4) Conclusion: A conditional CT strategy is effective in reducing NA rates and avoids unnecessary CT in a large proportion of patients. Observation and repeated TUS might be useful in unclear cases.

Comparing the Accuracy of Ohmann and Alvarado Scoring Systems in Detection of Acute Appendicitis; a Cross-Sectional Study

Introduction:

Alvarado Scoring System (ASS) and Ohmann Scoring System (OSS) are two scoring systems for diagnosing acute appendicitis (AA). This study was designed to compare the diagnostic accuracy of the two mentioned scores in detection of acute abdominal cases at risk for AA.

Methods:

In this prospective cross-sectional study, patients admitted to the emergency departments of two academic hospitals in Qom, Iran, with right lower quadrant (RLQ) abdominal pain suspected to AA were evaluated. All cases were scored using ASS and OSS, and screening performance characteristics of the two scores were calculated and reported considering the pathologic findings as a gold standard.

Results:

174 patients with a preliminary AA diagnosis and the mean age of 38.1 ± 10.63 years (11- 73) were included in this study (62.07% male). At the optimal cutoff point of ≥7 for the ASS, the sensitivity and the specificity were 46.43% (95% CI: 37.97%-55.07%), 97.05% (95% CI: 84.67%-92.93%), respectively. At the optimal cutoff point of ≥11 for the OSS, the sensitivity and the specificity were 74.29% (95% CI: 66.22%-81.29%), and 55.88% (95% CI: 37.89% - 72.82%), respectively.

Conclusion:

Based on the finding of this study, the ASS ≥ 7 was more accurate than the OSS ≥ 11 for detection of AA. But it should be considered that the overall accuracy of Alvarado and Ohmann scores in this regard were fair (0.83) and poor (0.67), respectively.

Surgical Versus Conservative Management of Acute Appendicitis During the COVID-19 Pandemic: A Single-Centre Retrospective Study

Introduction The COVID-19 pandemic provoked a change to normal surgical practice in the United Kingdom and led to an increase in acute appendicitis (AA) patients being treated conservatively with antibiotics. We aim to analyse the management of patients presenting with AA to our institution during the first wave of the pandemic, comparing surgically and conservatively managed patients. Method All patients presenting to our centre with AA between March and July 2020 were included. Six-month follow-up data were collected retrospectively using electronic records. Patients were categorised into surgically and conservatively managed groups. The primary outcome was the complication rate (post-operative complications vs failure of antibiotic treatment) and the secondary outcomes were length of hospital stay and Alvarado score. Results  Fifty-seven patients (n=57) were admitted with AA, 45.6% (n=26) managed conservatively compared to 54.4% (n=31) treated surgically. Higher complication rates were observed amongst the conservatively managed group, although not found to be statistically significant (16% vs 35%; p=0.131). There was no significant difference in length of hospital stay observed between the two groups (surgical: median, 2; interquartile range, 2-3 vs conservative: median, 3; interquartile range, 2-4). White cell count (WCC) and Alvarado score were higher on admission in the surgical group with statistical significance (p=0.012 and p=0.028, respectively). Conclusions COVID-19 has led to a significant cohort of conservatively managed AA patients in the United Kingdom. We propose a stratification pathway based on clinical severity, Alvarado score and imaging to facilitate safe selection for conservative management of AA, in order to reduce failure of treatment rates in this patient group. Further UK-based studies will add to the evidence-based surrounding safe management of AA with conservative treatment.

Single-port laparoscopic appendicectomy versus conventional three-port approach for acute appendicitis: A systematic review, meta-analysis and trial sequential analysis of randomised controlled trials

AIMS

The aim of this systematic review and meta-analysis is to compare outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis.

METHODS

A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis and trial sequential analysis of outcomes were conducted. Post-operative pain at 12-h, cosmesis, need for an additional port(s), operative time, port-site hernia, ileus, surgical site infection (SSI), intra-abdominal collection, length of hospital stay (LOS), readmission, and reoperation were the evaluated outcome parameters.

RESULTS

Sixteen RCTs with total number of 2017 patients who underwent SPLA (n = 1009) or CLA (n = 1008) were included. SPLA was associated with a significantly higher cosmetic score (MD 1.11, P= 0.03) but significantly longer operative time (MD 7.08, P = 0.00001) compared to CLA. However, the difference was not significant between SPLA and CLA in the post-operative pain score at 12-h (MD -0.13, P = 0.69), need for additional port(s) (RR0.03, P = 0.07), port-site hernia (RD: 0.00, P = 0.68), ileus (RR 0.74, P = 0.51), SSI (RR 1.38, P = 0.28), post-operative intra-abdominal collection (RR 0.00, P = 0.62), LOS (MD -2.41, P = 0.16), readmission to the hospital (RR 0.45, P = 0.22), and return to theatre (RR 0.00, P = 0.49). Trial sequential analysis demonstrated that the meta-analysis is conclusive for most of the outcomes, except LOS and intra-abdominal collection.

CONCLUSION

Although SPLA is associated with a slightly longer operative time, its efficacy and safety are comparable to CLA in management of uncomplicated appendicitis. Moreover, it offers improved post-operative cosmesis. The available evidence is conclusive, and further trials may not be required.

Clinical-pathological features and treatment of acute appendicitis in the very elderly: an interim analysis of the FRAILESEL Italian multicentre prospective study

BACKGROUND

Emergency abdominal surgery in the elderly represents a global issue. Diagnosis of AA in old patients is often more difficult. Appendectomy remains the gold standard of treatment and, even though it is performed almost exclusively with a minimally invasive technique, it can still represent a great risk for the elderly patient, especially above 80 years of age. A careful selection of elderly patients to be directed to surgery is, therefore, fundamental. The primary aim was to critically appraise and compare the clinical-pathological characteristics and the outcomes between oldest old (≥ 80 years) and elderly (65-79 years) patients with Acute Appendicitis (AA).

METHODS

The FRAILESEL is a large, nationwide, multicentre, prospective study investigating the perioperative outcomes of patients aged ≥ 65 years who underwent emergency abdominal surgery. Particular focus has been directed to the clinical and biochemical presentation as well as to the need for operative procedures, type of surgical approach, morbidity and mortality, and in-hospital length of stay. Two multivariate logistic regression analyses were performed to assess perioperative risk factors for morbidity and mortality.

RESULTS

182 patients fulfilled the inclusion criteria. Mean age, ileocecal resection, OAD and ASA score ≥ 3 were related with both overall and major complication. The multivariate analysis showed that MPI and complicated appendicitis were independent factors associated with overall complications. OAD and ASA scores ≥ 3 were independent factors for both overall and major complications.

CONCLUSIONS

Age ≥ 80 years is not an independent risk factor for morbidities. POCUS is safe and effective for the diagnosis; however, a CECT is often needed. Having the oldest old a smaller functional organ reserve, an earlier intervention should be considered especially because they often show a delay in presentation and frequently exhibit a complicated appendicitis.

Acute complex appendicitis during the COVID-19 epidemic: A single-institution retrospective analysis based on real-world data

Objectives

To investigate the influence of Coronavirus Disease 2019 on incidence of acute complex appendicitis and management of acute appendicitis.

Methods

Patients undergoing acute appendicitis surgery in a single center during the COVID-19 epidemic from January to September 2020 and patients from January to September 2019 were taken as the epidemic group and control group respectively. The clinical characteristics and surgical pathological information were compared between the two groups. The primary outcome measure was complex appendicitis.

Results

A total of 235 patients were included in the study, containing 106 in the epidemic group and 129 in the control group. The patients in the epidemic group had a significantly longer interval from the onset of symptoms to registration (37.92 h vs 24.57 h, P = 0.028), from registration to admission (18.69 h vs 8.04 h, P < 0.001), and from admission to surgery (7.23 h vs 6.52 h, P = 0.016). The epidemic group had a higher incidence of suppurative appendicitis (86.8% vs 76.0%, P = 0.036) and a higher incidence of complex appendicitis (35.8% vs 19.4%, P = 0.005).

Conclusion

Higher incidence of acute complex appendicitis seemed to occur during COVID-19 outbreak.

Beneficios clínicos y de costos de un modelo de estandarización en el manejo de la apendicitis aguda

Introducción. La apendicitis aguda es la patología quirúrgica más frecuente en Colombia y en el mundo, con un riesgo de presentación del 7-8 % en la población general. El tratamiento de elección es la apendicectomía, la cual puede realizarse por vía convencional o por vía laparoscópica. El objetivo de este estudio fue comparar los desenlaces clínicos y costos de un modelo de estandarización en el manejo de la apendicitis aguda versus la no estandarización. Métodos. Estudio observacional, analítico, para comparar el manejo de atención estandarizado y no estandarizado. Se incluyeron pacientes mayores de 18 años, que ingresaron al servicio de urgencias con diagnóstico de apendicitis aguda en el período de enero de 2016 a diciembre de 2018, y quienes fueron llevados a apendicectomía convencional o laparoscópica en la institución. Resultados. Se incluyeron 1392 pacientes, 591 que cumplieron los criterios del modelo estandarizado y 801 que cumplieron los criterios del modelo no estandarizado. Al comparar los procesos de estandarización y no estandarización, se encontraron diferencias estadísticamente significativas en los resultados crudos de estancia hospitalaria y costos totales. En los estimativos ajustados por variables de confusión no se encontraron diferencias en los costos totales. Discusión. El modelo de estandarización demostró una disminución en los días de hospitalización. No encontró diferencias en términos de costos totales.

Risk of emergency surgery for complicated appendicitis: Japanese nationwide study

AIM

Appendicitis is divided into two categories: complicated appendicitis (CA) and uncomplicated appendicitis (UA). In pediatric patients with CA, the use of interval appendectomy (IA), which is non-operative management followed by elective surgery, has decreased the number of postoperative complications. Before discussing the merit of IA for adult patients, we need to clarify whether the frequency and seriousness of the complication rate after emergency surgery is higher for CA than for UA.

METHODS

This retrospective cohort study included adult patients who underwent appendectomy and who were registered in the National Clinical Database (NCD) from 2014 to 2016. Patients with CA who underwent emergency appendectomy comprised the CA group. Patients with UA comprised the UA group. Patients with chronic or recurrent appendicitis who underwent elective appendectomy comprised the elective appendectomy (EA) group. Primary outcomes were all morbidity, serious morbidity, and mortality within 30 days after appendectomy.

RESULTS

We included 109 256 patients in the study: 14 798 CA, 86 876 UA, and 7582 EA patients. Compared with the UA group, the rates of all morbidity, serious morbidity, and mortality were significantly higher in the CA group. All morbidity, serious morbidity, and mortality rates were significantly lower in the EA group than in the other two groups.

CONCLUSIONS

We confirmed that emergency surgery for CA places the patient at relatively higher risk. We also showed that the risk associated with EA is significantly lower than that for the other methods.

Appendicitis Mortality in a Resource-Limited Setting: Issues of Access and Failure to Rescue

BACKGROUND

Appendicitis is one of the most common emergency surgery conditions worldwide, and the incidence is increasing in low- and middle-income countries. Disparities in access to care can lead to disproportionate morbidity and mortality in resource-limited settings; however, outcomes following an appendectomy in low- and middle-income countries remain poorly described. Therefore, we aimed to describe the characteristics and outcomes of patients with appendicitis presenting to a tertiary care center in Malawi.

METHODS

We conducted a retrospective analysis of the Kamuzu Central Hospital (KCH) Acute Care Surgery database from 2013 to 2020. We included all patients ≥13 years with a postoperative diagnosis of acute appendicitis. We performed bivariate analysis by mortality, followed by a modified Poisson regression analysis to determine predictors of mortality.

RESULTS

We treated 214 adults at KCH for acute appendicitis. The majority experienced prehospital delays to care, presenting at least 1 week from symptom onset (n = 99, 46.3%). Twenty (9.4%) patients had appendiceal perforation. Mortality was 5.6%. The presence of a postoperative complication the only statistically significant predictor of mortality (RR 5.1 [CI 1.13-23.03], P = 0.04) when adjusting for age, shock, transferring, and time to presentation.

CONCLUSIONS

Delay to intervention due to inadequate access to care predisposes our population for worse postoperative outcomes. The increased risk of mortality associated with resultant surgical complications suggests that failure to rescue is a significant contributor to appendicitis-related deaths at KCH. Improvement in barriers to diagnosis and management of complications is necessary to reduce further preventable deaths from this disease.

Appendectomy as Teaching Operation: No Compromise in Safety-An Audit of 17,106 Patients

OBJECTIVE

In a surgical career, teaching of surgical procedures plays a central role. In this study we want to evaluate the influence of teaching in appendectomies on the in-hospital outcome.

DESIGN AND SETTING

Retrospectively, 26,436 cases from the national quality measurement database (AQC) between the years 2009 and 2017 were evaluated using the diagnosis and the procedure codes. Included were all cases with appendicitis (International Classification of Diseases diagnostic codes K35-K37), surgical treatment (appendectomy), and a documented teaching status of the procedure. Variables were sought in bivariate and multivariate analyses. The occurrence of any complication was the primary outcome, whereas in-hospital mortality was the secondary outcome.

PARTICIPANTS

A total of 17,106 patients with a mean age of 37 ± 19 years remained for final analysis. A total of 6267 operations (37%), were conducted as teaching-operations. Seventy-four percent of all teaching procedures were performed by residents.

RESULTS

We found no statistical association between teaching operations and complication rates or mortality. However, the teaching group showed longer duration of surgery (+ 11%).

CONCLUSIONS

There was no influence of the training status of the appendectomy procedure on complication rates and in-hospital mortality. However, there was a prolonged duration of surgery. Despite these statistically significant differences, a comparable clinical outcome was observed in all patients, thus justifying the benefits of resident training.

Acute Appendicitis in Childhood and Adulthood

BACKGROUND

Acute appendicitis is the most common cause of the acute abdomen, with an incidence of 1 per 1000 persons per year. It is one of the main differential diagnoses of unclear abdominal conditions.

METHODS

This review is based on pertinent publications that were retrieved by a selective search in the PubMed and Cochrane Library databases.

RESULTS

In addition to the medical history, physical examination and laboratory tests, abdominal ultrasonography should be performed to establish the diagnosis (and sometimes computed tomography [CT] or magnetic resonance imaging [MRI], if ultrasonography is insufficient). Before any treatment is provided, appendicitis is classified as either uncomplicated or complicated. In both types of appendicitis, the decision to treat surgically or conservatively must be based on the overall clinical picture and the patient's risk factors. Appendectomy is the treatment of choice for acute appendicitis in all age groups. In Germany, appendectomy is mainly performed laparoscopically in patients with low morbidity. Uncomplicated appendicitis can, alternatively, be treated conservatively under certain circumstances. A meta-analysis of five randomized, controlled trials has revealed that ca. 37% of adult patients treated conservatively undergo appendectomy within one year. Complicated appendicitis is a serious disease; it can also potentially be treated conservatively (with antibiotics, with or without placement of a drain) as an alternative to surgical treatment.

CONCLUSION

Conservative treatment is being performed more frequently, but the current state of the evidence does not justify a change of the standard therapy from surgery to conservative treatment.

Revisiting Amyand's Hernia: A 20-Year Systematic Review

PURPOSE

Protrusion of the appendix within an inguinal hernia is termed an Amyand's hernia. A systematic review of case reports and case series of Amyand's hernia was performed, with emphasis on surgical decision-making.

METHODS

The English literature (2000-2019) was reviewed, using PubMed and Embase, combining the terms "hernia", "inguinal", "appendix", "appendicitis" and "Amyand". Overall, 231 studies were included, describing 442 patients.

RESULTS

Mean age of patients was 34 ± 32 years (adults 57.5%, children 42.5%). 91% were males, while a left-sided Amyand's hernia was observed in 9.5%. Of 156 elective hernia repairs, 38.5% underwent appendectomy and 61.5% simple reduction of the appendix. 88% of the adult patients had a mesh repair, without complications. Of 281 acute cases, hernial complications (76%) and acute appendicitis (12%) were the most common preoperative surgical indications. Appendectomy was performed in 79%, more extensive operations in 8% and simple reduction in 13% of cases. A mesh was used in 19% of adult patients following any type of resection and in 81% following reduction of the appendix. Among acute cases, mortality was 1.8% and morbidity 9.2%. Surgical site infections were observed in 3.6%, all of which in patients without mesh implantation.

CONCLUSION

In elective Amyand's hernia cases, appendectomy may be considered in certain patients, provided faecal spillage is avoided, to prevent mesh infection. In cases of appendicitis, prosthetic mesh may be used, if the surgical field is relatively clean, whereas endogenous tissue repairs are preferred in cases of heavy contamination.

Impact of the COVID-19 pandemic on management and outcomes in acute appendicitis: Should these new practices be the norm?

Background

In early 2020, the COVID-19 pandemic significantly altered management of surgical patients globally. International guidelines recommended that non-operative management be implemented wherever possible (e.g. in proven uncomplicated appendicitis) to reduce pressure on healthcare services and reduce risk of peri-operative viral transmission. We sought to compare our management and outcomes of appendicitis during lockdown vs a non-pandemic period.

Methods

All presentations to our department with a clinical diagnosis of acute appendicitis between 12/03/2020 and 30/06/2020 were compared to the same 110-day period in 2019. Quantity and severity of presentations, use of radiological investigations, rate of operative intervention and histopathological findings were variables collected for comparison.

Results

There was a reduction in appendicitis presentations (from 74 to 56 cases), and an increase in radiological imaging (from 70.27% to 89.29%) (P = 0.007) from 2019 to 2020. In 2019, 93.24% of patients had appendicectomy, compared to 71.42% in 2020(P < 0.001). This decrease was most pronounced in uncomplicated cases, whose operative rates dropped from 90.32% to 62.5% (P = 0.009). Post-operative histology confirmed appendicitis in 73.9% in 2019, compared to 97.5% in 2020 (P = 0.001). Normal appendiceal pathology was reported for 17 cases (24.64%) in 2019, compared to none in 2020 (P < 0.001) – a 0% negative appendicectomy rate (NAR).

Discussion

The 0% NAR in 2020 is due to a combination of increased CT imaging, a higher threshold to operate, and is impacted by increased disease severity due to delayed patient presentation. This study adds to growing literature promoting routine use of radiological imaging to confirm appendicitis diagnosis. As we enter a second lockdown, patients should be encouraged to avoid late presentations, and surgical departments should continue using radiological imaging more liberally in guiding appendicitis management.

Platelet indices in patients with acute appendicitis: a systematic review with meta-analysis

Correlation between blood inflammatory parameters and acute appendicitis (AA) remains controversial. This meta-analysis aims to evaluate whether platelet (PLT) indices including mean platelet volume (MPV), PLT count, and platelet distribution width (PDW) are associated with AA. Pubmed, Embase, and Cochrane Library databases were searched for observational studies published from inception through April 2020 by two independent investigators. Studies reporting associations between platelet indices and AA were selected for inclusion. Standardized mean difference (SMD) and 95% confidence interval (CI) were estimated for continuous outcomes using a DerSimonian-Laird random-effects model. Of 842 records identified, 17 studies with a total of 6793 subjects met our inclusion criteria. Meta-analysis indicated that compared with those in healthy controls, significant decrease in MPV levels was observed in subjects with AA (SMD - 0.34; 95% CI - 0.56 to - 0.12; P = 0.003). Subgroup analyses represented a significant reduction of MPV levels in patients aged ≥ 30 years and non-complicated/non-perforated AA. Due to the small number of studies and patients included in each subgroup, these subgroup analyses need to be interpreted with caution. However, none of the levels of PLT (SMD - 0.13; 95% CI - 0.28-0.012; P = 0.071) or PDW (SMD 0.30; 95% CI - 0.22-0.83; P = 0.257) was seen decrease or increase in subjects with AA. This meta-analysis indicates a significant decrease in MPV levels in patients with AA, which makes MPV have the potential of serving as a biomarker for AA. The associations of other PLT indices with AA need to be further examined.

Comparison of acute appendicitis before and within lockdown period in COVID-19 era: A retrospective study from rural Nepal

Introduction

The world has been engulfed with the pandemic of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which have created significant impact in the emergency surgical health delivery including acute appendicitis. The main aim of this study was to compare the demographic and clinical parameters between two cohorts before the onset of lockdown and within the pandemic.

Methods

A retrospective analysis was performed between two groups A and B, who presented with acute appendicitis three months prior to and after initiation of lockdown on March 24 2020 respectively in one of the tertiary centers of Nepal. These two cohorts were compared in demographics, clinicopathological characteristics and surgical aspects of acute appendicitis.

Results

There were 42 patients in group A and 50 patients in group B. Mean age of the patients was 31.32±17.18 years with male preponderance in group B (N = 29). Mean duration of pain increased significantly in group B [57.8±25.9(B) vs 42.3±25.0(A) hours, P = 0.004] along with mean duration of surgery [51.06±9.4(B) vs 45.27±11.8(A) minutes, P = 0.015]. There was significant decrease in post-operative hospital stay among group B patients [3.04±1.1(B) vs 3.86±0.67(A) days, P = 0.0001]. Complicated cases increased in group B including appendicular perforation in 10 cases. Similarly, mean duration of presentation to hospital significantly increased in group B patients with perforation [69.6±21.01 vs 51.57±17.63 hours, P = 0.008].

Conclusion

During the adversity of the current pandemic, increased number of cases of acute appendicitis can be dealt with surgery as the chances of late presentation and complexity of the lesion exists.

Quarantine and Appendicitis: A Macro-Area Experience

PURPOSE

Appendicitis is the most frequent urgency in pediatric age; the aim of this study was to investigate the association of quarantine for severe acute respiratory syndrome coronavirus 2 pandemic and the incidence of pediatric appendicitis in a specific macro area.

METHODS

We retrospectively analyzed the medical records of consecutive patients who underwent surgical exploration for acute appendicitis in the period March-April since 2014. This specific quarantine period was divided into two phases as indicated by National government. Patient data, demographics, characteristics and outcomes were studied and evaluated comparing patients treated during quarantine especially phase 1 vs. phase 2 (March-April 2020).

RESULTS

After reviewing medical charts following the inclusion and exclusion criteria, 155 patients were studied; focusing on the final outcome, it is possible to show a decreased amount of appendicitis during phase 1 and a progressive increase during phase 2; respect to previous years, there was a statistical increase in severity of appendicitis during quarantine (gangrenous vs. phlegmonous appendicitis).

CONCLUSION

During this specific quarantine there was a reduction in appendicitis and a progressive increase during phase 2. These results offer new perspective among disease incidences during lockdown.

Acute appendicitis: a case report of hyperinfection with Enterobius vermicularis

Acute appendicitis is one of the most common causes of abdominal emergent surgical disease worldwide. Enterobius vermicularis, a human intestinal parasite, is reported to be associated with acute appendicitis. We report a case of an 8-year-old girl who was admitted to the emergency unit with complaints of severe abdominal pain and was diagnosed with acute appendicitis. Microscopic pathological examination showed lymphoid follicles with prominent germinal centers and mantle zones within the appendix wall. Cross-sections of multiple female and male Enterobius vermicularis worms and a few longitudinal sections of E.vermicularis were seen. E. vermicularis is one of the most common human parasitic infections, so the possibility of infection of the appendix with E. vermicularis should be considered in the differential diagnosis of agents of appendicitis.

Single-port laparoscopic appendicectomy versus conventional three-port approach for acute appendicitis in children: a systematic review and meta-analysis

AIM

To evaluate comparative outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis in children.

METHODS

A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis of outcomes were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. Operative time, surgical site infection, intra-abdominal collection, incisional hernia, length of hospital stay (LOS), additional port/s and conversion to open were the evaluated outcome parameters.

RESULTS

Four RCTs reporting a total number of 520 patients who underwent SPLA (n = 260) or CLA (n = 260) were included. There was no difference between SPLA and CLA group in post-operative collection (risk difference (RD) - 0.00, P = 0.94), surgical site infection (RD 0.02, P = 0.25), incisional hernia (RD 0.00 P = 1), LOS (mean difference (MD) 0.73 P = 0.93), need for additional port/s (RD 0.04, P = 0.24) and conversion to open (RD 0.00, P = 1). However, there was a significantly longer operative time in the SPLA group (MD 9.80, P = 0.00001). The certainty of the evidence was judged to be moderate for all outcomes.

CONCLUSIONS

SPLA and CLA seem to have comparable efficacy and safety in children with acute appendicitis although the former may be associated with longer procedure time. Future high-quality RCTs with adequate sample sizes are required to provide stronger evidence in favour of an intervention.

Same-day discharge after appendectomy for acute appendicitis: a systematic review and meta-analysis

PURPOSE

Patients presenting with acute appendicitis are usually hospitalized for a few days for appendectomy and postoperative recovery. Shortening length of stay may reduce costs and improve patient satisfaction. The purpose of this study was to assess the safety of same-day discharge after appendectomy for acute appendicitis.

METHODS

A systematic review was performed according to PRISMA guidelines. A literature search of EMBASE, Ovid MEDLINE, Web of Science, Cochrane Central, and Google Scholar was conducted from inception to April 14, 2020. Two reviewers independently screened the literature and selected studies that addressed discharge on the same calendar day as the appendectomy. Risk of bias was assessed with the ROBINS-I tool. Main outcomes were hospital readmission, complications, and unplanned hospital visits in the postoperative course. A random effects model was used to pool risk ratios for the main outcomes.

RESULTS

Of the 1912 articles screened, 17 comparative studies and 8 non-comparative studies met the inclusion criteria. Most only included laparoscopic procedure for uncomplicated appendicitis. Most studies were considered at moderate or serious risk of bias. In meta-analysis, same-day discharge (vs. overnight hospitalization) was not associated with increased rates of readmission, complication, and unplanned hospital visits. Non-comparative studies demonstrated low rates of readmission, complications, and unplanned hospital visits after same-day discharge.

CONCLUSION

This study suggests that same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis is safe without an increased risk of readmission, complications, or unplanned hospital visits. Hence, same-day discharge may be further encouraged in selected patients.

TRIAL REGISTRATION

PROSPERO registration no. CRD42018115948.

Appendectomy: prognostic factors in the brazilian unified health system

INTRODUCTION

Acute appendicitis (AA) is the most common cause of surgical acute abdomen. Postoperative complications in emergency care are reflections of the surgical procedure and pre- and postoperative factors.

OBJECTIVE

Define prognostic factors for patients who underwent appendectomy, comparing them with the literature.

METHODS

Descriptive observational study with a cross-sectional design based on data from the emergency/urgency appendectomy records between September 2018 and April 2019. Variables of interest were considered based on intrinsic patient data, clinical status, and perioperative management factors. Primary outcomes considered: postoperative complications from hospital admission discharge and prolonged hospital stay for > 2 days. Secondary outcome: death. The results were evaluated by Fisher's exact test (p <0.05).

RESULTS

We identified 48 patients undergoing an appendectomy. Young adults accounted for 68.7%. From the total, 58.3% were males, 6 (12.5%) had hospitalization> 2 days, 4 (8.3%) had complications and no deaths. Among the variables, the stage of AA, the time of complaint up until seeking care, and advanced age were correlated with worse prognosis during hospitalization (p <0.05). The emergence of immediate postoperative complications was correlated with longer hospital stay (p <0.05).

DISCUSSION

The descriptive data of the sample converge with the epidemiological profile of patients with AA in the literature, corroborating the applicability of conventional guidelines. The results strengthen the hypothesis that the patient's flow with abdominal manifestations is complicated from the first contact with SUS to the resolution of the condition.

CONCLUSION

Knowledge of the epidemiological profile and perioperative predictors that are most related to complications favor the appropriate management of patients.

The usefulness and positive predictive value of ultrasonography and computed tomography in the diagnosis of acute appendicitis in adults: a retrospective study

OBJECTIVE

To analyze the evolution of the use of imaging tests (ultrasonography and computed tomography (CT)) in the diagnosis of acute appendicitis. To determine the positive predictive value of these tests and the percentage of negative and complicated appendectomies.

MATERIAL AND METHODS

This retrospective study compared adults who underwent appendectomy for suspected acute appendicitis at our tertiary hospital during 2015 versus similar patients at our center during 2007.

RESULTS

A total of 278 patients were included. The rate of negative appendectomies descended to 5%. The positive predictive value of ultrasonography increased to 97.4% in 2015, and the positive predictive value of CT and combined CT and ultrasonography was 100%. The rate of complicated appendicitis increased (23% in 2015).

CONCLUSIONS

The use of imaging tests increased, and the rate of "blind" laparotomies decreased. Nevertheless, the rate of complicated appendicitis increased.

Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study

Background

Surgical strategies are being adapted to face the COVID‐19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis.

Methods

The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic.

Results

Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X‐ray plus molecular testing (PCR) being the commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P < 0·001). One‐third changed their approach from laparoscopic to open surgery owing to the popular (but evidence‐lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one‐third felt that patients who did present had more severe appendicitis than they usually observe.

Conclusion

Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS‐CoV‐2.

Comparing the Postoperative Outcomes of Single-Incision Laparoscopic Appendectomy and Three Port Appendectomy With Enhanced Recovery After Surgery Protocol for Acute Appendicitis: A Propensity Score Matching Analysis

PURPOSE

The objective of this study was to compare the perioperative outcomes between single-incision laparoscopic appendectomy (SILA) and 3-port conventional laparoscopic appendectomy (CLA) in enhanced recovery after surgery (ERAS) protocol.

METHODS

Of 101 laparoscopic appendectomy with ERAS protocol cases for appendicitis from March 2019 to April 2020, 54 patients underwent SILA with multimodal analgesic approach (group 1) while 47 patients received CLA with multimodal analgesic approach (group 2). SILA and CLA were compared with the single institution's ERAS protocol. To adjust for baseline differences and selection bias, operative outcomes and complications were compared after propensity score matching (PSM).

RESULTS

After 1:1 PSM, well-matched 35 patients in each group were evaluated. Postoperative hospital stays for patients in group 1 (1.2 ± 0.8 vs. 1.6 ± 0.8 days, P = 0.037) were significantly lesser than those for patients in group 2. However, opioid consumption (2.0 mg vs. 1.4 mg, P=0.1) and the postoperative scores of visual analogue scale for pain at 6 hours (2.4±1.9 vs. 2.8 ± 1.4, P = 0.260) and 12 hours (2.4 ± 2.0 vs. 2.9 ± 1.5, P = 0.257) did not show significant difference between the 2 groups.

CONCLUSION

SILA resulted in shortening the length of hospitalization without increase in complications or readmission rates compared to CLA with ERAS protocol.

Reasons for Undesirable Pregnancy Outcomes among Women with Appendicitis: The Experience of a Tertiary Center

Background

Although laparoscopic appendectomy increases its popularity today, the answer to the question of whether to perform open or laparoscopic appendectomy during pregnancy is appropriate in many studies, and the choice of surgery depends on the surgeon. Herein, we aimed to evaluate the variables that affect undesirable pregnancy outcomes that occur as a result of appendicitis during pregnancy.

Methods

Seventy-eight pregnant patients with acute appendicitis who underwent laparoscopic or open technique intervention enrolled in this retrospective study. In addition to the demographic structure of the patients, surgical technique, the number of pregnancies, multiple pregnancy status, surgical pathologies, laboratory values, radiological imaging methods, and length of hospital stay were evaluated. The severity of appendicitis was classified according to the pathology results. The patients were divided into two groups according to the outcomes of their pregnancy. Preterm delivery and abortion involved in the study as a single complication section.

Results

The mean age of the pregnant patients was 28.6 ± 5. Of the 78 pregnant women with appendicitis, 47.4% had their first pregnancy, 37.2% had their second pregnancy, and 15.4% had 3 or more pregnancies. The preterm delivery and abortus were 19.5% in the open appendectomy (OA) group and 16.2% in the laparoscopic appendectomy (LA) group. No statistically significant difference was detected in this group in terms of appendicitis pathology triggering preterm delivery or abortion (p 0.075). When white blood count (WBC) and C-reactive protein (CRP) were evaluated by laboratory findings, CRP was found to be statistically significantly higher in patients with preterm birth (p 0.042).

Conclusion

Consequently, acute appendicitis may cause serious intra-abdominal infection and inflammation in addition to the complexity of the diagnosis due to the nature of pregnancy, as well as undesired pregnancy outcomes with the surgical technique, or independently with other variables.

[Recommendations on treatment of acute appendicitis : Recommendations of an expert group based on the current literature]

The paradigm shift in the treatment concept for acute appendicitis is currently the subject of intensive discussions. The diagnosis and differentiation of an uncomplicated from a complicated appendicitis as well as the selection of an adequate treatment is very challenging, especially since nonoperative treatment models have been published. The laparoscopic appendectomy is still the standard for most cases. Guidelines for the treatment of acute appendicitis do not exist in Germany. Therefore, a group of experts elaborated 21 recommendations on the treatment of acute appendicitis after 3 meetings. After initial definition of population, intervention, comparison and outcome (PICO) questions, recommendations have been finalized through the Delphi voting system. The results were evaluated according to the current literature. The aim of this initiative was to define a basic support for decision making in the clinical routine for treatment of acute appendicitis.

Complicated appendicitis are common during the epidemic period of 2019 novel coronavirus (2019-nCoV)

Objectives

To assess the prevalence of complicated appendicitis (including gangrene, abscess and perforation) after the outbreak of the 2019-nCoV epidemic and to identify the risk factors associated with complicated appendicitis.

Methods

Two groups were established in the study consisting of: one group for cases of acute appendicitis before the 2019-nCoV epidemic (before January 1, 2020; pre-epidemic group) and another group for those after the epidemic outbreak (after January 1, 2020; epidemic group). These two groups were compared in terms of demographic and clinical characteristics, prevalence of complicated appendicitis, and treatment intention. A multivariate analysis model using binary logistic regression was constructed.

Results

A total of 163 patients were included in this study, with 105 in the pre-epidemic group and 58 in the epidemic group. In the epidemic group, the interval from the onset of symptoms to admission was 65.0 h, which is significantly longer than the 17.3 h interval noted in the pre-epidemic group (P < 0.001). The prevalence of complicated appendicitis after the epidemic outbreak was significantly higher than before the outbreak (51.7% vs. 12.4%, P < 0.001). In addition, the epidemic group had a lower score of patient’s intention to seek treatment than the pre-epidemic group (9.5 ± 2.7 vs. 3.4 ± 2.6, P < 0.001). Based on the multivariate analysis, the risk factors for complicated appendicitis included the time from symptoms onset to admission (OR = 1.075) and the patients’ intention to receive treatment (OR = 0.541).

Conclusion

Complicated appendicitis was more common in patients with acute appendicitis after the outbreak of the 2019-nCoV epidemic.

Unfinished Business: A Systematic Review of Stump Appendicitis

BACKGROUND

Stump appendicitis is defined as interval inflammation of any residual appendicular tissue, after an appendicectomy. We present a systematic review of case series and case reports on stump appendicitis, emphasising on risk factors, diagnosis and surgical management.

METHODS

The English literature (1945-2018) was reviewed, using PubMed, Embase and GoogleScholar, combining the terms "appendix", "appendicitis", "stump", "residual", "recurrent" and "retained". In total, 127 studies were included, describing 164 patients (males 59%, mean age 36 ± 17 years).

RESULTS

Index surgery was open in 59% and laparoscopic in 38%. It was described as "difficult" or "complicated" in 31%. 20% of patients reported episodes of recurrent abdominal pain during the time interval between index and stump appendicitis (range 2 weeks to 60 years, median 2 years). Right lower quadrant pain was the most frequent complain (88%), leukocytosis was found in 56%, whereas 92% of patients underwent imaging testing, which was diagnostic or highly suspicious in 67.5%. Mean delay between beginning of symptoms and surgery was 2.4 ± 2.3 days. The operative approach was open in 61% and laparoscopic in 35% of cases. The operation was characterised as "difficult" or "complicated" in 45%. In the majority (88%), a completion stump appendicectomy was performed, with 11% requiring more extensive procedures. Mean length of resected stump was 3.1 ± 1.6 cm (range 0.5-10 cm).

CONCLUSIONS

Stump appendicitis may occur following both open and laparoscopic approach, when the residual stump is > 0.5 cm. Its clinical significance lies in the delayed diagnosis, leading to higher incidence of complications and the need for more extensive surgery.

Epidemiology and Risk Factors for Superficial Surgical Site Infections after Appendectomy for Acute Appendicitis: A Secondary Data Analysis

Background: The identification of risk factors for superficial surgical site infections (SSSIs) associated with appendectomy is paramount in the management of patients with acute appendicitis (AA). Methods: This study was a secondary data analysis from a prospective multi-center observational study. It included all consecutive hospitalized patients with AA who underwent appendectomy and were monitored for complications at 30 days after the intervention. A case-control approach was used to evaluate risk factors associated with the occurrence of SSSI. Results: Among 2,667 patients, 156 (5.8%) developed an SSSI. The series included 1,449 males (54.3%) and 1,218 females with a median age of 29 years (interquartile range [IQR] 20-45 years). Antimicrobial therapy within the previous 30 days was reported by 170 patients (6.4%), and a C-reactive protein concentration (CRP) >50 mg/L was observed in 609 (22.8%). A total of 960 patients (36.0%) underwent open surgery, 1,699 (63.7%) laparoscopic surgery, and 8 (0.3%) another surgical intervention. In 2,575 patients (95.6%), a pathological appendix was detected during the operation. In 776 patients (29.1%), an intra-operative abdominal drain (IAD) was placed; 125 patients (4.7%) were admitted to the intensive care unit. The median hospital length of stay was 3 days (IQR 2-5 days). The overall mortality rate was 0.11%. Multinomial logistic regression analysis of risk factors demonstrated that statistically significant risk factors independently associated with the occurrence of SSSIs were antimicrobial therapy within the previous 30 days, CRP >50 mg/L, open surgical procedures, presence of IAD, and intra-operative findings of complex appendicitis. Conclusions: Knowledge of five easily recognizable variables, assessable at hospital admission or as soon as the surgical intervention is concluded, might identify patients with a greater risk of developing an SSSI.

[Laparoscopic surgery for advanced appendicular peritonitis]

OBJECTIVE

To evaluate the results of laparoscopic treatment of patients with advanced appendicular peritonitis.

MATERIAL AND METHODS

There were 271 patients with acute appendicitis complicated by peritonitis. The main group consisted of patients who underwent laparoscopic appendectomy after diagnostic laparoscopy (n=231), the control group - diagnostic laparoscopy followed by conversion to median laparotomy (n=36). Four extremely ill patients were operated through laparotomy and excluded from the further analysis.

RESULTS

Diagnostic laparoscopy was performed in 267 patients with advanced appendicular peritonitis. Laparoscopic appendectomy, debridement and abdominal drainage were performed in 231 (85.2%) patients. Mean age of patients was 44±18.5 years, duration of disease - 36.2±20.3 hours. Diffuse peritonitis was diagnosed in 219 (82%) patients, advanced peritonitis - in 48 (16.5%) cases. Incidence of conversion was 13.5%. Mortality was absent in both groups. Postoperative morbidity was significantly higher in the conversion group (72.2% vs. 29.4%, p<0.0001).

CONCLUSION

Laparoscopic interventions for common appendicular peritonitis are feasible, effective and reduce postoperative morbidity.

The value of post-operative antibiotic therapy after laparoscopic appendectomy for complicated acute appendicitis: a prospective, randomized, double-blinded, placebo-controlled phase III study (ABAP study)

BACKGROUND

Approximately 30% of appendectomies are for complicated acute appendicitis (CAA). With laparoscopy, the main post-operative complication is deep abscesses (12% of cases of CAA, versus 4% for open surgery). A recent cohort study compared short and long courses of postoperative antibiotic therapy in patients with CAA. There was no significant intergroup difference in the post-operative complication rate (12% of organ/space surgical site infection (SSI)). Moreover, antibiotic therapy is increasingly less indicated for other situations (non-complicated appendicitis, post-operative course of cholecystitis, perianal abscess), calling into question whether post-operative antibiotic therapy is required after laparoscopic appendectomy for CAA.

METHODS/DESIGN

This study is a prospective, multicenter, parallel-group, randomized (1:1), double-blinded, placebo-controlled, phase III non-inferiority study with blind evaluation of the primary efficacy criterion. The primary objective is to evaluate the impact of the absence of post-operative antibiotic therapy on the organ/space surgical site infection (SSI) rate in patients presenting with CAA (other than in cases of generalized peritonitis). Patients in the experimental group will receive at least one dose of preoperative and perioperative antibiotic therapy (2 g ceftriaxone by intravenous injection every 24 h up to the operation) and metronidazole (500 mg by intravenous injection every 8 h up to the operation) and, in the post-operative period, a placebo for ceftriaxone (2 g/24 h in one intravenous injection) and a placebo for metronidazole (1500 mg/24 h in three intravenous injections, for 3 days). In the control group, patients will receive at least one dose of preoperative and perioperative antibiotic therapy (2 g ceftriaxone by intravenous injection every 24 h up to the operation) and metronidazole (500 mg by intravenous injection every 8 h up to the operation) and, in the post-operative period, antibiotic therapy (ceftriaxone 2 g/24 h and metronidazole 1500 mg/24 h for 3 days). In the event of allergy to ceftriaxone, it will be replaced by levofloxacin (500 mg/24 h in one intravenous injection, for 3 days). The expected organ space SSI rate is 12% in the population of patients with CAA operated on by laparoscopy. With a non-inferiority margin of 5%, a two-sided alpha risk of 5%, a beta risk of 20%, and a loss-to-follow-up rate of 10%, the calculated sample size is 1476 included patients, i.e., 738 per group. Due to three interim analyses at 10%, 25%, and 50% of the planned sample size, the total sample size increases to 1494 patients (747 per arm).

TRIAL REGISTRATION

Ethical authorization by the Comité de Protection des Personnes and the Agence Nationale de Sécurité du Médicament: ID-RCB 2017-00334-59. Registered on ClinicalTrials.gov (NCT03688295) on 28 September 2018.

Which appendicitis scoring system is most suitable for pregnant patients? A comparison of nine different systems

BACKGROUND

Acute appendicitis is the most common non-gynecological emergency during pregnancy. The diagnosis of appendicitis during pregnancy is challenging due to changes in both physiological and laboratory variables. Guidelines suggest patients with suspected acute appendicitis should be stratified based on clinical scoring systems, to optimize the use of diagnostic imaging and prevent unnecessary surgery. Surgeons require additional information beyond that provided by imaging studies before deciding upon exploratory laparoscopy in patients with a high suspicion of appendicitis. Various scoring methods have been evaluated for the diagnosis of acute appendicitis. However, there is no consensus on a method to use during pregnancy, and a detailed comparison of existing scoring methods for this purpose has not yet been conducted. The purpose of this study was to evaluate the efficacy of the most popular scoring systems applied to diagnose acute appendicitis during pregnancy.

METHODS

This single-center retrospective study included 79 pregnant patients who were admitted to the emergency department with abdominal pain between May 2014 and May 2019. The patients were diagnosed with acute appendicitis and underwent an appendectomy. As a control group, the study also included 79 non-pregnant patients who underwent appendectomy within the last 1.5 years. To ensure that the groups were similar, women in the case group were stratified according to age, and the proportions of women in the strata were determined. The women in the control group were similarly stratified. Women were randomly selected from the strata to prevent bias. Both laboratory and examination findings required for each scoring method were obtained and assessed separately for each patient. Negative appendectomy rates were evaluated according to pathology results. Categorical variables were compared using the chi-square test. A p value < 0.05 was considered to indicate significance. Receiver operator characteristic curve analysis was used to identify the best threshold value and to assess the performance of the test scores in terms of diagnosing appendicitis.

RESULTS

Among all scoring systems, the Tzanakis score was most efficacious at predicting appendicitis in non-pregnant women. The positive predictive value (PPV) of the Tzanakis score was 90.6%, whereas the negative predictive value (NPV) was 46.7%. The RIPASA score performed the best among the scoring systems in pregnant women. It was associated with a PPV of 94.40%, NPV of 44%, and sensitivity and specificity of 78.46% and 78.57%, respectively.

CONCLUSION

Although the RIPASA score can be used to efficaciously diagnose acute appendicitis in pregnant women, a specific scoring system is needed for diagnosis during the gestation period.

"Analysis of readmissions to the emergency department among patients presenting with abdominal pain"

BACKGROUND

Abdominal pain is one of the most common complaints among patients admitted to the Emergency Department (ED). Diagnosis and management of abdominal pain may be a challenge and there are patients who require admission to the ED more than once in a short period of time. Our purpose was to assess the incidence of readmissions among patients treated in the ED due to abdominal pain and to investigate the impact of readmission on the further course of treatment.

METHODS

We conducted a prospective observational study, which included patients admitted to the ED in one academic, teaching hospital presenting with non-traumatic abdominal pain in a three-month period. Analyzed factors included demographic data, details related to first and subsequent visits in the ED and the course of hospitalization.

RESULTS

Overall, 928 patients were included to the study and 101 (10.88%) patients were admitted to the ED more than once during three-month period. Patients visiting ED repeatedly were older (p = 0.03) and more likely to be hospitalized (p < 0.01) compared to single-visit patients. Patients during their subsequent visits spent more time in the ED (p = 0.01), had greater chance to repeat their appointment (p = 0.04), be admitted to the hospital (p < 0.01) and were more likely diagnosed with cholelithiasis (p = 0.03) compared to patients on their initial visit. If admitted to the surgical department they were also more often qualified for surgical procedure than patients on their first visit (p < 0.01). In a group of patients admitted to the surgical department there were no significant differences in rates of conversion, postoperative complications and mortality between subgroups.

CONCLUSIONS

Readmissions among patients presenting with abdominal pain are a common phenomenon with prevalence of 10.88%. They are most commonly associated with cholelithiasis and occur more frequently among older patients, which suggests, that elderly require more attention during ED managements.

Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines

BACKGROUND AND AIMS

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.

METHODS

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.

CONCLUSIONS

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.

Nongynecologic Causes of Pelvic Pain: Ultrasound First

Ultrasonography (US) is often the first-line imaging study used to evaluate women who present with acute or chronic pelvic pain. Detection of nongynecologic causes of pelvic pain is critical, because delay in diagnosis can cause significant morbidity and mortality. Evaluation of these entities requires a variety of transducers to achieve optimal imaging depth and changes in patient positioning. Specific imaging techniques (such as graded compression) may be required if bowel pathology is suspected. Contrast-enhanced ultrasonography is increasingly used to improve detection of certain entities. The US appearance of common gastrointestinal and urinary tract-related causes of pelvic pain is reviewed.

Consensus Statement of the Italian Polispecialistic Society of Young Surgeons (SPIGC): Diagnosis and Treatment of Acute Appendicitis

Background: Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.Methods: This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.Results: Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.