The Global Incidence of Appendicitis: A Systematic Review of Population-based Studies

Factors Affecting Patient Outcomes in Acute Appendicitis in Rural Areas: An Observational Cohort Study

BACKGROUND

The most common surgical emergency both in developed and non-developed countries is acute appendicitis and it has a time-dependent clinical course. In this observational cohort study, we aim to investigate the factors affecting patient outcomes in acute appendicitis at a rural hospital.

METHODS

This observational cohort study was held between November 2012 and May 2014 at a rural hospital. Patients' pre-operative, perioperative, and post-operative data were collected prospectively. Patients were followed-up for 12-months.

RESULTS

A total of 151 patients were recorded. Factors significantly associated with complicated cases (abscess/perforation) were referral region as remote towns (OR:7.94, 95%CI [3.46-18.23]; p < 0.001), referral season as winter (OR:2.47, %95CI [1.14-5.36]; p = 0.022), pre-operative hospital delay (OR:6.52, 95%CI [3.49-12.20]; p < 0.001), and duration of referral (OR:1.01, 95%CI [1.00-1.01]; p < 0.001). In the multivariate analysis, only pre-operative hospital delay remained as a significant factor (OR:5.87, 95%CI [2.85 - 12.07]; p < 0.001). Factors affecting length of hospital stay (LoHS) were referral region as remote towns (95%CI, β = 3.10 [2.28-3.93], t = 1.91; p < 0.001), abscess/perforation (95%CI, β = 4.70 [4.04-5.36], t = 14.05; p < 0.001), pre-operative hospital delay (95%CI, β = 1.25 [0.87-1.62], t = 6.58; p < 0.001), and duration of referral (95%CI, β = 0.011 [0.01-0.14], t = 7.34; p < 0.001). In the multivariate analysis, all four factors stayed significant. The rate of complicated appendicitis was significantly high in winter than other seasons for patients referring from remote towns (75% vs 33%, p < 0.001).

CONCLUSIONS

This observational cohort study is the only study specifically focused on the effect of season and region on abscess/perforation rates, LoHS, and accessibility to hospital in patients with acute appendicitis.

Appendectomy and Non-Typhoidal Salmonella Infection: A Population-Based Matched Cohort Study

The potential association between appendectomy and non-typhoidal Salmonella (NTS) infection has not been elucidated. We hypothesized that appendectomy may be associated with gut vulnerability to NTS. The data were retrospectively collected from the Taiwan National Health Insurance Research Database to describe the incidence rates of NTS infection requiring hospital admission among patients with and without an appendectomy. A total of 208,585 individuals aged ≥18 years with an appendectomy were enrolled from January 2000 to December 2012, and compared with a control group of 208,585 individuals who had never received an appendectomy matched by propensity score (1:1) by index year, age, sex, occupation, and comorbidities. An appendectomy was defined by the International Classification of Diseases, Ninth Revision, Clinical Modification Procedure Codes. The main outcome was patients who were hospitalized for NTS. Cox proportional hazards models were applied to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs). Two sensitivity analyses were conducted for cross-validation. Of the 417,170 participants (215,221 (51.6%) male), 208,585 individuals (50.0%) had an appendectomy, and 112 individuals developed NTS infection requiring hospitalization. In the fully adjusted multivariable Cox proportional hazards regression model, the appendectomy group had an increased risk of NTS infection (adjusted HR (aHR), 1.61; 95% CI, 1.20-2.17). Females and individuals aged 18 to 30 years with a history of appendectomy had a statistically higher risk of NTS than the control group (aHR, 1.92; 95% CI, 1.26-2.93 and aHR, 2.67; 95% CI, 1.41-5.07). In this study, appendectomy was positively associated with subsequent hospitalization for NTS. The mechanism behind this association remains uncertain and needs further studies to clarify the interactions between appendectomy and NTS.

Risk of Hematologic Malignant Neoplasms From Abdominopelvic Computed Tomographic Radiation in Patients Who Underwent Appendectomy

Importance

Whether computed tomography (CT) radiation is truly carcinogenic remains controversial. Large epidemiological studies that purportedly showed an association between CT radiation and carcinogenesis were limited by confounding by indication and reverse causation, because the reasons for CT examination were unknown.

Objective

To measure the risk of hematologic malignant neoplasms associated with perioperative abdominopelvic CT radiation among patients who underwent appendectomy for acute appendicitis.

Design, Setting, and Participants

This nationwide population-based cohort study used the National Health Insurance Service claims database in South Korea to assess 825 820 patients who underwent appendectomy for appendicitis from January 1, 2005, to December 31, 2015, and had no underlying risk factors for cancer. Patients were divided into CT-exposed (n = 306 727) or CT-unexposed (n = 519 093) groups. The study was terminated on December 31, 2017, and data were analyzed from October 30, 2018, to September 27, 2020.

Exposures

Perioperative abdominopelvic CT examination from 7 days before to 7 days after appendectomy.

Main Outcomes and Measures

The primary outcome was the incidence rate ratio (IRR) of hematologic malignant neoplasms for both groups. The secondary outcomes were IRR of abdominopelvic organ cancers and IRR of all cancers. The lag period was 2 years for the primary outcome and 5 years for secondary outcomes. The IRRs were calculated using Poisson regression models with adjustment for age and sex.

Results

Among the study population of 825 820 patients (52.9% male; median age, 28 [interquartile range, 15-41] years), hematologic malignant neoplasms developed in 323 patients in the CT-exposed group during 1 486 518 person-years and 500 patients in the CT-unexposed group during 3 422 059 person-years. For all hematologic malignant neoplasms, the IRR for the CT-exposed vs CT-unexposed group was 1.26 (95% CI, 1.09-1.45; P = .002). In terms of individual categories of hematologic malignant neoplasms, the CT-exposed group had an elevated risk only for leukemia (IRR, 1.40 [98.75% CI, 1.04-1.87, adjusted by Bonferroni correction]; P = .005). There was no between-group difference in incidence rate of abdominopelvic organ cancers (IRR, 1.07 [95% CI, 1.00-1.15]; P = .06) and that of all cancers (IRR, 1.04 [95% CI, 0.99-1.09]; P = .14).

Conclusions and Relevance

This study controlled for reverse causation bias by defining the reasons for CT scan, and findings suggest that abdominopelvic CT radiation is associated with a higher incidence of hematologic malignant neoplasms. Efforts should be continued for judicious use of CT examinations.

Human immunodeficiency virus infection is associated with a differential increase in cytokine response and increased risk of perforation in acute appendicitis

HIV infection causes increased perforation rate in acute appendicitis and alters cytokine profile resulting in increased pro-inflammatory cytokines in serum but decreased in peritoneal fluid. It is also accompanied by increased anti-inflammatory cytokines.

Management of Acute Appendicitis during COVID-19 Pandemic in a Tertiary Care Centre: A Descriptive Cross-sectional Study

INTRODUCTION

Acute appendicitis is the most common reason for abdominal surgery in children. Though appendectomy considered the gold standard there are a lot of complications related to it. Conservative management of acute appendicitis is not new to medical science. In pandemic like COVID-19 when all the health systems were about to shut-down because of lack of manpower and resources, we started a trial of non-operative management. The main aim of this study is to find out the management of acute appendicitis during COVID-19.

METHODS

This was a descriptive cross-sectional study conducted in a tertiary care centre. Data collection was done from the record section which included the patients diagnosed with acute appendicitis from February 2020 to July 2020 after obtaining ethical clearance from Institutional Review Committee. Cases of appendicular lump, appendicular abscess, appendicular perforations have been excluded. Data was collected and entry was done in Statistical Package for the Social Science software version 20, point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.

RESULTS

The conservative management of acute appendicitis was done in 44 cases (55.7%) while 35 cases (44.3%) had to undergo appendectomy.

CONCLUSIONS

COVID-19 can complicate the perioperative course as a result of direct lung injury and multiple organ dysfunctions and can also bring serious threats to the safety of medical staffs involved in managing the acute appendicitis case operatively, so conservative management can be considered as an alternative way of management of acute appendicitis in the pandemic outbreak.

The Worldwide Epidemiology of Acute Appendicitis: An Analysis of the Global Health Data Exchange Dataset

BACKGROUND

This study aims to describe the worldwide epidemiology and changing disease trends of acute appendicitis (AA).

METHODS

Epidemiological data on the incidence of AA and deaths were collected from the Global Health Data Exchange repository from 1990 to 2019. Data were stratified by age, sex and Socio-Demographic Index (SDI).

RESULTS

In 2019, there were an estimated 17.7 million cases (incidence 228/100,000) with over 33,400 deaths (0.43/100,000). Both the absolute number and the incidence had increased from 1990 to 2019 (+ 38.8% and + 11.4%, respectively). The number of deaths and deaths per 100,000 declined during this period (- 21.8% and - 46.2%, respectively). These trends were largely similar in all 5 SDI groups. There was a significant difference in the incidence of AA between the SDI groups, with low SDI group having the lowest and high SDI group having the highest. The high SDI group had the lowest mortality rate (Kruskall-Wallis test, p < 0.001). The peak incidence was in the 15-19-year age group. The mortality rate increased exponentially from the third decade of life.

CONCLUSIONS

The mortality rate of AA is declining worldwide, while the incidence is increasing. The peak incidence is in the 15-19-year group.

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.

Seasonal Variation in Cases of Acute Appendicitis

Objectives

To investigate whether the incidence of acute appendicitis increases in summer and whether complicated cases present more in summer.

Methods

A single-center cross-sectional, retrospective study on 697 cases of appendicitis admitted in the year 2018. Inclusion criteria: patients admitted with acute appendicitis who underwent appendectomy of all ages. Exclusion criteria: conservative management. Analysis was performed using Microsoft Excel. Pearson correlation coefficient was calculated to assess the correlation between monthly incidence of appendicitis and mean temperature in that month.

Results

Fifty-one patients who were managed conservatively were excluded. Accordingly, 646 patients were included. Ages ranged from three to 77 years. Males comprised the majority (500, 77.4%). Gangrenous, perforated, and purulent appendices were regarded as complicated appendicitis. The highest number of cases were admitted in summer (234), comprising 36.2% of cases. Complicated cases were equal to 65, of which 23 (35.4%) were admitted in summer and 30 (46.2%) in winter. The highest number of cases was during the month of July (68), while the lowest (40) was during February. This corresponded to the highest recorded mean temperature (36.2°C) and second lowest (19.8°C), respectively. Moderate positive correlation (Pearson's R 0.5183) between the monthly incidence of appendicitis and the mean temperature is noted.

Conclusion

More cases of appendicitis were noted during summer. Monthly incidence correlated positively with the temperature. Larger numbers over several years are needed to draw better conclusions and reach the possible causes behind such variation.

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.

The Rolling Stones: A case report of two surgical abdomens linked by migrating gallstones

INTRODUCTION

Acute abdominal pain accounts for 5% of all presentations to the emergency department (Stoker et al., 2009). Two of the most common causes are acute appendicitis and acute cholecystitis (Ferris et al., 2017).

PRESENTATION

A 70-year-old man presented with acute calculous cholecystitis. He subsequently deteriorated clinically and re-imaging revealed interval migration of stones from the biliary system to the appendix with resultant acute appendicitis.

DISCUSSION

Although both acute appendicitis and acute cholecystitis are common, dual pathology is rare. There are a small number of case reports of gallstones causing appendicitis (Vicari, 1964; Siegal et al., 1990; Meade, 1960).

CONCLUSION

Our case report nicely illustrates. a) The importance of considering dual pathology, especially when there is an unexpected change in the patient's clinical status. b) The CT features of two common acute surgical pathologies. c) The value of cholecystostomy- performed in the Interventional Radiology suite- as a temporizing measure to allow the patient to recover from a critical illness.

Appendicitis during the COVID-19 lockdown: results of a multicenter analysis in Germany

Purpose

The COVID-19 pandemic has transformed medical care worldwide. General surgery has been affected in elective procedures, yet the implications for emergency surgery are unclear. The current study analyzes the effect of the COVID-19 lockdown in spring 2020 on appendicitis treatment in Germany.

Methods

Hospitals that provided emergency surgical care during the COVID-19 lockdown were invited to participate. All patients diagnosed with appendicitis during the lockdown period (10 weeks) and, as a comparison group, patients from the same period in 2019 were analyzed. Clinical and laboratory parameters, intraoperative and pathological findings, and postoperative outcomes were analyzed.

Results

A total of 1915 appendectomies from 41 surgical departments in Germany were included. Compared to 2019 the number of appendectomies decreased by 13.5% (1.027 to 888, p=0.003) during the first 2020 COVID-19 lockdown. The delay between the onset of symptoms and medical consultation was substantially longer in the COVID-19 risk group and for the elderly. The rate of complicated appendicitis increased (58.2 to 64.4%), while the absolute number of complicated appendicitis decreased from 597 to 569, (p=0.012). The rate of negative appendectomies decreased significantly (6.7 to 4.6%; p=0.012). Overall postoperative morbidity and mortality, however, did not change.

Conclusion

The COVID-19 lockdown had significant effects on abdominal emergency surgery in Germany. These seem to result from a stricter selection and a longer waiting time between the onset of symptoms and medical consultation for risk patients. However, the standard of emergency surgical care in Germany was maintained.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02090-3.

Appendicitis is a Severe Disease in Elderly Patients: A Twenty-Year Audit

Background and Objectives:

Life expectancy has increased substantially. Elderly patients currently represent a large part of patients requiring emergency abdominal surgery. The aim of this study was to evaluate the postoperative outcomes of elderly patients who underwent appendectomy in a single French tertiary center.

Methods:

We retrospectively reviewed the medical records of all patients who underwent appendectomy for acute appendicitis between January 1, 1994 and December 31, 2014. We used the French threshold of ≥ 75 y-old to define elderly patients. Hence, elderly patients who underwent appendectomy were compared to the younger group.

Results:

During the study period, 2,060 consecutive patients underwent appendectomy for acute appendicitis. Laparoscopic appendectomy was performed in 52% of cases. Similar rates of laparoscopic approach were recorded in both groups, but conversion to open surgery was six times more frequent in elderly patients (17% vs. 3%; P < .0001). A higher incidence of complicated appendicitis was observed in the elderly group (63% vs. 13.6%; P < .0001). Complications occurred more frequently in the elderly group (46% vs. 8%; P < .0001). 30-d mortality was 0.15% for patients < 75 y and 6.15% for elderly patients (P < .0001). Unsuspected presence of an appendiceal neoplasm was higher (7.7%) in the elderly population.

Conclusion:

This study highlights the fact that appendicitis in the elderly is associated with a higher rate of complicated appendicitis, morbidity, and mortality.

Differences between inflamed and non inflamed appendices diagnosed as acute appendicitis

Background

Despite the great advances in diagnostic methods, the incidence of the surgical removal of a morphologically normal appendix in patients with clinical and complementary signs of acute appendicitis continues to exceed 20%. This study aimed to compare the clinical, laboratory, and ultrasound findings of inflammatory and noninflammatory appendiceal disorders diagnosed as acute appendicitis.

Methods

The medical records of 208 patients with clinical, laboratory, and ultrasound findings indicative of acute appendicitis were studied. The patients were divided into two groups: group 1 comprising 94 patients whose appendicular histological results suggested a normal appendix and group 2 comprising 114 patients with histopathological tests confirming acute appendicitis. The variables analyzed were age at the time of surgery, sex, nausea and vomiting, inappetence, fever, pain migrating to the right iliac fossa, pain on palpation of the right iliac fossa, Blumberg's sign, blood counts, ultrasound findings, and Alvarado score.

Results

An inflamed appendix was associated with inappetence, pain on palpation of the right iliac fossa, appendiceal diameter >6 mm, and Alvarado score >6 (p < 0.001). In contrast, fever was more frequently found in noninflammatory appendiceal disorders (p < 0.001).

Conclusion

Inappetence, pain on palpation of the right iliac fossa, appendiceal diameter > 6 mm, and Alvarado score > 6 indicate an inflammatory appendiceal disease, whereas fever is more often present in noninflammatory appendiceal diseases.

Mortalidad perioperatoria de pacientes sometidos a apendicectomías en el régimen contributivo de Colombia

Introducción. La mortalidad perioperatoria se considera una de las herramientas clave para medir la fuerza del sistema de salud de un país en el área quirúrgica. Actualmente, no se cuenta con las cifras totales de las apendicectomías realizadas en nuestro pais, a pesar de ser un procedimiento quirúrgico extremadamente común. Métodos. Estudio de cohorte retrospectivo con datos de pacientes de todas las edades, reportados como afiliados al sistema de salud contributivo de Colombia y a quienes se les realizó una apendicectomía entre el 1° de enero de 2011 y el 31 de diciembre de 2016. La información se obtuvo de bases de datos nacionales y se procesó a partir del cálculo de variables, como la tasa de mortalidad perioperatoria y el volumen quirúrgico, estimando una tasa de mortalidad a treinta días, por sexo, grupo etario y región geográfica. Resultados. Entre las 231.570 apendicectomías que se identificaron, se halló una mayor tasa de mortalidad perioperatoria en el grupo etario de hombres mayores de 80 años con 17,3 %. La región oriental presentó la menor tasa de mortalidad con 0,01 %. El mayor volumen quirúrgico se presentó en el año 2012 y el menor en el año 2016. Discusión. La tasa de mortalidad de apendicectomía en diferentes grupos etarios es similar a la de otros países de ingresos medios y bajos, en tanto que la mayor heterogeneidad de la tasa de mortalidad entre las diferentes regiones, se percibe en los grupos de menores de un año y de mayores de 65 años. Este estudio se constituye como una aproximación inicial a la tasa de mortalidad en apendicectomías realizadas en Colombia.

Quality Outcomes in Appendicitis Care: Identifying Opportunities to Improve Care

INTRODUCTION

Appendicitis is one of the most common causes of acute abdominal pain requiring surgical intervention, but the variability of diagnosis and management continue to challenge the surgeons. Aim: This study assessed patients undergoing appendectomy to identify opportunities to improve diagnostic accuracy and outcomes.

METHODS

An ethically approved retrospective cohort study was undertaken between March 2016 and March 2017 at a single university hospital of all consecutive adult and paediatric patients undergoing appendectomy. Demographic data including age, gender, co-morbidities, presentation and triage timings along with investigation, imaging and operative data were analysed. Appendicitis was defined as acute based on histology coupled with intraoperative grading with the American Association for the Surgery of Trauma (AAST) grades. Complications using the Clavien-Dindo classification along with 30-day re-admission rates and the negative appendectomy rates (NAR) were recorded and categorised greater and less than 25%. The use of scoring systems was assessed, and retrospective scoring performed to compare the Alvarado, Adult Appendicitis Score (AAS) and the Appendicitis Inflammatory Response (AIR) score. Results: A total of 201 patients were studied, 115 male and 86 females, of which 136/201 (67.6%) were adults and 65/201 (32.3%) paediatric. Of the adult group, 83 were male and 53 were female, and of the paediatric group, 32 were male and 33 were female. Median age was 20 years (range: 5 years to 81 years) and no patient below the age of 5 years had an appendectomy during our study period. All patients were admitted via the emergency department and median time from triage to surgical review was 2 h and 38 min, (range: 10 min to 26 h and 10 min). Median time from emergency department review to surgical review, 55 min (range: 5 min to 6 h and 43 min). Median time to operating theatre was 21 h from admission (range: 45 min to 140 h and 30 min). Out of the total patients, 173 (86.1%) underwent laparoscopic approach, 28 (13.9%) had an open approach and 12 (6.9%) of the 173 were converted to open. Acute appendicitis occurred in 166/201 (82.6%). There was no significant association between grade of appendicitis and surgeons' categorical NAR rate (p = 0.07). Imaging was performed in 118/201 (58.7%); abdominal ultrasound (US) in 53 (26.4%), abdominal computed tomography (CT) in 59 (29.2%) and both US and CT in 6 (3%). The best cut-off point was 4 (sensitivity 84.3% and specificity of 65.7%) for AIR score, 9 (sensitivity of 74.7% and specificity of 68.6%) for AAS, and 7 (sensitivity of 77.7% and specificity of 71.4%) for the Alvarado score. Twenty-four (11.9%) were re-admitted, due to pain in 16 (58.3%), collections in 3 (25%), 1 (4.2%) wound abscess, 1 (4.2%) stump appendicitis, 1 (4.2%) small bowel obstruction and 1 (4.2%) fresh rectal bleeding. CT guided drainage was performed in 2 (8.3%). One patient had release of wound collection under general anaesthetic whereas another patient had laparoscopic drain placement. A laparotomy was undertaken in 3 (12.5%) patients with division of adhesions in 1, the appendicular stump removed in 1 and 1 had multiple collections drained.

CONCLUSION

The negative appendectomy and re-admission rates were unacceptably high and need to be reduced. Minimising surgical variance with use of scoring systems and introduction of pathways may be a strategy to reduce NAR. New systems of feedback need to be introduced to improve outcomes.

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.

Appendectomy in Patients with Morbid Obesity: Laparoscopic versus Conventional Technique

BACKGROUND Our aim was to determine the optimum appendectomy technique in patients with morbid obesity by evaluating laparoscopic appendectomy (LA) and open appendectomy (OA) operations performed in these patients. MATERIAL AND METHODS The records of 2179 patients who underwent appendectomy for acute appendicitis between January 2010 and April 2019 were evaluated retrospectively. Patients were excluded for the following: age.

DIALAPP: a prospective validation of a new diagnostic algorithm for acute appendicitis

Purpose

The management of patients with suspected appendicitis remains a challenge in daily clinical practice, and the optimal management algorithm is still being debated. Negative appendectomy rates (NAR) continue to range between 10 and 15%. This prospective study evaluated the accuracy of a diagnostic pathway in acute appendicitis using clinical risk stratification (Alvarado score), routine ultrasonography, gynecology consult for females, and selected CT after clinical reassessment.

Methods

Patients presenting with suspected appendicitis between November 2015 and September 2017 from age 18 years and above were included. Decision-making followed a clear management pathway. Patients were followed up for 6 months after discharge. The hypothesis was that the algorithm can reduce the NAR to a value of under 10%.

Results

A total of 183 patients were included. In 65 of 69 appendectomies, acute appendicitis was confirmed by histopathology, corresponding to a NAR of 5.8%. Notably, all 4 NAR appendectomies had other pathologies of the appendix. The perforation rate was 24.6%. Only 36 patients (19.7%) received a CT scan. The follow-up rate after 30 days achieved 69%, including no patients with missed appendicitis. The sensitivity and specificity of the diagnostic pathway was 100% and 96.6%, respectively. The potential saving in costs can be as much as 19.8 million €/100,000 cases presenting with the suspicion of appendicitis.

Conclusion

The risk-stratified diagnostic algorithm yields a high diagnostic accuracy for patients with suspicion of appendicitis. Its implementation can safely reduce the NAR, simultaneously minimizing the use of CT scans and optimizing healthcare-related costs in the treatment of acute appendicitis.

Trial registration

ClinicalTrials.gov Identifier: NCT02627781 (December 2015)

Gender-specific Performance of a Diagnostic Score in Acute Appendicitis

BACKGROUND/AIM

Although a negative appendectomy in female patients with acute abdominal pain (AAP) can be twice as frequent as in male patients, the accuracy of diagnostic scores (DSs) in acute appendicitis (AA) is rarely considered among patients with AAP. The aim was to study the gender-specific performance of a DS in AA.

PATIENTS AND METHODS

As an extension of the World Organisation of Gastro-Enterology Research Committee (OMGE) AAP study, 1,333 patients presenting with AAP were inclu ded in the study. The clinical history and diagnostic symptoms (n=22), signs (n=14) and laboratory tests (n=3) were recorded in each patient.

RESULTS

The most significant diagnostic predictors were used to construct DS formulas for AA diagnosis, separately for both genders. The formulas were tested at 6 different cut-off levels to find the best diagnostic performance for AA in females and males. The highest specificities of the DS_LC- [DS without leucocyte count (LC)] and DS_LC+ (DS with LC) scores in detecting AA were 98% (95% CI=97-99%) and 98% (95% CI=96-99%), respectively. In the ROC comparison test, there was no statistically significant difference in the performance of DS_LC- and DS_LC+ in female and male patients.

CONCLUSION

Our gender-specific DS reached very high AUC values for AA (0.948-0.956) in both genders, and there was no statistically significant difference in the AUC values of DS_LC- and DS_LC+ between women and men with AAP.

Geographic Variation in Appendiceal Perforation Rates in Canada: a Population-Based Cohort Study

BACKGROUND

We hypothesized that patients living in rural neighborhoods experience delayed access to surgical services manifesting in increased appendiceal perforation rates in cases of appendicitis.

METHODS

This population-based cohort study included adult patients with acute appendicitis in Canada (excluding Quebec) between April 2008 and March 2015. The main outcome of interest was rate of perforation. Predictors of interest included socioeconomic, geographic, and individual predictors of perforation. Spatial analysis was used to analyze spatial clustering of perforation.

RESULTS

We identified 143,195 patients throughout the course of the study. The average perforation rate across our study was 35.9% (n = 51,456). Cluster analysis identified 286 (24%) neighborhoods with perforation rates greater than the average. Rural neighborhoods had a 1.89 times higher odds of being in a high perforation cluster (95% CI 1.08-3.08, p = 0.024). Compared to neighborhoods > 75 km from the admitting hospital, closer neighborhoods were less likely to be in a high perforation cluster (0-35 km OR 0.64, 95% CI 0.38-0.98, p = 0.049; 36-75 km OR 0.60, 95% CI 0.37-0.92, p = 0.019). Patients admitted to small community hospitals had a 0.51 times lower odds of perforation than those admitted to academic centers (95% CI 0.47-0.54, p < 0.001) and those who lived in high perforation clusters had a 1.42 times higher odds of perforation (95% CI 1.39-1.46, p < 0.001).

CONCLUSION

Neighborhoods located far from hospitals have increased appendiceal perforation rates. Also, patients with appendicitis treated at small community hospitals have significantly lower odds of perforation. From a policy point of view, patients with symptoms of appendicitis can be safely treated at the nearest hospital.

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.

Discordant outcomes of laparoscopic versus open appendectomy for suspected appendicitis during pregnancy in published meta-analyses: an overview of systematic reviews

OBJECTIVES

Our study aimed to explore the discrepancy of results between overlapping systematic reviews (SRs) of laparoscopic appendectomy (LA) versus open appendectomy (OA) for suspected appendicitis during pregnancy.

METHODS

MEDLINE, Embase, and Cochrane Database of Systematic Reviews (CDSR) were searched for SRs published from January 1, 2017 to September 10, 2019. SRs and meta-analyses (MA) that compared outcomes of LA versus OA during pregnancy were used. Data regarding the methodology of SR/MA, included studies, efficacy and safety outcomes were extracted. SR quality was analysed with AMSTAR 2.

RESULTS

Four SRs were found, published between April 2018 and April 2019. These reviews included a variety of primary studies, ranging from 17 to 22, and number of included patients varied from 4694 to 6276. A total of 13 outcomes were analyzed. Nine outcomes were included in more than one review; among them, discrepancies between summary effect sizes in meta-analyses were found in four outcomes: preterm birth, Apgar score at 5 min, length of stay in hospital, and wound infection rates. One primary study, which included more than half of the total number of patients in analyzed reviews, showed a predominant effect on the outcome for fetal loss. All four SRs had critically low methodological quality.

CONCLUSIONS

The outcomes of LA versus OA for suspected appendicitis in pregnancy represented in four recent SRs do not provide consistent results. Such uncertainties require new, high-quality primary and secondary evidence on this topic.

Acute appendicitis: Clinical anatomy of the new palpation sign

INTRODUCTION

Currently, diagnosis of acute appendicitis (AA) is challenging. Here, we aim to propose using the new palpation sign to diagnose AA and establish the effectiveness of clinical examination using a proprietary diagnostic palpation procedure.

MATERIALS AND METHODS

We retrospectively analyzed 2,883 patients of all ages who were examined for suspected AA, of whom 532 patients required surgical intervention, using the new palpation sign. Patients were divided into three age categories. Based on the correlation between clinical data and histological findings, clinical examination finding was defined as false negative, false positive, and positive. Pearson correlation analysis was performed to assess the correlation between patients' sex and age distribution and clinical and histological findings.

RESULTS

There was a strong correlation (r > .95) for distribution of total number of examined patients (distributed in groups by sex and age) versus false-positive clinical findings, total number of examined patients (distributed in groups by sex and age) versus positive clinical findings, and total number of examined patients (distributed in groups by age) versus histology in phlegmonous and gangrenous appendicitis. Correlations (r = .94 and .90) were observed for distribution of total number of examined patients (distributed in groups by age) versus negative histological findings and Byron's obliterating appendicopathy. Pearson's chi-squared test showed no significant difference between expected and observed frequencies of both clinical and histologic findings.

CONCLUSIONS

The new palpation sign can be used to diagnose early and later stage appendicitis, especially in children and young women, and is very effective in indicating surgery for AA.

Increasing incidence of complicated appendicitis during COVID-19 pandemic

Background

The novel coronavirus (COVID-19) strain has resulted in restrictions potentially impacting patients presenting with acute appendicitis and their disease burden.

Methods

All acute appendicitis admissions (281 patients) between 1/1/2018-4/30/2020 were reviewed. Two groups were created: 6 weeks before (Group A) and 6 weeks after (Group B) the date elective surgeries were postponed in Massachusetts for COVID-19. Acute appendicitis incidence and disease characteristics were compared between the groups. Similar time periods from 2018 to 2019 were also compared.

Results

Fifty-four appendicitis patients were categorized in Group A and thirty-seven in Group B. Those who underwent surgery were compared and revealed a 45.5% decrease (CI: 64.2,-26.7) in uncomplicated appendicitis, a 21.1% increase (CI:3.9,38.3) in perforated appendicitis and a 29% increase (CI:11.5,46.5) in gangrenous appendicitis. Significant differences in the incidence of uncomplicated and complicated appendicitis were also noted when comparing 2020 to previous years.

Conclusions

The significant increase in complicated appendicitis and simultaneous significant decrease in uncomplicated appendicitis during the COVID-19 pandemic indicate that patients are not seeking appropriate, timely surgical care.

Unusual infectious agents detected in appendectomy specimens: A retrospective analysis of 42 cases

OBJECTIVES

The aim of this study was to evaluate the clinical and histopathological features of 42 patients with unusual infectious agents detected in their appendectomy specimens.

MATERIAL AND METHODS

Between January 1999 and November 2018, 2.754 patients underwent emergency or incidental appendectomy in our clinic, and their pathology reports were retrospectively reviewed. Unusual infectious agents or eosinophilic infiltration of the appendix were reported in the initial pathological examinations of 57 patients. The pathological slides of these patients were re-examined by histopathologists. The examinations revealed that 15 of these patients had no microscopic findings suggestive of parasitic infections. The remaining 42 patients with unusual appendiceal infectious agents were included into the study.

RESULTS

A total of 42 patients (25 females and 17 males) aged 18 to 75 years were included into this study. While 32 of these patients (76%) underwent emergency appendectomy with a presumed diagnosis of acute appendicitis (AAp), the remaining 10 patients underwent incidental appendectomy for various reasons. Twenty-two patients (52.4%) had histopathological changes consistent with AAp while 20 patients had no evidence of AAp. Histopathological examination revealed infection with Enterobius vermicularis in 38 of the patients, Taenia species in 2, and Ascaris lumbricoides and Actinomyces species in 1 patient each. A total of 24 patients were treated for infections with mebendazole (n = 20), albendazole (n =1), niclosamide (n = 2), and amoxicillin (n = 1).

CONCLUSION

Unusual infectious agents should be considered as factors potentially triggering AAp, especially in patients living in endemic areas. The appendiceal stump should be inspected for parasite residues.

Cohort study of 1241 patients to identify predictors of negative appendicectomy

BACKGROUND

Acute Appendicitis is the most common surgical presentation within Australia. Despite the increasing use of radiological investigations to aid clinical diagnosis, many appendectomies result in a histologically normal appendix. This study examines the histological negative appendicectomy rate (NAR) in a metropolitan hospital and determine factors associated with a negative appendicectomy (NA).

METHODS

Patients who underwent emergency appendicectomy for suspected acute appendicitis at Logan Hospital, Australia, between February 2016 and March 2019 inclusive were included. Clinicopathologic and imaging variables were analysed for associations with NA.

RESULTS

A total of 1241 patients underwent emergency appendicectomy of which 121 patients (9.8%) had a NA. The NAR for clinical diagnosis alone (no imaging) was 9.9%, 14.5% for ultrasonography alone and computed tomography scan alone was 4.9%. Univariate analysis revealed age <27 years (P < 0.001), absence of hypertension (P = 0.008), symptoms >48 hours (P < 0.001), absence of leucocytosis (P < 0.001), undergoing ultrasonography only (P < 0.001), undergoing computed tomography scan only (P < 0.001), macroscopically normal appendix (P < 0.001) and time to operation >24 hours (P < 0.001) were associated with NA. Multivariate analysis identified symptoms >48 h at presentation (odds ratio (OR) 1.98, 95% confidence interval (CI) 1.20-3.24; P = 0.007), absence of leucocytosis (OR 2.41, 95% CI 1.52-3.81; P < 0.001) and macroscopically normal appendix (OR 5.70, 95% CI 3.49-9.33; P < 0.001) to be associated with a NA.

CONCLUSION

The NAR reported is lowest in an Australian institution. The identified predictors of NA will be useful in identifying patients who would truly benefit from an appendicectomy versus those would have a higher rate of NA who may be suitable to be treated non-operatively to be spared the unnecessary morbidity of surgery.

Risk Factors for Readmission After Short-Hospital-Stay Laparoscopic Appendectomy

BACKGROUND

Single-day discharge is a common practice among patients undergoing laparoscopic appendectomy (LA). We aimed to determine risk factors associated with readmission in patients with short hospital stay after LA.

METHODS

We performed a retrospective analysis of all patients who underwent LA during the period 2006-2019. Patients with length of hospital stay shorter than 24 h were included. Demographics, operative variables, and postoperative outcomes were analyzed. Multivariable logistic regression was performed to determine risk factors for readmission.

RESULTS

A total of 2009 LA were performed during the study period; 1506 (75%) patients had short hospital stay and were included in the analysis. Median age was 31 (14-85) years, and 720 (48%) were female. Mild peritonitis was diagnosed in 423 (28%) patients, and 121 (8%) had gangrenous/perforated appendicitis. Mean surgical time was 51(14-180) min. Conversion rate was 0.4%. There were 143 (9%) postoperative complications, including 29 (1.9%) patients with postoperative intra-abdominal abscess. Nine patients (0.6%) underwent reoperation, and only 26 (1.7%) patients were readmitted. The mean time to hospital readmission was 6 (1-14) days. Although age >50 years, obesity, mild peritonitis, and complicated appendicitis were more frequent among patients readmitted, only age >50 years (OR 3.54 95% CI 1.51-8.30) and mild peritonitis (OR 6.16 95% CI 1.80-34.93) were found as independent risk factors for readmission.

CONCLUSION

Most patients undergoing LA can be safely discharged within 24 h of admission. Patients over 50 years old and/or with localized peritonitis have significantly higher risk of readmission and therefore may need a closer postoperative follow-up.

Predictors for prolonged length of stay after laparoscopic appendectomy for complicated acute appendicitis in adults

BACKGROUND

Appendicitis-related hospitalizations linked with peritonitis or postoperative complications result in longer lengths of stay and higher costs. The aim of the present study was to assess the independent association between potential predictors and prolonged hospitalization after laparoscopic appendectomy (LA) for complicated acute appendicitis (CAA).

METHODS

A retrospective cohort study was conducted on adult patients diagnosed with CAA in which LA was attempted. The primary outcome was a prolonged length of stay (LOS) after surgery, defined as hospitalizations longer than or equal to the 75th percentile for LOS, including the day of discharge. Hierarchical regression models were run to elucidate the independent predictors for the variable of interest.

RESULTS

The present study involved 160 patients with a mean age of 50.71 years. The conversion rate was 1.9%, and the overall postoperative morbidity rate was 23.8%. The median length of stay (LOS) was 5 days (75th percentile: 7 days). Multivariate analyses included nine variables that are statistically and/or clinically relevant to assess its relationship with a prolonged LOS: three preoperative (age, sex, and comorbidity), four intraoperative (appendix gangrene, perforation, degree of peritonitis, and drain placement), and two postoperative (immediate ICU admission and complications). The development of postoperative complications (OR 6.162, 95% CI 2.451-15.493; p = 0.000) and the placement of an abdominal drain (OR 3.438, 95% CI 1.107-10.683; p = 0.033) were found to be independent predictors for prolonged LOS. For patients not presenting postoperative complications, drain placement was the only independent predictor for the outcome (OR 7.853, 95% CI 1.520-40.558; p = 0.014). Sensitivity analyses showed confirmatory results.

CONCLUSION

The intraoperative process of care has a clear impact on LOS after LA for CAA in adults; therefore, the decision of whether to drain in these situations should be made more restrictively yet with judicious caution.

Influence of the coronavirus 2 (SARS-Cov-2) pandemic on acute appendicitis

INTRODUCTION

Acute appendicitis (AA) is the most common abdominal surgical emergency. No specific studies have been found that evaluate the impact of the coronavirus 2 (SARS-Cov-2) pandemic on AA and its surgical management. An analysis was made on the influence of this new pathology on the clinical course of AA.

MATERIAL AND METHODS

Retrospective observational study was conducted on patients operated on for AA from January to April 2020. They were classified according to the time of the appendectomy, before the declaration of the state of alarm (Pre-COVID-19), and after its declaration (Post-COVID-19) in Spain, one the most affected countries in the world. An evaluation was made of demographic variables, duration of symptoms, type of appendicitis, surgical time, hospital stay, and postoperative complications.

RESULTS

The study included 66 patients (41 Pre-COVID-19; 25 Post-COVID-19) with mean age of 10.7 ± 3 and 9.3 ± 3.1; P = .073, respectively. Fever was found in a higher number of post-COVID-19 patients (52 vs 19.5%; P = .013), as well as a higher CRP (72.7 ± 96.2 vs 31.3 ± 36.2 mg/dL; P = .042). This group presented with a higher proportion of complicated appendicitis when compared to Pre-COVID-19 (32 vs 7.3%; P = .015). The mean hospital stay was longer in the Post-COVID-19 group (5.6 ± 5.9 vs 3.2 ± 4.3 days; P = .041). No differences were found in the time of onset of symptoms or surgical time.

CONCLUSIONS

The SARS-Cov-2 pandemic influenced the time of diagnosis of appendicitis, as well as its course, and mean hospital stay. Peritonitis was more frequently seen. As a result of the significant circumstances, delaying diagnosis and treatment of AA during SARS-Cov-2 pandemic, inappropriate management of this common surgical disorder has been noticed.

[Influence of the coronavirus 2 (SARS-Cov-2) pandemic on acute appendicitis]

INTRODUCTION

Acute appendicitis (AA) is the most common abdominal surgical emergency. No specific studies have been found that evaluate the impact of the coronavirus 2 (SARS-Cov-2) pandemic on AA and its surgical management. An analysis was made on the influence of this new pathology on the clinical course of AA.

MATERIAL AND METHODS

Retrospective observational study was conducted on patients operated on for AA from January to April 2020. They were classified according to the time of the appendectomy, before the declaration of the state of alarm (pre-COVID-19), and after its declaration (post-COVID-19) in Spain, one the most affected countries in the world. An evaluation was made of demographic variables, duration of symptoms, type of appendicitis, surgical time, hospital stay, and postoperative complications.

RESULTS

The study included 66 patients (41 pre-COVID-19; 25 post-COVID-19) with mean age of 10.7 ± 3 and 9.3 ± 3.1; P = .073, respectively. Fever was found in a higher number of post-COVID-19 patients (52 vs. 19.5%; P = 0.013), as well as a higher CRP (72.7 ± 96.2 vs. 31.3 ± 36.2 mg/dL; P = 0.042). This group presented with a higher proportion of complicated appendicitis when compared to pre-COVID-19 (32 vs. 7.3%; P = 0.015). The mean hospital stay was longer in the post-COVID-19 group (5.6 ± 5.9 vs. 3.2 ± 4.3 days; P = 0.041). No differences were found in the time of onset of symptoms or surgical time.

CONCLUSIONS

The SARS-Cov-2 pandemic influenced the time of diagnosis of appendicitis, as well as its course, and mean hospital stay. Peritonitis was more frequently seen. As a result of the significant circumstances, delaying diagnosis and treatment of AA during SARS-Cov-2 pandemic, inappropriate management of this common surgical disorder has been noticed.

Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations

BACKGROUND

Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines.

METHODS

The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020.

RESULTS

The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible.

CONCLUSIONS

The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.

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.

The effect of laparoscopic and open surgery on oxidative DNA damage and IL-37 in children with acute appendicitis

BACKGROUND

Although laparoscopic appendectomy (LA) is considered to be minimally invasive compared with open appendectomy (OA), there are few studies showing this in terms of cytokines and oxidative stress markers.

AIM

LA and OA techniques have been compared in terms of different conditions such as operation time and complication rate. Here, we compared how oxidative DNA damage and some cytokines levels change in relation to LA and OA.

METHOD

This study was performed in children diagnosed with acute appendicitis in our hospital. The study was conducted on 30 children with acute appendicitis in each group. Oxidative DNA damage and malondialdehyde levels were determined by high-performance liquid chromatography, and interleukin-1β, interleukin-37, ischaemia-modified albumin and total thiol levels were determined by enzyme-linked immunosorbent assays.

RESULTS

There was a dramatic decrease in ischaemia-modified albumin (IMA) levels after LA. However, there were no statistically significant differences in pre- and postoperative IMA levels in the OA group. Oxidative DNA damage and malondialdehyde levels were low significantly according to preoperative levels after the LA and OA. Total thiol levels were high in children who underwent LA while they were low after OA. In addition, postoperative interleukin-1β levels were low in both groups. Furthermore, IL-37 levels postoperatively were low in the LA group, while there was no significant change in the OA group.

CONCLUSION

LA had a more positive effect on oxidative DNA damage, IL-1β and IL-37 than the OA. In addition, surgical stress was reduced with LA.

Is interval appendectomy really needed? A closer look at neoplasm rates in adult patients undergoing interval appendectomy after complicated appendicitis

BACKGROUND

The treatment algorithm for appendicitis is evolving, with recent interest in non-operative management. However, the safety of non-operative management for patients with complicated appendicitis has been questioned due to concern for increased risk of occult appendiceal neoplasm in this patient population. Our study aims to determine the rate of neoplasms discovered during interval appendectomy for patients with complicated appendicitis and determine the necessity of interval appendectomy.

METHODS

A retrospective chart review was conducted on interval appendectomies performed in adult patients for complicated appendicitis at our institution over a 9-year period. Interval appendectomy was defined as appendectomy delayed from initial presentation with appendicitis. Complicated appendicitis was defined as perforation, phlegmon, and/or abscess as seen on computed tomography at time of presentation.

RESULTS

We identified 402 patients who underwent interval appendectomy for complicated appendicitis. A total of 36 appendiceal neoplasms were discovered on final pathology with an overall neoplasm rate of 9%. Patients with an appendiceal neoplasm were significantly older (56.6 years vs 45.1 years, p < 0.01). No patients under the age of 30 had a neoplasm. The rate of appendiceal neoplasms in patients 30 years and older was 11%. The rate for patients 50 years and older was 16%. For patients 80 years and older, the rate of appendiceal neoplasm was 43%.

CONCLUSION

The risk of occult appendiceal neoplasm is low in patients under the age of 30; however, there was an 11% rate of appendiceal neoplasm in patients 30 years and older. The risk increases with increased age, with a 16% risk in patients 50 years and older. Given these findings, we recommend consideration of interval appendectomy in all patients 30 years and older with complicated appendicitis.

The Decreasing Incidence of Acute Appendicitis During COVID-19: A Retrospective Multi-centre Study

Background

As the novel coronavirus disease 19 (COVID-19) spreads, a decrease in the number of patients with acute appendicitis (AA) has been noted in our institutions. The aim of this study was to compare the incidence and severity of AA before and during the COVID-19 pandemic.

Methods

A retrospective cohort analysis was performed between December 2019 and April 2020 in the four high-volume centres that provide health care to the municipality of Jerusalem, Israel. Two groups were created. Group A consisted of patients who presented in the 7 weeks prior to COVID-19 first being diagnosed, whilst those in the 7 weeks after were allocated to Group B. A comparison was performed between the clinicopathological features of the patients in each group as was the changing incidence of AA.

Results

A total of 378 patients were identified, 237 in Group A and 141 in Group B (62.7% vs. 37.3%). Following the onset of COVID-19, the weekly incidence of AA decreased by 40.7% (p = 0.02). There was no significant difference between the groups in terms of the length of preoperative symptoms or surgery, need for postoperative peritoneal drainage or the distribution of complicated versus uncomplicated appendicitis.

Conclusions

The significant decrease in the number of patients admitted with AA during the onset of COVID-19 possibly represents successful resolution of mild appendicitis treated symptomatically by patients at home. Further research is needed to corroborate this assumption and identify those patients who may benefit from this treatment pathway.

The Understated Malignancy Potential of Nonoperative Acute Appendicitis

Cancer of the appendix is rare and is most commonly found incidentally on pathology after an appendectomy for uncomplicated appendicitis (UA). The medical management alternative with antibiotics and observation remains an ongoing debate. The purpose of our study was to develop modern epidemiological data for adult patients completing an appendectomy for UA secondary to an appendiceal neoplasm (AN). ACS-NSQIP database was queried (2005–2016) to identify patients completing an appendectomy. Cohorts of patients who were diagnosed with UA and an AN were included in the study. Relevant perioperative clinical and outcomes data were collected. Type of AN, surgical procedure, and mortality were analyzed. A total of 239,615 UA patients were identified, of whom 2,773 (1.2%) met the inclusion criteria of AN. Patients with AN were predominantly white (79.5%), with a mean age of 54.5 ± 15.9 years, and 54.6 per cent were females. AN pathology findings included malignant neoplasm (64.5%), malignant carcinoid (17.3%), benign carcinoid (9.3%), and benign neoplasm (8.8%). The overall reported incidence was 1.2 per cent and the mortality rate was 0.7 per cent. Our study emphasizes surgical intervention in adult UA maintains a 1 per cent incidence of AN, and treatment with antibiotics alone will presumably lead to a delay in surgical treatment and progression of disease.

Convolutional-neural-network-based diagnosis of appendicitis via CT scans in patients with acute abdominal pain presenting in the emergency department

Acute appendicitis is one of the most common causes of abdominal emergencies. We investigated the feasibility of a neural-network-based diagnosis algorithm of appendicitis by using computed tomography (CT) for patients with acute abdominal pain visiting the emergency room (ER). A neural-network-based diagnostic algorithm of appendicitis was developed and validated using CT data from three institutions who visited the ER with abdominal pain and underwent abdominopelvic CT. For input data, 3D isotropic cubes including the appendix were manually extracted and labeled as appendicitis or a normal appendix. A 3D convolutional neural network (CNN) was trained to binary classification on the input. For model development and testing, 8-fold cross validation was conducted for internal validation and an ensemble model was used for external validation. Diagnostic performance was excellent in both the internal and external validation with an accuracy larger than 90%. The CNN-based diagnosis algorithm may be feasible in diagnosing acute appendicitis using the CT data of patients visiting the ER with acute abdominal pain.