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Mao BP, Collins G, Ayeni FE, Vagg DJ. Risk factors for developing intra-abdominal abscess following appendicectomy for acute appendicitis: a retrospective cohort study. Langenbecks Arch Surg 2024; 409:246. [PMID: 39120614 PMCID: PMC11315757 DOI: 10.1007/s00423-024-03421-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 07/14/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Laparoscopic appendicectomy is commonly performed in Australia for treatment of acute appendicitis. Intra-abdominal abscess (IAA) is a potential complication following appendicectomy for acute appendicitis. Risk factors for developing post-operative IAA remain controversial and poorly defined. Laparoscopic washout may be performed for patients who develop complication(s) including IAA. The aim of this study was to define risk factors for both the development of IAA and identify patients who may require laparoscopic washout following appendicectomy. METHODS Data were obtained from 423 patients who underwent laparoscopic appendicectomy over a five-year period (2012-2017). Clinical (fever, haemodynamics, examination findings), biochemical (white cell count, neutrophil count, C-reactive protein, bilirubin, albumin), radiological (CT free fluid), and operative factors (inflammation, suppuration, free-fluid, perforation, histopathology) collected in the pre-, peri-, and post-operative period(s) were analysed. RESULTS 23 (5.4%) patients developed post-operative IAA. Duration of intravenous antibiotics was significantly longer in patients who developed IAA and in those who required laparoscopic washout (p < 0.0001). C-reactive protein (CRP) on admission (p < 0.05) and appendiceal perforation (p = 0.0005) were significantly higher in patients who either developed IAA or needed laparoscopic washout. No clinical or radiological finding predicted either the development of IAA or need for laparoscopic washout. CONCLUSION Elevated CRP on admission may predict the development of post-operative IAA formation or the need for laparoscopic washout post-appendicectomy. Prolonged post-operative antibiotic use appears independent of the development of IAA as well as the need for laparoscopic washout. These data highlight the need for clear guidelines on peri-operative antibiotic use following appendicectomy.
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Affiliation(s)
- B P Mao
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
- Concord Repatriation General Hospital, Sydney, NSW, Australia.
| | - G Collins
- Department of Surgery, Nepean Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - F E Ayeni
- Nepean Institute of Academic Surgery, Nepean Clinical School, Sydney, NSW, Australia
| | - D J Vagg
- Department of Surgery, Nepean Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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2
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Li YJ, Chen YY, Lin XL, Zhang WZ. Evaluation of the clinical effects of atropine in combination with remifentanil in children undergoing surgery for acute appendicitis. World J Gastrointest Surg 2024; 16:2065-2072. [PMID: 39087103 PMCID: PMC11287676 DOI: 10.4240/wjgs.v16.i7.2065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 07/22/2024] Open
Abstract
BACKGROUND Acute appendicitis (AA) is the most common cause of acute abdomen in children. Anesthesia significantly influences the surgical treatment of AA in children, making the scientific and effective selection of anesthetics crucial. AIM To assess the clinical effect of atropine (ATR) in combination with remifentanil (REMI) in children undergoing surgery for AA. METHODS In total, 108 cases of pediatric AA treated between May 2020 and May 2023 were selected, 58 of which received ATR + REMI [research group (RG)] and 50 who received REMI [control group (CG)]. Comparative analyses were conducted on the time to loss of eyelash reflex, pain resolution time, recovery time from anesthesia, incidence of adverse events (AEs; respiratory depression, hypoxemia, bradycardia, nausea and vomiting, and hypotension), intraoperative responses (head shaking, limb activity, orientation recovery, safe departure time from the operating room), hemodynamic parameters [oxygen saturation (SPO2), mean arterial pressure, heart rate, and respiratory rate], postoperative sedation score (Ramsay score), and pain level [the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale]. RESULTS Compared with the CG, the RG showed significantly shorter time to loss of eyelash reflex, pain resolution, recovery from anesthesia, and safe departure from the operating room. Furthermore, the incidence rates of overall AEs (head shaking, limb activity, etc.) were lower, and influences on intraoperative hemodynamic parameters and stress response indexes were fewer. The Ramsay score at 30 min after extubation and the FLACC score at 60 min after extubation were significantly lower in the RG than in the CG. CONCLUSION ATR + REMI is superior to REMI alone in children undergoing AA surgery, with a lower incidence of AEs, fewer influences on hemodynamics and stress responses, and better post-anesthesia recovery.
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Affiliation(s)
- Yu-Juan Li
- Department of Anesthesiology, Shanxi Provincial Children’s Hospital, Taiyuan 030013, Shanxi Province, China
| | - Yong-Yan Chen
- Department of Anesthesiology, Shanxi Provincial Children’s Hospital, Taiyuan 030013, Shanxi Province, China
| | - Xia-Lan Lin
- Department of Anesthesiology, Shanxi Provincial Children’s Hospital, Taiyuan 030013, Shanxi Province, China
| | - Wei-Zhi Zhang
- Department of Anesthesiology, Shanxi Provincial Children’s Hospital, Taiyuan 030013, Shanxi Province, China
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3
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Huston JM, Barie PS, Dellinger EP, Forrester JD, Duane TM, Tessier JM, Sawyer RG, Cainzos MA, Rasa K, Chipman JG, Kao LS, Pieracci FM, Colling KP, Heffernan DS, Lester J. The Surgical Infection Society Guidelines on the Management of Intra-Abdominal Infection: 2024 Update. Surg Infect (Larchmt) 2024. [PMID: 38990709 DOI: 10.1089/sur.2024.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024] Open
Abstract
Background: The Surgical Infection Society (SIS) published evidence-based guidelines for the management of intra-abdominal infection (IAI) in 1992, 2002, 2010, and 2017. Here, we present the most recent guideline update based on a systematic review of current literature. Methods: The writing group, including current and former members of the SIS Therapeutics and Guidelines Committee and other individuals with content or guideline expertise within the SIS, working with a professional librarian, performed a systematic review using PubMed/Medline, the Cochrane Library, Embase, and Web of Science from 2016 until February 2024. Keyword descriptors combined "surgical site infections" or "intra-abdominal infections" in adults limited to randomized controlled trials, systematic reviews, and meta-analyses. Additional relevant publications not in the initial search but identified during literature review were included. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system was utilized to evaluate the evidence. The strength of each recommendation was rated strong (1) or weak (2). The quality of the evidence was rated high (A), moderate (B), or weak (C). The guideline contains new recommendations and updates to recommendations from previous IAI guideline versions. Final recommendations were developed by an iterative process. All writing group members voted to accept or reject each recommendation. Results: This updated evidence-based guideline contains recommendations from the SIS for the treatment of adult patients with IAI. Evidence-based recommendations were developed for antimicrobial agent selection, timing, route of administration, duration, and de-escalation; timing of source control; treatment of specific pathogens; treatment of specific intra-abdominal disease processes; and implementation of hospital-based antimicrobial agent stewardship programs. Summary: This document contains the most up-to-date recommendations from the SIS on the prevention and management of IAI in adult patients.
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Affiliation(s)
- Jared M Huston
- Departments of Surgery and Science Education, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, New Hyde Park, New York, USA
| | - Philip S Barie
- Departments of Surgery and Medicine, Weill Cornell Medicine, East Northport, New York, USA
| | | | | | - Therese M Duane
- Department of Surgery, Medical City Plano, Plano, Texas, USA
| | - Jeffrey M Tessier
- Division of Infectious Diseases and Geographic Medicine, University of Texas-Southwestern, Dallas, Texas, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Miguel A Cainzos
- Department of Surgery, University of Santiago de Compostela, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Kemal Rasa
- Department of Surgery, Anadolu Medical Center, Kocaeli, Turkey
| | - Jeffrey G Chipman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lillian S Kao
- Department of Surgery, UTHealth Houston John P. and Kathrine G. McGovern Medical School, Houston, Texas, USA
| | - Frederic M Pieracci
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, Colorado, USA
| | - Kristin P Colling
- Department of Trauma and Critical Care Surgery, Essentia Health, St. Mary's Medical Center, Duluth, Minnesota, USA
| | - Daithi S Heffernan
- Department of Surgery, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Janice Lester
- Health Sciences Library, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York, USA
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Kurian J, Winant AJ, Hull NC, Lee EY. Pediatric Acute Abdomen: Bread-and-Butter Diagnoses. Semin Roentgenol 2024; 59:312-331. [PMID: 38997184 DOI: 10.1053/j.ro.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Jessica Kurian
- Department of Radiology, Westchester Medical Center, Valhalla, NY.
| | - Abbey J Winant
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
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Sartelli M, Barie P, Agnoletti V, Al-Hasan MN, Ansaloni L, Biffl W, Buonomo L, Blot S, Cheadle WG, Coimbra R, De Simone B, Duane TM, Fugazzola P, Giamarellou H, Hardcastle TC, Hecker A, Inaba K, Kirkpatrick AW, Labricciosa FM, Leone M, Martin-Loeches I, Maier RV, Marwah S, Maves RC, Mingoli A, Montravers P, Ordóñez CA, Palmieri M, Podda M, Rello J, Sawyer RG, Sganga G, Tattevin P, Thapaliya D, Tessier J, Tolonen M, Ulrych J, Vallicelli C, Watkins RR, Catena F, Coccolini F. Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery. World J Emerg Surg 2024; 19:22. [PMID: 38851700 PMCID: PMC11161965 DOI: 10.1186/s13017-024-00552-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/01/2024] [Indexed: 06/10/2024] Open
Abstract
Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient's clinical condition, and the host's immune status should be assessed continuously to optimize the management of patients with complicated IAIs.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, Macerata, 62100, Italy.
| | - Philip Barie
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, Bufalini Hospital - AUSL della Romagna, Cesena, Italy
| | - Majdi N Al-Hasan
- Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, SC, USA
| | - Luca Ansaloni
- Department of General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Walter Biffl
- Division of Trauma and Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Luis Buonomo
- Emergency, Urgency and Trauma Surgery, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Stijn Blot
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - William G Cheadle
- Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center - CECORC - Riverside University Health System, Moreno Valley, CA, USA
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | | | | | - Paola Fugazzola
- Department of General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Helen Giamarellou
- First Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Timothy C Hardcastle
- Department of Surgical Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Andrew W Kirkpatrick
- Department of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | | | - Marc Leone
- Department of Anaesthesia and Intensive Care Unit, AP-HM, Aix-Marseille University, North Hospital, Marseille, France
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organisation, St James's Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
- Centro de Investigacion Biomedica En Red Entermedades Respiratorias, Institute of Health Carlos III, Madrid, Spain
- Pulmonary Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Ronald V Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Sanjay Marwah
- Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, India
| | - Ryan C Maves
- Section of Infectious Diseases, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Andrea Mingoli
- Emergency Department, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Philippe Montravers
- Anesthesiology and Critical Care Medicine Department, DMU PARABOL, Bichat Hospital, AP-HP, Université Paris Cité, Paris, France
| | - Carlos A Ordóñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Miriam Palmieri
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, Macerata, 62100, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Jordi Rello
- Global Health eCore, Vall d'Hebron University Hospital Campus, Barcelona, 08035, Spain
- Medicine Department, Universitat Internacional de Catalunya, Sant Cugat del Valles, Spain
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Pierre Tattevin
- Infectious Disease and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | | | - Jeffrey Tessier
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matti Tolonen
- Emergency Surgery department, Meilahti Tower Hospital, HUS Helsinki University Hospital, Haartmaninkatu 4, Helsinki, Finland
| | - Jan Ulrych
- First Department of Surgery, Department of Abdominal, Thoracic Surgery and Traumatology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Carlo Vallicelli
- Emergency and General Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Richard R Watkins
- Department of Medicine, Division of Infectious Diseases, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Fausto Catena
- Emergency and General Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Unit, Pisa University Hospital, Pisa, Italy
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Korah M, Tennakoon L, Knowlton LM, Tung J, Spain DA, Ko A. Management of Uncomplicated Appendicitis in Adults: A Nationwide Analysis From 2018 to 2019. J Surg Res 2024; 298:307-315. [PMID: 38640616 DOI: 10.1016/j.jss.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/08/2024] [Accepted: 03/17/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION Nonoperative management (NOM) of uncomplicated appendicitis (UA) has been increasingly utilized in recent years. The aim of this study was to describe nationwide trends of sociodemographic characteristics, outcomes, and costs of patients undergoing medical versus surgical management for UA. METHODS The 2018-2019 National (Nationwide) Inpatient Sample was queried for adults (age ≥18 y) with UA; diagnosis, as well as laparoscopic and open appendectomy, were defined by the International Classification of Diseases, 10th Revision, Clinical Modification codes. We examined several characteristics, including cost of care and length of hospital stay. RESULTS Among the 167,125 patients with UA, 137,644 (82.4%) underwent operative management and 29,481 (17.6%) underwent NOM. In bivariate analysis, we found that patients who had NOM were older (53 versus 43 y, P < 0.001) and more likely to have Medicare (33.6% versus 16.1%, P < 0.001), with higher prevalence of comorbidities such as diabetes (7.8% versus 5.5%, P < 0.001). The majority of NOM patients were treated at urban teaching hospitals (74.5% versus 66.3%, P < 0.001). They had longer LOS's (5.4 versus 2.3 d, P < 0.001) with higher inpatient costs ($15,584 versus $11,559, P < 0.001) than those who had an appendectomy. Through logistic regression we found that older patients had up to 4.03-times greater odds of undergoing NOM (95% CI: 3.22-5.05, P < 0.001). CONCLUSIONS NOM of UA is more commonly utilized in patients with comorbidities, older age, and those treated in teaching hospitals. This may, however, come at the price of longer length of stay and higher costs. Further guidelines need to be developed to clearly delineate which patients could benefit from NOM.
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Affiliation(s)
- Maria Korah
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Lisa M Knowlton
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Jamie Tung
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Ara Ko
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California.
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Cappuccio M, Bianco P, Rotondo M, Spiezia S, D'Ambrosio M, Menegon Tasselli F, Guerra G, Avella P. Current use of artificial intelligence in the diagnosis and management of acute appendicitis. Minerva Surg 2024; 79:326-338. [PMID: 38477067 DOI: 10.23736/s2724-5691.23.10156-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Acute appendicitis is a common and time-sensitive surgical emergency, requiring rapid and accurate diagnosis and management to prevent complications. Artificial intelligence (AI) has emerged as a transformative tool in healthcare, offering significant potential to improve the diagnosis and management of acute appendicitis. This review provides an overview of the evolving role of AI in the diagnosis and management of acute appendicitis, highlighting its benefits, challenges, and future perspectives. EVIDENCE ACQUISITION We performed a literature search on articles published from 2018 to September 2023. We included only original articles. EVIDENCE SYNTHESIS Overall, 121 studies were examined. We included 32 studies: 23 studies addressed the diagnosis, five the differentiation between complicated and uncomplicated appendicitis, and 4 studies the management of acute appendicitis. CONCLUSIONS AI is poised to revolutionize the diagnosis and management of acute appendicitis by improving accuracy, speed and consistency. It could potentially reduce healthcare costs. As AI technologies continue to evolve, further research and collaboration are needed to fully realize their potential in the diagnosis and management of acute appendicitis.
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Affiliation(s)
- Micaela Cappuccio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Paolo Bianco
- Hepatobiliary and Pancreatic Surgery Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | - Marco Rotondo
- V. Tiberio Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Salvatore Spiezia
- V. Tiberio Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Marco D'Ambrosio
- V. Tiberio Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | | | - Germano Guerra
- V. Tiberio Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Pasquale Avella
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy -
- Hepatobiliary and Pancreatic Surgery Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
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Moran BJ. Appendicitis to multivisceral transplantation: a career experience with appendiceal malignancy. Ann R Coll Surg Engl 2024; 106:219-225. [PMID: 37367485 PMCID: PMC10904263 DOI: 10.1308/rcsann.2023.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 06/28/2023] Open
Abstract
John Hunter is regarded as the father of scientific surgery. His principles involved reasoning, observation and experimentation. His most powerful saying was: "Why not try the experiment?" This manuscript charts a career in abdominal surgery ranging from the treatment of appendicitis to the development of the largest appendiceal tumour centre in the world. The journey has led to the first report of a successful multivisceral and abdominal wall transplant for patients with recurrent non-resectable pseudomyxoma peritonei. We all stand on the shoulders of giants and surgery progresses by learning from the past while being prepared to experiment into the future.
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Affiliation(s)
- BJ Moran
- Hampshire Hospitals NHS Foundation Trust, UK
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Butts CA, Byerly S, Nahmias J, Gelbard R, Ziesmann M, Bruns B, Davidson GH, Di Saverio S, Esposito TJ, Fischkoff K, Joseph B, Kaafarani H, Mentula P, Podda M, Sakran JV, Salminen P, Sammalkorpi H, Sawyer RG, Skeete D, Tesoriero R, Yeh DD. A core outcome set for appendicitis: A consensus approach utilizing modified Delphi methodology. J Trauma Acute Care Surg 2024; 96:487-492. [PMID: 37751156 DOI: 10.1097/ta.0000000000004144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND Appendicitis is one of the most common pathologies encountered by general and acute care surgeons. The current literature is inconsistent, as it is fraught with outcome heterogeneity, especially in the area of nonoperative management. We sought to develop a core outcome set (COS) for future appendicitis studies to facilitate outcome standardization and future data pooling. METHODS A modified Delphi study was conducted after identification of content experts in the field of appendicitis using both the Eastern Association for the Surgery of Trauma (EAST) landmark appendicitis articles and consensus from the EAST ad hoc COS taskforce on appendicitis. The study incorporated three rounds. Round 1 utilized free text outcome suggestions, then in rounds 2 and 3 the suggests were scored using a Likert scale of 1 to 9 with 1 to 3 denoting a less important outcome, 4 to 6 denoting an important but noncritical outcome, and 7 to 9 denoting a critically important outcome. Core outcome status consensus was defined a priori as >70% of scores 7 to 9 and <15% of scores 1 to 3. RESULTS Seventeen panelists initially agreed to participate in the study with 16 completing the process (94%). Thirty-two unique potential outcomes were initially suggested in round 1 and 10 (31%) met consensus with one outcome meeting exclusion at the end of round 2. At completion of round 3, a total of 17 (53%) outcomes achieved COS consensus. CONCLUSION An international panel of 16 appendicitis experts achieved consensus on 17 core outcomes that should be incorporated into future appendicitis studies as a minimum set of standardized outcomes to help frame future cohort-based studies on appendicitis. LEVEL OF EVIDENCE Diagnostic Test or Criteria; Level V.
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Affiliation(s)
- Christopher A Butts
- From the Division of Trauma, Acute Care Surgery & Surgical Critical Care (C.A.B.), Department of Surgery, Reading Hospital-Tower Health, West Reading, Pennsylvania; Department of Surgery, University of Tennessee Health Science Center (S.B.), Memphis, Tennessee; UC Irvine Healthcare, Orange (J.N.), California; Department of Surgery, University of Alabama at Birmingham (R.G.), Birmingham, Alabama; University of Manitoba, Winnipeg (M.Z.), Manitoba, Canada; Department of Surgery, University of Texas Southwestern, Dallas (B.B.), Texas; Department of Surgery, University of Washington, Seattle (G.H.D.), Washington; AST5 ASR Marche, Hospital Madonna del Soccorso (S.D.S.), San Benedetto del Tronto, Italy; Department of Medicine, University of Illinois School of Medicine (T.J.E.), Peoria, Illinois; Department of Surgery, Columbia University Irving Medical Center (K.F.), New York, New York; Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery (B.J.), College of Medicine, University of Arizona, Tuscon, Arizona; Trauma, Emergency Surgery, and Surgical Critical Care (H.K.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Gastroenterological Surgery (P.M., H.S.), Helsinki University Hospital, Helsinki, Finland; Department of General and Emergency Surgery (M.P.), Cagliari University Hospital, Cagliari, Italy; Division of Acute Care Surgery, Department of Surgery (J.V.S.), Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Surgery (P.S.), University of Turku, Turku, Finland; Department of Surgery, Western Michigan University School of Medicine: Western Michigan University Homer Stryker MD School of Medicine (R.G.S.), Kalamazoo, Michigan; Roy J. and Lucille A. Carver College of Medicine (D.S.), University of Iowa, Iowa City, Iowa; Division of General Surgery, Trauma and Surgical Critical Care, Acute Care Surgery (R.T.), Zuckerberg San Francisco General Hospital, San Francisco, California; and Ernest E Moore Shock Trauma Center at Denver Health (D.D.Y.), University of Colorado, Denver, Colorado
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Brucchi F, Bracchetti G, Fugazzola P, Viganò J, Filisetti C, Ansaloni L, Dal Mas F, Cobianchi L, Danelli P. A meta-analysis and trial sequential analysis comparing nonoperative versus operative management for uncomplicated appendicitis: a focus on randomized controlled trials. World J Emerg Surg 2024; 19:2. [PMID: 38218862 PMCID: PMC10787963 DOI: 10.1186/s13017-023-00531-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/20/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND The aim of this study is to provide a meta-analysis of randomized controlled trials (RCT) comparing conservative and surgical treatment in a population of adults with uncomplicated acute appendicitis. METHODS A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL. We have exclusively incorporated randomized controlled trials (RCTs). Studies involving participants with complicated appendicitis or children were excluded. The variables considered are as follows: treatment complications, complication-free treatment success at index admission and at 1 year follow-up, length of hospital stay (LOS), quality of life (QoL) and costs. RESULTS Eight RCTs involving 3213 participants (1615 antibiotics/1598 appendectomy) were included. There was no significant difference between the two treatments in terms of complication rates (RR = 0.66; 95% CI 0.61-1.04, P = 0.07, I2 = 69%). Antibiotics had a reduced treatment efficacy compared with appendectomy (RR = 0.80; 95% CI 0.71 to 0.90, p < 0.00001, I2 = 87%) and at 1 year was successful in 540 out of 837 (64.6%, RR = 0.69, 95% confidence interval 0.61 to 0.77, p < 0.00001, I2 = 81%) participants. There was no difference in LOS (mean difference - 0.58 days 95% confidence interval - 1.59 to 0.43, p = 0.26, I2 = 99%). The trial sequential analysis has revealed that, concerning the three primary outcomes, it is improbable that forthcoming RCTs will significantly alter the existing body of evidence. CONCLUSIONS As further large-scale trials have been conducted, antibiotic therapy proved to be safe, less expensive, but also less effective than surgical treatment. In order to ensure well-informed decisions, further research is needed to explore patient preferences and quality of life outcomes.
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Affiliation(s)
- Francesco Brucchi
- University of Milan, Via Festa Del Perdono 7, 20122, Milan, Italy.
- , Milan, Italy.
| | - Greta Bracchetti
- University of Milan, Via Festa Del Perdono 7, 20122, Milan, Italy
| | - Paola Fugazzola
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Jacopo Viganò
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Claudia Filisetti
- Department of Pediatric Surgery, Buzzi Children's Hospital, 20154, Milan, Italy
| | - Luca Ansaloni
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
| | - Francesca Dal Mas
- Department of Management, Università Ca' Foscari, Dorsoduro 3246, 30123, Venezia, Italy
| | - Lorenzo Cobianchi
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Piergiorgio Danelli
- Division of General Surgery, Department of Biomedical and Clinical Sciences, University of Milan, L. Sacco University Hospital, 20157, Milan, Italy
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11
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Peng N, He Q, Bai J, Chen C, Liu GG. Hospitalization Costs for Patients with Acute Appendicitis: An Update Using Real-World Data from a Large Province in China. Risk Manag Healthc Policy 2023; 16:2805-2817. [PMID: 38145209 PMCID: PMC10748862 DOI: 10.2147/rmhp.s436853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/17/2023] [Indexed: 12/26/2023] Open
Abstract
Purpose The aim of this study is to investigate the factors influencing hospitalization costs for patients diagnosed with acute appendicitis in China. Methods We conducted a cross-sectional study using data from Provincial Health Statistics Support System Database from S Province in China. This dataset contained all hospital's electronic medical records from January 1, 2015 to December 31, 2018 including both public and private hospitals. The target population was identified based on the principal diagnosis of appendicitis (ICD-10: K35). To examine the impact of various factors on hospitalization costs, we conducted a multivariate linear regression analysis. Furthermore, we employed the Shapley value decomposition method to gain a more comprehensive understanding of the factors that influenced hospitalization costs and their respective levels of importance. Results Our study comprised 317,200 cases. During the period from 2015 to 2018, the average hospitalization expenses for patients with acute appendicitis were estimated at approximately 7014 RMB (1061 USD), which accounts for a considerable 12% of China's per capita GDP. The results of this study demonstrate a significant correlation between various factors, such as the patient's age, gender, marital status, occupation, payment method, number of complications, treatment method, hospital tier, and ownership, and the total hospitalization costs and subcomponents of hospitalization costs. Notably, the treatment method employed had the most substantial impact on hospitalization costs. Conclusion To the best of knowledge, this is one of the first studies to investigate the hospitalization costs of acute appendicitis incorporating both patient-level and hospital-level covariates, using a large sample size. To reduce the costs associated with acute appendicitis in China, it is recommended to consider suitable treatment options and explore the option of receiving medical care at lower-tier and privately-owned healthcare facilities.
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Affiliation(s)
- Nan Peng
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, 211198, People’s Republic of China
| | - Qinghong He
- Institute of Economics, Chinese Academy of Social Sciences, Beijing, 100836, People’s Republic of China
| | - Jie Bai
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, 211198, People’s Republic of China
| | - Chen Chen
- Department of Global Health, School of Public Health, Wuhan University, Wuhan, 430071, People’s Republic of China
| | - Gordon G Liu
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, 211198, People’s Republic of China
- Institute for Global Health and Development, Peking University, Beijing, 100080, People’s Republic of China
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12
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Cioffi SPB, Altomare M, Podda M, Spota A, Granieri S, Reitano E, Zamburlini B, Virdis F, Bini R, Gupta S, Torzilli G, Mingoli A, Chiara O, Cimbanassi S. The burden of the knowledge-to-action gap in acute appendicitis. Surg Endosc 2023; 37:9617-9632. [PMID: 37884735 PMCID: PMC10709474 DOI: 10.1007/s00464-023-10449-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/05/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND The burden of emergency general surgery (EGS) is higher compared to elective surgery. Acute appendicitis (AA) is one of the most frequent diseases and its management is dictated by published international clinical practice guidelines (CPG). Adherence to CPG has been reported as heterogeneous. Barriers to clinical implementation were not studied. This study explored barriers to adherence to CPG and the clinico-economic impact of poor compliance. METHODS Data were extracted from the three-year data lock of the REsiDENT-1 registry, a prospective resident-led multicenter trial. We identified 7 items from CPG published from the European Association of Endoscopic Surgery (EAES) and the World Society of Emergency Surgery (WSES). We applied our classification proposal and used a five-point Likert scale (Ls) to assess laparoscopic appendectomy (LA) difficulty. Descriptive analyses were performed to explore compliance and group comparisons to assess the impact on outcomes and related costs. We ran logistic regressions to identify barriers and facilitators to implementation of CPG. RESULTS From 2019 to 2022, 653 LA were included from 24 centers. 69 residents performed and coordinated data collection. We identified low compliance with recommendations on peritoneal irrigation (PI) (25.73%), abdominal drains (AD) (34.68%), and antibiotic stewardship (34.17%). Poor compliance on PI and AD was associated to higher infectious complications in uncomplicated AA. Hospitalizations were significantly longer in non-compliance except for PI in uncomplicated AA, and costs significantly higher, exception made for antibiotic stewardship in complicated AA. The strongest barriers to CPG implementation were complicated AA and technically challenging LA for PI and AD. Longer operative times and the use of PI negatively affected antibiotic stewardship in uncomplicated AA. Compliance was higher in teaching hospitals and in emergency surgery units. CONCLUSIONS We confirmed low compliance with standardized items influenced by environmental factors and non-evidence-based practices in complex LA. Antibiotic stewardship is sub-optimal. Not following CPG may not influence clinical complications but has an impact in terms of logistics, costs and on the non-measurable magnitude of antibiotic resistance. Structured educational interventions and institutional bundles are required.
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Affiliation(s)
- Stefano Piero Bernardo Cioffi
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, Rome, Italy.
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy.
| | - Michele Altomare
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, Rome, Italy
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | - Mauro Podda
- Department of Surgical Sciences, Cagliari State University, Cagliari, Italy
| | - Andrea Spota
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | - Stefano Granieri
- General Surgery Unit, ASST-Brianza, Vimercate Hospital, Vimercate, Italy
| | - Elisa Reitano
- Division of General Surgery, Department of Translational Medicine, Maggiore Della Carità Hospital, University of Eastern Piedmont, Novara, Italy
- Research Institute Against Digestive Cancer, IRCAD, Strasbourg, France
| | - Beatrice Zamburlini
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Francesco Virdis
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | - Roberto Bini
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | | | | | - Andrea Mingoli
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, Rome, Italy
| | - Osvaldo Chiara
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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13
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Hsiao YW, Hsiao CY, Huang J, Lai PS, Chen PY. Surgical Outcomes and Quality of Care Among Adult Appendicitis Patients: A Comparative Study of Tertiary Care Hospitals and Regional Hospitals. World J Surg 2023; 47:3149-3158. [PMID: 37851067 DOI: 10.1007/s00268-023-07219-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Acute appendicitis is one of the most common abdominal emergencies, with management approaches that vary depending on the available resources and setting. However, there is a lack of studies on the differences of surgical outcomes and quality of care between tertiary care hospitals and regional hospitals. METHODS This multicenter retrospective study included 2158 consecutive adult patients between January 2014 and June 2018 at three hospitals. The patient cohort was divided into regional hospital group (N = 1223) and tertiary care hospital group (N = 935). Baseline characteristics and perioperative outcomes were compared, and factors associated with surgical delay and postoperative complication were investigated. RESULTS Patients in tertiary care hospital group had longer surgical waiting time (17.3 vs. 12.0 h, p < 0.001), higher risks of surgical delay exceeding 24 h (OR = 2.94, 95% CI 2.17-4.01, p < 0.001), longer operation time (64 vs. 50 min, p < 0.001), more appendix perforation (22.4 vs. 13.3%, p < 0.001), and higher hospital cost compared with regional hospital group. In multivariate analysis, factors associated with surgical delay were tertiary care hospital (OR = 2.94, 95% CI 2.18-4.01, p < 0.001) and delay diagnosis (OR = 18.7, 95% CI 11.7-30.1, p < 0.001), while those associated with postoperative complications were older age (OR = 1.02, 95% CI 1.00-1.04, p = 0.013), male sex (OR = 2.38, 95% CI 1.11-5.52, p = 0.031), surgical delay (OR = 2.99, 95% CI 1.30-6.47, p = 0.007), and appendix perforation (OR = 5.61, 95% CI 2.72-11.85, p < 0.001). CONCLUSIONS Patients at tertiary care hospitals had longer waiting time, more surgical delays, and appendix perforations, and these were risk factors of postoperative complications. Establishing an effective referral system to redirect appendicitis patients with less complex medical histories from tertiary care hospitals to regional hospitals may enhance the quality of patient care and outcomes, while also reducing medical costs.
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Affiliation(s)
- Ya-Wen Hsiao
- Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhongzheng District, Taipei, Taiwan
| | - Chih-Yang Hsiao
- Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhongzheng District, Taipei, Taiwan.
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan.
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - John Huang
- Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhongzheng District, Taipei, Taiwan
| | - Peng-Sheng Lai
- Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yunlin County, Taiwan
| | - Po-Yen Chen
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu County, Taiwan
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14
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Moran B. Conservative management of appendicitis: general adoption may be jumping the gun. Br J Surg 2023; 110:1601-1602. [PMID: 37856698 DOI: 10.1093/bjs/znad334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/23/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Brendan Moran
- Peritoneal Malignancy Institute, Basingstoke Hospital, North Hampshire Foundation Trust, Basingstoke, UK
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15
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Zhang T, Cheng Y, Zhou Y, Zhang Z, Qi S, Pan Z. Diagnostic performance of type I hypersensitivity-specific markers combined with CRP and IL-6 in complicated acute appendicitis in pediatric patients. Int Immunopharmacol 2023; 124:110977. [PMID: 37774482 DOI: 10.1016/j.intimp.2023.110977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE In this study, the diagnostic value of C-reactive protein (CRP), interleukin-6 (IL)-6, and specific markers for type I hypersensitivity were evaluated in pediatric patients with severe acute appendicitis. METHODS A total of 140 pediatric patients with "acute appendicitis" who underwent surgery at the Department of General Surgery of the Anhui Provincial Pediatric Patients' Hospital between December 2022 and April 2023 were studied retrospectively. The data collected included the gender, age, onset time, white blood cell count (WBC), CRP, procalcitonin (PCT), serum IgE, serum IL-4, serum IL-5, serum IL-6, serum IL-9, and serum IL-13 levels. The pediatric patients were divided into two groups based on the intraoperative situation and postoperative pathology: the non-complicated acute appendicitis group (NCAA) and the complicated acute appendicitis group (CAA). We analyzed the data from both groups using univariate and multivariate logistic regression models and constructed an ROC curve. RESULTS The CAA group outperformed the NCAA group in terms of onset time, WBC, CRP, PCT, IgE, IL-6, IL-9, and IL-13 levels (P < 0.05), but there was no statistically significant difference between the two groups in terms of gender, IL-4, or IL-5 levels (P > 0.05). Then, significant independent variables were incorporated into multivariate logistic regression. According to the results, CRP, IgE, IL-6, and IL-13 are all independent risk factors for CAA. The OR and 95% CI for each factor are as follows: CRP (OR = 1.073, 95%CI: 1.010-1.140, P = 0.022), IgE (OR = 0.975, 95%CI: 0.952-0.999, P = 0.038), IL-6 (OR = 1.494, 95%CI: 1.052-2.121, P = 0.025), and IL-13 (OR = 1.310, 95%CI: 1.036-1.657, P = 0.024). The receiving operator characteristics analysis yielded area under the curve (AUC) values of 0.8187, 0.9083, 0.8947, and 0.8394, respectively, for CRP, IgE, IL-6, and IL-13, confirming their significance in the diagnosis of CAA (P < 0.05). CONCLUSION Risk factors for CAA include CRP, IgE, IL-6, and IL-13. The combination of these serological markers can be used to diagnose CAA.
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Affiliation(s)
- Tao Zhang
- Department of General Surgery, Anhui Provincial Children's Hospital, Children's Hospital of Fudan University Anhui Hospital, Children's Hospital of Anhui Medical University, Hefei 230000, Anhui, China; The Fifth Clinical Medical College of Anhui Medical University, Hefei 230000, Anhui, China
| | - Yuan Cheng
- Department of General Surgery, Anhui Provincial Children's Hospital, Children's Hospital of Fudan University Anhui Hospital, Children's Hospital of Anhui Medical University, Hefei 230000, Anhui, China
| | - Yuliang Zhou
- Department of General Surgery, Anhui Provincial Children's Hospital, Children's Hospital of Fudan University Anhui Hospital, Children's Hospital of Anhui Medical University, Hefei 230000, Anhui, China
| | - Zhenqiang Zhang
- Department of General Surgery, Anhui Provincial Children's Hospital, Children's Hospital of Fudan University Anhui Hospital, Children's Hospital of Anhui Medical University, Hefei 230000, Anhui, China
| | - Shiqin Qi
- Department of General Surgery, Anhui Provincial Children's Hospital, Children's Hospital of Fudan University Anhui Hospital, Children's Hospital of Anhui Medical University, Hefei 230000, Anhui, China
| | - Zhubin Pan
- Department of General Surgery, Anhui Provincial Children's Hospital, Children's Hospital of Fudan University Anhui Hospital, Children's Hospital of Anhui Medical University, Hefei 230000, Anhui, China; The Fifth Clinical Medical College of Anhui Medical University, Hefei 230000, Anhui, China.
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16
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Brune M, Thaqi M, Bartow K. Appendiceal Vaginal Fistula: A Rare Complication of Nonoperative Appendicitis Management. Cureus 2023; 15:e49699. [PMID: 38161951 PMCID: PMC10757317 DOI: 10.7759/cureus.49699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
Appendicitis is one of the most common conditions encountered in emergency surgical practice. An appendico-cutaneous fistula is a rare complication of appendicitis. An appendico-vaginal fistula is extremely rare. To our knowledge, based on a thorough review of the literature using PubMed, MEDLINE, and Google Scholar, only three other cases of an appendico-vaginal fistula have been reported. We present one such case in a 43-year-old female with a history of partial hysterectomy, recurrent abscesses that had failed to respond to repeated drainage and antibiotic treatment, and nonoperative treatment of appendicitis.
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Affiliation(s)
- Madison Brune
- Surgery, University of Missouri School of Medicine, Columbia, USA
| | - Milot Thaqi
- Surgery, University of Missouri School of Medicine, Columbia, USA
| | - Kevin Bartow
- Surgery, University of Missouri School of Medicine, Columbia, USA
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17
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Fernandez Trokhimtchouk T, Morillo Cox Á, Flores LF, Reinoso Brito D, Andrade A. Coexistence of Acute Appendicitis and Sigmoid Diverticulitis. Cureus 2023; 15:e47642. [PMID: 38022345 PMCID: PMC10668632 DOI: 10.7759/cureus.47642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Abstract
In recent years, there has been a notable increase in acute diverticulitis cases, attributed to modern lifestyles and improved diagnostic techniques. We present a rare case of concurrent acute appendicitis and diverticulitis in a 35-year-old male who came to the emergency department with abdominal pain. While appendicitis typically requires surgery, diverticulitis is often managed conservatively. Computed tomography is key in diagnosis and decision-making. Despite their differing treatments, cases like this challenge the perception of their rarity. This case prompts consideration of multifocal abdominal pathology. Recognizing concurrent appendicitis and diverticulitis is crucial for guiding appropriate diagnostic and treatment strategies, potentially including non-operative management in select cases.
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Affiliation(s)
| | | | - Luis F Flores
- General Surgery, Universidad Internacional del Ecuador, Quito, ECU
| | | | - Andres Andrade
- General and Colorectal Surgery, Axxis Hospital, Quito, ECU
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18
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Ceresoli M, Fumagalli C, Fugazzola P, Zanini N, Magnone S, Ravasi M, Bonalumi J, Morezzi D, Bova R, Sargenti B, Schiavone L, Lucianetti A, Catena F, Ansaloni L, Braga M. Outpatient Non-operative Management of Uncomplicated Acute Appendicitis: A Non-inferiority Study. World J Surg 2023; 47:2378-2385. [PMID: 37210423 PMCID: PMC10474178 DOI: 10.1007/s00268-023-07065-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 05/22/2023]
Abstract
INTRODUCTION Non-operative management (NOM) of uncomplicated acute appendicitis is a well-established alternative to upfront surgery. The administration of intravenous broad-spectrum antibiotics is usually performed in hospital, and only one study described outpatient NOM. The aim of this multicentre retrospective non-inferiority study was to evaluate both safety and non-inferiority of outpatient compared to inpatient NOM in uncomplicated acute appendicitis. METHODS The study included 668 consecutive patients with uncomplicated acute appendicitis. Patients were treated according to the surgeon's preference: 364 upfront appendectomy, 157 inpatient NOM (inNOM), and 147 outpatient NOM (outNOM). The primary endpoint was the 30-day appendectomy rate, with a non-inferiority limit of 5%. Secondary endpoints were negative appendectomy rate, 30-day unplanned emergency department (ED) visits, and length of stay. RESULTS 30-day appendectomies were 16 (10.9%) in the outNOM group and 23 (14.6%) in the inNOM group (p = 0.327). OutNOM was non-inferior to inNOM with a risk difference of-3.80% 97.5% CI (- 12.57; 4.97). No difference was found between inNOM and outNOM groups for the number of complicated appendicitis (3 vs. 5) and negative appendectomy (1 vs. 0). Twenty-six (17.7%) outNOM patients required an unplanned ED visit after a median of 1 (1-4) days. In the outNOM group, the mean cumulative in-hospital stay was 0.89 (1.94) days compared with 3.94 (2.17) days in the inNOM group (p < 0.001). CONCLUSIONS Outpatient NOM was non-inferior to inpatient NOM with regard to the 30-day appendectomy rate, while a shorter hospital stay was found in the outNOM group. Further, studies are required to confirm these findings.
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Affiliation(s)
- Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy.
| | - Chiara Fumagalli
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
| | - Paola Fugazzola
- General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Nicola Zanini
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Stefano Magnone
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Michela Ravasi
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
| | - Jacopo Bonalumi
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
| | - Daniele Morezzi
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Raffaele Bova
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Benedetta Sargenti
- General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Luca Schiavone
- General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | | | - Fausto Catena
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Braga
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
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19
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Viennet M, Tapia S, Cottenet J, Bernard A, Ortega-Deballon P, Quantin C. Increased risk of colon cancer after acute appendicitis: a nationwide, population-based study. EClinicalMedicine 2023; 63:102196. [PMID: 37680941 PMCID: PMC10480545 DOI: 10.1016/j.eclinm.2023.102196] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 08/10/2023] [Accepted: 08/16/2023] [Indexed: 09/09/2023] Open
Abstract
Background Acute appendicitis is the most common digestive disease requiring emergency surgery. Colorectal cancer is the third most common cancer in France. An increased risk of colorectal cancer after acute appendicitis has been suggested. We aimed to assess the frequency of hospitalization for colon cancer after appendicitis in a nationwide analysis. Methods Using the French Hospital Discharge Database (PMSI), we included all patients aged 18-59 years presenting with acute appendicitis between 2010 and 2015. Univariate and multivariate analyses were performed to compare colon cancer occurrence in these patients vs a control-matched population with a hospital stay for trauma in the same period. Patients presenting strong risk factors for colorectal cancer were excluded. Findings A total of 230,349 patients with acute appendicitis (exposed group) were included. We used a propensity score to match each exposed patient with two unexposed patients (controls) to ensure the comparability of the groups, resulting in a control group of 460,698 patients. Univariate analysis found significantly more colon cancer in the appendicitis group, especially during the first year after appendicitis (5 per 10,000 vs 1 per 10,000, p < 0.000, this corresponds to 111 patients in the appendicitis group), namely within the first 6 months. Survival analysis confirmed patients treated for appendicitis present a 4 times higher risk of being diagnosed with colon cancer than control patients during the first year of follow-up (sHR = 4.67 (95% CI: 3.51-6.21), and 8 times higher during the first 6 months (sHR = 8.39; 95% CI: 5.41-12.99). The association was even more marked for right-sided colon cancer (sHR = 8.25; 95% CI: 5.03-13.54 during the 1st year). While the risk of diagnosis of colon cancer was also significant for patients over 40 years, it was even greater in patients under 40 years, who had between a 6-fold and 12-fold increase in risk. Interpretation In this population-based study, we found that acute appendicitis seems to be a warning sign for colon cancer (reverse causality) in both middle-aged and younger adults. The risk of presenting with cancer colon was higher during the first six months after acute appendicitis. This raises the issue of routine diagnostic work-up in adults presenting with acute appendicitis. Funding Regional Council of Burgundy.
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Affiliation(s)
- Manon Viennet
- Department of Digestive Surgical Oncology, Dijon University Hospital, Dijon, France
| | - Solène Tapia
- Department Medical Information, Dijon University Hospital, Dijon, France
| | - Jonathan Cottenet
- Department Medical Information, Dijon University Hospital, Dijon, France
| | - Alain Bernard
- Department Medical Information, Dijon University Hospital, Dijon, France
| | - Pablo Ortega-Deballon
- Department of Digestive Surgical Oncology, Dijon University Hospital, Dijon, France
- Inserm CIC 1432 Clinical Investigation Unit, Dijon University Hospital, Dijon, France
- Inserm Unit 1231, Locoregional Therapy in Surgical Oncology, Dijon, France
| | - Catherine Quantin
- Department Medical Information, Dijon University Hospital, Dijon, France
- Inserm CIC 1432 Clinical Investigation Unit, Dijon University Hospital, Dijon, France
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20
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Error in Figures. JAMA Surg 2023; 158:892. [PMID: 37342047 PMCID: PMC10285670 DOI: 10.1001/jamasurg.2023.2493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
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21
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Liu J, Chen G, Mao X, Jiang Z, Jiang N, Xia N, Lin A, Duan G. Single-incision laparoscopic appendectomy versus traditional three-hole laparoscopic appendectomy for acute appendicitis in children by senior pediatric surgeons: a multicenter study from China. Front Pediatr 2023; 11:1224113. [PMID: 37492606 PMCID: PMC10364637 DOI: 10.3389/fped.2023.1224113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/26/2023] [Indexed: 07/27/2023] Open
Abstract
Objective The aim of this study was to evaluate the clinical efficacy of single-incision laparoscopy appendectomy (SILA) and traditional three-hole laparoscopy appendectomy (THLA) for the treatment of acute appendicitis in children. Methods The clinical data of children (<14 years old) who underwent laparoscopic appendectomy at Yijishan Hospital of Wannan Medical College, Hubei Provincial Maternal Health Hospital and Qingdao Women and Children's Medical Center from January 2019 to June 2022 were retrospectively analyzed. According to the operation method, the patients were assigned to the SILA group or the THLA group. The clinical data, including the efficacy, and the surgical details, including the complications, of the two surgical methods were compared. The personal information of the children and the time of disease onset were recorded. Results In this study, the data of 588 patients, including 385 patients in the THLA group and 203 patients in the SILA group were collected. The baseline characteristics between the two groups of patients before surgery were comparable. There was no significant difference in the average operation time between the THLA group and the SILA group (56.31 ± 1.83 min vs. 57.48 ± 1.15 min, P > 0.05). There was also no significant difference in the average length of hospital stay between the THLA group and the SILA group (6.91 ± 0.24 days vs. 7.16 ± 0.36 days, P > 0.05). However, the FLACC scores of the SILA group (3.71 ± 0.78) were significantly lower than those of the THLA group (3.99 ± 0.56) on the second postoperative day, and the difference was significant (P < 0.05). The score of the questionnaire evaluating cosmetic appearance of the postoperative abdomen was significantly higher in the SILA group (15.81 ± 0.36) than in the THLA group (13.10 ± 0.24) (P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P > 0.05). Conclusion SILA is more advantageous in terms of postoperative FLACC scores and cosmetic appearance in children than THLA. There was no significant difference in the incidence of complications or other aspects between the two surgical methods.
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Affiliation(s)
- Jie Liu
- Department of Pediatric Surgery, Yijishan Hospital of Wannan Medical College, Wannan Medical College, Wuhu, China
- Clinical Medicine School of Wannan Medical College, Wannan Medical College, Wuhu, China
| | - Guoxian Chen
- Clinical Medicine School of Wannan Medical College, Wannan Medical College, Wuhu, China
- Department of Medical Biology of Wannan Medical College, Wannan Medical College, Wuhu, China
| | - Xiaowen Mao
- Department of Pediatric Surgery, Maternal and Child Health Hospital of Hubei, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhihui Jiang
- Department of General Surgery, Qingdao Women and Children’s Hospital, Qingdao, China
| | - Nannan Jiang
- Department of Pediatric Surgery, Yijishan Hospital of Wannan Medical College, Wannan Medical College, Wuhu, China
| | - Nan Xia
- Institute of Digital Medicine and Computer-Assisted Surgery of Qingdao University, Qingdao University, Qingdao, China
- Shandong Provincial Key Laboratory of Digital Medicine and Computer-Assisted Surgery, Qingdao, China
| | - Aiqin Lin
- Department of Medical Biology of Wannan Medical College, Wannan Medical College, Wuhu, China
| | - Guangqi Duan
- Department of Pediatric Surgery, Yijishan Hospital of Wannan Medical College, Wannan Medical College, Wuhu, China
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22
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Petruzziello C, Saviano A, Ojetti V. Probiotics, the Immune Response and Acute Appendicitis: A Review. Vaccines (Basel) 2023; 11:1170. [PMID: 37514986 PMCID: PMC10383843 DOI: 10.3390/vaccines11071170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023] Open
Abstract
Acute appendicitis is a common reason for admission to the Emergency Department (ED). It affects almost 70% of people under 30 years of age and 10% over 60 years of age. Its diagnosis includes the combination of clinical signs, laboratory tests and imaging. For years, surgical appendectomy has been the first-line therapy for acute appendicitis, but currently the management has shown some changes, in particular in patients with uncomplicated appendicitis. Recent studies have investigated the use of probiotics as an adjunctive therapy with promising results in conferring health benefits to patients with acute appendicitis. The aim of our review is to summarize the results of clinical studies about probiotics and the immunological response in acute appendicitis, discussing the limitations and future directions of this research.
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Affiliation(s)
- Carmine Petruzziello
- Emergency Department, Ospedale San Carlo di Nancy-GVM Care & Research, 00165 Rome, Italy
| | - Angela Saviano
- Emergency Department, Ospedale Policlinico A. Gemelli, 00135 Rome, Italy
| | - Veronica Ojetti
- Emergency Department, Ospedale San Carlo di Nancy-GVM Care & Research, 00165 Rome, Italy
- Emergency Department, Ospedale Policlinico A. Gemelli, 00135 Rome, Italy
- Università Cattolica del Sacro Cuore, 00135 Rome, Italy
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23
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Pogorelić Z, Janković Marendić I, Čohadžić T, Jukić M. Clinical Outcomes of Daytime Versus Nighttime Laparoscopic Appendectomy in Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040750. [PMID: 37189999 DOI: 10.3390/children10040750] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023]
Abstract
Aim of the study: To evaluate the clinical outcomes and complication rate of laparoscopic appendectomy in children operated on during the daytime versus nighttime. Methods: A total of 303 children who underwent laparoscopic appendectomy for acute appendicitis between 1 January 2020 and 31 December 2022 were enrolled in this retrospective study. The patients were divided into two study groups. The first group consisted of the patients who underwent laparoscopic appendectomy during the day shift from 07:00-21:00 (n = 171), while the patients in the second group underwent laparoscopic appendectomy during the night shift from 21:00-07:00 (n = 132). The groups were compared for baseline clinical and laboratory data, treatment outcomes, and complications. The Mann-Whitney U test was used to compare continuous variables, while the Chi-square test was used to compare categorical variables. A two-sided Fisher's exact test was used when the frequency of events in a certain cell was low. All p values less than 0.05 were considered significant. Results: The proportion of complicated appendicitis was almost the same in both patient groups (n = 63, 36.8% vs. n = 49, 37.1%, p = 0.960). Out of the total number of patients presenting during the daytime and nighttime, 11 (6.4%) and 10 (7.6%) developed a postoperative complication, respectively (p = 0.697). Additionally, rates of readmission (n = 5 (2.9%) vs. n = 2 (1.5%); p = 0.703), redo-surgery (n = 3 (1.7%) vs. n = 0; p = 0.260), conversion to open surgery (n = 0 vs. n = 1 (0.8%); p = 0.435) and length of hospital stay (n = 3 (IQR 1, 5) vs. n = 3 (IQR 2, 5); p = 0.368) did not differ significantly between daytime and nighttime appendectomies. The duration of the surgery was significantly shorter in patients presenting during the day than in those presenting at night (26 min (IQR 22, 40) vs. 37 min (31, 46); p < 0.001). Conclusions: Different shift times did not affect the treatment outcomes or complication rates for children receiving laparoscopic appendectomy.
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Affiliation(s)
- Zenon Pogorelić
- Department of Pediatric Surgery, University Hospital of Split, 21000 Split, Croatia
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia
| | | | - Tin Čohadžić
- Department of Pediatric Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Miro Jukić
- Department of Pediatric Surgery, University Hospital of Split, 21000 Split, Croatia
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia
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24
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Liu Z, Ma X, Zhu C, Fang JY. Risk of colorectal cancer after appendectomy: A systematic review and meta-analysis. J Gastroenterol Hepatol 2023; 38:350-358. [PMID: 36637673 DOI: 10.1111/jgh.16108] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 12/21/2022] [Accepted: 01/11/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIM Appendectomy is associated with various diseases, but whether it increases the risk of colorectal cancer (CRC) remains uncertain. We conducted a systematic review and meta-analysis aimed at investigating the suggested correlation between appendectomy and CRC. METHODS Systematic retrieval was performed using the PubMed, Embase, Cochrane library, Web of Science, and ClinicalTrials.gov databases up to May 4, 2022, for studies reported the influence of appendectomy on CRC, colon cancer (CC) or rectal cancer (RC). Odd ratios (ORs) and 95% confidence intervals (CIs) of CRC after appendectomy were pooled using the random effects model. Subgroup analyses were carried on by region, sex, and tumor location. RESULTS Our search identified 1743 articles, of which 22 studies from three continents published between 1964 and 2022 were eligible for inclusion. Overall, people with appendectomy had a higher risk of CRC (OR = 1.31; 95% CI [1.05, 1.62]). But the risk for Europeans was not significant (OR = 0.94; 95% CI [0.87, 1.02]; I2 = 0%), while for Americans and Asians, appendectomy would increase the risk of CRC (OR = 1.68; 95% CI [1.15, 2.44]; I2 = 65% and OR = 1.46; 95% CI [1.04, 2.05]; I2 = 98%), especially in females and in developing countries. It is worth noting that appendectomy might be a protective factor for CC in European women (OR = 0.87; 95% CI [0.77, 0.98]; I2 = 0%). CONCLUSIONS Appendectomy may be a risk factor for CRC, with varying degrees in different populations. More high-quality cross-regional studies are needed for better clinical decision making.
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Affiliation(s)
- Zhuhui Liu
- Division of Gastroenterology and Hepatology; Shanghai Institute of Digestive Disease; NHC Key Laboratory of Digestive Diseases; State Key Laboratory for Oncogenes and Related Genes; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xinyue Ma
- Division of Gastroenterology and Hepatology; Shanghai Institute of Digestive Disease; NHC Key Laboratory of Digestive Diseases; State Key Laboratory for Oncogenes and Related Genes; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chunqi Zhu
- Division of Gastroenterology and Hepatology; Shanghai Institute of Digestive Disease; NHC Key Laboratory of Digestive Diseases; State Key Laboratory for Oncogenes and Related Genes; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jing-Yuan Fang
- Division of Gastroenterology and Hepatology; Shanghai Institute of Digestive Disease; NHC Key Laboratory of Digestive Diseases; State Key Laboratory for Oncogenes and Related Genes; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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25
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Barie PS, Kao LS, Moody M, Sawyer RG. Infection or Inflammation: Are Uncomplicated Acute Appendicitis, Acute Cholecystitis, and Acute Diverticulitis Infectious Diseases? Surg Infect (Larchmt) 2023; 24:99-111. [PMID: 36656157 DOI: 10.1089/sur.2022.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: It is recognized increasingly that common surgical infections of the peritoneal cavity may be treated with antibiotic agents alone, or source control surgery with short-course antimicrobial therapy. By extension, testable hypotheses have emerged that such infections may not actually be infectious diseases, but rather represent inflammation that can be treated successfully with neither surgery nor antibiotic agents. The aim of this review is to examine extant data to determine which of uncomplicated acute appendicitis (uAA), uncomplicated acute calculous cholecystitis (uACC), or uncomplicated mild acute diverticulitis (umAD) might be amenable to management using supportive therapy alone, consistent with the principles of antimicrobial stewardship. Methods: Review of pertinent English-language literature and expert opinion. Results: Only two small trials have examined whether uAA can be managed with observation and supportive therapy alone, one of which is underpowered and was stopped prematurely because of challenging patient recruitment. Data are insufficient to determine the safety and efficacy of non-antibiotic therapy of uAA. Uncomplicated acute calculous cholecystitis is not primarily an infectious disease; infection is a secondary phenomenon. Even when bactibilia is present, there is no high-quality evidence to suggest that mild disease should be treated with antibiotic agents. There is evidence to indicate that antibiotic prophylaxis is indicated for urgent/emergency cholecystectomy for uACC, but not in the post-operative period. Uncomplicated mild acute diverticulitis, generally Hinchey 1a or 1b in current nomenclature, does not benefit from antimicrobial agents based on multiple clinical studies. The implication is that umAD is inflammatory and not an infectious disease. Non-antimicrobial management is reasonable. Conclusions: Among the considered disease entities, the evidence is strongest that umAD is not an infectious disease and can be treated without antibiotic agents, intermediate regarding uACC, and lacking for uAA. A plausible hypothesis is that these inflammatory conditions are related to disruption of the normal microbiome, resulting in dysbiosis, which is defined as an imbalance of the natural microflora, especially of the gut, that is believed to contribute to a range of conditions of ill health. As for restorative pre- or probiotic therapy to reconstitute the microbiome, no recommendation can be made in terms of treatment, but it is not recommended for prevention of primary or recurrent disease.
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Affiliation(s)
- Philip S Barie
- Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Lillian S Kao
- Department of Surgery, UTHealth Houston John P. and Kathrine G. McGovern Medical School, Houston, Texas, USA
| | - Mikayla Moody
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
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26
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Talan DA, Salminen P. Management of Acute Uncomplicated Appendicitis. JAMA Surg 2023; 158:328-329. [PMID: 36515927 DOI: 10.1001/jamasurg.2022.6541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- David A Talan
- Ronald Reagan UCLA Medical Center, Department of Emergency Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland.,Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
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27
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Ullah S, Ali FS, Liu BR. Management of Acute Uncomplicated Appendicitis. JAMA Surg 2023; 158:328. [PMID: 36515963 DOI: 10.1001/jamasurg.2022.6538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Saif Ullah
- Department of Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Faisal S Ali
- Gastroenterology, Hepatology, and Nutrition Department, University of Texas Health Science Center at Houston, Houston
| | - Bing-Rong Liu
- Department of Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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28
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de Almeida Leite RM, Ricciardi R. Management of Acute Uncomplicated Appendicitis-Reply. JAMA Surg 2023; 158:329. [PMID: 36515936 DOI: 10.1001/jamasurg.2022.6544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
| | - Rocco Ricciardi
- Department of Colon and Rectal Surgery, Massachusetts General Hospital, Boston
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29
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Schena CA, de’Angelis GL, Carra MC, Bianchi G, de’Angelis N. Antimicrobial Challenge in Acute Care Surgery. Antibiotics (Basel) 2022; 11:antibiotics11101315. [PMID: 36289973 PMCID: PMC9598495 DOI: 10.3390/antibiotics11101315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 12/07/2022] Open
Abstract
The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients’ morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.
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Affiliation(s)
- Carlo Alberto Schena
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
| | - Gian Luigi de’Angelis
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
- Correspondence:
| | - Maria Clotilde Carra
- Rothschild Hospital, AP-HP, Université Paris Cité, U.F.R. of Odontology, 75006 Paris, France
| | - Giorgio Bianchi
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
| | - Nicola de’Angelis
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
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