Appendectomy versus antibiotic treatment for acute appendicitis

Interhospital variation in the non-operative management of uncomplicated appendicitis in adults

Background

Recent randomized trials have suggested non-operative management to be a safe alternative to appendectomy for acute uncomplicated appendicitis. Yet, there remains significant variability in treatment approach. This study sought to characterize center-level variation in non-operative management within a national cohort of adults presenting with appendicitis.

Methods

The 2016-2020 Nationwide Readmissions Database was queried to identify all adult (≥18 years) hospitalizations for acute uncomplicated appendicitis. Hierarchical, mixed-effects models were developed to ascertain factors linked with non-operative management. Bayesian methodology was applied to predict random effects, which were then used to rank centers by increasing hospital-attributed rate of non-operative management. Institutions with high center-specific rates of non-operative management (>90th percentile) were considered low-operating hospitals (LOH).

Results

Of an estimated 447,500 patients, 52,523 (11.7 %) were managed non-operatively. Compared to those undergoing appendectomy, the non-operative cohort was older, more commonly male, and of a higher comorbidity burden. Approximately 30 % in the variability of non-operative management was attributable to hospital effects, with absolute, risk-adjusted rates ranging from 0.5 to 22.5 %. Centers with non-operative management rates ≥90th percentile were considered LOH.Following risk adjustment, among patients undergoing appendectomy, care at LOH was linked with greater odds of postoperative infection, resource utilization, and non-elective readmission.

Conclusions

We identified significant interhospital variation in the utilization of non-operative management for acute uncomplicated appendicitis. Further, we found LOH to be associated with inferior outcomes following surgical management. Future work is needed to assess the care pathways that contribute to increased utilization of non-operative strategies, and disseminate best practices across institutions.

Antibiotic treatment after appendectomy for acute complicated appendicitis to prevent intrabdominal abscess and wound infections

INTRODUCTION

The purpose of this analysis was to investigate the most appropriate duration of postoperative antibiotic treatment to minimize the incidence of intraabdominal abscesses and wound infections in patients with complicated appendicitis.

MATERIALS AND METHODS

In this retrospective study, which included 396 adult patients who underwent appendectomy for complicated appendicitis between January 2010 and December 2020 at the University Hospital Erlangen, patients were classified into two groups based on the duration of their postoperative antibiotic intake: ≤ 3 postoperative days (group 1) vs. ≥ 4 postoperative days (group 2). The incidence of postoperative intraabdominal abscesses and wound infections were compared between the groups. Additionally, multivariate risk factor analysis for the occurrence of intraabdominal abscesses and wound infections was performed.

RESULTS

The two groups contained 226 and 170 patients, respectively. The incidence of postoperative intraabdominal abscesses (2% vs. 3%, p = 0.507) and wound infections (3% vs. 6%, p = 0.080) did not differ significantly between the groups. Multivariate analysis revealed that an additional cecum resection (OR 5.5 (95% CI 1.4-21.5), p = 0.014) was an independent risk factor for intraabdominal abscesses. A higher BMI (OR 5.9 (95% CI 1.2-29.2), p = 0.030) and conversion to an open procedure (OR 5.2 (95% CI 1.4-20.0), p = 0.016) were identified as independent risk factors for wound infections.

CONCLUSION

The duration of postoperative antibiotic therapy does not appear to influence the incidence of postoperative intraabdominal abscesses and wound infections. Therefore, short-term postoperative antibiotic treatment should be preferred.

Navigating appendicitis care during the Covid-19 pandemic: a retrospective cohort study in China

BACKGROUND

The emergence of the COVID-19 pandemic in December 2019 initiated a global transformation in healthcare practices, particularly with respect to hospital management. PCR testing mandates for medical treatment seekers were introduced to mitigate virus transmission.

AIMS

This study examines the impact of these changes on the management of patients with appendicitis.

METHODS

We conducted a retrospective analysis of medical records for 748 patients diagnosed with appendicitis who underwent surgery at a tertiary care hospital during two distinct periods, the pre-pandemic year 2019 and the post-pandemic year 2021. Patient demographics, clinical characteristics, laboratory data, surgical outcomes, and hospital stay duration were assessed.

RESULTS

While no significant differences were observed in the general characteristics of patients between the two groups, the time from hospital visit to operation increased significantly during the pandemic. Unexpectedly, delayed surgical intervention was associated with shorter hospital stays but did not directly impact complication rates. There was no discernible variation in the type of surgery or surgical timing based on symptom onset. The pandemic also prompted an increase in appendicitis cases, potentially related to coronavirus protein expression within the appendix.

CONCLUSIONS

The COVID-19 pandemic has reshaped the landscape of appendicitis management. This study underscores the complex interplay of factors, including changes in hospital protocols, patient concerns, and surgical timing. Further research is needed to explore the potential link between COVID-19 and appendicitis. These insights are valuable for informing healthcare practices during and beyond the pandemic.

Appendectomy versus antibiotic treatment for acute appendicitis

BACKGROUND

Acute appendicitis is one of the most common emergency general surgical conditions worldwide. Uncomplicated/simple appendicitis can be treated with appendectomy or antibiotics. Some studies have suggested possible benefits with antibiotics with reduced complications, length of hospital stay, and the number of days off work. However, surgery may improve success of treatment as antibiotic treatment is associated with recurrence and future need for surgery.

OBJECTIVES

To assess the effects of antibiotic treatment for uncomplicated/simple acute appendicitis compared with appendectomy for resolution of symptoms and complications.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trial registers (World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov) on 19 July 2022. We also searched for unpublished studies in conference proceedings together with reference checking and citation search. There were no restrictions on date, publication status, or language of publication.

SELECTION CRITERIA

We included parallel-group randomised controlled trials (RCTs) only. We included studies where most participants were adults with uncomplicated/simple appendicitis. Interventions included antibiotics (by any route) compared with appendectomy (open or laparoscopic).

DATA COLLECTION AND ANALYSIS

We used standard methodology expected by Cochrane. We used GRADE to assess the certainty of evidence for each outcome. Primary outcomes included mortality and success of treatment, and secondary outcomes included number of participants requiring appendectomy in the antibiotic group, complications, pain, length of hospital stay, sick leave, malignancy in the antibiotic group, negative appendectomy rate, and quality of life. Success of treatment definitions were heterogeneous although mainly based on resolution of symptoms rather than incorporation of long-term recurrence or need for surgery in the antibiotic group.

MAIN RESULTS

We included 13 studies in the review covering 1675 participants randomised to antibiotics and 1683 participants randomised to appendectomy. One study was unpublished. All were conducted in secondary care and two studies received pharmaceutical funding. All studies used broad-spectrum antibiotic regimens expected to cover gastrointestinal bacteria. Most studies used predominantly laparoscopic surgery, but some included mainly open procedures. Six studies included adults and children. Almost all studies aimed to exclude participants with complicated appendicitis prior to randomisation, although one study included 12% with perforation. The diagnostic technique was clinical assessment and imaging in most studies. Only one study limited inclusion by sex (male only). Follow-up ranged from hospital admission only to seven years. Certainty of evidence was mainly affected by risk of bias (due to lack of blinding and loss to follow-up) and imprecision. Primary outcomes It is uncertain whether there was any difference in mortality due to the very low-certainty evidence (Peto odds ratio (OR) 0.51, 95% confidence interval (CI) 0.05 to 4.95; 1 study, 492 participants). There may be 76 more people per 1000 having unsuccessful treatment in the antibiotic group compared with surgery, which did not reach our predefined level for clinical significance (risk ratio (RR) 0.91, 95% CI 0.87 to 0.96; I2 = 69%; 7 studies, 2471 participants; low-certainty evidence). Secondary outcomes At one year, 30.7% (95% CI 24.0 to 37.8; I2 = 80%; 9 studies, 1396 participants) of participants in the antibiotic group required appendectomy or, alternatively, more than two-thirds of antibiotic-treated participants avoided surgery in the first year, but the evidence is very uncertain. Regarding complications, it is uncertain whether there is any difference in episodes of Clostridium difficile diarrhoea due to very low-certainty evidence (Peto OR 0.97, 95% CI 0.24 to 3.89; 1 study, 1332 participants). There may be a clinically significant reduction in wound infections with antibiotics (RR 0.25, 95% CI 0.09 to 0.68; I2 = 16%; 9 studies, 2606 participants; low-certainty evidence). It is uncertain whether antibiotics affect the incidence of intra-abdominal abscess or collection (RR 1.58, 95% CI 0.61 to 4.07; I2 = 19%; 6 studies, 1831 participants), or reoperation (Peto OR 0.13, 95% CI 0.01 to 2.16; 1 study, 492 participants) due to very low-certainty evidence, mainly due to rare events causing imprecision and risk of bias. It is uncertain if antibiotics prolonged length of hospital stay by half a day due to the very low-certainty evidence (MD 0.54, 95% CI 0.06 to 1.01; I2 = 97%; 11 studies, 3192 participants). The incidence of malignancy was 0.3% (95% CI 0 to 1.5; 5 studies, 403 participants) in the antibiotic group although follow-up was variable. Antibiotics probably increased the number of negative appendectomies at surgery (RR 3.16, 95% CI 1.54 to 6.49; I2 = 17%; 5 studies, 707 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Antibiotics may be associated with higher rates of unsuccessful treatment for 76 per 1000 people, although differences may not be clinically significant. It is uncertain if antibiotics increase length of hospital stay by half a day. Antibiotics may reduce wound infections. A third of the participants initially treated with antibiotics required subsequent appendectomy or two-thirds avoided surgery within one year, but the evidence is very uncertain. There were too few data from the included studies to comment on major complications.

Exploring the role of an artificial intelligence chatbot on appendicitis management: an experimental study on ChatGPT

BACKGROUND

Appendicitis is a common surgical condition that requires urgent medical attention. Recent advancements in artificial intelligence and large language processing, such as ChatGPT, have demonstrated potential in supporting healthcare management and scientific research. This study aims to evaluate the accuracy and comprehensiveness of ChatGPT's knowledge on appendicitis management.

METHODS

Six questions related to appendicitis management were created by experienced RACS qualified general surgeons to assess ChatGPT's ability to provide accurate information. The criteria of ChatGPT answers' accuracy were compared with current healthcare guidelines for appendicitis and subjective evaluation by two RACS qualified General Surgeons. Additionally, ChatGPT was then asked to provide five high level evidence references to support its responses.

RESULTS

ChatGPT provided clinically relevant information on appendicitis management, however, was inconsistent in doing so and often provided superficial information. Further to this, ChatGPT encountered difficulties in generating relevant references, with some being either non-existent or incorrect.

CONCLUSION

ChatGPT has the potential to provide timely and comprehensible medical information on appendicitis management to laypersons. However, its issue of inaccuracy in information and production of non-existent or erroneous references presents a challenge for researchers and clinicians who may inadvertently employ such information in their research or healthcare. Therefore, clinicians should exercise caution when using ChatGPT for these purposes.

Comparison of open and laparoscopic techniques in the surgical treatment of acute appendicitis

OBJECTIVE

Acute appendicitis (AA) is the most common cause of acute abdomen and appendectomy is one of the most common surgical procedures. In this study, we aimed to compare open appendectomy (OA) and laparoscopic (LA) surgical techniques in the treatment of AA.

METHODS

The data of 236 patients treated with the diagnosis of AA in 2019-2020 were analyzed. Of these patients, 85 patients who received OA and 84 patients who received LA were included in the study. Then, the two groups were compared in terms of demographic, laboratory, clinical, and surgical treatments.

RESULTS

A total of 169 patients were included in the study. The mean age was 34.9 years (range 16-78), and the male-to-female ratio was 0.69. Statistical analysis revealed that the OA group had more leukocytosis, more female gender, and longer operation time than the LA group, but the LA group's complication rate was lower (p<0.05).

CONCLUSION

LA offers less morbidity, a shorter duration of hospital stay, and a fast return to normal activities compared to OA. In the surgical treatment of AA, LA can be applied as a routine and first-line treatment.

Bacterial profile and antibiotic selection for pediatric appendicitis: A retrospective cohort study

OBJECTIVE

The objective of this study was to identify the predominant bacteria cultured from the surface of removed appendices in pediatric patients with acute appendicitis and determine the appropriate choice of antibiotics for preoperative and postoperative management.

METHODS

A 2-year retrospective cohort study was conducted at Mediclinic Parkview Hospital, Dubai, UAE. Patients under 14 years of age with diagnosed acute appendicitis who underwent laparoscopic appendectomy were included. Swab cultures, along with demographic, laboratory, and pathology data, were analyzed.

RESULTS

Out of the 56 enrolled patients, 27 (48 %) exhibited bacterial growth on swab cultures, while 29 (52 %) showed no bacterial growth. Escherichia coli (E. coli) was the predominant isolated bacteria, present in 23/27 patients (85 %). Seven patients had co-infections involving E. coli and other bacteria, with Pseudomonas being the second most common bacteria identified in 7/27 patients (25 %). Antibiotic sensitivity testing indicated that 85 % of the isolated bacteria were sensitive to Gentamicin, 63 % to Amoxicillin/Clavulanic acid, 59 % to Trimethoprim + Sulfamethoxazole, and 27 % to Cefazolin.

CONCLUSION

E. coli was the most prevalent bacteria identified on swabs taken from inflamed appendices in pediatric patients. Amoxicillin/Clavulanic acid was determined to be an appropriate choice for preoperative prophylaxis. This study provides valuable insights for guiding the management of pediatric appendicitis and facilitating the appropriate and judicious use of antibiotics.

Comparison of the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to compare the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis.

METHODS

We searched the randomized controlled studies (RCTs) comparing appendectomy with antibiotic treatment for uncomplicated acute appendicitis in the electronic database including Pubmed, Embase, Cochrane, Web of Science, CNKI, VIP, and WanFang. The primary outcomes included complication-free treatment success at 1 year, complications, surgical complications, and the complicated appendicitis rates. Secondary outcomes included negative appendicitis, length of hospital stay, the quality of life at 1 month, and the impact of an appendicolith on antibiotic therapy.

RESULTS

Twelve randomized controlled studies were included. Compared with surgery group, the antibiotic group decreased the complication-free treatment success at 1 year (RR 0.81; 95% CI 0.73-0.91; z = 3.65; p = 0.000). Statistically significance was existed between antibiotic group and surgical group with both surgical types(open and laparoscopic) (RR 0.43; 95% CI 0.31-0.58; z = 5.36; p = 0.000), while no between the antibiotic treatment and laparoscopic surgery (RR 0.72; 95% CI 0.41-1.24; z = 1.19; p = 0.236). There was no statistically significant differences between two groups of surgical complications (RR 1.38; 95% CI 0.70-2.73; z = 0.93; p = 0.353), the complicated appendicitis rate (RR 0.71; 95% CI 0.36-1.42; z = 0.96; p = 0.338), negative appendectomy rate (RR 1.11; 95% CI 0.69-1.79; z = 0.43; p = 0.670), duration of hospital stay (SMD 0.08; 95%CI -0.11-0.27; z = 0.80; p = 0.422), and quality of life at 1 month (SMD 0.09; 95%CI -0.03-0.20; z = 1.53; p = 0.127). However, in the antibiotic treatment group, appendicolith rates were statistically higher in those whose symptoms did not improve (RR 2.94; 95% CI 1.28-6.74; z = 2.55; p = 0.011).

CONCLUSIONS

Although the cure rate of antibiotics is lower than surgery, antibiotic treatment is still a reasonable option for patients with uncomplicated acute appendicitis who do not want surgery without having to worry about complications or complicating the original illness.

Adherence to the Antibiotic Prophylaxis Guidelines for Appendectomy in Bahrain: An Observational Study

Background Appendicitis is a common clinical problem that has multifactorial etiologies. Accounting for almost 1 million hospital days per year, it poses serious health hazards. If not treated on time, it may burst. Surgical intervention is the best option in such cases. Prophylactic use of antibiotics has been shown to reduce post-operative infections. Methodology This prospective observational study aimed to evaluate the adherence to the antibiotic prophylaxis guidelines for appendectomy in patients admitted to the surgical department at Salmanyia Medical Complex in Bahrain from January to August 2020. From the electronic records of these patients, information was extracted and evaluated regarding demographic data, the type of antibiotics given for prophylaxis, the timing of the administration of the antibiotics, and any alternative antibiotic given based on local hospital guidelines. Results The current study revealed that the majority of the patients (98%, N=273) admitted to the Salmanyia Medical Complex, Bahrain, were not administered the antibiotics within the prescribed time (30-60 minutes) as per hospital guidelines. Also, the antibiotics administered for prophylaxis prior to the appendectomy procedure were not according to the guidelines, i.e., Cefazolin 1g with Metronidazole 500 mg. Out of a total of 278 patients included in the study, none were administered the right choice as provided by the local guidelines. Second, 1.8% of patients (5 out of 278) were not administered any antibiotics for prophylaxis prior to the surgical procedure for appendicitis. Conclusion The study concluded that most patients were not administered antibiotics according to the local guidelines of the hospital.

Energy Devices for Clipless-Sutureless Laparoscopic Appendectomy: A Systematic Review and Meta-Analysis on Utility and Safety

Background and Objectives: While laparoscopic appendectomy is standardized, techniques for appendiceal stump closure and mesoappendix division remain variable. Novel vessel sealing techniques are increasingly utilized ubiquitously. We sought to systematically summarize all relevant data and to define the current evidence on the safety and utility of energy devices for clipless−sutureless laparoscopic appendectomy in this systematic review and meta-analysis. Materials and Methods: This review was conducted following the PRISMA guidelines. PubMed, Embase, Scopus, and Web of Science were systematically searched. Inclusion criteria included studies with laparoscopic appendectomy for appendicitis. The intervention included patients undergoing division of mesoappendix and/or securing of the appendicular base using diathermy (Monopolar or Bipolar or LigaSure Sealing Device) or Harmonic Scalpel (Group A) compared to patients undergoing division of mesoappendix and/or securing of the appendicular base using endoclip or Hem-o-lok or ligature (Group B). The methodological quality of the included studies was assessed using the Downs and Black scale. The outcomes of surgical site infection (SSI) or intra-abdominal collection, postoperative ileus, average operative duration, and length of hospital stay (LHS) were compared. Results: Six comparative studies were included; three were retrospective, two were prospective, and one was ambispective. Meta-analysis revealed a shorter operative duration in Group A with respect to appendicular base ligation (MD −12.34, 95% CI −16.57 to −8.11, p < 0.00001) and mesoappendix division (MD −8.06, 95% CI −14.03 to −2.09, p = 0.008). The pooled risk ratios showed no difference in SSI between groups. Additionally, no difference was observed in LHS. The risk of postoperative ileus was higher in group B regarding mesoappendix division (RR 0.56, 95% CI 0.34 to 0.93, p = 0.02), but no difference was found concerning appendicular base ligation. The included studies showed a moderate-to-high risk of bias. Conclusions: Clipless−sutureless laparoscopic appendectomy is safe and fast. Postoperative ileus seems less common with energy devices for mesoappendix division. However, the studies included have a moderate-to-high risk of bias. Further studies addressing the individual devices with surgeons of similar levels are needed.

Surgical Site Infection Following Single-Port Appendectomy: A Systematic Review of the Literature and Meta-Analysis

Introduction

Surgical site infections (SSIs) are one of the most common postoperative complications after appendectomy leading to recurrent surgery, prolonged hospital stay, and the use of antibiotics. Numerous studies and meta-analyses have been published on the effect of open versus conventional laparoscopic appendectomy (CLA) reporting faster postoperative recovery and less postoperative pain for CLA. A development from CLA has been the single-port appendectomy (SPA), associated with a better cosmesis but seemingly having a higher risk of wound infections. The aim of this systematic literature review and meta-analysis is to investigate whether reduced port or SPA alters the ratio of SSIs.

Methods

Pubmed, Embase, and Cochrane databases were screened for suitable articles. All articles published between January 1, 2002, and March 23, 2022, were included. Articles regarding children below the age of 18 were excluded as well as manuscripts that investigated solemnly open appendectomies. Articles were screened for inclusion criteria by two independent authors. Incidence of SSI was the primary outcome. Duration of operation and length of hospital stay were defined as secondary outcomes.

Results

A total of 25 studies were found through a database search describing 5484 patients. A total of 2749 patients received SPA and 2735 received CLA. There was no statistical difference in the rate of SSI (P = 0.98). A total of 22 studies including 4699 patients reported the duration of operation (2223 SPA and 2476 CLA). There was a significantly shorter operation time seen in CLA. The length of hospital stay was reported in 23 studies (4735 patients: 2235 SPA and 2500 CLA). A shorter hospital stay was seen in the SPA group (P &lt; 0.00001). Separately performed analysis of randomized controlled trials could not confirm this effect (P = 0.29).

Discussion

SPA is an equally safe procedure considering SSI compared to CLA and does not lead to an increased risk of SSI. A longer operation time for SPA and a minor difference in the length of stay does lead to the use of SPA in selected patients only.

Efficacy and Safety of Non-Operative Management of Uncomplicated Acute Appendicitis Compared to Appendectomy: An Umbrella Review of Systematic Reviews and Meta-Analyses

BACKGROUND

Non-operative management (NOM) of uncomplicated acute appendicitis (AA) has been introduced as an alternative to appendectomy. This umbrella review aimed to provide an overview of the efficacy and safety of NOM of uncomplicated AA in the published systematic reviews.

METHODS

This umbrella review has been reported in line with the PRISMA guidelines and umbrella review approach. Systematic reviews with and without meta-analyses on the efficacy of NOM of AA were analyzed. The quality of the reviews was assessed with the AMSTAR 2 tool. The main outcomes measures were the treatment failure and complication rates of NOM and hospital stay as compared to appendectomy.

RESULTS

Eighteen systematic reviews were included to this umbrella review. Eight reviews documented higher odds of failure with NOM, whereas two reviews revealed similar odds of failure. Six reviews reported lower odds of complications with NOM, six reported similar odds, and one reported lower odds of complications with surgery. Eight reviews reported similar hospital stay between NOM and appendectomy, one reported longer stay with NOM and another reported shorter stay with NOM. Pooled analyses showed that NOM was associated with higher treatment failure overall, in children-only, adults only, and RCTs-only meta-analyses. NOM was associated with lower complications overall, yet children-only and RCTs-only analyses revealed similar complications to surgery. NOM was associated with shorter stay in the overall and adult-only analysis, but not in the children-only analysis.

CONCLUSIONS

NOM of AA is associated with higher treatment failure, marginally lower rate of complications and shorter stay than appendectomy.

Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis

BACKGROUND

Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children.

OBJECTIVES

The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective.

SELECTION CRITERIA

We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies.

DATA COLLECTION AND ANALYSIS

We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity.

MAIN RESULTS

We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains.

AUTHORS' CONCLUSIONS

MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.

Abdominal drainage to prevent intra-peritoneal abscess after appendectomy for complicated appendicitis

BACKGROUND

This is the second update of a Cochrane Review first published in 2015 and last updated in 2018. Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. Patients who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer postoperative complications. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial.

OBJECTIVES

To assess the safety and efficacy of abdominal drainage to prevent intraperitoneal abscess after appendectomy (irrespective of open or laparoscopic) for complicated appendicitis; to compare the effects of different types of surgical drains; and to evaluate the optimal time for drain removal.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, Web of Science, the World Health Organization International Trials Registry Platform, ClinicalTrials.gov, Chinese Biomedical Literature Database, and three trials registers on 24 February 2020, together with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared abdominal drainage versus no drainage in people undergoing emergency open or laparoscopic appendectomy for complicated appendicitis. We also included RCTs that compared different types of drains and different schedules for drain removal in people undergoing appendectomy for complicated appendicitis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We used the GRADE approach to assess evidence certainty. We included intraperitoneal abscess as the primary outcome. Secondary outcomes were wound infection, morbidity, mortality, hospital stay, hospital costs, pain, and quality of life.

MAIN RESULTS

Use of drain versus no drain We included six RCTs (521 participants) comparing abdominal drainage and no drainage in participants undergoing emergency open appendectomy for complicated appendicitis. The studies were conducted in North America, Asia, and Africa. The majority of participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open appendectomy. None of the trials was assessed as at low risk of bias. The evidence is very uncertain regarding the effects of abdominal drainage versus no drainage on intraperitoneal abscess at 30 days (risk ratio (RR) 1.23, 95% confidence interval (CI) 0.47 to 3.21; 5 RCTs; 453 participants; very low-certainty evidence) or wound infection at 30 days (RR 2.01, 95% CI 0.88 to 4.56; 5 RCTs; 478 participants; very low-certainty evidence). There were seven deaths in the drainage group (N = 183) compared to one in the no-drainage group (N = 180), equating to an increase in the risk of 30-day mortality from 0.6% to 2.7% (Peto odds ratio 4.88, 95% CI 1.18 to 20.09; 4 RCTs; 363 participants; low-certainty evidence). Abdominal drainage may increase 30-day overall complication rate (morbidity; RR 6.67, 95% CI 2.13 to 20.87; 1 RCT; 90 participants; low-certainty evidence) and hospital stay by 2.17 days (95% CI 1.76 to 2.58; 3 RCTs; 298 participants; low-certainty evidence) compared to no drainage. The outcomes hospital costs, pain, and quality of life were not reported in any of the included studies. There were no RCTs comparing the use of drain versus no drain in participants undergoing emergency laparoscopic appendectomy for complicated appendicitis. Open drain versus closed drain There were no RCTs comparing open drain versus closed drain for complicated appendicitis. Early versus late drain removal There were no RCTs comparing early versus late drain removal for complicated appendicitis.

AUTHORS' CONCLUSIONS

The certainty of the currently available evidence is low to very low. The effect of abdominal drainage on the prevention of intraperitoneal abscess or wound infection after open appendectomy is uncertain for patients with complicated appendicitis. The increased rates for overall complication rate and hospital stay for the drainage group compared to the no-drainage group are based on low-certainty evidence. Consequently, there is no evidence for any clinical improvement with the use of abdominal drainage in patients undergoing open appendectomy for complicated appendicitis. The increased risk of mortality with drainage comes from eight deaths observed in just under 400 recruited participants. Larger studies are needed to more reliably determine the effects of drainage on morbidity and mortality outcomes.

SARS-CoV-2 infection is not associated with a higher rate of post-operative complications in adult appendectomy patients in Peru: Cross-sectional study

Background

We present outcomes of patients with SARS-CoV-2 undergoing appendectomy in order to aid in clarification of current controversies regarding safety of therapeutic options for emergency surgical diseases in patients with SARS-CoV-2. Peru has the greatest number of per capita deaths due to SARS-CoV-2 of any country and is one of few with a COVID-dedicated hospital.

Materials and methods

This prospective observational study included all adult patients with acute appendicitis admitted to an urban, public, COVID-dedicated hospital over two months. Baseline characteristics and post-operative outcomes at 28 days are reported.

Results

58 patients, 35 male and 23 female, ages 15-73 years with SARS-CoV-2 as diagnosed by IgM (12%), IgG (19%) or both (69%) and acute appendicitis as diagnosed using the Alvarado Score and confirmed intraoperatively were enrolled. All patients presented with right lower quadrant pain, 86% with leukocytosis, 88% with nausea/emesis and no patients with respiratory complaints. All patients underwent open appendectomy, 90% under regional anesthesia. Average operative time was 54±25 minutes, length of stay 2.5±1.5 days. 14% of patients had a post-operative complication, all were minor, four (7%) incisional surgical site infections, one (2%) organ space, and three (5%) incisional seromas, no deaths or serious complications.

Conclusion

Open surgical management of acute appendicitis with regional anesthesia in adults with pre-operative diagnosis of SARS-CoV-2 is feasible and not associated with an increased frequency or severity of post-operative complications, longer operative time, or extended hospitalization as compared to reports in similar patients without SARS-CoV-2.

A local experience of non-operative management for an appendicitis cohort during COVID-19

BACKGROUND

During the first United Kingdom COVID-19 wave, the Royal Colleges of Surgeons initially recommended conservative management with antibiotics instead of surgery for appendicitis. This study compared local outcomes of appendicitis during this period with a pre-COVID-19 cohort.

METHODS

An observational study was conducted in a district general hospital. All episodes of appendicitis were prospectively studied from 25th March 2020 until 26th May 2020 and compared with a retrospective pre-COVID cohort from 27th November 2019 until 29th January 2020. Primary outcome was 30-day treatment failure of simple appendicitis for conservatively managed cases during COVID-19 compared to surgically managed cases pre-pandemic. Treatment failure was defined as any unplanned radiological or surgical intervention.

RESULTS

Over nine weeks, there were 39 cases of appendicitis during COVID-19 and 50 cases pre-COVID-19. Twenty-six and 50 cases underwent appendicectomy during and pre-COVID-19 respectively. There was no difference in 30-day postoperative complication rates and nor were there any peri-operative COVID-19 infections.Twelve cases of simple appendicitis underwent conservative management during COVID-19 and were compared with 23 operatively managed simple cases pre-pandemic. There was a higher failure rate in the conservative versus operative group (33.3 vs 0% OR = 24.88, 95% CI 1.21 to 512.9, p=0.0095). Length of stay was similar (1.5 vs 2.0 p=0.576).

DISCUSSION

Locally, conservative management was more likely to fail than initial appendicectomy. We suggest that surgery should remain first line for appendicitis, with conservative management reserved for those with suspected or proven COVID-19 infection.

An observational study of innate immune responses in patients with acute appendicitis

Acute appendicitis is a common surgical emergency worldwide. Exaggerated immune responses could be associated with appendicitis. This study aimed at characterizing immune responses towards a large variety of gut commensals and pathogens, and pattern recognition receptor (PRR) ligands, and investigating the course of systemic inflammation in a prospective cohort of acute appendicitis patients. PBMC responses of 23 patients of the cohort and 23 healthy controls were characterized more than 8 months post-surgery. Serum cytokine levels were measured in 23 patients at the time of appendicitis and after one month. CRP, WBC and percentage of neutrophils were analyzed in the total cohort of 325 patients. No differences in PBMC responses were found between patients and controls. Stronger IL-10 responses were found following complicated appendicitis. A trend towards lower IL-8 responses was shown following gangrenous appendicitis. Serum IL-10 and IL-6 were significantly elevated at presentation, and IL-6, IL-8 and TNF-α levels were higher in complicated appendicitis. Routine biomarkers could predict severity of appendicitis with high specificities, but low sensitivities. Cytokine responses in patients following acute appendicitis did not differ from healthy controls. Higher serum cytokine levels were found in acute complicated and gangrenous cases. Further research into discriminative biomarkers is warranted.

The Role of Minimally Invasive Surgery in Appendectomy Within a Hernia

We present three cases where an inflamed incarcerated appendix was in a femoral, inguinal, and an umbilical hernia. All three patients underwent an appendectomy laparoscopically. The hernias in two of the patients (femoral and inguinal) were left unrepaired as the primary goal was to relieve the patients' symptoms and achieve source control. The hernia was repaired primarily in the patient with an umbilical hernia intraoperatively. At three months follow-up, none of the patients had a clinically visible hernia.

What Information Are Patients Receiving from the Internet about the Operative and Nonoperative Management of Acute Appendicitis?

INTRODUCTION

Recent studies suggest that nonoperative management of appendicitis (NOMA) may be a reasonable option for managing uncomplicated acute appendicitis. We examined the Internet to see if patients are likely to find the information they need to make an informed decision between the 2 options.

METHODS

A list of 29 search terms was established by a focus group and then entered into Google, resulting in 49 unique webpages, each reviewed by 3 reviewers. Consensus was obtained for bias (surgery, NOMA, or balanced), webpage type, JAMA score, reading grade, and DISCERN score, a measure of quality of written information for patients.

RESULTS

Thirty of the 49 websites (61%) favored surgery, while 13 (27%) favored NOMA, and 6 sites (12%) provided balanced information. Twelve of 49 sites (24%) did not list NOMA as an option. The majority of patient-directed (11/12 = 92%) and physician-directed (7/9 = 78%) webpages favored surgery, whereas academic webpages presented a more balanced distribution. Academic and physician-directed webpages ranked higher than commercial and news webpages (median ranks 3 and 4 vs. 7.5 and 8). Only 8/49 sites (16%) mentioned that the presence of a fecalith predicts the failure of NOMA. Reading grades were almost all well above the recommended grade 8 level.

CONCLUSION

Most of the webpages available on the Internet do not provide enough information, nor are they sufficiently understandable to allow most patients to make an informed decision about the current options for the management of acute appendicitis.

Clinical prediction of complicated appendicitis: A case-control study utilizing logistic regression

BACKGROUND

Since high-quality evidence on conservative treatment of acute appendicitis using antibiotics has increased, differentiation of patients with complicated appendicitis (CA) from those with simple appendicitis (SA) has become increasingly important. Previous studies have revealed that male gender, advanced age, comorbid conditions, prehospital delay, fever, and anorexia are risk factors of perforated appendicitis. Elevated serum C-reactive protein (CRP) level and hyponatremia have also been reported as predictive biomarkers of CA. However, confounding between various factors is problematic because most previous studies were limited to univariate analysis.

AIM

To evaluate non-laboratory and laboratory predictive factors of CA using logistic regression analyses.

METHODS

We performed an exploratory, single-center, retrospective case-control study that evaluated 198 patients (83.9%) with SA and 38 patients (16.1%) with CA. Diagnoses were confirmed by computed tomography images for all cases. We compared age, sex, onset-to-visit interval, epigastric/periumbilical pain, right lower quadrant pain, nausea/vomiting, diarrhea, anorexia, medical history (of previous non-surgically treated appendicitis, diabetes, hypertension, dyslipidemia, liver cirrhosis, hemodialysis, chronic lung diseases, malignant tumors, immunosuppressant use, and antiplatelet use), vital signs, physical findings, and laboratory data to select the explanatory variates for logistic regression. Based on the univariate comparisons, we performed logistic regression for clinical differentiation between CA and SA using only non-laboratory factors and also including both non-laboratory and laboratory factors.

RESULTS

The 236 eligible patients consisted of 198 patients (83.9%) with SA and 38 patients (16.1%) with CA. The median ages were 34 years old [interquartile ranges (IR), 24-45 years] in the SA group and 49 years old (IR, 35-63 years) in the CA group (P < 0.001). The median onset-to-visit interval was 1 d (IR, 0-1) and 1 d (IR, 1-2) in the SA and CA groups, respectively (P < 0.001). Heart rate, body temperature, and serum CRP level in the CA group were significantly higher than in the SA group; glomerular filtration rate and serum sodium were significantly lower in the CA group. Anorexia was significantly more prevalent in the CA group. The regression model including age, onset-to-visit interval, anorexia, tachycardia, and fever as non-laboratory predictive factors of CA (Model 1) showed that age ≥ 65 years old, longer onset-to-visit interval, and anorexia had significantly high odds ratios. The logistic regression for prediction of CA including age, onset-to-visit interval, anorexia, serum CRP level, hyponatremia (serum sodium < 135 mEq/L), and glomerular filtration rate < 60 mL/min/1.73 m² (Model 2) showed that only elevated CRP levels had significantly high odds ratios. Under the curve values of receiver operating characteristics curves of each regression model were 0.74 for Model 1 and 0.87 for Model 2.

CONCLUSION

Our logistic regression analysis on differentiating factors of CA from SA showed that high CRP level was a strong dose-dependent predictor of CA.

Non-operative management of acute appendicitis in a pediatric patient with concomitant COVID-19 infection

Introduction

In late December 2019, reports emerged from Wuhan, China of a novel corovonavirus SARS-CoV-2, which caused severe acute respiratory distress syndrome referred to as COVID-19. As the virus spread, reports of severe perioperative complications, including fatalities, began to emerge in the literature. We present a case of a previously healthy patient who developed classic symptoms of appendicitis. The patient was also found to be positive for COVID-19. Given the risks to both the patient and surgical team, we elected to pursue a non-operative management strategy for this patient with appendicitis.

Materials and methods

A 13 year old female with COVID-19 presented with a day of right lower quadrant abdominal pain. A computerized tomography (CT) scan diagnosed uncomplicated appendicitis. The patient was successfully treated non-operatively with antibiotics and discharged home.

Conclusion

To our knowledge, this case illustrates the first report of a pediatric patient with concomitant appendicitis and COVID-19 infection. We have been able to utilize a non-operative management strategy to effectively treat the patient's acute appendicitis, while protecting her from the risks of undergoing a general anesthetic as well as the operative team. We hope this report can provide others with a potential management strategy for similar patients.

The Correlation between Complete Blood Count Parameters and Appendix Diameter for the Diagnosis of Acute Appendicitis

Acute appendicitis is one of the most common causes of acute abdominal diseases seen between the ages of 10 and 19, mostly seen in males. The lifetime risk of developing acute appendicitis is 8.6% for males and 6.7% for females. We aimed to investigate the efficacy of the complete blood count parameters, C-reactive protein, and Lymphocyte-C-reactive Protein Ratio laboratory tests in the diagnosis of acute appendicitis, as well as their relationship with appendix diameter. We retrospectively examined all patients who underwent appendectomy between 1 January 2012 and 30 June 2019 in the General Surgery Clinic of Gaziosmanpasa University Faculty of Medicine. Laboratory tests, imaging findings, age, and gender were recorded. Lymphoid hyperplasia is considered as normal appendix—in other words, as negative appendicitis. The distribution of Lymphoid hyperplasia and appendicitis rates were statistically different in the groups formed according to appendix diameter (≤6 and >6 mm) (p < 0.001). We found a significant correlation between appendix diameter and WBC (White blood count), Lymphocyte, Neutrophil, RDW(Red blood cell distribution width), NLR(Neutrophil to lymphocyte ratio), and PLT/L (Platelet to lymphocyte ratio), MPV (Mean platelet volume) and RDW were significantly different in patients with an appendix diameter of ≤6 mm (p = 0.007, p = 0.006, respectively). WBC, Neutrophil, PDW, and NLR values were significantly different between appendicitis and hyperplasia groups in patients with an appendix diameter of >6 mm. The sensitivity of the NLR score (cutoff = 2.6057) in the diagnosis of appendicitis was 86.1% and selectivity was 50% in these patients. Complete blood count parameters evaluation with the clinical findings revealed that NLR is an important parameter that may help the diagnosis of acute appendicitis with an appendix diameter of >6 mm. In patients whose pathological results indicated acute appendicitis but who had a diameter of ≤6 mm, we found an elevated MPV and low RDW values.

Accuracy of Nonenhanced CT vs Contrast-Enhanced CT for Diagnosis of Acute Appendicitis in Adults

BACKGROUND

Acute appendicitis is one of the most common causes of acute abdominal pain requiring emergency intervention. It is often difficult for the clinician to make an accurate diagnosis due to nonspecific and overlapping clinical symptoms. Computed tomography (CT) has become the imaging modality of choice for the evaluation of suspected acute appendicitis. The main purpose of our study was to compare nonenhanced CT (NECT) with contrast-enhanced CT (CECT) for the diagnosis of acute appendicitis.

MATERIAL AND METHODS

A total of 140 patients were enrolled in the study. Two abdominal radiologists-masked to both the clinical information and the final diagnosis-retrospectively reviewed the computed tomographic findings and made an imaging diagnosis based on (1) NECT only, (2) CECT only, and (3) both NECT and CECT. With the final diagnosis as the reference standard, the accuracy of each CT technique was estimated.

RESULTS

The respective sensitivity, specificity, and accuracy for NECT, CECT, and NECT + CECT for the diagnosis of acute appendicitis were 80.7%, 86.7%, and 84.3%; 86.0%, 81.9%, and 83.6%; and, 87.7%, 80.7%, and 83.6%. There was no significant difference in the diagnosis of acute appendicitis among the 3 techniques. In order to make a correct diagnosis, the presence of at least 3 imaging findings for NECT or at least 4 for CECT had the best diagnostic accuracy. We also found that 9.25 mm was the optimal cut-off threshold for the detection of patients with acute appendicitis.

CONCLUSION

Our study allowed direct comparison between NECT, CECT, and NECT + CECT combined. There was no difference in the ability of each CT technique for diagnosing patients with acute appendicitis. For a patient whom iodinated contrast media is contraindicated or a patient who has an increased risk of severe adverse reaction, we would encourage the use of NECT because it provides comparable diagnostic accuracy without further exposing such patient to the contrast media.

Risk factors for appendiceal neoplasm and malignancy among patients with acute appendicitis

PURPOSE

Non-operative management of acute uncomplicated appendicitis has shown promising results but might carry the risk of delayed diagnosis of premalignant or malignant appendiceal tumors found by chance in 0.7-2.5% of appendiceal specimen after appendectomy. Purpose of this study was to analyze whether appendiceal tumors are associated with a complicated appendicitis and to determine risk factors for appendiceal neoplasm and malignancy in patients with acute appendicitis.

METHODS

We performed a retrospective analysis of 1033 adult patients, who underwent appendectomy for acute appendicitis from 2010 to 2016 at the University hospital Erlangen. Data included patients' demographics; comorbidities; pre-, intra- and postoperative findings; and histopathological results. Complicated appendicitis was defined in the presence of perforation or abscess.

RESULTS

Appendiceal neoplasm respectively malignancy rate was 2.8% respectively 1.5%. Using univariate analysis, we identified seven risk factors at least for appendiceal neoplasm or malignancy: age, ASA, C-reactive protein, appendiceal diameter, perforation, intraoperative perithyphilitic abscess, and complicated appendicitis. Risk for appendiceal neoplasm or malignancy was 4.4% respectively 2.7% in complicated acute appendicitis compared to 2.0% respectively 1.0% in uncomplicated appendicitis (p = 0.043 respectively p = 0.060). In multivariate analysis, age ≥ 50 years and a diameter of the appendix in the sonography ≥ 13 mm were independent risk factors predicting the presence of appendiceal neoplasm and malignancy.

CONCLUSION

Among patients with appendicitis, there are relevant risk factors predicting appendiceal tumors, especially age and appendiceal diameter in sonography. But the identified risk factors have a low sensitivity and specificity, so obtaining a confident preoperative diagnosis is challenging.

Medical Treatment: An Emerging Standard in Acute Appendicitis?

Appendicectomy has been accepted as the gold standard for the management of appendicitis over the years, but there has been an increasing evidence and trend toward the conservative approach to the management of appendicitis. The aim of this review is to search existing literature and to evaluate and compare the conservative and operative approaches to the management of appendicitis. An electronic search of published literature was conducted through Pubmed, Google Scholar, Embase, and Medline using a variety of search items to find relevant observational studies, randomized clinical trials, systematic reviews, and meta-analyses. Bibliographies of selected articles were also analyzed for publications of interest relevant to the scope of the topic. The articles that reported primary outcomes after the management of appendicitis, complications, economic implications, and duration of follow-up were reviewed in detail. The major primary outcomes show a high recurrence rate and failed treatment associated with the conservative management of appendicitis. The other outcomes obtained show that there is an increased incidence of complications associated with operative management. Economic implications and cost-effectiveness analysis show that conservative treatment may be preferred. The length of hospital stay was significantly higher in conservative approach to management; however, shorter time off activities was observed. In general, the conservative management of appendicitis is still regarded as safe, effective, and efficacious, and further research with well-constructed study design, and larger sample size is required.

Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients

Importance

Health care professionals have shown significant interest in nonoperative management for uncomplicated appendicitis, but long-term population-level data are lacking.

Objective

To compare the outcomes of nonoperatively managed appendicitis against appendectomy.

Design, Setting, and Participants

This national retrospective cohort study used claims data from a private insurance database to compare patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, undergoing appendectomy vs nonoperative management. Coarsened exact matching was applied before multivariate analysis to reduce imbalance between groups. Data were analyzed from February 12 through May 1, 2018.

Exposures

Appendectomy (control arm) or nonoperative management (treatment arm).

Main Outcomes and Measures

Short-term primary clinical outcomes included emergency department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections. Long-term primary clinical outcomes were small-bowel obstructions, incisional hernias, and appendiceal cancers. Nonoperative management failure was defined by hospital readmission with appendicitis diagnosis and an appendicitis-associated operation or procedure. Secondary outcomes included number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care. Covariates included age, sex, region, insurance plan type, admission year, and Charlson comorbidity index.

Results

Of 58 329 patients with uncomplicated appendicitis (52.7% men; mean [SD] age, 31.9 [16.5] years), 55 709 (95.5%) underwent appendectomy and 2620 (4.5%) underwent nonoperative management. Patients in the nonoperative management group were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P < .001) and to develop an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P = .02). Patients in the nonoperative management group required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs 0.3 [1.4] visits; adjusted +1.11 visits; P < .001) and had lower index hospitalization cost (unadjusted mean [SD], $11 502 [$9287] vs $13 551 [$10 160]; adjusted -$2117, P < .001), but total cost of appendicitis care was higher when follow-up care was considered (unadjusted, $14 934 [$31 122] vs $14 186 [$10 889]; adjusted +$785; P = .003). During a mean (SD) of 3.2 (1.7) years of follow-up, failure of nonoperative management occurred in 101 patients (3.9%); median time to recurrence was 42 days (interquartile range, 8-125 days). Among the patients who experienced treatment failure, 44 did so within 30 days.

Conclusions and Relevance

According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.

[Antibiotic treatment vs. appendectomy for non-perforated appendicitis in adults]

For decades, the mandatory treatment for acute uncomplicated appendicitis was urgent appendicectomy. This dogma has now been questioned by several randomized controlled trials, which demonstrated the safety of antibiotic treatment of uncomplicated appendicitis without increased morbidity and mortality. The efficacy of this conservative treatment, however, is inferior to surgery: Within the first year after antibiotic treatment of acute appendicitis, approximately 30% of patients require appendicectomy. Within 5 years the rate of appendicectomy increases to 40% and the life-long risk of appendicectomy after conservative treatment can be expected to be even higher. The advantages of conservative treatment of appendicitis are faster recovery and the lack of postoperative wound pain; however, all currently available trials compared conservative treatment almost exclusively with conventional appendicectomy, trials comparing laparoscopic appendicectomy to antibiotics are currently not available. As laparoscopic appendicectomy is a well-established and safe treatment ubiquitously available in Germany, conservative treatment in patients with uncomplicated appendicitis cannot generally be recommended. As antibiotic treatment is a less effective but equally safe procedure, it can be offered to selected patients only.

Multi-institutional trial of non-operative management and surgery for uncomplicated appendicitis in children: Design and rationale

Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children's hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a "successful" treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.

Operative Versus Nonoperative Management of Appendicitis: A Long-Term Cost Effectiveness Analysis

Background. Recent clinical trials suggest that nonoperative management (NOM) of patients with acute, uncomplicated appendicitis is an acceptable alternative to surgery. However, limited data exist comparing the long-term cost-effectiveness of nonoperative treatment strategies. Design. We constructed a Markov model comparing the cost-effectiveness of three treatment strategies for uncomplicated appendicitis: 1) laparoscopic appendectomy, 2) inpatient NOM, and 3) outpatient NOM. The model assessed lifetime costs and outcomes from a third-party payer perspective. The preferred strategy was the one yielding the greatest utility without exceeding a $50,000 willingness-to-pay threshold. Results. Outpatient NOM cost $233,700 over a lifetime; laparoscopic appendectomy cost $2500 more while inpatient NOM cost $7300 more. Outpatient NOM generated 24.9270 quality-adjusted life-years (QALYs), while laparoscopic appendectomy and inpatient NOM yielded 0.0709 and 0.0005 additional QALYs, respectively. Laparoscopic appendectomy was cost-effective compared with outpatient NOM (incremental cost-effectiveness ratio $32,300 per QALY gained); inpatient NOM was dominated by laparoscopic appendectomy. In one-way sensitivity analyses, the preferred strategy changed when varying perioperative mortality, probability of appendiceal malignancy or recurrent appendicitis after NOM, probability of a complicated recurrence, and appendectomy cost. A two-way sensitivity analysis showed that the rates of NOM failure and appendicitis recurrence described in randomized trials exceeded the values required for NOM to be preferred. Limitations. There are limited NOM data to generate long-term model probabilities. Health state utilities were often drawn from single studies and may significantly influence model outcomes. Conclusion. Laparoscopic appendectomy is a cost-effective treatment for acute uncomplicated appendicitis over a lifetime time horizon. Inpatient NOM was never the preferred strategy in the scenarios considered here. These results emphasize the importance of considering long-term costs and outcomes when evaluating NOM.

Antibiotic therapy for acute uncomplicated appendicitis: a systematic review and meta-analysis

PURPOSE

Appendectomy has been the gold standard for every form of appendicitis. In recent years, though, it has repeatedly been claimed that for acute uncomplicated appendicitis, antibiotic therapy can be an equivalent treatment. The aim of this meta-analysis was to determine if antibiotic therapy is a safe and effective alternative to appendectomy for acute uncomplicated appendicitis.

METHODS

In a systematic literature review, relevant databases were searched for randomized studies comparing appendectomy with antibiotic treatment for uncomplicated acute appendicitis. Two independent reviewers performed study selection and data extraction. The primary endpoint was the successful treatment of appendicitis. Secondary endpoints were pain intensity, duration of hospitalization, absence from work, and the incidence of complications.

RESULTS

Five randomized controlled studies (n = 1430 patients) fulfilled the inclusion criteria. Of the 727 patients treated initially with antibiotics, 272 (37.4%) underwent secondary appendectomy within 1 year (treatment effectiveness: 62.6% compared to 96.3% in the surgical group, RR 0.65, 95% CI 0.55-0.76, p < 0.00001). Neither duration of hospital stay (MD 0.11 days, 95% CI: - 0.22-0.43, p = 0.53) nor the probability of complication-free treatment (RR 1.08, 95% CI: 0.97-1.22, p = 0.16) were significantly different between the two treatments. Absence from work was significantly shorter in the antibiotic group (MD - 2.49 days, 95% CI: - 4.59-- 0.40, p = 0.02).

CONCLUSIONS

This meta-analysis shows that appendectomy is more effective than antibiotic therapy for definitive cure of acute uncomplicated appendicitis. However, since the incidence of complications does not differ between the two treatments, antibiotic therapy might be a reasonable alternative for selected patients.

Ingested metallic foreign body impacted in the vermiform appendix presenting as acute appendicitis: Case report

•

Foreign body appendicitis in children may be caused by a variety of ingested foreign bodies.

•

Pins are the most common cause of foreign body appendicitis.

•

The reported incidence of bowel perforation is less than 1%, especially with sharp, thin, pointed or long objects.

Introduction

Ingestion of foreign bodies and their impaction at the lumen of the appendix is a very rare finding and only few cases have been reported all over the world. A variety of metallic foreign bodies when ingested may be lodged in the lumen of the appendix such as screws, bird shots, and needles. This is called in most literatures as foreign body appendicitis.

Case presentation

A 4-year-old boy with history of an accidental ingestion of a metallic nail presented to the emergency department one week later with right iliac fossa pain and one attack of vomiting. During abdominal examination there was tenderness and rebound tenderness at the right iliac fossa. Plain abdominal X-ray showed the metallic nail in the region of the right iliac fossa. Ultrasound examination was normal apart from tenderness of putting the probe on the right lilac fossa. The white blood cell counts were 14,000 cell per microliter.

During surgery the nail was found to be impacted inside the lumen of the vermiform appendix causing inflammation of the appendix. Appendicectomy done and the patient discharged on the third day in a good general condition.

Conclusion

Acute appendicitis may be caused by a variety of causes including ingested foreign bodies if impacted in its lumen. When the patient has signs of generalized peritonitis it is important to exclude bowel perforation. The surgery can be done by the open surgery or laparoscopically.

Management of acute abdomen in pregnancy: current perspectives

Acute abdomen in pregnancy represents a unique diagnostic and therapeutic challenge. Acute abdominal pain in pregnancy can occur due to obstetric factors as well for reasons that are unrelated to pregnancy. The diagnostic approach of acute abdomen during pregnancy can be tricky owing to the altered clinical presentations brought about by the anatomical and physiological changes of gestation along with the reluctance to use certain radiological investigations for fear of harming the fetus. Delay in diagnosis and treatment can lead to adverse outcomes for both the mother and fetus. In this article, we attempt to review and discuss the various etiologies, the current concepts of diagnosis, and treatment, with a view to developing a strategy for timely diagnosis and management of pregnant women presenting with acute abdominal pain.

Conservative treatment of acute appendicitis

Acute appendicitis has been considered by surgeons a progressive disease leading to perforation for more than 100 years. In the last decades the theories about this concept gained attention, especially in adults. However, appendectomy for acute appendicitis remains the most common urgent/emergent surgical procedure. At present, accumulating evidences are showing the changing in clinical practice towards the non-operative management of several cases of acute appendicitis either non-complicated or complicated. The present review aims to show the literature results regarding the non-operative management of acute appendicitis in non-complicated and in complicated cases.

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment of choice for acute appendicitis. However, in consequence of the evolution of endoscopic surgery, the operation can also be performed with minimally invasive surgery. Due to smaller incisions, the laparoscopic approach may be associated with reduced postoperative pain, reduced wound infection rate, and shorter time until return to normal activity.This is an update of the review published in 2010.

OBJECTIVES

To compare the effects of laparoscopic appendectomy (LA) and open appendectomy (OA) with regard to benefits and harms.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE and Embase (9 February 2018). We identified proposed and ongoing studies from World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and EU Clinical Trials Register (9 February 2018). We handsearched reference lists of identified studies and the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing LA versus OA in adults or children.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias, and extracted data. We performed the meta-analyses using Review Manager 5. We calculated the Peto odds ratio (OR) for very rare outcomes, and the mean difference (MD) for continuous outcomes (or standardised mean differences (SMD) if researchers used different scales such as quality of life) with 95% confidence intervals (CI). We used GRADE to rate the quality of the evidence.

MAIN RESULTS

We identified 85 studies involving 9765 participants. Seventy-five trials included 8520 adults and 10 trials included 1245 children. Most studies had risk of bias issues, with attrition bias being the largest source across studies due to incomplete outcome data.In adults, pain intensity on day one was reduced by 0.75 cm on a 10 cm VAS after LA (MD -0.75, 95% CI -1.04 to -0.45; 20 RCTs; 2421 participants; low-quality evidence). Wound infections were less likely after LA (Peto OR 0.42, 95% CI 0.35 to 0.51; 63 RCTs; 7612 participants; moderate-quality evidence), but the incidence of intra-abdominal abscesses was increased following LA (Peto OR 1.65, 95% CI 1.12 to 2.43; 53 RCTs; 6677 participants; moderate-quality evidence).The length of hospital stay was shortened by one day after LA (MD -0.96, 95% CI -1.23 to -0.70; 46 RCTs; 5127 participant; low-quality evidence). The time until return to normal activity occurred five days earlier after LA than after OA (MD -4.97, 95% CI -6.77 to -3.16; 17 RCTs; 1653 participants; low-quality evidence). Two studies showed better quality of life scores following LA, but used different scales, and therefore no pooled estimates were presented. One used the SF-36 questionnaire two weeks after surgery and the other used the Gastro-intestinal Quality of Life Index six weeks and six months after surgery (both low-quality evidence).In children, we found no differences in pain intensity on day one (MD -0.80, 95% CI -1.65 to 0.05; 1 RCT; 61 participants; low-quality evidence), intra-abdominal abscesses after LA (Peto OR 0.54, 95% CI 0.24 to 1.22; 9 RCTs; 1185 participants; low-quality evidence) or time until return to normal activity (MD -0.50, 95% CI -1.30 to 0.30; 1 RCT; 383 participants; moderate-quality evidence). However, wound infections were less likely after LA (Peto OR 0.25, 95% CI 0.15 to 0.42; 10 RCTs; 1245 participants; moderate-quality evidence) and the length of hospital stay was shortened by 0.8 days after LA (MD -0.81, 95% CI -1.01 to -0.62; 6 RCTs; 316 participants; low-quality evidence). Quality of life was not reported in any of the included studies.

AUTHORS' CONCLUSIONS

Except for a higher rate of intra-abdominal abscesses after LA in adults, LA showed advantages over OA in pain intensity on day one, wound infections, length of hospital stay and time until return to normal activity in adults. In contrast, LA showed advantages over OA in wound infections and length of hospital stay in children. Two studies reported better quality of life scores in adults. No study reported this outcome in children. However, the quality of evidence ranged from very low to moderate and some of the clinical effects of LA were small and of limited clinical relevance. Future studies with low risk of bias should investigate, in particular, the quality of life in children.

Is abdominal drainage after open emergency appendectomy for complicated appendicitis beneficial or waste of money? A single centre retrospective cohort study

Background

Appendicitis is a medical condition that causes painful inflammation of the appendix. For acute appendicitis, appendectomy is immediately required as any delay may lead to serious complications such as gangrenous or perforated appendicitis with or without localized abscess formation. Patients who had appendectomy for complicated appendicitis are more prone to develop post-operative complications such as peritoneal abscess or wound infection. Sometimes, abdominal drainage is used to reduce these complications. However, the advantage of the abdominal drainage to minimize post-operative complications is not clear. Therefore, the aim of this study was to investigate whether the use of abdominal drainage after open emergency appendectomy for complicated appendicitis (perforated appendicitis with localized abscess formation only) can prevent or significantly reduce post-operative complications such as intra-peritoneal abscess formation or wound infection.

Methods

In this retrospective cohort study, files and notes were reviewed retrospectively for patients who had open emergency appendectomy for complicated appendicitis (perforated appendicitis with localized abscess formation only) and who had already been admitted and discharged from the surgical wards of Kerbala medical university/Imam Hussein medical city hospital/Kerbala/Iraq. Patients were selected according to specific inclusion and exclusion criteria. Patients were divided into two groups; drainage and non-drainage groups. The drainage group had intra-abdominal drain inserted after the surgery, while the non-drainage group had no drain placed post-operatively. A comparison between both groups was done in terms of these parameters; (i) the development of post operative intra-peritoneal abscess and or wound infection. (ii) The length and cost of hospital stay. (iii) The mortality outcomes. Statistical analysis was done using Pearson Chi-square test, Independent sample t-test and Mann-Whitney U Test.

Results

Of 227 patients with open emergency appendectomy for complicated appendicitis, 114 had received abdominal drain after the surgery. Fifty out of 114 patients (43.9%) with abdominal drainage developed post-operative intra-peritoneal abscess (abdominal or pelvic) while 53 out of 113 patients (46.9%) without drainage developed the same complication (P = 0.65). It was also revealed that for patients with drainage, 42 patients (36.8%) had post-operative wound infection, whereas this number was 38 (33.6%) for patients without drainage (P = 0.61). On the other hand, the patients with drain had significantly longer length of hospital stay (mean length of stay: 4.99 days versus 2.12 days, P < 0.001) and significantly higher cost (median cost per patient: $120 versus $60, P < 0.001).

Conclusion

Installation of abdominal drainage after open emergency appendectomy for complicated appendicitis did not bring any considerable advantage in terms of prevention or significant reduction of post-operative intra-peritoneal abscess and wound infection. Rather, it lengthened the hospital stay and doubled the cost of operation.

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The use of abdominal drain after open appendectomy for complicated appendicitis does not bring any considerable advantage in terms of prevention or significant reduction of post-operative intra-peritoneal abscess and wound infection.

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Insertion of drain lengthens hospital stay and doubles the cost of operation.

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No mortality complications had been identified in both drain and non drain groups.

Are antibiotics a safe and effective treatment for acute uncomplicated appendicitis?- First update

UPDATE

This Living FRISBEE (Living FRIendly Summary of the Body of Evidence using Epistemonikos) is an update of the summary published in January 2016.

INTRODUCTION

Appendicitis is a typical cause of acute abdominal pain and the most frequent cause of emergency abdominal surgery. In the last two decades, increasing evidence has been published about the use of antibiotics as an exclusive treatment for acute appendicitis.

METHODS

To answer this question, we used Epistemonikos, the largest database of systematic reviews in health, which is maintained through searches from multiple sources of information, including MEDLINE, EMBASE, Cochrane, among others. We extracted the data from the identified reviews, reanalyzed the data from the primary studies, performed a meta-analysis and prepared a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified 23 systematic reviews including 28 primary studies, of which eight were randomized trials. We concluded the exclusive use of antibiotics for the treatment of uncomplicated acute appendicitis could be less effective than appendectomy, but it might be associated with a lower rate of complications.

Abdominal drainage to prevent intra-peritoneal abscess after open appendectomy for complicated appendicitis

BACKGROUND

Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. Patients who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer from postoperative complications. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial.This is an update of the review first published in 2015.

OBJECTIVES

To assess the safety and efficacy of abdominal drainage to prevent intra-peritoneal abscess after open appendectomy for complicated appendicitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 6), Ovid MEDLINE (1946 to 30 June 2017), Ovid Embase (1974 to 30 June 2017), Science Citation Index Expanded (1900 to 30 June 2017), World Health Organization International Clinical Trials Registry Platform (30 June 2017), ClinicalTrials.gov (30 June 2017) and Chinese Biomedical Literature Database (CBM) (1978 to 30 June 2017).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared abdominal drainage and no drainage in people undergoing emergency open appendectomy for complicated appendicitis.

DATA COLLECTION AND ANALYSIS

Two review authors identified the trials for inclusion, collected the data, and assessed the risk of bias independently. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio for very rare outcomes), and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). We used GRADE to rate the quality of evidence.

MAIN RESULTS

We included six RCTs (521 participants), comparing abdominal drainage and no drainage in patients undergoing emergency open appendectomy for complicated appendicitis. The studies were conducted in North America, Asia and Africa. The majority of the participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open appendectomy. None of the trials was at low risk of bias.There was insufficient evidence to determine the effects of abdominal drainage and no drainage on intra-peritoneal abscess at 14 days (RR 1.23, 95% CI 0.47 to 3.21; 5 RCTs; 453 participants; very low-quality evidence) or for wound infection at 14 days (RR 2.01, 95% CI 0.88 to 4.56; 5 RCTs; 478 participants; very low-quality evidence). The increased risk of 30-day overall complication rate (morbidity) in the drainage group was rated as very low-quality evidence (RR 6.67, 95% CI 2.13 to 20.87; 1 RCT; 90 participants). There were seven deaths in the drainage group (N = 183) compared to one in the no drainage group (N = 180), equating to an increase in the risk of 30-day mortality from 0.6% to 2.7% (Peto odds ratio (OR) 4.88, 95% CI 1.18 to 20.09; 4 RCTs; 363 participants; moderate-quality evidence). There is 'very low-quality' evidence that drainage increases hospital stay compared to the no drainage group by 2.17 days (95% CI 1.76 to 2.58; 3 RCTs; 298 participants).Other outlined outcomes, hospital costs, pain, and quality of life, were not reported in any of the included studies.

AUTHORS' CONCLUSIONS

The quality of the current evidence is very low. The effect of abdominal drainage on the prevention of intra-peritoneal abscess or wound infection after open appendectomy is uncertain for patients with complicated appendicitis. The increased rates for overall complication rate and hospital stay for the drainage group compared to no drainage group is also subject to great uncertainty. Thus, there is no evidence for any clinical improvement by using abdominal drainage in patients undergoing open appendectomy for complicated appendicitis. The increased risk of mortality with drainage comes from eight deaths observed in just under 400 people recruited to the studies. Larger studies are needed to determine the effects of drainage on morbidity and mortality outcomes more reliably.

Non-operative management of appendicitis in children

While appendicectomy has been considered the mainstay of treatment for children with acute appendicitis for many decades, there has been a great deal of recent interest in non-operative treatment (NOT) with antibiotics alone. Initial results suggest that many children with appendicitis can indeed be safely treated with NOT and can be spared the surgeon's knife. Many as yet unanswered questions remain, however, before NOT can be considered a realistic and reliable alternative to surgery. This review summaries current knowledge and understanding of the role of NOT in children with appendicitis and outlines and discusses the outstanding knowledge gaps.

Prospective Observational Study on acute Appendicitis Worldwide (POSAW)

BACKGROUND

Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments.

METHODS

This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016-September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study.

RESULTS

A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%.

CONCLUSIONS

The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.

Bayesian network meta-analysis of the effects of single-incision laparoscopic surgery, conventional laparoscopic appendectomy and open appendectomy for the treatment of acute appendicitis

The present study aimed to systematically evaluate the effectiveness of single-incision laparoscopic surgery (SILS), conventional laparoscopic appendectomy (CLA) and open appendectomy (OA) for the treatment of acute appendicitis. PubMed and Embase databases were systematically searched to identify relevant studies comparing the effectiveness of different appendectomy methods for treating acute appendicitis published prior to April 2016. ADDIS 1.16.5 software was used for data analysis. Heterogeneity was assessed using I² statistic. Odds ratios or standardized mean differences and 95% confidence intervals were calculated and pooled accordingly. Consistency was assessed using node-splitting analysis and inconsistency standard deviation. Convergence was assessed with the Brooks-Gelman-Rubin method using Potential Scale Reduction Factor (PSRF). Surgical procedure duration, duration of hospital stay, wound infection and incidence of abscesses were compared. A total of 24 eligible studies were included in this meta-analysis. A consistency model was used to pool data regarding the four outcomes. The PSRFs in each item were all <1.03. Pooled results showed that, compared with OA, SILS and CLA were associated with significantly shorter durations of hospital stay (all P<0.01) and lower risk of wound infection (SILS vs. OA P=0.02 and CLA vs. OA P<0.01, respectively), but no significant differences were identified between SILS and CLA. However, compared with OA, SILS exhibited a significantly longer surgical procedure duration (P=0.01) and lower incidence of abscesses (P=0.04), while no significant difference was observed between OA and CLA. This comprehensive network meta-analysis indicated that laparoscopic appendectomy, including SILS and CLA, may have more advantages for acute appendicitis compared with OA. Furthermore, SILS procedures require improvement and simplification to reduce the surgical procedure duration.

Closure methods of the appendix stump for complications during laparoscopic appendectomy

BACKGROUND

Laparoscopic appendectomy is amongst the most common general surgical procedures performed in the developed world. Arguably, the most critical part of this procedure is effective closure of the appendix stump to prevent catastrophic intra-abdominal complications from a faecal leak into the abdominal cavity. A variety of methods to close the appendix stump are used worldwide; these can be broadly divided into traditional ligatures (such as intracorporeal or extracorporeal ligatures or Roeder loops) and mechanical devices (such as stapling devices, clips, or electrothermal devices). However, the optimal method remains unclear.

OBJECTIVES

To compare all surgical techniques now used for appendix stump closure during laparoscopic appendectomy.

SEARCH METHODS

In June 2017, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 6) in the Cochrane Library, MEDLINE Ovid (1946 to 14 June 2017), Embase Ovid (1974 to 14 June 2017), Science Citation Index - Expanded (14 June 2017), China Biological Medicine Database (CBM), the World Health Organization International Trials Registry Platform search portal, ClinicalTrials.gov, Current Controlled Trials, the Chinese Clinical Trials Register, and the EU Clinical Trials Register (all in June 2017). We searched the reference lists of relevant publications as well as meeting abstracts and Conference Proceedings Citation Index to look for additional relevant clinical trials.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared mechanical appendix stump closure (stapler, clips, or electrothermal devices) versus ligation (Endoloop, Roeder loop, or intracorporeal knot techniques) for uncomplicated appendicitis.

DATA COLLECTION AND ANALYSIS

Two review authors identified trials for inclusion, collected data, and assessed risk of bias independently. We performed the meta-analysis using Review Manager 5. We calculated the odds ratio (OR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).

MAIN RESULTS

We included eight randomised studies encompassing 850 participants. Five studies compared titanium clips versus ligature, two studies compared an endoscopic stapler device versus ligature, and one study compared an endoscopic stapler device, titanium clips, and ligature. In our analyses of primary outcomes, we found no differences in total complications (OR 0.97, 95% CI 0.27 to 3.50, 8 RCTs, very low-quality evidence), intraoperative complications (OR 0.93, 95% CI 0.34 to 2.55, 8 RCTs, very low-quality evidence), or postoperative complications (OR 0.80, 95% CI 0.21 to 3.13, 8 RCTs, very low-quality evidence) between ligature and all types of mechanical devices. However, our analyses of secondary outcomes revealed that use of mechanical devices saved approximately nine minutes of total operating time when compared with use of a ligature (mean difference (MD) -9.04 minutes, 95% CI -12.97 to -5.11 minutes, 8 RCTs, very low-quality evidence). However, this finding did not translate into a clinically or statistically significant reduction in inpatient hospital stay (MD 0.02 days, 95% CI -0.12 to 0.17 days, 8 RCTs, very low-quality evidence). Available information was insufficient for reliable comparison of total hospital costs and postoperative pain/quality of life between the two approaches. Overall, evidence across all analyses was of very low quality, with substantial potential for confounding factors. Given the limitations of all studies in terms of bias and the low quality of available evidence, a clear conclusion regarding superiority of any one particular type of mechanical device over another is not possible.

AUTHORS' CONCLUSIONS

Evidence is insufficient at present to advocate omission of conventional ligature-based appendix stump closure in favour of any single type of mechanical device over another in uncomplicated appendicitis.

Appendicular bleeding: an excepcional cause of lower hemorrhage

Chronic complications of acute appendicitis managed in a conservative manner are not frequent. We present a case of acute lower gastrointestinal hemorrhage in a young patient with a previous acute appendicitis without surgical intervention. The colonoscopy detected an appendicular bleeding which was surgically treated. The anatomopathological diagnosis was granulomatous appendicitis. The clinical evolution of the patient was favorable without bleeding recurrence. Appendicular hemorrhage can be an unusual complication-however potentially severe-of acute appendicitis not treated surgically.

A prospective non-randomized controlled, multicenter trial comparing Appendectomy and Conservative Treatment for Patients with Uncomplicated Acute Appendicitis (the ACTUAA study)

PURPOSE

Acute appendicitis (AA) is among the most common causes of lower abdominal pain and admissions to the emergency department. Over the past 20 years, there has been a renewed interest in the conservative management of uncomplicated AA, and several studies demonstrated that an antibiotic-first strategy is a viable treatment option for uncomplicated AA. The aim of this prospective non-randomized controlled, multicenter trial is to compare antibiotic therapy and emergency appendectomy as treatment for patients with uncomplicated AA confirmed by US and/or CT or MRI scan.

METHODS

All adult patients in the age range 18 to 65 years with suspected AA, consecutively admitted to the Surgical Department of the 13 participating Italian Hospitals, will be invited to take part in the study. A multicenter prospective collected registry developed by surgeons, radiologists, and pathologists with expertise in the diagnosis and treatment of uncomplicated acute appendicitis represents the best research method to assess the long-term role of antibiotics in the management of the disease. Comparison will be made between surgical and antibiotic-first approaches to uncomplicated AA through the analysis of the primary outcome measure of complication-free treatment success rate based on 1-year follow-up. Quality of life, length of hospital stay, pain evaluation, and time to return to normal activity will be evaluated as secondary outcome measures.

TRIAL REGISTRATION

Clinicaltrials.gov ID: NCT03080103.