Changing incidence of acute appendicitis and nonspecific abdominal pain between 1987 and 2007 in Finland

Controversies and Future Directions in Management of Acute Appendicitis: An Updated Comprehensive Review

Globally, acute appendicitis has an estimated lifetime risk of 7-8%. However, there are numerous controversies surrounding the management of acute appendicitis, and the best treatment approach depends on patient characteristics. Non-operative management (NOM), which involves the utilization of antibiotics and aggressive intravenous hydration, and surgical appendectomy are valid treatment options for healthy adults. NOM is also ideal for poor surgical candidates. Another important consideration is the timing of surgery, i.e., the role of interval appendectomy (IA) and the possibility of delaying surgery for a few hours on index admission. IA refers to surgical removal of the appendix 8-12 weeks after the initial diagnosis of appendicitis. It is ideal in patients with a contained appendiceal perforation on initial presentation, wherein an initial nonoperative approach is preferred. Furthermore, IA can help distinguish malignant and non-malignant causes of acute appendicitis, while reducing the risk of recurrence. On the contrary, a decision to delay appendectomy for a few hours on index admission should be made based on the patients' baseline health status and severity of appendicitis. Post-operatively, surgical drain placement may help reduce postoperative complications; however, it carries an increased risk of drain occlusion, fistula formation, and paralytic ileus. Furthermore, one of the most critical aspects of appendectomy is the closure of the appendiceal stump, which can be achieved with the help of endoclips, sutures, staples, and endoloops. In this review, we discuss different aspects of management of acute appendicitis, current controversies in management, and the potential role of endoscopic appendectomy as a future treatment option.

Incidence of acute diverticulitis compared to appendicitis in emergency wards: a 10-year nationwide register and cohort study from Finland

BACKGROUND

The two most common abdominal infections in emergency departments (ED) are acute appendicitis (AA) and sigmoid diverticulitis (AD). The frequency of ED visits for diverticulitis has increased strongly in many countries during recent decades. The aim of this study was to analyze the nationwide changes in AD rate requiring hospital admission compared to AA during a 10-year study period.

METHODS

Register data of AD and AA in the whole of Finland were obtained between the years 2009 and 2018. Changes in the incidence and surgical treatment of AD in the whole country were compared to those of AA. Patient demographics and treatment of AD were analyzed in greater detail from a smaller cohort (n = 614).

RESULTS

The incidence of AD increased from 262 to 413 cases (58%) per 100,000 inhabitants during 10 years and emergency surgery for AD decreased from 27 to 24 cases per 100,000 (11%). The incidence of AA remained stable and varied from 118 to 124 annual cases per 100,000 inhabitants. In a patient cohort of AD (n = 614), most of the patients (68%) had only one episode of diverticulitis during 10 years; 16% were operated urgently, with a mortality of 8%. Disease-specific mortality increased from 0% to 5.7% along with patient age when comparing the age groups <50 years and > 70 years, respectively.

CONCLUSIONS

Our study indicates that the incidence of acute diverticulitis is still increasing and is now 2-3 times higher than that of appendicitis in emergency departments.

A novel Appendicitis TriMOdal prediction Score (ATMOS) for acute appendicitis in pregnancy: a retrospective observational study

Several scoring systems exist for the management of acute appendicitis (AA) during pregnancy. However, the systems are based on the nonpregnant adult population. The aim of this study was to create a highly accurate scoring system that can be applied to pregnant women and to compare it to the most commonly used scores in general population and pregnant women. The creation and subsequent implementation of a highly accurate score system could shorten the diagnostic period and minimize the use of (ionizing) diagnostic imaging allowing the selection of the best treatment approach in pregnant patients with acute appendicitis. A single-center, retrospective cohort observational study was conducted at the University Hospital Centre Zagreb, Zagreb, Croatia. Data were extracted from medical records of pregnant patients with suspected AA from January 2010 to December 2020. A total of 59 pregnant patients diagnosed with AA during pregnancy were identified, 41 were treated surgically, and 18 had non-surgical management. The main objective of our study was the detection of predictive factors of AA during pregnancy. Anorexia, pain migration to the right lower quadrant, rebound pain, axillary temperature over 37.3 °C, CRP/platelet ratio > 0.0422, neutrophil/lymphocyte ratio > 7.182, and ultrasonic signs of AA were scored. Scoring in Appendicitis TriMOdal Score (ATMOS) consists of positive clinical parameter, each bringing 1 point and other parameters mentioned above that bring 2 points each. The score ranges from 0 to 10. Our model of ATMOS yields a high area under the receiver-operating characteristic curve of 0.963. The positive likelihood ratio is 9.97 (95% CI 2.64-38.00), and the negative likelihood ratio is 0.1 (95% CI 0.03-0.31), meaning that 94% of cases with ATMOS > 4 have AA, while less than 13% with an ATMOS ≤ 4 have the diagnosis of AA. The potential of ATMOS differentiating AA during pregnancy was demonstrated. Future prospective, randomized trials are needed to evaluate its accuracy and whether it should be used instead of Alvarado or Tzanakis scores in clinical decision-making.Trial registration number ClinicalTrials.gov-NCT05202483. Date of registration: January 21, 2022.

Incidence of Pediatric Perforated Appendicitis during the COVID-19 Pandemic; a Systematic Review and Meta-Analysis

INTRODUCTION

COVID-19 has affected the pattern of referral to medical centers and quarantine against COVID-19 might delay referral and management of surgical emergencies. This study aimed to compare the pooled event rate of pediatric perforated appendicitis before and during the COVID-19 pandemic.

METHODS

This was a systematic review and meta-analysis study based on the PRISMA guidelines. Scopus, Web of Sciences, and PubMed databases were searched for studies reporting the rate of perforated appendicitis based on the post-appendectomy observations or imaging methods. The Egger bias test and funnel plot were used to detect and depict publication bias. Statistical analysis was performed in Comprehensive Meta-analysis package version 3.

RESULTS

Twelve studies were eligible for inclusion in our study. The pooled prevalence of pediatric perforated appendicitis in the pre-COVID era was 28.5% (CI95%: 28.3 to 28.7%) with a heterogeneity of 99%. In the COVID era, the event rate proportion was 39.4% (CI95%: 36.6 to 42.3%) with a heterogeneity of 99%. There was a significant difference in the subgroup analysis within the pre-COVID and COVID era (P<0.001), showing a higher perforation rate in the COVID era.

CONCLUSION

Our study showed that during the COVID-19 pandemic, the rate of perforated appendicitis has significantly increased in comparison to before the COVID-19 pandemic.

Frailty in elderly patients with acute appendicitis

PURPOSE

Acute appendicitis in the elderly is becoming increasingly recognized for its often severe course. For various elective and urgent operations in older patients, frailty is a risk factor for poor outcomes. However, there is a lack of data on frailty in elderly patients with acute appendicitis.

METHODS

Patients over 65 years old who underwent surgery for acute appendicitis in three hospitals between January 2015 and September 2020 were assessed with the Hospital Frailty Risk Score (HFRS) and the modified Frailty Index (mFI). Outcomes of interest, including morbidity, mortality, and length of stay, were recorded.

RESULTS

While frailty can be measured with both tests, the mFI has better applicability and takes significantly less time to implement compared to the HFRS (21.6 s vs. 80.3 s, p < 0.0001) while providing the same information value. Patients who exhibited frailty according to either assessment had a significantly higher rate of milder (OR 5.85/2.87, p < 0.0001/0.009) and serious (OR 4.92/3.61, p < 0.011/0.029) complications, more admissions to the intensive care unit (OR 5.16/7.36, p < 0.0001), and an almost doubled length of stay (12.7 days vs. 6.6 days, p < 0.005). Up to 31% of these patients required institutional care after discharge, which is significantly more than those without frailty (p < 0.0001). Furthermore, the mortality rate in frail patients was significantly elevated to 17%, compared to less than 1% in non-frail patients (p = 0.018).

CONCLUSION

In elderly patients, frailty is a significant risk factor for negative outcomes. Frailty can be assessed more quickly and reliably with the mFI compared to the HFRS.

Hospitalization Trends for Acute Appendicitis in Spain, 1998 to 2017

The incidence of acute appendicitis decreased in Western countries from 1930 to at least the early 1990s, when epidemiological data started becoming scarcer. This study aimed to assess the trend in annual hospitalizations for acute appendicitis in all people Spain for a 20-year period between 1998 and 2017. This observational study analyzing direct age-standardized hospital admission rates by gender and age group (0–14 years, 15–34 years, 35–44 years, 45–64 years, and ≥65 years). Joinpoint regression models were fitted to evaluate changes in trends. There were 789,533 emergency hospital admissions for acute appendicitis between 1998 and 2017: 58.9% in boys and men and 41.1% in girls and women. Overall, there was a significant increase in admissions for this cause from 1998 to 2009, with an annual percent change (APC) of 0.6%. Following the peak in 2009, admission rates decreased by around 1.0% annually until 2017. The length of hospital stay gradually decreased from 4.5 days in 1998 to 3.4 days in 2017. The trends in hospital admissions for acute appendicitis in Spain changed over the study period, decreasing from 2009, especially in people younger than 35 years.

Abdominal fellowship-trained versus generalist radiologist accuracy when interpreting MR and CT for the diagnosis of appendicitis

OBJECTIVES

To compare the diagnostic accuracy of generalist radiologists working in a community setting against abdominal radiologists working in an academic setting for the interpretation of MR when diagnosing acute appendicitis among emergency department patients.

METHODS

This observational study examined MR image interpretation (non-contrast MR with diffusion-weighted imaging and intravenous contrast-enhanced MR) from a prospectively enrolled cohort at an academic hospital over 18 months. Eligible patients had an abdominopelvic CT ordered to evaluate for appendicitis and were > 11 years old. The reference standard was a combination of surgery and pathology results, phone follow-up, and chart review. Six radiologists blinded to clinical information, three each from community and academic practices, independently interpreted MR and CT images in random order. We calculated test characteristics for both individual and group (consensus) diagnostic accuracy then performed Chi-square tests to identify any differences between the subgroups.

RESULTS

Analysis included 198 patients (114 women) with a mean age of 31.6 years and an appendicitis prevalence of 32.3%. For generalist radiologists, the sensitivity and specificity (95% confidence interval) were 93.8% (84.6-98.0%) and 88.8% (82.2-93.2%) for MR and 96.9% (88.7-99.8%) and 91.8% (85.8-95.5%) for CT. For fellowship-trained radiologists, the sensitivity and specificity were 96.9% (88.2-99.5%) and 89.6% (82.8-94%) for MR and 98.4% (90.5-99.9%) and 93.3% (87.3-96.7%) for CT. No statistically significant differences were detected between radiologist groups (p = 1.0, p = 0.53, respectively) or when comparing MR to CT (p = 0.21, p = 0.17, respectively).

CONCLUSIONS

MR is a reliable, radiation-free imaging alternative to CT for the evaluation of appendicitis in community-based generalist radiology practices.

KEY POINTS

• There was no significant difference in MR image interpretation accuracy between generalist and abdominal fellowship-trained radiologists when evaluating sensitivity (p = 1.0) and specificity (p = 0.53). • There was no significant difference in accuracy comparing MR to CT imaging for diagnosing appendicitis for either sensitivity (p = 0.21) or specificity (p = 0.17). • With experience, generalist radiologists enhanced their MR interpretation accuracy as demonstrated by improved interpretation sensitivity (OR 2.89 CI 1.44-5.77, p = 0.003) and decreased mean interpretation time (5 to 3.89 min).

Geographic Association Between Incidence of Acute Appendicitis and Socioeconomic Status

Importance

Some studies based on proportions of patients with perforated appendicitis (PA) among all patients with acute appendicitis (AA) have found an association between socioeconomic status (SES) and risk of perforation. A potential limitation is their use of proportions, which assumes that incidence of AA is evenly distributed across populations at risk. This assumption may be invalid, and SES may have a more complex association with both AA and PA.

Objective

To generate population-based incidences of AA and PA and to examine geographic patterns of incidence alongside geographic patterns of SES.

Design, Setting, and Participants

Retrospective study of data from Washington's Comprehensive Hospital Abstract Reporting System and the 2010 US census. Geographic methods were used to identify patterns of age- and sex-standardized incidence in Washington State between 2008 and 2012. The study included all patients discharged with International Classification of Diseases, Ninth Revision codes for AA or PA. Data were analyzed between November 2016 and December 2018.

Exposures

Location of primary residence.

Main Outcomes and Measures

Age- and sex-standardized incidence for AA and PA was generated for each census tract (CT). Global spatial autocorrelation was examined using Moran index (0.0 = completely random incidence; 1.0 = fully dependent on location). Clusters of low-incidence CTs (cold spots) and high-incidence CTs (hot spots) were identified for AA. Census-based SES data were aggregated for hot spots and cold spots and then compared.

Results

Statewide, over the 5-year study period, there were 35 730 patients with AA (including 9780 cases of PA), of whom 16 574 were women (46.4%). Median age of the cohort was 29 years (IQR, 16-48 years). Statewide incidence of AA and PA was 106 and 29 per 100 000 person-years (PY), respectively. Crude incidence was higher within the male population and peaked at age 10 to 19 years. Age- and sex-standardized incidence of AA demonstrated significant positive spatial autocorrelation (Moran index, 0.30; P < .001), but autocorrelation for PA was only half as strong (0.16; P < .001). Median incidence of AA was 118.1 per 100 000 PY among hot spots vs 86.2 per 100 000 PY among cold spots (P < .001). Socioeconomic status was higher in cold spots vs hot spots: mean proportion of college-educated adults was 56% vs 26% (P < .001), and mean per capita income was $44 691 vs $30 027 (P < .001).

Conclusions and Relevance

Age- and sex-standardized incidence of appendicitis is not randomly distributed across geographic subunits, and geographic clustering of AA is twice as strong as PA. Socioeconomic advantages, such as higher income and secondary education, are strongly associated with lower incidence of AA. These findings challenge conventional views that AA occurs randomly and has no predisposing characteristics beyond age/sex. Socioeconomic status, and likely other geographically circumscribed factors, are associated with incidence of AA.

Nighttime Appendectomy is Safe and has Similar Outcomes as Daytime Appendectomy: A Study of 1198 Appendectomies

Introduction:

Although it is controversial whether appendectomy can be safely delayed, it is often unnecessary to postpone operation as a shorter delay may increase patient comfort, enables quicker recovery, and decreases costs. In this study, we sought to study whether the time of day influences the outcomes among patients operated on for acute appendicitis.

Materials and Methods:

Consecutive patients undergoing appendectomy at Tampere University Hospital between 1 September 2014 and 30 April 2017 for acute appendicitis were included. Primary outcome measures were postoperative morbidity, mortality, length of hospital stay, and amount of intraoperative bleeding. Appendectomies were divided into daytime and nighttime operations.

Results:

A total of 1198 patients underwent appendectomy, of which 65% were operated during daytime and 35% during nighttime. Patient and disease-related characteristics were similar in both groups. The overall morbidity and mortality rates were 4.8% and 0.2%, respectively. No time categories were associated with risk of complications or complication severity. Neither was there difference in operation time and clinically significant difference in intraoperative bleeding. Patients undergoing surgery during night hours had a shorter hospital stay. In multivariate analysis, only complicated appendicitis was associated with worse outcomes.

Discussion:

We have shown that nighttime appendectomy is associated with similar outcomes than daytime appendectomy. Subsequently, appendectomy should be planned for the next available slot, minimizing delay whenever possible.

Seasonal and climatic variation in the incidence of adult acute appendicitis: a seven year longitudinal analysis

Background

Acute appendicitis represents an extremely common surgical emergency, yet its aetiology remains uncertain. A multifactorial understanding of its causation has emerged along with increasing evidence of seasonal variation.

This study seeks to find evidence for such a circannual trend within the United Kingdom (UK), and further assess key meteorological indicators which may be causative of any such variation.

Methods

The patient records of a region health body in the North East of England were retrospectively assessed over a 7-year period. The incident cases of acute appendicitis were recorded and averaged by month before undergoing statistical analysis for variation and correlation with average temperature, sunlight hours, and rainfall.

Results

The incidence of acute appendicitis revealed significant seasonal variation with only 38 incident cases in the months of January compared to 73 in July, a 92.1% increase.

Only a weak correlation was seen between incidence and average sunlight hours/rainfall, however a significant, positive correlation was found between incidence and average temperature (r = 0.58, p = 0.048).

Conclusion

Compelling evidence is found to support the existence of a circannual trend for acute appendicitis. Data suggests a seasonal peak in the month of July, accompanied by a low in January, a finding that develops the understanding of this trend from previously equivocal research in the UK.

A clear correlation is also established between the incidence of acute appendicitis and average temperature. The 92.1% increase between the coolest and warmest months suggests a greater magnitude for this as a risk factor than has previously been shown.

Disease burden of appendectomy for appendicitis: a population-based cohort study

Background

Few large-scale epidemiologic studies evaluate the clinical and economic burden of appendicitis. These data may impact future research and treatment strategies. In this study, the objective was to determine the burden of appendectomy for appendicitis in terms of incidence rates, length of hospital stay (LOS) and hospital costs on a national level. In addition, outcomes were compared for subgroups based on surgical treatment, age and hospital setting.

Methods

Observational retrospective population-based cohort study using the national Dutch healthcare reimbursement registry, which covers hospital registration and reimbursement for 17 million inhabitants. Patients with a diagnosis of appendicitis who underwent appendectomy between 2006 and 2016 were included. Primary outcomes were incidence rates, LOS and hospital costs.

Results

A total of 135,025 patients were included. Some 53% of patients was male, and 64% was treated in a general hospital. The overall incidence rate of appendectomy was 81 per 100,000 inhabitants and showed a significant decreasing trend across time and age. Mean ± SD LOS per patient was 3.66 ± 3.5 days. LOS showed a significant increase with age and was significantly longer for open versus minimally invasive appendectomy. Mean ± SD hospital costs per patient were €3700 ± 1284. Costs were initially lower for open compared to minimally invasive appendectomy, but were similar from 2012 onward. Compared to non-university hospitals, patients treated in university hospitals had a significantly longer LOS and higher costs.

Conclusions

Appendectomy for appendicitis represents a substantial clinical and economic burden in the Netherlands. A preference for minimally invasive technique seems justified.

Association between the Alvarado score and surgical and histopathological findings in acute appendicitis

OBJECTIVE

to compare the results of the Alvarado score with the surgical findings and the results of the histopathological examination of the appendix of patients operated on for acute appendicitis.

METHODS

we conducted an observational study with a cross-sectional design of 101 patients aged 14 years and over undergoing emergency appendectomy. The evaluation comprised the Alvarado score, gender, age, ethnicity and time of evolution. We obtained data regarding the surgical aspect of the appendix, postoperative complications and the result of the histopathological examination. The pre-established confidence interval was 95%. We calculated sensitivity, specificity, positive and negative predictive values of the score, and performed an analysis through the ROC curve.

RESULTS

we found a statistically significant (p=0.002) association between the Alvarado score and the diagnostic confirmation using a cutoff score of six or greater, with a sensitivity of 72% and a specificity of 87.5%. A score greater than or equal to six showed a greater tendency to present more advanced stages of acute appendicitis in both surgical and histopathological findings when compared with a score lower than six. Males presented greater chances of complications when compared with females (p=0.003).

CONCLUSION

the Alvarado score proved to be a good method for diagnostic screening in acute appendicitis, since scores greater than or equal to six are associated with a higher probability of diagnostic confirmation and more advanced stages of the acute disease.

Occurrence and Treatment of Pediatric Appendicitis in Finland 2004-2014

BACKGROUND

We aimed to investigate the trends in occurrence and the treatment approaches of appendicitis in Finnish children.

MATERIAL AND METHODS

All patients aged <16 y hospitalized for appendicitis in Finland in 2004-2014 were included. Data were retrospectively collected from the Finnish Care Register for Health Care and Statistics Finland.

RESULTS

Altogether 8494 children were hospitalized for appendicitis, with standardized incidence rate of 80.7 (95% confidence interval 79.0-82.0)/100,000 person years. The incidence rate of appendicitis decreased by 3.3% per year during the study period. Appendicitis was more common with increasing age, in boys compared to girls at 8 to 15 y of age, and during the summer compared to the other seasons. Most children (83.2%) were treated with conventional open appendectomy, but laparoscopic appendectomies were slowly increasing during the study period. The length of hospital stay (LOS) was shorter in boys than girls, in those treated laparoscopically, and in those with uncomplicated appendicitis. There was no significant seasonal variation in the LOS. However, the LOS decreased during the study period.

CONCLUSIONS

The incidence of pediatric appendicitis is decreasing, and there is a decreasing trend in LOS. While still relatively rare in the Finnish pediatric surgical centers, the use of laparoscopic appendectomy is increasing.

Mortality Related to Appendectomy; a Population Based Analysis over Two Decades in Finland

OBJECT

To define the mortality rate of appendectomy patients and appendectomy-related risk factors.

BACKGROUND

Appendectomy has been considered as a safe operation and negative appendectomies acceptable in order to avoid perforations. There are few publications on appendectomy-related mortality. Removal of a normal appendix has been suggested to be related to a higher mortality rate versus removal of an inflamed appendix.

METHODS

Data on all appendectomy patients between 1990 and 2010 in Finland were retrieved from the Discharge Register of the National Institute for Health and Welfare and combined with data from the Death Certificate Register of Statistics Finland. Thirty-day mortality was identified and compared with overall mortality. Detailed information from death certificates of patients dying within 30-day post-surgery was collected and analyzed.

RESULTS

Over the study period, the thirty-day post-appendectomy mortality rate was 2.1/1000. Increased mortality was found in patients over 60 years of age. Negative appendectomy and complicated appendicitis were related to mortality. The negative appendectomy rate was higher in patients older than 40 years of age. During the study period, both mortality and the rate of negative appendectomies decreased, while the rate of laparoscopic appendectomies increased.

CONCLUSIONS

Post-appendectomy mortality is related to both negative appendectomies and complicated appendicitis. Diagnostic accuracy is fundamental in the care of patients with acute appendicitis, especially in the elderly. Improved diagnostic accuracy may have reduced mortality over the last two decades in Finland.

Non-specific abdominal pain remains as the most common reason for acute abdomen: 26-year retrospective audit in one emergency unit

OBJECTIVE

Distribution of diagnoses causing acute abdominal pain (AAP) may change because of population aging, increased obesity, advanced diagnostic imaging and changes in nutritional habits. Our aim was to evaluate the diagnoses causing AAP during a 26-year period.

MATERIALS AND METHODS

This was a retrospective cross-sectional cohort study in one emergency department (ED) covering population about 250,000. All patients admitted to the ED in 1986, 2003 and 2012 were evaluated from hospital electronic database. Demographic data, utilization of diagnostic tests, surgical treatment and discharge diagnosis were analyzed. Statistical data of population aging, obesity and alcohol consumption during 1980-2012 were obtained from national registers.

RESULTS

The AAP patients represented 10-20% of our total ED census. The most common causes of AAP were nonspecific abdominal pain (NSAP, 31-37%), acute appendicitis (11-23%), biliary disease (9-11%), bowel obstruction (5-7%), acute pancreatitis (4-8%) and acute diverticulitis (1-7%). The percentage of NSAP remained highest throughout the study period. Decrease in the number of acute appendicitis (from 23 to 11%; p < .0001), increase in acute diverticulitis (from 1 to 5%; p ≤ .0001) and acute pancreatitis (from 4 to 7%; p = .0273) was observed over time. The utilization of diagnostic imaging increased significantly (CT from 2 to 37% and US from 4 to 38%, p < .0001). Hospital mortality was very low (1-2%).

CONCLUSIONS

NSAP is still the main differential diagnostic problem in the ED. Except acute appendicitis, distribution of specific diagnoses causing AAP remained rather stable through 26-year audit.

Severe Complications of Laparoscopic and Conventional Appendectomy Reported to the Finnish Patient Insurance Centre

BACKGROUND

Appendectomy is considered a safe operation, the related complications being minor. Negative exploration is an accepted procedure to avoid complications of appendicitis. Treatment with antibiotics is under debate as a primary treatment for appendicitis. The aim of this study was to collect and analyze detailed information on complications and morbidity related to appendectomy using the information of the nationwide Patient Insurance Association (PIA) database and to study the incidence of patient claims and compensated injuries related to appendectomy in Finland.

METHODS

Patients' claims from 1990 to 2010 were collected from the PIA register. Complications were classified using the accordion severity grading system. Severe complications were selected for more detailed analyses. Laparoscopic and open surgeries were compared. Factors related to compensated claims were assessed. For statistical analysis, Fisher's exact test, logistic multivariate regression, and the Mann-Kendall function were used.

RESULTS

Appendectomy complications leading to a patient insurance claim in Finland are rare (0.2 %). The rate of patients' claims after laparoscopic surgery was higher than after open surgery (p < 0.001), but the rate of compensated claims was equal. During the study period, complications after laparoscopic procedures more often led to additional surgery or organ failure (p = 0.03). Of the patients with a compensated injury, only 57 % had appendicitis. Preoperative computed tomography was used in only 6 % of these cases.

CONCLUSIONS

Patient injuries and claims regarding severe complications after appendectomy are rare. The complications related to laparoscopic appendectomy were more severe than those of open surgery.

Acute Mesenteric Ischemia Is a More Common Cause than Expected of Acute Abdomen in the Elderly

BACKGROUND

The incidence of acute mesenteric ischemia (AMI) increases exponentially with age. The significance of AMI as a differential diagnosis in elderly patients with acute abdomen may be underestimated.

METHODS

Consecutive patients hospitalized for AMI between 2009 and 2013 were retrospectively identified in a well-defined population. Acute appendicitis, ruptured abdominal aortic aneurysm, acute pancreatitis, and acute cholecystitis were used as reference diagnoses, and the age-specific incidence rates were calculated. In addition, long-term mortality risk was assessed for AMI survivors.

RESULTS

The in-hospital incidence rates of AMI, acute obstructive mesenteric ischemia, and non-obstructive mesenteric ischemia were 7.3, 4.5, and 2.0/100,000/year, respectively. AMI was more common than ruptured abdominal aortic aneurysm, and the age-specific incidence of AMI was higher than the incidence of acute appendicitis in patients over age 75 years with acute abdomen. During the follow-up, the age-adjusted risk of death was 1.8 times higher in AMI survivors than in survivors of acute cholecystitis.

CONCLUSION

AMI may be a more common cause of acute abdomen in elderly patients than is generally thought, emphasizing the importance of performing urgent computed tomography with contrast enhancement preferably in arterial and venous phases in these patients.

Continuous absorbable intradermal sutures yield better cosmetic results than nonabsorbable interrupted sutures in open appendectomy wounds: a prospective, randomized trial

BACKGROUND

Acute appendicitis is the most common reason for abdominal surgery in young adults and children. Open appendectomy is still the treatment often chosen because it is simple, safe, and effective. Our aim was to study whether cosmetic results of appendectomy wounds are better after using continuous absorbable intradermal (A) sutures compared with wound closure with interrupted nonabsorbable (NA) sutures.

METHODS

A total of 206 adult patients with clinically suspected appendicitis were allocated to the study and prospectively randomized into two wound-closure groups: the interrupted NA suture group and the A suture group. Of these, 193 patients with sufficient data were invited to the outpatient clinic for cosmetic analysis. Cosmetic results were evaluated after a median of 14 months. For subjective scar assessment, the Vancouver scar scale, the patient and observer scar assessment scale (POSAS), and a visual analog scale (VAS) were used. Objective evaluation was carried out by measuring surface area, average width, and estimated concentration change (ECC) of hemoglobin and melanin in the scar using spectrocutometry. For statistical analyses we used the Mann-Whitney test and Student's t test.

RESULTS

Both objective and subjective analyses showed better cosmetic results for absorbable intradermal suturing. The difference between the two groups was statistically significant as regards POSAS in both patient (p = 0.032) and observer scales (p = 0.001), and VAS (p = 0.002). Scar surface area was significantly smaller in group A than in group NA (p = 0.002). ECC measurements showed higher values for melanin in group NA than in group A (p = 0.034).

CONCLUSION

Continuous intradermal absorbable suturing yields a better cosmetic result than interrupted nonabsorbable suturing in lower abdominal transverse appendectomy.

Seasonal variations of acute appendicitis and nonspecific abdominal pain in Finland

AIM: To investigate whether seasonal changes had an effect on the incidence of acute appendicitis (AA) or nonspecific abdominal pain (NSAP).

METHODS: We carried out a national register study of all patients with a hospital discharge diagnosis of AA and acute NSAP in Finland. Data were analyzed for the whole country and correlated to seasonal and weather parameters (temperature, humidity). Moreover, additional sub-analyses were performed for five geographically different area of Finland.

RESULTS: The observation period spanned 21 years, with 186558 appendectomies, of which 137528 (74%) cases were reported as AA. The incidence of AA declined for 32% over the study period. The average incidence of the NSAP was 34/10000 per year. The mean annual temperature, but not relative humidity, showed clear geographical variations. The incidence of AA decreased significantly during the cold months of the year. No correlation was detected between temperature and incidence of NSAP. Humidity had a statistically significant impact on NSAP.

CONCLUSION: The incidence of acute appendicitis is declining in Finland. We detected a clear seasonality in the incidence of AA and NSAP.

Acute appendicitis in the elderly: risk factors for perforation

BACKGROUND

Acute appendicitis is the most common surgical emergency and becomes serious when it perforates. Perforation is more frequent in the elderly patients. The aim of this study was to identify the risk factors of perforation in elderly patients who presented with acute appendicitis.

METHODOLOGY

The medical records of 214 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis over a period of 10 years (2003-2013) were retrospectively reviewed. Patients were grouped into those with perforated and those with nonperforated appendicitis. Comparison was made between both groups in regard to demography, clinical presentation, and time delay to surgery, diagnosis, hospital stay and postoperative complications. Clinical assessment, Ultrasonography and Computerized tomography, in that order, were used for diagnosis. The incidence of perforation was also compared with a previous report from the same region 10 years earlier.

RESULTS

During the study period, a total of 214 patients over the age of 60 years had acute appendicitis, 103 males and 111 females. Appendix was found perforated in 87 (41%) patients, 46 (53%) males and 41 (47%) females. Of all patients, 31% were diagnosed by clinical assessment alone, 40% needed US and 29% CT scan. Of all the risk factors studied, the patient's pre-hospital time delay was the most important risk factor for perforation. Perforation rate was not dependent on the presence of comorbid diseases or in-hospital time delay. Post operative complications occurred in 44 (21%) patients and they were three times more common in the perforated group, 33 (75%) patients in the perforated and 11 (25%) in the nonperforated group. There were 6 deaths (3%), 4 in the perforated and 2 in the nonperforated group.

CONCLUSION

Acute appendicitis in elderly patients is a serious disease that requires early diagnosis and treatment. Appendiceal Perforation increases both mortality and morbidity. All elderly patients presented to the hospital with abdominal pain should be admitted and investigated. The early use of CT scan can cut short the way to the appropriate treatment.

Outpatient antibiotic use and the incidence of acute appendicitis in Finland: a nationwide study from 1990-2008

BACKGROUND

The incidence of acute appendicitis (AA) has decreased in Finland. We hypothesized that changing trends in outpatient antibiotic use might explain at least part of this declining incidence of AA.

METHODS

The number of all patients with AA in Finland was extracted from the national data base from 1990 to 2008. For comparison, the incidence of acute diverticulitis of the colon (AD) was also recorded. All outpatient prescriptions of antibiotics belonging to the major groups of these drugs were also recorded. We used unit root and co-integration analyses for statistical analysis of the data in the study.

RESULTS

The incidence of AA in Finland declined from 14.5 to 9.8 per 10,000 inhabitants (32%) and the incidence of AD increased by 47% between 1993 and 2007. The total outpatient use of antibiotics did not increase during this same period, but the use of antibiotics effective widely against colonic pathogens (macrolides, fluoroquinolones, and cephalosporins) increased significantly. No correlation was found between the incidence of AA, that of AD, and the use of different groups of antibiotics.

CONCLUSIONS

Our nationwide registry study indicated that changes in outpatient antibiotic use do not explain the decreasing trend in AA in Finland. Other factors, such as improved diagnosis of AA, may have some role in the decreasing incidence of AA.

A prospective randomized controlled multicenter trial comparing antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis (APPAC trial)

Background

Although the standard treatment of acute appendicitis (AA) consists of an early appendectomy, there has recently been both an interest and an increase in the use of antibiotic therapy as the primary treatment for uncomplicated AA. However, the use of antibiotic therapy in the treatment of uncomplicated AA is still controversial.

Methods/design

The APPAC trial is a randomized prospective controlled, open label, non-inferiority multicenter trial designed to compare antibiotic therapy (ertapenem) with emergency appendectomy in the treatment of uncomplicated AA. The primary endpoint of the study is the success of the randomized treatment. In the antibiotic treatment arm successful treatment is defined as being discharged from the hospital without the need for surgical intervention and no recurrent appendicitis during a minimum follow-up of one-year (treatment efficacy). Treatment efficacy in the operative treatment arm is defined as successful appendectomy evaluated to be 100%. Secondary endpoints are post-intervention complications, overall morbidity and mortality, the length of hospital stay and sick leave, treatment costs and pain scores (VAS, visual analoque scale). A maximum of 610 adult patients (aged 18–60 years) with a CT scan confirmed uncomplicated AA will be enrolled from six hospitals and randomized by a closed envelope method in a 1:1 ratio either to undergo emergency appendectomy or to receive ertapenem (1 g per day) for three days continued by oral levofloxacin (500 mg per day) plus metronidazole (1.5 g per day) for seven days. Follow-up by a telephone interview will be at 1 week, 2 months and 1, 3, 5 and 10 years; the primary and secondary endpoints of the trial will be evaluated at each time point.

Discussion

The APPAC trial aims to provide level I evidence to support the hypothesis that approximately 75–85% of patients with uncomplicated AA can be treated with effective antibiotic therapy avoiding unnecessary appendectomies and the related operative morbidity, also resulting in major cost savings.

Trial registration

Clinicaltrials.gov http://NCT01022567

Usefulness index in nonspecific abdominal pain--an aid in the diagnosis?

OBJECTIVE

In 1990, Lavelle and Kanagaratnam introduced Usefulness Index (UI) test for assessment of usefulness of clinical observations. Although, nonspecific abdominal pain (NSAP) is the most common diagnosis among secondary care patients with acute abdominal pain, the efficiency of UI test is rarely considered in NSAP.

METHODS

In an extension of the World Organisation of Gastro-Enterology Research Committee (OMGE) acute abdominal pain study, 1333 patients presenting with acute abdominal pain were included in the study. The clinical signs (n = 14) and tests (n = 3) in each patient were recorded in detail, using a predefined structured data collection sheet, and the collected data were compared with the final diagnoses of the patients.

RESULTS

The most significant clinical tests and signs of NSAP in univariate analysis were (UI = Usefulness Index and RR = risk ratio): rigidity (UI = 0.36, RR = 32.2), rebound (UI = 0.33, RR = 6.3), guarding (UI = 0.25, RR = 4.9), Murphy's positive (UI = 0.13, 8.9), bowel sounds (UI = 0.12, RR = 3.3), and renal tenderness (UI = 0.12, RR = 2.2). The sensitivity of the doctors' initial decision in detecting NSAP was 0.70 with a specificity of 0.83 and with the UI = 0.37 and RR = 11.4.

CONCLUSION

The patients with negative test results in rigidity, rebound, guarding, Murphy's, and bowel sounds tended to be at risk for NSAP and in these patients the UI test could be an aid for clinician to differentiate NSAP from other causes of acute abdominal pain.