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Hosokawa Y, Moritani M, Makuuchi Y, Nagakawa Y. Indication of conservative treatment by antibiotics for uncomplicated and complicated acute appendicitis. World J Gastrointest Surg 2024; 16:2538-2545. [DOI: 10.4240/wjgs.v16.i8.2538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Acute appendicitis is one of the most common emergency abdominal disease, and recent studies have evaluated conservative treatment using antibiotics for uncomplicated appendicitis. Although the efficacy of conservative treatment for uncomplicated appendicitis is known, its efficacy for complicated appendicitis remains unknown, so are risk factors for the conservative treatment of appendicitis. In our institution, conservative treatment has long been the first choice for most appendicitis cases, except for perforation. Therefore, this novel study investigated the outcomes of conservative treatment for uncomplicated and complicated acute appendicitis and the risk factors associated with conservative treatment.
AIM To investigate the indication of conservative treatment by antibiotics for uncomplicated and complicated acute appendicitis
METHODS We investigated 270 patients who received conservative treatment for acute appendicitis at the Nishitokyo Central General Hospital, between April 2011 and February 2022. Twenty-eight (10.3%) patients were resistant to conservative treatment and underwent surgery. We retrospectively investigated the outcomes of conservative treatment for appendicitis and the risk factors for resistance to conservative treatment using the receiver operating characteristic curves and Cox hazard model.
RESULTS Two hundred and forty-two (89.7%) patients improved with conservative treatment. The significant and independent predictors of resistance to conservative treatment were body temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid visible on computed tomography (CT). The rate of resistance to conservative treatment was 66.7% (6/9) for patients with the above three factors, 22.9% (8/35) for patients with two factors (appendicolith and body temperature ≥ 37.3 °C), 16.7% (2/12) for patients with two factors (Douglas sinus fluid and appendicolith) and 11.1% (1/9) for patients with two factors (Douglas sinus fluid and body temperature ≥ 37.3 °C).
CONCLUSION A temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid on CT might be clinical risk factors of resistance to conservative treatment for acute appendicitis.
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Affiliation(s)
- Yuichi Hosokawa
- Department of Surgery, Nishitokyo Central General Hospital, Tokyo 188-0014, Japan
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo 166-0023, Japan
| | - Masato Moritani
- Department of Surgery, Nishitokyo Central General Hospital, Tokyo 188-0014, Japan
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo 166-0023, Japan
| | - Yosuke Makuuchi
- Department of Surgery, Nishitokyo Central General Hospital, Tokyo 188-0014, Japan
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo 166-0023, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo 166-0023, Japan
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2
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Adams SE, Perera MRS, Fung S, Maxton J, Karpelowsky J. Non-operative management of uncomplicated appendicitis in children: a randomized, controlled, non-inferiority study evaluating safety and efficacy. ANZ J Surg 2024. [PMID: 38873960 DOI: 10.1111/ans.19119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 03/29/2024] [Accepted: 05/27/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Appendicitis is the commonest paediatric surgical emergency. Adult studies suggest non-operative management (NOM) may have a place in care. There have been no adequately powered randomized controlled trials in children. OBJECTIVE to determine the safety and efficacy of NOM for paediatric simple appendicitis. METHODS A non-inferiority randomized controlled trial was conducted comparing operative (OM) to NOM of SA in children aged five-15 years. Primary outcome was treatment success (no unplanned or unnecessary operation, or complication) at 30 days and 12 months, with a non-inferiority margin of 15%. (anzctr.org.au: ACTRN12616000788471). RESULTS From 11 June 2016 to 30 November 2020, 222 children were randomized: 94 (42.34%) to OM and 128 (57.66%) to NOM. Non-inferiority of NOM was not demonstrated at either time point, with 45.67% of NOM patients subsequently undergoing operation. There was no significant difference in complications. CONCLUSIONS While noninferiority was not shown, NOM was safe, with no difference in adverse outcomes between the two groups. Further research to refine the place of NOM of simple appendicitis in children is required, including nuanced patient selection, longer term evaluation, the place of choice, and the acceptability of the treatment for children and their carers.
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Affiliation(s)
- Susan Elizabeth Adams
- Toby Bowring Department of Paediatric Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Meegodage Roshell Swindri Perera
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Saskia Fung
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jordon Maxton
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jonathan Karpelowsky
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Paediatric Surgery, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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3
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Scheijmans JCG, Bom WJ, Ghori UH, van Geloven AAW, Hannink G, van Rossem CC, van de Wouw L, Huisman PM, van Hemert A, Franken RJ, Oosterling SJ, Rosman C, Koens L, Stoker J, Dijkgraaf MGW, Boermeester MA. Development and Validation of the Scoring System of Appendicitis Severity 2.0. JAMA Surg 2024; 159:642-649. [PMID: 38536188 PMCID: PMC10974687 DOI: 10.1001/jamasurg.2024.0235] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/26/2023] [Indexed: 06/13/2024]
Abstract
Importance When considering nonoperative treatment in a patient with acute appendicitis, it is crucial to accurately rule out complicated appendicitis. The Atema score, also referred to as the Scoring System of Appendicitis Severity (SAS), has been designed to differentiate between uncomplicated and complicated appendicitis but has not been prospectively externally validated. Objective To externally validate the SAS and, in case of failure, to develop an improved SAS (2.0) for estimating the probability of complicated appendicitis. Design, Setting, and Participants This prospective study included adult patients who underwent operations for suspected acute appendicitis at 11 hospitals in the Netherlands between January 2020 and August 2021. Main Outcomes and Measures Appendicitis severity was predicted according to the SAS in 795 patients and its sensitivity and negative predictive value (NPV) for complicated appendicitis were calculated. Since the predefined targets of 95% for both were not met, the SAS 2.0 was developed using the same cohort. This clinical prediction model was developed with multivariable regression using clinical, biochemical, and imaging findings. The SAS 2.0 was externally validated in a temporal validation cohort consisting of 565 patients. Results In total, 1360 patients were included, 463 of whom (34.5%) had complicated appendicitis. Validation of the SAS resulted in a sensitivity of 83.6% (95% CI, 78.8-87.6) and an NPV of 85.0% (95% CI, 80.6-88.8), meaning that the predefined targets were not achieved. Therefore, the SAS 2.0 was developed, internally validated (C statistic, 0.87; 95% CI, 0.84-0.89), and subsequently externally validated (C statistic, 0.86; 95% CI, 0.82-0.89). The SAS 2.0 was designed to calculate a patient's individual probability of having complicated appendicitis along with a 95% CI. Conclusions and Relevance In this study, external validation of the SAS fell short in accurately distinguishing complicated from uncomplicated appendicitis. The newly developed and externally validated SAS 2.0 was able to assess an individual patient's probability of having complicated appendicitis with high accuracy in patients with acute appendicitis. Use of this patient-specific risk assessment tool can be helpful when considering and discussing nonoperative treatment of acute appendicitis with patients.
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Affiliation(s)
| | - Wouter J. Bom
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Umme Habiba Ghori
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Lieke van de Wouw
- Department of Surgery, Tergooi Medical Center, Hilversum, the Netherlands
| | - Peter M. Huisman
- Department of Radiology, Tergooi Medical Center, Hilversum, the Netherlands
| | - Annemiek van Hemert
- Department of Surgery, Spaarne Gasthuis, Haarlem and Hoofddorp, the Netherlands
| | - Rutger J. Franken
- Department of Surgery, Spaarne Gasthuis, Haarlem and Hoofddorp, the Netherlands
| | | | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lianne Koens
- Department of Pathology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, the Netherlands
| | - Marcel G. W. Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, the Netherlands
- Methodology, Amsterdam Public Health, Amsterdam, the Netherlands
| | - Marja A. Boermeester
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, the Netherlands
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Pogorelić Z, Babić V, Bašković M, Ercegović V, Mrklić I. Management and Incidence of Enterobius vermicularis Infestation in Appendectomy Specimens: A Cross-Sectional Study of 6359 Appendectomies. J Clin Med 2024; 13:3198. [PMID: 38892909 PMCID: PMC11172809 DOI: 10.3390/jcm13113198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 05/13/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Background: The role of Enterobius vermicularis infestation in the context of appendicitis is largely overlooked, but Enterobius vermicularis is considered an unexpected and significant appendicectomy finding. The aim of this study was to investigate the frequency of Enterobius vermicularis findings in appendectomies and to evaluate the clinical and histopathologic features of patients with Enterobius vermicularis-associated acute appendicitis and those with appendiceal Enterobius vermicularis infestation. Methods: The medical records of all children who underwent an appendectomy in two large pediatric centers in Croatia between 1 January 2009 and 1 January 2024 were retrospectively reviewed. Of 6359 appendectomies, 61 (0.96%) children were diagnosed with Enterobius vermicularis on histopathology and included in further analysis. The groups were compared with regard to demographic characteristics, laboratory values, clinical features and histopathological findings. Results: The incidence of enterobiasis fluctuated slightly in the individual study years, but was constant overall. The median age of all patients was 11 years (IQR 8.5, 13), with females predominating (60.7%). Acute appendicitis was observed in 34% of the appendiceal species. The patients with Enterobius vermicularis infestation, without appendicitis, were younger (9 years (IQR 8, 13) vs. 12 years (IQR 10, 15); p = 0.020), had longer duration of symptoms (36 h (IQR, 12, 48) vs. 24 h (IQR, 12, 36); p = 0.034), lower body temperature (37 °C (IQR 36.8, 37.4) vs. 37.6 °C (IQR, 37, 38.6) p = 0.012), lower Appendicitis Inflammation Response (AIR) score (3 (IQR 2, 5) vs. 7 (IQR 5, 9.5) p < 0.001), lower incidence of rebound tenderness (57.1% vs. 20%; p = 0.003) and less frequent vomiting (12.5% vs. 47.6%; p = 0.004) compared to the patients with Enterobius vermicularis-associated acute appendicitis. Acute inflammatory markers in the laboratory showed significantly higher values in the group of patients with acute appendicitis: C-reactive protein (p = 0.009), White blood cells (p = 0.001) and neutrophils (p < 0.001). Eosinophilia was not found in any of the groups, although eosinophil counts were significantly higher in children who had Enterobius vermicularis infestation than in those with Enterobius vermicularis-related appendicitis (2.5% (IQR 0.9, 4.3) vs. 1.8% (IQR 0.7, 2.1); p = 0.040). Conclusions: Pediatric surgeons should consider Enterobius vermicularis infestation as a differential diagnosis when removing a vermiform appendix. Younger age, longer duration of symptoms, lower body temperature, lower AIR score, lower diameter of the appendix and normal laboratory inflammatory markers could predict Enterobius vermicularis infection in children presenting with right iliac fossa pain and avoid unnecessary appendectomy.
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Affiliation(s)
- Zenon Pogorelić
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia
- Department of Pediatric Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Vlade Babić
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia
| | - Marko Bašković
- Department of Pediatric Surgery, Children’s Hospital Zagreb, 10000 Zagreb, Croatia
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Vladimir Ercegović
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia
| | - Ivana Mrklić
- Department of Pathology, Forensic Medicine and Cytology, University Hospital of Split, 21000 Split, Croatia
- Department of Pathology, School of Medicine, University of Split, 21000 Split, Croatia
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5
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Iresjö BM, Blomström S, Engström C, Johnsson E, Lundholm K. Acute appendicitis: A block-randomized study on active observation with or without antibiotic treatment. Surgery 2024; 175:929-935. [PMID: 38218686 DOI: 10.1016/j.surg.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Antibiotic treatment of unselected patients with acute appendicitis is safe and effective. However, it is unknown to what extent early provision of antibiotic treatment may represent overtreatment due to spontaneous healing of appendix inflammation. The aim of the present study was to evaluate the role of antibiotic treatment versus active in-hospital observation on spontaneous regression of acute appendicitis. METHOD Patients who sought acute medical care at Sahlgrenska University Hospital were block-randomized according to age (18-60 years) and systemic inflammation (C-reactive protein <60 mg/L, white blood cell <13,000/μL), in combination with clinical and abdominal characteristics of acute appendicitis. Study patients received antibiotic treatment and active observation, while control patients were allocated to classic active "wait and see observation" for either disease regression or the need for surgical exploration. According to our standard surgical care, certified surgeons in charge decided whether and when appendectomy was necessary. In total, 1,019 patients were screened for eligibility; 203 patients met inclusion criteria, 126 were accepted to participate, 29 declined, and 48 were missed for inclusion. RESULTS The antibiotic group (n = 69) and the control group (n = 57) were comparable at inclusion. Appendectomy at first hospital stay was 28% and 53% for study and control patients (χ2, P < .004). Life table analysis indicated a time-dependent difference in the need for appendectomy during follow-up (P < .03). Antibiotics prevented surgical exploration and appendectomy by 72% to 50% compared to 47% to 37% in the control group across the time course follow-ups between 5 and 1,200 days. CONCLUSION Early antibiotic treatment is superior to traditional "wait and see observation" to avoid surgical exploration and appendectomy.
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Affiliation(s)
- Britt-Marie Iresjö
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Sara Blomström
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Cecilia Engström
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Erik Johnsson
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Kent Lundholm
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
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6
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Chin X, Mallika Arachchige S, Orbell-Smith JL, Da Rocha D, Gandhi A. Conservative Versus Surgical Management of Acute Appendicitis: A Systematic Review. Cureus 2024; 16:e52697. [PMID: 38384640 PMCID: PMC10879736 DOI: 10.7759/cureus.52697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 02/23/2024] Open
Abstract
Recent studies have discussed the role of antibiotic treatment in the conservative management of acute appendicitis and whether antibiotics are a safe option to replace appendicectomy, which has been the gold standard treatment of acute appendicitis for many years. The bibliographic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, Medline, and PubMed comparing conservative versus surgical treatment of acute appendicitis were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty-one studies consisting of systematic reviews and meta-analyses involving 44,699 participants were identified. At least 17,865 participants were treated with antibiotics. Our studies compare antibiotic versus appendicectomy among acute appendicitis patients ranging from 7 to 94 years of age. In most studies, patients received parenteral antibiotics for a total of one to three days, and oral antibiotics such as oral cephalosporin plus metronidazole, oral amoxicillin/clavulanate, oral fluoroquinolones plus Tinidazole upon hospital discharge for a total of 7 to 10 days. The total course of antibiotics for both parenteral and oral regimes ranged from 2 to 16 days, with 10 days being the commonest duration. The recurrence rate following initial antibiotic treatment at one-year follow-up ranged from 13% to 38%, while the mean duration of recurrence ranged from three to eight months. The majority of the patients with recurrence underwent appendicectomy, while some patients were either given a repeat or different course of antibiotics due to the possible presence of antibiotic resistance; however, only 2.4% of the patients were successfully treated upon completion of the second course of antibiotics. Most of the studies concluded that appendicectomy remains the gold standard treatment for uncomplicated acute appendicitis, given its higher efficacy and lower complication rates. Although antibiotic treatment cannot be routinely recommended, it can be considered an appropriate alternative in selected patients with uncomplicated appendicitis who wish to avoid surgery and also acknowledge the risk of recurrence and the potential need for subsequent surgery at the same time.
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Affiliation(s)
- Xinlin Chin
- General Surgery, Mackay Base Hospital, Mackay, AUS
- Medicine, James Cook University, Mackay, AUS
- Medicine and Dentistry, Griffith University, Birtinya, AUS
| | | | | | | | - Anil Gandhi
- General Surgery, Monash University, Faculty of Medicine, Nursing and Health Sciences, Selangor, MYS
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7
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Pogorelić Z, Ercegović V, Bašković M, Jukić M, Karaman I, Mrklić I. Incidence and Management of Appendiceal Neuroendocrine Tumors in Pediatric Population: A Bicentric Experience with 6285 Appendectomies. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1899. [PMID: 38136101 PMCID: PMC10741616 DOI: 10.3390/children10121899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/03/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Neuroendocrine tumors (NETs) are rare tumors that arise from neuroendocrine cells and are the most common tumors of the appendix. NETs of the appendix usually cause no symptoms and often go unnoticed until they cause acute appendicitis or are discovered during an accidental appendectomy. As the trend towards the conservative treatment of acute appendicitis increases in the pediatric population, the question arises as to whether the majority of NETs go undetected and are only discovered at an advanced stage. The purpose of the proposed study is to review the incidence and outcomes of treatment for NETs of the appendix in children and include the data presented in the data pool for further review. METHODS From 1 January 2009 to 1 November 2023, a total of 6285 appendectomies were performed in two large pediatric centers in Croatia. After a retrospective review of the case records and histopathologic findings, a total of 31 children (0.49%) were diagnosed with NET of the appendix and included in the further analysis. The primary outcome of this study was the incidence and treatment outcome of pediatric patients diagnosed with NET of the appendix. Secondary outcomes included the patients' demographic, clinical, and laboratory data and the histopathologic characteristics of tumor species. RESULTS The overall incidence of NETs of the appendix was stable over the study years, with minor fluctuations. The median age of patients was 14 (interquartile range-IQR: 12, 16) years, with a female predominance (64.5%). The majority of patients (96.8%) presented with acute abdominal pain and underwent appendectomy because acute appendicitis was suspected. Acute appendicitis was confirmed by histopathology in 18 (58%) cases. NETs of the appendix were not detected preoperatively in any of the patients. Among patients with confirmed acute appendicitis, most (n = 14; 77.8%) were found to have non-perforated acute appendicitis. In most children, the tumor was located at the tip of the appendix (n = 18; 58.1%), and the majority of tumors had a diameter of less than 1 cm (n = 21, 67.7%). The mitotic count (n = 25, 80.6%) and Ki-67 proliferation index (n = 23, 74.2%) were low in most patients, so most tumors were classified as NET G1 (n = 25, 80.6%), while NET G2 and NET G3 were found in four (12.9%) and two (6.5%) patients, respectively. All children were treated with appendectomy only. The median follow-up time was 54 (IQR: 24, 95) months. CONCLUSIONS The incidence of appendiceal NET among pediatric patients is very low. NET occurs most frequently in adolescents, with a female predominance. Most tumors are less than 1 cm in diameter, located at the tip, and associated with non-perforated appendicitis. Appendectomy is the treatment of choice, and major surgery was not necessary in our cohort.
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Affiliation(s)
- Zenon Pogorelić
- Department of Pediatric Surgery, University Hospital of Split, 21 000 Split, Croatia;
- Department of Surgery, School of Medicine, University of Split, 21 000 Split, Croatia;
| | - Vladimir Ercegović
- Department of Surgery, School of Medicine, University of Split, 21 000 Split, Croatia;
| | - Marko Bašković
- Department of Pediatric Surgery, Children’s Hospital Zagreb, 10 000 Zagreb, Croatia;
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10 000 Zagreb, Croatia
| | - Miro Jukić
- Department of Pediatric Surgery, University Hospital of Split, 21 000 Split, Croatia;
- Department of Surgery, School of Medicine, University of Split, 21 000 Split, Croatia;
| | - Ivana Karaman
- Department of Pathology, Forensic Medicine and Cytology, University Hospital of Split, 21 000 Split, Croatia; (I.K.); (I.M.)
| | - Ivana Mrklić
- Department of Pathology, Forensic Medicine and Cytology, University Hospital of Split, 21 000 Split, Croatia; (I.K.); (I.M.)
- Department of Pathology, University of Split School of Medicine, 21 000 Split, Croatia
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Alsaggaf A, Owiwi Y, Shalaby M, Ghallab A, Zidan M, Alawi A, Bustangi N, Awad M, Bana A, Al Zeair S, Afandi A, Basyouni A, Al Nasser I, Raml E, Raboei E. Non-operative treatment for simple acute appendicitis (NOTA) in children during the COVID-19 era: new lessons from the pandemic. Sci Rep 2023; 13:18766. [PMID: 37907760 PMCID: PMC10618159 DOI: 10.1038/s41598-023-46172-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 10/28/2023] [Indexed: 11/02/2023] Open
Abstract
Coronavirus (COVID-19) was a pandemic disease that was affecting our medical and surgical daily practice badly. The surgical management of acute appendicitis was the gold standard, but new studies suggest the safety of antibiotic treatment alone. Non-operative treatment for simple acute appendicitis (NOTA) avoids surgery, the risks of general anesthesia, and long hospital stays. It also decreases the risk of exposure to coronavirus. We aimed to study the cost-effectiveness and outcome of NOTA during the COVID-19 pandemic and compared it to single-incision pediatric endo-surgery appendectomy (SIPESA). A prospective cohort study for NOTA of patients from 6 to 12 years old in the COVID-19 pandemic period from April 1st, 2020, to April 30th, 2021, patients were divided into two groups: Group S was managed by SIPESA, and Group N was managed by NOTA. Family education and assurance with detailed explanation were done for early detection of any complications, and we continue monitoring the patients until their complete recovery. Group S had 24 cases (40%), mean age 9.3 years. Group N had 36 cases (60%), mean age 9.1 years. Six cases (17%) in group N were converted to surgical management in the first 6 months of the study. The mean cost dropped from $2736/day to $400/day. The mean psychological stress for the children improved from 4.4 in April to 2 in September. The mean follow-up was 3.5 months. NOTA is a feasible, cost-effective approach, and we recommend it, as we have learned this lesson during the COVID-19 pandemic days.
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Affiliation(s)
- Ameen Alsaggaf
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Yazeed Owiwi
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Mohamed Shalaby
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia.
- Pediatric Surgery Unit, Faculty of Medicine, Tanta University, Tanta, Egypt.
| | - Alaa Ghallab
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Mazen Zidan
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Ahmed Alawi
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Nasir Bustangi
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed Awad
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
- Pediatric Surgery Unit, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Abdulelah Bana
- Radiology Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Saad Al Zeair
- Radiology Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Ahmed Afandi
- Surgical Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Ahmed Basyouni
- Surgical Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Ibrahim Al Nasser
- Radiology Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Enas Raml
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Enaam Raboei
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
- Medical Reference Center, Jeddah, Saudi Arabia
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9
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Alsulaimani N, Alotaibi R, Almasoudi R, Alamoudi R, Alsharif S, Alawi A. Parental Knowledge of Appendicitis and Its Management Options Among Children of Makkah Region, Saudi Arabia. Cureus 2023; 15:e47928. [PMID: 38034265 PMCID: PMC10684831 DOI: 10.7759/cureus.47928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Despite decades of studies, appendicitis in children still presents several uncertainties regarding optimal treatment. OBJECTIVES To assess parental understanding of appendicitis, along with its risks and treatment, and to determine attitudes to operative and non-operative treatment of uncomplicated appendicitis. METHODS This is a cross-sectional study. The current study has targeted all parents who visited the pediatric outpatient departments or clinics at three different hospitals in Makkah and Jeddah City, including Maternity and Children Hospital (MCH) in Makkah, King Fahad Armed Force Hospital (KFAFH), and Saudi German Private Hospital (SGH) in Jeddah. Data was collected via an online Google form and was analyzed by using SPSS. RESULTS A total of 408 subjects were involved in this study. The majority of them were females (74.5%); 25.5% were males. Most of the study participants aged between 25 and 34 years. Our results found that the average knowledge score of the study population was 4.1±1.81 out of 11. Only 23.5% of them had good knowledge about appendicitis. More than half of the respondents identified the appendix as a part of the digestive system and most of the study population were aware of the current treatment for appendicitis, which is surgery (80.9%). Female participants and respondents who knew someone that has been treated for appendicitis were significantly associated with a better level of knowledge about appendicitis (P-values: 0.011 and 0.033, respectively). Moreover, we found that educational level significantly influenced preference for treatment with antibiotics and surgery if appendicitis happened again (P-value: 0.049). CONCLUSION The study population had poor knowledge of appendicitis and its management options. The highlighted criteria of self-reported relevance to parents should be addressed in all appendicitis counseling and consent. We advocate for the establishment of national public awareness campaigns, as well as increased research and clinical trials. Understanding lay views of treatment alternatives and efficacy will influence future approaches to appendicitis therapy by analyzing the community's preference for emerging treatment modalities and identifying future directions for patient-centered clinical trials.
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Affiliation(s)
| | - Ruba Alotaibi
- Department of Medicine, Umm Al-Qura University, Makkah, SAU
| | | | - Renad Alamoudi
- Department of Medicine, Umm Al-Qura University, Makkah, SAU
| | - Sarah Alsharif
- Department of Medicine, Umm Al-Qura University, Makkah, SAU
| | - Ahmed Alawi
- Pediatric Surgery, King Fahad Armed Forces Hospital, Jeddah, SAU
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Cai JH, Zhou H, Liang D, Chen Q, Xiao Y, Li GM. Parsimonious clinical prediction model for the diagnosis of complicated appendicitis. Heliyon 2023; 9:e19067. [PMID: 37636395 PMCID: PMC10457507 DOI: 10.1016/j.heliyon.2023.e19067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023] Open
Abstract
Objective To develop a logistic regression model that combines clinical and radiological parameters for prediction of complicated appendicitis. Methods 248 patients with histologically proven uncomplicated (n = 214) and complicated (n = 34) acute appendicitis were analyzed retrospectively. All patients had undergone a presurgical abdominal and/or pelvic computed tomography (CT) scan, assessed by two radiologists. A model using univariate and multivariate logistic regression analyses was developed, and the strength of association between independent predictors and complicated acute appendicitis was evaluated by adjusted odds radio. Clinical parameters were gender, age, anorexia, vomiting, duration of symptoms, right lower abdominal quadrant (RLQ) tenderness, rebound tenderness, body temperature, white blood cell (WBC) count, and neutrophil ratio. Radiological parameters were appendix diameter, appendicolith, caecal wall thickening, mesenteric lymphadenopathy, extraluminal air, abscess, fat stranding, and periappendicular fluid. Results Four features (body temperature>37.2 °C, vomiting, appendicolith, and periappendiceal fluid) were included in the logistic regression model, and yielded an area under the curve (AUC) of 0.87 (95% confidence interval (CI), 0.80-0.93), sensitive of 88%, and specificity of 74%. Conclusion The logistic regression model makes an accurate and simple prediction of complicated appendicitis possible.
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Affiliation(s)
- Jia-hui Cai
- Department of Radiology, Guangzhou Hospital of Integrated Traditional and West Medicine, Yingbin Avenue No. 87, Huadu District, Guangzhou, 510800, Guangdong, China
| | - Hui Zhou
- Department of Radiology, Qingyuan People's Hospital, Yinquan Road No. B24, Qingyuan, 511500, Guangdong, China
| | - Dan Liang
- Department of Radiology, Guangzhou First People's Hospital, Panfu Road No.1, Guangzhou, 510000, Guangdong, China
| | - Qiao Chen
- Department of Radiology, Qingyuan People's Hospital, Yinquan Road No. B24, Qingyuan, 511500, Guangdong, China
| | - Yeyu Xiao
- Department of Radiology, Guangzhou Hospital of Integrated Traditional and West Medicine, Yingbin Avenue No. 87, Huadu District, Guangzhou, 510800, Guangdong, China
| | - Guang-ming Li
- Department of Radiology, Qingyuan People's Hospital, Yinquan Road No. B24, Qingyuan, 511500, Guangdong, China
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Xu H, Yang S, Xing J, Wang Y, Sun W, Rong L, Liu H. Comparison of the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis: a systematic review and meta-analysis. BMC Surg 2023; 23:208. [PMID: 37488583 PMCID: PMC10367319 DOI: 10.1186/s12893-023-02108-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/14/2023] [Indexed: 07/26/2023] Open
Abstract
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.
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Affiliation(s)
- Hongxia Xu
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China.
| | - Shaohui Yang
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China
| | - Jiankun Xing
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China
| | - Yan Wang
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China
| | - Weiqiang Sun
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China
| | - Lingyan Rong
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China
| | - Huihui Liu
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China
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Andric M, Stockheim J, Rahimli M, Klös M, Esser T, Soldatovic I, Dölling M, Al-Madhi S, Acciuffi S, Croner R, Perrakis A. Management of acute appendicitis during COVID-19 pandemic. Single center data from a tertiary care hospital in Germany. Innov Surg Sci 2023; 8:39-48. [PMID: 38058775 PMCID: PMC10696938 DOI: 10.1515/iss-2022-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/03/2023] [Indexed: 12/08/2023] Open
Abstract
Objectives The unexpected global overload of the health system during COVID-19 pandemic has caused changes in management of acute appendicitis worldwide. Whereas conservative treatment was widely recommended, the appendicectomy remained standard therapy in Germany. We aimed to investigate the impact of COVID-19 pandemic on treatment routine for acute appendicitis at University Hospital of Magdeburg. Methods Adult patients with clinical and/or radiological diagnosis of acute appendicitis were included in the single center retrospective study. Data was collected to patient demographics, treatment modality and outcomes including morbidity and length of stay. The patient data related to COVID-19 period from March 22, 2020 to December 31, 2021 (649 days) were compared to the Non-COVID-19 period from June 12, 2018 to March 21, 2020 (649 days). Subgroup analysis related to conservative or surgical treatment has been performed. Results A total of 385 patients was included in the study, 203 (52.73 %) during Non-COVID-19 period and 182 (47.27 %) during COVID-19 period. Mean age of entire collective was 43.28 years, containing 43.9 % female patients (p=0.095). Conservative treatment was accomplished in 49 patients (12.7 % of entire collective), increasing from 9.9 % to 15.9 % during COVID-19 period (p=0.074). Laparoscopic appendicectomy was performed in 99.3 % (n=152) of operated patients during COVID-19 period (p=0.013), followed by less postoperative complications compared to reference period (23.5 % vs. 13.1 %, p=0.015). The initiation of antibiotic therapy after the diagnosis increased from 37.9 % to 53.3 % (p=0.002) during COVID-19 period regardless the following treatment modality. Antibiotic treatment showed shorter duration during pandemic period (5.57 days vs. 3.16 days, p<0.001) and it was given longer in the conservative treatment group (5.63 days vs. 4.26 days, p=0.02). The overall length of stay was shorter during COVID-19 period (4.67 days vs. 4.12 days, p=0.052) and in the conservative treatment group (3.08 days vs. 4.47 days, p<0.001). However, the overall morbidity was lower during the COVID-19 period than before (17.2 % vs. 7.7 %, p=0.005) and for conservative therapy compared to appendicectomy (2 % vs. 14.3 %, p=0.016). There was no mortality documented. Conclusions According to our findings the COVID-19 pandemic had a relevant impact on treatment of acute appendicitis, but it was possible to maintain the traditional diagnostic and treatment pathway. Although laparoscopic appendicectomy remains a recommended procedure, the conservative treatment of uncomplicated appendicitis with excellent short-term outcome can be a safe alternative to surgery during potential new wave of COVID-19 pandemic and in the daily routine.
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Affiliation(s)
- Mihailo Andric
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Jessica Stockheim
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Mirhasan Rahimli
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Michael Klös
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Torben Esser
- Institute of Microbiology and Hospital Hygiene, University Hospital Magdeburg, Magdeburg, Germany
| | - Ivan Soldatovic
- Institute for Medical statistics, Faculty of Medicine, University Belgrade, Belgrade, Serbia
| | - Maximilian Dölling
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Sara Al-Madhi
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Sara Acciuffi
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Roland Croner
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Aristotelis Perrakis
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
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Felber J, Gross B, Rahrisch A, Waltersbacher E, Trips E, Schröttner P, Fitze G, Schultz J. Bacterial pathogens in pediatric appendicitis: a comprehensive retrospective study. Front Cell Infect Microbiol 2023; 13:1027769. [PMID: 37228669 PMCID: PMC10205019 DOI: 10.3389/fcimb.2023.1027769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 03/30/2023] [Indexed: 05/27/2023] Open
Abstract
Background Appendicitis is a frequent condition, with peak incidences in the second decade of life. Its pathogenesis is under debate, but bacterial infections are crucial, and antibiotic treatment remains essential. Rare bacteria are accused of causing complications, and various calculated antibiotics are propagated, yet there is no comprehensive microbiological analysis of pediatric appendicitis. Here we review different pre-analytic pathways, identify rare and common bacterial pathogens and their antibiotic resistances, correlate clinical courses, and evaluate standard calculated antibiotics in a large pediatric cohort. Method We reviewed 579 patient records and microbiological results of intraoperative swabs in standard Amies agar media or fluid samples after appendectomies for appendicitis between May 2011 and April 2019. Bacteria were cultured and identified via VITEK 2 or MALDI-TOF MS. Minimal inhibitory concentrations were reevaluated according to EUCAST 2022. Results were correlated to clinical courses. Results Of 579 analyzed patients, in 372 patients we got 1330 bacterial growths with resistograms. 1259 times, bacteria could be identified to species level. 102 different bacteria could be cultivated. 49% of catarrhal and 52% of phlegmonous appendices resulted in bacterial growth. In gangrenous appendicitis, only 38% remained sterile, while this number reduced to 4% after perforation. Many fluid samples remained sterile even when unsterile swabs had been taken simultaneously. 40 common enteral genera were responsible for 76.5% of bacterial identifications in 96.8% of patients. However, 69 rare bacteria were found in 187 patients without specifically elevated risk for complications. Conclusion Amies agar gel swabs performed superior to fluid samples and should be a standard in appendectomies. Even catarrhal appendices were only sterile in 51%, which is interesting in view of a possible viral cause. According to our resistograms, the best in vitro antibiotic was imipenem with 88.4% susceptible strains, followed by piperacillin-tazobactam, cefuroxime with metronidazole, and ampicillin-sulbactam to which only 21.6% of bacteria were susceptible. Bacterial growths and higher resistances correlate to an elevated risk of complications. Rare bacteria are found in many patients, but there is no specific consequence regarding antibiotic susceptibility, clinical course, or complications. Prospective, comprehensive studies are needed to further elicit pediatric appendicitis microbiology and antibiotic treatment.
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Affiliation(s)
- Julia Felber
- Department of Pediatric Surgery, University Hospital Dresden – Technical University of Dresden, Dresden, Germany
| | - Benedikt Gross
- Department of Pediatric Surgery, University Hospital Dresden – Technical University of Dresden, Dresden, Germany
| | - Arend Rahrisch
- Department of Pediatric Surgery, University Hospital Dresden – Technical University of Dresden, Dresden, Germany
| | - Eric Waltersbacher
- Department of Pediatric Surgery, University Hospital Dresden – Technical University of Dresden, Dresden, Germany
| | - Evelyn Trips
- Coordination Centre for Clinical Trials, Faculty of Medicine Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Percy Schröttner
- Institute for Microbiology and Virology, University Hospital Dresden – Technical University of Dresden, Dresden, Germany
| | - Guido Fitze
- Department of Pediatric Surgery, University Hospital Dresden – Technical University of Dresden, Dresden, Germany
| | - Jurek Schultz
- Department of Pediatric Surgery, University Hospital Dresden – Technical University of Dresden, Dresden, Germany
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Demirtürk HC, Tanriverdi HI, Taneli F, Ayhan S, Günşar C. Effectiveness of nonsurgical antibiotic treatment in the experimental appendicitis model in rats. ANNALS OF PEDIATRIC SURGERY 2022. [DOI: 10.1186/s43159-022-00187-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
In this study, we aimed to demonstrate efficacy and laboratory follow-up criteria of nonsurgical antibiotic treatment in uncomplicated acute appendicitis. We established an experimental appendicitis model in rats, and antibiotic treatment was evaluated by biochemical and immunohistochemical changes.
Materials and method
In the study, 28 rats were divided into 4 groups. Group 1 constituted the group of sham; group 2 was the control group that appendicitis model was created and did not receive any treatment. Group 3 was created as an appendicitis model and was given regular antibiotic treatment. In group 4, appendicitis model was created, and appendectomy was performed on the 2nd day. Blood samples were taken from the rats on the 0, 2nd, and 7th days in all groups. Rats in groups 1, 2, and 3 underwent appendectomy with laparotomy under anesthesia on the 7th day. Serum C-reactive protein (CRP), procalcitonin, and leukocyte levels were measured for biochemical analysis. In immunohistochemical evaluation, inflammation severity of the tissue samples taken from appendices was evaluated. Also, tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) levels of tissue samples were evaluated.
Results
A statistically significant difference in CRP values was observed between groups 1 and 2 on the 7th day (p = 0.046), between groups 1 and 4 on 0 and 2nd days (p = 0.004, p = 0.004), between groups 2 and 3 on 0, 2nd, and 7th days (p = 0.018, 0.013, 0.025), between groups 2 and 4 on 0, 2nd, and 7th days (p = 0.002, p = 0.002, p = 0.009), and between groups 3 and 4 on 0 and 2nd days (p = 0.013, p = 0.025). There was a significant difference in procalcitonin values between groups 1 and 3 on the 7th day (p = 0.032) and between groups 1 and 4 on day 0 (p = 0.019). A significant difference was also observed in TNF-α and IL-6 inflammation between groups 2 and 3 (p = 0.031, p = 0.018) and between groups 2 and 4 (p = 0.031, p = 0.01).
Conclusion
Acute uncomplicated and early appendicitis may be treated with antibiotics. According to our results, CRP levels are useful as follow-up criterion in experimental appendicitis model. Clinical studies on the assessment of CRP levels in the course of nonsurgical treatment in the patients with acute appendicitis will reveal out the effectiveness of this marker.
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Muacevic A, Adler JR, Saleem N, Seerat MI, Hussain MI, Javed I, Muhammad Ali S. The Efficacy of Conservative Management in Uncomplicated Acute Appendicitis - A Single-Center Retrospective Study. Cureus 2022; 14:e32606. [PMID: 36654610 PMCID: PMC9840891 DOI: 10.7759/cureus.32606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Background Acute appendicitis remains the most common cause of lower abdominal pain leading to emergency visits. Even though the standard treatment of acute appendicitis remains appendectomy, in recent times, multiple randomized control trials and meta-analyses have deduced conservative treatment as a successful alternative treatment. During the coronavirus disease (COVID) pandemic, with a shortage of staff and resources, treatment with conservative management of uncomplicated acute appendicitis became very beneficial under certain circumstances and conditions. This study aimed to assess whether it is effective to manage patients with uncomplicated acute appendicitis with antibiotic therapy. Methodology This was a single hospital based retrospective, cross-sectional study from Jan 2015 to May 2020. Patients with clinical and radiological features of uncomplicated acute appendicitis with Alvarado's score >6 were included in the study. Patients were kept on antibiotics, intravenous fluids, and analgesia as part of a conservative regime. Those who failed to respond to conservative therapy were managed surgically. The follow-up period was six months. Results One hundred eighty-two cases of uncomplicated acute appendicitis were included and managed conservatively, of which 52.2% were males while 47.8% were females. The median age of the patients was 26 years. Conservative treatment was successful in 26.2% of the patients, with a recurrence of 5.5% in the six-month follow-up period. The mean number of days of hospital stay was three days in patients treated with conservative or surgical treatment. Conclusion Conservative management is gaining popularity, and many centers are inclined towards non-operative management; however, appendectomy remains the gold standard treatment for appendicitis.
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Mendoza-Ortiz B, Herrera-Tarapues JC, Mendoza-Ortiz A, Quemba-Mesa MP. Comparación de la seguridad y la eficacia del uso de antibióticos frente a la apendicectomía en el tratamiento de la apendicitis no complicada en adultos. Revisión sistemática y metaanálisis. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.2188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introducción. La apendicitis aguda es una emergencia quirúrgica frecuente, en la cual el tratamiento de tipo conservador basado en antibióticos se ha identificado como una opción terapéutica que necesita seguir siendo estudiada. El objetivo de este estudio fue determinar las diferencias en seguridad y eficacia del uso de antibióticos en comparación con la apendicectomía en adultos con apendicitis no complicada.
Métodos. Revisión sistemática y metaanálisis. Se encontraron 452 estudios; después de una selección, 45 se evaluaron en texto completo y 15 para calidad metodológica; 11 estudios fueron seleccionados y 9 incluidos en el metaanálisis.
Resultados. Se contó con 3186 participantes, de los cuales 1512 fueron tratados con terapia antibiótica y 1674 sometidos a apendicectomía. Se identificó estancia hospitalaria más corta en los pacientes sometidos a apendicectomía (SMD: 0,28; IC95%: 0,14 a 0,41). Para los pacientes tratados con terapia antibiótica, se evidenció puntajes de riesgo menores en las escalas de diagnóstico de apendicitis (SMD: -0,13; IC95%: -0,22 a -0,04), menor éxito terapéutico en un 16 % (RR: 0,84; IC95%: 0,77 a 0,92) y reducción del riesgo de complicaciones del 63 % (RR: 0,37; IC95%: 0,25 a 0,53). Se encontró alta heterogeneidad y riesgo de sesgo de publicación.
Conclusiones. La terapia antibiótica necesita mayor evidencia para desenlaces como calidad de vida, satisfacción, dolor, o complicaciones específicas, entre otros, que permitan hacer comparaciones más contundentes. Los pacientes que consideren el manejo conservador necesitan ser adecuadamente asesorados y monitorizados para optimizar sus posibilidades de resultados favorables y la oportuna identificación de complicaciones que necesiten de otros abordajes.
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Herrod PJJ, Kwok AT, Lobo DN. Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis. BJS Open 2022; 6:6667669. [PMID: 35971796 PMCID: PMC9379374 DOI: 10.1093/bjsopen/zrac100] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/01/2022] [Accepted: 07/08/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND This aim of this study was to provide an updated meta-analysis comparing antibiotic therapy with appendicectomy in adults (16 years or older) with uncomplicated acute appendicitis. METHODS A search for randomized clinical trials comparing antibiotic therapy with appendicectomy in adults with uncomplicated acute appendicitis from inception to 3 October 2021 in MEDLINE, Embase and CENTRAL with no language constraints was performed. Studies were excluded if they included paediatric participants or those with complicated appendicitis. Data on complications of treatment, treatment efficacy (defined in the antibiotic group as not undergoing appendicectomy within 1 year of enrolment, versus surgery without complications or no negative histology in the appendicectomy group), readmissions, and length of stay (LOS) were presented. RESULTS Eight RCTs involving 3203 participants (1613 antibiotics/1590 appendicectomy; 2041 males/1162 females) were included. There was no significant benefit of antibiotic treatment on complication rates (risk ratio (RR) 0.66, 95 per cent c.i. 0.41 to 1.04). Antibiotics had a reduced treatment efficacy compared with appendicectomy (RR 0.75, 95 per cent c.i. 0.63 to 0.89). Antibiotic treatment at 1 year was successful in 1016 of 1613 (62.9 per cent) participants. There was a six-fold increase in hospital readmissions within 1 year of enrolment in participants receiving antibiotic treatment (RR 6.28, 95 per cent c.i. 2.87 to 13.74). There was no difference in index admission LOS (mean difference 0.15 days (95 per cent c.i. -0.05 to 0.35)). CONCLUSIONS Earlier optimism regarding the benefits of antibiotic therapy for uncomplicated acute appendicitis does not persist at the same level now that further, large trials have been included. If antibiotic treatment is to be offered routinely as first-line therapy, patients should be counselled appropriately.
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Affiliation(s)
- Philip J J Herrod
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Alex T Kwok
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Dileep N Lobo
- Correspondence to: Dileep N. Lobo, Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK (e-mail: )
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Gran MV, Kjønås D, Gunnarsson U, Strigård K, Revhaug A, Aahlin EK. Antibiotic treatment for appendicitis in Norway and Sweden: a nationwide survey on treatment practices. BMC Surg 2022; 22:229. [PMID: 35705946 PMCID: PMC9202227 DOI: 10.1186/s12893-022-01680-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 06/03/2022] [Indexed: 12/01/2022] Open
Abstract
Background Appendicitis is one of the most common causes of acute abdomen. Uncomplicated appendicitis is as an inflamed appendix without perforation, gangrene or abscess formation. Recent trials show that one can safely treat uncomplicated appendicitis with antibiotics, given patient approval and appropriate follow-up. A recent study has also indicated no difference between antibiotic treatment and placebo. Our aim was to investigate if Norwegian and Swedish surgical departments treat uncomplicated appendicitis with antibiotics and to explore their opinions on this treatment practice.
Methods A questionnaire was distributed to all heads of department in hospitals that treat appendicitis in Norway and Sweden. Answers were collected using a REDCap survey. Answers were compared between centers and nations and the results were presented anonymously. Results We sent the questionnaire to 94 eligible recipients and received 61 (65%) answers. In total, 8/61 (13%) departments stated that they have established antibiotic treatment as sole treatment for uncomplicated appendicitis. Almost half of the responders stated that they have used antibiotics sporadically to treat uncomplicated appendicitis. Lack of evidence and guidelines were noted as reasons why antibiotic treatment has not been implemented as sole treatment. Conclusions Most Norwegian and Swedish departments have not implemented antibiotic treatment as the sole treatment for uncomplicated appendicitis. Despite several recent large trials on this subject, lack of evidence and guidelines was the most frequently reported reason in our survey.
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Affiliation(s)
- M V Gran
- Department of Gastrointestinal Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - D Kjønås
- Department of Gastrointestinal and HPB Surgery, University Hospital of Northern Norway, Tromsø, Norway
| | - U Gunnarsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - K Strigård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - A Revhaug
- Department of Gastrointestinal and HPB Surgery, University Hospital of Northern Norway, Tromsø, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, N-9037, Tromsø, Norway.
| | - E K Aahlin
- Department of Gastrointestinal and HPB Surgery, University Hospital of Northern Norway, Tromsø, Norway
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19
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Authors’ Reply: Efficacy and Safety of Non-operative Management of Uncomplicated Acute Appendicitis Compared to Appendectomy: An Umbrella Review of Systematic Reviews and Meta-analyses. World J Surg 2022; 46:2010-2011. [PMID: 35637353 DOI: 10.1007/s00268-022-06606-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
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20
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Kwok AT, Herrod PJJ, Lobo DN. Letter to the Editor: Efficacy and Safety of Non-operative Management of Uncomplicated Acute Appendicitis Compared to Appendectomy: An Umbrella Review of Systematic Reviews and Meta-analyses. World J Surg 2022; 46:2008-2009. [PMID: 35585253 DOI: 10.1007/s00268-022-06602-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Alex T Kwok
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Philip J J Herrod
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK. .,MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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21
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Bolmers MDM, de Jonge J, Bom WJ, van Rossem CC, van Geloven AAW, Bemelman WA. In-hospital Delay of Appendectomy in Acute, Complicated Appendicitis. J Gastrointest Surg 2022; 26:1063-1069. [PMID: 35048258 DOI: 10.1007/s11605-021-05220-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 10/14/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Present theory is that uncomplicated and complicated appendicitis are different entities. Recent studies suggest it is safe to delay surgery in patients with uncomplicated appendicitis. We hypothesize that patients with complicated appendicitis are at higher risk for postoperative complications when surgery is delayed. METHODS Data was used from the multicenter, prospective SNAPSHOT appendicitis study of 1975 patients undergoing surgery for suspected appendicitis. Adult patients (≥ 18 years) who underwent appendectomy for appendicitis were included in this study. The primary outcome was the difference in postoperative complications between patients with complicated appendicitis who were operated within and after 8 h after hospital presentation. Secondary outcomes were the incidence of both uncomplicated and complicated appendicitis in relationship to delay of appendectomy. Follow-up was 30 days. A multivariable analysis was performed. RESULTS Of 1341 adult patients with appendicitis, 34.3% had complicated appendicitis. In patients with complicated appendicitis, 22.8% developed a postoperative complication compared to 8.2% for uncomplicated appendicitis (P < 0.001). Delay in surgery (> 8 h) increased the complication rate in patients with complicated appendicitis (28.1%) compared to surgery within 8 h (18.3%; P = 0.01). Multivariate analysis showed a delay in surgery as an independent predictor for a postoperative complication in patients with complicated appendicitis (OR 1.71; 95%CI 1.01-2.68, P = 0.02). CONCLUSION In-hospital delay of surgery (> 8 h) in patients with complicated appendicitis is associated with a higher risk of a postoperative complication. It is important that we recognize and treat these patients early.
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Affiliation(s)
- M D M Bolmers
- Department of Surgery, Dijklander Hospital, Hoorn, The Netherlands. .,Department of Surgery, Tergooi Hospital, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands.
| | - J de Jonge
- Department of Surgery, Tergooi Hospital, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands
| | - W J Bom
- Department of Surgery, Tergooi Hospital, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands
| | - C C van Rossem
- Department of Surgery, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - A A W van Geloven
- Department of Surgery, Tergooi Hospital, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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22
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Bom WJ, Scheijmans JCG, Ubels S, van Geloven AAW, Gans SL, Tytgat KMAJ, van Rossem CC, Koens L, Stoker J, Bemelman WA, Dijkgraaf MGW, Boermeester MA. Optimising diagnostics to discriminate complicated from uncomplicated appendicitis: a prospective cohort study protocol. BMJ Open 2022; 12:e054304. [PMID: 35365522 PMCID: PMC8977816 DOI: 10.1136/bmjopen-2021-054304] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Growing evidence is showing that complicated and uncomplicated appendicitis are two different entities that may be treated differently. A correct diagnosis of the type of appendicitis is therefore essential. The Scoring system of Appendicitis Severity (SAS) combines clinical, laboratory and imaging findings. The SAS rules out complicated appendicitis in 95% (negative predictive value, NPV) and detects 95% (sensitivity) of patients with complicated appendicitis in adults suspected of acute appendicitis. However, this scoring system has not yet been validated externally. In this study, we aim to provide a prospective external validation of the SAS in a new cohort of patients with clinical suspicion of appendicitis. We will optimise the score when necessary. METHODS AND ANALYSIS The SAS will be validated in 795 consecutive adult patients diagnosed with acute appendicitis confirmed by imaging. Data will be collected prospectively in multiple centres. The predicted diagnosis based on the SAS score will be compared with the combined surgical and histological diagnosis. Diagnostic accuracy for ruling out complicated appendicitis will be calculated. If the SAS does not reach a sensitivity and NPV of 95% in its present form, the score will be optimised. After optimisation, a second external validation will be performed in a new group of 328 patients. Furthermore, the diagnostic accuracy of the clinical perspective of the treating physician for differentiation between uncomplicated and complicated appendicitis and the patient's preferences for different treatment options will be assessed. ETHICS AND DISSEMINATION Ethical approval was granted by the Amsterdam UMC Medical Ethics Committee (reference W19_416 # 19.483). Because of the observational nature of this study, the study does not fall under the scope of the Medical Research Involving Human Subjects Act. Results will be presented in peer-reviewed journals. This protocol is submitted for publication before analysis of the results.
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Affiliation(s)
- Wouter J Bom
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Surgery, Tergooi Hospitals, Hilversum, The Netherlands
| | - Jochem C G Scheijmans
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sander Ubels
- Departement of Surgery, Universitair Medisch Centrum Sint Radboud, Nijmegen, The Netherlands
| | | | - Sarah L Gans
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kristien M A J Tytgat
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | | | - Lianne Koens
- Pathology, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel G W Dijkgraaf
- Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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23
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Rashid A, Gupta A, Adiamah A, West J, Grainge M, Humes DJ. Mortality Following Appendicectomy in Patients with Liver Cirrhosis: A Systematic Review and Meta-Analysis. World J Surg 2022; 46:531-541. [PMID: 34988603 PMCID: PMC8731215 DOI: 10.1007/s00268-021-06373-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2021] [Indexed: 02/07/2023]
Abstract
Introduction With the global prevalence of liver cirrhosis rising, this systematic review aimed to define the perioperative risk of mortality in these patients following appendicectomy. Methods Systematic searches of Medline, EMBASE, Cochrane Library databases, ICTRP, and Clinical trials.gov were undertaken to identify studies including patients with cirrhosis undergoing appendicectomy, published since database inception to March 2021. Studies had to report mortality. Two review authors independently identified eligible studies and extracted data. Pooled analysis of in-patient and 30-day mortality was performed. Results Of the 948 studies identified, four were included and this comprised three nationwide database studies (USA and Denmark) and one multi-centre observational study (Japan). A total of 923 patients had cirrhosis and 167,211 patients did not. In-patient mortality ranged from 0 to 1.7% in patients with cirrhosis and 0.17 to 0.3% in patients without. 30-day mortality was 9% in patients with cirrhosis compared to 0.3% in those without. One study stratified cirrhotic patients into compensated and decompensated groups. In patients with compensated cirrhosis, mortality following laparoscopic appendicectomy (0.5%) was significantly lower than open appendicectomy (3.2%). The meta-analysis highlighted a tenfold increase in perioperative mortality in cirrhotic patients (OR 9.92 (95% CI 4.67 to 21.06, I2 = 28%). All studies reported an increased length of stay in patients with cirrhosis. Conclusion This review suggests that appendicectomy in the cirrhotic population is associated with increased mortality. LA may be safer in this population. Lack of information on cirrhosis severity and failure to control for age and co-morbidities make the results difficult to interpret. Further large population-based studies are required.
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Affiliation(s)
- Adil Rashid
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
| | - Alisha Gupta
- School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Alfred Adiamah
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Joe West
- Division of Epidemiology and Public Health, School of Medicine, Clinical Sciences Building, City Hospital, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Matthew Grainge
- Division of Epidemiology and Public Health, School of Medicine, Clinical Sciences Building, City Hospital, University of Nottingham, Nottingham, NG5 1PB, UK
| | - David J Humes
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.,Division of Epidemiology and Public Health, School of Medicine, Clinical Sciences Building, City Hospital, University of Nottingham, Nottingham, NG5 1PB, UK
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24
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Bolmers MDM, Bom WJ, Scheijmans JCG, van Geloven AAW, Boermeester MA, Bemelman WA, van Rossem CC. Accuracy of imaging in discriminating complicated from uncomplicated appendicitis in daily clinical practice. Int J Colorectal Dis 2022; 37:1385-1391. [PMID: 35583564 PMCID: PMC9167165 DOI: 10.1007/s00384-022-04173-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Radiologic imaging can accurately diagnose acute appendicitis, but little is known about its discriminatory capacity between complicated and uncomplicated appendicitis. OBJECTIVE This study aims to investigate the accuracy of imaging in discriminating complicated from uncomplicated appendicitis. METHODS Data was used from the prospective, nationwide, observational SNAPSHOT appendicitis database, including patients with suspected acute appendicitis who were planned for an appendectomy. Usage of ultrasound (US), CT, MRI or a combination was recorded. Radiological reports were used to group for complicated or uncomplicated appendicitis. The reference standard was based on operative and pathological findings. Primary outcomes were sensitivity and specificity in discriminating complicated from uncomplicated appendicitis. Secondary outcomes were diagnostic accuracy results per imaging modality and for the subgroups age, BMI, and sex. RESULTS Preoperative imaging was performed in 1964 patients. In 1434 patients (73%), only US was used; in 109 (6%) patients, only CT was used; and 421 (21%) patients underwent US followed by CT or MRI. Overall, imaging workup as practiced, following the national guideline, had a poor sensitivity for complicated appendicitis of only 35%, although specificity was as high as 93%. For US, accuracy for complicated appendicitis was higher in children than in adults; sensitivity 41.2% vs. 26.4% and specificity 94.6% vs. 93.4%, respectively, p = 0.003. For relevant subgroups such as age, sex and BMI, no other differences in the discriminatory performance were found. CONCLUSION A diagnostic workup with stepwise imaging, using a conditional CT or MRI strategy, poorly discriminates between complicated and uncomplicated appendicitis in daily practice.
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Affiliation(s)
| | - Wouter J. Bom
- Department of Surgery, UMC, Location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands ,Department of Surgery, Tergooi MC, Hilversum, The Netherlands
| | - Jochem C. G. Scheijmans
- Department of Surgery, UMC, Location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marja. A. Boermeester
- Department of Surgery, UMC, Location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - Willem A. Bemelman
- Department of Surgery, UMC, Location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
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25
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Psaltis E, Zaitoun AM, Neal KR, Lobo DN. Immunohistochemical Inflammation in Histologically Normal Appendices in Patients with Right Iliac Fossa Pain. World J Surg 2021; 45:3592-3602. [PMID: 34392384 PMCID: PMC8572837 DOI: 10.1007/s00268-021-06288-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2021] [Indexed: 12/02/2022]
Abstract
BACKGROUND Histologically normal appendices resected for right iliac fossa pain in children demonstrate immunohistochemical markers of inflammation. We aimed to establish if subclinical inflammation was present in histologically normal appendices resected from adults with right iliac fossa pain. METHODS Immunohistochemistry was performed on formalin-fixed paraffin-embedded appendices for tumour necrosis factor (TNF)-α, interleukin (IL)-6, IL-2R and serotonin in four groups: Group I (n = 120): uncomplicated appendicitis, Group II (n = 118): complicated appendicitis (perforation or gangrene), Group III (n = 104): histologically normal appendices resected for right iliac fossa pain and Group IV (n = 106) appendices resected at elective colectomy. Expression was quantified using the H-scoring system. RESULTS Median, interquartile range expression of TNF-α was increased in Groups I (5.9, 3.1-9.8), II (6.8, 3.6-12.1) and III (9.8, 6.2-15.2) when compared with Group IV (3.0, 1.4-4.7, p < 0.01). Epithelial expression of IL-6 in Groups II (44.0, 8.0-97.0) and III (71.0, 18.5-130.0) was increased when compared with Group IV (9.5, 1.0-60.2, p < 0.01). Expression of mucosal IL-2R in Groups I (47.4, 34.8-69.0), II (37.8, 25.4-60.4) and III (18.4, 10.1-34.7) was increased when compared with Group IV (2.8, 1.2-5.7, p < 0.01). Serotonin content in Groups I (3.0, 0-30.0) and II (0, 0-8.5) was decreased when compared with Groups III (49.7, 16.7-107.5) and IV (43.5, 9.5-115.8, p < 0.01). CONCLUSION Histologically normal appendices resected from symptomatic patients exhibited increased proinflammatory cytokine expression on immunohistochemistry suggesting the presence of an inflammatory process not detected on conventional microscopy.
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Affiliation(s)
- Emmanouil Psaltis
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Abed M Zaitoun
- Pathology, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Keith R Neal
- Public Health and Epidemiology, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK.
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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26
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Haijanen J, Sippola S, Tammilehto V, Grönroos J, Mäntyoja S, Löyttyniemi E, Niiniviita H, Salminen P. Diagnostic accuracy using low-dose versus standard radiation dose CT in suspected acute appendicitis: prospective cohort study. Br J Surg 2021; 108:1483-1490. [PMID: 34761262 PMCID: PMC10364876 DOI: 10.1093/bjs/znab383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/05/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Contrast-enhanced CT is the reference standard used in diagnostic imaging for acute appendicitis in adults. The radiation dose has been of concern. This study aimed to assess whether a lower radiation dose would affect the diagnostic accuracy of CT. METHODS This was a prospective single-centre cohort study of patients (aged over 16 years) with suspected appendicitis evaluated for enrolment in concurrent APPAC II-III trials. The diagnostic accuracy of contrast-enhanced low- and standard-dose CT was compared with study protocols guiding imaging based on BMI; this enabled direct CT imaging comparison only in patients with a BMI below 30 kg/m2. The on-call CT diagnosis was compared with the final clinical diagnosis. RESULTS Among all 856 patients investigated, the accuracy of low-dose (454 patients) and standard-dose (402 patients) CT in identifying patients with and without appendicitis was 98·0 and 98·5 per cent respectively. In patients with a BMI under 30 kg/m2, respective values were 98·2 per cent (434 patients) and 98·6 per cent (210 patients) (P = 1·000). The corresponding accuracy for differentiating between uncomplicated and complicated acute appendicitis was 90·3 and 87·6 per cent in all patients, and 89·8 and 88·4 per cent respectively among those with a BMI below 30 kg/m2 (P = 0·663). The median radiation dose in the whole low- and standard-dose CT groups was 3 and 7 mSv respectively. In the group with BMI below 30 kg/m2, corresponding median doses were 3 and 5 mSv (P < 0·001). CONCLUSION Low- and standard-dose CT were accurate both in identifying appendicitis and in differentiating between uncomplicated and complicated acute appendicitis. Low-dose CT was associated with a significant radiation dose reduction, suggesting that it should be standard clinical practice at least in patients with a BMI below 30 kg/m2.
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Affiliation(s)
- Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland.,Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - Ville Tammilehto
- Department of Radiology, Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Siiri Mäntyoja
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | | | - Hannele Niiniviita
- Department of Radiology, Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland.,Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
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Al Hashmi FY, Al Zuabi A, Hachim IY, Mannaerts GHH, Bekdache O. Conservative management of acute appendicitis in the era of COVID 19: A multicenter prospective observational study at the United Arab Emirates. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021; 36:100389. [PMID: 34568625 PMCID: PMC8386107 DOI: 10.1016/j.ijso.2021.100389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/05/2021] [Accepted: 08/07/2021] [Indexed: 12/17/2022]
Abstract
Background & Aims Since its emergence in December 2019, the COVID-19 pandemic resulted in a profound impact on the health care system worldwide. We propose herein to evaluate the impact of implementing conservative management as an alternative approach to surgical appendectomy during COVID19 pandemic. Materials and Methods Our study is a prospective multicenter study that includes a cohort of 158 patients admitted to the surgical departments in both Tawam Hospital and SSMC hospital, Abu Dhabi, UAE, from February 2020 till July 2020. Results Our results showed a significant decrease in length of hospital stay (LOS) (2.32 ± 0.83 days) among conservatively treated group compared to the surgically treated group (2.8 ± 1.47 days). Also, short term follow-up showed that 90% of those patients did not require further operative intervention or developed complications. Out of the 110 patients that were swapped for COVID19, nine (8.18%) were confirmed to be positive. Our protocol was to avoid surgical management for COVID19 positive patients unless indicated. This resulted in (8/9) of COVID19 positive patients to be treated conservatively. Conclusions In conclusion, our results showed that the implementation of conservative management in treating patients with acute appendicitis who were COVID19 positive maybe essential in reducing viral transmission risks as well as avoiding operative risks on COVID19 positive patients.
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Affiliation(s)
- Fatima Y Al Hashmi
- General Surgery Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Abeer Al Zuabi
- General Surgery Division, Tawam Hospital, Al Ain, United Arab Emirates
| | - Ibrahim Yaseen Hachim
- Clinical Sciences Department, College of Medicine, University of Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, United Arab Emirates
| | | | - Omar Bekdache
- Trauma Service, Tawam Hospital, Al Ain, United Arab Emirates
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28
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Javanmard-Emamghissi H, Hollyman M, Boyd-Carson H, Doleman B, Adiamah A, Lund JN, Moler-Zapata S, Grieve R, Moug SJ, Tierney GM. Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study. Br J Surg 2021; 108:1351-1359. [PMID: 34476484 PMCID: PMC8499866 DOI: 10.1093/bjs/znab287] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/20/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Uncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up. METHODS A prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment. RESULTS A total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P < 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery. CONCLUSION This study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions.
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Affiliation(s)
- H Javanmard-Emamghissi
- Faculty of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - M Hollyman
- Upper Gastrointestinal Surgery Department, Musgrove Park Hospital, Taunton, UK
| | - H Boyd-Carson
- Colorectal Department, Royal Derby Hospital, Derby, UK
| | - B Doleman
- Faculty of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - A Adiamah
- Department of Gastrointestinal Surgery, NIHR Nottingham Digestive Disease Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J N Lund
- Faculty of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - S Moler-Zapata
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - R Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - S J Moug
- Colorectal Department, Royal Alexandra Hospital, Paisley, UK
| | - G M Tierney
- Colorectal Department, Royal Derby Hospital, Derby, UK
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Bom WJ, Scheijmans JCG, Gans SL, Van Geloven AAW, Boermeester MA. Population preference for treatment of uncomplicated appendicitis. BJS Open 2021; 5:6342604. [PMID: 34355241 PMCID: PMC8411439 DOI: 10.1093/bjsopen/zrab058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/18/2021] [Indexed: 12/13/2022] Open
Abstract
Background Non-operative treatment of uncomplicated appendicitis is safe and increasing in popularity, but has other risks and benefits compared with appendicectomy. This study aimed to explore the preference of the general population regarding operative or antibiotic treatment of uncomplicated appendicitis. Methods In this prospective study, a clinical scenario and questionnaire were submitted to a panel comprising a sample of an average adult population. The survey was distributed by an independent, external research bureau, and included a comprehensive explanation of the risks and benefits of both treatment options. The primary outcome was the proportion of participants who would prefer antibiotics over surgery. Secondary outcomes were reasons for this preference and the accepted recurrence rate within 1 year when treated with antibiotics only. All outcomes were weighted for the average Dutch population. Results Of 254 participants, 49.2 per cent preferred antibiotic treatment for uncomplicated appendicitis, 44.5 per cent preferred surgery, and 6.3 per cent could not make a decision. About half of the participants preferring antibiotics would accept a recurrence risk of more than 50 per cent within 1 year. Avoiding surgery was their main reason. In participants preferring surgery, many tolerated a recurrence risk of no more than 10 per cent when treated with antibiotics. Removal of the cause of appendicitis was their main reason. Conclusion Around half of the average population sample preferred antibiotics over surgical treatment of uncomplicated appendicitis and were willing to accept a high recurrence risk to avoid surgery initially. Participants who preferred surgery tolerated only a very low recurrence risk with antibiotic treatment.
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Affiliation(s)
- W J Bom
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - J C G Scheijmans
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - S L Gans
- Department of Surgery, Gelre Hospitals, Apeldoorn, the Netherlands
| | - A A W Van Geloven
- Department of Surgery, Tergooi Hospitals, Hilversum, the Netherlands
| | - M A Boermeester
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, the Netherlands
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30
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Dalbaşı E, Akgül ÖL. Are average platelet volume, red cell distribution width and platelet distribution width guiding markers for acute appendicitis treatment options? Int J Clin Pract 2021; 75:e14232. [PMID: 33866650 DOI: 10.1111/ijcp.14232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/26/2021] [Accepted: 04/10/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acute appendicitis (AA) is the most common cause of surgery performed for the acute abdomen. The standard treatment for AA patients has been appendectomy for more than a century. The use of broad-spectrum antibiotics, the medical treatment option has come to the fore in the treatment of uncomplicated AA. AIM Evaluate whether white blood cell (WBC), platelet count, mean platelet volume (MPV), platelet distribution width (PDW), red cell distribution width (RDW) and C-reactive protein (CRP) values of patients diagnosed with uncomplicated AA clinically, with laboratory tests and radiologically with abdominal computed tomography (CT) could be a marker for choosing medical or surgical treatment. MATERIALS AND METHODS 519 patients aged between 20 and 65 years who were diagnosed with uncomplicated AA by abdominal CT in our centre between January 2016 and January 2019 were retrospectively analysed. The presence of at least one of the criteria of 7 mm or more appendix diameter and oedema or fluid accumulation around the appendix was accepted as uncomplicated AA. After the diagnosis of AA, 223 patients were treated medically, while 296 patients underwent laparoscopic appendectomy. The first group included patients who were treated medically and the second group included patients who underwent laparoscopic appendectomy. RESULTS Group 2 patients had higher mean platelet count (P < .005) and RDW (P = .003) values compared to Group 1 patients, while mean PDW (P < .001) values were lower compared to those of Group 1 patients. The differences between the mean WBC, CRP and MPV values of the groups were not statistically significant (P > .05). CONCLUSIONS Recently, studies supporting antibiotic therapy have been conducted in patients diagnosed with AA. As a result, we think that PDW, RDW, and platelet values in patients diagnosed with uncomplicated AA may be a guide in choosing patients to be treated with surgery or antibiotics.
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Affiliation(s)
- Erkan Dalbaşı
- Memorial Diyarbakır Hospital General Surgery Department, Diyarbakır, Turkey
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31
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Scheijmans JCG, Borgstein ABJ, Puylaert CAJ, Bom WJ, Bachiri S, van Bodegraven EA, Brandsma ATA, Ter Brugge FM, de Castro SMM, Couvreur R, Franken LC, Gaspersz MP, de Graaff MR, Groenen H, Kleipool SC, Kuypers TJL, Martens MH, Mens DM, Orsini RG, Reneerkens NJMM, Schok T, Sedee WJA, Tavakoli Rad S, Volders JH, Weeder PD, Prins JM, Gietema HA, Stoker J, Gisbertz SS, Besselink MGH, Boermeester MA. Impact of the COVID-19 pandemic on incidence and severity of acute appendicitis: a comparison between 2019 and 2020. BMC Emerg Med 2021; 21:61. [PMID: 33980150 PMCID: PMC8114672 DOI: 10.1186/s12873-021-00454-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/23/2021] [Indexed: 01/03/2023] Open
Abstract
Background During the COVID-19 pandemic, a decrease in the number of patients presenting with acute appendicitis was observed. It is unclear whether this caused a shift towards more complicated cases of acute appendicitis. We compared a cohort of patients diagnosed with acute appendicitis during the 2020 COVID-19 pandemic with a 2019 control cohort. Methods We retrospectively included consecutive adult patients in 21 hospitals presenting with acute appendicitis in a COVID-19 pandemic cohort (March 15 – April 30, 2020) and a control cohort (March 15 – April 30, 2019). Primary outcome was the proportion of complicated appendicitis. Secondary outcomes included prehospital delay, appendicitis severity, and postoperative complication rates. Results The COVID-19 pandemic cohort comprised 607 patients vs. 642 patients in the control cohort. During the COVID-19 pandemic, a higher proportion of complicated appendicitis was seen (46.9% vs. 38.5%; p = 0.003). More patients had symptoms exceeding 24 h (61.1% vs. 56.2%, respectively, p = 0.048). After correction for prehospital delay, presentation during the first wave of the COVID-19 pandemic was still associated with a higher rate of complicated appendicitis. Patients presenting > 24 h after onset of symptoms during the COVID-19 pandemic were older (median 45 vs. 37 years; p = 0.001) and had more postoperative complications (15.3% vs. 6.7%; p = 0.002). Conclusions Although the incidence of acute appendicitis was slightly lower during the first wave of the 2020 COVID-19 pandemic, more patients presented with a delay and with complicated appendicitis than in a corresponding period in 2019. Spontaneous resolution of mild appendicitis may have contributed to the increased proportion of patients with complicated appendicitis. Late presenting patients were older and experienced more postoperative complications compared to the control cohort. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00454-y.
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Affiliation(s)
- Jochem C G Scheijmans
- Department of Surgery, Amsterdam UMC, location AMC, Amstserdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Alexander B J Borgstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Carl A J Puylaert
- Department of Radiology and Nuclear Medicine, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Wouter J Bom
- Department of Surgery, Amsterdam UMC, location AMC, Amstserdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Said Bachiri
- Department of Surgery, Noordwest Hospital Group, Alkmaar, the Netherlands
| | | | | | | | | | - Roy Couvreur
- Department of Surgery, Haaglanden Medical Center, The Hague, the Netherlands
| | - Lotte C Franken
- Departement of Surgery, Flevo Hospital, Almere, the Netherlands
| | - Marcia P Gaspersz
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Hannah Groenen
- Department of Surgery, Tergooi Hospitals, Hilversum, the Netherlands
| | | | - Toon J L Kuypers
- Department of Surgery, Elisabeth - Tweesteden Hospital, Tilburg, the Netherlands
| | - Milou H Martens
- Department of Surgery, Zuyderland Medical Center, Sittard-Geleen/Heerlen, the Netherlands
| | - David M Mens
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Ricardo G Orsini
- Department of Surgery, Maastricht UMC+, Maastricht, the Netherlands
| | | | - Thomas Schok
- Department of Surgery, VieCuri Medisch Centrum for Noord-Limburg, Venlo, the Netherlands
| | - Wouter J A Sedee
- Department of Emergency Medicine, St Jansdal Hospital, Harderwijk, the Netherlands
| | | | - José H Volders
- Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Pepijn D Weeder
- Department of Surgery, Spaarne Gasthuis, Haarlem, and Hoofddorp, the Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity (AI&II), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hester A Gietema
- Department of Radiology and Nuclear Medicine, Maastricht UMC+, Maastricht, the Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G H Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam UMC, location AMC, Amstserdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
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Javanmard-Emamghissi H, Boyd-Carson H, Hollyman M, Doleman B, Adiamah A, Lund JN, Clifford R, Dickerson L, Richards S, Pearce L, Cornish J, Hare S, Lockwood S, Moug SJ, Tierney GM. The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study. Tech Coloproctol 2021; 25:401-411. [PMID: 32671661 PMCID: PMC7362319 DOI: 10.1007/s10151-020-02297-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/05/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK). METHODS Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up. RESULTS The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26-49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1-4] days vs. 3 [2-4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive. CONCLUSION COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.
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Affiliation(s)
| | | | | | - B Doleman
- Royal Derby Hospital, University of Nottingham at Derby, Derby, UK
| | - A Adiamah
- NIHR Nottingham Digestive Disease Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J N Lund
- Royal Derby Hospital, University of Nottingham at Derby, Derby, UK
| | | | | | | | - L Pearce
- Salford Royal NHS Trust, Salford, UK
| | - J Cornish
- Cardiff Royal Infirmary, Cardiff, UK
| | - S Hare
- Medway Maritime Hospital, Kent, UK
| | | | - S J Moug
- Royal Alexandra Hospital, Paisley, UK
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33
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Thapa Basnet A, Singh S, Thapa B, Kayastha A. Management of Acute Appendicitis during COVID-19 Pandemic in a Tertiary Care Centre: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc 2021; 59:252-255. [PMID: 34506434 PMCID: PMC8369543 DOI: 10.31729/jnma.6307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Acute appendicitis is the most common reason for abdominal surgery in children. Though appendectomy considered the gold standard there are a lot of complications related to it. Conservative management of acute appendicitis is not new to medical science. In pandemic like COVID-19 when all the health systems were about to shut-down because of lack of manpower and resources, we started a trial of non-operative management. The main aim of this study is to find out the management of acute appendicitis during COVID-19. METHODS This was a descriptive cross-sectional study conducted in a tertiary care centre. Data collection was done from the record section which included the patients diagnosed with acute appendicitis from February 2020 to July 2020 after obtaining ethical clearance from Institutional Review Committee. Cases of appendicular lump, appendicular abscess, appendicular perforations have been excluded. Data was collected and entry was done in Statistical Package for the Social Science software version 20, point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS The conservative management of acute appendicitis was done in 44 cases (55.7%) while 35 cases (44.3%) had to undergo appendectomy. CONCLUSIONS COVID-19 can complicate the perioperative course as a result of direct lung injury and multiple organ dysfunctions and can also bring serious threats to the safety of medical staffs involved in managing the acute appendicitis case operatively, so conservative management can be considered as an alternative way of management of acute appendicitis in the pandemic outbreak.
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Affiliation(s)
- Anupama Thapa Basnet
- Department of Pediatric Surgery, Kanti Children's Hospital, Maharajganj, Kathmandu, Nepal
| | - Suraj Singh
- Department of Pediatric Surgery, Kanti Children's Hospital, Maharajganj, Kathmandu, Nepal
| | - Bijay Thapa
- Department of Pediatric Surgery, Kanti Children's Hospital, Maharajganj, Kathmandu, Nepal
| | - Anuj Kayastha
- Department of Pediatric Surgery, Kanti Children's Hospital, Maharajganj, Kathmandu, Nepal
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Zaman S, Mohamedahmed AYY, Srinivasan A, Stonelake S, Sillah AK, Hajibandeh S, Hajibandeh S. Single-port laparoscopic appendicectomy versus conventional three-port approach for acute appendicitis: A systematic review, meta-analysis and trial sequential analysis of randomised controlled trials. Surgeon 2021; 19:365-379. [PMID: 33752983 DOI: 10.1016/j.surge.2021.01.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 01/12/2021] [Indexed: 12/14/2022]
Abstract
AIMS The aim of this systematic review and meta-analysis is to compare outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis. METHODS A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis and trial sequential analysis of outcomes were conducted. Post-operative pain at 12-h, cosmesis, need for an additional port(s), operative time, port-site hernia, ileus, surgical site infection (SSI), intra-abdominal collection, length of hospital stay (LOS), readmission, and reoperation were the evaluated outcome parameters. RESULTS Sixteen RCTs with total number of 2017 patients who underwent SPLA (n = 1009) or CLA (n = 1008) were included. SPLA was associated with a significantly higher cosmetic score (MD 1.11, P= 0.03) but significantly longer operative time (MD 7.08, P = 0.00001) compared to CLA. However, the difference was not significant between SPLA and CLA in the post-operative pain score at 12-h (MD -0.13, P = 0.69), need for additional port(s) (RR0.03, P = 0.07), port-site hernia (RD: 0.00, P = 0.68), ileus (RR 0.74, P = 0.51), SSI (RR 1.38, P = 0.28), post-operative intra-abdominal collection (RR 0.00, P = 0.62), LOS (MD -2.41, P = 0.16), readmission to the hospital (RR 0.45, P = 0.22), and return to theatre (RR 0.00, P = 0.49). Trial sequential analysis demonstrated that the meta-analysis is conclusive for most of the outcomes, except LOS and intra-abdominal collection. CONCLUSION Although SPLA is associated with a slightly longer operative time, its efficacy and safety are comparable to CLA in management of uncomplicated appendicitis. Moreover, it offers improved post-operative cosmesis. The available evidence is conclusive, and further trials may not be required.
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Affiliation(s)
- Shafquat Zaman
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Ali Yasen Y Mohamedahmed
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.
| | - Ananth Srinivasan
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Stephen Stonelake
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Abdul Karim Sillah
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Shahab Hajibandeh
- Department of General Surgery, Glan Clwyd Hospital, Rhyl, Denbighshire, UK
| | - Shahin Hajibandeh
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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Falih Noori Alsubsiee I, Falih Noori Alsubsiee A. Appendicectomy for Uncomplicated Simple Appendicitis: Is It Always Required? Surg Res Pract 2021; 2021:8848162. [PMID: 33791405 PMCID: PMC7984904 DOI: 10.1155/2021/8848162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/16/2021] [Accepted: 03/02/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Although appendicectomy is still the classical and standard treatment for acute appendicitis, initial conservative antibiotic only treatment for simple uncomplicated cases has been proposed and tried as a feasible and effective approach. The objective of this study was to evaluate the efficacy and outcomes of antibiotics treatment for acute simple uncomplicated appendicitis. METHODS This is a prospective controlled nonrandomized study in which a total of 156 patients whose ages range from 16 to 54 years presenting with clinical diagnosis of acute uncomplicated appendicitis were assigned for conservative antibiotics treatment, which consists of ceftriaxone I gram twice daily and metronidazole infusions, 500 mg in 100 ml, 3 times daily for 48 to 72 hours to be converted on oral antibiotics after clinical improvement for 5 to 7 days. Patients who failed to initial conservative treatment and those who had recurring symptoms of appendicitis were presented for appendectomy. RESULTS Antibiotic treatment was successful and feasible in 138 (88.5%) patients. Progression of the signs and symptoms despite full medical treatment was observed in 11 (7%) patients during the same admission. Further 7 (4.5%) patients showed recurrence of the symptoms during follow-up period of 6-12 months after successful initial conservative treatment and also proceeded for appendicectomy. CONCLUSION Nonoperative antibiotic treatment of acute simple appendicitis is safe, feasible, and effective for properly selected cases, thus avoiding unnecessary surgery with its possible complications.
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Zaman S, Mohamedahmed AYY, Stonelake S, Srinivasan A, Sillah AK, Hajibandeh S, Hajibandeh S. Single-port laparoscopic appendicectomy versus conventional three-port approach for acute appendicitis in children: a systematic review and meta-analysis. Pediatr Surg Int 2021; 37:119-127. [PMID: 33201303 DOI: 10.1007/s00383-020-04776-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2020] [Indexed: 02/07/2023]
Abstract
AIM To evaluate comparative outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis in children. METHODS A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis of outcomes were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. Operative time, surgical site infection, intra-abdominal collection, incisional hernia, length of hospital stay (LOS), additional port/s and conversion to open were the evaluated outcome parameters. RESULTS Four RCTs reporting a total number of 520 patients who underwent SPLA (n = 260) or CLA (n = 260) were included. There was no difference between SPLA and CLA group in post-operative collection (risk difference (RD) - 0.00, P = 0.94), surgical site infection (RD 0.02, P = 0.25), incisional hernia (RD 0.00 P = 1), LOS (mean difference (MD) 0.73 P = 0.93), need for additional port/s (RD 0.04, P = 0.24) and conversion to open (RD 0.00, P = 1). However, there was a significantly longer operative time in the SPLA group (MD 9.80, P = 0.00001). The certainty of the evidence was judged to be moderate for all outcomes. CONCLUSIONS SPLA and CLA seem to have comparable efficacy and safety in children with acute appendicitis although the former may be associated with longer procedure time. Future high-quality RCTs with adequate sample sizes are required to provide stronger evidence in favour of an intervention.
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Affiliation(s)
- Shafquat Zaman
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Ali Yasen Y Mohamedahmed
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.
| | - Stephen Stonelake
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Ananth Srinivasan
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Abdul Karim Sillah
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Shahab Hajibandeh
- Department of General Surgery, Glan Clwyd Hospital, Rhyl, Denbighshire, UK
| | - Shahin Hajibandeh
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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Bom WJ, Bolmers MD, Gans SL, van Rossem CC, van Geloven AAW, Bossuyt PMM, Stoker J, Boermeester MA. Discriminating complicated from uncomplicated appendicitis by ultrasound imaging, computed tomography or magnetic resonance imaging: systematic review and meta-analysis of diagnostic accuracy. BJS Open 2020; 5:6045669. [PMID: 33688952 PMCID: PMC7944501 DOI: 10.1093/bjsopen/zraa030] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/20/2020] [Accepted: 09/28/2020] [Indexed: 12/12/2022] Open
Abstract
Background Discriminating complicated from uncomplicated appendicitis is crucial. Patients with suspected complicated appendicitis are best treated by emergency surgery, whereas those with uncomplicated appendicitis may be treated with antibiotics alone. This study aimed to obtain summary estimates of the accuracy of ultrasound imaging, CT and MRI in discriminating complicated from uncomplicated appendicitis Methods A systematic literature review was conducted by an electronic search in PubMed, Embase and the Cochrane Library for studies describing the diagnostic accuracy of complicated versus uncomplicated appendicitis. Studies were included if the population comprised adults, and surgery or pathology was used as a reference standard. Risk of bias and applicability were assessed with QUADAS-2. Bivariable logitnormal random-effect models were used to estimate mean sensitivity and specificity. Results Two studies reporting on ultrasound imaging, 11 studies on CT, one on MRI, and one on ultrasonography with conditional CT were included. Summary estimates for sensitivity and specificity in detecting complicated appendicitis could be calculated only for CT, because of lack of data for the other imaging modalities. For CT, mean sensitivity was 78 (95 per cent c.i. 64 to 88) per cent, and mean specificity was 91 (85 to 99) per cent. At a median prevalence of 25 per cent, the positive predictive value of CT for complicated appendicitis would be 74 per cent and its negative predictive value 93 per cent. Conclusion Ultrasound imaging, CT and MRI have limitations in discriminating between complicated and uncomplicated appendicitis. Although CT has far from perfect sensitivity, its negative predictive value for complicated appendicitis is high.
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Affiliation(s)
- W J Bom
- Department of Surgery, Amsterdam University Medical Centre, Location Academic Medical Centre, Amsterdam Gastroenterology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands.,Department of Surgery, Tergooi Hospital Hilversum, Hilversum, the Netherlands
| | - M D Bolmers
- Department of Surgery, Amsterdam University Medical Centre, Location Academic Medical Centre, Amsterdam Gastroenterology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - S L Gans
- Department of Surgery, Amsterdam University Medical Centre, Location Academic Medical Centre, Amsterdam Gastroenterology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - C C van Rossem
- Department of Surgery, Tergooi Hospital Hilversum, Hilversum, the Netherlands
| | - A A W van Geloven
- Department of Surgery, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - P M M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, Amsterdam Public Health, University of Amsterdam, Amsterdam, the Netherlands
| | - J Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, Location Academic Medical Centre, Amsterdam Gastroenterology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - M A Boermeester
- Department of Surgery, Amsterdam University Medical Centre, Location Academic Medical Centre, Amsterdam Gastroenterology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
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Outcomes after appendectomy in children with acute appendicitis treated at a tertiary paediatric centre: results from a retrospective cohort study. Langenbecks Arch Surg 2020; 406:163-169. [PMID: 32860108 PMCID: PMC7870764 DOI: 10.1007/s00423-020-01976-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/23/2020] [Indexed: 11/03/2022]
Abstract
PURPOSE In general, an appendectomy is presumed to have a limited burden of disease. However, in current literature, reported complication rates vary. This study aims to provide additional insights in the incidence of post-appendectomy complications in children with acute appendicitis. METHODS This retrospective cohort study included children (0-17 years old) that underwent appendectomy at our tertiary referral centre for suspected acute appendicitis (January 2011-December 2018). Children referred to our centre, and those that underwent non-operative treatment were excluded. Post-appendectomy complications were recorded from electronic medical charts using predefined definitions and classified as severe (Clavien-Dindo III-IV) or less severe (Clavien-Dindo I-II). RESULTS A total of 131 children were included. Simple and complex appendicitis was diagnosed in 66 (50%) and 60 (46%) children, respectively. A non-inflamed appendix was seen in five (4%) children. One or more complications were identified in 33 (25%) patients. Eight (12%) children with simple appendicitis developed a complication, three of these were severe. In children with complex appendicitis, 23 (38%) children developed a complication, 14 of these were severe. CONCLUSION This study shows a high rate of complications compared with current literature, both in children with simple and complex appendicitis. This is probably the result of our definition of complications and being a tertiary referral centre receiving more severe appendicitis cases. However, these results still show that appendectomy is not always a routine procedure with only few complications. Substantiating the need to keep optimizing treatment for children with appendicitis.
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Lee HJ, Woo JY, Byun J. Right hydronephrosis as a sign of complicated appendicitis. Eur J Radiol 2020; 131:109241. [PMID: 32916410 DOI: 10.1016/j.ejrad.2020.109241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/09/2020] [Accepted: 08/10/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Acute appendicitis is known for one of the most common cause of acute abdomen. However, it is still challenging to clearly distinguish complicated from uncomplicated appendicitis preoperatively. We investigated the association between right hydronephrosis and complicated appendicitis compared with other computed tomography (CT) findings of acute appendicitis. MATERIALS AND METHODS 1275 patients who pathologically diagnosed with acute appendicitis were included. They were classified into the complicated appendicitis and uncomplicated appendicitis groups based on their histopathological results. We reviewed their CT findings, including right hydronephrosis, appendiceal wall defect, periappendiceal abscess, extraluminal or intraluminal free air, appendicolith, appendiceal dilatation, appendiceal wall thickening, periappendiceal infiltration, periappendiceal fluid collection, and ascites. Comparison between the two groups was performed and the diagnostic performance of each CT finding was evaluated. The location of appendix and periureteral extension of periappendiceal infiltration were evaluated in patients with right hydronephrosis. RESULTS Out of 1275 patients, 29 (2.3 %) patients showed right hydronephrosis. Right hydronephrosis was significantly related to complicated appendicitis with the odds ratio of 4.90 (95 % confidence interval, 1.62-14.83; P = 0.005). Right hydronephrosis yielded specificity of 99.3 %. All patients with right hydronephrosis accompanied with periappendiceal infiltration and 28 (96.6 %) patients showed periureteral extension. Subcecal and pelvic areas are the most common locations, with 11 (37.9 %) patients each. CONCLUSION The presence of right hydronephrosis was specific finding for complicated appendicitis and it could be considered as one of indirect sign of complicated appendicitis.
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Affiliation(s)
- Hyung Ju Lee
- Department of Radiology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Ji Young Woo
- Department of Radiology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
| | - Jieun Byun
- Department of Radiology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
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Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial. Ann Surg 2020; 271:1030-1035. [PMID: 31800496 DOI: 10.1097/sla.0000000000003646] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the safety and feasibility of nonoperative treatment of acute nonperforated appendicitis in children during 5 years of follow-up. METHODS A 4-year follow-up of a previous randomized controlled pilot trial, including 50 children with acute nonperforated appendicitis, was performed. The patients were initially randomized to nonoperative treatment with antibiotics or appendectomy with 1-year follow-up previously reported. Data were extracted from the computerized notes and telephone interviews.The primary outcome was treatment failure, defined as need for a secondary intervention under general anesthesia, related to the previous diagnosis of acute nonperforated appendicitis. RESULTS The children were followed up for at least 5 years [median 5.3 (range 5.0-5.6)] after inclusion. There were no failures in the appendectomy group (0/26) and 11 failures in the nonoperative group (11/24). Nine failures had occurred during the first year after inclusion, 2 of whom had histologically confirmed appendicitis. There were 2 further patients with recurrent acute appendicitis 1 to 5 years after inclusion. Both these patients had uncomplicated laparoscopic appendectomies for histologically confirmed acute appendicitis. There were no losses to follow-up. CONCLUSIONS At 5 years of follow-up 46% of children treated with antibiotics for acute nonperforated appendicitis had undergone an appendectomy, although acute appendicitis was only histologically confirmed in 4/24 (17%). Treatment with antibiotics seems to be safe in the intermediate-term; none of the children previously treated nonoperatively re-presented with complicated appendicitis.
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Heeren N, Gass M. [Can Uncomplicated Adult Appendicitis Also Be Treated Conservatively?]. PRAXIS 2020; 109:465-470. [PMID: 32345175 DOI: 10.1024/1661-8157/a003452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Can Uncomplicated Adult Appendicitis Also Be Treated Conservatively? Abstract. For more than a century, appendectomy has been the first-line treatment for acute appendicitis. Despite modern imaging, it is not an easy disease to diagnose and is one of the most common emergency procedures worldwide. Conservative therapy for uncomplicated adult appendicitis is increasingly becoming the focus of discussion. Due to current data, a recommendation for conservative therapy of uncomplicated adult appendicitis can not be given. For the time being it should be reserved for a selected patient group.
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Affiliation(s)
| | - Markus Gass
- Abteilung für Viszeralchirurgie, Luzerner Kantonsspital, Luzern
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Ranaweera C, Brar A, Somers GR, Sheikh F, Pierro A, Zani A. Management of pediatric appendiceal carcinoid: a single institution experience from 5000 appendectomies. Pediatr Surg Int 2019; 35:1427-1430. [PMID: 31555859 DOI: 10.1007/s00383-019-04575-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2019] [Indexed: 12/20/2022]
Abstract
AIM OF THE STUDY Appendiceal carcinoid (neuroendocrine tumor or NET) is a rare neuroendocrine neoplasm often found incidentally following appendectomy for appendicitis. Surgery for appendicitis is currently under scrutiny and children are increasingly managed conservatively with antibiotics alone. Herein, we aimed to review our experience with the management of appendiceal carcinoids at our institution. METHODS Following ethical approval, we reviewed the charts of all patients who underwent appendectomy for appendicitis at our institution between 2000 and 2018. The pathology registry was consulted to identify children diagnosed with appendiceal carcinoid. Outcome measures included incidence, demographics, and management. MAIN RESULTS During the study period, 32 children (23 female) had an appendiceal carcinoid confirmed at pathology. Of these, 13 were initially treated with appendectomy (total of 5,059 appendectomies: 0.3% incidence). The other 19 had an appendectomy elsewhere by an adult general surgeon and were referred to our institution for further management. Overall, the mean age at diagnosis was 13 ± 2.7 years and all patient had a preoperative diagnosis of appendicitis, none of suspected carcinoid. Most children (75%) had acute non-perforated appendicitis. The overall mean size of the lesion was 1 ± 0.9 cm, with a > 2 cm lesion in 3 patients. Following diagnosis, 12 children (38%) underwent an ileocolic resection, due to carcinoid size, invasiveness, and margin clearance. CONCLUSIONS In our cohort, the incidence of appendiceal carcinoid among children with appendicitis is very low. Most carcinoids are small, located at the tip, associated with non-perforated appendicitis, and present in girls. Most were treated with appendectomy alone, with more extensive surgery performed in one third of children.
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Affiliation(s)
- Chirath Ranaweera
- Division of General and Thoracic Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Amanpreet Brar
- Division of General and Thoracic Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Gino R Somers
- Division of Pathology, Department of Pediatric Laboratory Medicine, Hospital for Sick Children, Toronto, Canada
| | - Furqan Sheikh
- Division of Hematology/Oncology, Hospital for Sick Children, Toronto, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Augusto Zani
- Division of General and Thoracic Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Vanhatalo S, Munukka E, Sippola S, Jalkanen S, Grönroos J, Marttila H, Eerola E, Hurme S, Hakanen AJ, Salminen P. Prospective multicentre cohort trial on acute appendicitis and microbiota, aetiology and effects of antimicrobial treatment: study protocol for the MAPPAC (Microbiology APPendicitis ACuta) trial. BMJ Open 2019; 9:e031137. [PMID: 31494621 PMCID: PMC6731800 DOI: 10.1136/bmjopen-2019-031137] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Based on the epidemiological and clinical data, acute appendicitis can present either as uncomplicated or complicated. The aetiology of these different appendicitis forms remains unknown. Antibiotic therapy has been shown to be safe, efficient and cost-effective for CT-confirmed uncomplicated acute appendicitis. Despite appendicitis being one of the most common surgical emergencies, there are very few reports on appendicitis aetiology and pathophysiology focusing on the differences between uncomplicated and complicated appendicitis. Microbiology APPendicitis ACuta (MAPPAC) trial aims to evaluate these microbiological and immunological aspects including immune response in the aetiology of these different forms also assessing both antibiotics non-responders and appendicitis recurrence. In addition, MAPPAC aims to determine antibiotic and placebo effects on gut microbiota composition and antimicrobial resistance. METHODS AND ANALYSIS MAPPAC is a prospective clinical trial with both single-centre and multicentre arm conducted in close synergy with concurrent trials APPendicitis ACuta II (APPAC II) (per oral (p.o.) vs intravenous+p.o. antibiotics, NCT03236961) and APPAC III (double-blind trial placebo vs antibiotics, NCT03234296) randomised clinical trials. Based on the enrolment for these trials, patients with CT-confirmed uncomplicated acute appendicitis are recruited also to the MAPPAC study. In addition to these conservatively treated randomised patients with uncomplicated acute appendicitis, MAPPAC will recruit patients with uncomplicated and complicated appendicitis undergoing appendectomy. Rectal and appendiceal swabs, appendicolith, faecal and serum samples, appendiceal biopsies and clinical data are collected during the hospital stay for microbiological and immunological analyses in both study arms with the longitudinal study arm collecting faecal samples also during follow-up up to 12 months after appendicitis treatment. ETHICS AND DISSEMINATION This study has been approved by the Ethics Committee of the Hospital District of Southwest Finland (Turku University Hospital, approval number ATMK:142/1800/2016) and the Finnish Medicines Agency. Results of the trial will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03257423.
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Affiliation(s)
- Sanja Vanhatalo
- Institute of Biomedicine, Research Center for Cancer, Infections and Immunity, University of Turku, Turku, Finland
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Eveliina Munukka
- Microbiome Biobank, Faculty of Medicine, University of Turku, Turku, Finland
- Department of Clinical Microbiology, Turku University Hospital, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Sirpa Jalkanen
- Medicity and Institute of Biomedicine, University of Turku, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Harri Marttila
- Department of Hospital Hygiene and Infection Control, Turku University Hospital, Turku, Finland
| | - Erkki Eerola
- Institute of Biomedicine, Research Center for Cancer, Infections and Immunity, University of Turku, Turku, Finland
- Department of Clinical Microbiology, Turku University Hospital, Turku, Finland
| | - Saija Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Antti J Hakanen
- Institute of Biomedicine, Research Center for Cancer, Infections and Immunity, University of Turku, Turku, Finland
- Department of Clinical Microbiology, Turku University Hospital, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
- Satakunta Hospital District, Pori, Finland
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Marticorena Garcia SR, Hamm B, Sack I. Tomoelastography for non-invasive detection and treatment monitoring in acute appendicitis. BMJ Case Rep 2019; 12:12/8/e230791. [PMID: 31451472 DOI: 10.1136/bcr-2019-230791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Acute appendicitis is the most common cause of the acute abdomen syndrome and can be treated either surgically or conservatively with antibiotics. This case demonstrates the first time use of mechanics based MRI by tomoelastography with generation of quantitative maps of tissue stiffness (shear wave speed in m/s) and tissue fluidity (shear modulus loss angle, in rad) in a case of uncomplicated acute appendicitis with antibiotic treatment at (i) baseline, (ii) the end of treatment (EOT) and (iii) the 10 day follow-up after EOT. Baseline maps of stiffness and fluidity revealed to the naked eye the extent of intestinal inflammation by markedly increased values of stiffness and fluidity (2.56±0.12 m/s, 1.37±0.24 rad) compared with normal values, indicating the immediate response to antibiotic treatment at EOT (1.47±0.28 m/s, 0.80±0.11 rad) and persistent normalisation at follow-up (1.54±0.22 m/s, 0.92±0.22 rad). Tomoelastography is a non-invasive, quantitative imaging method for mechanics based characterisation and follow-up of acute appendicitis.
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Affiliation(s)
| | - Bernd Hamm
- Radiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ingolf Sack
- Radiology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Abstract
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.
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Haijanen J, Sippola S, Tuominen R, Grönroos J, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Salminen P. Cost analysis of antibiotic therapy versus appendectomy for treatment of uncomplicated acute appendicitis: 5-year results of the APPAC randomized clinical trial. PLoS One 2019; 14:e0220202. [PMID: 31344073 PMCID: PMC6657874 DOI: 10.1371/journal.pone.0220202] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/10/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The efficacy and safety of antibiotic treatment for uncomplicated acute appendicitis has been established at long-term follow-up with the majority of recurrences shown to occur within the first year. Overall costs of antibiotics are significantly lower compared with appendectomy at short-term follow-up, but long-term durability of these cost savings is unclear. The study objective was to compare the long-term overall costs of antibiotic therapy versus appendectomy in the treatment of uncomplicated acute appendicitis in the APPAC (APPendicitis ACuta) trial at 5 years. METHODS AND FINDINGS This multicentre, non-inferiority randomized clinical trial randomly assigned 530 adult patients with CT-confirmed uncomplicated acute appendicitis to appendectomy or antibiotic treatment at six Finnish hospitals. All major costs during the 5-year follow-up were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis. Between November 2009 and June 2012, 273 patients were randomized to appendectomy and 257 to antibiotics. The overall costs of appendectomy were 1.4 times higher (p<0.001) (€5716; 95% CI: €5510 to €5925) compared with antibiotic therapy (€4171; 95% CI: €3879 to €4463) resulting in cost savings of €1545 per patient (95% CI: €1193 to €1899; p<0.001) in the antibiotic group. At 5 years, the majority (61%, n = 156) of antibiotic group patients did not undergo appendectomy. CONCLUSIONS At 5-year follow-up antibiotic treatment resulted in significantly lower overall costs compared with appendectomy. As the majority of appendicitis recurrences occur within the first year after the initial antibiotic treatment, these results suggest that treating uncomplicated acute appendicitis with antibiotics instead of appendectomy results in lower overall costs even at longer-term follow-up.
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Affiliation(s)
- Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Risto Tuominen
- Department of Public Health, University of Turku, Turku, Finland
- University of Namibia, Windhoek, Namibia
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Hannu Paajanen
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Tero Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Pia Nordström
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - Markku Aarnio
- Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - Tuomo Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Saija Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
- * E-mail:
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The efficacy of antibiotic treatment versus surgical treatment of uncomplicated acute appendicitis: Systematic review and network meta-analysis of randomized controlled trial. Am J Surg 2019; 218:192-200. [PMID: 30340760 DOI: 10.1016/j.amjsurg.2018.10.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/14/2018] [Accepted: 10/05/2018] [Indexed: 12/26/2022]
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In-hospital perforation risk in acute appendicitis: Age matters. Am J Surg 2019; 219:65-70. [PMID: 31186116 DOI: 10.1016/j.amjsurg.2019.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/20/2019] [Accepted: 05/28/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Controversy exists regarding how quickly an adult with appendicitis requires surgery to prevent perforation, and recent literature on antibiotic use as definitive treatment has complicated this question further. Since perforation is associated with worse outcomes, particularly in the elderly, efforts to prevent this complication are warranted. We studied risk factors for in-hospital perforation in patients diagnosed by admission CT with non-perforated acute appendicitis. METHODS We evaluated baseline demographics, symptom duration, and time from admission to antibiotics and surgery. Outcome measure was perforation diagnosed intra-operatively by attending surgeon. RESULTS Of 700 patients, 84 (12%) sustained in-hospital perforation; time from admission to operation or antibiotics were not associated. Duration of symptoms >24 h (aOR = 2.23, 95% CI = 1.33-3.72, p < 0.001) increased perforation risk. Patient age over 46 years (aOR = 4.54, 95% CI = 2.04-10.06, p < 0.001) was also associated with higher risk that increased with increasing age. CONCLUSION Time to operation and antibiotic timing were not associated with in-hospital perforation in a general adult population. However, these findings suggest a possible benefit to expedient surgery in older patients.
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Kang CB, Li WQ, Zheng JW, Li XW, Lin DP, Chen XF, Wang DZ, Yao N, Liu XK, Qu J. Preoperative assessment of complicated appendicitis through stress reaction and clinical manifestations. Medicine (Baltimore) 2019; 98:e15768. [PMID: 31169674 PMCID: PMC6571411 DOI: 10.1097/md.0000000000015768] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study assessed the severity of the disease through the preoperative clinical manifestations and inflammatory reaction indicators of acute appendicitis, and established a score table to predict complicated appendicitis (CA).The clinical data of 238 patients with acute appendicitis in our hospital were retrospectively analyzed, which included 18 patients with acute simple appendicitis (7.6%), 170 patients with acute purulent appendicitis (72.0%), and 48 patients with acute gangrene and perforation (20.3%). The clinical manifestations and inflammatory reaction indicators were analyzed by univariate logistic regression. Multivariate logistic regression analysis was performed to screen out the independent risk factors of CA. The β coefficients of independent risk factors entering the multivariate model were assigned by rounding, and the total score was the sum of values of all factors. Finally, verification and analysis were performed for the predictive model, and the operating characteristic curve (ROC) curve was drawn. Then, the area under the curve (AUC) was compared with the THRIVE scale, and the Hosmer-Lemeshow method was used to evaluate whether the model fitted well.The multivariate logistic regression analysis of independent risk factors was performed, and the values were rounded to the variable assignment based on the β coefficient values. The plotted ROC and AUC was calculated as 0.857 (P < .001). Using the Hosmer-Lemeshow method, the X-value was 12.430, suggesting that the prediction model fitted well.The scoring system can quickly determine whether this is a CA, allowing for an earlier and correct diagnosis and treatment. Furthermore, the scoring system was convenient, economical, and affordable. Moreover, it is easy to popularized and promote.
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Affiliation(s)
| | | | | | | | | | | | | | - Nan Yao
- Department of General Surgery
| | - Xue-Kai Liu
- Department of Laboratory, Aerospace Center Hospital, Beijing, China
| | - Jun Qu
- Department of General Surgery
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Development of a Two Port Laparoscopic Appendectomy Technique at a Rural Hospital. Minim Invasive Surg 2019; 2019:9761968. [PMID: 31236293 PMCID: PMC6545795 DOI: 10.1155/2019/9761968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/18/2019] [Indexed: 01/25/2023] Open
Abstract
Background Laparoscopic appendectomy (LA) is most commonly performed using two 5-mm and one 10/12-mm ports. Various attempts to reduce the number and size of ports have been made and new technologies such as single port LA have been introduced. Appendix and mesoappendix are usually divided with a stapler or energy device with electrocautery, clips, and endoloop being cheaper options. Patients and Methods This study includes 51 consecutive LAs performed at a rural hospital. Patients were divided into 4 groups: group 1 was the standard technique group (n=12), group 2 served as a “try-out” (n=12), group 3 served as feasibility group (n=12), and group 4 was the final patient cohort in which the optimized technique was preferably used (n=15). Results Median age of the study cohort was 35.4 (range: 6.2-80.6) years, and 55% of patients were male. Whereas in G1 all patients had standard port placement (10/12-mm, 2x5-mm), in an increasing number of patients in G2-4 only two 5-mm ports and the 2.3-mm Teleflex minigrasper were inserted. Usage of staplers and/or energy devices was reduced from 100% in G1 to 20% in G4, and in the majority of cases both the appendix and the vascular pedicle were secured with an endoloop. The new technique did not add time to the procedure or total OR time. No stump-leaks or surgical site infections were encountered in this series, and there were no conversions to open surgery. Cost savings when not using a stapler or energy device are approximately 400$ per case; the minigrasper added approximately 200$ to the case. Discussion LA with use of two ports and a portless needle grasper is feasible in the majority of cases and was associated with high patient satisfaction and excellent cosmetic results. Avoiding energy devices and staplers is cost saving; the endoloop securely controls appendix and mesoappendix.
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