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Lamm R, Kumar SS, Collings AT, Haskins IN, Abou-Setta A, Narula N, Nepal P, Hanna NM, Athanasiadis DI, Scholz S, Bradley JF, Train AT, Pucher PH, Quinteros F, Slater B. Diagnosis and treatment of appendicitis: systematic review and meta-analysis. Surg Endosc 2023; 37:8933-8990. [PMID: 37914953 DOI: 10.1007/s00464-023-10456-5] [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: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children. METHODS Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively. RESULTS 2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04). CONCLUSIONS This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.
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Affiliation(s)
- Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Thomas Jefferson University, 1015 Walnut Street, 613 Curtis, Philadelphia, PA, 19107, USA.
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Nisha Narula
- Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Pramod Nepal
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joel F Bradley
- Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Philip H Pucher
- Department of Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago Medicine, Chicago, IL, USA
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Kupietzky A, Finkin M, Dover R, Eliezer Lourie NE, Mordechai-Heyn T, Juster EY, Mazeh H, Mizrahi I. Higher Rates of Complicated Appendicitis During the COVID-19 Pandemic: A Year-to-Year Analysis. J Surg Res 2023; 290:304-309. [PMID: 37329625 PMCID: PMC10208264 DOI: 10.1016/j.jss.2023.05.007] [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: 11/20/2022] [Revised: 04/03/2023] [Accepted: 05/12/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION The COVID-19 pandemic impacted presentation, management strategies, and patient outcomes of numerous medical conditions. The aim of this study is to perform a year-to-year comparison of clinical outcomes of patients with acute appendicitis (AA) before and during the pandemic. METHODS Patients treated for AA during the initial 12-mo period of the pandemic at our institute were compared to those treated for AA during the 12-mo period before. Clinical and laboratory parameters, treatment strategies, intraoperative findings, pathology reports, and postoperative outcomes were compared. RESULTS During the study period, 541 patients presented with AA. The median (interquartile range) age was 28 (21-40) y and 292 (54%) were males. 262 (48%) patients presented during the pre-COVID-19 period, while 279 patients (52%) presented during the COVID 19 pandemic. The groups were comparable for baseline clinical data and imaging results upon index admission. There was no significant difference in rate of nonoperative treatment between the Pre-COVID-19 and During-COVID-19 eras (51% versus 53%, P = 0.6) as well as the success rate of such treatment (95.4% versus 96.4%, P = 0.3). Significantly more patients presented with a periappendicular abscess during COVID-19 (4.6% versus 1.1%, P = 0.01) and median (interquartile range) operative time was significantly longer (78 (61-90) versus 32.5 (27-45) min, P < 0.001). Pathology reports revealed a higher rate of perforated appendicitis during COVID-19 (27.4% versus 10.2%, P < 0.001). CONCLUSIONS Patients with AA present with higher rates of perforated and complicated appendicitis during the COVID-19 pandemic. The success rates of nonoperative management in selected patients with noncomplicated AA did not change during the pandemic and is a safe, feasible, option.
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Affiliation(s)
- Amram Kupietzky
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Miriam Finkin
- Faculty of Medicine, Department of Military Medicine and "Tzameret", Hebrew University of Jerusalem and Medical Corps, Israel Defense Forces, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Roi Dover
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Nachum Emil Eliezer Lourie
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tzlil Mordechai-Heyn
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eyal Yonathan Juster
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Haggi Mazeh
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ido Mizrahi
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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Shiihara M, Sudo Y, Matsushita N, Kubota T, Hibi Y, Osugi H, Inoue T. Usefulness of Preoperative Predictors of Pathological Complicated Appendicitis. Dig Surg 2023; 40:121-129. [PMID: 37285808 DOI: 10.1159/000531284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 05/17/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Complicated appendicitis (CA) is often indicated for emergency surgery; however, preoperative predictors of pathological CA (pCA) remain unclear. Furthermore, characteristics of CA that can be treated conservatively have not yet been established. METHODS 305 consecutive patients diagnosed with acute appendicitis were reviewed. The patients were divided into two groups: an emergency surgery and a conservative treatment group. The emergency surgery group was pathologically classified as having uncomplicated appendicitis (pUA) and pCA, and the preoperative predictors of pCA were retrospectively assessed. Based on the preoperative pCA predictors, a predictive nomogram whether conservative treatment would be successful or not was created. The predictors were applied to the conservative treatment group, and the outcomes were investigated. RESULTS In the multiple logistic regression analysis of the factors contributing to pCA, C-reactive protein ≥3.5 mg/dL, ascites, appendiceal wall defect, and periappendiceal fluid collection were independent risk factors. Over 90% of cases without any of the above four preoperative pCA predictors were pUA. The accuracy of the nomogram was 0.938. CONCLUSION Our preoperative predictors and nomogram are useful to aid in distinguishing pCA and pUA and to predict whether or not conservative treatment will be successful. Some CA can be treated with conservative treatment.
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Affiliation(s)
| | - Yasuhiro Sudo
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | | | - Takeshi Kubota
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | - Yasuhiro Hibi
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | - Harushi Osugi
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | - Tatsuo Inoue
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
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Minneci PC, Hade EM, Gil LA, Metzger GA, Saito JM, Mak GZ, Hirschl RB, Gadepalli S, Helmrath MA, Leys CM, Sato TT, Lal DR, Landman MP, Kabre R, Fallat ME, Cooper JN, Deans KJ. Demographic and Clinical Characteristics Associated With the Failure of Nonoperative Management of Uncomplicated Appendicitis in Children: Secondary Analysis of a Nonrandomized Clinical Trial. JAMA Netw Open 2022; 5:e229712. [PMID: 35499827 PMCID: PMC9062687 DOI: 10.1001/jamanetworkopen.2022.9712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The factors associated with the failure of nonoperative management of appendicitis and the differences in patient-reported outcomes between successful and unsuccessful nonoperative management remain unknown. OBJECTIVES To investigate factors associated with the failure of nonoperative management of appendicitis and compare patient-reported outcomes between patients whose treatment succeeded and those whose treatment failed. DESIGN, SETTING, AND PARTICIPANTS This study was a planned subgroup secondary analysis conducted in 10 children's hospitals that included 370 children aged 7 to 17 years with uncomplicated appendicitis enrolled in a prospective, nonrandomized clinical trial between May 1, 2015, and October 31, 2018, with 1-year follow-up comparing nonoperative management with antibiotics vs surgery for uncomplicated appendicitis. Statistical analysis was performed from November 1, 2019, to February 12, 2022. INTERVENTIONS Nonoperative management with antibiotics vs surgery. MAIN OUTCOMES AND MEASURES Failure of nonoperative management and patient-reported outcomes. The relative risk (RR) of failure based on sociodemographic and clinical characteristics was calculated. Patient-reported outcomes were compared based on the success or failure of nonoperative management. RESULTS Of 370 patients (34.6% of 1068 total patients; 229 boys [61.9%]; median age, 12.3 years [IQR, 10.0-14.6 years]) enrolled in the nonoperative group, treatment failure occurred for 125 patients (33.8%) at 1 year, with 53 patients (14.3%) undergoing appendectomy during initial hospitalization and 72 patients (19.5%) experiencing delayed treatment failure after hospital discharge. Higher patient-reported pain at presentation was associated with increased risk of in-hospital treatment failure (RR, 2.1 [95% CI, 1.0-4.4]) but not delayed treatment failure (RR, 1.3 [95% CI, 0.7-2.3]) or overall treatment failure at 1 year (RR, 1.5 [95% CI, 1.0-2.2]). Pain duration greater than 24 hours was associated with decreased risk of delayed treatment failure (RR, 0.3 [95% CI, 0.1-1.0]) but not in-hospital treatment failure (RR, 1.2 [95% CI, 0.5-2.7]) or treatment failure at 1 year (RR, 0.7 [95% CI, 0.4-1.2]). There was no increased risk of treatment failure associated with age, white blood cell count, sex, race, ethnicity, primary language, insurance status, transfer status, symptoms at presentation, or imaging results. Health care satisfaction at 30 days and patient-reported, health-related quality of life at 30 days and 1 year were not different. Satisfaction with the decision was higher with successful nonoperative management at 30 days (28.0 vs 27.0; difference, 1.0 [95% CI, 0.01-2.0]) and 1 year (28.1 vs 27.0; difference, 1.1 [95% CI, 0.2-2.0]). CONCLUSIONS AND RELEVANCE This analysis suggests that a higher pain level at presentation was associated with a higher risk of initial failure of nonoperative management and that a longer duration of pain was associated with lower risk of delayed treatment failure. Although satisfaction was high in both groups, satisfaction with the treatment decision was higher among patients with successful nonoperative management at 1 year. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02271932.
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Affiliation(s)
- Peter C. Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, Ohio
| | - Erinn M. Hade
- Department of Population Health, Division of Biostatistics, New York University Grossman School of Medicine, New York
| | - Lindsay A. Gil
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, Ohio
| | - Gregory A. Metzger
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, Ohio
| | - Jacqueline M. Saito
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Grace Z. Mak
- Section of Pediatric Surgery, Department of Surgery, University of Chicago Medicine and Biologic Sciences, Chicago, Illinois
| | - Ronald B. Hirschl
- Division of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor
| | - Samir Gadepalli
- Division of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor
| | - Michael A. Helmrath
- Division of Pediatric Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Charles M. Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Thomas T. Sato
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Dave R. Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Matthew P. Landman
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Rashmi Kabre
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mary E. Fallat
- Division of Pediatric Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Jennifer N. Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, Ohio
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