Spontaneous Resolution of Uncomplicated Appendicitis may Explain Increase in Proportion of Complicated Appendicitis During Covid-19 Pandemic: a Systematic Review and Meta-analysis

The impact of timing on outcomes in appendicectomy: a systematic review and network meta-analysis

INTRODUCTION

Appendicectomy remains the standard treatment for appendicitis. There is a lack of clarity on the timeframe in which surgery should be performed to avoid unfavourable outcomes.

AIM

To perform a systematic review and network meta-analysis to evaluate the impact the (1)time-of-day surgery is performed (2), time elapsed from symptom onset to hospital presentation (patient time) (3), time elapsed from hospital presentation to surgery (hospital time), and (4)time elapsed from symptom onset to surgery (total time) have on appendicectomy outcomes.

METHODS

A systematic review was performed as per PRISMA-NMA guidelines. The time-of-day which surgery was done was divided into day, evening and night. The other groups were divided into < 24 h, 24-48 h and > 48 h. The rate of complicated appendicitis, operative time, perforation, post-operative complications, surgical site infection (SSI), length of stay (LOS), readmission and mortality rates were analysed.

RESULTS

Sixteen studies were included with a total of 232,678 patients. The time of day at which surgery was performed had no impact on outcomes. The incidence of complicated appendicitis, post-operative complications and LOS were significantly better when the hospital time and total time were < 24 h. Readmission and mortality rates were significantly better when the hospital time was < 48 h. SSI, operative time, and the rate of perforation were comparable in all groups.

CONCLUSION

Appendicectomy within 24 h of hospital admission is associated with improved outcomes compared to patients having surgery 24-48 and > 48 h after admission. The time-of-day which surgery is performed does not impact outcomes.

Resolution of Sonographic Appendicitis in Pediatrics: a Point of Care Ultrasound Case-Series

Studies of pediatric appendicitis treated conservatively show a considerable rate of recurrence. Point of care ultrasound (POCUS) imaging at our facility is routinely performed for abdominal pain and may be more likely than radiology-performed ultrasound to encounter cases that then self-resolve. We present a case series collected from a POCUS quality assurance review from 2019 through 2022. Five children were identified with sonographic appendicitis on review of stored POCUS images, and subsequent improvement of pain. A pediatric radiologist reviewed blinded images and agreed with the POCUS interpretation in all five cases. No child in this series received antibiotics. The national patient database was used to ensure that the patients in this series did not present elsewhere with appendicitis. We suggest that these cases represent early appendicitis that self-resolved. Patients should be aware that POCUS showed signs of appendicitis, and should seek medical attention for recurrence of symptoms.

Acute appendicitis: A block-randomized study on active observation with or without antibiotic treatment

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.

Impact of the COVID-19 pandemic on the clinical management trends for acute appendicitis among the under-25s: a retrospective study

OBJECTIVE

To describe the COVID-19 pandemic's impact on acute appendicitis management on children and young people (CYP).

DESIGN

Retrospective cohort study.

SETTING

All English National Health Service hospitals.

PATIENTS

Acute appendicitis admissions (all, simple, complex) by CYP (under-5s, 5-9s, 10-24s).

EXPOSURE

Study pandemic period: February 2020-March 2021. Comparator pre-pandemic period: February 2015-January 2020.

MAIN OUTCOME MEASURES

Monthly appendicectomy and laparoscopic appendicectomy rate trends and absolute differences between pandemic month and the pre-pandemic average. Proportions of appendicitis admissions comprising complex appendicitis by hospital with or without specialist paediatric centres were compared.

RESULTS

101 462 acute appendicitis admissions were analysed. Appendicectomy rates fell most in April 2020 for the 5-9s (-18.4% (95% CI -26.8% to -10.0%)) and 10-24s (-28.4% (-38.9% to -18.0%)), driven by reductions in appendicectomies for simple appendicitis. This was equivalent to -54 procedures (-68.4 to -39.6) and -512 (-555.9 to -467.3) for the 5-9s and 10-24s, respectively. Laparoscopic appendicectomies fell in April 2020 for the 5-9s (-15.5% (-23.2% to -7.8%)) and 10-24s (-44.8% (-57.9% to -31.6%) across all types, which was equivalent to -43 (-56.1 to 30.3) and -643 (-692.5 to -593.1) procedures for the 5-9s and 10-24s, respectively. A larger proportion of complex appendicitis admissions were treated within trusts with specialist paediatric centres during the pandemic.

CONCLUSIONS

For CYP across English hospitals, a sharp recovery followed a steep reduction in appendicectomy rates in April 2020, due to concerns with COVID-19 transmission. This builds on smaller-sized studies reporting the immediate short-term impacts.