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

Is non-operative treatment of acute appendicitis possible: A narrative review

Introduction

Acute appendicitis (AA) represents the most frequent surgical emergency. Perforation was long considered the ultimate outcome of AA, prompting appendectomy; which remains the standard treatment. New data have clarified the role of the appendix, justifying conservative treatment. This narrative review aims to summarize the evidence regarding the non-operative treatment (NOT) of AA in adults.

Methods

The literature search was performed via the PubMed Medline database. Our criteria-based selection resulted in a total of 48 articles for review.

Results

Recent trials and meta-analyses have assessed NOT, which support primary antibiotic treatment of uncomplicated AA. Although it has a significant recurrence and failure rate, NOT does not appear to increase the risk of appendicular perforation. Moreover, NOT compared with appendectomy, seems to be associated with less morbidity, lower cost of care and preserved quality of life.

Conclusion

First-line NOT seems to be a reasonable approach for the treatment of uncomplicated CT-confirmed AA. Careful patient screening would definitely enhance the success rate.

Retrospective analysis of the incidence of appendiceal neoplasm and malignancy in patients treated for suspected acute appendicitis

BACKGROUND

Nonoperative management of uncomplicated appendicitis is currently being promoted as treatment option, albeit 0.7-2.5% of appendectomies performed due to suspected acute appendicitis show histologically malignant findings. The purpose of this study was to investigate the incidence of neoplasm and malignancy of the appendix in patients presenting with suspected acute appendicitis in real world setting.

METHODS

This is a retrospective single-centre investigation of 457 patients undergoing appendectomy between the years 2017-2020. The patients' demographics, symptoms and diagnosis, intraoperative findings, and histopathological results were analysed.

RESULTS

In 3.7% (n = 17) histological analysis revealed neoplasms or malignancies. Median age was 48 years (20-90 years), without sex predominance. Leukocytes (11.3 ± 3.7 G/l) and C-reactive protein (54.2 ± 69.0 mg/l) were elevated. Histological analysis revealed low-grade mucinous appendiceal neoplasia (n = 3), sessile serrated adenoma of the appendix (n = 3), neuroendocrine tumours (n = 7), appendiceal adenocarcinoma of intestinal type (n = 3), and goblet cell carcinoma (n = 1). Additional treatment varied between no treatment or follow-up due to early tumour stage (n = 4), follow-up care (n = 3), additional surgical treatment (n = 8), or best supportive care (n = 2).

CONCLUSIONS

Preoperative diagnosis of appendiceal tumours is difficult. Nonoperative management of patients with acute, uncomplicated appendicitis potentially prevents the correct diagnosis of malignant appendiceal pathologies. Therefore, close follow-up or surgical removal of the appendix is mandatory.

Risk of appendiceal malignancy in conservatively treated acute appendicitis

BACKGROUND AND AIMS

Appendectomy has historically been the standard treatment of acute appendicitis, but lately, conservative treatment of uncomplicated acute appendicitis with antibiotics has successfully been used in selected patients. Complicated acute appendicitis is often treated conservatively initially, but may benefit from interval appendectomy due to the higher risk of appendiceal malignancy and recurrence. Recommendations for follow-up after conservatively treated appendicitis vary. Furthermore, the risk of underlying malignancy and the necessity of routine interval appendectomy are unclear. This study aims to evaluate follow-up status, recurrence, and underlying appendiceal malignancy in conservatively treated uncomplicated and complicated acute appendicitis.

METHODS

This study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and data on follow-up, recurrence, number of appendectomies after initial conservative treatment, and underlying malignancy were retrieved from medical charts.

RESULTS

The study cohort included 391 patients, 152 with uncomplicated and 239 with complicated acute appendicitis. Median time of study follow-up was 52 months. The recurrence risk was 23 (15.1%) after uncomplicated and 58 (24.3%) after complicated acute appendicitis (p = 0.030). During follow-up, 55 (23%) patients with complicated acute appendicitis underwent appendectomy. Appendiceal malignancies were found in 12 (5%) patients with previous complicated acute appendicitis versus no appendiceal malignancies after uncomplicated acute appendicitis (p = 0.002).

CONCLUSION

The risk of appendiceal malignancy and recurrent appendicitis was significantly higher in patients with complicated acute appendicitis compared with uncomplicated acute appendicitis.

Incidence rate and histology of appendiceal neoplasms in complicated versus uncomplicated appendicitis: A meta-analysis and systematic review

INTRODUCTION

Studies evaluating the rate and histology of appendiceal neoplasms between complicated and uncomplicated appendicitis include a small number of patients. Therefore, we sought a meta-analysis and systematic review comparing the rates and types of appendiceal neoplasm between complicated and uncomplicated appendicitis.

METHODS

We included articles published from the time of inception of the datasets to September 30, 2022. The electronic databases included English publications in Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, and Scopus.

RESULTS

A total of 4962 patients with appendicitis enrolled in 4 comparative studies were included. The mean age was 43.55 years (16- 94), and half were male (51%). Based on intra-operative findings, 1394 (38%) had complicated appendicitis, and 3558 (62%) had uncomplicated appendicitis. The overall incidence rate of neoplasm was 1.98%. No significant difference was found in the incidence rate of appendiceal neoplasm between complicated (3.29%) and uncomplicated (1.49%) appendicitis (OR 0.44, 95% CI 0.16- 1.23; p < 0.087; I2 = 54.9%). The most common appendiceal neoplasms were Neuroendocrine Tumors (NET) (49.21%), Nonmucinous Adenocarcinoma (24.24%), Mixed Adeno-Neuroendocrine Tumor (MANEC) (11.40%), Mucinous Adenocarcinoma (4.44%). There was a significant difference between complicated and uncomplicated appendicitis in rates of adenocarcinoma (50% vs. 13%), NET (31% vs. 74%), MANEC (19% vs. 13%) (P < 0.001).

CONCLUSION

While there was no significant difference in the overall neoplasm rate between complicated and uncomplicated appendicitis, the NET rate was significantly higher in uncomplicated appendicitis. In comparison, the Adenocarcinoma rate was considerably higher in Complicated appendicitis. These findings emphasize the importance of evaluating risk factors for neoplasm when considering appendectomy in patients with appendicitis.

High Incidence of Appendiceal Neoplasms in the Elderly: A Critical Concern for Non-Surgical Treatment

OBJECTIVE

Appendiceal neoplasms (ANs) are rare tumors that are often discovered incidentally during histopathological examinations. The increasing incidence of ANs is a critical issue in the non-operative management of acute appendicitis. This study aimed to document the temporal trends over a 12-year period by analyzing the clinical presentation, imaging findings, and histopathological features of ANs.

SUBJECTS AND METHODS

Health records of patients who underwent appendectomy from 2011 to 2022 were examined. Demographic and clinical data, laboratory results, imaging findings, and histopathological features were documented. The characteristics of both ANs and non-neoplastic cases were evaluated.

RESULTS

A total of 22,304 cases were identified, of which 330 (1.5%) were diagnosed with ANs. The odds ratio for ANs increased with age, with the highest odds ratio observed in patients aged 70 or older. Receiver Operating Characteristic analysis showed that age and appendiceal diameter were significant predictors of ANs. An optimal age cut-off point of 28.5 years was determined, yielding a sensitivity of 72% and a specificity of 64%. For appendiceal diameter, the optimal cut-off was found to be 9.5 mm, exhibiting a sensitivity of 77% and a specificity of 56%.

CONCLUSION

Although the incidence of ANs remains relatively low, a steady increase has been observed over the past decade. The increasing rate of ANs raises concerns regarding non-surgical management options. The results of this study highlight the importance of considering ANs as a potential diagnosis in older patients and in patients with an appendix diameter greater than 9.5 mm. These findings may have implications for treatment and management.

Risk factors for postoperative morbidity, prolonged length of stay and hospital readmission after appendectomy for acute appendicitis

PURPOSE

The aim of the present study was to identify risk factors associated with postoperative morbidity and major morbidity, with a prolonged length of hospital stay and with the need of readmission in patients undergoing appendectomy due to acute appendicitis.

METHODS

We performed a retrospective analysis of 1638 adult patients who underwent emergency appendectomy for preoperatively suspected acute appendicitis from 2010 to 2020 at the University Hospital Erlangen. Data including patient demographics, pre-, intra-, and postoperative findings were collected and compared between different outcome groups (morbidity, major morbidity, prolonged length of postoperative hospital stay (LOS) and readmission) from those patients with verified acute appendicitis (n = 1570).

RESULTS

Rate of negative appendectomies was 4%. In patients with verified acute appendicitis, morbidity, major morbidity and readmission occurred in 6%, 3% and 2%, respectively. Mean LOS was 3.9 days. Independent risk factors for morbidity were higher age, higher preoperative WBC-count and CRP, lower preoperative hemoglobin, longer time to surgery and longer duration of surgery. As independent risk factors for major morbidity could be identified higher age, higher preoperative CRP, lower preoperative hemoglobin and longer time to surgery. Eight parameters were independent risk factors for a prolonged LOS: higher age, higher preoperative WBC-count and CRP, lower preoperative hemoglobin, need for conversion, longer surgery duration, presence of intraoperative complicated appendicitis and of postoperative morbidity. Presence of malignancy and higher preoperative WBC-count were independent risk factors for readmission.

CONCLUSION

Among patients undergoing appendectomy for acute appendicitis, there are relevant risk factors predicting postoperative complications, prolonged hospital stays and readmission. Patients with the presence of the identified risk factors should receive special attention in the postoperative course and may benefit from a more individualized therapy.

A randomized, controlled multicenter feasibility pilot trial on imaging confirmed uncomplicated acute appendicitis: Appendectomy vs. symptomatic treatment in pediatric patients (the APPSYPP) trial study protocol

INTRODUCTION

Imaging-confirmed uncomplicated acute appendicitis can be effectively and safely treated with antibiotics in most adults and children. Symptomatic treatment may have similar efficacy and safety.

METHODS AND ANALYSIS

The APPSYPP trial is a randomized national multicenter feasibility superiority pilot study comparing appendectomy with symptomatic treatment in children with imaging-confirmed uncomplicated acute appendicitis.

INCLUSION CRITERIA

1) age ≥ 7 and < 16 years, 2) imaging-confirmed uncomplicated acute appendicitis and 3) CRP ≤ 65 mg/l. Patients are randomized to receive emergency laparoscopic appendectomy or symptomatic treatment. To ensure patient safety, symptomatically treated patients are hospitalized for at least 24 h receiving standard practice intravenous fluids and analgesics according to standard clinical practice. Primary outcome is 30-day treatment success defined by the absence of any treatment failure criteria. In appendectomy, treatment failure is defined as normal appendiceal histopathology or any postintervention complication requiring general anesthesia. In symptomatic treatment, treatment failure is defined as 1) inability for hospital discharge without appendectomy within 48 h after randomization with a finding of histopathologically inflamed appendix, 2) appendectomy during the initial hospital stay due to clinical progression of appendicitis with complicated acute appendicitis both histopathologically and surgically, 3) appendectomy with a histopathological finding of acute appendicitis after hospital discharge, or 4) any complication of appendicitis requiring general anesthesia. Detailed predefined secondary outcomes will be analyzed.

ETHICS AND DISSEMINATION

Study was approved by Ethics Committee of Helsinki University Hospital (ID:HUS/1993/2021), conducted in compliance with the declaration of Helsinki with results disseminated in peer-reviewed scientific journals.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05289713).

STRENGTHS AND LIMITATIONS OF THIS STUDY

Accessory spleen presenting with an episode of acute appendicitis; a case report of a very rare case

Introduction

The accessory spleen (AS) is a condition that results from improper placement of spleen cells. About 95 % of ASs are located in the splenic hilum proximal to the tail of the pancreas. Here we present a 23-year-old male diagnosed with AS in the appendix, following an episode of acute appendicitis.

Case presentation

A 23-year-old male patient who presented with typical symptoms of appendicitis and the examination and paraclinical findings were in favor of appendicitis. Intraoperative findings showed an inflamed appendix and a 2 cm solid mass in the mesoappendix. The pathology report showed acute appendicitis and normal spleen tissue.

Conclusion

The current study indicated an abnormal location of AS placed in the mesoappendix, which was presented with an episode of acute appendicitis.

•

The accessory spleen (AS) is a condition that results from improper placement of spleen cells.

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About 95% of ASs are located in the splenic hilum proximal to the tail of the pancreas.

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The remaining 5% are formed in the gastrosplenic ligament, wall of the stomach, wall of the intestine, and the mesentery or pelvic cavity

•

The current study indicated an abnormal location of AS placed in the mesoappendix, which was presented with an episode of acute appendicitis

Features on Computed Tomography That Correlate With Acute Appendicitis

Background: The purpose of this study is to investigate the relevant findings in adult patients admitted to Cabell Huntington Hospital who were diagnosed with acute appendicitis. Methods: Patients who had the postoperative diagnosis of acute appendicitis and a preoperative computed tomography (CT) scan from January 2011 through December 2016 were included in this retrospective chart review. Results: There were 592 patients. A thick, edematous appendix was the most common CT finding in acute appendicitis. The average diameter was 12.6 mm. The wall thickness correlated to the diameter of the appendix (P < 0.001). For comparison, we reviewed the CT scans of 50 trauma patients who had normal abdominal CT scans. The average diameter of a normal appendix was 4.9 mm (SD 1.139) with a range of 4-7 mm. Interestingly, the admission white blood cell count (P = 0.0372) as well as the thickness of the appendix (P < 0.0001) were strongly associated with increased length of stay. Conclusions: An appendiceal diameter greater than 9 mm should be considered abnormal and associated with acute appendicitis. Appendiceal size, white blood cell count, and age correlate with length of stay. Early antibiotics and early surgical intervention may decrease length of stay.

The association between appendicitis severity and patient age with appendiceal neoplasm histology-a population-based study

PURPOSE

Recent studies have reported alarming appendiceal tumor rates associated with complicated acute appendicitis, especially in patients presenting with a periappendicular abscess. However, the data on histology of appendiceal tumors among acute appendicitis patients is limited, especially in patient cohorts differentiating between uncomplicated and complicated acute appendicitis. We have previously reported the association of increased appendiceal tumor prevalence with complicated acute appendicitis in this population-based study. The objective of this secondary analysis was to evaluate the association of both appendicitis severity and patient age with appendiceal tumor histology.

METHODS

This nationwide population-based registry study (The Finnish Cancer Registry) was conducted from 2007 to 2013. All appendiceal tumors (n = 840) and available medical reports (n = 504) of these patients at eight study hospitals were previously evaluated, identifying altogether 250 patients with both acute appendicitis and appendiceal tumor.

RESULTS

The severity of acute appendicitis was significantly associated with more malignant tumor histology. The risk of adenocarcinoma or pseudomyxoma was significantly higher among patients with periappendicular abscess (OR 15.05, CI 95% 6.98-32.49, p < 0.001) and patients presenting with perforated acute appendicitis (OR 4.09, CI 95% 1.69-9.90, p = 0.0018) compared to patients with uncomplicated acute appendicitis. Similarly, patient age over 40 years was significantly associated with the risk of adenocarcinoma and pseudomyxoma (OR 26.46, Cl 95% 7.95-88.09, p < 0.001). Patient sex was not associated with a more malignant appendiceal tumor histology (p = 0.67).

CONCLUSION

More malignant appendiceal tumor histology of adenocarcinoma or pseudomyxoma was significantly associated with patient age over 40 years and complicated acute appendicitis, especially periappendicular abscess.

Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study

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.

Nonoperative management of appendicitis in children

Appendicitis is a common condition in childhood and adolescence that frequently requires urgent surgical intervention. For almost two centuries appendicitis has been recognized as a medical problem with a surgical solution. Currently the appendix can be removed with a minimally invasive approach, low anesthetic and surgical risk, and swift hospital discharge. Despite these advances, surgery and anesthesia have associated risks including postoperative infection, bleeding, hernia and organ injury among others. In addition, surgery requires time off of school and work to recover and associated healthcare costs can be significant. In both adult and pediatric populations, quality data suggesting a nonoperative approach is suggesting a change to the traditional surgical paradigm. Adults studies have demonstrated both safety and efficacy in the nonoperative management of acute appendicitis. In selected children with uncomplicated appendicitis, initial nonoperative management has been shown to be safe with fewer complications, fewer disability days and less healthcare costs while avoiding the risks inherent to surgery. Ongoing randomized controlled clinical trials in both the United States and Europe seek to further demonstrate the safety of nonoperative management and assist physicians with educating patients about the risk profile of their treatment decision. In complicated appendicitis presenting with abscess or acute appendiceal phlegmon, an initial nonoperative strategy with or without abscess drainage followed by interval appendectomy is the current state of the art though the utility of interval appendectomy is questioned.

Appendicitis with submucosal fecalith mimicking a submucosal tumor: a case report

Background

Submucosal fecalith(s) mimicking submucosal tumors of the gastrointestinal lumen are rare. Moreover, accurate preoperative diagnosis of these entities is exceedingly difficult, and the mechanism(s) of their formation remains unclear.

Case presentation

A 40-year-old woman visited the authors’ hospital due to lower abdominal pain and diarrhea. She had previously been treated for endometriosis. Laboratory investigation revealed increased C-reactive protein levels. Abdominal contrast-enhanced computed tomography revealed thickening of the appendix wall and dilation of the small intestine. The patient was diagnosed with paralytic ileus caused by appendicitis, and interval appendectomy was scheduled. She underwent laparoscopic-assisted appendectomy after conservative treatment. Partial cecal resection was selected due to the presence of an elastic mass in the cecum. The final pathological diagnosis was submucosal fecalith, not submucosal tumor. On day 5, the patient was discharged without any postoperative complications.

Conclusions

In cases of appendicitis with fecalith(s) that appear as submucosal tumor(s) on colonoscopy, submucosal fecalith mimicking submucosal tumor should be considered in the differential diagnosis.

Risk of appendiceal neoplasm after interval appendectomy for complicated appendicitis: A systematic review and meta-analysis

BACKGROUND

Non-operative management is often the treatment of choice in cases of complicated appendicitis and routine interval appendectomy is not usually recommended. Actually, recent studies show an alarming number of appendiceal neoplasms following interval appendectomy. The aim of this study is to evaluate the prevalence of appendiceal neoplasms and their histological types after interval appendectomy for complicated appendicitis in adults.

METHODS

A comprehensive literature search of the PubMed, Scopus and Web of Science databases was conducted according to the PRISMA statement. Studies reporting appendiceal neoplasm rates after interval appendectomy and histopathological characteristics were included. The most recent World Health Organization (WHO) classification of malignant tumours was considered. A pooled prevalence analysis for both prevalence and pathology was performed.

RESULTS

A total of eight studies was included: seven retrospective series and one randomized controlled trial. The pooled prevalence of neoplasms after interval appendectomy was 11% (95% CI 7-15; I² = 37.5%, p = 0.13). Appendiceal mucinous neoplasms occurred in 43% (95% CI 19-68), adenocarcinoma in 29% (95% CI 6-51), appendiceal neuroendocrine neoplasm in 21% (95% CI 6-36), globet cell carcinoma in 13% (95% CI -2-28), adenoma or serrated lesions in 20% (95% CI -0-41) of cases.

CONCLUSION

The risk of appendiceal neoplasm in patients treated with interval appendectomy for complicated appendicitis is 11%; mucinous neoplasm is the most common histopathological type. Further studies should investigate this association in order to clarify the biological pathway and clinical implications.

Appendiceal neoplasm incidence and mortality rates are on the rise in Australia

OBJECTIVES

The study aimed to examine the incidence and mortality rates of appendiceal neoplasms (ANs) in Australia.

METHODS

A retrospective analysis was performed on national data obtained from the Australian Institute of Health and Welfare (AIHW) from 1982 to 2013. Changes to the incidence, and the cancer-specific mortality following the diagnosis of ANs were analyzed over this time period, with stratification performed for histological subtype, gender, and age groups (<50y and ≥50y).

RESULTS

Incidence and mortality rates of ANs increased significantly across both genders and age groups. Incidence rates increased by 415%, from 0.40/100 000 population in 1982 to 2.06/100 000 in 2013. Overall mortality rates increased by 130%, from 0.057/100 000 during 1982-1985 to 0.131/100 000 during 2010-2013. Controlling for age group and gender, the incidence rates increased by 20% every four years (Incidence rate ratio (IRR) = 1.20, 95% confidence interval (CI): 1.17, 1.23, global P value<0.0001), and controlling for age, the mortality rates increased by 8% every four years (IRR = 1.08, 95% CI: 1.00, 1.17, global P-value = 0.0401).

CONCLUSION

The increasing use of CT scanning, improvements in pathological assessment of the appendix, and the growing aging population may have contributed in part to the apparent rise in the incidence of ANs.

Risk Factors for Appendiceal Cancer After Appendectomy

BACKGROUND

Appendiceal cancer (AC) is a rare malignancy usually diagnosed incidentally after appendectomy. Risk factors for AC are poorly understood. We sought to provide a descriptive analysis for patients with AC discovered after appendectomy for acute appendicitis (AA).

METHODS

The 2016-2017 American College of Surgeons-National Surgical Quality Improvement Program Procedure-Targeted Appendectomy database was queried for adult patients who underwent appendectomy for image-suspected AA. Patients with pathology consistent with AA were compared to patients found to have AC. A multivariable logistic regression model was used for analysis.

RESULTS

From 21 058 patients, 203 (1.0%) were found to have AC on pathology. Compared to patients with AA, patients with AC were older (median, 48 vs. 40 years old, P < .001). The AA group had a similar rate of perforated appendix compared to the AC group (16.3% vs. 13.4% P = .32). After adjusting for covariates, associated risk factors for AC were: age ≥65 years old (odds ratio (OR) 2.25, 1.5-3.38, P < .001), absence of leukocytosis (OR 1.58, 1.16-2.17, P = .004), and operative time ≥1 hour (OR 1.57, 1.14-2.16, P = .006). Gender, race, and history of smoking were not independent associated risk factors for AC.

CONCLUSION

The incidence of AC after appendectomy for suspected AA is approximately 1% in a large national analysis. These factors may be used to help identify patients at higher risk for AC after appendectomy.

National trends in the presentation of surgically resected appendiceal adenocarcinoma over a decade

BACKGROUND

Rates of nonoperative management of acute appendicitis and appendiceal adenocarcinoma have increased over a decade, but the presentation and outcomes of appendiceal adenocarcinoma over this period is not well-characterized.

METHODS

Patients with surgically resected Stage I-III appendiceal adenocarcinoma were identified from the 2006 to 2015 National Cancer Data Base and classified into two cohorts, 2006-2010 and 2011-2015, based on year of diagnosis. Three-year overall survival (OS) was analyzed using Cox proportional hazards regression and Kaplan-Meier survival estimates.

RESULTS

Of 4233 patients, 1369 (32.3%) and 2864 (67.7%) were diagnosed in 2006-2010 and 2011-2015, respectively. Following multivariable analysis, patients in 2011-2015 were more likely to be <40 years of age (6.4% vs. 4.7%, odds ratio [OR] 1.53, p .015), present with pT4 tumors (40.2% vs. 34.4%, OR 1.46, p .004), and undergo hyperthermic intraperitoneal chemotherapy (4.4% vs. 2.4%, OR 1.97, p .001). Comparing patients diagnosed in 2011-2015 to 2006-2010, adjusted 3-year OS was no different among all patients (81.1% vs. 79%, p .778).

CONCLUSIONS

There has been an increase in the proportion of patients with pT4 appendix tumors over time, primarily among older (≥60 years) patients. Even so, these shifts in presentation have not resulted in differences in survival outcomes.

An Unusual Case of Acute Appendicitis due to Metastatic Prostatic Adenocarcinoma

Acute appendicitis is a common surgical emergency in older adults. In the elderly, like in younger cohorts, acute appendicitis most commonly arises without neoplastic underpinnings. However, the occurrence of acute appendicitis in a patient with a concurrent abdominopelvic malignancy should trigger suspicion for the possibility of a metastatic appendiceal neoplasm. We present the case of a 66-year-old man with a background of a biochemically recurrent prostatic adenocarcinoma who presented to the emergency department with acute appendicitis. Histopathologic examination of the resected appendix revealed an unexpected metastatic spread from his prostatic adenocarcinoma.

[Antibiotics alone as an alternative to appendectomy for uncomplicated acute appendicitis in adults: Changes in treatment modalities related to the COVID-19 health crisis]

La saturation intrahospitalière liée à l’arrivée massive de patients atteints du COVID-19 nécessitant une prise en charge urgente conduit à reconsidérer la prise en charge des autres patients. Différer au maximum les hospitalisations et les opérations chirurgicales non urgentes est un des objectifs des chirurgiens afin de désengorger autant que possible le système de soins. Alors que la majorité des opérations programmées sont annulées, la réduction de la chirurgie d’urgence est évidemment compliquée à proposer sans altérer la qualité de la prise en charge et conduire à une perte de chance pour le patient. Cependant, l’appendicite aiguë constitue une situation spécifique bien particulière et la fréquence de cette pathologie conduit à considérer ce cas particulier. En effet, tandis que le traitement recommandé de l’appendicite aiguë non compliquée est chirurgical, l’alternative non chirurgicale par antibiothérapie seule a été largement évaluée dans la littérature au cours de travaux de qualité. Dans la mesure où la limite principale du traitement médical exclusif de l’appendicite aiguë non compliquée est le risque de récidive à distance, cette option thérapeutique représente une alternative de choix pour réduire la surcharge intrahospitalière dans ce contexte de crise sanitaire. L’objectif de ce travail est donc de mettre à disposition des médecins et des chirurgiens un guide pratique issu d’une analyse de la littérature sur le traitement médical de l’appendicite aiguë non compliquée de l’adulte afin de pouvoir proposer ce traitement alternatif aux bons patients et dans des bonnes conditions, notamment lorsque l’accès au bloc opératoire est impossible.

Antibiotics alone as an alternative to appendectomy for uncomplicated acute appendicitis in adults: Changes in treatment modalities related to the COVID-19 health crisis

The massive inflow of patients with COVID-19 requiring urgent care has overloaded hospitals in France and impacts the management of other patients. Deferring hospitalization and non-urgent surgeries has become a priority for surgeons today in order to relieve the health care system. It is obviously not simple to reduce emergency surgery without altering the quality of care or leading to a loss of chance for the patient. Acute appendicitis is a very specific situation and the prevalence of this disease leads us to reconsider this particular disease in the context of the COVID-19 crisis. Indeed, while the currently recommended treatment for uncomplicated acute appendicitis is surgical appendectomy, the non-surgical alternative of medical management by antibiotic therapy alone has been widely evaluated by high-quality studies in the literature. Insofar as the main limitation of exclusively medical treatment of uncomplicated acute appendicitis is the risk of recurrent appendicitis, this treatment option represents an alternative of choice to reduce the intra-hospital overload in this context of health crisis. The aim of this work is therefore to provide physicians and surgeons with a practical guide based on a review of the literature on the medical treatment of uncomplicated acute appendicitis in adults, to offer this alternative treatment to the right patients and under good conditions, especially when access to the operating room is limited or impossible.