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Dohner E, Kierdorf FJ, Langer R, Zuber M, Fahrner R. Retrospective analysis of the incidence of appendiceal neoplasm and malignancy in patients treated for suspected acute appendicitis. BMC Surg 2024; 24:121. [PMID: 38658891 PMCID: PMC11040831 DOI: 10.1186/s12893-024-02412-4] [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: 10/12/2023] [Accepted: 04/10/2024] [Indexed: 04/26/2024] Open
Abstract
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.
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Affiliation(s)
- Eliane Dohner
- Department of Surgery, Bürgerspital Solothurn, Solothurn, Switzerland
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Rupert Langer
- Institute of Pathology and Molecular Pathology, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Markus Zuber
- Department of Surgery, Bürgerspital Solothurn, Solothurn, Switzerland
- Clarunis University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital Basel and University Hospital, Basel, Switzerland
| | - René Fahrner
- Department of Surgery, Bürgerspital Solothurn, Solothurn, Switzerland.
- Department of Vascular Surgery, University Hospital Bern, University of Bern, Bern, Switzerland.
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Butts CA, Byerly S, Nahmias J, Gelbard R, Ziesmann M, Bruns B, Davidson GH, Di Saverio S, Esposito TJ, Fischkoff K, Joseph B, Kaafarani H, Mentula P, Podda M, Sakran JV, Salminen P, Sammalkorpi H, Sawyer RG, Skeete D, Tesoriero R, Yeh DD. A core outcome set for appendicitis: A consensus approach utilizing modified Delphi methodology. J Trauma Acute Care Surg 2024; 96:487-492. [PMID: 37751156 DOI: 10.1097/ta.0000000000004144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND Appendicitis is one of the most common pathologies encountered by general and acute care surgeons. The current literature is inconsistent, as it is fraught with outcome heterogeneity, especially in the area of nonoperative management. We sought to develop a core outcome set (COS) for future appendicitis studies to facilitate outcome standardization and future data pooling. METHODS A modified Delphi study was conducted after identification of content experts in the field of appendicitis using both the Eastern Association for the Surgery of Trauma (EAST) landmark appendicitis articles and consensus from the EAST ad hoc COS taskforce on appendicitis. The study incorporated three rounds. Round 1 utilized free text outcome suggestions, then in rounds 2 and 3 the suggests were scored using a Likert scale of 1 to 9 with 1 to 3 denoting a less important outcome, 4 to 6 denoting an important but noncritical outcome, and 7 to 9 denoting a critically important outcome. Core outcome status consensus was defined a priori as >70% of scores 7 to 9 and <15% of scores 1 to 3. RESULTS Seventeen panelists initially agreed to participate in the study with 16 completing the process (94%). Thirty-two unique potential outcomes were initially suggested in round 1 and 10 (31%) met consensus with one outcome meeting exclusion at the end of round 2. At completion of round 3, a total of 17 (53%) outcomes achieved COS consensus. CONCLUSION An international panel of 16 appendicitis experts achieved consensus on 17 core outcomes that should be incorporated into future appendicitis studies as a minimum set of standardized outcomes to help frame future cohort-based studies on appendicitis. LEVEL OF EVIDENCE Diagnostic Test or Criteria; Level V.
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Affiliation(s)
- Christopher A Butts
- From the Division of Trauma, Acute Care Surgery & Surgical Critical Care (C.A.B.), Department of Surgery, Reading Hospital-Tower Health, West Reading, Pennsylvania; Department of Surgery, University of Tennessee Health Science Center (S.B.), Memphis, Tennessee; UC Irvine Healthcare, Orange (J.N.), California; Department of Surgery, University of Alabama at Birmingham (R.G.), Birmingham, Alabama; University of Manitoba, Winnipeg (M.Z.), Manitoba, Canada; Department of Surgery, University of Texas Southwestern, Dallas (B.B.), Texas; Department of Surgery, University of Washington, Seattle (G.H.D.), Washington; AST5 ASR Marche, Hospital Madonna del Soccorso (S.D.S.), San Benedetto del Tronto, Italy; Department of Medicine, University of Illinois School of Medicine (T.J.E.), Peoria, Illinois; Department of Surgery, Columbia University Irving Medical Center (K.F.), New York, New York; Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery (B.J.), College of Medicine, University of Arizona, Tuscon, Arizona; Trauma, Emergency Surgery, and Surgical Critical Care (H.K.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Gastroenterological Surgery (P.M., H.S.), Helsinki University Hospital, Helsinki, Finland; Department of General and Emergency Surgery (M.P.), Cagliari University Hospital, Cagliari, Italy; Division of Acute Care Surgery, Department of Surgery (J.V.S.), Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Surgery (P.S.), University of Turku, Turku, Finland; Department of Surgery, Western Michigan University School of Medicine: Western Michigan University Homer Stryker MD School of Medicine (R.G.S.), Kalamazoo, Michigan; Roy J. and Lucille A. Carver College of Medicine (D.S.), University of Iowa, Iowa City, Iowa; Division of General Surgery, Trauma and Surgical Critical Care, Acute Care Surgery (R.T.), Zuckerberg San Francisco General Hospital, San Francisco, California; and Ernest E Moore Shock Trauma Center at Denver Health (D.D.Y.), University of Colorado, Denver, Colorado
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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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Lee SH, Park SS, Seo HS. Risks Associated with Surgical Treatment for Appendicitis in Hematologic Patients. Cancers (Basel) 2023; 15:5049. [PMID: 37894416 PMCID: PMC10605880 DOI: 10.3390/cancers15205049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/18/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
Appendicitis is a prevalent surgical emergency. Although appendectomy has traditionally been the go-to treatment, recent studies suggest antibiotics can be equally effective for uncomplicated cases. However, evidence is scant regarding patients with hematologic disorders. This study delves into the surgical risks tied to appendicitis in patients with underlying hematologic conditions. A retrospective analysis was carried out on patients diagnosed with appendicitis and hematologic disorders from January 2000 to June 2021. Patients were pinpointed using ICD-10 diagnostic codes, and surgical procedures were identified based on the hospital's surgical fee codes. Hematologic conditions were sorted into risk levels, and patient treatments were scrutinized. Among the 131 initially identified patients, 89 were included in the study. Out of these, 75 underwent surgical procedures, while 14 received non-surgical treatments. The surgical group displayed better preoperative laboratory outcomes. Clinical characteristics, hematologic disease risk, and severity of appendicitis appeared not to be related to surgical complications. Patients without surgical complications showed improvement in preoperative absolute neutrophil count (ANC) and platelet counts. Lower preoperative ANCs and platelet counts were associated with extended hospital stays. For patients with hematologic disorders diagnosed with appendicitis, thorough preoperative laboratory evaluations followed by minimally invasive appendectomy appear to be a safe route without heightening the risk of severe complications compared to non-surgical management.
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Affiliation(s)
- Seung Hyun Lee
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea;
| | - Sung-Soo Park
- Division of Hematology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea;
| | - Ho Seok Seo
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea;
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
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Núñez-Rocha RE, Girón F, Rodríguez L, Camargo-Gómez D, Restrepo-Bonilla C, Panqueva RDPL, Cadena M, Nassar R, Herrera-Almario GE, Hernández-Restrepo JD. Incidence of appendiceal neoplasms in appendectomy patients. BMC Surg 2023; 23:287. [PMID: 37735406 PMCID: PMC10512515 DOI: 10.1186/s12893-023-02183-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/04/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Non-operative management has been suggested as a therapy for uncomplicated appendicitis. Notwithstanding, the risk of missing an appendiceal tumor must be considered, being the surgical piece crucial to rule out neoplasms. Therefore, we aim to determine the incidence of appendiceal neoplasms in patients with acute appendicitis, tumor types and the importance of the anatomopathological study of the surgical piece. STUDY DESIGN Retrospective study in which we described patients who underwent emergent appendectomy with histopathological findings of appendiceal neoplasms from January 2012 to September 2018. Descriptive analysis included demographic variables, diagnostic methods, and surgical techniques. RESULTS 2993 patients diagnosed with acute appendicitis who underwent an emergency appendectomy. 64 neoplasms of the appendix were found with an incidence of 2,14%. 67.2% were women, the mean age was 46,4 years (± 19.5). The most frequent appendiceal neoplasms were neuroendocrine tumors (42,2%), followed by appendiceal mucinous neoplasms (35,9%), sessile serrated adenomas (18,8%), and adenocarcinomas (3,1%). In 89,1% of the cases, acute appendicitis was determined by imaging, and 14% of cases were suspected intraoperatively. Appendectomy was performed in 78,1% without additional procedures. CONCLUSIONS Appendiceal tumors are rare and must be ruled out in patients with suspected acute appendicitis. The incidence of incidental neoplasms is higher in this study than in the previously reported series. This information must be included in decision-making when considering treatment options for acute appendicitis.
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Affiliation(s)
- Ricardo E Núñez-Rocha
- Hospital Universitario Fundación Santa Fe de Bogotá, Calle 119 No. 7-14, Bogotá, DC, Colombia
- School of Medicine, Universidad de los Andes, Cundinamarca, Colombia
| | - Felipe Girón
- Hospital Universitario Fundación Santa Fe de Bogotá, Calle 119 No. 7-14, Bogotá, DC, Colombia.
- School of Medicine, Universidad de los Andes, Cundinamarca, Colombia.
| | - Lina Rodríguez
- School of Medicine, Universidad de los Andes, Cundinamarca, Colombia
| | | | | | - Rocío Del Pilar López Panqueva
- Hospital Universitario Fundación Santa Fe de Bogotá, Calle 119 No. 7-14, Bogotá, DC, Colombia
- School of Medicine, Universidad de los Andes, Cundinamarca, Colombia
| | - Manuel Cadena
- Hospital Universitario Fundación Santa Fe de Bogotá, Calle 119 No. 7-14, Bogotá, DC, Colombia
- School of Medicine, Universidad de los Andes, Cundinamarca, Colombia
| | - Ricardo Nassar
- Hospital Universitario Fundación Santa Fe de Bogotá, Calle 119 No. 7-14, Bogotá, DC, Colombia
- School of Medicine, Universidad de los Andes, Cundinamarca, Colombia
| | - Gabriel E Herrera-Almario
- Hospital Universitario Fundación Santa Fe de Bogotá, Calle 119 No. 7-14, Bogotá, DC, Colombia
- School of Medicine, Universidad de los Andes, Cundinamarca, Colombia
| | - Juan David Hernández-Restrepo
- Hospital Universitario Fundación Santa Fe de Bogotá, Calle 119 No. 7-14, Bogotá, DC, Colombia
- School of Medicine, Universidad de los Andes, Cundinamarca, Colombia
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Norimatsu Y, Ito K, Takemura N, Inagaki F, Mihara F, Tsukada K, Oka S, Kokudo N. Surgical management of appendicitis in patients with human immunodeficiency virus (HIV) positivity: a propensity score-matched analysis in a base hospital for HIV treatment in Japan. Surg Today 2023; 53:1013-1018. [PMID: 36808245 PMCID: PMC9940061 DOI: 10.1007/s00595-023-02661-5] [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: 09/23/2022] [Accepted: 12/28/2022] [Indexed: 02/23/2023]
Abstract
PURPOSE To investigate the impact of human immunodeficiency virus (HIV) infection on surgical outcomes after appendectomy. METHODS Data on patients who underwent appendectomy for acute appendicitis between 2010 and 2020 at our hospital were investigated retrospectively. The patients were classified into HIV-positive and HIV-negative groups using propensity score-matching (PSM) analysis, adjusting for the five reported risk factors for postoperative complications: age, sex, Blumberg's sign, C-reactive protein level, and white blood cell count. We compared the postoperative outcomes of the two groups. HIV infection parameters, including the number and proportion of CD4 + lymphocytes and the HIV-RNA levels were also compared before and after appendectomy in the HIV-positive patients. RESULTS Among 636 patients enrolled, 42 were HIV-positive and 594 were HIV-negative. Postoperative complications occurred in five HIV-positive patients and eight HIV-negative patients, with no significant difference in the incidence (p = 0.405) or severity of any complication (p = 0.655) between the groups. HIV infection was well-controlled preoperatively using antiretroviral therapy (83.3%). There was no deterioration in parameters and no changes in the postoperative treatment in any of the HIV-positive patients. CONCLUSION Advances in antiviral drugs have made appendectomy a safe and feasible procedure for HIV-positive patients, with similar postoperative complication risks to HIV-negative patients.
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Affiliation(s)
- Yu Norimatsu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Kyoji Ito
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Nobuyuki Takemura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan.
| | - Fuyuki Inagaki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Fuminori Mihara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Kunihisa Tsukada
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shinichi Oka
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
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Alajaimi J, Almansoor M, Almutawa A, Almusalam MM, Bakry H. Are Antibiotics the New Appendectomy? Cureus 2023; 15:e44506. [PMID: 37790034 PMCID: PMC10544542 DOI: 10.7759/cureus.44506] [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: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Prior to the development of laparoscopic procedures, open appendectomy was the standard of care for the majority of appendicitis cases. Recently, studies have debated using antibiotics as a first-line treatment in uncomplicated appendicitis cases. The definition of uncomplicated appendicitis is not always clear-cut; however, with the large-scale accessibility of radiologic techniques, it is becoming increasingly easier to classify patient groups. As suggested by clinical and radiological patient data, this has raised the speculation of considering antibiotic therapy as the sole treatment modality in uncomplicated appendicitis cases. We aim to compare the options of surgery and antibiotics only in terms of efficacy, complications, and financial cost. A range of databases and search strategies were adopted, and various databases were used, including PubMed, ScienceDirect, Google Scholar, and JAMA. Collectively, 30 studies were reviewed, but only 18 were included. Efficacy rates were higher in the appendectomy group. Nevertheless, the antibiotics-only group maintained an efficacy rate greater than 70% at one-year follow-up. Risk factors that decreased the efficacy in medical management included the presence of appendicolith, neoplasm, appendiceal dilatation, peri-appendiceal fluid collection, higher mean temperature, CRP, and bilirubin. Complications were more frequent and significant in the surgery group. These included complications related to anaesthesia, surgical site infections, damage to nearby structures, and pulmonary embolism. Despite several years of follow-up and disease recurrences, higher financial costs were observed in surgically treated patients compared to the antibiotics-only group. Given the high success rates post-appendectomy for acute appendicitis over the decades, the efficacy of conservatively treated acute appendicitis raises a strong argument when choosing one of the two options. The efficacy remained consistently higher across the literature in the surgery group than in the antibiotics-only group. However, it is still arguable that antibiotics may be a preferable option given an efficacy rate of more than 70% at one year and overall higher complications associated with surgery. The argument of missing a neoplasm by avoiding surgery is valid. However, most are carcinoid neuroendocrine neoplasms with a low probability of metastasis (<5%) and are usually considered benign. Given the current practice focused on conservative and minimally invasive treatments and recently the COVID-19 pandemic, with its restrictions and lessons learnt, antibiotics may be the future standard for treating uncomplicated acute appendicitis. Lastly, we noticed higher efficacy rates in articles published recently than those published at least five to ten years earlier. Antibiotics-only therapy for uncomplicated appendicitis is cost-effective with fewer complications than surgery. However, appendectomies have higher efficacy. Thus, surgical treatment prevails as the standard of care. Future literature should yield larger sample sizes and explore the numbers of emergency appendectomies mandated following antibiotics-only therapy.
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Affiliation(s)
- Janan Alajaimi
- School of Medicine, Royal College of Surgeons in Ireland, Busaiteen, BHR
| | - Manar Almansoor
- School of Medicine, Royal College of Surgeons in Ireland, Busaiteen, BHR
| | - Amina Almutawa
- School of Medicine, Royal College of Surgeons in Ireland, Busaiteen, BHR
| | | | - Husham Bakry
- General Surgery, King Hamad University Hospital, Busaiteen, BHR
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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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Echevarria S, Rauf F, Hussain N, Zaka H, Farwa UE, Ahsan N, Broomfield A, Akbar A, Khawaja UA. Typical and Atypical Presentations of Appendicitis and Their Implications for Diagnosis and Treatment: A Literature Review. Cureus 2023; 15:e37024. [PMID: 37143626 PMCID: PMC10152406 DOI: 10.7759/cureus.37024] [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: 04/01/2023] [Indexed: 05/06/2023] Open
Abstract
Appendicitis, an acute inflammation of the appendix, affects all demographic groups and exhibits various incidences and clinical manifestations. While acute appendicitis typically presents with colicky periumbilical abdominal pain that localizes to the right lower quadrant, atypical presentations are more common in children, geriatric, and pregnant patient populations, leading to delays in diagnosis. Clinical evaluation, clinical scoring systems, and inflammatory markers are commonly used, but their limitations have led to the increased use of diagnostic imaging in patients suspected of appendicitis. Acute appendicitis is managed by non-operative and operative management, depending on whether it is uncomplicated or complicated. Developing diagnostic pathways to improve outcomes and reduce complications is crucial. Although medical advancements have been made, diagnosing and managing appendicitis can be challenging, mainly when patients are present atypically. This literature review aims to comprehensively review typical and atypical presentations of appendicitis and their current implications for diagnosis and treatment modalities in pediatric, adult, pregnant, and geriatric patient populations.
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Affiliation(s)
| | - Fatima Rauf
- Internal Medicine, Rawalpindi Medical University, Rawalpindi, PAK
| | - Nabeel Hussain
- Internal Medicine, Saba University School-Medicine, Devens, USA
| | - Hira Zaka
- Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Umm-E- Farwa
- Surgery, Jinnah Sindh Medical University, Karachi, PAK
| | - Nayab Ahsan
- Internal Medicine, Quaid-e-Azam Medical College, Bahawalpur, PAK
| | - Alison Broomfield
- Family Medicine, Spartan Health Sciences University, Vieux Fort, LCA
| | - Anum Akbar
- Pediatrics, University of Nebraska Medical Center, Omaha, USA
| | - Uzzam Ahmed Khawaja
- Pulmonary and Critical Care Medicine, Jinnah Medical and Dental College, Karachi, PAK
- Clinical and Translational Research, Dr Ferrer BioPharma, South Miami, USA
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Guo X, Yang H, Li J, Zeng L, Wang C, Yang R, Yang Y. Application value of high-frequency ultrasonography in endoscopic retrograde appendicitis therapy for pediatric acute appendicitis. Surg Endosc 2023; 37:3814-3822. [PMID: 36690894 DOI: 10.1007/s00464-022-09779-6] [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: 05/11/2022] [Accepted: 11/27/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Endoscopic retrograde appendicitis therapy (ERAT) is a new method of treating acute appendicitis that has emerged in recent years in children, but the application of radiological examination in the diagnosis and treatment of pediatric diseases is greatly limited. Therefore, high-frequency ultrasonography imaging has attracted more and more attention because of its advantages such as non-invasiveness, no radiation, and a simpler procedure. This study aims to explore the application value of high-frequency ultrasonography in ERAT for pediatric acute appendicitis. METHODS A retrospective analysis was conducted on 136 children admitted to our hospital from January 2020 to October 2021 who were definitively diagnosed with acute appendicitis and underwent endoscopic retrograde intra-appendiceal irrigation treatment under the guidance of high-frequency ultrasonography. They were divided into the preschool age group (< 6 years) and school age group (≥ 6 years) according to age. Before the operation and at 1-2 days after ERAT, the external diameter of the appendix, as well as the thickness of the intestinal wall, mucosal layer, and muscular layer in each group were measured by high-frequency ultrasonography and recorded in detail. During the operation, a stent was placed under real-time guidance, and the situation in the cavity was observed. The clinical data of the two groups of children before and after the operation were collected, and the recurrence status after treatment was followed up. RESULTS Endoscopic treatment was completed in 131 patients with a success rate of 96.32%. There was no significant difference between the two groups in appendix diameter, intestinal wall, or muscular layer after the operation when compared to those before the operation (p > 0.05), but there was a significant difference in the mucosal thickness after operation when compared to before the operation (p < 0.05). Abdominal pain in the two groups was significantly relieved immediately after the operation, and the white blood cell count returned to normal, with a significant difference before and after the ERAT operation (p < 0.05). CONCLUSION Endoscopic intra-appendiceal irrigation under the guidance of high-frequency ultrasonography is a real-time and convenient method that is safe and effective in treating pediatric acute appendicitis.
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Affiliation(s)
- Xiaoya Guo
- Department of Ultrasound Diagnosis, Tangdu Hospital of Air Force Military Medical University, Xi'an, China
| | - Hengli Yang
- Department of Ultrasound Diagnosis, The Second Affiliated Hospital of Xi'an Medical College, Xi'an, China
| | - Jinghua Li
- Department of Ultrasound Diagnosis, Tangdu Hospital of Air Force Military Medical University, Xi'an, China
| | - Lingchao Zeng
- Department of Pediatrics, Tangdu Hospital of Air Force Military Medical University, Xi'an, China
| | - Chunhui Wang
- Department of Pediatrics, Tangdu Hospital of Air Force Military Medical University, Xi'an, China
| | - Ruijing Yang
- Department of Ultrasound Diagnosis, Tangdu Hospital of Air Force Military Medical University, Xi'an, China.
| | - Yilin Yang
- Department of Ultrasound Diagnosis, Tangdu Hospital of Air Force Military Medical University, Xi'an, China.
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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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Abstract
IMPORTANCE Acute appendicitis is the most common abdominal surgical emergency in the world, with an annual incidence of 96.5 to 100 cases per 100 000 adults. OBSERVATIONS The clinical diagnosis of acute appendicitis is based on history and physical, laboratory evaluation, and imaging. Classic symptoms of appendicitis include vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever. The diagnosis of acute appendicitis is made in approximately 90% of patients presenting with these symptoms. Laparoscopic appendectomy remains the most common treatment. However, increasing evidence suggests that broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, successfully treats uncomplicated acute appendicitis in approximately 70% of patients. Specific imaging findings on computed tomography (CT), such as appendiceal dilatation (appendiceal diameter ≥7 mm), or presence of appendicoliths, defined as the conglomeration of feces in the appendiceal lumen, identify patients for whom an antibiotics-first management strategy is more likely to fail. CT findings of appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with higher risk of treatment failure (≈40%) of an antibiotics-first approach. Therefore, surgical management should be recommended in patients with CT findings of appendicolith, mass effect, or a dilated appendix who are fit for surgery, defined as having relatively low risk of adverse outcomes or postoperative mortality and morbidity. In patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy. In unfit patients without these high-risk CT findings, the antibiotics-first approach is recommended, and surgery may be considered if antibiotic treatment fails. In unfit patients with high-risk CT findings, perioperative risk assessment as well as patient preferences should be considered. CONCLUSIONS AND RELEVANCE Acute appendicitis affects 96.5 to 100 people per 100 000 adults per year worldwide. Appendectomy remains first-line therapy for acute appendicitis, but treatment with antibiotics rather than surgery is appropriate in selected patients with uncomplicated appendicitis.
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Affiliation(s)
- Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Erik Karl Paulson
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Theodore N Pappas
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Teng TZJ, Thong XR, Lau KY, Balasubramaniam S, Shelat VG. Acute appendicitis–advances and controversies. World J Gastrointest Surg 2021; 13:1293-1314. [PMID: 34950421 PMCID: PMC8649565 DOI: 10.4240/wjgs.v13.i11.1293] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/24/2021] [Accepted: 09/29/2021] [Indexed: 02/06/2023] Open
Abstract
Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon’s practice. With the recent advancements in AA’s management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon’s repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic’s repercussions on patients and how surgeons’ practices have evolved in the context of AA.
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Affiliation(s)
- Thomas Zheng Jie Teng
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | - Xuan Rong Thong
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | - Kai Yuan Lau
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
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Cost-Utility Analysis of Antibiotic Therapy versus Appendicectomy for Acute Uncomplicated Appendicitis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168473. [PMID: 34444222 PMCID: PMC8392297 DOI: 10.3390/ijerph18168473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 08/03/2021] [Accepted: 08/06/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Current UK National Health Service (NHS) guidelines recommend appendicectomy as gold standard treatment for acute uncomplicated appendicitis. However, an alternative non-surgical management involves administrating antibiotic-only therapy with significantly lower costs. Therefore, a UK-based cost-utility analysis (CUA) was performed to compare appendicectomy with an antibiotic-only treatment from an NHS perspective. METHODS This economic evaluation modelled health-outcome data using the ACTUAA (2021) prospective multicentre trial. The non-randomised control trial followed 318 patients given either antibiotic therapy or appendicectomy, with quality of life (QOL) assessed using the SF-12 questionnaires administered 1-year post-treatment. A CUA was conducted over a 1-year time horizon, measuring benefits in quality adjusted life years (QALYs) and costs in pound sterling using a propensity score-matched approach to control for selection based on observable factors. RESULTS The CUA produced an incremental cost-effectiveness ratio (ICER) of -GBP 23,278.51 (-EUR 27,227.80) per QALY. Therefore, for each QALY gained using antibiotic-only treatment instead of appendicectomy, an extra GBP 23,278.51 was saved. Additionally, two sensitivity analyses were conducted to account for post-operative or post-treatment complications. The antibiotic-only option remained dominant in both scenarios. CONCLUSION While the results do not rely on a randomized sample, the analysis based on a 1-year follow-up suggested that antibiotics were largely more cost-effective than appendicectomy and led to improved QOL outcomes for patients. The ICER value of -GBP 23,278.51 demonstrates that the NHS must give further consideration to the current gold standard treatment in acute uncomplicated appendicitis.
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Guevara-Cuellar CA, Rengifo-Mosquera MP, Parody-Rúa E. Cost-effectiveness analysis of nonoperative management versus open and laparoscopic surgery for uncomplicated acute appendicitis in Colombia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:34. [PMID: 34112179 PMCID: PMC8194214 DOI: 10.1186/s12962-021-00288-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/01/2021] [Indexed: 02/07/2023] Open
Abstract
Background Traditionally, uncomplicated acute appendicitis (AA) has been treated with appendectomy. However, the surgical alternatives might carry out significant complications, impaired quality of life, and higher costs than nonoperative treatment. Consequently, it is necessary to evaluate the different therapeutic alternatives' cost-effectiveness in patients diagnosed with uncomplicated appendicitis. Methods We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18–60 years with a diagnosis of uncomplicated AA from the payer´s perspective at the secondary and tertiary health care level. The time horizon was 5 years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed. Methods We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18–60 years with a diagnosis of uncomplicated AA from the payer’s perspective at the secondary and tertiary health care level. The time horizon was five years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed. Results LA presents a lower cost ($363 ± 35) than OA ($384 ± 41) and NOM ($392 ± 44). NOM exhibited higher QALYs (3.3332 ± 0.0276) in contrast with LA (3.3310 ± 0.057) and OA (3.3261 ± 0.0707). LA dominated the OA. The ICER between LA and NOM was $24,000/QALY. LA has a 52% probability of generating the highest NMB versus its counterparts, followed by NOM (30%) and OA (18%). There is a probability of 0.69 that laparoscopy generates more significant benefit than medical management. The mean value of that incremental NMB would be $93.7 per patient. Conclusions LA is a cost-effectiveness alternative in the management of patients with uncomplicated AA. Besides, LA has a high probability of producing more significant monetary benefits than NOM and OA from the payer’s perspective in the Colombian health system. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-021-00288-2.
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Affiliation(s)
| | | | - Elizabeth Parody-Rúa
- Faculty of Health Sciences, Universidad Icesi, Calle 18 No. 122-135 Pance, 70000, Cali, Colombia
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