Laparoscopic appendectomy versus antibiotic treatment for acute appendicitis-a systematic review

Income-Based Disparities in Outcomes Following Pediatric Appendectomy: A National Analysis

BACKGROUND

Appendectomy remains a common pediatric surgical procedure with an estimated 80,000 operations performed each year. While prior work has reported the existence of racial disparities in postoperative outcomes, we sought to characterize potential income-based inequalities using a national cohort.

METHODS

All non-elective pediatric (<18 years) hospitalizations for appendectomy were tabulated in the 2016-2020 National Inpatient Sample. Only those in the highest (HI) and lowest income (LI) quartiles were considered for analysis. Multivariable regression models were developed to assess the independent association of income and postoperative major adverse events (MAE).

RESULTS

Of an estimated 87,830 patients, 36,845 (42.0%) were HI and 50,985 (58.0%) were LI. On average, LI patients were younger (11 [7-14] vs 12 [8-15] years, P < .001), more frequently insured by Medicaid (70.7 vs 27.3%, P < .05), and more commonly of Hispanic ethnicity (50.8 vs 23.4%, P < .001). Following risk adjustment, the LI cohort was associated with greater odds of MAE (adjusted odds ratio [AOR] 1.30 95% confidence interval [CI] 1.06-1.64). Specifically, low-income status was linked with increased odds of infectious (AOR 1.65, 95% CI 1.12-2.42) and respiratory (AOR 1.67, 95% CI 1.06-2.62) complications. Further, LI was associated with a $1670 decrement in costs ([2220-$1120]) and a +.32-day increase in duration of stay (95% CI [.21-.44]).

CONCLUSION

Pediatric patients of the lowest income quartile faced increased risk of major adverse events following appendectomy compared to those of highest income. Novel risk stratification methods and standardized care pathways are needed to ameliorate socioeconomic disparities in postoperative outcomes.

Appendectomy: Cross-sectional study of the effects of COVID-19 in a hospital in South Brazil

Background

COVID-19 has further burdened the Brazilian healthcare system, especially emergencies. Patients may have delayed seeking care for surgical abdominal pain. Delays in the approach may have impacted clinical evolution and outcomes. This study evaluated appendectomies and their complications performed by the public system during one-year follow-up of COVID-19 in a hospital in southern Brazil.

Materials and methods

In this hospital-based cross-sectional study, we included adult patients who underwent appendectomy from March 2019 to April 2021 (n = 162). Patients were divided into pre-pandemic (n = 78) and pandemic (n = 84) groups based on the surgery date. The analyzed variables included hospitalization duration, intensive care unit (ICU) admission, surgical approach, histopathological findings, COVID-19 testing, patient outcomes, and 30-day survival rate.

Results

The cohorts exhibited similar epidemiology, with the sex ratio and average age being maintained. No statistical difference was found in the 30-day survival rate and clinical outcomes. Of the four patients admitted to the ICU, three belonged to the pandemic cohort and tested negative for COVID-19. Only 47.6 % of the patients in the pandemic cohort underwent COVID-19 polymerase chain reaction examination; one tested positive (2.5 %).

Conclusion

This study demonstrated that there was no increased risk for appendectomies during the first wave of the pandemic. Surgeries were safe during this period. Patients continued to access the emergency service despite surgical abdominal pain and restrictive measures imposed by health authorities. The similar results observed across cohorts are attributed to the readiness of the teams and the availability of medical surgical equipment in safe quantities.

Meta-analysis of postoperative incision infection risk factors in colorectal cancer surgery

Objective

To evaluate the risk factors for postoperative incision infection in colorectal cancer, this meta-analysis aimed to identify key variables impacting infection incidence following colorectal cancer surgery.

Methods

Utilizing a meta-analytical approach, studies published from January 2015 to December 2022 were systematically collected and analyzed through the assessment of factors like body mass index, diabetes, albumin levels, malnutrition, and surgical duration.

Results

The meta-analysis of eleven high-quality studies revealed that elevated BMI, diabetes, low albumin levels, malnutrition, and extended surgical duration were associated with increased infection risk, while laparoscopic procedures showed potential for risk reduction.

Conclusions

This study underscores the significance of preoperative risk assessment and management in mitigating postoperative incision infections in colorectal cancer patients. The findings present actionable insights for clinicians to enhance patient prognoses and overall quality of life.

Single-port laparoscopic appendectomy using new surgical procedure versus conventional three-port laparoscopic appendectomy

The aim of this study was to compare the clinic outcomes between new single-port laparoscopic appendectomy (NSLA) and conventional three-port laparoscopic appendectomy (CTLA) for patients with acute appendicitis. Patients who were diagnosed with acute appendicitis and underwent appendectomy were retrospectively collected from a single clinical center from September 2021 to June 2023. Baseline characteristics, surgical information, and postoperative information were compared between the NSLA group and the CTLA group. Univariate and multivariate logistic regression analyses were used to find out the predictors of overall complications. A total of 296 patients were enrolled from a single clinical medical center. There were 146 (49.3%) males and 150 (50.7%) females. There were 54 (18.2%) patients in the NSLA group and 242 (81.8%) patients in the CTLA group. After data analysis, we found the patients in the NSLA group had a shorter postoperative hospital stay (P < 0.01) than the CTLA group. The other outcomes including intraoperative blood loss (P = 0.167), operation time (P = 0.282), nature of the appendix (P = 0.971), and overall complications (P = 0.543) were not statistically different. After univariate and multivariate logistic regression analysis, we found that age (P = 0.018, OR = 1.039, 95% CI = 1.007-1.072), neutrophil percentage (P = 0.018, OR = 1.070, 95% CI = 1.011-1.132), and fever (P = 0.019, OR = 6.112, 95% CI = 1.340-27.886) were the predictors of overall complications. However, the surgical procedure (NSLA versus CTLA) was not a predictor of overall complications (P = 0.376, OR = 1.964, 95% CI = 0.440-8.768). Compared with CTLA, there was no significant increase in postoperative overall complications with NSLA, making it a safe and feasible new surgical procedure. More studies are needed to evaluate the long-term results.

Beyond acute appendicitis: a single-institution experience of unexpected pathology findings after 989 consecutive emergency appendectomy

INTRODUCTION

Appendiceal neoplasms (ANs) are rare, with an estimated incidence of around 1%: neuroendocrine tumours (NETs) and low-grade appendiceal mucinous neoplasms (LAMNs) comprise most cases. Most tumours are cured by appendectomy alone, although some require right hemicolectomy and intra-operative chemotherapy. The aim of the present study is to evaluate our institution's experience in terms of the prevalence of AN, their histological types, treatment and outcomes in adult patients undergoing emergency appendectomy.

MATERIAL AND METHODS

Single-centre retrospective cohort analysis of patients treated for acute appendicitis at a large academic medical centre. Patients with a diagnosis of acute appendicitis (AA) where further compared with patients with acute appendicitis and a histologically confirmed diagnosis of appendiceal neoplasm (AN).

RESULTS

A diagnosis of acute appendicitis was made in 1200 patients. Of these, 989 patients underwent emergency appendectomy. The overall incidence of appendiceal neoplasm was 9.3% (92 patients). AN rate increased with increasing age. Patients under the age of 30 had a 3.8% (14/367 patients) rate of occult neoplasm, whereas patients between 40 and 89 years and older had a 13.0% rate of neoplasm. No difference was found in clinical presentations and type of approach while we found a lower complicated appendicitis rate in the AN group.

CONCLUSION

ANs are less rare with respect to the literature; however, clinically, there are no specific signs of suspicious and simple appendicectomy appears to be curative in most cases. However, age plays an important role; older patients are at higher risk for AN. ANs still challenge the non-operative management concept introduced into the surgical literature.

Effects of evidence-based nursing on surgical site wound infection in patients undergoing acute appendicitis surgery: A meta-analysis

This study aimed to comprehensively evaluate the effects of evidence-based nursing (EBN) intervention on wound infection and postoperative complications in patients after appendectomy for acute appendicitis (AA), with the expectation of providing a theoretical basis for postoperative care in AA. Randomised controlled trials (RCTs) on the postoperative application of EBN in patients with AA were searched in PubMed, Web of Science, Cochrane Library, Embase, China Biomedical Literature Database, Wanfang and China National Knowledge Infrastructure from the inception of databases to October 2023. Two authors screened and evaluated the literature based on the inclusion and exclusion criteria, and data were extracted from the final included literature. Stata software (version 17.0) was employed for data analysis. In total, 29 RCTs involving 2848 patients with AA were included, with 1424 in the EBN group and 1424 in the conventional care group. The analyses revealed that patients with AA who experienced EBN were significantly less likely to develop postoperative wound infections (odds ratio [OR] = 0.23, 95% confidence intervals [CIs]: 0.14-0.38, p < 0.001) and postoperative complications (OR = 0.20, 95% CI: 0.15-0.26, p < 0.001) as opposed to conventional care. Available evidence suggests that EBN can effectively reduce the risk of wound infection and postoperative complications in patients undergoing appendectomy for AA, thereby improving patient prognosis. This finding is worth promoting in the clinical practice.

Appendiceal Vaginal Fistula: A Rare Complication of Nonoperative Appendicitis Management

Appendicitis is one of the most common conditions encountered in emergency surgical practice. An appendico-cutaneous fistula is a rare complication of appendicitis. An appendico-vaginal fistula is extremely rare. To our knowledge, based on a thorough review of the literature using PubMed, MEDLINE, and Google Scholar, only three other cases of an appendico-vaginal fistula have been reported. We present one such case in a 43-year-old female with a history of partial hysterectomy, recurrent abscesses that had failed to respond to repeated drainage and antibiotic treatment, and nonoperative treatment of appendicitis.

[Incidental finding of appendiceal mucinous neoplasms]

Low-grade appendiceal mucinous neoplasms (LAMN) are rare and are diagnosed in at least 0.13% of appendectomies in Germany, although significant underreporting is likely. Perforation of the tumors can result in abdominal mucinous collections, so-called pseudomyxoma peritonei (PMP). The challenge in the treatment of LAMN is the adequate approach to the incidental finding of these tumors. If a mucinous neoplasm is preoperatively suspected in cases of an acute condition, usually appendicitis, it must be weighed up whether a conservative approach is justifiable or whether immediate appendectomy is necessary. If this is the case, an intraoperative perforation of the appendix must be avoided and the complete abdominal cavity must be inspected for mucin deposits. If conservative treatment is possible, further treatment should take place at a specialized center. If the neoplasm is first found incidentally during surgery, perforation of the appendix should also be avoided and the entire abdominal cavity should be inspected for a PMP. If a PMP is present cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) should be performed in a specialized center. If LAMN are found during the postoperative histological work-up, it should be evaluated whether a perforation was present and mucin collections are noted in the surgical report. In the case of LAMN without evidence of a PMP, appendectomy is the adequate treatment. In cases of intra-abdominal mucinous collections, samples should be taken and further treatment should be performed at a center with sufficient expertise. An ileocecal resection or oncological hemicolectomy is not indicated. After adequate treatment, all patients should receive a follow-up using cross-sectional imaging (preferably magnetic resonance imaging, MRI) and determination of the tumor markers CEA, CA 19-9 and CA 125.

Perforated appendicitis treated with laparoscopic appendicectomy or open appendicectomy: A meta-analysis

Aim

This analysis compared the impact of laparoscopic appendicectomy (LA) and open appendicectomy (OA) on treating adult perforated appendicitis (PA).

Methods

Articles relating to LA and OA in treating PA were retrieved from databases including PubMed, Cochrane Library and Embase since their founding to January 2022. These articles were independently filtered based on the inclusion and exclusion criteria by two investigators. The quality of these articles was assessed and article data were extracted. Dichotomous data were presented in the form of odd's ratio (OR), whereas continuous data were in the form of weighted mean difference (WMD). The included articles reported at least one of the following outcomes: intra-abdominal abscess (IAA), wound infection, operative time, hospital stay and complications.

Results

Three randomised control trials (198 LA cases vs. 205 OA cases) and 12 case - control trials (914 LA cases vs. 2192 OA cases) were included. This analysis revealed that although the IAA formation rate was similar in the LA and OA groups (OR: 1.28, 95% confidence interval [CI]: 0.87-1.88), the wound infection rate was lower in the LA group (OR: 0.38, 95% CI: 0.28-0.51). Furthermore, LA was associated with shorter hospital stay (WMD: -1.43 days, 95% CI: -2.33--0.52) and fewer complications than OA (OR: 0.40, 95% CI: 0.28-0.57).

Conclusion

LA has significant benefits in treating PA and is associated with better post-operative outcomes such as shorter hospital stay, lower incidence of wound infection and other complications. However, more studies with randomised and large-sample populations are still required to determine the clinical benefit of LA in treating PA.

Single-port laparoscopic appendectomy using a needle-type grasping forceps compared with conventional three-port laparoscopic appendectomy for patients with acute uncomplicated appendicitis: a single-center retrospective study

Objective

To compare the clinical outcomes between single-port laparoscopic appendectomy using a needle-type grasping forceps (SLAN) and conventional three-port laparoscopic appendectomy (CLA) for patients with uncomplicated appendicitis.

Methods

We retrospectively collected clinical data of patients with uncomplicated appendicitis who underwent SLAN or CLA from May 2019 to May 2021 in our center. The patients’ baseline characteristics, perioperative outcomes, and follow-up data were compared between the two groups. Additionally, baseline characteristics were compared with postoperative outcomes in the SLAN group.

Results

Ninety-six patients were enrolled (SLAN group, n = 32; CLA group, n = 64). The SLAN group had a shorter hospital stay, lower 24-hour postoperative visual analogue scale scores, shorter postoperative fasting time, lower frequency of antibiotic administration, and longer operative time than the CLA group. In the SLAN group, younger patients had a longer appendix and male patients had a thicker appendix; additionally, patients with an appendiceal diameter of 0.6 to 1.0 cm had a longer postoperative hospital stay and higher frequency of antibiotic administration.

Conclusions

Compared with CLA, SLAN may be less invasive, provide faster postoperative recovery, and result in better cosmesis for patients with uncomplicated appendicitis. Further research should be performed to evaluate the long-term outcomes.

Surgical Site Infection Following Single-Port Appendectomy: A Systematic Review of the Literature and Meta-Analysis

Introduction

Surgical site infections (SSIs) are one of the most common postoperative complications after appendectomy leading to recurrent surgery, prolonged hospital stay, and the use of antibiotics. Numerous studies and meta-analyses have been published on the effect of open versus conventional laparoscopic appendectomy (CLA) reporting faster postoperative recovery and less postoperative pain for CLA. A development from CLA has been the single-port appendectomy (SPA), associated with a better cosmesis but seemingly having a higher risk of wound infections. The aim of this systematic literature review and meta-analysis is to investigate whether reduced port or SPA alters the ratio of SSIs.

Methods

Pubmed, Embase, and Cochrane databases were screened for suitable articles. All articles published between January 1, 2002, and March 23, 2022, were included. Articles regarding children below the age of 18 were excluded as well as manuscripts that investigated solemnly open appendectomies. Articles were screened for inclusion criteria by two independent authors. Incidence of SSI was the primary outcome. Duration of operation and length of hospital stay were defined as secondary outcomes.

Results

A total of 25 studies were found through a database search describing 5484 patients. A total of 2749 patients received SPA and 2735 received CLA. There was no statistical difference in the rate of SSI (P = 0.98). A total of 22 studies including 4699 patients reported the duration of operation (2223 SPA and 2476 CLA). There was a significantly shorter operation time seen in CLA. The length of hospital stay was reported in 23 studies (4735 patients: 2235 SPA and 2500 CLA). A shorter hospital stay was seen in the SPA group (P &lt; 0.00001). Separately performed analysis of randomized controlled trials could not confirm this effect (P = 0.29).

Discussion

SPA is an equally safe procedure considering SSI compared to CLA and does not lead to an increased risk of SSI. A longer operation time for SPA and a minor difference in the length of stay does lead to the use of SPA in selected patients only.

Presentation and outcomes of acute appendicitis during COVID-19 pandemic: lessons learned from the Middle East-a multicentre prospective cohort study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic had a striking impact on healthcare services in the world. The present study aimed to investigate the impact of the COVID-19 pandemic on the presentation management and outcomes of acute appendicitis (AA) in different centers in the Middle East.

METHODS

This multicenter cohort study compared the presentation and outcomes of patients with AA who presented during the COVID-19 pandemic in comparison to patients who presented before the onset of the pandemic. Demographic data, clinical presentation, management strategy, and outcomes were prospectively collected and compared.

RESULTS

Seven hundred seventy-one patients presented with AA during the COVID pandemic versus 1174 in the pre-COVID period. Delayed and complex presentation of AA was significantly more observed during the pandemic period. Seventy-six percent of patients underwent CT scanning to confirm the diagnosis of AA during the pandemic period, compared to 62.7% in the pre-COVID period. Non-operative management (NOM) was more frequently employed in the pandemic period. Postoperative complications were higher amid the pandemic as compared to before its onset. Reoperation and readmission rates were significantly higher in the COVID period, whereas the negative appendicectomy rate was significantly lower in the pandemic period (p = 0.0001).

CONCLUSION

During the COVID-19 pandemic, a remarkable decrease in the number of patients with AA was seen along with a higher incidence of complex AA, greater use of CT scanning, and more application of NOM. The rates of postoperative complications, reoperation, and readmission were significantly higher during the COVID period.