Prompt or delayed appendectomy? Influence of timing of surgery for acute appendicitis

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

INTRODUCTION

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of preoperative factors and waiting time on post-appendectomy complications: a retrospective study

BACKGROUND

Several factors are associated with increased postoperative complications after appendectomies. However, few studies combined these potential factors for comprehensive prediction of surgical outcomes. Whether high-risk patients benefit from a shorter waiting time for surgery remains unclear. This study aimed to explore the impact of surgical waiting time and potential risk factors on postoperative complications.

METHODS

A total of 1343 patients diagnosed with acute appendicitis requiring an emergent appendectomy were included from 2013 to 2018. The preoperative risk factors associated with postoperative complications were selected and the probability of postoperative complications was calculated by multivariate logistic regression model. Patients were divided into four groups based on the risk (high & low) and time to surgery (> 12 & ≤12 hours). The odds ratios for complications were evaluated between groups.

RESULTS

The selected risk factors included age, neutrophil-lymphocyte ratio, systemic inflammatory response syndrome and abdominal pain duration. Compared with low-risk patients with time to surgery ≤12 hours, high-risk patients with time to surgery > 12 hours had significant increased overall postoperative complication rate (16.85% vs. 8.16%, p = 0.002) and a trend toward increased surgical site infection rate (10.99% vs. 6.46%, p = 0.058). When operated within 12 hours, there was no difference in outcomes between high- and low-risk patients. On the other hand, time to surgery > 12 hours did not increase complication rate in low-risk patients.

CONCLUSIONS

The surgical outcome may be affected by preoperative factors and time to surgery. It is suggested that high-risk patients receive appendectomy within 12 hours to avoid increased postoperative complications.

Timing of surgical operation for patients with intra-abdominal infection: A systematic review and meta-analysis

BACKGROUND

Intra-abdominal infections (IAIs) is the most common type of surgical infection, with high associated morbidity and mortality rates. In recent years, due to the use of antibiotics, various drug-resistant bacteria have emerged, making the treatment of abdominal infections more challenging. Early surgical exploration can reduce the mortality of patients with abdominal infection and the occurrence of complications. However, available evidence regarding the optimal timing of IAI surgery is still weak. In study, we compared the effects of operation time on patients with abdominal cavity infection and tried to confirm the best timing of surgery.

AIM

To assess the efficacy of early vs delayed surgical exploration in the treatment of IAI, in terms of overall mortality.

METHODS

A systematic literature search was performed using PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Ovid, and ScienceDirect. The systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses method. Based on the timing of the surgical operation, we divided the literature into two groups: Early surgery and delayed surgery. For the early and delayed surgery groups, the intervention was performed with and after 12 h of the initial surgical intervention, respectively. The main outcome measure was the mortality rate. The literature search was performed from May 5 to 20, 2021. We also searched the World Health Organization International Clinical Trials Registry Platform search portal and ClinicalTrials.gov on May 20, 2021, for ongoing trials. This study was registered with the International Prospective Register of Systematic Reviews.

RESULTS

We identified nine eligible trial comparisons. Early surgical exploration of patients with IAIs (performed within 12 h) has significantly reduced the mortality and complications of patients, improved the survival rate, and shortened the hospital stay.

CONCLUSION

Early surgical exploration within 12 h may be more effective for the treatment of IAIs relative to a delayed operation.

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.

Delayed Presentation and Referral Time from General Practitioners Contribute to Increased Complicated Appendicitis during the Initial COVID-19 Pandemic Period in Japan

Objectives

This study aims to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the situation of acute appendicitis (AA) with respect to patients' and general practitioners' behaviors in a general community hospital in Japan.

Methods

The surgical outcomes and periods from symptom onset to medical presentation besides practitioners' referral time for consecutive AA patients were compared between the control (January 2016 to March 2020) and COVID-19 periods (April 2020 to April 2021).

Results

Eighty-three patients who underwent emergency surgery for AA were reviewed. Complicated appendicitis significantly increased in the COVID-19 period (63.6% vs. 31.2%, P = 0.023). In the COVID-19 period, the time from symptom onset to the medical presentation (2.2 vs. 0.9 days, P < 0.001) was significantly longer than in the control period. Among the patients who first presented to a general practitioner, the referral time from the practitioner to our hospital was significantly longer in the COVID-19 period (1.6 vs. 0.7 days, P = 0.017). Furthermore, among patients with a fever of higher than 38°C at medical presentation, the time from symptom onset to medical presentation was significantly longer in the COVID-19 period (3.0 vs. 0.7 days, P = 0.015). There was no difference in severe postoperative complications.

Conclusions

Hesitation to seek surgical treatment for AA was seen in both the patients and practitioners in the COVID-19 period. The delay in surgical treatment presumably led to the increase in severe AA. In a pandemic era, timely care for emergent conditions is a crucial challenge.

Demonstration of a new entity of non-perforated appendicitis through studying cluster of appendicitis

Differential diagnosis and management for perforated appendicitis and non-perforated appendicitis are current hot topics. The aim of this study is to demonstrate a new entity of non-perforated appendicitis, “acute hemorrhagic appendicitis” through studying cluster of acute appendicitis among Tibetan students at a high school in central China. Over the 11-year period, there were 120 patients with more female patients (102 of 499, 20.4%) than male patients (18 of 474, 3.8%) among 973 Tibetan students. 117 patients’ clinical data were available. Clinical manifestations were identical to classic appendicitis. However, axilla temperature, white blood cell counts and neutrophil level were elevated mildly in 12 (10.3%), 19 (16.2%) and 12 (10.3%) patients respectively. Pathologically, the resected appendices exhibited focal or diffuse hemorrhages in mucosa and/or submucosa, and infiltration by eosinophil and by lymphocytes. No patients had perforated appendicitis. The median time from the onset to surgery was 3 days (IQR, 2–4). All patients were discharged with full recovery. In conclusion, “acute hemorrhagic appendicitis” represented a new entity of non-perforated appendicitis with unique cause and pathogenesis, which might be treated with antibiotics alone or self-limited. Studying the cluster is a reliable method to find new entity of appendicitis.

Defining the optimal time to appendectomy: A step toward precision surgery

BACKGROUND

We aimed to investigate the association between time from admission to appendectomy on perioperative outcomes in order to determine optimal time-to-surgery windows.

METHODS

We performed a retrospective review of all the appendectomies performed between July 2018 to May 2020. We first compared the perioperative outcomes using preselected time-to-surgery cut-offs, then determined optimal safe windows for surgery, and finally identified subgroups of patients who may require early intervention.

RESULTS

Six hundred twenty-one appendectomies were performed in the time period. The patients with a time-to-surgery of ≥12 hours had a significantly longer length of stay (median 2 days [interquartile range 1-3] vs 3 days [interquartile range 2-4], mean difference = 0.74 [95% confidence interval 0.32-1.17, P = .0006]) and higher 30-day readmission risk (odds ratio 2.58, 95% confidence interval 1.12-5.96, P = .0266) versus those with a time-to-surgery of <12 hours. These differences persisted when the time-to-surgery was dichotomized by <24 or ≥24 hours. A time-to-surgery beyond 25 hours was associated with a 3.34-fold increased odds of open conversion (P = .040), longer operation time (mean difference 15.8 mins, 95% confidence interval 3.4-28.3, P = .013) and longer postoperative length of stay (mean difference 10.3 hours, 95% confidence interval 3.4-20.2, P = .042) versus a time-to-surgery of <25 hours. The patients with time-to-surgery beyond 11 hours had a 1.35-fold increased odds of 30-day readmission (95% confidence interval 1.02-5.43, P = .046) compared with those who underwent appendectomy before 11 hours. Older patients, patients with American Society of Anesthesiologist score II to III, and individuals with long duration of preadmission symptoms had higher risk of prolonged operation time, open conversion, increased length of stay, and postoperative morbidity with increasing time-to-surgery.

CONCLUSION

This study identified the safe windows for appendectomy to be 11 to 25 hours from admission for most perioperative outcomes. However, certain patient subgroups may be less tolerant of surgical delays.

Time to Surgery Does Not Impact Outcome in Pediatric Appendicitis

Background: Despite the high prevalence of acute appendicitis in children and substantial resource utilization associated with this condition, no consensus has been reached on optimal timing for performing appendectomies. The aim of this study was to examine the association between time to appendectomy and outcomes and assess the feasibility of delayed appendectomy in children. Patients and Methods: We performed a retrospective analysis of all patients younger than 14 years of age undergoing an appendectomy for suspected appendicitis. We divided our patients into two groups based on whether their time to appendectomy was shorter or longer than eight hours: group A, early appendectomy and group B, delayed appendectomy. Then we compared the two study groups regarding demographic, clinical, and radiographic characteristics, peri-operative data, and outcomes. Results: During the eight-year study period, a total of 1,141 patients underwent appendectomies. After applying exclusion criteria, 852 children were included: 544 (63.8%) in group A and 308 (36.2%) in group B. There were no differences in the rate of complicated appendicitis at exploration, post-operative complications, length of post-operative hospital stay, and 30-day re-admission rate between the two study groups. Conclusions: Our study demonstrated that delaying appendectomy within 24 hours of presentation is safe and feasible for pediatric acute appendicitis. Therefore, patients presenting during nighttime hours could be initially treated conservatively with antibiotic agents. This allows the surgeon to delay surgery to the following day.

In-hospital delay of surgery increases the rate of complicated appendicitis in patients presenting with short duration of symptoms: a retrospective cohort study

PURPOSE

Current practice allows for surgery for acute appendicitis to be delayed up to 24 h in the belief that there will be no increase in complicated appendicitis rates. We evaluated the combined effect of Patient Time (between symptom onset and hospital admission) and Hospital Time (between hospital admission and surgery) on the surgical outcome. We hypothesized that in patients with a short Patient Time, increased Hospital Times will be associated with a higher rate of complicated appendicitis, even in patients operated within 24 h.

METHODS

Retrospective evaluation of medical files of patients operated for acute appendicitis between 12/2006 and 12/2016.

RESULTS

Of 2749 patients with acute appendicitis included in this analysis, 818 (29.8%) were admitted with symptom onset the same day as admission, 577 (21.0%) reported symptom onset had started the previous day but less than 24 h before admission, and 1354 (49.3%) had over 24 h of symptoms. In patients with symptom onset the same day, a gradual increase in the rate of complicated appendicitis was noted with increasing Hospital Times (≤ 6 h-6.3%; 6-12 h-9.9%; 12-18 h-14.7%; and 18-24 h-12.7%; p = 0.017). In all other patients no differences in the rate of complicated appendicitis were noted as long as the patients were operated within 24 h of admission.

CONCLUSION

In patients with a short Patient Time, delaying operation is associated with an increased rate of complicated appendicitis and this group of patients should be prioritized for early surgery.

CLINICAL TRIALS

Study registered as ClinicalTrials.gov Identifier: NCT04689906 ( https://clinicaltrials.gov/ct2/show/NCT04689906?term=ashkenazi+itamar&draw=2&rank=2 ).

Delayed diagnosis and subsequently increased severity of acute appendicitis (compatible with clinical-pathologic grounds) during the COVID-19 pandemic: an observational case-control study

Background

During a global crisis like the current COVID-19 pandemic, delayed admission to hospital in cases of emergent medical illness may lead to serious adverse consequences. We aimed to determine whether such delayed admission affected the severity of an inflammatory process regarding acute appendicitis, and its convalescence.

Methods

In a retrospective observational cohort case-control study, we analyzed the medical data of 60 patients who were emergently and consecutively admitted to our hospital due to acute appendicitis as established by clinical presentation and imaging modalities, during the period of the COVID-19 pandemic (our study group). We matched a statistically control group consisting of 97 patients who were admitted during a previous 12-month period for the same etiology. All underwent laparoscopic appendectomy. The main study parameters included intraoperative findings (validated by histopathology), duration of abdominal pain prior to admission, hospital stay and postoperative convalescence (reflecting the consequences of delay in diagnosis and surgery).

Results

The mean duration of abdominal pain until surgery was significantly longer in the study group. The rate of advanced appendicitis (suppurative and gangrenous appendicitis as well as peri-appendicular abscess) was greater in the study than in the control group (38.3 vs. 21.6%, 23.3 vs. 16.5%, and 5 vs. 1% respectively), as well as mean hospital stay.

Conclusions

A global crisis like the current viral pandemic may significantly affect emergent admissions to hospital (as in case of acute appendicitis), leading to delayed surgical interventions and its consequences.

Possibility for avoidance of urgent nighttime operations for acute appendicitis in a regional core university hospital

INTRODUCTION

In recent years, a shortage of surgeons and anesthesiologists, particularly in regional hospitals, has become a social issue in Japan. In such hospitals, urgent surgery at night has been performed with difficulty. Therefore, we retrospectively assessed the outcomes of appendectomies for the patients visited at nighttime in our hospital categorized as a local university hospital.

METHODS

A retrospective review was conducted on 82 patients of acute appendicitis presented to our hospital between 5:30 p.m. to 8:30 a.m., between January 2014 and April 2019. We compared patients who underwent urgent nighttime appendectomy (group A) and patients who underwent appendectomy during the daytime, or so-called short interval appendectomy (group B). The evaluated factors were preoperative characteristics (age, sex, body mass index, cardiopulmonary complications, laboratory data, body temperature, presence of the Blumberg sign, and CT findings), operation characteristics, and postoperative characteristics (surgical-site infection [SSI], complications, and length of hospital stay).

RESULTS

Patients in group A were significantly younger than patients in group B. Patients in group A were significant more likely to experience an SSI.

DISCUSSION

Patients diagnosed with acute appendicitis during the nighttime can undergo short interval appendectomy, which leads to a decreased risk of SSI, has no effect on length of hospital stay after surgery, and lessens medical staff burden.

Revisiting delayed appendectomy in patients with acute appendicitis

Acute appendicitis (AA) is the most common acute abdomen, and appendectomy is the most common nonelective surgery performed worldwide. Despite the long history of understanding this disease and enhancements to medical care, many challenges remain in the diagnosis and treatment of AA. One of these challenges is the timing of appendectomy. In recent decades, extensive studies focused on this topic have been conducted, but there have been no conclusive answers. From the onset of symptoms to appendectomy, many factors can cause delay in the surgical intervention. Some are inevitable, and some can be modified and improved. The favorable and unfavorable results of these factors vary according to different situations. The purpose of this review is to discuss the causes of appendectomy delay and its risk-related costs. This review also explores strategies to balance the positive and negative effects of delayed appendectomy.

Delta neutrophil index and symptomatic time are effective factors for predicting perforated appendicitis

Appendicitis is a common intra-abdominal inflammatory disease, and morbidity increases with age when perforation occurs. Because, not all patients require emergency surgery, there have been numerous studies on factors for predicting perforated appendicitis. In this study, we aimed to confirm whether the delta neutrophil index (DNI) and the time from symptom onset to surgery are effective predictors for perforated appendicitis in different age groups.This was a retrospective study conducted on 542 appendicitis patients who underwent surgery at Kangdong Sacred Heart Hospital. The simple group consisted of 431 subjects, and the perforation group consisted of 111 subjects.Multiple logistic regression analyses demonstrated that age, neutrophil percentage, DNI, C-reactive protein (CRP), and symptomatic time were significant predictors of perforation. Analysis of the receiver-operating characteristic curve showed that the DNI was the most reliable predictive value. In the analyses according to age, the perforation rate was higher in the >65-year-age group; these patients also had a higher DNI, CRP, and symptomatic time. In the DNI analysis using receiver operating characteristic (ROC) analysis, the area under the curve was higher in the >65-year-age group than in other age groups. In addition, the cutoff values have been determined and perforation occurred significantly in the group with a DNI value of 2.1 or higher and a symptomatic time of 33 hours or longer.DNI is effective in predicting perforation in patients with appendicitis compared with other inflammatory factors. Furthermore, the simultaneous measurement of symptomatic time and DNI is helpful in predicting perforation and determining whether emergency surgery is necessary.

Predictive Value of Neutrophil Count for Postoperative Complications in Children after Surgery of Perforated Appendicitis

Introduction: Perforated appendicitis (PA) in children is associated with a considerable risk for postoperative complications (POCs) such as wound infection and intra-abdominal abscess.

The aim of this study was to determine the diagnostic accuracy of hematological parameters in the early POC detection in children after PA surgery.

Materials and Methods: The study enrolled 71 patients with PA divided into two groups: 14 patients with POC (POC+ group) and 57 patients without POC (POC− group). Clinical and hematological parameters were followed preoperatively, prior to the surgery (PRO) and postoperatively on day 2 (POD2) and day 4 (POD4).

Results: The POC+ group had longer duration of higher axillar temperature as well as extended intensive and inpatient care. This group also had a significantly lower absolute neutrophil count ratio between POD2 and POD4. According to the receiver operating characteristic curve analysis, relative neutrophil count on POD4 higher than 71.8% and the ratio of absolute neutrophil count between POD2 and POD4 lower than 44.5% were found to be useful for predicting POC.

Conclusion: Absolute neutrophil count ratio between POD2 and POD4 and relative neutrophil count at POD4 could be efficient in identifying children at higher risk of developing POC after PA surgery.

Impact of Delay in Appendectomy on the Outcome of Appendicitis: A Post Hoc Analysis of an EAST Multicenter Study

Background: Association between time-to-appendectomy and clinical outcomes is controversial with conflicting data regarding risk of perforation. The purpose of this study was to explore the associations between in-hospital delay in treatment of simple appendicitis with the incidence of complicated appendicitis discovered at appendectomy. Methods: The Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) database was queried and patients with acute appendicitis diagnosed on imaging were included. Upgrade was defined as gangrenous or perforated finding at appendectomy. Time intervals from emergency department (ED) triage to appendectomy were recorded in six-hour groups. Upgrade percentage for each group was presented and rates of a composite end point (30-day incidence of surgical site infection, abscess, wound complication, Clavien-Dindo complication, secondary intervention, ED visit, hospital re-admission, and mortality) were compared with Bonferroni correction to determine statistical significance (p = 0.05/9 = 0.005). Results: Of 3,004 included subjects, 484 (16%) experienced upgrade at appendectomy. Upgrade rates (%, 95% confidence interval [CI]) were: group 0-6 hours, 17% (95% CI, 14-19); group 6-11 hours, 15% (95% CI, 13-17%); group 12-17 hours, 16% (95% CI, 13-19); group 18-23 hours, 17% (95% CI, 12-23); group 24-29 hours, 30% (95% CI, 20-43); and group 30+ hours, 24% (95% CI, 14-37) (p = 0.014, NS by Bonferroni). Of 484 subjects with upgrade, 200 (41%; 95% CI, 37-46) had a worse composite outcome compared with 518 (21%; CI, 19-22) of 2,520 subjects with no upgrade (p < 0.001). The upgrade group was older (49 ± 17 years vs 39 ± 16 years), had a higher Charlson comorbidity index (CCI; 1.6 ± 1.9 vs 0.7 ± 1.4) and was more likely to have positive smoking history (20% vs 14%), and prior surgery (30% vs 22%; p < 0.001). Conclusions: We propose that ≥24-hour delay from ED triage to appendectomy is not associated with increased rate of severity upgrade from simple to complicated appendicitis. When upgrade occurs, it is correlated with older age, higher CCI, smoking history, and prior surgery and is associated with worse clinical outcomes.

Consensus Statement of the Italian Polispecialistic Society of Young Surgeons (SPIGC): Diagnosis and Treatment of Acute Appendicitis

Background: Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.Methods: This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.Results: Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.

AppendiXNet: Deep Learning for Diagnosis of Appendicitis from A Small Dataset of CT Exams Using Video Pretraining

The development of deep learning algorithms for complex tasks in digital medicine has relied on the availability of large labeled training datasets, usually containing hundreds of thousands of examples. The purpose of this study was to develop a 3D deep learning model, AppendiXNet, to detect appendicitis, one of the most common life-threatening abdominal emergencies, using a small training dataset of less than 500 training CT exams. We explored whether pretraining the model on a large collection of natural videos would improve the performance of the model over training the model from scratch. AppendiXNet was pretrained on a large collection of YouTube videos called Kinetics, consisting of approximately 500,000 video clips and annotated for one of 600 human action classes, and then fine-tuned on a small dataset of 438 CT scans annotated for appendicitis. We found that pretraining the 3D model on natural videos significantly improved the performance of the model from an AUC of 0.724 (95% CI 0.625, 0.823) to 0.810 (95% CI 0.725, 0.895). The application of deep learning to detect abnormalities on CT examinations using video pretraining could generalize effectively to other challenging cross-sectional medical imaging tasks when training data is limited.

Is postponed laparoscopic appendectomy justified for patients with acute appendicitis?

INTRODUCTION

Recent meta-analyses revealed that laparoscopic appendectomy (LA) is a feasible procedure even for patients with complicated appendicitis. More than a few patients with acute appendicitis arrive at the hospital during night shifts and have their operation postponed for various reasons. However, the feasibility and disadvantages of this so-called "postponed laparoscopic appendectomy" (PLA) remain controversial.

METHODS

We included 149 patients who underwent LA for acute appendicitis within 48 h of diagnosis between January 2013 and May 2018. Patients were divided into an immediate LA group (patients who underwent LA within 4 h of diagnosis, n = 84) and a PLA group (patients who underwent LA 4-48 h after diagnosis, n = 65). Comparisons were made between these groups.

RESULTS

The preoperative characteristics of the patients in the immediate LA and PLA groups were not significantly different. Operative time was significantly longer in the PLA group than in the LA group (92.5 ± 40.8 vs 78.1 ± 29.7 min, P = 0.012). The incidence of postoperative complications (grade II or higher) was significantly greater in the PLA group than in the LA group (32.3% vs 17.8%, P = 0.041). Multivariate analysis revealed that a preoperative CT finding of periappendiceal fluid (P = 0.005, odds ratio = 4.71) and surgery 4-48 h after diagnosis (P = 0.005, odds ratio = 4.425) were independent risk factors of postoperative complications (grade II or higher).

CONCLUSIONS

For patients with acute appendicitis, surgeons should perform immediate LA, if that is the patient's preferred surgical treatment, as long as there is no special reason to postpone surgery.

Risk Factors for Perforated Appendicitis in the Acute Care Surgery Era-Minimizing the Patient's Delayed Presentation Factor

BACKGROUND

Numerous factors contribute to advanced disease or increased complications in patients with acute appendicitis (AA). This study aimed to identify risk factors associated with AA perforation, including the effect of system time (ST) delay, after controlling for patient time (PT) delay. In this study, PT was controlled (to less than or equal to 24 h) to better understand the effect of ST delay on AA perforation.

METHODS

Medical records of patients who underwent surgery for AA at a tertiary referral hospital from October 2009 through September 2013 were reviewed. Data collected included demographics, body mass index, presence of fecalith, PT (i.e., duration of time from symptom onset to arrival in emergency department), and ST (i.e., duration of time from arrival in emergency department to operating room). AA was classified as simple (acute, nonperforated) versus advanced (gangrenous, perforated).

RESULTS

Seven hundred forty-seven patients underwent surgery for AA. After excluding patients with PT > 24 h, 445 patients fit the study criteria, of which 358 patients with simple AA and 87 patients with advanced disease. Advanced appendicitis patients were older and had higher body mass index, longer PT, higher WBC, and higher incidence of fecaliths. Both groups had similar ST. Risk factors for advanced appendicitis after multiple regression analysis are age >50 y old, WBC >15,000, the presence of fecaliths, and PT delay >12 h.

CONCLUSIONS

Once PT delay was limited to ≤24 h, the ST delay of >12 h did not adversely affect the incidence of advanced AA. Age >50 y, WBC >15,000, PT delay >12 h, and the presence of fecaliths were identified as risk factors associated with advanced AA.

Meta-analysis of in-hospital delay before surgery as a risk factor for complications in patients with acute appendicitis

Background

The traditional fear that every case of acute appendicitis will eventually perforate has led to the generally accepted emergency appendicectomy with minimized delay. However, emergency and thereby sometimes night‐time surgery is associated with several drawbacks, whereas the consequences of surgery after limited delay are unclear. This systematic review aimed to assess in‐hospital delay before surgery as risk factor for complicated appendicitis and postoperative morbidity in patients with acute appendicitis.

Methods

PubMed and EMBASE were searched from 1990 to 2016 for studies including patients who underwent appendicectomy for acute appendicitis, reported in two or more predefined time intervals. The primary outcome measure was complicated appendicitis after surgery (perforated or gangrenous appendicitis); other outcomes were postoperative surgical‐site infection and morbidity. Adjusted odds ratios (ORs) were pooled using forest plots if possible. Unadjusted data were pooled using generalized linear mixed models.

Results

Forty‐five studies with 152 314 patients were included. Pooled adjusted ORs revealed no significantly higher risk for complicated appendicitis when appendicectomy was delayed for 7–12 or 13–24 h (OR 1·07, 95 per cent c.i. 0·98 to 1·17, and OR 1·09, 0·95 to 1·24, respectively). Meta‐analysis of unadjusted data supported these findings by yielding no increased risk for complicated appendicitis or postoperative complications with a delay of 24–48 h.

Conclusion

This meta‐analysis demonstrates that delaying appendicectomy for presumed uncomplicated appendicitis for up to 24 h after admission does not appear to be a risk factor for complicated appendicitis, postoperative surgical‐site infection or morbidity. Delaying appendicectomy for up to 24 h may be an acceptable alternative for patients with no preoperative signs of complicated appendicitis.

Delay is safe

Effects of Timing of Appendectomy on the Risks of Perforation and Postoperative Complications of Acute Appendicitis

BACKGROUND

It is generally believed that appendectomy should be performed immediately to prevent perforation and complications. Therefore, our objectives were to investigate the effect of timing of appendectomy on the incidence of perforation and complications.

METHODS

We retrospectively reviewed the medical records of patients who underwent laparoscopic appendectomy between January 2014 and June 2015. The time from symptom onset to appendectomy was categorized into three periods: time from symptom onset to hospital admission (symptomatic time), time from admission to appendectomy (hospitalization time), and time from symptom onset to appendectomy [symptomatic period + hospitalization period (overall time)]. Multivariable analyses were performed to identify independent factors associated with perforation and complications.

RESULTS

A total of 1753 patients were included in the present study. Perforation occurred in 28.2% of patients, and postoperative complications occurred in 10.0% of patients. Multivariable analysis showed that BT > 38 °C (P = 0.006), WBC count >13,000 cells/µl (P = 0.02), neutrophil ratio >80% (P < 0.001), and symptomatic time >24 h (P < 0.001) were independent factors of appendiceal perforation, while the neutrophil ratio >80% (P < 0.001) and symptomatic time >48 h (P = 0.003) were independently associated with complications.

CONCLUSIONS

The present study showed that the symptomatic time and overall time were significantly associated with perforation and complications, whereas hospitalization time was not associated with either perforation or complications.

Influence of Time to Appendectomy and Operative Duration on Hospital Cost in Children with Uncomplicated Appendicitis

BACKGROUND

The goal of this study was to examine the influence of time to appendectomy (TTA) and operative duration (OD) on hospital cost as surrogate measures of perioperative efficiency.

STUDY DESIGN

We conducted a retrospective cohort analysis of 2,116 children undergoing appendectomy for uncomplicated appendicitis at 16 children's hospitals from January 2013 to December 2014. Time to appendectomy (emergency department presentation to incision) and OD were obtained from the NSQIP Pediatric Appendectomy Pilot Database and merged with cost data from the Pediatric Health Information System Database. Multivariate regression was used to examine the influence of TTA and OD (categorized by quartiles of hospital-level means) on hospital cost, adjusting for patient and hospital-level characteristics.

RESULTS

Median TTA and OD across all patients was 7.3 hours (interquartile range 4.4 to 12.4 hours) and 36 minutes (interquartile range 26 to 49 minutes), respectively. The longest quartile of OD was associated with 38% higher total cost ($2,512/case; rate ratio [RR] 1.38; 95% CI 1.27 to 1.5; p < 0.001) and 27% higher operating room-associated cost ($960/case; RR 1.27; 95% CI 1.22 to 1.34; p < 0.001) compared with the shortest quartile. The longest quartile of TTA was associated with 23% higher total cost ($1,589/case; RR 1.23; 95% CI 1.14 to 1.32; p < 0.001) and 53% higher room-associated cost ($906/case; RR 1.53; 95% CI 1.35 to 1.74; p < 0.001) compared with the shortest quartile. The influence of TTA and OD were independent but potentiating effects, with median cost for hospitals in both the longest quartiles of TTA and OD being 79% higher than those in the shortest quartiles.

CONCLUSIONS

Longer TTA and OD were independently associated with increased hospital cost, with OD being the most significant driver of cost variation across hospitals. Identification of best practices from high-efficiency hospitals might provide a high-yield strategy for improving value in appendicitis care.

Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children

IMPORTANCE

Management of appendicitis as an urgent rather than emergency procedure has become an increasingly common practice in children. Controversy remains as to whether this practice is associated with increased risk of complicated appendicitis and adverse events.

OBJECTIVE

To examine the association between time to appendectomy (TTA) and risk of complicated appendicitis and postoperative complications.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study using the Pediatric National Surgical Quality Improvement Program appendectomy pilot database, 2429 children younger than 18 years who underwent appendectomy within 24 hours of presentation at 23 children's hospitals from January 1, 2013, through December 31, 2014, were studied.

EXPOSURES

The main exposure was TTA, defined as the time from emergency department presentation to appendectomy. Patients were further categorized into early and late TTA groups based on whether their TTA was shorter or longer than their hospital's median TTA. Exposures were defined in this manner to compare rates of complicated appendicitis within a time frame sensitive to each hospital's existing infrastructure and diagnostic practices.

MAIN OUTCOMES AND MEASURES

The primary outcome was complicated appendicitis documented at operation. The association between treatment delay and complicated appendicitis was examined across all hospitals by using TTA as a continuous variable and at the level of individual hospitals by using TTA as a categorical variable comparing outcomes between late and early TTA groups. Secondary outcomes included length of stay (LOS) and postoperative complications (incisional and organ space infections, percutaneous drainage procedures, unplanned reoperation, and hospital revisits).

RESULTS

Of the 6767 patients who met the inclusion criteria, 2429 were included in the analysis (median age, 10 years; interquartile range, 8-13 years; 1467 [60.4%] male). Median hospital TTA was 7.4 hours (range, 5.0-19.2 hours), and 574 patients (23.6%) were diagnosed with complicated appendicitis (range, 5.2%-51.1% across hospitals). In multivariable analyses, increasing TTA was not associated with risk of complicated appendicitis (odds ratio per 1-hour increase in TTA, 0.99; 95% CI, 0.97-1.02). The odds ratios of complicated appendicitis for late vs early TTA across hospitals ranged from 0.39 to 9.63, and only 1 of the 23 hospitals had a statistically significant increase in their late TTA group (odds ratio, 9.63; 95% CI, 1.08-86.17; P = .03). Increasing TTA was associated with longer LOS (increase in mean LOS for each additional hour of TTA, 0.06 days; 95% CI, 0.03-0.08 days; P < .001) but was not associated with increased risk of any of the other secondary outcomes.

CONCLUSIONS AND RELEVANCE

Delay of appendectomy within 24 hours of presentation was not associated with increased risk of complicated appendicitis or adverse outcomes. These results support the premise that appendectomy can be safely performed as an urgent rather than emergency procedure.

Risk factors for morbidity after appendectomy

INTRODUCTION

The aim of the present study was to evaluate the risk factors for postoperative complications after an appendectomy with special regard to both the time period from hospital admission to operation and night time surgery.

PATIENTS AND METHODS

Patients who underwent an appendectomy due to acute appendicitis and were admitted to the University Hospital Aachen between January 2003 and January 2014 were included in this retrospective analysis. Regarding the occurrence of postoperative complications, patients were divided into the following two groups: the group with complications (group 1) and the group without complications (group 2).

RESULTS

Of the 2136 patients who were included in this study, 165 patients (group 1) exhibited complications, and in 1971 patients (group 2), no complications appeared. After a univariate logistic regression analysis, six predictors for postoperative complications were found and are described as follows: (1) complicated appendicitis (odds ratio (OR) 4.8 (3.46-6.66), p < 0.001), (2) operation at night (OR 1.62 (1.17-2.24), p = 0.004), (3) conversion from laparoscopic to open access (OR 37.08 (12.95-106.17), p < 0.001), (4) an age > 70 years (OR 6.00 (3.64-9.89), p < 0.001), (5) elevated CRP (OR 1.01 (1.01-1.01), p < 0.001) and (6) increased WBC count (OR 1.04 (1.01-1.07), p = 0.003). After multivariate logistic regression analysis, a significant association was demonstrated for complicated appendicitis (1.88 (1.06-3.32), p < 0.031), conversion to open access (OR 16.33 (4.52-58.98), p < 0.001), elevated CRP (OR 1.00 (1.00-1.01), p = 0.017) and an age > 70 years (OR 3.91 (2.12-7.21), p < 0.001). The time interval between hospital admission and operation was not associated with postoperative complications in the univariate and multivariate logistic regression analyses, respectively. However, the interaction between complicated appendicitis and the time interval to operation was significant (OR 1.024 (1.00-1.05), p = 0.028).

CONCLUSION

Based on our findings, surgical delay in the case of appendicitis and operation at night did not increase the risk for postoperative complications. However, the mean waiting time was less than 12 h and patients aged 70 years or older were at a higher risk for postoperative complications. Furthermore, for the subgroup of patients with complicated appendicitis, the time interval to surgery had a significant influence on the occurrence of postoperative complications. Therefore, the contemporary operation depending on the clinical symptoms and patient age remains our recommendation.

Delaying Appendectomy Does Not Lead to Higher Rates of Surgical Site Infections: A Multi-institutional Analysis of Children With Appendicitis

OBJECTIVES

To investigate the association between time to appendectomy and the risk of surgical site infections (SSIs) in children with appendicitis across multiple NSQIP-Pediatrics institutions.

BACKGROUND

Several recently published single institution retrospective studies have reported conflicting relationships between delaying appendectomy and the risk of increasing surgical site infections (SSI) in both children and adults. This study combines data from NSQIP-Pediatrics with institutional data to perform a multi-institutional analysis to examine the effects of delaying appendectomy on surgical site infections.

METHODS

Data from NSQIP-Pediatrics between January 2010 and June 2012 for cases of appendectomy for appendicitis at 6 institutions (preoperative characteristics, time of operation, and postoperative occurrences) were combined with data from medical record review (length of symptoms; times of initial presentation, emergency department (ED) triage, and admission; and diagnosis as simple appendicitis (SA, acute) or complicated appendicitis (CA, gangrenous/ruptured)). Cochran-Armitage tests for trend and multivariable logistic regression models were used to evaluate associations between time to appendectomy and SSI.

RESULTS

Of the 1338 patients included, 70% had SA and 30% had CA. Postoperative SSIs were more common in CA (5.7% vs 1.2%, P < 0.001). SSI rates did not differ significantly across hospitals (P = 0.17). Compared with patients who did not develop an SSI, patients who developed an SSI had similar times between ED triage and appendectomy (median (interquartile range) 11.5 hours (6.4-14.7) versus 9.7 hours (5.8-15.6, P = 0.36), and similar times from admission to appendectomy (5.5 hours (1.9-10.2) versus 4.3 hours (1.4-9.9), P = 0.36). Independent risk factors for SSI were CA (Odds Ratio (95% CI): 3.46 (1.48-8.10), P = 0.004), longer symptom duration (OR for a 10-hour increase: 1.05 (1.01-1.10), P = 0.02), and presence of sepsis/septic shock (2.70 (1.17-6.28), P = 0.02).

CONCLUSIONS

A 16-hour delay from ED presentation or a 12-hour delay from hospital admission to appendectomy was not associated with an increased risk for SSI.

The Established Acute Surgical Unit: A reduction in nighttime appendicectomy without increased morbidity

INTRODUCTION

Nighttime surgery for non-life threatening disease has been associated with poorer outcomes, but delaying surgery for acute appendicitis may also be detrimental. The aim was to assess the effect of the Acute Surgical Unit [ASU] model on nighttime surgery rates and outcomes for patients undergoing appendicectomy.

METHOD

A retrospective review of medical records of patients having an appendicectomy. Primary outcomes were nighttime surgery rate, time from presentation to surgery, perforation rate, complication rate and length of stay.

RESULTS

There was a large increase in workload: Pre ASU 278, Early ASU 553 and Est. ASU 923. There was a significant decrease in nighttime surgery rates: Pre ASU 46.9%, Early ASU 30.2% and Established ASU 28.3% (Pre vs. Early p < 0.001; Pre vs. Est. p < 0.001; Early vs. Est p = 0.004). When comparing the Pre ASU and Established ASU groups there was an increase in mean time from presentation to surgery (Pre 14.43 Hrs, Est. 18.65 Hrs; p = 0.001), an increase in perforation rate that was not significant (Pre 9.8%, Est. 14.2%; p = 0.05) and similar complication rates (Pre 8.66%, Est. 7.04%; p = 0.37). There was a significant decrease in length of stay between the Early and Established ASU groups (Pre 3.1 D, Est. 2.8D, p = 0.01). At our institution there was no statistically significant increase in complications for patients undergoing nighttime appendicectomy (Night 10.0%, Day 8.2%; p = 0.16).

CONCLUSION

There was a significant decrease in nighttime surgery, without any difference in morbidity or length of stay for patients treated within the Established ASU (compared to Pre ASU group).

LEVEL OF EVIDENCE

IIb.

Delay Between Onset of Symptoms and Surgery in Acute Appendicitis Increases Perioperative Morbidity: A Prospective Study

BACKGROUND

Despite significant progress in surgery, controversy persists about timing of appendectomy. Objective of this prospective observational study was to determine associations between time interval from onset of symptoms in appendicitis to appendectomy and postoperative complications.

METHODS

After institutional review board approval, all adult consecutive patients subjected to emergency appendectomy between 1/9/2013 and 1/12/2014 were prospectively enrolled. Data collection included demographics, open vs. laparoscopic appendectomy, comprehensive complication index (CCI), and 30-day follow-up. To determine time-dependent associations between delay of surgery and complications all patients were stratified into subgroups based on 12-h time intervals from onset of abdominal pain to surgery. Primary outcome was complications per CCI in correlation to delay from symptoms to appendectomy. Secondary outcomes included duration of surgery, hospital length of stay (HLOS), and incidence of complication within 30-day follow-up.

RESULTS

A total of 266 patients with a mean age of 35.4 ± 14.8 years met inclusion criteria. Overall, 83.1 % of patients were subjected to laparoscopic appendectomy. Delay to surgery in 12-h increments showed stepwise-adjusted increase in complications per CCI (adj. P = 0.037). Also, delay to appendectomy increased significantly duration of surgery and HLOS, respectively (adj. P < 0.001 and adj. P < 0.001). Overall, 5.7 % of patients developed a surgical site infection after hospital discharge.

CONCLUSION

Extended time interval from the onset of initial symptoms to appendectomy is associated with increased complications per CCI, duration of surgery, and HLOS in acute appendicitis. Prompt appendectomy in acute appendicitis is warranted.

Effect of surgical timing and outcomes for appendicitis severity

PURPOSE

This study was aimed to evaluate the effect of time of surgery for acute appendicitis on surgical outcomes to optimize the timing of appendectomies.

METHODS

Medical records of patients who underwent an appendectomy were reviewed to obtain data on time of symptom onset, time of hospital presentation, and start times of surgery. Surgical findings were used to define appendicitis as either uncomplicated or complicated. The uncomplicated group included patients with simple, focal, or suppurative appendicitis, and the complicated group included patients with gangrenous, perforated appendicitis or periappendiceal abscess formation. The 2 groups were analyzed by age, sex, and time.

RESULTS

A total of 192 patients were analyzed. The mean time from symptom onset to start of operation showed a significant difference between both groups (1,652.9 minutes vs. 3,383.8 minutes, P < 0.001). The mean time from hospital visit to start of operation showed no difference between both groups (398.7 minutes vs. 402.0 minutes, P = 0.895). Operating within 24 hours of symptom onset had a relative risk of 1.738 (95% confidence interval, 1.319-2.425) for complications. Operating more than 36 hours after symptom onset was associated with an increased risk of postoperative ileus and a longer hospital stay.

CONCLUSION

Complicated appendicitis is associated with a delay in surgery from symptom onset rather than a delay at hospital arrival. Surgeons should take into account the time from symptom onset when deciding on the timing of appendectomy. We recommend that appendectomy be performed within 36 hours from symptom onset.

Appendectomy: Should it Be Performed So Quickly?

Controversy surrounds appendectomy timings and their effects on postoperative outcomes. This study evaluated the influence of hospital delays on perforation rates and complications in patients with acute appendicitis. From January 2008 to December 2013, the cases of 4148 consecutive patients who had undergone appendectomies for suspected appendicitis were reviewed. The patients' demographic data, times from symptom onset to hospital arrival (prehospital delay), times from hospital arrival to surgery (hospital delay), histological findings, and postoperative outcomes were documented. Perforation rates and complications were assessed at each time interval between symptom onset and surgery. Perforation rates and complications increased with longer prehospital delays, but no correlations were evident between hospital delays and perforation rates or between hospital delays and complications. Although delaying appendectomies for >18 hours had no statistically significant impact on perforation rates (25.3 vs 19.4%, P = 0.133), it caused more complications (8.7 vs 3.8%, P = 0.023) compared with cases delayed for 12 to 18 hours. Multivariate analyses determined that hospital delays were not associated with increased risks of perforation, complications, wound infections, or intra-abdominal abscesses. However, a >18-hour hospital delay was associated with a significantly increased risk of postoperative ileus (odds ratio = 2.94, 95% confidence interval = 1.17-7.41, P = 0.022). Hospital delays were not associated with significantly increased risks of perforation and complications. However, patients with perforated appendicitis had higher risks of developing postoperative ileus if hospital delays were >18 hours. Therefore, hospital delays of ≤18 hours are safe, but caution is required if delays are >18 hours.

Computed tomography to operating room in less than 3 hours minimizes complications from appendicitis

BACKGROUND

The aim of our study is to select patients with nonperforated appendicitis verified by computed tomography (CT) scan and to determine if there is a temporal component to perforation.

METHODS

A retrospective cohort study of patients with CT scan evidence of nonperforated appendicitis from 2007 to 2012.

RESULTS

411 patients, aged 39.7 ± 16.25 years (47.5% male) were included in the study. 330 patients (80.3%) were nonperforated at surgery. Analysis of 3-hour intervals from CT scan to operating room (OR) revealed an absolute reduction in the rate of perforation from 27% at the 6- to 9-hour interval, to 17% and 10% at the 3- to 6-hour and 0- to 3-hour intervals, respectively, (P < .04). All organ space infections occurred in patients who were delayed to the OR greater than 3 hours. Mean length of hospitalization was .93 days and 2.81 days, respectively, in nonperforated and perforated appendicitis patients (P < .001).

CONCLUSIONS

Delays to the OR were associated with increased risk of perforation. Patients with uncomplicated appendicitis had shorter hospitalization and fewer postoperative wound infections.

Evaluating the effect of time process measures on appendectomy clinical outcomes

BACKGROUND

With varied reports on the impact of time to appendectomy on clinical outcomes, we examined the effects of pre-operative delays in pediatric acute appendicitis.

METHODS

Children with acute appendicitis (January 2013-June 2014) were identified from a prospective database. Univariate analyses compared time metrics, patient characteristics, and disease severity with postoperative complications (POC) and organ space surgical site infection (OSSI), and multivariate logistic regression determined predictors of POC and OSSI.

RESULTS

1211 patients underwent appendectomy. Median age was 10.4years (IQR 7.8-13years). 537 patients (45%) had complex appendicitis. Overall, POC was 11% (n=133), and OSSI was 9% (n=105). Neither time from presentation to appendectomy nor diagnosis to appendectomy increased POCs. On univariate analyses, operative time (OT) was longer in patients with POC (57min (IQR 49-75) vs. 46min (IQR 36-57), p<0.001 and OSSI (60min (IQR 51-80) vs. 46min (IQR 37-57), p<0.001. However, after adjusting for confounding factors, disease severity remained the most significant predictor of POC (OR 6.5, 95% CI 2.79-15.23) and OSSI (OR 76.6, 95% CI 7.87-745.65).

CONCLUSION

Pre-operative delays were not associated with increased POC or OSSI. The strongest predictor of POC or OSSI was disease severity, for which operative time may represent a surrogate.

Risk and outcomes of 24-h delayed and weekend appendectomies

BACKGROUND

Time interval from hospital admission to operative intervention has been suggested as a crucial risk factor for a number of surgical procedures. In this study, we aim to compare postappendectomy outcomes for operations performed 24 h after admission or on the weekend to within 24 h and weekday operations, respectively.

MATERIAL AND METHODS

A cross-sectional study using the Nationwide Inpatient Sample database, 2004-2009. The study population included patients who underwent appendectomy for acute appendicitis.

RESULTS

A total of 265,972 records were identified, of which 221,745 (83.4%) patients had appendectomy on the same day of admission, whereas 16.6% had the procedure the following day. Next day operations were more likely to be associated with postoperative complications (OR = 1.26, 95% CI = [1.19-1.33], P < 0.001). A hospital stay of >3 d was also more common for next day interventions (P < 0.001). Appendectomies performed on weekends had a higher risk of complications compared to other days (OR = 1.08, 95% CI = [1.02-1.14], P = 0.005). Teaching and urban hospitals were more likely to perform appendectomies on the day after admission (P < 0.05). Older patients (≥35 years), females, Blacks and Hispanics, and those on Medicaid or Medicare were all at higher risk of next day intervention (P < 0.01 each). The average cost of next day operations was higher compared to same day operations ($9890.11 ± 119.64 versus $8744.57 ± 77.67, P < 0.001).

CONCLUSIONS

Appendectomies performed 1 d after admission or on the weekend are associated with disadvantageous outcomes. Demographic factors, in addition to hospital attributes, place certain subpopulations at higher risk of next day appendectomies.

A lower neutrophil to lymphocyte ratio is closely associated with catarrhal appendicitis versus severe appendicitis

PURPOSE

Catarrhal appendicitis (CA) could be treated effectively with antibiotics in some patients because of the milder inflammation associated with this form of appendicitis. Although several trials have compared surgery with antibiotic therapy for acute appendicitis (AA), the indications for antibiotic therapy remain controversial.

METHODS

The subjects of this study were 342 patients who underwent appendectomy at our hospital between January, 2000 and March, 2013. The patients were divided into two groups based on the severity of their appendicitis: Group A comprised patients with severe appendicitis and Group B comprised patients with CA. Statistical analyses were performed to assess the clinical features associated with CA.

RESULTS

Multivariate analysis of the eight clinical features correlated with CA according to univariate analysis revealed that the neutrophil to lymphocyte ratio (NLR) (<5/>5), age (<38/>38 years), fever (<38/>38 °C), white blood cell count (<11.5/>11.5 × 10³/mm³) and serum level of C-reactive protein (<110/>110 mg/L) were significantly associated with CA. The NLR (<5/>5) (OR 0.421; 95 % CI 0.218-0.811; P = 0.010) was the most useful predictor of CA, because the area under the ROC curve of NLR was the lowest of all these features.

CONCLUSION

The preoperative NLR in patients undergoing appendectomy is closely associated with CA.

Optimal timing of appendectomy in the pediatric population

BACKGROUND

No consensus has been reached on optimal timing for performing appendectomies. We compared immediate and delayed appendectomies in pediatric patients presenting with suspected acute appendicitis to determine differences in postsurgical complications and perforation rates.

METHODS

A retrospective cohort study was performed of all children who underwent appendectomy during a 4-y period. Cutoffs used were 6, 8, and 12 h from admission to operating room (OR). The Student t-tests and chi-square tests were performed to compare continuous and categorical variables, respectively. A logistic regression model was fitted to determine predictors of appendiceal perforation. P values <0.05 were considered significant.

RESULTS

Analysis included 484 patients with mean elapsed time from admission to OR of 394 min, with 262 subjects in the immediate and 222 subjects in the delayed >6 h groups. Surgical site infections (SSIs), perforations, and small bowel obstructions were similar between groups, and no statistically significant differences were found for SSIs in the nonperforated delayed versus immediate groups (P = 0.964). Time from admission to the OR did not predict perforation (P = 0.921), although white blood cell count at the time of admission was a significant predictor of perforation (odds ratio, 1.08; P < 0.001).

CONCLUSIONS

For suspected acute appendicitis, delaying appendectomy after admission for >6 h demonstrated no differences in SSI or perforation rates compared with immediate appendectomy. Waiting to perform an appendectomy until the following day has equal outcomes to immediate surgical procedure and may improve overall quality of patient care by limiting surgeon fatigue.

Effect of time delays for appendectomy as observed on computed tomography in patients with noncomplicated appendicitis

OBJECTIVES

Delaying appendectomy is a controversial issue. This study aimed at identifying the effect of time delays in surgery, especially for patients with noncomplicated appendicitis on computed tomography (CT).

METHODS

Postappendectomy patients were analyzed from October 2013 to August 2014. Among the patients, data of those with findings of noncomplicated appendicitis on CT were gathered and the following time parameters were reviewed: CT examination time and appendectomy time. Other basic information and postoperative complications were checked. Patients were divided into a noncomplicated appendicitis group and a complicated appendicitis group. Perforated appendicitis and periappendiceal abscesses were regarded as complicated appendicitis. All other appendicitis from simple, focal to suppurative, and gangrenous appendicitis were regarded as noncomplicated appendicitis.

RESULTS

In total, 397 patients were enrolled. The mean age was 33.2 years and the number of male/female patients was 216:181, respectively. The mean times from CT to operation were 5.9 vs 6.3hours for both the noncomplicated and complicated appendicitis groups (P=.758). The time from CT to operation showed no statistical relation to occurrences of complicated appendicitis, or postoperative complications such as ileuses, wound complications, and length of hospital stay.

CONCLUSIONS

The time from CT to operation has no effect on the results of appendicitis. Further study in large-scaled, multicenter setting might yield more reliable results.

Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals

OBJECTIVES

The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies.

METHODS

Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression.

RESULTS

Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014).

CONCLUSIONS

Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes.

Appendicectomies performed >48 hours after admission to a dedicated acute general surgical unit

INTRODUCTION

Acute general surgical units (AGSUs) are changing the way in which acute appendicitis is managed. In the AGSU at John Hunter Hospital, some patients wait more than 48 hours from admission to undergo an appendicectomy, usually because they are not unwell enough to precipitate an operation before that time. We analysed this subgroup of appendicectomy patients to determine how effectively they are being managed and how this might be improved.

METHODS

A retrospective review of prospectively collected data was conducted of all patients who received an appendicectomy while admitted under the AGSU at John Hunter Hospital in the five years between January 2009 and December 2013.

RESULTS

A total of 1,039 appendicectomies were performed in the study period, with 81 patients (7.8%) waiting >48 hours for their operation (delayed appendicectomy group). Overall, the negative appendicectomy (NA) rate was 21.6%; the NA rate in delayed appendicectomies was 50.62% and a non-therapeutic operation occurred in 47% of this group (n=38). No significant difference was found in the incidence of perforation/gangrenous appendicitis between patients having surgery in <48 hours and the delayed appendicectomy groups (11.2% vs 9.9%, p=0.85). A combination of negative diagnostic imaging result, a normal white cell count and normal C-reactive protein (ie a negative 'triple test') was the best predictor of a negative appendicectomy (p=0.0158, negative predictive value: 0.91, 95% confidence interval: 0.59-0.99), in the delayed appendicectomy group.

CONCLUSIONS

In the delayed appendicectomy group, the incidence of perforation/gangrenous appendicitis was not significantly different from that found in patients having appendicectomy performed sooner. However, the NA and non-therapeutic operation rates were unacceptably high. An appendix triple test can improve diagnostic accuracy significantly without an unacceptable rise in the rates of perforation/gangrenous appendicitis.

Single-incision laparoscopic appendectomy versus conventional 3-port laparoscopic appendectomy for appendicitis: an updated meta-analysis of randomized controlled trials

PURPOSE

To compare the efficacy and safety of single-incision laparoscopic appendectomy (SILA) and conventional 3-port laparoscopic appendectomy (3-port LA) for appendectomy.

METHODS

We searched the PubMed, Embase, Springer link, and the Cochrane library databases up to April, 2014, for relevant randomized controlled trials (RCTs). Data were pooled by weighted mean differences (WMDs) or odds ratios (ORs) with their 95% confidence intervals (CIs).

RESULTS

We found 11 RCTs, with a collective total of 731 patients treated with SILA and 725 patients treated with 3-point LA. Results indicated no significant differences between SILA and 3-port LA in primary outcomes, including wound infection, intra-abdominal abscess, postoperative ileus, and total postoperative complications, and some secondary outcomes, including postoperative pain scores and length of hospital stay. However, SILA was associated with significantly longer operative times (WMD = 6.78, 95% CI = 3.78-9.79, P < 0.00001) and higher doses of analgesia (WMD = 0.96, 95% CI = 0.45-1.47, P = 0.0002) than the 3-port LA.

CONCLUSION

Although there was no significant difference in the safety of SILA vs. that of 3-port LA, our findings do not support the application of SILA because of its significantly longer operative times and the higher doses of analgesia required compared with those for 3-point LA.

The preoperative serum C-reactive protein level is a useful predictor of surgical site infections in patients undergoing appendectomy

PURPOSE

Although surgical site infections (SSI) are a major postoperative complication of appendectomy, few studies have focused on the risk factors for SSI. In this study, we investigated the risk factors for SSI in patients who had undergone appendectomy.

METHODS

Three hundred patients who had undergone open appendectomy were enrolled. The patients were divided into two groups based on the presence or absence of SSI. A statistical analysis was performed to assess the clinical features associated with SSI after appendectomy.

RESULTS

A multivariate analysis using the results of univariate analyses revealed that the serum C-reactive protein (CRP) level (≤ 65/> 65, mg/l), length of the operation (≤ 80/> 80, min) and pathology (catarrhal, phlegmonous/gangrenous) were associated with SSI. Among these three clinical features, only the CRP level was found to predict the risk of SSI prior to appendectomy (odds ratio 3.797; 95 % confidence intervals 1.305-11.04; P = 0.014).

CONCLUSION

Preoperative elevation of the serum CRP level (> 65 mg/l) is a valuable predictor of SSI in patients undergoing appendectomy.

Implementation of the acute care surgery model provides benefits in the surgical treatment of the acute appendicitis

BACKGROUND

Several reports have indicated the benefits of the acute care surgery (ACS) model in surgical outcomes. We tried to delineate the impact of the ACS model on surgical efficiency and quality.

METHODS

Before the ACS model was implemented, abdominal surgical emergencies were evaluated by an on-call nontrauma general surgeon (pre-ACS model). An in-house trauma surgeon treated all patients with trauma or nontrauma abdominal surgical emergencies after the ACS model. Patients with acute appendicitis who underwent appendectomies were included. We conducted a pre- and poststudy to compare the time patients were in the emergency department and surgical qualities.

RESULTS

There were 146 and 159 patients enrolled in the pre-ACS model and ACS model, respectively. The overall ED length of stay in the ACS model was significantly shorter than that in the pre-ACS model (300.3 ± 61.7 vs 719.1 ± 339.0 minutes, P < .001). Hospital LOS was also significantly shorter in the ACS model than in the pre-ACS model (2.44 ± 1.39 vs 3.83 ± 2.21 days, P = .022).

CONCLUSION

The ACS model may improve abdominal surgical efficiency and quality. Our study results echoed the benefits of the implementation of the ACS model shown in North America.

Efficacy of transumbilical laparoscopic-assisted appendectomy for appendicitis: a four-year experience at a single center

PURPOSE

To compare the surgical outcomes after transumbilical laparoscopic-assisted appendectomy (TULAA) and open appendectomy (OA) at a single institution.

METHODS

We compared the surgical outcomes for 94 consecutive patients who underwent TULAA between April 2010 and March 2014 to those for 91 consecutive patients who underwent OA between April 2006 and March 2010.

RESULTS

There were no significant differences in the clinicopathological backgrounds between the two groups. Although the lengths of the operations were similar in both groups, the postoperative hospital stay was significantly shorter in the TULAA group (4.7 days vs. 5.4 days, P = 0.02). The need for abdominal drain insertion was significantly reduced in the TULAA group owing to sufficient intraperitoneal exploration (P = 0.03). The incidence of postoperative complications was also lower in the TULAA group, but the difference was not significant (8.6 % vs. 12.1 %, P = 0.31). In complicated cases, a lower incidence of surgical site infection was confirmed in the TULAA group (6.7 % vs. 20.7 %, P = 0.12).

CONCLUSION

Our results demonstrated that TULAA provided better surgical outcomes, especially a faster recovery. TULAA could be an effective procedure incorporating both open and laparoscopic techniques, and can be implemented as a standard procedure for the treatment of appendicitis, regardless of disease severity.