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Kumar SS, Collings AT, Lamm R, Haskins IN, Scholz S, Nepal P, Train AT, Athanasiadis DI, Pucher PH, Bradley JF, Hanna NM, Quinteros F, Narula N, Slater BJ. SAGES guideline for the diagnosis and treatment of appendicitis. Surg Endosc 2024; 38:2974-2994. [PMID: 38740595 DOI: 10.1007/s00464-024-10813-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/21/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis. METHODS A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. RESULTS Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty. CONCLUSIONS These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.
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Affiliation(s)
- Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pramod Nepal
- Division of Colon & Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | | | - Philip H Pucher
- School of Pharmacy and Biosciences, University of Portsmouth & Department of General Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Joel F Bradley
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Nisha Narula
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Bethany J Slater
- University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, USA.
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Takeda K, Yamada T, Uehara K, Matsuda A, Shinji S, Yokoyama Y, Takahashi G, Iwai T, Kuriyama S, Miyasaka T, Kanaka S, Yoshida H. The benefits of interval appendectomy and risk factors for nonoperative management failure in the therapeutic strategy for complicated appendicitis. Surg Today 2024:10.1007/s00595-024-02842-w. [PMID: 38598170 DOI: 10.1007/s00595-024-02842-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/17/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE Emergency surgery (ES) for complicated appendicitis (CA) is associated with high morbidity. Interval appendectomy (IA) decreases this rate; however, nonoperative management (NOM) is not always successful. Some patients require unplanned ES due to NOM failure (IA failure: IA-F). This study aimed to verify the benefits of IA and to evaluate the risk factors for NOM failure. METHODS Patients diagnosed with CA who underwent surgery between January 2012 and December 2021 were included in this study. We compared the surgical outcomes of the ES group with those of the IA success (IA-S) and IA-F groups. We also analyzed 14 factors that predicted NOM failure. RESULTS Among 302 patients, the rate of severe complications (Clavien-Dindo grade ≥ III) was significantly higher in the ES group (N = 165) than in the IA-S group (N = 102). The rates were equal between the ES (N = 165) and IA-F (N = 35) groups. NOM was successful in 110 patients and failed in 27. Lack of abscesses, comorbidities, high WBC count, and free air were independent risk factors for NOM failure. CONCLUSIONS Considering the benefits of IA and the non-inferior surgical outcomes of IA-F compared to ES, IA is a good therapeutic strategy for CA. However, in patients exhibiting four independent risk factors for NOM failure, careful monitoring of unplanned ES is necessary.
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Affiliation(s)
- Kohki Takeda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan.
| | - Takeshi Yamada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Kay Uehara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Akihisa Matsuda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Seiichi Shinji
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Yasuyuki Yokoyama
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Goro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Takuma Iwai
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Sho Kuriyama
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Toshimitsu Miyasaka
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Shintaro Kanaka
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
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Xu H, Yang S, Xing J, Wang Y, Sun W, Rong L, Liu H. Comparison of the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis: a systematic review and meta-analysis. BMC Surg 2023; 23:208. [PMID: 37488583 PMCID: PMC10367319 DOI: 10.1186/s12893-023-02108-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/14/2023] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVE This meta-analysis aimed to compare the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis. METHODS We searched the randomized controlled studies (RCTs) comparing appendectomy with antibiotic treatment for uncomplicated acute appendicitis in the electronic database including Pubmed, Embase, Cochrane, Web of Science, CNKI, VIP, and WanFang. The primary outcomes included complication-free treatment success at 1 year, complications, surgical complications, and the complicated appendicitis rates. Secondary outcomes included negative appendicitis, length of hospital stay, the quality of life at 1 month, and the impact of an appendicolith on antibiotic therapy. RESULTS Twelve randomized controlled studies were included. Compared with surgery group, the antibiotic group decreased the complication-free treatment success at 1 year (RR 0.81; 95% CI 0.73-0.91; z = 3.65; p = 0.000). Statistically significance was existed between antibiotic group and surgical group with both surgical types(open and laparoscopic) (RR 0.43; 95% CI 0.31-0.58; z = 5.36; p = 0.000), while no between the antibiotic treatment and laparoscopic surgery (RR 0.72; 95% CI 0.41-1.24; z = 1.19; p = 0.236). There was no statistically significant differences between two groups of surgical complications (RR 1.38; 95% CI 0.70-2.73; z = 0.93; p = 0.353), the complicated appendicitis rate (RR 0.71; 95% CI 0.36-1.42; z = 0.96; p = 0.338), negative appendectomy rate (RR 1.11; 95% CI 0.69-1.79; z = 0.43; p = 0.670), duration of hospital stay (SMD 0.08; 95%CI -0.11-0.27; z = 0.80; p = 0.422), and quality of life at 1 month (SMD 0.09; 95%CI -0.03-0.20; z = 1.53; p = 0.127). However, in the antibiotic treatment group, appendicolith rates were statistically higher in those whose symptoms did not improve (RR 2.94; 95% CI 1.28-6.74; z = 2.55; p = 0.011). CONCLUSIONS Although the cure rate of antibiotics is lower than surgery, antibiotic treatment is still a reasonable option for patients with uncomplicated acute appendicitis who do not want surgery without having to worry about complications or complicating the original illness.
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Affiliation(s)
- Hongxia Xu
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China.
| | - Shaohui Yang
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China
| | - Jiankun Xing
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China
| | - Yan Wang
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China
| | - Weiqiang Sun
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China
| | - Lingyan Rong
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China
| | - Huihui Liu
- Department of Clinical Pharmacy, Wendeng Hospital of Traditional Chinese Orthopedics and Traumatology of Shandong Province, No.1 Fengshan Road, Wendeng District, Weihai City, 264400, Shandong Province, China
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Barie PS, Kao LS, Moody M, Sawyer RG. Infection or Inflammation: Are Uncomplicated Acute Appendicitis, Acute Cholecystitis, and Acute Diverticulitis Infectious Diseases? Surg Infect (Larchmt) 2023; 24:99-111. [PMID: 36656157 DOI: 10.1089/sur.2022.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: It is recognized increasingly that common surgical infections of the peritoneal cavity may be treated with antibiotic agents alone, or source control surgery with short-course antimicrobial therapy. By extension, testable hypotheses have emerged that such infections may not actually be infectious diseases, but rather represent inflammation that can be treated successfully with neither surgery nor antibiotic agents. The aim of this review is to examine extant data to determine which of uncomplicated acute appendicitis (uAA), uncomplicated acute calculous cholecystitis (uACC), or uncomplicated mild acute diverticulitis (umAD) might be amenable to management using supportive therapy alone, consistent with the principles of antimicrobial stewardship. Methods: Review of pertinent English-language literature and expert opinion. Results: Only two small trials have examined whether uAA can be managed with observation and supportive therapy alone, one of which is underpowered and was stopped prematurely because of challenging patient recruitment. Data are insufficient to determine the safety and efficacy of non-antibiotic therapy of uAA. Uncomplicated acute calculous cholecystitis is not primarily an infectious disease; infection is a secondary phenomenon. Even when bactibilia is present, there is no high-quality evidence to suggest that mild disease should be treated with antibiotic agents. There is evidence to indicate that antibiotic prophylaxis is indicated for urgent/emergency cholecystectomy for uACC, but not in the post-operative period. Uncomplicated mild acute diverticulitis, generally Hinchey 1a or 1b in current nomenclature, does not benefit from antimicrobial agents based on multiple clinical studies. The implication is that umAD is inflammatory and not an infectious disease. Non-antimicrobial management is reasonable. Conclusions: Among the considered disease entities, the evidence is strongest that umAD is not an infectious disease and can be treated without antibiotic agents, intermediate regarding uACC, and lacking for uAA. A plausible hypothesis is that these inflammatory conditions are related to disruption of the normal microbiome, resulting in dysbiosis, which is defined as an imbalance of the natural microflora, especially of the gut, that is believed to contribute to a range of conditions of ill health. As for restorative pre- or probiotic therapy to reconstitute the microbiome, no recommendation can be made in terms of treatment, but it is not recommended for prevention of primary or recurrent disease.
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Affiliation(s)
- Philip S Barie
- Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Lillian S Kao
- Department of Surgery, UTHealth Houston John P. and Kathrine G. McGovern Medical School, Houston, Texas, USA
| | - Mikayla Moody
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
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Babington EA. Appendicoliths, the little giants: A narrative review. Radiography (Lond) 2023; 29:1-7. [PMID: 36179409 DOI: 10.1016/j.radi.2022.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/30/2022] [Accepted: 09/14/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVES This narrative review aims to collate the data in the existing literature on appendicoliths, by reviewing the available information on appendicoliths that have been previously reported in 24 publications, and providing the information in one article. KEY FINDINGS Appendicoliths are frequent culprits in causing luminal obstruction of the appendix, leading to appendicitis. They are calcified masses formed as a result of the aggregation of faecal particulates and inorganic salts within the lumen of the appendix. The presence of appendicoliths in an inflamed appendix influences the patient's treatment, as surgery is usually done to avoid appendix perforation and abscess formation, and also to prevent a future recurrence of the disease. Appendicoliths are mostly imaged using CT, Ultrasound, and plain X-rays; however, CT is the most frequently used modality, particularly in the imaging of complications caused by 'retained' appendicoliths. 'Retained' appendicoliths and their consequential abscesses have been reported in the sub-hepatic and intrahepatic regions, pelvic and tubo-ovarian regions, gluteal region, subcutaneous layer, subphrenic region, and through the diaphragm into the chest cavity. CONCLUSION This review provides useful information on the imaging appearances and complications caused by the presence of appendicoliths in an inflamed appendix, and it also provides information on the clinical implications of 'dropped' appendicoliths during appendectomy. IMPLICATIONS FOR PRACTICE Based on the findings of this review, it is recommended that the appropriate imaging modality (ultrasound and/or CT) should be considered when imaging appendicoliths and its complications. It is also suggested that retained appendicolith be considered a differential diagnosis when imaging patients with a history of appendectomy due to complicated appendicitis/perforation.
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Affiliation(s)
- Emmanuel A Babington
- Sheffield Hallam University, Sheffield, UK; Sonographer at the University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK.
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