Acute Appendicitis in the Adult Population: Modelled Decision Analysis Supports a Conservative Approach

Laparoscopic Appendectomy: A Safe and Definitive Solution for Suspected Appendicitis

Introduction

Since conservative antibiotic treatment in uncomplicated appendicitis might not solve the clinical problem definitively, it has to compete with the results of today's laparoscopic appendectomy.

Methods

In a county hospital, accommodating also a pediatric department, all cases of appendectomy for suspected appendicitis over 15 years were analyzed retrospectively for the following items: beginning of symptoms, time from admission to surgery, surgical technique as "open," "laparoscopic" or "converted," if perforated at operation and histological confirmation of acute inflammation. Surgical morbidity was detected in distinct categories. To evaluate changes over time, 3 time periods of 5 years each were defined.

Results

Resulting in a total of 1,956 cases there were 731 in group I, 633 in group II and 592 in group III within the 3 time periods, respectively. The median age was 17 years. The percentage of perforations was 16.8%. Those patients had - with 47 compared to 27 h - a significantly prolonged time from the beginning of symptoms to admission (p = 0.0001). The proportion of laparoscopic surgery rose from 83.3 (group I) to 98.3% (group III; p = 0.0001). The median postoperative hospital stay diminished from 4 to 3 days in nonperforated (p = 0.0001) and from 8 to 7 days in perforated cases (p = 0.0009). Surgical morbidity was reduced from 4.1% in the first to 1.7% in the third observation period (p = 0.0144). There were no surgical site infections during the last 5 years.

Conclusions

Timely laparoscopic appendectomy in case of suspected appendicitis can be offered with an extraordinary low morbidity. Taking into account the complete solution of the otherwise pending threat, compared to conservative antibiotic treatment, it is safe and definitive.

Options in Bariatric Surgery: Modeled Decision Analysis Supports One-Anastomosis Gastric Bypass as the Treatment of Choice when Type 2 Diabetes Is Present

BACKGROUND

Obesity and type 2 diabetes mellitus (T2DM) represent significant healthcare burdens. Surgical management is superior to traditional medical therapy. Laparoscopic sleeve gastrectomy (LSG) and gastric bypass (both Roux-en-Y (RYGB) and one anastomosis gastric bypass (OAGB) are the most commonly performed metabolic procedures. It remains unclear which gives the optimal quality-of-life pay-off in the context of T2DM. This study compares LSG, RYGB, and OAGB in the management of T2DM and obesity using modeled decision analysis. Alternative approaches were assessed considering efficacy of interventions, post-operative complications, and quality of life outcomes to determine the optimal approach.

METHODS

Modeled decision analysis was performed from the patent's perspective comparing best medical management (MM), SG, RYGB, OAGB, and LAGB. The base case is a 40-year-old female with a body mass index (BMI) of 40 and T2DM. Input variables were calculated based on published decision analyses and a literature review. Utilities were based on previous studies. Sensitivity analysis was performed. The payoff was quality-adjusted life years (QALYs) 5 years from intervention. TreeAge Pro modeling software was used for analysis.

RESULTS

In 5-years post-procedure, OAGB gave the optimal QALY payoff of 3.65 QALYs (reviewer 2). RYGB gave 3.47, SG gave 3.08, LAGB gave 2.62 and MM 2.45 QALYs. Three input variables proved sensitive. RYGB is optimal if its metabolic improvement rates exceed 86%. It is also optimal if metabolic improvement rates in OAGB drop below 71.8% or if the utility of OAGB drops below 0.759.

CONCLUSION

OAGB gives the optimal QALY payoff in treatment of T2DM. RYGB and SG also improve metabolic outcomes and remain viable options in selected patients.

Long-Term Results Following Antibiotic Treatment of Acute Appendicitis in Adults

BACKGROUND

Antibiotic treatment of acute appendicitis has gained interest and inquiries. Reports have demonstrated both safety and high resolution of symptoms and inflammation following antibiotic treatment of appendicitis, but information on long-term results is required. Our present aim was therefore to evaluate long-term recurrence rate of initial antibiotics-alone treatment for suspected acute appendicitis.

METHODS

Patients with favourable response to antibiotics in earlier randomized (RCT, n = 97) and population-based (PBT, n = 342) studies as well as subsequently treated non-randomized (Non-R, n = 271) patients are evaluated for long-term risk to relapse demanding surgical appendectomy; altogether 710 patients.

RESULTS

Clinical characteristics among randomized and non-randomized patients were similar without any statistical difference according to abdominal symptoms and degree of systemic inflammation (CRP, WCC) when antibiotic treatment started. Females and males showed the same results. The median follow-up time was 2162 days (5.92 years), and the range across highest and lowest follow-up was 3495 days (range 2-3497) for the entire group, without significant differences among subgroups (RCT, PBT, Non-R). The cumulative probability for relapse of appendicitis demanding appendectomy was: 0.09, 0.12, 0.12 and 0.13 at 1-, 2-, 3- and 5-year follow-up, with a probability of 0.86 ± 0.013 without appendectomy after 8 years. This may imply an overall benefit of 60-70% by antibiotics during expected 10-year follow-up accounting for initial treatment failures at 10-23% in our published reports.

CONCLUSION

Antibiotic treatment is safe and effective as a first-line therapy in unselected adults with acute appendicitis with a risk around 15% for long-term relapse following favourable initial treatment response.

Prospective validation of neutrophil-to-lymphocyte ratio as a diagnostic and management adjunct in acute appendicitis

BACKGROUND

No optimal biomarker exists that accurately diagnoses appendicitis or predicts severity, estimates post-operative complications or total length of hospital stay (LOS).

AIM

To prospectively validate the utility of neutrophil-to-lymphocyte (NLR) ratio in predicting the severity of appendicitis, LOS, and 30-day complication rates.

METHODS

Patients who were admitted with a provisional diagnosis of acute appendicitis over a period of 18 months (Oct 2014-April 2016) were included. Patient demographics and blood results were prospectively collected. Details of imaging, operative intervention, severity of appendicitis, length of stay, and 30-days post admission complications were recorded. Recommended cut-off values of NLR and C-reactive protein for severity of appendicitis were determined using receiver operating characteristic analysis (ROC). These cut-off values were compared with C-reactive protein levels. Mann-Whitney test was performed to assess the correlations between LOS and 30-day complications to NLR.

RESULTS

Four hundred fifty-three patients were included in the study; 55.2% (n = 245) were female with mean patient age of 23 years. Two-thirds (n = 281, 62.03%) underwent operative management. Histologically, appendicitis was confirmed in 214 (76%) patients. A NLR of >6.36 or CRP of >28 were statistically associated with complicated acute appendicitis, with a median of one extra hospital day (p < 0.0001). Mean NLR was statistically higher in patients with post-operative complications (14.42 vs. 7.29 for simple appendicitis group, p < 0.001).

CONCLUSION

This confirms previous reports that NLR is a simple, readily available adjunct in predicting severity of appendicitis. Additionally, it can aid delineating severe appendicitis that should proceed to surgery without substantial delay.