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Liang Y, Sailai M, Ding R, Yimamu B, Kazi T, He M, Liu Z, Lin J, Liu Y, Deng C, Huang J, Zhang X, Chen Z, Su Y. Predictive model for identification of gangrenous or perforated appendicitis in adults: a multicenter retrospective study. BMC Gastroenterol 2024; 24:355. [PMID: 39385074 PMCID: PMC11462916 DOI: 10.1186/s12876-024-03445-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 10/01/2024] [Indexed: 10/11/2024] Open
Abstract
BACKGROUND Gangrene and perforation are severe complications of acute appendicitis, associated with a higher mortality rate compared to uncomplicated appendicitis. Accurate preoperative identification of Gangrenous or perforated appendicitis (GPA) is crucial for timely surgical intervention. METHODS This retrospective multicenter study includes 796 patients who underwent appendectomy. Univariate and multivariate logistic regression analyses are used to develop a nomogram model for predicting GPA based on laboratory tests and computed tomography (CT) findings. The model is validated using an external dataset. RESULTS Seven independent predictors were included in the nomogram: white blood cell count, lymphocyte count, D-dimer, serum glucose, albumin, maximum outer diameter of the appendix, and presence of appendiceal fecalith. The nomogram achieved good discrimination and calibration in both the training and testing sets. In the training set, the AUC was 0.806 (95%CI: 0.763-0.849), and the sensitivity and specificity were 82.1% and 66.9%, respectively. The Hosmer-Lemeshow test showed good calibration (P = 0.7378). In the testing set, the AUC was 0.799 (95%CI: 0.741-0.856), and the sensitivity and specificity were 70.5% and 75.3%, respectively. Decision curve analysis (DCA) confirmed the clinical utility of the nomogram. CONCLUSION The laboratory test-CT nomogram model can effectively identify GPA patients, aiding in surgical decision-making and improving patient outcomes.
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Affiliation(s)
- Yun Liang
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Maimaitiaili Sailai
- Department of General Surgery, The First People's Hospital of Kashagr, Xinjiang Uygur Autonomous Region, Kashagr Region, 844000, China
| | - Rui Ding
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Baihitiyaer Yimamu
- Department of General Surgery, The First People's Hospital of Kashagr, Xinjiang Uygur Autonomous Region, Kashagr Region, 844000, China
| | - Tayierjiang Kazi
- Department of General Surgery, The First People's Hospital of Kashagr, Xinjiang Uygur Autonomous Region, Kashagr Region, 844000, China
| | - Ming He
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Zehui Liu
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Junyu Lin
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Yile Liu
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Chaolun Deng
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Jiangtao Huang
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Xingwei Zhang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, 510655, China.
| | - Zheng Chen
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China.
| | - Yonghui Su
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China.
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Zengin A, Bağ YM, Öğüt MZ, Sağlam K. The role of C-reactive protein/albumin ratio and prognostic nutritional index in the diagnosis of complicated acute appendicitis. Turk J Surg 2024; 40:54-58. [PMID: 39035999 PMCID: PMC11257719 DOI: 10.47717/turkjsurg.2024.6301] [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: 02/14/2023] [Accepted: 03/12/2024] [Indexed: 07/23/2024]
Abstract
Objectives C-reactive protein (CRP) levels increase and albumin levels decrease in patients with inflammation. CRP/albumin ratio (CAR) is a new inflammation-associated prognostic indicator. The prognostic nutritional index (PNI) was described as a simple and neutral indicator of adverse outcomes not only in chronic diseases but also in acute conditions. The aim of this study was to investigate the clinical significance of the CAR and PNI value in differentiating complicated acute appendicitis (AA). Material and Methods We retrospectively examined the medical records of 187 patients with AA. Patients were divided into two groups according to pathological results [non-complicated (n= 161) and complicated (n= 26)]. Demographic, clinical, laboratory, and pathological data were examined and compared between the groups. Logistic regression analyses were performed to determine the independent predictors for complicated AA. Results Median age of the study group was 32 (23-41) years, and most of the patients were males (n= 101, 54%). Patients in the complicated AA group were significantly older compared to the patients in the non-complicated AA group [38 (32-49.5) years vs. 30 (22-41) years, p= 0.002]. The complicated AA group had significantly higher CAR level compared to the non-complicated AA group (p= 0.001). The length of hospital stay was significantly longer in the complicated AA group compared to the non-complicated AA group [2.5 (2-4.25) days vs. 1 (1-2) days, p <0.001]. Other variables (including PNI) did not significantly differ between the groups. In univariate logistic regression analysis, only age was found to be a significant variable (OR= 1.045, 95% CI= 1.016-10.74, p= 0.002), but in multiple variate logistic regression analysis, no variable was found to be significant in predicting complicated AA. Conclusion We concluded that CAR and PNI value are not independent predictors of complicated AA.
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Affiliation(s)
- Akile Zengin
- Department of Gastrointestinal Surgery, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Türkiye
| | - Yusuf Murat Bağ
- Clinic of General Surgery, Ankara Training and Research Hospital, Ankara, Türkiye
| | - Mehmet Zeki Öğüt
- Clinic of General Surgery, Elazığ Fethi Sekin City Hospital, Elazığ, Türkiye
| | - Kutay Sağlam
- Department of Gastrointestinal Surgery, Uludağ University Faculty of Medicine, Bursa, Türkiye
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Lamm R, Kumar SS, Collings AT, Haskins IN, Abou-Setta A, Narula N, Nepal P, Hanna NM, Athanasiadis DI, Scholz S, Bradley JF, Train AT, Pucher PH, Quinteros F, Slater B. Diagnosis and treatment of appendicitis: systematic review and meta-analysis. Surg Endosc 2023; 37:8933-8990. [PMID: 37914953 DOI: 10.1007/s00464-023-10456-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children. METHODS Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively. RESULTS 2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04). CONCLUSIONS This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.
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Affiliation(s)
- Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Thomas Jefferson University, 1015 Walnut Street, 613 Curtis, Philadelphia, PA, 19107, USA.
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Nisha Narula
- Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Pramod Nepal
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joel F Bradley
- Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Philip H Pucher
- Department of Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago Medicine, Chicago, IL, USA
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Moisés De Almeida Leite R, de Souza AV, Cauley C, Goldstone R, Francone T, Bay CP, Ricciardi R. Effect of Plastic Bag Extraction in Minimally Invasive Appendectomy. Am Surg 2023; 89:4604-4609. [PMID: 36041882 DOI: 10.1177/00031348221124320] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
BACKGROUND Evidence regarding the effects of plastic bag use for appendix removal during minimally invasive appendectomy remains scarce and conflicting. OBJECTIVE This study aimed to analyze the effects of plastic bag use during minimally invasive appendectomy on preoperative infection risk, morbidity and mortality. DESIGN This retrospective analysis of the prospective National Surgical Quality Improvement Program (NSQIP) cohort program. SETTING This study included data from the NSQIP database between the years of 2016 and 2019. PATIENT Adult patients undergoing minimally invasive (laparoscopic or robotic) without unplanned conversion to open surgery. INTERVENTION Use of plastic bag for specimen removal during appendectomy. MAIN OUTCOME MEASURES Risk ratios for the incidence of superficial surgical site infection, intra-abdominal abscess, overall medical morbidity, and overall mortality. RESULTS There were 43 783 cases of minimally invasive appendectomy in the NSQIP database between the years of 2016 and 2019. Among those who reported information regarding use of plastic bag, 28 589 (91.87%) reported use of plastic bag for specimen removal. Use of plastic bag was associated with a significant decrease in superficial surgical site infection (RR .39 (95% CI: .31-.49), P < .001), and in the risk of postoperative intra-abdominal abscess (RR: 0.66 (.57-.77), P < .001)). We also observed a robust reduction in overall medical-related morbidity and overall mortality, even after adjusting for multiple confounders. LIMITATIONS Observational nature of the study cannot exclude residual bias. Also, there was a significant rate of missing values for plastic bag use, which may bias results. CONCLUSIONS In this global prospective cohort using NSQIP database, use of plastic bag for appendix removal during minimally invasive appendectomy was associated with a significant improvement in surgical related outcomes and reduction in morbidity and overall mortality.
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Affiliation(s)
| | | | | | | | | | - Camden P Bay
- Brigham and Women's Hospital Department of Radiology, Boston, MA, USA
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Yoon EJ, Kim JW, Hong JH, Song SG, Kim HC, Hur YH, Kim HJ. Thermal Injury to the Subhepatic Appendix Following Percutaneous Ultrasound-Guided Radiofrequency Ablation for Hepatocellular Carcinoma: A Case Report. Diagnostics (Basel) 2023; 13:3322. [PMID: 37958216 PMCID: PMC10647334 DOI: 10.3390/diagnostics13213322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/25/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
We present the first documented case of a fistula between the treated zone and the appendix after RFA in a patient with HCC. Contrast-enhanced CT and MRI revealed a subcapsular hepatic nodule with image findings of HCC located adjacent to the ascending colon and cecum. An ultrasound-guided core needle biopsy was subsequently performed to distinguish between hepatic metastasis and HCC. Post-RFA imaging identified a low-attenuating ablated area adjacent to an air-filled appendix. The patient later experienced complications, including increased liver enzymes and an abscess at the ablation site. Imaging revealed a fistulous tract between the RFA zone and the appendix. Over the following months, the patient underwent conservative treatment involving intravenous antibiotics and repeated percutaneous drainage, exhibiting eventual symptom relief and an absence of the fistulous tract upon subsequent imaging. This case highlights the rare complications that can arise during RFA due to peculiar anatomical variations, such as a subhepatic appendix, resulting from midgut malrotation and previous surgery. It is imperative for operators to be cognizant of potential anatomical variations when considering RFA treatment, ensuring comprehensive pre-procedural imaging and post-procedure monitoring. This case also emphasizes the potential viability of nonoperative management in complex scenarios in which surgical interventions pose significant risks.
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Affiliation(s)
- Eun Ju Yoon
- Department of Radiology, Chosun University Hospital and Chosun University College of Medicine, Gwangju 61453, Republic of Korea (S.G.S.); (H.C.K.)
| | - Jin Woong Kim
- Department of Radiology, Chosun University Hospital and Chosun University College of Medicine, Gwangju 61453, Republic of Korea (S.G.S.); (H.C.K.)
| | - Jun Hyung Hong
- Department of Radiology, Chosun University Hospital and Chosun University College of Medicine, Gwangju 61453, Republic of Korea (S.G.S.); (H.C.K.)
| | - Sang Gook Song
- Department of Radiology, Chosun University Hospital and Chosun University College of Medicine, Gwangju 61453, Republic of Korea (S.G.S.); (H.C.K.)
| | - Hyun Chul Kim
- Department of Radiology, Chosun University Hospital and Chosun University College of Medicine, Gwangju 61453, Republic of Korea (S.G.S.); (H.C.K.)
| | - Young Hoe Hur
- Department of Hepato-Biliary-Pancreas Surgery, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Gwangju 61469, Republic of Korea
| | - Hyung Joong Kim
- Department of Biomedical Engineering, Kyung Hee University, Seoul 02447, Republic of Korea
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Kobayashi T, Hidaka E, Koganezawa I, Nakagawa M, Yokozuka K, Ochiai S, Gunji T, Sano T, Tomita K, Tabuchi S, Chiba N, Kawachi S. Development of a scoring model based on objective factors to predict gangrenous/perforated appendicitis. BMC Gastroenterol 2023; 23:198. [PMID: 37286951 DOI: 10.1186/s12876-023-02767-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/15/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND The mortality rate of gangrenous/perforated appendicitis is higher than that of uncomplicated appendicitis. However, non-operative management of such patients is ineffective. This necessitates their careful exam at presentation to identify gangrenous/perforated appendicitis and aid surgical decision-making. Therefore, this study aimed to develop a new scoring model based on objective findings to predict gangrenous/perforated appendicitis in adults. METHODS We retrospectively analyzed 151 patients with acute appendicitis who underwent emergency surgery between January 2014 and June 2021. We performed univariate and multivariate analyses to identify independent objective predictors of gangrenous/perforated appendicitis, and a new scoring model was developed based on logistic regression coefficients for independent predictors. Receiver operating characteristic (ROC) curve analysis and the Hosmer-Lemeshow test were performed to assess the discrimination and calibration of the model. Finally, the scores were classified into three categories based on the probability of gangrenous/perforated appendicitis. RESULTS Among the 151 patients, 85 and 66 patients were diagnosed with gangrenous/perforated appendicitis and uncomplicated appendicitis, respectively. Using the multivariate analysis, C-reactive protein level, maximal outer diameter of the appendix, and presence of appendiceal fecalith were identified as independent predictors for developing gangrenous/perforated appendicitis. Our novel scoring model was developed based on three independent predictors and ranged from 0 to 3. The area under the ROC curve was 0.792 (95% confidence interval, 0.721-0.863), and the Hosmer-Lemeshow test showed a good calibration of the novel scoring model (P = 0.716). Three risk categories were classified: low, moderate, and high risk with probabilities of 30.9%, 63.8%, and 94.4%, respectively. CONCLUSIONS Our scoring model can objectively and reproducibly identify gangrenous/perforated appendicitis with good diagnostic accuracy and help in determining the degree of urgency and in making decisions about appendicitis management.
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Affiliation(s)
- Toshimichi Kobayashi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Eiji Hidaka
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Itsuki Koganezawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Masashi Nakagawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Kei Yokozuka
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Shigeto Ochiai
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Takahiro Gunji
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Toru Sano
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Koichi Tomita
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Satoshi Tabuchi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Naokazu Chiba
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Shigeyuki Kawachi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan.
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Iantorno SE, Skarda DE, Bucher BT. Concurrent SARS-COV-19 and acute appendicitis: Management and outcomes across United States children's hospitals. Surgery 2023; 173:936-943. [PMID: 36621446 PMCID: PMC9820025 DOI: 10.1016/j.surg.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/02/2022] [Accepted: 12/11/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Nonoperative management of acute appendicitis is a safe and effective alternative to appendectomy, though rates of treatment failure and disease recurrence are significant. The purpose of this study was to determine whether COVID-19-positive children with acute appendicitis were more likely to undergo nonoperative management when compared to COVID-19-negative peers and to compare clinical outcomes and healthcare use for these groups. METHODS A retrospective cohort study of children <18 years with acute appendicitis across 45 US Children's Hospitals during the first 12 months of the COVID-19 pandemic was performed. Operative management was defined as appendectomy or percutaneous drain placement, whereas nonoperative management was defined as admission with antibiotics alone. Multivariable hierarchical logistic regression using an exact matched cohort was used to determine the association between COVID-19 positivity and nonoperative management. The secondary outcomes included intensive care unit admission, mechanical ventilation, length of stay, nonoperative management failure rates, and hospital variation in nonoperative management. RESULTS Of 17,481 children in the cohort, 581 (3.3%) were positive for COVID-19. The odds of nonoperative management was significantly higher in the COVID-19-positive group (adjusted odds ratio [95% confidence interval]: 13.4 [10.7-16.8], P < .001). Patients positive for COVID-19 had increased odds of intensive care unit admission (adjusted odds ratio [95% confidence interval]: 3.78 [2.01-7.12], P < .001) and longer length of stay (median 2 days vs 1 day, P < .001). Hospital rates of nonoperative management ranged from 0% to 100% for COVID-19-positive patients and 0% to 42% for COVID-19-negative patients. CONCLUSION Children with concurrent acute appendicitis and COVID-19 positivity are significantly more likely to undergo nonoperative management. Both groups experience infrequent nonoperative management failure rates and rare intensive care unit admissions. Marked hospital variability in nonoperative management practices was demonstrated.
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Affiliation(s)
- Stephanie E Iantorno
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT.
| | - David E Skarda
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Brian T Bucher
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
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Echevarria S, Rauf F, Hussain N, Zaka H, Farwa UE, Ahsan N, Broomfield A, Akbar A, Khawaja UA. Typical and Atypical Presentations of Appendicitis and Their Implications for Diagnosis and Treatment: A Literature Review. Cureus 2023; 15:e37024. [PMID: 37143626 PMCID: PMC10152406 DOI: 10.7759/cureus.37024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2023] [Indexed: 05/06/2023] Open
Abstract
Appendicitis, an acute inflammation of the appendix, affects all demographic groups and exhibits various incidences and clinical manifestations. While acute appendicitis typically presents with colicky periumbilical abdominal pain that localizes to the right lower quadrant, atypical presentations are more common in children, geriatric, and pregnant patient populations, leading to delays in diagnosis. Clinical evaluation, clinical scoring systems, and inflammatory markers are commonly used, but their limitations have led to the increased use of diagnostic imaging in patients suspected of appendicitis. Acute appendicitis is managed by non-operative and operative management, depending on whether it is uncomplicated or complicated. Developing diagnostic pathways to improve outcomes and reduce complications is crucial. Although medical advancements have been made, diagnosing and managing appendicitis can be challenging, mainly when patients are present atypically. This literature review aims to comprehensively review typical and atypical presentations of appendicitis and their current implications for diagnosis and treatment modalities in pediatric, adult, pregnant, and geriatric patient populations.
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Affiliation(s)
| | - Fatima Rauf
- Internal Medicine, Rawalpindi Medical University, Rawalpindi, PAK
| | - Nabeel Hussain
- Internal Medicine, Saba University School-Medicine, Devens, USA
| | - Hira Zaka
- Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Umm-E- Farwa
- Surgery, Jinnah Sindh Medical University, Karachi, PAK
| | - Nayab Ahsan
- Internal Medicine, Quaid-e-Azam Medical College, Bahawalpur, PAK
| | - Alison Broomfield
- Family Medicine, Spartan Health Sciences University, Vieux Fort, LCA
| | - Anum Akbar
- Pediatrics, University of Nebraska Medical Center, Omaha, USA
| | - Uzzam Ahmed Khawaja
- Pulmonary and Critical Care Medicine, Jinnah Medical and Dental College, Karachi, PAK
- Clinical and Translational Research, Dr Ferrer BioPharma, South Miami, USA
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Muacevic A, Adler JR. Perforated Appendicitis Masquerading as Bilateral Tubo-Ovarian Abscess. Cureus 2022; 14:e30464. [PMID: 36407274 PMCID: PMC9673187 DOI: 10.7759/cureus.30464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 01/25/2023] Open
Abstract
Acute appendicitis is a highly common cause of abdominal pain that presents with nausea and vomiting, characteristic physical exam findings, and imaging evidence of appendiceal inflammation. In the absence of these signs, diagnosis can be difficult. This case report demonstrates an uncommon presentation of appendicitis that led to a delay in diagnosis and aims to discuss the ways in which similar misdiagnoses can be avoided for clinicians in the future.
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de Almeida Leite RM, de Souza AV, Bay CP, Cauley C, Bordeianou L, Goldstone R, Francone T, Kunitake H, Ricciardi R. Delayed Operative Management in Complicated Acute Appendicitis-Is Avoiding Extended Resection Worth the Wait ? Results from a Global Cohort Study. J Gastrointest Surg 2022; 26:1482-1489. [PMID: 35449429 DOI: 10.1007/s11605-022-05311-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/11/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal management of complicated acute appendicitis remains undefined. According to current guidelines, a trial of non-operative management with delayed appendectomy may be associated with better outcomes for patients, including a reduced rate of extended resection appendectomy. METHODS We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement program to analyze the outcomes of hemodynamically stable patients presenting with complicated (abscess, perforation, or both) appendicitis submitted to early (less than 24 h) or delayed (24 h or more) operative management. RESULTS Delayed operative management was associated with a significant reduction of the rate of extended resection appendectomy (RR: 2.15, 95% CI: 1.59 - 2.81, p < 0.001). Delayed operative management was associated with a non-significant trend towards reduced mortality (RR: 2.17; 95% CI: 0.98-2.85, p = 0.05). Delayed operative management was also associated with a significant decrease in total operative time and a significant reduction in the rate of postoperative abscess. There was no association between delayed intervention and medical related morbidity (RR: 1.01; 95% CI 0.91-1.11, p 0.811). However, delayed operative management was associated with a significant increase in total length of stay (coefficient 1.10; 95% CI: 1.02 to 1.18, p < 0.001). CONCLUSION Delayed operative management may be associated with a reduction in the need of extended resection appendectomy, shorter operative time, and a trend towards reduced mortality. On the other hand, it may also be associated with an increased length of in-hospital stay and short-term morbidity.
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Affiliation(s)
- Rodrigo Moisés de Almeida Leite
- Harvard Medical School, Boston, MA, USA.,Section of Colon & Rectal Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA
| | | | | | - Christy Cauley
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Rob Goldstone
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Todd Francone
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hiroko Kunitake
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rocco Ricciardi
- Section of Colon & Rectal Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA.
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Kanaka S, Mizutani S, Yokoyama Y, Matsutani T, Chihara N, Katsuno A, Takata H, Nakata R, Mishima K, Wada Y, Shimizu T, Yamagiwa R, Haruna T, Nakamura Y, Hamaguchi A, Taniai N, Yoshida H. Periappendiceal fluid collection on preoperative computed tomography can be an indication for interval appendectomy: a retrospective study. World J Emerg Surg 2022; 17:30. [PMID: 35637469 PMCID: PMC9153096 DOI: 10.1186/s13017-022-00437-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/25/2022] [Indexed: 12/04/2022] Open
Abstract
Background The treatment strategies for acute appendicitis, such as emergency appendectomy (EA), interval appendectomy (IA), and repeating nonoperative management (NOM), are controversial. In this study, we examined the preoperative factors that can be used to distinguish which patients should undergo IA. Methods We retrospectively identified 902 patients who underwent surgery for appendicitis in our hospital from January 2010 to December 2021. Of these patients, 776 were included in this study. The patients were divided into two groups: those with a periappendiceal fluid collection (PAFC) on preoperative computed tomography (PAFC-positive group, n = 170) and those without a PAFC (PAFC-negative group, n = 606). In each group, we compared patients who underwent EA and IA. Results In the PAFC-positive group, patients who underwent EA had a significantly higher postoperative complication rate than those who underwent IA (40.5% vs. 24.0%, p = 0.037). In the multivariate analysis, only the presence of PAFC was significantly associated with an increased risk of postoperative complications (odds ratio, 7.11; 95% confidence interval, 2.73–18.60; p < 0.001). The presence of PAFC alone was not significantly associated with an increased risk of IA or NOM failure (odds ratio, 1.48; 95% confidence interval, 0.19–11.7; p = 0.71). The rate of neoplasia on pathologic examination was significantly higher in the PAFC-positive than PAFC-negative group (7.6% vs. 1.5%, p < 0.001); the rate of carcinoma was also higher in the PAFC-positive group (2.4% vs. 0.17%, p = 0.02). Conclusions The presence of PAFC on preoperative computed tomography was found to be a risk factor for postoperative complications but not IA or NOM failure. It was also correlated with neoplasia as the etiology of appendicitis. Therefore, PAFC positivity is useful as an indication for IA.
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Affiliation(s)
- Shintaro Kanaka
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan.
| | - Satoshi Mizutani
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Yasuyuki Yokoyama
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Takeshi Matsutani
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Naoto Chihara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Akira Katsuno
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Hideyuki Takata
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Ryosuke Nakata
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Keisuke Mishima
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Yudai Wada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Takao Shimizu
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Ryo Yamagiwa
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Takahiro Haruna
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Yuka Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Akira Hamaguchi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Nobuhiko Taniai
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
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12
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Ashbrook M, Cheng V, Sandhu K, Matsuo K, Schellenberg M, Inaba K, Matsushima K. Management of Complicated Appendicitis During Pregnancy in the US. JAMA Netw Open 2022; 5:e227555. [PMID: 35426921 PMCID: PMC9012961 DOI: 10.1001/jamanetworkopen.2022.7555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Data are sparse regarding the optimal treatment for complicated appendicitis during pregnancy. OBJECTIVE To compare nonoperative and operative management in complicated appendicitis during pregnancy. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using National Inpatient Sample data from between January 2003 and September 2015. This database approximates a 20% stratified sample of US inpatient hospital discharges. Included individuals were pregnant women discharged with the diagnosis of complicated appendicitis. Data were analyzed from February 2020 through February 2022. EXPOSURES Study patients were categorized into 3 groups: those with successful nonoperative management, failed nonoperative management with delayed operation, or immediate operation for complicated appendicitis. MAIN OUTCOMES AND MEASURES Clinical outcomes, including maternal infectious complications and perinatal complications, hospital length of stay, and total hospital charges. RESULTS Among 8087 pregnant women with complicated appendicitis (median [IQR] age, 27 [22-32] years), nonoperative management of complicated appendicitis was successful among 954 patients (11.8%) and failed among 2646 patients (32.7%), who underwent delayed operation; 4487 patients (55.5%) underwent immediate operation. In multivariate analysis, successful nonoperative management was associated with higher odds of amniotic infection (odds ratio [OR], 4.35; 95% CI, 2.22-8.53; P < .001) and sepsis (OR, 1.52; 95% CI, 1.10-2.11; P = .01) compared with immediate operation, while there was no significant difference in preterm delivery, preterm labor, or abortion. However, failed nonoperative management that required delayed operation was associated with higher odds of preterm delivery, preterm labor, or abortion compared with immediate operation (OR, 1.45; 95% CI, 1.24-1.68; P < .001). Immediate operation was associated with decreased hospital charges compared with nonoperative management that was successful (regression coefficient [RC], 0.09; 95% CI, 0.07-0.11; P < .001) and that failed (RC, 0.12; 95% CI: 0.11-0.14; P < .001). In subgroup multivariate logistic regression analysis, each day in delay to surgery was associated with an increase in odds of preterm delivery, preterm labor, or abortion by 23% (OR, 1.23; 95% CI, 1.18-1.29; P < .001). CONCLUSIONS AND RELEVANCE This study found that immediate operation for complicated appendicitis in pregnant women was associated with lower odds of maternal infectious complications without higher odds of perinatal or other maternal complications compared with successful nonoperative management. Failed nonoperative management was associated with worse clinical outcomes.
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Affiliation(s)
- Matthew Ashbrook
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles
| | - Vincent Cheng
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles
| | - Kulmeet Sandhu
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Koji Matsuo
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles
| | - Morgan Schellenberg
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles
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Tunc E, Fraundorf E, Worley S, Aquino M, Magnuson D, Lampl BS, Jennings S, Fertel BS. The use of a pediatric appendicitis pathway in a large integrated health system reduced computed tomography imaging in the ED. Am J Emerg Med 2021; 50:211-217. [PMID: 34392140 DOI: 10.1016/j.ajem.2021.07.064] [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: 01/11/2021] [Revised: 07/27/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Appendicitis is the most common cause of an acute surgical abdomen in children. Diagnosis is often challenging as few pediatric patients present with classic symptoms. Clinicians are thus dependent on imaging to reach an accurate diagnosis. Although computerized tomography (CT) has high sensitivity and specificity, it has the disadvantage of imparting ionizing radiation. Ultrasound (US) is readily available and has comparable accuracy to CT when performed by experienced sonographers. We sought to examine the impact of a system-wide process improvement plan on CT use and other metrics in pediatric patients who presented to the Emergency Department (ED) with suspected appendicitis. METHODS This is a retrospective study of the impact of a Pediatric Appendicitis Pathway (PAP) within a large integrated hospital system with 12 EDs including 3 designated hub EDs. Patients were placed in an initial risk category utilizing the Pediatric Appendicitis Score (PAS), and received US of the appendix at a hub ED if indicated by the PAS. Patients presenting to community EDs who required US appendix were transferred to hub EDs for imaging. Patients presenting in the 6-month pre-implementation period were compared to patients presenting in a 14-month post-implementation period on CT and US utilization, negative and missed appendectomy rates, and ED length of stay (LOS). RESULTS 1874 patients (401 pre-PAP and 1473 post-PAP) were included in the study. At the hub EDs the rate of CT imaging for suspected appendicitis was reduced from 31% to 17% with a resultant increase in US utilization from 83% (333/401) to 90% (1331/1473) (p < 0.001). At community general EDs (404 pre-PAP and 449 post-PAP), the rate of CT was decreased from 45% (181/404) to 32%(144/449) (p < 0.001)) There was no significant change in the negative appendectomy rate pre-PAP (1/59 = 1.7%) and post-PAP (4/168 = 2.4%) (p = 0.99) at the hub EDs. There were no missed appendicitis cases after PAP implementation compared to 1 case in the pre-PAP period. Overall LOS was similar pre and post-PAP, however LOS was longer in patients that required transfer from community general EDs to hub EDs (median 264 vs 342 min, p < 0.001). CONCLUSIONS A PAP that stratified patients into risk groups using the PAS and encouraged the use of US as a first line imaging modality, reduced the number of CT performed in a large integrated health system without significant changes to clinical outcomes. Furthermore, transferring select patients for an US as opposed to obtaining an initial CT in community general EDs was feasible and reduced CT use in the pediatric population.
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Affiliation(s)
- Emine Tunc
- Department of Pediatrics, University of Washington, Seattle, WA, United States of America
| | - Erika Fraundorf
- Division of Pediatric Emergency Medicine, Emergency Services Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Sarah Worley
- Department of Quantitative Health Sciences, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Michael Aquino
- Division of Pediatric Radiology, Imaging Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - David Magnuson
- Division of Pediatric Surgery, Digestive Disease Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Brooke S Lampl
- Division of Pediatric Radiology, Imaging Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Stephanie Jennings
- Division of Pediatric Hospital Medicine, Pediatric Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Baruch S Fertel
- Emergency Services Institute and Enterprise Quality and Safety, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America.
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14
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Guevara-Cuellar CA, Rengifo-Mosquera MP, Parody-Rúa E. Cost-effectiveness analysis of nonoperative management versus open and laparoscopic surgery for uncomplicated acute appendicitis in Colombia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:34. [PMID: 34112179 PMCID: PMC8194214 DOI: 10.1186/s12962-021-00288-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/01/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Traditionally, uncomplicated acute appendicitis (AA) has been treated with appendectomy. However, the surgical alternatives might carry out significant complications, impaired quality of life, and higher costs than nonoperative treatment. Consequently, it is necessary to evaluate the different therapeutic alternatives' cost-effectiveness in patients diagnosed with uncomplicated appendicitis. METHODS We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18-60 years with a diagnosis of uncomplicated AA from the payer´s perspective at the secondary and tertiary health care level. The time horizon was 5 years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed. METHODS We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18-60 years with a diagnosis of uncomplicated AA from the payer's perspective at the secondary and tertiary health care level. The time horizon was five years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed. RESULTS LA presents a lower cost ($363 ± 35) than OA ($384 ± 41) and NOM ($392 ± 44). NOM exhibited higher QALYs (3.3332 ± 0.0276) in contrast with LA (3.3310 ± 0.057) and OA (3.3261 ± 0.0707). LA dominated the OA. The ICER between LA and NOM was $24,000/QALY. LA has a 52% probability of generating the highest NMB versus its counterparts, followed by NOM (30%) and OA (18%). There is a probability of 0.69 that laparoscopy generates more significant benefit than medical management. The mean value of that incremental NMB would be $93.7 per patient. CONCLUSIONS LA is a cost-effectiveness alternative in the management of patients with uncomplicated AA. Besides, LA has a high probability of producing more significant monetary benefits than NOM and OA from the payer's perspective in the Colombian health system.
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Affiliation(s)
| | | | - Elizabeth Parody-Rúa
- Faculty of Health Sciences, Universidad Icesi, Calle 18 No. 122-135 Pance, 70000, Cali, Colombia
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15
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Collard MK, Christou N, Lakkis Z, Mege D, Bridoux V, Millet I, Sabbagh C, Loriau J, Lefevre JH, Ronot M, Maggiori L. Adult appendicitis: Clinical practice guidelines from the French Society of Digestive Surgery and the Society of Abdominal and Digestive Imaging. J Visc Surg 2021; 158:242-252. [PMID: 33419677 DOI: 10.1016/j.jviscsurg.2020.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The French Society of Digestive Surgery (SFCD) and the Society of Abdominal and Digestive Imaging (SIAD) have collaborated to propose recommendations for clinical practice in the management of adult appendicitis. METHODS An analysis of the literature was carried out according to the methodology of the French National Authority for Health (HAS). A selection was performed from collected references and then a manual review of the references listed in the selected articles was made in search of additional relevant articles. The research was limited to articles whose language of publication was English or French. Articles focusing on the pediatric population were excluded. Based on the literature review, the working group proposed recommendations whenever possible. These recommendations were reviewed and approved by a committee of experts. RESULTS Recommendations about appendicitis in adult patients were proposed with regard to clinical, laboratory and radiological diagnostic modalities, treatment strategy for uncomplicated and complicated appendicitis, surgical technique, and specificities in the case of macroscopically healthy appendix, terminal ileitis and appendicitis in the elderly and in pregnant women. CONCLUSION These recommendations for clinical practice may be useful to the surgeon in optimizing the management of acute appendicitis in adults.
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Affiliation(s)
- M K Collard
- Department of digestive surgery, Sorbonne université, Saint-Antoine hospital, AP-HP, Paris, France
| | - N Christou
- Department of digestive, general and endocrine surgery, CHU Dupuytren, Limoges, France
| | - Z Lakkis
- Department of visceral, digestive and oncological surgery, CHU Besançon, Besançon, France
| | - D Mege
- Department of digestive and general surgery, Timone hospital, Marseille, France
| | - V Bridoux
- Department of digestive surgery, Charles-Nicolle hospital, Rouen, France
| | - I Millet
- Radiology department, Lapeyronie hospital, Montpellier, France
| | - C Sabbagh
- Department of digestive surgery, CHU Amiens-Picardie, Amiens, France
| | - J Loriau
- Department of digestive surgery, Saint-Joseph hospital, Paris, France
| | - J H Lefevre
- Department of digestive surgery, Sorbonne université, Saint-Antoine hospital, AP-HP, Paris, France
| | - M Ronot
- Radiology department, Beaujon hospital, Clichy-la-Garenne, France
| | - L Maggiori
- Department of digestive, oncologic and endocrine surgery, Saint-Louis Hospital, Assistance Publique-Hopitaux de Paris (AP-HP), Université de Paris, Paris, France.
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Abstract
Appendicitis is a common occurrence in both the adult and pediatric populations. The condition most commonly occurs between the ages of 10 and 20 years with a lifetime risk of 8.6% and 6.7% for males and females respectively. Its diagnosis focuses on clinical presentation and imaging modalities classified according to scoring systems such as the Alvarado scoring system. A number of imaging modalities can be used, with CT being the most common one. For acute appendicitis, surgical intervention is considered to be the gold standard of treatment. However, recent research has focused on other modalities of treatment including antibiotics and endoscopic retrograde appendicitis therapy (ERAT) to avoid surgical complications.
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Affiliation(s)
- Michael Krzyzak
- Internal Medicine, Staten Island University Hospital - Northwell Health, New York, USA
| | - Stephen M Mulrooney
- Gastroenterology, Staten Island University Hospital - Northwell Health, New York, USA
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17
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Hester CA, Pickett M, Abdelfattah KR, Cripps MW, Dultz LA, Dumas RP, Grant JL, Luk S, Minei J, Park C, Shoultz TH. Comparison of Appendectomy for Perforated Appendicitis With and Without Abscess: A National Surgical Quality Improvement Program Analysis. J Surg Res 2020; 251:159-167. [PMID: 32151825 DOI: 10.1016/j.jss.2019.12.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/15/2019] [Accepted: 12/29/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Outcomes of appendectomy stratified by type of complicated appendicitis (CA) features are poorly researched, and the evidence to guide operative versus nonoperative management for CA is lacking. This study aimed to determine laparoscopic-to-open conversion risk, postoperative abscess risk, unplanned readmission risk, and length of hospital stay (LOS) associated with appendectomy in patients with perforated appendicitis without abscess (PA) and perforated appendicitis with abscess (PAWA) compared with a control cohort of nonperforated appendicitis (NPA). METHODS The 2016-2017 National Surgical Quality Improvement Program Appendectomy-targeted database identified 12,537 (76.1%) patients with NPA, 2142 (13.0%) patients with PA, and 1799 (10.9%) patients with PAWA. Chi-squared analysis and analysis of variance were used to compare categorical and continuous variables. Binary logistic and linear regression models were used to compare risk-adjusted outcomes. RESULTS Compared with NPA, PA and PAWA had higher rates of conversion (0.8% versus 4.9% and 6.5%, respectively; P < 0.001), postoperative abscess requiring intervention (0.6% versus 4.8% and 7.0%, respectively; P < 0.001), readmission (2.8% versus 7.7% and 7.6%, respectively; P < 0.001), and longer median LOS (1 day versus 2 days and 2 days, respectively; P < 0.001). PA and PAWA were associated with increased odds of postoperative abscess (odds ratio [OR]: 7.18, 95% confidence interval [CI]: 5.2-9.8 and OR: 9.94, 95% CI: 7.3-13.5, respectively), readmission (OR: 2.70, 95% CI: 2.1-3.3 and OR: 2.66, 95% CI: 2.2-3.3, respectively), and conversion (OR: 5.51, 95% CI: 4.0-7.5 and OR: 7.43, 95% CI: 5.5-10.1, respectively). PA was associated with an increased LOS of 1.7 days and PAWA with 1.9 days of LOS (95% CI: 1.5-1.8 and 1.7-2.1, respectively). CONCLUSIONS Individual features of CA were independently associated with outcomes. Further research is needed to determine if surgical management is superior to nonoperative management for CA.
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Affiliation(s)
- Caitlin A Hester
- Department of Surgery, Division of General and Acute Care Surgery, Dallas, Texas
| | - Maryanne Pickett
- Department of Surgery, Division of General and Acute Care Surgery, Dallas, Texas
| | - Kareem R Abdelfattah
- Department of Surgery, Division of General and Acute Care Surgery, Dallas, Texas
| | - Michael W Cripps
- Department of Surgery, Division of General and Acute Care Surgery, Dallas, Texas
| | - Linda A Dultz
- Department of Surgery, Division of General and Acute Care Surgery, Dallas, Texas
| | - Ryan P Dumas
- Department of Surgery, Division of General and Acute Care Surgery, Dallas, Texas
| | - Jennifer L Grant
- Department of Surgery, Division of General and Acute Care Surgery, Dallas, Texas
| | - Stephen Luk
- Department of Surgery, Division of General and Acute Care Surgery, Dallas, Texas
| | - Joseph Minei
- Department of Surgery, Division of General and Acute Care Surgery, Dallas, Texas
| | - Caroline Park
- Department of Surgery, Division of General and Acute Care Surgery, Dallas, Texas
| | - Thomas H Shoultz
- Department of Surgery, Division of General and Acute Care Surgery, Dallas, Texas.
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