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Laudon AD, Beaulieu-Jones BR, Gitonga B, Yang FF, Chen E, Flum DR, Lerner K, Evans HL, Thompson L, Azar FK, Charboneau A, Simianu VV, Sanchez SE, Drake FT. Power Has Pitfalls: (In)accuracy of Administrative Data for Nonoperative Management of Appendicitis. J Surg Res 2024; 302:428-436. [PMID: 39153365 DOI: 10.1016/j.jss.2024.07.076] [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: 12/08/2023] [Revised: 07/09/2024] [Accepted: 07/19/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Nonoperative management (NOM) of uncomplicated appendicitis is increasingly common. Effectiveness of NOM has been studied by identifying patients via International Classification of Diseases (ICD) 9/ICD-10 codes for uncomplicated appendicitis and no code for appendectomy. We sought to assess the accuracy of such administrative definitions. METHODS We retrospectively identified patients with ICD-9/ICD-10 codes for appendicitis at five sites across the United States. Initial management plan and clinical severity were recorded by trained abstractors. We identified a gold standard cohort of patients with surgeon-diagnosed uncomplicated appendicitis and planned NOM. We defined two administrative cohorts with ICD-9/ICD-10 codes for uncomplicated appendicitis and either no surgery during initial admission (definition #1) or no surgery on day 0-1 of admission (definition #2). We compared each definition to the gold standard. RESULTS Among 1224 patients with uncomplicated appendicitis, 72 (5.9%) underwent planned NOM. NOM patients were older (median [Q1-Q3] of 37 [27-56] versus 32 [25-44] y) and less frequently male (51.4% versus 54.9%), White (54.1% versus 67.6%), and privately insured (38.9% versus 50.2%) than patients managed operatively. Definition #1 had sensitivity of 0.81 and positive predictive value of 0.87 for NOM of uncomplicated appendicitis. Definition #2 had sensitivity of 0.83 and positive predictive value of 0.72. The gold standard cohort had a true failure/recurrence rate of 23.6%, compared with apparent rates of 25.4% and 39.8%, respectively. CONCLUSIONS Administrative definitions are prone to misclassification in identifying planned NOM of uncomplicated appendicitis. This likely impacts outcomes in studies using administrative databases. Investigators should disclose how misclassification may affect results and select an administrative definition that optimally balances sensitivity and specificity for their research question.
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Affiliation(s)
- Aksel D Laudon
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts.
| | - Brendin R Beaulieu-Jones
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Baraka Gitonga
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Frank F Yang
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Elizabeth Chen
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Dave R Flum
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Kasey Lerner
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Heather L Evans
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Lauren Thompson
- Department of Surgery, Florida Atlantic University Schmidt College of Medicine, Boca Raton, Florida
| | - Faris K Azar
- Department of Surgery, Saint Mary's Medical Center, West Palm Beach, Florida
| | - Alex Charboneau
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Sabrina E Sanchez
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - F Thurston Drake
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
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Ramadan S, Olsson Å, Ekberg O, Buchwald P. Predictive factors for recurrent acute appendicitis after conservative treatment. Scand J Gastroenterol 2024; 59:933-938. [PMID: 38814018 DOI: 10.1080/00365521.2024.2359438] [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: 02/26/2024] [Revised: 05/06/2024] [Accepted: 05/19/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Conservative treatment of acute appendicitis is gaining popularity, and identifying patients with a higher risk of recurrence is becoming increasingly important. Previous studies have suggested that older age, male sex, diabetes, appendicolith and abscess formation may be contributing factors, however, results from the adult population are inconsistent. AIM This study aims to identify predictive factors for recurrent appendicitis after conservative treatment. METHODS This retrospective study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and follow-up data were retrieved from medical charts and radiologic images. Uni -and multivariable logistic regression analysis were performed using Stata Statistical Software. RESULTS In total, 379 patients with conservatively treated acute appendicitis were identified, of which 78 (20.6%) had recurrence. All patients were followed-up for a minimum of 41 months after the first diagnosis of acute appendicitis unless appendectomy after successful conservative treatment or death occurred during follow-up. The median time to recurrence was 6.5 (1-17.8) months. After multivariable logistic regression analysis, external appendix diameter >10 mm [OR 2.4 (CI 1.37-4.21), p = .002] and intra-abdominal abscess [OR 2.05 (CI 1.18-3.56), p = .011] on computed tomography were significant independent risk factors for recurrent appendicitis. Appendicolith was not associated with an increased risk of recurrence. CONCLUSION This study suggests abscess formation and appendix distension of >10 mm to be potential risk factors for recurrent acute appendicitis after initial successful conservative treatment.
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Affiliation(s)
- Shaima Ramadan
- Department of Surgery, Colorectal Unit, Skåne University Hospital Malmö, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Åsa Olsson
- Department of Surgery, Colorectal Unit, Skåne University Hospital Malmö, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Olle Ekberg
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Translational Medicine, Division of Medical Radiology, Skåne University Hospital Malmö, Malmö, Sweden
| | - Pamela Buchwald
- Department of Surgery, Colorectal Unit, Skåne University Hospital Malmö, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
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Ali K, Chervu NL, Sakowitz S, Bakhtiyar SS, Benharash P, Mohseni S, Keeley JA. Interhospital variation in the nonoperative management of acute cholecystitis. PLoS One 2024; 19:e0300851. [PMID: 38857278 PMCID: PMC11164333 DOI: 10.1371/journal.pone.0300851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/05/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Cholecystectomy remains the standard management for acute cholecystitis. Given that rates of nonoperative management have increased, we hypothesize the existence of significant hospital-level variability in operative rates. Thus, we characterized patients who were managed nonoperatively at normal and lower operative hospitals (>90th percentile). METHODS All adult admissions for acute cholecystitis were queried using the 2016-2019 Nationwide Readmissions Database. Centers were ranked by nonoperative rate using multi-level, mixed effects modeling. Hospitals in the top decile of nonoperative rate (>9.4%) were classified as Low Operative Hospitals (LOH; others:nLOH). Separate regression models were created to determine factors associated with nonoperative management at LOH and nLOH. RESULTS Of an estimated 418,545 patients, 9.9% were managed at 880 LOH. Multilevel modeling demonstrated that 20.6% of the variability was due to hospital factors alone. After adjustment, older age (Adjusted Odds Ratio [AOR] 1.02/year, 95% Confidence Interval [CI] 1.01-1.02) and public insurance (Medicare AOR 1.31, CI 1.21-1.43 and Medicaid AOR 1.43, CI 1.31-1.57; reference: Private Insurance) were associated with nonoperative management at LOH. These were similar at nLOH. At LOH, SNH status (AOR 1.17, CI 1.07-1.28) and small institution size (AOR 1.20, CI 1.09-1.34) were associated with increased odds of nonoperative management. CONCLUSION We noted a significant variability in the interhospital variation of the nonoperative management of acute cholecystitis. Nevertheless, comparable clinical and socioeconomic factors contribute to nonoperative management at both LOH and non-LOH. Directed strategies to address persistent non-clinical disparities are necessary to minimize deviation from standard protocol and ensure equitable care.
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Affiliation(s)
- Konmal Ali
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Nikhil L. Chervu
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Sara Sakowitz
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | | | - Peyman Benharash
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Jessica A. Keeley
- Division of Trauma and Critical Care, Department of Surgery, Harbor-UCLA Medical Center, Los Angeles, CA, United States of America
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Laverde BLB, Maak M, Langheinrich M, Kersting S, Denz A, Krautz C, Weber GF, Grützmann R, Brunner M. Antibiotic treatment after appendectomy for acute complicated appendicitis to prevent intrabdominal abscess and wound infections. Langenbecks Arch Surg 2024; 409:180. [PMID: 38850459 PMCID: PMC11162365 DOI: 10.1007/s00423-024-03367-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 05/26/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION The purpose of this analysis was to investigate the most appropriate duration of postoperative antibiotic treatment to minimize the incidence of intraabdominal abscesses and wound infections in patients with complicated appendicitis. MATERIALS AND METHODS In this retrospective study, which included 396 adult patients who underwent appendectomy for complicated appendicitis between January 2010 and December 2020 at the University Hospital Erlangen, patients were classified into two groups based on the duration of their postoperative antibiotic intake: ≤ 3 postoperative days (group 1) vs. ≥ 4 postoperative days (group 2). The incidence of postoperative intraabdominal abscesses and wound infections were compared between the groups. Additionally, multivariate risk factor analysis for the occurrence of intraabdominal abscesses and wound infections was performed. RESULTS The two groups contained 226 and 170 patients, respectively. The incidence of postoperative intraabdominal abscesses (2% vs. 3%, p = 0.507) and wound infections (3% vs. 6%, p = 0.080) did not differ significantly between the groups. Multivariate analysis revealed that an additional cecum resection (OR 5.5 (95% CI 1.4-21.5), p = 0.014) was an independent risk factor for intraabdominal abscesses. A higher BMI (OR 5.9 (95% CI 1.2-29.2), p = 0.030) and conversion to an open procedure (OR 5.2 (95% CI 1.4-20.0), p = 0.016) were identified as independent risk factors for wound infections. CONCLUSION The duration of postoperative antibiotic therapy does not appear to influence the incidence of postoperative intraabdominal abscesses and wound infections. Therefore, short-term postoperative antibiotic treatment should be preferred.
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Affiliation(s)
- Bruno Leonardo Bancke Laverde
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Matthias Maak
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Melanie Langheinrich
- Department of General, Visceral, Thoracic and Vascular Surgery, University Greifswald, Ferdinand- Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Stephan Kersting
- Department of General, Visceral, Thoracic and Vascular Surgery, University Greifswald, Ferdinand- Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Axel Denz
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Georg F Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany.
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Michelson KA, Bucher BT, Neuman MI. Cost and Late Hospital Care of Publicly Insured Children After Appendectomy. J Surg Res 2024; 297:41-46. [PMID: 38430861 PMCID: PMC11023751 DOI: 10.1016/j.jss.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 01/03/2024] [Accepted: 02/05/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Immediate complications of appendicitis are common, but the prevalence of long-term complications is uncertain. METHODS We studied all publicly-insured children in the US with uncomplicated or complicated appendicitis in 2018-2019 using administrative claims. The main outcome was late hospital care defined as hospitalization or abdominal procedure within 180 d of an appendicitis discharge, excluding interval appendectomies. Time to late hospital care was evaluated using Cox regression. We evaluated health-care expenditures arising from appendicitis episodes. RESULTS Among 95,942 children with appendicitis, 5727 (6.0%) had late hospital care, with 5062 requiring rehospitalization and 2012 (2.1%) surgery. The median time to late hospital care was 10 d (interquartile range 4-33). Age under 5 y (compared with >14 y, hazard ratio [HR] 1.88, 95% confidence interval [CI] 1.70-2.08), complex chronic conditions (HR 2.35, 95% CI 2.13-2.59), and complicated appendicitis (HR 2.81, 95% CI 2.67, 2.96) were each associated with time to late hospital care. Expenditures over 180 d were a median $6553 and $19,589 respectively in those requiring no late hospital care versus those requiring it (P < 0.001). CONCLUSIONS Late hospital care is uncommon in pediatric appendicitis but is costly. Prevention efforts should be targeted to the youngest, most complex children, and those with complicated appendicitis at presentation.
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Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.
| | - Brian T Bucher
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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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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Prajapat B, Chejara R, Mittal MK, S V A, Kalwaniya DS. Evaluation of Factors Predicting Successful Outcome in Patients Undergoing Expectant Management of Uncomplicated Acute Appendicitis. Cureus 2023; 15:e48687. [PMID: 38024038 PMCID: PMC10640851 DOI: 10.7759/cureus.48687] [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: 11/12/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Expectant management, or non-operative management (NOM), with standalone intravenous antibiotic therapy, has emerged as an effective alternative to appendectomy for the treatment of uncomplicated acute appendicitis. Various clinical, biochemical, and radiological factors have been implicated in predicting the success or failure of outcomes. Therefore, it is important to identify patients at the onset who are likely to have successful outcomes for conservative management of uncomplicated acute appendicitis. METHODS We prospectively enrolled 85 surgical patients diagnosed with uncomplicated acute appendicitis in our study. On admission, clinical features such as duration of symptoms, pulse rate (PR), history of fever within 24 hours of admission, modified Alvarado score and adult appendicitis score, biochemical parameters such as C-reactive protein (CRP), and hematological parameters such as total leukocyte count (TLC) were recorded. Radiological imaging of patients, namely ultrasonography and contrast-enhanced CT abdomen to evaluate appendix diameter and mural enhancement, was also undertaken. The outcome of expectant management for these patients (success or failure) was recorded, and the above-mentioned factors were evaluated to find a possible correlation with successful expectant management. RESULTS We found that among 85 patients, 77.6% had a successful NOM of appendicitis, whereas 22.4% had a failed NOM of appendicitis. The duration of symptoms, pulse rate, fever within 24 hours of admission, TLC, percentage of neutrophils, CRP level, appendix diameter, modified Alvarado score, and adult appendicitis score were found to be statistically significant predictors of successful NOM of appendicitis according to univariate analysis. According to multivariable analysis, pulse rate and appendix diameter value were found to be statistically significant predictors of successful NOM of appendicitis. With each beat per minute (bpm) increase in pulse rate, there was a 0.30% decrease in the probability of a successful NOM of appendicitis. With each mm increase in appendix diameter, there was an 82% decrease in the probability of a successful NOM of appendicitis. CONCLUSION From our study, it can be concluded that patients who met the following criteria, i.e., duration of symptoms before presenting to surgical emergency less than two days, presence of fever within 24 hours of presenting to surgical emergency, pulse rate >90 bpm, TLC >12000 cells/dL, CRP >20 mg/L, appendix diameter >10 mm, modified Alvarado score ≥ 9, and adult appendicitis score ≥ 18, have a higher probability of failure of NOM and hence should be excluded from expectant management.
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Affiliation(s)
- Bhrigu Prajapat
- General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - Rajkumar Chejara
- General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | | | - Arya S V
- General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - Dheer S Kalwaniya
- General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
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Wu Y, Cai Z, Cheng J, Zhang B, Wang G, Li W, Zhang Z. An adult female patient with single atrium and single ventricle undergoing appendectomy: A case report. Front Cardiovasc Med 2023; 10:1110269. [PMID: 36818334 PMCID: PMC9936086 DOI: 10.3389/fcvm.2023.1110269] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/13/2023] [Indexed: 02/05/2023] Open
Abstract
Appendicitis is one of the common diseases, and appendectomy is one of the most commonly performed procedures. Single atrium and single ventricle are rare heart diseases, and very few patients survive to adulthood. We report a patient with single atrial and single ventricles undergoing appendectomy with transverse abdominis plane block and dexmedetomidine sedation anesthesia with smooth postoperative appendectomy.
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Affiliation(s)
- Yu Wu
- Department of Anesthesiology, The 980th Hospital (Bethune International Peace Hospital) of the Joint Logistic Support Force, Shijiazhuang, China
| | - Zenghua Cai
- Department of Anesthesiology, The 980th Hospital (Bethune International Peace Hospital) of the Joint Logistic Support Force, Shijiazhuang, China
| | - Jianzheng Cheng
- Department of Anesthesiology, The 980th Hospital (Bethune International Peace Hospital) of the Joint Logistic Support Force, Shijiazhuang, China
| | - Bo Zhang
- Department of General Surgery, The 980th Hospital (Bethune International Peace Hospital) of the Joint Logistic Support Force, Shijiazhuang, China
| | - Guoji Wang
- Department of Anesthesiology, The 980th Hospital (Bethune International Peace Hospital) of the Joint Logistic Support Force, Shijiazhuang, China
| | - Wei Li
- Department of General Surgery, The 980th Hospital (Bethune International Peace Hospital) of the Joint Logistic Support Force, Shijiazhuang, China,Wei Li,
| | - Zaiwang Zhang
- Department of Anesthesiology, The 980th Hospital (Bethune International Peace Hospital) of the Joint Logistic Support Force, Shijiazhuang, China,*Correspondence: Zaiwang Zhang,
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Bancke Laverde BL, Maak M, Langheinrich M, Kersting S, Denz A, Krautz C, Weber GF, Grützmann R, Brunner M. Risk factors for postoperative morbidity, prolonged length of stay and hospital readmission after appendectomy for acute appendicitis. Eur J Trauma Emerg Surg 2023; 49:1355-1366. [PMID: 36708422 DOI: 10.1007/s00068-023-02225-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 01/09/2023] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- Bruno Leonardo Bancke Laverde
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Matthias Maak
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Melanie Langheinrich
- Department of General, Visceral, Thoracic and Vascular Surgery, University Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Stephan Kersting
- Department of General, Visceral, Thoracic and Vascular Surgery, University Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Axel Denz
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Georg Ferdinand Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany.
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10
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Noubani M, McCarthy E, Zhang X, Yang J, Spaniolas K, Pryor AD, Powers K. [S073]-The impact of interval appendectomy timing on follow-up adverse outcomes. Surg Endosc 2022; 37:3154-3161. [PMID: 35962228 DOI: 10.1007/s00464-022-09517-y] [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: 02/13/2022] [Accepted: 07/26/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE This study aims to compare the timing of interval appendectomy (IA) and its impact on post-operative outcomes. METHODS A retrospective analysis was performed for adult patients diagnosed with appendicitis between 2006 and 2017. IA was defined as a follow-up appendectomy > 1 week and < 2 years after the initial presentation. Time intervals were divided into 4 groups based on patient quartiles: 1-6 weeks, 7-9 weeks, 10-15 weeks, and > 15 weeks. The primary outcome measure was length of stay (LOS). Secondary outcomes included 30-day readmission and IA post-operative complications. Tertiary outcomes included 30-day mortality and colonoscopy suggesting neoplasm or Inflammatory Bowel Disease. RESULTS A total of 5069 patients' records whose interval appendectomy fell > 1 week and < 2 years after initial presentation were analyzed. Among them, 1006 (19.85%) underwent an initial percutaneous abscess drainage at diagnosis. The median timing for IA was 9.2 weeks. Patients with IA at 1-6 weeks were more likely to have longer LOS when compared to 7-9 weeks (ratio 1.33, 95% CI 1.2-1.48) and 10-15 weeks (ratio 1.38, 95% CI 1.25-1.52). IA between 7 and 9 weeks (ratio 0.81, 95% CI 0.73-0.89) and 10-15 weeks (ratio 0.78, 95% CI 0.71-0.86) was associated with significantly shorter LOS compared to those receiving the operation after 15 weeks. Further, patients requiring abscess drainage (ratio 1.2, 95% CI 1.13-1.34) or those with comorbidities (ratio 1.51, 95% CI 1.39-1.63) were more likely to have longer LOS at IA. Socioeconomic and demographic differences including Black, Hispanic, and those with Medicare and Medicaid insurance had a greater LOS after their IA. CONCLUSION LOS remains lowest among patients undergoing IA between 7-9 weeks and 10-15 weeks after initial appendicitis presentation. Patients with lower socioeconomic status or from racial minorities had a longer LOS after IA.
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Affiliation(s)
- Mohammad Noubani
- Department of Surgery, Health Sciences Center, Stony Brook University Hospital, 182 Christian Ave., Stony Brook, NY, 11790, USA.
| | - Elizabeth McCarthy
- Department of Surgery, Health Sciences Center, Stony Brook University Hospital, 182 Christian Ave., Stony Brook, NY, 11790, USA
| | - Xiaoyue Zhang
- Department of Family, Population and Preventative Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Jie Yang
- Department of Family, Population and Preventative Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Konstantinos Spaniolas
- Department of Surgery, Health Sciences Center, Stony Brook University Hospital, 182 Christian Ave., Stony Brook, NY, 11790, USA
| | - Aurora D Pryor
- Department of Surgery, Health Sciences Center, Stony Brook University Hospital, 182 Christian Ave., Stony Brook, NY, 11790, USA
| | - Kinga Powers
- Department of Surgery, Health Sciences Center, Stony Brook University Hospital, 182 Christian Ave., Stony Brook, NY, 11790, USA
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11
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Wright Z, Essien F, Renshaw J, Wiggins M, Brown A, Osswald M. Appendiceal disease in hematopoietic cell transplantation. Clin Case Rep 2022; 10:e05047. [PMID: 35140939 PMCID: PMC8813669 DOI: 10.1002/ccr3.5047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 12/29/2022] Open
Abstract
Appendiceal diseases are rare reported complications during hematopoietic stem cell transplantation with no guidance on management in the published literature. Medical therapy may be considered in selected patients prior to surgical solutions.
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Affiliation(s)
- Zachary Wright
- Hematology/Oncology and Bone Marrow Transplant San Antonio Military Medical CenterFT Sam HoustonTexasUSA
| | | | - John Renshaw
- Hematology/Oncology and Bone Marrow Transplant San Antonio Military Medical CenterFT Sam HoustonTexasUSA
| | - Michael Wiggins
- Hematology/Oncology and Bone Marrow Transplant San Antonio Military Medical CenterFT Sam HoustonTexasUSA
| | - Alexander Brown
- Hematology/Oncology and Bone Marrow Transplant San Antonio Military Medical CenterFT Sam HoustonTexasUSA
| | - Michael Osswald
- Hematology/Oncology and Bone Marrow Transplant San Antonio Military Medical CenterFT Sam HoustonTexasUSA
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12
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Teng TZJ, Thong XR, Lau KY, Balasubramaniam S, Shelat VG. Acute appendicitis–advances and controversies. World J Gastrointest Surg 2021; 13:1293-1314. [PMID: 34950421 PMCID: PMC8649565 DOI: 10.4240/wjgs.v13.i11.1293] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/24/2021] [Accepted: 09/29/2021] [Indexed: 02/06/2023] Open
Abstract
Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon’s practice. With the recent advancements in AA’s management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon’s repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic’s repercussions on patients and how surgeons’ practices have evolved in the context of AA.
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Affiliation(s)
- Thomas Zheng Jie Teng
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | - Xuan Rong Thong
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | - Kai Yuan Lau
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
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13
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Gale R, Eberlein S, Fuller G, Khalil C, Almario CV, Spiegel BMR. Public Perspectives on Decisions About Emergency Care Seeking for Care Unrelated to COVID-19 During the COVID-19 Pandemic. JAMA Netw Open 2021; 4:e2120940. [PMID: 34410398 PMCID: PMC8377572 DOI: 10.1001/jamanetworkopen.2021.20940] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Delaying critical care for treatable conditions owing to fear of contracting COVID-19 in the emergency department (ED) is associated with avoidable morbidity and mortality. OBJECTIVE To assess and quantify how people decided whether to present to the ED during the COVID-19 pandemic for care unrelated to COVID-19 using conjoint analysis, a form of trade-off analysis that examines how individuals make complex decisions. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional survey study was conducted using a nationwide sample from June 1, 2020, during the initial peak of the COVID-19 pandemic. Included participants were adults aged 18 years or older in the US who self-reported that they had not tested positive for COVID-19. Data were analyzed from July 2020 through May 2021. EXPOSURES Participants completed a self-administered online survey. MAIN OUTCOMES AND MEASURES Using a choice-based conjoint analysis survey, the relative importance was assessed for the following attributes for individuals in deciding whether to seek ED care for symptoms consistent with myocardial infarction or appendicitis: reduction in chance of dying because of ED treatment, crowdedness of ED with other patients, and chance of contracting COVID-19 in the ED. We also performed latent class analyses using conjoint data to identify distinct segments of the respondent population with similar choice patterns. Logistic regression was then used to explore whether patient sociodemographics and political affiliations were factors associated with decision-making. RESULTS Among 1981 individuals invited to participate, 933 respondents (47.1%) completed the survey; participants' mean (SD) age was 40.1 (13.0) years, and 491 (52.6%) were women. In latent class analyses, 158 individuals (16.9%) with symptoms of myocardial infarction and 238 individuals (25.5%) with symptoms of appendicitis prioritized avoidance of COVID-19 exposure in the ED (ie, chance of contracting COVID-19 in the ED or crowdedness of ED with other patients) over seeking appropriate care for symptoms. Having a usual source of care was a factor associated with lower odds of prioritizing avoidance of COVID-19 exposure (myocardial infarction scenario: adjusted odds ratio, 0.49 [95% CI, 0.32-0.76]; P = .001; appendicitis scenario: adjusted odds ratio, 0.57 [95% CI, 0.40-0.82]; P = .003), but most sociodemographic factors and political affiliations were not factors associated with decision-making. CONCLUSIONS AND RELEVANCE This study found that up to one-quarter of individuals were willing to forgo potentially life-saving ED care to avoid exposure to COVID-19. These findings suggest that health care systems and public health organizations should develop effective communications for patients and the community at large that reassure and encourage timely health care for critical needs during the ongoing COVID-19 pandemic and other scenarios.
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Affiliation(s)
- Rebecca Gale
- Cedars-Sinai Center for Outcomes Research and Education, Los Angeles, California
| | - Samuel Eberlein
- Cedars-Sinai Center for Outcomes Research and Education, Los Angeles, California
| | - Garth Fuller
- Cedars-Sinai Center for Outcomes Research and Education, Los Angeles, California
| | - Carine Khalil
- Cedars-Sinai Center for Outcomes Research and Education, Los Angeles, California
| | - Christopher V Almario
- Cedars-Sinai Center for Outcomes Research and Education, Los Angeles, California
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Brennan M R Spiegel
- Cedars-Sinai Center for Outcomes Research and Education, Los Angeles, California
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Health Policy and Management, University of California, Los Angeles Fielding School of Public Health
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14
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Skendelas JP, Alemany VS, Au V, Rao D, McNelis J, Kim PK. Appendiceal adenocarcinoma found by surgery for acute appendicitis is associated with older age. BMC Surg 2021; 21:228. [PMID: 33934697 PMCID: PMC8088755 DOI: 10.1186/s12893-021-01224-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/21/2021] [Indexed: 02/20/2023] Open
Abstract
BACKGROUND Appendectomy for acute appendicitis is the most common procedure performed emergently by general surgeons in the United States. The current management of acute appendicitis is increasingly controversial as non-operative management gains favor. Although rare, appendiceal neoplasms are often found as an incidental finding in the setting of appendectomy. Criteria and screening for appendiceal neoplasms are not standardized among surgical societies. METHODS The National Surgical Quality Improvement Program (NSQIP) database was queried for all patients who underwent appendectomy over a 9-year period (2010-2018). Over the same time period, patients who underwent appendectomy in two municipal hospitals in The Bronx, New York City, USA were reviewed. RESULTS We found a 1.7% incidence of appendiceal neoplasms locally and a 0.53% incidence of appendiceal tumors in a national population sample. Both groups demonstrated an increased incidence of appendiceal carcinoma by age. This finding was most pronounced after the age of 40 in both local and national populations. In our study, the incidence of appendiceal tumors increased with each decade interval up to the age of 80 and peaked at 2.1% in patients between 70 and 79 years. CONCLUSIONS Appendiceal adenocarcinomas were identified in patients with acute appendicitis that seem to be associated with increasing age. The presence of an appendiceal malignancy should be considered in the management of older patients with acute appendicitis before a decision to embark on non-operative therapy.
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Affiliation(s)
- John P Skendelas
- Jacobi Medical Center, Bronx, NY, USA
- North Central Bronx Hospital, Bronx, NY, USA
- Montefiore Medical Center, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Vincent Au
- Jacobi Medical Center, Bronx, NY, USA
- Montefiore Medical Center, Bronx, NY, USA
| | - Devika Rao
- Jacobi Medical Center, Bronx, NY, USA
- North Central Bronx Hospital, Bronx, NY, USA
- Montefiore Medical Center, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - John McNelis
- Jacobi Medical Center, Bronx, NY, USA
- North Central Bronx Hospital, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Peter K Kim
- Jacobi Medical Center, Bronx, NY, USA.
- North Central Bronx Hospital, Bronx, NY, USA.
- Albert Einstein College of Medicine, Bronx, NY, USA.
- Jacobi Medical Center, 1400 Pelham Parkway, Building 1, Room 510, Bronx, NY, 10461, USA.
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15
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Falih Noori Alsubsiee I, Falih Noori Alsubsiee A. Appendicectomy for Uncomplicated Simple Appendicitis: Is It Always Required? Surg Res Pract 2021; 2021:8848162. [PMID: 33791405 PMCID: PMC7984904 DOI: 10.1155/2021/8848162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/16/2021] [Accepted: 03/02/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Although appendicectomy is still the classical and standard treatment for acute appendicitis, initial conservative antibiotic only treatment for simple uncomplicated cases has been proposed and tried as a feasible and effective approach. The objective of this study was to evaluate the efficacy and outcomes of antibiotics treatment for acute simple uncomplicated appendicitis. METHODS This is a prospective controlled nonrandomized study in which a total of 156 patients whose ages range from 16 to 54 years presenting with clinical diagnosis of acute uncomplicated appendicitis were assigned for conservative antibiotics treatment, which consists of ceftriaxone I gram twice daily and metronidazole infusions, 500 mg in 100 ml, 3 times daily for 48 to 72 hours to be converted on oral antibiotics after clinical improvement for 5 to 7 days. Patients who failed to initial conservative treatment and those who had recurring symptoms of appendicitis were presented for appendectomy. RESULTS Antibiotic treatment was successful and feasible in 138 (88.5%) patients. Progression of the signs and symptoms despite full medical treatment was observed in 11 (7%) patients during the same admission. Further 7 (4.5%) patients showed recurrence of the symptoms during follow-up period of 6-12 months after successful initial conservative treatment and also proceeded for appendicectomy. CONCLUSION Nonoperative antibiotic treatment of acute simple appendicitis is safe, feasible, and effective for properly selected cases, thus avoiding unnecessary surgery with its possible complications.
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16
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Mikaeel RR, Young JP, Hardingham JE, Tapia Rico G, Hewett PJ, Symonds EL, Edwards S, Smith E, Tomita Y, Uylaki W, Horsnell M, Price TJ. Appendiceal neoplasm incidence and mortality rates are on the rise in Australia. Expert Rev Gastroenterol Hepatol 2021; 15:203-210. [PMID: 33022181 DOI: 10.1080/17474124.2021.1832467] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The study aimed to examine the incidence and mortality rates of appendiceal neoplasms (ANs) in Australia. METHODS A retrospective analysis was performed on national data obtained from the Australian Institute of Health and Welfare (AIHW) from 1982 to 2013. Changes to the incidence, and the cancer-specific mortality following the diagnosis of ANs were analyzed over this time period, with stratification performed for histological subtype, gender, and age groups (<50y and ≥50y). RESULTS Incidence and mortality rates of ANs increased significantly across both genders and age groups. Incidence rates increased by 415%, from 0.40/100 000 population in 1982 to 2.06/100 000 in 2013. Overall mortality rates increased by 130%, from 0.057/100 000 during 1982-1985 to 0.131/100 000 during 2010-2013. Controlling for age group and gender, the incidence rates increased by 20% every four years (Incidence rate ratio (IRR) = 1.20, 95% confidence interval (CI): 1.17, 1.23, global P value<0.0001), and controlling for age, the mortality rates increased by 8% every four years (IRR = 1.08, 95% CI: 1.00, 1.17, global P-value = 0.0401). CONCLUSION The increasing use of CT scanning, improvements in pathological assessment of the appendix, and the growing aging population may have contributed in part to the apparent rise in the incidence of ANs.
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Affiliation(s)
- Reger R Mikaeel
- Department of Haematology and Oncology, The Queen Elizabeth Hospital , Woodville South, Australia.,SAHMRI Colorectal Node, Basil Hetzel Institute , Woodville South, Australia.,Faculty of Health and Medical Sciences, University of Adelaide , Adelaide, Australia.,Department of Biology, College of Science, University of Duhok , Duhok, Kurdistan
| | - Joanne P Young
- Department of Haematology and Oncology, The Queen Elizabeth Hospital , Woodville South, Australia.,SAHMRI Colorectal Node, Basil Hetzel Institute , Woodville South, Australia.,Faculty of Health and Medical Sciences, University of Adelaide , Adelaide, Australia
| | - Jennifer E Hardingham
- Department of Haematology and Oncology, The Queen Elizabeth Hospital , Woodville South, Australia.,SAHMRI Colorectal Node, Basil Hetzel Institute , Woodville South, Australia.,Faculty of Health and Medical Sciences, University of Adelaide , Adelaide, Australia
| | - Gonzalo Tapia Rico
- Department of Medical Oncology, Royal Adelaide Hospital , Adelaide, Australia
| | - Peter J Hewett
- University of Adelaide Department of Surgery, The Queen Elizabeth Hospital , Woodville South, Australia
| | - Erin L Symonds
- Bowel Health Service, Flinders Medical Centre , Bedford Park, Australia.,Finders Centre for Innovation in Cancer, Flinders University , Bedford Park, Australia
| | - Suzanne Edwards
- Adelaide Health Technology Assessment (AHTA), School of Public Health, The University of Adelaide , Adelaide, Australia
| | - Eric Smith
- Department of Haematology and Oncology, The Queen Elizabeth Hospital , Woodville South, Australia.,University of Adelaide Department of Surgery, The Queen Elizabeth Hospital , Woodville South, Australia
| | - Yoko Tomita
- Department of Haematology and Oncology, The Queen Elizabeth Hospital , Woodville South, Australia
| | - Wendy Uylaki
- Department of Haematology and Oncology, The Queen Elizabeth Hospital , Woodville South, Australia.,Department of Gastroenterology, The Queen Elizabeth Hospital , Woodville South, Australia
| | - Mehgan Horsnell
- Department of Haematology and Oncology, The Queen Elizabeth Hospital , Woodville South, Australia
| | - Timothy J Price
- Department of Haematology and Oncology, The Queen Elizabeth Hospital , Woodville South, Australia.,Faculty of Health and Medical Sciences, University of Adelaide , Adelaide, Australia
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17
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Monsonis B, Zins M, Orliac C, Mandoul C, Boulay-Coletta I, Curros-Doyon F, Molinari N, Taourel P, Millet I. Retrospective case-control study to predict a potential underlying appendiceal tumor in an acute appendicitis context based on a CT-scoring system. Eur J Radiol 2021; 136:109525. [PMID: 33454458 DOI: 10.1016/j.ejrad.2021.109525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/26/2020] [Accepted: 01/02/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To assess CT signs to discriminate an appendiceal tumor versus a non-tumoral appendix in an acute appendicitis context. METHODS A 10-year bicentric retrospective case-control study was performed in adults. Patients with a histopathological appendiceal tumor and appendicitis were paired for age and sex with patients with non-tumorous appendicitis (1/3 ratio, respectively). Two senior radiologists blindly analyzed numerous CT findings with final consensus to perform univariate and multivariate statistical analyses. A diagnostic CT scan score was calculated with a bootstrap internal validation. Reproducibility was assessed based on the kappa statistic. RESULTS A total of 208 patients (51 +/- 21 years; 114 males) were included (52 patients in the tumor group and 156 in the non-tumor group). In the multivariate analysis, an appendicolith and fat stranding were protective factors with OR = 0.2 (p = 0.01) and OR = 0.3 (p = 0.02), respectively, while mural calcifications (OR = 47, p = 0.0001), an appendix mass (OR = 7.1, p = 0.008), a focal asymmetric wall abnormality (OR = 4.9, p = 0, 001), or a ≥ 15 mm diameter (OR = 3.5, p = 0.009) were positive predictive factors of an underlying tumor. Using a ≥1 cut-off, our diagnostic score had an AUC = 0.87 (95 % CI, 0.82-0.93) and a positive likelihood ratio = 13.5 (95 % CI, 6.7-27.1). CONCLUSION We developed a reliable scoring system based on CT findings, which is highly predictive of an underlying appendiceal neoplasm in an appendicitis context using a ≥1 cut-off.
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Affiliation(s)
- B Monsonis
- Department of Medical Imaging, Lapeyronie University Hospital, 371 avenue du Doyen Gaston Giraud, 34295, Montpellier, France
| | - M Zins
- Department of Medical Imaging, Saint Joseph's Hospital, 185 rue Raymond Losserand, 75014, Paris, France
| | - C Orliac
- Department of Medical Imaging, Lapeyronie University Hospital, 371 avenue du Doyen Gaston Giraud, 34295, Montpellier, France
| | - C Mandoul
- Department of Medical Imaging, Lapeyronie University Hospital, 371 avenue du Doyen Gaston Giraud, 34295, Montpellier, France; University of Montpellier, France
| | - I Boulay-Coletta
- Department of Medical Imaging, Saint Joseph's Hospital, 185 rue Raymond Losserand, 75014, Paris, France
| | - F Curros-Doyon
- Department of Medical Imaging, Lapeyronie University Hospital, 371 avenue du Doyen Gaston Giraud, 34295, Montpellier, France
| | - N Molinari
- Department of Statistics, Montpellier University Hospital, 39 Avenue Charles Flahault, 34090, Montpellier, France; University of Montpellier, France
| | - P Taourel
- Department of Medical Imaging, Lapeyronie University Hospital, 371 avenue du Doyen Gaston Giraud, 34295, Montpellier, France; University of Montpellier, France
| | - I Millet
- Department of Medical Imaging, Lapeyronie University Hospital, 371 avenue du Doyen Gaston Giraud, 34295, Montpellier, France; University of Montpellier, France.
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18
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Shannon AB, Song Y, Roses RE, Fraker DL, Miura JT, Karakousis GC. National trends in the presentation of surgically resected appendiceal adenocarcinoma over a decade. J Surg Oncol 2020; 123:606-613. [PMID: 33169840 DOI: 10.1002/jso.26295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/12/2020] [Accepted: 11/01/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Rates of nonoperative management of acute appendicitis and appendiceal adenocarcinoma have increased over a decade, but the presentation and outcomes of appendiceal adenocarcinoma over this period is not well-characterized. METHODS Patients with surgically resected Stage I-III appendiceal adenocarcinoma were identified from the 2006 to 2015 National Cancer Data Base and classified into two cohorts, 2006-2010 and 2011-2015, based on year of diagnosis. Three-year overall survival (OS) was analyzed using Cox proportional hazards regression and Kaplan-Meier survival estimates. RESULTS Of 4233 patients, 1369 (32.3%) and 2864 (67.7%) were diagnosed in 2006-2010 and 2011-2015, respectively. Following multivariable analysis, patients in 2011-2015 were more likely to be <40 years of age (6.4% vs. 4.7%, odds ratio [OR] 1.53, p .015), present with pT4 tumors (40.2% vs. 34.4%, OR 1.46, p .004), and undergo hyperthermic intraperitoneal chemotherapy (4.4% vs. 2.4%, OR 1.97, p .001). Comparing patients diagnosed in 2011-2015 to 2006-2010, adjusted 3-year OS was no different among all patients (81.1% vs. 79%, p .778). CONCLUSIONS There has been an increase in the proportion of patients with pT4 appendix tumors over time, primarily among older (≥60 years) patients. Even so, these shifts in presentation have not resulted in differences in survival outcomes.
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Affiliation(s)
- Adrienne B Shannon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yun Song
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert E Roses
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas L Fraker
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John T Miura
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Giorgos C Karakousis
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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19
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Piri SM, Saeedi Moghaddam S, Ghodsi Z, Yoosefi M, Rezaei N, Saadat S, Mansouri A, Sharif-Alhoseini M, Salamati P, Jazayeri SB, Khajavi A, Moradi Lakeh M, Mokdad AH, O'Reilly G, Rahimi-Movaghar V. Trend of Appendicitis Mortality at National and Provincial Levels in Iran from 1990 to 2015. ARCHIVES OF IRANIAN MEDICINE 2020; 23:302-311. [PMID: 32383614 DOI: 10.34172/aim.2020.19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 01/21/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Appendicitis is one of the most preventable causes of death worldwide. We aimed to determine the trend of mortality due to appendicitis by sex and age at national and provincial levels in Iran during 26 years. METHODS Data were collected from Iran Death Registration System (DRS), cemetery databanks in Tehran and Esfahan, and the national population and housing censuses of Iran. The estimated population was determined for each group from 1990 to 2015 using a growth model. Incompleteness, misalignment, and misclassification in the DRS were addressed and multiple imputation methods were used for dealing with missing data. ICD-10 codes were converted to Global Burden of Disease (GBD) codes to allow comparison of the results with the GBD study. A Spatio-Temporal model and Gaussian Process Regression were used to predict the levels and trends in child and adult mortality rates, as well as cause fractions. RESULTS From 1990 to 2015, 6,982 deaths due to appendicitis were estimated in Iran. The age-standardized mortality rate per 100000 decreased from 0.72 (95% UI: 0.46-1.12) in 1990 to 0.11 (0.07-0.16) in 2015, a reduction of 84.72% over the course of 26 years. The male: female ratio was 1.13 during the 26 years of the study with an average annual percent change of -2.31% for women and -2.63% for men. Among men and women, appendicitis mortality rate had the highest magnitude of decline in the province of Zanjan and the lowest in the province of Hormozgan. In 1990, the lowest age-standardized appendicitis-related mortality was observed in both women and men in the province of Alborz and the highest mortality rate among men were observed in the province of Lorestan. In 2015, the lowest mortality rates in women and men were in the province of Tehran. The highest mortality rates in women were in Hormozgan, and in men were in Golestan province. CONCLUSION The mortality rate due to appendicitis has declined at national and provincial levels in Iran. Understanding the causes of differences across provinces and the trend over years can be useful in priority setting for policy makers to inform preventive actions to further decrease mortality from appendicitis.
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Affiliation(s)
- Seyed Mohammad Piri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sahar Saeedi Moghaddam
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Ghodsi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Moein Yoosefi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Nazila Rezaei
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Soheil Saadat
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Anita Mansouri
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Sharif-Alhoseini
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Payman Salamati
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Behzad Jazayeri
- Department of Surgery, Kaiser Permanente Fontana Medical Center, Fontana, CA, USA.,Arrowhead Regional Medical Center, Department of Surgery, Colton, CA, USA
| | - Alireza Khajavi
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Student Research Committee, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maziar Moradi Lakeh
- Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali H Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Washington, USA
| | - Gerard O'Reilly
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
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20
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Charalampopoulos AA, Kopanakis KG, Koliakos NN, Dimopoulos IK, Farrugia FA, Karouta AG, Papaconstantinou DC, Paspalla AA, Zavras NI. Conservative treatment versus surgery for the first episode of acute appendicitis: retrospective analysis of 429 cases. Chirurgia (Bucur) 2020. [DOI: 10.23736/s0394-9508.18.04922-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Brunner M, Lapins P, Langheinrich M, Baecker J, Krautz C, Kersting S, Weber GF, Grützmann R, Maak M. Risk factors for appendiceal neoplasm and malignancy among patients with acute appendicitis. Int J Colorectal Dis 2020; 35:157-163. [PMID: 31811385 DOI: 10.1007/s00384-019-03453-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Non-operative management of acute uncomplicated appendicitis has shown promising results but might carry the risk of delayed diagnosis of premalignant or malignant appendiceal tumors found by chance in 0.7-2.5% of appendiceal specimen after appendectomy. Purpose of this study was to analyze whether appendiceal tumors are associated with a complicated appendicitis and to determine risk factors for appendiceal neoplasm and malignancy in patients with acute appendicitis. METHODS We performed a retrospective analysis of 1033 adult patients, who underwent appendectomy for acute appendicitis from 2010 to 2016 at the University hospital Erlangen. Data included patients' demographics; comorbidities; pre-, intra- and postoperative findings; and histopathological results. Complicated appendicitis was defined in the presence of perforation or abscess. RESULTS Appendiceal neoplasm respectively malignancy rate was 2.8% respectively 1.5%. Using univariate analysis, we identified seven risk factors at least for appendiceal neoplasm or malignancy: age, ASA, C-reactive protein, appendiceal diameter, perforation, intraoperative perithyphilitic abscess, and complicated appendicitis. Risk for appendiceal neoplasm or malignancy was 4.4% respectively 2.7% in complicated acute appendicitis compared to 2.0% respectively 1.0% in uncomplicated appendicitis (p = 0.043 respectively p = 0.060). In multivariate analysis, age ≥ 50 years and a diameter of the appendix in the sonography ≥ 13 mm were independent risk factors predicting the presence of appendiceal neoplasm and malignancy. CONCLUSION Among patients with appendicitis, there are relevant risk factors predicting appendiceal tumors, especially age and appendiceal diameter in sonography. But the identified risk factors have a low sensitivity and specificity, so obtaining a confident preoperative diagnosis is challenging.
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Affiliation(s)
- Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany.
| | - Philipp Lapins
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Melanie Langheinrich
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Justus Baecker
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Stephan Kersting
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Georg F Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Matthias Maak
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
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22
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de Virgilio C, Grigorian A, Petrie BA, Arnell TD. Right Lower Quadrant Abdominal Pain. Surgery 2020. [DOI: 10.1007/978-3-030-05387-1_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Sceats LA, Trickey AW, Morris AM, Kin C, Staudenmayer KL. Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients. JAMA Surg 2019; 154:141-149. [PMID: 30427983 DOI: 10.1001/jamasurg.2018.4282] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance Health care professionals have shown significant interest in nonoperative management for uncomplicated appendicitis, but long-term population-level data are lacking. Objective To compare the outcomes of nonoperatively managed appendicitis against appendectomy. Design, Setting, and Participants This national retrospective cohort study used claims data from a private insurance database to compare patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, undergoing appendectomy vs nonoperative management. Coarsened exact matching was applied before multivariate analysis to reduce imbalance between groups. Data were analyzed from February 12 through May 1, 2018. Exposures Appendectomy (control arm) or nonoperative management (treatment arm). Main Outcomes and Measures Short-term primary clinical outcomes included emergency department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections. Long-term primary clinical outcomes were small-bowel obstructions, incisional hernias, and appendiceal cancers. Nonoperative management failure was defined by hospital readmission with appendicitis diagnosis and an appendicitis-associated operation or procedure. Secondary outcomes included number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care. Covariates included age, sex, region, insurance plan type, admission year, and Charlson comorbidity index. Results Of 58 329 patients with uncomplicated appendicitis (52.7% men; mean [SD] age, 31.9 [16.5] years), 55 709 (95.5%) underwent appendectomy and 2620 (4.5%) underwent nonoperative management. Patients in the nonoperative management group were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P < .001) and to develop an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P = .02). Patients in the nonoperative management group required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs 0.3 [1.4] visits; adjusted +1.11 visits; P < .001) and had lower index hospitalization cost (unadjusted mean [SD], $11 502 [$9287] vs $13 551 [$10 160]; adjusted -$2117, P < .001), but total cost of appendicitis care was higher when follow-up care was considered (unadjusted, $14 934 [$31 122] vs $14 186 [$10 889]; adjusted +$785; P = .003). During a mean (SD) of 3.2 (1.7) years of follow-up, failure of nonoperative management occurred in 101 patients (3.9%); median time to recurrence was 42 days (interquartile range, 8-125 days). Among the patients who experienced treatment failure, 44 did so within 30 days. Conclusions and Relevance According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.
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Affiliation(s)
- Lindsay A Sceats
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Arden M Morris
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Cindy Kin
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Kristan L Staudenmayer
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Stanford University, Stanford, California
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24
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Yu YR, Rosenfeld EH, Dadjoo S, Orth RC, Lopez ME, Shah SR, Naik-Mathuria BJ. Accuracy of surgeon prediction of appendicitis severity in pediatric patients. J Pediatr Surg 2019; 54:2274-2278. [PMID: 31097307 DOI: 10.1016/j.jpedsurg.2019.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/08/2019] [Accepted: 04/16/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Clinical prediction of disease severity is important as one considers nonoperative management of simple appendicitis. This study assesses the accuracy of surgeons' prediction of appendicitis severity. METHODS From February to August 2016, pediatric surgeons at a single institution were asked to predict whether patients had simple or complex appendicitis preoperatively based on clinical data, imaging, and general assessment. Receiver operating characteristic curves were generated to determine area under the curve (AUC) and optimal cutoff points of clinical findings for diagnosing simple appendicitis. Outcomes included sensitivity and specificity of variables to identify simple appendicitis. Predictions were compared to operative findings using χ2. A p-value<0.05 was considered statistically significant. RESULTS Of 125 cases (median age 9 years [IQR 7-13], 58% male), simple appendicitis was predicted in 77 (62%) and complex appendicitis in 48 (38%). Predictions were accurate in 59 (77%) simple cases and 45 (94%) complex cases. Although surgeon prediction was more accurate than individual imaging or clinical findings and was highly sensitive (95%) for diagnosing simple appendicitis, specificity was only 71%. Lower WBC (<15.5 × 103/μL, AUC 0.61, p = 0.05), afebrile (<100.4 °F, AUC 0.86, p < 0.01), and shorter symptom duration (≤ 1.5 days, AUC 0.71, p < 0.001) were associated with simple appendicitis. Of 18 complex cases (14%) inaccurately predicted as simple, 17 (94%) lacked diffuse tenderness, 15 (83%) were well-appearing, 11 (61%) had ultrasound findings of simple appendicitis, 11 (61%) had ≤2 days of symptoms, and 8 (44%) were afebrile (<100.4 °F). CONCLUSION While surgeon prediction of simple appendicitis is more accurate than ultrasound or clinical data alone, diagnostic accuracy is still limited. TYPE OF STUDY Prospective survey. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Yangyang R Yu
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030.
| | - Eric H Rosenfeld
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030
| | - Shaahin Dadjoo
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030
| | - Robert C Orth
- Division of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street Suite 470, Houston, TX 77030
| | - Monica E Lopez
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030
| | - Sohail R Shah
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030
| | - Bindi J Naik-Mathuria
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030
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25
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Miyano G, Ochi T, Seo S, Nakamura H, Okawada M, Doi T, Koga H, Lane GJ, Yamataka A. Factors affecting non-operative management of uncomplicated appendicitis in children: Should laparoscopic appendectomy be immediate, interval, or emergency? Asian J Endosc Surg 2019; 12:434-438. [PMID: 30548102 DOI: 10.1111/ases.12677] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/11/2018] [Accepted: 10/28/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION We conducted a prospective non-randomized comparison of children with uncomplicated appendicitis treated either by primary laparoscopic appendectomy (PLA) or by non-operative management (NOM) followed by interval laparoscopic appendectomy (ILA) if NOM was successful or emergency laparoscopic appendectomy (ELA) if NOM was unsuccessful. METHODS Before 2015, all patients with uncomplicated appendicitis underwent PLA using a standard three-port technique. Postoperatively, piperacillin/tazobactam was administered until the white blood cell count was less than 10 000/μL and patients were afebrile. Since 2015, in cases of uncomplicated appendicitis, intravenous analgesia has been administered once after assessment, and then NOM has been immediately employed, with repeat doses of piperacillin/tazobactam administered every 8 h after admission. We have also used standard management cut-off criteria to determine when to perform laparoscopic appendectomy after NOM: if NOM fails, ELA is performed within 6 h, and if NOM is successful, ILA is planned. RESULTS There were 103 eligible subjects for this study. Eleven cases of suspected complicated appendicitis were excluded, leaving 34 PLA cases and 58 NOM cases. After NOM, 27 patients were treated with ILA and 31 with ELA. There was one recurrence after successful NOM, and in two cases, patients' parents refused to consent to ILA after successful NOM. There were more perforations and significantly more residual abscesses in ELA than in PLA. Operative time and postoperative hospitalization were significantly longer among ELA patients than among PLA patients, and operative time was significantly shorter during ILA than in PLA. CONCLUSION Further evaluation is required to confirm which patients will benefit most from NOM and what role PLA has in treating uncomplicated appendicitis.
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Affiliation(s)
- Go Miyano
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Takanori Ochi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Shogo Seo
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroki Nakamura
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Manabu Okawada
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Takashi Doi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Geoffrey J Lane
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
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26
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Hanson AL, Crosby RD, Basson MD. Patient Preferences for Surgery or Antibiotics for the Treatment of Acute Appendicitis. JAMA Surg 2019; 153:471-478. [PMID: 29322168 DOI: 10.1001/jamasurg.2017.5310] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Studies have compared surgical with nonsurgical therapy for acute uncomplicated appendicitis, but none of these studies have a patient-centered perspective. Objectives To evaluate how patients might choose between surgical and nonsurgical therapy for acute uncomplicated appendicitis and to identify targets to make antibiotic treatment more appealing. Design, Setting, and Participants This study comprised an online survey and an in-person sensitivity analysis survey. For the web survey, a convenience sample of 1728 respondents were asked to imagine that they or their child had acute uncomplicated appendicitis, provided information about laparoscopic and open appendectomy and antibiotic treatment alone, and asked which treatment they might choose. The web survey was open from April 17, 2016, through June 16, 2016, and was disseminated via email link, a poster with a Quick Response code, and social media. For the sensitivity analysis, 220 respondents were given the same scenario and options. Those who chose surgery were asked whether certain factors influenced their decision; each factor was incrementally improved during questioning about whether respondents would consider switching to antibiotics. These participants were recruited at public venues from June 3, 2016, to July 31, 2016. Web survey data were analyzed from June 17, 2016, to September 21, 2017. Sensitivity analysis data were analyzed from August 1, 2016, to September 21, 2017. Main Outcomes and Measures Treatment preferences. Results Among the 1728 web survey respondents, 1225 (70.9%) were female and 500 (28.9%) were male (3 [0.2%] either did not answer or responded as "gender fluid" within the comments section of the survey), and most self-reported being between 50 and 59 years of age (391 [22.6%]) and being non-Hispanic white (1563 [90.5%]). For themselves, 1482 respondents (85.8%) chose laparoscopic appendectomy, 84 (4.9%) chose open appendectomy, and 162 (9.4%) chose antibiotics alone. For their child, 1372 respondents (79.4%) chose laparoscopic appendectomy, 106 (6.1%) open appendectomy, and 250 (14.5%) antibiotics alone. Respondents were somewhat more likely to choose antibiotics for themselves if they had education beyond college (105 [12.6%]; P < .001), identified as other than non-Hispanic white (24 [14.9%]; P < .001), or did not know anyone who had previously been hospitalized (12 [15.8%]; P = .02), but they were less likely to choose antibiotics if they were surgeons (11 [5.4%]; P = .008). Of the 220 participants interviewed for the sensitivity analysis, 120 (54.5%) were female and 100 (45.5%) were male, and most self-reported being between 18 and 24 years of age (53 [24.1%]) and being non-Hispanic white (204 [92.7%]). Their responses suggested that improvements in the short- and long-term failure rate of antibiotic treatment-rather than reductions in the duration of hospitalization or antibiotic treatment-were more likely to increase the desirability of choosing antibiotics. Conclusions and Relevance Most patients may choose surgical intervention over antibiotics alone in treatment of acute uncomplicated appendicitis, but a meaningful number may choose nonoperative management. Therefore, from a patient-centered perspective, this option should be discussed with patients, and future research could be directed at reducing the failure and recurrence rates of antibiotic treatment for appendicitis.
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Affiliation(s)
- Alexis L Hanson
- Department of Surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks
| | - Ross D Crosby
- Department of Psychiatry and Behavioral Science, University of North Dakota School of Medicine and Health Sciences, Grand Forks.,Neuropsychiatric Research Institute, Fargo, North Dakota
| | - Marc D Basson
- Department of Surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks
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27
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Minneci PC, Hade EM, Lawrence AE, Saito JM, Mak GZ, Hirschl RB, Gadepalli S, Helmrath MA, Leys CM, Sato TT, Lal DR, Landman MP, Kabre R, Fallat ME, Fischer BA, Cooper JN, Deans KJ. Multi-institutional trial of non-operative management and surgery for uncomplicated appendicitis in children: Design and rationale. Contemp Clin Trials 2019; 83:10-17. [PMID: 31254670 PMCID: PMC7073001 DOI: 10.1016/j.cct.2019.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/17/2019] [Accepted: 06/25/2019] [Indexed: 12/29/2022]
Abstract
Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children's hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a "successful" treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.
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Affiliation(s)
- Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Erinn M Hade
- Departments of Biomedical Informatics and Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Amy E Lawrence
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jacqueline M Saito
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Grace Z Mak
- Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine and Biologic Sciences, Chicago, IL, USA
| | - Ronald B Hirschl
- Division of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Samir Gadepalli
- Division of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Michael A Helmrath
- Division of Pediatric Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Thomas T Sato
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Matthew P Landman
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rashmi Kabre
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mary E Fallat
- Division of Pediatric Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Beth A Fischer
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Katherine J Deans
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
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28
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Sceats LA, Ku S, Coughran A, Barnes B, Grimm E, Muffly M, Spain DA, Kin C, Owens DK, Goldhaber-Fiebert JD. Operative Versus Nonoperative Management of Appendicitis: A Long-Term Cost Effectiveness Analysis. MDM Policy Pract 2019; 4:2381468319866448. [PMID: 31453362 PMCID: PMC6699012 DOI: 10.1177/2381468319866448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 06/27/2019] [Indexed: 12/17/2022] Open
Abstract
Background. Recent clinical trials suggest that nonoperative management (NOM) of patients with acute, uncomplicated appendicitis is an acceptable alternative to surgery. However, limited data exist comparing the long-term cost-effectiveness of nonoperative treatment strategies. Design. We constructed a Markov model comparing the cost-effectiveness of three treatment strategies for uncomplicated appendicitis: 1) laparoscopic appendectomy, 2) inpatient NOM, and 3) outpatient NOM. The model assessed lifetime costs and outcomes from a third-party payer perspective. The preferred strategy was the one yielding the greatest utility without exceeding a $50,000 willingness-to-pay threshold. Results. Outpatient NOM cost $233,700 over a lifetime; laparoscopic appendectomy cost $2500 more while inpatient NOM cost $7300 more. Outpatient NOM generated 24.9270 quality-adjusted life-years (QALYs), while laparoscopic appendectomy and inpatient NOM yielded 0.0709 and 0.0005 additional QALYs, respectively. Laparoscopic appendectomy was cost-effective compared with outpatient NOM (incremental cost-effectiveness ratio $32,300 per QALY gained); inpatient NOM was dominated by laparoscopic appendectomy. In one-way sensitivity analyses, the preferred strategy changed when varying perioperative mortality, probability of appendiceal malignancy or recurrent appendicitis after NOM, probability of a complicated recurrence, and appendectomy cost. A two-way sensitivity analysis showed that the rates of NOM failure and appendicitis recurrence described in randomized trials exceeded the values required for NOM to be preferred. Limitations. There are limited NOM data to generate long-term model probabilities. Health state utilities were often drawn from single studies and may significantly influence model outcomes. Conclusion. Laparoscopic appendectomy is a cost-effective treatment for acute uncomplicated appendicitis over a lifetime time horizon. Inpatient NOM was never the preferred strategy in the scenarios considered here. These results emphasize the importance of considering long-term costs and outcomes when evaluating NOM.
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Affiliation(s)
- Lindsay A. Sceats
- Stanford-Surgery Policy Improvement Research and
Education (S-SPIRE) Center, Department of Surgery, Stanford University,
Stanford, California
| | - Seul Ku
- School of Medicine, Stanford University,
Stanford, California
| | - Alanna Coughran
- School of Medicine, Stanford University,
Stanford, California
| | - Britainy Barnes
- School of Medicine, Stanford University,
Stanford, California
| | - Emily Grimm
- Department of Management Science and
Engineering, Stanford University, Stanford, California
| | - Matthew Muffly
- Stanford University, Stanford, California;
Stanford University Medical Center, Stanford, California
| | - David A. Spain
- Section of Acute Care Surgery, Department of
Surgery, Stanford University, Stanford, California
| | - Cindy Kin
- Stanford-Surgery Policy Improvement Research and
Education (S-SPIRE) Center, Department of Surgery, Stanford University,
Stanford, California
| | - Douglas K. Owens
- Center for Primary Care and Outcomes Research,
School of Medicine, Stanford University, Stanford, California
- VA Palo Alto Health Care System, Palo Alto,
California
| | - Jeremy D. Goldhaber-Fiebert
- Center for Primary Care and Outcomes Research,
School of Medicine, Stanford University, Stanford, California
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Abstract
BACKGROUND We developed a protocol to identify candidates for non-operative management (NOM) of uncomplicated appendicitis. Our objective was to evaluate protocol efficacy with the null hypothesis that clinical outcomes, hospital readmission rates, and hospital charges would be unchanged after protocol implementation. METHODS We performed a single-center 4-year propensity score matched retrospective cohort analysis of 406 patients with acute uncomplicated appendicitis. The protocol recommended NOM for patients with modified Alvarado score ≤6 and no appendicolith. Patients admitted before (n = 203) and after (n = 203) protocol implementation were matched by Charlson comorbidity index, duration of symptoms, and modified Alvarado score. Outcomes included operative management, days on antibiotic therapy, length of stay, and hospital charges, as well as readmissions, complications, and mortality within 180 days. RESULTS Baseline characteristics were similar between groups (age 31 years, ASA class 2.0, Charlson comorbidity index 0.0). Protocol compliance was higher when the protocol recommended appendectomy (97%) rather than NOM (73%, p < 0.001). The incidence of operative management decreased from 99% to 82% after protocol implementation (p < 0.001). In the protocol group, there was a lower incidence of open surgery (4% vs. 10%, p = 0.044) despite a longer interval between admission and surgery (8.6 vs. 7.1 hours, p < 0.001). After protocol implementation, 51 patients had NOM: 18 failed NOM during admission and 6 failed NOM after discharge. Compared to the pre-protocol group, the protocol group had similar length of stay, antibiotic days, and overall complication rates, but more readmissions (6% vs. 1%, p = 0.019) and lower hospital charges for the index admission ($5,630 vs. $6,878, p < 0.001). CONCLUSIONS Implementation of a protocol to identify candidates for NOM of acute uncomplicated appendicitis was associated with lower rates of open surgery, fewer appendectomies, decreased hospital charges, and no difference in overall complications despite high rates of readmission and failure of NOM. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Reitz KM, Zuckerbraun BS. Treating the Patient With Appendicitis, Not Just the Appendicitis. JAMA Surg 2019; 154:149. [PMID: 30427979 DOI: 10.1001/jamasurg.2018.4300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Al-Mulhim AS. Readmission after antibiotic management of uncomplicated acute appendicitis in adults: prospective study. Eur J Trauma Emerg Surg 2018; 46:841-846. [PMID: 30367181 DOI: 10.1007/s00068-018-1038-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 10/19/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute appendicitis is the most common surgical cause of acute abdomen. Many randomized studies compare between antibiotic and surgery, and such studies indicated that antibiotics might treat acute appendicitis. However, there are concerns about selection bias in previous studies. Hence, to overcome this worry; we used in this study a full-scale population-based application. PATIENTS AND METHODS We identified 327 adult patients who were admitted to surgical ward with diagnosis of uncomplicated acute appendicitis between March 2013 and February 2016. All patients received antibiotic therapy after confirming the diagnosis by computed tomography. Endpoints were treatment efficacy, readmission, and complications in 1 year of follow-up. RESULTS Of the 327 patients include in this study, 8 (2.5%) patients failed initial non-operative (antibiotic) management and underwent operation during their initial hospitalization. Of 319 available for 1-year follow-up, 280 patients (87.8%) did not require appendectomy; while 39 patients (12.2%) need readmission within 1 year. CONCLUSIONS Antibiotics are a safe and visible option in acute appendicitis management. This approach needs careful assessment and evaluation for each individual patient before it is used as the first-line therapy.
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Siletz A, Grotts J, Lewis C, Tillou A, Cheaito A, Cryer H. Monitoring Complications of Medically Managed Acute Appendicitis. Am Surg 2018. [DOI: 10.1177/000313481808401030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Nonoperative management of acute appendicitis is becoming widespread, but recurrence and the potential for a complicated course are important concerns. An admission report-based institutional database was created to monitor appendicitis treatment outcomes. Complications and complexity of surgery were recorded based on manual chart review. A cohort of patients spanning one year was analyzed. Initial management was operative in 181 (82%) and nonoperative in 39 (18%) cases. There were no differences in demographics, BMI, or Alvarado score. One operative patient and 17 non-operative patients required additional treatment for recurrence/nonresolution (0.6% vs 44%, P < 0.00001). Twenty-eight (15%) operative patients and 17 (44%) nonoperative patients had complications ( P = 0.0003). Thirty-six (19.9%) operations in the operative group and 8 (53.3%) in the non-operative group were classified as complex ( P = 0.007). Hospital stay was longer in the nonoperative group (one vs two days, P = 0.005). Two incidental malignancies in the operative group and one in the nonoperative group were identified. These results are consistent with prior studies showing that recurrence/nonresolution is common after nonoperative management. For patients with recurrence/nonresolution, surgery may be more complex.
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Affiliation(s)
- Anaar Siletz
- Departments of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Jonathan Grotts
- Departments of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Catherine Lewis
- Departments of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Areti Tillou
- Departments of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Ali Cheaito
- Departments of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Henry Cryer
- Departments of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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Pahlkotter M, Melmer PD, Holmes S, Davis JM, Sciarretta JD. Appendiceal Carcinoids and the Reality of Nonoperative Acute Appendicitis: Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database. Am Surg 2018. [DOI: 10.1177/000313481808400710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
| | | | - Sharon Holmes
- Grand Strand Medical Center Myrtle Beach, South Carolina
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Ulysses Syndrome: The Modern-day Odyssey of Pediatric Patients With Uncomplicated Acute Appendicitis. Ann Surg 2018; 267:1011-1012. [PMID: 29401107 DOI: 10.1097/sla.0000000000002686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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35
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Horattas MC, Horattas IK, Vasiliou EM. Early Uncomplicated Appendicitis—Who Can We Treat Nonoperatively?. Am Surg 2018. [DOI: 10.1177/000313481808400221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This study evaluated nonoperative treatment for mild appendicitis and reviewed selection criteria to be used in introducing this option into clinical practice. A retrospective review of 73 consecutive cases of appendicitis treated by a single surgeon from 2011 to 2013 was completed. Patients who were diagnosed with mild appendicitis meeting the criteria of an APPENDICITIS scoring algorithm proposed in this manuscript were considered for nonoperative management. An additional 17 patients with mild appendicitis were offered and successfully treated nonoperatively between 2014 and 2016 and reviewed. Of these original 73 patients, 37 had moderate to severe appendicitis and directly underwent appendectomy. The remaining patients were diagnosed with mild appendicitis and considered eligible for nonoperative management. Of these, 14 patients were offered nonoperative therapy. Thirteen responded successfully; one patient responded partially, but later opted for surgery. In 2014, this scoring system and preliminary results were shared with the other surgeons in our department. Nonoperative management was then selectively adopted by a few of the surgeons from 2014 to 2016 with another 17 patients (APPENDICITIS score of 0 or 1) being offered and successfully managed nonoperatively. Patients with mild or early appendicitis can be successfully managed nonoperatively. A proposed APPENDICITIS scoring system may provide a helpful mnemonic for successfully selecting patients for this option.
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Horn CB, Tian D, Bochicchio GV, Turnbull IR. Incidence, demographics, and outcomes of nonoperative management of appendicitis in the United States. J Surg Res 2017; 223:251-258. [PMID: 29198605 DOI: 10.1016/j.jss.2017.10.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 09/08/2017] [Accepted: 10/12/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Appendicitis is the most common intraabdominal surgical emergency in the United States, with over 250,000 cases each year. Several recent studies have evaluated the efficacy of nonoperative management of appendicitis. We measured changes in the treatment of appendicitis in the United States from 1998 to 2014 and evaluated outcomes in the contemporary cohort of appendicitis cases from 2010 to 2014. METHODS The National Inpatient Sample was queried for cases with a principal diagnosis of appendicitis. Cases with peritoneal abscesses were excluded. We determined trends in management and then compared cases managed nonoperatively versus those managed with early operation for demographics and outcomes including mortality, total charges, and length of stay using univariate analysis, binary logistic regression analysis, and case-control matching. RESULTS Although early operation remains the dominant treatment for acute appendicitis in the United States, there is an accelerating trend in nonoperative management. Nonoperative management is associated with increased age, number of comorbidities, and inpatient diagnoses. In univariate, multiple regression, and case-control analysis, nonoperative management is associated with decreased total charges but significantly increased risk of mortality. CONCLUSIONS Elderly patients and patients with medical comorbidities are more likely to be treated nonoperatively for appendicitis than younger patients. Although previously published data support nonoperative management of appendicitis in low-risk surgical patients, we suggest that elderly or medically complex patients may benefit from early operative treatment of appendicitis and are potentially at risk of poor outcomes from nonoperative management.
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Affiliation(s)
- Christopher B Horn
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Dajun Tian
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Grant V Bochicchio
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Isaiah R Turnbull
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.
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Loftus TJ, Brakenridge SC, Croft CA, Stephen Smith R, Efron PA, Moore FA, Mohr AM, Jordan JR. Successful nonoperative management of uncomplicated appendicitis: predictors and outcomes. J Surg Res 2017; 222:212-218.e2. [PMID: 29146455 DOI: 10.1016/j.jss.2017.10.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 08/27/2017] [Accepted: 10/11/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Our objective was to identify predictors of successful nonoperative management (NOM) of uncomplicated appendicitis. We hypothesized that the absence of diabetes, absence of an appendicolith, short duration of symptoms, absence of systemic inflammation, and low modified Alvarado score would predict successful NOM. METHODS We performed a retrospective cohort analysis of 81 consecutive patients who underwent NOM of uncomplicated appendicitis. Successful NOM was defined as resolution of appendicitis with antibiotics alone and no recurrent appendicitis within 180 days. Patients with successful NOM (n = 36) were compared with patients who failed NOM (n = 45). Multivariable logistic regression was used to identify predictors of successful NOM, expressed as odds ratios (ORs) with 95% confidence intervals. Model strength was assessed by calculating area under the receiver operating characteristic curve (AUC). RESULTS Patient age (35 years), the American Society of Anesthesiologists class (2.0), and Charlson comorbidity index (0.0) were similar between groups. Independent predictors of successful NOM were duration of symptoms prior to admission >25 hours: OR 4.17 (1.42-12.24), maximum temperature within 6 hours of admission <37.3°C: OR 8.07 (1.79-36.38), modified Alvarado score <4: OR 9.06 (1.26-64.93), and appendiceal diameter <13 mm: OR 17.55 (1.30-237.28); model AUC: 0.81 (0.72-0.90). CONCLUSIONS Patients with a longer duration of symptoms prior to admission were more likely to have successful NOM. Other independent predictors of successful NOM included lower temperature, lower modified Alvarado score, and smaller appendiceal diameter. These findings provide a framework for clinical decision-making and large-scale derivation and validation of a model to predict successful NOM of uncomplicated appendicitis.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida; University of Florida Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Scott C Brakenridge
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida; University of Florida Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Chasen A Croft
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida
| | - R Stephen Smith
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida
| | - Philip A Efron
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida; University of Florida Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Frederick A Moore
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida; University of Florida Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Alicia M Mohr
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida; University of Florida Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Janeen R Jordan
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida; Orange Park Medical Center in Jacksonville, Orange Park, Florida.
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Poon SHT, Lee JWY, Ng KM, Chiu GWY, Wong BYK, Foo CC, Law WL. The current management of acute uncomplicated appendicitis: should there be a change in paradigm? A systematic review of the literatures and analysis of treatment performance. World J Emerg Surg 2017; 12:46. [PMID: 29075315 PMCID: PMC5644137 DOI: 10.1186/s13017-017-0157-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 10/10/2017] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Appendectomy has long been the mainstay of intervention for acute appendicitis, aiming at preventing perforation, peritonitis, abscess formation and recurrence. With better understanding of the disease process, non-operative management (NOM) with antibiotics alone has been proved a feasible treatment for uncomplicated appendicitis. This article aimed at systematically reviewing the available literatures and discussing the question whether NOM should replace appendectomy as the standard first-line treatment for uncomplicated appendicitis. METHOD A search of the Embase, Pubmed and Cochrane Library was performed using the keywords 'acute appendicitis' and 'antibiotic therapy'. Meta-analysis with inverse variance model for continuous variable and Mantel Haenzel Model for dichotomous variable was performed to evaluate the one year treatment efficacy, morbidities rate, sick leave duration and length of hospital stay associated with emergency appendectomy and NOM. RESULTS Six randomized control trials were identified out of 1943 publications. NOM had a significant lower treatment efficacy rate at one year, 0.10 (95% CI 0.03-0.36, p < 0.01), when compared to appendectomy. The morbidities rate was comparable between the two interventions. The length of hospital stay was longer, with a mean difference of 1.08 days (95% CI 0.09-2.07, p = 0.03), and the sick leave duration was shorter, a mean difference of 3.37 days (95% CI -5.90 to -0.85 days, p < 0.01) for NOM. CONCLUSION The paradigm remains unchanged, that appendectomy is the gold standard of treatment for uncomplicated appendicitis, given its higher efficacy rate when compared to NOM.
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Affiliation(s)
- Samuel Ho Ting Poon
- The Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Jennifer Wah Yan Lee
- The Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Ka Man Ng
- The Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Gloria Wing Yan Chiu
- The Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Brian Yung Kong Wong
- The Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Chi Chung Foo
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China
| | - Wai Lun Law
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China
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Xu J, Adams S, Liu YC, Karpelowsky J. Nonoperative management in children with early acute appendicitis: A systematic review. J Pediatr Surg 2017; 52:1409-1415. [PMID: 28535960 DOI: 10.1016/j.jpedsurg.2017.05.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 04/11/2017] [Accepted: 05/04/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Appendectomy has remained the gold standard treatment of acute appendicitis for more than 100years. Nonoperative management (NOM) has been shown to be a valid treatment alternative for acute uncomplicated appendicitis in adults. A systematic review of available evidence comparing operative management (OM) and NOM in children with acute uncomplicated appendicitis was performed. METHODS Systematic searches of MedLine, Embase, and a clinical trial register (https://clinicaltrials.gov/) were performed in March 2016. Only articles that studied NOM for uncomplicated appendicitis in children were included. Data generation was performed independently by two authors, and quality was assessed using the rating schema by the Oxford Centre for Evidence-Based Medicine. RESULTS 15 articles were selected: four retrospective analyses, four prospective cohort studies, four prospective nonrandomized comparative trials and one randomized controlled trial (RCT). Initial success of the NOM groups (a cure within two weeks of intervention) ranged from 58 to 100%, with 0.1-31.8% recurrence at one year. CONCLUSION Although present literature is scarce, publications support the feasibility of further studies investigating NOM of acute uncomplicated appendicitis in children. Higher quality prospective RCTs with larger sample sizes and robust randomization methods, studying the noninferiority of NOM with antibiotics compared with OM are required to establish its utility. LEVEL OF EVIDENCE This manuscript is a systematic review and thus assigned the lowest evidence used from the manuscripts analyzed which is a Level IV.
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Affiliation(s)
- Jane Xu
- The School of Women's and Children's Health, The University of New South Wales, New South Wales, Australia
| | - Susan Adams
- The School of Women's and Children's Health, The University of New South Wales, New South Wales, Australia; Department of Pediatric Surgery, Sydney Children's Hospital, Randwick, New South Wales, Australia.
| | - Yingrui Cyril Liu
- Department of Pediatric Surgery, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Jonathan Karpelowsky
- Division of Child and Adolescent Health, The University of Sydney, New South Wales, Australia; Department of Pediatric Surgery, The Children's Hospital at Westmead, New South Wales, Australia
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Sagebiel TL, Mohamed A, Matamoros A, Taggart MW, Doamekpor F, Raghav KP, Mann GN, Mansfield PF, Eng C, Royal RE, Foo WC, Ensor JE, Fournier KF, Overman MJ. Utility of Appendiceal Calcifications Detected on Computed Tomography as a Predictor for an Underlying Appendiceal Epithelial Neoplasm. Ann Surg Oncol 2017; 24:3667-3672. [PMID: 28831698 DOI: 10.1245/s10434-017-6052-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Mucinous appendiceal neoplasms can contain radiopaque calcifications. Whether appendiceal radiographic calcifications indicate the presence of an appendiceal epithelial neoplasm is unknown. This study aimed to determine whether appendiceal calcifications detected by computed tomography (CT) correlate with the presence of appendiceal epithelial neoplasms. METHODS From prospective appendiceal and pathology databases, 332 cases of appendiceal neoplasm and 136 cases of control appendectomy were identified, respectively. Only cases with preoperative CT scans available for review were included in the study. Images were reviewed by two abdominal radiologists. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated, and the kappa statistic was used to determine agreement between the radiologists' interpretations. RESULTS Interobserver agreement between the radiologists was substantial, with a kappa of 0.74. Appendiceal mural calcifications were identified on CT scans in 106 appendiceal neoplasm cases (32%) and in 1 control case (1%) (P = 0.0001). In the appendiceal neoplasm subgroup, the presence of radiographic calcifications was associated with mucinous histology (35% vs 17%; P = 0.006; odds ratio [OR], 0.38; 95% confidence interval [CI], 0.18-0.78) and with well-differentiated histologic grade (40% vs 24%; P = 0.002; OR, 0.47; 95% CI, 0.29-0.76). The findings showed a sensitivity of 31.9% (95% CI, 26.9-37.2%), a specificity of 99.3% (95% CI, 96-100%), a PPV of 99.1% (95% CI, 94.9-100%), and an NPV of 37.4% (95% CI, 32.4-42.6%). CONCLUSION This case-control study showed that appendiceal mural calcifications detected on CT are associated with underlying appendiceal epithelial neoplasms and that the identification of incidental mural appendiceal calcifications may have an impact on decisions regarding surgical intervention.
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Affiliation(s)
- Tara L Sagebiel
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Amr Mohamed
- Wayne State University, Karmanos Cancer Institute, Detroit, MI, USA
| | - Aurelio Matamoros
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Melissa W Taggart
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Kanwal P Raghav
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gary N Mann
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul F Mansfield
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cathy Eng
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard E Royal
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wai Chin Foo
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joe E Ensor
- Houston Methodist Research Institute, Houston, TX, USA
| | - Keith F Fournier
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael J Overman
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Benoit MF, Kosnik CL, Kent EA. Appendectomy at Gynecologic Surgery: Feasibility and Outcomes in a High Risk Gynecologic Population—Revealing a High Rate of Incidental Appendiceal Cancer. J Gynecol Surg 2017. [DOI: 10.1089/gyn.2016.0123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Michelle F. Benoit
- Division of Gynecologic Oncology, Group Health/Kaiser Permanente, Bellevue, WA
| | - Callan L. Kosnik
- Division of Gynecologic Oncology, Group Health/Kaiser Permanente, Bellevue, WA
| | - Emma A. Kent
- Division of Gynecologic Oncology, Group Health/Kaiser Permanente, Bellevue, WA
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43
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Sippola S, Grönroos J, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Salminen P. Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial. Br J Surg 2017; 104:1355-1361. [PMID: 28677879 DOI: 10.1002/bjs.10575] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 02/14/2017] [Accepted: 03/28/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND An increasing amount of evidence supports antibiotic therapy for treating uncomplicated acute appendicitis. The objective of this study was to compare the costs of antibiotics alone versus appendicectomy in treating uncomplicated acute appendicitis within the randomized controlled APPAC (APPendicitis ACuta) trial. METHODS The APPAC multicentre, non-inferiority RCT was conducted on patients with CT-confirmed uncomplicated acute appendicitis. Patients were assigned randomly to appendicectomy or antibiotic treatment. All costs were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis during the 1-year follow-up. The cost estimates were based on cost levels for the year 2012. RESULTS Some 273 patients were assigned to the appendicectomy group and 257 to antibiotic treatment. Most patients randomized to antibiotic treatment did not require appendicectomy during the 1-year follow-up. In the operative group, overall societal costs (€5989·2, 95 per cent c.i. 5787·3 to 6191·1) were 1·6 times higher (€2244·8, 1940·5 to 2549·1) than those in the antibiotic group (€3744·4, 3514·6 to 3974·2). In both groups, productivity losses represented a slightly higher proportion of overall societal costs than all treatment costs together, with diagnostics and medicines having a minor role. Those in the operative group were prescribed significantly more sick leave than those in the antibiotic group (mean(s.d.) 17·0(8·3) (95 per cent c.i. 16·0 to 18·0) versus 9·2(6·9) (8·3 to 10·0) days respectively; P < 0·001). When the age and sex of the patient as well as the hospital were controlled for simultaneously, the operative treatment generated significantly more costs in all models. CONCLUSION Patients receiving antibiotic therapy for uncomplicated appendicitis incurred lower costs than those who had surgery.
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Affiliation(s)
- S Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - J Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - R Tuominen
- Department of Public Health, University of Turku, Turku, Finland.,Primary Health Care Unit, Hospital District of Southwest Finland, Turku, Finland.,University of Namibia, Windhoek, Namibia
| | - H Paajanen
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland.,Institute of Clinical Medicine, University of Eastern Finland, Joensuu, Finland
| | - T Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - P Nordström
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - M Aarnio
- Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - T Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland.,Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - S Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - P Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
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Abstract
BACKGROUND As nonoperative management of appendicitis gains popularity, vigilance for appendiceal tumors becomes increasingly important. We hypothesized that, among patients presenting with acute appendicitis, those with advanced age, multiple comorbidities, atypical presentation, and complicated appendicitis would be more likely to have underlying appendiceal tumors. METHODS We performed a 4-year retrospective cohort analysis of 677 consecutive adult patients who underwent appendectomy for appendicitis at our tertiary care center. Patients with an appendiceal tumor on their final pathology report were compared to patients with no tumor. Conditions present on admission were used to create a multivariate logistic regression model to predict appendiceal tumor. Risk factors were reported as odds ratio (OR) [95% CI]. Model strength was assessed by area under the receiver operating characteristic curve. RESULTS Seventeen patients (2.5%) had an appendiceal tumor. Within this group. 14 underwent immediate appendectomy, two initially had nonoperative management but failed to improve on antibiotics and underwent appendectomy during the initial admission, and one had successful nonoperative management and elective appendectomy 19 days after discharge. Four variables contributed to the multivariate model to predict the presence appendiceal tumor: age ≥ 50 (OR 3.6 [1.1-11.4]), outpatient steroid/immunosuppressant use (OR 12.1 [2.0-72.5]), the absence of migratory right lower quadrant pain (OR 4.7 [1.2-18.1]), and the appearance of a phlegmon on CT scan (OR 7.0 [1.6-30.2]); model area under the receiver operating characteristic curve: 0.860 [0.705-0.969]. CONCLUSION For patients presenting with acute appendicitis, conditions present on admission may predict underlying appendiceal tumor. Patients with advanced age, multiple comorbidities, atypical presentation, and complicated appendicitis should be considered for appendectomy during the index admission or at earliest convenience if nonoperative management is necessary. LEVEL OF EVIDENCE Prognostic study, level III.
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45
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Affiliation(s)
- Sandra Werner
- Case Western Reserve University School of Medicine, Cleveland, OH; Department of Emergency Medicine, MetroHealth Medical Center, Cleveland, OH.
| | - Andy Grock
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine, LAC + USC, Los Angeles, CA
| | - Jessica Mason
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, CA
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Rosen DR, Inaba K, Oh PJ, Gutierrez AC, Strumwasser AM, Biswas S, Cala M, Ault GT. Outpatient Laparoscopic Appendectomy: Feasible in a Public County Hospital? J Am Coll Surg 2017; 224:S1072-7515(17)30181-3. [PMID: 28433247 DOI: 10.1016/j.jamcollsurg.2017.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Outpatient laparoscopic appendectomy is being used increasingly as a treatment option for acute, uncomplicated appendicitis. This was a prospective validation study in a large, urban, public safety-net hospital. STUDY DESIGN From 2014 to 2016, all patients undergoing laparoscopic appendectomy for acute, uncomplicated appendicitis were enrolled in a prospective observational trial. Standard baseline perioperative practice (control group) was documented for 1 year. An outpatient appendectomy protocol was then introduced. Inclusion criteria required intraoperative confirmation of uncomplicated appendicitis and strict discharge criteria, including physician assessment before discharge. Data collection then continued for 1 year (outpatient group). The outcomes measures examined included complications, length of stay, nursing transitions, emergency department visits, readmissions, and patient satisfaction. RESULTS The study enrolled 351 patients (178 control, 173 outpatient). Of the 173 candidates for outpatient appendectomy, 113 went home. Reasons for admission included surgeon discretion due to intraoperative findings/medical comorbidities and lack of transportation home. The outpatient group had shorter operative time (69 vs 83 minutes; p < 0.001), longer time in recovery (242 vs 141 minutes; p < 0.001), fewer nursing transitions (4 vs 5; p < 0.001), and shorter postoperative length of stay (9 vs 19 hours; p < 0.001). There was no difference in complications, emergency department visits, or readmissions. In the outpatient group, none of the patients sent home from recovery had postoperative complications or required readmission. Satisfaction surveys revealed no change in satisfaction with either protocol. CONCLUSIONS Outpatient appendectomy is safe in a public hospital and results in shorter hospital length of stay and decreased healthcare costs. Strict criteria for discharge are important to identify patients who should be admitted for observation.
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Affiliation(s)
- David R Rosen
- Division of Colon and Rectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Kenji Inaba
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Paul J Oh
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Adam C Gutierrez
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Aaron M Strumwasser
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Subarna Biswas
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Melody Cala
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Glenn T Ault
- Division of Colon and Rectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Tsai MC, Lin HC, Lee CZ. Diabetes increases the risk of an appendectomy in patients with antibiotic treatment of noncomplicated appendicitis. Am J Surg 2016; 214:24-28. [PMID: 27616688 DOI: 10.1016/j.amjsurg.2016.07.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/23/2016] [Accepted: 07/23/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND This retrospective cohort study examined whether diabetic patients have a higher risk for recurrent appendicitis during a 1-year follow-up period after successful antibiotic treatment for patients with acute uncomplicated appendicitis than nondiabetic patients using a population-based database. METHODS We included 541 appendicitis patients who received antibiotic treatment for acute appendicitis. We individually tracked each patient for a 1-year period to identify those who subsequently underwent an appendectomy during the follow-up period. RESULTS Cox proportional hazard regressions suggested that the adjusted hazard ratio of an appendectomy during the 1-year follow-up period was 1.75 for appendicitis patients with diabetes than appendicitis patients without diabetes. We found that among females, the adjusted hazard ratio of an appendectomy was 2.18 for acute appendicitis patients with diabetes than their counterparts without diabetes. However, we failed to observe this relationship in males. CONCLUSIONS We demonstrated a relationship between diabetes and a subsequent appendectomy in females who underwent antibiotic treatment for noncomplicated appendicitis.
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Affiliation(s)
- Ming-Chieh Tsai
- Division of Gastroenterology, Department of Internal Medicine, Hsinchu Cathay General Hospital, Taipei, Taiwan; School of Health Care Administration, Taipei Medical University Hospital, Taipei, Taiwan
| | - Herng-Ching Lin
- School of Health Care Administration, Taipei Medical University Hospital, Taipei, Taiwan; Sleep Research Center, Taipei Medical University, Taipei, Taiwan
| | - Cha-Ze Lee
- Division of Gastroenterology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan.
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Abstract
Acute appendicitis is the most common cause of emergent surgery in children. Historically, surgical dogma dictated emergent appendectomy due to concern for impending perforation. Recently, however, there has been a paradigm shift in both the understanding of its pathophysiology as well as its treatment to more nonoperative management. No longer is it considered a spectrum from uncomplicated appendicitis inevitably progressing to complicated appendicitis over time. Rather, uncomplicated and complicated appendicitis are now considered two distinct pathophysiologic entities. This change requires not only educating the patients and their families but also the general practitioners who will be managing treatment expectations and caring for patients long term. In this article, we review the pathophysiology of appendicitis, including the differentiation between uncomplicated and complicated appendicitis, as well as the new treatment paradigms. [Pediatr Ann. 2016;45(7):e235-e240.].
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Davis CR, Trevatt A, Dixit A, Datta V. Systematic review of clinical outcomes after prophylactic surgery. Ann R Coll Surg Engl 2016; 98:353-7. [PMID: 27023639 PMCID: PMC5209958 DOI: 10.1308/rcsann.2016.0089] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2015] [Indexed: 12/15/2022] Open
Abstract
Introduction Prophylactic appendicectomy is performed prior to military, polar and space expeditions to prevent acute appendicitis in the field. However, the risk-benefit ratio of prophylactic surgery is controversial. This study aimed to systematically review the evidence for prophylactic appendicectomy. It is supplemented by a clinical example of prophylactic surgery resulting in life-threatening complications. Methods A systematic review was performed using MEDLINE(®) and the Cochrane Central Register of Controlled Trials. Keyword variants of 'prophylaxis' and 'appendicectomy' were combined to identify potential papers for inclusion. Papers related to prophylactic appendicectomy risks and benefits were reviewed. Results Overall, 511 papers were identified, with 37 papers satisfying the inclusion criteria. Nine reported outcomes after incidental appendicectomy during concurrent surgical procedures. No papers focused explicitly on prophylactic appendicectomy in asymptomatic patients. The clinical example outlined acute obstruction secondary to adhesions from a prophylactic appendicectomy. Complications after elective appendicectomy versus the natural history of acute appendicitis in scenarios such as polar expeditions or covert operations suggest prophylactic appendicectomy may be appropriate prior to extreme situations. Nevertheless, the long-term risk of adhesion related complications render prophylactic appendicectomy feasible only when the short-term risk of acute appendicitis outweighs the long-term risks of surgery. Conclusions Prophylactic appendicectomy is rarely performed and not without risk. This is the first documented evidence of long-term complications following prophylactic appendicectomy. Surgery should be considered on an individual basis by balancing the risks of acute appendicitis in the field with the potential consequences of an otherwise unnecessary surgical procedure in a healthy patient.
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Affiliation(s)
- C R Davis
- Guy's and St Thomas' NHS Foundation Trust , UK
| | - Aej Trevatt
- Guy's and St Thomas' NHS Foundation Trust , UK
| | - A Dixit
- Guy's and St Thomas' NHS Foundation Trust , UK
| | - V Datta
- Guy's and St Thomas' NHS Foundation Trust , UK
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Abstract
Although most frequently presenting with lower abdominal pain, appendicitis, colitis, and diverticulitis can cause pain throughout the abdomen and can cause peritoneal and retroperitoneal symptoms. Evaluation and management of lower intestinal disease requires a nuanced approach by the emergency physician, sometimes requiring computed tomography, ultrasonography, MRI, layered imaging, shared decision making, serial examination, and/or close follow-up. Once a presumed or confirmed diagnosis is made, appropriate treatment is initiated, and may include surgery, antibiotics, and/or steroids. Appendicitis patients should be admitted. Diverticulitis and inflammatory bowel disease can frequently be managed on an outpatient basis, but may require admission and surgical consultation.
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Affiliation(s)
- David J Carlberg
- Department of Emergency Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Road, NW, G-CCC, Washington, DC 20007, USA.
| | - Stephen D Lee
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
| | - Jeffrey S Dubin
- Department of Emergency Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Road, NW, G-CCC, Washington, DC 20007, USA; Department of Emergency Medicine, MedStar Washington Hospital Center, 110 Irving Street, NW, Washington, DC 20010, USA
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