The impact of postoperative abscess formation in perforated appendicitis

Effect of intraoperative abdominal lavage versus suction alone on postoperative wound infection in patients with appendicitis: A meta-analysis

There is much controversy about the application of abdominal irrigation in the prevention of wound infection (WI) and intra-abdominal abscess (IAA) in the postoperative period. Therefore, we performed a meta-analysis of the effect of suctioning and lavage on appendectomy to assess the efficacy of either suctioning or lavage. Data were collected and estimated with RevMan 5.3 software. Based on our research, we found 563 publications in our database, and we eventually chose seven of them to analyse. The main results were IAA after the operation and WI. Inclusion criteria were clinical trials of an appendectomy with suctioning or lavage. In the end, seven trials were chosen to meet the eligibility criteria, and the majority were retrospective. The results of seven studies showed that there was no statistically significant difference between abdominal lavage and suctioning treatment for post-operative WI (OR, 1.82; 95% CI, 0.40, 2.61; p = 0.96); There was no statistically significant difference between the two groups in the risk of postoperative abdominal abscess after operation (OR, 1.16; 95% CI, 0.71, 1.89; p = 0.56). No evidence has been found that the use of abdominal lavage in the treatment of postoperative infectious complications after appendectomy is superior to aspiration.

Lack of Routine Postoperative Labs Not Associated With Complications in Pediatric Perforated Appendicitis

INTRODUCTION

Postoperative (postop) management of pediatric perforated appendicitis varies significantly, and postop intra-abdominal abscesses (IAA) remain a significant issue. Between 2019 and 2020, our standardized protocol included routine postop labs after an appendectomy for perforated appendicitis. However, given the lack of predictive utility of these routine labs, we discontinued this practice in 2021. We hypothesize that discontinuing routine postop labs will not be associated with an increase in complication rates after an appendectomy for pediatric perforated appendicitis.

METHODS

A single-institution, retrospective review of all pediatric appendectomies for perforated appendicitis from January 2019 to December 2021 was conducted at University Hospitals Rainbow Babies and Children's Hospital in Cleveland, Ohio. Data were collected on rate of complications (IAA development, re-admissions, bowel obstructions, superficial surgical site infections, intensive care unit transfers, Clostridium difficile infections, allergic reactions, and transfusions), postop imaging, postop interventions, and length of stay. Statistical analysis was completed using Fisher's exact test and Mann-Whitney U-test.

RESULTS

A total of 109 patients (2019-2020 n = 61, 2021 n = 48) were included in the study. All 61 patients from 2019 to 2020 had postop labs compared to only eight patients in 2021. There was no statistically significant difference between the two groups in overall complication rates, but there was a decrease in IAAs reported in 2021 (P = 0.03). There were no statistically significant differences in other complications, postop imaging usage, or postop interventions. The median length of stay was 4.5 d in 2021 compared to 6.0 d in 2019-2020 (P = 0.009).

CONCLUSIONS

Discontinuing routine postop labs is not associated with an increase in overall complications rates. Further studies are needed to determine whether routine postop labs can be safely removed in pediatric patients with perforated appendicitis, which would reduce patient discomfort and care costs.

A Magnetic Resonance Imaging Protocol for the Evaluation of Pediatric Postappendectomy Abscess: A Quality Improvement Project

INTRODUCTION

Computed tomography (CT) scans are often used when cross-sectional imaging is required for evaluation of postappendectomy abscess, exposing children to a source of ionizing radiation. Our aim was to decrease the use of CT scans in pediatric postappendectomy patients by 50% in 12 mo and to sustain those results for 1 y.

METHODS

A comprehensive magnetic resonance imaging protocol was introduced in 2018 at a tertiary children's hospital within a general health system to replace CT scans in suspected pediatric postappendectomy abscess. Diagnostic and clinical outcomes were compared preprotocol (2015-2017) and postprotocol (2018-2022) implementation using standard univariate statistics. P < 0.05 was considered significant. Quality improvement methodology was used to design and implement the protocol.

RESULTS

Sixty eight pediatric postappendectomy patients received cross-sectional imaging during the study period. Overall, CT scans were used exclusively (100%, n = 27) in the preimplementation period compared to 31.7% (n = 13) of cross-sectional imaging in the postimplementation period. However, in the first year of protocol implementation, CT scan use only decreased to 78% of cross-sectional studies performed. The majority of protocol deviations (54%) also occurred in this time period. With improved education and reinforcement, CT scan utilization decreased to approximately 24% of cross-sectional studies annually. Missed abscess rate, time to diagnosis, drainage procedure type, readmission, and reoperation were similar between preimplementation and postimplementation periods.

CONCLUSIONS

Implementation of a postappendectomy abscess magnetic resonance imaging protocol was associated with decreased CT utilization in the pediatric population, while maintaining comparable diagnostic evaluation and clinical outcomes. Adherence to quality improvement principles facilitated achieving goals and sustaining gains.

Povidone-iodine intra-abdominal irrigation versus no irrigation in pediatric perforated appendicitis: A secondary economic analysis of a Bayesian randomized controlled trial

BACKGROUND

A pilot randomized controlled trial (RCT) conducted in children (2-17 ​y) with perforated appendicitis demonstrated an 89% probability of reduced intra-abdominal abscess (IAA) rate with povidone-iodine (PVI) irrigation, compared with no irrigation (NI). We hypothesized that PVI also reduced 30-day hospital costs.

METHODS

We conducted a retrospective economic analysis of a pilot RCT. Hospital costs, inflated to 2019 U.S. dollars, were obtained for index admissions and 30-day emergency visits and readmissions. Cost differences between groups were assessed using frequentist and Bayesian generalized linear models.

RESULTS

We observed a 95% Bayesian probability that PVI reduced 30-day mean total hospital costs ($16,555 [PVI] versus $18,509 [NI]; Bayesian cost ratio: 0.90, 95% CrI, 0.78-1.03). The mean absolute difference per patient was $1,954 less with PVI (95% CI, -$4,288 to $379).

CONCLUSIONS

PVI likely reduced the IAA rate and 30-day hospital costs, suggesting the intervention is both clinically superior and cost saving.

Antibiotic treatment of post-appendectomy abscesses in children, regardless of size: a twelve years' experience

Intra-abdominal abscesses are a common issue after appendectomy. Antibiotics have shown efficacy in treating smaller abscesses, while larger ones have traditionally been treated with drainage. This study assesses the efficacy of antibiotics for post-appendectomy intra-abdominal abscess (PAA) in children regardless of size. Case-control study of children with PAA admitted at our hospital from 2010 to 2022. The efficacy of antibiotics was compared between abscesses less and more than 6 cm in diameter. The Institutional Review Board has approved this study. A total of 1766 appendectomies were performed from 2010 to 2022 with an incidence of PAA of 5% (n = 89): age 9.3 IQR 5.8, 63% male (n = 56). Sixty-seven patients presented with a ≤ 6 cm abscess (controls) and 22 children had a > 6 cm PAA (cases). Length of intravenous antibiotics were higher in cases (15 IQR 7 days) than controls (12 IQR 4 days), p = 0.003. The efficacy of antibiotics in controls was 97% whereas 86.4% in cases (p = 0.094), reoperation was needed in 2/67 controls and 3/22 cases, with no differences in complications or readmission. The length of stay was longer in cases (15 IQR 6 days) than controls (13 IQR 5 days), p = 0.042. Antibiotics seem a safe treatment for PAA in children regardless of the size. However, this approach is associated with a longer period of intravenous antibiotics and hospital stay, although not with a higher rate of therapeutic failure, complications or reoperations.

The Diagnostic Accuracy of Hyperbilirubinemia in Predicting Appendicitis and Appendiceal Perforation

Background Every diagnostic tool that may assist in the identification of appendicitis is of great importance to emergency general surgeons. While recent research has indicated that hyperbilirubinemia can serve as a valuable predictor of appendiceal perforation, these studies have not specifically examined the role of bilirubin as an indicator for acute appendicitis. This study aimed to assess the role of hyperbilirubinemia as a diagnostic factor in detecting appendicitis and appendiceal perforation. Methodology This single-center retrospective study involved 333 patients with acute appendicitis who underwent an emergency appendectomy at a model three hospital between January 2021 and December 2022. Statistical analysis was performed using STATA/SE 18.0 for Windows (StataCorp., College Station, TX, USA) to compare bilirubin levels, white blood cell count (WCC), and C-reactive protein (CRP) among normal appendices, non-perforated appendicitis, and perforated appendicitis. Results Among 333 patients, 60.66% were male, and 39.34% were female, with a male-to-female ratio of 1.54:1. The average hospital stay was 3.27 ± 3.02 days. Hyperbilirubinemia was observed in 25.53% (85 individuals). Among the 51 cases of perforated appendicitis, 70.59% had elevated bilirubin levels of above 20 μmol/L. Significantly more patients with appendiceal perforation had hyperbilirubinemia than non-perforated appendicitis (70.59% vs. 19.03%, p < 0.001). Bilirubin had higher specificity (94.29%) for detecting non-perforated appendicitis than normal appendices (odds ratio = 3.88), while WCC and CRP showed higher sensitivities. WCC had a sensitivity of 73.28% and a specificity of 42.86%, and CRP had a sensitivity of 76.53% and a specificity of 60.00%. When comparing perforated appendicitis with non-perforated appendicitis, bilirubin showed a specificity of 80.97% and an odds ratio of 10.21. The likelihood of a patient with hyperbilirubinemia having perforated appendicitis was more than 10 times higher than those without appendiceal perforation, suggesting it to be a potential indicator for appendiceal perforation. WCC showed a specificity of 26.72% and an odds ratio of 4.28, while CRP had a specificity of 23.48% and an odds ratio of 4.91. Conclusions The significant association between bilirubin levels and appendicitis highlights its potential as a valuable marker for predicting appendicitis and appendiceal perforation. The simplicity, cost-effectiveness, and diagnostic value of bilirubin assessment support its routine use in suspected cases of acute appendicitis.

Can magnetic resonance imaging replace computed tomography scans in the evaluation of pediatric post-appendectomy abscess?

BACKGROUND

Computed tomography scans have been used when cross-axial imaging is required to evaluate pediatric post-appendectomy abscesses. To reduce a source of radiation exposure, our institution converted to using contrast-enhanced magnetic resonance imaging to replace computed tomography scans in this clinical context. Our aim is to evaluate the performance of magnetic resonance imaging compared to computed tomography scans and associated clinical outcomes in this patient population.

METHODS

A contrast-enhanced comprehensive magnetic resonance imaging protocol was implemented to evaluate a post-appendectomy abscess in 2018. A retrospective chart review was performed from 2015 to 2022 for pediatric patients (<18 years old) with prior appendectomy and subsequent cross-sectional imaging to evaluate for an intraabdominal abscess. Patient characteristics and clinical parameters between the 2 modalities were abstracted and compared using standard univariate statistics.

RESULTS

There were a total of 72 post-appendectomy patients who received cross-axial imaging, which included 43 computed tomography scans and 29 magnetic resonance imaging during the study interval. Patient demographics were comparable between cohorts and rates of perforated appendicitis at the index operation (computed tomography: 79.1% vs magnetic resonance imaging: 86.2%). Missed abscess rate, abscess size, management technique, drainage culture results, readmission, and reoperation were similar between imaging modalities. Median request to scan time was longer for magnetic resonance imaging than computed tomography (191.5 vs 108 minutes, P = .04). The median duration of a comprehensive magnetic resonance imaging scan was 32 minutes (interquartile range 28-50.5 minutes).

CONCLUSION

Contrast-enhanced magnetic resonance imaging provides an alternative cross-sectional imaging modality to computed tomography scans to evaluate pediatric post-appendectomy abscesses.

Comparison between laparoscopic versus open appendectomy in morbid obese patients

Purpose

To evaluate the laparoscopic approach advantages for the management of acute appendicitis in morbidly obese patients.

Methods

A prospective study included all morbidly obese patients who had presented to the emergency department at Sohag University Hospitals and were diagnosed with acute appendicitis between the 1st of June 2022 and the 31st of January 2023. All those patients were invited to participate in the research by randomization. The authors informed patients and their first-degree relatives about both techniques, signed a consent form for participation in the study. The authors categorized them into two groups; laparoscopic approach (group I) and open approach (group II). Comparisons were based on operative time, intraoperative complications, length of hospital stay, postoperative complications, and time until return to normal daily activities.

Results

The study enrolled 64 patients: 33 had a laparoscopic appendectomy, and 31 had an open appendectomy. The groups were similar in terms of clinicopathologic characteristics. The operating time was significantly shorter for Group I patients than Group II (Group I, 49.09±16.21 min vs. Group II, 68.03±15.78 min; P value less than 0.05). Regarding the length of hospital stay, twenty-six patients (78.8%) were discharged within the 1st 24 h in the laparoscopic group versus 17 patients (54.8%) in the open group (P value 0.041). The time until return to the routine daily work was significantly shorter in the laparoscopic group (11.27±2.6 days) than in the open group (17.23±4.8 days) (P value less 0.05). Four postoperative complications were reported in the study population: wound complications (infection, seroma formation), residual abdominal abscess, paralytic ileus, and thromboembolic complications (Deep venous thrombosis and pulmonary embolism). Group II had a statistically significant higher complication rate (32.3%) than Group I (9.09%) (P value 0.007).

Conclusion

Laparoscopic appendectomy had superior clinical outcomes than an open appendectomy in morbidly obese patients. In addition to minimal invasiveness and better cosmetic results, it has a great advantage as a diagnostic and therapeutic tool in morbidly obese patients with suspected appendicitis. It is also a safe and feasible approach with a low rate of complications with a well-trained expert surgeon.

Perforated appendicitis: The solution to pollution is not dilution

BACKGROUND

Surgical dogma states that the "solution to pollution is dilution." We hypothesized that withholding irrigation during pediatric Single Incision Laparoscopic Surgery (SILS) appendectomies for perforated appendicitis would decrease postoperative abscess rate.

METHODS

From May 2011 to 5/2015, during SILS appendectomies, saline irrigation and suctioning was performed. From June 2015 to 8/2021, only suctioning was performed. The operations and peri-operative management were otherwise identical. We retrospectively reviewed 46 patients in the Irrigation (I) Group and 91 patients in the Non-Irrigation (NI) Group.

RESULTS

Abscess rate decreased from 19.6% in Group I to 9.9% in Group NI, but this did not reach statistical significance (p = 0.12). Operative duration was significantly longer in patients who developed postoperative abscesses in Group NI (odds ratio 1.67, p = 0.002) and overall (odds ratio 1.45, p = 0.0002).

CONCLUSIONS

Withholding irrigation during SILS appendectomies trended toward a decreased postoperative abscess rate. Increased operative times were associated with postoperative abscess formation.

Using Microbiology Culture in Pediatric Appendicitis to Risk Stratify Patients: A Cohort Study

Background: We sought to investigate the value of intra-operative microbiology samples in pediatric appendicitis. Proposed benefits include tailoring post-operative antimicrobial management, risk-stratifying patients, and reducing post-operative intra-abdominal abscess formation. Patients and Methods: All cases of appendicitis managed with appendicectomy in a single center were collected from January 2015 to August 2020. Intra-operative microbiology samples were taken routinely. Post-operative outcomes were analyzed with reference to culture and sensitivity results. Histologic findings were further categorized as normal, simple, or complex. Results: Six hundred seventy-eight children had appendicectomies, and 608 had both microbiology and histology samples taken. Intra-abdominal fluid collection and subsequent intervention rates were 22% and 9%, respectively. There were more collections in those with a culture positive result (p < 0.001), and those growing each of three recognized organisms, Escherichia coli (p < 0.001), Pseudomonas aeruginosa (p = 0.01), and Streptococcus anginosus group (p < 0.001). Intervention rate was higher in the culture-positive result group (p = 0.002) and the Streptococcus anginosus group (p < 0.001). Conclusions: This study shows an increased risk of developing a collection with the isolation of one of three key organisms (Escherichia coli, Pseudomonas aeruginosa, Streptococcus anginosus group). Sersoal swabs are an effective and practical method of gathering information on organisms. Microbiologic yield was correlated to the severity of appendicitis. Isolation of Streptococcus anginosus increases the incidence of collections to 50%. This is useful to empower surgeons to prognosticate patients' potential outcomes based on both intra-operative, and microbiologic findings, and is useful in counseling patients and managing expectations. A prolonged course of antibiotic agents or higher dose may mitigate this risk.

Delayed Surgery for Perforated Appendicitis is Feasible in Children Without Compromising the Outcome in Selected Cases

BACKGROUND AND AIM

The relationship between time to surgery and risk of postoperative complications and re-intervention has not been conclusively investigated in pediatric perforated appendicitis (PA). The aim of this study was to determine whether time to appendectomy (TTA) is a risk factor for postoperative complications and re-intervention in a cohort of children undergoing appendectomy for PA.

METHODS

A total of 254 children (age: 8.7 ± 3.7 years) undergoing appendectomy for PA were retrospectively evaluated and stratified into Group I-III according to the Clavien-Dindo classification for postoperative complications (Group I n = 218, 86%; Group II n = 7, 3%; Group III n = 29, 11%).

RESULTS

The TTA was comparable between all groups (group I: 8.8 ± 9.2 h; group II: 7.8 ± 5.3 h; group III: 9.5 ± 9.6 h; overall: 8.8 ± 9.1 h; p = 0.885). A C-reactive protein (CRP) value at admission of  ≥128.6 mg/l indicated a higher risk for developing Grade II complications with no need for re-intervention (OR: 3.963; 95% CI: 1.810-8.678; p = 0.001) and Grade III complications with the need for re-intervention (OR: 3.346; 95% CI: 1.456-7.690; p = 0.004). This risk was independent of the TTA (OR: 1.007; 95% CI: 0.980-1.035; p = 0.613).

CONCLUSIONS

Appendectomy can be delayed by an average time delay of about 9 h in children with PA without increasing the risk of postoperative complications and re-intervention, also in patients at high risk defined by the initial CRP level ≥ 128.6 mg/l. This data may support the correct risk-adjusted scheduling of surgical interventions in times of limited capacity.

Performance optimization of support vector machine with oppositional grasshopper optimization for acute appendicitis diagnosis

Preoperative differentiation of complicated and uncomplicated appendicitis is challenging. The research goal was to construct a new intelligent diagnostic rule that is accurate, fast, noninvasive, and cost-effective, distinguishing between complicated and uncomplicated appendicitis. Overall, 298 patients with acute appendicitis from the Wenzhou Central Hospital were recruited, and information on their demographic characteristics, clinical findings, and laboratory data was retrospectively reviewed and applied in this study. First, the most significant variables, including C-reactive protein (CRP), heart rate, body temperature, and neutrophils discriminating complicated from uncomplicated appendicitis, were identified using random forest analysis. Second, an improved grasshopper optimization algorithm-based support vector machine was used to construct the diagnostic model to discriminate complicated appendicitis (CAP) from uncomplicated appendicitis (UAP). The resultant optimal model can produce an average of 83.56% accuracy, 81.71% sensitivity, 85.33% specificity, and 0.6732 Matthews correlation coefficients. Based on existing routinely available markers, the proposed intelligent diagnosis model is highly reliable. Thus, the model can potentially be used to assist doctors in making correct clinical decisions.

Aspiration versus peritoneal lavage in appendicitis: a meta-analysis

BACKGROUND

Acute appendicitis is one of the most frequent abdominal surgical emergencies. Intra-abdominal abscess is a frequent post-operative complication. The aim of this meta-analysis was to compare peritoneal irrigation and suction versus suction only when performing appendectomy for complicated appendicitis.

METHODS

According to PRISMA guidelines, a systematic review was conducted and registered into the Prospero register (CRD42020186848). The risk of bias was defined to be from low to moderate.

RESULTS

Seventeen studies (9 RCTs and 8 CCTs) were selected, including 5315 patients. There was no statistical significance in post-operative intra-abdominal abscess in open (RR 1.27, 95% CI 0.75-2.15; I2 = 74%) and laparoscopic group (RR 1.51, 95% CI 0.73-3.13; I2 = 83%). No statistical significance in reoperation rate in open (RR 1.27, 95% CI 0.04-2.49; I2 = 18%) and laparoscopic group (RR 1.42, 95% CI 0.64-2.49; I2 = 18%). In both open and laparoscopic groups, operative time was lower in the suction group (RR 7.13, 95% CI 3.14-11.12); no statistical significance was found for hospital stay (MD - 0.39, 95% CI - 1.07 to 0.30; I2 = 91%) and the rate of wound infection (MD 1.16, 95% CI 0.56-2.38; I2 = 71%).

CONCLUSIONS

This systematic review has failed to demonstrate the statistical superiority of employing intra-operative peritoneal irrigation and suction over suction-only to reduce the rate of post-operative complications after appendectomy, but all the articles report clinical superiority in terms of post-operative abscess, wound infection and operative times in suction-only group.

Comparison of intra-abdominal abscess formation after laparoscopic and open appendectomy for complicated and uncomplicated appendicitis: a retrospective study

INTRODUCTION

Acute appendicitis (AA) is one of the most common causes of acute abdominal pain seen in emergency departments and appendectomy has been the preferred treatment of this disease for decades. Postoperative intra-abdominal abscess (PIAA) complicates 3% to 25% of appendectomies and the risk is highest following complicated appendicitis. However, the risk for intra-abdominal abscess formation after appendectomy is still a matter of debate.

AIM

To evaluate PIAA formation after open appendectomy (OA) and laparoscopic appendectomy (LA), in particular in complicated appendicitis.

MATERIAL AND METHODS

From January 2003 to December 2018, records of patients who underwent appendectomy with diagnosis of appendicitis were retrieved from a computer database for analysis.

RESULTS

During the study period, 1809 appendectomies were performed in our institution (939 LAs and 850 OAs). Twenty conversion cases were recorded. There was no difference between the incidences of PIAA (LA, 3.73% (35/939) and OA, 3.41% (29/850); p > 0.05). The incidence of PIAA in those with complicated appendicitis was: LA, 11/212 (5.19%) vs. OA 14/198 (7.07%); p > 0.05.

CONCLUSIONS

This retrospective study shows that the technique of appendectomy does not appear to affect the incidence of IAAs either in uncomplicated or in complicated appendicitis. However, laparoscopic appendectomy has the advantages of laparoscopic procedures, such as lower hospital stay and earlier return to activities, and should therefore be preferred for acute appendicitis.

Benefits and Reduced Hospital Costs of Direct Surgery in Perforated Appendicitis With Abscess Cost-effectiveness Analysis of Treatment Complicated Appendicitis

PURPOSE

Elective interval appendectomy (IA) after percutaneous catheter drainage (PCD) is traditionally advocated for perforated appendicitis with an abscess. However, this is not the only way to manage these patients when we consider the cost-effectiveness of treatment. This study compared the outcomes and cost-effectiveness of patients who underwent IA and those who underwent direct surgery.

MATERIALS AND METHODS

A retrospective analysis of 79 patients who were diagnosed with perforated appendicitis with abscess was conducted. We compared the hospital course, outcomes, and total medical costs between the 2 groups.

RESULTS

Forty-three patients underwent PCD insertion for the management of appendiceal abscess (IA group), and 36 underwent appendectomy (DS group). There was no significant difference in abscess size (5.67 vs. 5.35 cm, P=0.15), appendectomy method (laparoscopic/open 39/4 vs. 37/5, P=0.523), or complications (7 vs. 6 cases, P=0.963) between the 2 groups. The operation time was longer in the DS group (83.8 vs. 112.7 min, P<0.001). However, length of hospitalization (15.4 vs. 7.7 d, P<0.001) and total hospital cost (US$2090.47 vs. US$3402.22, P<0.001) was greater in the IA group.

CONCLUSION

Direct surgery without PCD insertion in perforated appendicitis accompanied by abscess is more cost-effective and reduces the total length of hospitalization compared with the traditional IA.

Irrigation during laparoscopic appendectomy for complicated appendicitis increases the operative time and reoperation rate: a meta-analysis of randomized clinical trials

This meta-analysis of randomized clinical trials (RCT) aimed to compare peritoneal irrigation followed by suction with aspiration only during laparoscopic surgery for complicated appendicitis (LA). PRISMA guidelines with the random-effects model were adopted using Review Manager Version 5.3 for pooled estimates. We retained six eligible RCT published between 2012 and 2019. They involved a total of 1019 patients (541 patients in the aspiration group and 478 patients in the irrigation group). Aspiration only during LA is associated with shorter operative time (MD = 8.50 min, 95% CI [- 12.97 to - 4.02], p = 0.0002) and lower reoperation rate (OR = 0.37 95% CI [0.14-0.96], p = 0.04). There was no difference between aspiration group and irrigation group in terms of Intraperitoneal abscess (IPA) (OR = 0.99 95% CI [0.54-1.81], p = 0.95), morbidity rate (OR = 1.14 95% CI [0.44-2.98], p = 0.79), wound infection (OR = 0.94 95% CI [0.20-4.40], p = 0.94), and hospital stay (MD = 0.65 day, 95% CI [- 0.52 to 1.82], p = 0.27). Irrigation during LA prevents post-appendectomy IPA in neither adults nor pediatric patients. However, it lengthens the operative time and involves a higher reoperation rate.

Post-operative abscess in inguinal hernial sac-case report of an unusual complication of perforated acute appendicitis

Acute appendicitis is a common condition, with a lifetime risk of 7–8%. Common complications of surgical management include bleeding, bowel injury, residual abscess formation and post-operative ileus. This is a rare case of a 50-year-old male who underwent laparoscopic converted to open appendicectomy for perforated acute appendicitis, with a complication of post-operative fluid collection that extended into the right inguinal hernia sac.

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

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

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

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

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

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

Effects of Sequence of Irrigation, Suction, and Extraction in Cases of Acute Purulent Appendicitis or Gangrenous Perforated Appendicitis After Laparoscopic Appendectomy

Objective: To evaluate rates of postoperative infection in patients with acute purulent appendicitis or gangrenous perforated appendicitis after laparoscopic appendectomy (LA). Methods: In this retrospective cohort study the medical records of patients who had undergone LA for acute appendicitis at Yijishan Hospital of Wannan Medical College between January 2015 and December 2019 were reviewed. The patients were divided into 2 groups based on the sequential order in which peritoneal irrigation, suction, and extraction of appendix had been performed. In Group 1 peritoneal irrigation and suction had been performed before extraction of the appendix, and in Group 2 they had been performed after extraction of the appendix. Demographic details, surgery duration, time to first flatus, length of hospital stay, total hospitalization expenses, and postoperative complications were analyzed. Results: The final study sample included 571 patients, 116 (20.3%) in Group 1 and 455 (79.7%) in Group 2. There were no significant differences in demographic characteristics, preoperative white blood cell counts, surgery durations, lengths of hospital stay, or total hospitalization expenses between the 2 groups (P > .05). Time to first flatus was significantly shorter in Group 1 (2.1 ± 0.5 days) than in Group 2 (2.3 ± 0.6) (P = .016), and the incidence of surgical wound infection was lower in Group 1 (6.9%) than in Group 2 (14.1%) (P = .038). There were no significant differences in the rates of intra-abdominal abscess, small bowel obstruction, or readmission within 30 days between the 2 groups (P > .05). Conclusion: Patients with acute purulent appendicitis or gangrenous perforated appendicitis are at high risk of surgical wound infection. Peritoneal irrigation and suction before appendix extraction may reduce the incidence of postoperative wound infection.

Pediatric Appendectomy: Optimal Surgical Timing and Risk Assessment

Appendicitis is one of the most common pediatric surgical problems. In the older surgical paradigm, appendectomy was considered to be an emergent procedure; however, with changes to resident work hours and other economic factors, the operation has evolved into an urgent and deliberately planned intervention. This paradigm shift in care has not necessarily seen universal buy-in by all stakeholders. Skeptics worry about the higher incidence of complications, particularly intra-abdominal abscess (IAA), associated with the delay to appendectomy with this strategy. Development of IAA after pediatric appendectomy greatly burdens the healthcare system, incapacitates patients, and limits family functionality. The risk factors that influence the development of IAA after appendectomy were evaluated in 220 children admitted to a large urban teaching hospital over a recent 1.5-year period. Preoperative risk factors included in the study were age, sex, weight, ethnicity, duration and nature of symptoms, white cell count, and ultrasound or computed tomography scan findings (appendicolith, peritoneal fluid, abscess, phlegmon), failed nonoperative management, antibiotics administered, and timing. Intraoperative factors included were timing of appendectomy, surgical and pathological findings of perforation, open or laparoscopic procedure, and use of staple or Endoloop to ligate the appendix. Postoperative factors included were duration and type of antibiotic therapy. There were 94 (43%) perforated and 126 (57%) nonperforated appendicitis during the study period. The incidence of postoperative IAA was 4.5 per cent (nine of 220). Children operated on after overnight antibiotics and resuscitation had a significantly lower risk of IAA as compared with children managed by other strategies ( P < 0.0003). Of the preoperative factors, only the presence of a fever in the emergency department ( P < 0.001) and identification of complicated appendicitis on imaging ( P < 0.0001) were significant risk factors for postoperative abscess development. Perforated appendicitis carries a higher risk of development of IAA that is not reduced by an emergent operative or delayed nonoperative management strategy. The timing of appendectomy appears to be an extremely important factor in reducing the incidence of IAA after all presentations of appendectomy. The role of resuscitation and antibiotics in limiting the effects of the inflammatory cascade and development of laboratory markers that accurately measure the latter need to be the focus of further research in this field.

Intra-abdominal Abscess After Appendectomy-Are Drains Necessary in All Patients?

BACKGROUND

Research has shown that patients who develop a postoperative intra-abdominal abscess (PIAA) after appendectomy have a greater number of health care visits with drain placement. Our institution developed an algorithm to limit drain placement for only abscesses with a size >20 cm². We sought to determine the adherence to and effectiveness of this algorithm.

METHODS

This prospective observational study included patients aged 2-18 y old who developed a PIAA from September 2017 to June 2019. Outcomes were compared between patients with a small or large abscess. Analysis was performed in STATA; P < 0.05 was significant.

RESULTS

Thirty patients were included. The median age was 10.6 y (7, 11.7); 60% were men, and 60% were Caucasian. The median duration of symptoms before diagnosis of appendicitis was 3 d (2, 6). Thirteen patients (43%) were diagnosed with a PIAA while still inpatient, and 17 (57%) were readmitted at a later date. After algorithm implementation, 95% (n = 19) of patients with a large abscess had aspiration ± drain placement, whereas 30% (n = 3) with a small abscess underwent drainage. Length of stay after abscess diagnosis, total duration of antibiotics, and number of health care visits were the same between groups. One patient with a small abscess required reoperation for an obstruction, whereas one patient with a large abscess that was drained was readmitted for a recurrent abscess.

CONCLUSIONS

Small PIAA can be successfully managed without intervention. Our proposed algorithm can assist in determining which patients can be treated with antibiotics alone.

Irrigation Versus Suction Alone During Laparoscopic Appendectomy for Uncomplicated Acute Appendicitis

Purpose

To compare the surgical outcomes of peritoneal irrigation versus suction alone during laparoscopic appendectomy and to identify the risk factors of surgical site infection in patients with uncomplicated acute appendicitis.

Methods

Data from patients with uncomplicated acute appendicitis between January 2014 and March 2016 were reviewed. We compared the irrigation and suction alone groups with regard to the following parameters: postoperative complication incidence rate, length of hospital stay, operation time, time to flatus, time to diet commencement, and duration of postoperative antibiotic.

Results

A total of 578 patients underwent laparoscopic appendectomy for uncomplicated acute appendicitis. Twenty-five patients were excluded from the analysis because of need for drain insertion, loss to follow-up, simultaneous surgery for another indication, presence of an appendix tumor, or pregnancy. A total of 207 patients (37.4%) had undergone irrigation, and 346 patients (62.6%) received suction alone during laparoscopic appendectomy. The preoperative fever rate was significantly higher in the irrigation group than in the suction alone group. Operative time was also significantly longer in the irrigation group than in the suction alone group (53.8 ± 18.5 minutes vs. 57.8 ± 21.4 minutes, P = 0.027). The postoperative complication rate was higher in the irrigation group than in the suction alone group (4.5% vs. 12.6%, P = 0.001). Multiple logistic regression analysis showed that irrigation and preoperative fever were risk factors for surgical site infection after laparoscopic appendectomy for uncomplicated acute appendicitis.

Conclusion

There is no advantage to irrigating the peritoneal cavity over suction alone during laparoscopic appendectomy for uncomplicated acute appendicitis. Irrigation may actually prolong the operative time and therefore be detrimental.

Volume of Irrigation Does Not Affect Rate of Abscess in Perforated Appendicitis

Background: Although previous studies have evaluated whether use of irrigation decreases postoperative intraabdominal abscess (PO-IAA) formation, these studies treated irrigation as a dichotomous variable and concluded that no irrigation resulted in a decreased incidence of PO-IAA formation. However, a recent study found decreased incidence with small aliquots to a total volume of 6 L. We hypothesized that higher volumes of irrigation would result in a lower incidence of PO-IAA. Materials and Methods: A postoperative template was developed as a quality improvement initiative and included descriptors for complex appendicitis and volume of irrigation. Data were prospectively collected from February 2016 to December 2018. Patients with complex appendicitis (fibropurulent exudate, extraluminal fecalith, well-formed abscess, visible hole in the appendix) were identified and analyzed by using standard statistical analysis. Volume of irrigation was categorized for analysis. Results: Two thousand three hundred six appendicitis patients were identified; 408 had complex appendicitis (17.7%). Three hundred eighty-four patients with complex appendicitis had documented irrigation volumes. The overall incidence of PO-IAA was 13.8%. Irrigation was commonly used (92.7%). The median amount of irrigation was 1000 mL (500 mL, 2500 mL), but it ranged from none to 9000 mL. There was no overall difference in the volume of irrigation used between those who developed a PO-IAA and those who did not (P = .34). No specific intraoperative finding was associated with the development of PO-IAA. Increasing volume of irrigation did not lower PO-IAA incidence (P = .24). Conclusions: The volume of irrigation did not appear to affect the rate of PO-IAA formation. The use of irrigation should be left to the discretion of the operating surgeon.

Meta-analysis of studies comparing conservative treatment with antibiotics and appendectomy for acute appendicitis in the adult

BACKGROUND

Appendectomy is considered the first treatment choice for appendicitis. However, controversy exists since conservative therapy is associated with fewer complications than appendectomy for patients with acute appendicitis (AA). This meta-analysis aimed to compare the outcomes between conservative therapy and appendectomy in the management of adult AA.

METHODS

A literature search was performed to screen eligible clinical studies. Subgroup analyses of the uncomplicated population, complicated population and mixed population of randomized clinical trials were subsequently performed. Clinical outcomes included the overall effective rate of treatment, complication rate, relapse rate (reoperation rate) and overall length of stay (LOS).

RESULTS

Eleven trials totalling 2751 patients (conservative = 1463, appendectomy = 1288) were analysed. Patients receiving conservative treatment had a lower overall effective rate (OR: 0.11 ~ 0.17) and complication rate (OR: 0.21 ~ 0.51). The conservative group had a higher reoperation rate (5.6, 95% CI: 3.1% ~ 10.2%) than the appendectomy group (OR: 9.58 ~ 14.29). Conservative treatment was associated with a shorter overall length of stay (0.47 day, 95% CI: 0.45 ~ 0.5 day) than appendectomy.

CONCLUSIONS

For both uncomplicated and complicated adult AA, non-operative management with antibiotics was associated with significantly fewer complications and a shorter length of stay but a lower effective rate and higher relapse rate.

Efficacy of oral antibiotics in children with post-operative abscess from perforated appendicitis

BACKGROUND

Post-operative intra-abdominal abscess (PIAA) is the most common complication after appendectomy for perforated appendicitis (PA). Typically, intravenous antibiotics by a peripherally inserted venous catheter are utilized to treat the abscess. We sought to evaluate the role of oral antibiotics in this population.

METHODS

This is a retrospective review conducted of children between January 2005 and September 2015 with a PIAA. Demographics, clinical course, complications, and follow-up were analyzed using descriptive statistics. Comparative analysis was performed on those who were treated with oral vs IV antibiotics after diagnosis of PIAA.

RESULTS

103 children were included. Days of symptoms prior to admission were 3.2 ± 2.3 days with a WBC of 17.9 ± 6.4. Median time to diagnosis of PIAA from appendectomy was 7 days (7, 10). Mean total length of stay was 10 ± 3.4 days. 42% were treated with oral antibiotics (n = 43) versus 58% IV antibiotics (n = 60) at the time of discharge. We found a significant increase in total length of hospital stay (9.1 vs 10.7, p = 0.02) and number of medical encounters required for treatment (3.4 vs 4.4, p ≤ 0.01) in the IV group.

CONCLUSIONS

PIAA treatment after appendectomy for PA can be treated with oral antibiotics with equivalent outcomes as IV antibiotic treatment, but with shorter length of hospitalizations and less medical encounters required.

Neutropthil-to-Lymphocyte Ratio as a Predictor of Postsurgical Intraabdominal Abscess in Children Operated for Acute Appendicitis

Aim of the study: Postoperative intra-abdominal abscess (PIAA) is a frequent and severe complication of acute appendicitis (AA) with peritonitis. The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory marker that has been related to the development of peritonitis; however, its diagnostic role in predicting PIAA has not been evaluated. This is the first study that analyzes the usefulness of NLR as a predictor of PIAA in children operated for AA. Material and Methods: Retrospective observational study in children operated for AA in our institution during 2017-2018. Patients aged under 5 years or with incomplete laboratory determinations at hospital admission (blood count, C-reactive protein, and fibrinogen) were excluded. Demographic and laboratory parameters and the development of PIAA were analyzed. NLR was calculated by dividing the absolute number of neutrophils by the absolute number of lymphocytes. By means of ROC curves, we determined the sensitivity and specificity of the different laboratory parameters to predict the development of PIAA. Results: A total of 388 patients aged 10.5 ± 2.9 year were included. Twenty (5.2%) developed PIAA. NLR presented an area under the curve (AUC) of 0.85, significantly higher than the determination of leukocytes (AUC 0.69, p < 0.001), neutrophils (AUC 0.74, p < 0.001), fibrinogen (AUC 0.68, p < 0.001) and C-reactive protein (AUC 0.73, p < 0.001). We estimated the optimal cut-off point of NLR > 10.5, with a sensitivity of 85% and a specificity of 75.2%. Conclusions: NLR is the laboratory parameter with the highest sensitivity and specificity for predicting the development of PIAA in children operated for AA. It can be useful as a predictor of worse postoperative course.

Post-appendectomy pelvic abscess with extended-spectrum beta-lactamase producing Escherichia coli: A case report and review of literature

BACKGROUND

Appendicitis, the inflammation of the appendix, is the most common abdominal surgical emergency requiring expedient surgical intervention. Extended-spectrum beta-lactamases (ESBLs) are bacterial enzymes that catalyse the degradation of the beta-lactam ring of penicillins and cephalosporins (but without carbapenemase activity), leading to resistance of these bacteria to beta-lactam antibiotics. Recent increases in incidence of ESBL-producing bacteria have caused alarm worldwide. Proportion estimates of ESBL-Enterobacteriaceae hover around 46% in China, 42% in East Africa, 12% in Germany, and 8% in the United States.

CASE SUMMARY

The impact of ESBL-producing bacteria on appendiceal abscesses and consequent pelvic abscesses are yet to be examined in depth. A literature review using the search words “appendiceal abscesses” and “ESBL Escherichia coli (E. coli)” revealed very few cases involving ESBL E. coli in any capacity in the context of appendiceal abscesses. This report describes the clinical aspects of a patient with appendicitis who developed a postoperative pelvic abscess infected with ESBL-producing E. coli. In this report, we discuss the risk factors for contracting ESBL E. coli infection in appendicitis and post-appendectomy pelvis abscesses. We also discuss our management approach for post-appendectomy ESBL E. coli pelvic abscesses, including drainage, pathogen identification, and pathogen characterisation. When ESBL E. coli is confirmed, carbapenem antibiotics should be promptly administered, as was done efficaciously with this patient. Our report is the first one in a developed country involving ESBL E. coli related surgical complications in association with a routine laparoscopic appendectomy.

CONCLUSION

Our report is the first involving ESBL E. coli and appendiceal abscesses, and that too consequent to laparoscopic appendectomy.

Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial

PURPOSE

To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis.

METHODS

This was a randomized controlled trial of patients aged 4-17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I-contained perforation, II-localized contamination to right gutter/pelvis, and III-diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin-clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared.

RESULTS

Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3 ± 3.6 versus 10.1 ± 3.6, p < 0.05) with higher BMI (20.9 ± 5.8 versus 17.9 ± 3.5, p < 0.05). There were no differences in gender, comorbidities, or perforation grade (I-20.4% vs. 26.3%, II-36.4% vs. 34.2%, III-43.2% vs. 39.5%, all p > 0.05). Comparing IV to oral, there was no difference in length of stay (4.4 ± 1.5 versus 4.4 ± 2.0 days, p > 0.05), postoperative abscess rate (11.6% vs. 8.1%, p > 0.05), or readmission rate (14.0% vs. 16.2%, p > 0.05). Hospital and outpatient charges were higher in the IV group (p < 0.0001).

CONCLUSION

Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.

A Prospective Study on the Diagnostic Value of Hyperbilirubinemia as a Predictive Factor for Appendicular Perforation in Acute Appendicitis

Background

Appendicitis is one of the most common surgical emergency in general surgical practices. Early and prompt diagnosis is necessary to avoid life-threatening complications associated with it. The diagnosis is mainly clinically aided by imaging techniques. The physiological obstruction of the bile flow associated with appendicular pathology leads to hyperbilirubinemia, which can be used as a predictive factor of appendicular perforation.

Method

This prospective study was conducted in the department of general surgery in Madras Medical College and Rajiv Gandhi Government Hospital, Chennai, from January 2012 to November 2012. A total of 378 patients with the features of acute appendicitis or appendicular perforation admitted in the emergency surgical ward were included.

Results

Out of 378 of the study population, 18% had appendicular perforation and 82% had acute appendicitis. Out of 67 perforations, 60 patients have hyperbilirubinemia (90%) whereas out of 311 patients with appendicitis, only 89 (29%) of them had elevated bilirubin. Hyperbilirubinemia with a cutoff point of 0.9 mg% for appendicitis patients has a sensitivity of 89.6%, specificity of 71.4%, a positive predictive value of 27%, and a negative predictive value of 96.9%. Hyperbilirubinemia with a cutoff point of >1.3 mg% for appendicular perforation has a sensitivity of 80%, specificity of 89%, a positive predictive value of 93%, and a negative predictive value of 96%.

Conclusions

Hyperbilirubinemia with bilirubin levels more than 1.3 mg% are highly predictive of appendicular perforation and, hence, aid in prompt diagnosis. This can be combined with a clinical diagnosis and imaging for an accurate and precise diagnosis.

Should ambulatory appendectomy become the standard treatment for acute appendicitis?

Background

Appendectomy is increasingly performed as a 'short stay' or 'ambulatory' procedure, yet there is no consensus for selection of patients with acute appendicitis for ambulatory surgery (AS). We aimed to compare characteristics and outcomes of complicated and uncomplicated appendectomies performed in ambulatory vs. conventional settings, and to determine factors associated with unexpected re-consultations and re-hospitalizations.

Methods

The authors reviewed a consecutive series of 185 laparoscopic appendectomies. Whenever possible, patients were offered AS, defined as 'discharge on the same working day.' Multivariable regressions were performed to determine associations of unexpected re-consultations and re-hospitalizations with surgery type (ambulatory or conventional) and patient characteristics (age, gender, obesity, symptoms, appendicolith, perforations, appendix diameter, serologic results, American Society of Anesthesiologists score, and Saint-Antoine score).

Results

From the initial cohort, 117 patients (63.2%) were eligible for AS, of which 8 had peri- or post-operative contraindications. Therefore, 109 patients (58.9%) were operated by AS, with median length of stay 8.5 h (range, 3.3-20.5). Ambulatory cases had a lower incidence of complications (11.9%) than conventional cases (25.0%) (p = 0.029). Uni- and multi-variable regressions revealed that unexpected re-consultations were not significantly associated with any of the pre- or peri-operative variables but that unexpected re-hospitalizations were 4 times more likely for patients with appendicolith (OR, 4.32; p = 0.04).

Conclusions

Ambulatory surgery could be considered as a standard procedure for both complicated and uncomplicated acute appendicitis. Appendicolith was found to be an independent risk factor for unexpected re-hospitalization and should therefore trigger closer monitoring.

Optimal Timing of Postoperative Imaging for Complicated Appendicitis

PURPOSE

Approximately one quarter of children with complicated appendicitis develop postoperative abscess, leading to additional procedures and increased length of stay (LOS), but the optimal timing of postoperative imaging to detect abscess is unknown.

METHODS

The Pediatric Health Information System database was reviewed, and children who underwent laparoscopic appendectomy in 2013-2014 with postoperative LOS ≥5 days were included. Demographics, imaging, drainage procedures, LOS, and 30-day readmission were analyzed. Chi-squared analysis was performed.

RESULTS

A total of 21,985 patients underwent laparoscopic appendectomy and 3332 met inclusion criteria. A total of 1174 (35.2%) patients underwent postoperative imaging, among whom 38.4% underwent ultrasound and 75.0% underwent computed tomography scan. Timing of first imaging varied significantly between hospitals, ranging from 0% to 76% on postoperative day (POD) 5. Initial imaging was performed on POD 5, 6, and 7 in 19.7%, 31.3%, and 36.2%, respectively. Imaging on POD 5 compared with POD 7 was associated with shorter LOS (10.6 ± 5.7 versus 11.8 ± 4.4 days), but also lower rates of intervention (42.4% versus 50.8%), increased repeat imaging (10.8% versus 5.2%), and higher readmission rates (35.9% versus 28.2%) (P < .05).

CONCLUSION

Timing of postoperative imaging for complicated appendicitis is variable across hospitals. While earlier imaging was associated with a decreased LOS, these children also had lower rates of subsequent intervention coupled with higher rates of repeat imaging and readmission. These findings suggest that delaying imaging until at least POD 6 may maximize the diagnostic yield of imaging while decreasing radiation exposure and readmission. Prospective investigation should be undertaken to guide the development of standardized clinical practice guidelines for the management of perforated appendicitis.

Risk stratification in pediatric perforated appendicitis: Prospective correlation with outcomes and resource utilization

PURPOSE

Despite a wide spectrum of severity, perforated appendicitis in children is typically considered a single entity in outcomes studies. We performed a prospective cohort study to define a risk stratification system that correlates with outcomes and resource utilization.

METHODS

A prospective study was conducted of all children operated for perforated appendicitis between May 2015 and December 2016 at a tertiary free-standing university children's hospital. Surgical findings were classified into one of four grades of perforation: I. localized or contained perforation, II. Contained abscess with no generalized peritonitis, III. Generalized peritonitis with no dominant abscess, IV. Generalized peritonitis with one or more dominant abscesses. All patients were treated on a clinical pathway that involved all points of care from admission to final follow-up. Outcomes and resource utilization measures were analyzed using Fisher's exact test, Kruskal-Wallis test, One-way ANOVA, and logistic regression.

RESULTS

During the study period, 122 patients completed treatment, and 100% had documented follow-up at a median of 25days after operation. Grades of perforation were: I, 20.5%; II, 37.7%; III, 10.7%; IV, 31.1%. Postoperative abscesses occurred in 12 (9.8%) of patients, almost exclusively in Grade IV perforations. Hospital stay, duration of antibiotics, TPN utilization, and the incidence of postoperative imaging significantly increased with increasing grade of perforation.

CONCLUSION

Outcomes and resource utilization strongly correlate with increasing grade of perforated appendicitis. Postoperative abscesses, additional imaging, and additional invasive procedures occur disproportionately in patients who present with diffuse peritonitis and abscess formation. The current stratification allows risk-adjusted outcome reporting and appropriate assignment of resource burden.

LEVEL OF EVIDENCE

I (Prognosis Study).

Standardization of care for pediatric perforated appendicitis improves outcomes

BACKGROUND

The treatment of perforated appendicitis in children is characterized by significant variability in care, morbidity, resource utilization, and outcomes. We prospectively studied how minimization of care variability affects outcomes.

METHODS

A clinical pathway for perforated appendicitis, in use for three decades, was further standardized in May 2015 by initiation of a disease severity classification, refinement of discharge criteria, standardization of the operation, and establishment of criteria for use of postoperative total parenteral nutrition, imaging, and invasive procedures. Prospective evaluation of all children treated for 20months on the new fully standardized protocol was conducted and compared to a retrospective cohort treated over 58months prior to standardization. Differences between outcomes before and after standardization were analyzed using regression analysis techniques to adjust for disease severity.

RESULTS

Median follow-up time post discharge was 25 and 14days in the post- and prestandardization groups, respectively. Standardization significantly reduced postoperative abscess (9.8% vs. 17.4%, p=0.001) and hospital stay (p=0.002). Standardization reduced the odds of developing a postoperative abscess by four fold.

CONCLUSION

Minimizing variability of care at all points in the treatment of perforated appendicitis significantly improves outcomes.

TYPE OF STUDY

Prospective Cohort Study.

LEVEL OF EVIDENCE

Level II.

Rapid non-contrast magnetic resonance imaging for post appendectomy intra-abdominal abscess in children

BACKGROUND

Acute appendicitis, especially if perforated at presentation, is often complicated by postoperative abscess formation. The detection of a postoperative abscess relies primarily on imaging. This has traditionally been done with contrast-enhanced computed tomography. Non-contrast magnetic resonance imaging (MRI) has the potential to accurately detect intra-abdominal abscesses, especially with the use of diffusion-weighted imaging (DWI).

OBJECTIVE

To evaluate our single-center experience with a rapid non-contrast MRI protocol evaluating post-appendectomy abscesses in children with persistent postsurgical symptoms.

MATERIALS AND METHODS

In this retrospective, institutional review board-approved study, all patients underwent a clinically indicated non-contrast 1.5- or 3-Tesla abdomen/pelvis MRI consisting of single-shot fast spin echo, inversion recovery and DWI sequences. All MRI studies were reviewed by two blinded pediatric radiologists to identify the presence of a drainable fluid collection. Each fluid collection was further characterized as accessible or not accessible for percutaneous or transrectal drainage. Imaging findings were compared to clinical outcome.

RESULTS

Seven of the 15 patients had a clinically significant fluid collection, and 5 of these patients were treated with percutaneous drain placement or exploratory laparotomy. The other patients had a phlegmon or a clinically insignificant fluid collection and were discharged home within 48 h.

CONCLUSION

Rapid non-contrast MRI utilizing fluid-sensitive and DWI sequences can be used to identify drainable fluid collections in post-appendectomy patients. This protocol can be used to triage patients between conservative management vs. abscess drainage without oral/intravenous contrast or exposure to ionizing radiation.

Evaluation of the diagnostic value of serum level of total bilirubin in patients with suspected acute appendicitis

Introduction

Clinical diagnosis of acute appendicitis still remains a problem. Delays in diagnosis of acute appendicitis may cause perforation and septic peritonitis which result in increasing morbidity and mortality. The aim of this study was to determine the sensitivity, specificity and the diagnostic value of total serum bilirubin levels as a predictor of acute appendicitis.

Methods

In this cross-sectional study, patients who underwent appendectomy with the diagnosis of acute appendicitis from April 2012 to March 2013 at Emam Reza Hospital in Mashhad (Iran) were enrolled. Serum bilirubin-Total and Direct-, were measured. Then based on the final pathologic reports, patients were categorized into five groups of normal appendix, chronic inflammatory changes, acute appendicitis, gangrenous and/or necrotic changes, and perforated appendicitis. Independent sample t-test, ANOVA, and Chi-square test were used for data analysis by SPSS version 16.

Results

There were 174 patients studied, (117 male, 57 female) with a mean age of 27.15±0.7 years. All of the patients had rebound tenderness; 75.3% had nausea, 58.6% had anorexia and 21.3% had fever. The histological reports of all patients showed 76.4% acute appendicitis. Analyzing p-values for SGPT, SGOT, WBC was (p=0.903) and differential count was (p=0.959). The study showed no significant difference between the pathological groups. However, there were no significant differences in serum total bilirubin levels between the pathological groups. Total bilirubin showed sensitivity of 48% and specificity of 61% in the diagnosis of acute appendicitis. Total serum bilirubin more than 0.85 mg/dl was the cut-off value with the best performance for diagnosis of appendicitis.

Conclusion

Bilirubin levels are reliable, sensitive and specific to diagnosis and a prediction of complicated appendicitis.

Pre-operative CT predictors associated with 30-day adverse events in patients with appendiceal inflammatory masses who underwent immediate appendectomies

PURPOSE

To retrospectively evaluate pre-operative CT predictors that are associated with 30-day adverse events in patients who underwent immediate appendectomies for appendiceal inflammatory masses.

METHODS

This retrospective study was approved by our institutional review board, and the requirement for informed consent was waived. One hundred forty-four consecutive patients who underwent immediate appendectomies and were diagnosed with appendiceal inflammatory masses by pre-operative CT from January 2005 to December 2013 at a tertiary hospital were included. The main outcome measure was 30-day adverse events. Patient demographics and data for inflammatory markers including leukocyte counts, segmented neutrophils, and C-reactive protein levels were collected by a single radiologist. Pre- and post-operative CT findings were evaluated for features of appendiceal inflammatory masses, associated findings, and post-operative adverse events by two radiologists in a blinded fashion with consensus to assess surgical and pathologic results, post-operative outcomes, and original CT interpretations. Appendiceal inflammatory masses were defined as complicated appendicitis with a phlegmon or an abscess that was identified on pre-operative CT exam. Factors associated with 30-day adverse events were assessed using logistic regression analysis.

RESULTS

A total of 22 (15%) of the 144 patients (mean age [±SD] 44.6 ± 22.0 years, range 3-97 years) experienced 30-day adverse events: ten intra-abdominal abscesses, three wound infections, two cases of peritonitis, two small bowel obstructions, two intra-abdominal abscesses with peritonitis, one intra-abdominal abscess with wound infection, one intra-abdominal abscess with small bowel obstruction, and one case of peritonitis with small bowel obstruction. In univariate analysis, the presence of appendicolith (odds ratio [OR] 2.49, p = 0.048) and high-grade obstruction (OR 3.79; p = 0.01) were associated with adverse events. High-grade obstruction (adjusted OR 3.05; p = 0.04) was the only independent pre-operative predictor associated with 30-day adverse events in patients with appendiceal inflammatory masses.

CONCLUSIONS

High-grade obstruction was an independent pre-operative CT predictor associated with 30-day adverse events in patients who underwent immediate appendectomies for appendiceal inflammatory masses.

Irrigation versus suction alone during laparoscopic appendectomy; A randomized controlled equivalence trial

INTRODUCTION

The objective of this study was to compare operative peritoneal irrigation versus suction alone during laparoscopic appendectomy in adult patients; our hypothesis was that the two methods are equivalent in terms of rate of post-operative intra-abdominal abscess. There has been only one prospective, randomized, superiority trial in children, that showed non-significant difference in the rate of intra-abdominal abscess comparing irrigation to suction alone during laparoscopic appendectomy for perforated appendicitis. Non-significant difference in a superiority trial does not imply equivalence.

METHODS

This was a single-institution, prospective, randomized controlled equivalence study based on a null-hypothesis of non-equivalence between irrigation and suction alone. Adult patients with intra-operative findings of an acutely inflamed appendix, with suppuration or perforation localized to the right iliac fossa, paracolic gutter or pelvis were randomized to irrigation or suction alone. The primary endpoint was the rate of intra-abdominal abscess. An unconditional exact test of equivalence was used to test the null-hypothesis.

RESULTS

Eighty-one patients were included for analysis. Two (5%) of 40 patients in the irrigation group and two (4.9%) of 41 in the suction-only group developed postoperative intra-abdominal abscess. The 95% confidence interval for the difference between the two groups was -0.1200 to 0.1244, captured within the pre-defined δ limits (-0.15, 0.15). With reference to the rate of intra-abdominal abscess, equivalence was demonstrated between irrigation and suction-only techniques.

CONCLUSIONS

In patients with suppurative or perforated appendicitis, the rate of intra-abdominal abscess is equivalent between groups treated with peritoneal irrigation and suction alone.

Predicting Postoperative Complications After Pediatric Perforated Appendicitis

PURPOSE

Assessment of risk factors for postoperative complications following surgical treatment of pediatric perforated appendicitis (PA) is necessary to identify those patients in need of closer monitoring. In this study, we have investigated the impact of different risk factors on the occurrence of complications after an appendectomy in children with PA.

MATERIAL AND METHODS

The study was a retrospective, single-centre analysis of all pediatric PA conducted over a 10-year period. Preoperative clinical and laboratory results, intraoperative findings, and postoperative complications were analyzed. Risk factors were defined and a risk score was determined for postoperative complications and reinterventions.

RESULTS

Surgical treatment for appendicitis was performed in 840 pediatric patients during the observation period. 163 of the included patients were diagnosed with PA (mean age 8.9 ± 3.6 years). 19 (11.7%) patients developed postoperative complications, 17 (10.4%) of which required complication-related intervention. We identified five predictors of postoperative complications: the C-related protein value at admission, purulent peritonitis, open appendectomy (primary, secondary, or converted), placement of an abdominal drain, and administration of antibiotics not compliant to results from the subsequent antibiogram. The determined risk score was significantly higher in the complication group (p < .0001) and reintervention group (p < .001).

CONCLUSIONS

Postoperative complications following pediatric PA can be predicted using specific preoperative, intraoperative, and postoperative risk factors. In the high-risk group, an active prevention, detection, and intervention of any occurring complication is necessary and we present a new specific pediatric risk score to define patients at risk for complications.

Differentiation of early perforated from nonperforated appendicitis: MDCT findings, MDCT diagnostic performance, and clinical outcome

To determine the CT findings and assess their diagnostic performance in differentiating early perforated appendicitis from nonperforated appendicitis, and to compare therapeutic approaches and clinical outcomes between two types of appendicitis. Our retrospective study was approved by our institutional review board and informed consent was waived. From July 2012 to July 2013, 339 patients [mean age 40.8 years; age range 19-80 years; 183 male (mean age 40.5 years; age range 19-79 years) and 156 female (mean age 41.2 years; age range 19-80 years)] who underwent appendectomy with preoperative CT examination for suspected acute appendicitis were included, with exclusion of 37 patients with specific CT findings for advanced perforated appendicitis. And they were categorized into nonperforated and early perforated appendicitis groups according to surgical and pathologic reports. The following CT findings were evaluated by two radiologists blinded to pathologic and surgical findings: transverse diameter of the appendix, thickness of the appendiceal wall, the depth of intraluminal appendiceal fluid, appendiceal wall enhancement, presence or absence of focal defect in the appendiceal wall, intraluminal appendiceal air, appendicolith/fecalith, periappendiceal changes, cecal wall thickening, and free fluid. The type of surgical procedures, performance of surgical drainage, and the length of hospital stay were recorded. Univariate and multivariate logistic regression analysis were used to determine the CT findings for differentiating early perforated appendicitis from nonperforated appendicitis, a total of 75 (22%) of the 339 patients was diagnosed with early perforated appendicitis. Focal wall defect [adjusted odds ratio (aOR), 23.40; p < 0.001], circumferential periappendiceal changes (aOR, 5.63; p < 0.001), appendicoliths/fecaliths (aOR, 2.47; p = 0.015), and transverse diameter of the appendix (aOR, 1.22; p = 0.003) were independently differentiating variables for early perforated appendicitis. The transverse diameter of the appendix (≥11 mm) had the highest sensitivity (62.7%) and focal wall defect in the appendiceal wall showed the highest specificity (98.8%). The prevalence of surgical drainage was higher (p = 0.001) and the mean hospital stay was approximately one day longer (p < 0.001) in the early perforated group than nonperforated group. CT can be helpful in differentiating early perforated appendicitis from nonperforated appendicitis, although the sensitivity of the evaluated findings was somewhat limited.

Determinants of postoperative abscess occurrence and percutaneous drainage in children with perforated appendicitis

PURPOSE

Postoperative abscesses after perforated appendicitis have no clear risk factors or indications for percutaneous drainage. Our study addressed these two issues.

METHODS

A logistic regression model was used to delineate risk factors for postoperative abscess in children with perforated appendicitis treated during a recent 5-year period. Drainage of abscess was compared to antibiotic treatment.

RESULTS

Postoperative abscess occurred in 42 (14.8%) of 284 patients. Higher WBC count, presence of bowel obstruction at presentation, diffuse peritonitis with a dominant abscess at surgery, and one specific surgeon were significantly associated with postoperative abscess, while fever or pain requiring narcotics at the time of abscess diagnosis was significantly associated with drainage. Compared to non-drainage, those drained had longer hospital stay including readmissions (15.9 ± 5.3 vs. 12.2 ± 4.6 days, p < 0.005) and less readmissions (9.5 vs. 33.3%, p = 0.06). Over the 5-year period, there was no increased trend in abscess occurrence (p = 0.56), but there was an increased trend in the use of percutaneous drainage (p = 0.02).

CONCLUSIONS

The risk of a postoperative abscess can be predicted by specific clinical characteristics, surgical findings, and treatment-related factors. Percutaneous drainage was associated with longer hospital stays, but less readmissions.

Elevated serum bilirubin in assessing the likelihood of perforation in acute appendicitis: a diagnostic meta-analysis

Hyperbilirubinemia associates with perforated acute appendicitis, but the precise test characteristics have not been determined by sufficiently powered studies. A systematic literature search of reports on hyperbilirubinemia in acute appendicitis was performed. After review and quality assessment of eight studies encompassing a total of 4974 patients the sensitivity, specificity and other measures of accuracy of hyperbilirubinemia as a predictor of perforation in acute appendicitis were pooled using a random-effects model. Summary estimates for hyperbilirubinemia (cutoff 1 mg/dl) as a predictor of perforation in acute appendicitis were as follows: sensitivity, 0.49 (95% confidence interval [CI], 0.45-0.52); specificity, 0.82 (95% CI, 0.80-0.83); positive likelihood ratio, 2.51 (95% CI, 1.58-4.00); negative likelihood ratio, 0.58 (95% CI, 0.44-0.76); diagnostic odds ratio was 4.42 (95% CI, 2.21-8.83). In summary receiving operating characteristic (SROC) analysis, the area under curve was 0.73. The presence of hyperbilirubinemia does not alone distinguish a perforation in acute appendicitis. Serum bilirubin level is of some value as a predictor of appendiceal perforation. Patients with hyperbilirubinemia combined with symptoms and signs consistent with severe acute appendicitis should be considered for early appendectomy.

To drain or not to drain: an analysis of abscess drains in the treatment of appendicitis with abscess

BACKGROUND/PURPOSE

Perforated appendicitis is associated with abscess formation before or after appendectomy. Many abscesses are not amenable to drainage due to size or location. In this study, we compare patients who had a drain placed for an abscess to those who were treated without a drain.

METHODS

Data were retrospectively collected from January 2000 to March 2011. Abscess before or after appendectomy was assessed. CT scans were reviewed and abscess size was estimated using the product of the greatest anteroposterior and lateral dimensions from an axial image. Patients with abscess smaller than 5 cm(2) were excluded. Patients treated with a drain were compared to those without using t test for continuous variables and Fisher's exact for categorical variables.

RESULTS

Of 217 patients, those with drains had significantly more CT scans, total healthcare visits and larger abscess size. When match controlled for size, drain patients accrued more CT scans and healthcare visits. In a subset analysis of aspiration versus antibiotics only, there were more CT scans but no difference between length of stay, total healthcare visits, abscess size, recurrence, or complications.

CONCLUSIONS

Appendicitis-associated abscesses may be treated with antibiotics alone based on size, which improves resource utilization with fewer CT scans and healthcare visits.

Risk of perforation increases with delay in recognition and surgery for acute appendicitis

BACKGROUND

Appendicitis remains a common indication for urgent surgical intervention in the United States, and early appendectomy has long been advocated to mitigate the risk of appendiceal perforation. To better quantify the risk of perforation associated with delayed operative timing, this study examines the impact of length of inpatient stay preceding surgery on rates of perforated appendicitis in both adults and children.

METHODS

This study was a cross-sectional analysis using the National Inpatient Sample and Kids' Inpatient Database from 1988-2008. We selected patients with a discharge diagnosis of acute appendicitis (perforated or nonperforated) and receiving appendectomy within 7 d after admission. Patients electively admitted or receiving drainage procedures before appendectomy were excluded. We analyzed perforation rates as a function of both age and length of inpatient hospitalization before appendectomy.

RESULTS

Of 683,590 patients with a discharge diagnosis of appendicitis, 30.3% were recorded as perforated. Over 80% of patients underwent appendectomy on the day of admission, approximately 18% of operations were performed on hospital days 2-4, and later operations accounted for <1% of cases. During appendectomy on the day of admission, the perforation rate was 28.8%; this increased to 33.3% for surgeries on hospital day 2 and 78.8% by hospital day 8 (P<0.001). Adjusted for patient, procedure, and hospital characteristics, odds of perforation increased from 1.20 for adults and 1.08 for children on hospital day 2 to 4.76 for adults and 15.42 for children by hospital day 8 (P<0.001).

CONCLUSIONS

Greater inpatient delay before appendectomy is associated with increased perforation rates for children and adults within this population-based study. These findings align with previous studies and with the conventional progressive pathophysiologic appendicitis model. Randomized prospective studies are needed to determine which patients benefit from nonoperative versus surgically aggressive management strategies for acute appendicitis.