Complicated appendicitis increases the hospital length of stay

Therapeutic effectiveness and influencing factors of laparoscopic appendectomy with mesoappendix dissection in the treatment of acute appendicitis

BACKGROUND

Acute appendicitis (AP) is a frequently encountered surgical emergency, and appendectomy is conventionally regarded as the predominant treatment modality. Nevertheless, the therapeutic efficacy of this surgical approach remains to be improved. Thus, the exploration and implementation of surgical refinements are necessary.

AIM

To elucidate the therapeutic effectiveness and influencing factors of laparoscopic appendectomy (LA) with mesoappendix dissection in the treatment of AP.

METHODS

First, 150 patients with AP who visited Shangrao Municipal Hospital between January 2022 and June 2024 were enrolled in this study. Among them, 72 patients were assigned to the control group to receive conventional LA, whereas 78 cases were included in the observation group for LA with mesoappendix dissection. Subsequently, indicators such as therapeutic effectiveness, surgical indices (operation time, intraoperative blood loss, and hospital stay), postoperative recovery indices (time to ambulation, gastrointestinal function recovery time, and time to food intake), incidence of adverse events (postoperative bleeding, pelvic infection, puncture site infection, and ileus), and serum inflammatory factors [tumor necrosis factor (TNF)-α, interleukin (IL)-6, and C-reactive protein (CRP)] were collected and comparatively analyzed, and the influencing factors of therapeutic effectiveness in patients with AP were analyzed.

RESULTS

Compared with the control group, the observation group had higher clinical therapeutic effectiveness, less operation time, intraoperative blood loss, and hospital stay; shorter time to ambulation, gastrointestinal function recovery, and food intake; and a lower total incidence of adverse events, and this difference is statistically significant. In addition, the expression levels of various serum inflammatory factors in the observation group were significantly reduced postoperatively, which were markedly lower than those in the control group. Moreover, sex, age, body mass index, time from acute onset to admission, family medical history, preoperative TNF-α, preoperative IL-6, preoperative CRP, and treatment modality were identified to be not independent factors affecting the therapeutic effectiveness of LA with mesoappendix dissection in patients with AP.

CONCLUSION

Overall, LA with mesoappendix dissection has a remarkable curative effect in treating patients with AP, which is worthy of clinical promotion.

The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Acute Appendicitis: Recommendations for Perioperative Care

Background/Objectives: Acute appendicitis (AA) is one of the most common causes of emergency department visits due to acute abdominal pain, with a lifetime risk of 7-8%. Managing AA presents significant challenges, particularly among vulnerable patient groups, due to its association with substantial morbidity and mortality. Methods: The EUPEMEN (European PErioperative MEdical Networking) project aims to optimize perioperative care for AA by developing multidisciplinary guidelines that integrate theoretical knowledge and clinical expertise from five European countries. This study presents the key elements of the EUPEMEN protocol, which focuses on reducing surgical stress, optimizing perioperative care, and enhancing postoperative recovery. Results: Through this standardized approach, the protocol aims to lower postoperative morbidity and mortality, shorten hospital stays, and improve overall patient outcomes. The recommendations are tailored to address the variability in clinical practice across Europe and are designed to be widely implementable in diverse healthcare settings. Conclusions: The conclusions drawn from this study highlight the potential for the EUPEMEN protocol to significantly improve perioperative care standards for AA, demonstrating its value as a practical, adaptable tool for clinicians.

Using shock index, pediatric age adjusted (SIPA) to predict prolonged length of stay in perforated appendicitis: a retrospective review

PURPOSE

Hospital length of stay (LOS) following admission for appendicitis is difficult to predict. Shock index, pediatric age adjusted (SIPA) accurately identifies severely injured trauma patients and predicts mortality among children admitted to the ICU. Our aim was to determine if elevated SIPA at presentation, and time to normalization of SIPA, can identify children with perforated appendicitis and predict hospital LOS.

METHODS

This was a retrospective cohort study of children 1-17 years admitted to a quaternary care referral center with appendicitis after appendectomy in 2021. The primary outcomes were presence of perforated appendicitis and hospital LOS. Generalized linear regressions were performed. Covariates included in all models were age, sex, fecalith, initial temperature, and time from diagnosis to OR.

RESULTS

We included 169 patients; 53 (31.4%) had perforated appendicitis. After adjustment, elevated SIPA was associated with presence of perforated appendicitis (p = 0.0002) and longer LOS (p < 0.0001). A patient presenting with appendicitis and elevated SIPA had 5.447 times higher odds of having perforated appendicitis (95% CI: 2.262, 13.826), a mean hospital LOS 2.047 times longer (95% CI: 1.564, 2.683), a mean time to toleration of regular diet 4.995 times longer (95% CI: 2.914, 8.918), and a mean duration of antibiotics that is 1.761 times longer (95% CI: 1.383, 2.243) than a patient with normal SIPA.

CONCLUSION

In children with appendicitis, elevated SIPA at presentation is associated with higher risk of perforation. These findings support the incorporation of SIPA during triage of patients with appendicitis and counseling families after surgery.

LEVEL OF EVIDENCE

Level 3.

Appendicectomy pathway: Insights from electronic medical records of a local health district in Australia

BACKGROUND

This study aims to identify the common pathways of appendicectomy, the most common emergency surgery in Australia's public hospitals and any variations within a regional public health district in New South Wales, Australia.

METHODS

We analyzed the electronic medical records of 3,943 patients who underwent appendicectomy between January 2014 and July 2020 at 2 hospitals in the Illawarra Shoalhaven Local Health District, New South Wales, Australia, using the PM2 approach for surgical pathway identification and subsequent statistical analyses.

RESULTS

Among 3,943 patients, 3,606 (91.5%) followed an 11-step main pathway: (1) emergency department admission, (2) surgery booking, (3) anesthesia start, (4) operating room entry, (5) surgery start, (6) surgery end, (7) anesthesia end, (8) operating room discharge, (9) postanesthesia care unit admission, (10) postanesthesia care unit discharge, and (11) hospital discharge. The median length of stay was 48.13 hours (interquartile range 32.74). The main pathway differed from either variation 1 (n = 246, 6.2%) or variation 2 (n = 30, 0.8%) only in the timing and location of anesthesia administration or conclusion. Variation 3 (n = 26, 0.7%) included patients who underwent appendicectomy twice, whereas variation 4 (n = 25, 0.6%) included patients booked for surgery before emergency department admission through community doctor referrals. Thirteen exceptional cases experienced combinations of the aforementioned pathways. The length of stay and phase durations varied between the main pathway and these variations.

CONCLUSION

The appendicectomy pathway was largely standardized across the studied hospitals, with the location of anesthesia administration or conclusion affecting specific stages but not the overall length of stay. Only a complex 2-surgery pathway increased length of stay.

Clinical Scoring Systems to Diagnose Complicated Acute Appendicitis in a Rural Hospital: Are They Good Enough?

Introduction Acute appendicitis (AA) is the most common surgical emergency in developed countries, whose incidence peaks in the second and third decades. The risk of mortality in uncomplicated AA is very low. There are many scoring systems to predict AA. Prediction scores are used less frequently to predict complicated AA. Rural hospitals are often constrained by a lack of round-the-clock imaging or special laboratory services, which may enable accurate diagnosis. Materials and methods This study aimed to determine whether prediction scores without imaging or C-reactive protein (CRP) levels could predict complicated AA in a rural setting. All cases of AA for the previous 13 months were recruited for the study. Demographic data, clinical signs and symptoms, complete blood counts, intraoperative findings, and the corresponding histopathological results were collated. The scoring systems (Alvarado, RIPASA, Tzanakis, and Ohmann) were calculated from the clinical and laboratory data. Demographic variables, clinical features, and histopathological findings are described as frequencies/proportions. Chi-squared and Student's t-tests were used to analyze differences between patients with complicated and uncomplicated AA. A receiver operating curve (ROC) analysis was performed to calculate the area under the curve (AUC) and determine whether appendicitis scores could predict complicated AA. Results There were 76 patients with a mean age of 29.1±13.0 years. Serositis was observed in 65% of the patients; mucosal ulceration was the most common microscopic finding, with a pathological diagnosis of AA in 58 (76.3%) patients. Rovsing's sign and the presence of phlegmon and granuloma were significantly different between those with and without complicated AA. The clinical prediction scores were not significantly different between the two groups. The Tzanakis and Ohmann scores were significant (cutoff: 6.5 and 7.25, p=0.001 and 0.01, respectively) in diagnosing AA (sensitivity/specificity of 98.3/66.7 and 98.3/94.4, respectively). With a cutoff of 5.75, the RIPASA score, with an AUC of 0.663 (p=0.09), showed the highest sensitivity (90.7) and specificity (76.6) for diagnosing complicated AA. Conclusion Diagnosing AA based solely on clinical presentation remains a challenge. This study showed that clinical scores such as those of Alvarado, RIPASA, Tzanakis, and Ohmann could not accurately predict complicated AA. Scoring systems without imaging and intraoperative diagnoses are not infallible; therefore, histopathological examination of the resected appendix is mandatory.

Cold Therapy for Pain Control in Pediatric Appendectomy Patients: A Randomized Controlled Trial

PURPOSE

Topical ice has been shown to reduce pain scores and opioid use in adults with midline abdominal incisions. This study was designed to evaluate the efficacy of a cold therapy system in children following laparoscopic appendectomy.

METHODS

Patients 7 years and older who underwent laparoscopic appendectomy at our institution from December 2021-September 2022 were eligible. Patients were randomized to standard pain therapy (control) or standard plus cold therapy (treatment) utilizing a modified ice machine system with cool abdominal pad postoperatively. Pain scores on the first 3 postoperative days (PODs), postoperative narcotic consumption, and patient satisfaction were analyzed.

RESULTS

Fifty-eight patients were randomized, 29 to each group. Average survey response rate was 74% in control and 89% in treatment patients. There was no significant difference in median pain scores or narcotic use between groups. Cold therapy contributed to subjective pain improvement in 71%, 74%, and 50% of respondents on PODs 1, 2, and 3 respectively.

CONCLUSION

A majority of patients reported cold therapy to be a helpful adjunct in pain control after appendectomy, though it did not reduce postoperative pain scores or narcotic use in our cohort - likely due to this population's naturally expedient recovery and low baseline narcotic requirement.

TYPE OF STUDY

Randomized Controlled Trial.

LEVEL OF EVIDENCE

Level I.

Ethnic disparities in pediatric appendicitis: the impact of hispanic ethnicity on presentation, complications, and postoperative outcomes

PURPOSE

Our study investigates ethnic disparities in pediatric appendicitis, focusing on the impact of Hispanic ethnicity on presentation, complications, and postoperative outcomes.

METHODS

We conducted a retrospective analysis of pediatric patients undergoing appendectomy for acute appendicitis from 2015 to 2020 using the National Surgical Quality Improvement Program-Pediatric database. We compared 30-day postoperative complications, postoperative length of stay, and postoperative interventions between Hispanic and non-Hispanic White patients.

RESULTS

65,976 patients were included, of which 23,462 (35.56%) were Hispanic and 42,514 (64.44%) non-Hispanic White. Hispanic children were more likely to present to the hospital with complicated appendicitis (31.75% vs. 25.15%, P < 0.0001) and sepsis (25.22% vs. 19.02%, P < 0.0001) compared to non-Hispanic White. Hispanics had higher rates of serious complications (4.06% vs. 3.55%, P = 0.001) but not overall complications (5.37% vs. 5.09%, P = 0.12). However, after multivariate analysis, Hispanic ethnicity was not associated with an increased rate of serious postoperative complications (OR 0.93, CI 0.85-1.01, P = 0.088); it was associated with less overall complications (OR 0.88, CI 0.81-0.96, P = 0.003) but a longer postoperative length of stay (OR 1.09, CI 1.04-1.14, P < 0.0001).

CONCLUSION

Hispanic children are more likely to present with complicated appendicitis, contributing to increased postoperative complications. Notably, upon adjustment for the impact of complicated appendicitis, our findings suggest potentially favorable outcomes for Hispanic ethnicity. This emphasizes the need to understand delays in presentation to improve outcomes in the Hispanic population.

An Update on Acute Appendicitis in Lebanon: Insights From a Single-Center Retrospective Study

Background Acute appendicitis is the most common surgical emergency worldwide with scarce reports about its prevalence in the Middle East. To date, no epidemiological article has described the incidence of appendicitis in Lebanon. Our primary objective was to estimate the rate of appendicitis in a single center in Lebanon. Our secondary objectives included identifying differences between simple and complicated appendicitis regarding demographics, pre and postoperative characteristics, and symptoms and signs of appendicitis. Methodology A retrospective study was conducted at a single central university hospital in Lebanon. Patients with a clear diagnosis of acute appendicitis were included. Pregnant women, lactating women, patients with organ dysfunction, and patients younger than 18 years old or older than 80 years old were excluded. We reviewed and collected the data of patients who presented to the hospital between November 2018 and November 2019 and November 2020 and November 2021. Results A total of 95 patients were included in our study, with 35 women and 60 men. The mean body mass index of patients with simple appendicitis was 19.14 ± 9.66 kg/m² compared to 18.97 ± 10.37 kg/m² in patients with complicated appendicitis (p = 0.94). A total of 42.3% of patients who used antibiotics 24 hours after the operation had simple appendicitis, whereas 20.8% had complicated appendicitis (p = 0.004). Conclusions Antibiotic usage and the length of hospital stay were correlated with the severity of appendicitis, as reported in the literature. Further randomized studies with a larger number of patients and covering several hospitals in Lebanon are warranted.