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Dahiya DS, Akram H, Goyal A, Khan AM, Shahnoor S, Hassan KM, Gangwani MK, Ali H, Pinnam BSM, Alsakarneh S, Canakis A, Sheikh AB, Chandan S, Sohail AH. Controversies and Future Directions in Management of Acute Appendicitis: An Updated Comprehensive Review. J Clin Med 2024; 13:3034. [PMID: 38892745 PMCID: PMC11172822 DOI: 10.3390/jcm13113034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/12/2024] [Accepted: 05/17/2024] [Indexed: 06/21/2024] Open
Abstract
Globally, acute appendicitis has an estimated lifetime risk of 7-8%. However, there are numerous controversies surrounding the management of acute appendicitis, and the best treatment approach depends on patient characteristics. Non-operative management (NOM), which involves the utilization of antibiotics and aggressive intravenous hydration, and surgical appendectomy are valid treatment options for healthy adults. NOM is also ideal for poor surgical candidates. Another important consideration is the timing of surgery, i.e., the role of interval appendectomy (IA) and the possibility of delaying surgery for a few hours on index admission. IA refers to surgical removal of the appendix 8-12 weeks after the initial diagnosis of appendicitis. It is ideal in patients with a contained appendiceal perforation on initial presentation, wherein an initial nonoperative approach is preferred. Furthermore, IA can help distinguish malignant and non-malignant causes of acute appendicitis, while reducing the risk of recurrence. On the contrary, a decision to delay appendectomy for a few hours on index admission should be made based on the patients' baseline health status and severity of appendicitis. Post-operatively, surgical drain placement may help reduce postoperative complications; however, it carries an increased risk of drain occlusion, fistula formation, and paralytic ileus. Furthermore, one of the most critical aspects of appendectomy is the closure of the appendiceal stump, which can be achieved with the help of endoclips, sutures, staples, and endoloops. In this review, we discuss different aspects of management of acute appendicitis, current controversies in management, and the potential role of endoscopic appendectomy as a future treatment option.
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Affiliation(s)
- Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology & Motility, The University of Kansas School of Medicine, Kansas City, KS 66160, USA
| | - Hamzah Akram
- Department of Internal Medicine, Hamilton Health Sciences, Hamilton, ON L8N 3Z5, Canada
| | - Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai 400012, India
| | - Abdul Moiz Khan
- Department of Internal Medicine, Ayub Medical College, Abbottabad 22020, Pakistan
| | - Syeda Shahnoor
- Department of Internal Medicine, Dow University of Health Sciences, Karachi 74200, Pakistan
| | - Khawaja M. Hassan
- Department of Internal Medicine, King Edward Medical University, Lahore 54000, Pakistan
| | - Manesh Kumar Gangwani
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Hassam Ali
- Division of Gastroenterology, Hepatology and Nutrition, East Carolina University/Brody School of Medicine, Greenville, NC 27858, USA
| | - Bhanu Siva Mohan Pinnam
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL 60612, USA
| | - Saqr Alsakarneh
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64110, USA
| | - Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM 87131, USA
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, NE 68178, USA
| | - Amir Humza Sohail
- Department of Surgery, University of New Mexico, Albuquerque, NM 87131, USA
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Wang Y, Ma L, Lu X, Yan X. Effect of endoscopic retrograde appendicitis therapy on surgical site wound infection and hospital stay in patients with acute appendicitis: A meta-analysis. Int Wound J 2023; 20:4281-4290. [PMID: 37500538 PMCID: PMC10681414 DOI: 10.1111/iwj.14330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023] Open
Abstract
In this meta-analysis, we comprehensively evaluated the effect of endoscopic retrograde appendicitis therapy (ERAT) on surgical site infections and other perioperative outcomes in patients with acute appendicitis. Relevant studies on ERAT for acute appendicitis were retrieved from PubMed, EMBASE, Web of Science, China National Knowledge Infrastructure, and Wanfang Data, from database inception to June 2023. Statistical analyses were performed using RevMan 5.4. Heterogeneity among the included studies was analysed, and odds ratios (ORs) or standardised mean differences (SMDs), along with their respective 95% confidence intervals (CIs), were calculated. In total, 24 studies involving 1937 patients were included in the meta-analysis. ERAT reduced the surgical duration (SMD: -1.70, 95% CI: -2.24 to -1.16, p < 0.001) and length of hospital stay (SMD: -2.09, 95% CI: -2.64 to -1.53, p < 0.001) significantly more than open appendectomy (OA) did. Furthermore, ERAT decreased the incidence of surgical site wound infections (OR: 0.22, 95% CI: 0.13-0.37, p < 0.001) and postoperative complications (OR: 0.16, 95% CI: 0.11-0.21, p < 0.001) more than OA did. This study demonstrated that ERAT is a safe and effective endoscopic treatment modality for acute appendicitis, contributing to a significant reduction in the surgical duration, length of hospital stay, and incidence of surgical site wound infections and postoperative complications. Hence, ERAT has clinical significance and the potential for further application and dissemination.
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Affiliation(s)
- Yin Wang
- Department of GastroenterologyThe People's Hospital of BozhouBozhouChina
| | - Lan Ma
- Department of Infectious DiseaseThe People's Hospital of BozhouBozhouChina
| | - Xingjun Lu
- Department of GastroenterologyThe People's Hospital of BozhouBozhouChina
| | - Xiuxia Yan
- Department of Intensive Care UnitThe People's Hospital of BozhouBozhouChina
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Alajaimi J, Almansoor M, Almutawa A, Almusalam MM, Bakry H. Are Antibiotics the New Appendectomy? Cureus 2023; 15:e44506. [PMID: 37790034 PMCID: PMC10544542 DOI: 10.7759/cureus.44506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Prior to the development of laparoscopic procedures, open appendectomy was the standard of care for the majority of appendicitis cases. Recently, studies have debated using antibiotics as a first-line treatment in uncomplicated appendicitis cases. The definition of uncomplicated appendicitis is not always clear-cut; however, with the large-scale accessibility of radiologic techniques, it is becoming increasingly easier to classify patient groups. As suggested by clinical and radiological patient data, this has raised the speculation of considering antibiotic therapy as the sole treatment modality in uncomplicated appendicitis cases. We aim to compare the options of surgery and antibiotics only in terms of efficacy, complications, and financial cost. A range of databases and search strategies were adopted, and various databases were used, including PubMed, ScienceDirect, Google Scholar, and JAMA. Collectively, 30 studies were reviewed, but only 18 were included. Efficacy rates were higher in the appendectomy group. Nevertheless, the antibiotics-only group maintained an efficacy rate greater than 70% at one-year follow-up. Risk factors that decreased the efficacy in medical management included the presence of appendicolith, neoplasm, appendiceal dilatation, peri-appendiceal fluid collection, higher mean temperature, CRP, and bilirubin. Complications were more frequent and significant in the surgery group. These included complications related to anaesthesia, surgical site infections, damage to nearby structures, and pulmonary embolism. Despite several years of follow-up and disease recurrences, higher financial costs were observed in surgically treated patients compared to the antibiotics-only group. Given the high success rates post-appendectomy for acute appendicitis over the decades, the efficacy of conservatively treated acute appendicitis raises a strong argument when choosing one of the two options. The efficacy remained consistently higher across the literature in the surgery group than in the antibiotics-only group. However, it is still arguable that antibiotics may be a preferable option given an efficacy rate of more than 70% at one year and overall higher complications associated with surgery. The argument of missing a neoplasm by avoiding surgery is valid. However, most are carcinoid neuroendocrine neoplasms with a low probability of metastasis (<5%) and are usually considered benign. Given the current practice focused on conservative and minimally invasive treatments and recently the COVID-19 pandemic, with its restrictions and lessons learnt, antibiotics may be the future standard for treating uncomplicated acute appendicitis. Lastly, we noticed higher efficacy rates in articles published recently than those published at least five to ten years earlier. Antibiotics-only therapy for uncomplicated appendicitis is cost-effective with fewer complications than surgery. However, appendectomies have higher efficacy. Thus, surgical treatment prevails as the standard of care. Future literature should yield larger sample sizes and explore the numbers of emergency appendectomies mandated following antibiotics-only therapy.
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Affiliation(s)
- Janan Alajaimi
- School of Medicine, Royal College of Surgeons in Ireland, Busaiteen, BHR
| | - Manar Almansoor
- School of Medicine, Royal College of Surgeons in Ireland, Busaiteen, BHR
| | - Amina Almutawa
- School of Medicine, Royal College of Surgeons in Ireland, Busaiteen, BHR
| | | | - Husham Bakry
- General Surgery, King Hamad University Hospital, Busaiteen, BHR
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Tarar B, Batool S, Majeed S, Saleem A. Comparison Between Early Appendectomy vs. Conservative Management in Cases of Appendicular Mass. Cureus 2023; 15:e37986. [PMID: 37223186 PMCID: PMC10202446 DOI: 10.7759/cureus.37986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2023] [Indexed: 05/25/2023] Open
Abstract
INTRODUCTION At present, the treatment of choice for appendicular masses is unclear. Recent studies claimed that conservative management of appendicular masses was safe in terms of frequency of perforation. However, there is controversy in the existing literature. OBJECTIVE This research is designed to compare the results of early appendectomy versus conservative management of appendicular masses. MATERIAL AND METHODS It was a randomized controlled trial performed in the Combined Military Hospital, Lahore. The study lasted six months, from 01/03/2019 to 30/09/2019. It involved 60 patients of both genders aged between 16 and 70 years diagnosed with appendicular masses with an Alvarado score of 4-7. These patients were randomly divided into two treatment groups. In Group A patients, an early appendectomy was performed, while patients in Group B were managed conservatively. Outcome variables were the mean length of hospital stay and frequency of appendicular perforation. RESULTS The mean age of the patients was 26.8±11.9 years. There were 33 (55.0%) male and 27 (45.0%) female patients, with a male-to-female ratio of 1.2:1. The mean length of hospital stay was significantly longer in patients managed conservatively as compared to those undergoing early appendectomy (2.80±1.54 vs. 1.83±0.83; p=0.004). However, the frequency of perforation was not significantly higher in the conservative group as compared to the early appendectomy group (16.7% vs. 10.0%; p=0.448). CONCLUSION Conservative management of patients with appendicular mass was associated with prolonged hospital stays, yet it was found equally safe in terms of frequency of appendicular perforation, which advocates conservative management of patients with appendicular mass, particularly in high-risk patients.
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Affiliation(s)
- Bilal Tarar
- General Surgery, Northwick Park Hospital, London, GBR
| | - Sadaf Batool
- Surgery, Chesterfield Royal Hospital, Chesterfield, GBR
| | - Shahid Majeed
- General Surgery, Combined Military Hospital, Lahore, PAK
| | - Aimen Saleem
- Paediatric Surgery, Children's Hospital and Medical Center, Lahore, PAK
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Yadao S, Lamture Y, Huse S. Uses of Antibiotics Alone in Case of Uncomplicated Appendicitis. Cureus 2022; 14:e28488. [PMID: 36176829 PMCID: PMC9513284 DOI: 10.7759/cureus.28488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/27/2022] [Indexed: 12/03/2022] Open
Abstract
The frequent abdominal surgical emergency is acute appendicitis with a significantly less lifelong risk. One of the most common surgeries manifested is an appendectomy, but with recent advances, non-operative management has evolved using antibiotics. In adult patients with simple appendicitis, we identified the role of surgical and non-surgical therapy. One of the most common surgeries manifested is an appendectomy, but with recent advances, non-operative management has evolved using antibiotics. In adults suffering from mild appendicitis, we identified the role of surgical and non-surgical therapy. The analysis indicated that the Antibiotics versus Primary Appendectomy in Children (APAC) did not establish non-inferiority of antibiotics vs. appendectomy with a pre-specified small margin. In contrast to the majority of appendectomies that are carried out laparoscopically, the surgeries were almost usually open. Appendectomies, both laparoscopic and open, are not the same procedure. Antibiotic therapy is effective in about 60% of cases of simple appendicitis. A surgery-only strategy would reduce antibiotic exposure, a factor to consider in these days of antimicrobial stewardship. Therefore, studies are being conducted on whether to shift alone on antibiotics or with appendectomy to have better results with fewer complications. Future studies should focus on appendicitis features and long-term unfavorable consequences, including antibiotic resistance or Clostridium difficile colitis, most responsive to antibiotics by utilizing laparoscopic procedures as controls. Using it along with appendectomy may change the outcome showing a better prognosis.
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Yang B, Kong L, Ullah S, Zhao L, Liu D, Li D, Shi X, Jia X, Dalal P, Liu B. Endoscopic retrograde appendicitis therapy versus laparoscopic appendectomy for uncomplicated acute appendicitis. Endoscopy 2022; 54:747-754. [PMID: 35021234 PMCID: PMC9329065 DOI: 10.1055/a-1737-6381] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic retrograde appendicitis therapy (ERAT) is a new and minimally invasive technique for the treatment of acute appendicitis. This study aimed to assess the efficacy and clinical outcomes of ERAT versus laparoscopic appendectomy for patients with uncomplicated acute appendicitis. METHODS We adopted propensity score matching (1:1) to compare ERAT and laparoscopic appendectomy in patients with uncomplicated acute appendicitis between April 2017 and March 2020. We reviewed 2880 patients with suspected acute appendicitis, of whom 422 patients with uncomplicated acute appendicitis met the matching criteria (ERAT 79; laparoscopic appendectomy 343), yielding 78 pairs of patients. RESULTS The rate of curative treatment within 1 year after ERAT was 92.1 % (95 % confidence interval [CI] 83.8 % to 96.3 %). The percentage of patients recording visual analog scale values of ≤ 3 for pain at 6 hours after treatment was 94.7 % (95 %CI 87.2 % to 97.9 %) in the ERAT group, which was significantly higher than that in the laparoscopic appendectomy group (83.3 %; 95 %CI 73.5 % to 90.0 %). Median procedure time and median hospital length of stay were significantly lower in the ERAT group compared with the laparoscopic appendectomy group. At 1 year, the median recurrence time was 50 days (interquartile range 25-127) in the ERAT group. The overall adverse event rate was 24.4 % (95 %CI 14.8 % to 33.9 %) in the laparoscopic appendectomy group and 18.4 % (95 %CI 9.7 % to 27.1 %) in the ERAT group, with no significant difference between the two groups. CONCLUSION ERAT was a technically feasible method of treating uncomplicated acute appendicitis compared with laparoscopic appendectomy.
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Affiliation(s)
- Baohong Yang
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Department of Oncology, Weifang People’s Hospital (The First Affiliated Hospital of Weifang Medical University), Weifang, Shandong, China
| | - Lingjian Kong
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Saif Ullah
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Lixia Zhao
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Dan Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Deliang Li
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xuezhong Shi
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Xiaocan Jia
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Paras Dalal
- Department of Radiology, Harefield Hospital, Harefield, United kingdom
| | - Bingrong Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Emile SH, Sakr A, Shalaby M, Elfeki H. Efficacy and Safety of Non-Operative Management of Uncomplicated Acute Appendicitis Compared to Appendectomy: An Umbrella Review of Systematic Reviews and Meta-Analyses. World J Surg 2022; 46:1022-1038. [PMID: 35024922 PMCID: PMC8756749 DOI: 10.1007/s00268-022-06446-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Non-operative management (NOM) of uncomplicated acute appendicitis (AA) has been introduced as an alternative to appendectomy. This umbrella review aimed to provide an overview of the efficacy and safety of NOM of uncomplicated AA in the published systematic reviews. METHODS This umbrella review has been reported in line with the PRISMA guidelines and umbrella review approach. Systematic reviews with and without meta-analyses on the efficacy of NOM of AA were analyzed. The quality of the reviews was assessed with the AMSTAR 2 tool. The main outcomes measures were the treatment failure and complication rates of NOM and hospital stay as compared to appendectomy. RESULTS Eighteen systematic reviews were included to this umbrella review. Eight reviews documented higher odds of failure with NOM, whereas two reviews revealed similar odds of failure. Six reviews reported lower odds of complications with NOM, six reported similar odds, and one reported lower odds of complications with surgery. Eight reviews reported similar hospital stay between NOM and appendectomy, one reported longer stay with NOM and another reported shorter stay with NOM. Pooled analyses showed that NOM was associated with higher treatment failure overall, in children-only, adults only, and RCTs-only meta-analyses. NOM was associated with lower complications overall, yet children-only and RCTs-only analyses revealed similar complications to surgery. NOM was associated with shorter stay in the overall and adult-only analysis, but not in the children-only analysis. CONCLUSIONS NOM of AA is associated with higher treatment failure, marginally lower rate of complications and shorter stay than appendectomy.
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Affiliation(s)
- Sameh Hany Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Ahmad Sakr
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Mostafa Shalaby
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Hossam Elfeki
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
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D'Souza N, Hicks G, Beable R, Higginson A, Rud B. Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis. Cochrane Database Syst Rev 2021; 12:CD012028. [PMID: 34905621 PMCID: PMC8670723 DOI: 10.1002/14651858.cd012028.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children. OBJECTIVES The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective. SELECTION CRITERIA We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies. DATA COLLECTION AND ANALYSIS We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity. MAIN RESULTS We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains. AUTHORS' CONCLUSIONS MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.
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Affiliation(s)
| | | | | | | | - Bo Rud
- Gastrounit, Copenhagen University Hospital Hvidovre , Hvidovre, Denmark
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Park SH, Park SS, Lee DW, Park HC, Park SC, Hong CW, Sohn DK, Han KS, Chang HJ, Oh JH. Comparison between early surgical treatment and conservative treatment of appendicitis in cancer patients. ANZ J Surg 2021; 91:2067-2073. [PMID: 34476891 DOI: 10.1111/ans.17180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/02/2021] [Accepted: 08/15/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUNDS In cancer patients, the optimal appendicitis treatment has not been established. Therefore, we aimed to determine the ideal treatment option for appendicitis in cancer patients. METHODS This retrospective study included 185 cancer patients with acute appendicitis who were divided into the early surgical group (n = 152) involving surgery performed within 48 h following the appendicitis diagnosis or the conservative group (n = 33) involving intravenous antibiotics. We compared the appendicitis treatment efficacy between the groups. RESULTS In the early surgical group, the antibiotic duration [5.5 days (4.0-8.0) vs. 17.0 days (12.5-25.0), p < 0.001] and hospital stay length [7.0 days (5.0-11.75) vs. 10.0 days (8.0-32.0), p < 0.001] were significantly shorter. Regarding pathology, 16/171 (9.4%) patients who underwent surgery exhibited appendiceal tumours. During the 1-year follow-up period, one recurrence occurred in each group [1/152 (0.7%) vs. 1/33 (3.0%), p = 0.326]. The 1-year treatment success rate was higher in the early surgical group [99.3% (151/152) vs. 42.4% (14/33), p < 0.001]. CONCLUSION Early surgical treatment yielded a significantly higher success rate than conservative treatment for appendicitis in cancer patients. Surgery for appendicitis in cancer patients should be considered not only for treatment but also for pathologic confirmation.
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Affiliation(s)
- Sin Hye Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Sung Sil Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Dong Woon Lee
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Hyoung-Chul Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Chang Won Hong
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Kyung Su Han
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Hee Jin Chang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
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Effect of Endoscopic Appendix Intubation and Irrigation on Acute Uncomplicated Appendicitis. World J Surg 2021; 45:3313-3319. [PMID: 34324027 DOI: 10.1007/s00268-021-06258-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To investigate the efficacy and safety of endoscopic appendix intubation and irrigation (EAI) on acute uncomplicated appendicitis. METHODS This prospective non-randomized study examined 169 patients with suspected acute uncomplicated appendicitis at The First Affiliated Hospital of Fujian Medical University from October 2015 to 2017. Patients were divided into three groups: endoscopic appendix intubation and irrigation (EAI, n = 18), laparoscopic appendectomy (LA, n = 87), and antibiotic alone (A, n = 64). The treatment success rate, duration of hospitalization, medical costs, operation time, duration of abdominal pain, fasting time, complications, and recurrence were analyzed. RESULTS The three groups had no significant differences in baseline characteristics (age, gender, Alvarado score, white blood cell count, and neutrophil count; all P > 0.05). Compared to the LA group, the EAI group had shorter durations of the operation, fasting, and abdominal pain; less use of oral and intravenous antibiotics; and lower medical costs (all P < 0.05). Compared to the A group, the EAI group had shorter durations of abdominal pain and hospitalization, and less use of intravenous antibiotics (all P < 0.05). The EAI group had no complications, but 3 patients (3.4%) in the LA group had surgery-related complications. CONCLUSION EAI is a safe and effective treatment for acute uncomplicated appendicitis. Patients who received EAI had shorter durations of abdominal pain and hospitalization than those who received LA or conservative antibiotic treatment. TRIAL REGISTRATION NUMBER AND AGENCY ChiCTR-IPN-15006565, Chinese Clinical Trial Registry.
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Falih Noori Alsubsiee I, Falih Noori Alsubsiee A. Appendicectomy for Uncomplicated Simple Appendicitis: Is It Always Required? Surg Res Pract 2021; 2021:8848162. [PMID: 33791405 PMCID: PMC7984904 DOI: 10.1155/2021/8848162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/16/2021] [Accepted: 03/02/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Although appendicectomy is still the classical and standard treatment for acute appendicitis, initial conservative antibiotic only treatment for simple uncomplicated cases has been proposed and tried as a feasible and effective approach. The objective of this study was to evaluate the efficacy and outcomes of antibiotics treatment for acute simple uncomplicated appendicitis. METHODS This is a prospective controlled nonrandomized study in which a total of 156 patients whose ages range from 16 to 54 years presenting with clinical diagnosis of acute uncomplicated appendicitis were assigned for conservative antibiotics treatment, which consists of ceftriaxone I gram twice daily and metronidazole infusions, 500 mg in 100 ml, 3 times daily for 48 to 72 hours to be converted on oral antibiotics after clinical improvement for 5 to 7 days. Patients who failed to initial conservative treatment and those who had recurring symptoms of appendicitis were presented for appendectomy. RESULTS Antibiotic treatment was successful and feasible in 138 (88.5%) patients. Progression of the signs and symptoms despite full medical treatment was observed in 11 (7%) patients during the same admission. Further 7 (4.5%) patients showed recurrence of the symptoms during follow-up period of 6-12 months after successful initial conservative treatment and also proceeded for appendicectomy. CONCLUSION Nonoperative antibiotic treatment of acute simple appendicitis is safe, feasible, and effective for properly selected cases, thus avoiding unnecessary surgery with its possible complications.
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12
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Song X, Shi M, Liu W, Ge Y, Wang P. Relative CT number of periappendiceal fat stranding may be an applicable index for estimating the severity of acute appendicitis. Br J Radiol 2021; 94:20200437. [PMID: 33684313 PMCID: PMC8010530 DOI: 10.1259/bjr.20200437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objectives: To investigate the feasibility of relative CT numbers to periappendiceal fat attenuation as an applicable index for estimating the severity of acute appendicitis. Methods: In total, 308 consecutive surgery-confirmed acute appendicitis patients and 243 controls with available preoperative CT were analyzed retrospectively. The radiological parameters were appendix diameter, length, and wall thickness as concurrent appendicitis signs. CT numbers of periappendiceal fat, mesenteric fat, subcutaneous fat in the anterior and posterior abdominal wall, retroperitoneal fat, gluteal subcutaneous fat and psoas major muscle were measured, as well as the relative CT numbers of periappendiceal fat compared with other locations. Results: There were 287 suppurative acute appendicitis (SAA) and 21 gangrenous or perforated acute appendicitis (GPAA) cases confirmed by pathology. The CT number of periappendiceal fat was significantly higher in patients than in controls (P<0.01) although there was a wide overlap (−72.33 HU–117.43 HU). Significant differences in relative CT numbers were observed between the groups in gluteal subcutaneous fat (RCTgl) and psoas major muscle (RCTps) (P<0.01). The AUCs of RCTgl and RCTps showed high accuracy to discriminate acute appendicitis from controls (AUC = 0.803, 0.761; 0.854, 0.847) and GPAA from SAA (AUC = 0.905, 0.851). Conclusions: Attenuation of periappendiceal fat on CT is related to the severity of appendicitis, and relative CT numbers (RCTgl and RCTps) could be an applicable index for severity determination. Advances in knowledge: Periappendiceal fat infiltration is related to the severity of acute appendicitis (especially relative CT number). Other clinical and CT features also need to be considered in the evaluation of inflammation.
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Affiliation(s)
- Xinhong Song
- Department of Radiology, Yantai Affiliated Hospital of Binzhou Medical University, No 717 Jinbu Road, Yantai, Shandong 264100, PR China
| | - Mingqi Shi
- Department of Radiology, Yantai Affiliated Hospital of Binzhou Medical University, No 717 Jinbu Road, Yantai, Shandong 264100, PR China
| | - Wei Liu
- Department of Radiology, Yantai Affiliated Hospital of Binzhou Medical University, No 717 Jinbu Road, Yantai, Shandong 264100, PR China
| | - Yansong Ge
- Department of Radiology, Yantai Affiliated Hospital of Binzhou Medical University, No 717 Jinbu Road, Yantai, Shandong 264100, PR China
| | - Peiyuan Wang
- Department of Radiology, Yantai Affiliated Hospital of Binzhou Medical University, No 717 Jinbu Road, Yantai, Shandong 264100, PR China
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13
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Somers K, Abd Elwahab S, Raza MZ, O'Grady S, DeMarchi J, Butt A, Burke J, Robb W, Power C, McCawley N, McNamara D, Kearney D, Hill ADK. Impact of the COVID-19 pandemic on management and outcomes in acute appendicitis: Should these new practices be the norm? Surgeon 2021; 19:e310-e317. [PMID: 33750630 PMCID: PMC7879062 DOI: 10.1016/j.surge.2021.01.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/12/2021] [Indexed: 02/09/2023]
Abstract
Background In early 2020, the COVID-19 pandemic significantly altered management of surgical patients globally. International guidelines recommended that non-operative management be implemented wherever possible (e.g. in proven uncomplicated appendicitis) to reduce pressure on healthcare services and reduce risk of peri-operative viral transmission. We sought to compare our management and outcomes of appendicitis during lockdown vs a non-pandemic period. Methods All presentations to our department with a clinical diagnosis of acute appendicitis between 12/03/2020 and 30/06/2020 were compared to the same 110-day period in 2019. Quantity and severity of presentations, use of radiological investigations, rate of operative intervention and histopathological findings were variables collected for comparison. Results There was a reduction in appendicitis presentations (from 74 to 56 cases), and an increase in radiological imaging (from 70.27% to 89.29%) (P = 0.007) from 2019 to 2020. In 2019, 93.24% of patients had appendicectomy, compared to 71.42% in 2020(P < 0.001). This decrease was most pronounced in uncomplicated cases, whose operative rates dropped from 90.32% to 62.5% (P = 0.009). Post-operative histology confirmed appendicitis in 73.9% in 2019, compared to 97.5% in 2020 (P = 0.001). Normal appendiceal pathology was reported for 17 cases (24.64%) in 2019, compared to none in 2020 (P < 0.001) – a 0% negative appendicectomy rate (NAR). Discussion The 0% NAR in 2020 is due to a combination of increased CT imaging, a higher threshold to operate, and is impacted by increased disease severity due to delayed patient presentation. This study adds to growing literature promoting routine use of radiological imaging to confirm appendicitis diagnosis. As we enter a second lockdown, patients should be encouraged to avoid late presentations, and surgical departments should continue using radiological imaging more liberally in guiding appendicitis management.
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Affiliation(s)
- Kate Somers
- Department of Surgery, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin 9, Ireland.
| | - Sami Abd Elwahab
- Department of Surgery, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin 9, Ireland
| | | | - Sorcha O'Grady
- Department of Surgery, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin 9, Ireland
| | - Joshua DeMarchi
- Department of Surgery, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin 9, Ireland
| | - Abeeda Butt
- Department of Surgery, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin 9, Ireland
| | - John Burke
- Department of Surgery, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin 9, Ireland
| | - William Robb
- Department of Surgery, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin 9, Ireland
| | - Colm Power
- Department of Surgery, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin 9, Ireland
| | - Niamh McCawley
- Department of Surgery, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin 9, Ireland
| | - Deborah McNamara
- Department of Surgery, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin 9, Ireland
| | - David Kearney
- Department of Surgery, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin 9, Ireland
| | - Arnold D K Hill
- Department of Surgery, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin 9, Ireland
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14
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Hall NJ, Sherratt FC, Eaton S, Reading I, Walker E, Chorozoglou M, Beasant L, Wood W, Stanton M, Corbett HJ, Rex D, Hutchings N, Dixon E, Grist S, Hoff WV, Crawley E, Blazeby J, Young B. Conservative treatment for uncomplicated appendicitis in children: the CONTRACT feasibility study, including feasibility RCT. Health Technol Assess 2021; 25:1-192. [PMID: 33630732 PMCID: PMC7958256 DOI: 10.3310/hta25100] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Although non-operative treatment is known to be effective for the treatment of uncomplicated acute appendicitis in children, randomised trial data comparing important outcomes of non-operative treatment with those of appendicectomy are lacking. OBJECTIVES The objectives were to ascertain the feasibility of conducting a multicentre randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of a non-operative treatment pathway with appendicectomy for the treatment of uncomplicated acute appendicitis in children. DESIGN This was a mixed-methods study, which included a feasibility randomised controlled trial, embedded and parallel qualitative and survey studies, a parallel health economic feasibility study and the development of a core outcome set. SETTING This study was set in three specialist NHS paediatric surgical units in England. PARTICIPANTS Children (aged 4-15 years) clinically diagnosed with uncomplicated acute appendicitis participated in the feasibility randomised controlled trial. Children, their families, recruiting clinicians and other health-care professionals involved in caring for children with appendicitis took part in the qualitative study. UK specialist paediatric surgeons took part in the survey. Specialist paediatric surgeons, adult general surgeons who treat children, and children and young people who previously had appendicitis, along with their families, took part in the development of the core outcome set. INTERVENTIONS Participants in the feasibility randomised controlled trial were randomised to a non-operative treatment pathway (broad-spectrum antibiotics and active observation) or appendicectomy. MAIN OUTCOME MEASURES The primary outcome measure was the proportion of eligible patients recruited to the feasibility trial. DATA SOURCES Data were sourced from NHS case notes, questionnaire responses, transcribed audio-recordings of recruitment discussions and qualitative interviews. RESULTS Overall, 50% (95% confidence interval 40% to 59%) of 115 eligible patients approached about the trial agreed to participate and were randomised. There was high acceptance of randomisation and good adherence to trial procedures and follow-up (follow-up rates of 89%, 85% and 85% at 6 weeks, 3 months and 6 months, respectively). More participants had perforated appendicitis than had been anticipated. Qualitative work enabled us to communicate about the trial effectively with patients and families, to design and deliver bespoke training to optimise recruitment and to understand how to optimise the design and delivery of a future trial. The health economic study indicated that the main cost drivers are the ward stay cost and the cost of the operation; it has also informed quality-of-life assessment methods for future work. A core outcome set for the treatment of uncomplicated acute appendicitis in children and young people was developed, containing 14 outcomes. There is adequate surgeon interest to justify proceeding to an effectiveness trial, with 51% of those surveyed expressing a willingness to recruit with an unchanged trial protocol. LIMITATIONS Because the feasibility randomised controlled trial was performed in only three centres, successful recruitment across a larger number of sites cannot be guaranteed. However, the qualitative work has informed a bespoke training package to facilitate this. Although survey results suggest adequate clinician interest to make a larger trial possible, actual participation may differ, and equipoise may have changed over time. CONCLUSIONS A future effectiveness trial is feasible, following limited additional preparation, to establish appropriate outcome measures and case identification. It is recommended to include a limited package of qualitative work to optimise recruitment, in particular at new centres. FUTURE WORK Prior to proceeding to an effectiveness trial, there is a need to develop a robust method for distinguishing children with uncomplicated acute appendicitis from those with more advanced appendicitis, and to reach agreement on a primary outcome measure and effect size that is acceptable to all stakeholder groups involved. TRIAL REGISTRATION Current Controlled Trials ISRCTN15830435. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nigel J Hall
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Frances C Sherratt
- Department of Health Services Research, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Simon Eaton
- University College London Great Ormond Street Institute of Child Health, Department of Population Health Sciences, University College London, London, UK
| | - Isabel Reading
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Erin Walker
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Maria Chorozoglou
- Southampton Health Technology Assessment Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Lucy Beasant
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, Bristol, UK
| | - Wendy Wood
- National Institute for Health Research (NIHR), Research Design Service South Central, University of Southampton, Southampton, UK
| | - Michael Stanton
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Harriet J Corbett
- Department of Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Dean Rex
- Department of Paediatric Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Natalie Hutchings
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Elizabeth Dixon
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Simon Grist
- Patient and public involvement representative
| | - William Van't Hoff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Esther Crawley
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Blazeby
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Bridget Young
- Department of Health Services Research, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
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15
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A supercritical assisted process for the production of amoxicillin-loaded liposomes for antimicrobial applications. J Supercrit Fluids 2020. [DOI: 10.1016/j.supflu.2020.104842] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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Cross W, Kowdley GC. Laparoscopic Appendectomy for Acute Appendicitis: A Safe Same-day Surgery Procedure? Am Surg 2020. [DOI: 10.1177/000313481307900822] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over 250,000 cases of appendicitis occur annually in the United States. The mainstay of treatment is surgical removal with admission. Recently, antibiotic therapy as an alternative has been introduced and the state of Maryland has incentivized 23-hour procedures. We studied patients with appendicitis discharged from the recovery room and those with length of stay (LOS) less than 24 hours. We retrospectively reviewed all appendectomies performed from June 2010 to October 2012 by three general surgeons. We excluded cases that were converted to open, appendectomies performed in the setting of another disease process, and incidental appendectomies. A total of 84 laparoscopic appendectomies were included. Of these, 55 patients had LOS less than 24 hours. Pathology, comorbidities, and readmission were recorded. χ2 analysis was used for determining statistical significance. Average LOS for all patients was 25 hours with a minimum stay of 2 hours and a maximum stay of 96 hours. For patients discharged in less than 24 hours, there was one readmission and 52 (95%) of these patients had simple appendicitis on pathology. A total of 19 patients (22%) were discharged in less than 7 hours (from the recovery room). Among these patients, there were no readmissions, and 18 (95%) were cases of simple appendicitis ( P = 0.4431). There was no significant difference in complications or readmission between patients discharged in less than 24 hours and those who stayed longer. Our subgroup analysis indicated that discharge from the postanesthesia care unit after uncomplicated laparoscopic appendectomy should be further evaluated.
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Affiliation(s)
- Wirt Cross
- From Saint Agnes Hospital, Baltimore, Maryland
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17
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Schumm MA, Childers CP, Wu JX, Zanocco KA. Cost Saving of Short Hospitalization Nonoperative Management for Acute Uncomplicated Appendicitis. J Surg Res 2020; 255:77-85. [PMID: 32543382 DOI: 10.1016/j.jss.2020.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nonoperative management (NOM) of uncomplicated appendicitis has gained recognition as an alternative to surgery. In the largest published randomized trial (Appendicitis Acuta), patients received a 3-d hospital stay for intravenous antibiotics; however, cost implications for health care systems remain unknown. We hypothesized short stay protocols would be cost saving compared with a long stay protocol. MATERIALS AND METHODS We constructed a Markov model comparing the cost of three protocols for NOM of acute uncomplicated appendicitis: (1) long stay (3-d hospitalization), (2) short stay (1-d hospitalization), and (3) emergency department (ED) discharge. The long stay protocol was modeled on data from the APPAC trial. Model variables were abstracted from national database and literature review. One-way and two-way sensitivity analyses were performed to determine the impact of uncertainty on the model. RESULTS The long stay treatment protocol had a total 5-y projected cost of $10,735 per patient. The short stay treatment protocol costs $8026 per patient, and the ED discharge protocol costs $6,825, which was $2709 and $3910 less than the long stay protocol, respectively. One-way sensitivity analysis demonstrated that the relative risk of treatment failure with the short stay protocol needed to exceed 6.3 (absolute risk increase of 31%) and with the ED discharge protocol needed to exceed 8.75 (absolute risk increase of 45%) in order for the long stay protocol to become cost saving. CONCLUSIONS Short duration hospitalization protocols to treat appendicitis nonoperatively with antibiotics are cost saving under almost all model scenarios. Future consideration of patient preferences and health-related quality of life will need to be made to determine if short stay treatment protocols are cost-effective.
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Affiliation(s)
- Max A Schumm
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California.
| | | | - James X Wu
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Kyle A Zanocco
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
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18
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Heeren N, Gass M. [Can Uncomplicated Adult Appendicitis Also Be Treated Conservatively?]. PRAXIS 2020; 109:465-470. [PMID: 32345175 DOI: 10.1024/1661-8157/a003452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Can Uncomplicated Adult Appendicitis Also Be Treated Conservatively? Abstract. For more than a century, appendectomy has been the first-line treatment for acute appendicitis. Despite modern imaging, it is not an easy disease to diagnose and is one of the most common emergency procedures worldwide. Conservative therapy for uncomplicated adult appendicitis is increasingly becoming the focus of discussion. Due to current data, a recommendation for conservative therapy of uncomplicated adult appendicitis can not be given. For the time being it should be reserved for a selected patient group.
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Affiliation(s)
| | - Markus Gass
- Abteilung für Viszeralchirurgie, Luzerner Kantonsspital, Luzern
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19
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Guaitoli E, Gallo G, Cardone E, Conti L, Famularo S, Formisano G, Galli F, Giuliani G, Martino A, Pasculli A, Patini R, Soriero D, Pappalardo V, Casoni Pattacini G, Sparavigna M, Meniconi R, Mazzari A, Barra F, Orsenigo E, Pertile D. Consensus Statement of the Italian Polispecialistic Society of Young Surgeons (SPIGC): Diagnosis and Treatment of Acute Appendicitis. J INVEST SURG 2020; 34:1089-1103. [PMID: 32167385 DOI: 10.1080/08941939.2020.1740360] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.Methods: This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.Results: Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.
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Affiliation(s)
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Eleonora Cardone
- Department of Surgery, Santa Maria del Popolo degli Incurabili Hospital, Napoli, Italy
| | - Luigi Conti
- Department of Surgery, G. Da Saliceto Hospital, Piacenza, Italy
| | - Simone Famularo
- Department of Medicine and Surgery University of Milan Bicocca HPB Unit, San Gerardo Hospital, Monza, Italy
| | - Giampaolo Formisano
- Department of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | | | - Giuseppe Giuliani
- Department of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Antonio Martino
- Department of General Surgery, University of Genoa, Genova, Italy
| | | | - Romeo Patini
- Odontostomatology and Oral Surgery, Sacro Cuore Hospital, Rome, Italy
| | - Domenico Soriero
- Department of General Surgery, University of Genoa, Genova, Italy
| | | | | | - Marco Sparavigna
- Department of General Surgery, University of Genoa, Genova, Italy
| | - Roberto Meniconi
- Department of General Surgeon and Transplantations, San Camillo-Forlanini Hospital, Rome, Italy
| | - Andrea Mazzari
- Mini Invasive and General Surgery, Cristo Re Hospital, Rome, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy
| | - Elena Orsenigo
- Department of General and Emergency Surgery, San Raffaele Scientific Institute, Milano, Italy
| | - Davide Pertile
- Department of General Surgery, University of Genoa, Genova, Italy
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20
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Ninh A, Wood K, Bui AH, Leitman IM. Risk Factors and Outcomes for Sepsis after Appendectomy in Adults. Surg Infect (Larchmt) 2019; 20:601-606. [DOI: 10.1089/sur.2019.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Allen Ninh
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kasey Wood
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anthony H. Bui
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - I. Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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21
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Bolakale-Rufai IK, Irabor DO. Medical Treatment: An Emerging Standard in Acute Appendicitis? Niger Med J 2019; 60:226-233. [PMID: 31844350 PMCID: PMC6900903 DOI: 10.4103/nmj.nmj_65_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/07/2019] [Accepted: 10/07/2019] [Indexed: 11/04/2022] Open
Abstract
Appendicectomy has been accepted as the gold standard for the management of appendicitis over the years, but there has been an increasing evidence and trend toward the conservative approach to the management of appendicitis. The aim of this review is to search existing literature and to evaluate and compare the conservative and operative approaches to the management of appendicitis. An electronic search of published literature was conducted through Pubmed, Google Scholar, Embase, and Medline using a variety of search items to find relevant observational studies, randomized clinical trials, systematic reviews, and meta-analyses. Bibliographies of selected articles were also analyzed for publications of interest relevant to the scope of the topic. The articles that reported primary outcomes after the management of appendicitis, complications, economic implications, and duration of follow-up were reviewed in detail. The major primary outcomes show a high recurrence rate and failed treatment associated with the conservative management of appendicitis. The other outcomes obtained show that there is an increased incidence of complications associated with operative management. Economic implications and cost-effectiveness analysis show that conservative treatment may be preferred. The length of hospital stay was significantly higher in conservative approach to management; however, shorter time off activities was observed. In general, the conservative management of appendicitis is still regarded as safe, effective, and efficacious, and further research with well-constructed study design, and larger sample size is required.
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Affiliation(s)
| | - David O. Irabor
- Department of Surgery, University College Hospital, Ibadan, Oyo-State, Nigeria
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22
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Abstract
For decades, the mandatory treatment for acute uncomplicated appendicitis was urgent appendicectomy. This dogma has now been questioned by several randomized controlled trials, which demonstrated the safety of antibiotic treatment of uncomplicated appendicitis without increased morbidity and mortality. The efficacy of this conservative treatment, however, is inferior to surgery: Within the first year after antibiotic treatment of acute appendicitis, approximately 30% of patients require appendicectomy. Within 5 years the rate of appendicectomy increases to 40% and the life-long risk of appendicectomy after conservative treatment can be expected to be even higher. The advantages of conservative treatment of appendicitis are faster recovery and the lack of postoperative wound pain; however, all currently available trials compared conservative treatment almost exclusively with conventional appendicectomy, trials comparing laparoscopic appendicectomy to antibiotics are currently not available. As laparoscopic appendicectomy is a well-established and safe treatment ubiquitously available in Germany, conservative treatment in patients with uncomplicated appendicitis cannot generally be recommended. As antibiotic treatment is a less effective but equally safe procedure, it can be offered to selected patients only.
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Minneci PC, Hade EM, Lawrence AE, Saito JM, Mak GZ, Hirschl RB, Gadepalli S, Helmrath MA, Leys CM, Sato TT, Lal DR, Landman MP, Kabre R, Fallat ME, Fischer BA, Cooper JN, Deans KJ. Multi-institutional trial of non-operative management and surgery for uncomplicated appendicitis in children: Design and rationale. Contemp Clin Trials 2019; 83:10-17. [PMID: 31254670 PMCID: PMC7073001 DOI: 10.1016/j.cct.2019.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/17/2019] [Accepted: 06/25/2019] [Indexed: 12/29/2022]
Abstract
Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children's hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a "successful" treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.
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Affiliation(s)
- Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Erinn M Hade
- Departments of Biomedical Informatics and Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Amy E Lawrence
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jacqueline M Saito
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Grace Z Mak
- Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine and Biologic Sciences, Chicago, IL, USA
| | - Ronald B Hirschl
- Division of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Samir Gadepalli
- Division of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Michael A Helmrath
- Division of Pediatric Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Thomas T Sato
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Matthew P Landman
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rashmi Kabre
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mary E Fallat
- Division of Pediatric Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Beth A Fischer
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Katherine J Deans
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
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The efficacy of antibiotic treatment versus surgical treatment of uncomplicated acute appendicitis: Systematic review and network meta-analysis of randomized controlled trial. Am J Surg 2019; 218:192-200. [PMID: 30340760 DOI: 10.1016/j.amjsurg.2018.10.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/14/2018] [Accepted: 10/05/2018] [Indexed: 12/26/2022]
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Felber A, Catalano D, Stafford C, Francone TD, Roberts PL, Marcello PW, Ricciardi R. What is the Long-Term Follow-Up of Nonoperatively Treated Patients with Appendicitis? Am Surg 2019. [DOI: 10.1177/000313481908500520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this study, we determine outcomes after nonoperative treatment of appendicitis. First, we abstracted data for patients discharged with a diagnosis of appendicitis from a tertiary care facility from August 1, 2007, through June 30, 2017. For patients treated nonoperatively, we collected additional medical treatment for appendicitis, future surgical treatment, and date of last follow-up. In our study, we identified 487 patients treated for appendicitis. From this group, 66 patients were successfully treated nonoperatively. Eight patients (12%) had an interval appendectomy at a mean follow-up time of two months. Of the 58 remaining patients, 20 (34%) did not have any further appendicitis-related issues over a mean follow-up period of 25 months. A total of 38 (66%) had recurring or additional concerns requiring further treatment or emergent surgery within a mean time of four months. A large proportion, 76 per cent (n = 29), required unscheduled or emergent appendectomy. There were more patients diagnosed with an abscess (55%) in the group that had further appendicitis issues. In conclusion, nonoperative treatment of appendicitis is associated with significant likelihood of future appendicitis-related treatment or emergency surgery (66%). In addition, patients diagnosed with an abscess are at particularly high risk of future appendicitis-related issues.
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Affiliation(s)
- Andrew Felber
- Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Deven Catalano
- Division of Colon and Rectal Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Caitlin Stafford
- Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Todd D. Francone
- Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Patricia L. Roberts
- Division of Colon and Rectal Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Peter W. Marcello
- Division of Colon and Rectal Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Rocco Ricciardi
- Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts; and
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Timmerman C, Hernandez AO, Ortiz C, Huertas VL, Lopez R, Huerta S. Current View on the Nonoperative Management of Acute Appendicitis in a County Hospital in Guatemala. J Surg Res 2019; 237:108-109. [DOI: 10.1016/j.jss.2018.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 02/20/2018] [Accepted: 03/06/2018] [Indexed: 12/29/2022]
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Sojar SH, Goldner JSV, Krishnamoorthy K, Murphy SA, Masiakos PT, Klig JE. A 17-Year-Old Boy With High-Functioning Autism, Gastrointestinal Illness, and Seizures. Pediatrics 2019; 143:peds.2017-3964. [PMID: 30545828 DOI: 10.1542/peds.2017-3964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2018] [Indexed: 11/24/2022] Open
Abstract
A healthy 17-year-old boy with a high-functioning pervasive developmental disorder presented to the emergency department after having a 4-minute episode of seizure-like activity in the setting of presumed viral gastroenteritis. Within an hour of emergency department arrival, he developed a forehead-sparing facial droop, right-sided ptosis, and expressive aphasia, prompting stroke team assessment and urgent neuroimaging. Laboratory results later revealed a serum sodium of 119 mmol/L. Neurologic deficits self-resolved, and a full physical examination revealed diffuse abdominal tenderness in the lower abdomen with rebound tenderness in the right-lower quadrant. The patient was admitted to the PICU for electrolyte management and monitoring. A computed tomography (CT) scan of the abdomen obtained the following morning revealed the patient's final diagnosis.
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Affiliation(s)
- Sakina H Sojar
- Massachusetts General Hospital, Boston, Massachusetts; and
| | | | | | - Sarah A Murphy
- Massachusetts General Hospital, Boston, Massachusetts; and
| | | | - Jean E Klig
- Massachusetts General Hospital, Boston, Massachusetts; and
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Gómez López JR, Martín Del Olmo JC, Montenegro Martín MA, Concejo Cutoli P, Martín Esteban ML, Toledano Trincado M, López Mestanza IC, Vaquero Puerta C. Laparoscopic Appendectomy in the Setting of Clinical Prediction Rules. J Laparoendosc Adv Surg Tech A 2018; 29:184-191. [PMID: 30585754 DOI: 10.1089/lap.2018.0707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Acute appendicitis (AA) is the most frequent surgical entity in the emergency department, but its correct diagnosis remains challenging. To improve diagnosis, clinical prediction rules (CPRs) have been created to establish objective scores for the probability of suffering AA. In this study, we establish scores indicating whether laparoscopy would be superior to clinical observation or repeat diagnostic test. METHODS A retrospective observational study was conducted with 433 patients submitted to surgery for suspected AA using a laparoscopic approach. The Alvarado, Raja Isteri Pengiran Anak Saleha Appendicitis, appendicitis inflammatory response, and adult appendicitis score scales were applied in each case to establish a high, medium, or low probability of suffering AA. RESULTS Of the 433 patients analyzed, 381 (88.0%) had AA. Twelve (2.8%) were converted to open surgery, and complications were observed in 54 (12.5%) cases. The CPRs studied showed statistically significant differences between AA and negative appendectomies. However, in patients with intermediate probability scores, the diagnostic accuracy of the CPRs evaluated was not adequate. CONCLUSIONS Laparoscopic surgery can serve as a diagnostic tool for patients with intermediate AA probability scores because of its low associated morbidity and mortality and because it affords a direct diagnosis of the problem, allowing determination of the appropriate treatment.
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Coccolini F, Fugazzola P, Sartelli M, Cicuttin E, Sibilla MG, Leandro G, De' Angelis GL, Gaiani F, Di Mario F, Tomasoni M, Catena F, Ansaloni L. Conservative treatment of acute appendicitis. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:119-134. [PMID: 30561405 PMCID: PMC6502196 DOI: 10.23750/abm.v89i9-s.7905] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Indexed: 12/17/2022]
Abstract
Acute appendicitis has been considered by surgeons a progressive disease leading to perforation for more than 100 years. In the last decades the theories about this concept gained attention, especially in adults. However, appendectomy for acute appendicitis remains the most common urgent/emergent surgical procedure. At present, accumulating evidences are showing the changing in clinical practice towards the non-operative management of several cases of acute appendicitis either non-complicated or complicated. The present review aims to show the literature results regarding the non-operative management of acute appendicitis in non-complicated and in complicated cases.
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Affiliation(s)
- Federico Coccolini
- Emergency, General and Trauma Surgery dept., Bufalini hospital, Cesena, Italy.
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Al-Mulhim AS. Readmission after antibiotic management of uncomplicated acute appendicitis in adults: prospective study. Eur J Trauma Emerg Surg 2018; 46:841-846. [PMID: 30367181 DOI: 10.1007/s00068-018-1038-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 10/19/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute appendicitis is the most common surgical cause of acute abdomen. Many randomized studies compare between antibiotic and surgery, and such studies indicated that antibiotics might treat acute appendicitis. However, there are concerns about selection bias in previous studies. Hence, to overcome this worry; we used in this study a full-scale population-based application. PATIENTS AND METHODS We identified 327 adult patients who were admitted to surgical ward with diagnosis of uncomplicated acute appendicitis between March 2013 and February 2016. All patients received antibiotic therapy after confirming the diagnosis by computed tomography. Endpoints were treatment efficacy, readmission, and complications in 1 year of follow-up. RESULTS Of the 327 patients include in this study, 8 (2.5%) patients failed initial non-operative (antibiotic) management and underwent operation during their initial hospitalization. Of 319 available for 1-year follow-up, 280 patients (87.8%) did not require appendectomy; while 39 patients (12.2%) need readmission within 1 year. CONCLUSIONS Antibiotics are a safe and visible option in acute appendicitis management. This approach needs careful assessment and evaluation for each individual patient before it is used as the first-line therapy.
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31
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March B, Leigh L, Brussius-Coelho M, Holmes M, Pockney P, Gani J. Can CRP velocity in right iliac fossa pain identify patients for intervention? A prospective observational cohort study. Surgeon 2018; 17:284-290. [PMID: 30309747 DOI: 10.1016/j.surge.2018.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/11/2018] [Accepted: 08/25/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Previous studies have shown single CRP measurements at time of presentation to have limited predictive benefit for appendicitis. Our objective was to determine the diagnostic utility of serial CRP measurements (to determine CRP velocity [CRPv]) in patients with right iliac fossa (RIF) pain. METHODS A single-centre prospective observational study was conducted on adult patients admitted with RIF pain. CRP was measured on admission, at midnight, and the following morning. Appendicitis was diagnosed on histopathology, or diagnostic imaging in non-operatively managed patients. Therapeutic interventions included all appropriate operative procedures and effective non-operative treatment with antibiotics. Logistic regression was used to generate predictors of therapeutic intervention, and then used to create a new risk score incorporating CRPv. RESULTS 98 of 112 (87.5%) participants had complete CRP data. 58 patients met the criteria for appendicitis (59.2%). Most patients presented with intermediate Modified Alvarado Scores (MAS) 5-6 (40.8%) or Appendicitis Inflammatory Response Scores (AIRS) 5-8 (49%). Our risk score had an AUROC of 0.88 (95% CI 0.81-0.96) in predicting therapeutic intervention. This score was superior to MAS, AIRS, and single admission biomarker measurements. Patients with an increasing CRPv had 14 times the odds (OR 14.07, 95% CI 0.63-315.2) of complicated appendicitis, and no cases of complicated appendicitis were observed in patients with a flat CRPv. CONCLUSIONS CRP velocity is superior to single CRP at predicting intervention. Our v-Score shows promise as a decision making-aide by predicting the need for surgical intervention in RIF pain. A flat CRPv identifies a group of patients with a very low risk of complicated appendicitis.
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Affiliation(s)
- Brayden March
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia
| | - Lucy Leigh
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | | | - Merran Holmes
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia
| | - Peter Pockney
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia
| | - Jon Gani
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia.
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Gorter RR, van der Lee JH, Heijsters FACJ, Cense HA, Bakx R, Kneepkens CMF, Wijnen MH, van der Steeg AFW, In't Hof KH, Offringa M, Heij HA. Outcome of initially nonoperative treatment for acute simple appendicitis in children. J Pediatr Surg 2018; 53:1849-1854. [PMID: 29395151 DOI: 10.1016/j.jpedsurg.2017.12.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 12/05/2017] [Accepted: 12/08/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE To compare the outcome of initially nonoperative treatment with immediate appendectomy for simple appendicitis in children. METHODS Between September 2012 and June 2014 children aged 7-17 years with a radiologically confirmed simple appendicitis were invited to participate in a multicentre prospective cohort study in which they were treated with an initially nonoperative treatment strategy; nonparticipants underwent immediate appendectomy. In October 2015, their rates of complications and subsequent appendectomies, and health-related quality of life (HRQOL) were assessed. RESULTS In this period, 25 children were treated with an initially nonoperative treatment strategy and 19 with immediate appendectomy; median (range) follow-up was 25 (16-36) and 26 (17-34) months, respectively. The percentage [95%CI] of patients experiencing complications in the initially nonoperative group and the immediate appendectomy group was 12 [4-30]% and 11 [3-31]%, respectively. In total 6/25 children (24%) underwent an appendectomy; none of the 6 patients operated subsequently experienced any postappendectomy complications. Overall, HRQOL in the nonoperative treatment group was similar to that of healthy peers. CONCLUSIONS Outcome of initially nonoperative treatment for acute simple appendicitis in children is similar to the outcome in those who undergo immediate appendectomy. Initially nonoperative management seems to be able to avoid appendectomy in 3 out of 4 children. LEVEL OF EVIDENCE 2 (prospective comparative study). This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
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Affiliation(s)
- Ramon R Gorter
- Paediatric Surgical Centre of Amsterdam. Emma Children's Hospital AMC and VU University Medical Centre, Amsterdam, the Netherlands; Department of Surgery, Red Cross Hospital. Beverwijk, the Netherlands.
| | - Johanna H van der Lee
- Paediatric Clinical Research Office, Division Woman and Child, Academic Medical Centre, Amsterdam, the Netherlands
| | - Florence A C J Heijsters
- Paediatric Surgical Centre of Amsterdam. Emma Children's Hospital AMC and VU University Medical Centre, Amsterdam, the Netherlands
| | - Huibert A Cense
- Department of Surgery, Red Cross Hospital. Beverwijk, the Netherlands
| | - Roel Bakx
- Paediatric Surgical Centre of Amsterdam. Emma Children's Hospital AMC and VU University Medical Centre, Amsterdam, the Netherlands
| | - C M Frank Kneepkens
- Department of Paediatric Gastroenterology, VU University Medical Centre, Amsterdam, the Netherlands
| | - Marc H Wijnen
- Department of Paediatric Surgery. Princess Maxima Centre, Utrecht, the Netherlands
| | - Alida F W van der Steeg
- Paediatric Surgical Centre of Amsterdam. Emma Children's Hospital AMC and VU University Medical Centre, Amsterdam, the Netherlands; Centre of Research on Psychology in Somatic Disease (CoRPS), Tilburg University, the Netherlands
| | | | - Martin Offringa
- Child Health Evaluation Sciences (CHES), The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Hugo A Heij
- Paediatric Surgical Centre of Amsterdam. Emma Children's Hospital AMC and VU University Medical Centre, Amsterdam, the Netherlands
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Cirocco WC, Ellison EC. 75 years of the Central Surgical Association: The last quarter century. Surgery 2018; 164:626-639. [PMID: 30093280 DOI: 10.1016/j.surg.2018.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 06/21/2018] [Indexed: 10/28/2022]
Affiliation(s)
- William C Cirocco
- The Ohio State University, Wexner College of Medicine, Department of Surgery, N711 Doan Hall, 410 West 10th Avenue, Columbus, OH.
| | - E Christopher Ellison
- The Ohio State University, Wexner College of Medicine, Department of Surgery, N711 Doan Hall, 410 West 10th Avenue, Columbus, OH
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Allende R, Muñoz R. Are antibiotics a safe and effective treatment for acute uncomplicated appendicitis?- First update. Medwave 2018; 18:e7228. [PMID: 26817927 DOI: 10.5867/medwave.2018.04.7229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 04/23/2018] [Indexed: 11/27/2022] Open
Abstract
UPDATE This Living FRISBEE (Living FRIendly Summary of the Body of Evidence using Epistemonikos) is an update of the summary published in January 2016. INTRODUCTION Appendicitis is a typical cause of acute abdominal pain and the most frequent cause of emergency abdominal surgery. In the last two decades, increasing evidence has been published about the use of antibiotics as an exclusive treatment for acute appendicitis. METHODS To answer this question, we used Epistemonikos, the largest database of systematic reviews in health, which is maintained through searches from multiple sources of information, including MEDLINE, EMBASE, Cochrane, among others. We extracted the data from the identified reviews, reanalyzed the data from the primary studies, performed a meta-analysis and prepared a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS We identified 23 systematic reviews including 28 primary studies, of which eight were randomized trials. We concluded the exclusive use of antibiotics for the treatment of uncomplicated acute appendicitis could be less effective than appendectomy, but it might be associated with a lower rate of complications.
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Affiliation(s)
- Rubén Allende
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile
| | - Rodrigo Muñoz
- Proyecto Epistemonikos, Santiago, Chile; Departamento de Cirugía Digestiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile. . Address: Centro Evidencia UC, Pontificia Universidad Católica de Chile, Diagonal Paraguay 476, Santiago, Chile
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Renteria O, Shahid Z, Huerta S. Outcomes of appendectomy in elderly veteran patients. Surgery 2018; 164:460-465. [PMID: 29914654 DOI: 10.1016/j.surg.2018.04.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/31/2018] [Accepted: 04/11/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Some studies indicate that noncomplicated acute appendicitis might be treated exclusively with antibiotics instead of an appendectomy. This study was undertaken to assess outcomes in elderly veterans and to determine if operative intervention would lead to substantial complications such that a nonoperative strategy should be investigated. METHODS A retrospective, single-institution analysis was conducted of patients who underwent an appendectomy at the VA North Texas Health Care System over a period of 12 years (from July 2005 to June 2017). Patients who underwent an appendectomy for cancer, interval appendectomy, exploratory laparotomy for perforated appendicitis, or appendectomy as part of another major operation were excluded from the study. Patients were then grouped as elderly (≥60 years old) and young (<60 years old), and differences in outcome were assessed. Univariate and multivariate analyses were also performed to determine if age and comorbid conditions were independent predictors of complications in both cohorts. RESULTS Of patients who underwent an appendectomy for acute appendicitis (n = 257, male = 90.7%, age = 45.4 ± standard deviation 15.6 years, body mass index = 30.3 ± 6.3 kg/m2), 195 were young (38.7 ± 11.2 years old) and 62 elderly (66 ± 5 years old). More patients were male in the elderly cohort (98.4% vs 88%; P = .01). The incidence of gangrenous and perforated appendicitis was greater in elderly patients (11.3% and 14.4% vs 24 % and 40%, P < .01 each). Diabetes and hypertension, as well as a history of cardiac, pulmonary, and renal diseases, were more than 2-fold greater in older patients. Complications and 30-day readmission rates were similar in both groups (young vs elderly: 7.2% and 9% vs 9.7% and 11%, P > .5 each). Logistic regression analysis showed that age and American Society of Anesthesia level were not independent predictors of complications. A history of cardiac disease and open operation independently predicted complications regardless of age. Unexpected malignancy was 3% in the elderly and 1.5% in the young cohort (P = .6) CONCLUSION: Complicated appendicitis is more common in elderly patients. Appendectomy in elderly veteran patients has a low rate of complications similar to younger patients and the private sector. Operative intervention in this group of patients is not prohibitive. Further studies are needed to determine if nonoperative intervention is noninferior to an appendectomy in this high-risk patient population.
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Affiliation(s)
- Oswaldo Renteria
- University of Texas Southwestern Medical Center, Department of Surgery, Dallas, TX
| | - Zain Shahid
- University of Texas Southwestern Medical Center, Department of Surgery, Dallas, TX
| | - Sergio Huerta
- University of Texas Southwestern Medical Center, Department of Surgery, Dallas, TX; VA North Texas Health Care System, Department of Surgery, Dallas, TX.
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Hutchings N, Wood W, Reading I, Walker E, Blazeby JM, van’t Hoff W, Young B, Crawley EM, Eaton S, Chorozoglou M, Sherratt FC, Beasant L, Corbett H, Stanton MP, Grist S, Dixon E, Hall NJ. CONTRACT Study - CONservative TReatment of Appendicitis in Children (feasibility): study protocol for a randomised controlled Trial. Trials 2018; 19:153. [PMID: 29499722 PMCID: PMC5833142 DOI: 10.1186/s13063-018-2520-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 02/02/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Currently, the routine treatment for acute appendicitis in the United Kingdom is an appendicectomy. However, there is increasing scientific interest and research into non-operative treatment of appendicitis in adults and children. While a number of studies have investigated non-operative treatment of appendicitis in adults, this research cannot be applied to the paediatric population. Ultimately, we aim to perform a UK-based multicentre randomised controlled trial (RCT) to test the clinical and cost effectiveness of non-operative treatment of acute uncomplicated appendicitis in children, as compared with appendicectomy. First, we will undertake a feasibility study to assess the feasibility of performing such a trial. METHODS/DESIGN The study involves a feasibility RCT with a nested qualitative research to optimise recruitment as well as a health economic substudy. Children (aged 4-15 years inclusive) diagnosed with acute uncomplicated appendicitis that would normally be treated with an appendicectomy are eligible for the RCT. Exclusion criteria include clinical/radiological suspicion of perforated appendicitis, appendix mass or previous non-operative treatment of appendicitis. Participants will be randomised into one of two arms. Participants in the intervention arm are treated with antibiotics and regular clinical assessment to ensure clinical improvement. Participants in the control arm will receive appendicectomy. Randomisation will be minimised by age, sex, duration of symptoms and centre. Children and families who are approached for the RCT will be invited to participate in the embedded qualitative substudy, which includes recording of recruitment consultants and subsequent interviews with participants and non-participants and their families and recruiters. Analyses of these will inform interventions to optimise recruitment. The main study outcomes include recruitment rate (primary outcome), identification of strategies to optimise recruitment, performance of trial treatment pathways, clinical outcomes and safety of non-operative treatment. We have involved children, young people and parents in study design and delivery. DISCUSSION In this study we will explore the feasibility of performing a full efficacy RCT comparing non-operative treatment with appendicectomy in children with acute uncomplicated appendicitis. Factors determining success of the present study include recruitment rate, safety of non-operative treatment and adequate interest in the future RCT. Ultimately this feasibility study will form the foundation of the main RCT and reinforce its design. TRIAL REGISTRATION ISRCTN15830435 . Registered on 8 February 2017.
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Affiliation(s)
- Natalie Hutchings
- Southampton Clinical Trials Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Wendy Wood
- National Institute of Health Research (NIHR), Research Design Service South Central, University of Southampton, Southampton, UK
| | - Isabel Reading
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Erin Walker
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jane M. Blazeby
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - William van’t Hoff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Bridget Young
- Institute of Psychology, Health & Society, University of Liverpool, Liverpool, UK
| | - Esther M. Crawley
- Centre for Child and Adolescent Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Simon Eaton
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Maria Chorozoglou
- Southampton Health Technology Assessment Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Frances C. Sherratt
- Institute of Psychology, Health & Society, University of Liverpool, Liverpool, UK
| | - Lucy Beasant
- Centre for Child and Adolescent Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Harriet Corbett
- Department of Paediatric Surgery, Alder Hey Children’s NHS Foundation Trust, East Prescott Road, Liverpool, L14 5AB UK
| | - Michael P. Stanton
- Department of Paediatric Surgery and Urology, Southampton Children’s Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Simon Grist
- Patient and Public Involvement Representative, Southampton, UK
| | - Elizabeth Dixon
- Southampton Clinical Trials Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nigel J. Hall
- Department of Paediatric Surgery and Urology, Southampton Children’s Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University Surgery Unit, Faculty of Medicine, University of Southampton, Mailpoint 816, Tremona Road, Southampton, SO16 6YD UK
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Horattas MC, Horattas IK, Vasiliou EM. Early Uncomplicated Appendicitis—Who Can We Treat Nonoperatively?. Am Surg 2018. [DOI: 10.1177/000313481808400221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This study evaluated nonoperative treatment for mild appendicitis and reviewed selection criteria to be used in introducing this option into clinical practice. A retrospective review of 73 consecutive cases of appendicitis treated by a single surgeon from 2011 to 2013 was completed. Patients who were diagnosed with mild appendicitis meeting the criteria of an APPENDICITIS scoring algorithm proposed in this manuscript were considered for nonoperative management. An additional 17 patients with mild appendicitis were offered and successfully treated nonoperatively between 2014 and 2016 and reviewed. Of these original 73 patients, 37 had moderate to severe appendicitis and directly underwent appendectomy. The remaining patients were diagnosed with mild appendicitis and considered eligible for nonoperative management. Of these, 14 patients were offered nonoperative therapy. Thirteen responded successfully; one patient responded partially, but later opted for surgery. In 2014, this scoring system and preliminary results were shared with the other surgeons in our department. Nonoperative management was then selectively adopted by a few of the surgeons from 2014 to 2016 with another 17 patients (APPENDICITIS score of 0 or 1) being offered and successfully managed nonoperatively. Patients with mild or early appendicitis can be successfully managed nonoperatively. A proposed APPENDICITIS scoring system may provide a helpful mnemonic for successfully selecting patients for this option.
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Widdecombe J, Owen M. Case study: Laparoscopic appendicectomy requirements and human factors surrounding emergency care. J Perioper Pract 2018; 27:104-109. [PMID: 29328802 DOI: 10.1177/175045891702700504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 10/20/2016] [Indexed: 01/12/2023]
Abstract
The purpose of this case study is to inform practitioners of the requirements for non-scheduled surgery and the legal, professional and ethical issues surrounding emergencies. Areas for learning include the surgical requirements for appendectomy, evaluation of the differences between scheduled and unscheduled care, and consideration of the vital role that human factors play in emergency situations.
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Alnaser MKH, Hassan QA, Hindosh LN. Effectiveness of conservative management of uncomplicated acute appendicitis: A single hospital based prospective study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2017.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sartelli M, Baiocchi GL, Di Saverio S, Ferrara F, Labricciosa FM, Ansaloni L, Coccolini F, Vijayan D, Abbas A, Abongwa HK, Agboola J, Ahmed A, Akhmeteli L, Akkapulu N, Akkucuk S, Altintoprak F, Andreiev AL, Anyfantakis D, Atanasov B, Bala M, Balalis D, Baraket O, Bellanova G, Beltran M, Melo RB, Bini R, Bouliaris K, Brunelli D, Castillo A, Catani M, Che Jusoh A, Chichom-Mefire A, Cocorullo G, Coimbra R, Colak E, Costa S, Das K, Delibegovic S, Demetrashvili Z, Di Carlo I, Kiseleva N, El Zalabany T, Faro M, Ferreira M, Fraga GP, Gachabayov M, Ghnnam WM, Giménez Maurel T, Gkiokas G, Gomes CA, Griffiths E, Guner A, Gupta S, Hecker A, Hirano ES, Hodonou A, Hutan M, Ioannidis O, Isik A, Ivakhov G, Jain S, Jokubauskas M, Karamarkovic A, Kauhanen S, Kaushik R, Kavalakat A, Kenig J, Khokha V, Khor D, Kim D, Kim JI, Kong V, Lasithiotakis K, Leão P, Leon M, Litvin A, Lohsiriwat V, López-Tomassetti Fernandez E, Lostoridis E, Maciel J, Major P, Dimova A, Manatakis D, Marinis A, Martinez-Perez A, Marwah S, McFarlane M, Mesina C, Pędziwiatr M, Michalopoulos N, Misiakos E, Mohamedahmed A, Moldovanu R, Montori G, Mysore Narayana R, Negoi I, Nikolopoulos I, Novelli G, Novikovs V, Olaoye I, Omari A, Ordoñez CA, Ouadii M, Ozkan Z, Pal A, Palini GM, Partecke LI, Pata F, Pędziwiatr M, Pereira Júnior GA, Pintar T, Pisarska M, Ploneda-Valencia CF, Pouggouras K, Prabhu V, Ramakrishnapillai P, Regimbeau JM, Reitz M, Rios-Cruz D, Saar S, Sakakushev B, Seretis C, Sazhin A, Shelat V, Skrovina M, Smirnov D, Spyropoulos C, Strzałka M, Talving P, Teixeira Gonsaga RA, Theobald G, Tomadze G, Torba M, Tranà C, Ulrych J, Uzunoğlu MY, Vasilescu A, Occhionorelli S, Venara A, Vereczkei A, Vettoretto N, Vlad N, Walędziak M, Yilmaz TU, Yuan KC, Yunfeng C, Zilinskas J, Grelpois G, Catena F. Prospective Observational Study on acute Appendicitis Worldwide (POSAW). World J Emerg Surg 2018; 13:19. [PMID: 29686725 PMCID: PMC5902943 DOI: 10.1186/s13017-018-0179-0] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 04/04/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments. METHODS This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016-September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study. RESULTS A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%. CONCLUSIONS The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.
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Affiliation(s)
| | - Gian L. Baiocchi
- 0000000417571846grid.7637.5Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Salomone Di Saverio
- 0000 0004 1759 7093grid.416290.8Emergency Surgery, Maggiore Hospital, Bologna, Italy
| | - Francesco Ferrara
- grid.414126.4General Surgery and Polytrauma, San Carlo Borromeo Hospital, Milan, Italy
| | - Francesco M. Labricciosa
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, UNIVPM, Ancona, Italy
| | - Luca Ansaloni
- 0000 0004 1758 8744grid.414682.dDepartment of Surgery, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- 0000 0004 1758 8744grid.414682.dDepartment of Surgery, Bufalini Hospital, Cesena, Italy
| | - Deepak Vijayan
- 0000 0004 0376 6589grid.412563.7General Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ashraf Abbas
- grid.469958.fEmergency Surgery, Mansoura University Hospital, Mansoura, Egypt
| | | | - John Agboola
- Surgery, Kwara State General Hospital, Ilorin, Kwara Nigeria
| | - Adamu Ahmed
- 0000 0004 4688 7583grid.413221.7Surgery, Ahmadu Bello University Teaching Hospital Zaria, Zaria, Nigeria
| | | | - Nezih Akkapulu
- 0000 0001 1457 1144grid.411548.dGeneral Surgery, Baskent Universitesi Adana Eğitim ve Uygulama Hastanesi, Adana, Turkey
| | - Seckin Akkucuk
- 0000 0001 0680 7823grid.14352.31General Surgery, Training and Research Hospital of Mustafa Kemal University, Hatay, Turkey
| | - Fatih Altintoprak
- 0000 0001 0682 3030grid.49746.38General Surgery, Sakarya University School of Medicine, Sakarya, Turkey
| | - Aurelia L. Andreiev
- 0000 0004 0376 6589grid.412563.7General Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Boiko Atanasov
- 0000 0001 0726 0380grid.35371.33Department of General Surgery, Medical University of Plovdiv, UMHAT Eurohospital, Plovdiv, Bulgaria
| | - Miklosh Bala
- 0000 0001 2221 2926grid.17788.31General Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Dimitrios Balalis
- Surgical Department, Agios Savvas Anticaner Hospital, Athens, Greece
| | - Oussama Baraket
- General Surgery, Hospital Habib Bouguefa de Bizerte, Bizerte, Tunisia
| | | | - Marcelo Beltran
- Surgery, Hospital San Juan de Dios de La Serena, La Serena, Chile
| | - Renato Bessa Melo
- 0000 0000 9375 4688grid.414556.7General Surgery, Centro Hospitalar São João, Porto, Portugal
| | - Roberto Bini
- 0000 0004 1760 7116grid.415044.0General and Emergency Surgery, San Giovanni Bosco Hospital, Turin, Italy
| | | | | | - Adrian Castillo
- 0000 0001 0157 6501grid.239844.0Department of Surgery, Harbor-UCLA Medical Center, Torrance, USA
| | - Marco Catani
- grid.7841.aDEA, La Sapienza Università di Roma, Policlinico Umberto I, Rome, Italy
| | - Asri Che Jusoh
- General Surgery, Kuala Krai Hospital, Kuala Krai, Kelantan Malaysia
| | | | - Gianfranco Cocorullo
- 0000 0004 1756 3088grid.412510.3Emergency Surgery, Azienda Ospedaliera Universitaria Policlinico Paolo Giaccone, Palermo, Italy
| | - Raul Coimbra
- 0000 0001 2107 4242grid.266100.3Trauma/Acute Care Surgery, University of California San Diego, San Diego, USA
| | - Elif Colak
- General Surgery, Samsun Training and Research Hospital, Samsun, Turkey
| | - Silvia Costa
- 0000 0000 8902 4519grid.418336.bSurgery, CHVNG/E, EPE, Vila Nova de Gaia, Portugal
| | - Koray Das
- 0000 0004 0642 7670grid.413791.9General Surgery, Numune Training and Research Hospital, Adana, Turkey
| | - Samir Delibegovic
- 0000 0001 0682 9061grid.412410.2Colorectal Surgery, Clinic for Surgery, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | | | - Isidoro Di Carlo
- 0000 0004 0637 437Xgrid.413542.5Surgery, Hamad General Hospital, Doha, Qatar
| | - Nadezda Kiseleva
- 0000 0004 0375 2558grid.488518.8General and Emergency Surgery, Riga East University Hospital “Gailezers”, Riga, Latvia
| | | | - Mario Faro
- 0000 0004 0643 8839grid.412368.aDepartment of General Surgery, Trauma and Emergency Surgery Division, ABC Medical School, Santo Andreì, SP Brazil
| | - Margarida Ferreira
- 0000 0000 8563 4416grid.414708.eGeneral Surgery, Hospital Garcia de Orta, Lisbon, Portugal
| | - Gustavo P. Fraga
- 0000 0001 0723 2494grid.411087.bDivision of Trauma Surgery, Hospital de Clinicas, University of Campinas (Unicamp), Campinas, Brazil
| | - Mahir Gachabayov
- Department of Abdominal Surgery, Vladimir City Clinical Hospital of Emergency Medicine, Vladimir, Russia
| | - Wagih M. Ghnnam
- 0000000103426662grid.10251.37General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Teresa Giménez Maurel
- 0000 0000 9854 2756grid.411106.3Cirugía General y del Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Georgios Gkiokas
- 0000 0001 2155 0800grid.5216.0Second Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Carlos A. Gomes
- Surgery, Therezinha de Jesus University Hospital, Juiz de Fora, Brazil
| | - Ewen Griffiths
- 0000 0004 0376 6589grid.412563.7Upper GI/General Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ali Guner
- 0000 0001 2186 0630grid.31564.35Department of General Surgery, Karadeniz Technical University, Farabi Hospital, Trabzon, Turkey
| | - Sanjay Gupta
- 0000 0004 1767 2831grid.413220.6Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Andreas Hecker
- 0000 0000 8584 9230grid.411067.5Department of General and Thoracic Surgery, University Hospital, Giessen, Germany
| | - Elcio S. Hirano
- 0000 0001 0723 2494grid.411087.bDivision of Trauma Surgery, Hospital de Clinicas, University of Campinas (Unicamp), Campinas, Brazil
| | | | - Martin Hutan
- Surgical Department, Landesklinikum Hainburg, Hainburg An Der Donau, Austria
| | - Orestis Ioannidis
- 0000000109457005grid.4793.94th Surgical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- grid.414012.2General Hospital “George Papanikoalou”, Thessaloniki, Greece
| | - Arda Isik
- 0000 0001 1498 7262grid.412176.7General Surgery, Erzincan University Mengucek Gazi Training and Research Hospital, Erzincan, Turkey
| | | | - Sumita Jain
- 0000 0004 1767 3615grid.416077.3Surgery, S M S Medical college, Jaipur, India
| | - Mantas Jokubauskas
- 0000 0004 0575 8750grid.48349.32Department of Surgery, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Aleksandar Karamarkovic
- 0000 0001 2166 9385grid.7149.bClinic for Emergency Surgery, Faculty of Medicine University of Belgrade, Belgrade, Serbia
| | - Saila Kauhanen
- 0000 0004 0628 215Xgrid.410552.7Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Robin Kaushik
- 0000 0004 1767 2831grid.413220.6Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Alfie Kavalakat
- 0000 0004 1802 2603grid.464600.0General Surgery, Jubilee Mission Medical College & Research Institute, Thrissur, India
| | - Jakub Kenig
- 0000 0001 2162 9631grid.5522.03rd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | | | - Desmond Khor
- 0000 0001 0084 1895grid.411409.9Acute Care Surgery, LAC+USC Medical Center, California, USA
| | - Dennis Kim
- 0000 0001 0157 6501grid.239844.0Department of Surgery, Harbor-UCLA Medical Center, Torrance, USA
| | - Jae I. Kim
- 0000 0004 0371 8173grid.411633.2Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Victor Kong
- 0000 0004 0576 7753grid.414386.cDepartment of Surgery, Edendale Hospital, Pietermaritzburg, South Africa
| | | | - Pedro Leão
- General Surgery, Colorectal Unit, Hospital de Braga, Braga, Portugal
| | - Miguel Leon
- grid.419651.eGeneral and Digestive Surgery, Hospital Fundación Jimenez Diaz, Madrid, Spain
| | - Andrey Litvin
- Surgical Disciplines, Regional Clinical Hospital, Kaliningrad, Russia
| | - Varut Lohsiriwat
- grid.416009.aFaculty of Medicine, Department of Surgery, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - James Maciel
- 0000 0001 0157 6501grid.239844.0Department of Surgery, Harbor-UCLA Medical Center, Torrance, USA
| | - Piotr Major
- 0000 0001 2162 9631grid.5522.02nd Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Ana Dimova
- 0000 0004 0397 9648grid.412688.1Clinic of surgery, Department of Gastrointestinal Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Dimitrios Manatakis
- grid.414012.2Surgical Department, Konstantopouleio General Hospital, Athens, Greece
| | | | - Aleix Martinez-Perez
- 0000 0004 1770 9825grid.411289.7Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Sanjay Marwah
- 0000 0004 1771 1642grid.412572.7Department of General Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | - Michael McFarlane
- 0000 0001 2322 4996grid.12916.3dDepartment of Surgery, Radiology, Anaesthetics and Intensive Care, University of the West Indies, Kingston, Jamaica
- 0000 0004 0500 5353grid.412963.bUniversity Hospital of the West Indies, Kingston, Jamaica
| | - Cristian Mesina
- Department of Surgery Second Surgical Clinic, Emergency Hospital of Craiova, Craiova, Romania
| | - Michał Pędziwiatr
- 0000 0001 1216 0093grid.412700.0Department of General Surgery and Emergency Medicine, University Hospital, Kraków, Poland
| | - Nickos Michalopoulos
- 0000 0004 0576 4544grid.411222.63rd Department of Surgery, Ahepa University Hospital, Thessaloniki, Greece
| | - Evangelos Misiakos
- 0000 0001 2155 0800grid.5216.03rd Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | | | - Radu Moldovanu
- Department of Visceral, Digestive and Oncologic Surgery, Clinique Sainte Marie, Cambrai, France
| | - Giulia Montori
- 0000 0004 1758 8744grid.414682.dDepartment of Surgery, Bufalini Hospital, Cesena, Italy
| | | | - Ionut Negoi
- General Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | | | - Giuseppe Novelli
- grid.414614.2General, Emergency Surgery, Infermi Hospital, Rimini, Italy
| | - Viktors Novikovs
- 0000 0004 0375 2558grid.488518.8General and Emergency Surgery, Riga East University Hospital “Gailezers”, Riga, Latvia
| | - Iyiade Olaoye
- 0000 0000 8878 5287grid.412975.cSurgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Abdelkarim Omari
- 0000 0004 0411 3985grid.460946.9General Surgery, King Abdullah University Hospital, Irbid, Jordan
| | - Carlos A. Ordoñez
- grid.477264.4Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili and Universidad del Valle, Cali, Colombia
| | - Mouaqit Ouadii
- Surgery Departement, Medical School of Fezm, Sidi Mohamed Benabdellah University, Fez, Morocco
| | - Zeynep Ozkan
- General Surgery, Elazig Training and Research Hospital, Elazig, Turkey
| | - Ajay Pal
- 0000 0004 0645 6578grid.411275.4General Surgery, King George’s Medical University, Lucknow, India
| | - Gian M. Palini
- grid.414614.2General, Emergency Surgery, Infermi Hospital, Rimini, Italy
| | | | - Francesco Pata
- Department of General Surgery, Sant’Antonio Abate Hospital, Gallarate, Italy
| | - Michał Pędziwiatr
- 0000 0001 1216 0093grid.412700.0Department of Emergency Surgery and Trauma Centre, University Hospital, Kraków, Poland
| | | | - Tadeja Pintar
- 0000 0004 0571 7705grid.29524.38Abdominal surgery, UMC Ljubljana, Ljubljana, Slovenia
| | - Magdalena Pisarska
- 0000 0001 1216 0093grid.412700.0Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, The University Hospital in Krakow, Kraków, Poland
| | - Cesar F. Ploneda-Valencia
- 0000 0001 0432 668Xgrid.459608.6General Surgery, Hospital Civil de Guadalajara “Dr. Juan I. Menchaca”, Guadalajara, Mexico
| | | | - Vinod Prabhu
- 0000 0004 0503 0903grid.411681.bSurgery, Bharati Vidyapeeth Deemed University Medical College & Hospital, Sangli, Maharashtra India
| | | | - Jean-Marc Regimbeau
- 0000 0004 0593 702Xgrid.134996.0Digestive Surgery, CHU Amiens-Picardie, Amiens, France
| | - Marianne Reitz
- General Surgery, Hospital Municipal Dr. Jose de Carvalho Florence, Sao Jose Dos Campos, Brazil
| | - Daniel Rios-Cruz
- General Surgery, Hospital General Regional # 1 I.M.S.S, Cuernavaca, Mexico
| | - Sten Saar
- Acute Care Surgery, North Estonia Medical Center, Tallinn, Estonia
| | - Boris Sakakushev
- General Surgery, University Hospital St George, Plovdiv, Bulgaria
| | - Charalampos Seretis
- 0000 0004 0399 9948grid.416281.8General Surgery, Russells Hall Hospital, Birmingham, UK
| | | | - Vishal Shelat
- grid.240988.fGeneral Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Matej Skrovina
- Surgery, Hospital & Oncological Centre Novy Jicin, Novy Jicin, Czech Republic
| | - Dmitry Smirnov
- General Surgery, Clinical Hospital at Chelyabinsk Station OJSC “Russian Railways”, Chelyabinsk, Russian Federation
| | | | - Marcin Strzałka
- 0000 0001 2162 9631grid.5522.0General Surgery and Polytrauma, University Hospital, Medical College, Jagiellonian University, Kraków, Poland
| | - Peep Talving
- Acute Care Surgery, North Estonia Medical Center, Tallinn, Estonia
| | | | - George Theobald
- 0000 0004 0376 6589grid.412563.7General Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gia Tomadze
- 0000 0004 0428 8304grid.412274.6Surgery Department #2, Tbilisi State Medical University, Tbilisi, Georgia
| | - Myftar Torba
- General Surgery, Trauma University Hospital, Tirana, Albania
| | - Cristian Tranà
- Department of Surgery, Macerata Hospital, Macerata, Italy
| | - Jan Ulrych
- 0000 0000 9100 9940grid.411798.21st Department of Surgery—Department of Abdominal Thoracic Surgery and Traumatology, General University Hospital, Prague, Czech Republic
| | - Mustafa Y. Uzunoğlu
- 0000 0001 0680 7823grid.14352.31General Surgery, Training and Research Hospital of Mustafa Kemal University, Hatay, Turkey
| | - Alin Vasilescu
- First Surgical Clinic, St. Spiridon University Hospital, Iasi, Romania
| | | | - Aurélien Venara
- 0000 0004 0472 0283grid.411147.6Digestive and Endocrinal Surgery, University Hospital, Angers, France
| | - Andras Vereczkei
- 0000 0001 0663 9479grid.9679.1Department of Surgery, Medical School University of Pécs, Pécs, Hungary
| | | | - Nutu Vlad
- First Surgical Clinic, St. Spiridon University Hospital, Iasi, Romania
| | - Maciej Walędziak
- 0000 0004 0620 0839grid.415641.3Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine in Warsaw, Warsaw, Poland
| | - Tonguç U. Yilmaz
- 0000 0001 0691 9040grid.411105.0Department of General Surgery, Kocaeli University, Kocaeli, Turkey
| | - Kuo-Ching Yuan
- Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cui Yunfeng
- grid.417036.7Department of Surgery, Tianjin Nankai Hospital, Tianjin, China
| | - Justas Zilinskas
- 0000 0004 0575 8750grid.48349.32Department of Surgery, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Gérard Grelpois
- 0000 0004 0593 702Xgrid.134996.0Digestive Surgery, CHU Amiens-Picardie, Amiens, France
| | - Fausto Catena
- grid.469958.fEmergency Surgery, Mansoura University Hospital, Mansoura, Egypt
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Kim C, Kang B, Park J, Ha Y. The Use of Clinician-Performed Ultrasonography to Determine the Treatment Method for Suspected Paediatric Appendicitis. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791502200104] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To investigate whether the clinician-performed ultrasonography based on the specific criteria for paediatric appendicitis could decrease the negative appendectomy rate without treatment failure. Methods The study was a retrospective review of paediatric patients with suspected appendicitis who presented at the emergency department of a teaching hospital over a period of 18 months. The clinicians performed the ultrasound and decided whether the patients with suspected appendicitis should be referred to surgery or managed conservatively. The determinative ultrasound criteria were the presence of periappendiceal fat infiltration and/or an obstructing appendicolith. Results The 166 paediatric patients with suspected appendicitis underwent ultrasonography performed by clinicians on weekdays; forty (24.1%) cases with an obstructing appendicolith and/or periappendiceal fat infiltration were treated surgically, and none had a pathologically negative appendectomy, which was significantly lower than the number in the computed tomography scan group (10.4%, 11/106) on weeknights or weekends. The remaining 126 (75.8%) patients without obstructing appendicolith or periappendiceal fat infiltration were treated conservatively, regardless of their appendiceal diameter, and no patients experienced a treatment failure. Conclusions The clinician-performed ultrasonography bases on the strict use of above specific ultrasound criteria to determine treatment strategies for suspected paediatric appendicitis can reduce the negative appendectomies without treatment failure. (Hong Kong j.emerg.med. 2015;22:31-40)
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Affiliation(s)
| | | | - Jb Park
- Seoul Hospital, Department of Emergency Medicine, Soonchunhyang University College of Medicine, Republic of Korea
| | - Yr Ha
- Daejin Medical Center Bundang Jesaeng General Hospital, Department of Emergency Medicine, Republic of Korea
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Read A, Xu J, Adams S, Karpelowsky J. Five lessons in uncomplicated appendicitis: Can we remove the surgery? J Paediatr Child Health 2017; 53:1127-1130. [PMID: 29148199 DOI: 10.1111/jpc.13741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/17/2017] [Accepted: 08/29/2017] [Indexed: 12/27/2022]
Abstract
Appendicectomy has remained the treatment of choice for appendicitis for over a century and is the most commonly performed emergency operation in children. However, emerging evidence suggests that appendicectomy may not always be necessary in uncomplicated appendicitis, with early paediatric trials demonstrating that antibiotic-only therapy can be safe and effective. Further rigorously designed and appropriately powered studies are necessarily to establish the place of non-operative management of uncomplicated appendicitis in the future.
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Affiliation(s)
- Andrew Read
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Paediatric Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Jane Xu
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Susan Adams
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Paediatric Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia.,Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Jonathan Karpelowsky
- Department of Paediatric Surgery, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Division of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
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A prospective non-randomized controlled, multicenter trial comparing Appendectomy and Conservative Treatment for Patients with Uncomplicated Acute Appendicitis (the ACTUAA study). Int J Colorectal Dis 2017; 32:1649-1660. [PMID: 28812175 DOI: 10.1007/s00384-017-2878-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Acute appendicitis (AA) is among the most common causes of lower abdominal pain and admissions to the emergency department. Over the past 20 years, there has been a renewed interest in the conservative management of uncomplicated AA, and several studies demonstrated that an antibiotic-first strategy is a viable treatment option for uncomplicated AA. The aim of this prospective non-randomized controlled, multicenter trial is to compare antibiotic therapy and emergency appendectomy as treatment for patients with uncomplicated AA confirmed by US and/or CT or MRI scan. METHODS All adult patients in the age range 18 to 65 years with suspected AA, consecutively admitted to the Surgical Department of the 13 participating Italian Hospitals, will be invited to take part in the study. A multicenter prospective collected registry developed by surgeons, radiologists, and pathologists with expertise in the diagnosis and treatment of uncomplicated acute appendicitis represents the best research method to assess the long-term role of antibiotics in the management of the disease. Comparison will be made between surgical and antibiotic-first approaches to uncomplicated AA through the analysis of the primary outcome measure of complication-free treatment success rate based on 1-year follow-up. Quality of life, length of hospital stay, pain evaluation, and time to return to normal activity will be evaluated as secondary outcome measures. TRIAL REGISTRATION Clinicaltrials.gov ID: NCT03080103.
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Antibiotics-first strategy for uncomplicated acute appendicitis in adults is associated with increased rates of peritonitis at surgery. A systematic review with meta-analysis of randomized controlled trials comparing appendectomy and non-operative management with antibiotics. Surgeon 2017; 15:303-314. [PMID: 28284517 DOI: 10.1016/j.surge.2017.02.001] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/29/2016] [Accepted: 02/07/2017] [Indexed: 12/17/2022]
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Xu J, Adams S, Liu YC, Karpelowsky J. Nonoperative management in children with early acute appendicitis: A systematic review. J Pediatr Surg 2017; 52:1409-1415. [PMID: 28535960 DOI: 10.1016/j.jpedsurg.2017.05.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 04/11/2017] [Accepted: 05/04/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Appendectomy has remained the gold standard treatment of acute appendicitis for more than 100years. Nonoperative management (NOM) has been shown to be a valid treatment alternative for acute uncomplicated appendicitis in adults. A systematic review of available evidence comparing operative management (OM) and NOM in children with acute uncomplicated appendicitis was performed. METHODS Systematic searches of MedLine, Embase, and a clinical trial register (https://clinicaltrials.gov/) were performed in March 2016. Only articles that studied NOM for uncomplicated appendicitis in children were included. Data generation was performed independently by two authors, and quality was assessed using the rating schema by the Oxford Centre for Evidence-Based Medicine. RESULTS 15 articles were selected: four retrospective analyses, four prospective cohort studies, four prospective nonrandomized comparative trials and one randomized controlled trial (RCT). Initial success of the NOM groups (a cure within two weeks of intervention) ranged from 58 to 100%, with 0.1-31.8% recurrence at one year. CONCLUSION Although present literature is scarce, publications support the feasibility of further studies investigating NOM of acute uncomplicated appendicitis in children. Higher quality prospective RCTs with larger sample sizes and robust randomization methods, studying the noninferiority of NOM with antibiotics compared with OM are required to establish its utility. LEVEL OF EVIDENCE This manuscript is a systematic review and thus assigned the lowest evidence used from the manuscripts analyzed which is a Level IV.
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Affiliation(s)
- Jane Xu
- The School of Women's and Children's Health, The University of New South Wales, New South Wales, Australia
| | - Susan Adams
- The School of Women's and Children's Health, The University of New South Wales, New South Wales, Australia; Department of Pediatric Surgery, Sydney Children's Hospital, Randwick, New South Wales, Australia.
| | - Yingrui Cyril Liu
- Department of Pediatric Surgery, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Jonathan Karpelowsky
- Division of Child and Adolescent Health, The University of Sydney, New South Wales, Australia; Department of Pediatric Surgery, The Children's Hospital at Westmead, New South Wales, Australia
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46
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Serres SK, Cameron DB, Glass CC, Graham DA, Zurakowski D, Karki M, Anandalwar SP, Rangel SJ. Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children. JAMA Pediatr 2017; 171. [PMID: 28628705 PMCID: PMC5710637 DOI: 10.1001/jamapediatrics.2017.0885] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Management of appendicitis as an urgent rather than emergency procedure has become an increasingly common practice in children. Controversy remains as to whether this practice is associated with increased risk of complicated appendicitis and adverse events. OBJECTIVE To examine the association between time to appendectomy (TTA) and risk of complicated appendicitis and postoperative complications. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study using the Pediatric National Surgical Quality Improvement Program appendectomy pilot database, 2429 children younger than 18 years who underwent appendectomy within 24 hours of presentation at 23 children's hospitals from January 1, 2013, through December 31, 2014, were studied. EXPOSURES The main exposure was TTA, defined as the time from emergency department presentation to appendectomy. Patients were further categorized into early and late TTA groups based on whether their TTA was shorter or longer than their hospital's median TTA. Exposures were defined in this manner to compare rates of complicated appendicitis within a time frame sensitive to each hospital's existing infrastructure and diagnostic practices. MAIN OUTCOMES AND MEASURES The primary outcome was complicated appendicitis documented at operation. The association between treatment delay and complicated appendicitis was examined across all hospitals by using TTA as a continuous variable and at the level of individual hospitals by using TTA as a categorical variable comparing outcomes between late and early TTA groups. Secondary outcomes included length of stay (LOS) and postoperative complications (incisional and organ space infections, percutaneous drainage procedures, unplanned reoperation, and hospital revisits). RESULTS Of the 6767 patients who met the inclusion criteria, 2429 were included in the analysis (median age, 10 years; interquartile range, 8-13 years; 1467 [60.4%] male). Median hospital TTA was 7.4 hours (range, 5.0-19.2 hours), and 574 patients (23.6%) were diagnosed with complicated appendicitis (range, 5.2%-51.1% across hospitals). In multivariable analyses, increasing TTA was not associated with risk of complicated appendicitis (odds ratio per 1-hour increase in TTA, 0.99; 95% CI, 0.97-1.02). The odds ratios of complicated appendicitis for late vs early TTA across hospitals ranged from 0.39 to 9.63, and only 1 of the 23 hospitals had a statistically significant increase in their late TTA group (odds ratio, 9.63; 95% CI, 1.08-86.17; P = .03). Increasing TTA was associated with longer LOS (increase in mean LOS for each additional hour of TTA, 0.06 days; 95% CI, 0.03-0.08 days; P < .001) but was not associated with increased risk of any of the other secondary outcomes. CONCLUSIONS AND RELEVANCE Delay of appendectomy within 24 hours of presentation was not associated with increased risk of complicated appendicitis or adverse outcomes. These results support the premise that appendectomy can be safely performed as an urgent rather than emergency procedure.
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Affiliation(s)
- Stephanie K. Serres
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Danielle B. Cameron
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Charity C. Glass
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dionne A. Graham
- Center for Applied Quality Analytics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- Department of Anesthesiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mahima Karki
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Seema P. Anandalwar
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shawn J. Rangel
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Sippola S, Grönroos J, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Salminen P. Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial. Br J Surg 2017; 104:1355-1361. [PMID: 28677879 DOI: 10.1002/bjs.10575] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 02/14/2017] [Accepted: 03/28/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND An increasing amount of evidence supports antibiotic therapy for treating uncomplicated acute appendicitis. The objective of this study was to compare the costs of antibiotics alone versus appendicectomy in treating uncomplicated acute appendicitis within the randomized controlled APPAC (APPendicitis ACuta) trial. METHODS The APPAC multicentre, non-inferiority RCT was conducted on patients with CT-confirmed uncomplicated acute appendicitis. Patients were assigned randomly to appendicectomy or antibiotic treatment. All costs were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis during the 1-year follow-up. The cost estimates were based on cost levels for the year 2012. RESULTS Some 273 patients were assigned to the appendicectomy group and 257 to antibiotic treatment. Most patients randomized to antibiotic treatment did not require appendicectomy during the 1-year follow-up. In the operative group, overall societal costs (€5989·2, 95 per cent c.i. 5787·3 to 6191·1) were 1·6 times higher (€2244·8, 1940·5 to 2549·1) than those in the antibiotic group (€3744·4, 3514·6 to 3974·2). In both groups, productivity losses represented a slightly higher proportion of overall societal costs than all treatment costs together, with diagnostics and medicines having a minor role. Those in the operative group were prescribed significantly more sick leave than those in the antibiotic group (mean(s.d.) 17·0(8·3) (95 per cent c.i. 16·0 to 18·0) versus 9·2(6·9) (8·3 to 10·0) days respectively; P < 0·001). When the age and sex of the patient as well as the hospital were controlled for simultaneously, the operative treatment generated significantly more costs in all models. CONCLUSION Patients receiving antibiotic therapy for uncomplicated appendicitis incurred lower costs than those who had surgery.
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Affiliation(s)
- S Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - J Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - R Tuominen
- Department of Public Health, University of Turku, Turku, Finland.,Primary Health Care Unit, Hospital District of Southwest Finland, Turku, Finland.,University of Namibia, Windhoek, Namibia
| | - H Paajanen
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland.,Institute of Clinical Medicine, University of Eastern Finland, Joensuu, Finland
| | - T Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - P Nordström
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - M Aarnio
- Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - T Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland.,Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - S Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - P Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
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Huston JM, Kao LS, Chang PK, Sanders JM, Buckman S, Adams CA, Cocanour CS, Parli SE, Grabowski J, Diaz J, Tessier JM, Duane TM. Antibiotics vs. Appendectomy for Acute Uncomplicated Appendicitis in Adults: Review of the Evidence and Future Directions. Surg Infect (Larchmt) 2017; 18:527-535. [PMID: 28614043 DOI: 10.1089/sur.2017.073] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute appendicitis is the most common abdominal surgical emergency in the United States, with a lifetime risk of 7%-8%. The treatment paradigm for complicated appendicitis has evolved over the past decade, and many cases now are managed by broad-spectrum antibiotics. We determined the role of non-operative and operative management in adult patients with uncomplicated appendicitis. METHODS Several meta-analyses have attempted to clarify the debate. Arguably the most influential is the Appendicitis Acuta (APPAC) Trial. RESULTS According to the non-inferiority analysis and a pre-specified non-inferiority margin of -24%, the APPAC did not demonstrate non-inferiority of antibiotics vs. appendectomy. Significantly, however, the operations were nearly always open, whereas the majority of appendectomies in the United States are done laparoscopically; and laparoscopic and open appendectomies are not equivalent operations. Treatment with antibiotics is efficacious more than 70% of the time. However, a switch to an antimicrobial-only approach may result in a greater probability of antimicrobial-associated collateral damage, both to the host patient and to antibiotic susceptibility patterns. A surgery-only approach would result in a reduction in antibiotic exposure, a consideration in these days of focus on antimicrobial stewardship. CONCLUSION Future studies should focus on isolating the characteristics of appendicitis most susceptible to antibiotics, using laparoscopic operations as controls and identifying long-term side effects such as antibiotic resistance or Clostridium difficile colitis.
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Affiliation(s)
- Jared M Huston
- 1 Deparment of Surgery, Hofstra Northwell School of Medicine at Hofstra University , Hempstead, New York
| | - Lillian S Kao
- 2 Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston , Houston, Texas
| | - Phillip K Chang
- 3 Department of Surgery, University of Kentucky College of Medicine , Lexington, Kentucky
| | - James M Sanders
- 4 Department of Pharmacy, John Peter Smith Health Network , Fort Worth, Texas
| | - Sara Buckman
- 5 Department of Surgery, Washington University in St. Louis School of Medicine , St. Louis, Missouri
| | - Charles A Adams
- 6 Department of Surgery, Warren Alpert School of Medicine of Brown University , Providence, Rhode Island
| | - Christine S Cocanour
- 7 Department of Surgery, University of California Davis School of Medicine , Sacramento, California
| | - Sarah E Parli
- 8 Department of Pharmacy, University of Kentucky College of Pharmacy , Lexington, Kentucky
| | - Julia Grabowski
- 9 Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Northwestern University , Chicago, Illinois
| | - Jose Diaz
- 10 Department of Surgery, RA Cowley Shock Trauma Center, University of Maryland School of Medicine , Baltimore, Maryland
| | - Jeffrey M Tessier
- 11 Antimicrobial Stewardship, John Peter Smith Health Network , Fort Worth, Texas
| | - Therese M Duane
- 12 Department of Surgery, John Peter Smith Health Network , Fort Worth, Texas
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49
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Huang L, Yin Y, Yang L, Wang C, Li Y, Zhou Z. Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children: A Meta-analysis. JAMA Pediatr 2017; 171:426-434. [PMID: 28346589 PMCID: PMC5470362 DOI: 10.1001/jamapediatrics.2017.0057] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Antibiotic therapy for acute uncomplicated appendicitis is effective in adult patients, but its application in pediatric patients remains controversial. OBJECTIVE To compare the safety and efficacy of antibiotic treatment vs appendectomy as the primary therapy for acute uncomplicated appendicitis in pediatric patients. DATA SOURCES The PubMed, MEDLINE, EMBASE, and Cochrane Library databases and the Cochrane Controlled Trials Register for randomized clinical trials were searched through April 17, 2016. The search was limited to studies published in English. Search terms included appendicitis, antibiotics, appendectomy, randomized controlled trial, controlled clinical trial, randomized, placebo, drug therapy, randomly, and trial. STUDY SELECTION Randomized clinical trials and prospective clinical controlled trials comparing antibiotic therapy with appendectomy for acute uncomplicated appendicitis in pediatric patients (aged 5-18 years) were included in the meta-analysis. The outcomes included at least 2 of the following terms: success rate of antibiotic treatment and appendectomy, complications, readmissions, length of stay, total cost, and disability days. DATA EXTRACTION AND SYNTHESIS Data were independently extracted by 2 reviewers. The quality of the included studies was examined in accordance with the Cochrane guidelines and the Newcastle-Ottawa criteria. Data were pooled using a logistic fixed-effects model, and the subgroup pooled risk ratio with or without appendicolith was estimated. MAIN OUTCOMES AND MEASURES The primary outcome was the success rate of treatment. The hypothesis was formulated before data collection. RESULTS A total of 527 articles were screened. In 5 unique studies, 404 unique patients with uncomplicated appendicitis (aged 5-15 years) were enrolled. Nonoperative treatment was successful in 152 of 168 patients (90.5%), with a Mantel-Haenszel fixed-effects risk ratio of 8.92 (95% CI, 2.67-29.79; heterogeneity, P = .99; I2 = 0%). Subgroup analysis showed that the risk for treatment failure in patients with appendicolith increased, with a Mantel-Haenszel fixed-effects risk ratio of 10.43 (95% CI, 1.46-74.26; heterogeneity, P = .91; I2 = 0%). CONCLUSIONS AND RELEVANCE This meta-analysis shows that antibiotics as the initial treatment for pediatric patients with uncomplicated appendicitis may be feasible and effective without increasing the risk for complications. However, the failure rate, mainly caused by the presence of appendicolith, is higher than for appendectomy. Surgery is preferably suggested for uncomplicated appendicitis with appendicolith.
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Affiliation(s)
- Libin Huang
- Department of Gastrointestinal Surgery, West China Hospital and State Key Laboratory of Biotherapy, Sichuan University, Chengdu, China,Laboratory of Digestive Surgery, West China Hospital and State Key Laboratory of Biotherapy, Sichuan University, Chengdu, China
| | - Yuan Yin
- Department of Gastrointestinal Surgery, West China Hospital and State Key Laboratory of Biotherapy, Sichuan University, Chengdu, China
| | - Lie Yang
- Department of Gastrointestinal Surgery, West China Hospital and State Key Laboratory of Biotherapy, Sichuan University, Chengdu, China
| | - Cun Wang
- Department of Gastrointestinal Surgery, West China Hospital and State Key Laboratory of Biotherapy, Sichuan University, Chengdu, China
| | - Yuan Li
- Laboratory of Digestive Surgery, West China Hospital and State Key Laboratory of Biotherapy, Sichuan University, Chengdu, China,Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zongguang Zhou
- Department of Gastrointestinal Surgery, West China Hospital and State Key Laboratory of Biotherapy, Sichuan University, Chengdu, China,Laboratory of Digestive Surgery, West China Hospital and State Key Laboratory of Biotherapy, Sichuan University, Chengdu, China
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50
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Rosen DR, Inaba K, Oh PJ, Gutierrez AC, Strumwasser AM, Biswas S, Cala M, Ault GT. Outpatient Laparoscopic Appendectomy: Feasible in a Public County Hospital? J Am Coll Surg 2017; 224:S1072-7515(17)30181-3. [PMID: 28433247 DOI: 10.1016/j.jamcollsurg.2017.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Outpatient laparoscopic appendectomy is being used increasingly as a treatment option for acute, uncomplicated appendicitis. This was a prospective validation study in a large, urban, public safety-net hospital. STUDY DESIGN From 2014 to 2016, all patients undergoing laparoscopic appendectomy for acute, uncomplicated appendicitis were enrolled in a prospective observational trial. Standard baseline perioperative practice (control group) was documented for 1 year. An outpatient appendectomy protocol was then introduced. Inclusion criteria required intraoperative confirmation of uncomplicated appendicitis and strict discharge criteria, including physician assessment before discharge. Data collection then continued for 1 year (outpatient group). The outcomes measures examined included complications, length of stay, nursing transitions, emergency department visits, readmissions, and patient satisfaction. RESULTS The study enrolled 351 patients (178 control, 173 outpatient). Of the 173 candidates for outpatient appendectomy, 113 went home. Reasons for admission included surgeon discretion due to intraoperative findings/medical comorbidities and lack of transportation home. The outpatient group had shorter operative time (69 vs 83 minutes; p < 0.001), longer time in recovery (242 vs 141 minutes; p < 0.001), fewer nursing transitions (4 vs 5; p < 0.001), and shorter postoperative length of stay (9 vs 19 hours; p < 0.001). There was no difference in complications, emergency department visits, or readmissions. In the outpatient group, none of the patients sent home from recovery had postoperative complications or required readmission. Satisfaction surveys revealed no change in satisfaction with either protocol. CONCLUSIONS Outpatient appendectomy is safe in a public hospital and results in shorter hospital length of stay and decreased healthcare costs. Strict criteria for discharge are important to identify patients who should be admitted for observation.
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Affiliation(s)
- David R Rosen
- Division of Colon and Rectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Kenji Inaba
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Paul J Oh
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Adam C Gutierrez
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Aaron M Strumwasser
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Subarna Biswas
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Melody Cala
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LAC+USC Medical Center, Los Angeles, CA
| | - Glenn T Ault
- Division of Colon and Rectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
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