The evolving management of the appendix mass in the era of laparoscopy and interventional radiology

Risk Factors of Recurrent Appendiceal Abscess after Initial Non-Surgical Treatment without Drainage of Children with Appendiceal Abscess: A Single Center Retrospective Review

Background: Exploration of the risk factors of recurrent appendiceal abscess after initial non-surgical treatment without drainage in children with appendiceal abscess. Patients and Methods: The medical records of all children diagnosed with appendiceal abscess and who were treated conservatively in the Children's Hospital of Chongqing Medical University from June 2012 to June 2020 were collected. The collected cases were divided into the recurrent group and the non-recurrent group, and all clinical indicators were compared. Logistic regression analysis was used to determine the risk factors for recurrent appendiceal abscess in children. Results: One hundred twenty-four patients were included and among them, 62 (50.0%) had clinical manifestations of recurrent appendiceal abscess (the recurrent group) and five patients (8%) suffered several instances of recurrence. Duration of intravenous antibiotic agents (odds ratio [OR], 0.905; 95% confidence interval [CI], 0.820-1.000) was independently associated with the recurrence of appendiceal abscess. The risk of recurrence was increased in children with the white blood cell (WBC) count at discharge greater than 8 × 10⁹/L (OR, 2.702; 95% CI,1.172-6.231), the ratio of mass size to body surface area (BSA) at discharge greater than 4.255 (OR, 1.369; 95% CI, 1.104-1.697), and without continuous oral antibiotic agents after discharge (OR, 3.111; 95% CI, 1.240-7. 802). Conclusions: Interval appendectomy is recommended for children with WBC count at discharge greater than 8 × 10⁹/L, and the ratio of mass size to BSA at discharge greater than 4.255, because they are more likely to develop recurrent appendiceal abscess after initial conservative treatment. The duration of intravenous antibiotic agents is an independent factor of the recurrence of appendiceal abscess, and a longer course of intravenous antibiotic agents is strongly associated with a reduced risk of recurrence. Continued oral antibiotic agents after discharge can effectively reduce the risk of recurrence of appendiceal abscesses.

Identifying Recurrence Risk Factors in CT-Confirmed Acute Appendicitis in Adults Managed Non-operatively During the COVID-19 Pandemic

Background/Objective: Acute appendicitis (AA) is predominantly managed with appendectomy, but can be treated non-operatively, leading to a high risk of recurrence. Non-operative management has been more common since the COVID-19 pandemic affected the feasibility of performing surgery. This case-control study analyzed non-operatively managed patients in order to identify clinical and radiological factors associated with recurrence risk. 

Methods: Over 12 months, 48 adults with CT-proven AA managed non-operatively were identified, and followed up for at least six further months to assess them for recurrence (readmission to hospital more than 14 days after discharge and after symptom resolution, requiring treatment for appendicitis). Clinical and CT data were collected and a Cox regression survival analysis was performed to produce hazards ratios (HRs).

Results: Of the 48 patients, 12 (25%) experienced a recurrence up until the end of the follow-up period, eight of whom were then treated operatively, and four treated non-operatively. On the univariate analysis, greater recurrence risk was observed in patients with diabetes mellitus, higher heart rate (on admission and maximum value during admission), lower white cell count and neutrophils and appendiceal wall thinning on CT. On the multivariate analysis, diabetes mellitus (HR=7.72, p=0.021) and higher heart rate (HR=1.08, p=0.018) were associated with statistically significant greater recurrence risk.

Conclusions: Diabetes mellitus and higher heart rate on admission are associated with greater recurrence risk of AA managed non-operatively. No CT findings were associated with statistically significant greater risk. Clinicians should, therefore, consider DM and heart rate when making decisions on appendicitis management, especially during the COVID-19 pandemic but also beyond it.

Classification of acute appendicitis (CAA): treatment directed new classification based on imaging (ultrasound, computed tomography) and pathology

PURPOSE

Acute appendicitis (AA) is amongst the most common causes of acute abdominal pain. In spite of progress based on risk stratifications, "negative" appendectomies are performed in up to 30% of patients whilst the appendix perforates in others. Preoperative classification of AA based on imaging is therefore recommended. The aim was to classify AA based on imaging (ultrasound/US, computed tomography/CT), surgical pathology, and/or histopathology in order to differentiate between complicated and uncomplicated AA. A new classification of acute appendicitis (CAA) shall be illustrated by typical US and CT images and be employed in a diagnostic and therapeutic algorithm.

METHODS

Medline, Embase, and the Cochrane Library were searched. Any study after 1970, which investigated clinical scores, pathology, US, CT, magnetic resonance imaging, and treatment of AA, was included. Typical images were taken from the author's image database.

RESULTS

Five main types of AA are defined, normal appendix (type 0), nonvisualised appendix (type X), uncomplicated AA (type 1), complicated AA without perforation (type 2), and complicated AA with perforation (type 3). The imaging modality is indicated by an additional letter, e.g., type p3b for free perforation on pathology. Standardised reporting of the appendix evaluation by US and CT is presented, as well as algorithms for AA management. Imaging features indicating imminent perforation, as well as likely recurrence, were both classified as complicated AA.

CONCLUSION

Imaging is mandatory in suspected AA. The CAA clearly separates uncomplicated from complicated forms of AA allowing nonoperative management in selected patients with uncomplicated forms of AA.

The feasibility of interval laparoscopic appendectomy and appropriate patient selection: A retrospective study of adult appendiceal masses

INTRODUCTION

We examined the safety and effectiveness of interval laparoscopic appendectomy (ILA) for adult appendiceal mass (AAM) and then used a novel white blood cell (WBC) parameter to identify the types of AAM cases for which nonsurgical treatment followed by ILA is effective.

METHODS

We reviewed the cases of 956 patients who had undergone appendectomy between April 2012 and March 2018 at our facility. Of these patients, 49 had AAM, including 34 who underwent ILA. We examined the safety and effectiveness of ILA by comparing it with laparoscopic appendectomy (LA); specifically, the 34 cases treated with ILA were compared with 477 cases of adult uncomplicated appendicitis treated with LA from the same patient cohort. We then examined the factors associated with not successfully completing the planned nonsurgical treatment and interval before ILA. Patient demographics and clinical variables were reviewed.

RESULTS

Patients who had undergone ILA had longer operative times than those who had undergone LA (P = .0059), but they also had shorter postoperative hospital stays (P < .001). There were no significant differences in other perioperative variables. Multivariate analysis showed that a ratio of WBC count on day 3 and day 0 from the start of nonsurgical treatment (WBC day3/day0) of 0.906 or higher was significantly associated with not completing the nonsurgical treatment and interval before ILA (P = .045).

CONCLUSION

A comparison of the procedures found that ILA for AAM was almost as safe and effective as LA for adult uncomplicated appendicitis. The WBC day3/day0 ratio can be an objective parameter to assess the effectiveness of the nonsurgical treatment before ILA earlier in the course of treatment.

Early versus delayed (interval) appendicectomy for the management of appendicular abscess and phlegmon: a systematic review and meta-analysis

OBJECTIVE

The safety and role of emergency (EA) versus interval appendicectomy (IA) for appendicular abscess and phlegmon remains debatable with no optimal strategy identified. The aim of this systematic review and meta-analysis is to evaluate outcomes of managing appendicular abscesses and phlegmon with emergency or interval appendicectomy.

METHODS

We conducted a systematic search of electronic databases using key terms including 'appendicular abscess', 'appendicular phlegmon' and 'interval appendicectomy'. Randomised controlled trials and observational studies comparing the two management approaches were included. Operative time, post-operation complication, unplanned bowel resection, rate of surgical site infection, post-operative length of stay and overall mortality rate were evaluated.

RESULTS

We identified six studies (2 RCTs and 4 observational studies) with a total of 9264 patients of whom (n = 1352) underwent IA, and (n 7912) underwent EA. The EA group was associated with statistically significant unplanned bowel resection (OR 0.55, 95% CI [0.33-0.90], P = 0.02) and longer total operating time (MD - 14.11, 95% CI [- 18.26-- 9.96] P = 0.00001). However, the following parameters were compared for both EA and IA groups; there were no significant statistical differences: surgical site infection (OR 0.49, 95% CI [0.17-1.38], P = 0.18), post-operative intra-abdominal collection (RD - 0.01, 95% CI [- 0.04-0.01], P = 0.29), total length of hospital stay (MD 1.83, 95% CI [- 0.19-3.85], P = 0.08), post-operative length of hospital stay (MD - 0.27, 95% CI [- 3.66-3.13], P = 0.88) and mortality rate (MD - 0.27, 95% CI [- 3.66-3.13], P = 0.66).

CONCLUSION

Emergency operation for appendicular abscess and phlegmon may lead to a higher rate of reported morbidity when compared with interval appendicectomy. Although emergency appendicectomy performed for appendicular abscess and phlegmon is a feasible and safe operative approach, it is associated with significantly increased operative time and unplanned bowel resection (ileocolic and right hemicolectomies) compared to interval appendicectomy.

Early appendectomy for appendicular mass: operative findings and outcome in 220 children—a developing country perspective

Background

Lump or mass formation due to delayed presentation after appendicitis is common, and it is frequently complicated by perforation, gangrene, pus, or abscess formation. Care of patients and management vary between developed world and developing country. The aim of the study is to analyze outcome of early surgery for appendicular mass from a developing country perspective. 220 patients of appendicular mass who underwent early appendectomy over a period of 5 years in the Department of Pediatric Surgery, at author’s institute were retrospectively reviewed. Early appendectomy was defined as appendectomy done within 24 h of admission. Presentation, examination findings, investigations, type of surgery, operative findings, post-operative complications, and hospital stay were analyzed.

Results

Age of patients ranged from 2 to 12 years (mean 9.04 ± 2.54 years) and male to female ratio was 2:1. Abdominal pain was the most common presentation followed by vomiting and fever. Mean pain duration was 4.35 ± 4.23 days. There was raised temperature in 140 (63.64%) patients, 154 (74.04%) had tachycardia, and 75.86% had raised WBC count. Laparoscopic appendectomy was done in 31 (14.09%) patients, and the rest 189 (85.91%) patients underwent open surgery. Perforated appendix was the most common (171 patients, 77.73%) peri-operative finding followed by formation of pus (135 patients, 61%). Pus was found more in patients less than 5 years old (18 patients out of 23) than patients more than 5 years old (114 patients out of 197) (P = 0.045). Younger patients also had significantly more complications (39.13% vs 17.26%, P = .000) and hospital stays (mean 15.61 days vs 9.87 days, P = 0.014) than older boys. Complications developed in 42 (19.09%) patients, and wound dehiscence (26 patients, 11.82%) was the most common complication.

Conclusion

Early appendectomy for appendicular mass is a feasible option in the developing world, and laparoscopic appendectomy has good prospect.

Low intra-operative diagnostic accuracy does not affect postoperative treatment of acute appendicitis

BACKGROUND

The intra-operative classification of appendicitis defines postoperative treatment. The correct designation can influence patient recovery, complications and hospital costs. Recent research has shown that intra-operative classification criteria varies among surgeons, and is not always the same as the pathologist's report. Classification accuracy can lower costs by preventing unnecessary treatment or sub-optimal interventions.

METHODS

During a period of 4 months, N = 133 appendix specimens were received and evaluated by the pathology department of a single teaching hospital. Five surgeons extracted the specimens and one experienced pathologist drew the histopathology reports. A comparison between the surgeons' classifications and the pathologist's was made. Classification accuracy was determined and statistical analyses was performed using chi-square, and p values were obtained. A p < 0.05 was considered significant.

RESULTS

A total of N = 133 specimens were obtained, 127 belonged to patients following emergency surgery due to acute abdominal pain; the other six were from elective hemi-colectomies for right colonic adenocarcinomas, and were not included. Of the 127 specimens analyzed, 14 (11%) were negative, 21 (16.5%) were edematous, 81 (63.7%) were phlegmonous and 11 (8.6%) were gangrenous. A total of 18 (14%) perforated appendices were also reported. Surgical accuracy was 60.6% (N = 67) with a statistically significant p < 0.001. Only five patients with incorrect intraoperative classifications received unnecessary or lacked treatment.

CONCLUSIONS

An overall accuracy of 60.6% is seen when the surgical classification is compared to the pathological classification. Although the surgeons' accuracy is low when comparing intra-operative versus histopathological classification, this variation in designation does not affect postoperative treatment significantly.

Appendiceal Crohn's disease: a rare differential of right iliac fossa pain

A 30-year-old man with a history of severe right iliac fossa pain was referred to the surgical emergency unit. His symptoms began 3 days prior as mild, non-specific abdominal pain which progressively localised to the right iliac fossa and worsened in severity. Investigations were suggestive of acute appendicitis, and therefore a laparoscopic appendicectomy was planned. Laparoscopy revealed a thickened, necrotic appendix with a mass at the base of the appendix, in keeping with the appearance of an appendiceal malignancy. Subsequently a right hemicolectomy was performed. Histology revealed active chronic inflammation and granulomas highly suggestive of appendiceal Crohn's disease. Since, the patient has made a good recovery and presently shows no further signs of Crohn's disease. This case is demonstrative of one of many rare findings on histological examination of the appendix. It emphasises the need for a wide differential when investigating right iliac fossa pain.

Comparison of treatment methods of appendiceal mass and abscess: A prospective Cohort Study

Background

The aim of our prospective study is to compare and analyze the results of two treatment methods of appendiceal mass and abscess: emergency surgery and conservative treatment with and without interval surgery.

Materials and methods

74 Patients with the diagnosis of appendiceal mass or abscess were enrolled in this study. The patients were assigned into two groups: the emergency surgery group and the conservative management group. The conservative management group was subdivided into two groups: interval surgery group and the ambulatory follow-up observation group without interval surgery. Several clinical characteristics were determined and compared between the groups. Among patients who underwent surgery, the surgical methods, operation time, postoperative hospitalization period, and post-surgical complications were analyzed. In the ambulatory follow-up observation group, recurrence of appendicitis was assessed.

Results

Comparison of the emergency surgery group and interval surgery group revealed that the interval surgery group was characterized by shorter operation time (P = 0.008), a smallernumber of postoperative complications (P = 0.02) and also shorter postoperative hospital stay (P = 0.009). In the ambulatory follow-up observation group, recurrence of appendicitis developed in 3 (13%) patients. US or CT-guided PCD was performed in all 3 patients on the conservative treatment stage. Comparing the interval surgery and recurrent appendicitis groups revealed statistically significant difference: operation time (P = 0.04) as well as postoperative hospital stay (P = 0.04) were shorter in recurrent appendicitis group. In 3 (4.1%) patients, the cause of the appendiceal mass was caecal cancer (2 cases) and Crohn's disease.

Conclusion

Conservative treatment without interval surgery seems to be the preferred method for treatment of appendiceal mass and abscess. Patients can be operated on only in case of recurrence of appendicitis. US or CT PCD of appendiceal abscess presents the risk-factor for the development of recurrence of appendicitis. CT and colonoscopy within 4–6 weeks after completing the conservative treatment is recommended to be performed in all patients.

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Conservative treatment without interval surgery should be the method of choice for treatment of appendiceal mass and abscess.

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Patients should be operated only in case of recurrence of appendicitis.

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US or CT PCD of appendiceal abscess present the risk-factor for the development of recurrence of appendicitis.

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All patients should be performed CT and colonoscopy in 4–6 weeks after completing the conservative treatment.