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Guo LM, Jiang ZH, Liu HZ. Systemic immune-inflammation index combined with pediatric appendicitis score in assessing the severity and prognosis for paediatric appendicitis. World J Gastrointest Surg 2024; 16:2565-2573. [PMID: 39220085 PMCID: PMC11362941 DOI: 10.4240/wjgs.v16.i8.2565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/02/2024] [Accepted: 07/04/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Pediatric appendicitis is a common cause of abdominal pain in children and is recognized as a significant surgical emergency. A prompt and accurate diagnosis is essential to prevent complications such as perforation and peritonitis. AIM To investigate the predictive value of the systemic immune-inflammation index (SII) combined with the pediatric appendicitis score (PAS) for the assessment of disease severity and surgical outcomes in children aged 5 years and older with appendicitis. METHODS Clinical data of 104 children diagnosed with acute appendicitis were analyzed. The participants were categorized into the acute appendicitis group and chronic appendicitis group based on disease presentation and further stratified into the good prognosis group and poor prognosis group based on prognosis. The SII and PAS were measured, and a joint model using the combined SII and PAS was constructed to predict disease severity and surgical outcomes. RESULTS Significant differences were observed in the SII and PAS parameters between the acute appendicitis group and chronic appendicitis group. Correlation analysis showed associations among the SII, PAS, and disease severity, with the combined SII and PAS model demonstrating significant predictive value for assessing disease severity [aera under the curve (AUC) = 0.914] and predicting surgical outcomes (AUC = 0.857) in children aged 5 years and older with appendicitis. CONCLUSION The study findings support the potential of integrating the SII with the PAS for assessing disease severity and predicting surgical outcomes in pediatric appendicitis, indicating the clinical utility of the combined SII and PAS model in guiding clinical decision-making and optimizing surgical management strategies for pediatric patients with appendicitis.
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Affiliation(s)
- Li-Ming Guo
- Department of General Surgery, Qingdao Women and Children’s Hospital, Qingdao 266000, Shandong Province, China
| | - Zhi-Hui Jiang
- Department of General Surgery, Qingdao Women and Children’s Hospital, Qingdao 266000, Shandong Province, China
| | - Hong-Zhen Liu
- Department of Pediatric Surgery, Children's Hospital Affiliated to Shandong University, Jinan 250022, Shandong Province, China
- Department of Pediatric Surgery, Jinan Children's Hospital, Jinan 250022, Shandong Province, China
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2
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Vanhatalo S, Mäkilä E, Hakanen AJ, Munukka E, Salonen J, Saarinen T, Grönroos J, Sippola S, Salminen P. Appendicolith classification: physical and chemical properties of appendicoliths in patients with CT diagnosed acute appendicitis - a prospective cohort study. BMJ Open Gastroenterol 2024; 11:e001403. [PMID: 39160081 PMCID: PMC11337665 DOI: 10.1136/bmjgast-2024-001403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 07/29/2024] [Indexed: 08/21/2024] Open
Abstract
OBJECTIVE Appendicoliths are associated with a more complicated course of acute appendicitis and failure of non-operative treatment. We aimed to update the appendicolith classification originally described in 1966 and to assess the association of appendicolith characteristics with appendicitis severity. DESIGN This prospective predefined MAPPAC-trial (ClinicalTrials.gov NCT03257423) substudy included patients with CT diagnosed appendicitis presenting with an appendicolith. CT visible appendicoliths were harvested at surgery, measured and characterised by morphological examination complemented with micro-CT and micro-X-ray fluorescence spectroscopy. Patients were categorised into two groups: appendicolith appendicitis without other complications and appendicolith appendicitis with complications (appendiceal gangrene, perforation and/or abscess). The association of appendicolith classification and characteristics with appendicitis severity was evaluated. RESULTS Of 78 patients with a CT appendicolith, 41 appendicoliths were collected and classified based on the degree of hardness into three classes. The hardest appendicoliths (class 3) were less common (19.5%) presenting with a stone-hard outer layer and concentrically layered inner structure around a core. The layered inner structure was also observed in class 2 appendicoliths, but was absent in soft, class 1 appendicoliths. Appendicolith hardness or measures (maximum length, diameter and weight) were not associated with appendicitis severity. The spatial distribution of the main inorganic elements of calcium and phosphorus varied within most appendicoliths. CONCLUSION This updated classification confirms categorisation of CT visible appendicoliths into three classes based on their physical and chemical characteristics. The data on clinical and aetiopathological characteristics of appendicoliths is scarce and using this systematic classification would add to this understanding.
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Affiliation(s)
- Sanja Vanhatalo
- Institute of Biomedicine, University of Turku, Turku, Finland
- Department of Clinical Microbiology, TYKS Turku University Hospital, Turku, Finland
| | - Ermei Mäkilä
- Department of Physics and Astronomy, University of Turku, Turku, Finland
| | - Antti J Hakanen
- Institute of Biomedicine, University of Turku, Turku, Finland
- Clinical Microbiome Bank, Department of Clinical Microbiology, Microbe center, Turku University Hospital and University of Turku, Turku, Finland
| | - Eveliina Munukka
- Institute of Biomedicine, University of Turku, Turku, Finland
- Department of Clinical Microbiology, TYKS Turku University Hospital, Turku, Finland
| | - Jarno Salonen
- Department of Physics and Astronomy, University of Turku, Turku, Finland
| | - Timo Saarinen
- Department of Geography and Geology, University of Turku, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, TYKS Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, TYKS Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, TYKS Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
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Selänne L, Haijanen J, Sippola S, Hurme S, Rautio T, Nordström P, Rantanen T, Pinta T, Ilves I, Mattila A, Rintala J, Marttila H, Meriläinen S, Laukkarinen J, Sävelä EL, Paajanen H, Grönroos J, Salminen P. Three-Year Outcomes of Oral Antibiotics vs Intravenous and Oral Antibiotics for Uncomplicated Acute Appendicitis: A Secondary Analysis of the APPAC II Randomized Clinical Trial. JAMA Surg 2024; 159:727-735. [PMID: 38630471 PMCID: PMC11024776 DOI: 10.1001/jamasurg.2023.5947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/27/2023] [Indexed: 04/20/2024]
Abstract
Importance Current short-term evidence has shown that uncomplicated acute appendicitis can be treated successfully with oral antibiotics alone, but longer-term results are lacking. Objective To assess the treatment effectiveness of oral antibiotic monotherapy compared with combined intravenous (IV) and oral antibiotics in computed tomography-confirmed uncomplicated acute appendicitis at a longer-term follow-up. Design, Setting, and Participants This secondary analysis of a predefined year 3 follow-up of the Appendicitis Acuta II (APPAC II) noninferiority, multicenter randomized clinical trial compared oral moxifloxacin with combined IV ertapenem plus oral levofloxacin and metronidazole for the treatment of uncomplicated acute appendicitis. The trial was conducted at 9 university and central hospitals in Finland from April 2017 to November 2018, with the last follow-up in November 2022. Participants included patients aged 18 to 60 years, who were randomized to receive either oral antibiotics monotherapy (n = 301) or combined IV and oral antibiotics (n = 298). Interventions Antibiotics monotherapy consisted of oral moxifloxacin, 400 mg/d, for 7 days. Combined IV and oral antibiotics consisted of IV ertapenem sodium, 1 g/d, for 2 days plus oral levofloxacin, 500 mg/d, and metronidazole, 500 mg 3 times/d, for 5 days. Main Outcomes and Measures The primary end point was treatment success, defined as the resolution of acute appendicitis and discharge from hospital without the need for surgical intervention and no appendicitis recurrence at the year 3 follow-up evaluated using a noninferiority design. The secondary end points included late (after 1 year) appendicitis recurrence as well as treatment-related adverse events, quality of life, length of hospital stay, and length of sick leave, which were evaluated using a superiority design. Results After exclusions, 599 patients (mean [SD] age, 36 [12] years; 336 males [56.1%]) were randomized; after withdrawal and loss to follow-up, 582 patients (99.8%) were available for the year 3 follow-up. The treatment success at year 3 was 63.4% (1-sided 95% CI, 58.8% to ∞) in the oral antibiotic monotherapy group and 65.2% (1-sided 95% CI, 60.5% to ∞) in the combined IV and oral antibiotics group. The difference in treatment success rate between the groups at year 3 was -1.8 percentage points (1-sided 95% CI, -8.3 percentage points to ∞; P = .14 for noninferiority), with the CI limit exceeding the noninferiority margin. There were no significant differences between groups in treatment-related adverse events, quality of life, length of hospital stay, or length of sick leave. Conclusions and Relevance This secondary analysis of the APPAC II trial found a slightly higher appendectomy rate in patients who received oral antibiotic monotherapy; however, noninferiority of oral antibiotic monotherapy compared with combined IV and oral antibiotics could not be demonstrated. The results encourage future studies to assess oral antibiotic monotherapy as a viable treatment alternative for uncomplicated acute appendicitis. Trial Registration ClinicalTrials.gov Identifier: NCT03236961.
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Affiliation(s)
- Liisa Selänne
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Saija Hurme
- Department of Biostatistics, University of Turku and Turku University Hospital, Turku, Finland
| | - Tero Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Pia Nordström
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Tuomo Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
- Department of Surgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Tarja Pinta
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Imre Ilves
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Anne Mattila
- Wellbeing Services County of Central Finland, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Jukka Rintala
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Department of Surgery, Rovaniemi Central Hospital, Rovaniemi, Finland
| | - Harri Marttila
- Department of Hospital Hygiene and Infection Control, Turku University Hospital, Turku, Finland
| | - Sanna Meriläinen
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | | | - Hannu Paajanen
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
- Department of Surgery, Satakunta Central Hospital, Pori, Finland
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Cappuccio M, Bianco P, Rotondo M, Spiezia S, D'Ambrosio M, Menegon Tasselli F, Guerra G, Avella P. Current use of artificial intelligence in the diagnosis and management of acute appendicitis. Minerva Surg 2024; 79:326-338. [PMID: 38477067 DOI: 10.23736/s2724-5691.23.10156-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Acute appendicitis is a common and time-sensitive surgical emergency, requiring rapid and accurate diagnosis and management to prevent complications. Artificial intelligence (AI) has emerged as a transformative tool in healthcare, offering significant potential to improve the diagnosis and management of acute appendicitis. This review provides an overview of the evolving role of AI in the diagnosis and management of acute appendicitis, highlighting its benefits, challenges, and future perspectives. EVIDENCE ACQUISITION We performed a literature search on articles published from 2018 to September 2023. We included only original articles. EVIDENCE SYNTHESIS Overall, 121 studies were examined. We included 32 studies: 23 studies addressed the diagnosis, five the differentiation between complicated and uncomplicated appendicitis, and 4 studies the management of acute appendicitis. CONCLUSIONS AI is poised to revolutionize the diagnosis and management of acute appendicitis by improving accuracy, speed and consistency. It could potentially reduce healthcare costs. As AI technologies continue to evolve, further research and collaboration are needed to fully realize their potential in the diagnosis and management of acute appendicitis.
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Affiliation(s)
- Micaela Cappuccio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Paolo Bianco
- Hepatobiliary and Pancreatic Surgery Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | - Marco Rotondo
- V. Tiberio Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Salvatore Spiezia
- V. Tiberio Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Marco D'Ambrosio
- V. Tiberio Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | | | - Germano Guerra
- V. Tiberio Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Pasquale Avella
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy -
- Hepatobiliary and Pancreatic Surgery Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
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Decker E, Ndzi A, Kenny S, Harwood R. Systematic Review and Meta-analysis to Compare the Short- and Long-term Outcomes of Non-operative Management With Early Operative Management of Simple Appendicitis in Children After the COVID-19 Pandemic. J Pediatr Surg 2024; 59:1050-1057. [PMID: 38158255 DOI: 10.1016/j.jpedsurg.2023.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/27/2023] [Accepted: 12/16/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Non-operative management (NOM) of simple appendicitis is becoming an increasingly researched treatment option. This systematic review aims to describe the short and long-term failure rates of NOM and the complication rate of appendicectomy in children with simple appendicitis. METHODS The systematic review was registered a priori (CRD42022322149). Study inclusion criteria are: participants aged ≤ 18 years of age; groups undergoing both NOM and appendicectomy for simple appendicitis; outcomes including one or more of: NOM failure rate at 30 days or 1 year and beyond; study design: RCT or case control study. Four databases were searched and 3 reviewers determined study eligibility and data extraction. Risk of bias was assessed and meta-analysis was performed using Stata. RESULTS The database search identified 2731 articles, 14 studies met the inclusion criteria; 4 RCTs and 10 case controlled studies. All studies had moderate-serious risk of bias. There were no deaths in either group in any study. Meta-analysis demonstrated a 30 day failure rate of 20 % (95 % CI 11-29 %) and 11 studies reported failure rate at 1 year or beyond at 32 % (95 % CI 25-38 %). Rates of significant complications of appendicectomy was 1 % (95 % CI 0-1 %). CONCLUSIONS Non-operative management of simple appendicitis in children is safe, with moderate early success. The failure rate increases over time, resulting in eventual appendicectomy in a third of the children diagnosed with appendicitis. These data will enable clinicians to have an informed discussion with children and their parents about their treatment options for simple appendicitis. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Emily Decker
- Department of Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Agnes Ndzi
- Department of Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Simon Kenny
- Department of Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK; ISMIB, University of Liverpool, Liverpool, UK; Children and Young People Transformation Programme, NHSE/I, UK
| | - Rachel Harwood
- Department of Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK; ISMIB, University of Liverpool, Liverpool, UK; Children and Young People Transformation Programme, NHSE/I, UK.
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Bendib H. Is non-operative treatment of acute appendicitis possible: A narrative review. Afr J Emerg Med 2024; 14:84-90. [PMID: 38617036 PMCID: PMC11010839 DOI: 10.1016/j.afjem.2024.03.006] [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] [Received: 07/04/2023] [Revised: 03/19/2024] [Accepted: 03/28/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction Acute appendicitis (AA) represents the most frequent surgical emergency. Perforation was long considered the ultimate outcome of AA, prompting appendectomy; which remains the standard treatment. New data have clarified the role of the appendix, justifying conservative treatment. This narrative review aims to summarize the evidence regarding the non-operative treatment (NOT) of AA in adults. Methods The literature search was performed via the PubMed Medline database. Our criteria-based selection resulted in a total of 48 articles for review. Results Recent trials and meta-analyses have assessed NOT, which support primary antibiotic treatment of uncomplicated AA. Although it has a significant recurrence and failure rate, NOT does not appear to increase the risk of appendicular perforation. Moreover, NOT compared with appendectomy, seems to be associated with less morbidity, lower cost of care and preserved quality of life. Conclusion First-line NOT seems to be a reasonable approach for the treatment of uncomplicated CT-confirmed AA. Careful patient screening would definitely enhance the success rate.
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Affiliation(s)
- Hani Bendib
- Department of General Surgery, EPH Kouba, Algiers, Algeria
- Faculty of Medicine, Algiers 1 University, Algeria
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7
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Haijanen J, Salminen P. Improved Tool to Assess Complicated Appendicitis Probability. JAMA Surg 2024; 159:649-650. [PMID: 38536203 DOI: 10.1001/jamasurg.2024.0236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Affiliation(s)
- Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
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8
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de Wijkerslooth EM, Boerma EJG, van Rossem CC, Koopmanschap MA, Baeten CI, Beverdam FH, Bosmans JW, Consten EC, Dekker JWT, Emous M, van Geloven AA, Gijsen AF, Heijnen LA, Jairam AP, van der Ploeg AP, Steenvoorde P, Toorenvliet BR, Vermaas M, Wiering B, Wijnhoven BP, van den Boom AL. Two Days Versus Five Days of Postoperative Antibiotics for Complex Appendicitis: Cost Analysis of a Randomized, Noninferiority Trial. Ann Surg 2024; 279:885-890. [PMID: 37698025 PMCID: PMC10997181 DOI: 10.1097/sla.0000000000006089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To compare costs for 2 days versus 5 days of postoperative antibiotics within the antibiotics after an aPPendectomy In Complex appendicitis trial.Background:Recent studies suggest that restrictive antibiotic use leads to a significant reduction in hospital stays without compromising patient safety. Its potential effect on societal costs remains underexplored. METHODS This was a pragmatic, open-label, multicenter clinical trial powered for noninferiority. Patients with complex appendicitis (age ≥ 8 years) were randomly allocated to 2 days or 5 days of intravenous antibiotics after appendectomy. Patient inclusion lasted from June 2017 to June 2021 in 15 Dutch hospitals. The final follow-up was on September 1, 2021. The primary trial endpoint was a composite endpoint of infectious complications and mortality within 90 days. In the present study, the main outcome measures were overall societal costs (comprising direct health care costs and costs related to productivity loss) and cost-effectiveness. Direct health care costs were recorded based on data in the electronic patient files, complemented by a telephone follow-up at 90 days. In addition, data on loss of productivity were acquired through the validated Productivity Cost Questionnaire at 4 weeks after surgery. Cost estimates were based on prices for the year 2019. RESULTS In total, 1005 patients were evaluated in the "intention-to-treat" analysis: 502 patients were allocated to the 2-day group and 503 to the 5-day group. The mean difference in overall societal costs was - €625 (95% CI: -€ 958 to -€ 278) to the advantage of the 2-day group. This difference was largely explained by reduced hospital stay. Productivity losses were similar between the study groups. Restricting postoperative antibiotics to 2 days was cost-effective, with estimated cost savings of €31,117 per additional infectious complication. CONCLUSIONS Two days of postoperative antibiotics for complex appendicitis results in a statistically significant and relevant cost reduction, as compared with 5 days. Findings apply to laparoscopic appendectomy in a well-resourced health care setting.
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Affiliation(s)
| | - Evert-Jan G. Boerma
- Departments of Surgery, Zuyderland Medical Center, Heerlen/Sittard, The Netherlands
| | | | - Marc A. Koopmanschap
- Departments of Surgery, Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Coen I.M. Baeten
- Departments of Surgery, Groene Hart Hospital, Gouda, The Netherlands
| | | | | | - Esther C.J. Consten
- Departments of Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Departments of Surgery, University Medical Center Groningen, The Netherlands
| | | | - Marloes Emous
- Departments of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | | | - Anton F. Gijsen
- Departments of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - Luc A. Heijnen
- Departments of Surgery, Northwest Clinics, Alkmaar/Den Helder, The Netherlands
| | - An P. Jairam
- Departments of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Pascal Steenvoorde
- Departments of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | | | - Maarten Vermaas
- Departments of Surgery, IJsselland Hospital, Capelle a/d Ijssel, The Netherlands
| | - Bas Wiering
- Departments of Surgery, Slingeland Hospital, Doetinchem, The Netherlands
| | - Bas P.L. Wijnhoven
- Departments of Surgery, Erasmus MC—University Medical Center, Rotterdam, The Netherlands
| | - Anne Loes van den Boom
- Departments of Surgery, Erasmus MC—University Medical Center, Rotterdam, The Netherlands
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9
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Iresjö BM, Blomström S, Engström C, Johnsson E, Lundholm K. Acute appendicitis: A block-randomized study on active observation with or without antibiotic treatment. Surgery 2024; 175:929-935. [PMID: 38218686 DOI: 10.1016/j.surg.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Antibiotic treatment of unselected patients with acute appendicitis is safe and effective. However, it is unknown to what extent early provision of antibiotic treatment may represent overtreatment due to spontaneous healing of appendix inflammation. The aim of the present study was to evaluate the role of antibiotic treatment versus active in-hospital observation on spontaneous regression of acute appendicitis. METHOD Patients who sought acute medical care at Sahlgrenska University Hospital were block-randomized according to age (18-60 years) and systemic inflammation (C-reactive protein <60 mg/L, white blood cell <13,000/μL), in combination with clinical and abdominal characteristics of acute appendicitis. Study patients received antibiotic treatment and active observation, while control patients were allocated to classic active "wait and see observation" for either disease regression or the need for surgical exploration. According to our standard surgical care, certified surgeons in charge decided whether and when appendectomy was necessary. In total, 1,019 patients were screened for eligibility; 203 patients met inclusion criteria, 126 were accepted to participate, 29 declined, and 48 were missed for inclusion. RESULTS The antibiotic group (n = 69) and the control group (n = 57) were comparable at inclusion. Appendectomy at first hospital stay was 28% and 53% for study and control patients (χ2, P < .004). Life table analysis indicated a time-dependent difference in the need for appendectomy during follow-up (P < .03). Antibiotics prevented surgical exploration and appendectomy by 72% to 50% compared to 47% to 37% in the control group across the time course follow-ups between 5 and 1,200 days. CONCLUSION Early antibiotic treatment is superior to traditional "wait and see observation" to avoid surgical exploration and appendectomy.
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Affiliation(s)
- Britt-Marie Iresjö
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Sara Blomström
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Cecilia Engström
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Erik Johnsson
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Kent Lundholm
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
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10
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Fransvea P, Puccioni C, Altieri G, D'Agostino L, Costa G, Tropeano G, La Greca A, Brisinda G, Sganga G. Beyond acute appendicitis: a single-institution experience of unexpected pathology findings after 989 consecutive emergency appendectomy. Langenbecks Arch Surg 2024; 409:87. [PMID: 38441707 DOI: 10.1007/s00423-024-03277-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/27/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Appendiceal neoplasms (ANs) are rare, with an estimated incidence of around 1%: neuroendocrine tumours (NETs) and low-grade appendiceal mucinous neoplasms (LAMNs) comprise most cases. Most tumours are cured by appendectomy alone, although some require right hemicolectomy and intra-operative chemotherapy. The aim of the present study is to evaluate our institution's experience in terms of the prevalence of AN, their histological types, treatment and outcomes in adult patients undergoing emergency appendectomy. MATERIAL AND METHODS Single-centre retrospective cohort analysis of patients treated for acute appendicitis at a large academic medical centre. Patients with a diagnosis of acute appendicitis (AA) where further compared with patients with acute appendicitis and a histologically confirmed diagnosis of appendiceal neoplasm (AN). RESULTS A diagnosis of acute appendicitis was made in 1200 patients. Of these, 989 patients underwent emergency appendectomy. The overall incidence of appendiceal neoplasm was 9.3% (92 patients). AN rate increased with increasing age. Patients under the age of 30 had a 3.8% (14/367 patients) rate of occult neoplasm, whereas patients between 40 and 89 years and older had a 13.0% rate of neoplasm. No difference was found in clinical presentations and type of approach while we found a lower complicated appendicitis rate in the AN group. CONCLUSION ANs are less rare with respect to the literature; however, clinically, there are no specific signs of suspicious and simple appendicectomy appears to be curative in most cases. However, age plays an important role; older patients are at higher risk for AN. ANs still challenge the non-operative management concept introduced into the surgical literature.
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Affiliation(s)
- Pietro Fransvea
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy.
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy.
| | - Caterina Puccioni
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy
| | - Gaia Altieri
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Luca D'Agostino
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Gianluca Costa
- Surgery Center, Colorectal Surgery Clinical and Research Unit - Fondazione Policlinico Universitario Campus Bio-Medico, University Campus Bio-Medico of Rome, Rome, Italy
| | - Giuseppe Tropeano
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Antonio La Greca
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy
| | - Giuseppe Brisinda
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy
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11
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Andersson RE. Author's Reply: Spontaneous Resolution of Uncomplicated Appendicitis may Explain Increase in Proportion of Complicated Appendicitis During Covid-19 Pandemic: A Systematic Review and Meta-analysis by Andersson et al. World J Surg 2023; 47:3443-3444. [PMID: 37845340 DOI: 10.1007/s00268-023-07211-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Roland Erik Andersson
- Department of Surgery, Ryhov Hospital, Jönköping, Sweden.
- Department of Biomedical and Clinical Sciences, Linköpings Universitet, 58185, Linköping, Sweden.
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12
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Pata F, Nardo B, Ielpo B, Di Martino M, Murzi V, Di Saverio S, Yang B, Ortenzi M, Pisanu A, Pellino G, Podda M. Endoscopic retrograde appendicitis therapy versus appendectomy or antibiotics in the modern approach to uncomplicated acute appendicitis: A systematic review and meta-analysis. Surgery 2023; 174:1292-1301. [PMID: 37806859 DOI: 10.1016/j.surg.2023.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/09/2023] [Accepted: 08/16/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Endoscopic retrograde appendicitis therapy has been proposed as an alternative strategy for treating appendicitis, but debate exists on its role compared with conventional treatment. METHODS This systematic review was performed on MEDLINE, Cochrane Central Register of Controlled Trials, and EMBASE. The last search was in April of 2023. The risk ratio with a 95% confidence interval was calculated for dichotomous variables, and the mean difference with a 95% confidence interval for continuous variables. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool (randomized controlled trials) and the Risk of Bias in Non-Randomized Studies of Intervention tool (non-randomized controlled trials). RESULTS Six studies met the eligibility criteria. Four studies compared endoscopic retrograde appendicitis therapy (n = 236 patients) and appendectomy (n = 339) and found no differences in technical success during index admission (risk ratio 0.97, 95% confidence interval [0.92,1.02]). Appendectomy showed superior outcomes for recurrence at 1-year follow-up (risk ratio 11.28, 95% confidence interval [2.61,48.73]). Endoscopic retrograde appendicitis therapy required shorter procedural time (mean difference -14.38, 95% confidence interval [-20.17, -8.59]) and length of hospital stay (mean difference -1.19, 95% confidence interval [-2.37, -0.01]), with lower post-intervention abdominal pain (risk ratio 0.21, 95% confidence interval [0.14,0.32]). Two studies compared endoscopic retrograde appendicitis therapy (n = 269) and antibiotic treatment (n = 280). Technical success during admission (risk ratio 1.11, 95% confidence interval [0.91,1.35]) and appendicitis recurrence (risk ratio 1.07, 95% confidence interval [0.08,14.87]) did not differ, but endoscopic retrograde appendicitis therapy decreased the length of hospitalization (mean difference -1.91, 95% confidence interval [-3.18, -0.64]). CONCLUSION This meta-analysis did not identify significant differences between endoscopic retrograde appendicitis therapy and appendectomy or antibiotics regarding technical success during index admission and treatment efficacy at 1-year follow-up. However, a high risk of imprecision limits these results. The advantages of endoscopic retrograde appendicitis therapy in terms of reduced procedural times and shorter lengths of stay must be balanced against the increased risk of having an appendicitis recurrence at one year.
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Affiliation(s)
- Francesco Pata
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy; General Surgery Unit, Department of Surgery, AO Annunziata, Cosenza, Italy. https://twitter.com/drfrancescopata
| | - Bruno Nardo
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy; General Surgery Unit, Department of Surgery, AO Annunziata, Cosenza, Italy
| | - Benedetto Ielpo
- Hepatobiliary and Pancreatic Surgery Unit, Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Spain. https://twitter.com/IelpoB
| | - Marcello Di Martino
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy. https://twitter.com/MarcDiMartino
| | - Valentina Murzi
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Salomone Di Saverio
- Department of Surgery, "Madonna del Soccorso" Hospital, San Benedetto del Tronto, Italy. https://twitter.com/salo75
| | - Baohong Yang
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Monica Ortenzi
- Department of General and Emergency Surgery, Polytechnic University of Marche, Ancona, Italy. https://twitter.com/ortenzi_monica
| | - Adolfo Pisanu
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli," Naples; Department of Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain. https://twitter.com/GianlucaPellino
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy.
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13
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Moran B. Conservative management of appendicitis: general adoption may be jumping the gun. Br J Surg 2023; 110:1601-1602. [PMID: 37856698 DOI: 10.1093/bjs/znad334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/23/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Brendan Moran
- Peritoneal Malignancy Institute, Basingstoke Hospital, North Hampshire Foundation Trust, Basingstoke, UK
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14
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Flum DR. Factors associated with recurrent appendicitis after successful treatment with antibiotics. Br J Surg 2023; 110:1482-1489. [PMID: 37459231 PMCID: PMC10564398 DOI: 10.1093/bjs/znad218] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 05/04/2023] [Accepted: 05/24/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND As more patients with appendicitis are treated with antibiotics, factors associated with recurrence may help inform individualized prognostication and decision-making. METHODS This cohort study, using data from the Comparison of Outcomes of Antibiotic Drugs and Appendectomy trial, examined patients treated with antibiotics who did not undergo appendicectomy in the first 30 days. Patients who had appendicectomy between 30 days and 1 year were compared with those who did not. Marginalized logistic regression models were used to calculate adjusted risk differences (RDs) to estimate the association between baseline patient factors and the risk of undergoing an appendicectomy between 30 days and 1 year. RESULTS Of 601 patients treated with antibiotics who did not undergo appendicectomy within 30 days (mean age 38.0 years; 217 women (36.1 per cent)), 144 had an appendicectomy and 56 were lost to follow-up between 30 days and 1 year. The estimated rate of appendicectomy between 30 days and 1 year was 28.6 (95 per cent c.i. 25.0 to 32.8) per cent. After adjustment for other factors, nausea, vomiting, or anorexia at baseline presentation was associated with an increased rate of appendicectomy between 30 days and 1 year (adjusted RD 17.52, 95 per cent c.i. 8.64 to 26.40). The presence of an appendicolith (adjusted RD 3.64, -6.08 to 13.36), or an abscess, perforation, or fat stranding on initial imaging (adjusted RD -7.23, -17.41 to 2.95) was not strongly associated with appendicectomy between 30 days and 1 year. CONCLUSION Most factors commonly associated with appendicitis severity were not strongly associated with an increased risk of undergoing appendicectomy in the longer term after treatment with antibiotics.
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Affiliation(s)
- David R Flum
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle, Washington, USA
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15
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Ceresoli M, Fumagalli C, Fugazzola P, Zanini N, Magnone S, Ravasi M, Bonalumi J, Morezzi D, Bova R, Sargenti B, Schiavone L, Lucianetti A, Catena F, Ansaloni L, Braga M. Outpatient Non-operative Management of Uncomplicated Acute Appendicitis: A Non-inferiority Study. World J Surg 2023; 47:2378-2385. [PMID: 37210423 PMCID: PMC10474178 DOI: 10.1007/s00268-023-07065-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 05/22/2023]
Abstract
INTRODUCTION Non-operative management (NOM) of uncomplicated acute appendicitis is a well-established alternative to upfront surgery. The administration of intravenous broad-spectrum antibiotics is usually performed in hospital, and only one study described outpatient NOM. The aim of this multicentre retrospective non-inferiority study was to evaluate both safety and non-inferiority of outpatient compared to inpatient NOM in uncomplicated acute appendicitis. METHODS The study included 668 consecutive patients with uncomplicated acute appendicitis. Patients were treated according to the surgeon's preference: 364 upfront appendectomy, 157 inpatient NOM (inNOM), and 147 outpatient NOM (outNOM). The primary endpoint was the 30-day appendectomy rate, with a non-inferiority limit of 5%. Secondary endpoints were negative appendectomy rate, 30-day unplanned emergency department (ED) visits, and length of stay. RESULTS 30-day appendectomies were 16 (10.9%) in the outNOM group and 23 (14.6%) in the inNOM group (p = 0.327). OutNOM was non-inferior to inNOM with a risk difference of-3.80% 97.5% CI (- 12.57; 4.97). No difference was found between inNOM and outNOM groups for the number of complicated appendicitis (3 vs. 5) and negative appendectomy (1 vs. 0). Twenty-six (17.7%) outNOM patients required an unplanned ED visit after a median of 1 (1-4) days. In the outNOM group, the mean cumulative in-hospital stay was 0.89 (1.94) days compared with 3.94 (2.17) days in the inNOM group (p < 0.001). CONCLUSIONS Outpatient NOM was non-inferior to inpatient NOM with regard to the 30-day appendectomy rate, while a shorter hospital stay was found in the outNOM group. Further, studies are required to confirm these findings.
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Affiliation(s)
- Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy.
| | - Chiara Fumagalli
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
| | - Paola Fugazzola
- General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Nicola Zanini
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Stefano Magnone
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Michela Ravasi
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
| | - Jacopo Bonalumi
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
| | - Daniele Morezzi
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Raffaele Bova
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Benedetta Sargenti
- General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Luca Schiavone
- General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | | | - Fausto Catena
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Braga
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
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16
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Collard MK, Bardin J, Marquet B, Laurin M, Ogier-Denis É. Correlation between the presence of a cecal appendix and reduced diarrhea severity in primates: new insights into the presumed function of the appendix. Sci Rep 2023; 13:15897. [PMID: 37741857 PMCID: PMC10517977 DOI: 10.1038/s41598-023-43070-5] [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: 03/13/2023] [Accepted: 09/19/2023] [Indexed: 09/25/2023] Open
Abstract
Increased severity or recurrence risk of some specific infectious diarrhea, such a salmonellosis or Clostridium difficile colitis, have been reported after an appendectomy in human patients. While several other mammals also possess an appendix, the suspected protective function against diarrhea conferred by this structure is known only in humans. From a retrospective collection of veterinary records of 1251 primates attributed to 45 species, including 13 species with an appendix and 32 without, we identified 2855 episodes of diarrhea, 13% of which were classified as severe diarrhea requiring a therapeutic medication or associated with a fatal issue. We identified a lower risk of severe diarrhea among primate species with an appendix, especially in the early part of life when the risk of diarrhea is maximal. Moreover, we observed a delayed onset of diarrhea and of severe diarrhea in species possessing an appendix. Interestingly, none of the primates with an appendix were diagnosed, treated or died of an acute appendicitis during the 20 years of veterinarian follow-up. These results clarify the function of the appendix among primates, as protection against diarrhea. This supports its presumed function in humans and is congruent with the existence of a selective advantage conferred by this structure.
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Affiliation(s)
- Maxime K Collard
- Centre de Recherche sur l'Inflammation, INSERM, U1149, CNRS, ERL8252, Team Gut Inflammation, Université de Paris, BP 416, 75018, Paris, France.
- Department of Colorectal Surgery, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France.
| | - Jérémie Bardin
- CR2P (Centre de Recherche en Paléontologie - Paris; UMR 7207), CNRS/MNHN/Sorbonne Université, Muséum National d'Histoire Naturelle, Paris, France
| | | | - Michel Laurin
- CR2P (Centre de Recherche en Paléontologie - Paris; UMR 7207), CNRS/MNHN/Sorbonne Université, Muséum National d'Histoire Naturelle, Paris, France
| | - Éric Ogier-Denis
- Centre de Recherche sur l'Inflammation, INSERM, U1149, CNRS, ERL8252, Team Gut Inflammation, Université de Paris, BP 416, 75018, Paris, France
- INSERM U1242, Centre Eugène Marquis, Université de Rennes 1, Rennes, France
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17
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Andersson RE, Agiorgiti M, Bendtsen M. Spontaneous Resolution of Uncomplicated Appendicitis may Explain Increase in Proportion of Complicated Appendicitis During Covid-19 Pandemic: a Systematic Review and Meta-analysis. World J Surg 2023; 47:1901-1916. [PMID: 37140609 PMCID: PMC10158710 DOI: 10.1007/s00268-023-07027-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Reports of an increased proportion of complicated appendicitis during the Covid-19 pandemic suggest a worse outcome due to delay secondary to the restrained access to health care, but may be explained by a concomitant decrease in uncomplicated appendicitis. We analyze the impact of the pandemic on the incidences of complicated and uncomplicated appendicitis. METHOD We did a systematic literature search in the PubMed, Embase and Web Of Science databases on December 21, 2022 with the search terms (appendicitis OR appendectomy) AND ("COVID" OR SARS-Cov2 OR "coronavirus"). Studies reporting the number of complicated and uncomplicated appendicitis during identical calendar periods in 2020 and the pre-pandemic year(s) were included. Reports with indications suggesting a change in how the patients were diagnosed and managed between the two periods were excluded. No protocol was prepared in advance. We did random effects meta-analysis of the change in proportion of complicated appendicitis, expressed as the risk ratio (RR), and of the change in number of patients with complicated and uncomplicated appendicitis during the pandemic compared with pre-pandemic periods, expressed as the incidence ratio (IR). We did separate analyses for studies based on single- and multi-center and regional data, age-categories and prehospital delay. RESULTS The meta-analysis of 100,059 patients in 63 reports from 25 countries shows an increase in the proportion of complicated appendicitis during the pandemic period (RR 1.39, 95% confidence interval (95% CI 1.25, 1.53). This was mainly explained by a decreased incidence of uncomplicated appendicitis (incidence ratio (IR) 0.66, 95% CI 0.59, 0.73). No increase in complicated appendicitis was seen in multi-center and regional reports combined (IR 0.98, 95% CI 0.90, 1.07). CONCLUSION The increased proportion of complicated appendicitis during Covid-19 is explained by a decrease in the incidence of uncomplicated appendicitis, whereas the incidence of complicated appendicitis remained stable. This result is more evident in the multi-center and regional based reports. This suggests an increase in spontaneously resolving appendicitis due to the restrained access to health care. This has important principal implications for the management of patients with suspected appendicitis.
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Affiliation(s)
- Roland E Andersson
- Department of Surgery, County Hospital Ryhov, Box 1024, SE 551 11, Jönköping, Region Jönköpings Län, Sweden.
- Futurum, Academy for Health and Care, Jönköping, Region Jönköpings Län, Sweden.
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Maria Agiorgiti
- Bra Liv Eksjö Primary Care Centre, Eksjö, Region Jönköping County, Sweden
- Department of Experimental Physiology, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Marcus Bendtsen
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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18
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Barie PS, Kao LS, Moody M, Sawyer RG. Infection or Inflammation: Are Uncomplicated Acute Appendicitis, Acute Cholecystitis, and Acute Diverticulitis Infectious Diseases? Surg Infect (Larchmt) 2023; 24:99-111. [PMID: 36656157 DOI: 10.1089/sur.2022.363] [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: 01/20/2023] Open
Abstract
Background: It is recognized increasingly that common surgical infections of the peritoneal cavity may be treated with antibiotic agents alone, or source control surgery with short-course antimicrobial therapy. By extension, testable hypotheses have emerged that such infections may not actually be infectious diseases, but rather represent inflammation that can be treated successfully with neither surgery nor antibiotic agents. The aim of this review is to examine extant data to determine which of uncomplicated acute appendicitis (uAA), uncomplicated acute calculous cholecystitis (uACC), or uncomplicated mild acute diverticulitis (umAD) might be amenable to management using supportive therapy alone, consistent with the principles of antimicrobial stewardship. Methods: Review of pertinent English-language literature and expert opinion. Results: Only two small trials have examined whether uAA can be managed with observation and supportive therapy alone, one of which is underpowered and was stopped prematurely because of challenging patient recruitment. Data are insufficient to determine the safety and efficacy of non-antibiotic therapy of uAA. Uncomplicated acute calculous cholecystitis is not primarily an infectious disease; infection is a secondary phenomenon. Even when bactibilia is present, there is no high-quality evidence to suggest that mild disease should be treated with antibiotic agents. There is evidence to indicate that antibiotic prophylaxis is indicated for urgent/emergency cholecystectomy for uACC, but not in the post-operative period. Uncomplicated mild acute diverticulitis, generally Hinchey 1a or 1b in current nomenclature, does not benefit from antimicrobial agents based on multiple clinical studies. The implication is that umAD is inflammatory and not an infectious disease. Non-antimicrobial management is reasonable. Conclusions: Among the considered disease entities, the evidence is strongest that umAD is not an infectious disease and can be treated without antibiotic agents, intermediate regarding uACC, and lacking for uAA. A plausible hypothesis is that these inflammatory conditions are related to disruption of the normal microbiome, resulting in dysbiosis, which is defined as an imbalance of the natural microflora, especially of the gut, that is believed to contribute to a range of conditions of ill health. As for restorative pre- or probiotic therapy to reconstitute the microbiome, no recommendation can be made in terms of treatment, but it is not recommended for prevention of primary or recurrent disease.
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Affiliation(s)
- Philip S Barie
- Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Lillian S Kao
- Department of Surgery, UTHealth Houston John P. and Kathrine G. McGovern Medical School, Houston, Texas, USA
| | - Mikayla Moody
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
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19
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Surgical Emergencies in the Pregnant Patient. Curr Probl Surg 2023; 60:101304. [PMID: 37169419 DOI: 10.1016/j.cpsurg.2023.101304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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20
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Mean Platelet Volume in the Diagnosis of Acute Appendicitis in the Pediatric Population: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2022; 12:diagnostics12071596. [PMID: 35885500 PMCID: PMC9318144 DOI: 10.3390/diagnostics12071596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Mean Platelet Volume (MPV) has been suggested as a biomarker for acute appendicitis (AA) in the adult population. The utility of MPV in pediatric AA remains vague. This systematic review and meta-analysis aimed to systematically summarize and compare all relevant data on MPV as a diagnostic biomarker for AA in children. Methods: Databases were systematically searched using keywords ((mean platelet volume) OR mpv) AND (appendicitis). The inclusion criteria were all comparative studies of MPV in children aged less than 18 years and diagnosed with AA. Two authors independently assessed the methodological quality using the Downs and Black scale. Results: We included fourteen studies in the final meta-analysis; most were retrospective. Eight studies compared the MPV values between AA and non-AA; four studies compared the same between AA and healthy controls; two studies compared the MPV values among all three groups. The estimated heterogeneity among the studies for all outcomes was high and statistically significant. The pooling the data showed no statistically significant difference in MPV (weighted mean difference (WMD) = −0.42, 95% CI = (−1.04, 0.20), p = 0.19) between AA and healthy controls or AA and non-AA cases (WMD = 0.01, 95% CI = (−0.15, 0.17), p = 0.90). Conclusion: While MPV levels seem to have some utility in adult AA diagnosis, MPV levels should not dictate treatment options in pediatric AA.
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