Complicated appendicitis and considerations for interval appendectomy. JAAPA. 2018;31:35-41. [PMID: 30153202 DOI: 10.1097/01.jaa.0000544304.30954.40]

Evaluation of the clinical effects of atropine in combination with remifentanil in children undergoing surgery for acute appendicitis

BACKGROUND

Acute appendicitis (AA) is the most common cause of acute abdomen in children. Anesthesia significantly influences the surgical treatment of AA in children, making the scientific and effective selection of anesthetics crucial.

AIM

To assess the clinical effect of atropine (ATR) in combination with remifentanil (REMI) in children undergoing surgery for AA.

METHODS

In total, 108 cases of pediatric AA treated between May 2020 and May 2023 were selected, 58 of which received ATR + REMI [research group (RG)] and 50 who received REMI [control group (CG)]. Comparative analyses were conducted on the time to loss of eyelash reflex, pain resolution time, recovery time from anesthesia, incidence of adverse events (AEs; respiratory depression, hypoxemia, bradycardia, nausea and vomiting, and hypotension), intraoperative responses (head shaking, limb activity, orientation recovery, safe departure time from the operating room), hemodynamic parameters [oxygen saturation (SPO2), mean arterial pressure, heart rate, and respiratory rate], postoperative sedation score (Ramsay score), and pain level [the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale].

RESULTS

Compared with the CG, the RG showed significantly shorter time to loss of eyelash reflex, pain resolution, recovery from anesthesia, and safe departure from the operating room. Furthermore, the incidence rates of overall AEs (head shaking, limb activity, etc.) were lower, and influences on intraoperative hemodynamic parameters and stress response indexes were fewer. The Ramsay score at 30 min after extubation and the FLACC score at 60 min after extubation were significantly lower in the RG than in the CG.

CONCLUSION

ATR + REMI is superior to REMI alone in children undergoing AA surgery, with a lower incidence of AEs, fewer influences on hemodynamics and stress responses, and better post-anesthesia recovery.

Current use of artificial intelligence in the diagnosis and management of acute appendicitis

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.

Usefulness of extended inflammatory parameters related to neutrophil activation reported by Sysmex XN-1000 hematology analyzer for predicting complicated acute appendicitis. Comparison with canonical inflammatory laboratory tests

AIM

Accurate diagnosis of complicated appendicitis is of importance to ensure that patients receive early and effective treatment, minimizing the risk of postoperative complications to promote successful recovery. Biochemical markers are a promising tool to identify complicated appendicitis. We aimed to evaluate the potential role of novel parameters related with neutrophil activation, known as "Extended Inflammation Parameters" (EIP), included in blood cell count reported by Sysmex XN-Series analyzers, compared to other canonical biomarkers in identifying complicated appendicitis.

METHOD

Prospective observational study including patients with confirmed diagnosis of acute appendicitis. C-reactive protein (CRP), procalcitonin, cell blood count, including white blood cell (WBC), absolute neutrophil (ANC) and immature granulocyte (IG) count and EIP (neutrophil reactivity [NEUT-RI] and granularity intensity [NEUT-GI]) were analyzed before surgery. Their accuracy to diagnose complicated appendicitis was tested in an ROC curve analysis.

RESULTS

Our population study included 119 patients, and appendicitis was complicated in 58 (48.7%). NLR, CRP and procalcitonin levels, ANC and IG count and NEUT-RI and NEUT-GI were higher in patients with complicated appendicitis. Regarding accuracy for complicated appendicitis, CRP was the biomarker with the highest performance (ROC AUC: 0.829), with an optimal cutoff of 73.1 mg/L (sensitivity: 63.8%, specificity: 88.5%). NEUT-RI and NEUT-GI achieved both significant but poor accuracy, with ROC AUC of 0.606 and 0.637, respectively.

CONCLUSIONS

Novel laboratory tests reported by Sysmex XN-Series analyzers have poor accuracy for identifying complicated appendicitis. In this study, CRP was the biomarker with the highest performance and may be useful as predictor of the severity of acute appendicitis.

The presence and the anatomical variations of the accessory appendicular artery: A systematic review of 604 cases

INTRODUCTION

The accessory appendicular artery (AAA) is an accessory source of blood supply to the appendix. Its existence and potential point of origin are seldom addressed in the literature.

METHODS

To fill this knowledge gap, we performed a systematic review of all available studies involving both cadaveric and surgical specimens and documented the presence and the origin of the AAA, following the guidelines outlined in the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement.

RESULTS

Eleven studies, with an overall of 604 specimens were included. Our research revealed that the AAA is notably absent in most cases (83.6%). When present, it most commonly originates from the posterior cecal artery (12.4%), followed by the descending branch of the ileocolic artery (2%), and the ileal branch of the ileocolic artery (0.7%). Instances of origin from the anterior cecal, common cecal, or the ileocolic trunk were even more infrequent. Based on our observations, we introduced a new simplified classification system.

DISCUSSION

The effect of an accessory artery on the process of appendicitis remains to be clarified. We firmly recommend that surgeons should consider the possible presence and various origins of the AAA during appendectomy procedures to avoid serious complications.

Beyond a vestigial organ: effects of the appendix on gut microbiome and colorectal cancer

The role of appendectomy in the pathogenesis of colorectal cancer (CRC) is a recent topic of contention. Given that appendectomy remains one of the most commonly performed operations and a first-line management strategy of acute appendicitis, it is inherently crucial to elucidate the association between prior appendectomy and subsequent development of CRC, as there may be long-term health repercussions. In this review, we summarize the data behind the relationship of CRC in post-appendectomy patients, discuss the role of the microbiome in relation to appendectomy and CRC pathogenesis, and provide an appraisal of our current understanding of the function of the appendix. We seek to piece together the current landscape surrounding the microbiome and immunological changes in the colon post-appendectomy and suggest a direction for future research involving molecular, transcriptomic, and immunologic analysis to complement our current understanding of the alterations in gut microbiome.

Causal effects of gut microbiota on appendicitis: a two-sample Mendelian randomization study

Background

Previous research has posited a potential correlation between the gut microbiota and the onset of appendicitis; however, the precise causal connection between appendicitis and the gut microbiota remains an unresolved and contentious issue.

Methods

In this investigation, we performed a Mendelian randomization (MR) analysis employing publicly accessible summary data extracted from genome-wide association studies (GWAS) to elucidate the potential causal nexus between the gut microbiota and the development of appendicitis. We initially identified instrumental variables (IVs) through a comprehensive array of screening methodologies, subsequently executing MR analyses using the Inverse Variance Weighted (IVW) technique as our primary approach, supplemented by several alternative methods such as MR Egger, weighted median, simple mode, and weighted mode. Additionally, we implemented a series of sensitivity analysis procedures, encompassing Cochran's Q test, MR-Egger intercept test, Mendelian Randomized Polymorphism Residual and Outlier (MR-PRESSO) test, and a leave-one-out test, to affirm the robustness and validity of our findings.

Results

Our investigation indicates that an elevated prevalence of Deltaproteobacteria, Christensenellaceae, Desulfovibrionaceae, Eubacterium ruminantium group, Lachnospiraceae NK4A136 group, Methanobrevibacter, Desulfovibrionales, and Euryarchaeota is inversely associated with the risk of appendicitis. Conversely, we observed a positive correlation between an increased abundance of Family XIII, Howardella, and Veillonella and the susceptibility to appendicitis. Sensitivity analyses have corroborated the robustness of these findings, and Mendelian randomization analyses provided no indications of reverse causality.

Conclusion

Our Mendelian randomization (MR) analysis has unveiled potential advantageous or detrimental causal associations between the gut microbiota and the occurrence of appendicitis. This study offers novel theoretical and empirical insights into the understanding of appendicitis pathogenesis, along with its implications for preventive and therapeutic strategies.

Interval appendectomy as a safe and feasible treatment approach after conservative treatment for appendicitis with abscess: a retrospective, single-center cohort study

Emergency appendectomy (EA) is the gold standard management for acute appendicitis (AA). However, whether EA or interval appendectomy (IA) after conservative treatment is the optimal approach in AA with abscess remains controversial. This study compared IA and EA in patients presenting with AA accompanied by abscess. This was a retrospective single-center study including 446 consecutive patients undergoing appendectomy between April 2009 and March 2023. AA with abscess was defined as a pericecal abscess observed by computed tomography or abdominal ultrasonography, and patients with signs of peritoneal irritation were excluded. Perioperative outcomes were compared between the patients who directly underwent EA and those who underwent IA after conservative treatment. Among 42 patients (9.4%) with AA and abscess, 34 and 8 patients underwent IA and EA, respectively. The rates of ileocecal resection and postoperative complications were lower in the IA group than in the EA group (3% vs. 50%, P < 0.001 and 9% vs. 75%, P < 0.001, respectively). Colonoscopy before IA was performed in 16 of the 17 patients aged ≥ 40 years in the IA group, and one patient underwent ileocecal resection because of suspicious neoplasm in the root of the appendix. IA after conservative treatment might be considered as the useful therapeutic option for AA with abscess. Colonoscopy during the waiting period between the initial diagnosis and IA should be considered in patients aged ≥ 40 years who may have malignant changes. Implementing IA as a first-line treatment will be beneficial to both patients and healthcare providers.

Endometriosis of the Appendix: When Appendicitis Is Less Than Straightforward

We present a case report of a 49-year-old female with a history of ulcerative colitis who originally presented to the general surgery clinic after an incidental finding on computed tomography was concerning for a dilated, fluid-filled appendix. She ultimately underwent a laparoscopic appendectomy. The pathology returned consistent with early acute appendicitis, with endometrial tissue along the outer wall of the appendix. We then performed a literature review regarding appendiceal masses and the occurrence of endometriomas and/or endometriosis of the appendix. A PubMed search was performed using the key words of appendix and appendicitis and endometrioma. Specific articles were examined mentioning the occurrence of endometriomas of the appendix and isolated endometriosis of the appendix. Between 2% and 6% of cases of appendicitis present due to an appendiceal mass, usually an inflammatory phlegmon. A variety of other causes, including primary malignancy, secondary malignancy, and combinations of pathologies, may lead to the eventual removal of the appendix. Specifically, endometriosis of the appendix is reported in less than 1% of females on post-appendectomy pathologic analysis. Although specific symptoms may guide a provider, there are few distinguishing symptoms that would point a provider toward a different etiology, to include malignancy, for appendicitis. Further information is needed to determine when a patient has an increased risk for an underlying pathology when presenting with appendicitis. This information will help drive continued treatment and lead to improved screening for appendiceal masses.

Pre-appendectomy hyponatremia is associated with increased rates of complicated appendicitis

Background

Acute appendicitis is one of the most common surgical emergencies worldwide. Preoperative assessment of the risk of complicated appendicitis may aid in treatment planning. We sought to investigate the association between pre-appendectomy hyponatremia and diagnosis of complicated appendicitis.

Methods

The TriNetX platform, a federated health research network that aggregates de-identified electronic health record data of over 90 million patients across the United States, was queried for patients who underwent appendectomy starting January 2019 and who had at least one sodium value from the preoperative period. The study population was stratified into three age groups: pediatric (age < 18), adult (age 18-64), and older adult (age ≥ 65). These groups were subdivided into patients with preoperative hyponatremia (<135 mmol/L) and normonatremia (135-145 mmol/L).

Results

Among the 61,245 patients who met inclusion criteria, 17,546 were included for analysis following propensity score matching. The odds of complicated appendicitis were highest in pediatric patients (age < 18) with pre-appendectomy hyponatremia (odds ratio [OR] = 2.91, 95 % CI [2.53, 3.35]). Patients age 18-64 and aged ≥ 65 with preoperative hyponatremia also demonstrated increased odds of a complicated appendicitis diagnosis, but to a lesser extent (OR = 2.11, 95 % CI [1.92, 2.32] (OR = 1.49, 95 % CI [1.25, 1.77], respectively).

Conclusions

In a large analysis of matched patients with acute appendicitis, we found an association between immediate preoperative hyponatremia and complicated appendicitis. Future studies are indicated to further evaluate the role of hyponatremia as a potential diagnostic marker for complicated appendicitis in all age groups.

Key message

This study suggests a role of hyponatremia as one of multiple variables to incorporate into future clinical decision tools for complicated acute appendicitis.

The global, regional, and national burden of appendicitis in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Appendicitis is the most common abdominal surgical emergency worldwide, and its burden has been changing. We report the level and trends of appendicitis prevalence, and incidence; and years lived with disability (YLD) in 204 countries and territories from 1990 to 2019, based on data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

The numbers and age-standardized prevalence, incidence, and YLD rates per 100,000 population of appendicitis were estimated across regions and countries by age, sex, and sociodemographic index (SDI). All the estimates were reported with 95% uncertainty intervals (UIs).

RESULTS

Globally, the age-standardized prevalence and incidence rates of appendicitis in 2019 were 8.7 (95% UI 6.9 to 11.0) and 229.9 (95% UI 180.9 to 291.0) per 100,000 population, with increases of 20.8% (95% UI 18.9 to 23.0%) and 20.5% (95% UI 18.7 to 22.8%) from 1990 to 2019, respectively. Additionally, the age-standardized YLDs rate was 2.7 (95% UI 1.8 to 3.9) in 2019, with an increase of 20.4% (95% UI 16.2 to 25.1%) from 1990 to 2019. In 2019, the age-standardized prevalence, incidence, and YLD rates peaked in the 15-to-19-year age groups in both male and female individuals. However, no statistically significant differences were observed between the male and female individuals in all groups. Ethiopia, India, and Nigeria showed the largest increases in the age-standardized prevalence rate between 1990 and 2019. Generally, positive associations were found between the age-standardized YLD rates and SDI at the regional and national levels.

CONCLUSIONS

Appendicitis remains a major public health challenge globally. Increasing awareness of appendicitis and its risk factors and the importance of early diagnosis and treatment is warranted to reduce its the burden.

Validity of Machine Learning in Detecting Complicated Appendicitis in a Resource-Limited Setting: Findings from Vietnam

Background

Complicated appendicitis, a potentially life-threatening condition, is common. However, the diagnosis of this condition is mainly based on physician's experiences and advanced diagnostic equipment. This study built and validated machine learning models to facilitate the detection of complicated appendicitis.

Methods

A retrospective cohort study was conducted based on medical charts of all patients undergoing a laparoscopic appendectomy at a city hospital during 2016-2020. The synthetic minority over-sampling technique (SMOTE) was used to adjust for the imbalance. Multiple classification approaches were used to train and validate models including support vector machine (SVM), decision tree (DT), K-nearest neighbor (KNN), logistic regression (LR), artificial neural network (ANN), and gradient boosting (GB).

Results

Among 1,950 patients included in the data analysis, there were 483 patients identified as having complicated appendicitis (24.8%). Based on data without SMOTE adjustment for imbalance, the accuracy levels and AUCs were high in all models using different parameters, ranging from 0.687 to 0.815. After adjusting for imbalance data using SMOTE, AUC and accuracy levels in the models using imbalance adjusted data were higher. Of these, the GB had all AUC and accuracy values of approximately 0.8 or more in both adjusted and unadjusted data.

Conclusions

Machine learning approaches including SVM, DT, logistic, KNN, ANN, and GB have a high level of validity in classifying patients with complicated appendicitis and patients without complicated appendicitis. Among these, GB had the highest level of validity and should be used or further validated. Our study indicates the beneficial potentials of machine learning techniques in a clinical setting in general and in the diagnosis of complicated appendicitis in particular.

Characteristics of Patients Presented with Complicated Appendicitis in Adama, Ethiopia: A Cross-Sectional Study

BACKGROUND

Complicated appendicitis (CA) is defined as perforated appendicitis, peritonitis, peri-appendicular abscess, or appendicular mass. One-third of patients who develop appendicitis are diagnosed with CA at presentation. Studies regarding the prevalence of CA are lacking in low-income countries, and the characteristics of patients presented with CA are incoherently identified.

OBJECTIVE

To assess the prevalence and the significant characteristics associated with CA among patients admitted with the diagnosis of acute appendicitis at Adama Hospital Medical College.

METHODS

A cross-sectional study was conducted from January 1, 2018, up to December 31, 2019. From a total of 1043 patients during the study period, the charts of 431 patients were selected using a systematic random sampling technique. Data were collected by a structured checklist. Bivariate and multivariable binary logistic regression analyses were employed to assess the association of patients' characteristics with CA.

RESULTS

Out of 431 patients, 157 (36.4%) had CA. Characteristics of patients having a significant association with CA were found to be generalized abdominal tenderness (AOR: 27.48, 95% CI: 4.03, 187.24), diagnosis with peritonitis (AOR: 14.87, 95% CI: 4.05, 54.54), right lower quadrant (RLQ) abdominal mass (AOR: 7.79, 95% CI: 2.02, 29.99), shock (10.37, 95% CI: 3.18, 33.76), white blood cell (WBC) count >11,000 (AOR: 2.16, 95% CI: 1.02, 4.61), onset to visit interval of 8-14 days (AOR: 10.45, 95% CI: 2.4, 45.52) and ultrasound report of acute appendicitis (AOR: 0.33, 95% CI: 0.13, 0.85), appendiceal abscess (AOR: 5.05, 95% CI: 1.48, 17.31), and appendiceal mass (AOR: 6.04, 95% CI: 1.45, 25.14).

CONCLUSION

The prevalence of CA was very high. Generalized abdominal tenderness, RLQ abdominal mass, shock, WBC count, onset to visit interval, abdominopelvic ultrasound report, and clinical diagnosis of peritonitis were significantly associated with CA.

Coronavirus Disease Pandemic Effect on Medical-Seeking Behaviors Even in One Resource-Competent Community: A Case Controlled Study

(1) Background: The coronavirus disease 2019 (COVID-19) pandemic had overwhelming impacts on medical services. During its initial surge, Taiwan was unique in maintaining its medical services without imposing travel restrictions, which provided an ideal environment in which to test if the fear of becoming infected with COVID-19 interfered with health-seeking behavior (HSB). We tested this hypothesis among adults with acute complicated appendicitis (ACA). (2) Methods: Adults with acute appendicitis were enrolled between 1 January and 30 June 2020 (COVID-19 period). The first two quarters of the preceding 3 years were defined as a historical control group. Outcome measures included the rate of ACA and the number of hospital stays. (3) Results: The COVID-19 era included 145 patients with acute appendicitis. Compared to the historical control (320 patients), the COVID-19 era was significantly associated with a higher length of symptom duration until presentation to the emergency room within >48 h (17.2% vs. 9.1%, p = 0.011), a higher incidence of ACA (29.7% vs. 19.4%, p = 0.014), and a longer length of hospital stays (5.0 days vs. 4.0 days, p = 0.043). The adjusted models showed that the COVID-19 period had a significant relationship with a higher rate of ACA (odds ratio (OR) = 1.87; 95% confidence interval (CI): 1.23-2.52; p = 0.008) and longer length of hospital stays (OR= 2.10; 95% CI: 0.92 to 3.31; p < 0.001). (4) Conclusions: The fear of COVID-19 may prohibit patients from seeking medical help, worsening their clinical outcomes. The surgical community should take action to provide scientific information to relive mental stress.

[S073]-The impact of interval appendectomy timing on follow-up adverse outcomes

OBJECTIVE

This study aims to compare the timing of interval appendectomy (IA) and its impact on post-operative outcomes.

METHODS

A retrospective analysis was performed for adult patients diagnosed with appendicitis between 2006 and 2017. IA was defined as a follow-up appendectomy > 1 week and < 2 years after the initial presentation. Time intervals were divided into 4 groups based on patient quartiles: 1-6 weeks, 7-9 weeks, 10-15 weeks, and > 15 weeks. The primary outcome measure was length of stay (LOS). Secondary outcomes included 30-day readmission and IA post-operative complications. Tertiary outcomes included 30-day mortality and colonoscopy suggesting neoplasm or Inflammatory Bowel Disease.

RESULTS

A total of 5069 patients' records whose interval appendectomy fell > 1 week and < 2 years after initial presentation were analyzed. Among them, 1006 (19.85%) underwent an initial percutaneous abscess drainage at diagnosis. The median timing for IA was 9.2 weeks. Patients with IA at 1-6 weeks were more likely to have longer LOS when compared to 7-9 weeks (ratio 1.33, 95% CI 1.2-1.48) and 10-15 weeks (ratio 1.38, 95% CI 1.25-1.52). IA between 7 and 9 weeks (ratio 0.81, 95% CI 0.73-0.89) and 10-15 weeks (ratio 0.78, 95% CI 0.71-0.86) was associated with significantly shorter LOS compared to those receiving the operation after 15 weeks. Further, patients requiring abscess drainage (ratio 1.2, 95% CI 1.13-1.34) or those with comorbidities (ratio 1.51, 95% CI 1.39-1.63) were more likely to have longer LOS at IA. Socioeconomic and demographic differences including Black, Hispanic, and those with Medicare and Medicaid insurance had a greater LOS after their IA.

CONCLUSION

LOS remains lowest among patients undergoing IA between 7-9 weeks and 10-15 weeks after initial appendicitis presentation. Patients with lower socioeconomic status or from racial minorities had a longer LOS after IA.

Fibrinogen as a Marker of Overall and Complicated Acute Appendicitis: A Systematic Review and Meta-Analysis

INTRODUCTION

We performed a systematic review and meta-analysis to evaluate the diagnostic value of fibrinogen (FB) for acute appendicitis and whether it can distinguish between uncomplicated and complicated appendicitis.

METHODS

A search of electronic information sources was conducted to identify all studies reporting FB in patients with clinical suspicion or confirmed diagnosis of acute appendicitis. We considered two comparisons: (1) appendicitis versus no appendicitis and (2) uncomplicated appendicitis versus complicated appendicitis. To assess the diagnostic value of FB, sensitivity, specificity, diagnostic odds ratios, summary receiver operating characteristic curves, area under the curve, and 95% confidence intervals (95% CIs) were estimated.

RESULTS

Seven studies (917 confirmed appendicitis and 1026 controls) for overall appendicitis and eight studies (602 complicated appendicitis and 1386 uncomplicated appendicitis) for complicated appendicitis were identified. The pooled sensitivity and specificity of FB for the diagnosis of appendicitis were 0.62 (95% CI: 0.58-0.65) and 0.79 (95% CI: 0.77-0.82), respectively. FB was more accurate in diagnosing complicated appendicitis, with a pooled sensitivity of 0.74 (95% CI: 0.69-0.78), specificity of 0.76 (95% CI: 0.73-0.78), and the area under the curve was 0.84.

CONCLUSIONS

As per this meta-analysis, FB has a potential diagnostic value in overall appendicitis and that it has a higher diagnostic value in the diagnosis of complicated appendicitis. Future well-designed prospective studies are needed to corroborate the findings.

Comparison of Single-Dermatome Laparoscopic Appendectomy With Standard Laparoscopic Appendectomy in Terms of Postoperative Pain and Patient Satisfaction: A Randomized Controlled Trial

BACKGROUND

Laparoscopic appendectomy (LA), used since 1980, is a common surgical technique for acute appendicitis (AA) treatment. Laparoscopic surgical techniques can achieve higher patient satisfaction than conventional open surgery techniques. However, many patients complain of severe pain after laparoscopic abdominal surgeries. In this study, we compared single-dermatome laparoscopic appendectomy (SDLA), wherein all trocars were placed at the same dermatome field, with standard laparoscopic appendectomy (SLA), wherein trocars were placed at multiple dermatome sites, in terms of postoperative pain and patient satisfaction.

MATERIALS AND METHODS

The study was designed as a double-blind randomized controlled trial. Patients who underwent LA for AA between May 2019 and December 2019 were included in the study and randomized into 2 groups, wherein patients were included sequentially. The first group was operated with SLA surgery, whereas the second group was operated with SDLA surgery. All patients were assessed in terms of visual analog scale (VAS) scores, hemodynamic parameters, and patient satisfaction at postoperative 1, 2, 4, 6, 12, and 24 hours.

RESULTS

In the SLA technique, VAS values at postoperative 1, 2, and 4 hours were significantly higher than in the SDLA ( P =0.009; P <0.05). No significant difference was observed between the surgical techniques in terms of VAS levels at postoperative 6, 12, and 24 hours ( P >0.05). In the SDLA group, patient satisfaction was significantly higher than in the SLA group ( P =0.024; P <0.05).

CONCLUSIONS

In our study, SDLA caused less pain in AA cases during postoperative period than SLA. Further, the SDLA method achieved higher patient satisfaction during the postoperative period than the SLA method.

Complicated appendicitis increases the hospital length of stay

Background

There are insufficient data from Saudi Arabia regarding appendectomy outcomes and hospital length of stay. Further, there is a need to compare the length of stay of Saudi patients and the literature. The purpose is to evaluate the surgical outcomes and hospital length of stay for complicated appendicitis and simple appendicitis.

Method

This is a single-center retrospective review of patients who had undergone an appendectomy between 2016 and 2018. The patients were divided into 2 groups: complicated appendicitis versus simple appendicitis.

Results

Of 449 patients who underwent appendectomy, 60 (13.4%) had complicated appendicitis. The complicated appendicitis was significantly associated with increased age, pain duration, neutrophilia, high C-reactive protein, fecalith presence, and free fluid. The incidence rate of surgical site infection was 5.8% (identified in 26 patients). Compared to simple appendicitis, complicated appendicitis was associated more with wound infection (1.8% vs 10%, respectively, P = .001), postoperative collection (1.2% vs 11.6%, respectively, P = .001), and readmission within 30 days (2.3% vs 13.4%, respectively, P = .001). By multivariate analysis, factors associated more with increased hospitalization were pain duration (hazard ratio = 2.37, 95% confidence interval = 1.09–5.16, P = .029), operative time (hazard ratio = 2.09, 95% confidence interval = 1.04–4.21, P = .038), and complicated appendicitis (hazard ratio = 6.61, 95% confidence interval = 2.67–14.21, P = .001).

Conclusion

Complicated appendicitis correlates with significant morbidity, readmission rate, and 6 times more hospital LOS than simple appendicitis. This review might help in appreciating the burden of complicated appendicitis on hospital length of stay, which needs allocating patients and planning the discharge day for hospitals with limited beds.

•

Practically one fifth of acute appendicitis will be complicated.

•

Complicated appendicitis increases conversion to open, surgical site infection, hospital length of stay, and 30-day readmission rate.

•

Prolonged operation time and complicated appendicitis are independent risk factors to increase hospitalization.

Pelvic Health Assessment in Adult Females Following Pediatric Appendicitis: A Monocentric Retrospective Case-Control Study

Background: The anatomical location of the appendix in females determines its close contact with the internal genitalia, involving the latter in case of acute appendicitis (AA). The aim of this study was to evaluate the incidence of pelvic health impairment in adult women who underwent appendicectomy during childhood. Materials and Methods: A retrospective observational study was conducted including all female patients who underwent appendicectomy for acute appendicitis at our Center between January 1985 and December 1995. The patients were divided into two groups, i.e., complicated AA (Group A) and not complicated AA (Group B), and were asked to respond to a questionnaire investigating their general health status, fertility impairment, ectopic pregnancies, miscarriages, endometriosis, and chronic pelvic pain. The same questionnaire was administered to female volunteers with past medical history (PMH) negative for AA. The data were compared using chi-square test and Fisher exact test (a p value < 0.05 was considered for statistical significance). Results: In total, 75 patients operated for AA during childhood (22 in Group A and 53 in group B) and 44 female volunteers with PMH negative for AA (group C) were enrolled in the study. Seventeen patients (77.3%) in group A, 40 (75.4%) in group B, and 29 (65.9%) in group C (p > 0.05) had pregnancies. The number of miscarriages among women who became pregnant in their life was 5 in group A, 13 in group B, and 12 in group C (p > 0.05). Chronic pelvic pain was reported by 7 out of 22 (31.8%) patients in group A, 7 out of 53 (13.2%) in group B, and 5 out of 44 (11.4%) in group C (A vs. C: p = 0.04, OR = 3.64; A vs. B: p = 0.06 and B vs. C: p = 0.52). Conclusions: In our series, AA, complicated or not, neither determined repercussions on fertility, risk of miscarriages, and ectopic pregnancies nor increased the risk of developing endometriosis. However, women who experienced complicated AA showed a higher prevalence of chronic pelvic pain onset in adulthood compared to healthy women.

Comparative Accuracy of ICD-9 vs ICD-10 Codes for Acute Appendicitis

BACKGROUND

ICD codes are used to identify patients with appendicitis and to classify disease severity for reimbursement and research purposes. We sought to compare the accuracy of ICD-9 vs ICD-10 codes in classifying appendicitis as uncomplicated vs complicated (defined as perforated, necrotic, or abscess) compared with the clinical gold standard: surgeon characterization of the appendix in the operative report.

STUDY DESIGN

This is a retrospective review of operative reports and discharge ICD-9/10 codes for patients 18 years or older who underwent noninterval, nonincidental appendectomy from January 2012 to December 2019 at a tertiary referral center. Sensitivity, specificity, and positive predictive value were calculated for ICD-9/10 codes to classify appendicitis as complicated when compared with surgeon description. Chi-square testing was used to compare agreement between ICD-9/10 codes and surgeon description.

RESULTS

A total of 1,585 patients underwent appendectomy. ICD-9 codes had higher sensitivity than ICD-10 codes for complicated appendicitis (sensitivity 0.84 and 0.54, respectively) and a similar positive predictive value (0.77 and 0.76, respectively). Overall, 91% of ICD-9 codes agreed with surgical description of disease, but 84.4% of ICD-10 codes agreed with surgical description (p < 0.01). Among cases classified as complicated by the surgeon, 84% (79/94) had an accurate ICD-9 code for complicated disease, but only 53.8% (57/106) of cases had an accurate ICD-10 code (p < 0.01).

CONCLUSIONS

Compared with ICD-9 codes, ICD-10 codes were less accurate in characterizing severity of appendicitis. The ICD-10 coding schema does not provide an accurate representation of disease severity. Until this system is improved, significant caution is needed for people who rely on these data for billing, quality improvement, and research purposes.

A Retrospective Analysis of Conservative Management Versus Early Surgical Intervention in Appendicular Lump

Introduction

Acute appendicitis happens to be increasingly common in school-going children and early part of adult life, peak incidence reaching in the teens and early twenties. Luminal obstruction of the vermiform appendix is thought to be essential for the development of appendicular ischemia, gangrene, and perforation. The treatment of choice in acute appendicitis is emergency appendectomy. Appendicitis particularly puts the surgeon in a dilemma whenever the patient presents late by around four to seven days. In case of delay in presentation, complications like appendicular lump formation occur. The factors that make the clinical presentation inconsistent which in turn makes the diagnosis challenging in the case of acute appendicitis are the variable position of the appendix, the degree/grade of inflammation, and the age of the patient.

At present, the standard treatment is the Ochsner-Sherren regimen universalized by Oschner and has been mostly practised over many decades as the standard care for the appendicular lump. Conservative regimen does not work in a few cases where urgent surgical exploration is necessary. This study was conducted to compare early appendectomy versus conservative management followed by interval appendectomy in case of appendicular mass and to make a better strategy for effective management of patients with complicated appendicitis.

Methods

A total of 112 patients were diagnosed as having an appendicular lump as per the available records between June 2018 and June 2021. The total study population was divided into two comparative groups depending upon the treatment they received. The patients in group-1 received medical treatment and those in group-2 had undergone surgical management. The patients in group-1 were treated according to the Ochsner-Sherren regimen. The patients in group-2 were the patients in whom emergency appendectomy was done. If the general condition of the patient did not improve, pain and tenderness didn’t subside, the size of phlegmon or abscess was increasing and other features of the acute abdomen were persistent, then it was regarded as a failure of medical treatment and the patient was prepared for surgery on an emergency basis.

Results

Out of 1192 cases of acute appendicitis admitted between June 2018 and June 2021, a total of 112 patients were diagnosed with an appendicular lump. As per the record, 64 patients were managed conventionally as per the Ochsner-Sherren regimen followed by elective interval appendectomy (group-1) and 48 cases were managed with an emergency surgical procedure (group-2).

In group-1, out of 64 patients, non-operative treatment was successful in 58 patients (90.62%). Among the remaining patients, there was a failure of non-operative treatment in six patients and they were subjected to emergency surgical exploration (9.37%). So a total of 58 patients underwent interval appendectomy after six weeks. Out of 54 patients who had undergone emergency appendectomy in both groups, the per-operative finding was an appendicular lump in 55.5% of patients while a total of 44 patients in group-2, were discharged from the hospital within six days (91.66%). But in group-1, only 16 patients were discharged from the hospital within six days (25%), rest were discharged from the hospital after more than seven days of stay.

Conclusion

Early appendectomy in appendicular mass is safe due to the improvements in surgical techniques and better postoperative care.

Clinical characteristics of older Japanese patients with acute appendicitis: A post hoc analysis

BACKGROUND

Acute appendicitis (AA) in older patients can look different from AA in younger patients. Although it is crucial that primary care physicians can recognize AA in patients of any age, few Japanese studies have examined the characteristics of older AA patients. To address this, we evaluated the clinical characteristics of older Japanese patients with AA.

METHODS

We performed a post hoc analysis of the data from a previous Japanese single-center study. We analyzed the clinical information of both younger (age: 16-64 years) and older patients (age: ≥65 years).

RESULTS

A cohort of 236 patients consisting of 219 (92.8%) younger patients and 17 (7.2%) older patients was evaluated. The median ages of the younger and older patients were 34 (interquartile range [IR], 24-45) and 78 years (IR, 74-81), respectively. The prevalence of complicated appendicitis (CA) (older: 41.2% vs. younger: 14.2%), comorbidities (70.6% vs. 13.2%), and thrombocytopenia (17.7% vs. 4.1%), along with serum C-reactive protein (CRP) level (6.7 mg/dl vs. 1.0 mg/dl), was significantly higher in older patients. Significantly fewer older patients had epigastric pain (17.7% vs. 53.0%). Logistic regression evaluating the characteristics of older AA patients showed that CRP >5 mg/dl had a high odds ratio (OR) (5.01; 95% CI, 1.73-14.54), while epigastric pain had a low OR (0.24; 95% CI, 0.06-0.90).

CONCLUSION

Our study reveals a higher prevalence of CA and comorbidities in older patients, and suggests that a lack of epigastric pain, thrombocytopenia, and higher serum CRP level are characteristics of older AA patients.

Recurrent appendicitis following successful drainage of appendicular abscess in adult without interval appendectomy during COVID-19. Prospective cohort study

BACKGROUND

COVID-19 infection is a global pandemic that affected routine health services and made patients fear to consult for medical health problems, even acute abdominal pain. Subsequently, the incidence of complicated appendicitis increased during the Covid-19 pandemic. This study aimed to evaluate recurrent appendicitis after successful drainage of appendicular abscess during COVID-19.

MATERIAL AND METHODS

A prospective cohort study conducted in the surgical emergency units of our Universities' Hospitals between March 15, 2020 to August 15, 2020 including patients who were admitted with the diagnosis of an appendicular abscess and who underwent open or radiological drainage. Main outcomes included incidence, severity, and risk factors of recurrent appendicitis in patients without interval appendectomy.

RESULTS

A total of 316 patients were included for analysis. The mean age of the patients was 37 years (SD ± 13). About two-thirds of patients were males (60.1%). More than one-third (39.6%) had co-morbidities; type 2 diabetes mellitus (T2DM) (22.5%) and hypertension (17.1%) were the most frequent. Approximately one quarter (25.6%) had confirmed COVID 19 infection. About one-third of the patients (30.4%) had recurrent appendicitis. More than half of them (56.3%) showed recurrence after three months, and 43.8% of patients showed recurrence in the first three months. The most frequent grade was grade I (63.5%). Most patients (77.1%) underwent open surgery. Age, T2DM, hypertension, COVID-19 infection and abscess size >3 cm were significantly risking predictors for recurrent appendicitis.

CONCLUSIONS

Interval appendectomy is suggested to prevent 56.3% of recurrent appendicitis that occurs after 3 months. We recommend performing interval appendectomy in older age, people with diabetes, COVID-19 infected, and abscesses more than 3 cm in diameter.

RESEARCH QUESTION

Is interval appendectomy preventing a high incidence of recurrent appendicitis after successful drainage of appendicular abscess during COVID-19 pandemic?

Impact of the COVID-19 pandemic on acute appendicitis in children

Background and objectives

Since the COVID-19 pandemic confinement was established in Spain on March 9, 2020, the number of visits to the pediatric Emergency Department (ED) has decreased dramatically, probably due to the fear of parents becoming infected in the hospital environment. The aim of this work was to analyze the medium-term consequences during the first 9 months after the onset of the COVID-19 pandemic in children with acute appendicitis (AA).

Material and methods

A retrospective study was performed on children operated on for AA in our institution between 2017 and 2020, who were distributed in two groups according to the date of surgery: COVID-19 group (after March 9, 2020) and control group (before March 9, 2020). Demographic variables, associated symptoms, time from symptoms onset, hospital stay, rate of complicated AA and postoperative complications were analyzed.

Results

A total of 1274 patients were included (288 COVID group; 986 control group), without demographic differences. Time from symptom onset was significantly longer in COVID-19 group (34.5 vs. 24.2 h; p = 0.021), although no differences in associated symptoms were observed between both groups. COVID-19 group presented a higher rate of complicated AA (20.1% vs. 14%; OR: 1.55; CI 95% [1.10–2.18]; p = 0.008), a longer hospital stay (3.5 vs. 2.8 days; p = 0.042) as well as a higher rate of postoperative complications (21.5% vs. 15.7%; OR: 1.47; CI 95% [(1.06–2.04)]; p = 0.008).

Conclusion

In our experience there was a negative medium-term effects of the COVID-19 pandemic on children with acute appendicitis: delayed ED visits, increased rate of complicated AA, increased hospital stay and increased postoperative complications.

Modern Management of the Appendix: So Many Options

Nonoperative management (NOM) of acute appendicitis is becoming more popular, especially in resource-strapped locations, to minimize hospital system costs. In uncomplicated cases of appendicitis, NOM can effectively treat the patient. It does carry a 39.1% risk of recurrence in 5 years, and operative management (OM) does not increase morbidity or risk of complication, so the authors recommend laparoscopic OM for uncomplicated appendicitis. For complicated cases of appendicitis, the authors recommend initial NOM with interval appendectomy in all patients. All appendicitis patients should undergo surveillance endoscopy if older than 40 years to rule out a contributing neoplasm.

Detection of methanogens in peri-appendicular abscesses: Report of four cases

The aetiology of appendicular abscess is predominantly microbial with aerobic and anaerobic bacteria from gut flora. In this study, by using specific laboratory tools, we co-detected Methanobrevibacter oralis and Methanobrevibacter smithii among a mixture of enterobacteria including Escherichia coli, Enterococcus faecium and Enterococcus avium in four unrelated cases of postoperative appendiceal abscesses. These unprecedented observations raise a question on the role of methanogens in peri-appendicular abscesses, supporting antibiotics as an alternative therapeutic option for appendicitis, including antibiotics active against methanogens such as metronidazole or fusidic acid.

Fecalith in the Proximal Area of the Appendix is a Predictor of Failure of Nonoperative Treatment for Complicated Appendicitis in Adults

BACKGROUND

The management of complicated appendicitis remains controversial, since this disease has various clinical presentations and is associated with high rates of adverse events. Although initial nonoperative treatment is generally employed for complicated appendicitis, its clinical presentation and the predictors of nonoperative treatment failure are unclear.

METHODS

Patients diagnosed with complicated appendicitis in our hospital between April 2015 and March 2020 were enrolled. In total, 113 patients were classified into three categories: emergency appendectomy, failure of nonoperative treatment and successful nonoperative treatment. The primary outcome was the rate of failure of nonoperative treatment, as assessed by logistic regression analysis. The secondary outcomes were the operative procedures and postoperative courses of the three groups.

RESULTS

Of 113 patients, 45 (40%) underwent emergency appendectomy, 25 (22%) failed nonoperative treatment, and 43 (38%) had successful nonoperative treatment. Among these successful cases, 38 patients (88%) underwent interval appendectomy. In multivariate analyses, the presence of a fecalith in the proximal area of the appendix was an independent risk factor for failure of nonoperative treatment (odds ratio, 20.5; 95% confidence interval, 4.37-95.7, P < 0.001). Postoperative outcomes were more unfavorable in cases of failed nonoperative treatment than in cases of emergency and interval appendectomy.

CONCLUSIONS

The presence of a fecalith in the proximal area of the appendix is an independent predictor for failure of nonoperative treatment for complicated appendicitis in adults. Patients with this risk factor should be considered candidates for surgical treatment.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

High-volume center analysis and systematic review of stump appendicitis: solving the pending issue

PURPOSE

Stump appendicitis (SA) is a rare long-term complication after laparoscopic appendectomy (LA) that can be associated with high morbidity due to delayed diagnosis. We aimed to determine the incidence, risk factors, diagnosis, and management of SA by reviewing our large cohort of LA and performing a systematic review of the literature.

METHODS

We retrospectively reviewed data of all patients who developed SA after LA between 2006 and 2020. Demographics, peri-operative variables, and postoperative outcomes were analyzed. A systematic review of the PubMed/MEDLINE, Embase and GoogleScholar bibliographic databases was also performed to identify publications regarding SA following LA.

RESULTS

A total of 2,019 patients underwent LA; 5 (0.25%) developed SA after a median of 292 days. The most common symptom at presentation was right lower quadrant pain. Four SA (80%) occurred in patients with a history of complicated appendicitis at index operation. All patients were diagnosed with computed tomography and underwent completion stump appendectomy by laparoscopy. No postoperative complications were recorded. A total of 55 studies with 76 cases of SA after LA were identified in the systematic review. Most SA (98.7%) underwent surgery: 52% by laparoscopic approach and 36% through an open approach. Stump appendectomy was performed in 94.4% cases and an extended resection in 5.6%.

CONCLUSION

Although SA is a rare complication after LA, a high index of clinical suspicious and imaging studies are key for early diagnosis and treatment. A laparoscopic resection of the inflamed appendiceal stump is feasible, safe, and highly effective. A minority of patients with severe cecum compromise may need extended resections or conversion to open surgery.

Laparoscopic Appendectomy in the Days of COVID-19

BACKGROUND

Acute appendicitis is one of the most common emergencies treated by general surgeons. The treatment of choice in the majority of cases is laparoscopic appendectomy. In the era of the COVID-19 pandemic, there is a concern for a delayed referral of patients and thus a more advanced presentation of the disease leading to a prolonged and complicated course.

METHODS

Retrospective review of a computerized database of patients who were admitted with acute appendicitis and underwent laparoscopic appendectomy during the COVID pandemic in a single tertiary center in Israel. Patients were compared with those who were admitted and operated for appendicitis in the same period in the previous year.

RESULTS

One hundred twenty-three patients underwent laparoscopic appendectomy in the study period in 2020, compared with 109 who had surgery in 2019. During the COVID pandemic 41 patients presented with complicated appendicitis versus 22 patients in 2019 (P=0.0174). The placement of peritoneal drains was more prevalent during the pandemic, 5.5% versus 11.4%, and the use of stapler device for appendicular stump closure (P=0.0105).

CONCLUSIONS

During the first stage of the COVID-19 pandemic, there was a significant increase in the rate of complicated appendicitis. Patients should be strongly encouraged not to refrain from medical treatment and go to the emergency room with the persistence of symptoms.

An effect of the COVID-19 pandemic: Significantly more complicated appendicitis due to delayed presentation of patients!

Aims of the study

The novel coronavirus pandemic has affected emergency department consultations for surgical pathologies. The aim of our study was to compare the number of acute appendicitis cases and the proportion of complicated appendicitis before and during the COVID-19 pandemic.

Methods

We retrospectively analyzed all data collected from a multi-center database of patients presenting to the emergency department for acute appendicitis during the COVID-19 pandemic from March 12 to June 6, 2020, and compared these data with those from the same periods in 2017, 2018, and 2019. The number of acute appendicitis cases, proportion of complicated appendicitis, and pre- and postoperative patient characteristics were evaluated.

Results

A total of 306 patients were included in this evaluation. Sixty-five patients presented during the 2020 COVID-19 pandemic lockdown (group A), and 241 patients in previous years (group B: 2017–2019). The number of consultations for acute appendicitis decreased by almost 20 percent during the pandemic compared with previous periods, with a significant increase in complicated appendicitis (52% in group A versus 20% in group B, p < 0,001.). Comparing the two groups, significant differences were also noted in the duration of symptoms (symptoms > 48h in 61% and 26%, p < 0,001), the intervention time (77 vs 61 minutes, p = 0,002), length of hospital stay (hospitalization of > 2 days in 63% and 32%, p < 0.001) and duration of antibiotic treatment (antibiotics > 3 days in 36% and 24% p = 0.001).

Conclusions

The COVID-19 pandemic resulted in a decreased number of consultations for acute appendicitis, with a higher proportion of complicated appendicitis, most likely due to patient delay in consulting the emergency department at symptom onset. Patients and general practitioners should be aware of this problem to avoid a time delay from initial symptoms to consultation.

An asymptomatic detachment of the appendix evolved to giant abscess and complete colliquative necrosis: pivotal role of computed tomography in patient management

Acute appendicitis (AA) is one of the most common causes of acute abdominal pain and it generally affects young males in the second or third decade of their life. Due to its often insidious presentations, the diagnosis is challenging and, if delayed, can lead to life-threatening complications. This report describes a rare case of an almost asymptomatic complicated appendicitis caused by an appendicolith followed by spontaneous detachment of the vermiform appendix and its complete colliquative necrosis with abscess formation. Thus far this is the first case of spontaneous appendix avulsion in an adult where the appendix is entirely colliquated into an abscess.

Re-laparoscopy for the treatment of complications after laparoscopic appendectomy: is it possible to maintain the minimally invasive approach?

Despite laparoscopy is considered an adequate tool for the diagnosis and management of postoperative surgical complications, its role after laparoscopic appendectomy (LA) remains uncertain. The aim of this study was to evaluate whether laparoscopy is useful for treating complications after laparoscopic appendectomy. A retrospective analysis of a prospectively collected database of patients undergoing LA, who needed a reoperation for postoperative complications during the period 2006-2020, was performed. Demographics, operative variables, and postoperative outcomes were analyzed. A total of 2019 LA were performed, and 41 patients (2%) underwent a RL for post appendectomy complications. Twenty-three patients (56%) were male. The mean age was 32 years old (16-92 years). The majority of patients (75%) had a complicated acute appendicitis in the first operation. The most common findings at RL were generalized peritonitis (36.4%) and intraabdominal abscesses (26.8%). Five patients (12.1%) developed stump appendicitis, all of them as a late complication. The procedures were completed laparoscopically in 85% and 6 patients (15%) required conversion to an open approach. Three patients (7.3%) required a percutaneous drainage and two patients (4.9%) needed an additional surgery (laparotomy) after RL, all of them presenting with generalized peritonitis at the RL. No mortality was registered. Re-laparoscopy is feasible, safe, and highly effective for the diagnosis and treatment of post appendectomy complications. RL should be encouraged to avoid more aggressive procedures.

Clinical prediction of complicated appendicitis: A case-control study utilizing logistic regression

BACKGROUND

Since high-quality evidence on conservative treatment of acute appendicitis using antibiotics has increased, differentiation of patients with complicated appendicitis (CA) from those with simple appendicitis (SA) has become increasingly important. Previous studies have revealed that male gender, advanced age, comorbid conditions, prehospital delay, fever, and anorexia are risk factors of perforated appendicitis. Elevated serum C-reactive protein (CRP) level and hyponatremia have also been reported as predictive biomarkers of CA. However, confounding between various factors is problematic because most previous studies were limited to univariate analysis.

AIM

To evaluate non-laboratory and laboratory predictive factors of CA using logistic regression analyses.

METHODS

We performed an exploratory, single-center, retrospective case-control study that evaluated 198 patients (83.9%) with SA and 38 patients (16.1%) with CA. Diagnoses were confirmed by computed tomography images for all cases. We compared age, sex, onset-to-visit interval, epigastric/periumbilical pain, right lower quadrant pain, nausea/vomiting, diarrhea, anorexia, medical history (of previous non-surgically treated appendicitis, diabetes, hypertension, dyslipidemia, liver cirrhosis, hemodialysis, chronic lung diseases, malignant tumors, immunosuppressant use, and antiplatelet use), vital signs, physical findings, and laboratory data to select the explanatory variates for logistic regression. Based on the univariate comparisons, we performed logistic regression for clinical differentiation between CA and SA using only non-laboratory factors and also including both non-laboratory and laboratory factors.

RESULTS

The 236 eligible patients consisted of 198 patients (83.9%) with SA and 38 patients (16.1%) with CA. The median ages were 34 years old [interquartile ranges (IR), 24-45 years] in the SA group and 49 years old (IR, 35-63 years) in the CA group (P < 0.001). The median onset-to-visit interval was 1 d (IR, 0-1) and 1 d (IR, 1-2) in the SA and CA groups, respectively (P < 0.001). Heart rate, body temperature, and serum CRP level in the CA group were significantly higher than in the SA group; glomerular filtration rate and serum sodium were significantly lower in the CA group. Anorexia was significantly more prevalent in the CA group. The regression model including age, onset-to-visit interval, anorexia, tachycardia, and fever as non-laboratory predictive factors of CA (Model 1) showed that age ≥ 65 years old, longer onset-to-visit interval, and anorexia had significantly high odds ratios. The logistic regression for prediction of CA including age, onset-to-visit interval, anorexia, serum CRP level, hyponatremia (serum sodium < 135 mEq/L), and glomerular filtration rate < 60 mL/min/1.73 m² (Model 2) showed that only elevated CRP levels had significantly high odds ratios. Under the curve values of receiver operating characteristics curves of each regression model were 0.74 for Model 1 and 0.87 for Model 2.

CONCLUSION

Our logistic regression analysis on differentiating factors of CA from SA showed that high CRP level was a strong dose-dependent predictor of CA.

Comparison of laparoscopic and open appendectomy on wound infection and healing in complicated appendicitis

The aim of this study was to investigate the effects of laparoscopic and open surgery on the development of postoperative surgical wound infection and wound healing between complicated appendicitis patients. Patients with complicated appendicitis were divided into those underwent laparoscopic and open surgical procedures according to the surgical method. Patients were followed up with regard to development of any postoperative wound infection, and medical, radiological, and surgical treatment methods and results were recorded. A total of 363 patients who underwent appendectomy were examined, of which 103 (28.4%) had complicated appendicitis. Postoperative wound infection rate in patients who underwent open surgery was 15.9%, while it was 6.8% in the laparoscopic surgery group. There was no statistically significant difference between the two groups in terms of infection development rates (P > .05). The rate of surgical drainage use and rehospitalisation was significantly higher in the group with wound infection than in the group without wound infection. (P < .05). We suggest that in terms of wound infection and wound healing, laparoscopic surgery should be the method of choice for patients with complicated appendicitis. In order to reduce the frequency of wound infection, drains should not be kept for a long time in patients undergoing appendectomy.

Clinical outcomes of single-site laparoscopic interval appendectomy for severe complicated appendicitis: Comparison to conventional emergency appendectomy

AIM

Single-site laparoscopic interval appendectomy (SLIA) for severe complicated appendicitis after conservative treatment (CT) to ameliorate inflammation and eradicate the abscess should be safer and less invasive than emergency appendectomy (EA). However, only a few reports have been published regarding SLIA.

METHODS

We retrospectively collected data on 264 consecutive patients admitted to Kinan Hospital for treatment of appendicitis between 2012 and 2018. The safety and feasibility of SLIA and its perioperative outcomes for severe complicated appendicitis were investigated.

RESULTS

A total of 61 patients were included in this study, 25 of whom underwent CT and 36 EA. Among the 25 patients who underwent CT, 23 (92.0%) succeeded; a total of 16 patients (69.5%) underwent SLIA. Compared to the EA group, the SLIA group had less bleeding (median volume 8.5 vs 50 mL, P = .005) and lower rate of expansion surgery (0% vs 27.8%, P = .022). Although the postoperative hospital stay was shorter in the SLIA group than in the EA group (9 vs 12 days, P = .008), the total hospital stay, including the CT period, was longer in the SLIA group than in the EA group (24 vs 12 days, P < .001).

CONCLUSION

SLIA is safe, feasible, and less invasive than EA and may provide the advantages of minimally invasive surgery even if appendicitis is severe. SLIA may be a promising option for complicated appendicitis in select cases despite its disadvantage of prolonging the hospital stay.