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Takeda K, Yamada T, Uehara K, Matsuda A, Shinji S, Yokoyama Y, Takahashi G, Iwai T, Kuriyama S, Miyasaka T, Kanaka S, Yoshida H. The benefits of interval appendectomy and risk factors for nonoperative management failure in the therapeutic strategy for complicated appendicitis. Surg Today 2024:10.1007/s00595-024-02842-w. [PMID: 38598170 DOI: 10.1007/s00595-024-02842-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/17/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE Emergency surgery (ES) for complicated appendicitis (CA) is associated with high morbidity. Interval appendectomy (IA) decreases this rate; however, nonoperative management (NOM) is not always successful. Some patients require unplanned ES due to NOM failure (IA failure: IA-F). This study aimed to verify the benefits of IA and to evaluate the risk factors for NOM failure. METHODS Patients diagnosed with CA who underwent surgery between January 2012 and December 2021 were included in this study. We compared the surgical outcomes of the ES group with those of the IA success (IA-S) and IA-F groups. We also analyzed 14 factors that predicted NOM failure. RESULTS Among 302 patients, the rate of severe complications (Clavien-Dindo grade ≥ III) was significantly higher in the ES group (N = 165) than in the IA-S group (N = 102). The rates were equal between the ES (N = 165) and IA-F (N = 35) groups. NOM was successful in 110 patients and failed in 27. Lack of abscesses, comorbidities, high WBC count, and free air were independent risk factors for NOM failure. CONCLUSIONS Considering the benefits of IA and the non-inferior surgical outcomes of IA-F compared to ES, IA is a good therapeutic strategy for CA. However, in patients exhibiting four independent risk factors for NOM failure, careful monitoring of unplanned ES is necessary.
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Affiliation(s)
- Kohki Takeda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan.
| | - Takeshi Yamada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Kay Uehara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Akihisa Matsuda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Seiichi Shinji
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Yasuyuki Yokoyama
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Goro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Takuma Iwai
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Sho Kuriyama
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Toshimitsu Miyasaka
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Shintaro Kanaka
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
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Yoon EJ, Kim JW, Hong JH, Song SG, Kim HC, Hur YH, Kim HJ. Thermal Injury to the Subhepatic Appendix Following Percutaneous Ultrasound-Guided Radiofrequency Ablation for Hepatocellular Carcinoma: A Case Report. Diagnostics (Basel) 2023; 13:3322. [PMID: 37958216 PMCID: PMC10647334 DOI: 10.3390/diagnostics13213322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/25/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
We present the first documented case of a fistula between the treated zone and the appendix after RFA in a patient with HCC. Contrast-enhanced CT and MRI revealed a subcapsular hepatic nodule with image findings of HCC located adjacent to the ascending colon and cecum. An ultrasound-guided core needle biopsy was subsequently performed to distinguish between hepatic metastasis and HCC. Post-RFA imaging identified a low-attenuating ablated area adjacent to an air-filled appendix. The patient later experienced complications, including increased liver enzymes and an abscess at the ablation site. Imaging revealed a fistulous tract between the RFA zone and the appendix. Over the following months, the patient underwent conservative treatment involving intravenous antibiotics and repeated percutaneous drainage, exhibiting eventual symptom relief and an absence of the fistulous tract upon subsequent imaging. This case highlights the rare complications that can arise during RFA due to peculiar anatomical variations, such as a subhepatic appendix, resulting from midgut malrotation and previous surgery. It is imperative for operators to be cognizant of potential anatomical variations when considering RFA treatment, ensuring comprehensive pre-procedural imaging and post-procedure monitoring. This case also emphasizes the potential viability of nonoperative management in complex scenarios in which surgical interventions pose significant risks.
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Affiliation(s)
- Eun Ju Yoon
- Department of Radiology, Chosun University Hospital and Chosun University College of Medicine, Gwangju 61453, Republic of Korea (S.G.S.); (H.C.K.)
| | - Jin Woong Kim
- Department of Radiology, Chosun University Hospital and Chosun University College of Medicine, Gwangju 61453, Republic of Korea (S.G.S.); (H.C.K.)
| | - Jun Hyung Hong
- Department of Radiology, Chosun University Hospital and Chosun University College of Medicine, Gwangju 61453, Republic of Korea (S.G.S.); (H.C.K.)
| | - Sang Gook Song
- Department of Radiology, Chosun University Hospital and Chosun University College of Medicine, Gwangju 61453, Republic of Korea (S.G.S.); (H.C.K.)
| | - Hyun Chul Kim
- Department of Radiology, Chosun University Hospital and Chosun University College of Medicine, Gwangju 61453, Republic of Korea (S.G.S.); (H.C.K.)
| | - Young Hoe Hur
- Department of Hepato-Biliary-Pancreas Surgery, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Gwangju 61469, Republic of Korea
| | - Hyung Joong Kim
- Department of Biomedical Engineering, Kyung Hee University, Seoul 02447, Republic of Korea
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Kobayashi T, Hidaka E, Koganezawa I, Nakagawa M, Yokozuka K, Ochiai S, Gunji T, Sano T, Tomita K, Tabuchi S, Chiba N, Kawachi S. Development of a scoring model based on objective factors to predict gangrenous/perforated appendicitis. BMC Gastroenterol 2023; 23:198. [PMID: 37286951 DOI: 10.1186/s12876-023-02767-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/15/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND The mortality rate of gangrenous/perforated appendicitis is higher than that of uncomplicated appendicitis. However, non-operative management of such patients is ineffective. This necessitates their careful exam at presentation to identify gangrenous/perforated appendicitis and aid surgical decision-making. Therefore, this study aimed to develop a new scoring model based on objective findings to predict gangrenous/perforated appendicitis in adults. METHODS We retrospectively analyzed 151 patients with acute appendicitis who underwent emergency surgery between January 2014 and June 2021. We performed univariate and multivariate analyses to identify independent objective predictors of gangrenous/perforated appendicitis, and a new scoring model was developed based on logistic regression coefficients for independent predictors. Receiver operating characteristic (ROC) curve analysis and the Hosmer-Lemeshow test were performed to assess the discrimination and calibration of the model. Finally, the scores were classified into three categories based on the probability of gangrenous/perforated appendicitis. RESULTS Among the 151 patients, 85 and 66 patients were diagnosed with gangrenous/perforated appendicitis and uncomplicated appendicitis, respectively. Using the multivariate analysis, C-reactive protein level, maximal outer diameter of the appendix, and presence of appendiceal fecalith were identified as independent predictors for developing gangrenous/perforated appendicitis. Our novel scoring model was developed based on three independent predictors and ranged from 0 to 3. The area under the ROC curve was 0.792 (95% confidence interval, 0.721-0.863), and the Hosmer-Lemeshow test showed a good calibration of the novel scoring model (P = 0.716). Three risk categories were classified: low, moderate, and high risk with probabilities of 30.9%, 63.8%, and 94.4%, respectively. CONCLUSIONS Our scoring model can objectively and reproducibly identify gangrenous/perforated appendicitis with good diagnostic accuracy and help in determining the degree of urgency and in making decisions about appendicitis management.
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Affiliation(s)
- Toshimichi Kobayashi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Eiji Hidaka
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Itsuki Koganezawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Masashi Nakagawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Kei Yokozuka
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Shigeto Ochiai
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Takahiro Gunji
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Toru Sano
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Koichi Tomita
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Satoshi Tabuchi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Naokazu Chiba
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Shigeyuki Kawachi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University, Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan.
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Muacevic A, Adler JR. Perforated Appendicitis Masquerading as Bilateral Tubo-Ovarian Abscess. Cureus 2022; 14:e30464. [PMID: 36407274 PMCID: PMC9673187 DOI: 10.7759/cureus.30464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 01/25/2023] Open
Abstract
Acute appendicitis is a highly common cause of abdominal pain that presents with nausea and vomiting, characteristic physical exam findings, and imaging evidence of appendiceal inflammation. In the absence of these signs, diagnosis can be difficult. This case report demonstrates an uncommon presentation of appendicitis that led to a delay in diagnosis and aims to discuss the ways in which similar misdiagnoses can be avoided for clinicians in the future.
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Djemai K, Gouriet F, Sielezneff I, Mege D, Drancourt M, Grine G. Detection of methanogens in peri-appendicular abscesses: Report of four cases. Anaerobe 2021; 72:102470. [PMID: 34743984 DOI: 10.1016/j.anaerobe.2021.102470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- K Djemai
- Aix-Marseille Univ, IRD, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France
| | - F Gouriet
- Aix-Marseille Univ, IRD, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France
| | - I Sielezneff
- Department of Digestive Surgery, Aix Marseille Univ, APHM, Timone University Hospital, Marseille, France
| | - D Mege
- Department of Digestive Surgery, Aix Marseille Univ, APHM, Timone University Hospital, Marseille, France
| | - M Drancourt
- Aix-Marseille Univ, IRD, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France
| | - G Grine
- IHU Méditerranée Infection, Marseille, France; Aix-Marseille Université, UFR Odontologie, Marseille, France.
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Kim E, Kim K, Park Y. Benefits and Reduced Hospital Costs of Direct Surgery in Perforated Appendicitis With Abscess Cost-effectiveness Analysis of Treatment Complicated Appendicitis. Surg Laparosc Endosc Percutan Tech 2021; 31:707-710. [PMID: 34231538 PMCID: PMC8635246 DOI: 10.1097/sle.0000000000000968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/24/2021] [Indexed: 11/26/2022]
Abstract
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.
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Kohga A, Kawabe A, Yajima K, Okumura T, Yamashita K, Isogaki J, Suzuki K, Muramatsu K. Does the presence of an appendicolith or abscess predict failure of nonoperative management of patients with acute appendicitis? Emerg Radiol 2021; 28:977-983. [PMID: 34173083 DOI: 10.1007/s10140-021-01951-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/24/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE Nonoperative management (NOM) has been widely accepted as one of the standard treatments for patients with acute appendicitis. However, predictive factors for the failure of NOM have not been thoroughly investigated. METHODS A total of 196 patients with acute appendicitis underwent NOM between April 2014 and December 2020. Of these 196 patients, 24 patients failed NOM and required emergency surgery (failure group: n = 24), while the other 172 patients were successfully treated with NOM (success group: n = 172). These two groups were compared, and the predictive factors for the failure of NOM were investigated. RESULTS The number of patients who had a previous history of stroke was significantly increased in the failure group (12.5% vs. 2.9%, p = 0.026). Incarceration of an appendicolith on CT images was significantly associated with the failure group (20.8% vs. 1.7%, p < 0.001), while neither the presence of an appendicolith nor abscess was associated. The presence of periappendiceal fluid was significantly associated with the failure group (50.0% vs. 26.7%, p = 0.019). The incarceration of an appendicolith (p < 0.001, odds ratio = 19.85) and periappendiceal fluid (p = 0.009, odds ratio = 3.62) were found to be independent risk factors for failure of NOM. Neither the presence of an appendicolith nor abscess was associated with the recurrence of appendicitis. CONCLUSIONS The presence of an appendicolith or abscess was not a crucial factor for surgery. Incarceration of an appendicolith and periappendiceal fluid on CT images was predictive factors for the failure of NOM.
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Affiliation(s)
- Atsushi Kohga
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan.
| | - Akihiro Kawabe
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Kiyoshige Yajima
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Takuya Okumura
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Kimihiro Yamashita
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Jun Isogaki
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Kenji Suzuki
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Katsuaki Muramatsu
- Division of Radiology, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
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Lee Y, Cho H, Gwak G, Bae B, Yang K. Scoring System for Differentiation of Complicated Appendicitis in Pediatric Patients: Appendicitis Scoring System in Children. Glob Pediatr Health 2021; 8:2333794X211022268. [PMID: 34164569 PMCID: PMC8191077 DOI: 10.1177/2333794x211022268] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/10/2021] [Indexed: 11/15/2022] Open
Abstract
Although several scoring systems have been used to differentiate simple acute appendicitis from perforated appendicitis, no particular system has been widely accepted. Therefore, this study aimed to investigate preoperative factors associated with complicated appendicitis and to develop a scoring system that distinguishes complicated appendicitis in children aged <10 years. Patients aged <10 years who underwent surgical treatment for acute appendicitis between 2011 and 2019 were included in this study, after excluding those with insufficient medical records, with other diseases that affect the length of hospitalization, or without formal reports of abdominal computed tomography (CT) or ultrasonography (US). Complicated appendicitis was defined as hospitalization for ≥5 days postoperatively or readmission within 30 days postoperatively. Patient characteristics, symptoms, physical examination, laboratory data, and radiographic results were collected to determine predictors of complicated appendicitis. The mean age of 279 patients was 7.3 years. Among them, 57 patients had complicated appendicitis. A scoring system was developed based on the following 5 independent risk factors derived from multiple logistic regression analysis: body temperature, anorexia, diarrhea, C-reactive protein (CRP) level, and presence of periappendiceal free fluid on CT or US. The scoring system resulted in an area under the curve of .898 (P < .001). For patients aged <10 years, a new model that includes objective factors, such as body temperature, CRP levels, and radiography results, might help predict complicated appendicitis and determine treatment plans.
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Affiliation(s)
- Yujin Lee
- Department of General Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Hyunjin Cho
- Department of General Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Geumhee Gwak
- Department of General Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Byungnoe Bae
- Department of General Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Keunho Yang
- Department of General Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
- Keunho Yang, Department of General Surgery, Inje University Sanggye Paik Hospital, Dongil-Ro 1342, Nowon-Gu, 01757 Seoul, Republic of Korea.
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Schumm MA, Childers CP, Wu JX, Zanocco KA. Cost Saving of Short Hospitalization Nonoperative Management for Acute Uncomplicated Appendicitis. J Surg Res 2020; 255:77-85. [PMID: 32543382 DOI: 10.1016/j.jss.2020.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nonoperative management (NOM) of uncomplicated appendicitis has gained recognition as an alternative to surgery. In the largest published randomized trial (Appendicitis Acuta), patients received a 3-d hospital stay for intravenous antibiotics; however, cost implications for health care systems remain unknown. We hypothesized short stay protocols would be cost saving compared with a long stay protocol. MATERIALS AND METHODS We constructed a Markov model comparing the cost of three protocols for NOM of acute uncomplicated appendicitis: (1) long stay (3-d hospitalization), (2) short stay (1-d hospitalization), and (3) emergency department (ED) discharge. The long stay protocol was modeled on data from the APPAC trial. Model variables were abstracted from national database and literature review. One-way and two-way sensitivity analyses were performed to determine the impact of uncertainty on the model. RESULTS The long stay treatment protocol had a total 5-y projected cost of $10,735 per patient. The short stay treatment protocol costs $8026 per patient, and the ED discharge protocol costs $6,825, which was $2709 and $3910 less than the long stay protocol, respectively. One-way sensitivity analysis demonstrated that the relative risk of treatment failure with the short stay protocol needed to exceed 6.3 (absolute risk increase of 31%) and with the ED discharge protocol needed to exceed 8.75 (absolute risk increase of 45%) in order for the long stay protocol to become cost saving. CONCLUSIONS Short duration hospitalization protocols to treat appendicitis nonoperatively with antibiotics are cost saving under almost all model scenarios. Future consideration of patient preferences and health-related quality of life will need to be made to determine if short stay treatment protocols are cost-effective.
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Affiliation(s)
- Max A Schumm
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California.
| | | | - James X Wu
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Kyle A Zanocco
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
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Güler Y, Karabulut Z, Çaliş H, Şengül S. Comparison of laparoscopic and open appendectomy on wound infection and healing in complicated appendicitis. Int Wound J 2020; 17:957-965. [PMID: 32266786 DOI: 10.1111/iwj.13347] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/19/2020] [Accepted: 03/13/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Yılmaz Güler
- Department of General Surgery, Alanya Alaaddin Keykubat University Medical Faculty Training and Research Hospital, Antalya, Turkey
| | - Zülfikar Karabulut
- Department of General Surgery, Alanya Alaaddin Keykubat University Faculty of Medicine, Antalya, Turkey
| | - Hasan Çaliş
- Department of General Surgery, Alanya Alaaddin Keykubat University Faculty of Medicine, Antalya, Turkey
| | - Serkan Şengül
- Department of General Surgery, Alanya Alaaddin Keykubat University Faculty of Medicine, Antalya, Turkey
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Wang V, Kriger D, Fanous E, Lee A, Zakhary B, Coimbra R, Depew AJ. Should All Complicated Appendicitis be Treated the Same? the Answer is No. Am Surg 2019. [DOI: 10.1177/000313481908501023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Delayed presentation of acute appendicitis is associated with increased complications. We hypothesized that the outcomes of appendectomy in delayed presentations of acute appendicitis (>72 hours of pain) were dependent on radiologic findings rather than late presentation. We reviewed records from 2009 to 2015 and analyzed delayed presentations of acute appendicitis. We divided patients into three groups based on specific CT findings: uncomplicated appendicitis (UA), phlegmon or abscess (PA), and other perforated appendicitis (PERF, signs of perforation without abscess or phlegmon). One hundred thirty-eight patients were included in this study (58 in the UA, 67 in the PA, and 13 in the PERF groups). Overall, 78 (57%) patients underwent early appendectomy (EA) and 60 (43%) underwent initial conservative management. The incidence of adverse events was lower in EA than that in initial conservative management (17% vs 42%, P = 0.005). EA in the UA group was associated with shorter hospitalization (3.2 vs 5.6 days, P < 0.001) and less adverse events (6% vs 29%, P < 0.05). Severe adverse events (two colectomies and one fecal fistula) were observed in the PA group. In conclusion, in these late presentations of appendicitis, complicated appendicitis was common. EA was safe in selected patients, however, and associated with decreased adverse events.
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Affiliation(s)
- Victoria Wang
- Department of Surgery, Riverside University Health System Medical Center, Moreno Valley, California
| | - Diego Kriger
- Department of Surgery, Riverside University Health System Medical Center, Moreno Valley, California
| | - Elias Fanous
- Department of Surgery, Riverside University Health System Medical Center, Moreno Valley, California
| | - Alfred Lee
- Department of Surgery, Riverside University Health System Medical Center, Moreno Valley, California
| | - Bishoy Zakhary
- Department of Surgery, Riverside University Health System Medical Center, Moreno Valley, California
| | - Raul Coimbra
- Department of Surgery, Riverside University Health System Medical Center, Moreno Valley, California
| | - Aron J. Depew
- Department of Surgery, Riverside University Health System Medical Center, Moreno Valley, California
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12
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Dhillon NK, Barmparas G, Lin TL, Alban RF, Melo N, Yang AR, Margulies DR, Ley EJ. Unexpected complicated appendicitis in the elderly diagnosed with acute appendicitis. Am J Surg 2019; 218:1219-1222. [PMID: 31481154 DOI: 10.1016/j.amjsurg.2019.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/10/2019] [Accepted: 08/16/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND This study determined the prevalence of complicated appendicitis in elderly patients diagnosed preoperatively with uncomplicated appendicitis. METHODS Patients with a preoperative diagnosis of uncomplicated appendicitis at an academic hospital from 11/2013 to 05/2017 were reviewed. Patients ≥65 years were compared to those younger. Pathology reports were categorized as either uncomplicated or complicated (COMP). The primary outcome was the prevalence of COMP appendicitis. RESULTS The prevalence of COMP appendicitis increased with age after 20 years with an abrupt increase after 65 years. Patients ≥65 years were more likely to have COMP appendicitis (48.1% vs. 15.5%; OR: 5.1; p < 0.01) and prolonged stays (3.8 vs. 2.3 days; p < 0.01). CONCLUSION Nearly half of elderly patients had pathologic confirmation of complicated appendicitis despite no preoperative clinical or radiographic suspicion for complicated appendicitis. Nonoperative management of acute appendicitis in the elderly may not be appropriate due to the high rate of unexpected complicated appendicitis.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Ting-Lung Lin
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Rodrigo F Alban
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Nicolas Melo
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Audrey R Yang
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Daniel R Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Abstract
Acute appendicitis is one of the most common surgical emergencies. Of the 300,000 appendectomies performed each year, 25% are due to complicated appendicitis. This article reviews the incidence and pathophysiology of acute appendicitis, the nonoperative management of complicated appendicitis, and the rationales for and against interval appendectomy.
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Acute Jejunoileal Diverticulitis: Multicenter Descriptive Study of 33 Patients. AJR Am J Roentgenol 2018; 210:1245-1251. [DOI: 10.2214/ajr.17.18777] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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15
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Horn CB, Coleoglou Centeno AA, Guerra JJ, Mazuski JE, Bochicchio GV, Turnbull IR. Drain Failure in Intra-Abdominal Abscesses Associated with Appendicitis. Surg Infect (Larchmt) 2018; 19:321-325. [PMID: 29431586 DOI: 10.1089/sur.2017.224] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Previous studies have suggested that percutaneous drainage and interval appendectomy is an effective treatment for appendicitis with associated abscess. Few studies to date have analyzed risk factors for failed drain management. We hypothesized that older patients with more co-morbidities would be at higher risk for failing conservative treatment. METHODS The 2010-2014 editions of the National Inpatient Sample (NIS) were queried for patients with diagnoses of peri-appendiceal abscesses. Minors and elective admissions were excluded. We identified patients who underwent percutaneous drainage and defined drain failure as undergoing a surgical operation after drainage but during the same inpatient visit to assess for factors associated with failure of drainage alone as a treatment. After univariable analysis, binomial logistic regression was used to assess for independent risk factors. Frequencies were analyzed by χ2 and continuous variables by Student's t-test. RESULTS A total of 2,209 patients with appendiceal abscesses received drains; 561 patients (25.4%) failed conservative management and underwent operative intervention. On univariable analysis, patients who failed conservative management were younger, more likely to be Hispanic, have more inpatient diagnoses, and to have undergone drainage earlier in the hospital course. Multivariable regression demonstrated that the number of diagnoses, female sex, and Hispanic race were predictive of failure of drainage alone. Older age, West and Midwest census regions, and later drain placement were predictive of successful treatment with drainage alone. Failure was associated with more charges and longer hospital stay but not with a higher mortality rate. CONCLUSION Approximately a quarter of patients will fail management of appendiceal abscess with percutaneous drain placement alone. Risk factors for failure are patient complexity, female sex, earlier drainage, and Hispanic race. Failure of drainage is associated with higher total charges and longer hospital stay; however, no change in the mortality rate was noted.
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Affiliation(s)
- Christopher B Horn
- Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | | | - Jarot J Guerra
- Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - John E Mazuski
- Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Grant V Bochicchio
- Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Isaiah R Turnbull
- Department of Surgery, Washington University in St Louis , St. Louis, Missouri
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Tsai HY, Chao HC, Yu WJ. Early appendectomy shortens antibiotic course and hospital stay in children with early perforated appendicitis. Pediatr Neonatol 2017; 58:406-414. [PMID: 28254405 DOI: 10.1016/j.pedneo.2016.09.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/10/2016] [Accepted: 09/20/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The optimal management of perforated appendicitis in the pediatric population has been controversial. This study aimed to compare the therapeutic efficacy between conservative treatment (CS) and early appendectomy (EA) in pediatric perforated appendicitis, and to determine whether surgical intervention is an optimal treatment modality for early perforated appendicitis in children. METHODS Patients treated between January 2012 and April 2014, aged 0-18 years, with an imaging-based diagnosis of perforated appendicitis were retrospectively reviewed. Patients were classified into nonabscess and abscess groups by image findings, and were further categorized into CS and EA groups by treatment modality. Early perforated appendicitis was defined as having duration of symptoms≤7 days, C-reactive protein level≤200 mg/L, maximum abscess diameter≤5 cm, and absence of general peritonitis, and unstable vital signs. The clinical features and therapeutic outcomes were compared between CS and EA in each group. RESULTS A total of 326 patients had confirmed appendicitis, including 116 patients with an image diagnosis of perforation. The CS group had a significantly longer duration of symptoms, larger abscesses, and higher serum C-reactive protein levels at presentation (all p<0.05). Patients in the EA group had a shorter antibiotic course and length of hospitalization, and a lower rate of antibiotic escalation than those in the CS group (p<0.001, p<0.001, and p<0.05, respectively). In patients with early perforated appendicitis, the CS and EA groups showed no difference in baseline disease severity. Patients in the EA group also had a shorter antibiotic course and length of hospitalization than those in the CS group (p<0.001 and p<0.001, respectively). CONCLUSION Compared with CS, EA shortens the antibiotic course and hospital stay in pediatric early perforated appendicitis, even in the presence of small abscesses.
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Affiliation(s)
- Hsin-Yu Tsai
- Division of Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Guishan District, Taoyuan City, Taiwan
| | - Hsun-Chin Chao
- Division of Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Guishan District, Taoyuan City, Taiwan.
| | - Wan-Ju Yu
- Division of Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Guishan District, Taoyuan City, Taiwan
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Kim MS, Kim HJ, Park HW, Kwon HJ, Lee SY, Kook SH, Park HJ, Choi YJ. Impact of high-grade obstruction on outcomes in patients with appendiceal inflammatory masses managed by nonoperative treatment. Ann Surg Treat Res 2017; 92:429-435. [PMID: 28580348 PMCID: PMC5453876 DOI: 10.4174/astr.2017.92.6.429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 11/28/2016] [Accepted: 01/17/2017] [Indexed: 12/26/2022] Open
Abstract
Purpose To retrospectively assess the impact of high-grade obstructions identified on initial CT on outcomes of patients with appendiceal inflammatory masses managed by nonoperative treatment. Methods Institutional Review Boards approved this retrospective study and informed consent was waived. Included were 52 consecutive patients diagnosed with appendiceal inflammatory masses by CT scan and managed by nonoperative treatment. The main outcome measure was treatment failure and secondary outcomes were complications and initial and total hospital stay. Patient demographics, inflammatory markers, and CT findings for presence of an appendiceal inflammatory mass and high-grade obstruction were assessed. Patients with and without high-grade obstruction were compared for patient characteristics and outcomes using Fisher exact test and Student t-test. Results Among 52 patients, 14 (27%) had high-grade obstruction on CT examination at presentation. No significant differences were observed in patient characteristics (P > 0.05), treatment failure (P = 0.33), complications (P = 0.29), or initial (P = 0.73) or total (P = 0.72) hospitalization between patients with and without high-grade obstruction. Conclusion For patients who were managed by nonoperative treatment for appendiceal inflammatory masses, the presence of high-grade obstruction identified on initial CT scan did not significantly affect outcomes of treatment failure, complications, and initial and total hospitalization.
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Affiliation(s)
- Mi Sung Kim
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Jung Kim
- Department of Radiology, Daejin Medical Center, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hae Won Park
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Heon-Ju Kwon
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - So-Yeon Lee
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin Ho Kook
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee-Jin Park
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Jung Choi
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Lotti M. Second date appendectomy: Operating for failure of nonoperative treatment in perforated appendicitis. Am J Emerg Med 2017; 35:939.e3-939.e6. [PMID: 28063718 DOI: 10.1016/j.ajem.2016.12.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 12/29/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Nonoperative treatment of acute appendicitis is embraced by many surgical teams, driven by low to moderate quality randomized studies that support noninferiority of antibiotics versus appendectomy for treatment of acute uncomplicated appendicitis. Several flaws of these studies have emerged, especially in the recruitment strategy and in the diagnostic criteria that were used. The growing confidence given to antibiotics, together with the lack of reliable criteria to distinguish between uncomplicated and perforated appendicitis, exposes patients with perforated appendicitis to the likelihood to be treated with antibiotics instead of surgery. Among them, those patients who experience a temporary relief of symptoms due to antibiotics, followed by early recurrence of disease when antibiotics are discontinued, are likely to undergo appendectomy at their second date. Second date appendectomy, i.e. the removal of the appendix when acute inflammation relapses within the scar of a previously unhealed perforated appendicitis, is the unwanted child of the nonoperative treatment and a new challenge for both the surgeon and the patient. METHODS Between June and July 2016, two patients were readmitted and operated for failure of nonoperative treatment with antibiotics. RESULTS A video is presented, which focuses on the different anatomic presentation and technical challenges between prompt and second date laparoscopic appendectomy. CONCLUSIONS When proposing nonoperative treatment for acute appendicitis, surgeons should be aware and inform their patients that if the appendix is perforated and an incomplete healing and early recurrence occur, a second date appendectomy could be a more challenging operation compared to a prompt appendectomy.
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Affiliation(s)
- Marco Lotti
- Advanced Surgical Oncology Unit, Department of General Surgery 1, Papa Giovanni XXIII Hospital, Bergamo, Italy.
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19
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Gandy RC, Wang F. Should the non-operative management of appendicitis be the new standard of care? ANZ J Surg 2016; 86:228-31. [PMID: 26991357 DOI: 10.1111/ans.13506] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 02/02/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Robert C. Gandy
- Department of Surgery, Prince of Wales Hospital; Sydney New South Wales Australia
- Prince of Wales Clinical School, The University of New South Wales; Sydney New South Wales Australia
| | - Frank Wang
- Department of Surgery, Campbelltown Hospital; Campbelltown New South Wales Australia
- Academic Division of Surgery, Western Sydney University; Sydney New South Wales Australia
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van den Bogaard VAB, Euser SM, van der Ploeg T, de Korte N, Sanders DGM, de Winter D, Vergroesen D, van Groningen K, de Winter P. Diagnosing perforated appendicitis in pediatric patients: a new model. J Pediatr Surg 2016; 51:444-8. [PMID: 26628202 DOI: 10.1016/j.jpedsurg.2015.10.054] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 10/21/2015] [Accepted: 10/21/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Studies have investigated sensitivity and specificity of symptoms and tests for diagnosing appendicitis in children. Less is known with regard to the predictive value of these symptoms and tests with respect to the severity of appendicitis. The aim of this study was to determine the predictive value of patient's characteristics and tests for discriminating between perforated and nonperforated appendicitis in children. PATIENTS AND METHODS Pediatric patients who underwent an appendectomy at Spaarne Hospital Hoofddorp, the Netherlands, between January 1, 2009 and December 31, 2013, were included. Baseline patient's characteristics, history, physical examination, laboratory data and results of ultrasounds were collected. Univariate and multivariate logistic regressions were used to determine predictors of perforation. RESULTS In total, 375 patients were included in this study of which 97 children (25.9%) had significant signs of perforation. Univariate analysis showed that age, duration of complaints, temperature, vomiting, CRP, WBC, different findings on ultrasound and the diameter of the appendix were good predictors of a perforated appendicitis. The final multivariate prediction model included temperature, CRP, clearly visible appendix and free fluids on ultrasound and diameter of the appendix and resulted in an area under the curve (AUC) of 0.91 showing sensitivity and specificity of respectively 85.2% and 81.2%. CONCLUSION This prediction model can be used for identification of 'high-risk' children for a perforated appendicitis and might be helpful to prevent complications and longer hospitalization by bringing these children to theater earlier.
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Affiliation(s)
| | - Sjoerd M Euser
- Regional Public Health Laboratory Kennemerland, Haarlem, the Netherlands
| | | | - Niels de Korte
- Department of Surgery, Spaarne Hospital, Hoofddorp, the Netherlands
| | - Dave G M Sanders
- Department of Radiology, Spaarne Hospital, Hoofddorp, the Netherlands
| | - Derek de Winter
- Department of Pediatrics, Spaarne Hospital, Hoofddorp, the Netherlands
| | | | | | - Peter de Winter
- Department of Pediatrics, Spaarne Hospital, Hoofddorp, the Netherlands
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Wu JX, Dawes AJ, Sacks GD, Brunicardi FC, Keeler EB. Cost effectiveness of nonoperative management versus laparoscopic appendectomy for acute uncomplicated appendicitis. Surgery 2015. [PMID: 26195106 DOI: 10.1016/j.surg.2015.06.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Appendectomy remains the gold standard in the treatment of acute, uncomplicated appendicitis in the United States. Nonetheless, there is growing evidence that nonoperative management is safe and efficacious. METHODS We constructed a decision tree to compare nonoperative management of appendicitis with laparoscopic appendectomy in otherwise healthy adults. Model variables were abstracted from a literature review, data from the Healthcare Cost and Utilization Project data, the Medicare Physician Fee schedule, and the American College of Surgeons Surgical Risk Calculator. Uncertainty surrounding parameters of the model was assessed via 1-way and probabilistic sensitivity analyses. RESULTS Operative management cost $12,213 per patient. Nonoperative management without interval appendectomy (IA) was the dominant strategy, costing $1,865 less and producing 0.03 more quality-adjusted life-years (QALYs). Nonoperative management with IA cost $4,271 more than operative management, but yielded only 0.01 additional QALY. One-way sensitivity analysis suggested operative management would become the preferred strategy if the recurrence rate was >40.5% or the total cost of appendectomy was decreased to <$5,468. Probabilistic sensitivity analysis confirmed nonoperative management without IA was the preferred strategy in 95.6% of cases. CONCLUSION Nonoperative management without IA is the least costly, most effective treatment for acute, uncomplicated appendicitis and warrants further evaluation in a disease thought to be definitively surgical.
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Affiliation(s)
- James X Wu
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA.
| | - Aaron J Dawes
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA; VA Greater Los Angeles Healthcare System, Los Angeles, CA; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Greg D Sacks
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA; VA Greater Los Angeles Healthcare System, Los Angeles, CA; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
| | | | - Emmett B Keeler
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA; RAND Corporation, Santa Monica, CA
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Clinical Evaluation of Acute Appendicitis. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2014. [DOI: 10.1016/j.cpem.2014.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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