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Calpin GG, Hembrecht S, Giblin K, Hehir C, Dowling GP, Hill ADK. The impact of timing on outcomes in appendicectomy: a systematic review and network meta-analysis. World J Emerg Surg 2024; 19:24. [PMID: 38877592 PMCID: PMC11177546 DOI: 10.1186/s13017-024-00549-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 05/26/2024] [Indexed: 06/16/2024] Open
Abstract
INTRODUCTION Appendicectomy remains the standard treatment for appendicitis. There is a lack of clarity on the timeframe in which surgery should be performed to avoid unfavourable outcomes. AIM To perform a systematic review and network meta-analysis to evaluate the impact the (1)time-of-day surgery is performed (2), time elapsed from symptom onset to hospital presentation (patient time) (3), time elapsed from hospital presentation to surgery (hospital time), and (4)time elapsed from symptom onset to surgery (total time) have on appendicectomy outcomes. METHODS A systematic review was performed as per PRISMA-NMA guidelines. The time-of-day which surgery was done was divided into day, evening and night. The other groups were divided into < 24 h, 24-48 h and > 48 h. The rate of complicated appendicitis, operative time, perforation, post-operative complications, surgical site infection (SSI), length of stay (LOS), readmission and mortality rates were analysed. RESULTS Sixteen studies were included with a total of 232,678 patients. The time of day at which surgery was performed had no impact on outcomes. The incidence of complicated appendicitis, post-operative complications and LOS were significantly better when the hospital time and total time were < 24 h. Readmission and mortality rates were significantly better when the hospital time was < 48 h. SSI, operative time, and the rate of perforation were comparable in all groups. CONCLUSION Appendicectomy within 24 h of hospital admission is associated with improved outcomes compared to patients having surgery 24-48 and > 48 h after admission. The time-of-day which surgery is performed does not impact outcomes.
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Affiliation(s)
- Gavin G Calpin
- Department of Surgery Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, 123 St Stephens Green Dublin 2, Dublin, Ireland.
| | - Sandra Hembrecht
- Department of Surgery Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, 123 St Stephens Green Dublin 2, Dublin, Ireland
| | - Katie Giblin
- Royal College of Surgeons in Ireland, 123 St Stephens Green Dublin 2, Dublin, Ireland
| | - Cian Hehir
- Department of Surgery Beaumont Hospital, Dublin, Ireland
| | - Gavin P Dowling
- Royal College of Surgeons in Ireland, 123 St Stephens Green Dublin 2, Dublin, Ireland
| | - Arnold D K Hill
- Department of Surgery Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, 123 St Stephens Green Dublin 2, Dublin, Ireland
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Patel SV, Zhang L, Mir ZM, Lemke M, Leeper WR, Allen LJ, Walser E, Vogt K. Delayed Versus Early Laparoscopic Appendectomy for Adult Patients With Acute Appendicitis: A Randomized Controlled Trial. Ann Surg 2024; 279:88-93. [PMID: 37436871 DOI: 10.1097/sla.0000000000005996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVE To assess whether delaying appendectomy until the following morning is non-inferior to immediate surgery in those with acute appendicitis presenting at night. BACKGROUND Despite a lack of supporting evidence, those with acute appendicitis who present at night frequently have surgery delayed until the after morning. METHODS The delay trial is a noninferiority randomized controlled trial conducted between 2018 and 22 at 2 tertiary care hospitals in Canada. Adults with imaging confirmed acute appendicitis who presented at night (8:00 pm -4:00 am ). Delaying surgery until after 6:00 am was compared with immediate surgery. The primary outcome was 30-day postoperative complications. An a prior noninferiority margin of 15% was deemed clinically relevant. RESULTS One hundred twenty-seven of the planned 140 patients were enrolled in the Delayed Versus Early Laparoscopic Appendectomy (DELAY) trial (59 in the delayed group and 68 in the immediate group). The two groups were similar at baseline. The mean time between the decision to operate and surgery was longer in the delayed group (11.0 vs 4.4 hours, P < 0.0001). The primary outcome occurred in 6/59 (10.2%) of those in the delayed group versus 15/67 (22.4%) of those in the immediate group ( P = 0.07). The difference between groups met the a priori noninferiority criteria of +15% (risk difference -12.2%, 95% CI: -24.4% to +0.4%, test of noninferiority P < 0.0001). CONCLUSIONS The DELAY study is the first trial to assess delaying appendectomy in those with acute appendicitis. We demonstrate the noninferiority of delaying surgery until the after morning.
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Affiliation(s)
- Sunil V Patel
- Department of Surgery, Queen's University, Kingston General Hospital, Kingston, ON, Canada
| | - Lisa Zhang
- Department of Surgery, Queen's University, Kingston General Hospital, Kingston, ON, Canada
- Department of Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Zuhaib M Mir
- Department of Surgery, Queen's University, Kingston General Hospital, Kingston, ON, Canada
| | - Madeline Lemke
- Department of Surgery, Western University, London, ON, Canada
| | | | - Laura J Allen
- Department of Surgery, Western University, London, ON, Canada
| | - Eric Walser
- Department of Surgery, Western University, London, ON, Canada
| | - Kelly Vogt
- Department of Surgery, Western University, London, ON, Canada
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Pogorelić Z, Janković Marendić I, Čohadžić T, Jukić M. Clinical Outcomes of Daytime Versus Nighttime Laparoscopic Appendectomy in Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040750. [PMID: 37189999 DOI: 10.3390/children10040750] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023]
Abstract
Aim of the study: To evaluate the clinical outcomes and complication rate of laparoscopic appendectomy in children operated on during the daytime versus nighttime. Methods: A total of 303 children who underwent laparoscopic appendectomy for acute appendicitis between 1 January 2020 and 31 December 2022 were enrolled in this retrospective study. The patients were divided into two study groups. The first group consisted of the patients who underwent laparoscopic appendectomy during the day shift from 07:00-21:00 (n = 171), while the patients in the second group underwent laparoscopic appendectomy during the night shift from 21:00-07:00 (n = 132). The groups were compared for baseline clinical and laboratory data, treatment outcomes, and complications. The Mann-Whitney U test was used to compare continuous variables, while the Chi-square test was used to compare categorical variables. A two-sided Fisher's exact test was used when the frequency of events in a certain cell was low. All p values less than 0.05 were considered significant. Results: The proportion of complicated appendicitis was almost the same in both patient groups (n = 63, 36.8% vs. n = 49, 37.1%, p = 0.960). Out of the total number of patients presenting during the daytime and nighttime, 11 (6.4%) and 10 (7.6%) developed a postoperative complication, respectively (p = 0.697). Additionally, rates of readmission (n = 5 (2.9%) vs. n = 2 (1.5%); p = 0.703), redo-surgery (n = 3 (1.7%) vs. n = 0; p = 0.260), conversion to open surgery (n = 0 vs. n = 1 (0.8%); p = 0.435) and length of hospital stay (n = 3 (IQR 1, 5) vs. n = 3 (IQR 2, 5); p = 0.368) did not differ significantly between daytime and nighttime appendectomies. The duration of the surgery was significantly shorter in patients presenting during the day than in those presenting at night (26 min (IQR 22, 40) vs. 37 min (31, 46); p < 0.001). Conclusions: Different shift times did not affect the treatment outcomes or complication rates for children receiving laparoscopic appendectomy.
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Affiliation(s)
- Zenon Pogorelić
- Department of Pediatric Surgery, University Hospital of Split, 21000 Split, Croatia
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia
| | | | - Tin Čohadžić
- Department of Pediatric Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Miro Jukić
- Department of Pediatric Surgery, University Hospital of Split, 21000 Split, Croatia
- Department of Surgery, School of Medicine, University of Split, 21000 Split, Croatia
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Yoon KW, Choi K, Yoo K, Gil E, Park CM. Clinical significance of acute care surgery system as a part of hospital medical emergency team for hospitalized patients. Ann Surg Treat Res 2023; 104:43-50. [PMID: 36685770 PMCID: PMC9830047 DOI: 10.4174/astr.2023.104.1.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/27/2022] [Accepted: 10/20/2022] [Indexed: 01/04/2023] Open
Abstract
Purpose Acute care surgery (ACS) has been practiced in several tertiary hospitals in South Korea since the late 2000s. The medical emergency team (MET) has improved the management of patients with clinical deterioration during hospitalization. This study aimed to identify the clinical effectiveness of collaboration between ACS and MET in hospitalized patients. Methods This was an observational before-and-after study. Emergency surgical cases of hospitalized patients were included in this study. Patients hospitalized in the Department of Emergency Medicine or Department of Surgery, directly comanaged by ACS were excluded. The primary outcome was in-hospital mortality rate. The secondary outcome was the alarm-to-operation interval, as recorded by a Modified Early Warning Score (MEWS) of >4. Results In total, 240 patients were included in the analysis (131 in the pre-ACS group and 109 in the post-ACS group). The in-hospital mortality rates in the pre- and post-ACS groups were 17.6% and 22.9%, respectively (P = 0.300). MEWS of >4 within 72 hours was recorded in 62 cases (31 in each group), and the median alarm-to-operation intervals of each group were 11 hours 16 minutes and 6 hours 41 minutes, respectively (P = 0.040). Conclusion Implementation of the ACS system resulted in faster surgical intervention in hospitalized patients, the need for which was detected early by the MET. The in-hospital mortality rates before and after ACS implementation were not significantly different.
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Affiliation(s)
- Kyoung Won Yoon
- Division of Critical Care, Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea.,Sungkyunkwan University Graduate School of Medicine, Suwon, Korea
| | - Kyoungjin Choi
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keesang Yoo
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eunmi Gil
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chi-Min Park
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Elliott-Dawe C, Chen J, Zadinsky JK. Case-Mix Moderation of the Relationship Between OR Performance Metrics and Utilization. AORN J 2022; 116:547-555. [PMID: 36440941 DOI: 10.1002/aorn.13824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/05/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022]
Abstract
We investigated the impact of the case-mix ratio of inpatients to outpatients on the relationships between OR utilization and late starts, turnover time, delays, cancellations, and idle time at an academic medical center in the southeastern United States. After extracting 55 months of data from the surgical repository, we used simple and multiple linear regression models to analyze the data and determine the strength and direction of the relationships among the variables. We compared models comprising proportionally more inpatients to models comprising proportionally more outpatients for each metric to ascertain the effects of case mix on OR utilization. Idle time had the greatest effect on OR utilization, followed by late starts and turnover time. Case mix moderated the relationship between OR utilization and the metrics of cancellations and turnover time. Perioperative leaders may enhance OR utilization by monitoring and addressing idle time and late starts and scheduling an appropriate mix of inpatients and outpatients.
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Kabir T, Syn NL, Shaw V, Tan YHA, Chua HW, Ong LWL, Koh FH, Ladlad J, Barco JB, Wang P, Kui Y, Blasiak A, Zhao JJ, Ho D, Kam JH, Ngaserin S. Defining the optimal time to appendectomy: A step toward precision surgery. Surgery 2022; 172:798-806. [PMID: 35850731 DOI: 10.1016/j.surg.2022.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/06/2022] [Accepted: 04/09/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND We aimed to investigate the association between time from admission to appendectomy on perioperative outcomes in order to determine optimal time-to-surgery windows. METHODS We performed a retrospective review of all the appendectomies performed between July 2018 to May 2020. We first compared the perioperative outcomes using preselected time-to-surgery cut-offs, then determined optimal safe windows for surgery, and finally identified subgroups of patients who may require early intervention. RESULTS Six hundred twenty-one appendectomies were performed in the time period. The patients with a time-to-surgery of ≥12 hours had a significantly longer length of stay (median 2 days [interquartile range 1-3] vs 3 days [interquartile range 2-4], mean difference = 0.74 [95% confidence interval 0.32-1.17, P = .0006]) and higher 30-day readmission risk (odds ratio 2.58, 95% confidence interval 1.12-5.96, P = .0266) versus those with a time-to-surgery of <12 hours. These differences persisted when the time-to-surgery was dichotomized by <24 or ≥24 hours. A time-to-surgery beyond 25 hours was associated with a 3.34-fold increased odds of open conversion (P = .040), longer operation time (mean difference 15.8 mins, 95% confidence interval 3.4-28.3, P = .013) and longer postoperative length of stay (mean difference 10.3 hours, 95% confidence interval 3.4-20.2, P = .042) versus a time-to-surgery of <25 hours. The patients with time-to-surgery beyond 11 hours had a 1.35-fold increased odds of 30-day readmission (95% confidence interval 1.02-5.43, P = .046) compared with those who underwent appendectomy before 11 hours. Older patients, patients with American Society of Anesthesiologist score II to III, and individuals with long duration of preadmission symptoms had higher risk of prolonged operation time, open conversion, increased length of stay, and postoperative morbidity with increasing time-to-surgery. CONCLUSION This study identified the safe windows for appendectomy to be 11 to 25 hours from admission for most perioperative outcomes. However, certain patient subgroups may be less tolerant of surgical delays.
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Affiliation(s)
- Tousif Kabir
- Department of General Surgery, Sengkang General Hospital, Singapore.
| | - Nicholas L Syn
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore. https://twitter.com/Nicholas_Syn
| | - Vera Shaw
- Department of General Surgery, Sengkang General Hospital, Singapore
| | | | - Hui Wen Chua
- Department of General Surgery, Sengkang General Hospital, Singapore
| | | | - Frederick H Koh
- Department of General Surgery, Sengkang General Hospital, Singapore
| | - Jasmine Ladlad
- Department of General Surgery, Sengkang General Hospital, Singapore
| | - Jason Bae Barco
- Department of General Surgery, Sengkang General Hospital, Singapore
| | - Peter Wang
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore; The Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - You Kui
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore; The Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Agata Blasiak
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore; The Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Biomedical Engineering, NUS Engineering, National University of Singapore, Singapore
| | - Joseph J Zhao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Dean Ho
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore; The Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Biomedical Engineering, NUS Engineering, National University of Singapore, Singapore
| | - Juinn Huar Kam
- Department of General Surgery, Sengkang General Hospital, Singapore
| | - Sabrina Ngaserin
- Department of General Surgery, Sengkang General Hospital, Singapore
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Laparoscopic delayed and interval appendectomy in the workstyle reform era. Surg Today 2021; 52:1023-1030. [PMID: 34796402 DOI: 10.1007/s00595-021-02416-0] [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: 07/15/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Excessive working hours have been reported to contribute to burnout among surgeons. In Japan, work-style reform is a problem that needs immediate attention. Acute appendectomy, which often occurs at nighttime, is one of the most common emergency surgeries. The feasibility of delayed and interval appendectomy remains to be investigated. METHODS Two hundred forty-five consecutive patients who underwent laparoscopic appendectomy in our hospital were enrolled. They were divided into three groups: emergency appendectomy (immediate surgery, soon after the diagnosis [EA group], n = 153), delayed appendectomy (surgery during daytime the following day [DA group], n = 38) and interval appendectomy (antibiotics treatment followed by selective surgery three to four months later [IA group], n = 54). The clinical background and surgical outcomes were compared. Next, the residents' excess working time per month was calculated. RESULTS The surgical outcomes (operation time, blood loss, length of hospital stay, postoperative complications) were similar between the EA and DA groups. However, no DA was performed during nighttime hours whereas 15.7% of EA was performed during nighttime hours (p = 0.0007). The surgical outcomes of the IA group were also comparable. The residents' excess working time declined following the introduction of DA and workstyle reform. CONCLUSION Delayed and interval laparoscopic appendectomy are feasible, and can be performed to promote workstyle reform without impairing patient safety.
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Vansevičienė I, Bučinskaitė D, Malcius D, Lukošiūtė-Urbonienė A, Beržanskis M, Čekanauskas E, Barauskas V. Did the COVID-19 Pandemic Prolong the Time Till Diagnosis and Worsen Outcomes for Children with Acute Appendicitis? Medicina (B Aires) 2021; 57:medicina57111234. [PMID: 34833452 PMCID: PMC8623899 DOI: 10.3390/medicina57111234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 12/24/2022] Open
Abstract
Background and Objectives: Our aim was to see if the COVID-19 pandemic led to an increase of time until diagnosis, operation, and time spent in Emergency room (ER), and if it resulted in more cases of complicated appendicitis and complication rates in children. Materials and Methods: We conducted a retrospective analysis of patients admitted to the Pediatric Surgery Department with acute appendicitis during a 4-month period of the first COVID-19 pandemic and compared it to the previous year data—the same 4-month period in 2019. Results: During the pandemic, the time spent in the ER until arriving at the department increased significantly 2.85 vs. 0.98 h p < 0.001, and the time spent in the department until the operation 5.31 vs. 2.66 h, p = 0.03. However, the time from the beginning of symptoms till ER, operation time and the length of stay at the hospital, as well as the overall time until operation did not differ and did not result in an increase of complicated appendicitis cases or postoperative complications. Conclusions: The COVID-19-implemented quarantine led to an increase of the time from the emergency room to the operating room by 4 h. This delay did not result in a higher rate of complicated appendicitis and complication rates, allowing for surgery to be postponed to daytime hours if needed.
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Affiliation(s)
- Idilė Vansevičienė
- Pediatric Surgery Department, Lithuanian University of Health Sciences, Eivenių Str. 2, LT-50161 Kaunas, Lithuania; (D.M.); (A.L.-U.); (M.B.); (E.Č.); (V.B.)
- Correspondence: ; Tel.: +370-6260-4046
| | - Danielė Bučinskaitė
- Department of Surgery, Lithuanian University of Health Sciences, Eivenių Str. 2, LT-50161 Kaunas, Lithuania;
| | - Dalius Malcius
- Pediatric Surgery Department, Lithuanian University of Health Sciences, Eivenių Str. 2, LT-50161 Kaunas, Lithuania; (D.M.); (A.L.-U.); (M.B.); (E.Č.); (V.B.)
| | - Aušra Lukošiūtė-Urbonienė
- Pediatric Surgery Department, Lithuanian University of Health Sciences, Eivenių Str. 2, LT-50161 Kaunas, Lithuania; (D.M.); (A.L.-U.); (M.B.); (E.Č.); (V.B.)
| | - Mindaugas Beržanskis
- Pediatric Surgery Department, Lithuanian University of Health Sciences, Eivenių Str. 2, LT-50161 Kaunas, Lithuania; (D.M.); (A.L.-U.); (M.B.); (E.Č.); (V.B.)
| | - Emilis Čekanauskas
- Pediatric Surgery Department, Lithuanian University of Health Sciences, Eivenių Str. 2, LT-50161 Kaunas, Lithuania; (D.M.); (A.L.-U.); (M.B.); (E.Č.); (V.B.)
| | - Vidmantas Barauskas
- Pediatric Surgery Department, Lithuanian University of Health Sciences, Eivenių Str. 2, LT-50161 Kaunas, Lithuania; (D.M.); (A.L.-U.); (M.B.); (E.Č.); (V.B.)
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Hoffmann JC, Trimborn CP, Hoffmann M, Schröder R, Förster S, Dirks K, Tannapfel A, Anthuber M, Hollerweger A. Classification of acute appendicitis (CAA): treatment directed new classification based on imaging (ultrasound, computed tomography) and pathology. Int J Colorectal Dis 2021; 36:2347-2360. [PMID: 34143276 DOI: 10.1007/s00384-021-03940-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE Acute appendicitis (AA) is amongst the most common causes of acute abdominal pain. In spite of progress based on risk stratifications, "negative" appendectomies are performed in up to 30% of patients whilst the appendix perforates in others. Preoperative classification of AA based on imaging is therefore recommended. The aim was to classify AA based on imaging (ultrasound/US, computed tomography/CT), surgical pathology, and/or histopathology in order to differentiate between complicated and uncomplicated AA. A new classification of acute appendicitis (CAA) shall be illustrated by typical US and CT images and be employed in a diagnostic and therapeutic algorithm. METHODS Medline, Embase, and the Cochrane Library were searched. Any study after 1970, which investigated clinical scores, pathology, US, CT, magnetic resonance imaging, and treatment of AA, was included. Typical images were taken from the author's image database. RESULTS Five main types of AA are defined, normal appendix (type 0), nonvisualised appendix (type X), uncomplicated AA (type 1), complicated AA without perforation (type 2), and complicated AA with perforation (type 3). The imaging modality is indicated by an additional letter, e.g., type p3b for free perforation on pathology. Standardised reporting of the appendix evaluation by US and CT is presented, as well as algorithms for AA management. Imaging features indicating imminent perforation, as well as likely recurrence, were both classified as complicated AA. CONCLUSION Imaging is mandatory in suspected AA. The CAA clearly separates uncomplicated from complicated forms of AA allowing nonoperative management in selected patients with uncomplicated forms of AA.
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Affiliation(s)
- Jörg C Hoffmann
- Medizinische Klinik I mit Schwerpunkt Gastroenterologie, Diabetologie, Rheumatologie und Onkologie, St. Marien- und St. Annastiftskrankenhaus, Salzburger Straße 15, D67067, Ludwigshafen, Germany.
| | - Claus-Peter Trimborn
- Medizinische Klinik I mit Schwerpunkt Gastroenterologie, Diabetologie, Rheumatologie und Onkologie, St. Marien- und St. Annastiftskrankenhaus, Salzburger Straße 15, D67067, Ludwigshafen, Germany
| | - Michael Hoffmann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ralf Schröder
- Radiologische Klinik, St. Marien- und St. Annastiftskrankenhaus Ludwigshafen, Ludwigshafen, Germany
| | - Sarah Förster
- Institut für Pathologie der Ruhr-Universität Bochum, Bochum, Germany
| | - Klaus Dirks
- Gastroenterologie, Allgemeine Innere Medizin und Geriatrie, Rems-Murr-Kliniken Winnenden, Winnenden, Germany
| | - Andrea Tannapfel
- Institut für Pathologie der Ruhr-Universität Bochum, Bochum, Germany
| | - Matthias Anthuber
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Alois Hollerweger
- Abteilung für Radiologie und Nuklearmedizin Krankenhaus der Barmherzigen Brüder Salzburg, Salzburg, Austria
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Zhang L, Lemke M, Mir ZM, Patel SV. Delayed vs. Early Appendectomy (DELAY) trial for adult patients with acute appendicitis: Study protocol for a randomized controlled trial. Contemp Clin Trials 2021; 102:106288. [PMID: 33497834 DOI: 10.1016/j.cct.2021.106288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/12/2021] [Accepted: 01/12/2021] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Early appendectomy in patients diagnosed with acute appendicitis is the current standard of treatment in North America. Timely intervention is suggested to avoid the complications associated with perforated appendicitis; however, safety of nighttime operating is a competing concern, with mixed results demonstrated thus far. OBJECTIVES This multi-center prospective randomized controlled trial aims to assess whether delaying appendectomy until the following morning versus early appendectomy overnight affects the rate of surgical complications in adult patients diagnosed with acute appendicitis in the evening hours. METHODS This is a randomized, controlled trial across two academic institutions with blinded outcome assessors. Patients presenting with imaging-confirmed appendicitis with an expected appendectomy between 8 pm and 4 am and within 6 h of decision to operate will be randomized to early appendectomy (with 6 h of randomization, control arm) or delayed to the following morning (after 6 am, intervention arm). Primary outcome will be 30 day postoperative complications, defined as a composite of: mortality, readmission to hospital, emergency department visit, percutaneous drain insertion, reoperation, prolonged hospital stay (>7 days), and postoperative complications. Secondary outcome measures are operative time, length of stay, time to emergency department visit and compliance to treatment. DISCUSSION This is a feasible and pragmatic clinical trial, intended to provide evidence for challenging decision making for the most common surgical disease worldwide. Results of this study will aid surgeons and health care administrators on how to appropriately triage appendectomies for patients with acute appendicitis who present overnight.
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Affiliation(s)
- Lisa Zhang
- Department of Surgery, Queen's University, Victory 3, Kingston General Hospital, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.
| | - Madeline Lemke
- Department of Surgery, Western University, 339 Windermere Road, London, Ontario N6A 5A5, Canada.
| | - Zuhaib M Mir
- Department of Surgery, Queen's University, Victory 3, Kingston General Hospital, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.
| | - Sunil V Patel
- Department of Surgery, Queen's University, Victory 3, Kingston General Hospital, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.
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11
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Westfall KM, Charles AG. Risk of Perforation in the Era of Nonemergent Management for Acute Appendicitis. Am Surg 2020. [DOI: 10.1177/000313481908501124] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Prompt appendectomy has long been the standard of care for acute appendicitis because of the risk of progression to perforation. Recently, studies have suggested nonemergent management of acute appendicitis. Our study aimed to determine changes in risk of rupture and complications in patients with appendicitis, with increasing time from symptom onset to treatment. Retrospective study of patients aged ≥18 years presenting to the University of North Carolina Hospitals with signs and symptoms of acute appendicitis who subsequently underwent appendectomy from 2011 to 2015 was performed. Demographic, clinical, laboratory, and pathologic data were reviewed. Bivariate analysis was performed to assess variables associated with increased risk of perforation. Poisson regression modeling was completed to evaluate the risk of perforation and postoperative abscess based on time from symptoms to treatment. Within our database of 1007 patients, the mean time from onset of symptoms to operative intervention was 3.24 ± 2.2 days. Modified Poisson regression modeling demonstrated the relative risk for perforation increases by 9% (RR 1.09, P < 0.001) for each day delay. Age (RR 1.03), male gender (RR 1.50), temperature on admission (RR 1.32), and the presence of fecalith (RR 1.89) statistically significantly increased the risk of perforation. Furthermore, for each day delay, there is an 8% increased risk of postoperative abscess (RR 1.08, P = 0.027). The relative risk for appendiceal perforation is 9 per cent per day delay with a resultant 8 per cent increased risk of postoperative abscess. Thus, appendectomy for acute appendicitis should remain an emergent procedure, given that delays in operative management lead to complications and increases in cost of care.
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Affiliation(s)
- Kristen M. Westfall
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anthony G. Charles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Khalili M, Suwanabol PA. Commentary on "Short-term outcome after appendectomy is related to preoperative delay but not to the time of day of the procedure: A nationwide retrospective cohort study of 9224 patients". Int J Surg 2020; 77:76. [PMID: 32200054 DOI: 10.1016/j.ijsu.2020.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 03/15/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Marian Khalili
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
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Effect of Daytime Versus Night-time on Outcome in Patients Undergoing Emergent Neurosurgical Procedures. J Neurosurg Anesthesiol 2019; 32:315-322. [DOI: 10.1097/ana.0000000000000600] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Hornor MA, Liu JY, Hu QL, Ko CY, Wick E, Maggard-Gibbons M. Surgical Technical Evidence Review for Acute Appendectomy Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. J Am Coll Surg 2018; 227:605-617.e2. [PMID: 30316962 DOI: 10.1016/j.jamcollsurg.2018.09.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Melissa A Hornor
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; American College of Surgeons, Chicago, IL.
| | - Jessica Y Liu
- American College of Surgeons, Chicago, IL; Department of Surgery, Emory University, Atlanta, GA
| | - Q Lina Hu
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Melinda Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
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