Interval laparoscopic appendectomy after antibiotic therapy for appendiceal abscess in elderly patients

Risk of appendiceal neoplasm in patients with appendix disorders

The most common appendicular disease is acute appendicitis, with a lifetime risk of 7%–8%. Complicated cases, which can occur in 2%–7% of patients, can significantly impact the severity of the condition and may require different management approaches. Nonoperative management with possible delayed appendectomy has been suggested for selected patients, however, there is a non-negligible risk of missing an underlying malignancy, which is reported to be as high as 11%. Diagnostic work-up is paramount to achieve optimal treatment with good results.

Development and validation of a new scoring system to discriminate between uncomplicated and complicated appendicitis

A scoring system to discriminate between uncomplicated and complicated appendicitis is beneficial to determine the optimal treatment for acute appendicitis. We developed a scoring system to discriminate between uncomplicated and complicated appendicitis and assessed the clinical usefulness of the scoring system using external validation. A total of 299 patients with acute appendicitis were retrospectively reviewed. One hundred and ninety-nine patients were assigned to the model development group, while the other 100 patients were assigned to an external validation group. A scoring system for complicated appendicitis was created using a final multivariate logistic regression model with six independent predictors. The area under the receiver operating characteristic curve of the scoring system was 0.882 (95% confidence interval: 0.835-0.929). The cutoff point of the scoring system was 12, and the sensitivity and specificity were 82.9% and 86.2%, respectively. In the external validation group, the area under the receiver operating characteristic curve of the scoring system was 0.868 (95% confidence interval 0.794-0.942), and there was no significant difference between the groups in the area under the receiver operating characteristic curve (P = 0.750). Our newly developed scoring system may contribute to prompt determination of the optimal treatment for acute appendicitis.

Development of a scoring model based on objective factors to predict gangrenous/perforated appendicitis

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.

The Impact of the Coronavirus Disease - 19 Pandemic on the Clinical Characteristics and Treatment of Adult Patients with Acute Appendicitis

Purpose

This study aimed to investigate the characteristics, severity, and treatment of adult patients with acute appendicitis in Korea over a 2-year period during the coronavirus disease (COVID-19) pandemic compared to those before the pandemic. We also investigated whether there were any changes in clinical characteristics of acute appendicitis before and after vaccination against the coronavirus.

Methods

We retrospectively reviewed the medical records of patients who were diagnosed with acute appendicitis at our institution between March 1, 2019, and August 31, 2021. We divided the patients into three groups (pre-pandemic, before vaccination, and after vaccination) and analyzed the clinical outcomes.

Results

The time from symptom onset to hospital arrival and the time from symptom onset to operation increased during the COVID-19 pandemic period compared to the pre-pandemic period. The rate of complicated appendicitis during the pandemic was higher than that before the pandemic. In addition, the number of new daily cases showed a positive correlation with the time from symptom onset to hospital arrival (OR, 0.03; 95% CI, 0.02 to 0.04; P < 0.001) and complicated appendicitis (OR, 1.002; 95% CI, 1.001–1.002; P = 0.0017). The vaccination rate showed a negative correlation with the time from symptom onset to hospital arrival (OR, −2.26; 95% CI, −3.42 to −1.11; P < 0.001) and complicated appendicitis (OR, 0.915; 95% CI, 0.84 to 0.996; P = 0.0404).

Conclusions

Employing hospital-wide efforts, such as screening by rapid PCR testing, to avoid further time delays, and nationwide efforts, such as vaccination, to shorten the time from symptom onset to hospital arrival, are necessary to maintain the quality of treatment of acute appendicitis during an infectious disease pandemic.

Comparison of Clinical Features and Outcomes of Appendectomy in Elderly vs. Non-Elderly: A Systematic Review and Meta-Analysis

Background

The objective of this study is to compare clinical and surgical outcomes of appendectomy among elderly and non-elderly subjects.

Methods

A systematic search was conducted on PubMed, Scopus, and Google academic databases. Studies, observational in design, that compared peri-and postoperative outcomes of appendectomy, in patients with acute appendicitis, between elderly and non-elderly/younger subjects were considered for inclusion. Statistical analysis was performed using STATA software.

Results

A total of 15 studies were included. Compared to non-elderly patients, those that were elderly had an increased risk of complicated appendicitis [relative risk (RR), 2.38; 95% CI: 2.13, 2.66], peritonitis [RR, 1.88; 95% CI: 1.36, 2.59], and conversion from laparoscopic to open appendectomy [RR, 3.02; 95% CI: 2.31, 3.95]. The risk of overall postoperative complications [RR, 2.59; 95% CI: 2.19, 3.06], intra-abdominal abscess [RR, 1.84; 95% CI: 1.15, 2.96], wound infection [RR, 3.80; 95% CI: 2.57, 5.61], and use of postoperative drainage [RR, 1.14; 95% CI: 1.09, 1.19] was higher among the elderly. The risk of readmission (30 days) [RR, 1.61; 95% CI: 1.16, 2.24] and mortality (30 days) [RR, 12.48; 95% CI: 3.65, 42.7] was also higher among elderly.

Conclusions

Findings suggest an increased risk of peri-and postoperative complications among elderly subjects undergoing appendectomy, compared to non-elderly subjects.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021286157.

Acute Appendicitis in the Elderly: A Literature Review on an Increasingly Frequent Surgical Problem

With increased life expectancy and the growing total population of elderly patients, there has been rise in the number of cases of acute appendicitis in elderly people. Although acute appendicitis is not the most typical pathological condition in the elderly, it is not uncommon. Most of these patients require surgical treatment, and as with any acute surgical pathology in advanced age, treatment possibilities are affected by comorbidities, overall health status, and an increased risk of complications. In this literature review we discuss differences in acute appendicitis in the elderly population, with a focus on clinical signs, diagnostics, pathogenesis, treatment, and results.