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Mangal R, Stead TG, Ganti L, Rosario J. Diagnosing Appendicitis in Pregnancy Via Ultrasonography. Cureus 2019; 11:e5562. [PMID: 31695982 PMCID: PMC6820664 DOI: 10.7759/cureus.5562] [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] [Indexed: 11/24/2022] Open
Abstract
The authors present a case of acute appendicitis during a first trimester pregnancy. Appendicitis in pregnancy is especially dangerous because perforation of the appendix increases the likelihood of maternal and fetal morbidity significantly. For this reason, it is important to diagnose and treat suspected appendicitis in pregnancy as soon as possible. The patient was diagnosed with appendicitis via a transabdominal ultrasound. She was provided antibiotics and underwent a laparoscopic appendectomy and recovered without complications.
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Affiliation(s)
- Rohan Mangal
- Emergency Medicine, Johns Hopkins University, Baltimore, USA
| | - Tej G Stead
- Emergency Medicine, Brown University, Providence, USA
| | - Latha Ganti
- Emergency Medicine, Envision Physician Services, Orlando, USA
| | - Javier Rosario
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
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Sekar H, Rajesh Thamaran N, Stoker D, Das S, Yoong W. Should the laparoscopic approach be the norm for appendicectomy in the third trimester of pregnancy? BMJ Case Rep 2019; 12:12/4/e228192. [PMID: 30954960 DOI: 10.1136/bcr-2018-228192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Our case describes a pregnant woman with acute appendicitis who presented in the third trimester and underwent a laparoscopic appendicectomy. She made a rapid postoperative recovery and the pregnancy was otherwise uncomplicated, ending with a spontaneous vaginal birth at 41 weeks. The diagnosis of acute appendicitis can be unclear in pregnancy. Difficulty in establishing diagnosis due to atypical presentation often leads to delay in surgery, resulting in significant maternal and fetal morbidity and mortality. Surgical intervention should be prompt in cases of suspected appendicitis and the laparoscopic approach is advocated in the first two trimesters. In the third trimester (after 28 weeks), laparotomy is often performed due to the size of the uterus and the theoretical risk of inadvertent perforation with trocar placement. More recently, several authors have described successful outcomes following laparoscopic appendicectomy after 28 weeks and with increasing reassuring data, we suggest that this minimally invasive approach should be considered in managing appendicitis in the third trimester.
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Affiliation(s)
- Hashviniya Sekar
- Obstetrics and Gynaecology, Royal Free London NHS Foundation Trust, London, UK
| | | | - David Stoker
- General Surgery, North Middlesex University Hospital NHS Trust, London, UK
| | - Sayantana Das
- Obstetrics and Gynaecology, Royal London Hospital, London, UK
| | - Wai Yoong
- Obstetrics and Gynaecology, North Middlesex University Hospital NHS Trust, London, UK
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Ball E, Waters N, Cooper N, Talati C, Mallick R, Rabas S, Mukherjee A, Sri Ranjan Y, Thaha M, Doodia R, Keedwell R, Madhra M, Kuruba N, Malhas R, Gaughan E, Tompsett K, Gibson H, Wright H, Gnanachandran C, Hookaway T, Baker C, Murali K, Jurkovic D, Amso N, Clark J, Thangaratinam S, Chalhoub T, Kaloo P, Saridogan E. Evidence-Based Guideline on Laparoscopy in Pregnancy: Commissioned by the British Society for Gynaecological Endoscopy (BSGE) Endorsed by the Royal College of Obstetricians & Gynaecologists (RCOG). Facts Views Vis Obgyn 2019; 11:5-25. [PMID: 31695854 PMCID: PMC6822954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Laparoscopy is widely utilised to diagnose and treat acute and chronic, gynaecological and general surgical conditions. It has only been in recent years that laparoscopy has become an acceptable surgical alternative to open surgery in pregnancy. To date there is little clinical guidance pertaining to laparoscopic surgery in pregnancy. This is why the BSGE commissioned this guideline. MEDLINE, EMBASE, CINAHL and the Cochrane library were searched up to February 2017 and evidence was collated and graded following the NICE-approved process. The conditions included in this guideline are laparoscopic management of acute appendicitis, acute gall bladder disease and symptomatic benign adnexal tumours in pregnancy. The intended audience for this guideline is obstetricians and gynaecologists in secondary and tertiary care, general surgeons and anaesthetists. However, only laparoscopists who have adequate laparoscopic skills and who perform complex laparoscopic surgery regularly should undertake laparoscopy in pregnant women, since much of the evidence stems from specialised centres.
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Affiliation(s)
| | - N Waters
- Royal Surrey County Hospital NHS Trust
| | | | | | - R Mallick
- Brighton and Sussex University Hospitals NHS Trust
| | - S Rabas
- Queen’s Hospital London and King George Hospital
| | | | | | | | | | | | | | - N Kuruba
- Norfolk and Norwich University Hospital
| | | | | | | | - H Gibson
- Barking, Havering and Redbridge University Hospitals NHS Trust
| | - H Wright
- North Manchester General Hospital
| | | | | | | | - K Murali
- Salisbury District and General Hospital
| | | | - N Amso
- Cardiff University School of Medicine
| | | | | | | | - P Kaloo
- Gloucestershire Hospitals NHS Foundation Trust
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Iwamura S, Hashida H, Yoh T, Kitano S, Mizumoto M, Kitamura K, Kondo M, Kobayashi H, Kaihara S, Hosotani R. Laparoscopic appendectomy during the third trimester: Case presentation and literature review. Asian J Endosc Surg 2018; 11:413-416. [PMID: 29314749 DOI: 10.1111/ases.12456] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 11/12/2017] [Accepted: 11/29/2017] [Indexed: 11/28/2022]
Abstract
Acute appendicitis is the most common general surgical problem encountered during pregnancy. Laparoscopic appendectomy (LA) is widely accepted as a minimally invasive procedure for acute appendicitis. However, LA during the third trimester is associated with problems, including technical difficulty, risk of preterm delivery, and fetal loss. We successfully managed three cases of LA during the third trimester between 2011 and 2016. None of the cases required conversion to an open procedure, and none of the patients had postoperative complications and/or fetal loss. We reviewed the literature using the PubMED database from 2007 to 2016 to acquire further evidence and identified 6 reports and 17 cases. The conversion rate was 11.8% (2 cases), the complication rate was 6.67% (1 case), and the preterm delivery rate was 20% (3 cases); no fetal loss was observed. Our study and literature review highlights the role of LA as a potentially feasible treatment approach for appendicitis during the third trimester.
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Affiliation(s)
- Sena Iwamura
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hiroki Hashida
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tomoaki Yoh
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shoichi Kitano
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Motoko Mizumoto
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Koji Kitamura
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Masato Kondo
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hiroyuki Kobayashi
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Satoshi Kaihara
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ryo Hosotani
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
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Abstract
Objectives This study aimed to determine the change in anatomical location of appendix in full-term pregnancy. Study design This was a descriptive cross-sectional study. Place and duration of study Liaquat National University Hospital, Karachi, Pakistan, Department of General Surgery, January 01 to July 31, 2010. Patients and methods Full-term pregnant women undergoing caesarean section were enrolled. The anatomical position of the appendix was noted by visual inspection with reference to the transtubercular plane (TTP). SPSS-10 was used for analysis. Results Seventy-seven full-term pregnant female patients who underwent caesarean section were included in the study. Their mean age was 29 years, the mean height was 5.3 feet, and mean gestational age was 38 weeks. Appendix was found at the normal anatomical location in 63 out of 77 patients (81.8%), while it was located above the TTP in 14 patients (18.2%). Conclusion Appendix does not migrate up with increasing gestational age in the majority of pregnant women. In most full-term pregnant female patients, appendix is located at the normal anatomical position.
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Affiliation(s)
- Aliya Ishaq
- Department of General Surgery, Liaquat National University Hospital, Karachi, Pakistan,
| | | | - Turab Pishori
- Department of General Surgery, Liaquat National University Hospital, Karachi, Pakistan,
| | - Rufina Soomro
- Department of General Surgery, Liaquat National University Hospital, Karachi, Pakistan,
| | - Shadab Khan
- Surgical Oncology Department, Shaukat Khanum Hospital, Lahore, Pakistan
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Tase A, Kamarizan MFA, Swarnkar K. Appendicitis in pregnancy: Difficulties in diagnosis and management. Guidance for the emergency general surgeon: A systematic review. INTERNATIONAL JOURNAL OF SURGERY OPEN 2017. [DOI: 10.1016/j.ijso.2017.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Franca Neto AHD, Amorim MMRD, Nóbrega BMSV. Acute appendicitis in pregnancy: literature review. Rev Assoc Med Bras (1992) 2016; 61:170-7. [PMID: 26107368 DOI: 10.1590/1806-9282.61.02.170] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 07/03/2014] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION suspected appendicitis is the most common indication for surgery in non-obstetric conditions during pregnancy and occurs in about one in 500 to one in 635 pregnancies per year. This occurs more often in the second trimester of pregnancy. Acute appendicitis is the most common general surgical problem encountered during pregnancy. METHODS a literature review on research of scientific articles, under the terms "acute appendicitis" and "pregnancy", in PubMed, Lilacs/SciELO, Scopus, Cochrane Library and Uptodate databases. RESULTS the clinical manifestations of appendicitis are similar to non-pregnant women, however, without a classic presentation, which often occurs, diagnosis is difficult and must be supported by imaging. DISCUSSION clinical diagnosis should be strongly suspected in pregnant women with classic findings such as abdominal pain that migrates to the right lower quadrant. The main purpose of imaging is to reduce delays in surgical intervention due to diagnostic uncertainty. A secondary objective is to reduce, but not eliminate, the negative appendectomy rate. Differential diagnosis of suspected acute appendicitis usually includes pathologies considered in non-pregnant people. CONCLUSION the imaging study of choice is ultrasound, MRI may be used when the former is not conclusive and, as a last resort, a CT scan can be performed. The treatment remains appendectomy by laparotomy, since the feasibility of video- assisted surgery in these cases remains controversial.
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Laparoscopic appendectomy and cholecystectomy versus open: a study in 1999 pregnant patients. Surg Endosc 2015; 30:593-602. [PMID: 26091987 DOI: 10.1007/s00464-015-4244-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 05/18/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND When pregnant patients require surgery, whether to perform an operation open or laparoscopic is often debated. We evaluated the impact of laparoscopy for common general surgical problems in pregnancy to determine safety and trends in operative approach over time. METHODS Pregnant patients undergoing appendectomy or cholecystectomy were identified using the National Surgical Quality Improvement Program (NSQIP) database. We analyzed demographics, operative characteristics, and outcomes. Univariate comparison and multivariate regression analysis (MVA) were performed adjusting for confounding factors: age, body mass index (BMI), diabetes, and smoking, and an additional MVA was performed for perforated cases. RESULTS A total of 1999 pregnant patients between 2005 and 2012 were evaluated. Of 1335 appendectomies, 894 were performed laparoscopically (LA) and 441 open (OA). For 664 cholecystectomies, 606 were laparoscopic (LC) and 58 open (OC). There were no deaths. For LA versus OA, patient characteristics were not different {age: 27.7 vs. 28.2 years, p = 0.19; diabetes: 1.8 vs. 0.9%, p = 0.24; smoking: 19 vs. 16.1%, p = 0.2} except for BMI (27.9 vs. 28.4 kg/m(2); p = 0.03). LA had shorter operative times (ORT), length of stay (LOS), and fewer postoperative complications compared to OA. In MVA, difference between approaches remained statistically significant for ORT (<0.0001), LOS (<0.01), and wound complications (<0.01). MVA was performed for perforated cases alone: LA had equal ORT (p = 0.19) yet shorter LOS (p = <0.001). The majority of LA were performed in the last 4 years versus the first 4 years (61 vs. 39%, p < 0.001). For LC versus OC, patient characteristics were not different: age (28.3 vs. 28.7 years; p = 0.33), BMI (31.4 vs. 33.2 kg/m(2), p = 0.25), diabetes (2.8 vs. 3.5%, p = 0.68), and smoking (21.1 vs. 25.9%, p = 0.4). LC had a shorter ORT, LOS, and fewer postoperative complications than OC. In MVA, the difference between approaches remained statistically significant for ORT (<0.0001), LOS (<0.0001), and minor complications (<0.01). In MVA for cholecystitis with perforation, no difference was seen for LOS, ORT, or postoperative complications (p > 0.05). The percentage of LC cases appeared to increase over time (89 vs. 93%, p = 0.06). CONCLUSION While fetal events are unknown, LA and LC in pregnant patients demonstrated shorter ORT, LOS, and reduced complications and were performed more frequently over time. Even in perforated cases, laparoscopy appears safe in pregnant patients.
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Walker HGM, Al Samaraee A, Mills SJ, Kalbassi MR. Laparoscopic appendicectomy in pregnancy: a systematic review of the published evidence. Int J Surg 2014; 12:1235-41. [PMID: 25219891 DOI: 10.1016/j.ijsu.2014.08.406] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Revised: 08/08/2014] [Accepted: 08/27/2014] [Indexed: 01/12/2023]
Abstract
UNLABELLED Surgical intervention for acute appendicitis during pregnancy carries significant risk to both mother and foetus. The safety of Laparoscopic Appendicectomy in pregnancy has been a matter of debate among clinicians. We have critically reviewed the available published evidence in regards with this debate. CONCLUSION There is no strong current evidence as to the preferred modality of appendicectomy; open or laparoscopic, during pregnancy from the prospect of foetal or maternal safety. However, low grade evidence shows that laparoscopic appendicectomy during pregnancy might be associated with higher rates of foetal loss.
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Affiliation(s)
- Humphrey G M Walker
- Department of General Surgery, Wansbeck General Hospital, Ashington NE63 9JJ, UK
| | - Ahmad Al Samaraee
- Department of General Surgery, Wansbeck General Hospital, Ashington NE63 9JJ, UK.
| | - Sarah J Mills
- Department of General Surgery, Wansbeck General Hospital, Ashington NE63 9JJ, UK
| | - M Reza Kalbassi
- Department of General Surgery, Wansbeck General Hospital, Ashington NE63 9JJ, UK
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Reporting of Complications. Patient Saf Surg 2014. [DOI: 10.1007/978-1-4471-4369-7_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Abstract
We report a case of neuronal hypertrophy associated with acute appendicitis in which significant neuronal fibers and the number of ganglion cells increased in the absence of inflammatory cells. Differential diagnosis from diffuse ganglioneuromatosis by the pathologic findings of resected specimen was difficult. A 33-year-old Japanese female visited our hospital complaining of acute abdominal pain. The patient underwent appendectomy upon the diagnosis of acute appendicitis on the day of admission. Postoperative examinations found no neoplastic lesions in other organs or inherited disorders such as multiple endocrine neoplasia (MEN) type 2b and von Recklinghausen's disease (VRD). The pathologic diagnosis was neuronal hypertrophy of the appendix. Because the clinical outcomes of diffuse ganglioneuromatosis and neuronal hypertrophy of the gastrointestinal tract are quite different, clinical and pathologic examination should be carefully carried out for lesions in which significant proliferation of neuronal components is seen.
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