Meta-analysis of studies comparing conservative treatment with antibiotics and appendectomy for acute appendicitis in the adult

Indication of conservative treatment by antibiotics for uncomplicated and complicated acute appendicitis

BACKGROUND

Acute appendicitis is one of the most common emergency abdominal disease, and recent studies have evaluated conservative treatment using antibiotics for uncomplicated appendicitis. Although the efficacy of conservative treatment for uncomplicated appendicitis is known, its efficacy for complicated appendicitis remains unknown, so are risk factors for the conservative treatment of appendicitis. In our institution, conservative treatment has long been the first choice for most appendicitis cases, except for perforation. Therefore, this novel study investigated the outcomes of conservative treatment for uncomplicated and complicated acute appendicitis and the risk factors associated with conservative treatment.

AIM

To investigate the indication of conservative treatment by antibiotics for uncomplicated and complicated acute appendicitis.

METHODS

We investigated 270 patients who received conservative treatment for acute appendicitis at the Nishitokyo Central General Hospital, between April 2011 and February 2022. Twenty-eight (10.3%) patients were resistant to conservative treatment and underwent surgery. We retrospectively investigated the outcomes of conservative treatment for appendicitis and the risk factors for resistance to conservative treatment using the receiver operating characteristic curves and Cox hazard model.

RESULTS

Two hundred and forty-two (89.7%) patients improved with conservative treatment. The significant and independent predictors of resistance to conservative treatment were body temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid visible on computed tomography (CT). The rate of resistance to conservative treatment was 66.7% (6/9) for patients with the above three factors, 22.9% (8/35) for patients with two factors (appendicolith and body temperature ≥ 37.3 °C), 16.7% (2/12) for patients with two factors (Douglas sinus fluid and appendicolith) and 11.1% (1/9) for patients with two factors (Douglas sinus fluid and body temperature ≥ 37.3 °C).

CONCLUSION

A temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid on CT might be clinical risk factors of resistance to conservative treatment for acute appendicitis.

Predictive factors for recurrent acute appendicitis after conservative treatment

INTRODUCTION

Conservative treatment of acute appendicitis is gaining popularity, and identifying patients with a higher risk of recurrence is becoming increasingly important. Previous studies have suggested that older age, male sex, diabetes, appendicolith and abscess formation may be contributing factors, however, results from the adult population are inconsistent.

AIM

This study aims to identify predictive factors for recurrent appendicitis after conservative treatment.

METHODS

This retrospective study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and follow-up data were retrieved from medical charts and radiologic images. Uni -and multivariable logistic regression analysis were performed using Stata Statistical Software.

RESULTS

In total, 379 patients with conservatively treated acute appendicitis were identified, of which 78 (20.6%) had recurrence. All patients were followed-up for a minimum of 41 months after the first diagnosis of acute appendicitis unless appendectomy after successful conservative treatment or death occurred during follow-up. The median time to recurrence was 6.5 (1-17.8) months. After multivariable logistic regression analysis, external appendix diameter >10 mm [OR 2.4 (CI 1.37-4.21), p = .002] and intra-abdominal abscess [OR 2.05 (CI 1.18-3.56), p = .011] on computed tomography were significant independent risk factors for recurrent appendicitis. Appendicolith was not associated with an increased risk of recurrence.

CONCLUSION

This study suggests abscess formation and appendix distension of >10 mm to be potential risk factors for recurrent acute appendicitis after initial successful conservative treatment.

Endoscopic retrograde appendicitis therapy: current and the future

This article presents an overview of endoscopic retrograde appendicitis therapy (ERAT), an innovative and minimally invasive treatment for appendicitis with an appendix-preserving manner. Since its initial application in 2009, ERAT has gained significant popularity in China, due to its rapid recovery and minimal risk of complications. The ERAT procedures comprise several steps, including appendiceal orifice access and intubation, appendiceal lumen imaging, decompression and irrigation, fecalith removal, and stenting. ERAT has been used in various forms of complicated appendicitis, such as in pregnant women and children, with continuous improvements in both technique and safety. It has the potential to become the preferred diagnostic and treatment method for appendicitis. Until 2023, over 10,000 ERAT procedures have been successfully conducted in China, and the technique has gained more attention worldwide. However, challenges remain, including training, standardization of ERAT practice, research and technology improvement, enhancing public awareness, and fostering international collaboration. In summary, ERAT can be the standard treatment for appendicitis treatment, which represents a paradigm shift in the conventional clinical practice.

Retrospective analysis of the incidence of appendiceal neoplasm and malignancy in patients treated for suspected acute appendicitis

BACKGROUND

Nonoperative management of uncomplicated appendicitis is currently being promoted as treatment option, albeit 0.7-2.5% of appendectomies performed due to suspected acute appendicitis show histologically malignant findings. The purpose of this study was to investigate the incidence of neoplasm and malignancy of the appendix in patients presenting with suspected acute appendicitis in real world setting.

METHODS

This is a retrospective single-centre investigation of 457 patients undergoing appendectomy between the years 2017-2020. The patients' demographics, symptoms and diagnosis, intraoperative findings, and histopathological results were analysed.

RESULTS

In 3.7% (n = 17) histological analysis revealed neoplasms or malignancies. Median age was 48 years (20-90 years), without sex predominance. Leukocytes (11.3 ± 3.7 G/l) and C-reactive protein (54.2 ± 69.0 mg/l) were elevated. Histological analysis revealed low-grade mucinous appendiceal neoplasia (n = 3), sessile serrated adenoma of the appendix (n = 3), neuroendocrine tumours (n = 7), appendiceal adenocarcinoma of intestinal type (n = 3), and goblet cell carcinoma (n = 1). Additional treatment varied between no treatment or follow-up due to early tumour stage (n = 4), follow-up care (n = 3), additional surgical treatment (n = 8), or best supportive care (n = 2).

CONCLUSIONS

Preoperative diagnosis of appendiceal tumours is difficult. Nonoperative management of patients with acute, uncomplicated appendicitis potentially prevents the correct diagnosis of malignant appendiceal pathologies. Therefore, close follow-up or surgical removal of the appendix is mandatory.

Intraoperative bacterial cultures fail to reliably predict the bacterial spectrum encountered during infectious complications after appendicitis

Acute appendicitis is a common surgical emergency. Complicated appendicitis usually warrants perioperative antibiotic treatment in order to prevent infectious complications. Whether routine microbiological testing benefits the individual patient is a topic of debate. The goal of our study was to assess perioperative antibiotic prescriptions as well as the benefit of microbiological testing during the appendectomy as a predictor for bacteria encountered in infectious complications. This is a retrospective analysis of 1218 consecutive patients that underwent appendectomy at a tertiary referral center between 2014 and 2021. The patient charts were systematically analyzed regarding intraoperative outcome, microbiologic results, and postoperative infectious complications. 1218 patients were included in this study of which 768 were uncomplicated appendicitis (UA) and 450 were complicated appendicitis (CA). Microbiological testing was performed in 39.2% of UA cases (33.6% of which grew bacteria) compared to 74.9% of CA cases (78.6% positive cultures). The strongest individual predictors for SSI were gangrenous and perforated appendicitis. A total of 58 surgical-site infections developed, of which 49 were intra-abdominal fluid collections or abscesses. Thirty-two patients had revision surgery or CT-guided drainage for SSI. In the cases where microbiological testing was done both during the appendectomy and the SSI, 13/18 showed different bacteria on culture testing. The infectious outcome was favorable in 98.3%. While microbiological testing offers insights into resistance patterns, it is of little benefit for the individual patient, given the low predictive value for bacteria found during SSI. Achieving source control combined with empiric antibiotic coverage leads to favorable outcomes independent of culture results.

Conservative Versus Surgical Management of Acute Appendicitis: A Systematic Review

Recent studies have discussed the role of antibiotic treatment in the conservative management of acute appendicitis and whether antibiotics are a safe option to replace appendicectomy, which has been the gold standard treatment of acute appendicitis for many years. The bibliographic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, Medline, and PubMed comparing conservative versus surgical treatment of acute appendicitis were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty-one studies consisting of systematic reviews and meta-analyses involving 44,699 participants were identified. At least 17,865 participants were treated with antibiotics. Our studies compare antibiotic versus appendicectomy among acute appendicitis patients ranging from 7 to 94 years of age. In most studies, patients received parenteral antibiotics for a total of one to three days, and oral antibiotics such as oral cephalosporin plus metronidazole, oral amoxicillin/clavulanate, oral fluoroquinolones plus Tinidazole upon hospital discharge for a total of 7 to 10 days. The total course of antibiotics for both parenteral and oral regimes ranged from 2 to 16 days, with 10 days being the commonest duration. The recurrence rate following initial antibiotic treatment at one-year follow-up ranged from 13% to 38%, while the mean duration of recurrence ranged from three to eight months. The majority of the patients with recurrence underwent appendicectomy, while some patients were either given a repeat or different course of antibiotics due to the possible presence of antibiotic resistance; however, only 2.4% of the patients were successfully treated upon completion of the second course of antibiotics. Most of the studies concluded that appendicectomy remains the gold standard treatment for uncomplicated acute appendicitis, given its higher efficacy and lower complication rates. Although antibiotic treatment cannot be routinely recommended, it can be considered an appropriate alternative in selected patients with uncomplicated appendicitis who wish to avoid surgery and also acknowledge the risk of recurrence and the potential need for subsequent surgery at the same time.

Risk of appendiceal malignancy in conservatively treated acute appendicitis

BACKGROUND AND AIMS

Appendectomy has historically been the standard treatment of acute appendicitis, but lately, conservative treatment of uncomplicated acute appendicitis with antibiotics has successfully been used in selected patients. Complicated acute appendicitis is often treated conservatively initially, but may benefit from interval appendectomy due to the higher risk of appendiceal malignancy and recurrence. Recommendations for follow-up after conservatively treated appendicitis vary. Furthermore, the risk of underlying malignancy and the necessity of routine interval appendectomy are unclear. This study aims to evaluate follow-up status, recurrence, and underlying appendiceal malignancy in conservatively treated uncomplicated and complicated acute appendicitis.

METHODS

This study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and data on follow-up, recurrence, number of appendectomies after initial conservative treatment, and underlying malignancy were retrieved from medical charts.

RESULTS

The study cohort included 391 patients, 152 with uncomplicated and 239 with complicated acute appendicitis. Median time of study follow-up was 52 months. The recurrence risk was 23 (15.1%) after uncomplicated and 58 (24.3%) after complicated acute appendicitis (p = 0.030). During follow-up, 55 (23%) patients with complicated acute appendicitis underwent appendectomy. Appendiceal malignancies were found in 12 (5%) patients with previous complicated acute appendicitis versus no appendiceal malignancies after uncomplicated acute appendicitis (p = 0.002).

CONCLUSION

The risk of appendiceal malignancy and recurrent appendicitis was significantly higher in patients with complicated acute appendicitis compared with uncomplicated acute appendicitis.

Risks Associated with Surgical Treatment for Appendicitis in Hematologic Patients

Appendicitis is a prevalent surgical emergency. Although appendectomy has traditionally been the go-to treatment, recent studies suggest antibiotics can be equally effective for uncomplicated cases. However, evidence is scant regarding patients with hematologic disorders. This study delves into the surgical risks tied to appendicitis in patients with underlying hematologic conditions. A retrospective analysis was carried out on patients diagnosed with appendicitis and hematologic disorders from January 2000 to June 2021. Patients were pinpointed using ICD-10 diagnostic codes, and surgical procedures were identified based on the hospital's surgical fee codes. Hematologic conditions were sorted into risk levels, and patient treatments were scrutinized. Among the 131 initially identified patients, 89 were included in the study. Out of these, 75 underwent surgical procedures, while 14 received non-surgical treatments. The surgical group displayed better preoperative laboratory outcomes. Clinical characteristics, hematologic disease risk, and severity of appendicitis appeared not to be related to surgical complications. Patients without surgical complications showed improvement in preoperative absolute neutrophil count (ANC) and platelet counts. Lower preoperative ANCs and platelet counts were associated with extended hospital stays. For patients with hematologic disorders diagnosed with appendicitis, thorough preoperative laboratory evaluations followed by minimally invasive appendectomy appear to be a safe route without heightening the risk of severe complications compared to non-surgical management.

Are Antibiotics the New Appendectomy?

Prior to the development of laparoscopic procedures, open appendectomy was the standard of care for the majority of appendicitis cases. Recently, studies have debated using antibiotics as a first-line treatment in uncomplicated appendicitis cases. The definition of uncomplicated appendicitis is not always clear-cut; however, with the large-scale accessibility of radiologic techniques, it is becoming increasingly easier to classify patient groups. As suggested by clinical and radiological patient data, this has raised the speculation of considering antibiotic therapy as the sole treatment modality in uncomplicated appendicitis cases. We aim to compare the options of surgery and antibiotics only in terms of efficacy, complications, and financial cost. A range of databases and search strategies were adopted, and various databases were used, including PubMed, ScienceDirect, Google Scholar, and JAMA. Collectively, 30 studies were reviewed, but only 18 were included. Efficacy rates were higher in the appendectomy group. Nevertheless, the antibiotics-only group maintained an efficacy rate greater than 70% at one-year follow-up. Risk factors that decreased the efficacy in medical management included the presence of appendicolith, neoplasm, appendiceal dilatation, peri-appendiceal fluid collection, higher mean temperature, CRP, and bilirubin. Complications were more frequent and significant in the surgery group. These included complications related to anaesthesia, surgical site infections, damage to nearby structures, and pulmonary embolism. Despite several years of follow-up and disease recurrences, higher financial costs were observed in surgically treated patients compared to the antibiotics-only group. Given the high success rates post-appendectomy for acute appendicitis over the decades, the efficacy of conservatively treated acute appendicitis raises a strong argument when choosing one of the two options. The efficacy remained consistently higher across the literature in the surgery group than in the antibiotics-only group. However, it is still arguable that antibiotics may be a preferable option given an efficacy rate of more than 70% at one year and overall higher complications associated with surgery. The argument of missing a neoplasm by avoiding surgery is valid. However, most are carcinoid neuroendocrine neoplasms with a low probability of metastasis (<5%) and are usually considered benign. Given the current practice focused on conservative and minimally invasive treatments and recently the COVID-19 pandemic, with its restrictions and lessons learnt, antibiotics may be the future standard for treating uncomplicated acute appendicitis. Lastly, we noticed higher efficacy rates in articles published recently than those published at least five to ten years earlier. Antibiotics-only therapy for uncomplicated appendicitis is cost-effective with fewer complications than surgery. However, appendectomies have higher efficacy. Thus, surgical treatment prevails as the standard of care. Future literature should yield larger sample sizes and explore the numbers of emergency appendectomies mandated following antibiotics-only therapy.

Comparison of the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to compare the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis.

METHODS

We searched the randomized controlled studies (RCTs) comparing appendectomy with antibiotic treatment for uncomplicated acute appendicitis in the electronic database including Pubmed, Embase, Cochrane, Web of Science, CNKI, VIP, and WanFang. The primary outcomes included complication-free treatment success at 1 year, complications, surgical complications, and the complicated appendicitis rates. Secondary outcomes included negative appendicitis, length of hospital stay, the quality of life at 1 month, and the impact of an appendicolith on antibiotic therapy.

RESULTS

Twelve randomized controlled studies were included. Compared with surgery group, the antibiotic group decreased the complication-free treatment success at 1 year (RR 0.81; 95% CI 0.73-0.91; z = 3.65; p = 0.000). Statistically significance was existed between antibiotic group and surgical group with both surgical types(open and laparoscopic) (RR 0.43; 95% CI 0.31-0.58; z = 5.36; p = 0.000), while no between the antibiotic treatment and laparoscopic surgery (RR 0.72; 95% CI 0.41-1.24; z = 1.19; p = 0.236). There was no statistically significant differences between two groups of surgical complications (RR 1.38; 95% CI 0.70-2.73; z = 0.93; p = 0.353), the complicated appendicitis rate (RR 0.71; 95% CI 0.36-1.42; z = 0.96; p = 0.338), negative appendectomy rate (RR 1.11; 95% CI 0.69-1.79; z = 0.43; p = 0.670), duration of hospital stay (SMD 0.08; 95%CI -0.11-0.27; z = 0.80; p = 0.422), and quality of life at 1 month (SMD 0.09; 95%CI -0.03-0.20; z = 1.53; p = 0.127). However, in the antibiotic treatment group, appendicolith rates were statistically higher in those whose symptoms did not improve (RR 2.94; 95% CI 1.28-6.74; z = 2.55; p = 0.011).

CONCLUSIONS

Although the cure rate of antibiotics is lower than surgery, antibiotic treatment is still a reasonable option for patients with uncomplicated acute appendicitis who do not want surgery without having to worry about complications or complicating the original illness.

Outcomes of Nonoperative vs Operative Management of Acute Appendicitis in Older Adults in the US

Importance

Although the incidence of acute appendicitis among adults 65 years and older is high, these patients are underrepresented in randomized clinical trials comparing nonoperative vs operative management of appendicitis; it is unclear whether current trial data can be used to guide treatment in older adults.

Objective

To compare outcomes following nonoperative vs operative management of appendicitis in older adults and assess whether they differ from results in younger patients.

Design, Setting, and Participants

This retrospective cohort study used US hospital admissions data from the Agency for Healthcare Research and Quality's National Inpatient Sample from 2004 to 2017. Of 723 889 adult patients with acute uncomplicated appendicitis, 474 845 with known procedure date who survived 24 hours postprocedure and did not have inflammatory bowel disease were included (43 846 who were treated nonoperatively and 430 999 with appendectomy) were included. Data were analyzed from October 2021 to April 2022.

Exposures

Nonoperative vs operative management.

Main Outcomes and Measures

The primary outcome was incidence of posttreatment complications. Secondary outcomes included mortality, length of stay, and inpatient costs. Differences were estimated using inverse probability weighting of the propensity score with sensitivity analysis to quantify effects of unmeasured confounding.

Results

The median (IQR) age in the overall cohort was 39 (27-54) years, and 29 948 participants (51.3%) were female. In patients 65 years and older, nonoperative management was associated with a 3.72% decrease in risk of complications (95% CI, 2.99-4.46) and a 1.82% increase in mortality (95% CI, 1.49-2.15) along with increased length of hospitalization and costs. Outcomes in patients younger than 65 years were significantly different than in older adults, with only minor differences between nonoperative and operative management with respect to morbidity and mortality, and smaller differences in length of hospitalization and costs. Morbidity and mortality results were somewhat sensitive to bias from unmeasured confounding.

Conclusions and Relevance

Nonoperative management was associated with reduced complications in older but not younger patients; however, operative management was associated with reduced mortality, hospital length of stay, and overall costs across all age groups. The different outcomes of nonoperative vs operative management of appendicitis in older and younger adults highlights the need for a randomized clinical trial to determine the best approach for managing appendicitis in older patients.

Varying negative appendectomy rates after laparoscopic appendectomy: a systematic review and meta-analysis

PURPOSE

Appendicitis is a common cause of acute abdominal pain, and treatment with laparoscopy has become increasingly common during the past two decades. Guidelines recommend that normal appendices are removed if operated for suspected acute appendicitis. It is unclear how many patients are affected by this recommendation. The aim of this study was to estimate the rate of negative appendectomies in patients undergoing laparoscopic surgery for suspected acute appendicitis.

METHODS

This study was reported following the PRISMA 2020 statement. A systematic search was conducted in PubMed and Embase for retrospective or prospective cohort studies (with n ≥ 100) including patients with suspected acute appendicitis. The primary outcome was the histopathologically confirmed negative appendectomy rate after a laparoscopic approach with a 95% confidence interval (CI). We performed subgroup analyses on geographical region, age, sex, and use of preoperative imaging or scoring systems. The risk of bias was assessed using the Newcastle-Ottawa Scale. Certainty of the evidence was assessed using GRADE.

RESULTS

In total, 74 studies were identified, summing up to 76,688 patients. The negative appendectomy rate varied from 0% to 46% in the included studies (interquartile range 4-20%). The meta-analysis estimated the negative appendectomy rate to be 13% (95% CI 12-14%) with large variations between the individual studies. Sensitivity analyses did not change the estimate. The certainty of evidence by GRADE was moderate due to inconsistency in point estimates.

CONCLUSION

The overall estimated negative appendectomy rate after laparoscopic surgery was 13% with moderate certainty of evidence. The negative appendectomy rate varied greatly between studies.

The efficacy of hemoglobin, albumin, lymphocytes, and platelets (HALP) score in signifying acute appendicitis severity and postoperative outcomes

The HALP score, which is a combined index composed of hemoglobin, albumin, lymphocyte, and platelet, is a new indicator showing both inflammation and nutritional status. This study aims to evaluate the relationship of this combined index consisting of simple laboratory values with the degree of appendicitis complication and postoperative results in patients operated on for acute appendicitis. The data of 684 patients operated for acute appendicitis between January 2017 and December 2022 and inclusion criteria were analyzed with a single-center retrospective cross-sectional study design. Using routine laboratory data, patients' HALP scores were divided into two groups as low and high. The cut-off value of the HALP score according to the presence of postoperative complications was determined as < 31.2 by ROC analysis and the ROC curve. Patients were grouped as HALP score cut-off value below (group 1) and above (group 2). Complicated appendicitis and postoperative outcomes were compared to the HALP score groups. According to the cut-off value of the HALP score, 113 (16.5%) of the patients were in Group 1, and 571 (83.5%) were in Group 2. Complications developed in 15 (26%) patients (p < 0.001). Low HALP scores were a significant risk factor for peri-appendicular abscess (OR 29.12 95% CI 12.39-68.43), appendicitis perforation (OR = 20.82 95% 12.67-34.19), gangrenous appendicitis (OR = 35, 54, 95% 13.33-94.77), and postoperative complications (OR = 15.29 95% 7.95-29.41) (p < 0.001). Besides clinical and radiological findings, the HALP score shows the degree of acute appendicitis complication. It can be used as a simple, inexpensive, and easily applicable diagnostic tool.

Age-related disparities and trends in national healthcare spending for management of appendicitis in the United States: A retrospective cost-analysis

BACKGROUND

Changes in clinical care for appendicitis have impacted healthcare use associated with treatment. We evaluated national trends and assessed factors associated with healthcare costs for appendicitis in the United States.

DESIGN

The Disease Expenditure Project, the Global Burden of Disease study, and the National Inpatient Sample were used to estimate total national expenditures, per-capita costs for incident cases, and factors associated with inpatient costs for appendicitis management, respectively. The national estimates of appendicitis costs were obtained from 1996 to 2016. Appendicitis incidence was estimated to calculate per-capita costs. After application of survey weights for the stratified sample design, 191,180 weighted discharges for appendicitis from the 2016 National Inpatient Sample study were evaluated. The Disease Expenditure Project and the Global Burden of Disease study were used to estimate total and per-capita spending. Temporal trends were evaluated using joinpoint regression, expressed as annual percent change. Multivariable linear regression was used to evaluate patient factors associated with total hospital charges.

RESULTS

In 2016, total spending on appendicitis was $9.3 billion (95% confidence interval: $8.0-$10.8], a 2-fold increase from $4.7 billion ($4.0-$5.3) in 1996. Per-capita spending decreased significantly after 2011 (annual percent change -3.7% [-4.4% to -2.9%]). Patients ≥65 years accounted for 64.1% (61.1%-67.3%) of total spending for appendicitis. The hospital charges for older patients were significantly higher among those undergoing appendectomy.

CONCLUSION

Overall healthcare spending for appendicitis has doubled from 1996 to 2016, but per capita spending has decreased since 2011, driven by improved efficiency of inpatient care. Nearly two-thirds of spending is on patients ≥65 years, with significantly higher costs associated with surgical management in this population.

Prediction of Perforated and Nonperforated Acute Appendicitis Using Machine Learning-Based Explainable Artificial Intelligence

Background: The primary aim of this study was to create a machine learning (ML) model that can predict perforated and nonperforated acute appendicitis (AAp) with high accuracy and to demonstrate the clinical interpretability of the model with explainable artificial intelligence (XAI). Method: A total of 1797 patients who underwent appendectomy with a preliminary diagnosis of AAp between May 2009 and March 2022 were included in the study. Considering the histopathological examination, the patients were divided into two groups as AAp (n = 1465) and non-AAp (NA; n = 332); the non-AAp group is also referred to as negative appendectomy. Subsequently, patients confirmed to have AAp were divided into two subgroups: nonperforated (n = 1161) and perforated AAp (n = 304). The missing values in the data set were assigned using the Random Forest method. The Boruta variable selection method was used to identify the most important variables associated with AAp and perforated AAp. The class imbalance problem in the data set was resolved by the SMOTE method. The CatBoost model was used to classify AAp and non-AAp patients and perforated and nonperforated AAp patients. The performance of the model in the holdout test set was evaluated with accuracy, F1- score, sensitivity, specificity, and area under the receiver operator curve (AUC). The SHAP method, which is one of the XAI methods, was used to interpret the model results. Results: The CatBoost model could distinguish AAp patients from non-AAp individuals with an accuracy of 88.2% (85.6–90.8%), while distinguishing perforated AAp patients from nonperforated AAp individuals with an accuracy of 92% (89.6–94.5%). According to the results of the SHAP method applied to the CatBoost model, it was observed that high total bilirubin, WBC, Netrophil, WLR, NLR, CRP, and WNR values, and low PNR, PDW, and MCV values increased the prediction of AAp biochemically. On the other hand, high CRP, Age, Total Bilirubin, PLT, RDW, WBC, MCV, WLR, NLR, and Neutrophil values, and low Lymphocyte, PDW, MPV, and PNR values were observed to increase the prediction of perforated AAp. Conclusion: For the first time in the literature, a new approach combining ML and XAI methods was tried to predict AAp and perforated AAp, and both clinical conditions were predicted with high accuracy. This new approach proved successful in showing how well which demographic and biochemical parameters could explain the current clinical situation in predicting AAp and perforated AAp.

Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study

INTRODUCTION

Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications.

MATERIAL AND METHODS

We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy (ClinicalTrials.gov Registration: NCT04365491). We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. Outcome measures of interest were the incidence of complications, unplanned reoperation, readmission, admission to the ICU, death, hospital length of stay, and procedure duration. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs).

RESULTS

Three-thousand seven hundred sixty-eight consecutive adult patients, included from 71 centers in 14 countries, were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1379(37.0%), with a stapler in 1421(38.1%) and between clips in 929(24.9%). The technique for securely dividing the appendix at its base in acutely inflamed (AAST Grade 1) appendicitis was equally divided between division between looped ligatures, clips and stapled transection. However, the technique used differed in complicated appendicitis (AAST Grade 2 +) compared with uncomplicated (Grade 1), with a shift toward transection of the appendix base by stapler (58% vs. 38%; p < 0.001). While no statistical difference in outcomes could be detected between different techniques for division of appendix base, decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41-0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11-0.96), p = 0.045] complications could be detected when using energy devices.

CONCLUSIONS

Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Technique selection for both mesoappendix transection and appendix resection correlates with AAST grade. Higher grade led to more ultrasonic tissue transection and stapled appendix resection. Higher AAST appendicitis grade also correlated with infection-related complication occurrence. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intraoperative surgical technique toward advanced adjuncts.

The role of imaging in the diagnosis of acute appendicitis during the COVID-19 pandemic: a retrospective cohort study

Acute appendicitis is one of the most common general surgical emergencies worldwide; however, its diagnosis remains challenging, with a high proportion of negative appendicectomies. The purpose of this study was to investigate the benefit of routine use of pre-operative imaging for the evaluation of suspected appendicitis. This retrospective cohort study included all cases of appendicectomies performed for suspected acute appendicitis during the first and second peaks of the COVID-19 pandemic, between March 2020 and February 2021. The control group included all cases of appendicectomies performed for suspected acute appendicitis in the previous 12 months (March 2019-February 2020). One hundred and four patients underwent appendicectomy in the study group, compared to 209 in the control group, with similar gender distribution but a significantly higher median age in the study group (33 vs. 28, p = 0.001). The two groups had similar rates of perforation and similar median white cell count (WCC) and CRP. Imaging was used in 80.77% of the patients in the study group, compared to 61.72% in the control group (p = 0.001), with 55.77% of patients in the study group undergoing CT scans. Despite this, the negative appendicectomy rate (NAR) in the two groups did not differ significantly (11.54% vs. 15.79%, p = 0.320). The increase in the use of imaging for the diagnosis of acute appendicitis during the COVID-19 pandemic did not lead to a significantly lower negative appendicectomy rate. Registration: The study was pre-registered at ClinicalTrials.gov (NCT05205681).

Conservative antibiotic treatment of pediatric acute uncomplicated appendicitis during the COVID-19 pandemic: a prospective comparative cohort study

BACKGROUND

Our study aimed to compare the clinical outcomes and cost-efficiency of antibiotic management versus laparoscopic appendectomy for acute uncomplicated appendicitis (AUA) in children during the COVID-19 pandemic when resources were limited and transmission risks uncertain.

METHOD

In this prospective comparative cohort study, we analyzed the data of 139 children diagnosed with AUA meeting the following inclusion criteria: 5-18 years of age, symptoms duration of ≤ 48 h, appendix diameter ≤ 11 mm and no appendicolith. Treatment outcomes between non-operative management group (78/139) and upfront laparoscopic appendectomy group (61/139) were compared. Antibiotic regimes were intravenous ceftriaxone/metronidazole or amoxicillin/clavulanic acid for 48 h, followed by oral antibiotics to complete total 10-days course.

RESULTS

8/78 (10.3%) children had early failure (within 48 h) requiring appendectomy. 17/70 (24.3%) patients experienced late recurrence within mean follow-up time of 16.2 ± 4.7 months. There were no statistical differences in peri-operative complications, negative appendicectomy rate, and incidence of perforation and hospitalization duration between antibiotic and surgical treatment groups. Cost per patient in upfront surgical group was significantly higher ($6208.5 ± 5284.0) than antibiotic group ($3588.6 ± 3829.8; p = 0.001).

CONCLUSION

Despite 24.3% risk of recurrence of appendicitis in 16.2 ± 4.7 months, antibiotic therapy for AUA appears to be a safe and cost-effective alternative to upfront appendectomy.

The Efficacy of Conservative Management in Uncomplicated Acute Appendicitis - A Single-Center Retrospective Study

Background Acute appendicitis remains the most common cause of lower abdominal pain leading to emergency visits. Even though the standard treatment of acute appendicitis remains appendectomy, in recent times, multiple randomized control trials and meta-analyses have deduced conservative treatment as a successful alternative treatment. During the coronavirus disease (COVID) pandemic, with a shortage of staff and resources, treatment with conservative management of uncomplicated acute appendicitis became very beneficial under certain circumstances and conditions. This study aimed to assess whether it is effective to manage patients with uncomplicated acute appendicitis with antibiotic therapy. Methodology This was a single hospital based retrospective, cross-sectional study from Jan 2015 to May 2020. Patients with clinical and radiological features of uncomplicated acute appendicitis with Alvarado's score >6 were included in the study. Patients were kept on antibiotics, intravenous fluids, and analgesia as part of a conservative regime. Those who failed to respond to conservative therapy were managed surgically. The follow-up period was six months. Results One hundred eighty-two cases of uncomplicated acute appendicitis were included and managed conservatively, of which 52.2% were males while 47.8% were females. The median age of the patients was 26 years. Conservative treatment was successful in 26.2% of the patients, with a recurrence of 5.5% in the six-month follow-up period. The mean number of days of hospital stay was three days in patients treated with conservative or surgical treatment. Conclusion Conservative management is gaining popularity, and many centers are inclined towards non-operative management; however, appendectomy remains the gold standard treatment for appendicitis.

The Impact of the COVID-19 Pandemic on the Incidence, Severity, and Management of Acute Appendicitis: A Single Center Experience in Thailand

PURPOSE

For more than two years since the COVID-19 pandemic, human lives have changed, including the healthcare system. Management of acute appendicitis, the most common emergency surgical disease, has been inevitably affected. This study aimed to assess the effect of the COVID-19 pandemic on the incident rate of complicated appendicitis, management, outcome, and complication of acute appendicitis. Patients and Methods. This study was a retrospective cohort study comparing 574 patients diagnosed with acute appendicitis before the COVID-19 outbreak and 434 patients diagnosed with acute appendicitis during the COVID-19 outbreak. Patient demographic data, type of appendicitis, type of treatment, time to surgery, length of stay, cost, and complications were collected and analyzed.

RESULTS

During the COVID-19 pandemic, the number of patients diagnosed with acute appendicitis was reduced. CT scan usage for diagnosis was increased compared to pre-COVID-19. Most patients diagnosed with acute appendicitis received operative treatment in both groups. Median time to surgery was significantly longer during the COVID-19 pandemic, 11.93 hours compared to 9.62 hours pre-COVID-19, p-value <0.001 (relative risk 1.5, 95% CI 1.29-1.76, p value 0.041). The incidence of complicated appendicitis was not higher during COVID-19. Compared to pre-COVID-19, ICU admission rate, the use of a mechanical ventilator, length of stay, and cost increased in the univariate analysis but were not statistically significant in the multivariate analyses. Other treatment complications had no statistically significant difference.

CONCLUSION

The incidence of complicated appendicitis did not increase during the COVID-19 pandemic. The operation waiting time significantly increased but did not increase the rate of treatment complications in a well-prepared hospital system.

Effect of the COVID-19 pandemic on patients with presumed diagnosis of acute appendicitis

BACKGROUND

Acute appendicitis (AAp) is the most frequent cause of acute abdominal pain, and appendectomy is the most frequent emergency procedure that is performed worldwide. The coronavirus disease 2019 (COVID-19) pandemic has caused delays in managing diseases requiring emergency approaches such as AAp and trauma.

AIM

To compare the demographic, clinical, and histopathological outcomes of patients with AAp who underwent appendectomy during pre-COVID-19 and COVID-19 periods.

METHODS

The demographic, clinical, biochemical, and histopathological parameters were evaluated and compared in patients who underwent appendectomy with the presumed diagnosis of AAp in the pre-COVID-19 (October 2018-March 2020) and COVID-19 (March 2020-July 2021) periods.

RESULTS

Admissions to our tertiary care hospital for AAp increased 44.8% in the COVID-19 period. Pre-COVID-19 (n = 154) and COVID-19 (n = 223) periods were compared for various parameters, and we found that there were statistically significant differences in terms of variables such as procedures performed on the weekdays or weekends [odds ratio (OR): 1.76; P = 0.018], presence of AAp findings on ultrasonography (OR: 15.4; P < 0.001), confirmation of AAp in the histopathologic analysis (OR: 2.6; P = 0.003), determination of perforation in the appendectomy specimen (OR: 2.2; P = 0.004), the diameter of the appendix (P < 0.001), and hospital stay (P = 0.003). There was no statistically significant difference in terms of interval between the initiation of symptoms and admission to the hospital between the pre-COVID-19 (median: 24 h; interquartile range: 34) and COVID-19 (median: 36 h; interquartile range: 60) periods (P = 0.348). The interval between the initiation of symptoms until the hospital admission was significantly longer in patients with perforated AAp regardless of the COVID-19 or pre-COVID-19 status (P < 0.001).

CONCLUSION

The present study showed that in the COVID-19 period, the ultrasonographic determination rate of AAp, perforation rate of AAp, and duration of hospital stay increased. On the other hand, negative appendectomy rate decreased. There was no statistically significant delay in hospital admissions that would delay the diagnosis of AAp in the COVID-19 period.

Comparación de la seguridad y la eficacia del uso de antibióticos frente a la apendicectomía en el tratamiento de la apendicitis no complicada en adultos. Revisión sistemática y metaanálisis

Introducción. La apendicitis aguda es una emergencia quirúrgica frecuente, en la cual el tratamiento de tipo conservador basado en antibióticos se ha identificado como una opción terapéutica que necesita seguir siendo estudiada. El objetivo de este estudio fue determinar las diferencias en seguridad y eficacia del uso de antibióticos en comparación con la apendicectomía en adultos con apendicitis no complicada. Métodos. Revisión sistemática y metaanálisis. Se encontraron 452 estudios; después de una selección, 45 se evaluaron en texto completo y 15 para calidad metodológica; 11 estudios fueron seleccionados y 9 incluidos en el metaanálisis. Resultados. Se contó con 3186 participantes, de los cuales 1512 fueron tratados con terapia antibiótica y 1674 sometidos a apendicectomía. Se identificó estancia hospitalaria más corta en los pacientes sometidos a apendicectomía (SMD: 0,28; IC95%: 0,14 a 0,41). Para los pacientes tratados con terapia antibiótica, se evidenció puntajes de riesgo menores en las escalas de diagnóstico de apendicitis (SMD: -0,13; IC95%: -0,22 a -0,04), menor éxito terapéutico en un 16 % (RR: 0,84; IC95%: 0,77 a 0,92) y reducción del riesgo de complicaciones del 63 % (RR: 0,37; IC95%: 0,25 a 0,53). Se encontró alta heterogeneidad y riesgo de sesgo de publicación. Conclusiones. La terapia antibiótica necesita mayor evidencia para desenlaces como calidad de vida, satisfacción, dolor, o complicaciones específicas, entre otros, que permitan hacer comparaciones más contundentes. Los pacientes que consideren el manejo conservador necesitan ser adecuadamente asesorados y monitorizados para optimizar sus posibilidades de resultados favorables y la oportuna identificación de complicaciones que necesiten de otros abordajes.

Identifying Recurrence Risk Factors in CT-Confirmed Acute Appendicitis in Adults Managed Non-operatively During the COVID-19 Pandemic

Background/Objective: Acute appendicitis (AA) is predominantly managed with appendectomy, but can be treated non-operatively, leading to a high risk of recurrence. Non-operative management has been more common since the COVID-19 pandemic affected the feasibility of performing surgery. This case-control study analyzed non-operatively managed patients in order to identify clinical and radiological factors associated with recurrence risk. 

Methods: Over 12 months, 48 adults with CT-proven AA managed non-operatively were identified, and followed up for at least six further months to assess them for recurrence (readmission to hospital more than 14 days after discharge and after symptom resolution, requiring treatment for appendicitis). Clinical and CT data were collected and a Cox regression survival analysis was performed to produce hazards ratios (HRs).

Results: Of the 48 patients, 12 (25%) experienced a recurrence up until the end of the follow-up period, eight of whom were then treated operatively, and four treated non-operatively. On the univariate analysis, greater recurrence risk was observed in patients with diabetes mellitus, higher heart rate (on admission and maximum value during admission), lower white cell count and neutrophils and appendiceal wall thinning on CT. On the multivariate analysis, diabetes mellitus (HR=7.72, p=0.021) and higher heart rate (HR=1.08, p=0.018) were associated with statistically significant greater recurrence risk.

Conclusions: Diabetes mellitus and higher heart rate on admission are associated with greater recurrence risk of AA managed non-operatively. No CT findings were associated with statistically significant greater risk. Clinicians should, therefore, consider DM and heart rate when making decisions on appendicitis management, especially during the COVID-19 pandemic but also beyond it.

Nonoperative vs Operative Management of Uncomplicated Acute Appendicitis: A Systematic Review and Meta-analysis

Importance

Appendectomy remains the standard of care for uncomplicated acute appendicitis despite several randomized clinical trials pointing to the safety and efficacy of nonoperative management of this disease. A meta-analysis of randomized clinical trials may contribute to the body of evidence and help surgeons select which patients may benefit from surgical and nonsurgical treatment.

Objective

To assess the efficacy and safety of nonoperative management vs appendectomy for acute uncomplicated appendicitis.

Data Sources

A systematic review was conducted using indexed sources (Embase and PubMed) to search for published randomized clinical trials in English comparing nonoperative management with appendectomy in adult patients presenting with uncomplicated acute appendicitis. To increase sensitivity, no limits were set for outcomes reported, sex, or year of publication. All nonrandomized or quasi-randomized trials were excluded, and validated primers were used.

Study Selection

Among 1504 studies imported for screening, 805 were duplicates, and 595 were excluded for irrelevancy. A further 96 were excluded after full-text review, mainly owing to wrong study design or inclusion of pediatric populations. Eight studies met the inclusion criteria and were selected for the meta-analysis.

Data Extraction and Synthesis

Meta-extraction was conducted with independent extraction by multiple reviewers using the Covidence platform for systematic reviews and in accordance with PRISMA guidelines. Data were pooled by a random-effects model.

Main Outcomes and Measures

Treatment success and major adverse effects at 30 days' follow-up.

Results

The main outcome (treatment success proportion at 30 days of follow-up) was not significantly different in the operative and nonoperative management cohorts (risk ratio [RR], 0.85; 95% CI, 0.66-1.11). Likewise, the percentage of major adverse effects was similar in both cohorts (RR, 0.72; 95% CI, 0.29-1.79). However, in the nonoperative management group, length of stay was significantly longer (RR, 1.48; 95% CI, 1.26-1.70), and a median cumulative incidence of 18% of recurrent appendicitis was observed.

Conclusions and Relevance

These results point to the general safety and efficacy of nonoperative management of uncomplicated acute appendicitis. However, this strategy may be associated with an increase in duration of hospital stay and a higher rate of recurrent appendicitis. This meta-analysis may help inform decision-making in nonoperative management of uncomplicated acute appendicitis.

Antibiotic use during the first 6 months of COVID-19 pandemic in Iran: A large-scale multi-centre study

WHAT IS KNOWN AND OBJECTIVE

Although antibiotics are ineffective against viral infections, epidemiological studies have revealed that the COVID-19 pandemic resulted in the overuse of antibiotics and disruption of antimicrobial stewardship programmes. We investigated the pattern of antibiotic use during the first 6 months of the COVID-19 pandemic in Iran.

METHODS

A multi-centre retrospective study was designed to investigate the use of 16 broad-spectrum antibiotics in 12 medical centres. The rate of antibiotic use was calculated and reported based on the Defined Daily Dose (DDD) per 100 hospital bed-days. The bacterial co-infection rate was also reported.

RESULTS AND DISCUSSION

Totally, 43,791 hospitalized COVID-19 patients were recruited in this study. It was found that 121.6 DDD of antibiotics were used per 100 hospital bed-days, which estimated that each patient received approximately 1.21 DDDs of antibiotics every day. However, the bacterial co-infections were detected only in 14.4% of the cases. A direct correlation was observed between the rate of antibiotic use and mortality (r[142] = 0.237, p = 0.004). The rate of antibiotic consumption was not significantly different between the ICU and non-ICU settings (p = 0.15).

WHAT IS NEW AND CONCLUSION

In this study, widespread antibiotic use was detected in the absence of the confirmed bacterial coinfection in COVID-19 patients. This over-consumption of broad-spectrum antibiotics may be associated with increased mortality in hospitalized COVID-19 patients, which can be an alarming finding.

Conversion from Laparoscopic to Open Appendectomy: Trends, Risk Factors and Outcomes. A 15-Year Single-Center Analysis of 2193 Adult Patients

Background

Laparoscopic appendectomy (LA) has become the standard of care for the management of acute appendicitis in adult patients. Despite the increasing experience in laparoscopy, conversion to open surgery might still occur. We aimed to identify preoperative and intraoperative risk factors for conversion and determine surgical outcomes in this population.

Methods

We performed a retrospective analysis of a consecutive series of patients undergoing LA during the period 2006–2020. The cohort was divided into two groups: patients who underwent a fully laparoscopic appendectomy (FLA) and patients who were converted to open appendectomy (CA). Demographics, perioperative variables and postoperative outcomes were compared between both groups. Independent risk factors for conversion were determined by logistic regression analysis.

Results

A total of 2193 patients were included for analysis; 2141 (98%) underwent FLA and 52 (2%) CA. Conversion rates decreased significantly over time (p = 0.006). Patients with CA had significantly higher overall postoperative morbidity rates (FLA 14.9% vs. CA 48.0%, p < 0.0001) and longer mean length of hospital stay (FLA 1.7 vs. CA 5 days). In the multivariate analysis, obesity (p < 0.001), previous abdominal operations (p = 0.013), peritonitis (p = 0.003) and complicated appendicitis (p < 0.001) were independent risk factor for conversion.

Conclusions

Although conversion from laparoscopic to open appendectomy is infrequent and has decreased over time, it is associated with significantly higher postoperative morbidity. Patients with previous abdominal operations, obesity and complicated appendicitis should be thoroughly advised about the higher risk of conversion.

Treatment strategies and perforation rate of acute appendicitis during the early phase of the Covid-19 Pandemic: A Swedish cohort study

Introduction

It is unknown whether the COVID-19 pandemic has had an impact on emergency surgical care in Sweden. This study aimed to compare frequency, treatment strategies, severity, and complication rate of appendicitis during the initial phase of the COVID-19 pandemic with those of previous years.

Methods

In this single-center study, we identified all patients admitted with appendicitis between March 16 and June 16, 2020, at the Stockholm South General Hospital, and compared these with patients hospitalized with appendicitis during the same calendar period the three previous years. We used multivariate logistic regression to calculate Odds Ratios (OR) with 95% confidence intervals as measurement of the association between appendicitis treatment and perforation rate during the COVID-19 period compared to the nonCOVID-19 periods.

Results

In all, 892 patients hospitalized with appendicitis were identified, 241 (27%) in 2020 (Covid period group) and the remaining 651 (73%) during the same calendar periods 2017-2019 (nonCovid period group). Appendicitis during the COVID-19 period was associated with double the risk for undergoing conservative treatment (OR 2.15 [95% CI 1.44-3.21]), and a decreased risk for being diagnosed with perforated appendicitis (OR 0.68 [95% CI 0.48-0.98]).

Conclusions

Patients admitted with appendicitis during the early phase of the COVID-19 pandemic in Stockholm, Sweden, were more likely to receive conservative treatment and less likely to suffer from perforated appendicitis compared to patients hospitalized before the pandemic. Hypothetically, this difference could have been due to pandemic-associated resource reallocation, or it may simply reflect an increasing trend towards conservative management of appendicitis.

Are the immature granulocyte count and percentage important in continue medical treatment in acute appendicitis? A prospective, randomized, and controlled study

BACKGROUND

Although appendectomy is still a curative therapy for acute appendicitis, medical treatment has come to the fore in uncomplicated cases. This study aimed to determine the importance of immature granulocyte (IG) count and percentage for the role of medical treatment success in uncomplicated acute appendicitis.

METHODS

Acute appendicitis cases were prospectively registered between July 2019 and April 2020. Using ball drawing, patients were divided into two groups as medical treatment (Group M) and undergo appendectomy (Group A). Group M was divided into two subgroups as those who responded to medical treatment medically responded (MR) and failed medical treatment (MF) within 24 h of follow-up. Changes in IG count and percentage, C-reactive protein levels, neutrophil-lymphocyte ratio, and white blood cell count between initial administration and 24th h of follow-up were examined.

RESULTS

Sixty-four patients who met the inclusion criteria were followed as 31 patients in Group A and 33 in Group M. At Sub-group MF 11 patients and Subgroup MR 22 patients were followed up. At the 24th h of the follow-up, the IG count and percentage were higher in the Group MF (for IG count: Between Group A and MF, p=0.002; between Group A and Group MR, p=0.111; and between Group MR and MF, p<0.001) (for IG percentage: Between Group A and MF, p=0.001; between Group A and MR, p=0.809; and between Group MF and MR, p=0.001). This decrease in the IG count and percentage suggests that the response to medical treatment was effective [for IG count: F (148.862) = 61, p≤0.001, η2=0.707] [for IG percentage: F (10.157) = 0.252, p≤0.001, η2=0.504].

CONCLUSION

IG count and percentage are effective for evaluating the success of medical treatment of uncomplicated acute ap-pendicitis and they guide in the decision to continue medical treatment of uncomplicated acute appendicitis.

Complicated appendicitis increases the hospital length of stay

Background

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

Method

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

Results

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

Conclusion

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

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Practically one fifth of acute appendicitis will be complicated.

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

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

Safety of laparoscopic surgery during pregnancy: a Korean nationwide population-based study

BACKGROUND

The optimal surgical approach to perform during pregnancy is still controversial. This study evaluated pregnancy and operative outcomes in women undergoing an appendectomy or cholecystectomy during pregnancy, and compared them between the laparoscopic and open approach using nationwide population-based data.

METHODS

Between 2009 and 2019, a total of 2941 pregnant women with procedure codes for an appendectomy or cholecystectomy were extracted from the Korean National Health Insurance claims data (laparoscopy: 1504; open: 1437). Surgical outcomes [length of stay (LOS), anesthesia time, 30-day readmission rates, transfusion rates, second laparotomy, and 30-day mortality rates] and pregnancy outcomes (live birth rate, overall and spontaneous abortion rates, threatened abortion rate, type of delivery, preterm labor, stillbirth, fetal screening abnormalities, and intrauterine growth retardation) were compared between the open and laparoscopic groups.

RESULTS

The laparoscopic group had a significantly shorter LOS than the open group, and transfusions were less frequent in the laparoscopic group. Mortality, 30-day readmission rates, and second laparotomy were not statistically significant between the two groups. There were no significant differences in fetal loss and live birth rates between the two groups in all gestational ages. Preterm labor within 30 days of surgery was more frequent in the laparoscopy group than in the open surgery group, especially for those in their first and third trimesters. Open procedures were associated with an increased rate of cesarean sections.

CONCLUSIONS

Laparoscopic surgery was found to be feasible and safe without adverse postoperative outcomes. Careful observation of postoperative preterm labor is necessary, especially for women who undergo laparoscopic surgery in their first and third trimesters.

Acute complicated appendicitis caused by an ingested toothpick – A case report

Introduction and importance

Acute appendicitis is one of the most common presentations to the emergency department, particularly in young adults. A combination of clinical suspicion, inflammatory blood markers and imaging modalities such as ultrasound and CT are used for its definitive diagnosis. Early detection and intervention are paramount to reduce morbidity and mortality. Laparoscopic appendicectomy is the current gold standard in the management of appendicitis, especially if complicated according to EAES guidelines. There are few documented cases in the literature of acute appendicitis secondary to foreign body ingestion. On account of this, there are currently no guidelines for its management. Our literature review highlights the importance of surgical management of foreign body acute appendicitis.

Case presentation

This case report describes the rare presentation of acute complicated appendicitis caused by an ingested toothpick in a 64 year old woman. The patient was admitted with a 3 day history of lower abdominal pain, localizing to the right iliac fossa with raised inflammatory markers. CT imaging reported acute complicated appendicitis. Laparoscopic appendicectomy was performed during which a toothpick was seen protruding through the appendiceal wall. Post operatively the patient was treated with IV antibiotics for 5 days prior to discharge.

Clinical discussion

Due to the rare nature of foreign body appendicitis there are no specific guidelines on the respective surgical approach. A literature review showed that in the setting of foreign body appendicitis, surgical intervention is paramount with no scope for conservative management.

Conclusion

Surgical approach is based on the clinical judgement and skillset of the operating surgeon.

•

Remember foreign body ingestion as a cause of appendicitis

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Management of foreign body appendicitis is surgical intervention.

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Open vs laparoscopic approach depends on the surgeons clinical judgement, preference and skillset.

The Impact of COVID-19 on Acute Surgical Admissions at the Sunshine Coast University Hospital

Purpose

It has been noted in international literature that acute surgical admissions and number of operations reduced as a result of coronavirus disease2019 (COVID-19). This study assesses the impact of the COVID-19 pandemic on the number of acute surgical admissions, operations, and length of stay (LoS) at the Sunshine Coast University Hospital (SCUH), Queensland, Australia.

Methodology

A retrospective study was conducted on patients admitted to the Acute Surgical Unit (ASU) during March and April for the years 2018, 2019, and 2020. Admission data for ASU patients in 2018 and 2019 were combined (pre-COVID) and compared with 2020 (COVID) to determine impact of the pandemic on presentations and procedures.

Results

ASU admissions reduced in 2020 (461 patients) compared with pre-COVID years (mean: 545 patients per year). There was an increase in the number (%) of operations performed in 2020, 175 patients (38%) compared with pre-COVID years, mean 158 patients (29%), p = 0.001. There was a significant decrease in the number (%) of functional presentations in 2020, 29 patients (6.3%) compared with pre-COVID years, mean 105 patients (9.6%), p = 0.04. LoS was not significantly different (52 hours vs. 54 hours, p = 0.11).

Conclusion

COVID-19 has reduced the absolute number of acute surgical admissions at SCUH. This effectively reduced triage workload. Contrary to the literature, this study did not demonstrate a reduction in the number of operations or change in LoS. These data could be used by health administrators to help with resource allocation during future pandemics.

Did the severity of appendicitis increase during the COVID-19 pandemic?

BACKGROUND

This study aimed to assess the severity of appendicitis during the coronavirus disease 2019 (COVID-19) pandemic, as patients with appendicitis may procrastinate seeking medical attention during the pandemic.

METHODS

Information on patients with appendicitis who were treated at the Taipei City Hospital during the COVID-19 pandemic (January 1, 2020 to June 30, 2020) was retrieved. Patients who were diagnosed with appendicitis and treated at the same hospital from January 1, 2019 to July 1, 2019 were designated as the control group. Multivariate logistic regression analysis was conducted to assess changes in the severity of appendicitis (at a 2-week interval) between the two groups.

RESULTS

We identified 307 (study group: 149; control group: 158) consecutive patients with appendicitis. The mean age was 46.2 +- 19.8 years. Between the two groups, there were no significant differences in age, sex, comorbidity, surgery type (laparoscopic or open appendectomy) or surgery time. The number of patients in the study group decreased between January 29, 2020 and April 21, 2020, which paralleled the period of spikes in the confirmed COVID-19 cases and restricted daily activities. The percentage of uncomplicated and complicated appendicitis (excluding mild appendicitis or normal appendix) in the study group increased between February 26 and March 10, as well as between April 8 and April 21. In the multivariate regression analysis, the odds of uncomplicated and complicated appendicitis increased in three bi-weeks for the study group but not in the control group.

CONCLUSION

The severity of acute appendicitis might increase during the COVID-19 pandemic, because patients with mild appendicitis (or abdominal pain) may hesitate to seek help.

Periappendiceal fat-stranding models for discriminating between complicated and uncomplicated acute appendicitis: a diagnostic and validation study

BACKGROUND

Recent studies have reported promising outcomes of non-operative treatment for uncomplicated appendicitis; however, the preoperative prediction of complicated appendicitis is challenging. We developed models by incorporating fat stranding (FS), which is commonly observed in perforated appendicitis.

MATERIAL AND METHODS

We reviewed the data of 402 consecutive patients with confirmed acute appendicitis from our prospective registry. Multivariate logistic regression was performed to select clinical and radiographic factors predicting complicated acute appendicitis in our model 1 (involving backward elimination) and model 2 (involving stepwise selection). We compared c statistics among scoring systems developed by Bröker et al. (in J Surg Res 176(1):79-83. https://doi.org/10.1016/j.jss.2011.09.049 , 2012), Imaoka et al. (in World J Emerg Surg 11(1):1-5, 2016), Khan et al. (in Cureus. https://doi.org/1010.7759/cureus.4765 , 2019), Kim et al. (in Ann Coloproctol 31(5):192, 2015), Kang et al. (in Medicine 98(23): e15768, 2019), Atema et al. (in Br J Surg 102(8):979-990. https://doi.org/10.1002/bjs.9835 , 2015), Avanesov et al. (in Eur Radiol 28(9):3601-3610, 2018), and Kim et al. (in Abdom Radiol 46:1-12, 2020). Finally, we examined our models by performing the integrated discrimination improvement (IDI) test.

RESULTS

Among enrolled patients, 64 (15.9%) had complicated acute appendicitis. We developed new 10-point scoring models by including the following variables: C-reactive protein, neutrophil to lymphocyte ratio, and computed tomography features of FS, ascites, and appendicolith. A cutoff score of ≥ 6 exhibited a high sensitivity of 82.8% and a specificity of 82.8% for model 1 and 81.3% and 82.3% for model 2, respectively, with c statistics of 0.878 (model 1) and 0.879 (model 2). Compared with the model developed by Bröker et al. which included C-reactive protein and the abdominal pain duration (c statistic: 0.778), the models developed by Atema et al. (c statistic: 0.826, IDI: 5.92%, P = 0.0248), H.Y Kim et al. (c statistics: 0.838, IDI: 13.82%, P = 0.0248), and our two models (IDI: 18.29%, P < 0.0001) demonstrated a significantly higher diagnostic accuracy.

CONCLUSION

Our models and the scoring systems developed by Atema et al. and Kim et al. were validated to have a high diagnostic accuracy; moreover, our models included the lowest number of variables.

Conservative management of acute appendicitis in the era of COVID 19: A multicenter prospective observational study at the United Arab Emirates

Background & Aims

Since its emergence in December 2019, the COVID-19 pandemic resulted in a profound impact on the health care system worldwide. We propose herein to evaluate the impact of implementing conservative management as an alternative approach to surgical appendectomy during COVID19 pandemic.

Materials and Methods

Our study is a prospective multicenter study that includes a cohort of 158 patients admitted to the surgical departments in both Tawam Hospital and SSMC hospital, Abu Dhabi, UAE, from February 2020 till July 2020.

Results

Our results showed a significant decrease in length of hospital stay (LOS) (2.32 ± 0.83 days) among conservatively treated group compared to the surgically treated group (2.8 ± 1.47 days). Also, short term follow-up showed that 90% of those patients did not require further operative intervention or developed complications. Out of the 110 patients that were swapped for COVID19, nine (8.18%) were confirmed to be positive. Our protocol was to avoid surgical management for COVID19 positive patients unless indicated. This resulted in (8/9) of COVID19 positive patients to be treated conservatively.

Conclusions

In conclusion, our results showed that the implementation of conservative management in treating patients with acute appendicitis who were COVID19 positive maybe essential in reducing viral transmission risks as well as avoiding operative risks on COVID19 positive patients.

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.

Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study

BACKGROUND

Uncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up.

METHODS

A prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment.

RESULTS

A total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P < 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery.

CONCLUSION

This study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions.

Cost-Utility Analysis of Antibiotic Therapy versus Appendicectomy for Acute Uncomplicated Appendicitis

BACKGROUND

Current UK National Health Service (NHS) guidelines recommend appendicectomy as gold standard treatment for acute uncomplicated appendicitis. However, an alternative non-surgical management involves administrating antibiotic-only therapy with significantly lower costs. Therefore, a UK-based cost-utility analysis (CUA) was performed to compare appendicectomy with an antibiotic-only treatment from an NHS perspective.

METHODS

This economic evaluation modelled health-outcome data using the ACTUAA (2021) prospective multicentre trial. The non-randomised control trial followed 318 patients given either antibiotic therapy or appendicectomy, with quality of life (QOL) assessed using the SF-12 questionnaires administered 1-year post-treatment. A CUA was conducted over a 1-year time horizon, measuring benefits in quality adjusted life years (QALYs) and costs in pound sterling using a propensity score-matched approach to control for selection based on observable factors.

RESULTS

The CUA produced an incremental cost-effectiveness ratio (ICER) of -GBP 23,278.51 (-EUR 27,227.80) per QALY. Therefore, for each QALY gained using antibiotic-only treatment instead of appendicectomy, an extra GBP 23,278.51 was saved. Additionally, two sensitivity analyses were conducted to account for post-operative or post-treatment complications. The antibiotic-only option remained dominant in both scenarios.

CONCLUSION

While the results do not rely on a randomized sample, the analysis based on a 1-year follow-up suggested that antibiotics were largely more cost-effective than appendicectomy and led to improved QOL outcomes for patients. The ICER value of -GBP 23,278.51 demonstrates that the NHS must give further consideration to the current gold standard treatment in acute uncomplicated appendicitis.

A Randomized Clinical Trial Evaluating the Efficacy and Quality of Life of Antibiotic-only Treatment of Acute Uncomplicated Appendicitis: Results of the COMMA Trial

OBJECTIVE

Evaluate the efficacy and quality of life associated with conservative treatment of acute uncomplicated appendicitis.

SUMMARY BACKGROUND DATA

Conservative management with antibiotics only has emerged as a potential treatment option for acute uncomplicated appendicitis. However the reported failure rates are highly variable and there is a paucity of data in relation to quality of life.

METHODS

Symptomatic patients with radiological evidence of acute, uncomplicated appendicitis were randomized to either intravenous antibiotics only or undergo appendectomy.

RESULTS

One hundred eighty-six patients underwent randomization. In the antibiotic-only group, 23 patients (25.3%) experienced a recurrence within 1 year following randomization. There was a significantly better EQ-VAS quality of life score in the surgery group compared with the antibiotic-only group at 3 months (94.3 vs 91.0, P < 0.001) and 12 months postintervention (94.5 vs 90.4, P < 0.001). The EQ-5D-3L quality-of-life score was significantly higher in the surgery group indicating a better quality of life (0.976 vs 0.888, P < 0.001). The accumulated 12-month sickness days was 3.6 days shorter for the antibiotics only group (5.3 vs 8.9 days; P < 0.01). The mean length of stay in both groups was not significantly different (2.3 vs 2.8 days, P = 0.13). The mean total cost in the surgery group was significantly higher than antibiotics only group (€4,816 vs €3,077, P < 0.001).

CONCLUSIONS

Patients with acute, uncomplicated appendicitis treated with antibiotics only experience high recurrence rates and an inferior quality of life. Surgery should remain the mainstay of treatment for this commonly encountered acute surgical condition.

Does the presence of an appendicolith or abscess predict failure of nonoperative management of patients with acute appendicitis?

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.

The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study

BACKGROUND

Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK).

METHODS

Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up.

RESULTS

The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26-49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1-4] days vs. 3 [2-4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive.

CONCLUSION

COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.

Surgical Versus Conservative Management of Acute Appendicitis During the COVID-19 Pandemic: A Single-Centre Retrospective Study

Introduction The COVID-19 pandemic provoked a change to normal surgical practice in the United Kingdom and led to an increase in acute appendicitis (AA) patients being treated conservatively with antibiotics. We aim to analyse the management of patients presenting with AA to our institution during the first wave of the pandemic, comparing surgically and conservatively managed patients. Method All patients presenting to our centre with AA between March and July 2020 were included. Six-month follow-up data were collected retrospectively using electronic records. Patients were categorised into surgically and conservatively managed groups. The primary outcome was the complication rate (post-operative complications vs failure of antibiotic treatment) and the secondary outcomes were length of hospital stay and Alvarado score. Results  Fifty-seven patients (n=57) were admitted with AA, 45.6% (n=26) managed conservatively compared to 54.4% (n=31) treated surgically. Higher complication rates were observed amongst the conservatively managed group, although not found to be statistically significant (16% vs 35%; p=0.131). There was no significant difference in length of hospital stay observed between the two groups (surgical: median, 2; interquartile range, 2-3 vs conservative: median, 3; interquartile range, 2-4). White cell count (WCC) and Alvarado score were higher on admission in the surgical group with statistical significance (p=0.012 and p=0.028, respectively). Conclusions COVID-19 has led to a significant cohort of conservatively managed AA patients in the United Kingdom. We propose a stratification pathway based on clinical severity, Alvarado score and imaging to facilitate safe selection for conservative management of AA, in order to reduce failure of treatment rates in this patient group. Further UK-based studies will add to the evidence-based surrounding safe management of AA with conservative treatment.

Clinical-pathological features and treatment of acute appendicitis in the very elderly: an interim analysis of the FRAILESEL Italian multicentre prospective study

BACKGROUND

Emergency abdominal surgery in the elderly represents a global issue. Diagnosis of AA in old patients is often more difficult. Appendectomy remains the gold standard of treatment and, even though it is performed almost exclusively with a minimally invasive technique, it can still represent a great risk for the elderly patient, especially above 80 years of age. A careful selection of elderly patients to be directed to surgery is, therefore, fundamental. The primary aim was to critically appraise and compare the clinical-pathological characteristics and the outcomes between oldest old (≥ 80 years) and elderly (65-79 years) patients with Acute Appendicitis (AA).

METHODS

The FRAILESEL is a large, nationwide, multicentre, prospective study investigating the perioperative outcomes of patients aged ≥ 65 years who underwent emergency abdominal surgery. Particular focus has been directed to the clinical and biochemical presentation as well as to the need for operative procedures, type of surgical approach, morbidity and mortality, and in-hospital length of stay. Two multivariate logistic regression analyses were performed to assess perioperative risk factors for morbidity and mortality.

RESULTS

182 patients fulfilled the inclusion criteria. Mean age, ileocecal resection, OAD and ASA score ≥ 3 were related with both overall and major complication. The multivariate analysis showed that MPI and complicated appendicitis were independent factors associated with overall complications. OAD and ASA scores ≥ 3 were independent factors for both overall and major complications.

CONCLUSIONS

Age ≥ 80 years is not an independent risk factor for morbidities. POCUS is safe and effective for the diagnosis; however, a CECT is often needed. Having the oldest old a smaller functional organ reserve, an earlier intervention should be considered especially because they often show a delay in presentation and frequently exhibit a complicated appendicitis.

Appendicectomy for Uncomplicated Simple Appendicitis: Is It Always Required?

BACKGROUND

Although appendicectomy is still the classical and standard treatment for acute appendicitis, initial conservative antibiotic only treatment for simple uncomplicated cases has been proposed and tried as a feasible and effective approach. The objective of this study was to evaluate the efficacy and outcomes of antibiotics treatment for acute simple uncomplicated appendicitis.

METHODS

This is a prospective controlled nonrandomized study in which a total of 156 patients whose ages range from 16 to 54 years presenting with clinical diagnosis of acute uncomplicated appendicitis were assigned for conservative antibiotics treatment, which consists of ceftriaxone I gram twice daily and metronidazole infusions, 500 mg in 100 ml, 3 times daily for 48 to 72 hours to be converted on oral antibiotics after clinical improvement for 5 to 7 days. Patients who failed to initial conservative treatment and those who had recurring symptoms of appendicitis were presented for appendectomy.

RESULTS

Antibiotic treatment was successful and feasible in 138 (88.5%) patients. Progression of the signs and symptoms despite full medical treatment was observed in 11 (7%) patients during the same admission. Further 7 (4.5%) patients showed recurrence of the symptoms during follow-up period of 6-12 months after successful initial conservative treatment and also proceeded for appendicectomy.

CONCLUSION

Nonoperative antibiotic treatment of acute simple appendicitis is safe, feasible, and effective for properly selected cases, thus avoiding unnecessary surgery with its possible complications.

Clinical Outcomes of Acute Appendicitis During Pregnancy: Conservative Management and Appendectomy

PURPOSE

We have described the epidemiology, diagnostic modality, treatment patterns, and outcomes of acute appendicitis during pregnancy.

METHODS

Using a nationwide claim-based database in Japan, we analyzed the data of pregnant patients who were diagnosed with appendicitis between January 2005 and May 2019. Patient characteristics, imaging studies, length of hospital stay, proportion of fetal losses, complications, and type of antibiotics were examined.

RESULTS

The study included 169 patients, of whom 113 patients (67%) underwent conservative management, and appendectomies were performed on 56 patients (open 25% and laparoscopic 8%). The proportion of ultrasonography, computed tomography, and magnetic resonance imaging were 97%, 17%, and 5% (for conservative management); 88%, 39%, and 13% (for appendectomy); 86%, 38%, and 21% (for open appendectomy); and 93%, 43%, and 14% (for laparoscopic appendectomy), respectively. The proportion of complicated appendicitis was 6% in conservative management and 41% in appendectomy (40% in open appendectomy and 43% in laparoscopic appendectomy), respectively. The incidence of fetal loss was 4% in conservative management, 5% in appendectomy (2% in open appendectomy, and 14% in laparoscopic appendectomy). However, there was only one fetal loss (in laparoscopic appendectomy) in the same case of hospitalization. There were no maternal deaths or serious complications after any treatment.

CONCLUSION

All treatments showed acceptable outcomes in appendicitis during pregnancy. Conservative management is considered an acceptable option, especially in uncomplicated cases of appendicitis in pregnant women.

Suspected appendicitis and COVID-19, a change in investigation and management-a multicentre cohort study

Purpose

The COVID-19 pandemic has reformed global healthcare delivery. On 25 March 2020, Intercollegiate guidelines were published in the UK to promote safe surgical provision during the COVID-19 outbreak advocating non-operative management or avoidance of laparoscopy when surgery is essential. The effects of this on the investigation and management of appendicitis remain unknown.

Methods

We performed a multicentre, prospective, observational study from the start of the new guidelines to the 6th of May 2020. We included all patients referred to surgical teams with suspected appendicitis. A recent historical cohort was identified for comparison. The primary outcome was the impact of the COVID-19 pandemic on the use of non-operative management in appendicitis. Secondary outcomes included imaging, negative appendicectomy rate (NAR), length of stay (LOS) and 30-day complications.

Results

A total of 63/164 (38%) patients compared to 79/191 (41%) were diagnosed with appendicitis before and after the guidelines were introduced (p = 0.589). CT scanning increased (71/164 vs 105/191; p = 0.033) while ultrasound scanning decreased (71/164 vs 62/191; p = 0.037). Appendicitis was more likely to be managed non-operatively (11/63 vs 51/79; p < 0.001) and, of those managed surgically, with an open approach (3/52 vs 26/28 p < 0.001). The NAR also reduced (5/52 vs 0/28; p = 0.157). LOS was shorter in non-operatively managed patients (1 day vs 3 days; p < 0.001) without a difference in complications (10/51 vs 4/28; p = 0.760).

Conclusion

Introduction of the guidelines was associated with changes in practice. Despite these changes, short-term complications did not increase and LOS decreased. Questions remain on the longer-term complication rates in non-operatively managed patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-020-02023-6.

Did the COVID-19 Pandemic Cause a Delay in the Diagnosis of Acute Appendicitis?

BACKGROUND

Appendectomy for acute appendicitis remains one of the most common surgical procedures. This study aims to assess the clinical presentation and delays in diagnosing acute appendicitis during the COVID-19 pandemic.

METHODS

We evaluated data of all adult patients who underwent an appendectomy at our hospital between June 1, 2019 and June 1, 2020. Demographic data, admission type to the emergency room, radiological findings, pathological findings, and hospitalization time were noted. Patients were divided into four groups of 3-month periods, pre (Groups 5, 4, 3, 2) and during the pandemic (Group 1). Hospitalization time and perforation status of each group were compared. The hospital admission type and their effect on perforation were also evaluated.

RESULTS

Two hundred and fourteen patients were included; 135 patients were male, and 57 were female. The median age was 39 years. In Group 1 (pandemic period), 28.8% of patients were referred to us from pandemic hospitals. The median hospitalization time was 7.3 h before pandemics (Group 2-5), 5 h in the pandemic period (Group 1). Perforation rates were 27.8% in Group 1, 23.3% in Group 2, 16.3% in Group 3, 14.0% in Group 4, and 18.6% in Group 5 (0 = 0.58). There was no difference in the patients in Group 1 in the rate of perforated appendicitis in patients who were referred from other pandemic hospitals (29.4) and those admitted via our own emergency room (16.6%) (p = 0.27) during the pandemic period.

CONCLUSION

We did not observe any clear increase in the diagnosis of perforated appendicitis during the pandemic period, even in patients who were transferred from other hospitals.

Are there benefits to maintaining Covid-19 pandemic pathways for the long-term? A surgical assessment unit based study

Background

The Covid-19 pandemic has led to the introduction of conservative non-operative approaches to surgical management favouring community driven care. The aim of this study was to determine the effect of these pathways on patients attending a surgical assessment unit (SAU).

Method

This was a retrospective observational cohort study. We included all consecutive attendances to the SAU in April 2020 (Covid-19 period) and April 2019 (pre-Covid-19). The Covid-19 period saw a shift in clinical practice towards a more conservative approach to the management of acute surgical presentations. The primary outcome measure was 30-day readmission. The secondary outcome measures were length of hospital stay, inpatient investigations undertaken and 30-day mortality.

Results

A total of 451 patients were included. This represented 277 and 174 attendances in pre-Covid-19, and Covid-19 groups respectively. The rates of unplanned 30-day readmission rates in the Covid-19 and pre-Covid-19 periods were 16.7% and 12.6% respectively (P = 0.232). There were significantly fewer planned follow-ups in the Covid-19 (36.2%) compared to the pre-Covid-19 group (49.1%; P < 0.01; OR 1.7, 95% CI 1.15–2.51). There were no significant differences in length of hospital stay (P = 0.802), and 30-day mortality rate (P = 0.716; OR 1.9, 95% CI 0.38–9.54) between the two periods.

Conclusion

There were no differences in 30-day readmission rates, length of hospital stay, and 30-day mortality with the changes to pathways. Our findings suggest the resource efficient conservative Covid-19 pathways could potentially continue long-term. However, further multi-centre studies with larger sample sizes and longer follow-up duration will be required to validate our findings.