Should ambulatory appendectomy become the standard treatment for acute appendicitis?

Awareness of Appendectomy and Its Complications Among Saudis

BACKGROUND

Acute appendicitis is one of the most common surgical causes of acute abdominal pain in adults and children in the emergency department. It is treated by appendectomy by either an open or laparoscopic approach. Although laparoscopic appendectomy has been used for the last 35 years, there are still indications for an open approach in some cases.

OBJECTIVES

 The aim of this study was to explore the awareness of the general population in Saudi Arabia of appendectomy according to the surgical approach.

METHODS

A cross-sectional survey using a questionnaire constructed by an expert based on Google Forms (Google, Mountain View, CA) was used from February to March 2022. Variables were demographical data, general knowledge, history of appendectomy, its surgical approach, and postoperative complications, if any.

RESULTS

The study included 162 participants. The awareness level of acute appendicitis was high (72.2%). History of appendectomy was almost 30% and was significantly more common in males than females (p = 0.045). The rate of postoperative complications showed a significant difference between open (4.3%) vs. laparoscopic approaches (8%) (p = 0.001).

CONCLUSION

 Young, educated Saudis are aware of the importance of surgical intervention for acute appendicitis. However, further hospital-based studies are recommended concerning the role of the surgical approach and its various impacts on postoperative complications.

A Study of Misconceptions About Appendicitis Among the Resident Population of the Aseer Region

BACKGROUND

Appendicitis is a common abdominal emergency requiring swift medical intervention. Misconceptions about this condition can lead to delayed diagnosis and potentially life-threatening complications. In the Aseer region of Saudi Arabia, where healthcare accessibility and awareness levels vary, addressing such misconceptions is of paramount importance. The aim of this study is to investigate and identify the prevalent misconceptions regarding appendicitis among the resident population of the Aseer region. Understanding the prevalent misconceptions and knowledge gaps is essential to develop targeted educational interventions and enhance public awareness.

METHODS

This study utilized a cross-sectional study design to investigate misconceptions about appendicitis among residents in the Aseer region. Over a period of three months, 329 Aseer region resident population were interviewed. The symptoms, causes, diagnosis, treatment, and preventive measures of appendicitis were all covered in a questionnaire that was created to gather information on people's knowledge of appendicitis. Data were collected using an online questionnaire. Descriptive analysis was performed using frequencies and percentages, while inferential analysis employed appropriate statistical tests such as chi-square.

RESULTS

 The study's 329 participants were made up of 56% men and 44% women. 40% of the sample size was between the ages of 18 and 30, 26% were between the ages of 31 and 40, 15% were between the ages of 41 and 50, and 10% were above 50 years, with those under the age of 18 years accounting for the smallest proportion (9%). The majority of the respondents (37%) were college graduates, 25% were college students, 23% were in high school and 15% were in middle school. Chi-square tests were conducted to examine the associations between background knowledge and pain area, as well as between background knowledge and source of information. For the association between background knowledge and pain area, the Chi-square test yielded a significant result (X² = 9.104, p = 0.028); the Chi-square test also revealed a significant result (X² = 8.078, p = 0.044) between background knowledge and the source of information about appendicitis.

CONCLUSION

The analysis suggests a notable knowledge gap among the participants, with a significant portion displaying limited understanding or responding with "I don't know" when queried about appendicitis. It is important to note that this observation includes middle school students, who may be too young to be expected to possess knowledge about medical conditions. Additionally, there appears to be gender-related variation in opinions, misconceptions, and understanding regarding appendicitis.

Adherence to the Antibiotic Prophylaxis Guidelines for Appendectomy in Bahrain: An Observational Study

Background Appendicitis is a common clinical problem that has multifactorial etiologies. Accounting for almost 1 million hospital days per year, it poses serious health hazards. If not treated on time, it may burst. Surgical intervention is the best option in such cases. Prophylactic use of antibiotics has been shown to reduce post-operative infections. Methodology This prospective observational study aimed to evaluate the adherence to the antibiotic prophylaxis guidelines for appendectomy in patients admitted to the surgical department at Salmanyia Medical Complex in Bahrain from January to August 2020. From the electronic records of these patients, information was extracted and evaluated regarding demographic data, the type of antibiotics given for prophylaxis, the timing of the administration of the antibiotics, and any alternative antibiotic given based on local hospital guidelines. Results The current study revealed that the majority of the patients (98%, N=273) admitted to the Salmanyia Medical Complex, Bahrain, were not administered the antibiotics within the prescribed time (30-60 minutes) as per hospital guidelines. Also, the antibiotics administered for prophylaxis prior to the appendectomy procedure were not according to the guidelines, i.e., Cefazolin 1g with Metronidazole 500 mg. Out of a total of 278 patients included in the study, none were administered the right choice as provided by the local guidelines. Second, 1.8% of patients (5 out of 278) were not administered any antibiotics for prophylaxis prior to the surgical procedure for appendicitis. Conclusion The study concluded that most patients were not administered antibiotics according to the local guidelines of the hospital.

Ambulatory appendectomy for acute appendicitis: Can we treat all the patients? A prospective study of 451 consecutive ambulatory appendectomies out of nearly 2,000 procedures

BACKGROUND

Acute appendicitis represents the leading cause of acute gastrointestinal disorders, but only a small series regarding ambulatory appendectomies are available. The aim of this study was to report the results of ambulatory (day-case) appendectomy for acute appendicitis in a large consecutive cohort and to improve selection criteria in order to extend the indications.

METHODS

All appendectomy procedures for acute appendicitis (March 2013 to June 2020) were included retrospectively. Criteria to select patients eligible for ambulatory appendectomy were based on our clinico-radiological St-Antoine's score ≥4.

RESULTS

In total, 1,730 consecutive patients had an appendectomy for acute appendicitis: 1,279 (74%) in conventional settings and 451 (26%) in ambulatory settings. In the conventional group, 360 (28%) patients had surgery deferred to the next morning, whereas in the ambulatory group, 309 patients (70%) were readmitted the next morning (P < .0001). In the ambulatory group, 376 (83%) patients satisfied the criteria (score ≥4), and 90.9% were discharged on postoperative day 0. Rates of unplanned consultation and readmission were not significantly different (5.1% vs 6.6% P = .243). Multivariate analysis of the entire cohort confirmed absence of radiological perforation as highly predictive of early discharge (odds ratio = 6.073). In our cohort, these patients had an early discharge rate of 86.4% compared to 90.2% in those with a St-Antoine's score ≥4. Considering only radiological evidence of perforation as a selection criterion for ambulatory appendectomy, 581 more patients would be eligible for ambulatory surgery (+60%).

CONCLUSION

Ambulatory surgery for acute appendicitis based on St-Antoine's score is safe. We propose to extend the indication for ambulatory management to all patients without radiological evidence of perforation.

Are only a few hours adequate for hospitalisation following mini-incision open appendectomy in paediatric patients?

BACKGROUND

A very short hospital length of stay following an open appendectomy in children with acute simple appendicitis has never been mentioned yet in the literature. The authors reviewed the outcome of these paediatric patients who were treated with the open technique.

MATERIALS AND METHODS

In this analytical cohort observational study, we retrospectively reviewed the medical records of the 115 consecutive patients who underwent open appendectomy from June 2017 to July 2021.

RESULTS

There were 84 patients whose appendices were inflammatory or suppurative and appendectomies were done only through McBurney's point. Of these, the average age was 9.11 ± 2.67 years. The mean length of the incision was 1.95 ± 0.48 cm. Nearly one-third (25/85) were discharged within 3 h following surgery. Of the remaining cases, nine patients were discharged within the same day. There were increased percentages of patients who were eligible for early discharge in each consecutive year.

CONCLUSION

The idea of immediate discharge within 3 h seems to be feasible for children with acute simple appendicitis who were treated with open appendectomy. We believe that the practice will be widely acknowledged and proceed to reduce the resources and the expenses in the hospital.

Post-Operative Day Zero Discharge after Laparoscopic Appendectomy Does Not Worsen High-Yield Outcomes: A NSQIP Database Observational Study

Background: Post-operative day zero (POD-0) discharge after laparoscopic appendectomy for uncomplicated appendicitis has been studied primarily in single-center or pediatric studies. A larger study from a national sample addressing high-yield outcomes can update and supplement current literature and evaluate early discharge rates.Methods: This is a retrospective, observational National Surgical Quality Improvement (NSQIP) database study of laparoscopic appendectomies for uncomplicated appendicitis performed 2016-2019, with discharge POD-0 or post-operative day one (POD-1). Study outcomes included any or serious complication, unplanned readmission, and unplanned return to operating room (OR). Unadjusted outcomes comparisons were estimated via chi-square tests. Multivariate logistic regression models were constructed to adjust for potential confounders (sex, ethnicity, frailty, ASA score, tobacco use and diabetes).Results: A total of 25,629 patients were included in this analysis. More patients were discharged POD-1 (n = 15,229) than POD-0 (n = 10,440). Rate of any or serious complication was lower in patients discharged POD-0 than POD-1 (any complication: 2.0 vs. 2.8, p = 0.0002, serious complication: 1.4 vs. 2.1, p < 0.0001). Unplanned return to OR and unplanned readmission rates were not different between POD-0 and POD-1 discharged groups (p = 0.9 and p = 0.6, respectively). These findings were robust to adjustment for covariates in logistic regression modeling.Conclusions: This study found that unplanned readmission and other outcomes do not appear to be adversely affected by early discharge after laparoscopic appendectomy for uncomplicated appendicitis, confirming prior evidence on the topic in a large, national sample. It also found that early discharge does not appear to be used in most of these patients.

Same day discharge after pediatric laparoscopic appendectomy in community hospitals

INTRODUCTION

Same-day discharge (SDD) protocols after pediatric laparoscopic appendectomy have not been well studied in a community hospital setting, especially when hospitals with low inpatient pediatric censuses are increasingly closing their pediatric units. This study evaluates the outcomes of a SDD protocol after pediatric appendectomy that was implemented across an integrated healthcare system in which hospitals experienced closure of pediatric units.

METHODS

Patients between ages 6 to 13 years-old who underwent laparoscopic appendectomy for uncomplicated appendicitis from January 1st 2015 to December 31st 2020 were reviewed. During the study period, an inter-hospital SDD protocol was introduced at nine hospitals, four of which closed their pediatric units.

RESULTS

There were 1293 patients in the pre-protocol cohort and 953 patients in the post-protocol cohort. There were 588 (45.5%) patients who underwent SDD in the pre-protocol cohort, compared with 804 (84.4%) patients in the post-protocol cohort (p<0.00001). Postoperative narcotics were prescribed to 358 (27.7%) patients in the pre-protocol cohort, compared to 482 (50.6%) patients in the post-protocol cohort (P<0.00001). There was no difference in the 30-day emergency department visit rate or 30-day readmission rate between the two cohorts. A subgroup analysis comparing the surgical outcomes at community hospitals with and without pediatric units after implementation of the SDD protocol showed no difference.

CONCLUSION

Same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis in community hospitals, even after pediatric unit closure, is safe and feasible. The decrease in postoperative LOS and the increase in SDD are not associated with higher complication rates.

Regional Anesthesia Techniques for Pain Management for Laparoscopic Surgery: a Review of the Current Literature

Purpose of Review

The field of regional anesthesia has evolved tremendously in the last 15 years. New anesthesia protocols for ambulatory surgery and enhanced recovery after surgery have been developed as well. The focus of these techniques and protocols has centered on patient satisfaction and pain control while minimizing the use of opioids. The field of ambulatory surgery and anesthesia continues to evolve, and regional anesthesia and its plane techniques are at the center of these changes.

Recent Findings

Recent research has shown that regional techniques contribute to better pain control and patient experience and may decrease patient readmission rates. The safety of these techniques has been validated when performed by experienced practitioners. New techniques such as the erector spinae block (ESP) have been studied in the setting of laparoscopic surgery with promising results.

Summary

Regional anesthesia techniques for patients presenting for laparoscopic surgery are safe and seem to provide benefits. Those are related to patient experience, pain control, and readmission rates. Different techniques can be applied to a specific type of intervention. Application of these techniques depend on the clinical picture and patient. Future research may help us clarify how these techniques may improve patient satisfaction and operating room efficiency. New regional blocks may also develop based on what we know today.

Evolving Trends in the Management of Acute Appendicitis During COVID-19 Waves: The ACIE Appy II Study

BACKGROUND

In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak.

METHODS

From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study.

RESULTS

A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM.

CONCLUSION

Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide.

Beneficios clínicos y de costos de un modelo de estandarización en el manejo de la apendicitis aguda

Introducción. La apendicitis aguda es la patología quirúrgica más frecuente en Colombia y en el mundo, con un riesgo de presentación del 7-8 % en la población general. El tratamiento de elección es la apendicectomía, la cual puede realizarse por vía convencional o por vía laparoscópica. El objetivo de este estudio fue comparar los desenlaces clínicos y costos de un modelo de estandarización en el manejo de la apendicitis aguda versus la no estandarización. Métodos. Estudio observacional, analítico, para comparar el manejo de atención estandarizado y no estandarizado. Se incluyeron pacientes mayores de 18 años, que ingresaron al servicio de urgencias con diagnóstico de apendicitis aguda en el período de enero de 2016 a diciembre de 2018, y quienes fueron llevados a apendicectomía convencional o laparoscópica en la institución. Resultados. Se incluyeron 1392 pacientes, 591 que cumplieron los criterios del modelo estandarizado y 801 que cumplieron los criterios del modelo no estandarizado. Al comparar los procesos de estandarización y no estandarización, se encontraron diferencias estadísticamente significativas en los resultados crudos de estancia hospitalaria y costos totales. En los estimativos ajustados por variables de confusión no se encontraron diferencias en los costos totales. Discusión. El modelo de estandarización demostró una disminución en los días de hospitalización. No encontró diferencias en términos de costos totales.

Where Did All the Appendicitis Go? Impact of the COVID-19 Pandemic on Volume, Management, and Outcomes of Acute Appendicitis in a Nationwide, Multicenter Analysis

Objective

The study objective was to evaluate effects of the COVID-19 pandemic on rates of emergency department (ED) acute appendicitis presentation, management strategies, and patient outcomes.

Summary Background Data

Acute appendicitis is the most commonly performed emergency surgery in the United States and is unlikely to improve without medical or surgical intervention. Dramatic reductions in ED visits prompted concern that individuals with serious conditions, such as acute appendicitis, were deferring treatment for fear of contracting COVID-19.

Methods

Patients from 146 hospitals with diagnosed appendicitis and arrival between March 2016 and May 2020 were selected. Electronic medical records data were retrospectively reviewed to retrieve patient data. Daily admissions were averaged from March 2016 through May 2019 and compared with March 2020. April-specific admissions were compared across the 5-year pre-COVID-19 period to April 2020 to identify differences in volume, demographics, disease severity, and outcomes.

Results

Appendicitis patient admissions in 2020 decreased throughout March into April, with April experiencing the fewest admissions. April 2020 experienced a substantial decrease in patients who presented with appendicitis, dropping 25.4%, from an average of 2030 patients (2016-2019) to 1516 in 2020. An even greater decrease of 33.8% was observed in pediatric patients (age <18). Overall, 77% of the 146 hospitals experienced a reduction in appendicitis admissions. There were no differences between years in percent of patients treated nonoperatively (P = 0.493) incidence of shock (P = 0.95), mortality (P = 0.24), or need for postoperative procedures (P = 0.81).

Conclusions

Acute appendicitis presentations decreased significantly during the COVID-19 pandemic, while overall management and patient outcomes did not differ from previous years. Further research is needed focusing on putative explanations for decreased hospital presentations unrelated to COVID-19 infection and possible implications for surgical management of uncomplicated acute appendicitis.Keywords: acute appendicitis, COVID-19, decreasing volumes, multicenter study.

Same-day discharge after appendectomy for acute appendicitis: a systematic review and meta-analysis

PURPOSE

Patients presenting with acute appendicitis are usually hospitalized for a few days for appendectomy and postoperative recovery. Shortening length of stay may reduce costs and improve patient satisfaction. The purpose of this study was to assess the safety of same-day discharge after appendectomy for acute appendicitis.

METHODS

A systematic review was performed according to PRISMA guidelines. A literature search of EMBASE, Ovid MEDLINE, Web of Science, Cochrane Central, and Google Scholar was conducted from inception to April 14, 2020. Two reviewers independently screened the literature and selected studies that addressed discharge on the same calendar day as the appendectomy. Risk of bias was assessed with the ROBINS-I tool. Main outcomes were hospital readmission, complications, and unplanned hospital visits in the postoperative course. A random effects model was used to pool risk ratios for the main outcomes.

RESULTS

Of the 1912 articles screened, 17 comparative studies and 8 non-comparative studies met the inclusion criteria. Most only included laparoscopic procedure for uncomplicated appendicitis. Most studies were considered at moderate or serious risk of bias. In meta-analysis, same-day discharge (vs. overnight hospitalization) was not associated with increased rates of readmission, complication, and unplanned hospital visits. Non-comparative studies demonstrated low rates of readmission, complications, and unplanned hospital visits after same-day discharge.

CONCLUSION

This study suggests that same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis is safe without an increased risk of readmission, complications, or unplanned hospital visits. Hence, same-day discharge may be further encouraged in selected patients.

TRIAL REGISTRATION

PROSPERO registration no. CRD42018115948.

Quality Outcomes in Appendicitis Care: Identifying Opportunities to Improve Care

INTRODUCTION

Appendicitis is one of the most common causes of acute abdominal pain requiring surgical intervention, but the variability of diagnosis and management continue to challenge the surgeons. Aim: This study assessed patients undergoing appendectomy to identify opportunities to improve diagnostic accuracy and outcomes.

METHODS

An ethically approved retrospective cohort study was undertaken between March 2016 and March 2017 at a single university hospital of all consecutive adult and paediatric patients undergoing appendectomy. Demographic data including age, gender, co-morbidities, presentation and triage timings along with investigation, imaging and operative data were analysed. Appendicitis was defined as acute based on histology coupled with intraoperative grading with the American Association for the Surgery of Trauma (AAST) grades. Complications using the Clavien-Dindo classification along with 30-day re-admission rates and the negative appendectomy rates (NAR) were recorded and categorised greater and less than 25%. The use of scoring systems was assessed, and retrospective scoring performed to compare the Alvarado, Adult Appendicitis Score (AAS) and the Appendicitis Inflammatory Response (AIR) score. Results: A total of 201 patients were studied, 115 male and 86 females, of which 136/201 (67.6%) were adults and 65/201 (32.3%) paediatric. Of the adult group, 83 were male and 53 were female, and of the paediatric group, 32 were male and 33 were female. Median age was 20 years (range: 5 years to 81 years) and no patient below the age of 5 years had an appendectomy during our study period. All patients were admitted via the emergency department and median time from triage to surgical review was 2 h and 38 min, (range: 10 min to 26 h and 10 min). Median time from emergency department review to surgical review, 55 min (range: 5 min to 6 h and 43 min). Median time to operating theatre was 21 h from admission (range: 45 min to 140 h and 30 min). Out of the total patients, 173 (86.1%) underwent laparoscopic approach, 28 (13.9%) had an open approach and 12 (6.9%) of the 173 were converted to open. Acute appendicitis occurred in 166/201 (82.6%). There was no significant association between grade of appendicitis and surgeons' categorical NAR rate (p = 0.07). Imaging was performed in 118/201 (58.7%); abdominal ultrasound (US) in 53 (26.4%), abdominal computed tomography (CT) in 59 (29.2%) and both US and CT in 6 (3%). The best cut-off point was 4 (sensitivity 84.3% and specificity of 65.7%) for AIR score, 9 (sensitivity of 74.7% and specificity of 68.6%) for AAS, and 7 (sensitivity of 77.7% and specificity of 71.4%) for the Alvarado score. Twenty-four (11.9%) were re-admitted, due to pain in 16 (58.3%), collections in 3 (25%), 1 (4.2%) wound abscess, 1 (4.2%) stump appendicitis, 1 (4.2%) small bowel obstruction and 1 (4.2%) fresh rectal bleeding. CT guided drainage was performed in 2 (8.3%). One patient had release of wound collection under general anaesthetic whereas another patient had laparoscopic drain placement. A laparotomy was undertaken in 3 (12.5%) patients with division of adhesions in 1, the appendicular stump removed in 1 and 1 had multiple collections drained.

CONCLUSION

The negative appendectomy and re-admission rates were unacceptably high and need to be reduced. Minimising surgical variance with use of scoring systems and introduction of pathways may be a strategy to reduce NAR. New systems of feedback need to be introduced to improve outcomes.

Is same-day discharge associated with increased 30-day postoperative complications and readmissions in patients undergoing laparoscopic adrenalectomy?

BACKGROUND

Advances in minimally invasive surgery and perioperative care have decreased substantially the duration of time that patients spend recovering in hospital, with many laparoscopic procedures now being performed on an ambulatory basis. There are limited studies, however, on same-day discharge after laparoscopic adrenalectomy. The objectives of this study were to investigate the outcomes and trends of ambulatory laparoscopic adrenalectomy in a multicenter cohort of patients.

METHODS

Adult patients who underwent elective laparoscopic adrenalectomy between 2005 and 2016 were identified in the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Baseline demographics and 30-day outcomes were compared between patients who underwent ambulatory laparoscopic adrenalectomy and those who were discharged after an inpatient stay. Multivariable logistic regression and Cox proportional hazards modelling were used to investigate the association between same-day discharge and 30-day complications and unplanned readmissions.

RESULTS

Of the 4,807 patients included in the study, 88 (1.8%) underwent ambulatory laparoscopic adrenalectomy and 4,719 (98.2%) were admitted after the adrenalectomy. The same-day discharge group contained fewer obese patients (37.2% vs 50%; P = .04), a lesser proportion of American Society of Anesthesiologists class III patients (45.5% vs 61%; P = .003), and more patients with primary aldosteronism (14.8% vs 6%; P = .002) compared with the inpatient group. After adjustment for confounders, same-day discharge was not associated with 30-day overall complications (OR 1.17, 95% CI 0.35-3.85; P = .80) or unplanned readmissions (HR 2.77, 95% CI 0.86-8.96; P = .09). The percentage of laparoscopic adrenalectomies performed on an ambulatory basis at hospitals participating in the ACS NSQIP remained low throughout the study period (0-3.1% per year) with no evidence of an increasing trend over time (P = .21).

CONCLUSION

Ambulatory laparoscopic adrenalectomy is a safe and feasible alternative to inpatient hospitalization in selected patients. Further study is needed to determine the cost savings, barriers to uptake, and optimal selection criteria for this approach.

Risk Factors for Readmission After Short-Hospital-Stay Laparoscopic Appendectomy

BACKGROUND

Single-day discharge is a common practice among patients undergoing laparoscopic appendectomy (LA). We aimed to determine risk factors associated with readmission in patients with short hospital stay after LA.

METHODS

We performed a retrospective analysis of all patients who underwent LA during the period 2006-2019. Patients with length of hospital stay shorter than 24 h were included. Demographics, operative variables, and postoperative outcomes were analyzed. Multivariable logistic regression was performed to determine risk factors for readmission.

RESULTS

A total of 2009 LA were performed during the study period; 1506 (75%) patients had short hospital stay and were included in the analysis. Median age was 31 (14-85) years, and 720 (48%) were female. Mild peritonitis was diagnosed in 423 (28%) patients, and 121 (8%) had gangrenous/perforated appendicitis. Mean surgical time was 51(14-180) min. Conversion rate was 0.4%. There were 143 (9%) postoperative complications, including 29 (1.9%) patients with postoperative intra-abdominal abscess. Nine patients (0.6%) underwent reoperation, and only 26 (1.7%) patients were readmitted. The mean time to hospital readmission was 6 (1-14) days. Although age >50 years, obesity, mild peritonitis, and complicated appendicitis were more frequent among patients readmitted, only age >50 years (OR 3.54 95% CI 1.51-8.30) and mild peritonitis (OR 6.16 95% CI 1.80-34.93) were found as independent risk factors for readmission.

CONCLUSION

Most patients undergoing LA can be safely discharged within 24 h of admission. Patients over 50 years old and/or with localized peritonitis have significantly higher risk of readmission and therefore may need a closer postoperative follow-up.

Predictors risk factors for acute complex appendicitis pain in patients: Are there gender differences?

Objective:

The purpose of this study is to determine the predictive risk factors for appendicitis and the cost-effectiveness of using abdominal helical computed tomography (CT) in comparison to abdominal ultrasonography (US) for the diagnosis of acute appendicitis in patients.

Subjects and Methods:

The typical case was a patient with abdominal pain in the right lower quadrant and suspicion of appendicitis. A total of 643 patients who were consequently treated with appendectomy upon diagnosis of acute appendicitis between January 2015 and December 2018 were included in the study. The four diagnostic alternatives chosen were US, CT, biochemistry parameters, and physical examination in the hospital.

Results:

There were statistically significant differences between male and female patients with regards to age, BMI, cigarette smoking, sheesha smoking, family history of diabetes, hypertension and family history of gastrointestinal discomfort (GI), anxiety (P < 0.001), red eye (P = 0.006), dizziness (P = 0.021), headache (P < 0.001), muscular symptoms, weakness and cramps (P < 0.001), bloating or swollen stomach (P < 0.001), UTI (P < 0.001), chest pain (P < 0.001), guarding (P < 0.001), loss of appetite (P = 0.004), nausea (P < 0.001) vomiting (P = 0.042), anorexia (P = 0.009), and constipation (P = 0.002). Moreover, there were statistically significant differences between male and female patients for pain (P < 0.001), pain right belly (P = 0.027), severe crumps (P = 0.007), high temperature and fever (P < 0.001), irritable bowel syndrome (P < 0.001), right iliac fossa (RIF) pain (P = 0.008), rebound tenderness (P = 0.024), positive bowel sounds (P = 0.029), and pointing tenderness (P < 0.001). Multivariate stepwise logistic regression showed nausea (P < 0.001), C-reactive protein (CRP) (P < 0.001), dizziness (P = 0.016), vomiting (P < 0.001), muscular symptoms (P = 0.007), irritable bowel syndrome (P = 0.034), guarding (P = 0.040), and loss appetite (P = 0.046) were considered at higher risk as predictors for appendicitis patients.

Conclusions:

CT is more cost-effective than the US and clinical examination for determining appendicitis. The current study suggested that nausea, C-reactive protein, dizziness, vomiting, muscular symptoms, irritable bowel syndrome, guarding, and loss appetite were considered as higher risk predictors for appendicitis patients.

Risk factors for serious morbidity, prolonged length of stay and hospital readmission after laparoscopic appendectomy - results from Pol-LA (Polish Laparoscopic Appendectomy) multicenter large cohort study

Laparoscopic appendectomy (LA) for treatment of acute appendicitis has gained acceptance with its considerable benefits over open appendectomy. LA, however, can involve some adverse outcomes: morbidity, prolonged length of hospital stay (LOS) and hospital readmission. Identification of predictive factors may help to identify and tailor treatment for patients with higher risk of these adverse events. Our aim was to identify risk factors for serious morbidity, prolonged LOS and hospital readmission after LA. A database compiled information of patients admitted for acute appendicitis from eighteen Polish and German surgical centers. It included factors related to the patient characteristics, peri- and postoperative period. Univariate and multivariate logistic regression models were used to identify risk factors for serious perioperative complications, prolonged LOS, and hospital readmissions in acute appendicitis cases. 4618 laparoscopic appendectomy patients were included. First, although several risk factors for serious perioperative complications (C-D III-V) were found in the univariate analysis, in the multivariate model only the presence of intraoperative adverse events (OR 4.09, 95% CI 1.32-12.65, p = 0.014) and complicated appendicitis (OR 3.63, 95% CI 1.74-7.61, p = 0.001) was statistically significant. Second, prolonged LOS was associated with the presence of complicated appendicitis (OR 2.8, 95% CI: 1.53-5.12, p = 0.001), postoperative morbidity (OR 5.01, 95% CI: 2.33-10.75, p < 0.001), conversions (OR 6.48, 95% CI: 3.48-12.08, p < 0.001) and reinterventions after primary procedure (OR 8.79, 95% CI: 3.2-24.14, p < 0.001) in the multivariate model. Third, although several risk factors for hospital readmissions were found in univariate analysis, in the multivariate model only the presence of postoperative complications (OR 10.33, 95% CI: 4.27-25.00), reintervention after primary procedure (OR 5.62, 95% CI: 2.17-14.54), and LA performed by resident (OR 1.96, 95% CI: 1.03-3.70) remained significant. Laparoscopic appendectomy is a safe procedure associated with low rates of complications, prolonged LOS, and readmissions. Risk factors for these adverse events include complicated appendicitis, postoperative morbidity, conversion, and re-intervention after the primary procedure. Any occurrence of these factors during treatment should alert the healthcare team to identify the patients that require more customized treatment to minimize the risk for adverse outcomes.

Ambulatory versus conventional laparoscopic appendectomy: a systematic review and meta-analysis

PURPOSE

Ambulatory laparoscopic appendectomy has gained popularity due to the improved understanding of patient selection criteria, the application of enhanced recovery pathways, and the potential for improving healthcare resource utilization. The aim of the review was to compare the morbidity and readmission rates between ambulatory and conventional laparoscopic appendectomy (LA).

METHODS

A systematic search was undertaken using PubMed, Embase, Cochrane, and Web of Science. Studies from 2014 to 2018, on adult patients undergoing ambulatory LA, were considered. Meta-analyses were conducted to pool the total number of complications and readmission events in the ambulatory and conventional groups.

RESULTS

A total of 5 studies met our inclusion criteria accounting for 7079 total of patients with acute appendicitis treated by ambulatory LA and 6370 patients treated by conventional LA. We included four observational studies (two prospective and two retrospective) and one randomized controlled trial. Length of stay was significantly lower in the ambulatory group (mean difference = - 15.63 h, 95% CI = - 21.78 to - 9.49, P = < 0.00001). The relative risk (RR) of reoperation was 0.49 (95% CI = 0.12-1.95, P = 0.31). The results demonstrated a pooled RR of overall morbidity of 0.79 (95% CI = 0.65-0.97, P = 0.02) and a pooled RR of readmission of 0.72 (95% CI = 0.59-0.88, P = 0.002), both results favoring the ambulatory LA group.

CONCLUSION

There is a lack of high-quality comparative studies making conclusive recommendations not possible at this time. Based on current data, ambulatory LA may be safe and feasible as compared with conventional LA.

Same-Day Discharge after Non-Perforated Laparoscopic Appendectomy Is Safe

Purpose: Several single-center studies have demonstrated same-day discharge (SDD) to be safe in adults undergoing laparoscopic appendectomy (LA) for non-perforated appendicitis (NPA). The proportion of SDD appendectomy patients nationally is unknown. We sought to identify the incidence of SDD among patients undergoing LA after NPA hypothesizing a similar risk of complications including superficial surgical site infections (SSSIs), post-operative intra-abdominal abscess, and 30-day readmission rates. Materials and methods: The 2016-2017 ACS-NSQIP Procedure-Targeted Appendectomy database was queried for adults undergoing LA with no intraoperative findings of perforation or abscess. Patients with SDD were compared to those discharged within two days. A multivariable logistic regression model was used for analysis. Results: From 16,931 patients undergoing LA, 3988 (23.6%) were SDD. Compared to those with a longer hospital stay, patients with SDD were of similar age (p = 0.29) and less likely to have a contaminated wound-class (58.5% vs. 62.6%, p < 0.001). After adjusting for age and comorbidities, patients with SDD had a similar risk of 30-day readmission (p = 0.088) and post-operative abscess (p = 0.739) but lower risk of SSSI (OR: 0.48, 0.28-0.82, p = 0.008), compared to those discharged within two days. Conclusions: Nearly a quarter of patients with NPA undergoing LA are discharged the same day. The risk of 30-day readmission is similar compared to those with a longer index hospital stay. Interestingly, the risk of SSSI is lower, however this may be related to differences in wound classification and/or selection bias. Regardless, SDD for NPA patients appears safe and should be utilized whenever possible.

Challenging the myth of outpatient craniotomy for brain tumor in a Sub-Saharan African setting: A case series of two patients in Ibadan, Nigeria

BACKGROUND

The concept of modern neuro-oncology hinges on strategic innovation and refinement of procedures with the intention to enhance safety, optimize extent of tumor resection, and improve not only survival but also the quality of life as well. One of such refinements includes same-day hospital admission, as well as early discharge following brain tumor surgeries. The latter has been further stretched to same-day discharge in particular settings to reduce the risk of nosocomial infections, cut brain tumor surgery costs, and improve patients' satisfaction. We highlight the challenges and possible benefits of outpatient craniotomy in a sub-Saharan African setting portrayed by the presence of lean resources and a predominant "out of pocket" health-care financing.

CASE DESCRIPTION

Outpatient craniotomy was performed in two selected patients harboring intra-axial tumors: a right temporal low-grade glioma and a left frontal metastasis. The clinical outcome proved successful at short- and long-term in both patients; complications related to surgery and same-day discharge were not reported.

CONCLUSION

Outpatient craniotomy is practicable and safe in resource-challenged environments and can further make brain tumor surgery cost effective and acceptable in carefully selected patients. Further prospective studies in similar settings but involving larger groups of patients are warranted.

Is early appendectomy in adults diagnosed with acute appendicitis mandatory? A prospective study

Introduction

Prompt appendectomy has long been the standard of care for acute appendicitis in order to prevent complications such as perforation, abscess formation, and diffuse purulent or fecal peritonitis, all resulting in increased morbidity and even mortality. Our study was designed to examine whether the time from the beginning of symptoms to operation correlates with the pathological degree of appendicitis, incidence of postoperative complications, or increased length of hospital stay.

Methods

A prospective study of 171 patients who underwent emergent appendectomy for acute appendicitis in the course of 2 years was conducted in a single tertiary medical center. The following parameters were monitored and correlated: demographics, time from the onset of symptoms until the arrival to the emergency department (patient interval (PI)), time from arrival to the emergency department (ED) until appendectomy (hospital interval (HI)), time from the onset of symptoms until appendectomy (total interval (TI)), physical examination, preoperative physical findings, laboratory data, pathologic findings, complications, and length of hospital stay.

Results

The degree of pathology and complications were analyzed according to the time intervals. The time elapsed from the onset of symptoms to surgery was associated with higher pathology grade (p = 0.01). We found that longer time from the onset of symptoms to hospital arrival correlates with higher pathology grade (p = 0.04), while there was no correlation between the hospital interval and pathology grade (p = 0.68). A significant correlation was found between the pathology grade and the incidence of postoperative complications as well as with increased length of hospital stay (p = 0.000).

Conclusion

Time elapsed from the symptom onset to appendectomy correlates with increased pathology grade and complication rate. This correlation was not related to the HI. Since the HI in our study was short, we recommend an early appendectomy in adults in order to shorten the TI and the resulting complications.

The significant impact of age on the clinical outcomes of laparoscopic appendectomy: Results from the Polish Laparoscopic Appendectomy multicenter large cohort study

Acute appendicitis (AA) is the most common surgical emergency and can occur at any age. Nearly all of the studies comparing outcomes of appendectomy between younger and older patients set cut-off point at 65 years. In this multicenter observational study, we aimed to compare laparoscopic appendectomy for AA in various groups of patients with particular interest in the elderly and very elderly in comparison to younger adults.Our multicenter observational study of 18 surgical units assessed the outcomes of 4618 laparoscopic appendectomies for AA. Patients were divided in 4 groups according to their age: Group 1-<40 years old; Group 2-between 40 and 64 years old; Group 3-between 65 and 74 years old; and Group 4-75 years old or older. Groups were compared in terms of peri- and postoperative outcomes.The ratio of complicated appendicitis grew with age (20.97% vs 37.50% vs 43.97% vs 56.84%, P < .001). Similarly, elderly patients more frequently suffered from perioperative complications (5.06% vs 9.3% vs 10.88% vs 13.68%, P < .001) and had the longest median length of stay (3 [Interquartile Range (IQR) 2-4] vs 3 [IQR 3-5], vs 4 [IQR 3-5], vs 5 [IQR 3-6], P < .001) as well as the rate of patients with prolonged length of hospital stay (LOS) >8 days. Logistic regression models comparing perioperative results of each of the 3 oldest groups compared with the youngest one showed significant differences in odds ratios of symptoms lasting >48 hours, presence of complicated appendicitis, perioperative morbidity, conversion rate, prolonged LOS (>8 days).The findings of this study confirm that the outcomes of laparoscopic approach to AA in different age groups are not the same regarding outcomes and the clinical picture. Older patients are at high risk both in the preoperative, intraoperative, and postoperative period. The differences are visible already at the age of 40 years old. Since delayed diagnosis and postponed surgery result in the development of complicated appendicitis, more effort should be placed in improving treatment patterns for the elderly and their clinical outcome.