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Kumar SS, Collings AT, Lamm R, Haskins IN, Scholz S, Nepal P, Train AT, Athanasiadis DI, Pucher PH, Bradley JF, Hanna NM, Quinteros F, Narula N, Slater BJ. SAGES guideline for the diagnosis and treatment of appendicitis. Surg Endosc 2024; 38:2974-2994. [PMID: 38740595 DOI: 10.1007/s00464-024-10813-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/21/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis. METHODS A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. RESULTS Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty. CONCLUSIONS These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.
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Affiliation(s)
- Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pramod Nepal
- Division of Colon & Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | | | - Philip H Pucher
- School of Pharmacy and Biosciences, University of Portsmouth & Department of General Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Joel F Bradley
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Nisha Narula
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Bethany J Slater
- University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, USA.
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Zarog M, O’Leary P, Kiernan M, Bolger J, Tibbitts P, Coffey S, Byrnes G, Peirce C, Dunne C, Coffey C. Circulating fibrocyte percentage and neutrophil-lymphocyte ratio are accurate biomarkers of uncomplicated and complicated appendicitis: a prospective cohort study. Int J Surg 2023; 109:343-351. [PMID: 37093074 PMCID: PMC10389644 DOI: 10.1097/js9.0000000000000234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/09/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND There is increasing evidence that uncomplicated appendicitis (UA) may be treated nonoperatively in cases of UA. This study aimed to evaluate and compare the diagnostic accuracy of circulating fibrocyte percentage (CFP), white blood cell count, C-reactive protein, and neutrophil-lymphocyte ratio (NLR) in diagnosing uncomplicated and complicated appendicitis. MATERIALS AND METHODS Eighty consecutive adult patients presenting with suspected appendicitis were recruited in a cohort-based prospective study between June 2015 and February 2016 at University Hospital Limerick in Ireland. Peripheral venous samples were obtained at the presentation. Clinical, biochemical, radiological, and histopathological parameters were recorded. The CFP was determined by dual-staining for CD45 and collagen-I using flow cytometry analysis and correlated with histopathological diagnoses. RESULTS Of the 46 patients who underwent appendicectomy, 34 (73.9%) had histologically proven acute appendicitis. A comparison of the diagnostic accuracy of biomarkers demonstrated the CFP had the highest diagnostic accuracy for UA (area under the curve=0.83, sensitivity=72.7%, specificity=83.3%, P=0.002). The NLR had the highest diagnostic accuracy in relation to complicated appendicitis (area under the curve=0.84, sensitivity=75.5%, specificity=83.3%, P=0.005). CONCLUSIONS CFP and NLR are accurate biomarkers of UA and complicated appendicitis.
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Haijanen J, Sippola S, Tammilehto V, Grönroos J, Mäntyoja S, Löyttyniemi E, Niiniviita H, Salminen P. Diagnostic accuracy using low-dose versus standard radiation dose CT in suspected acute appendicitis: prospective cohort study. Br J Surg 2021; 108:1483-1490. [PMID: 34761262 PMCID: PMC10364876 DOI: 10.1093/bjs/znab383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/05/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Contrast-enhanced CT is the reference standard used in diagnostic imaging for acute appendicitis in adults. The radiation dose has been of concern. This study aimed to assess whether a lower radiation dose would affect the diagnostic accuracy of CT. METHODS This was a prospective single-centre cohort study of patients (aged over 16 years) with suspected appendicitis evaluated for enrolment in concurrent APPAC II-III trials. The diagnostic accuracy of contrast-enhanced low- and standard-dose CT was compared with study protocols guiding imaging based on BMI; this enabled direct CT imaging comparison only in patients with a BMI below 30 kg/m2. The on-call CT diagnosis was compared with the final clinical diagnosis. RESULTS Among all 856 patients investigated, the accuracy of low-dose (454 patients) and standard-dose (402 patients) CT in identifying patients with and without appendicitis was 98·0 and 98·5 per cent respectively. In patients with a BMI under 30 kg/m2, respective values were 98·2 per cent (434 patients) and 98·6 per cent (210 patients) (P = 1·000). The corresponding accuracy for differentiating between uncomplicated and complicated acute appendicitis was 90·3 and 87·6 per cent in all patients, and 89·8 and 88·4 per cent respectively among those with a BMI below 30 kg/m2 (P = 0·663). The median radiation dose in the whole low- and standard-dose CT groups was 3 and 7 mSv respectively. In the group with BMI below 30 kg/m2, corresponding median doses were 3 and 5 mSv (P < 0·001). CONCLUSION Low- and standard-dose CT were accurate both in identifying appendicitis and in differentiating between uncomplicated and complicated acute appendicitis. Low-dose CT was associated with a significant radiation dose reduction, suggesting that it should be standard clinical practice at least in patients with a BMI below 30 kg/m2.
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Affiliation(s)
- Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland.,Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - Ville Tammilehto
- Department of Radiology, Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Siiri Mäntyoja
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | | | - Hannele Niiniviita
- Department of Radiology, Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland.,Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
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Thapa Basnet A, Singh S, Thapa B, Kayastha A. Management of Acute Appendicitis during COVID-19 Pandemic in a Tertiary Care Centre: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc 2021; 59:252-255. [PMID: 34506434 PMCID: PMC8369543 DOI: 10.31729/jnma.6307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Acute appendicitis is the most common reason for abdominal surgery in children. Though appendectomy considered the gold standard there are a lot of complications related to it. Conservative management of acute appendicitis is not new to medical science. In pandemic like COVID-19 when all the health systems were about to shut-down because of lack of manpower and resources, we started a trial of non-operative management. The main aim of this study is to find out the management of acute appendicitis during COVID-19. METHODS This was a descriptive cross-sectional study conducted in a tertiary care centre. Data collection was done from the record section which included the patients diagnosed with acute appendicitis from February 2020 to July 2020 after obtaining ethical clearance from Institutional Review Committee. Cases of appendicular lump, appendicular abscess, appendicular perforations have been excluded. Data was collected and entry was done in Statistical Package for the Social Science software version 20, point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS The conservative management of acute appendicitis was done in 44 cases (55.7%) while 35 cases (44.3%) had to undergo appendectomy. CONCLUSIONS COVID-19 can complicate the perioperative course as a result of direct lung injury and multiple organ dysfunctions and can also bring serious threats to the safety of medical staffs involved in managing the acute appendicitis case operatively, so conservative management can be considered as an alternative way of management of acute appendicitis in the pandemic outbreak.
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Affiliation(s)
- Anupama Thapa Basnet
- Department of Pediatric Surgery, Kanti Children's Hospital, Maharajganj, Kathmandu, Nepal
| | - Suraj Singh
- Department of Pediatric Surgery, Kanti Children's Hospital, Maharajganj, Kathmandu, Nepal
| | - Bijay Thapa
- Department of Pediatric Surgery, Kanti Children's Hospital, Maharajganj, Kathmandu, Nepal
| | - Anuj Kayastha
- Department of Pediatric Surgery, Kanti Children's Hospital, Maharajganj, Kathmandu, Nepal
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