Comparison of clinical and histopathological features of patients who underwent incidental or emergency appendectomy

Sex Differences in Appendicitis: A Systematic Review

Appendicitis is one of the most common gastrointestinal conditions a person can develop. Throughout the years of assessing the different focuses of appendicitis, such as origin, symptoms, labs, diagnosis, treatment, and complications, there have been mere mentions of sex differences. One of the most known sex differences in appendicitis is the fact that males are significantly more likely to develop appendicitis compared to females. Another postulated difference is that males may be more likely to develop a perforated appendix. These differences significantly affect the various aspects of diagnosing and treating appendicitis and may even influence the outcome of appendicitis. Sex difference analysis of conditions has been widely researched over the last two decades, and sex can influence and impact conditions from initial presentation to the outcome of treatment. This paper evaluates the sex differences in appendicitis concerning incidence, risk factors, symptoms, diagnosis technique, treatment, and outcomes across ages. Following PRISMA guidelines, this systematic review reviewed PubMed, ScienceDirect, and ProQuest databases for articles pertaining to sex differences in appendicitis. The original article count was 21,121, which was narrowed down to 28 publications. It was found that, as previously described, males had a significantly higher rate of appendicitis, as well as were at significant risk of perforated appendicitis. No official risk factors were found to differ between the sexes, but males were more likely to complain of symptoms like right lower quadrant cramps/tenderness/pain and loss of appetite. Scores such as the pediatric appendicitis score (PAS) and Ohmann have been used to diagnose appendicitis, but the PAS was significantly more accurate for females, and the Ohmann resulted in significantly fewer negative appendectomies in females as well. Ultrasound and computed tomography (CT) are still the gold standards for diagnosis; however, while time to CT was significantly delayed in females, they were more likely to undergo extensive imaging, possibly to rule out other conditions. Males were more likely to undergo open appendectomies compared to females, who more frequently underwent laparoscopic appendectomy, yet females were more likely to experience complications. Further research should evaluate the influences that can predict postoperative outcomes following appendectomies between sexes and how to prevent/reduce their occurrence.

Incidental appendicectomy in pancreas transplantation: A single-center study

BACKGROUND

Appendicitis in pancreatic transplant recipients can be challenging to diagnose and manage. Incidental appendicectomy (IA) during pancreas transplantation obviates the risk of appendicitis but potentially at the cost of increased operating time or early post-operative complications. This study reviewed the value of IA at a single center.

METHODS

This was a retrospective study of patients who underwent a pancreas transplant in our unit from January 1st, 2012 to December 31st, 2020, with end of follow-up on May 21st, 2023; recipients were grouped by whether or not an IA was performed during pancreas transplantation. Donor, recipient, operative, and graft outcomes were compared between the two groups. Post-transplant complications related to appendiceal pathology (or IA) were recorded and classified.

RESULTS

Two hundred forty-three patients underwent a pancreas transplant; 227 (93%) patients had an appendix in situ at transplantation, and of these 53 (23%) underwent an IA and 174 (77%) did not. There were no statistically significant differences in operative time (p = .06) or hospital stay (p = .50) between the two groups. In the IA cohort, there were no Clavien-Dindo Grade III-V complications relating to the appendicectomy. In those that did not undergo an IA, two patients (1%) subsequently required appendicectomy due to appendicitis. Comparison of pancreatic graft survival showed no statistically significant difference between the groups (p = .44).

CONCLUSIONS

This study suggests that IA is effective at reducing risks of post-transplant appendiceal complications without significantly prolonging inpatient stay or impairing graft survival. These data support the consideration of undertaking an IA for all patients undergoing a pancreas transplant.

Elevated total and direct bilirubin are associated with acute complicated appendicitis: a single-center based study in Saudi Arabia

BACKGROUND

Appendicitis is the most common abdominal surgical emergency and up to our knowledge no previous studies have been conducted in Saudi Arabia particularly at Qassim region and this study aimed to determine a total and direct bilirubin as a predictor of acute complicated appendicitis.

METHODS

Observational retrospective study that included patients admitted under the general surgery department with a diagnosis of acute appendicitis at King Saud Hospital, Unaizah, Saudi Arabia. Data on age, gender, BMI, diabetes mellitus, total and direct bilirubin, AST, ALT, sodium, and WBCs levels were obtained.

RESULT

Among the overall study population of 158 patients, the age median [IQR] was 24.5 [19-31], males were 99 (62.7%), and complicated appendicitis was 33 (20.9%). The multivariable analysis revealed that both elevated total and direct bilirubin are associated with complicated appendicitis (aOR = 3.79, 95% CI: 1.67-8.48, P = 0.001) and (aOR = 4.74, 95% CI: 2.07-10.86, P < 0.001) respectively. A receiver operating characteristic curve showed the best cutoff value of total and direct bilirubin as ≥ 15 µmol/L and ≥ 5 µmol/L respectively, with a sensitivity of 57.6%, and specificity of 73.6% for elevated total bilirubin, and a sensitivity of 54.6%, and specificity of 80% for elevated direct bilirubin.

CONCLUSION

Elevated total and direct bilirubin are associated with acute complicated appendicitis in this setting. However, it should be supportive factor for acute complicated appendicitis and not considered as standalone diagnostic test.

Oncological aspect of incidental appendectomy with regard to histopathological findings: A retrospective cohort study

INTRODUCTION

The aim of this retrospective cohort study was to describe the findings on histopathological examination of removed, macroscopically non-diseased, vermicular appendix during another primary surgical procedure (incidental appendectomy (IA)). Previous studies disapproved IA but were based on the possibility of complicated appendicitis. We observed the prevalence of neoplasms of the appendix in IA versus the appendectomy performed due to acute appendicitis (AA).

METHODS

The database of histopathology reports of the Surgery Department, University Hospital of Split was reviewed in the period from January 1, 2017, to December 31, 2021. A total of 2832 histopathology reports were reviewed.

RESULTS

There was no difference in gender distribution between these two groups, but AA had a statistically significantly lower median patient age compared to the group IA (40 vs. 68 years; P < 0.001). In the AA group, there were 84.5% acute appendicitis, 11.1% normal appendiceal reports, 3.2% appendiceal neoplasms, and 1.2% other pathologies. The group IA had 89.5% normal findings of the appendix, 7.2% appendiceal neoplasms, and 0.5% other pathology. The difference in neoplasm prevalence between IA and AA groups was 4.0% (95%CI: 2.2 to 5.8), P < 0.001. The number of incidental appendectomies needed to detect one neoplasm of the appendix is 25.

CONCLUSION

Incidental appendectomies in patients undergoing abdominal surgery revealed a relatively high prevalence of appendiceal neoplasms above the age of 60 years. Prospective studies about incidental appendectomies, their clinical consequences, and impact on prognosis should be performed to define the value of incidental appendectomy in those patients.

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.

Diagnostic accuracy of ultrasound in diagnosing acute appendicitis in pregnancy: a systematic review and meta-analysis

BACKGROUND

Lack of timely diagnosis of acute appendicitis (AA) can lead to perforation and peritonitis, which might be associated with complications such as miscarriage, preterm delivery, fetal loss, and even maternal mortality. The aim of the present systematic review and meta-analysis was to evaluate the accuracy of ultrasonography (US) for diagnosing AA in pregnant patients.

METHODS

We performed the present systematic review and meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Using a pre-designed standard datasheet, the two authors summarized the data of each study independently. Pregnant women with diagnosed or suspected AA, who have undergone ultrasonography, as well as using CT scan or surgery as the standard method, were included.

RESULTS

A total of 8 studies consisting of 1593 patients were included. The main analysis showed that the overall sensitivity and specificity were 77.6% and 75.3% for US in diagnosing AA in pregnancy. The sensitivity of US in the first, second, and third trimesters of pregnancy were 69%, 63%, and 51%, respectively. While the corresponding figures for specificity were 85%, 85%, and 65%. There was a significant difference in the diagnostic performance of US between the first two trimesters and the third one. The DORs in these three trimesters were 36, 26, and 1.92, respectively.

CONCLUSIONS

Ultrasound evaluation showed a low diagnostic accuracy for acute appendicitis in pregnant women, especially during the third trimester. These patients should be diagnosed early and accurately to prevent both complications and unnecessary operations. It can be recommended to consider alternative imaging, mostly after negative or uncertain US.

A retrospective study about incidental appendectomy during the laparoscopic treatment of intussusception

PURPOSE

We aim to see incidental appendectomy (IA) was worth or not during the laparoscopic treatment of intussusception.

METHODS

This study included forty-eight patients who underwent a laparoscopic procedure for idiopathic intussusception without intestinal resection between April 2014 and April 2021. The Chi-square or Fisher's exact tests for categorical variables and the Student t-test for continuous variables were used to analyze and compare patient characteristics.

RESULTS

IA was performed on 63% (30/48) of patients after surgical reduction, while 18 (37%), did not. Patients who underwent IA had a higher total cost (16,618 ± 2,174 vs.14,301 ± 5,206, P = 0.036), and a longer mean operation duration (59 ± 19 vs.45 ± 21, P = 0.025). The distribution of the PO time, length of hospital stay, PCs, and RI did not differ significantly. The histopathological evaluation of the 30 resected appendices revealed five (17%) with signs of acute inflammation, 20 (66%) with chronic signs of inflammation, and five (17%) with inconspicuous appendices.

CONCLUSION

IA is linked to a longer average operation time and a higher total cost. There is insufficient evidence to recommend IA during laparoscopic intussusception treatment. The risks and benefits of IA need further study.

Acute appendicitis–advances and controversies

Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon’s practice. With the recent advancements in AA’s management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon’s repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic’s repercussions on patients and how surgeons’ practices have evolved in the context of AA.

A cross-sectional study on evaluation of complete blood count-associated parameters for the diagnosis of acute appendicitis

BACKGROUND AND AIMS

Acute appendicitis is one of the common causes of abdominal surgeries, however, the rate of negative appendectomy is as high as 20% as the diagnosis of appendicitis is challenging. The study aimed to evaluate complete blood count (CBC)-associated parameters among positive and negative appendectomy patients and determine their diagnostic importance.

METHODS

In this cross-sectional study, patients who suspected of acute appendicitis were included. Preoperative blood samples taken from these patients for a complete blood count. Following parameters evaluated from their CBC: white blood cell (WBC), platelet (PLT), mean platelet volume (MPV), neutrophils-to-lymphocytes ratio, platelets-to-lymphocytes ratio, red cell distribution width (RDW), and platelet distribution width (PDW). These parameters analyzed for the positive and negative appendectomy patients using statistical analysis.

RESULTS

Of 200 patients included in the study, 30 patients (15%) underwent negative appendectomy. The mean neutrophils, WBC, red blood cells, neutrophils-to-lymphocytes, and platelets-to-lymphocytes ratio was significantly high among positive appendectomy patients, (P < .05), whereas MPV to platelet ratio was significantly less in this group. The highest diagnostic power for the diagnosis of appendicitis was of neutrophils-to-lymphocytes ratio with the sensitivity of 83.5% and the specificity of 90%.

CONCLUSION

The findings of our study indicate that neutrophils-to-lymphocytes ratio alone is not sufficient for preoperative diagnosis of acute appendicitis and other CBC-related parameters did not have good sensitivity and specificity. Further studies are therefore required in this area.

Inflammatory Markers and Duration of Symptoms Have a Close Connection With Diagnosis and Staging of Acute Appendicitis in Children

Background: For children with acute appendicitis (AA), a clear diagnosis is a challenge. The purpose of this study is to explore whether inflammatory markers in the blood combined with symptom duration are helpful in the diagnosis of acute appendicitis and in predicting the severity of acute appendicitis. Methods: All the selected patients underwent appendectomy between November 10, 2011 and November 15, 2019, in whom preoperative WBCC, CRP, and NE% had been measured in a short time. All patients were divided into two groups: uncomplicated AA and complicated AA, postoperatively. Results: For our standards, 813 patients were selected, 442 of them had complicated AA. The mean [standard deviation (SD)] age for the uncomplicated AA group was 9.78 ± 2.02 years and for the complicated AA group was 9.69 ± 2.16 years (P = 0.55). Elevated WBCC, CRP, and NE% had a higher relatively sensitivity in complicated AA than uncomplicated AA especially when WBCC, CRP, and NE% were at normal levels, which had a sensitivity of 100% in uncomplicated AA, but this only applied to nine patients. CRP values were significantly different in three time groups, whether uncomplicated or complicated AA. Conclusion: The combination of WBCC, CRP, and NE% values is very sensitive for the diagnosis of acute appendicitis, and when we predict complicated AA using the CRP value, we also need to consider the time of symptom onset.

Evaluation of liver transplant recipients underwent incidental appendectomies

OBJECTIVE

To assess the clinicopathological features of liver transplant recipients underwent incidental appendectomies.

METHODS

Between September 2002 and July 2019, 2500 patients underwent liver transplantation at our Liver Transplant Institute, including 38 (24 males, 14 females) who also underwent incidental appendectomies. Incidental appendectomies were performed on 24 patients during recipient hepatectomies and on 14 during relaparotomies due to various surgical conditions. The following patient parameters were retrospectively evaluated: age, sex, underlying liver disease, liver transplant type, appendectomy indication, appendix length (mm) and diameter (mm), presence of appendicitis, and histopathological findings.

RESULTS

The 38 patients who underwent incidental appendectomies had a mean age of 18.3±21.7 (range: 1-66) years and median appendix lengths and diameters of 55 (range: 19-90) mm and 6 (range: 4-20) mm, respectively. Histopathologically, the appendectomy specimens were classified as follows: vermiform appendix (n=16), lymphoid hyperplasia (n=13), acute appendicitis (n=3), fibrous obliteration (n=3), perforated appendicitis (n=1), mucinous cystadenoma (n=1), and appendiceal serosa invasion by sigmoid adenocarcinoma (n=1). There were no postoperative complications, including wound infections, abscesses, or leakage from the appendiceal stumps, related to the incidental appendectomies.

CONCLUSION

This study demonstrated that incidental appendectomies can be successfully performed in immunosuppressed patients. However, additional studies are required to confirm these results.

Unusual infectious agents detected in appendectomy specimens: A retrospective analysis of 42 cases

OBJECTIVES

The aim of this study was to evaluate the clinical and histopathological features of 42 patients with unusual infectious agents detected in their appendectomy specimens.

MATERIAL AND METHODS

Between January 1999 and November 2018, 2.754 patients underwent emergency or incidental appendectomy in our clinic, and their pathology reports were retrospectively reviewed. Unusual infectious agents or eosinophilic infiltration of the appendix were reported in the initial pathological examinations of 57 patients. The pathological slides of these patients were re-examined by histopathologists. The examinations revealed that 15 of these patients had no microscopic findings suggestive of parasitic infections. The remaining 42 patients with unusual appendiceal infectious agents were included into the study.

RESULTS

A total of 42 patients (25 females and 17 males) aged 18 to 75 years were included into this study. While 32 of these patients (76%) underwent emergency appendectomy with a presumed diagnosis of acute appendicitis (AAp), the remaining 10 patients underwent incidental appendectomy for various reasons. Twenty-two patients (52.4%) had histopathological changes consistent with AAp while 20 patients had no evidence of AAp. Histopathological examination revealed infection with Enterobius vermicularis in 38 of the patients, Taenia species in 2, and Ascaris lumbricoides and Actinomyces species in 1 patient each. A total of 24 patients were treated for infections with mebendazole (n = 20), albendazole (n =1), niclosamide (n = 2), and amoxicillin (n = 1).

CONCLUSION

Unusual infectious agents should be considered as factors potentially triggering AAp, especially in patients living in endemic areas. The appendiceal stump should be inspected for parasite residues.

The common motives for appendectomy in Hail Region Saudi Arabia

Background

Appendectomy remains the most common emergency surgery. With the lack of literature from Saudi Arabia regarding the treatment for appendix disorders, this study aimed to identify the common motives for appendectomy in Northern Saudi Arabia.

Methodology

Data referring to be resected appendix patients who were diagnosed during the period from January 2018 to December 2018 were included in the present study. The diagnosis of the resected appendix was confirmed by conventional histopathology.

Results

The most common cause for the appendectomy was acute appendicitis followed by gangrenous perforated appendicitis, chronic appendicitis, and lymphoid hyperplasia, representing 85/129(66%), 33/129(26%), 8/129(6%), and 3/129(2%), in this order.

Conclusion

Appendectomy is a common procedure for the treatment of a large section of patients with appendicitis and appendicitis like clinical features. Acute appendicitis was the most motive for appendectomy followed by gangrenous perforated appendicitis in Northern Saudi Arabia.

Histopathological features of incidental appendectomy specimens obtained from living liver donors

BACKGROUND/AIMS

To determine the histopathological features of incidental appendectomy specimens obtained from living liver donors (LLDs) Materials and Methods: Between September 2005 and November 2018, 1910 LLDs underwent living donor hepatectomy at our institute. Incidental appendectomy together with living donor hepatectomy (LDH) was performed in 170 LLDs. The decision for incidental appendectomy was made by experienced gastrointestinal surgeons. Histopathological features of the appendectomy specimens were analyzed by two pathologists, and the following parameters were retrospectively evaluated: age, sex, appendix length (mm), appendix width (mm), presence of appendicitis, and unusual histopathological findings.

RESULTS

Histopathological findings from 97 male and 73 female LLDs aged between 18 and 64 (median: 30) years were retrospectively examined. The length of the appendix vermiformis ranged from 25 to 120 (median: 70) mm, whereas its width ranged from 4 to 13 (median: 6) mm. The following histopathological findings were observed: normal appendix vermiformis (n=137), fibrous obliteration (n=13), acute appendicitis (n=5), enterobius vermicularis (n=4), lymphoid hyperplasia (n=4), low-grade appendiceal mucinous neoplasm (n=2), mucinous cystadenoma (n=1), grade 1 neuroendocrine tumor (n=1), hyperplastic polyp (n=1), enterobius vermicularis with fibrous obliteration (n=1), and acute appendicitis with eosinophilic infiltration (n=1).

CONCLUSION

This study showed that a careful inspection of the abdominal cavity was useful, and appendectomy should be performed when required. In addition, even if the macroscopic appearance of the appendectomy specimens is normal, histopathological evaluations facilitate an early diagnosis of numerous unusual appendiceal diseases.