1
|
Patel SV, Zhang L, Mir ZM, Lemke M, Leeper WR, Allen LJ, Walser E, Vogt K. Delayed Versus Early Laparoscopic Appendectomy for Adult Patients With Acute Appendicitis: A Randomized Controlled Trial. Ann Surg 2024; 279:88-93. [PMID: 37436871 DOI: 10.1097/sla.0000000000005996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVE To assess whether delaying appendectomy until the following morning is non-inferior to immediate surgery in those with acute appendicitis presenting at night. BACKGROUND Despite a lack of supporting evidence, those with acute appendicitis who present at night frequently have surgery delayed until the after morning. METHODS The delay trial is a noninferiority randomized controlled trial conducted between 2018 and 22 at 2 tertiary care hospitals in Canada. Adults with imaging confirmed acute appendicitis who presented at night (8:00 pm -4:00 am ). Delaying surgery until after 6:00 am was compared with immediate surgery. The primary outcome was 30-day postoperative complications. An a prior noninferiority margin of 15% was deemed clinically relevant. RESULTS One hundred twenty-seven of the planned 140 patients were enrolled in the Delayed Versus Early Laparoscopic Appendectomy (DELAY) trial (59 in the delayed group and 68 in the immediate group). The two groups were similar at baseline. The mean time between the decision to operate and surgery was longer in the delayed group (11.0 vs 4.4 hours, P < 0.0001). The primary outcome occurred in 6/59 (10.2%) of those in the delayed group versus 15/67 (22.4%) of those in the immediate group ( P = 0.07). The difference between groups met the a priori noninferiority criteria of +15% (risk difference -12.2%, 95% CI: -24.4% to +0.4%, test of noninferiority P < 0.0001). CONCLUSIONS The DELAY study is the first trial to assess delaying appendectomy in those with acute appendicitis. We demonstrate the noninferiority of delaying surgery until the after morning.
Collapse
Affiliation(s)
- Sunil V Patel
- Department of Surgery, Queen's University, Kingston General Hospital, Kingston, ON, Canada
| | - Lisa Zhang
- Department of Surgery, Queen's University, Kingston General Hospital, Kingston, ON, Canada
- Department of Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Zuhaib M Mir
- Department of Surgery, Queen's University, Kingston General Hospital, Kingston, ON, Canada
| | - Madeline Lemke
- Department of Surgery, Western University, London, ON, Canada
| | | | - Laura J Allen
- Department of Surgery, Western University, London, ON, Canada
| | - Eric Walser
- Department of Surgery, Western University, London, ON, Canada
| | - Kelly Vogt
- Department of Surgery, Western University, London, ON, Canada
| |
Collapse
|
2
|
Quevedo-Fernandez E, Gonzalez-Urquijo M, Hinojosa-Gonzalez DE, Morales-Flores LF, Morales-Morales CA, Zambrano-Lara M, Guajardo-Nieto D, Rodarte-Shade M. Analysis of deferral times in patients diagnosed with acute appendicitis. Asian J Surg 2023; 46:1187-1192. [PMID: 36041893 DOI: 10.1016/j.asjsur.2022.08.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/22/2022] [Accepted: 08/16/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION There are still controversies regarding the time of surgical management for acute appendicitis (AA). The main objective of this study was to recognize the surgical deferral time in patients with acute appendicitis and its relationship with the severity of presentation. MATERIALS AND METHODS We performed a retrospective review of prospectively collected data of all patients with acute appendicitis undergoing appendectomy from August 2018 to August 2020 in an academic, public hospital. Elapsed time from arrival to the emergency room to skin incision was determined. Patients were divided into three groups based on the elapsed time: less than 6 h, between 6 and 12 h, and more than 12 h. RESULTS A total of 782 patients were included. Of them, 443 (56.6%) patients had a surgical deferral time of less than 6 h, 238 (30.4%) patients between 6 and 12 h, and 101 (13%) patients of more than 12 h. Patients with more than 12 h of surgical deferral time had a more complicated clinical presentation (P = 0.013), a higher frequency of abscess formation (P = 0.022), higher requirement for the use of surgical drainage (P = 0.018), and longer length of hospital stay (P = <0.001). CONCLUSION Surgical deferral >12 h was associated with a higher incidence of complicated appendicitis, intra-abdominal abscesses, and overall hospital stay. However, in the multivariate analysis, only total evolution time, from the first symptom to surgery, was a significant independent predictor of complicated appendicitis.
Collapse
Affiliation(s)
- Enrique Quevedo-Fernandez
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Mauricio Gonzalez-Urquijo
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - David E Hinojosa-Gonzalez
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Luis Fernando Morales-Flores
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Carlos Antonio Morales-Morales
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Mario Zambrano-Lara
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Diego Guajardo-Nieto
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Mario Rodarte-Shade
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| |
Collapse
|
3
|
Guo Y, Ye D, Yang G, Liu G, Cui X, Tan S, Guo Y. Demonstration of a new entity of non-perforated appendicitis through studying cluster of appendicitis. Sci Rep 2022; 12:12464. [PMID: 35864301 PMCID: PMC9304339 DOI: 10.1038/s41598-022-16682-6] [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: 02/10/2022] [Accepted: 07/13/2022] [Indexed: 11/30/2022] Open
Abstract
Differential diagnosis and management for perforated appendicitis and non-perforated appendicitis are current hot topics. The aim of this study is to demonstrate a new entity of non-perforated appendicitis, “acute hemorrhagic appendicitis” through studying cluster of acute appendicitis among Tibetan students at a high school in central China. Over the 11-year period, there were 120 patients with more female patients (102 of 499, 20.4%) than male patients (18 of 474, 3.8%) among 973 Tibetan students. 117 patients’ clinical data were available. Clinical manifestations were identical to classic appendicitis. However, axilla temperature, white blood cell counts and neutrophil level were elevated mildly in 12 (10.3%), 19 (16.2%) and 12 (10.3%) patients respectively. Pathologically, the resected appendices exhibited focal or diffuse hemorrhages in mucosa and/or submucosa, and infiltration by eosinophil and by lymphocytes. No patients had perforated appendicitis. The median time from the onset to surgery was 3 days (IQR, 2–4). All patients were discharged with full recovery. In conclusion, “acute hemorrhagic appendicitis” represented a new entity of non-perforated appendicitis with unique cause and pathogenesis, which might be treated with antibiotics alone or self-limited. Studying the cluster is a reliable method to find new entity of appendicitis.
Collapse
Affiliation(s)
- Yitian Guo
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Jiefang Road 238, Wuchang, Wuhan, 430060, Hubei, China
| | - Deqiang Ye
- Department of Surgery, Infectious Disease Hospital Affiliated to Nanchang University (Nanchang Ninth Hospital), 167 Hongdu Middle Avenue, Qingshanhu District, Nanchang, 330002, Jiangxi, China
| | - Guifang Yang
- Department of Pathology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuchang, Wuhan, 430071, Hubei, China
| | - Guozhen Liu
- Swedish Bellevue Primary Care Clinic, 1200 112th Ave, Bellevue, WA, 98004, USA
| | - Xiaochen Cui
- Department of Epidemiology and Biostatistics, Wuhan University School of Public Health, 115 Donghu Road, Wuchang, Wuhan, 430071, Hubei, China.,Department of Child Health Care, Wuhu Maternity and Child Health Care Hospital, Jiujiang, Wuhu, 241000, Anhi, China
| | - Shiyun Tan
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Jiefang Road 238, Wuchang, Wuhan, 430060, Hubei, China.
| | - Yi Guo
- Department of Epidemiology and Biostatistics, Wuhan University School of Public Health, 115 Donghu Road, Wuchang, Wuhan, 430071, Hubei, China.
| |
Collapse
|
4
|
Mori M, Narushima K, Hirano A, Kano Y, Chiba F, Edamoto Y, Yoshida M. Preoperative neutrophil-to-lymphocyte ratio may contribute to the prediction of postoperative infectious complications in patients with acute appendicitis: a retrospective study. BMC Surg 2022; 22:78. [PMID: 35241053 PMCID: PMC8892689 DOI: 10.1186/s12893-022-01529-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several studies have assessed various clinical variables to identify risk factors for postoperative complications in patients with acute appendicitis. However, few studies have focused on the relationships between systemic inflammatory variables and postoperative complications in patients with acute appendicitis. We investigated the relationships between postoperative complications and systemic inflammatory variables, and assessed the clinical utility of these variables as predictors of postoperative complications in patients with acute appendicitis. METHODS We retrospectively reviewed 181 patients who underwent immediate appendectomy for acute appendicitis. All postoperative complications were classified as infectious or noninfectious, and we evaluated the relationships between postoperative complications and clinical factors including the preoperative neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio. RESULTS In total, 28 patients (15.5%) had postoperative Clavien-Dindo grade II-IV complications; 17 patients (9.4%) and 11 patients (6.1%) were categorized as the infectious and noninfectious complication groups, respectively. The cutoff value of the preoperative neutrophil-to-lymphocyte ratio for all complications was 11.3, and multivariate analysis revealed that the preoperative neutrophil-to-lymphocyte ratio was an independent predictor of any postoperative complication (odds ratio: 4.223, 95% confidence interval: 1.335-13.352; P = 0.014). The cutoff value of the preoperative neutrophil-to-lymphocyte ratio for infectious complications was 11.4, and multivariate analysis revealed that the preoperative neutrophil-to-lymphocyte ratio was an independent predictor of infectious complications (odds ratio: 4.235, 95% confidence interval: 1.137-15.776; P = 0.031). CONCLUSIONS In patients with acute appendicitis, the preoperative neutrophil-to-lymphocyte ratio may be a useful predictor of all postoperative complications, especially infectious complications.
Collapse
Affiliation(s)
- Mikito Mori
- Department of Surgery, Secomedic Hospital, 696-1 Toyotomi-cho, Funabashi, Chiba, 274-0053, Japan.
| | - Kazuo Narushima
- Department of Surgery, Secomedic Hospital, 696-1 Toyotomi-cho, Funabashi, Chiba, 274-0053, Japan
| | - Atsushi Hirano
- Department of Surgery, Secomedic Hospital, 696-1 Toyotomi-cho, Funabashi, Chiba, 274-0053, Japan
| | - Yoshihiko Kano
- Department of Surgery, Secomedic Hospital, 696-1 Toyotomi-cho, Funabashi, Chiba, 274-0053, Japan
| | - Fumihiro Chiba
- Department of Surgery, Secomedic Hospital, 696-1 Toyotomi-cho, Funabashi, Chiba, 274-0053, Japan
| | - Yoshihiro Edamoto
- Department of Surgery, Secomedic Hospital, 696-1 Toyotomi-cho, Funabashi, Chiba, 274-0053, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare Ichikawa Hospital, 6-1-14 Kounodai, Ichikawa, Chiba, 272-0827, Japan
| |
Collapse
|
5
|
Zhang L, Lemke M, Mir ZM, Patel SV. Delayed vs. Early Appendectomy (DELAY) trial for adult patients with acute appendicitis: Study protocol for a randomized controlled trial. Contemp Clin Trials 2021; 102:106288. [PMID: 33497834 DOI: 10.1016/j.cct.2021.106288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/12/2021] [Accepted: 01/12/2021] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Early appendectomy in patients diagnosed with acute appendicitis is the current standard of treatment in North America. Timely intervention is suggested to avoid the complications associated with perforated appendicitis; however, safety of nighttime operating is a competing concern, with mixed results demonstrated thus far. OBJECTIVES This multi-center prospective randomized controlled trial aims to assess whether delaying appendectomy until the following morning versus early appendectomy overnight affects the rate of surgical complications in adult patients diagnosed with acute appendicitis in the evening hours. METHODS This is a randomized, controlled trial across two academic institutions with blinded outcome assessors. Patients presenting with imaging-confirmed appendicitis with an expected appendectomy between 8 pm and 4 am and within 6 h of decision to operate will be randomized to early appendectomy (with 6 h of randomization, control arm) or delayed to the following morning (after 6 am, intervention arm). Primary outcome will be 30 day postoperative complications, defined as a composite of: mortality, readmission to hospital, emergency department visit, percutaneous drain insertion, reoperation, prolonged hospital stay (>7 days), and postoperative complications. Secondary outcome measures are operative time, length of stay, time to emergency department visit and compliance to treatment. DISCUSSION This is a feasible and pragmatic clinical trial, intended to provide evidence for challenging decision making for the most common surgical disease worldwide. Results of this study will aid surgeons and health care administrators on how to appropriately triage appendectomies for patients with acute appendicitis who present overnight.
Collapse
Affiliation(s)
- Lisa Zhang
- Department of Surgery, Queen's University, Victory 3, Kingston General Hospital, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.
| | - Madeline Lemke
- Department of Surgery, Western University, 339 Windermere Road, London, Ontario N6A 5A5, Canada.
| | - Zuhaib M Mir
- Department of Surgery, Queen's University, Victory 3, Kingston General Hospital, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.
| | - Sunil V Patel
- Department of Surgery, Queen's University, Victory 3, Kingston General Hospital, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.
| |
Collapse
|
6
|
Zhang P, Zhang Q, Zhao H, Li Y. Factors affecting the length of hospital stay after laparoscopic appendectomy: A single center study. PLoS One 2020; 15:e0243575. [PMID: 33296384 PMCID: PMC7725291 DOI: 10.1371/journal.pone.0243575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/23/2020] [Indexed: 12/26/2022] Open
Abstract
AIM This study aimed to explore factors may affect the length of hospital stay after laparoscopic appendectomy. METHODS The data of 636 patients undergoing laparoscopic appendectomy between July 2016 and July 2019 in Beijing Tsinghua Changgung Hospital were retrospectively analyzed. The patients were divided into group A (hospital stay ≤3 days, 348 patients) and group B (hospital stay >3 days, 288 patients) according to their hospital stay.Sex, age, disease onset time(time from onset to admission), nausea, vomiting, diarrhea, peritonitis, comorbidities, and history of appendicitis; preoperative body temperature (T), white blood cell (WBC) count, percentage of neutrophilic granulocytes, and preoperative C-reactive protein (CRP) level; time from diagnosis to surgery. appendix diameter, appendicolith, and ascites in ultrasound or CT; surgical time(the surgery start time was the time of skin incision, and the end time was the time the anesthesia intubation was removed), intraoperative blood loss (the volume of blood infiltrating into a gauze was calculated by weighing the gauze infiltrated with water and calculating the volume of water), intraoperative adhesions or effusions, and stump closure methods, convert to open appendectomy, appendix pathology(perforated or gangrenous appendicitis were defined as complicated appendicitis and simple or suppurative appendicitis were defined as uncomplicated appendicitis) and antibiotic treatment schemes were analyzed. RESULTS Significant differences were detected between group A and group B in age (37.10 ± 13.52y vs 42.94 ± 15.57y, P<0.01), disease onset time (21.36 ± 16.56 h vs 32.52 ± 27.99 h, P <0.01), time from diagnosis to surgery (8.63 ± 7.29 h vs 10.70 ± 8.47 h, P<0.01); surgical time(64.09 ± 17.24 min vs 86.19 ± 39.96 min, P < 0.01); peritonitis(52.9% vs 74%, P < 0.01), comorbidities (12.4% vs 20.5%, P < 0.01), appendicolith (27.6% vs 41.7%, P < 0.01), ascites before the surgery(13.8% vs 22.9%, P < 0.01), intraoperative adhesions or effusions(56% vs 80.2%, P < 0.01); preoperative temperature (37.11 ± 0.64°C vs 37.54 ± 0.90°C, P < 0.01); preoperative WBC count (13.06 ± 3.39 × 109/L vs 14.21 ± 4.54 × 109/L, P = 0.04);preoperative CRP level(18.99 ± 31.72 mg/L vs 32.46 ± 46.68 mg/L, P < 0.01); appendix diameter(10.22 ± 2.59 mm vs 11.26 ± 3.23 mm, P < 0.01); intraoperative blood loss (9.36 ± 7.29 mL vs 13.74 ± 13.49 mL, P < 0.01); using Hem-o-lok for stump closure(30.7% vs 38.5%, P = 0.04); complicated appendicitis (9.5% vs 45.8%, P < 0.01); and using ertapenem for antibiotic treatment after the surgery(4.3% vs 21.5%, P < 0.01). Multivariate analysis demonstrated that age (OR = 1.021; 95%CI = 1.007-1.036), peritonitis (OR = 1.603; 95% CI = 1.062-2.419), preoperative WBC count (OR = 1.084; 95% CI = 1.025-1.046), preoperative CRP level (OR = 1.010; 95% CI = 1.005-1.015), time from diagnosis to surgery (OR = 1.043; 95% CI = 1.015-1.072), appendicolith (OR = 1.852; 95% CI = 1.222-2.807), complicated appendicitis (OR = 3.536; 95% CI = 2.132-5.863), surgical time (OR = 1.025; 95% CI = 1.016-1.034), use of Hem-o-lok for stump closure (OR = 1.894; 95% CI = 1.257-2.852), and use of ertapenem for antibiotic treatment (OR = 3.076; 95% CI = 1.483-6.378) were the risk factors for a prolonged hospital stay. CONCLUSIONS The patient with appendicitis was older and had peritonitis, higher preoperative WBC count or CRP level, longer time from diagnosis to surgery, appendicolith, and complicated appendicitis, predicting a prolonged hospital stay. Shorter surgical time and the use of silk ligation for stump closure and cephalosporins + metronidazole for antibiotic treatment might be better choices to obtain a shorter hospital stay.
Collapse
Affiliation(s)
- Peng Zhang
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Qian Zhang
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Hongwei Zhao
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yuanxin Li
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- * E-mail:
| |
Collapse
|
7
|
Liang X, Sun Y. Invited commentary on "Short-term outcome after appendectomy is related to preoperative delay but not to the time of day of the procedure: A nationwide retrospective cohort study of 9224 patients". Int J Surg 2020; 79:140. [PMID: 32442691 DOI: 10.1016/j.ijsu.2020.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/12/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Xuan Liang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University. Beijing, China
| | - Yanxia Sun
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University. Beijing, China.
| |
Collapse
|
8
|
Kohga A, Yajima K, Okumura T, Yamashita K, Isogaki J, Suzuki K, Muramatsu K, Komiyama A, Kawabe A. Is postponed laparoscopic appendectomy justified for patients with acute appendicitis? Asian J Endosc Surg 2019; 12:423-428. [PMID: 30430740 DOI: 10.1111/ases.12670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 09/28/2018] [Accepted: 10/15/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Recent meta-analyses revealed that laparoscopic appendectomy (LA) is a feasible procedure even for patients with complicated appendicitis. More than a few patients with acute appendicitis arrive at the hospital during night shifts and have their operation postponed for various reasons. However, the feasibility and disadvantages of this so-called "postponed laparoscopic appendectomy" (PLA) remain controversial. METHODS We included 149 patients who underwent LA for acute appendicitis within 48 h of diagnosis between January 2013 and May 2018. Patients were divided into an immediate LA group (patients who underwent LA within 4 h of diagnosis, n = 84) and a PLA group (patients who underwent LA 4-48 h after diagnosis, n = 65). Comparisons were made between these groups. RESULTS The preoperative characteristics of the patients in the immediate LA and PLA groups were not significantly different. Operative time was significantly longer in the PLA group than in the LA group (92.5 ± 40.8 vs 78.1 ± 29.7 min, P = 0.012). The incidence of postoperative complications (grade II or higher) was significantly greater in the PLA group than in the LA group (32.3% vs 17.8%, P = 0.041). Multivariate analysis revealed that a preoperative CT finding of periappendiceal fluid (P = 0.005, odds ratio = 4.71) and surgery 4-48 h after diagnosis (P = 0.005, odds ratio = 4.425) were independent risk factors of postoperative complications (grade II or higher). CONCLUSIONS For patients with acute appendicitis, surgeons should perform immediate LA, if that is the patient's preferred surgical treatment, as long as there is no special reason to postpone surgery.
Collapse
Affiliation(s)
- Atsushi Kohga
- Division of Surgery, Fujinomiya City General Hospital, Fujinomiya, Japan
| | - Kiyoshige Yajima
- Division of Surgery, Fujinomiya City General Hospital, Fujinomiya, Japan
| | - Takuya Okumura
- Division of Surgery, Fujinomiya City General Hospital, Fujinomiya, Japan
| | - Kimihiro Yamashita
- Division of Surgery, Fujinomiya City General Hospital, Fujinomiya, Japan
| | - Jun Isogaki
- Division of Surgery, Fujinomiya City General Hospital, Fujinomiya, Japan
| | - Kenji Suzuki
- Division of Surgery, Fujinomiya City General Hospital, Fujinomiya, Japan
| | - Katsuaki Muramatsu
- Division of Radiology, Fujinomiya City General Hospital, Fujinomiya, Japan
| | - Akira Komiyama
- Division of Pathology, Fujinomiya City General Hospital, Fujinomiya, Japan
| | - Akihiro Kawabe
- Division of Surgery, Fujinomiya City General Hospital, Fujinomiya, Japan
| |
Collapse
|
9
|
Aktürk OM, Çakır M, Yıldırım D, Akıncı M. C-reactive protein and red cell distribution width as indicators of complications in patients with acute appendicitis. ARCHIVES OF CLINICAL AND EXPERIMENTAL MEDICINE 2019. [DOI: 10.25000/acem.546308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
|
10
|
In-hospital perforation risk in acute appendicitis: Age matters. Am J Surg 2019; 219:65-70. [PMID: 31186116 DOI: 10.1016/j.amjsurg.2019.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/20/2019] [Accepted: 05/28/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Controversy exists regarding how quickly an adult with appendicitis requires surgery to prevent perforation, and recent literature on antibiotic use as definitive treatment has complicated this question further. Since perforation is associated with worse outcomes, particularly in the elderly, efforts to prevent this complication are warranted. We studied risk factors for in-hospital perforation in patients diagnosed by admission CT with non-perforated acute appendicitis. METHODS We evaluated baseline demographics, symptom duration, and time from admission to antibiotics and surgery. Outcome measure was perforation diagnosed intra-operatively by attending surgeon. RESULTS Of 700 patients, 84 (12%) sustained in-hospital perforation; time from admission to operation or antibiotics were not associated. Duration of symptoms >24 h (aOR = 2.23, 95% CI = 1.33-3.72, p < 0.001) increased perforation risk. Patient age over 46 years (aOR = 4.54, 95% CI = 2.04-10.06, p < 0.001) was also associated with higher risk that increased with increasing age. CONCLUSION Time to operation and antibiotic timing were not associated with in-hospital perforation in a general adult population. However, these findings suggest a possible benefit to expedient surgery in older patients.
Collapse
|
11
|
Isani MA, Jackson J, Barry WE, Mallicote MU, Rosenberg D, Stein JE, Jensen AR, Kim ES. Non-Operative Management is More Cost-Effective than Immediate Operation in Perforated Appendicitis Patients with Seven or More Days of Symptoms. J Surg Res 2019; 240:70-79. [PMID: 30909067 DOI: 10.1016/j.jss.2019.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/15/2019] [Accepted: 02/21/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Management of perforated appendicitis in children remains controversial. Nonoperative (NO) and immediate operative (IO) strategies are used with varying outcomes. We hypothesized that IO intervention for patients with perforated appendicitis would be more cost-effective than NO management. METHODS A retrospective chart review of all patients with appendicitis from 2012 to 2015 was performed. Patients with perforated appendicitis were defined by evidence of perforation on imaging. We excluded patients who presented with sepsis, organ failure, and ventriculoperitoneal shunts. NO management was determined by surgeon preference. Univariate and multivariate analyses were performed. RESULTS IO was performed on 145 patients with perforated appendicitis, whereas 83 were treated with NO management. Compared to IO patients, NO patients incurred higher overall costs, greater length of stay, more readmissions, complications, peripherally inserted central venous catheter lines, interventional radiology drains, and unplanned clinic and emergency department visits (P < 0.0001 for all). Multivariate analysis adjusting for age, days of symptoms, admission C-reactive protein and white blood cell count revealed that NO management was independently associated with increased costs (OR 1.35, 1.12-1.62, 95% CI). Cost curves demonstrated that total cost for IO surpasses that of NO management when patients present with greater than 6.3 d of symptoms (P = 0.01). CONCLUSIONS Our data suggest that IO is more cost-effective than NO management for patients with perforated appendicitis who present with less than 6.3 d of symptoms, after which point, NO management is more cost-effective. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Mubina A Isani
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Jeremy Jackson
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Wesley E Barry
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Michael U Mallicote
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - David Rosenberg
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - James E Stein
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Aaron R Jensen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Eugene S Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.
| |
Collapse
|
12
|
van Dijk ST, van Dijk AH, Dijkgraaf MG, Boermeester MA. Meta-analysis of in-hospital delay before surgery as a risk factor for complications in patients with acute appendicitis. Br J Surg 2019; 105:933-945. [PMID: 29902346 PMCID: PMC6033184 DOI: 10.1002/bjs.10873] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 01/12/2018] [Accepted: 03/08/2018] [Indexed: 12/15/2022]
Abstract
Background The traditional fear that every case of acute appendicitis will eventually perforate has led to the generally accepted emergency appendicectomy with minimized delay. However, emergency and thereby sometimes night‐time surgery is associated with several drawbacks, whereas the consequences of surgery after limited delay are unclear. This systematic review aimed to assess in‐hospital delay before surgery as risk factor for complicated appendicitis and postoperative morbidity in patients with acute appendicitis. Methods PubMed and EMBASE were searched from 1990 to 2016 for studies including patients who underwent appendicectomy for acute appendicitis, reported in two or more predefined time intervals. The primary outcome measure was complicated appendicitis after surgery (perforated or gangrenous appendicitis); other outcomes were postoperative surgical‐site infection and morbidity. Adjusted odds ratios (ORs) were pooled using forest plots if possible. Unadjusted data were pooled using generalized linear mixed models. Results Forty‐five studies with 152 314 patients were included. Pooled adjusted ORs revealed no significantly higher risk for complicated appendicitis when appendicectomy was delayed for 7–12 or 13–24 h (OR 1·07, 95 per cent c.i. 0·98 to 1·17, and OR 1·09, 0·95 to 1·24, respectively). Meta‐analysis of unadjusted data supported these findings by yielding no increased risk for complicated appendicitis or postoperative complications with a delay of 24–48 h. Conclusion This meta‐analysis demonstrates that delaying appendicectomy for presumed uncomplicated appendicitis for up to 24 h after admission does not appear to be a risk factor for complicated appendicitis, postoperative surgical‐site infection or morbidity. Delaying appendicectomy for up to 24 h may be an acceptable alternative for patients with no preoperative signs of complicated appendicitis. Delay is safe
Collapse
Affiliation(s)
- S T van Dijk
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - A H van Dijk
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - M G Dijkgraaf
- Clinical Research Unit, Academic Medical Centre, Amsterdam, Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| |
Collapse
|
13
|
Fullerton K, Depinet H, Iyer S, Hall M, Herr S, Morton I, Lee T, Melzer-Lange M. Association of Hospital Resources and Imaging Choice for Appendicitis in Pediatric Emergency Departments. Acad Emerg Med 2017; 24:400-409. [PMID: 28039951 DOI: 10.1111/acem.13156] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/22/2016] [Accepted: 12/19/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Abdominal pain and concern for appendicitis are common chief complaints in patients presenting to the pediatric emergency department (PED). Although many professional organizations recommend decreasing use of computed tomography (CT) and choosing ultrasound as first-line imaging for pediatric appendicitis, significant variability persists in imaging utilization. This study investigated practice variation across children's hospitals in the diagnostic imaging evaluation of appendicitis and determined hospital-level characteristics associated with the likelihood of ultrasound as the first imaging modality. METHODS This was a multicenter (seven children's hospitals) retrospective investigation. Data from chart review of 160 consecutive patients aged 3-18 years diagnosed with appendicitis from each site were compared with a survey of site medical directors regarding hospital resource availability, usual practices, and departmental-level demographics. RESULTS In the diagnostic evaluation of 1,090 children with appendicitis, CT scan was performed first for 22.4% of patients, with a range across PEDs of 3.1% to 83.8%. Ultrasound was performed for 54.0% of patients with a range of 2.5% to 96.9%. The only hospital-level factor significantly associated with ultrasound as the first imaging modality was 24-hour availability of in-house ultrasound (odds ratio = 29.2, 95% confidence interval = 1.2-691.8). CONCLUSION Across children's hospitals, significant practice variation exists regarding diagnostic imaging in the evaluation of patients with appendicitis. Variation in hospital-level resources may impact the diagnostic evaluation of patients with appendicitis. Availability of 24-hour in-house ultrasound significantly increases the likelihood of ultrasound as first imaging and decreases CT scans. Hospitals aiming to increase the use of ultrasound should consider adding 24-hour in-house coverage.
Collapse
Affiliation(s)
| | - Holly Depinet
- Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Sujit Iyer
- Dell Children's Medical Center; Austin TX
| | - Matt Hall
- Children's Hospital Association; Overland Park KS
| | | | - Inge Morton
- Children's Hospital Los Angeles; Los Angeles CA
| | | | | | | |
Collapse
|
14
|
Debnath J, George RA, Ravikumar R. Imaging in acute appendicitis: What, when, and why? Med J Armed Forces India 2016; 73:74-79. [PMID: 28123249 DOI: 10.1016/j.mjafi.2016.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 02/18/2016] [Indexed: 02/07/2023] Open
Abstract
Acute appendicitis (AA) is the commonest cause of pain abdomen requiring surgical intervention. Diagnosis as well as management of acute appendicitis is mired in controversies and contradictions even today. Clinicians often face the dilemma of balancing negative appendectomy rate and perforation rate if the diagnosis is based on clinical scoring alone. Laboratory results are often non-specific. Imaging has an important role not only in diagnosing appendicitis and its complication but also suggesting alternate diagnosis in appropriate cases. However, there is no universally accepted diagnostic imaging algorithm for appendicitis. Imaging of acute appendicitis needs to be streamlined keeping pros and cons of the available investigative modalities. Radiography has practically no role today in the diagnosis and management of acute appendicitis. Ultrasonography (USG) should be the first line imaging modality for all ages, particularly for children and non-obese young adults including women of reproductive age group. If USG findings are unequivocal and correlate with clinical assessment, no further imaging is needed. In case of equivocal USG findings or clinico-radiological dissociation, follow-up/further imaging (computed tomography (CT) scan/magnetic resonance imaging (MRI)) is recommended. In pediatric and pregnant patients with inconclusive initial USG, MRI is the next option. Routine use of CT scan for diagnosis of AA needs to be discouraged. Our proposed version of a practical imaging algorithm, with USG first and always has been incorporated in the article.
Collapse
Affiliation(s)
- Jyotindu Debnath
- Professor, Department of Radiodiagnosis, Armed Forces Medical College, Pune 411040, India
| | - R A George
- Senior Adviser (Radiodiagnosis), Command Hospital (Air Force), Bengaluru, India
| | - R Ravikumar
- Professor & Head, Department of Radiodiagnosis, Armed Forces Medical College, Pune 411040, India
| |
Collapse
|
15
|
Al-Qurayshi Z, Kadi A, Srivastav S, Kandil E. Risk and outcomes of 24-h delayed and weekend appendectomies. J Surg Res 2016; 203:246-252.e1. [PMID: 27083692 DOI: 10.1016/j.jss.2016.03.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/02/2016] [Accepted: 03/11/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Time interval from hospital admission to operative intervention has been suggested as a crucial risk factor for a number of surgical procedures. In this study, we aim to compare postappendectomy outcomes for operations performed 24 h after admission or on the weekend to within 24 h and weekday operations, respectively. MATERIAL AND METHODS A cross-sectional study using the Nationwide Inpatient Sample database, 2004-2009. The study population included patients who underwent appendectomy for acute appendicitis. RESULTS A total of 265,972 records were identified, of which 221,745 (83.4%) patients had appendectomy on the same day of admission, whereas 16.6% had the procedure the following day. Next day operations were more likely to be associated with postoperative complications (OR = 1.26, 95% CI = [1.19-1.33], P < 0.001). A hospital stay of >3 d was also more common for next day interventions (P < 0.001). Appendectomies performed on weekends had a higher risk of complications compared to other days (OR = 1.08, 95% CI = [1.02-1.14], P = 0.005). Teaching and urban hospitals were more likely to perform appendectomies on the day after admission (P < 0.05). Older patients (≥35 years), females, Blacks and Hispanics, and those on Medicaid or Medicare were all at higher risk of next day intervention (P < 0.01 each). The average cost of next day operations was higher compared to same day operations ($9890.11 ± 119.64 versus $8744.57 ± 77.67, P < 0.001). CONCLUSIONS Appendectomies performed 1 d after admission or on the weekend are associated with disadvantageous outcomes. Demographic factors, in addition to hospital attributes, place certain subpopulations at higher risk of next day appendectomies.
Collapse
Affiliation(s)
- Zaid Al-Qurayshi
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Abida Kadi
- Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Sudesh Srivastav
- Department of Biostatistics and Bioinformatics, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana.
| |
Collapse
|