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de Wijkerslooth EM, Boerma EJG, van Rossem CC, Koopmanschap MA, Baeten CI, Beverdam FH, Bosmans JW, Consten EC, Dekker JWT, Emous M, van Geloven AA, Gijsen AF, Heijnen LA, Jairam AP, van der Ploeg AP, Steenvoorde P, Toorenvliet BR, Vermaas M, Wiering B, Wijnhoven BP, van den Boom AL. Two Days Versus Five Days of Postoperative Antibiotics for Complex Appendicitis: Cost Analysis of a Randomized, Noninferiority Trial. Ann Surg 2024; 279:885-890. [PMID: 37698025 PMCID: PMC10997181 DOI: 10.1097/sla.0000000000006089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To compare costs for 2 days versus 5 days of postoperative antibiotics within the antibiotics after an aPPendectomy In Complex appendicitis trial.Background:Recent studies suggest that restrictive antibiotic use leads to a significant reduction in hospital stays without compromising patient safety. Its potential effect on societal costs remains underexplored. METHODS This was a pragmatic, open-label, multicenter clinical trial powered for noninferiority. Patients with complex appendicitis (age ≥ 8 years) were randomly allocated to 2 days or 5 days of intravenous antibiotics after appendectomy. Patient inclusion lasted from June 2017 to June 2021 in 15 Dutch hospitals. The final follow-up was on September 1, 2021. The primary trial endpoint was a composite endpoint of infectious complications and mortality within 90 days. In the present study, the main outcome measures were overall societal costs (comprising direct health care costs and costs related to productivity loss) and cost-effectiveness. Direct health care costs were recorded based on data in the electronic patient files, complemented by a telephone follow-up at 90 days. In addition, data on loss of productivity were acquired through the validated Productivity Cost Questionnaire at 4 weeks after surgery. Cost estimates were based on prices for the year 2019. RESULTS In total, 1005 patients were evaluated in the "intention-to-treat" analysis: 502 patients were allocated to the 2-day group and 503 to the 5-day group. The mean difference in overall societal costs was - €625 (95% CI: -€ 958 to -€ 278) to the advantage of the 2-day group. This difference was largely explained by reduced hospital stay. Productivity losses were similar between the study groups. Restricting postoperative antibiotics to 2 days was cost-effective, with estimated cost savings of €31,117 per additional infectious complication. CONCLUSIONS Two days of postoperative antibiotics for complex appendicitis results in a statistically significant and relevant cost reduction, as compared with 5 days. Findings apply to laparoscopic appendectomy in a well-resourced health care setting.
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Affiliation(s)
| | - Evert-Jan G. Boerma
- Departments of Surgery, Zuyderland Medical Center, Heerlen/Sittard, The Netherlands
| | | | - Marc A. Koopmanschap
- Departments of Surgery, Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Coen I.M. Baeten
- Departments of Surgery, Groene Hart Hospital, Gouda, The Netherlands
| | | | | | - Esther C.J. Consten
- Departments of Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Departments of Surgery, University Medical Center Groningen, The Netherlands
| | | | - Marloes Emous
- Departments of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | | | - Anton F. Gijsen
- Departments of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - Luc A. Heijnen
- Departments of Surgery, Northwest Clinics, Alkmaar/Den Helder, The Netherlands
| | - An P. Jairam
- Departments of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Pascal Steenvoorde
- Departments of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | | | - Maarten Vermaas
- Departments of Surgery, IJsselland Hospital, Capelle a/d Ijssel, The Netherlands
| | - Bas Wiering
- Departments of Surgery, Slingeland Hospital, Doetinchem, The Netherlands
| | - Bas P.L. Wijnhoven
- Departments of Surgery, Erasmus MC—University Medical Center, Rotterdam, The Netherlands
| | - Anne Loes van den Boom
- Departments of Surgery, Erasmus MC—University Medical Center, Rotterdam, The Netherlands
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Beckermann J, Linnaus ME, Swartz H, Stewart S, York J, Gassner RR, Kasal CA, Seidel AG, Wachter CJ, Kooda KJ, Rich JR, Sawyer MD. Optimizing antibiotic management for patients with acute appendicitis: A quality improvement study. Surgery 2024; 175:1352-1357. [PMID: 38413304 DOI: 10.1016/j.surg.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 12/12/2023] [Accepted: 01/11/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND To decrease surgical site infections after appendectomy for acute appendicitis, preoperative broad-spectrum antibiotics are often used in clinical practice. However, this treatment strategy has come under scrutiny because of increasing rates of antibiotic-resistant infections. METHODS The aim of this multisite quality improvement project was to decrease the treatment of uncomplicated acute appendicitis with piperacillin-tazobactam without increasing the rate of surgical site infections. Our quality improvement intervention had 2 distinct components: (1) updating electronic health record orders to encourage preoperative administration of narrow-spectrum antibiotics and (2) educating surgeons and emergency department clinicians about selecting appropriate antibiotic therapy for acute appendicitis. Patient demographics, clinical characteristics, and outcomes were compared 6 months before and after implementation of the quality improvement intervention. RESULTS A total of 352 laparoscopic appendectomies were performed during the 6-month preintervention period, and 369 were performed during the 6-month postintervention period. The preintervention period and postintervention period groups had similar baseline demographics, vital signs, and laboratory test values. The rate of preoperative piperacillin-tazobactam administration significantly decreased after the intervention (51.4% preintervention period vs 20.1% postintervention period, P < .001). The rate of surgical site infections was similar in both groups (superficial surgical site infections = 1.4% preintervention period vs 0.8% postintervention period, P = .50; deep surgical site infections = 1.1% preintervention period vs 0.0% postintervention period, P = .06; and organ space surgical site infections = 3.1% preintervention period vs 3.0% postintervention period, P > .99). Rates of 30-day readmission, reoperation, and Clostridioides difficile infection also did not differ between groups. CONCLUSION Our quality improvement intervention successfully decreased piperacillin-tazobactam administration without increasing the rate of surgical site infections in patients with acute appendicitis.
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Affiliation(s)
- Jason Beckermann
- General and Trauma Surgery, Mayo Clinic Health System-Northwest Wisconsin region, Eau Claire, WI.
| | - Maria E Linnaus
- General and Trauma Surgery, Mayo Clinic Health System-Northwest Wisconsin region, Eau Claire, WI
| | | | | | | | | | - Christopher A Kasal
- General Surgery, Mayo Clinic Health System-Southeast Minnesota region, Red Wing, MN
| | - Annaliese G Seidel
- Department of Surgery, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Corey J Wachter
- Pharmacy Services, Mayo Clinic Health System-Northwest Wisconsin region, Eau Claire, WI
| | - Kirstin J Kooda
- Pharmacy Services, Critical Care, and General Surgery (Sawyer), Mayo Clinic, Rochester, MN
| | - Jennifer R Rich
- Research & Innovation, Mayo Clinic Health System-Northwest Wisconsin region, Eau Claire, WI
| | - Mark D Sawyer
- Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN
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Iresjö BM, Blomström S, Engström C, Johnsson E, Lundholm K. Acute appendicitis: A block-randomized study on active observation with or without antibiotic treatment. Surgery 2024; 175:929-935. [PMID: 38218686 DOI: 10.1016/j.surg.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Antibiotic treatment of unselected patients with acute appendicitis is safe and effective. However, it is unknown to what extent early provision of antibiotic treatment may represent overtreatment due to spontaneous healing of appendix inflammation. The aim of the present study was to evaluate the role of antibiotic treatment versus active in-hospital observation on spontaneous regression of acute appendicitis. METHOD Patients who sought acute medical care at Sahlgrenska University Hospital were block-randomized according to age (18-60 years) and systemic inflammation (C-reactive protein <60 mg/L, white blood cell <13,000/μL), in combination with clinical and abdominal characteristics of acute appendicitis. Study patients received antibiotic treatment and active observation, while control patients were allocated to classic active "wait and see observation" for either disease regression or the need for surgical exploration. According to our standard surgical care, certified surgeons in charge decided whether and when appendectomy was necessary. In total, 1,019 patients were screened for eligibility; 203 patients met inclusion criteria, 126 were accepted to participate, 29 declined, and 48 were missed for inclusion. RESULTS The antibiotic group (n = 69) and the control group (n = 57) were comparable at inclusion. Appendectomy at first hospital stay was 28% and 53% for study and control patients (χ2, P < .004). Life table analysis indicated a time-dependent difference in the need for appendectomy during follow-up (P < .03). Antibiotics prevented surgical exploration and appendectomy by 72% to 50% compared to 47% to 37% in the control group across the time course follow-ups between 5 and 1,200 days. CONCLUSION Early antibiotic treatment is superior to traditional "wait and see observation" to avoid surgical exploration and appendectomy.
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Affiliation(s)
- Britt-Marie Iresjö
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Sara Blomström
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Cecilia Engström
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Erik Johnsson
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Kent Lundholm
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
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Klinker S, Fitzsimmons A, Borgert A, Fisher M. Nonoperative Treatment of Diverticulitis and Appendicitis: Which Antibiotic Regimen Fails? J Surg Res 2024; 296:78-87. [PMID: 38232581 DOI: 10.1016/j.jss.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/16/2023] [Accepted: 12/17/2023] [Indexed: 01/19/2024]
Abstract
INTRODUCTION Diverticulitis and appendicitis are common emergency general surgical conditions. Both can be treated with antibiotics alone; however, no antibiotic regimen has been identified as superior to others. In this study, we review different antibiotic regimens and their rates of failure. METHODS Retrospective cohort study of patients treated empirically with antibiotics for diverticulitis or appendicitis from January 1, 2018, to December 31, 2020, at an independent academic hospital in the Midwest. RESULTS A total of 587 (appendicitis, n = 43; diverticulitis, n = 544) patients were included in the cohort. They were equally male (49%) and female (51%) with a median age of 59 y. Three major antibiotic classes were compared: cephalosporin + metronidazole (C + M), penicillins, and quinolone + metronidazole. Appendicitis patients were more likely to receive C + M for empiric treatment (73%, P < 0.001), while diverticulitis patients were more likely to receive quinolone + metronidazole (45%, P < 0.001). Patients empirically treated with antibiotics for appendicitis were more likely than those treated for diverticulitis to require additional antibiotics or procedure within 90 d (33% versus 13%, respectively; P = 0.005). Empiric treatment with C + M for diverticulitis was more likely to be associated with the need for additional antibiotics or procedures within 90 d than treatment with other regimens (P = 0.003). Choice of antibiotic for empiric treatment did not correlate with death at 90 d for appendicitis or diverticulitis. Diverticulitis patients who were initially treated as inpatients and were prescribed C + M at hospital discharge had a higher rate of death than those who were prescribed the other antibiotics (P = 0.04). CONCLUSIONS Empiric antibiotic treatment of appendicitis is more likely to be associated with additional antibiotics or procedure when compared with diverticulitis; however, antibiotic choice did not correlate with any of the other outcomes. Empiric treatment with a C + M for diverticulitis was more likely to be correlated with the need for additional antibiotics or procedure within 90 d.
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Affiliation(s)
- Samuel Klinker
- Department of Medical Education, General Surgery Residency, Gundersen Health System, La Crosse, Wisconsin.
| | - Alec Fitzsimmons
- Department of Medical Research, Gundersen Health System, La Crosse, Wisconsin
| | - Andrew Borgert
- Department of Medical Research, Gundersen Health System, La Crosse, Wisconsin
| | - Mason Fisher
- Department of General Surgery, Gundersen Health System, La Crosse, Wisconsin
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Arredondo Montero J, Antona G, Murillo Jaso E, Unzué Rico P, Antuñano Unanua I, Martín-Calvo N. Prospective evaluation of the emetogenic profile and analgesic efficacy of intravenous ibuprofen and metamizole in the immediate postoperative period of pediatric acute appendicitis. Cir Pediatr 2024; 37:67-74. [PMID: 38623799 DOI: 10.54847/cp.2024.02.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
BACKGROUND Literature comparing different alternatives for pain control in the immediate postoperative period of pediatric acute appendicitis (PAA) is scarce. MATERIALS AND METHODS We prospectively compared the analgesic and emetogenic profile of intravenous ibuprofen and metamizole in the immediate postoperative period of PAA. For this purpose, we used a sample of patients operated on in 2021 in our center. Participants were recruited on arrival at the Emergency Department and histopathological confirmation of the diagnosis was obtained in all of them. Pain was evaluated every 8 hours after the surgery with validated visual analog scales ranging from 0 to 10 points. Repeated measures ANOVA was used to compare the evolution of pain in the 48 hours after surgery between the two groups. RESULTS The sample included 95 patients (65% males) with a mean age of 9.7 years (sd: 3.14). 41 patients were treated with Ibuprofen (group 1) and 54 with metamizole (group 2). No significant differences were found in the level of pain either in the comparisons of point measurements or in its evolution in the 48 hours after surgery (p= 0.58). After adjusting for the received fluid therapy, children in the metamizole group had significantly more emetic episodes and needed significantly more doses of ondansetron. CONCLUSIONS In our cohort, ibuprofen had a similar analgesic efficacy and a better emetogenic profile than metamizole in the immediate postoperative period of PAA. Future prospective, adequately controlled studies with larger sample sizes are needed to validate these findings.
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Affiliation(s)
- J Arredondo Montero
- Pediatric Surgery Department. Complejo Asistencial Universitario de León. León (Spain). School of Medicine. University of Navarra. Pamplona (Spain)
| | - G Antona
- Pediatric Surgery Department. Hospital Universitario de Navarra. Pamplona (Spain)
| | - E Murillo Jaso
- Pediatric Anesthesia Department. Hospital Universitario de Navarra. Pamplona (Spain)
| | - P Unzué Rico
- Pediatric Anesthesia Department. Hospital Universitario de Navarra. Pamplona (Spain)
| | - I Antuñano Unanua
- Pediatric Anesthesia Department. Hospital Universitario de Navarra. Pamplona (Spain)
| | - N Martín-Calvo
- Department of Preventive Medicine and Public Health. School of Medicine. University de Navarra. Pamplona (Spain). IdiSNA, Instituto de Investigación Sanitaria de Navarra. Pamplona (Spain). CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn). Health Institute Carlos III. Madrid
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Yu CH, Chang CN, Wang CC. Causative microbes and antibiotic susceptibility of acute appendicitis in adults and children. Pediatr Neonatol 2024; 65:159-164. [PMID: 37741758 DOI: 10.1016/j.pedneo.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/15/2023] [Accepted: 08/24/2023] [Indexed: 09/25/2023] Open
Abstract
BACKGROUND In recent years, some studies have found that acute uncomplicated appendicitis can be treated with antibiotics alone. Because of the lack of relevant research on treating acute appendicitis in Taiwan, this study investigated the microbiological characteristics of acute appendicitis to permit accurate empirical antibiotic use for uncomplicated appendicitis. METHODS In this single-center retrospective cohort study, patients listed in the Taiwan National Health Insurance Research Database with a discharge diagnosis of acute appendicitis were identified. Data for bacterial specimens and antibiotic susceptibility tests among patients treated at Tri-Service General Hospital between January 2016 and December 2021 were analyzed. RESULTS Among 2805 patients diagnosed with acute appendicitis, 167 (6%) were <18 years old. The culture positivity rates among children and adults were 33% and 18%, respectively. In total, 367 aerobes and 207 anaerobes were isolated. The predominant aerobic gram-positive coccus was viridans group streptococci (8.9%), the most common aerobic gram-negative bacillus was Escherichia coli (27.9%), and the most common anaerobic microorganism was Bacteroides spp. (27.7%). The results of antibiotic susceptibility testing of the predominant microorganisms revealed that 86.3% of gram-positive aerobes were susceptible to ampicillin, 76.3% of gram-negative aerobes were susceptible to gentamicin, and all anaerobic isolates were susceptible to metronidazole. CONCLUSION Triple first-line antibiotic combination therapy, including ampicillin, gentamicin, and metronidazole, remains highly effective against the pathogens that cause acute appendicitis.
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Affiliation(s)
- Chia-Hsiang Yu
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Ning Chang
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Chien Wang
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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Hu A, Tian Y, Huang L, Chaudhury A, Mathur R, Sullivan GA, Reiter A, Raval MV. Association Between Common Empiric Antibiotic Regimens and Clostridioides Difficile Infection in Pediatric Appendicitis. J Pediatr Surg 2024; 59:515-521. [PMID: 38092651 DOI: 10.1016/j.jpedsurg.2023.10.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 09/26/2023] [Accepted: 10/26/2023] [Indexed: 02/15/2024]
Abstract
BACKGROUND Clostridioides Difficile Infection (CDI) is a serious antibiotic related complication that has been reported among children undergoing treatment of appendicitis. CDI likelihood amongst different empiric antibiotic regimens for appendicitis remains unclear but likely has important implications for antibiotic stewardship. METHODS A retrospective cohort study of the Pediatric Health Information System was used to examine patients ages 1 through 18 who received operative management of acute appendicitis. Common empiric antibiotic regimens 1) Ceftriaxone & Metronidazole (CM) 2) Piperacillin & Tazobactam (PT) and 3) Cefoxitin were compared. Study outcomes were CDI within 28 days post-appendectomy and 30-day post-appendectomy percutaneous drainage procedures. Subset analyses were repeated to only include hospitals that standardized empiric antibiotic choice. RESULTS Of 105,911 patients, 220 (0.21 %) developed CDI. CDI was more common in patients that received CM (CM 0.29 % vs PT 0.15 % vs Cefoxitin 0.18 %; P < 0.01). On adjusted analysis, PT was associated with a lower likelihood of CDI (OR, 0.48; 95%CI, 0.31-0.74) compared to CM which was consistent in hospitals with standardized antibiotic choice. Exposure to more unique antibiotic regimens (OR, 1.70; 95 % CI, 1.50-1.93) and higher total antibiotic days (OR, 1.17; 95 % CI 1.13-1.21) were associated with an increased likelihood of CDI. There was no significant difference in the likelihood of post-appendectomy percutaneous drainage between antibiotic regimens. CONCLUSIONS CDI is rare following appendectomy for pediatric appendicitis. While PT was associated with statistically lower rates of CDI compared to CM, antibiotic stewardship efforts to avoid mixed regimens and decrease overall antibiotic exposure warrant exploration. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Yao Tian
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Lynn Huang
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Azraa Chaudhury
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Radhika Mathur
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Gwynth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Audra Reiter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Gracias D, Siu A, Seth I, Dooreemeah D, Lee A. Exploring the role of an artificial intelligence chatbot on appendicitis management: an experimental study on ChatGPT. ANZ J Surg 2024; 94:342-352. [PMID: 37855397 DOI: 10.1111/ans.18736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/27/2023] [Accepted: 10/02/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Appendicitis is a common surgical condition that requires urgent medical attention. Recent advancements in artificial intelligence and large language processing, such as ChatGPT, have demonstrated potential in supporting healthcare management and scientific research. This study aims to evaluate the accuracy and comprehensiveness of ChatGPT's knowledge on appendicitis management. METHODS Six questions related to appendicitis management were created by experienced RACS qualified general surgeons to assess ChatGPT's ability to provide accurate information. The criteria of ChatGPT answers' accuracy were compared with current healthcare guidelines for appendicitis and subjective evaluation by two RACS qualified General Surgeons. Additionally, ChatGPT was then asked to provide five high level evidence references to support its responses. RESULTS ChatGPT provided clinically relevant information on appendicitis management, however, was inconsistent in doing so and often provided superficial information. Further to this, ChatGPT encountered difficulties in generating relevant references, with some being either non-existent or incorrect. CONCLUSION ChatGPT has the potential to provide timely and comprehensible medical information on appendicitis management to laypersons. However, its issue of inaccuracy in information and production of non-existent or erroneous references presents a challenge for researchers and clinicians who may inadvertently employ such information in their research or healthcare. Therefore, clinicians should exercise caution when using ChatGPT for these purposes.
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Affiliation(s)
- Dylan Gracias
- Department of Surgery, Townsville Hospital, Townsville, Queensland, Australia
| | - Adrian Siu
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Concord Institute of Academic Surgery, Concord Hospital, Concord, New South Wales, Australia
| | - Ishith Seth
- Department of Surgery, Peninsula Health, Melbourne, Victoria, Australia
- Department of Surgery, Bendigo Health, Bendigo, Victoria, Australia
| | | | - Angus Lee
- Department of Surgery, Bendigo Health, Bendigo, Victoria, Australia
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Leiritz E, Rezai J, Wagner M, Bardier A, Therwath A, Pocard M. Appendiceal adenocarcinoma, diagnosed after acute perforated appendicitis: Potential contribution of HIPEC. Eur J Surg Oncol 2024; 50:107959. [PMID: 38340494 DOI: 10.1016/j.ejso.2024.107959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/23/2023] [Accepted: 01/08/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Treatment of peritoneal metastasis from appendicular adenocarcinoma consists of cyto-reductive surgery (CRS) and Hyperthermic IntraPEritoneal Chemotherapy (HIPEC). In case of acute appendicular syndrome (AAS) the tumor is likely to be perforated. In that case, there is no treatment recommendation. We propose CRS and HIPEC. MATERIALS AND METHOD We listed 21 consecutive patients who were addressed for discovery of appendiceal adenocarcinoma. The emergency surgery was performed in a primary-care hospital. We evaluated the therapeutic algorithms, per operative decision, survival and recurrent rate. RESULTS Among the 21 patients, 4 patients were diagnosed as synchronous appendicular peritoneal metastasis, and underwent CRS and HIPEC. The other 17 patients with diagnosis of adenocarcinoma on anatomopathological samples, without peritoneal metastasis during appendectomy, were addressed. Between them 2 patients were denied CRS. Among the 15 operated patients, 8 patients had no peritoneal metastasis discovery during surgery, and therefore underwent prophylactic CRS and HIPEC. Peritoneal metastasis were discovered for the other 7 patients, who also underwent CRS and HIPEC. For the prophylactic group, the recurrence rate is 12,5 %, overall survival (OS) is 100 %. The rate of grade III-IV surgical complications after CRS and HIPEC was 36 % among the 19 patients who underwent surgery. CONCLUSION In case of appendectomy in emergency situations for perforated adenocarcinoma, half of the patients may have peritoneal metastasis. In case of non-identified peritoneal metastasis during CRS, performing a prophylactic HIPEC seems to be associated with an encouraging rate of peritoneal disease free situation at 5 years.
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Affiliation(s)
- Elsa Leiritz
- Department of Digestive, Hepatobiliary Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.
| | - Jérémy Rezai
- Department of Gastroenterology and Digestive Oncology, Pitié-Salpêtrière Hospital, Sorbonne University, UPMC University, Paris, France
| | - Mathilde Wagner
- Department of Radiology Diagnosis, Pitié-Salpêtrière Hospital, Sorbonne University, UPMC University, Paris, France
| | - Armelle Bardier
- Department of Pathology, Pitié-Salpêtrière Hospital, Sorbonne University, UPMC University, Paris, France
| | - Amu Therwath
- Université Paris Cité, INSERM, U1275 CAP Paris-Tech, F-75010, Paris, France
| | - Marc Pocard
- Department of Digestive, Hepatobiliary Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; Université Paris Cité, INSERM, U1275 CAP Paris-Tech, F-75010, Paris, France.
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Lipping E, Saar S, Reinsoo A, Bahhir A, Kirsimägi Ü, Lepner U, Talving P. Short Postoperative Intravenous Versus Oral Antibacterial Therapy in Complicated Acute Appendicitis: A Pilot Noninferiority Randomized Trial. Ann Surg 2024; 279:191-195. [PMID: 37747168 DOI: 10.1097/sla.0000000000006103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
OBJECTIVE The purpose of this study is to investigate noninferiority of postoperative oral administration of antibiotics in complicated appendicitis. BACKGROUND Recent investigations have used exclusively intravenous administration of antibiotics when comparing outcomes of postoperative antibacterial therapy in complicated appendicitis. We hypothesized that oral antibacterial treatment results in noninferior outcomes in terms of postoperative infectious complications as intravenous treatment. METHODS In this pilot, open-label, prospective randomized trial, all consecutive adult patients with complicated appendicitis, including gangrenous appendicitis, perforated appendicitis, and appendicitis with periappendicular abscess between November 2020 and January 2023, were randomly allocated to 24-hour intravenous administration of antibiotics versus 24-hour oral administration of antibiotics after appendectomy. Primary outcomes included 30-day postoperative complications per Comprehensive Complication Index. The secondary outcome was hospital length of stay. Follow-up analysis at 30 days was conducted per intention to treat and per protocol. The study was registered at ClinicalTrials.gov (NCT04947748). RESULTS A total of 104 patients were enrolled, with 51 and 53 cases allocated to the 24-hour intravenous and the 24-hour oral treatment group, respectively. Demographic profile and disease severity score for acute appendicitis were similar between the study groups. There were no significant differences between the study groups in terms of 30-day postoperative complications. Median Comprehensive Complication Index did not differ between the study groups. Hospital length of stay was similar in both groups. CONCLUSIONS In the current pilot randomized controlled trial, the 24-hour oral antibiotic administration resulted in noninferior outcomes when compared with the 24-hour intravenous administration of antibiotics after laparoscopic appendectomy in complicated appendicitis.
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Affiliation(s)
- Edgar Lipping
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Sten Saar
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Arvo Reinsoo
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Artjom Bahhir
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Ülle Kirsimägi
- Faculty of Medicine, University of Tartu, Tartu, Estonia
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Urmas Lepner
- Faculty of Medicine, University of Tartu, Tartu, Estonia
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Peep Talving
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
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11
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Brucchi F, Bracchetti G, Fugazzola P, Viganò J, Filisetti C, Ansaloni L, Dal Mas F, Cobianchi L, Danelli P. A meta-analysis and trial sequential analysis comparing nonoperative versus operative management for uncomplicated appendicitis: a focus on randomized controlled trials. World J Emerg Surg 2024; 19:2. [PMID: 38218862 PMCID: PMC10787963 DOI: 10.1186/s13017-023-00531-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/20/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND The aim of this study is to provide a meta-analysis of randomized controlled trials (RCT) comparing conservative and surgical treatment in a population of adults with uncomplicated acute appendicitis. METHODS A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL. We have exclusively incorporated randomized controlled trials (RCTs). Studies involving participants with complicated appendicitis or children were excluded. The variables considered are as follows: treatment complications, complication-free treatment success at index admission and at 1 year follow-up, length of hospital stay (LOS), quality of life (QoL) and costs. RESULTS Eight RCTs involving 3213 participants (1615 antibiotics/1598 appendectomy) were included. There was no significant difference between the two treatments in terms of complication rates (RR = 0.66; 95% CI 0.61-1.04, P = 0.07, I2 = 69%). Antibiotics had a reduced treatment efficacy compared with appendectomy (RR = 0.80; 95% CI 0.71 to 0.90, p < 0.00001, I2 = 87%) and at 1 year was successful in 540 out of 837 (64.6%, RR = 0.69, 95% confidence interval 0.61 to 0.77, p < 0.00001, I2 = 81%) participants. There was no difference in LOS (mean difference - 0.58 days 95% confidence interval - 1.59 to 0.43, p = 0.26, I2 = 99%). The trial sequential analysis has revealed that, concerning the three primary outcomes, it is improbable that forthcoming RCTs will significantly alter the existing body of evidence. CONCLUSIONS As further large-scale trials have been conducted, antibiotic therapy proved to be safe, less expensive, but also less effective than surgical treatment. In order to ensure well-informed decisions, further research is needed to explore patient preferences and quality of life outcomes.
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Affiliation(s)
- Francesco Brucchi
- University of Milan, Via Festa Del Perdono 7, 20122, Milan, Italy.
- , Milan, Italy.
| | - Greta Bracchetti
- University of Milan, Via Festa Del Perdono 7, 20122, Milan, Italy
| | - Paola Fugazzola
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Jacopo Viganò
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Claudia Filisetti
- Department of Pediatric Surgery, Buzzi Children's Hospital, 20154, Milan, Italy
| | - Luca Ansaloni
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
| | - Francesca Dal Mas
- Department of Management, Università Ca' Foscari, Dorsoduro 3246, 30123, Venezia, Italy
| | - Lorenzo Cobianchi
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Piergiorgio Danelli
- Division of General Surgery, Department of Biomedical and Clinical Sciences, University of Milan, L. Sacco University Hospital, 20157, Milan, Italy
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12
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Wang SB, Zheng QX, Gou ZM, Fan ZQ, Lv GY, Yang T. Comment on: factors associated with recurrent appendicitis after successful treatment with antibiotics. Br J Surg 2024; 111:znad339. [PMID: 38059907 DOI: 10.1093/bjs/znad339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/02/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Shi-Bo Wang
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Qi-Xuan Zheng
- Department of Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Zhao-Ming Gou
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Zhong-Qi Fan
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Guo-Yue Lv
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Tian Yang
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, First Hospital of Jilin University, Changchun, China
- Department of Hepatobiliary Surgery, The Third Affiliated Hospital of Navy Medical University, Shanghai, China
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13
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Flum DR, Rosen J, Voldal E. Author response: Factors associated with recurrent appendicitis after successful treatment with antibiotics. Br J Surg 2024; 111:znad340. [PMID: 38195083 DOI: 10.1093/bjs/znad340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/04/2023] [Indexed: 01/11/2024]
Affiliation(s)
- David R Flum
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Josh Rosen
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Emily Voldal
- Fred Hutchinson Cancer Center, HPTN, Seattle, Washington, USA
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14
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Durán Muñoz-Cruzado V, Navarro Morales L, Pareja Ciuró F, Aparicio Sánchez D, Tallón Aguilar L, Padillo-Ruiz J. Safety, Efficacy, and Cost-effectiveness of Outpatient Surgery for Uncomplicated Acute Appendicitis: The PENDI-CSI Randomized Clinical Trial. Ann Surg 2024; 279:24-28. [PMID: 37641981 DOI: 10.1097/sla.0000000000006083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
OBJECTIVE To evaluate the safety, efficacy, and cost-effectiveness of outpatient appendectomy in patients with uncomplicated acute appendicitis. BACKGROUND Given that acute appendicitis is the most common cause of acute abdomen, the introduction of outpatient appendectomy protocols could significantly improve the effectiveness and sustainability of health care systems. METHODS A total of 300 patients were enrolled from October 2018 to June 2021 in the PENDI-CSI randomized clinical trial: 149 were assigned to the outpatient surgery (OPS) group and 151 to the inpatient surgery (IPS) group, followed by 1 month postoperatively. All patients were aged older than 14 years and had uncomplicated acute appendicitis. Exclusion criteria were pregnancy, neoplasms, inflammatory bowel disease, and high anesthetic risk (ASA IV). The OPS group was discharged from the postanesthesia care unit while the IPS group was admitted. RESULTS In total, 128 patients in the OPS group (85.9%) were discharged without admission. Predictors whether patients in the OPS group had to be admitted were aged over 31 years [relative risk (RR): 2.42 (1.04-5.65)], hypertension [RR: 6.21 (3.22-11.97)], anesthetic risk II-III [RR: 2.63 (1.17-5.94)], previous abdominal surgery [RR: 3.34 (1.55-7.20)], postoperative pain with visual analog scale >6 [RR: 4.28 (2.67-6.86)], and postoperative fear [RR: 2.2 (1.04-4.67)]. There were no differences in terms of complications, readmissions, and reinterventions, and the perceived quality was similar in both groups. The outpatient modality produced savings of €1 034.97 per patient ( P < 0.001). CONCLUSIONS Outpatient appendectomy is safe and effective for uncomplicated acute appendicitis. Patient-perceived quality is similar to that of IPS, although it successfully reduces hospital costs compared with inpatient appendectomy.
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Affiliation(s)
- Virgina Durán Muñoz-Cruzado
- Division of General Surgery, Biomedical Institute of Seville (IBIS), Virgen del Rocío University Hospital. Seville, Spain
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15
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Russell KW, Skarda DE, Jones TW, Barnhart DC, Short SS. Cessation of Antibiotics for Complicated Appendicitis at Discharge Does Not Increase Risk of Post-operative Infection. J Pediatr Surg 2024; 59:91-95. [PMID: 37858398 DOI: 10.1016/j.jpedsurg.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 10/21/2023]
Abstract
PURPOSE The utilization of home antibiotic therapy following surgery for complicated pediatric appendicitis is highly variable. In 2019, we stopped home antibiotic therapy in this cohort at our institution. We sought to evaluate our outcomes following this protocol change. METHODS We queried our institutional NSQIP Pediatrics data for all children undergoing appendectomy for complicated appendicitis between January 2015 and May 2022. We identified two cohorts: those discharged with home antibiotics (1/1/15-4/30/19) and those discharged with no home antibiotics (5/1/19-4/30/22). Both groups were treated with response based parenteral antibiotics while hospitalized and discharged when clinically well. Our primary outcome was postoperative deep organ space infection requiring intervention (drainage, aspiration, reoperation, or antibiotics). Secondary outcomes included length of stay, superficial site infection, Clostridium difficile colitis, ER visits, post-operative CT imaging, and readmission. RESULTS There were 185 patients in the home antibiotic group (83% discharged with antibiotics) and 121 patients in the no home antibiotic group (8.3% discharged with antibiotics). There were no significant differences in deep organ space infection requiring intervention (7% vs. 7.4%, p = 1.0). Our length of stay was not different (4.5 days vs. 3.95 days, p = 0.32), nor were other secondary outcomes or patient characteristics. All patients had documented follow-up. CONCLUSIONS We did not identify differences in deep organ space infections, length of stay or other events after eliminating home antibiotic therapy in our complicated appendicitis cohort. The use of home antibiotics following surgery for complicated appendicitis should be reconsidered. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Katie W Russell
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA
| | - David E Skarda
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA
| | - Trahern W Jones
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City, UT, USA
| | - Douglas C Barnhart
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA
| | - Scott S Short
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA.
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16
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Dreznik Y, Paran M, Bilavsky E, Avinadav E, Kravarusic D. Antibiotic Treatment in Complicated Appendicitis: Can It Be Optimized? Isr Med Assoc J 2024; 26:30-33. [PMID: 38420639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND The management of complicated appendicitis is inconclusive. Guidelines have not been established for the use of personalized antibiotic treatment. OBJECTIVES To investigate specific risk factors to consider during the initial first-choice antibiotic therapy in children with complicated appendicitis. METHODS This study included all pediatric patients younger than 18 years of age who underwent a laparoscopic appendectomy during 2012-2022 at a single tertiary medical center. RESULTS In total, 300 pediatric patients underwent laparoscopic appendectomy due to complicated appendicitis. The patients were treated with ceftriaxone + metronidazole (CM). For 57 (19%) patients, the empirical treatment was changed to tazobactam/piperacillin (TP) due to resistant bacteria or clinical deterioration. The presence of generalized peritonitis during surgery and C-reactive protein (CRP) levels above 20 mg/L at admission were identified as risk factors for changing the antibiotic regimen from CM to TP. CONCLUSIONS Generalized peritonitis and CRP > 20 gr/L were highly correlated with changing the antibiotic regimen to TP. For such patients, initial treatment with TP may result in clinical improvement and shorter hospitalization.
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Affiliation(s)
- Yael Dreznik
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center, Petah Tikva, Israel, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maya Paran
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center, Petah Tikva, Israel, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efraim Bilavsky
- Department of Pediatrics C, Schneider Children's Medical Center, Petah Tikva, Israel, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efrat Avinadav
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center, Petah Tikva, Israel, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dragan Kravarusic
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center, Petah Tikva, Israel, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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17
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Garzon-González LN, Padilla LT, Patiño F, Hernández MA, Valero J, Molina ID, Ávila FF, Camacho-Moreno G. Association between bacterial resistance profile and the development of intra-abdominal abscesses in pediatric patients with perforated appendicitis: cohort study. Pediatr Surg Int 2023; 40:18. [PMID: 38082019 PMCID: PMC10713695 DOI: 10.1007/s00383-023-05570-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 12/18/2023]
Abstract
PURPOSE The objective of this study was to determine the association between the presence of a microorganism resistant to the antibiotic used in empirical therapy and the development of intra-abdominal abscesses in children with perforated appendicitis. METHODS A prospective cohort study was conducted in patients under 18 years of age who underwent laparoscopic appendectomy between November 1, 2019, and September 30, 2020, in whom perforated appendicitis was documented intraoperatively. Peritoneal fluid samples were taken for bacteria culture purposes, and clinical and microbiological data were collected from all patients. RESULTS A total of 232 patients were included in the study. The most isolated microorganisms were Escherichia coli (80.14%) and Pseudomonas aeruginosa (7.45%). In addition, 5.31% of E. coli isolates were classified as ESBL-producing organisms. No association was found between a germ resistant to empiric antimicrobial therapy and the development of a postoperative intra-abdominal abscess. Multivariate analysis showed that being a high-risk patient on admission (OR 2.89 (p = 0.01)) was associated with the development of intra-abdominal abscesses postoperatively. CONCLUSION E. coli was the most commonly isolated microorganism, with a low rate of ESBL-producing isolates. No association between resistance and risk of postoperative intra-abdominal abscess was found. However, it was identified that being a high-risk patient on admission was associated with this complication. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Luz Nélida Garzon-González
- Paediatric Surgery Resident, Department of Surgery, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
- HOMI-Fundación Hospital Pediátrico La Misericordia, Cra 14 # 1-65, Bogotá, Colombia
| | | | - Felipe Patiño
- Institute of Clinical Research, Universidad Nacional de Colombia, Bogotá, Colombia
| | - María Alejandra Hernández
- Paediatric Surgery Resident, Department of Surgery, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Juan Valero
- Department of Surgery, Faculty of Medicine, HOMI-Fundación Hospital Pediátrico La Misericordia, Universidad Nacional de Colombia, Bogotá, Colombia.
| | - Iván Dario Molina
- Department of Surgery, Faculty of Medicine, HOMI-Fundación Hospital Pediátrico La Misericordia, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Fernando Fierro Ávila
- Department of Surgery, Faculty of Medicine, HOMI-Fundación Hospital Pediátrico La Misericordia, Universidad Nacional de Colombia, Bogotá, Colombia
| | - German Camacho-Moreno
- Department of Paediatrics, Faculty of Medicine, HOMI-Fundación Hospital Pediátrico La Misericordia, Universidad Nacional de Colombia, Bogotá, Colombia
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18
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Pata F, Nardo B, Ielpo B, Di Martino M, Murzi V, Di Saverio S, Yang B, Ortenzi M, Pisanu A, Pellino G, Podda M. Endoscopic retrograde appendicitis therapy versus appendectomy or antibiotics in the modern approach to uncomplicated acute appendicitis: A systematic review and meta-analysis. Surgery 2023; 174:1292-1301. [PMID: 37806859 DOI: 10.1016/j.surg.2023.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/09/2023] [Accepted: 08/16/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Endoscopic retrograde appendicitis therapy has been proposed as an alternative strategy for treating appendicitis, but debate exists on its role compared with conventional treatment. METHODS This systematic review was performed on MEDLINE, Cochrane Central Register of Controlled Trials, and EMBASE. The last search was in April of 2023. The risk ratio with a 95% confidence interval was calculated for dichotomous variables, and the mean difference with a 95% confidence interval for continuous variables. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool (randomized controlled trials) and the Risk of Bias in Non-Randomized Studies of Intervention tool (non-randomized controlled trials). RESULTS Six studies met the eligibility criteria. Four studies compared endoscopic retrograde appendicitis therapy (n = 236 patients) and appendectomy (n = 339) and found no differences in technical success during index admission (risk ratio 0.97, 95% confidence interval [0.92,1.02]). Appendectomy showed superior outcomes for recurrence at 1-year follow-up (risk ratio 11.28, 95% confidence interval [2.61,48.73]). Endoscopic retrograde appendicitis therapy required shorter procedural time (mean difference -14.38, 95% confidence interval [-20.17, -8.59]) and length of hospital stay (mean difference -1.19, 95% confidence interval [-2.37, -0.01]), with lower post-intervention abdominal pain (risk ratio 0.21, 95% confidence interval [0.14,0.32]). Two studies compared endoscopic retrograde appendicitis therapy (n = 269) and antibiotic treatment (n = 280). Technical success during admission (risk ratio 1.11, 95% confidence interval [0.91,1.35]) and appendicitis recurrence (risk ratio 1.07, 95% confidence interval [0.08,14.87]) did not differ, but endoscopic retrograde appendicitis therapy decreased the length of hospitalization (mean difference -1.91, 95% confidence interval [-3.18, -0.64]). CONCLUSION This meta-analysis did not identify significant differences between endoscopic retrograde appendicitis therapy and appendectomy or antibiotics regarding technical success during index admission and treatment efficacy at 1-year follow-up. However, a high risk of imprecision limits these results. The advantages of endoscopic retrograde appendicitis therapy in terms of reduced procedural times and shorter lengths of stay must be balanced against the increased risk of having an appendicitis recurrence at one year.
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Affiliation(s)
- Francesco Pata
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy; General Surgery Unit, Department of Surgery, AO Annunziata, Cosenza, Italy. https://twitter.com/drfrancescopata
| | - Bruno Nardo
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy; General Surgery Unit, Department of Surgery, AO Annunziata, Cosenza, Italy
| | - Benedetto Ielpo
- Hepatobiliary and Pancreatic Surgery Unit, Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Spain. https://twitter.com/IelpoB
| | - Marcello Di Martino
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy. https://twitter.com/MarcDiMartino
| | - Valentina Murzi
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Salomone Di Saverio
- Department of Surgery, "Madonna del Soccorso" Hospital, San Benedetto del Tronto, Italy. https://twitter.com/salo75
| | - Baohong Yang
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Monica Ortenzi
- Department of General and Emergency Surgery, Polytechnic University of Marche, Ancona, Italy. https://twitter.com/ortenzi_monica
| | - Adolfo Pisanu
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli," Naples; Department of Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain. https://twitter.com/GianlucaPellino
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy.
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19
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Cheng V, Ashbrook M, Youssefzadeh AC, Kohrman N, Matsuo K, Inaba K, Matsushima K. Management for Acute Uncomplicated Appendicitis During Pregnancy: National Trends and Patient Outcomes. Ann Surg 2023; 278:932-936. [PMID: 37132381 DOI: 10.1097/sla.0000000000005893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVE This study analyzes national trends in the management of uncomplicated appendicitis during pregnancy, comparing outcomes for nonoperative management (NOM) and appendectomy. BACKGROUND In the nonpregnant population, several randomized controlled trials demonstrated noninferiority of NOM compared with appendectomy for acute uncomplicated appendicitis. However, it remains unclear whether these findings are generalizable to pregnant patients. METHODS The National Inpatient Sample was queried for pregnant women diagnosed with acute uncomplicated appendicitis from January 2003 to September 2015. Patients were categorized by treatment: NOM, laparoscopic appendectomy (LA), and open appendectomy. A quasi-experimental analysis with interrupted time series examined the relationship between the year of admission and the likelihood of receiving NOM. Multivariable logistic regression analyses were used to evaluate the association between treatment strategy and patient outcomes. RESULTS A total of 33,120 women satisfied the inclusion criteria. Respectively, 1070 (3.2%), 18,736 (56.6%), and 13,314 (40.2%) underwent NOM, LA, and open appendectomy. The NOM rate significantly increased between 2006 and 2015, with an annual increase of 13.9% (95% CI, 8.5-19.4, P <0.001). Compared with LA, NOM was significantly associated with higher rates of preterm abortion (odds ratio [OR]: 3.057, 95% CI, 2.210-4.229, P <0.001) and preterm labor/delivery (OR: 3.186, 95% CI, 2.326-4.365, P <0.001). Each day of delay to appendectomy was associated with significantly greater rates of preterm abortion (OR: 1.210, 95% CI, 1.123-1.303, P <0.001). CONCLUSIONS Although NOM has been increasing as a treatment for pregnant patients with uncomplicated appendicitis, compared with LA, it is associated with worse clinical outcomes.
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Affiliation(s)
- Vincent Cheng
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Matthew Ashbrook
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Ariane C Youssefzadeh
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Nathan Kohrman
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Koji Matsuo
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA
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Cioffi SPB, Altomare M, Podda M, Spota A, Granieri S, Reitano E, Zamburlini B, Virdis F, Bini R, Gupta S, Torzilli G, Mingoli A, Chiara O, Cimbanassi S. The burden of the knowledge-to-action gap in acute appendicitis. Surg Endosc 2023; 37:9617-9632. [PMID: 37884735 PMCID: PMC10709474 DOI: 10.1007/s00464-023-10449-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/05/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND The burden of emergency general surgery (EGS) is higher compared to elective surgery. Acute appendicitis (AA) is one of the most frequent diseases and its management is dictated by published international clinical practice guidelines (CPG). Adherence to CPG has been reported as heterogeneous. Barriers to clinical implementation were not studied. This study explored barriers to adherence to CPG and the clinico-economic impact of poor compliance. METHODS Data were extracted from the three-year data lock of the REsiDENT-1 registry, a prospective resident-led multicenter trial. We identified 7 items from CPG published from the European Association of Endoscopic Surgery (EAES) and the World Society of Emergency Surgery (WSES). We applied our classification proposal and used a five-point Likert scale (Ls) to assess laparoscopic appendectomy (LA) difficulty. Descriptive analyses were performed to explore compliance and group comparisons to assess the impact on outcomes and related costs. We ran logistic regressions to identify barriers and facilitators to implementation of CPG. RESULTS From 2019 to 2022, 653 LA were included from 24 centers. 69 residents performed and coordinated data collection. We identified low compliance with recommendations on peritoneal irrigation (PI) (25.73%), abdominal drains (AD) (34.68%), and antibiotic stewardship (34.17%). Poor compliance on PI and AD was associated to higher infectious complications in uncomplicated AA. Hospitalizations were significantly longer in non-compliance except for PI in uncomplicated AA, and costs significantly higher, exception made for antibiotic stewardship in complicated AA. The strongest barriers to CPG implementation were complicated AA and technically challenging LA for PI and AD. Longer operative times and the use of PI negatively affected antibiotic stewardship in uncomplicated AA. Compliance was higher in teaching hospitals and in emergency surgery units. CONCLUSIONS We confirmed low compliance with standardized items influenced by environmental factors and non-evidence-based practices in complex LA. Antibiotic stewardship is sub-optimal. Not following CPG may not influence clinical complications but has an impact in terms of logistics, costs and on the non-measurable magnitude of antibiotic resistance. Structured educational interventions and institutional bundles are required.
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Affiliation(s)
- Stefano Piero Bernardo Cioffi
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, Rome, Italy.
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy.
| | - Michele Altomare
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, Rome, Italy
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | - Mauro Podda
- Department of Surgical Sciences, Cagliari State University, Cagliari, Italy
| | - Andrea Spota
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | - Stefano Granieri
- General Surgery Unit, ASST-Brianza, Vimercate Hospital, Vimercate, Italy
| | - Elisa Reitano
- Division of General Surgery, Department of Translational Medicine, Maggiore Della Carità Hospital, University of Eastern Piedmont, Novara, Italy
- Research Institute Against Digestive Cancer, IRCAD, Strasbourg, France
| | - Beatrice Zamburlini
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Francesco Virdis
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | - Roberto Bini
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | | | | | - Andrea Mingoli
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, Rome, Italy
| | - Osvaldo Chiara
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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21
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Xu Z, Jin L, Wu W. Clinical efficacy and safety of endoscopic retrograde appendicitis treatment for acute appendicitis: A systematic review and meta-analysis. Clin Res Hepatol Gastroenterol 2023; 47:102241. [PMID: 37925019 DOI: 10.1016/j.clinre.2023.102241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/22/2023] [Accepted: 10/31/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVES To assess the efficacy and safety of endoscopic retrograde appendicitis treatment (ERAT) for acute appendicitis (AA) by conducting a meta-analysis of clinical randomized trials (RCTs). METHODS Eight electronic databases were searched. Study quality was assessed using the Cochrane risk of bias tool. RevMan5.3 and STATA14 software were used to for statistical analysis. RESULTS Twenty-six RCTs with 2236 subjects were analyzed. First, operative time, length of hospital stay and duration of bed rest were shorter in the ERAT groups than in the control groups, with the pooled MD and 95 % CI being -13.22(-20.09, -6.35)(p = 0.0002), -2.13 (-2.47, -1.80)(p < 0.00001) and -3.15 (-3.76, -2.53)(p < 0.00001), respectively. Second, patients in the ERAT groups had a lower incidence of complications than the control groups, with a pooled RR and 95 % CI of 0.25(0.18, 0.35)(p < 0.00001). Third, patients who received ERAT returned to normal temperature faster than the control groups, the pooled MD and 95 % CI was -3.39(-4.36, -2.42)(p<0.00001). Finally, the result showed that the recurrence rate in the ERAT groups was approximately twice that of control groups, with the pooled RR and 95 % CI being 2.10(1.02, 4.32)(p < 0.00001). CONCLUSIONS ERAT results in fewer complications and shorter recovery time. And compared to appendectomy, ERAT reduces operative time and intraoperative bleeding. However, the recurrence of acute appendicitis after ERAT remains a concern. And more multicenter and large-scale RCTs are needed to confirm the benefits of ERAT. SYSTEMATIC REVIEW REGISTRATION We have registered on the PROSPERO [https://www.crd.york.ac.uk/PROSPERO/], and the registration number is CRD42023420171.
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Affiliation(s)
- Zhigang Xu
- Department of Anorectal, Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen 518034, China
| | - Liang Jin
- Department of Anorectal, Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen 518034, China
| | - Wenjiang Wu
- Department of Anorectal, Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen 518034, China.
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22
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Xiao M, Liu X. Laparoscopic Appendectomy Combined with an "Antimicrobial-Free" Strategy for Acute Uncomplicated Appendicitis. J Laparoendosc Adv Surg Tech A 2023; 33:1134-1140. [PMID: 37733260 DOI: 10.1089/lap.2023.0215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
Objective: To explore the efficacy and safety of enhanced recovery protocol (ERP) combined with laparoscopic appendectomy (LA) in the treatment of acute uncomplicated appendicitis (AUA) without antibiotics. Methods: In this study, a total of 160 patients with AUA who underwent LA between January 2018 and December 2021 were included and divided into the antibiotic group (n = 80) or the no-antibiotic group (n = 80). The patients in the antibiotic group received the ERP combined with antimicrobials during the perioperative period, while those in the no-antibiotic group only received the ERP during the perioperative period. The clinical data of these patients were collected to compare the inflammation level and stress state before and after surgery. In addition, the incidence of postoperative complications and the recovery speed of the patients were compared between groups. Results: There were no significant differences in the inflammation level and stress state before or after surgery, the incidence of postoperative complications or the recovery speed between the antibiotic group and the no-antibiotic group (P > .05). Conclusion: The use of ERP combined with LA as an antimicrobial-free treatment scheme in the perioperative period was found to be safe and effective for patients with AUA. Therefore, this approach is clinically valuable.
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Affiliation(s)
- Mingsheng Xiao
- Department of Gastrointestinal Surgery, The Fifth People's Hospital of Chongqing, Nanan, Chongqing, China
| | - Xiao Liu
- Department of Gastrointestinal Surgery, The Fifth People's Hospital of Chongqing, Nanan, Chongqing, China
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23
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Moreno-Alfonso JC, Molina Caballero A, Pérez Martínez A. Antibiotic treatment of post-appendectomy abscesses in children, regardless of size: a twelve years' experience. Updates Surg 2023; 75:2267-2272. [PMID: 37794218 DOI: 10.1007/s13304-023-01654-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/23/2023] [Indexed: 10/06/2023]
Abstract
Intra-abdominal abscesses are a common issue after appendectomy. Antibiotics have shown efficacy in treating smaller abscesses, while larger ones have traditionally been treated with drainage. This study assesses the efficacy of antibiotics for post-appendectomy intra-abdominal abscess (PAA) in children regardless of size. Case-control study of children with PAA admitted at our hospital from 2010 to 2022. The efficacy of antibiotics was compared between abscesses less and more than 6 cm in diameter. The Institutional Review Board has approved this study. A total of 1766 appendectomies were performed from 2010 to 2022 with an incidence of PAA of 5% (n = 89): age 9.3 IQR 5.8, 63% male (n = 56). Sixty-seven patients presented with a ≤ 6 cm abscess (controls) and 22 children had a > 6 cm PAA (cases). Length of intravenous antibiotics were higher in cases (15 IQR 7 days) than controls (12 IQR 4 days), p = 0.003. The efficacy of antibiotics in controls was 97% whereas 86.4% in cases (p = 0.094), reoperation was needed in 2/67 controls and 3/22 cases, with no differences in complications or readmission. The length of stay was longer in cases (15 IQR 6 days) than controls (13 IQR 5 days), p = 0.042. Antibiotics seem a safe treatment for PAA in children regardless of the size. However, this approach is associated with a longer period of intravenous antibiotics and hospital stay, although not with a higher rate of therapeutic failure, complications or reoperations.
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Affiliation(s)
- Julio César Moreno-Alfonso
- Department of Pediatric Surgery, Hospital Universitario de Navarra, Irunlarrea Street, 3, 31008, Pamplona, Navarra, Spain.
- Doctoral School, Universidad Pública de Navarra (UPNA), Pamplona, Navarra, Spain.
| | - Ada Molina Caballero
- Department of Pediatric Surgery, Hospital Universitario de Navarra, Irunlarrea Street, 3, 31008, Pamplona, Navarra, Spain
| | - Alberto Pérez Martínez
- Department of Pediatric Surgery, Hospital Universitario de Navarra, Irunlarrea Street, 3, 31008, Pamplona, Navarra, Spain
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24
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Vu MT, Schwartz H, Straube S, Pondicherry N, Emanuels D, Dhanoa J, Bains J, Singh M, Stark N, Peabody C. Compass for antibiotic stewardship: using a digital tool to improve guideline adherence and drive clinician behaviour for appendicitis treatment in the emergency department. Emerg Med J 2023; 40:847-853. [PMID: 37907325 DOI: 10.1136/emermed-2022-213015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 10/04/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Antibiotic stewardship in the ED is important given the increasing prevalence of multidrug resistance associated with poorer patient outcomes. The use of broad-spectrum antibiotics in the ED for infections like appendicitis is common. At baseline, 75% of appendicitis cases at our institution received broad-spectrum ertapenem rather than the recommended narrower-spectrum ceftriaxone/metronidazole combination. We aimed to improve antibiotic stewardship by identifying barriers to guideline adherence and redesigning our appendicitis antibiotic guideline. METHODS Using the 'Fit between Individuals, Task and Technology (FITT)' framework, we identified barriers that preventclinicians from adhering to guidelines. We reformatted a clinical guideline and disseminated it using our ED's clinical decision support system (CDSS), E*Drive. Next, we examined E*Drive's user data and clinician surveys to assess utilisation and satisfaction. Finally, we conducted a retrospective chart review to measure clinician behaviour change in antibiotic prescription for appendicitis treatment. RESULTS Data demonstrated an upward trend in the number of monthly users of E*Drive from 1 April 2021 to 30 April 2022, with an average increase of 46 users per month. Our clinician survey results demonstrated that >95% of users strongly agree/agree that E*Drive improves access to clinical information, makes their job more efficient and that E*Drive is easy to access and navigate, with a Net Promoter Score increase from 26.0 to 78.3. 69.4% of patients treated for appendicitis in the post-intervention group received antibiotics concordant with our institutional guideline compared with 20.0% in the pre-intervention group (OR=9.07, 95% CI (3.84 to 21.41)). CONCLUSION Antibiotic stewardship can be improved by ensuring clinicians have access to convenient and up-to-date guidelines through clinical decision support systems. The FITT model can help guide projects by identifying individual, task and technology barriers. Sustained adherence to clinical guidelines through simplification of guideline content is a potentially powerful tool to influence clinician behaviour in the ED.
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Affiliation(s)
- Mai Trang Vu
- UCSF School of Medicine, San Francisco, California, USA
| | - Hope Schwartz
- UCSF School of Medicine, San Francisco, California, USA
| | - Steven Straube
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
| | | | | | - Jaskirat Dhanoa
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
| | - Jaskaran Bains
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
| | - Malini Singh
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
| | - Nicholas Stark
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
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25
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Moran B. Conservative management of appendicitis: general adoption may be jumping the gun. Br J Surg 2023; 110:1601-1602. [PMID: 37856698 DOI: 10.1093/bjs/znad334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/23/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Brendan Moran
- Peritoneal Malignancy Institute, Basingstoke Hospital, North Hampshire Foundation Trust, Basingstoke, UK
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26
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Yang FF, Monsell SE, Davidson GH, Mogal H, Voldal EC, Fannon EEC, Lawrence SO, Krishnadasan A, Talan DA, Bizzell B, Heagerty PJ, Comstock BA, Lavallee DC, Carter DW, Skeete DA, Alam HB, Glaser J, Mandell KA, Uribe L, Neufeld M, Guiden M, Schaetzel SM, Reiter SA, Millas SG, Winchell R, Thompson CM, Self WH, Kao LS, Dodwad SJ, Salzman D, Kaji AH, DeUgarte DA, Siparsky N, Price TP, Victory J, Jones A, Kutcher M, Liang MK, Cuschieri J, Johnson J, Odom SR, Kessler LG, Flum DR. Appendiceal neoplasms in patients treated with antibiotics for acute appendicitis: secondary analysis of the CODA randomized clinical trial. Br J Surg 2023; 110:1659-1662. [PMID: 37499092 PMCID: PMC11032191 DOI: 10.1093/bjs/znad240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023]
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27
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Jiang X, Wang M, Fan Z. Comment on: Endoscopic retrograde appendicitis therapy or antibiotics for uncomplicated appendicitis. Br J Surg 2023; 110:1900. [PMID: 37747418 DOI: 10.1093/bjs/znad313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 09/26/2023]
Affiliation(s)
- Xiaohan Jiang
- Department of Digestive Endoscopy, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, China
| | - Min Wang
- Department of Digestive Endoscopy, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, China
| | - Zhining Fan
- Department of Digestive Endoscopy, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, China
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28
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Nasir A, Li DL, Liu BR. Author response to: Comment on: Endoscopic retrograde appendicitis therapy or antibiotics for uncomplicated appendicitis. Br J Surg 2023; 110:1901. [PMID: 37772972 DOI: 10.1093/bjs/znad314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023]
Affiliation(s)
- Abdul Nasir
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - De-Liang Li
- Medical Research Centre, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bing-Rong Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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29
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Cong S, Wu G, Jin Y, Zhu L. Efficacy and Adverse Reactions of Dahuang Mudan decoction Combined with Laparoscopy in the Treatment of Appendicitis: A Meta-Analysis. Altern Ther Health Med 2023; 29:822-829. [PMID: 37773648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
Background Appendicitis is a common acute abdominal disease. Traditional Chinese medicine believes that acute appendicitis is caused by the accumulation of heat and toxin, and the formation of carbuncle and pus in the colon due to stasis. Therefore, treatment should be carried out to clear heat and detoxify, clear the organs, and eliminate carbuncle. Dahuang Mudan Tang contains various traditional Chinese medicines for clearing heat and detoxifying, which can be used to treat appendicitis. This study observes the therapeutic effect of Dahuang Mudan Tang on patients undergoing laparoscopic surgery for acute appendicitis. Methods Eight databases were searched by computer and inclusion criteria were pre determined before evaluation: (1) patients with appendicitis; (2) 18-70 years old; (3) Agree to this study and obtain randomized controlled trials at home and abroad on the combined treatment of appendicitis with caesarean section and rhubarb peony testing. Using RevMan 5.3 software, conduct a comprehensive evaluation of the cultivation quality and conduct data analysis. Results The meta-analysis ultimately included 16 papers. They are all considered randomized controlled trials. The overall efficiency of the test unit and control unit was reported in 12 surveys. The total effective rate of the experimental group was significantly higher than that of the control group (Odds Ratio (OR): (1.16; 95% Cl: 1.11,1.20; P < .001), and the duration of bowel sounds was also significantly higher than that of the control group. Standardized mean deviation (SMD): (-7.39; 95% Cl: -8.48, -6.30; P < .01), defecation time SMD: (-1.60; 95% Cl: -2.07, -1.12; P < .01). Conclusion Based on the total effective rate, defecation time, defecation time, CRP, IL-6, and adverse reactions of participants in this study, the combination of Dahuang Mudan Tang and laparoscopy in the treatment of appendicitis may be beneficial, which can improve clinical efficacy, inhibit inflammatory reactions, and promote postoperative recovery of patients. It is worth promoting and applying in clinical practice. However, these findings still require more high-quality research to confirm. Patients undergoing laparoscopic surgery for appendicitis were treated with Dahuang Mudan Tang combined with targeted intervention.
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30
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Quintero-Riaza VM, Chancí-Drago R, Guzmán-Arango N, Posada-Moreno P, López-Sandoval T, Ramírez-Sánchez IC, Vanegas-Munera JM. Aerobic Intraoperative Abdominal Cavity Culture Modifies Antibiotic Therapy and Reduces the Risk of Surgical Site Infection in Complicated Appendicitis with Peritonitis. J Gastrointest Surg 2023; 27:2563-2566. [PMID: 37340103 PMCID: PMC10661740 DOI: 10.1007/s11605-023-05736-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/30/2023] [Indexed: 06/22/2023]
Affiliation(s)
| | - Romario Chancí-Drago
- School of Health Sciences, Universidad Pontificia Bolivariana, Medellín, Colombia
| | | | - Pablo Posada-Moreno
- School of Health Sciences, Universidad Pontificia Bolivariana, Medellín, Colombia
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31
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Liu L, Zeng H, Fang Y, Zhang B, Yang Y, Bai J, Lin S, Xie S. The Endoscopic Retrograde Appendicitis Therapy for Acute Appendicitis in Children: A Systematic Review and Meta-Analysis. Altern Ther Health Med 2023; 29:342-346. [PMID: 37632960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/28/2023]
Abstract
Background Acute appendicitis (AA) is a prevalent abdominal emergency in children, and there has been growing interest in the use of endoscopic retrograde appendicitis treatment (ERAT) over the past two decades. A meta-analysis of published retrospective studies was conducted to investigate the clinical characteristics and therapeutic efficacy of ERAT for AA in children. Methods A systematic review and meta-analysis of retrospective studies were carried out, encompassing data from PUBMED, MEDLINE, Cochrane, China National Knowledge Infrastructure (CNKI), WanFang, and VIP Database. The search was limited to studies published between January 1, 2012, and June 31, 2022, with the final search conducted on October 31, 2022. No restrictions were imposed regarding publication or study design filters. The registration number in PROSPERO was CRD42022377739. Results Seven retrospective cohort studies with 423 patients were included. The majority of children who underwent ERAT were male (57.6%, 95% CI 52.8%-62.4%). The ERAT procedure had a high success rate (99.5%, 95% CI 98.2%-100.0%) and averaged around 49 minutes. ERAT's efficacy for treating acute appendicitis was high (99.0%, 95% CI 96.5%-100.0%), with a low recurrence rate (4.2%, 95% CI 2.2%-6.7%). Patients typically stayed in the hospital for about 4.3 days, and the rate of postoperative complications was around 3.9% (95% CI 2.0%-6.2%). Conclusions Despite the heterogeneity among studies, ERAT appears to be an effective treatment for acute uncomplicated appendicitis in children. It has a high success rate, a low recurrence rate, preserves the appendix's function, and causes minimal damage. ERAT could be considered a safe and effective treatment option for pediatric appendicitis.
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32
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Alsaggaf A, Owiwi Y, Shalaby M, Ghallab A, Zidan M, Alawi A, Bustangi N, Awad M, Bana A, Al Zeair S, Afandi A, Basyouni A, Al Nasser I, Raml E, Raboei E. Non-operative treatment for simple acute appendicitis (NOTA) in children during the COVID-19 era: new lessons from the pandemic. Sci Rep 2023; 13:18766. [PMID: 37907760 PMCID: PMC10618159 DOI: 10.1038/s41598-023-46172-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 10/28/2023] [Indexed: 11/02/2023] Open
Abstract
Coronavirus (COVID-19) was a pandemic disease that was affecting our medical and surgical daily practice badly. The surgical management of acute appendicitis was the gold standard, but new studies suggest the safety of antibiotic treatment alone. Non-operative treatment for simple acute appendicitis (NOTA) avoids surgery, the risks of general anesthesia, and long hospital stays. It also decreases the risk of exposure to coronavirus. We aimed to study the cost-effectiveness and outcome of NOTA during the COVID-19 pandemic and compared it to single-incision pediatric endo-surgery appendectomy (SIPESA). A prospective cohort study for NOTA of patients from 6 to 12 years old in the COVID-19 pandemic period from April 1st, 2020, to April 30th, 2021, patients were divided into two groups: Group S was managed by SIPESA, and Group N was managed by NOTA. Family education and assurance with detailed explanation were done for early detection of any complications, and we continue monitoring the patients until their complete recovery. Group S had 24 cases (40%), mean age 9.3 years. Group N had 36 cases (60%), mean age 9.1 years. Six cases (17%) in group N were converted to surgical management in the first 6 months of the study. The mean cost dropped from $2736/day to $400/day. The mean psychological stress for the children improved from 4.4 in April to 2 in September. The mean follow-up was 3.5 months. NOTA is a feasible, cost-effective approach, and we recommend it, as we have learned this lesson during the COVID-19 pandemic days.
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Affiliation(s)
- Ameen Alsaggaf
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Yazeed Owiwi
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Mohamed Shalaby
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia.
- Pediatric Surgery Unit, Faculty of Medicine, Tanta University, Tanta, Egypt.
| | - Alaa Ghallab
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Mazen Zidan
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Ahmed Alawi
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Nasir Bustangi
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed Awad
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
- Pediatric Surgery Unit, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Abdulelah Bana
- Radiology Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Saad Al Zeair
- Radiology Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Ahmed Afandi
- Surgical Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Ahmed Basyouni
- Surgical Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Ibrahim Al Nasser
- Radiology Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Enas Raml
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
| | - Enaam Raboei
- Pediatric Surgery Department, King Fahd Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia
- Medical Reference Center, Jeddah, Saudi Arabia
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Zeng BS, Tseng PT, Hsu CW. Duration of antibiotics in complicated appendicitis. Lancet 2023; 402:1326. [PMID: 37838434 DOI: 10.1016/s0140-6736(23)01565-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 07/24/2023] [Indexed: 10/16/2023]
Affiliation(s)
- Bing-Syuan Zeng
- Department of Internal Medicine, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Ping-Tao Tseng
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
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Moris D, Pappas T. Duration of antibiotics in complicated appendicitis. Lancet 2023; 402:1327. [PMID: 37838436 DOI: 10.1016/s0140-6736(23)01567-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 07/24/2023] [Indexed: 10/16/2023]
Affiliation(s)
- Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
| | - Theodore Pappas
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Ullah S, Shi Y, Liu BR. Duration of antibiotics in complicated appendicitis. Lancet 2023; 402:1325-1326. [PMID: 37838432 DOI: 10.1016/s0140-6736(23)01564-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 07/24/2023] [Indexed: 10/16/2023]
Affiliation(s)
- Saif Ullah
- Department of Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Yang Shi
- Department of Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Bing-Rong Liu
- Department of Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China.
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Meng J, Gao S. Duration of antibiotics in complicated appendicitis. Lancet 2023; 402:1326-1327. [PMID: 37838433 DOI: 10.1016/s0140-6736(23)01566-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 07/24/2023] [Indexed: 10/16/2023]
Affiliation(s)
- Jiahao Meng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Hunan 410008, China
| | - Shuguang Gao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Hunan 410008, China.
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de Wijkerslooth EML, Wijnhoven BPL, van den Boom AL. Duration of antibiotics in complicated appendicitis - Authors' reply. Lancet 2023; 402:1327-1328. [PMID: 37838435 DOI: 10.1016/s0140-6736(23)01563-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/24/2023] [Indexed: 10/16/2023]
Affiliation(s)
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC-University Medical Center, Rotterdam, Netherlands
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Flum DR. Factors associated with recurrent appendicitis after successful treatment with antibiotics. Br J Surg 2023; 110:1482-1489. [PMID: 37459231 PMCID: PMC10564398 DOI: 10.1093/bjs/znad218] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 05/04/2023] [Accepted: 05/24/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND As more patients with appendicitis are treated with antibiotics, factors associated with recurrence may help inform individualized prognostication and decision-making. METHODS This cohort study, using data from the Comparison of Outcomes of Antibiotic Drugs and Appendectomy trial, examined patients treated with antibiotics who did not undergo appendicectomy in the first 30 days. Patients who had appendicectomy between 30 days and 1 year were compared with those who did not. Marginalized logistic regression models were used to calculate adjusted risk differences (RDs) to estimate the association between baseline patient factors and the risk of undergoing an appendicectomy between 30 days and 1 year. RESULTS Of 601 patients treated with antibiotics who did not undergo appendicectomy within 30 days (mean age 38.0 years; 217 women (36.1 per cent)), 144 had an appendicectomy and 56 were lost to follow-up between 30 days and 1 year. The estimated rate of appendicectomy between 30 days and 1 year was 28.6 (95 per cent c.i. 25.0 to 32.8) per cent. After adjustment for other factors, nausea, vomiting, or anorexia at baseline presentation was associated with an increased rate of appendicectomy between 30 days and 1 year (adjusted RD 17.52, 95 per cent c.i. 8.64 to 26.40). The presence of an appendicolith (adjusted RD 3.64, -6.08 to 13.36), or an abscess, perforation, or fat stranding on initial imaging (adjusted RD -7.23, -17.41 to 2.95) was not strongly associated with appendicectomy between 30 days and 1 year. CONCLUSION Most factors commonly associated with appendicitis severity were not strongly associated with an increased risk of undergoing appendicectomy in the longer term after treatment with antibiotics.
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Affiliation(s)
- David R Flum
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle, Washington, USA
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Picard C, Abbo O, Munzer C, Ricco L, Dubois D, Lemoine C, Claudet I, Bréhin C. Non-operative treatment of acute appendicitis in children: clinical efficacy of amoxicillin-clavulanic acid in a retrospective single-centre study. BMJ Paediatr Open 2023; 7:e001855. [PMID: 37793677 PMCID: PMC10551930 DOI: 10.1136/bmjpo-2023-001855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/23/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND The success rate of non-operative treatment (NOT) of acute uncomplicated appendicitis (AUA) in children varies from 65% to 95%. There are no recommendations on the appropriate antibiotic therapy. OBJECTIVE To determine the clinical efficacy of amoxicillin-clavulanic acid for NOT of AUA in children. METHODS Design: Cross-sectional study in a single medical centre. SETTINGS Emergency department and Paediatric Visceral Surgery department of the Children Hospital in Toulouse, France. PATIENTS Patients 5-15 years old who were diagnosed with appendicitis, (1) With abdominal pain and a first episode of acute appendicitis, (2) With no radiological or ultrasound evidence of appendicolith, appendiceal perforation, pelvic abscess nor peritonitis, and (3) With non-septic general aspect, were included. INTERVENTIONS NOT consisted of hospital admission. The antibiotic treatment was a combination of amoxicillin and clavulanic acid (80 mg/kg/day of amoxicillin): intravenous regimen during 48 hours followed by oral route during 7 days. MAIN OUTCOME MEASURE Success rate of amoxicillin-clavulanic acid NOT in children with AUA at 2 years. RESULTS The initial success rate of amoxicillin-clavulanic acid NOT in children with AUA was 100% (104/104 patients). The success rate at 2 years was 85.6% (89/104) at discharge. None of the 15 patients who underwent surgery after recurrence of appendicitis presented with peritonitis, appendiceal perforation nor pelvic abscess. CONCLUSION Narrowed antibiotic therapy with amoxicillin and clavulanic acid seems to be an alternative to surgery in children with AUA. It is necessary to wait for the results of ongoing studies to confirm these results.
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Affiliation(s)
- Clémence Picard
- Emergency Care Unit, Hôpital des Enfants, Centre Hospitalier Universitaire Toulouse, Toulouse, France
| | - Olivier Abbo
- Pediatric Surgery Department, Hôpital des Enfants CHU Toulouse, Toulouse, France
| | - Caroline Munzer
- Pediatric Clinical Investigation Center, CHU Toulouse, Toulouse, France
| | - Lucas Ricco
- Emergency Care Unit, Hôpital des Enfants, Centre Hospitalier Universitaire Toulouse, Toulouse, France
| | | | - Cécile Lemoine
- Emergency Care Unit, Hôpital des Enfants, Centre Hospitalier Universitaire Toulouse, Toulouse, France
| | - Isabelle Claudet
- Emergency Care Unit, Hôpital des Enfants, Centre Hospitalier Universitaire Toulouse, Toulouse, France
| | - Camille Bréhin
- Emergency Care Unit, Hôpital des Enfants, Centre Hospitalier Universitaire Toulouse, Toulouse, France
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Pátková B, Svenningsson A, Almström M, Svensson JF, Eriksson S, Wester T, Eaton S. Long-Term Outcome of Nonoperative Treatment of Appendicitis. JAMA Surg 2023; 158:1105-1106. [PMID: 37556160 PMCID: PMC10413207 DOI: 10.1001/jamasurg.2023.2756] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/08/2023] [Indexed: 08/10/2023]
Abstract
This cohort study uses registry data to report the long-term outcomes of patients who participated in randomized clinical trials of antibiotics vs surgery in Sweden in the 1990s.
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Affiliation(s)
- Barbora Pátková
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Paediatric Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Anna Svenningsson
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Paediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Markus Almström
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Paediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Jan F. Svensson
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Paediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Staffan Eriksson
- Region Vastmanland- Uppsala University Centre for Clinical Research, Vasteras, Sweden
- Department of Surgery, Vastmanland Hospital, Vasteras, Sweden
| | - Tomas Wester
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Paediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Simon Eaton
- UCL Great Ormond Street Institute of Child Health, London, UK
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Atwood R, Benoit P, Hennrikus W, Kraemer L, Gunasingha RM, Kindvall A, Jessie E, Gosztyla C, Bradley M. Simple signage and targeted education can lead to process improvement in acute appendicitis care. BMJ Open Qual 2023; 12:e002327. [PMID: 37879672 PMCID: PMC10603529 DOI: 10.1136/bmjoq-2023-002327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 09/26/2023] [Indexed: 10/27/2023] Open
Abstract
INTRODUCTION An institution-wide protocol for uncomplicated acute appendicitis was created to improve compliance with best practices between the emergency department (ED), radiology and surgery. Awareness of the protocol was spread with the publication of a smartphone application and communication to clinical leadership. On interim review of quality metrics, poor protocol adherence in diagnostic imaging and antimicrobial stewardship was observed. The authors hypothesised that two further simple interventions would result in more efficient radiographic diagnosis and antimicrobial administration. MATERIALS AND METHODS Surgery residents received targeted in-person education on the appropriate antibiotic choices and diagnostic imaging in the protocol. Signs were placed in the emergency and radiology work areas, immediately adjacent to provider workstations highlighting the preferred imaging for patients with suspected appendicitis and the preferred antibiotic choices for those with proven appendicitis. Protocol adherence was compared before and after each intervention. RESULTS Targeted education was associated with improved antibiotic stewardship within the surgical department from 30% to 91% protocol adherence before/after intervention (p<0.005). Visible signs in the ED were associated with expedited antimicrobial administration from 50% to 90% of patients receiving antibiotics in the ED prior to being brought to the operating room before/after intervention (p<0.005). Diagnostic imaging after the placement of signs showed improved protocol adherence from 35% to 75% (p<0.005). CONCLUSION This study demonstrates that smartphone-based applications and communication among clinical leadership achieved suboptimal adherence to an institutional protocol. Targeted in-person education reinforcement and visible signage immediately adjacent to provider workstations were associated with significantly increased adherence. This type of initiative can be used in other aspects of acute care general surgery to further improve quality of care and hospital efficiency.
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Affiliation(s)
- Rex Atwood
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Patrick Benoit
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - William Hennrikus
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Laura Kraemer
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Rathnayaka Mudiyanselage Gunasingha
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Angela Kindvall
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Elliot Jessie
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Carolyn Gosztyla
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Matthew Bradley
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Lascano D, Zamora AK, Mahdi E, Ourshalimian S, Russell CJ, Kim E, Kelley-Quon LI. Gabapentin is Associated With Decreased Postoperative Opioid Use and Length of Stay After Appendectomy in Children With Perforated Appendicitis: A Propensity Score-Matched Analysis. J Pediatr Surg 2023; 58:1935-1941. [PMID: 37029026 PMCID: PMC10771856 DOI: 10.1016/j.jpedsurg.2023.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/17/2023] [Accepted: 03/13/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Gabapentin is increasingly used as an off-label, opioid-sparing pain medication in children. We investigated perioperative gabapentin administration and postoperative opioid use in children who underwent appendectomy for perforated appendicitis. METHODS A retrospective cohort study of healthy children ages 2-18 years undergoing appendectomy for perforated appendicitis from 2014 to 2019 was performed using the Pediatric Health Information System®. Propensity score matched (PSM) analysis was conducted with 1:1 matching based on patient and hospital characteristics. Multivariable linear regression analysis was used to evaluate an association between gabapentin, postoperative opioid use, and postoperative length of stay. RESULTS Of 29,467 children with perforated appendicitis who underwent appendectomy, 236 (0.8%) received gabapentin. In 2014, <10 children received gabapentin, but by 2019, 110 children received gabapentin. On univariate analysis of the PSM cohort, children receiving gabapentin had decreased total postoperative opiate use (2.3 SD ± 2.3 versus 3.0 SD ± 2.5 days, p < 0.001). On adjusted analysis, children receiving gabapentin had 0.65 fewer days of postoperative total opioid use (95% CI: -1.09, -0.21) and spent 0.69 fewer days in the hospital after surgery (95% CI: -1.30, -0.08). CONCLUSION While overall use is infrequent, gabapentin is increasingly administered to children with perforated appendicitis who undergo an appendectomy and is associated with decreased postoperative opioid use and reduced postoperative length of stay. Multimodal pain management strategies incorporating gabapentin may reduce postoperative opioid consumption, but further studies of drug safety are needed for this off-label use in children undergoing surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Danny Lascano
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Abigail K Zamora
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Elaa Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA; Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Eugene Kim
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA.
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Ceresoli M, Fumagalli C, Fugazzola P, Zanini N, Magnone S, Ravasi M, Bonalumi J, Morezzi D, Bova R, Sargenti B, Schiavone L, Lucianetti A, Catena F, Ansaloni L, Braga M. Outpatient Non-operative Management of Uncomplicated Acute Appendicitis: A Non-inferiority Study. World J Surg 2023; 47:2378-2385. [PMID: 37210423 PMCID: PMC10474178 DOI: 10.1007/s00268-023-07065-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 05/22/2023]
Abstract
INTRODUCTION Non-operative management (NOM) of uncomplicated acute appendicitis is a well-established alternative to upfront surgery. The administration of intravenous broad-spectrum antibiotics is usually performed in hospital, and only one study described outpatient NOM. The aim of this multicentre retrospective non-inferiority study was to evaluate both safety and non-inferiority of outpatient compared to inpatient NOM in uncomplicated acute appendicitis. METHODS The study included 668 consecutive patients with uncomplicated acute appendicitis. Patients were treated according to the surgeon's preference: 364 upfront appendectomy, 157 inpatient NOM (inNOM), and 147 outpatient NOM (outNOM). The primary endpoint was the 30-day appendectomy rate, with a non-inferiority limit of 5%. Secondary endpoints were negative appendectomy rate, 30-day unplanned emergency department (ED) visits, and length of stay. RESULTS 30-day appendectomies were 16 (10.9%) in the outNOM group and 23 (14.6%) in the inNOM group (p = 0.327). OutNOM was non-inferior to inNOM with a risk difference of-3.80% 97.5% CI (- 12.57; 4.97). No difference was found between inNOM and outNOM groups for the number of complicated appendicitis (3 vs. 5) and negative appendectomy (1 vs. 0). Twenty-six (17.7%) outNOM patients required an unplanned ED visit after a median of 1 (1-4) days. In the outNOM group, the mean cumulative in-hospital stay was 0.89 (1.94) days compared with 3.94 (2.17) days in the inNOM group (p < 0.001). CONCLUSIONS Outpatient NOM was non-inferior to inpatient NOM with regard to the 30-day appendectomy rate, while a shorter hospital stay was found in the outNOM group. Further, studies are required to confirm these findings.
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Affiliation(s)
- Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy.
| | - Chiara Fumagalli
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
| | - Paola Fugazzola
- General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Nicola Zanini
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Stefano Magnone
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Michela Ravasi
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
| | - Jacopo Bonalumi
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
| | - Daniele Morezzi
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Raffaele Bova
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Benedetta Sargenti
- General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Luca Schiavone
- General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | | | - Fausto Catena
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Braga
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
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Zehnder MJ, Cusini A. [Surgery, Antibiotic Treatment or Both?]. Praxis (Bern 1994) 2023; 112:578-580. [PMID: 37823815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
INTRODUCTION The 90-year-old female patient with underlying rheumatoid arthritis and spinal canal stenosis was admitted to hospital for pain control. The clinical exam of the lower abdomen was impressively painful and the inflammatory parameters were significantly increased. For further diagnosis a computer tomography was performed, showing a covered perforated appendicitis with a perityphlitic abscess. The conservative therapy with abscess drainage and antibiotics was successful.
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Affiliation(s)
| | - Alexia Cusini
- Infektiologie und Spitalhygiene, Kantonsspital Graubünden, Chur, Schweiz
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45
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Serrano E, Voldal EC, Machado-Aranda D, DeUgarte DA, Kao L, Drake T, Winchell R, Cuschieri J, Krishnadasan A, Talan DA, Siparsky N, Ayoung-Chee P, Self WH, McGonagill P, Mandell KA, Liang MK, Dodwad SJ, Thompson CM, Padilla RM, Fleischman R, Price TP, Jones A, Bernardi K, Garcia L, Evans HL, Sanchez SE, Odom S, Comstock BA, Heagerty PJ, Lawrence SO, Monsell SE, Fannon EE, Kessler LG, Flum DR, Davidson GH. Trial Participation and Outcomes Among English-Speaking and Spanish-Speaking Patients With Appendicitis Randomized to Antibiotics: A Secondary Analysis of the CODA Randomized Clinical Trial. JAMA Surg 2023; 158:901-908. [PMID: 37379001 PMCID: PMC10308294 DOI: 10.1001/jamasurg.2023.2277] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/28/2023] [Indexed: 06/29/2023]
Abstract
Importance Spanish-speaking participants are underrepresented in clinical trials, limiting study generalizability and contributing to ongoing health inequity. The Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial intentionally included Spanish-speaking participants. Objective To describe trial participation and compare clinical and patient-reported outcomes among Spanish-speaking and English-speaking participants with acute appendicitis randomized to antibiotics. Design, Setting, and Participants This study is a secondary analysis of the CODA trial, a pragmatic randomized trial comparing antibiotic therapy with appendectomy in adult patients with imaging-confirmed appendicitis enrolled at 25 centers across the US from May 1, 2016, to February 28, 2020. The trial was conducted in English and Spanish. All 776 participants randomized to antibiotics are included in this analysis. The data were analyzed from November 15, 2021, through August 24, 2022. Intervention Randomization to a 10-day course of antibiotics or appendectomy. Main Outcomes and Measures Trial participation, European Quality of Life-5 Dimensions (EQ-5D) questionnaire scores (higher scores indicating a better health status), rate of appendectomy, treatment satisfaction, decisional regret, and days of work missed. Outcomes are also reported for a subset of participants that were recruited from the 5 sites with a large proportion of Spanish-speaking participants. Results Among eligible patients 476 of 1050 Spanish speakers (45%) and 1076 of 3982 of English speakers (27%) consented, comprising the 1552 participants who underwent 1:1 randomization (mean age, 38.0 years; 976 male [63%]). Of the 776 participants randomized to antibiotics, 238 were Spanish speaking (31%). Among Spanish speakers randomized to antibiotics, the rate of appendectomy was 22% (95% CI, 17%-28%) at 30 days and 45% (95% CI, 38%-52%) at 1 year, while in English speakers, these rates were 20% (95% CI, 16%-23%) at 30 days and 42% (95% CI 38%-47%) at 1 year. Mean EQ-5D scores were 0.93 (95% CI, 0.92-0.95) among Spanish speakers and 0.92 (95% CI, 0.91-0.93) among English speakers. Symptom resolution at 30 days was reported by 68% (95% CI, 61%-74%) of Spanish speakers and 69% (95% CI, 64%-73%) of English speakers. Spanish speakers missed 6.69 (95% CI, 5.51-7.87) days of work on average, while English speakers missed 3.76 (95% CI, 3.20-4.32) days. Presentation to the emergency department or urgent care, hospitalization, treatment dissatisfaction, and decisional regret were low for both groups. Conclusions and Relevance A high proportion of Spanish speakers participated in the CODA trial. Clinical and most patient-reported outcomes were similar for English- and Spanish-speaking participants treated with antibiotics. Spanish speakers reported more days of missed work. Trial Registration ClinicalTrials.gov Identifier: NCT02800785.
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Affiliation(s)
- Elina Serrano
- University of Washington, Seattle
- Fred Hutch Cancer Center, Seattle, Washington
| | - Emily C. Voldal
- University of Washington, Seattle
- Fred Hutch Cancer Center, Seattle, Washington
| | | | | | - Lillian Kao
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston
| | | | | | - Joseph Cuschieri
- Harborview Medical Center, UW Medicine, Seattle, Washington
- University of California, San Francisco, San Francisco
| | | | - David A. Talan
- Olive View–UCLA Medical Center, Los Angeles, California
- Ronald Reagan UCLA Medical Center, Los Angeles, California
| | | | - Patricia Ayoung-Chee
- Bellevue Hospital Center, NYU School of Medicine, New York, New York
- Tisch Hospital, NYU Langone Medical Center, New York, New York
- Morehouse School of Medicine, Atlanta GA
| | - Wesley H. Self
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Mike K. Liang
- Lyndon B. Johnson General Hospital, University of Texas, Houston
- University of Houston, HCA Healthcare, Kingwood, Kingwood, Texas
| | - Shan-Jahan Dodwad
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston
| | - Callie M. Thompson
- Vanderbilt University Medical Center, Nashville, Tennessee
- University of Utah, Salt Lake City
| | | | | | | | - Alan Jones
- The University of Mississippi Medical Center, Jackson
| | - Karla Bernardi
- Lyndon B. Johnson General Hospital, University of Texas, Houston
| | - Luis Garcia
- University of Iowa Hospitals and Clinics, Iowa City
| | - Heather L. Evans
- Harborview Medical Center, UW Medicine, Seattle, Washington
- The Medical University of South Carolina, Charleston
| | | | - Stephen Odom
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Scheijmans JCG, Bom WJ, Heydari H, van Geloven AAW, Boermeester MA. Patient preference after treatment of uncomplicated appendicitis: surgery or antibiotics? Br J Surg 2023; 110:1221-1223. [PMID: 37395171 DOI: 10.1093/bjs/znad206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 07/04/2023]
Affiliation(s)
- Jochem C G Scheijmans
- Department of Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Wouter J Bom
- Department of Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Hamasa Heydari
- Department of Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marja A Boermeester
- Department of Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
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Weber F, Eger KI, March C, Croner RS, Meyer F. Manifestation of acute appendicitis as known but paradox visceral side effect of ulcerative colitis anti-inflammatory therapy with januskinase-inhibitor Tofacitinib (Xeljanz™). Pathol Res Pract 2023; 248:154333. [PMID: 37393666 DOI: 10.1016/j.prp.2023.154333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND The etiopathogenesis of accompanying inflammatory phenomena and consequences of immunomodulation constitute a challenging and innovative field in the medical treatment of patients with autoimmune diseases. AIM Based on i) clinical management experience gained from this challenging clinical case and ii) selective references of reports published in the scientific medical literature, we present an unusual counterfactual scientific case report. A patient diagnosed with ulcerative colitis undergoing januskinase (JAK)-inhibitor therapy developed acuteappendicitis as an unusual complication or as a visceral side effect of immunosuppressive/anti-inflammatory therapy. METHOD Scientific case report. RESULTS (case description): Medical history: A 52-year-old male presented with spasmodic pain in the right lower abdomen lasting for two days (no fever, no bowel movement changes (no stool irregularities), no vomiting). MEDICATION USED TO DATE Steroid-resistant ulcerative colitis treated with immunosuppressive therapy (Adalimumab administered for 10 months [next generation anti-TNFα mAb], Vendolizumab for 9 months [α4β7 integrin antagonist], Tofacitinib for 6 months); fructose intolerance, no previous abdominal surgery; medication: XeljanzTM (Tofacitinib, 5 mg 2x1; JAK-inhibitor; PFIZER PHARMA GmbH, Berlin,Germany); MutaflorTM (1x1; Ardeypharm GmbH, Herdecke, Germany). CLINICAL FINDINGS Pressure pain in the right lower abdomen with local muscular defense (Mc-Burney's/Lanz's point positive), no peritonism, Psoas-muscle sign positive. DIAGNOSTIC MEASURES Laboratory parameters: standard value of white blood cell count, CrP: 25 mg/l.-Transabdominal ultrasound revealed hypertrophic 'appendix vermiformis' with detectable target-phenomenon and surrounding fluid. DECISION-MAKING Indication for laparoscopic exploration. THERAPY Under perioperative single-shot antibiotic administration with UnacidTM, the patient underwent emergency laparoscopic appendectomy due to confirmed acute appendicitis with additional lavage and placement of local drainage. CLINICAL COURSE The postoperative phase was uneventful (sufficient analgetic therapy, removal of local drainage on the 2nd postoperative day). The patient was discharged four days after surgery. Histopathology confirmed ulcero-phlegmonous, acute purulent appendicitis with fibrinous purulent mesenteriolitis. FURTHER MEASURES Immunosuppressive therapy was continued. CONCLUSION Based on the paradoxon of an acute inflammatory disease (acute appendicitis) seen in the case of a patient undergoing immunosuppressive/anti-inflammatory treatment using a JAK-Inhibitor for ulcerative colitis, we consider this case worthy of publication although this side effect has previously been described in patients with rheumatoid arthritis. This might be the manifestation of i) an immunomodulatory effect that reduced or at least altered mucosal defense, including an increased risk of opportunistic infections, presenting as a specific visceral 'side effect' of the JAK-Inhibitor and/or as a consequence; ii) an induced alternative inflammatory mechanism/proinflammatory signal transduction and - theoretically - an intestinal drainage defect in the segment of right colic artery with consecutive collection of necrotic cells and activation of inflammatory mediators.
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Affiliation(s)
- F Weber
- Dept. of General, Abdominal, Vascular and Transplant Surgery, Germany
| | | | - C March
- Dept. of Radiology and Nuclear Medicine, Otto-von-Guericke University with University Hospital, Magdeburg, Germany
| | - R S Croner
- Dept. of General, Abdominal, Vascular and Transplant Surgery, Germany
| | - F Meyer
- Dept. of General, Abdominal, Vascular and Transplant Surgery, Germany.
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Thompson CM, Voldal EC, Davidson GH, Sanchez SE, Ayoung-Chee P, Victory J, Guiden M, Bizzell B, Glaser J, Hults C, Price TP, Siparsky N, Ohe K, Mandell KA, DeUgarte DA, Kaji AH, Uribe L, Kao LS, Mueck KM, Farjah F, Self WH, Clark S, Drake FT, Fischkoff K, Minko E, Cuschieri J, Faine B, Skeete DA, Dhanani N, Liang MK, Krishnadasan A, Talan DA, Fannon E, Kessler LG, Comstock BA, Heagerty PJ, Monsell SE, Lawrence SO, Flum DR, Lavallee DC. Perception of Treatment Success and Impact on Function with Antibiotics or Appendectomy for Appendicitis: A Randomized Clinical Trial with an Observational Cohort. Ann Surg 2023; 277:886-893. [PMID: 35815898 PMCID: PMC10174100 DOI: 10.1097/sla.0000000000005458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days. SUMMARY BACKGROUND DATA The Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes. METHODS We focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations. RESULTS The pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret. CONCLUSIONS Overall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT02800785.
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Affiliation(s)
- Callie M Thompson
- Vanderbilt University Medical Center, Nashville, TN
- University of Utah, Salt Lake City, UT
| | | | | | | | - Patricia Ayoung-Chee
- Tisch Hospital NYU Langone Medical Center, New York, NY
- Grady Health, Morehouse School of Medicine, Atlanta, GA
| | - Jesse Victory
- Bellevue Hospital Center NYU School of Medicine, New York, NY
| | | | | | - Jacob Glaser
- Providence Regional Medical Center Everett, Everett, WA
| | | | | | | | | | | | | | - Amy H Kaji
- Harbor-UCLA Medical Center, Torrance, CA
| | | | - Lillian S Kao
- McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Krislynn M Mueck
- McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | | | | | - Sunday Clark
- Boston University Medical Center, Boston, MA
- Weill Cornell Medicine, New York, NY
| | | | | | | | - Joseph Cuschieri
- Harborview Medical Center, Seattle, WA
- University of California, San Francisco, San Francisco, CA
| | - Brett Faine
- University of Iowa Hospitals and Clinics, Iowa City, IA
| | | | - Naila Dhanani
- University of Texas Lyndon B. Johnson General Hospital, Houston, TX
| | - Mike K Liang
- University of Texas Lyndon B. Johnson General Hospital, Houston, TX
- University of Houston, HCA Healthcare Kingwood, Kingwood, TX
| | | | - David A Talan
- Olive View-UCLA Medical Center, Sylmar, CA
- Ronald Reagan UCLA Medical Center, Westwood, CA
| | | | | | | | | | | | | | | | - Danielle C Lavallee
- University of Washington, Seattle, WA
- BC Academic Science Health Network, Vancouver, BC, Canada
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49
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Meier J, Stevens A, Bhat A, Berger M, Balentine C. Outcomes of Nonoperative vs Operative Management of Acute Appendicitis in Older Adults in the US. JAMA Surg 2023; 158:625-632. [PMID: 37017955 PMCID: PMC10077130 DOI: 10.1001/jamasurg.2023.0284] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 12/04/2022] [Indexed: 04/06/2023]
Abstract
Importance Although the incidence of acute appendicitis among adults 65 years and older is high, these patients are underrepresented in randomized clinical trials comparing nonoperative vs operative management of appendicitis; it is unclear whether current trial data can be used to guide treatment in older adults. Objective To compare outcomes following nonoperative vs operative management of appendicitis in older adults and assess whether they differ from results in younger patients. Design, Setting, and Participants This retrospective cohort study used US hospital admissions data from the Agency for Healthcare Research and Quality's National Inpatient Sample from 2004 to 2017. Of 723 889 adult patients with acute uncomplicated appendicitis, 474 845 with known procedure date who survived 24 hours postprocedure and did not have inflammatory bowel disease were included (43 846 who were treated nonoperatively and 430 999 with appendectomy) were included. Data were analyzed from October 2021 to April 2022. Exposures Nonoperative vs operative management. Main Outcomes and Measures The primary outcome was incidence of posttreatment complications. Secondary outcomes included mortality, length of stay, and inpatient costs. Differences were estimated using inverse probability weighting of the propensity score with sensitivity analysis to quantify effects of unmeasured confounding. Results The median (IQR) age in the overall cohort was 39 (27-54) years, and 29 948 participants (51.3%) were female. In patients 65 years and older, nonoperative management was associated with a 3.72% decrease in risk of complications (95% CI, 2.99-4.46) and a 1.82% increase in mortality (95% CI, 1.49-2.15) along with increased length of hospitalization and costs. Outcomes in patients younger than 65 years were significantly different than in older adults, with only minor differences between nonoperative and operative management with respect to morbidity and mortality, and smaller differences in length of hospitalization and costs. Morbidity and mortality results were somewhat sensitive to bias from unmeasured confounding. Conclusions and Relevance Nonoperative management was associated with reduced complications in older but not younger patients; however, operative management was associated with reduced mortality, hospital length of stay, and overall costs across all age groups. The different outcomes of nonoperative vs operative management of appendicitis in older and younger adults highlights the need for a randomized clinical trial to determine the best approach for managing appendicitis in older patients.
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Affiliation(s)
- Jennie Meier
- Department of Surgery, University of Texas Southwestern, Dallas
- Department of Surgery, North Texas Veterans Affairs Health Care System, Dallas
- Surgical Center for Outcomes, Implementation, & Novel Interventions, Dallas, Texas
| | - Audrey Stevens
- Department of Surgery, University of Texas Southwestern, Dallas
- Department of Surgery, North Texas Veterans Affairs Health Care System, Dallas
- Surgical Center for Outcomes, Implementation, & Novel Interventions, Dallas, Texas
| | - Archana Bhat
- Department of Surgery, University of Texas Southwestern, Dallas
- Department of Surgery, North Texas Veterans Affairs Health Care System, Dallas
- Surgical Center for Outcomes, Implementation, & Novel Interventions, Dallas, Texas
| | - Miles Berger
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Courtney Balentine
- Department of Surgery, University of Texas Southwestern, Dallas
- Department of Surgery, North Texas Veterans Affairs Health Care System, Dallas
- Surgical Center for Outcomes, Implementation, & Novel Interventions, Dallas, Texas
- Department of Surgery, University of Wisconsin, Madison
- Wisconsin Surgical Outcomes Research Program, Madison
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50
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Li D, Yang B, Liao J, Li Y, Liu D, Zhao L, Meng X, Hu H, Kong L, Podda M, Ullah S, Liu B. Endoscopic retrograde appendicitis therapy or antibiotics for uncomplicated appendicitis. Br J Surg 2023; 110:635-637. [PMID: 36745556 DOI: 10.1093/bjs/znad023] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/20/2022] [Accepted: 01/10/2023] [Indexed: 02/07/2023]
Affiliation(s)
- Deliang Li
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Baohong Yang
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Department of Oncology, Weifang People's Hospital (The First Affiliated Hospital of Weifang Medical University), Weifang, Shandong, China
| | - Juan Liao
- Department of Gastroenterology, West China School of Public Health, West China Forth Hospital, Non-communicable Diseases Research Center, West China-PUMC C.C. Chen Institute of Health, Sichuan University, Chengdu, China
| | - Yingchao Li
- Department of Gastroenterology, The First Affiliated Hospital of Xi 'an Jiaotong University, Xi an, China
| | - Dan Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Lixia Zhao
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xianmei Meng
- Department of Gastroenterology, The Second Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Inner Mongolia Institute of Digestive Diseases, Baotou, China
| | - Haiqing Hu
- Department of Gastroenterology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Lingjian Kong
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Mauro Podda
- Department of Surgical Science, Cagliari State University, Cagliari, Italy
| | - Saif Ullah
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Bingrong Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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