The Canadian Association of Radiologists (CAR) Pediatric Expert Panel is made up of pediatric physicians from the disciplines of radiology, emergency medicine, endocrinology, gastroenterology, general surgery, neurology, neurosurgery, respirology, orthopaedic surgery, otolaryngology, urology, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 50 clinical/diagnostic scenarios, a rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 32 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 133 recommendation statements across the 50 scenarios. This guideline presents the methods of development and the referral recommendations for head, neck, spine, hip, chest, abdomen, genitourinary, and non-accidental trauma clinical scenarios.

Appendicitis is a frequently encountered surgical condition, yet its diagnosis can be challenging. There is increasing research on the safety of leaving macroscopically normal appendices in situ, the necessity of routine histopathological assessment, and the impact of the intra-operative assessment on the post-operative course. We aimed to determine the sensitivity and specificity of the surgeon's intra-operative diagnosis of appendiceal pathology, which is an important factor in answering these questions.

Medline, Embase, the Cochrane Library and Web of Science were searched for studies listing the corresponding intra-operative and histopathological diagnoses of appendicectomies performed for suspected appendicitis. The primary outcome was the sensitivity and specificity of the surgeon at recognising an abnormal appendix, which we subjected to meta-analysis. Subgroup analysis was performed for paediatric and adult populations. Incidence of unexpected findings and if they were recognised intra-operatively was recorded.

42 articles were included in the systematic review. 26 studies featuring 17,374 patients were included in the meta-analysis, which found that surgeons' intra-operative diagnosis was 95.2 % (95 % CI 94.8-95.5 %) sensitive and 60 % (95 % CI 58.1-62 %) specific. Surgeons are slightly more sensitive and specific in paediatric populations (sensitivity 95.7 % (95 % CI 95-96.4 %), specificity 64.1 % (95 % CI 60-68 %)) compared with adult populations (sensitivity 93 % (95 % CI 91.3-94.5 %), specificity 56.5 % (95 % CI 50.1-62.6 %)), however, this difference was only statistically significant in sensitivity. 1.7 % of appendicectomy specimens had unexpected histopathological findings, of which very few were suspected intra-operatively.

Surgeons are highly sensitive but not very specific at recognising abnormal appendices intra-operatively.

Both patient and hospital-related factors determine the timing of appendicectomy for acute uncomplicated appendicitis. Recent literature suggests appendicectomy more than 24 h after hospital admission is associated with increased morbidity in adults. Current guidelines from the World Society of Emergency Surgery (WSES) recommend surgery within this timeframe to reduce the risk of complications. The aim of this study was to determine the time to surgery for patients with acute uncomplicated appendicitis and to compare this to the current WSES recommendations. This study also aimed to identify potential reasons for any in-hospital delay.

This study is a retrospective review of all patients who underwent appendicectomy for confirmed acute uncomplicated appendicitis at an adult university teaching hospital between September 2021 and September 2022. Patient demographics, clinical information, time of admission, time of surgery, time of discharge and surgical complication data were collected.

A total of 229 appendicectomies were performed during the study period. 138 (60 %) had a preoperative diagnosis of acute uncomplicated appendicitis. The median age was 36 years (range 17-93). Time to surgery was <24 h in 80 (58 %) patients and >24 h in 58 (42 %) patients. In patients with a delay of >24 h, 28 (48 %) had their surgery 24-36 h after admission, 23 (40 %) had their surgery between 36 and 48 h, and 7 (12 %) had their surgery >48 h after admission. Patients who were operated >24 h after admission had a higher rate of readmission, 4/58 (6.9 %) compared to 1/80 (1.25 %) in the less than 24 h group (p = 0.09). Delays in radiology, surgical ward beds and the lack of a dedicated emergency theatre may have contributed to extended waiting times.

The results of this study show that the majority (58 %) of patients within our cohort were operated on within the WSES guidelines. However, 42 % of patients had their surgery in excess of these recommendations. Extended waiting periods may be related to delays in radiology, surgical ward beds and a lack of a dedicated emergency theatre. Patients who were operated on greater than 24 h following their admission also had a higher rate of readmission.

The impact of socioeconomic status and distance to hospital on negative appendicectomy rates is unknown. These factors have been shown to be important predictors of health in a rural setting.

To determine whether socioeconomic status and road distance to hospital were risk factors for negative appendicectomy.

A retrospective analysis of all appendicectomies at a large rural hospital in Australia between January 2018 and December 2022 was performed. Patients' data were extracted from electronic medical records. Regression modelling was performed to determine whether socioeconomic status and road distance to hospital were risk factors for negative appendicectomy. The surgical outcomes for negative and positive appendicectomies were compared.

A total of 830 patients were included in our analysis, of which 106 (12.8%) had negative appendicectomy. The rate of negative appendicectomy was not significantly impacted by socioeconomic status (OR = 1.004, 95% CI 0.989-1.20, p = 0.583) or road distance to hospital (OR = 1, 95% CI 0.998-1.001, p = 0.635). There was no significant difference in complications and 30-day readmission rates between patients in the negative and positive appendicectomy groups.

In a rural setting, the risk of negative appendicectomy does not increase with lower socioeconomic status and longer road distance to hospital. This challenges the prevailing notion that rural surgeons have a lower threshold to operate on patients with lower socioeconomic status or who live further away from hospitals due to the perception that these patients have less access to healthcare.

Historically, urgent surgery was advocated in patients with suspected appendicitis because of the risk of perforation and possible complications. Although recent studies have shown that it is safe to delay surgery under certain circumstances, many studies do not report adjusted data and exclude patients based on risk factors. Furthermore, it is unclear whether an ultrasound-based diagnostic workup is sufficient to safely delay surgery. This large retrospective study aimed to analyze the risk-adjusted association between delayed appendectomy and perforation and complication rates.

Data from consecutive patients who underwent appendectomy for suspected appendicitis at a single institution were reviewed and analyzed. The investigated outcomes were perforation and complication rates. Propensity score (PS) matching was used to create equal groups regarding confounding factors, and multivariate analysis was performed to control for risk factors and to calculate adjusted odds ratios (ORs) for in-hospital delay.

Between January 2008 and June 2023, 4900 patients underwent appendectomy for suspected appendicitis. Ultrasound imaging was performed in 4754 patients. Multivariate analysis of PS-matched data showed no association between a waiting time of >12 h and perforation rate (OR, 0.93; 95% CI, 0.67-1.31; P =.69) or complication rate (OR, 0.90; 95% CI, 0.62-1.30; P =.56). Similar results were obtained for a waiting time of 18 h and perforation rate (OR, 0.96; 95% CI, 0.48-1.56; P =.88) or complication rate (adjusted OR, 0.97; 95% CI, 0.57-1.68; P =.93).

This large PS-matched analysis showed that it is safe to delay surgery by 12 and 18 h, even when the diagnostic workup is based on ultrasound. In patients with risk factors for complications, postponement of the procedure can be considered if it can improve overall conditions or allow the procedure to be performed with a higher level of expertise.

Introduction: Acute appendicitis (AA) is one of the most common surgically treated diseases, and perforation is a complication that increases morbidity and mortality. At our institution, providers frequently prescribe broad-spectrum antibiotics for patients with appendicitis. Methods: We performed a subset analysis of patients with perforated appendicitis in a multisite quality improvement project to decrease broad-spectrum antibiotic utilization for AA. Surgeons and emergency department providers were educated on antibiotic therapy for AAs. Electronic medical record (EMR) orders were optimized to encourage ceftriaxone plus metronidazole preoperatively and discourage piperacillin/tazobactam. Results: During the study periods, a total of 116 patients had perforated appendicitis and underwent laparoscopic appendectomy, 45 in the 6-month pre-protocol group (pre-AB) and 71 in the 6-month post-protocol group (post-AB). The groups were similar regarding baseline demographics, vital signs, and hematological workup. Preoperative piperacillin/tazobactam utilization rates were 62.2% in the pre-AB group and 25.4% in the post-AB group (p < 0.0001), and the utilization rates of ceftriaxone plus metronidazole were 8.9% and 53.5%, respectively. Thirty-day readmission rates were similar: 15.6% in the pre-AB group versus 5.6% in the post-AB group (p = 0.104). Surgical site infections (SSIs) were comparable among groups: superficial SSI 0.0% versus 2.8% (p = 0.521), deep SSI 4.4% versus 0.0% (p = 0.148), and organ space SSI 17.8% versus 8.5% (p = 0.152). No patient had a Clostridium difficile infection postoperatively. Conclusion: Education regarding antibiotic therapy and optimization of orders in the EMR can decrease the utilization of broad-spectrum antibiotics for acute perforated appendicitis without increasing SSIs.

Acute appendicitis (AA) is the most prevalent cause of acute abdominal pain, with an incidence rate ranging from 96.5 to 100 per 100,000 adults. The rapid and accurate identification of the type and risk level of AA continues to pose a significant challenge. We aimed to develop a model for preoperative differentiation between complicated and uncomplicated AA.

In this retrospective study, 1196 AA patients were selected. The preoperative and postoperative clinicopathological characteristics were analyzed retrospectively. Both univariate analysis and multivariate analyses were conducted using binary logistic regression to identify the predictive factor associated with complicated AA.

Among a total of 1196 AA patients, 465 (38.9 ​%) were identified as having complicated AA. Approximately 10 ​% of AA patients experienced postoperative complications. Multivariate logistic regression analysis indicated that several factors were associated with an increased risk of complicated AA, including male (P ​< ​0.001, OR ​= ​2.178), age (P ​< ​0.001, OR ​= ​1.028), days of abdominal pain before operation ​= ​3 (P ​< ​0.001, OR ​= ​3.616), days of abdominal pain before operation ​= ​4 (P ​< ​0.001, OR ​= ​7.528), temperature (P ​< ​0.001, OR ​= ​2.121), abdominal tension (P ​< ​0.001, OR ​= ​2.242), neutrophil (P ​< ​0.001, OR ​= ​1.053), fluid accumulates around the appendix (P ​= ​0.002, OR ​= ​2.010), appendiceal fecalith (P ​< ​0.001, OR ​= ​2.122), and the diameter of the appendix (P ​= ​0.002, OR ​= ​1.083).

The results of this study significantly advance the understanding of preoperative differentiation between complicated and uncomplicated AA. The predictive nomogram offers a valuable tool for clinicians, enhancing decision-making and improving patient outcomes.

While acute appendicitis poses a significant disease burden worldwide, its etiology is not completely known. Previous studies have separately demonstrated its associations with ambient temperature and seasonal influenza, but there was no study that examined two exposures concurrently, leaving room for confounding and failing to isolate the effects of these two factors. This study aims to quantify such associations under a unified model, using population-level data in Hong Kong from 1998 to 2019.

The study outcome of weekly acute appendicitis admissions was analyzed with a number of covariates. The major covariates of interest included weekly mean temperature and three strain-specific influenza-like illness-positive (ILI+) rates, which were proxies for the activities of the respective influenza strains. Other covariates including weekly mean relative humidity, total rainfall and a composite index for air pollution were used for confounder control. A generalized additive model under the framework of distributed-lag non-linear model and quasi-Poisson distribution was used for multivariate analysis.

A significant positive association between ambient temperature and acute appendicitis admission was found, with a cumulative adjusted relative risk (ARR) of 1.082 (95% CI: 1.065-1.099) comparing the 95th percentile to the median temperature. ILI + rates for influenza A/H1N1 and A/H3N2 were found to significantly and negatively associate with acute appendicitis admission, with cumulative ARRs of 0.961 (95% CI: 0.934-0.989) and 0.961 (95% CI: 0.929-0.993) respectively, comparing the 95th percentiles to zero. No significant association was found between ILI + rate for influenza B and acute appendicitis admission.

While high temperature was associated with acute appendicitis admission, a negative association of influenza infection was showed. The mechanisms underlying the above associations should be investigated in future studies, with the aim of formulating preventive strategies against acute appendicitis that take environmental exposures into consideration.

The aim of this study was to evaluate the diagnostic efficacy of ultrasonography (US) and computed tomography (CT) examination for acute appendicitis (AA). A total of 41 patients with suspected AA were enrolled in this study. CT scan was performed in 24 patients, and US was performed in 17 patients. Both CT scan and US were performed in 7 patients. The primary outcomes were the performance characteristics (sensitivity, specificity) of US and CT in the patients with suspected AA. The secondary outcomes included the diagnostic accuracy of CT and US. By using US, 6 patients (35%) were incorrectly diagnosed and 2 other patients (12%) had equivocal results. By using CT as the primary diagnostic tool, 4 patients (17%) were misdiagnosed and 8 patients (33%) had equivocal results. Even if the equivocal results of CT and US were excluded from the calculation, the sensitivity and specificity of CT was 88% and 71% respectively, while the sensitivity and specificity of US was 73% and 50%, respectively. Although CT and US are believed to be reliable diagnostic tool to precisely diagnose AA. The rate of negative appendectomy still remains high. There is a need to develop a more accurate methods to diagnose AA, and therefore rate of negative appendectomy can be reduced.

Appendicitis is the most common indication for emergent abdominal surgery in childhood. Intravenous antibiotic therapy reduces infections-related complications. Epidemiological data concerning bacterial pathogens are important in tailoring antibiotic stewardship recommendations.This study aims to assess trends over the years in bacterial distribution, and sensitivities (specifically multidrug-resistant [MDR] Enterobacteriaceae) in surgical appendicitis among two different ethnic communities in southern Israel.This was an observational, single-center, retrospective study. Included were children less than 18 years of age with surgical appendicitis treated in Soroka University Medical Center between 2010 and 2020 that had a positive intraoperative intraperitoneal bacterial swab culture. Data were assessed using univariable and multivariable analyses including multiple linear regression and negative binomial regressions with time series analysis to compare between periods during the study while accounting for confounders.Overall, 1,858 specimens were available for analysis from 2,264 children with confirmed surgical appendicitis. Pathogenic bacteria were recovered in 684 (36.8%), with nearly half polymicrobial. MDR Enterobacteriaceae pathogens were more common in the Arab-Bedouin community as compared with the Jewish community (32.6% vs. 18.6%, p < 0.001). Time series analysis detected an 8.7% significant increase in MDR pathogens per year (p = 0.003) with male children (10% per year [p = 0.016]), children younger than 12 years (10% per year [p = 0.014]), and children of the Arab-Bedouin community (8.7% per year [p = 0.025]) accounting for this increase in MDR isolates.MDR pathogens incidence has significantly increased between 2010 and 2020 and this should be considered in the choice of antibiotic therapies and antibiotic stewardship programs in the hospital and the community.

This study aims to provide a meta-analysis of randomized controlled trials (RCTs) comparing non-operative management (NOM) and operative management (OM) in a pediatric population with uncomplicated acute appendicitis.

A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines. A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL from inception to June 2024. Only randomized controlled trials (RCTs) were included, excluding studies involving adult patients and/or participants with complicated appendicitis. The variables considered were treatment complications, treatment efficacy during index admission and one-year follow-up, length of hospital stay (LOS), quality of life, and presence of appendicoliths.

Three RCTs involving 269 participants (134 antibiotics/135 appendectomy) were included. There was no statistically significant difference between the two treatments in terms of complication risk (combined RD = - 0.03; 95% CI - 0.11; 0.06, p = 0.54), even including complications related to NOM failure. The risk of complication-free treatment success rate in the antibiotic group is lower than in the surgery group (combined RD = - 0.05; 95% CI - 0.13; - 0.04; p = 0.29). In patients without appendicolith, the combined risk difference of treatment success between NOM and OM was not statistically significant - 0.01 (IC - 0.17; 0.16; p value: 0.93). There is no statistical difference in terms of efficacy at 1 year, between NOM and OM (combined RD = - 0.06; 95% CI - 0.21; 0.09), p = 0.44). The LOS in the NOM group is significantly longer than in the OM group (difference of median = - 19.90 h; 95% CI - 29.27; - 10.53, p < .0001).

This systematic review and meta-analysis provide evidence that NOM is safe and feasible for children with uncomplicated appendicitis and, in the group of patients without appendicolith, it is associated with a similar success rate to OM. However, more high-quality studies with adequate power and construction are still needed.

Acute appendicitis represents a prevalent condition within the spectrum of acute abdominal pathologies, exhibiting a diverse clinical presentation. Computed tomography (CT) imaging has emerged as a prospective diagnostic modality for the identification and differentiation of appendicitis. This review aims to synthesize current applications, progress, and challenges in integrating machine learning (ML) with CT for diagnosing acute appendicitis while exploring prospects. ML-driven advancements include automated detection, differential diagnosis, and severity stratification. For instance, deep learning models such as AppendiXNet achieved an AUC of 0.81 for appendicitis detection, while 3D convolutional neural networks (CNNs) demonstrated superior performance, with AUCs up to 0.95 and an accuracy of 91.5%. ML algorithms effectively differentiate appendicitis from similar conditions like diverticulitis, achieving AUCs between 0.951 and 0.972. They demonstrate remarkable proficiency in distinguishing between complex and straightforward cases through the innovative use of radiomics and hybrid models, achieving AUCs ranging from 0.80 to 0.96. Even with these advancements, challenges remain, such as the "black-box" nature of artificial intelligence, its integration into clinical workflows, and the significant resources required. Future directions emphasize interpretable models, multimodal data fusion, and cost-effective decision-support systems. By addressing these barriers, ML holds promise for refining diagnostic precision, optimizing treatment pathways, and reducing healthcare costs.

Ultrasound and multi-slice spiral computed tomography (CT) are frequently used to assist the diagnosis of acute appendicitis (AA), and the examination results may vary among different demographics. This study aimed to compare the diagnostic accuracy of ultrasound and CT for AA.

We performed a retrospective analysis of patients diagnosed with AA who underwent emergency surgery at our hospital from March 2021 to August 2023, with postoperative pathological results as the gold standard. Differences in the diagnostic accuracy of ultrasound and CT for different types of AA, age groups, and body mass index (BMI) values were then analyzed.

The overall sample comprised 279 confirmed cases of AA, with 64 cases of simple appendicitis, 127 cases of suppurative appendicitis, and 88 cases of gangrenous appendicitis. For these three pathological classifications, the diagnostic accuracy of ultrasound was 68.75% (44/64), 73.22% (93/127), and 81.81% (72/88), respectively, while the diagnostic accuracy of CT was 71.87% (46/64), 82.67% (105/127), and 90.90% (80/88), respectively. There was no statistically significant difference in the overall diagnostic accuracy between the two methods (P > 0.05). Subgroup analysis showed no difference in diagnostic accuracy between the two methods for patients with normal BMI (P > 0.05). However, for overweight, obese, and elderly patients, CT provided significantly better diagnostic accuracy than ultrasound (P < 0.05).

While ultrasound and CT have similar diagnostic accuracy for different pathological types of AA, CT is more accurate for overweight, obese, and elderly patients.

Antibiotic therapy is currently considered a safe and effective treatment alternative for computed tomography (CT)-confirmed uncomplicated acute appendicitis with recent studies reporting good results on both oral antibiotics only and outpatient management. Furthermore, there are promising pilot results on uncomplicated acute appendicitis management with symptomatic treatment (placebo). This trial aims to assess whether both antibiotics and hospitalization can be safely omitted from the treatment of uncomplicated acute appendicitis.

The APPAC IV (APPendicitis Acuta IV) trial is a randomized, double-blind, multicenter noninferiority clinical trial comparing oral moxifloxacin with oral placebo in an outpatient setting with a discharge directly from the emergency room (ER). Adult patients (18-60 years) with CT-confirmed uncomplicated acute appendicitis (absence of appendicolith, abscess, perforation, tumor, appendiceal diameter ⩾15 mm on CT, or body temperature >38 °C) will be enrolled in nine Finnish hospitals. Primary outcome is treatment success at 30 days, that is, the resolution of acute appendicitis resulting in discharge from the hospital without appendectomy during the 30-day follow-up evaluated using a noninferiority design with a noninferiority margin of 6 percentage points. Noninferiority will be evaluated using one-sided 95% confidence interval of proportion difference between groups. Secondary endpoints include postintervention complications, recurrent appendicitis after the 30-day follow-up, duration of hospital stay, admission to hospital and reason for admission, readmissions to emergency department or hospitalization, VAS pain scores, quality of life, sick leave, and treatment costs. The follow-up after discharge from the ER includes a phone call at day 1, and at 3-4 days, 30 days, and 1, 3, 5, 10, and 20 years. Those eligible patients, who decline to undergo randomization, will be invited to participate in a concurrent observational cohort study with follow-up at 30 days, and 1 and 5 years.

To our knowledge, APPAC IV trial is the first large randomized, double-blind, noninferiority multicenter clinical trial aiming to compare oral antibiotics and placebo for CT-diagnosed uncomplicated acute appendicitis in an outpatient setting. The study aims to bridge the major knowledge gap on whether antibiotics and hospitalization or both can be omitted in the treatment of uncomplicated acute appendicitis.

The study protocol has been approved by the Clinical Trials Information System (CTIS) of the European Medicines Agency (EMA), study number: 2023-506213-21-00 and the trial has been registered in ClinicalTrials.gov, NCT06210269.

Objectives: Pediatric acute appendicitis (AA) is one of the most prevalent acute abdominal conditions in pediatric surgery. Children with complicated acute appendicitis (CA) may need timely surgical decisions and have a worse prognosis. In this study, we explored the risk factors and developed a predictive model for complicated AA in children. Methods: A retrospective analysis was conducted on patients data from those hospitalized for acute appendicitis, confirmed by post-surgery pathological results, at Children's Hospital of Chongqing Medical University between September 2022 and October 2023. Lasso regression was performed to identify risk factors, and multivariate logistic regression analysis was used for model establishment. Results: Serum levels of IFN-γ, IL-5, IL-6, IL-8, and IL-10 before surgery were useful in classifying acute appendicitis in children. IL-6, IL-8, and IL-10, on their own, had high predictive values for CA in children. Independent risk factors for CA were age, IL-10, and IFN-γ. A multifactorial logistic regression prediction model was established, demonstrating good predictive efficacy. Its predictive sensitivity was 70.0%, specificity 73.9%, with an AUC of 0.7949. Furthermore, the results of the external validation indicated that the model's accuracy was good, with an AUC of 0.8567. Conclusions: Early identification of CA is imperative for timely clinical decision-making. Prediction models based on age, IL-10, and IFN-γ may be reliable and accurate in predicting the incidence of CA, which may lead to better clinical outcomes for children with AA.

Acute appendicitis is one of the most common non-gynecological and non-obstetric causes of acute abdominal conditions requiring urgent surgery during pregnancy. Due to the similarity between the symptoms of the disease and those of pregnancy, laboratory findings become particularly important in diagnosis. This study aimed to evaluate these parameters for the first time using a new index definition. Between 2015 and 2021, a total of 120 patients were included in the study, divided into the four groups: healthy pregnant woman (HPW), healthy woman (HW), unhealthy pregnant woman (UPW, pregnant patient with acute appendicitis), and unhealthy woman (UW, non-pregnant patient with acute appendicitis). Laboratory parameters, including white blood cell count (WBC), C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), ischemia-modified albumin (iMA), and platelet-lymphocyte ratio (PLR), were assessed. In this study, significant differences were observed in various laboratory parameters between groups, such as WBC, CRP, NLR, and PLR, indicating potential markers for differentiating between pregnant women with and without appendicitis. An index was created for the diagnosis of acute appendicitis in pregnant women and was named the Pregnant Index. The Pregnant Index (PGIndex) values of pregnant women without appendicitis were compared with those of pregnant women with appendicitis. It was found that the PGIndex value was significantly higher in pregnant women with appendicitis (p < 0.001). Using the ROC curve and Youden index, the PGIndex cut-off value to best differentiate between the two groups was 10.62. This value provided a sensitivity of 73.3%, specificity of 96.7%, positive predictive value of 95.7%, negative predictive value of 78.7%, and test accuracy of 85% for identifying pregnant women with appendicitis. Compared to other markers, the PGIndex had the highest accuracy value, and it was observed that patients with a PGIndex value above 10.62 had a significantly increased likelihood of having appendicitis. These results indicate that the PGIndex is a significant marker for detecting appendicitis in pregnant women. Laboratory parameters, particularly NLR and PLR, show promise as diagnostic tools for appendicitis in pregnant women. Incorporating these markers, the Pregnant Index (PGIndex) demonstrated high sensitivity and specificity in distinguishing between pregnant women with and without appendicitis. This is the first study using the Pregnant Index in pregnant women to diagnose appendicitis. Early diagnosis is crucial for preventing maternal and fetal morbidity and mortality associated with appendicitis during pregnancy.

Acute appendicitis is a common condition requiring surgical intervention, with a lifetime risk of 7-8%. Differentiating between uncomplicated and complicated appendicitis is essential for appropriate treatment and improved patient outcomes. This study aimed to utilize minimal, non-invasive data to distinguish between these forms of appendicitis, using advanced analytical methods for faster and more precise diagnosis. This retrospective study analyzed acute appendicitis cases from January 2018 to December 2022 at a tertiary care hospital. Data were gathered from 3,045 patients, including demographic details, clinical features, laboratory tests (Red Cell Distribution Width [RDW] and Mean Platelet Volume [MPV]), and imaging results. Patients were classified as having uncomplicated or complicated appendicitis based on surgical and histopathological findings. Statistical analyses, including multivariate logistic regression and ROC curve analyses, were performed using SPSS. Complicated appendicitis was defined based on surgical findings and histopathological criteria, including perforation, abscess formation, or gangrene. Uncomplicated appendicitis was defined as inflammation confined to the appendix without evidence of perforation or abscess. The study population comprised 1,869 males (61.37%) and 1,176 females (38.62%), with a mean age of 36.4 years. The mean RDW was 27.81%, and the mean MPV was 8.68 fL. Among the appendectomy cases, 50.7% were acute appendicitis, 10.3% were negative appendectomies, and 38.9% had complicated appendicitis. RDW was significantly higher in acute appendicitis than in negative cases (t = 2.45, p = 0.02) and even higher in complicated cases (t = 3.78, p = 0.001). MPV was highest in complicated appendicitis, consistent with increased inflammation severity (t = 2.56, p = 0.01). The sensitivity and specificity of RDW for identifying complicated appendicitis were 0.85 and 0.75, respectively, and for MPV, they were 0.80 and 0.70. Univariate logistic regression identified male sex and appendix diameter as significant predictors of complicated appendicitis. In multivariate analysis, appendix diameter remained significant (p = 0.01), and male sex approached significance (p = 0.06). The optimal cutoff for appendix diameter to differentiate appendicitis types was 10 mm, with an AUC of 0.82. RDW, MPV, and appendix diameter provide a reliable method for distinguishing between uncomplicated and complicated appendicitis. Combining these biomarkers enhances diagnostic accuracy and enables precise risk stratification for better patient management.

Background: Antibiotics within an hour of incision reduce the incidence of surgical site infection (SSI) in clean-contaminated abdominal surgery. However, patients undergoing emergency surgery for an intra-abdominal infectious process often receive treatment antibiotics and may not benefit from additional pre-incisional antibiotics (POA). We hypothesized that POA would not lead to a reduction in the occurrence of SSIs following emergency appendectomy. Patients and Methods: All patients at a single institution undergoing emergency appendectomies for acute appendicitis from 2013 to 2020 were included. Age, gender, perforation, body mass index (BMI), Elixhauser comorbidity index (ECI), surgical approach, emergency department antibiotics (EDA), EDA administration time, and pre-operative antibiotics were abstracted. Primary outcomes were superficial/deep and organ-space SSIs. Bi-variable logistic regression models assessed the independent impact of each tactic. Multi-variable models compared those receiving pre-incisional cefazolin with those receiving no POA. Results: Patients (n = 1380) had a mean age (standard deviation) of 39.5 (17.0) years, and 48.6% were female. Age, gender, perforated appendicitis, EDA, ECI, and BMI all were predictive of infection. POA were not predictive of SSI (p = 0.632). After adjustment for age, gender, perforation, EDA, EDA administration timing, ECI, and BMI, only perforation (odds ratio [OR]: 17.08, 95% confidence interval [CI] = 6.97-51.43) and male gender (OR: 2.75, 95% CI = 1.29-6.43) were associated with organ-space infection, whereas pre-incisional cefazolin was not (OR: 0.83, 95% CI = 0.38-1.97). Emergency department broad-spectrum antibiotics were associated with a lower incidence of superficial/deep infection (OR: 0.06, 95% CI = 0.00-0.68); however, pre-incisional cefazolin was not (OR: 0.71, 95% CI = 0.08-15.34). Conclusion: For patients undergoing emergency appendectomies who have received broad-spectrum antibiotic treatment, additional pre-incisional cefazolin does not reduce the incidence of superficial/deep or organ-space SSI.

Gangrenous appendicitis, a type of complicated appendicitis, is an indication of emergency surgery due to a high risk of perforation. However, it can be challenging to diagnose preoperatively. This study aimed to validate the predictive factors of patients with gangrenous appendicitis and develop a novel scoring model based on objective parameters.

This retrospective single-center study included 171 of 302 consecutive patients undergoing appendectomy between April 2014 and December 2023. Patients with perforation, chronic appendicitis, and appendicitis presenting with an abscess were excluded from the analysis. In other words, the study targeted Grades 1 and 2 on the American Association for the Surgery of Trauma (AAST) severity assessment scale. Computed tomography (CT) scan value was defined as the average value of fluid in the appendix lumen on plain CT scan. Univariate and multivariate analyses were performed to identify the independent objective predictors of gangrenous appendicitis. A new scoring model was developed based on the logistic regression coefficients of the independent predictors. The scores were then classified into three categories, and the probability of gangrenous appendicitis for each category was evaluated.

Overall, 46 (27%) and 125 (73%) patients presented with gangrenous appendicitis (=AAST Grade 2) and non-gangrenous (uncomplicated) appendicitis (=AAST Grade 1), respectively. The independent predictive factors of gangrenous appendicitis included a CT value of ≥24 HU, an appendiceal diameter of ≥12 mm, the presence of cecal mucosal edema, and a C-reactive protein level of ≥5.4 mg/dL. The scoring model, based on these four independent predictors, ranged from 0 to 4. The probability values of gangrenous appendicitis were 0%, 15%, and 97% in the low (0)-, moderate (1, 2)-, and high (3, 4)-risk categories, respectively.

Our scoring model may assist in decision-making concerning emergency surgery and appendicitis management.

To investigate the role of wound protectors (WPs) in surgical site infection (SSI) prevention in patients undergoing abdominal surgery.

Despite practitioners having pursued the ultimate aim of "getting to zero" for centuries, SSI is still a global healthcare burden. WPs are thought to be able to prevent the incision from bacterial contamination, however, contradictory results have been reported.

A meta-analysis was performed to compare the SSI rate in patients with and without WPs after abdominal surgery. It includes subgroup analysis of the SSI rate in different surgical sites and different degrees of wound contamination. A systematic literature search was conducted in the PubMed, Embase, Cochrane Library databases, and Web of Science from their respective inceptions until July 6, 2024. All randomized controlled trials with consistent definitions of SSI were included. The bias of each included RCT was assessed by using the Cochrane Risk of Bias 2. To evaluate the risks of random errors resulting from repeated significant testing, a trial sequential analysis was performed. The quality of evidence was assessed by using GRADEpro Guideline Development Tool.

A total of 4779 participants were involved in the 19 RCTs. The results showed that the application of WPs during abdominal surgery could significantly reduce the SSI rate (RR = 0.63, 95% CI: 0.50-0.80, P = 0.0001, very low certainty evidence). Subgroup analysis showed that the implementation of WPs significantly reduced the SSI rate after colorectal and gastrointestinal surgery (RR = 0.58, 95% CI: 0.38-0.91, P = 0.02, very low certainty evidence; RR = 0.49, 95% CI: 0.36-0.67, P < 0.00001, moderate certainty evidence, respectively), while had no clear protect role in other types of abdominal surgery. The WPs significantly reduced the SSI rate in patients with a clean-contaminated wound (RR = 0.64, 95% CI: 0.46-0.89, P = 0.008, very low certainty evidence) and contaminated or dirty wound (RR = 0.61, 95% CI: 0.41-0.92, P = 0.02, moderate certainty evidence), respectively.

The results indicated that the WPs should not be used indiscriminately in all abdominal but gastrointestinal surgery. For patients with contaminated or dirty incisions, WPs should be considered. More studies are needed to determine the effect of WPs in laparoscopic surgery.

Not applicable.

This study aims to investigate the factors associated with unplanned re-operations (UR) following transumbilical single-hole laparoscopic appendectomy (TUSILA) in pediatric patients.

We conducted a retrospective analysis of clinical data from children diagnosed with acute appendicitis (AA) who underwent TUSILA at our center between January 2020 and January 2024. All the operations were performed under single-port laparoscopy, including two methods of appendectomy, intra-TUSILA and extra-TUSILA. Patients were categorized into the UR and control groups to compare baseline characteristics, clinical data, postoperative management, and surgical outcomes.

The study included 188 patients (110 males and 78 females), with 4 (2.1%) in the UR group. Within the UR group, three cases (75%) necessitated re-operation due to adhesive intestinal obstruction, while one case (25%) was due to an appendiceal remnant fistula. The baseline characteristics, operation duration, intraoperative blood loss, surgeon experience, and postoperative fasting times showed no significant difference between the two groups (all P > 0.05). However, the incidences of procedures beyond standard TUSILA, lateral peritoneum lysis, appendiceal perforation, complicated appendicitis as confirmed by pathology, drainage tube placement, and the length of antibiotic duration were significantly higher in the UR group compared to the control group (all P < 0.05).

A notable percentage of pediatric patients undergoing TUSILA experience UR, primarily due to adhesive ileus, with a substantial proportion potentially linked to surgical technical errors and postoperative management.

Appendicolith can be incidentally detected on abdominal computer tomography (CT) without any signs of appendicitis. However, it has also been found to be a risk factor for failure of nonoperative management in acute appendicitis. The present retrospective study aimed to evaluate whether appendicolith predicts complicated appendicitis in patients with any appendicitis.

A retrospective chart review was conducted for patients undergoing appendectomy from January 2016 to December 2018. Appendicolith was considered to be present when it was described in a CT scan.

Of the 267 patients, appendicolith was found in 120 cases, while there were no in 147 cases in preoperative CT scans. In the case of complicated appendicitis (gangrenous or gangrenous perforated appendicitis), appendicolith was visible in CT scans in 57.7% of the patients. Of the patients with uncomplicated appendicitis, 38.3% had appendicolith in CT scan (p = 0.002). In univariate logistic regression analysis, based on the finding of the histological specimen, appendicolith was associated with complicated appendicitis (OR: 2.12; 95% CI: 1.28-3.51; p = 0.004). When adjusting for sex, age group (age ≤50 vs. >50 years), and duration of symptoms (≤24 vs. >24 h), the odds ratio was 3.52 (95% CI: 1.88-6.58; p < 0.001).

Our study found that appendicolith can be considered an independent risk factor for complicated appendicitis. Therefore, in the presence of appendicolith, surgical treatment should probably be preferred over nonsurgical treatment in acute appendicitis.

Acute appendicitis is the most common cause of surgical acute abdomen, and its classification into uncomplicated, phlegmonous, and complicated forms is crucial for guiding treatment strategies. This study aims to compare the preoperative laboratory findings and postoperative outcomes of phlegmonous appendicitis with uncomplicated and complicated appendicitis. This retrospective cohort study included 1,441 patients who underwent appendectomy between January 2019 and March 2021 at Ankara Bilkent City Hospital. Patients were classified based on histopathological findings into four groups: normal appendix, uncomplicated appendicitis, phlegmonous appendicitis, and complicated appendicitis. Preoperative laboratory values, postoperative complications, and length of hospital stay were analyzed. The distribution of patients was as follows: Group A (normal appendix, 7.6%), Group B (uncomplicated appendicitis, 59.8%), Group C (phlegmonous appendicitis, 17.6%), and Group D (complicated appendicitis, 15%). Phlegmonous appendicitis exhibited significantly higher leukocyte counts and appendix diameters compared to uncomplicated appendicitis but had lower CRP values than complicated appendicitis. The median hospital stay was similar for Groups A, B, and C (1 day) but significantly longer for Group D (2.1 days, p < 0,001). Complication rates were highest in Group D (24.1%) compared to the other groups. While phlegmonous appendicitis shares some clinical and laboratory characteristics with complicated appendicitis, its postoperative outcomes align more closely with those of uncomplicated appendicitis. This suggests that phlegmonous appendicitis may be more accurately classified as a variant of uncomplicated appendicitis, emphasizing the need for consistent classification to improve treatment strategies and patient outcomes.

Emergency surgery for acute bowel obstruction (ABO) is a common and occasionally technically demanding procedure, requiring both surgical skill and strategic planning. The risk entailed in teaching residents during ABO surgery has not been defined or investigated in detail to date. It is the aim of this study to reveal whether surgery for ABO, performed by resident surgeons under supervision, is safe and feasible.

A retrospective analysis was conducted of all emergency surgeries for ABO performed between 2009 and 2023 at a community-based hospital. Patients' general characteristics, procedural data and outcome parameters were compared. Differences between teaching procedures and non-teaching procedures were analysed.

The study was conducted at the Department of General and Visceral surgery at a community-based hospital (St. John of God Hospital Salzburg, Austria).

All emergency surgeries for ABO (n = 300 patients) that were performed during the study period were included.

Emergency surgery for ABO was performed in 300 patients during the study period, 15.3% of which operations were performed by residents under supervision and 84.7% by senior surgeons. No differences between these two groups were found in terms of patient characteristics, except for a past medical history of previous gynecologic or urologic surgery that was more frequent in the senior surgeon group (p = 0.02). Neither procedural data nor conversion rates from a minimally invasive (MIS) to an open (OS) approach, nor postoperative complication rates were found to be significantly different between these groups.

Emergency surgery for ABO, performed by residents under supervision, is safe and feasible, showing no significant differences in terms of complication rates, morbidity or mortality as compared to procedures performed by senior surgeons.

Acute appendicitis is one of the most common acute surgical diseases in the world today. Acute appendicitis can present with a well-recognized clinical presentation with abdominal pain which localize in the right lower quadrant. This presentation is more typical in men than in women of child baring age. Several clinical and laboratory calculations can be used to increase the likelihood of making a correct diagnosis. Various imaging modalities can be used to make the diagnosis which include ultrasound, computer tomography, and magnetic resonance imaging. Each study has well known sensitivity/specificity of positive predictive value of making the diagnosis of appendicitis. The management of acute appendicitis is based on the presentation of the patient and dividing it into uncomplicated and complicated disease. Each requires management with antibiotics and followed with timely appendectomy. Recent studies have demonstrated nonoperative management of uncomplicated appendicitis without no fecalith that can be managed with antibiotics alone. Complicated acute appendicitis should undergo timely surgical intervention. Patients presenting with a large appendiceal abscess or phlegmon should undergo percutaneous drainage and antibiotic management. There are certain patient populations that should be considered for surgical intervention. Pregnant patients as well as immunosuppressed patients should undergo timely surgical intervention to decrease the risk of complications. This review outlines the current principles of the diagnosis, imaging, and treatment of acute appendicitis based on the best available evidence of acute appendicitis in adults.

To evaluate the perioperative severity of acute appendicitis during the COVID-19 pandemic compared to the same periods in 2018 and 2019 in the Nancy-Metz region, France. Acute appendicitis is a common surgical emergency that can lead to severe complications if not treated promptly. The COVID-19 pandemic and subsequent lockdowns resulted in reduced hospital visits, potentially delaying treatment for appendicitis and increasing perioperative severity.

This retrospective, bicentric cohort study included 634 adult patients who underwent emergency appendectomy at the Nancy University Hospital and Metz Regional Hospital. The study compared patients from the pandemic period (March 17, 2020, to December 14, 2020) with those from the same periods in 2018 and 2019. The primary outcome was perioperative severity, defined by a Gomes score ≥ 3 and/or a Clavien-Dindo classification ≥ 3. Secondary outcomes included time to treatment, severity of biological inflammatory syndrome, postoperative complications, and hospitalization metrics. Logistic regression analyses were performed with adjustments for ASA scores.

The study included 194 patients from the COVID-19 cohort and 440 from the non-COVID cohort. The perioperative severity was higher during the COVID period (33.5% vs. 25.9%), though this difference was not statistically significant (p = 0.0845). Secondary outcomes such as time to treatment, severity of the inflammatory syndrome, and postoperative complications did not show significant differences between cohorts. However, the duration of postoperative antibiotic therapy was longer during the COVID period (6 days vs. 5 days, p = 0.0410).

The COVID-19 pandemic led to a non-significant increase in perioperative severity of acute appendicitis. Despite the challenges posed by the pandemic, the French healthcare system maintained effective management of surgical emergencies, with no significant increase in postoperative complications. Further research is required to explore the broader impact of the pandemic on the management of appendicitis.

To retrospectively evaluate the comparative efficacy and safety of percutaneous catheter drainage (PCD) combined with antibiotic therapy versus emergency laparoscopic surgery (ELS) for treating periappendiceal abscesses.

A retrospective study was conducted on 90 patients diagnosed with periappendiceal abscesses at Harbin Hospital of Traditional Chinese Medicine between March 2022 and December 2023. The study compared clinical outcomes between two groups: one receiving percutaneous catheter drainage (PCD) with antibiotic therapy and the other undergoing emergency laparoscopic surgery. The comparison encompassed key outcomes such as operative time, gastrointestinal function recovery, length of hospital stays, postoperative complication rate, recurrence rate, and the need for additional interventions.

The PCD group exhibited a significantly shorter operative time (P=0.02) and fewer postoperative complications (P=0.008) compared to the ELS group. During outpatient follow-up, six patients in the PCD group had a recurrence of appendicitis, which was statistically significant compared to the ELS group.

Ultrasound-guided PCD has been shown to be effective and safe in the management of periappendiceal abscesses in our single-center clinical study. It offers several benefits over ELS, such as reduced operative time and a decreased incidence of postoperative complications. Our results suggest that PCD, in conjunction with antibiotic therapy, is a feasible alternative to surgery, significantly reducing patient discomfort and healthcare resource consumption. However, these findings are specific to our center, and further multicenter studies are required to confirm these results and to establish guidelines for the optimal application of PCD in clinical practice.

This ESR Essentials article intends to provide detailed, step-by-step, information on the role of imaging in the diagnosis, procedural management, and follow-up of patients with fluid collections. Evidence-based medicine recommendations for the positioning of percutaneous drainages and/or for diagnostic/therapeutic aspiration of fluid collections are provided. Although medical history, clinical symptoms, physical examination, and laboratory tests can raise suspicions regarding a collection, an imaging assessment is usually necessary for the diagnosis. Radiologists can easily identify fluid collections that are clinically suspected by using a wide range of imaging modalities, such as ultrasound, CT, MRI, and cone-beam CT. Consequently, these imaging methods (either alone or combined), can be used to aspirate the collection or for the placement of a drainage catheter. The choice of imaging technique to be used is influenced by the location of the collection, operator preference, size, and content of the collection. In addition, it is of utmost importance to underline the role of the interventional radiologist in the management and follow-up of patients with percutaneous drains, in collaboration with surgeons, clinicians, and diagnostic radiologists. KEY POINTS: Indications for percutaneous imaging-guided drainage are supported by clinical findings, laboratory tests, and pre-procedural imaging. Deciding between aspiration or drain insertion should follow patient assessment and fluid collection characterization. The interventional radiologist should be part of the entire patient care process including follow-up.

Acute appendicitis (AA) is the leading cause of acute abdomen worldwide, with an incidence of 90-100 cases per 100,000 individuals annually and a lifetime risk of 7-12%. Despite its prevalence, historical accounts of AA are limited, particularly when compared to conditions like haemorrhoids, likely due to the appendix's internal location. This article traces the historical evolution of AA treatment from ancient times to the present, highlighting key contributions.

A review of common research databases and relevant literature on AA was conducted.

Evidence from ancient Egypt suggests early recognition of the appendix, referring to it as the "worm of the bowel." However, detailed anatomical descriptions and treatment approaches for AA did not emerge until the Renaissance, particularly with contributions from Leonardo da Vinci and Berengario da Carpi. The article traces the progression of AA management, including the first autopsies and surgeries, the development of surgical techniques predating anaesthesia and antisepsis, and advancements achieved from the nineteenth to the twenty-first century. The shift from conservative to surgical approaches is discussed, alongside innovations such as laparoscopic appendicectomy, single-incision laparoscopic surgery (SILS), natural orifice transluminal endoscopic surgery (NOTES), and endoscopic retrograde appendicitis therapy (ERAT). The impact of the COVID-19 pandemic on AA treatment, including adaptations in medical practices, is also explored.

This review highlights the significant historical developments in AA treatment and its pivotal role in advancing abdominal surgery.

Diagnostic error can result in the appendectomy of a normal appendix, commonly known as negative appendectomy (NA). Missed appendicitis (MA) is related to a poor outcome. The aim of this study was to determine whether there are factors in presentation associated with NA or MA.

This is a single-centre, retrospective chart review of histology-confirmed appendicitis over an eight-year period. We defined MA as appendicitis diagnosed within the week of a paediatric emergency department discharge for a similar presentation. Negative appendectomy was defined as a histologic examination of the appendix that lacked signs of inflammation.

A total of 845 children had appendicitis on pathologic examination. NA included 69 children, and MA 29 children. Inflammatory markers were lower for children with NA than for children with appendicitis, and children with NA were less likely to undergo CT. Almost half of the children with MA were discharged without laboratory evaluation, and almost three quarters were discharged without imaging evaluation. Half of the children with MA returned with complicated appendicitis.

Increased rates of laboratory and/or imaging evaluations in patients with abdominal pain or non-classic gastroenteritis, along with observation or early follow-up, may decrease MA. More frequent use of ultrasound and MRI may keep the NA rate to a minimum.

Guidelines for management and treatment of appendicitis recommends the removal of a normal-looking appendix, but the recommendations are deemed as weak because they are based on low quality evidence. We aimed to provide an overview of the recommendations from the European societies or associations of surgeons regarding the treatment of acute appendicitis and especially recommendations for the macroscopically normal-looking appendix.

European surgical societies were contacted and sent an electronic questionnaire. Questions concerned if the association had a national guideline or recommended an existing one, and if they recommended a specific approach for the management of the normal-looking appendix, including who decided to remove the appendix.

We contacted surgical societies from 28 European countries, and 17 surgical societies (61%) responded. Two societies had a national guideline for the treatment of appendicitis and one of these addressed how to treat the normal-looking appendix. Most societies (59%) answered that the operating surgeon decided whether to remove the normal-looking appendix. Eleven societies recommended using an existing guideline (65%), four societies (24%) did not recommend a guideline, and two societies did not know.

Only two surgical societies had a published national recommendation or guideline on the treatment of suspected appendicitis, only one had a guideline for the management of the normal-looking appendix, and most societies answered that the operating surgeon decided.

Background/Objectives: Differentiating complicated acute appendicitis (CA) and uncomplicated acute appendicitis (UC) is essential to guide clinical management. While CA requires urgent surgical management, UC can be treated with antibiotic therapy in selected cases. However, accurate identification of CA remains a clinical challenge. This study aimed to identify factors associated with CA and to develop a diagnostic severity scale. Methods: In this retrospective study, we included 132 adult patients (>16 years) with a confirmed postsurgical diagnosis of appendicitis, of whom 52 had CA and 80 had UA. Signs, symptoms, comorbidities, laboratory values, and ultrasonographic findings were evaluated to determine predictive factors and construct a diagnostic scale. Results: The factors most significantly associated with CA were elevated plasma concentrations of C-reactive protein (>7.150 mg/dL), fibrinogen (481.5 mg/dL), International Normalized Ratio (INR) (>1.150), and the presence of free fluid periappendicular. The combination of these factors within one scale showed an area under the curve (AUC) of 0.84, with a sensitivity of 78.75% and a specificity of 82.69%. Conclusions: Serum C-reactive protein concentration, fibrinogen, and INR can be employed individually or as part of a scale as important indicators in diagnosing CA.

Negative pressure wound therapy (NPWT) is a very effective method in the treatment of dehiscent, infected, and non-healing wounds. Difficult wound healing occurs especially in late pregnancy due to the rapid enlargement of the uterus and the constantly increasing tension of the entire abdominal wall. In cases of dehiscence of the surgical wound during pregnancy, proper subsequent treatment is needed, where it is necessary to consider the safety of the mother as well as the fetus. We report the case of a 30-week pregnant patient who was surgically treated for acute appendicitis in pregnancy with an open appendectomy approach. Postoperative complications resulted in wound dehiscence with complete defect in fascia, which was treated with negative V.A.C. ATS® Therapy System. The therapy was started in the 30th week of pregnancy and continued until delivery with regular check-ups and regular redressing of the vacuum-assisted closure (VAC) system. At 38 weeks of pregnancy, the patient delivered vaginally with continued VAC therapy in situ. The final suture took place 3 days after vaginal delivery. Non-healing wounds with abdominal wall defects should be treated using a multidisciplinary approach, and NPWT can be used. This therapy can also be used during pregnancy. Vaginal delivery is preferred because it reduces the risk of further formation or deepening of the abdominal wall defect after a sufficient time interval from the start of the treatment. This complex case with a literature review of surgical complications in pregnancy treated with NPWT therapy highlights the advantage of a multidisciplinary approach.

To evaluate intravenous meropenem and intraperitoneal 10% aqueous extract of Schinus terebinthifolius (aroeira) in elderly rats after autogenous fecal peritonitis.

Thirty 18-month-old Wistar rats underwent peritonitis with 4 mL/kg of autogenous fecal solution. They were stratified into groups: control without treatment; study I, treated with meropenem (40 mg/kg); and study II, treated with meropenem at the same dose and intraperitoneal 10% aqueous extract of aroeira. The animals were monitored for 15 days until euthanasia. The study was approved by Ethics Committee.

There was no significant weight loss in the study-II group (p = 0.6277), while the study-I group showed partially recovered weight (p = 0.0187). The study-II group had 90% negative blood cultures, while the study-I group had in 50% of the animals (p = 0.1479). Survival in the study-II group was higher than in study-I group (p = 0.0462). The morbidity score for abdominal and thoracic cavity was lower in the study-II group as compared with study-I group (p = 0.0001).

The use of meropenem associated with the intraperitoneal 10% aqueous aroeira extract after induction of autogenous fecal peritonitis in elderly rats produced greater survival, less weight loss, and lower morbidity compared to the use of meropenem alone.

The objective of this study was to develop a novel scoring model, assess its diagnostic value for complex appendicitis, and compare it with existing scoring systems. A total of 1,241 patients with acute appendicitis were included, comprising 868 patients in the modeling group (mean age, 35.6 ± 14.2 years; 52.4% men) and 373 patients in the validation group (mean age, 36.2 ± 13.8 years; 53.1% men). Among them, 28.4% (346/1,241) were diagnosed with complex appendicitis. The distribution of clinical features, laboratory results, and imaging findings was comparable between the two groups. The data from the modeling group were used to develop the MZXBTCH scoring system, which subsequently validated using the validation group data. Based on postoperative pathological diagnoses, the validation group (n = 373) was scored using the Alvarado, Raja Isteri Pengiran Anak Saleha (RIPASA), Appendicitis Inflammatory Response (AIR), and MZXBTCH scoring systems. Receiver operating characteristic (ROC) curves were plotted to compare the diagnostic efficacy of these scoring systems for complex appendicitis. Multivariate logistic regression analysis identified preoperative body temperature (odds ratio (OR) = 1.104; 95% confidence interval (CI) 1.067-1.143; P < 0.001), preoperative C-reactive protein (CRP) level (OR = 1.002; 95% CI 1.001-1.002; P < 0.001), lymphocyte percentage (OR = 0.994; 95% CI 0.990-0.996; P < 0.001), appendiceal fecal stones (OR = 1.127; 95% CI 1.068-1.190; P < 0.001), periappendiceal fat stranding (OR = 1.133; 95% CI 1.072-1.198; P < 0.001), and appendix diameter (OR = 1.013; 95% CI 1.004-1.022; P < 0.001) as independent risk factors for complex appendicitis. Using R programming, a nomogram based on these independent risk factors was constructed to derive MZXBTCH scores. ROC curve analysis of the MZXBTCH model indicated an area under the curve (AUC) of 0.773. ROC curve analysis revealed that the AUC values of the Alvarado, RIPASA, AIR, and MZXBTCH scoring systems were 0.66, 0.68, 0.76, and 0.82, respectively. Sensitivities were 64.29%, 66.33%, 68.37%, and 74.49%, and specificities were 55.64%, 60%, 75.64%, and 76.36%, respectively. Positive predictive values were 0.34, 0.37, 0.5, and 0.53, while negative predictive values were 0.81, 0.83, 0.87, and 0.89. Accuracy rates were 0.58, 0.62, 0.74, and 0.76, respectively. The MZXBTCH scoring system demonstrated higher sensitivity, specificity, and accuracy compared with the Alvarado, RIPASA, and AIR scoring systems in distinguishing complex appendicitis.

Acute appendicitis during pregnancy poses unique challenges due to altered anatomical and physiological dynamics and concern about foetal well-being. This study aimed to assess management strategies and outcomes of acute appendicitis during pregnancy, focusing on non-operative management versus surgical intervention.

The study is based on the computerized healthcare utilization database of Lombardy.

In Lombardy, a total of 1,231,040 deliveries were identified. Acute appendicitis during pregnancy occurred in 0.03% of cases, with 74.49% of these cases classified as uncomplicated. Appendicitis during pregnancy was associated with worse maternal and perinatal outcomes. Among uncomplicated cases, 38.46% were treated with non-operative management. Perinatal outcomes did not significantly differ between non-operative management and surgery groups. Additionally, a declining trend in surgical treatment over the study period was observed (P = 0.0477), possibly indicating a shift towards conservative management.

The findings suggest that non-operative management may be a viable option for selected pregnant patients with uncomplicated appendicitis, potentially avoiding surgical complications and allowing for faster recovery. Further research is warranted to validate these findings, explore evolving trends, and refine clinical guidelines for managing acute appendicitis during pregnancy.

Complicated appendicitis is associated with high morbidity, mortality, and healthcare costs. However, the relationship of preoperative in-hospital delay >24 h with complicated appendicitis and postoperative morbidity remains unclear. This meta-analysis investigated the effects of preoperative in-hospital delay on complicated appendicitis and postoperative morbidity in patients with acute appendicitis.

This study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR2) guidelines. The PubMed, Embase, Cochrane Library, and Web of Science databases up to October 14, 2023 (updated on March 16, 2024) were searched for randomized controlled trials and observational studies that evaluated the effect of preoperative in-hospital delays of >24 h on acute appendicitis. Odds ratios (OR) and 95% confidence intervals (CIs) were also determined.

We yielded 18 130 records, of which 28 studies (512 881 patients) were included in the meta-analysis. The risk of bias was considered serious, moderate, and low for 24, 3, and 1 study, respectively. Although preoperative in-hospital delays of >24 h were not associated with a higher risk of surgical-site infection (OR: 1.04, 95% CI: 0.97, 1.12, P =0.25), in-hospital delays of >24 h were a risk factor for complicated appendicitis (OR: 1.60, 95% CI: 1.25, 2.05, P =0.0002), and postoperative complications (OR: 1.51, 95% CI: 1.30, 1.75, P <0.00001). In addition, an in-hospital delay of >24 h before surgery increased the OR of postoperative mortality (OR: 1.81, 95% CI: 1.33, 2.45, P =0.0001). The sensitivity analyses also confirmed the robustness of our results.

An in-hospital delay of >24 h is a risk factor for complicated appendicitis, postoperative complications, and mortality. Given the subsequent adverse outcomes of in-hospital delays, appendectomy should not be delayed for >24 h.

Background Acute appendicitis in preschool children remains a diagnostic challenge despite advanced imaging techniques' widespread availability. The majority of these children come late, often with complications such as appendicular perforation, abscess development, and peritonitis. As a consequence, hospital stays are lengthy and linked with an increase in morbidity and mortality. In this research, we aim to predict the factors of acute appendicitis and its outcomes among the pediatric age group. Methods We conducted a retrospective study at the Maternity and Children's Hospital, Al Ahsa, Saudi Arabia, from 2022 to 2023 by reviewing the medical records of pediatric patients younger than 14 years admitted to the ER with acute appendicitis. We divided the patients into either complicated or simple appendicitis. We compared the two groups in terms of baseline characteristics, symptoms, and signs by using the Pediatric Appendicitis Score, duration of symptoms, and length of hospital stay as factors, and we assessed the significant predictive factors for the diagnosis of the type of appendicitis and length of hospital stay. Results During the study period, 246 children with a mean age of 10.1 ± 2.2 years and a male predominance of 171 (69.5%) presented with appendicitis. Simple appendicitis affected half of the participants (137, 55.7%) compared to complicated (76, 30.9%). Thirty-three children (13.4%) had a normal appendix. Complex appendicitis affected 76 (30.9%) of cases. Of those who received conservative treatment, 105 (42.7%) had a failure rate of 32 (30.5%). The mean hospital stay was 5.5 ± 4.0 days. Children under five years with complicated appendicitis had high appendicitis scores (p = < 0.05). Conclusion The predictive factors for pediatric appendicitis diagnosis are helpful in identifying those children who require intervention. However, the most crucial diagnostic instruments for determining the diagnosis of appendicitis in children are still the clinical signs and a physical abdominal examination.

While multiple studies have shown the safety and efficacy of non-operative management, appendectomy remains the standard treatment for uncomplicated acute appendicitis (UAA). This study presents a protocol for a meta-analysis comparing antibiotic therapy, endoscopic retrograde appendicitis therapy (ERAT) and appendectomy in patients with UAA.

We will conduct a systematic search of several databases, including PubMed, Web of Science, Embase, the China National Knowledge Infrastructure and the Cochrane Library. The search will cover the full range of database records up to September 2024. Eligible studies will include randomised-controlled trials (RCTs) evaluating the efficacy of antibiotic therapy, ERAT and appendectomy for UAA. The primary outcome will be treatment success, while secondary outcomes will include major complications, hospital costs, length of stay and recurrence of appendicitis. Two independent reviewers will select studies, extract data and assess bias risk. A Bayesian approach will be used for the network meta-analysis.

Ethical approval is not required as the study will use data from published RCTs. The findings will be disseminated through publication in peer-reviewed journals.

CRD42024554427.

Acute abdominal pain (AAP) constitutes 5-10% of all emergency department (ED) visits, with appendicitis being a prevalent AAP etiology often necessitating surgical intervention. The variability in AAP symptoms and causes, combined with the challenge of identifying appendicitis, complicate timely intervention. To estimate the risk of appendicitis, scoring systems such as the Alvarado score have been developed. However, diagnostic errors and delays remain common. Although various machine learning (ML) models have been proposed to enhance appendicitis detection, none have been seamlessly integrated into the ED workflows for AAP or are specifically designed to diagnose appendicitis as early as possible within the clinical decision-making process. To mimic daily clinical practice, this proof-of-concept study aims to develop ML models that support decision-making using comprehensive clinical data up to key decision points in the ED workflow to detect appendicitis in patients presenting with AAP.

Data from the Dutch triage system at the ED, vital signs, complete medical history and physical examination findings and routine laboratory test results were retrospectively extracted from 350 AAP patients presenting to the ED of a Dutch teaching hospital from 2016 to 2023. Two eXtreme Gradient Boosting ML models were developed to differentiate cases with appendicitis from other AAP causes: one model used all data up to and including physical examination, and the other was extended with routine laboratory test results. The performance of both models was evaluated on a validation set (n = 68) and compared to the Alvarado scoring system as well as three ED physicians in a reader study.

The ML models achieved AUROCs of 0.919 without laboratory test results and 0.923 with the addition of laboratory test results. The Alvarado scoring system attained an AUROC of 0.824. ED physicians achieved AUROCs of 0.894, 0.826, and 0.791 without laboratory test results, increasing to AUROCs of 0.923, 0.892, and 0.859 with laboratory test results.

Both ML models demonstrated comparable high accuracy in predicting appendicitis in patients with AAP, outperforming the Alvarado scoring system. The ML models matched or surpassed ED physician performance in detecting appendicitis, with the largest potential performance gain observed in absence of laboratory test results. Integration could assist ED physicians in early and accurate diagnosis of appendicitis.