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Kucukakcali Z, Akbulut S. Role of immature granulocyte and blood biomarkers in predicting perforated acute appendicitis using machine learning model. World J Clin Cases 2025; 13:104379. [DOI: 10.12998/wjcc.v13.i22.104379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2024] [Revised: 03/16/2025] [Accepted: 04/11/2025] [Indexed: 05/14/2025] Open
Abstract
BACKGROUND Acute appendicitis (AAp) is a prevalent medical condition characterized by inflammation of the appendix that frequently necessitates urgent surgical procedures. Approximately two-thirds of patients with AAp exhibit characteristic signs and symptoms; hence, negative AAp and complicated AAp are the primary concerns in research on AAp. In other terms, further investigations and algorithms are required for at least one third of patients to predict the clinical condition and distinguish them from uncomplicated patients with AAp.
AIM To use a Stochastic Gradient Boosting (SGB)-based machine learning (ML) algorithm to tell the difference between AAp patients who are complicated and those who are not, and to find some important biomarkers for both types of AAp by using modeling to get variable importance values.
METHODS This study analyzed an open access data set containing 140 people, including 41 healthy controls, 65 individuals with uncomplicated AAp, and 34 individuals with complicated AAp. We analyzed some demographic data (age, sex) of the patients and the following biochemical blood parameters: White blood cell (WBC) count, neutrophils, lymphocytes, monocytes, platelet count, neutrophil-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, mean platelet volume, neutrophil-to-immature granulocyte ratio, ferritin, total bilirubin, immature granulocyte count, immature granulocyte percent, and neutrophil-to-immature granulocyte ratio. We tested the SGB model using n-fold cross-validation. It was implemented with an 80-20 training-test split. We used variable importance values to identify the variables that were most effective on the target.
RESULTS The SGB model demonstrated excellent performance in distinguishing AAp from control patients with an accuracy of 96.3%, a micro aera under the curve (AUC) of 94.7%, a sensitivity of 94.7%, and a specificity of 100%. In distinguishing complicated AAp patients from uncomplicated ones, the model achieved an accuracy of 78.9%, a micro AUC of 79%, a sensitivity of 83.3%, and a specificity of 76.9%. The most useful biomarkers for confirming the AA diagnosis were WBC (100%), neutrophils (95.14%), and the lymphocyte-monocyte ratio (76.05%). On the other hand, the most useful biomarkers for accurate diagnosis of complicated AAp were total bilirubin (100%), WBC (96.90%), and the neutrophil-immature granulocytes ratio (64.05%).
CONCLUSION The SGB model achieved high accuracy rates in identifying AAp patients while it showed moderate performance in distinguishing complicated AAp patients from uncomplicated AAp patients. Although the model's accuracy in the classification of complicated AAp is moderate, the high variable importance obtained is clinically significant. We need further prospective validation studies, but the integration of such ML algorithms into clinical practice may improve diagnostic processes.
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Affiliation(s)
- Zeynep Kucukakcali
- Department of Biostatistics and Medical Informatics, Inonu University Faculty of Medicine, Malatya 44280, Türkiye
| | - Sami Akbulut
- Department of Biostatistics and Medical Informatics, Inonu University Faculty of Medicine, Malatya 44280, Türkiye
- Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya 44280, Türkiye
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Talan DA, Di Saverio S. Failure Rate of Nonoperative Treatment of Appendicitis-Closer to 15% Than 50%? JAMA Surg 2025:2833852. [PMID: 40366643 DOI: 10.1001/jamasurg.2025.1133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2025]
Abstract
This Viewpoint outlines the problems with the failure rates for nonoperative treatment of uncomplicated appendicitis (NOTA) reported in several major trials and discusses why NOTA may be preferable to appendectomy.
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Affiliation(s)
- David A Talan
- Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine, University of California, Los Angeles
| | - Salomone Di Saverio
- Department of General Surgery, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
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Zhan K, Bai Y, Liu T, Su X, Yang Q, Liu Y, Zhou X, Zhang Y, Tang J, Jiang Z, Yang X, Liu W. Visual Endoscopic Retrograde Appendicitis Therapy Vs Antibiotic Therapy for Treatment of Uncomplicated Acute Appendicitis. Am J Gastroenterol 2025; 120:1036-1044. [PMID: 39382581 DOI: 10.14309/ajg.0000000000003118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 09/18/2024] [Indexed: 10/10/2024]
Abstract
INTRODUCTION Visual endoscopic retrograde appendicitis therapy (V-ERAT) involves a single-use video scope, allowing for real-time visualization of the appendiceal lumen during the procedure to treat uncomplicated acute appendicitis (AA). This study aims to compare V-ERAT to antibiotic therapy in treating uncomplicated AA. METHODS This multicenter, retrospective cohort study was conducted at 9 hospitals in China from August 2021 to July 2023. Propensity score matching was performed to minimize selection bias. A total of 692 uncomplicated AA patients were included, with 188 undergoing V-ERAT and 504 receiving antibiotic therapy. The primary outcome was treatment success rate. The secondary outcomes included recurrent appendicitis rate, the appendectomy rate during the initial hospitalization, length of initial hospitalization, time to disease recurrence, and overall adverse events. RESULTS The treatment success rate did not differ between the V-ERAT and antibiotic groups (93.6%; 95% confidence interval [CI] 89.1%-96.7% vs 90.5%; 95% CI, 87.6%-92.9%) ( P = 0.225). However, V-ERAT demonstrated a significantly lower risk of appendicitis recurrence compared with antibiotic therapy during the follow-up (log-rank P < 0.001), with a hazard ratio of 0.14 (95% CI, 0.07-0.29, P < 0.001). V-ERAT was associated with a lower appendectomy rate during the initial hospitalization (4.3%; 95% CI, 1.9%-8.2% vs 9.5%; 95% CI, 7.1%-12.4%) ( P = 0.027), a shorter length of initial hospitalization (3 [interquartile range (IQR), 3-4] vs 4 [IQR, 4-6] days, P < 0.001), and a longer time to recurrence (269 [IQR, 210-318] vs 70 [IQR, 21-103] days, P < 0.001). The overall adverse event rates did not differ between the 2 groups (log-rank P = 0.064). DISCUSSION V-ERAT seems to be a safe and effective alternative to antibiotic therapy in treating uncomplicated AA, significantly reducing the risk of appendicitis recurrence.
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Affiliation(s)
- Ke Zhan
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Bai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tianyu Liu
- Department of Gastroenterology, Suining Central Hospital, Sichuan, China
| | - Xing Su
- Department of Gastroenterology, The People's Hospital of Chongqing Liangjiang New Area, Chongqing, China
| | - Qingqing Yang
- Department of Gastroenterology, Yubei District People's Hospital of Chongqing, Chongqing, China
| | - Yang Liu
- Department of Gastroenterology, Chongqing Iron and Steel General Hospital, Chongqing, China
| | - Xiangrong Zhou
- Department of Gastroenterology, Jianyang People's Hospital, Jianyang, Sichuan, China
| | - Yichuan Zhang
- Department of Gastroenterology, The Affiliated Hospital of Panzhihua University, Sichuan, China
| | - Jianhua Tang
- Department of Gastroenterology, Traditional Chinese Medicine Hospital of ChongQing Tongliang, Chongqing, China
| | - Zheng Jiang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Weihui Liu
- Department of Gastroenterology and Hepatology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
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Poehler D, Kirsch S, Dempsey M, Giombi K, Khavjou O. Impact analysis of expanding antibiotic use for treatment of uncomplicated appendicitis without appendicolith. J Comp Eff Res 2025; 14:e240234. [PMID: 40211938 PMCID: PMC12007479 DOI: 10.57264/cer-2024-0234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2024] [Accepted: 03/07/2025] [Indexed: 04/17/2025] Open
Abstract
Aim: Approximately 20% of patients with uncomplicated appendicitis receive antibiotics as a first-line treatment; this study explores the impacts of expanding patient uptake of first-line antibiotics for appendicitis treatment. Materials & methods: We model the impacts on the patient, caregiver, payer and total societal costs associated with expanding antibiotics use from 20 to 50% for patients with appendicitis through use of a decision-tree model. Results: Increasing antibiotics uptake to 50% of eligible appendicitis patients is expected to decrease overall societal economic costs by $192 million, and these savings are driven by a $493 million reduction in initial treatment costs. For patients and their caregivers, out-of-pocket costs are expected to decrease by $18 million, appendectomies by 27,410 and missed work hours by 639,682. Conclusion: Increasing national uptake of antibiotics for the treatment of appendicitis may reduce patient, payer and total societal costs with minimal impact to patient health outcomes. An expansion may also decrease the total number of appendectomies, appendectomy-related medical complications, and lost wages for patients and caregivers, with minimal decreases in the number of appendiceal cancer cases treated early.
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Affiliation(s)
- Diana Poehler
- RTI International, 3040 E. Cornwallis Road, P.O. Box 121, Research Triangle Park, NC 27709, USA
| | - Sydney Kirsch
- RTI International, 3040 E. Cornwallis Road, P.O. Box 121, Research Triangle Park, NC 27709, USA
| | - Matthew Dempsey
- RTI International, 3040 E. Cornwallis Road, P.O. Box 121, Research Triangle Park, NC 27709, USA
| | - Kristen Giombi
- RTI International, 3040 E. Cornwallis Road, P.O. Box 121, Research Triangle Park, NC 27709, USA
| | - Olga Khavjou
- RTI International, 3040 E. Cornwallis Road, P.O. Box 121, Research Triangle Park, NC 27709, USA
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Poprom N, Pattanaprateep O, Wilasrusmee C, Rattanasiri S, McKay GJ, Attia J, Thakkinstian A. Cost utility analysis of antibiotics compared with operative treatment in uncomplicated acute appendicitis. Sci Rep 2025; 15:14963. [PMID: 40301419 PMCID: PMC12041463 DOI: 10.1038/s41598-025-00111-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Accepted: 04/25/2025] [Indexed: 05/01/2025] Open
Abstract
Appendicitis is the most common acute abdominal condition affecting general surgical practice. Recently, conservative treatment with antibiotics has been considered as an alternative. Therefore, this study was conducted to evaluate if antibiotics could be cost-effective compared to laparoscopic appendectomy or open appendectomy. A prospective study was undertaken to estimate health-related quality of life for antibiotic and operative treatment, and to ascertain costs in a cohort. A societal perspective incremental cost-effectiveness ratio (ICER) at 1 year after surgery was estimated. A probabilistic sensitivity analyses was performed. ICERs were estimated comparisons between individual antibiotics, laparoscopic appendectomy, and open appendectomy in uncomplicated acute appendicitis. Antibiotics showed improved cost savings compared to operative treatments with an ICER of -113,973.09 USD per quality adjusted life year at 1 year. Based on one year findings, antibiotics represent a lower cost treatment option with better cost-utility compared to operative treatment options in uncomplicated acute appendicitis patients. As such, antibiotic treatment can be initially considered as an alternative option where resources are limited to minimize complication rates associated with operative treatments.
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Affiliation(s)
- Napaphat Poprom
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Rama VI Road, Bangkok, 10400, Thailand
- Faculty of Public Health, Chiang Mai University, Chiang Mai, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Rama VI Road, Bangkok, 10400, Thailand.
| | - Chumpon Wilasrusmee
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sasivimol Rattanasiri
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Rama VI Road, Bangkok, 10400, Thailand
| | - Gareth J McKay
- Centre for Public Health, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University of Belfast, Belfast, BT9 7BL, UK
| | - John Attia
- School of Medicine and Public Health, Centre for Clinical Epidemiology and Biostatistics, University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Rama VI Road, Bangkok, 10400, Thailand
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Mori H, Yamasaki K, Saishoji Y, Torisu Y, Mori T, Nagai Y, Izumi Y. Diagnostic accuracy of tongue coating in identifying acute appendicitis: a prospective cohort study. Emerg Med J 2025:emermed-2024-214210. [PMID: 40169241 DOI: 10.1136/emermed-2024-214210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 03/20/2025] [Indexed: 04/03/2025]
Abstract
BACKGROUND Acute appendicitis requires timely diagnosis. The diagnostic efficacy of tongue examination in making this diagnosis has not been established. This study investigates whether the Tongue Coating Index (TCI), a validated measure of tongue coating, can aid in diagnosing acute appendicitis. METHODS We conducted a prospective cohort study (1 September 2018-31 December 2020) at a single Japanese hospital. Adults (≥20 years) with suspected acute appendicitis, presenting to either the emergency department or general outpatient clinic, were enrolled. Tongue images were taken at presentation; two independent examiners-unrelated to clinical care and blinded to patient data-later scored these images using the TCI. A composite reference standard (clinical findings, imaging, histopathology, follow-up) was used to confirm appendicitis. We compared the TCI's diagnostic performance with the Alvarado score and its components using C-index, area under the curve (AUC), sensitivity and specificity. RESULTS Of 145 included patients, 69 (47.6%) were diagnosed with acute appendicitis. The TCI demonstrated comparable discriminative ability (C-index AUC 0.62; 95% CI, 0.53 to 0.71) to that of the Alvarado score (0.66; 95% CI, 0.57 to 0.75). Of Alvarado score components, migration of pain had an AUC of 0.63 (95% CI, 0.55 to 0.71), anorexia 0.58 (95% CI, 0.50 to 0.66) and tenderness in the right lower quadrant 0.55 (95% CI, 0.50 to 0.60). At a cut-off of 3, the TCI demonstrated high sensitivity of 96% (95% CI, 88% to 98%) but low specificity of 21% (95% CI, 13% to 32%). Conversely, at a cut-off of 10, the TCI showed increased specificity of 83% (95% CI, 73% to 90%) but reduced sensitivity of 29% (95% CI, 20% to 41%). CONCLUSION The TCI showed comparable diagnostic performance to the Alvarado score and its individual components. TCI may potentially serve as an additional non-invasive indicator for diagnosing or ruling out acute appendicitis. Further research is essential to validate its clinical utility.
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Affiliation(s)
- Hideki Mori
- Department of General Internal Medicine, NHO Nagasaki Medical Center, Omura, Nagasaki, Japan
| | - Kazumi Yamasaki
- Clinical Research Center, NHO Nagasaki Medical Center, Omura, Nagasaki, Japan
| | - Yusuke Saishoji
- Department of General Internal Medicine, NHO Nagasaki Medical Center, Omura, Nagasaki, Japan
| | - Yuichi Torisu
- Department of General Internal Medicine, NHO Nagasaki Medical Center, Omura, Nagasaki, Japan
| | - Takahiro Mori
- Department of General Internal Medicine, NHO Nagasaki Medical Center, Omura, Nagasaki, Japan
| | - Yuki Nagai
- Department of General Internal Medicine, NHO Nagasaki Medical Center, Omura, Nagasaki, Japan
| | - Yasumori Izumi
- Department of General Internal Medicine, NHO Nagasaki Medical Center, Omura, Nagasaki, Japan
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Mair A, Schiele S, Anthuber L, Hoffmann M, Müller G, Anthuber M, Schrempf MC. Safety of in-hospital delay of appendectomy - a propensity score-matched analysis of 4900 consecutive patients undergoing surgery for suspected appendicitis. J Gastrointest Surg 2025; 29:102003. [PMID: 40021081 DOI: 10.1016/j.gassur.2025.102003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2024] [Revised: 02/07/2025] [Accepted: 02/22/2025] [Indexed: 03/03/2025]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSION 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.
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Affiliation(s)
- Andrea Mair
- Department of General, Visceral, and Transplantation Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Stefan Schiele
- Department of Computational Statistics and Data Analysis, Institute of Mathematics, University of Augsburg, Augsburg, Germany
| | - Lena Anthuber
- Department of General, Visceral, and Transplantation Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Michael Hoffmann
- Department of General, Visceral, and Transplantation Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Gernot Müller
- Department of Computational Statistics and Data Analysis, Institute of Mathematics, University of Augsburg, Augsburg, Germany
| | - Matthias Anthuber
- Department of General, Visceral, and Transplantation Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Matthias C Schrempf
- Department of General, Visceral, and Transplantation Surgery, University Hospital Augsburg, Augsburg, Germany.
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Kupietzky A, Gross M, Dover R, Maden A, Parnasa SY, Shussman N, Mazeh H, Mizrahi I. Operative Outcomes of Patients With Recurrent Uncomplicated Appendicitis are Similar to Patients With Acute Uncomplicated Appendicitis. J Surg Res 2025; 308:209-215. [PMID: 40120525 DOI: 10.1016/j.jss.2025.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2024] [Revised: 02/18/2025] [Accepted: 02/22/2025] [Indexed: 03/25/2025]
Abstract
INTRODUCTION Nonoperative management (NOM) for uncomplicated acute appendicitis (AA) has been gaining popularity in recent years. As so, more patients present with recurrent AA after a successful past episode of NOM. The aim of this study is to assess the outcomes of patients who underwent appendectomy due to recurrent uncomplicated AA after a successful episode of NOM in the past, and to compare their operative and postoperative course to patients operated for uncomplicated AA during their index admission. METHODS A retrospective analysis identified patients who underwent appendectomy in our institution between 2017 and 2022. The study group included all consecutive patients who underwent an appendectomy due to recurrent uncomplicated AA after NOM for uncomplicated AA in the past. Their course and outcomes were compared to a cohort of consecutive patients without any prior episodes of AA, who underwent an appendectomy during their index admission. RESULTS During the study period, 102 patients underwent an appendectomy due to recurrent uncomplicated AA. This group was compared to 107 consecutive patients without prior episodes of AA, who underwent upfront surgery during their index admission. Analysis demonstrated no significant difference between the groups in the operative approach, resection-technique, overall postoperative complication rates, the use of peritoneal drains, and intraoperative findings. However, length of surgery was significantly shorter in the recurrent AA group than in the upfront appendectomy group (mean ± standard deviation, 34 ± 13.7 versus 50.7 ± 18 min; P < 0.001). Pathology analysis revealed a normal appendix in 11.8% of patients presenting with recurrent AA compared to 1.9% of patients in the upfront surgery group (P = 0.007). CONCLUSIONS This study demonstrates that surgery for recurrent uncomplicated AA after a successful episode of NOM appears to be safe and comparable to upfront surgery during the index admission for uncomplicated AA.
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Affiliation(s)
- Amram Kupietzky
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Mika Gross
- Department of Military Medicine and "Tzameret", Faculty of Medicine, Hebrew University of Jerusalem and Medical Corps, Israel Defense Forces, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Roi Dover
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ata Maden
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shani Y Parnasa
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Noam Shussman
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Haggi Mazeh
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ido Mizrahi
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Lee HG, Park IJ. Clinical outcomes and optimal indications for nonoperative management of acute appendicitis in adult patients: a comprehensive literature review. Ann Coloproctol 2025; 41:107-118. [PMID: 40313126 PMCID: PMC12046414 DOI: 10.3393/ac.2023.00192.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/02/2023] [Accepted: 04/06/2023] [Indexed: 05/03/2025] Open
Abstract
Appendectomy as the standard treatment for acute appendicitis has been challenged by accumulating evidence supporting nonoperative management with antibiotics as a potential primary treatment. This review aimed to summarize the clinical outcomes and the optimal indications for nonoperative management of acute appendicitis in adults. Current evidence suggests that uncomplicated and complicated appendicitis have different pathophysiologies and should be treated differently. Nonoperative management for uncomplicated appendicitis was not inferior to appendectomy in terms of complications and length of stay, with less than a 30% failure rate at 1 year. The risk of perforation and postoperative complications did not increase even if nonoperative management failed. Complicated appendicitis with localized abscess or phlegmon could also be treated conservatively, with a success rate of more than 80%. An interval appendectomy following successful nonoperative management is recommended only for patients over the age of 40 years to exclude appendiceal malignancy. The presence of appendicoliths increased the risk of treatment failure and complications; thus, it may be an indication for appendectomy. Nonoperative management is a safe and feasible option for both uncomplicated and complicated appendicitis. Patients should be informed that nonoperative management may be a safe alternative to surgery, with the possibility of treatment failure.
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Affiliation(s)
- Hyun Gu Lee
- Department of Surgery, Kyung Hee Universitiy Hospital at Gangdong, Kyung Hee Universtiy College of Medicine, Seoul, Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Monti M, Agamennone M, Wong MCY, Calevo MG, Losurdo G, Avanzini S, Mattioli G. Role of conservative management of acute appendicitis in pediatric age: a monocentric experience. Updates Surg 2025:10.1007/s13304-025-02136-x. [PMID: 40035919 DOI: 10.1007/s13304-025-02136-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Accepted: 02/24/2025] [Indexed: 03/06/2025]
Abstract
Historically, appendectomy was the standard treatment for acute appendicitis (AA). Recently, interest has grown in conservative management of uncomplicated AA (UA). This study compared outcomes between non-operative management (NOM) and appendectomy, exploring preoperative factors to guide optimal UA management. In a monocentric retrospective study, we reviewed data on 774 pediatric patients with a primary diagnosis of AA from July 2017 to July 2022. We analyzed demographic, clinical, laboratory, and ultrasound data at first and last admission. Operated patients were stratified by management type and surgery timing. Minimum follow-up was 6 months. Of the 530 children (68.5%) who underwent surgery at first admission, 316 had UA and 214 had CA. The 244 patients (31.5%) not indicated for surgery received intravenous antibiotics. Of these, 104 underwent appendectomy at second admission, with 9 presenting CA, requiring multiple antibiotic therapy and a hospital stay of 9.1 ± 3.1 days. Twenty-eight underwent surgery at their third admission and 112 never underwent surgery. In conclusion, more invasive approach may be preferable for patients with significant clinical signs at first presentation, minimizing hospital stay, costs, antibiotic use, and complications. Further studies on NOM in acute appendicitis are essential to optimize its use.
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Affiliation(s)
- Martina Monti
- Pediatric Surgery, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
- University of Genoa, DINOGMI, Genoa, Italy.
| | - Marco Agamennone
- Pediatric Surgery, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- University of Genoa, DINOGMI, Genoa, Italy
| | | | - Maria Grazia Calevo
- Epidemiology and Biostatistics Unit, Scientific Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giuseppe Losurdo
- IRCCS Istituto Giannina Gaslini, Infectious Diseases Unit, Genoa, Italy
| | - Stefano Avanzini
- Pediatric Surgery, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- University of Genoa, DINOGMI, Genoa, Italy
| | - Girolamo Mattioli
- Pediatric Surgery, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- University of Genoa, DINOGMI, Genoa, Italy
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11
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Salö M, Tiselius C, Rosemar A, Öst E, Sohlberg S, Andersson RE. Swedish national guidelines for diagnosis and management of acute appendicitis in adults and children. BJS Open 2025; 9:zrae165. [PMID: 40203150 PMCID: PMC11980984 DOI: 10.1093/bjsopen/zrae165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Revised: 11/19/2024] [Accepted: 12/15/2024] [Indexed: 04/11/2025] Open
Abstract
BACKGROUND Acute appendicitis is one of the most common causes of acute abdominal pain. Differences in the management of this large group of patients has important consequences for the patients and the healthcare system. Controversies regarding the understanding of the natural course of the disease, the utility of new diagnostic methods, and alternative treatments have lead to large variations in practice patterns between centres. These national guidelines present evidence-based recommendations aiming at a uniform, safe and cost-efficient management of this large group of patients. METHOD A working group of six experts with broad clinical and research experience was formed. Additional expertise from outside was consulted during the process. A national survey revealed significant variations in the management of patients with suspicion of appendicitis. The evidence provided in published guidelines and reviews were extracted and systematically graded, according to the GRADE methodology. This was supplemented by additional more recent and more directed search of the literature. Patients treated for appendicitis were involved through interviews. The guidelines were reviewed by external experts before the final version was determined. RESULTS The guidelines cover an extensive number of issues: pathology, epidemiology, aetiology, natural history, clinical and laboratory diagnosis, diagnostic scoring systems, diagnostic imaging, treatment, nursing care, follow-up, quality registers and quality indicators, among others. Special considerations related to children and pregnant women are covered. CONCLUSION These national guidelines present an extensive and thorough review of the current knowledge base related to appendicitis, and provide up-to-date evidence-based recommendations for the management of this large group of patients.
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Affiliation(s)
- Martin Salö
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden
- Department of Pediatric Surgery, Skåne University Hospital, Lund, Sweden
| | - Catarina Tiselius
- Department of Surgery, Västmanland Hospital Västerås, Västerås, Sweden
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
| | - Anders Rosemar
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital Östra, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elin Öst
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Sara Sohlberg
- Department of Women´s and Children´s Health, Uppsala University, Uppsala, Sweden
| | - Roland E Andersson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Futurum Academy for Health and Care, Jönköping County Council, Jönköping, Sweden
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12
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Lund H, Haijanen J, Suominen S, Hurme S, Sippola S, Rantanen T, Rautio T, Mattila A, Pinta T, Nordström P, Kössi J, Ilves I, Salminen P. A randomized double-blind noninferiority clinical multicenter trial on oral moxifloxacin versus placebo in the outpatient treatment of uncomplicated acute appendicitis: APPAC IV study protocol. Scand J Surg 2025; 114:3-12. [PMID: 39636024 DOI: 10.1177/14574969241293018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2024]
Abstract
BACKGROUND 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. METHODS 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. DISCUSSION 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. TRIAL REGISTRATION 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.
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Affiliation(s)
- Heidi Lund
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
- Department of Surgery, Satasairaala Hospital, Pori, Finland
| | - Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Saku Suominen
- Department of Surgery, University of Turku, Turku, Finland
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Saija Hurme
- Department of Biostatistics, University of Turku and Turku University Hospital, Turku, Finland
| | - Suvi Sippola
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Tuomo Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Tero Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Anne Mattila
- Department of Surgery, Nova Hospital, Jyväskylä, Finland
| | - Tarja Pinta
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Pia Nordström
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - Jyrki Kössi
- Division of Surgery, Lahti Central Hospital, Lahti, Finland
| | - Imre Ilves
- Division of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology Turku University Hospital P.O. Box 52 20521 Turku Finland
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13
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Sugai S, Sasabuchi Y, Yasunaga H, Aso S, Matsui H, Fushimi K, Yoshihara K, Nishijima K. Impact of gestational age on the management of acute appendicitis during pregnancy: A nationwide observational study. Int J Gynaecol Obstet 2025; 168:1047-1054. [PMID: 39441538 PMCID: PMC11823319 DOI: 10.1002/ijgo.15953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 09/25/2024] [Accepted: 09/29/2024] [Indexed: 10/25/2024]
Abstract
OBJECTIVE To compare conservative management and appendectomy for acute appendicitis during pregnancy by trimester. METHODS This retrospective cohort study used data from a national inpatient database from July 2010 to March 2022. Pregnant women diagnosed with acute appendicitis were included. Multivariable analysis using generalized estimating equations was performed to compare outcomes between conservative management and appendectomy across trimesters. The main outcomes were preterm labor, preterm delivery, or abortion; antepartum hemorrhage; duration of hospitalization; and duration of antibiotic use. RESULTS A total of 3158 individuals from 632 acute-care hospitals were eligible. The proportion of conservative management versus appendectomy by trimester were 507 (49.1%) versus 525 (50.9%) in the first, 690 (44.6%) versus 856 (55.4%) in the second, and 337 (58.1%) versus 243 (41.9%) in the third. In the second trimester, appendectomy was associated with a higher rate of preterm delivery, preterm labor, or abortion (odds ratio [OR], 2.91 [95% confidence interval (CI), 1.62-5.25]). Antepartum hemorrhage occurred more frequently for appendectomy in the first (OR, 2.12 [95% CI, 1.31-3.43]) and third (OR, 2.43 [95% CI, 1.79-3.31]) trimesters. Appendectomy was associated with a longer duration of hospitalization in the second (2.15 days; 95% CI, 1.14-3.17 days) and third (3.97 days; 95% CI, 2.22-5.71 days) trimesters. Antibiotic use duration was shorter for appendectomy in the first (-1.20 days [95% CI -1.51 to -0.90 days]) and second (-0.61 days [95% CI -0.90 to -0.32 days]) trimesters. CONCLUSIONS Clinical outcomes of acute appendicitis during pregnancy vary by trimester. Considering the appendectomy risks, conservative management may be viable depending on the clinical context and trimester.
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Affiliation(s)
- Shunya Sugai
- Department of Obstetrics and GynecologyNiigata University Medical and Dental HospitalNiigataJapan
| | - Yusuke Sasabuchi
- Department of Real‐World Evidence, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public HealthThe University of TokyoTokyoJapan
| | - Shotaro Aso
- Department of Health Services Research, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public HealthThe University of TokyoTokyoJapan
| | - Kiyohide Fushimi
- Department of Health Policy and InformaticsInstitute of Science Tokyo Graduate School of Medical and Dental SciencesTokyoJapan
| | - Kosuke Yoshihara
- Department of Obstetrics and GynecologyNiigata University Medical and Dental HospitalNiigataJapan
| | - Koji Nishijima
- Department of Obstetrics and GynecologyNiigata University Medical and Dental HospitalNiigataJapan
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14
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Scheijmans JCG, Haijanen J, Flum DR, Bom WJ, Davidson GH, Vons C, Hill AD, Ansaloni L, Talan DA, van Dijk ST, Monsell SE, Hurme S, Sippola S, Barry C, O'Grady S, Ceresoli M, Gorter RR, Hannink G, Dijkgraaf MG, Salminen P, Boermeester MA. Antibiotic treatment versus appendicectomy for acute appendicitis in adults: an individual patient data meta-analysis. Lancet Gastroenterol Hepatol 2025; 10:222-233. [PMID: 39827891 DOI: 10.1016/s2468-1253(24)00349-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Revised: 10/07/2024] [Accepted: 10/11/2024] [Indexed: 01/22/2025]
Abstract
BACKGROUND Randomised controlled trials (RCTs) have found antibiotics to be a feasible and safe alternative to appendicectomy in adults with imaging-confirmed acute appendicitis. However, patient inclusion criteria and outcome definitions vary greatly between RCTs. We aimed to compare antibiotics with appendicectomy for the treatment of acute appendicitis using individual patient data and uniform outcome definitions. METHODS In this individual patient data meta-analysis, we searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials without language restrictions between database inception and June 6, 2023, for RCTs comparing appendicectomy with antibiotics for the treatment of adults (≥18 years) with imaging-confirmed acute appendicitis. Studies without 1-year follow-up data on complications were excluded, as were patients. Corresponding authors of eligible studies were contacted and invited to share data; individual patient data were merged after validation. One-stage meta-analyses were conducted using a generalised, mixed-effects linear regression model, accounting for clustering of patients within studies. The primary outcome was the complication rate at 1-year follow-up, uniformly harmonised across trials using the Clavien-Dindo classification. Complications were further divided into minor (grade 1-2 or equivalent) and major (grade 3-5 or equivalent) complications. Appendicectomy rate during 1 year was a key secondary outcome but not considered a complication for the antibiotics group. Outcomes were described separately for patients with and without an appendicolith. This study is registered with PROSPERO, CRD42023391676. FINDINGS Of 887 potentially relevant articles, eight were eligible for inclusion, of which six RCTs could provide data for 2101 eligible patients (1050 assigned to antibiotics and 1051 assigned to appendicectomy; 830 [39·5%] women and 1271 [60·5%] men). All studies raised some bias concerns due to absence of blinding. One study was judged to have a high risk of bias due to the exclusion of eligible patients after randomisation, but these patients were eligible for inclusion in our meta-analysis. At 1 year, 57 (5·4%) of 1050 patients randomly assigned to antibiotics had a complication compared with 87 (8·3%) of 1051 patients randomly assigned to appendicectomy (odds ratio [OR] 0·49 [95% CI 0·20 to 1·20]; risk difference -4·5 percentage points [95% CI -11·6 to 2·6]). At 1 year, 1025 (97·5%) patients in the appendicectomy group had undergone appendicectomy compared with 356 (33·9%) patients in the antibiotics group. In patients with an appendicolith at pre-interventional imaging, there were more complications at 1 year among patients who received antibiotic treatment than among those who underwent appendicectomy (29 [15·0%] of 193 patients vs 12 [6·3%] of 190 patients; OR 2·82 [95% CI 1·11 to 7·18]; risk difference 13·2 percentage points [95% CI 2·3 to 24·2]). In the antibiotics group, 94 (48·7%) of 193 patients with an appendicolith underwent appendicectomy within 1 year versus 262 (30·6%) of 857 patients without an appendicolith. INTERPRETATION This meta-analysis showed that antibiotic treatment in adults with imaging-confirmed acute appendicitis was a safe alternative to surgery and resulted in around two-thirds of patients avoiding appendicectomy during the first year. In patients with an appendicolith, initial antibiotic treatment increased the risk of complications compared with appendicectomy, and around half of these patients assigned to antibiotics underwent step-up appendicectomy within 1 year. These data should be key components in shared decision making. FUNDING None.
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Affiliation(s)
- Jochem C G Scheijmans
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland; Department of Surgery, University of Turku, Turku, Finland
| | - David R Flum
- Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Wouter J Bom
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Giana H Davidson
- Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Corinne Vons
- Digestive Surgery Départment, Jean-Verdier Hôspital, Assistance Publique-Hôpitaux de Paris, Bondy, France
| | - Arnold D Hill
- Department of Surgery, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Luca Ansaloni
- Unit of General Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - David A Talan
- Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Stefan T van Dijk
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Sarah E Monsell
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Saija Hurme
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland; Department of Biostatistics, University of Turku, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland; Department of Surgery, University of Turku, Turku, Finland
| | - Caroline Barry
- Paris-Saclay University, UVSQ, Inserm U1018, CESP, Paris, France
| | - Sorcha O'Grady
- Department of Surgery, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Ramon R Gorter
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Gastroenterology and Metabolism Research Institute, and Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marcel G Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland; Department of Surgery, University of Turku, Turku, Finland
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands.
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Kianmanesh R, Amroun KL, Rhaiem R, Jazi AHD, Moazenzadeh H, Rached L, Zimmermann P, Durame A, Renard Y, Ravenet A, Bouche O, Deguelte S. C-reactive protein and digestive pathologies: A narrative review for daily clinical use. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2025; 30:10. [PMID: 40200962 PMCID: PMC11974606 DOI: 10.4103/jrms.jrms_537_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 11/02/2024] [Accepted: 01/20/2025] [Indexed: 04/10/2025]
Abstract
The aim of this narrative review is to familiarize clinicians, especially digestive surgeons, to adequately use of serum C-reactive protein as a reliable noninvasive biomarker in diverse practical clinical situations. We hope that the review will help clinicians for their decision-making when facing various digestive diseases including operative and nonoperative pathologies such as anastomotic leakage, pancreatitis, emergency situation, and digestive cancer management and prognosis.
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Affiliation(s)
- Reza Kianmanesh
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Koceila Lamine Amroun
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
- Department of Clinical Research, Aging and Fragility Unit UR 3797, Hospital University, Reims, France
| | - Rami Rhaiem
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Amir Hossein Davarpanah Jazi
- Department of Minimally Invasive and Bariatric Surgery, Hazrate Fatemeh Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hashem Moazenzadeh
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Linda Rached
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Perrine Zimmermann
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Adrien Durame
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Yohann Renard
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Ambroise Ravenet
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Olivier Bouche
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of Digestive Oncology, CHU Robert Debré, Reims, France
| | - Sophie Deguelte
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
- Department of Clinical Research, Aging and Fragility Unit UR 3797, Hospital University, Reims, France
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16
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Akın T, Martlı HF, Şahingöz E, Birben B, Er S, Çiftçi A, Doğan HT, Tez M. Phlegmonous appendicitis as a variant of uncomplicated appendicitis. Sci Rep 2025; 15:4387. [PMID: 39910212 PMCID: PMC11799189 DOI: 10.1038/s41598-025-85904-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2024] [Accepted: 01/07/2025] [Indexed: 02/07/2025] Open
Abstract
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.
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Affiliation(s)
- Tezcan Akın
- Department of Surgery, Bilkent City Hospital, Ankara, Turkey.
| | | | - Eda Şahingöz
- Department of Surgery, Bilkent City Hospital, Ankara, Turkey
| | - Birkan Birben
- Department of Surgery, Etlik City Hospital, Ankara, Turkey
| | - Sadettin Er
- Department of Surgery, Bilkent City Hospital, Ankara, Turkey
| | - Ayşe Çiftçi
- Department of Pathology, Bilkent City Hospital, Ankara, Turkey
| | | | - Mesut Tez
- Department of Surgery, Bilkent City Hospital, Ankara, Turkey
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17
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Diaz JJ, Ceresoli M, Herron T, Coccolini F. Current management of acute appendicitis in adults: What you need to know. J Trauma Acute Care Surg 2025; 98:181-189. [PMID: 39504344 DOI: 10.1097/ta.0000000000004471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2024]
Abstract
ABSTRACT 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.
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Affiliation(s)
- Jose J Diaz
- From the Division of Acute Care Surgery (J.J.D.), Tampa General Hospital, University of South Florida, Tampa, Florida; School of Medicine and Surgery (M.C.), University of Milano-Bicocca; General and Emergency Surgery Department (M.C.), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; Tampa General Hospital (T.H.), University of South Florida, Tampa, Florida; and Department of General Emergency and Trauma Surgery (F.C.), Pisa University Hospital, Pisa, Italy
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18
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Alvarez-Lozada LA, Fernandez-Reyes BA, Arrambide-Garza FJ, García-Leal M, Alvarez-Villalobos NA, Martínez-Garza JH, Fernández-Rodarte B, Elizondo-Omaña RE, Quiroga-Garza A. Clinical scores for acute appendicitis in adults: A systematic review and meta-analysis of diagnostic accuracy studies. Am J Surg 2025; 240:116123. [PMID: 39667296 DOI: 10.1016/j.amjsurg.2024.116123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Revised: 10/15/2024] [Accepted: 11/27/2024] [Indexed: 12/14/2024]
Abstract
INTRODUCTION Early diagnosis of acute appendicitis is crucial to prevent complications. Numerous scores exist, but a comprehensive review comparing them is lacking. This systematic review aimed to compare all published clinical scoring systems for diagnosing acute appendicitis in adults. METHODS A systematic review and meta-analysis included studies assessing the diagnostic accuracy of clinical scores compared to histopathological findings for appendicitis. Sensitivities, specificities, diagnostic odds ratios (DOR), and summary receiver operating characteristics (SROC) were calculated. RESULTS A total of 40 studies were included. The RIPASA score showed superior sensitivity (0.93 [95 % CI 0.78-0.98]; I2 = 96 %), specificity (0.81 [95 % CI 0.62-0.91]; I2 = 86 %), and DOR (45.3 [95 % CI 10.9-187.2]; I2 = 89 %). The AUC for the SROC curve of the RIPASA score was 0.913. A significant difference was found between the RIPASA score and both the Alvarado score (p < 0.002) and the Modified Alvarado score (p < 0.004) in SROC curves. CONCLUSIONS Our findings indicate that RIPASA is the most effective scoring system. Although the Alvarado score is the most studied, many other scores possess higher diagnostic accuracy.
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Affiliation(s)
- Luis Adrian Alvarez-Lozada
- Universidad Autonoma de Nuevo Leon, School of Medicine, Human Anatomy Department, Clinical-Surgical Research Group (GICQx), Mexico.
| | - Bernardo Alfonso Fernandez-Reyes
- Universidad Autonoma de Nuevo Leon, School of Medicine, Human Anatomy Department, Clinical-Surgical Research Group (GICQx), Mexico.
| | - Francisco Javier Arrambide-Garza
- Universidad Autonoma de Nuevo Leon, School of Medicine, Human Anatomy Department, Clinical-Surgical Research Group (GICQx), Mexico.
| | | | | | - Javier Humberto Martínez-Garza
- Universidad Autonoma de Nuevo Leon, School of Medicine, Human Anatomy Department, Clinical-Surgical Research Group (GICQx), Mexico.
| | - Bernardo Fernández-Rodarte
- Universidad Autonoma de Nuevo Leon, School of Medicine, Human Anatomy Department, Clinical-Surgical Research Group (GICQx), Mexico.
| | - Rodrigo E Elizondo-Omaña
- Universidad Autonoma de Nuevo Leon, School of Medicine, Human Anatomy Department, Clinical-Surgical Research Group (GICQx), Mexico.
| | - Alejandro Quiroga-Garza
- Universidad Autonoma de Nuevo Leon, School of Medicine, Human Anatomy Department, Clinical-Surgical Research Group (GICQx), Mexico; Instituto Mexicano del Seguro Social, Hospital de Traumatologia y Ortopedia #21, General Surgery Division, Mexico.
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19
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Rizzo CE, Venuto R, Tripodi P, Bartucciotto L, Ventura Spagnolo E, Nirta A, Genovese G, La Spina I, Sortino S, Nicita A, Loddo F, Romeo B, Squeri R, Genovese C. From Guidelines to Action: Tackling Risk Factors for Surgical Site Infections. Antibiotics (Basel) 2025; 14:40. [PMID: 39858326 PMCID: PMC11763291 DOI: 10.3390/antibiotics14010040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2024] [Revised: 12/30/2024] [Accepted: 01/03/2025] [Indexed: 01/27/2025] Open
Abstract
Background/Objectives: Surgical site infections are a serious public health concern, representing a significant burden on healthcare systems and society. Their occurrence is influenced by several factors, including patient demographics, healthcare facilities and the specific circumstances surrounding surgery. The use of prophylactic antibiotics in this context carries both potential benefits and risks. The aim of this study is to investigate potential risk factors that may adversely affect the development of SSIs, as well as to assess the appropriateness and adherence to perioperative antibiotic prophylaxis. Methods: This observational study was conducted from October 2023 to October 2024 at the University Hospital of Messina, Italy, a hospital performing both thoracic and vascular surgery. Data were collected using a questionnaire regarding socio-demographic data, risk factors, clinical and surgical data and details regarding the administration of antibiotics. Results: This study included 117 patients with an average age of 63 ± 12.36 SD years, 70.9% from the Thoracic Surgery Unit and 29.1% from the Vascular Surgery Unit. The most administered antibiotic was cefazolin, and antibiotic administration time was in compliance with the guidelines. Conclusions: Our data show that the implementation of evidence-based guidelines, healthcare professionals' education and correct antibiotic use can reduce the burden of SSIs by improving patient care.
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Affiliation(s)
- Caterina Elisabetta Rizzo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
- Department of Prevention, Local Health Authority of Messina, 98123 Messina, Italy
| | - Roberto Venuto
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
- Department of Prevention, Local Health Authority of Messina, 98123 Messina, Italy
| | - Paola Tripodi
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
| | - Linda Bartucciotto
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
| | - Elvira Ventura Spagnolo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
| | - Antonio Nirta
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
| | - Giovanni Genovese
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
- Department of Prevention, Local Health Authority of Messina, 98123 Messina, Italy
| | - Isabella La Spina
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
- Department of Prevention, Local Health Authority of Messina, 98123 Messina, Italy
| | - Sabrina Sortino
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
| | - Alessandro Nicita
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
| | - Francesco Loddo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
| | - Bruno Romeo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
- Department of Prevention, Local Health Authority of Messina, 98123 Messina, Italy
| | - Raffaele Squeri
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
| | - Cristina Genovese
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; (P.T.); (L.B.); (E.V.S.); (A.N.); (G.G.); (I.L.S.); (S.S.); (A.N.); (F.L.); (B.R.); (R.S.); (C.G.)
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20
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Wu L, Zhang ZG, Chen XY, Xu BX, Mao XP. Fascial involvement score on unenhanced CT potentially helps predict complicated appendicitis. Eur J Radiol 2025; 182:111843. [PMID: 39579579 DOI: 10.1016/j.ejrad.2024.111843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2024] [Revised: 10/15/2024] [Accepted: 11/19/2024] [Indexed: 11/25/2024]
Abstract
OBJECTIVES To assess the accuracy of diagnosing complicated appendicitis by examining changes in the involved fasciae on CT imaging. METHODS From January 1, 2020, to December 31, 2023, 273 patients (median age 50 years; range 14-80 years) with surgically and pathologically confirmed appendicitis were analyzed. Of these, 96 had complicated appendicitis and 177 had uncomplicated appendicitis. Fascial involvement score was assessed along with other CT findings and clinical data. Univariate and multivariate logistic regression analyses were conducted to identify potential predictors of complicated appendicitis. RESULTS Univariate analysis identified several features significantly associated with complicated appendicitis: age (P < 0.001), gender (P = 0.006), time from symptom onset to diagnosis (P = 0.015), CRP level (P < 0.001), fascial involvement score (P < 0.001), appendiceal diameter (P < 0.001), and the presence of extraluminal air (P < 0.001). Multivariate analysis revealed that the fascial involvement score (odds ratio 2.252; P < 0.001) and appendiceal diameter (odds ratio 1.263; P < 0.001) were independent risk factors for complicated appendicitis. The fascial involvement score demonstrated an area under the receiver operating characteristic curve of 0.896, with a cutoff value of 2.5. CONCLUSION Both the fascial involvement score and an appendiceal diameter of 14.5 mm or greater are independent predictors of complicated appendicitis.
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Affiliation(s)
- Lei Wu
- Department of Radiology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, No. 77 Changan Road, Zhangjiagang, Jiangsu Province 215600, China
| | - Zhi-Guo Zhang
- Department of Radiology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, No. 77 Changan Road, Zhangjiagang, Jiangsu Province 215600, China
| | - Xiao-Yu Chen
- Department of Radiology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, No. 77 Changan Road, Zhangjiagang, Jiangsu Province 215600, China
| | - Bing-Xian Xu
- Department of Radiology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, No. 77 Changan Road, Zhangjiagang, Jiangsu Province 215600, China
| | - Xu-Ping Mao
- Department of Radiology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, No. 77 Changan Road, Zhangjiagang, Jiangsu Province 215600, China.
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21
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Hougaard ES, Møller LK, Kristensen SAR, Høyer ME, Ellebaek MB, Al-Najami I. Patient reported outcomes after laparoscopic appendectomy for acute appendicitis. Langenbecks Arch Surg 2024; 410:15. [PMID: 39718656 DOI: 10.1007/s00423-024-03584-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2024] [Accepted: 12/16/2024] [Indexed: 12/25/2024]
Abstract
PURPOSE The purpose of this study is to establish more evidence to provide the clinicians with a greater knowledge on the patient reported outcomes and quality of life (QoL) after laparoscopic appendectomy (LA). METHOD 105 patients who had undergone LA for acute appendicitis regardless of severity, were included prospectively at Odense University Hospital, Svendborg. The patient reported consequence of surgery were assessed through the validated electronic survey from European-QoL questionnaire (5Q-5D-5L) including a self-reported VAS-score (0-100). The first survey was sent out the first day after surgery and the subsequent surveys at 7, 30 and 90 days. The replies was converted into an index-score expressing the QoL from 0 (death) to 1 (full health). RESULTS All patients experienced pain/discomfort at day 1. At day 7, 30 and 90 it was 95%, 45% and 25%, respectively. The median index-score at day 1, 7, 30 and 90 was 0.778, 0.840, 0.984 and 1.00, respectively.
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Affiliation(s)
- Emilie Schultz Hougaard
- Department of Surgery, Odense University Hospital, Odense, Denmark.
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark.
- Department of Surgery, Odense University Hospital, Baggoes Alle 31, Svendborg, 5700, Denmark.
| | - Lasse Kaalby Møller
- Department of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark
| | | | - Mai Elizabeth Høyer
- Department of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark
| | - Mark Bremholm Ellebaek
- Department of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark
| | - Issam Al-Najami
- Department of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark
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Zhang X, Zheng X, Jin H, Li A, Zhang H, Zhang D. Efficacy and safety of different antibiotic treatment versus surgical treatment for acute appendicitis: A network meta-analysis. World J Surg 2024; 48:2843-2854. [PMID: 39500855 DOI: 10.1002/wjs.12382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 08/21/2024] [Indexed: 12/06/2024]
Abstract
OBJECTIVE This systematic review and network meta-analysis compared various antibiotic treatments with surgical treatment for acute appendicitis. METHODS We searched PubMed, Embase, Cochrane Library, and Wanfang databases for randomized controlled trials (RCTs) that met the prespecified inclusion criteria up to July 2023. The interventions included various antibiotics and surgery. The outcomes measured were initial treatment success, treatment success at 1-year follow-up, and treatment-related complications. Meta-analysis was conducted using R software with the gemtc package. Surfaces under the cumulative ranking curves (SUCRA) were used to rank the interventions. RESULTS Thirteen RCTs involving nine treatments (cefotaxime [CTX] + tinidazole [TNZ], CTX + metronidazole [MTZ], ampicillin [AMP] + gentamicin [GEN] + MTZ, amoxicillin/clavulanate [AMC] + GEN, meropenem [MEM] + MTZ, AMC, ertapenem [ETP] + MTZ, ETP, and surgery) were included in this network meta-analysis. In head-to-head comparisons, no statistically significant difference was found between any two interventions for initial treatment success (p > 0.05). The SUCRA indicated that surgery ranked first (SUCRA, 66.5%) for initial treatment success. Surgery was associated with an increased treatment success rate at 1-year follow-up compared to AMC (OR = 0.01, 95% CrI = 0.00-0.14, p < 0.05), MEM + MTZ (OR = 0.06, 95% CrI = 0.00-0.42, p < 0.05), and AMP + GEN + MTZ (OR = 0.02, 95% CrI = 0.00-0.23, p < 0.05). No statistically significant differences were found between any two interventions regarding complications (p > 0.05). CONCLUSION Our network meta-analysis suggests that surgery ranks highest for initial treatment success and treatment success at 1-year follow-up. However, surgery may increase the complication rate.
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Affiliation(s)
- Xianhuan Zhang
- Emergency Department, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
| | - Xiaokang Zheng
- Emergency Department, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
| | - Hongfeng Jin
- Emergency Department, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
| | - Aiming Li
- Emergency Department, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
| | - Hao Zhang
- Emergency Department, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
| | - Dehua Zhang
- Emergency Department, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
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Lunardi N, Thornton M, Zarzaur BL, Agarwal S, Berger M, Sharath S, Kougias P, Bhat S, Frank K, Pham TH, Balentine CJ. Potential risks of nonoperative management of appendicitis in high-risk patients. Surgery 2024; 176:1568-1575. [PMID: 39327128 PMCID: PMC11563903 DOI: 10.1016/j.surg.2024.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/30/2024] [Accepted: 08/20/2024] [Indexed: 09/28/2024]
Abstract
INTRODUCTION The popularity of nonoperative management for acute appendicitis is based on the untested assumption that it offers a lower risk alternative to surgery in patients who are at high risk for morbidity and mortality with appendectomy. We hypothesized that patients who were at a high risk with appendectomy would also be at a high risk for complications following nonoperative management. METHODS This is a retrospective cohort study of patients with acute, uncomplicated appendicitis in the 2004-2017 National Inpatient Sample. We used a logistic regression model to predict the risk of morbidity or mortality following appendectomy and applied this model to predict the risk of patients managed nonoperatively. High risk was defined as ≥2 standard deviations above the mean predicted risk of morbidity or mortality. We used inverse probability weighting of the propensity score to compare outcomes of nonoperative versus operative management for high-risk patients. RESULTS The sample included 21,242 high-risk patients with a median age of 68 years (interquartile range 57-78), and 31% were managed nonoperatively. Compared to surgery, nonoperative management was associated with a 9% decrease in complications (95% confidence interval [CI] 7%-10%), 2% increase in mortality (95% CI 2%-3%), $10,202 increase in hospital costs (95% CI $9,065-$11,339), 3-day increase in length of stay (95% CI 2-3), and 9% greater likelihood of discharge to skilled nursing facilities (95% CI 8%-10%). CONCLUSION Nonoperative management of acute appendicitis in high-risk patients may reduce morbidity but increase mortality, duration of hospitalization, discharge to skilled facility, and costs. Surgeons should exercise caution when considering nonoperative management in these vulnerable patients.
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Affiliation(s)
- Nicole Lunardi
- Department of Surgery, University of Texas Southwestern, Dallas, TX; Department of Surgery, North Texas VA Health Care System, Dallas, TX
| | - Melissa Thornton
- Department of Surgery, University of Texas Southwestern, Dallas, TX; Department of Surgery, North Texas VA Health Care System, Dallas, TX
| | - Ben L Zarzaur
- Department of Surgery, University of Wisconsin-Madison, WI
| | | | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Sherene Sharath
- Department of Surgery, SUNY Downstate Health Sciences Center, Brooklyn, NY; Department of Epidemiology & Biostatistics, SUNY Downstate Health Sciences Center, Brooklyn, NY; Department of Surgery, New York Harbor Health Care System, Brooklyn, NY
| | - Panos Kougias
- Department of Surgery, SUNY Downstate Health Sciences Center, Brooklyn, NY; Department of Surgery, New York Harbor Health Care System, Brooklyn, NY
| | - Sneha Bhat
- Department of Surgery, University of Texas Southwestern, Dallas, TX
| | - Kenneth Frank
- Department of Counseling, Educational Psychology and Special Education, Michigan State University, East Lansing, MI
| | - Thai H Pham
- Department of Surgery, University of Texas Southwestern, Dallas, TX; Department of Surgery, North Texas VA Health Care System, Dallas, TX
| | - Courtney J Balentine
- Department of Surgery, University of Wisconsin-Madison, WI; Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin-Madison, Madison, WI; William S. Middleton VA, Madison, WI.
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Fransvea P, Chiarello MM, Fico V, Cariati M, Brisinda G. Influence of sarcopenia and frailty in the management of elderly patients with acute appendicitis. World J Clin Cases 2024; 12:6580-6586. [PMID: 39600486 PMCID: PMC11514337 DOI: 10.12998/wjcc.v12.i33.6580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 08/06/2024] [Accepted: 08/14/2024] [Indexed: 09/27/2024] Open
Abstract
In developed countries, the average life expectancy has been increasing and is now well over 80 years. Increased life expectancy is associated with an increased number of emergency surgical procedures performed in later age groups. Acute appendicitis is one of the most common surgical diseases, with a lifetime risk of 8%. A growing incidence of acute appendicitis has been registered in the elderly population and in the oldest groups (> 80 years). Among patients > 50-year-old who present to the emergency department for acute abdominal pain, 15% have acute appendicitis. In these patients, emergency surgery for acute appendicitis is challenging, and some important aspects must be considered. In the elderly, surgical treatment outcomes are influenced by sarcopenia. Sarcopenia must be considered a precursor of frailty, a risk factor for physical function decline. Sarcopenia has a negative impact on both elective and emergency surgery regarding mortality and morbidity. Aside from morbidity and mortality, the most crucial outcomes for older patients requiring emergency surgery are reduction in function decline and preoperative physical function maintenance. Therefore, prediction of function decline is critical. In emergency surgery, preoperative interventions are difficult to implement because of the narrow time window before surgery. In this editorial, we highlight the unique aspects of acute appendicitis in elderly patients and the influence of sarcopenia and frailty on the results of surgical treatment.
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Affiliation(s)
- Pietro Fransvea
- Emergency and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma 00168, Italy
| | | | - Valeria Fico
- Emergency and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma 00168, Italy
| | - Maria Cariati
- Department of Surgery, Provincial Health Authority, Crotone 88900, Italy
| | - Giuseppe Brisinda
- Emergency and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma 00168, Italy
- Translational Medicine and Surgery, Catholic School of Medicine, Roma 00168, Italy
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25
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Min L, Lu J, He H. Clinical significance of appendicoliths in conservative treatment of acute complicated appendicitis patients with peri-appendiceal abscess: a single-center retrospective study. Ann Med Surg (Lond) 2024; 86:6440-6446. [PMID: 39525752 PMCID: PMC11543195 DOI: 10.1097/ms9.0000000000002634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Accepted: 09/26/2024] [Indexed: 11/16/2024] Open
Abstract
Background This study aimed to analyze the clinical data of patients who received conservative treatment for acute complicated appendicitis with peri-appendiceal abscess, identify factors influencing the success rate, and improve treatment strategies. Methods The clinical data of acute complicated appendicitis patients with peri-appendiceal abscess who received conservative treatment at the Department of Emergency Surgery, Zhongshan Hospital, Fudan University, from January 2016 to March 2023, were retrospectively analyzed. Results A total of 80 patients were included in our study. Patients were divided into two groups based on the outcomes of ultrasound-guided drainage: The Drainage group (n=28) and the Antibiotic group (n=52). The baseline characteristics of the two groups were comparable. In the Antibiotic group, the surgery rate was 30.4% for patients with an appendicolith and 6.9% for those without. In the Drainage group, the surgery rate was 33.3% for patients with an appendicolith and 27.3% for those without. The presence of an appendicolith significantly correlated with the need for surgery in the Antibiotic group (P=0.026), but not in the Drainage group (P=0.771). For patients who underwent surgery, the incidence of surgical site infections did not differ significantly (P=0.656), and the median length of postoperative hospital stay was similar between the groups (4.0 days vs. 3.0 days, P=0.337). Conclusion The presence of an appendicolith is a risk factor for the failure of antibiotic therapy alone in acute complicated appendicitis patients with peri-appendiceal abscess. However, it does not affect the surgical rate in those who underwent successful drainage.
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Affiliation(s)
- Lingqiang Min
- Department of General Surgery/Emergency Surgery, Zhongshan Hospital, Fudan University
| | - Jing Lu
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Hongyong He
- Department of General Surgery/Emergency Surgery, Zhongshan Hospital, Fudan University
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26
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Javanmard-Emamghissi H, Doleman B, Lund JN, Hollyman M, Moug SJ, Tierney GM. Predictors of appendicectomy one year after antibiotic treatment for acute appendicitis: Insights from a prospective, multicentre, observational study. World J Surg 2024; 48:2658-2668. [PMID: 39327237 DOI: 10.1002/wjs.12337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Accepted: 08/21/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Surgeons are sometimes reluctant to manage uncomplicated appendicitis non-operatively. Reasons cited include the risk of recurrent appendicitis and the risk of missed appendiceal malignancy. The aim of this study was to address these uncertainties and determine the long-term efficacy of antibiotic versus operative management of appendicitis. METHOD One-year follow-up of patients enrolled in the multicentre, COVID:HAREM cohort study during March-June 2020 was performed. Initial operative or non-operative management was determined on a case-by-case basis by the responsible surgeon. Outcomes were appendicectomy rate at 1-year, histology of removed appendix and predictors of unsuccessful antibiotic treatment. RESULTS A total of 625 patients who had non-operative management were included. Emergency appendicectomy had been performed by 1-year in 24% (149/625), with a median time to appendicectomy of 12 days [IQR 1-77] from presentation. Thirty-one patients had elective appendicectomy. Normal histology was reported in 6% of emergency procedures and 58% of elective ones. There were 7 malignancies and 3 neuroendocrine tumors identified at histology. All patients with malignant histology had ≥1 risk factors for malignancy at initial presentation. Faecolithiasis (hazard ratios (HR) 2.3, 95% confidence intervals (CI) 1.51-3.49) and a high Adult Appendicitis Score (AAS >16; HR 2.44, 95% CI 1.52-3.92) were independent risk factors for unsuccessful non-operative management. CONCLUSION At 1 year, 71% of patients managed non-operatively did not undergo an appendicectomy. Recurrence of appendicitis was associated with faecolithiasis and a high AAS. Patients at higher risk for appendiceal malignancy should have targeted follow-up. These factors should be considered when counseling patients on non-operative management.
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Affiliation(s)
| | - Brett Doleman
- Division of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - Jonathan N Lund
- Division of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - Marianne Hollyman
- Exeter NIHR Biomedical Research Centre, Royal Devon and Exeter Hospital, Exeter, UK
| | - Susan J Moug
- Department of Colorectal Surgery, Royal Alexandra Hospital, Paisley, UK
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Min LQ, Lu J, He HY. Clinical significance of peri-appendiceal abscess and phlegmon in acute complicated appendicitis patients undergoing emergency appendectomy. World J Gastrointest Surg 2024; 16:3123-3132. [PMID: 39575278 PMCID: PMC11577409 DOI: 10.4240/wjgs.v16.i10.3123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 08/21/2024] [Accepted: 09/02/2024] [Indexed: 09/27/2024] Open
Abstract
BACKGROUND Although antibiotic therapy has become the primary treatment for acute uncomplicated appendicitis, the management of acute complicated appendicitis necessitates careful consideration of various treatment options. AIM To analyze the clinical data of patients who underwent emergency appendectomy for acute complicated appendicitis with peri-appendiceal abscess or phlegmon, identify factors influencing the postoperative length of hospital stay (LOS), and improve treatment strategies. METHODS The clinical data of acute complicated appendicitis patients with peri-appendiceal abscess or phlegmon who underwent emergency appendectomy at The Department of Emergency Surgery, Zhongshan Hospital, Fudan University from January 2016 to March 2023 were retrospectively analyzed. RESULTS A total of 234 patients were included in our study. The duration of symptoms and the presence of an appendicolith were significantly correlated with the occurrence of peri-appendiceal abscess in patients with acute complicated appendicitis (P < 0.001 and P = 0.015, respectively). Patients with symptoms lasting longer than 72 h had a significantly longer postoperative LOS compared to those with symptoms lasting 72 h or less [hazard ratio (HR), 1.208; 95%CI: 1.107-1.319; P < 0.001]. Additionally, patients with peri-appendiceal abscesses had a significantly longer postoperative LOS compared to those with phlegmon (HR, 1.217; 95%CI: 1.095-1.352; P < 0.001). The patients with peri-appendiceal abscesses were divided into two groups based on the median size of the abscess: Those with abscesses smaller than 5.0 cm (n = 69) and those with abscesses 5.0 cm or larger (n = 82). Patients with peri-appendiceal abscesses measuring 5.0 cm or larger had a significantly longer postoperative LOS than those with abscesses smaller than 5.0 cm (P = 0.038). CONCLUSION The duration of symptoms and the presence of an appendicolith are significant risk factors for the formation of peri-appendiceal abscesses in patients with acute complicated appendicitis. Patients with peri-appendiceal abscesses experience a significantly longer postoperative LOS compared to those with peri-appendiceal phlegmon.
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Affiliation(s)
- Ling-Qiang Min
- Department of General Surgery/Emergency Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jing Lu
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Hong-Yong He
- Department of General Surgery/Emergency Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Liang Y, Sailai M, Ding R, Yimamu B, Kazi T, He M, Liu Z, Lin J, Liu Y, Deng C, Huang J, Zhang X, Chen Z, Su Y. Predictive model for identification of gangrenous or perforated appendicitis in adults: a multicenter retrospective study. BMC Gastroenterol 2024; 24:355. [PMID: 39385074 PMCID: PMC11462916 DOI: 10.1186/s12876-024-03445-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 10/01/2024] [Indexed: 10/11/2024] Open
Abstract
BACKGROUND Gangrene and perforation are severe complications of acute appendicitis, associated with a higher mortality rate compared to uncomplicated appendicitis. Accurate preoperative identification of Gangrenous or perforated appendicitis (GPA) is crucial for timely surgical intervention. METHODS This retrospective multicenter study includes 796 patients who underwent appendectomy. Univariate and multivariate logistic regression analyses are used to develop a nomogram model for predicting GPA based on laboratory tests and computed tomography (CT) findings. The model is validated using an external dataset. RESULTS Seven independent predictors were included in the nomogram: white blood cell count, lymphocyte count, D-dimer, serum glucose, albumin, maximum outer diameter of the appendix, and presence of appendiceal fecalith. The nomogram achieved good discrimination and calibration in both the training and testing sets. In the training set, the AUC was 0.806 (95%CI: 0.763-0.849), and the sensitivity and specificity were 82.1% and 66.9%, respectively. The Hosmer-Lemeshow test showed good calibration (P = 0.7378). In the testing set, the AUC was 0.799 (95%CI: 0.741-0.856), and the sensitivity and specificity were 70.5% and 75.3%, respectively. Decision curve analysis (DCA) confirmed the clinical utility of the nomogram. CONCLUSION The laboratory test-CT nomogram model can effectively identify GPA patients, aiding in surgical decision-making and improving patient outcomes.
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Affiliation(s)
- Yun Liang
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Maimaitiaili Sailai
- Department of General Surgery, The First People's Hospital of Kashagr, Xinjiang Uygur Autonomous Region, Kashagr Region, 844000, China
| | - Rui Ding
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Baihitiyaer Yimamu
- Department of General Surgery, The First People's Hospital of Kashagr, Xinjiang Uygur Autonomous Region, Kashagr Region, 844000, China
| | - Tayierjiang Kazi
- Department of General Surgery, The First People's Hospital of Kashagr, Xinjiang Uygur Autonomous Region, Kashagr Region, 844000, China
| | - Ming He
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Zehui Liu
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Junyu Lin
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Yile Liu
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Chaolun Deng
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Jiangtao Huang
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China
| | - Xingwei Zhang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, 510655, China.
| | - Zheng Chen
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China.
| | - Yonghui Su
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat- Sen University, No.52 Mei Hua East Road, Xiang Zhou District, Zhuhai, Guangdong, 519000, China.
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Ferrara F, Peltrini R. Risk of appendiceal neoplasm in patients with appendix disorders. World J Clin Cases 2024; 12:6148-6150. [PMID: 39371555 PMCID: PMC11362891 DOI: 10.12998/wjcc.v12.i28.6148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 06/03/2024] [Accepted: 06/21/2024] [Indexed: 08/13/2024] Open
Abstract
The most common appendicular disease is acute appendicitis, with a lifetime risk of 7%-8%. Complicated cases, which can occur in 2%-7% of patients, can significantly impact the severity of the condition and may require different management approaches. Nonoperative management with possible delayed appendectomy has been suggested for selected patients, however, there is a non-negligible risk of missing an underlying malignancy, which is reported to be as high as 11%. Diagnostic work-up is paramount to achieve optimal treatment with good results.
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Affiliation(s)
- Francesco Ferrara
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me. Pre. C. C.), “Paolo Giaccone” Hospital, University of Palermo, Palermo 90127, Italy
| | - Roberto Peltrini
- Department of Public Health, University of Naples Federico II, Napoli 80131, Italy
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Laudon AD, Beaulieu-Jones BR, Gitonga B, Yang FF, Chen E, Flum DR, Lerner K, Evans HL, Thompson L, Azar FK, Charboneau A, Simianu VV, Sanchez SE, Drake FT. Power Has Pitfalls: (In)accuracy of Administrative Data for Nonoperative Management of Appendicitis. J Surg Res 2024; 302:428-436. [PMID: 39153365 DOI: 10.1016/j.jss.2024.07.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 07/09/2024] [Accepted: 07/19/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Nonoperative management (NOM) of uncomplicated appendicitis is increasingly common. Effectiveness of NOM has been studied by identifying patients via International Classification of Diseases (ICD) 9/ICD-10 codes for uncomplicated appendicitis and no code for appendectomy. We sought to assess the accuracy of such administrative definitions. METHODS We retrospectively identified patients with ICD-9/ICD-10 codes for appendicitis at five sites across the United States. Initial management plan and clinical severity were recorded by trained abstractors. We identified a gold standard cohort of patients with surgeon-diagnosed uncomplicated appendicitis and planned NOM. We defined two administrative cohorts with ICD-9/ICD-10 codes for uncomplicated appendicitis and either no surgery during initial admission (definition #1) or no surgery on day 0-1 of admission (definition #2). We compared each definition to the gold standard. RESULTS Among 1224 patients with uncomplicated appendicitis, 72 (5.9%) underwent planned NOM. NOM patients were older (median [Q1-Q3] of 37 [27-56] versus 32 [25-44] y) and less frequently male (51.4% versus 54.9%), White (54.1% versus 67.6%), and privately insured (38.9% versus 50.2%) than patients managed operatively. Definition #1 had sensitivity of 0.81 and positive predictive value of 0.87 for NOM of uncomplicated appendicitis. Definition #2 had sensitivity of 0.83 and positive predictive value of 0.72. The gold standard cohort had a true failure/recurrence rate of 23.6%, compared with apparent rates of 25.4% and 39.8%, respectively. CONCLUSIONS Administrative definitions are prone to misclassification in identifying planned NOM of uncomplicated appendicitis. This likely impacts outcomes in studies using administrative databases. Investigators should disclose how misclassification may affect results and select an administrative definition that optimally balances sensitivity and specificity for their research question.
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Affiliation(s)
- Aksel D Laudon
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts.
| | - Brendin R Beaulieu-Jones
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Baraka Gitonga
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Frank F Yang
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Elizabeth Chen
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Dave R Flum
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Kasey Lerner
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Heather L Evans
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Lauren Thompson
- Department of Surgery, Florida Atlantic University Schmidt College of Medicine, Boca Raton, Florida
| | - Faris K Azar
- Department of Surgery, Saint Mary's Medical Center, West Palm Beach, Florida
| | - Alex Charboneau
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Sabrina E Sanchez
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - F Thurston Drake
- Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
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Lin D, Su M, Guo Z, Hu J, Zhong Q, Chen Y, Deng J, Guo X. Direct visualization endoscopic retrograde appendicitis therapy for treatment of acute uncomplicated appendicitis. Surg Endosc 2024; 38:6156-6160. [PMID: 39179688 DOI: 10.1007/s00464-024-11112-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 07/16/2024] [Indexed: 08/26/2024]
Abstract
OBJECTIVE To investigate the diagnostic and therapeutic value of direct visualization (single-use eyeMax subscope) endoscopic management of acute uncomplicated appendicitis. METHODS Thirty-six patients diagnosed with acute uncomplicated appendicitis, confirmed by computed tomography or ultrasonography, from Jan 2023 to Feb 2024 were enrolled in this study. We collected demographics, colonoscopy findings, subscope findings, clinical outcomes of endoscopic retrograde appendicitis therapy (ERAT), and adverse events associated with ERAT. RESULTS Appendiceal intubation was successful for all 36 patients. Thirty-five patients (97.2%) were definitely confirmed as having acute uncomplicated appendicitis. One patient with negative appendicitis was diagnosed as having cecal diverticulitis with fecalith incarceration. The mean procedure time was 13.1 ± 13.6 min. One patient presented with worsening abdominal pain, and a computed tomography scan suggested a perforated appendix. The mean length of hospitalizations was 1.78 ± 2 days. The mean follow-up was 158 days; during this period, two patients (5.6%) experienced recurrent abdominal pain after 23 and 88 days and subsequently underwent laparoscopic appendectomy. CONCLUSION Direct visualization ERAT may be effective for diagnosing and treating acute uncomplicated appendicitis and seems to have a low complication rate.
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Affiliation(s)
- Dezheng Lin
- Department of Endoscopic Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Mingli Su
- Department of Endoscopic Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zehui Guo
- Department of Endoscopic Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jiancong Hu
- Department of Endoscopic Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Department of Endoscopy, Yuexi Hospital of the Sixth Affiliated Hospital, Sun Yat-Sen University, Xinyi, Guangdong, China
| | - Qinghua Zhong
- Department of Endoscopic Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yongcheng Chen
- Department of Endoscopic Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jiaxin Deng
- Department of Endoscopic Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Xuefeng Guo
- Department of Endoscopic Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China.
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.
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Hussain S, Akbar A, Rehman A, Jadoon SK, Ali AI, Mehraj A, Batool SW, Ali Akbar A, Imtiaz M, Tahir H. Investigation and Comparison of Preoperative Symptoms in Patients With Appendicitis and Cholecystitis Before Appendectomy and Cholecystectomy Surgeries. Cureus 2024; 16:e71637. [PMID: 39552973 PMCID: PMC11567171 DOI: 10.7759/cureus.71637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2024] [Indexed: 11/19/2024] Open
Abstract
INTRODUCTION Appendectomy and cholecystectomy are the surgical procedures to treat appendicitis and cholecystitis, respectively. However, there is a lack of investigation regarding these two similar types of abdominal complication-based disease which may primarily create confusion within patients. METHODS To understand the variation and similarities within the preoperative symptoms of these two diseases, we included 224 participants including both appendicitis (n = 175) and cholecystitis (n = 49) patients. We obtained the preoperative symptoms through physical check-ups, thorough observation, and questionnaires. RESULT We found several symptoms in both patients where abdominal pain was present in all patients in both groups. However, followed by abdominal pain, vomiting (118 (67.42%)), pain RIF (right iliac fossa) (101 (57.71%)), nausea (71 (40.57%)), and sharp pain (22 (12.57%)) were prevalent in the appendicitis group whereas tenderness (49 (100%)), epigastric pain (13 (26.53%)), and hypertension (10 (20.41%)) were prevalent in the cholecystitis group. However, fever was commonly present in several patients in both groups. Conclusion: Abdominal pain can be a major indicator of surgery in both appendicitis and cholecystitis patients. However, observation of other symptoms is crucial for initial symptomatic diagnosis and differentiating between these diseases.
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Affiliation(s)
| | - Amna Akbar
- General Surgery, District Headquarter Hospital, Jhelum Valley, Muzaffarabad, PAK
| | - Ayesha Rehman
- General Surgery, Divisional Headquarter Hospital, Mirpur, PAK
| | | | - Amir Iqbal Ali
- General Surgery, Combined Military Hospital, Muzaffarabad, PAK
| | - Adnan Mehraj
- General Surgery, Azad Jammu Kashmir Medical College, Muzaffarabad, PAK
| | | | - Aiza Ali Akbar
- Gynecology, Azad Jammu Kashmir Medical College, Muzaffarabad, PAK
| | - Maryam Imtiaz
- Medicine, Azad Jammu Kashmir Medical College, Muzaffarabad, PAK
| | - Husnain Tahir
- Medicine, Azad Jammu Kashmir Medical College, Muzaffarabad, PAK
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Rosen JE, Monsell SE, DePaoli SC, Fannon EC, Kohler JE, Reinke CE, Kao LS, Fransman RB, Stulberg JJ, Shapiro MB, Nehra D, Park PK, Sanchez SE, Fischkoff KN, Davidson GH, Flum DR. The Use and Impact of a Decision Support Tool for Appendicitis Treatment. Ann Surg 2024; 280:616-622. [PMID: 38916104 DOI: 10.1097/sla.0000000000006412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
OBJECTIVE Since introducing new and alternative treatment options may increase decisional conflict, we aimed to describe the use of the decision support tool (DST) and its impact on treatment preference and decisional conflict. BACKGROUND For the treatment of appendicitis, antibiotics are an effective alternative to appendectomy, with both approaches associated with a different set of risks (eg, recurrence vs surgical complications) and benefits (eg, more rapid return to work vs decreased chance of readmission). Patients often have limited knowledge of these treatment options, and DSTs that include video-based educational materials and questions to elicit patient preferences about outcomes may be helpful. Concurrent with the Comparing Outcomes of Drugs and Appendectomy trials, our group developed a DST for appendicitis treatment ( www.appyornot.org ). METHODS A retrospective cohort including people who self-reported current appendicitis and used the AppyOrNot DST between 2021 and 2023. Treatment preferences before and after the use of the DST, demographic information, and Ottawa Decisional Conflict Scale (DCS) were reported after completing the DST. RESULTS A total of 8243 people from 66 countries and all 50 U.S. states accessed the DST. Before the DST, 14% had a strong preference for antibiotics and 31% for appendectomy, with 55% undecided. After using the DST, the proportion in the undecided category decreased to 49% ( P < 0.0001). Of those who completed the Ottawa Decisional Conflict Score (DCS; n = 356), 52% reported the lowest level of decisional conflict (<25) after using the DST; 43% had a DCS score of 25 to 50, 5.1% had a DCS score of >50 and 2.5% had and DCS score of >75. CONCLUSIONS The publicly available DST appyornot.org reduced the proportion that was undecided about which treatment they favored and had a modest influence on those with strong treatment preferences. Decisional conflict was not common after use. The use of this DST is now a component of a nationwide implementation program aimed at improving the way surgeons share information about appendicitis treatment options. If its use can be successfully implemented, this may be a model for improving communication about treatment for patients experiencing emergency health conditions.
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Affiliation(s)
- Joshua E Rosen
- Department of Surgery, University of Washington, Seattle, WA
| | - Sarah E Monsell
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Sara C DePaoli
- Department of Surgery, University of Washington, Seattle, WA
| | - Erin C Fannon
- Department of Surgery, University of Washington, Seattle, WA
| | - Johnathan E Kohler
- University of California, Davis, UC Davis Children's Hospital, Sacramento, CA
| | | | | | - Ryan B Fransman
- Grady Health Center/Morehouse School of Medicine, SE, Atlanta, Georgia
| | | | | | - Deepika Nehra
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle WA
| | | | | | - Katherine N Fischkoff
- Columbia University Medical Center, Columbia University Medical Center Research Office, New York, NY
| | - Giana H Davidson
- Department of Surgery, University of Washington, SORCE, Seattle, WA
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, WA
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Schlottmann F, Masrur MA. Surgical reflections for the optimal management of acute appendicitis: From McBurney to Da Vinci. Curr Probl Surg 2024; 61:101553. [PMID: 39168533 DOI: 10.1016/j.cpsurg.2024.101553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Accepted: 06/20/2024] [Indexed: 08/23/2024]
Affiliation(s)
- Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina; Department of Surgery, University of Illinois at Chicago, Chicago, IL.
| | - Mario A Masrur
- Department of Surgery, University of Illinois at Chicago, Chicago, IL
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Adams SE, Perera MRS, Fung S, Maxton J, Karpelowsky J. Non-operative management of uncomplicated appendicitis in children: a randomized, controlled, non-inferiority study evaluating safety and efficacy. ANZ J Surg 2024; 94:1569-1577. [PMID: 38873960 DOI: 10.1111/ans.19119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 03/29/2024] [Accepted: 05/27/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Appendicitis is the commonest paediatric surgical emergency. Adult studies suggest non-operative management (NOM) may have a place in care. There have been no adequately powered randomized controlled trials in children. OBJECTIVE to determine the safety and efficacy of NOM for paediatric simple appendicitis. METHODS A non-inferiority randomized controlled trial was conducted comparing operative (OM) to NOM of SA in children aged five-15 years. Primary outcome was treatment success (no unplanned or unnecessary operation, or complication) at 30 days and 12 months, with a non-inferiority margin of 15%. (anzctr.org.au: ACTRN12616000788471). RESULTS From 11 June 2016 to 30 November 2020, 222 children were randomized: 94 (42.34%) to OM and 128 (57.66%) to NOM. Non-inferiority of NOM was not demonstrated at either time point, with 45.67% of NOM patients subsequently undergoing operation. There was no significant difference in complications. CONCLUSIONS While noninferiority was not shown, NOM was safe, with no difference in adverse outcomes between the two groups. Further research to refine the place of NOM of simple appendicitis in children is required, including nuanced patient selection, longer term evaluation, the place of choice, and the acceptability of the treatment for children and their carers.
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Affiliation(s)
- Susan Elizabeth Adams
- Toby Bowring Department of Paediatric Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Meegodage Roshell Swindri Perera
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Saskia Fung
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jordon Maxton
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jonathan Karpelowsky
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Paediatric Surgery, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Hu C, Guo CL, Lau HCH, Shi F, Zhang Z, Guo G, Liu G, Chen Y, Lau LHS, Zhang L, Sun X, Wong SH, Zhang L, She J, Yu J. Appendix removal affects the subsequent cancer risk in Asian adults: A territory-wide population-based cohort study. Cancer Lett 2024; 598:217087. [PMID: 38964732 DOI: 10.1016/j.canlet.2024.217087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/19/2024] [Accepted: 06/25/2024] [Indexed: 07/06/2024]
Abstract
Human appendix is critical for the maintenance of intestinal homeostasis. Appendicectomy has been the optimal treatment of acute appendicitis, yet the cancer incidence after appendix removal remains unclear. In this territory-wide retrospective cohort study, adult participants who underwent appendicectomy from 2000 to 2018 were retrieved from a population database (n = 43,983), while matched reference participants were retrieved as controls (n = 85,853). After appendicectomy, the overall cancer risk was significantly increased (subdistribution hazard ratio (SHR) = 1.124) compared to the non-appendicectomy group. Appendicectomy-treated males had higher cancer risk than males without appendicectomy (SHR = 1.197), while such difference was not observed in female participants. Significant increase in cancer risk was also observed in elder participants (age >60) with appendicectomy (SHR = 1.390). Appendicectomy was positively correlated with the risk of digestive tract and respiratory cancers including colon (SHR = 1.440), pancreas (SHR = 1.930), and trachea, bronchus, and lung (SHR = 1.394). In contrast, the risk of liver cancer was markedly decreased after appendicectomy (SHR = 0.713). In conclusion, we reported the association of appendicectomy with subsequent cancer incidence. These findings highlight the potential complication after appendix removal and the necessity of post-operative management to monitor and prevent long-term adverse events.
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Affiliation(s)
- Chenhao Hu
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Center for Gut Microbiome Research, Med-X Institute, The First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China; Department of High Talent, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Cosmos Liutao Guo
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease and Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Harry Cheuk-Hay Lau
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease and Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Feiyu Shi
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Center for Gut Microbiome Research, Med-X Institute, The First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China; Department of High Talent, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Zhe Zhang
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Center for Gut Microbiome Research, Med-X Institute, The First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China; Department of High Talent, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Gang Guo
- Center for Gut Microbiome Research, Med-X Institute, The First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China; Department of High Talent, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Gaixia Liu
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Center for Gut Microbiome Research, Med-X Institute, The First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China; Department of High Talent, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yinnan Chen
- Center for Gut Microbiome Research, Med-X Institute, The First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China; Department of High Talent, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Louis Ho-Shing Lau
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease and Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lei Zhang
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Center for Gut Microbiome Research, Med-X Institute, The First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China; Department of High Talent, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xuejun Sun
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Sunny Hei Wong
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease and Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Lei Zhang
- Artificial Intelligence and Modelling in Epidemiology Program, Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia; Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; China-Australia Joint Research Center for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, 710061, China.
| | - Junjun She
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Center for Gut Microbiome Research, Med-X Institute, The First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China; Department of High Talent, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
| | - Jun Yu
- Center for Gut Microbiome Research, Med-X Institute, The First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China; State Key Laboratory of Digestive Disease, Institute of Digestive Disease and Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China.
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Guo LM, Jiang ZH, Liu HZ. Systemic immune-inflammation index combined with pediatric appendicitis score in assessing the severity and prognosis for paediatric appendicitis. World J Gastrointest Surg 2024; 16:2565-2573. [PMID: 39220085 PMCID: PMC11362941 DOI: 10.4240/wjgs.v16.i8.2565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/02/2024] [Accepted: 07/04/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Pediatric appendicitis is a common cause of abdominal pain in children and is recognized as a significant surgical emergency. A prompt and accurate diagnosis is essential to prevent complications such as perforation and peritonitis. AIM To investigate the predictive value of the systemic immune-inflammation index (SII) combined with the pediatric appendicitis score (PAS) for the assessment of disease severity and surgical outcomes in children aged 5 years and older with appendicitis. METHODS Clinical data of 104 children diagnosed with acute appendicitis were analyzed. The participants were categorized into the acute appendicitis group and chronic appendicitis group based on disease presentation and further stratified into the good prognosis group and poor prognosis group based on prognosis. The SII and PAS were measured, and a joint model using the combined SII and PAS was constructed to predict disease severity and surgical outcomes. RESULTS Significant differences were observed in the SII and PAS parameters between the acute appendicitis group and chronic appendicitis group. Correlation analysis showed associations among the SII, PAS, and disease severity, with the combined SII and PAS model demonstrating significant predictive value for assessing disease severity [aera under the curve (AUC) = 0.914] and predicting surgical outcomes (AUC = 0.857) in children aged 5 years and older with appendicitis. CONCLUSION The study findings support the potential of integrating the SII with the PAS for assessing disease severity and predicting surgical outcomes in pediatric appendicitis, indicating the clinical utility of the combined SII and PAS model in guiding clinical decision-making and optimizing surgical management strategies for pediatric patients with appendicitis.
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Affiliation(s)
- Li-Ming Guo
- Department of General Surgery, Qingdao Women and Children’s Hospital, Qingdao 266000, Shandong Province, China
| | - Zhi-Hui Jiang
- Department of General Surgery, Qingdao Women and Children’s Hospital, Qingdao 266000, Shandong Province, China
| | - Hong-Zhen Liu
- Department of Pediatric Surgery, Children's Hospital Affiliated to Shandong University, Jinan 250022, Shandong Province, China
- Department of Pediatric Surgery, Jinan Children's Hospital, Jinan 250022, Shandong Province, China
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Mori M, Shuto K, Kosugi C, Narushima K, Hirano A, Usui A, Nojima H, Hirota M, Sazuka T, Yamazaki M, Fujino T, Yamazaki K, Shimizu H, Koda K. Development and validation of a new scoring system to discriminate between uncomplicated and complicated appendicitis. Sci Rep 2024; 14:19825. [PMID: 39191912 DOI: 10.1038/s41598-024-70904-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 08/22/2024] [Indexed: 08/29/2024] Open
Abstract
A scoring system to discriminate between uncomplicated and complicated appendicitis is beneficial to determine the optimal treatment for acute appendicitis. We developed a scoring system to discriminate between uncomplicated and complicated appendicitis and assessed the clinical usefulness of the scoring system using external validation. A total of 299 patients with acute appendicitis were retrospectively reviewed. One hundred and ninety-nine patients were assigned to the model development group, while the other 100 patients were assigned to an external validation group. A scoring system for complicated appendicitis was created using a final multivariate logistic regression model with six independent predictors. The area under the receiver operating characteristic curve of the scoring system was 0.882 (95% confidence interval: 0.835-0.929). The cutoff point of the scoring system was 12, and the sensitivity and specificity were 82.9% and 86.2%, respectively. In the external validation group, the area under the receiver operating characteristic curve of the scoring system was 0.868 (95% confidence interval 0.794-0.942), and there was no significant difference between the groups in the area under the receiver operating characteristic curve (P = 0.750). Our newly developed scoring system may contribute to prompt determination of the optimal treatment for acute appendicitis.
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Affiliation(s)
- Mikito Mori
- Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, 299-0111, Japan.
| | - Kiyohiko Shuto
- Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, 299-0111, Japan
| | - Chihiro Kosugi
- Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, 299-0111, Japan
| | - Kazuo Narushima
- Department of Esophago-Gastrointestinal Surgery, Chiba Cancer Center, Chiba, Japan
| | - Atsushi Hirano
- Department of Surgery, Secomedic Hospital, Funabashi, Japan
| | - Akihiro Usui
- Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, 299-0111, Japan
| | - Hiroyuki Nojima
- Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, 299-0111, Japan
| | - Mihono Hirota
- Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, 299-0111, Japan
| | - Tetsutaro Sazuka
- Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, 299-0111, Japan
| | - Masato Yamazaki
- Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, 299-0111, Japan
| | - Takashi Fujino
- Department of Pathology, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Kazuto Yamazaki
- Department of Pathology, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Hiroaki Shimizu
- Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, 299-0111, Japan
| | - Keiji Koda
- Department of Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, 299-0111, Japan
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Vanhatalo S, Mäkilä E, Hakanen AJ, Munukka E, Salonen J, Saarinen T, Grönroos J, Sippola S, Salminen P. Appendicolith classification: physical and chemical properties of appendicoliths in patients with CT diagnosed acute appendicitis - a prospective cohort study. BMJ Open Gastroenterol 2024; 11:e001403. [PMID: 39160081 PMCID: PMC11337665 DOI: 10.1136/bmjgast-2024-001403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 07/29/2024] [Indexed: 08/21/2024] Open
Abstract
OBJECTIVE Appendicoliths are associated with a more complicated course of acute appendicitis and failure of non-operative treatment. We aimed to update the appendicolith classification originally described in 1966 and to assess the association of appendicolith characteristics with appendicitis severity. DESIGN This prospective predefined MAPPAC-trial (ClinicalTrials.gov NCT03257423) substudy included patients with CT diagnosed appendicitis presenting with an appendicolith. CT visible appendicoliths were harvested at surgery, measured and characterised by morphological examination complemented with micro-CT and micro-X-ray fluorescence spectroscopy. Patients were categorised into two groups: appendicolith appendicitis without other complications and appendicolith appendicitis with complications (appendiceal gangrene, perforation and/or abscess). The association of appendicolith classification and characteristics with appendicitis severity was evaluated. RESULTS Of 78 patients with a CT appendicolith, 41 appendicoliths were collected and classified based on the degree of hardness into three classes. The hardest appendicoliths (class 3) were less common (19.5%) presenting with a stone-hard outer layer and concentrically layered inner structure around a core. The layered inner structure was also observed in class 2 appendicoliths, but was absent in soft, class 1 appendicoliths. Appendicolith hardness or measures (maximum length, diameter and weight) were not associated with appendicitis severity. The spatial distribution of the main inorganic elements of calcium and phosphorus varied within most appendicoliths. CONCLUSION This updated classification confirms categorisation of CT visible appendicoliths into three classes based on their physical and chemical characteristics. The data on clinical and aetiopathological characteristics of appendicoliths is scarce and using this systematic classification would add to this understanding.
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Affiliation(s)
- Sanja Vanhatalo
- Institute of Biomedicine, University of Turku, Turku, Finland
- Department of Clinical Microbiology, TYKS Turku University Hospital, Turku, Finland
| | - Ermei Mäkilä
- Department of Physics and Astronomy, University of Turku, Turku, Finland
| | - Antti J Hakanen
- Institute of Biomedicine, University of Turku, Turku, Finland
- Clinical Microbiome Bank, Department of Clinical Microbiology, Microbe center, Turku University Hospital and University of Turku, Turku, Finland
| | - Eveliina Munukka
- Institute of Biomedicine, University of Turku, Turku, Finland
- Department of Clinical Microbiology, TYKS Turku University Hospital, Turku, Finland
| | - Jarno Salonen
- Department of Physics and Astronomy, University of Turku, Turku, Finland
| | - Timo Saarinen
- Department of Geography and Geology, University of Turku, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, TYKS Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, TYKS Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, TYKS Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
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Ramadan S, Olsson Å, Ekberg O, Buchwald P. Predictive factors for recurrent acute appendicitis after conservative treatment. Scand J Gastroenterol 2024; 59:933-938. [PMID: 38814018 DOI: 10.1080/00365521.2024.2359438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/06/2024] [Accepted: 05/19/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Conservative treatment of acute appendicitis is gaining popularity, and identifying patients with a higher risk of recurrence is becoming increasingly important. Previous studies have suggested that older age, male sex, diabetes, appendicolith and abscess formation may be contributing factors, however, results from the adult population are inconsistent. AIM This study aims to identify predictive factors for recurrent appendicitis after conservative treatment. METHODS This retrospective study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and follow-up data were retrieved from medical charts and radiologic images. Uni -and multivariable logistic regression analysis were performed using Stata Statistical Software. RESULTS In total, 379 patients with conservatively treated acute appendicitis were identified, of which 78 (20.6%) had recurrence. All patients were followed-up for a minimum of 41 months after the first diagnosis of acute appendicitis unless appendectomy after successful conservative treatment or death occurred during follow-up. The median time to recurrence was 6.5 (1-17.8) months. After multivariable logistic regression analysis, external appendix diameter >10 mm [OR 2.4 (CI 1.37-4.21), p = .002] and intra-abdominal abscess [OR 2.05 (CI 1.18-3.56), p = .011] on computed tomography were significant independent risk factors for recurrent appendicitis. Appendicolith was not associated with an increased risk of recurrence. CONCLUSION This study suggests abscess formation and appendix distension of >10 mm to be potential risk factors for recurrent acute appendicitis after initial successful conservative treatment.
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Affiliation(s)
- Shaima Ramadan
- Department of Surgery, Colorectal Unit, Skåne University Hospital Malmö, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Åsa Olsson
- Department of Surgery, Colorectal Unit, Skåne University Hospital Malmö, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Olle Ekberg
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Translational Medicine, Division of Medical Radiology, Skåne University Hospital Malmö, Malmö, Sweden
| | - Pamela Buchwald
- Department of Surgery, Colorectal Unit, Skåne University Hospital Malmö, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
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Uttinger K, Baum P, Diers J, Seehofer D, Germer CT, Wiegering A. The impact of surgical timing on outcome in acute appendicitis in adults: a retrospective observational population-based cohort study. Int J Surg 2024; 110:4850-4858. [PMID: 38701524 PMCID: PMC11325913 DOI: 10.1097/js9.0000000000001528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Acute appendicitis is a global disease with high incidence. The main objective was to assess the association between time from admission to surgery (TAS) and surgery during emergency hours with operative outcome in light of conflicting evidence. METHODS This is a retrospective population-wide analysis of hospital billing data (2010-2021) of all adult patient records of surgically treated cases of acute appendicitis in Germany by TAS. The primary outcome was a composite clinical endpoint (CCE; prolonged length of stay, surgical site infection, interventional draining after surgery, revision surgery, ICU admission and/or in-hospital mortality). Cases of complicated appendicitis were identified using diagnosis (ICD-10) and procedural codes (resection beyond appendectomy). RESULTS 855 694 patient records were included, of which 27·6% (236,481) were complicated cases of acute appendicitis. 49·0% (418,821) were females and median age was 37 (interquartile range 22·5-51·5). Age, male sex, and comorbidity were associated with an increased proportion of CCE and in-hospital mortality. TAS was associated with a clinically relevant increase of CCE after 12 h in complicated appendicitis [Odd's ratio (OR), 1·19, 95% CI: 1·14-1·21] and after 24 h in uncomplicated appendicitis (OR 1·10, 95% CI: 1·02-1·19). Beyond the primary endpoint, the proportion of complicated appendicitis increased after TAS of 72 h. Surgery during emergency hours (6 pm-6.59 am) was associated with an increase of CCE and mortality (OR between 1·14 and 1·49). Age, female sex, night-time admission, weekend admission, a known previous surgery, obesity, and therapeutic anticoagulation were associated with delayed performance of surgery. CONCLUSION This work found an increase of a CCE after TAS of 12 h for complicated appendicitis and an increase of the CCE after TAS of 24 h for uncomplicated appendicitis with a stable proportion of complicated appendicitis in these time windows. Both CCE and mortality were increased if appendectomy was performed during emergency hours.
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Affiliation(s)
- Konstantin Uttinger
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Medical Centre
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, Leipzig University Medical Centre, Leipzig
| | - Philip Baum
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Medical Centre
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Medical Centre, Heidelberg, Germany
| | - Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Medical Centre
- Marienkrankenhaus, Hamburg
| | - Daniel Seehofer
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, Leipzig University Medical Centre, Leipzig
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Medical Centre
- Comprehensive Cancer Centre Mainfranken, Würzburg University Medical Centre
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Medical Centre
- Comprehensive Cancer Centre Mainfranken, Würzburg University Medical Centre
- Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg
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Khoraminejad B, Sakowitz S, Porter G, Chervu N, Ali K, Mallick S, Bakhtiyar SS, Benharash P. Interhospital variation in the non-operative management of uncomplicated appendicitis in adults. Surg Open Sci 2024; 20:32-37. [PMID: 38883576 PMCID: PMC11180347 DOI: 10.1016/j.sopen.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/24/2024] [Indexed: 06/18/2024] Open
Abstract
Background Recent randomized trials have suggested non-operative management to be a safe alternative to appendectomy for acute uncomplicated appendicitis. Yet, there remains significant variability in treatment approach. This study sought to characterize center-level variation in non-operative management within a national cohort of adults presenting with appendicitis. Methods The 2016-2020 Nationwide Readmissions Database was queried to identify all adult (≥18 years) hospitalizations for acute uncomplicated appendicitis. Hierarchical, mixed-effects models were developed to ascertain factors linked with non-operative management. Bayesian methodology was applied to predict random effects, which were then used to rank centers by increasing hospital-attributed rate of non-operative management. Institutions with high center-specific rates of non-operative management (>90th percentile) were considered low-operating hospitals (LOH). Results Of an estimated 447,500 patients, 52,523 (11.7 %) were managed non-operatively. Compared to those undergoing appendectomy, the non-operative cohort was older, more commonly male, and of a higher comorbidity burden. Approximately 30 % in the variability of non-operative management was attributable to hospital effects, with absolute, risk-adjusted rates ranging from 0.5 to 22.5 %. Centers with non-operative management rates ≥90th percentile were considered LOH.Following risk adjustment, among patients undergoing appendectomy, care at LOH was linked with greater odds of postoperative infection, resource utilization, and non-elective readmission. Conclusions We identified significant interhospital variation in the utilization of non-operative management for acute uncomplicated appendicitis. Further, we found LOH to be associated with inferior outcomes following surgical management. Future work is needed to assess the care pathways that contribute to increased utilization of non-operative strategies, and disseminate best practices across institutions.
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Affiliation(s)
- Baran Khoraminejad
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
- Boston University, Boston, MA, United States of America
| | - Sara Sakowitz
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Giselle Porter
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Nikhil Chervu
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Konmal Ali
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Saad Mallick
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, University of Colorado, Aurora, CO, United States of America
| | - Peyman Benharash
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
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Dölling M, Rahimli M, Pachmann J, Szep M, Al-Madhi S, Andric M, Kahlert UD, Hofmann T, Boettcher M, Muñoz LE, Herrmann M, Perrakis A, Croner RS. Hidden Appendicoliths and Their Impact on the Severity and Treatment of Acute Appendicitis. J Clin Med 2024; 13:4166. [PMID: 39064205 PMCID: PMC11278186 DOI: 10.3390/jcm13144166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 07/11/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Background/Objectives: In patients diagnosed with uncomplicated acute appendicitis (UAA), the absence of calcified deposits or stones, called appendicoliths, often leads to consideration of non-operative treatment (NOT), despite the notable treatment failure rate associated with this approach. Previous research has indirectly estimated the prevalence of appendicoliths to range between 15% and 38% retrospectively by CT scan, intraoperative palpation, and pathology report, thereby potentially missing certain concrements. Our hypothesis proposes that this reported prevalence significantly underestimates the occurrence of appendicoliths, which could explain the high failure rate of 29% of patients with appendicitis observed with NOT. Methods: In our prospective study, conducted with a cohort of 56 adult patients diagnosed with acute appendicitis (AA), we employed intraoperative extracorporeal incisions of the vermiform appendix, in addition to standard diagnostic methods. Results: Our findings revealed 50% more appendicoliths by intraoperative incision (n = 36, p < 0.001) compared to preoperative imaging (n = 24). Appendicoliths were present in 71.4% (n = 40, p < 0.001) of AA patients. Conclusions: These results suggest that conventional diagnostic procedures plausibly underestimate the actual prevalence of appendicoliths, potentially elucidating the frequent treatment failures observed in NOT approaches applied to patients with UAA.
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Affiliation(s)
- Maximilian Dölling
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Mirhasan Rahimli
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Jonas Pachmann
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Malik Szep
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Sara Al-Madhi
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Mihailo Andric
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Ulf D. Kahlert
- Molecular and Experimental Surgery, Department of General, Visceral, Vascular and Transplant Surgery, Faculty of Medicine, University Hospital Magdeburg, Otto-von-Guericke University, 39120 Magdeburg, Germany
| | - Tobias Hofmann
- Central Emergency Department, University Hospital Magdeburg, Otto-von-Guericke-University, 39120 Magdeburg, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Mannheim, University of Heidelberg, 68167 Mannheim, Germany
| | - Luis E. Muñoz
- Department of Internal Medicine 3—Rheumatology and Immunology, Universitätsklinikum Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie (DZI), Universitätsklinikum Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany
| | - Martin Herrmann
- Department of Pediatric Surgery, University Medical Center Mannheim, University of Heidelberg, 68167 Mannheim, Germany
- Department of Internal Medicine 3—Rheumatology and Immunology, Universitätsklinikum Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie (DZI), Universitätsklinikum Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany
| | - Aristotelis Perrakis
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
- Iatriko Medical Center, Department of General, Minimally Invasive Surgery and Surgical Oncology, 15125 Athens, Greece
| | - Roland S. Croner
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
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Kim HH, Park SS, Kim BC, Han KS, Kim B, Hong CW, Sohn DK, You K, Lee DW, Park SC. Treatment for appendicitis in cancer patients on chemotherapy: a retrospective cohort study. Ann Surg Treat Res 2024; 107:1-7. [PMID: 38978688 PMCID: PMC11227919 DOI: 10.4174/astr.2024.107.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 07/10/2024] Open
Abstract
Purpose Whether to perform surgery or conservatively manage appendicitis in immunosuppressed patients is a concern for clinicians. This study aimed to compare the outcomes of these 2 treatment options for appendicitis in patients with cancer undergoing chemotherapy. Methods This retrospective study included 206 patients with cancer who were diagnosed with acute appendicitis between August 2001 and December 2021. Among them, patients who received chemotherapy within 1 month were divided into surgical and conservative groups. We evaluated the outcomes, including treatment success within 1 year, 1-year recurrence, and the number of days from the diagnosis of appendicitis to chemotherapy restart, between the 2 groups. Results Among the 206 patients with cancer who were diagnosed with acute appendicitis, 78 received chemotherapy within 1 month. The patients were divided into surgery (n = 63) and conservative (n = 15) groups. In the surgery group, the duration of antibiotic therapy (7.0 days vs. 16.0 days, P < 0.001) and length of hospital stay (8.0 days vs. 27.5 days, P = 0.002) were significantly shorter than conservative groups. The duration from the diagnosis of appendicitis to the restart of chemotherapy was shorter in the surgery group (20.8 ± 15.1 days vs. 35.2 ± 28.2 days, P = 0.028). The treatment success rate within 1 year was higher in the surgery group (100% vs. 33.3%, P < 0.001). Conclusion Surgical treatment showed a significantly higher success rate than conservative treatment for appendicitis in patients less than 1 month after chemotherapy. Further prospective studies will be needed to clinically determine treatment options.
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Affiliation(s)
- Hyung Hwan Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Sil Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kyung Su Han
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Bun Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Chang Won Hong
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kiho You
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dong Woon Lee
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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45
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Selänne L, Haijanen J, Sippola S, Hurme S, Rautio T, Nordström P, Rantanen T, Pinta T, Ilves I, Mattila A, Rintala J, Marttila H, Meriläinen S, Laukkarinen J, Sävelä EL, Paajanen H, Grönroos J, Salminen P. Three-Year Outcomes of Oral Antibiotics vs Intravenous and Oral Antibiotics for Uncomplicated Acute Appendicitis: A Secondary Analysis of the APPAC II Randomized Clinical Trial. JAMA Surg 2024; 159:727-735. [PMID: 38630471 PMCID: PMC11024776 DOI: 10.1001/jamasurg.2023.5947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/27/2023] [Indexed: 04/20/2024]
Abstract
Importance Current short-term evidence has shown that uncomplicated acute appendicitis can be treated successfully with oral antibiotics alone, but longer-term results are lacking. Objective To assess the treatment effectiveness of oral antibiotic monotherapy compared with combined intravenous (IV) and oral antibiotics in computed tomography-confirmed uncomplicated acute appendicitis at a longer-term follow-up. Design, Setting, and Participants This secondary analysis of a predefined year 3 follow-up of the Appendicitis Acuta II (APPAC II) noninferiority, multicenter randomized clinical trial compared oral moxifloxacin with combined IV ertapenem plus oral levofloxacin and metronidazole for the treatment of uncomplicated acute appendicitis. The trial was conducted at 9 university and central hospitals in Finland from April 2017 to November 2018, with the last follow-up in November 2022. Participants included patients aged 18 to 60 years, who were randomized to receive either oral antibiotics monotherapy (n = 301) or combined IV and oral antibiotics (n = 298). Interventions Antibiotics monotherapy consisted of oral moxifloxacin, 400 mg/d, for 7 days. Combined IV and oral antibiotics consisted of IV ertapenem sodium, 1 g/d, for 2 days plus oral levofloxacin, 500 mg/d, and metronidazole, 500 mg 3 times/d, for 5 days. Main Outcomes and Measures The primary end point was treatment success, defined as the resolution of acute appendicitis and discharge from hospital without the need for surgical intervention and no appendicitis recurrence at the year 3 follow-up evaluated using a noninferiority design. The secondary end points included late (after 1 year) appendicitis recurrence as well as treatment-related adverse events, quality of life, length of hospital stay, and length of sick leave, which were evaluated using a superiority design. Results After exclusions, 599 patients (mean [SD] age, 36 [12] years; 336 males [56.1%]) were randomized; after withdrawal and loss to follow-up, 582 patients (99.8%) were available for the year 3 follow-up. The treatment success at year 3 was 63.4% (1-sided 95% CI, 58.8% to ∞) in the oral antibiotic monotherapy group and 65.2% (1-sided 95% CI, 60.5% to ∞) in the combined IV and oral antibiotics group. The difference in treatment success rate between the groups at year 3 was -1.8 percentage points (1-sided 95% CI, -8.3 percentage points to ∞; P = .14 for noninferiority), with the CI limit exceeding the noninferiority margin. There were no significant differences between groups in treatment-related adverse events, quality of life, length of hospital stay, or length of sick leave. Conclusions and Relevance This secondary analysis of the APPAC II trial found a slightly higher appendectomy rate in patients who received oral antibiotic monotherapy; however, noninferiority of oral antibiotic monotherapy compared with combined IV and oral antibiotics could not be demonstrated. The results encourage future studies to assess oral antibiotic monotherapy as a viable treatment alternative for uncomplicated acute appendicitis. Trial Registration ClinicalTrials.gov Identifier: NCT03236961.
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Affiliation(s)
- Liisa Selänne
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Saija Hurme
- Department of Biostatistics, University of Turku and Turku University Hospital, Turku, Finland
| | - Tero Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Pia Nordström
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Tuomo Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
- Department of Surgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Tarja Pinta
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Imre Ilves
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Anne Mattila
- Wellbeing Services County of Central Finland, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Jukka Rintala
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Department of Surgery, Rovaniemi Central Hospital, Rovaniemi, Finland
| | - Harri Marttila
- Department of Hospital Hygiene and Infection Control, Turku University Hospital, Turku, Finland
| | - Sanna Meriläinen
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | | | - Hannu Paajanen
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
- Department of Surgery, Satakunta Central Hospital, Pori, Finland
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46
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Jalava K, Sallinen V, Mentula P. Preoperative delay in uncomplicated appendicitis: the PERFECT trial - Authors' reply. Lancet 2024; 403:2693-2694. [PMID: 38908876 DOI: 10.1016/s0140-6736(24)00640-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/25/2024] [Indexed: 06/24/2024]
Affiliation(s)
- Karoliina Jalava
- Department of Gastroenterological Surgery, Helsinki University Hospital, University of Helsinki, Helsinki 00029, Finland
| | - Ville Sallinen
- Department of Gastroenterological Surgery, Helsinki University Hospital, University of Helsinki, Helsinki 00029, Finland; Department of Transplantation and Liver Surgery, Helsinki University Hospital, University of Helsinki, Helsinki 00029, Finland
| | - Panu Mentula
- Department of Gastroenterological Surgery, Helsinki University Hospital, University of Helsinki, Helsinki 00029, Finland.
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47
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Sartelli M, Tascini C, Coccolini F, Dellai F, Ansaloni L, Antonelli M, Bartoletti M, Bassetti M, Boncagni F, Carlini M, Cattelan AM, Cavaliere A, Ceresoli M, Cipriano A, Cortegiani A, Cortese F, Cristini F, Cucinotta E, Dalfino L, De Pascale G, De Rosa FG, Falcone M, Forfori F, Fugazzola P, Gatti M, Gentile I, Ghiadoni L, Giannella M, Giarratano A, Giordano A, Girardis M, Mastroianni C, Monti G, Montori G, Palmieri M, Pani M, Paolillo C, Parini D, Parruti G, Pasero D, Pea F, Peghin M, Petrosillo N, Podda M, Rizzo C, Rossolini GM, Russo A, Scoccia L, Sganga G, Signorini L, Stefani S, Tumbarello M, Tumietto F, Valentino M, Venditti M, Viaggi B, Vivaldi F, Zaghi C, Labricciosa FM, Abu-Zidan F, Catena F, Viale P. Management of intra-abdominal infections: recommendations by the Italian council for the optimization of antimicrobial use. World J Emerg Surg 2024; 19:23. [PMID: 38851757 PMCID: PMC11162065 DOI: 10.1186/s13017-024-00551-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/01/2024] [Indexed: 06/10/2024] Open
Abstract
Intra-abdominal infections (IAIs) are common surgical emergencies and are an important cause of morbidity and mortality in hospital settings, particularly if poorly managed. The cornerstones of effective IAIs management include early diagnosis, adequate source control, appropriate antimicrobial therapy, and early physiologic stabilization using intravenous fluids and vasopressor agents in critically ill patients. Adequate empiric antimicrobial therapy in patients with IAIs is of paramount importance because inappropriate antimicrobial therapy is associated with poor outcomes. Optimizing antimicrobial prescriptions improves treatment effectiveness, increases patients' safety, and minimizes the risk of opportunistic infections (such as Clostridioides difficile) and antimicrobial resistance selection. The growing emergence of multi-drug resistant organisms has caused an impending crisis with alarming implications, especially regarding Gram-negative bacteria. The Multidisciplinary and Intersociety Italian Council for the Optimization of Antimicrobial Use promoted a consensus conference on the antimicrobial management of IAIs, including emergency medicine specialists, radiologists, surgeons, intensivists, infectious disease specialists, clinical pharmacologists, hospital pharmacists, microbiologists and public health specialists. Relevant clinical questions were constructed by the Organizational Committee in order to investigate the topic. The expert panel produced recommendation statements based on the best scientific evidence from PubMed and EMBASE Library and experts' opinions. The statements were planned and graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence. On November 10, 2023, the experts met in Mestre (Italy) to debate the statements. After the approval of the statements, the expert panel met via email and virtual meetings to prepare and revise the definitive document. This document represents the executive summary of the consensus conference and comprises three sections. The first section focuses on the general principles of diagnosis and treatment of IAIs. The second section provides twenty-three evidence-based recommendations for the antimicrobial therapy of IAIs. The third section presents eight clinical diagnostic-therapeutic pathways for the most common IAIs. The document has been endorsed by the Italian Society of Surgery.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100, Macerata, Italy.
| | - Carlo Tascini
- Infectious Diseases Clinic, Santa Maria Della Misericordia University Hospital of Udine, ASUFC, Udine, Italy
- Infectious Diseases Clinic, Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Azienda Ospedaliero Universitaria Pisana, University Hospital, Pisa, Italy
| | - Fabiana Dellai
- Infectious Diseases Clinic, Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Luca Ansaloni
- Division of General Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Massimo Antonelli
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Michele Bartoletti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Infectious Disease Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Matteo Bassetti
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genoa, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Federico Boncagni
- Anesthesiology and Intensive Care Unit, Macerata Hospital, Macerata, Italy
| | - Massimo Carlini
- Department of General Surgery, S. Eugenio Hospital, Rome, Italy
| | - Anna Maria Cattelan
- Infectious and Tropical Diseases Unit, Padua University Hospital, Padua, Italy
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Arturo Cavaliere
- Unit of Hospital Pharmacy, Viterbo Local Health Authority, Viterbo, Italy
| | - Marco Ceresoli
- General and Emergency Surgery, Milano-Bicocca University, School of Medicine and Surgery, Monza, Italy
| | - Alessandro Cipriano
- Department of Emergency Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Andrea Cortegiani
- Department of Precision Medicine in Medical Surgical and Critical Care, University of Palermo, Palermo, Italy
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | | | - Francesco Cristini
- Infectious Diseases Unit, AUSL Romagna, Forlì and Cesena Hospitals, Forlì, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Eugenio Cucinotta
- Department of Human Pathology of the Adult and Evolutive Age "Gaetano Barresi", Section of General Surgery, University of Messina, Messina, Italy
| | - Lidia Dalfino
- Anesthesia and Intensive Care Unit, Department of Precision and Regenerative Medicine and Ionian Area, Polyclinic of Bari, University of Bari, Bari, Italy
| | - Gennaro De Pascale
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Francesco Forfori
- Anesthesia and Intensive Care, Anesthesia and Resuscitation Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Paola Fugazzola
- Division of General Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Ivan Gentile
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Lorenzo Ghiadoni
- Department of Emergency Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
- Department on Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonino Giarratano
- Department of Precision Medicine in Medical Surgical and Critical Care, University of Palermo, Palermo, Italy
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Alessio Giordano
- Unit of Emergency Surgery, Careggi University Hospital, Florence, Italy
| | - Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Claudio Mastroianni
- Department of Public Health and Infectious Diseases, AOU Policlinico Umberto 1, Sapienza University of Rome, Rome, Italy
| | - Gianpaola Monti
- Department of Anesthesia and Intensive Care, ASST GOM Niguarda Ca' Granda, Milan, Italy
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Vittorio Veneto, Italy
| | - Miriam Palmieri
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100, Macerata, Italy
| | - Marcello Pani
- Hospital Pharmacy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ciro Paolillo
- Emergency Department, University of Verona, Verona, Italy
| | - Dario Parini
- General Surgery Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy
| | - Daniela Pasero
- Department of Emergency, Anaesthesia and Intensive Care Unit, ASL1 Sassari, Sassari, Italy
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Maddalena Peghin
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria-ASST-Sette Laghi, Varese, Italy
| | - Nicola Petrosillo
- Infection Prevention and Control Service, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Caterina Rizzo
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Alessandro Russo
- Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
- Infectious and Tropical Disease Unit, "Renato Dulbecco" Teaching Hospital, Catanzaro, Italy
| | - Loredana Scoccia
- Hospital Pharmacy Unit, Macerata Hospital, AST Macerata, Macerata, Italy
| | - Gabriele Sganga
- Emergency and Trauma Surgery Unit, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Liana Signorini
- Unit of Infectious and Tropical Diseases, ASST Spedali Civili Di Brescia, Brescia, Italy
| | - Stefania Stefani
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Catania, Italy
| | - Mario Tumbarello
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
- Infectious and Tropical Diseases Unit, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Fabio Tumietto
- UO Antimicrobial Stewardship-AUSL Bologna, Bologna, Italy
| | | | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Bruno Viaggi
- Intensive Care Department, Careggi Hospital, Florence, Italy
| | | | - Claudia Zaghi
- General, Emergency and Trauma Surgery Department, Vicenza Hospital, Vicenza, Italy
| | | | - Fikri Abu-Zidan
- Statistics and Research Methodology, The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Fausto Catena
- Emergency and General Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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48
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Sartelli M, Barie P, Agnoletti V, Al-Hasan MN, Ansaloni L, Biffl W, Buonomo L, Blot S, Cheadle WG, Coimbra R, De Simone B, Duane TM, Fugazzola P, Giamarellou H, Hardcastle TC, Hecker A, Inaba K, Kirkpatrick AW, Labricciosa FM, Leone M, Martin-Loeches I, Maier RV, Marwah S, Maves RC, Mingoli A, Montravers P, Ordóñez CA, Palmieri M, Podda M, Rello J, Sawyer RG, Sganga G, Tattevin P, Thapaliya D, Tessier J, Tolonen M, Ulrych J, Vallicelli C, Watkins RR, Catena F, Coccolini F. Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery. World J Emerg Surg 2024; 19:22. [PMID: 38851700 PMCID: PMC11161965 DOI: 10.1186/s13017-024-00552-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/01/2024] [Indexed: 06/10/2024] Open
Abstract
Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient's clinical condition, and the host's immune status should be assessed continuously to optimize the management of patients with complicated IAIs.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, Macerata, 62100, Italy.
| | - Philip Barie
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, Bufalini Hospital - AUSL della Romagna, Cesena, Italy
| | - Majdi N Al-Hasan
- Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, SC, USA
| | - Luca Ansaloni
- Department of General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Walter Biffl
- Division of Trauma and Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Luis Buonomo
- Emergency, Urgency and Trauma Surgery, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Stijn Blot
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - William G Cheadle
- Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center - CECORC - Riverside University Health System, Moreno Valley, CA, USA
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | | | | | - Paola Fugazzola
- Department of General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Helen Giamarellou
- First Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Timothy C Hardcastle
- Department of Surgical Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Andrew W Kirkpatrick
- Department of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | | | - Marc Leone
- Department of Anaesthesia and Intensive Care Unit, AP-HM, Aix-Marseille University, North Hospital, Marseille, France
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organisation, St James's Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
- Centro de Investigacion Biomedica En Red Entermedades Respiratorias, Institute of Health Carlos III, Madrid, Spain
- Pulmonary Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Ronald V Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Sanjay Marwah
- Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, India
| | - Ryan C Maves
- Section of Infectious Diseases, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Andrea Mingoli
- Emergency Department, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Philippe Montravers
- Anesthesiology and Critical Care Medicine Department, DMU PARABOL, Bichat Hospital, AP-HP, Université Paris Cité, Paris, France
| | - Carlos A Ordóñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Miriam Palmieri
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, Macerata, 62100, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Jordi Rello
- Global Health eCore, Vall d'Hebron University Hospital Campus, Barcelona, 08035, Spain
- Medicine Department, Universitat Internacional de Catalunya, Sant Cugat del Valles, Spain
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Pierre Tattevin
- Infectious Disease and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | | | - Jeffrey Tessier
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matti Tolonen
- Emergency Surgery department, Meilahti Tower Hospital, HUS Helsinki University Hospital, Haartmaninkatu 4, Helsinki, Finland
| | - Jan Ulrych
- First Department of Surgery, Department of Abdominal, Thoracic Surgery and Traumatology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Carlo Vallicelli
- Emergency and General Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Richard R Watkins
- Department of Medicine, Division of Infectious Diseases, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Fausto Catena
- Emergency and General Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Unit, Pisa University Hospital, Pisa, Italy
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Laverde BLB, Maak M, Langheinrich M, Kersting S, Denz A, Krautz C, Weber GF, Grützmann R, Brunner M. Antibiotic treatment after appendectomy for acute complicated appendicitis to prevent intrabdominal abscess and wound infections. Langenbecks Arch Surg 2024; 409:180. [PMID: 38850459 PMCID: PMC11162365 DOI: 10.1007/s00423-024-03367-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 05/26/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION The purpose of this analysis was to investigate the most appropriate duration of postoperative antibiotic treatment to minimize the incidence of intraabdominal abscesses and wound infections in patients with complicated appendicitis. MATERIALS AND METHODS In this retrospective study, which included 396 adult patients who underwent appendectomy for complicated appendicitis between January 2010 and December 2020 at the University Hospital Erlangen, patients were classified into two groups based on the duration of their postoperative antibiotic intake: ≤ 3 postoperative days (group 1) vs. ≥ 4 postoperative days (group 2). The incidence of postoperative intraabdominal abscesses and wound infections were compared between the groups. Additionally, multivariate risk factor analysis for the occurrence of intraabdominal abscesses and wound infections was performed. RESULTS The two groups contained 226 and 170 patients, respectively. The incidence of postoperative intraabdominal abscesses (2% vs. 3%, p = 0.507) and wound infections (3% vs. 6%, p = 0.080) did not differ significantly between the groups. Multivariate analysis revealed that an additional cecum resection (OR 5.5 (95% CI 1.4-21.5), p = 0.014) was an independent risk factor for intraabdominal abscesses. A higher BMI (OR 5.9 (95% CI 1.2-29.2), p = 0.030) and conversion to an open procedure (OR 5.2 (95% CI 1.4-20.0), p = 0.016) were identified as independent risk factors for wound infections. CONCLUSION The duration of postoperative antibiotic therapy does not appear to influence the incidence of postoperative intraabdominal abscesses and wound infections. Therefore, short-term postoperative antibiotic treatment should be preferred.
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Affiliation(s)
- Bruno Leonardo Bancke Laverde
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Matthias Maak
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Melanie Langheinrich
- Department of General, Visceral, Thoracic and Vascular Surgery, University Greifswald, Ferdinand- Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Stephan Kersting
- Department of General, Visceral, Thoracic and Vascular Surgery, University Greifswald, Ferdinand- Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Axel Denz
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Georg F Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany.
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50
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Luksaite-Lukste R, Gecaite I, Marcinkeviciute K, Dumskis E, Samuilis A, Zvirblis T, Jasiunas E, Bausys A, Drungilas M, Luksta M, Kryzauskas M, Petrulionis M, Beisa A, Uselis S, Valeikaite-Taugininene G, Rackauskas R, Strupas K, Poskus T. Observation Safely Reduces the Use of the Computerized Tomography in Medium-to-Low-Risk Patients with Suspected Acute Appendicitis: Results of a Randomized Controlled Trial. J Clin Med 2024; 13:3363. [PMID: 38929896 PMCID: PMC11203661 DOI: 10.3390/jcm13123363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/28/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Objectives-The objective was to compare the effectiveness of observation in standard-of-care computed tomography (CT) in adult patients with suspected acute appendicitis (AA). Methods-Patients with clinically suspected AA and inconclusive diagnosis after primary clinical examination, laboratory examination, and transabdominal ultrasound (TUS) were eligible for the study, and they were randomized (1:1) to parallel groups: observation-group patients were observed for 8-12 h and then, repeated clinical and laboratory examinations and TUS were performed; CT group (control group) patients underwent abdominopelvic CT scan. The study utilized Statistical Analysis System 9.2 for data analysis, including tests, logistic regression, ROC analysis, and significance evaluation. Patients were enrolled in the study at Vilnius University Hospital Santaros Klinikos in Lithuania between December 2018 and June 2021. Results-A total of 160 patients (59 men, 101 women), with a mean age of 33.7 ± 14.71, were included, with 80 patients in each group. Observation resulted in a reduced likelihood of a CT scan compared with the CT group (36.3% vs. 100% p < 0.05). One diagnostic laparoscopy was performed in the observation group; there were no cases of negative appendectomy (NA) in the CT group. Both conditional CT and observation pathways resulted in high sensitivity and specificity (97.7% and 94.6% vs. 96.7% and 95.8%). Conclusions-Observation including the repeated evaluation of laboratory results and TUS significantly reduces the number of CT scans without increasing NA numbers or the number of complicated cases.
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Affiliation(s)
- Raminta Luksaite-Lukste
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (I.G.); (E.D.); (A.S.)
| | - Igne Gecaite
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (I.G.); (E.D.); (A.S.)
| | | | - Eimantas Dumskis
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (I.G.); (E.D.); (A.S.)
| | - Arturas Samuilis
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (I.G.); (E.D.); (A.S.)
| | - Tadas Zvirblis
- Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (K.M.); (T.Z.); (A.B.)
- Department of Mechanical and Material Engineering, Vilnius Gediminas Technical University, LT-03224 Vilnius, Lithuania
| | - Eugenijus Jasiunas
- Vilnius University Hospital Santaros Klinikos, LT-08406 Vilnius, Lithuania; (E.J.); (M.D.)
| | - Augustinas Bausys
- Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (K.M.); (T.Z.); (A.B.)
| | - Mantas Drungilas
- Vilnius University Hospital Santaros Klinikos, LT-08406 Vilnius, Lithuania; (E.J.); (M.D.)
| | - Martynas Luksta
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Marius Kryzauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Marius Petrulionis
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Augustas Beisa
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Simonas Uselis
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Gintare Valeikaite-Taugininene
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Rokas Rackauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
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