|
1
|
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.
Collapse
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
| |
Collapse
|
|
2
|
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.
Collapse
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
| |
Collapse
|
|
3
|
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.
Collapse
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
| |
Collapse
|
|
4
|
Song S, Zhao J, Tang Y, Li Y. An FUO patient diagnosed as appendicitis: a case report. BMC Infect Dis 2024; 24:993. [PMID: 39289623 PMCID: PMC11409626 DOI: 10.1186/s12879-024-09851-7] [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: 04/28/2024] [Accepted: 09/02/2024] [Indexed: 09/19/2024] Open
Abstract
BACKGROUND The diagnosis and management of fever of unknown origin pose significant challenges in the field of infectious diseases, as it is influenced by various factors. Infectious diseases have long been recognized as the primary etiology of fever of unknown origin. However, not all infectious diseases can definitively identify the causative pathogen and infection sites. CASE PRESENTATION we present a case report of an individual with fever, nausea, and anorexia but did not report any abdominal pain. Physical examination revealed no signs of abdominal tenderness. Repeated imaging studies including enhanced CT and color US of the appendix, only one color US suggested the possibility of appendicitis. Despite effective anti-infective treatment, the patient continued to experience low-grade fever, leading to the decision for laparoscopic exploration and subsequent appendectomy. Pathological findings confirmed the presence of appendicitis. After the surgical procedure, the patient's temperature and infectious markers returned to within normal range, ultimately leading to a diagnosis of appendicitis. CONCLUSIONS The atypical symptoms and signs, along with the negative imaging results, contribute to the under diagnosis of appendicitis and the progression of fever of unknown origin, thereby exacerbating the physical, mental, and economic burden on patients. Consequently, there are valuable insights to be gained regarding the management of both appendicitis and fever of unknown origin.
Collapse
Affiliation(s)
- Shupeng Song
- Department of Infectious Disease, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinqiu Zhao
- Department of Infectious Disease, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yingzi Tang
- Department of Pathology, Chongqing General Hospital, Chongqing, China
| | - Yongguo Li
- Department of Infectious Disease, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| |
Collapse
|
|
5
|
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
| |
Collapse
|
|
6
|
Bendib H. Is non-operative treatment of acute appendicitis possible: A narrative review. Afr J Emerg Med 2024; 14:84-90. [PMID: 38617036 PMCID: PMC11010839 DOI: 10.1016/j.afjem.2024.03.006] [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] [Received: 07/04/2023] [Revised: 03/19/2024] [Accepted: 03/28/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction Acute appendicitis (AA) represents the most frequent surgical emergency. Perforation was long considered the ultimate outcome of AA, prompting appendectomy; which remains the standard treatment. New data have clarified the role of the appendix, justifying conservative treatment. This narrative review aims to summarize the evidence regarding the non-operative treatment (NOT) of AA in adults. Methods The literature search was performed via the PubMed Medline database. Our criteria-based selection resulted in a total of 48 articles for review. Results Recent trials and meta-analyses have assessed NOT, which support primary antibiotic treatment of uncomplicated AA. Although it has a significant recurrence and failure rate, NOT does not appear to increase the risk of appendicular perforation. Moreover, NOT compared with appendectomy, seems to be associated with less morbidity, lower cost of care and preserved quality of life. Conclusion First-line NOT seems to be a reasonable approach for the treatment of uncomplicated CT-confirmed AA. Careful patient screening would definitely enhance the success rate.
Collapse
Affiliation(s)
- Hani Bendib
- Department of General Surgery, EPH Kouba, Algiers, Algeria
- Faculty of Medicine, Algiers 1 University, Algeria
| |
Collapse
|
|
7
|
Casas MA, Monrabal Lezama M, Schlottmann F. Medical and surgical treatment of acute appendicitis: Past, present and future. Curr Probl Surg 2024; 61:101458. [PMID: 38704174 DOI: 10.1016/j.cpsurg.2024.101458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/10/2024] [Accepted: 02/11/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Maria A Casas
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina; Department of Surgery, University of Illinois at Chicago, Chicago, IL.
| |
Collapse
|
|
8
|
Gal M, Maya P, Ofer K, Mansoor K, Benyamine A, Boris K. Acute Appendicitis in the Elderly: A Nationwide Retrospective Analysis. J Clin Med 2024; 13:2139. [PMID: 38610904 PMCID: PMC11012554 DOI: 10.3390/jcm13072139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/28/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Acute appendicitis (AA) in older individuals remains understudied. We aimed to assess AA characteristics in patients older than 60 years and evaluate the impact of comorbidities. Methods: This retrospective study analyzed data from the American National Inpatient Sample between 2016 and 2019 to compare AA characteristics in patients younger and older than 60 years. Results: Of the 538,400 patients included, 27.5% were older than 60 years. Younger patients had a higher appendectomy rate (p < 0.01), while the complicated appendicitis rate was higher in older patients. Superficial wound infection, systemic infection, and mortality rates were higher in older patients (p < 0.01). Risk factors for superficial wound infection in patients younger than 60 years included cerebrovascular disease, chronic kidney disease, hypertension, heart failure, and obesity, whereas only heart failure was a risk factor in older patients. Risk factors for systemic infection in young patients included hypertension, heart failure, obesity, and diabetes mellitus, while in older patients they included hypertension, heart failure, and obesity. Complicated appendicitis was not a risk factor for infections in either group. Conclusions: This study highlights a higher incidence of AA in older individuals than previously reported, with comorbidities posing differing risks for infections between age groups.
Collapse
Affiliation(s)
- Malkiely Gal
- Division of Surgery, Hillel Yaffe Medical Center, Hadera 38100, Israel
| | - Paran Maya
- Department of Pediatric and Adolescent Surgery, Schneider Children’s Medical Center, Petah Tikva 4920235, Israel;
| | - Kobo Ofer
- Division of Cardiology, Hillel Yaffe Medical Center, Hadera 38100, Israel
| | - Khan Mansoor
- Department of Major Trauma, Hull University Teaching Hospitals, Hull HU3 2JZ, UK
| | - Abbou Benyamine
- Hospital Administration Hillel Yaffe Medical Center, Hadera 38100, Israel;
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 31096, Israel
| | - Kessel Boris
- Division of Surgery, Hillel Yaffe Medical Center, Hadera 38100, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 31096, Israel
| |
Collapse
|
|
9
|
Iresjö BM, Blomström S, Engström C, Johnsson E, Lundholm K. Acute appendicitis: A block-randomized study on active observation with or without antibiotic treatment. Surgery 2024; 175:929-935. [PMID: 38218686 DOI: 10.1016/j.surg.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Antibiotic treatment of unselected patients with acute appendicitis is safe and effective. However, it is unknown to what extent early provision of antibiotic treatment may represent overtreatment due to spontaneous healing of appendix inflammation. The aim of the present study was to evaluate the role of antibiotic treatment versus active in-hospital observation on spontaneous regression of acute appendicitis. METHOD Patients who sought acute medical care at Sahlgrenska University Hospital were block-randomized according to age (18-60 years) and systemic inflammation (C-reactive protein <60 mg/L, white blood cell <13,000/μL), in combination with clinical and abdominal characteristics of acute appendicitis. Study patients received antibiotic treatment and active observation, while control patients were allocated to classic active "wait and see observation" for either disease regression or the need for surgical exploration. According to our standard surgical care, certified surgeons in charge decided whether and when appendectomy was necessary. In total, 1,019 patients were screened for eligibility; 203 patients met inclusion criteria, 126 were accepted to participate, 29 declined, and 48 were missed for inclusion. RESULTS The antibiotic group (n = 69) and the control group (n = 57) were comparable at inclusion. Appendectomy at first hospital stay was 28% and 53% for study and control patients (χ2, P < .004). Life table analysis indicated a time-dependent difference in the need for appendectomy during follow-up (P < .03). Antibiotics prevented surgical exploration and appendectomy by 72% to 50% compared to 47% to 37% in the control group across the time course follow-ups between 5 and 1,200 days. CONCLUSION Early antibiotic treatment is superior to traditional "wait and see observation" to avoid surgical exploration and appendectomy.
Collapse
Affiliation(s)
- Britt-Marie Iresjö
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Sara Blomström
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Cecilia Engström
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Erik Johnsson
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Kent Lundholm
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| |
Collapse
|
|
10
|
Prajapat B, Chejara R, Mittal MK, S V A, Kalwaniya DS. Evaluation of Factors Predicting Successful Outcome in Patients Undergoing Expectant Management of Uncomplicated Acute Appendicitis. Cureus 2023; 15:e48687. [PMID: 38024038 PMCID: PMC10640851 DOI: 10.7759/cureus.48687] [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: 11/12/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Expectant management, or non-operative management (NOM), with standalone intravenous antibiotic therapy, has emerged as an effective alternative to appendectomy for the treatment of uncomplicated acute appendicitis. Various clinical, biochemical, and radiological factors have been implicated in predicting the success or failure of outcomes. Therefore, it is important to identify patients at the onset who are likely to have successful outcomes for conservative management of uncomplicated acute appendicitis. METHODS We prospectively enrolled 85 surgical patients diagnosed with uncomplicated acute appendicitis in our study. On admission, clinical features such as duration of symptoms, pulse rate (PR), history of fever within 24 hours of admission, modified Alvarado score and adult appendicitis score, biochemical parameters such as C-reactive protein (CRP), and hematological parameters such as total leukocyte count (TLC) were recorded. Radiological imaging of patients, namely ultrasonography and contrast-enhanced CT abdomen to evaluate appendix diameter and mural enhancement, was also undertaken. The outcome of expectant management for these patients (success or failure) was recorded, and the above-mentioned factors were evaluated to find a possible correlation with successful expectant management. RESULTS We found that among 85 patients, 77.6% had a successful NOM of appendicitis, whereas 22.4% had a failed NOM of appendicitis. The duration of symptoms, pulse rate, fever within 24 hours of admission, TLC, percentage of neutrophils, CRP level, appendix diameter, modified Alvarado score, and adult appendicitis score were found to be statistically significant predictors of successful NOM of appendicitis according to univariate analysis. According to multivariable analysis, pulse rate and appendix diameter value were found to be statistically significant predictors of successful NOM of appendicitis. With each beat per minute (bpm) increase in pulse rate, there was a 0.30% decrease in the probability of a successful NOM of appendicitis. With each mm increase in appendix diameter, there was an 82% decrease in the probability of a successful NOM of appendicitis. CONCLUSION From our study, it can be concluded that patients who met the following criteria, i.e., duration of symptoms before presenting to surgical emergency less than two days, presence of fever within 24 hours of presenting to surgical emergency, pulse rate >90 bpm, TLC >12000 cells/dL, CRP >20 mg/L, appendix diameter >10 mm, modified Alvarado score ≥ 9, and adult appendicitis score ≥ 18, have a higher probability of failure of NOM and hence should be excluded from expectant management.
Collapse
Affiliation(s)
- Bhrigu Prajapat
- General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - Rajkumar Chejara
- General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | | | - Arya S V
- General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - Dheer S Kalwaniya
- General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| |
Collapse
|
|
11
|
Shiihara M, Sudo Y, Matsushita N, Kubota T, Hibi Y, Osugi H, Inoue T. Usefulness of Preoperative Predictors of Pathological Complicated Appendicitis. Dig Surg 2023; 40:121-129. [PMID: 37285808 DOI: 10.1159/000531284] [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: 08/27/2022] [Accepted: 05/17/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Complicated appendicitis (CA) is often indicated for emergency surgery; however, preoperative predictors of pathological CA (pCA) remain unclear. Furthermore, characteristics of CA that can be treated conservatively have not yet been established. METHODS 305 consecutive patients diagnosed with acute appendicitis were reviewed. The patients were divided into two groups: an emergency surgery and a conservative treatment group. The emergency surgery group was pathologically classified as having uncomplicated appendicitis (pUA) and pCA, and the preoperative predictors of pCA were retrospectively assessed. Based on the preoperative pCA predictors, a predictive nomogram whether conservative treatment would be successful or not was created. The predictors were applied to the conservative treatment group, and the outcomes were investigated. RESULTS In the multiple logistic regression analysis of the factors contributing to pCA, C-reactive protein ≥3.5 mg/dL, ascites, appendiceal wall defect, and periappendiceal fluid collection were independent risk factors. Over 90% of cases without any of the above four preoperative pCA predictors were pUA. The accuracy of the nomogram was 0.938. CONCLUSION Our preoperative predictors and nomogram are useful to aid in distinguishing pCA and pUA and to predict whether or not conservative treatment will be successful. Some CA can be treated with conservative treatment.
Collapse
Affiliation(s)
| | - Yasuhiro Sudo
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | | | - Takeshi Kubota
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | - Yasuhiro Hibi
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | - Harushi Osugi
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | - Tatsuo Inoue
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| |
Collapse
|
|
12
|
Echevarria S, Rauf F, Hussain N, Zaka H, Farwa UE, Ahsan N, Broomfield A, Akbar A, Khawaja UA. Typical and Atypical Presentations of Appendicitis and Their Implications for Diagnosis and Treatment: A Literature Review. Cureus 2023; 15:e37024. [PMID: 37143626 PMCID: PMC10152406 DOI: 10.7759/cureus.37024] [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: 04/01/2023] [Indexed: 05/06/2023] Open
Abstract
Appendicitis, an acute inflammation of the appendix, affects all demographic groups and exhibits various incidences and clinical manifestations. While acute appendicitis typically presents with colicky periumbilical abdominal pain that localizes to the right lower quadrant, atypical presentations are more common in children, geriatric, and pregnant patient populations, leading to delays in diagnosis. Clinical evaluation, clinical scoring systems, and inflammatory markers are commonly used, but their limitations have led to the increased use of diagnostic imaging in patients suspected of appendicitis. Acute appendicitis is managed by non-operative and operative management, depending on whether it is uncomplicated or complicated. Developing diagnostic pathways to improve outcomes and reduce complications is crucial. Although medical advancements have been made, diagnosing and managing appendicitis can be challenging, mainly when patients are present atypically. This literature review aims to comprehensively review typical and atypical presentations of appendicitis and their current implications for diagnosis and treatment modalities in pediatric, adult, pregnant, and geriatric patient populations.
Collapse
Affiliation(s)
| | - Fatima Rauf
- Internal Medicine, Rawalpindi Medical University, Rawalpindi, PAK
| | - Nabeel Hussain
- Internal Medicine, Saba University School-Medicine, Devens, USA
| | - Hira Zaka
- Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Umm-E- Farwa
- Surgery, Jinnah Sindh Medical University, Karachi, PAK
| | - Nayab Ahsan
- Internal Medicine, Quaid-e-Azam Medical College, Bahawalpur, PAK
| | - Alison Broomfield
- Family Medicine, Spartan Health Sciences University, Vieux Fort, LCA
| | - Anum Akbar
- Pediatrics, University of Nebraska Medical Center, Omaha, USA
| | - Uzzam Ahmed Khawaja
- Pulmonary and Critical Care Medicine, Jinnah Medical and Dental College, Karachi, PAK
- Clinical and Translational Research, Dr Ferrer BioPharma, South Miami, USA
| |
Collapse
|
|
13
|
Phan-Mai TA, Thai TT, Mai TQ, Vu KA, Mai CC, Nguyen DA. Validity of Machine Learning in Detecting Complicated Appendicitis in a Resource-Limited Setting: Findings from Vietnam. BIOMED RESEARCH INTERNATIONAL 2023; 2023:5013812. [PMID: 37090195 PMCID: PMC10121350 DOI: 10.1155/2023/5013812] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 11/30/2022] [Accepted: 03/28/2023] [Indexed: 04/25/2023]
Abstract
Background Complicated appendicitis, a potentially life-threatening condition, is common. However, the diagnosis of this condition is mainly based on physician's experiences and advanced diagnostic equipment. This study built and validated machine learning models to facilitate the detection of complicated appendicitis. Methods A retrospective cohort study was conducted based on medical charts of all patients undergoing a laparoscopic appendectomy at a city hospital during 2016-2020. The synthetic minority over-sampling technique (SMOTE) was used to adjust for the imbalance. Multiple classification approaches were used to train and validate models including support vector machine (SVM), decision tree (DT), K-nearest neighbor (KNN), logistic regression (LR), artificial neural network (ANN), and gradient boosting (GB). Results Among 1,950 patients included in the data analysis, there were 483 patients identified as having complicated appendicitis (24.8%). Based on data without SMOTE adjustment for imbalance, the accuracy levels and AUCs were high in all models using different parameters, ranging from 0.687 to 0.815. After adjusting for imbalance data using SMOTE, AUC and accuracy levels in the models using imbalance adjusted data were higher. Of these, the GB had all AUC and accuracy values of approximately 0.8 or more in both adjusted and unadjusted data. Conclusions Machine learning approaches including SVM, DT, logistic, KNN, ANN, and GB have a high level of validity in classifying patients with complicated appendicitis and patients without complicated appendicitis. Among these, GB had the highest level of validity and should be used or further validated. Our study indicates the beneficial potentials of machine learning techniques in a clinical setting in general and in the diagnosis of complicated appendicitis in particular.
Collapse
Affiliation(s)
- Tuong-Anh Phan-Mai
- General Surgery Department, Nhan dan Gia Dinh Hospital, 1 No Trang Long Street, Ward 7, Binh Thanh District, Ho Chi Minh City, Vietnam
| | - Truc Thanh Thai
- Department of Medical Statistics and Informatics, University of Medicine and Pharmacy at Ho Chi Minh City, 217 Hong Bang Street, Ward 11, District 5, Ho Chi Minh City, Vietnam
| | - Thanh Quoc Mai
- Department of Medical Statistics and Informatics, University of Medicine and Pharmacy at Ho Chi Minh City, 217 Hong Bang Street, Ward 11, District 5, Ho Chi Minh City, Vietnam
| | - Kiet Anh Vu
- Planning Department, Nhan dan Gia Dinh Hospital, 1 No Trang Long Street, Ward 7, Binh Thanh District, Ho Chi Minh City, Vietnam
| | - Cong Chi Mai
- General Surgery Department, Nhan dan Gia Dinh Hospital, 1 No Trang Long Street, Ward 7, Binh Thanh District, Ho Chi Minh City, Vietnam
| | - Dung Anh Nguyen
- General Surgery Department, Nhan dan Gia Dinh Hospital, 1 No Trang Long Street, Ward 7, Binh Thanh District, Ho Chi Minh City, Vietnam
| |
Collapse
|
|
14
|
Dibekoğlu C. Does the length matter in acute appendicitis for the perforation risk?: A retrospective cohort study. Medicine (Baltimore) 2022; 101:e32001. [PMID: 36482564 PMCID: PMC9726347 DOI: 10.1097/md.0000000000032001] [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] [Indexed: 12/13/2022] Open
Abstract
It has been hypothesized that short appendices increase intraluminal pressure more rapidly and perforate more frequently than long appendices. Two hundred seventy-seven adult patients were retrospectively analyzed and underwent an appendectomy between January 2015 and August 2021. Data extracted from patient records included sex, age, time from admission to operation (hospital interval), weekday or weekend operation time, and operative and pathological findings. Operation was performed on 273 patients, of whom 178 (65.2%) were male and 95 (34.8%) female. The mean age of the male patients was 31.7 ± 08 (range 18-67), and that of the female patients was 38.9 ± 1.4 (range 18-78). Perforation was observed in 57 (20.9%) patients. Sex was not a factor in the development of perforation (P = .95). The mean age of the patients with and without perforation was 40.1 ± 2.2 and 32.7 ± 0.7, respectively. The perforation rate increased with age (P = .003). Appendix lengths were similar in both groups, and length was not a factor in the development of perforation (P = .83). This study found that the development of perforated appendicitis is not related to the length of the appendix. The risk of perforation increased with age.
Collapse
Affiliation(s)
- Cengiz Dibekoğlu
- Department of General Surgery, Demiroglu Bilim University, İstanbul, Turkey
- * Correspondence: Cengiz Dibekoğlu, Istanbul Florence Nightingale Hastanesi, Abidei Hurriyet cad No. 156 Sisli Istanbul 34381, Turkey (e-mail: )
| |
Collapse
|
|
15
|
Demirtürk HC, Tanriverdi HI, Taneli F, Ayhan S, Günşar C. Effectiveness of nonsurgical antibiotic treatment in the experimental appendicitis model in rats. ANNALS OF PEDIATRIC SURGERY 2022. [DOI: 10.1186/s43159-022-00187-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
In this study, we aimed to demonstrate efficacy and laboratory follow-up criteria of nonsurgical antibiotic treatment in uncomplicated acute appendicitis. We established an experimental appendicitis model in rats, and antibiotic treatment was evaluated by biochemical and immunohistochemical changes.
Materials and method
In the study, 28 rats were divided into 4 groups. Group 1 constituted the group of sham; group 2 was the control group that appendicitis model was created and did not receive any treatment. Group 3 was created as an appendicitis model and was given regular antibiotic treatment. In group 4, appendicitis model was created, and appendectomy was performed on the 2nd day. Blood samples were taken from the rats on the 0, 2nd, and 7th days in all groups. Rats in groups 1, 2, and 3 underwent appendectomy with laparotomy under anesthesia on the 7th day. Serum C-reactive protein (CRP), procalcitonin, and leukocyte levels were measured for biochemical analysis. In immunohistochemical evaluation, inflammation severity of the tissue samples taken from appendices was evaluated. Also, tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) levels of tissue samples were evaluated.
Results
A statistically significant difference in CRP values was observed between groups 1 and 2 on the 7th day (p = 0.046), between groups 1 and 4 on 0 and 2nd days (p = 0.004, p = 0.004), between groups 2 and 3 on 0, 2nd, and 7th days (p = 0.018, 0.013, 0.025), between groups 2 and 4 on 0, 2nd, and 7th days (p = 0.002, p = 0.002, p = 0.009), and between groups 3 and 4 on 0 and 2nd days (p = 0.013, p = 0.025). There was a significant difference in procalcitonin values between groups 1 and 3 on the 7th day (p = 0.032) and between groups 1 and 4 on day 0 (p = 0.019). A significant difference was also observed in TNF-α and IL-6 inflammation between groups 2 and 3 (p = 0.031, p = 0.018) and between groups 2 and 4 (p = 0.031, p = 0.01).
Conclusion
Acute uncomplicated and early appendicitis may be treated with antibiotics. According to our results, CRP levels are useful as follow-up criterion in experimental appendicitis model. Clinical studies on the assessment of CRP levels in the course of nonsurgical treatment in the patients with acute appendicitis will reveal out the effectiveness of this marker.
Collapse
|
|
16
|
Kubota A, Yokoyama N, Sato D, Hashidate H, Nojiri S, Taguchi C, Otani T. Treatment for Appendicitis With Appendicolith by the Stone Size and Serum C-Reactive Protein Level. J Surg Res 2022; 280:179-185. [PMID: 35987167 DOI: 10.1016/j.jss.2022.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 04/29/2022] [Accepted: 06/06/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Appendicolith causes acute appendicitis. However, surgical indications for appendicolith-related acute appendicitis have not been established. We aimed to clarify the clinical features of appendicolith-associated appendicitis and determine an appropriate treatment strategy based on the initial presentation. MATERIALS AND METHODS We retrospectively reviewed the records of 479 consecutive patients with acute appendicitis and verified the therapeutic strategy as per the appendicolith and clinical status. RESULTS Appendicoliths were identified in 214 of 479 patients (44.6%) using computed tomography. Surgery was more frequently required in patients with appendicolith than in patients without appendicolith (82.7 versus 64.9%; P < 0.001). The stones were smaller and serum C-reactive protein (CRP) concentration was lower among patients with appendicoliths treated with medication alone than among those surgically treated (both P < 0.001). An appendicolith measuring ≤5 mm in diameter and CRP concentration ≤5.36 mg/dL were predictive of completion of nonsurgical therapy. CRP concentration >10 mg/dL and stone diameter of 10 mm were significantly associated with appendiceal perforation. CONCLUSIONS Nonsurgical therapy could be considered for patients with appendicoliths measuring ≤5 mm in diameter and in cases where the serum CRP concentration is ≤5 mg/dL. An appendicolith measuring >10 mm in diameter or CRP concentration >10 mg/dL is an indication for surgery.
Collapse
Affiliation(s)
- Akira Kubota
- Department of Digestive Surgery, Niigata City General Hospital, Niigata, Japan; Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University Hospital, Tokyo, Japan.
| | - Naoyuki Yokoyama
- Department of Digestive Surgery, Niigata City General Hospital, Niigata, Japan
| | - Daisuke Sato
- Department of Digestive Surgery, Niigata City General Hospital, Niigata, Japan
| | - Hideki Hashidate
- Department of Pathology, Niigata City General Hospital, Niigata, Japan
| | - Shuko Nojiri
- Medical Technology Innovation Center, Juntendo University Hospital, Tokyo, Japan
| | - Chie Taguchi
- Department of Industrial Engineering and Economics, Tokyo Institute of Technology, Tokyo, Japan
| | - Tetsuya Otani
- Department of Digestive Surgery, Niigata City General Hospital, Niigata, Japan
| |
Collapse
|
|
17
|
Writing Group for the CODA Collaborative, Monsell SE, Voldal EC, Davidson GH, Fischkoff K, Coleman N, Bizzell B, Price T, Narayan M, Siparsky N, Thompson CM, Ayoung-Chee P, Odom SR, Sanchez S, Drake FT, Johnson J, Cuschieri J, Evans HL, Liang MK, McGrane K, Hatch Q, Victory J, Wisler J, Salzberg M, Ferrigno L, Kaji A, DeUgarte DA, Gibbons MM, Alam HB, Scott J, Kao LS, Self WH, Winchell RJ, Villegas CM, Talan DA, Kessler LG, Lavallee DC, Krishnadasan A, Lawrence SO, Comstock B, Fannon E, Flum DR, Heagerty PJ. Patient Factors Associated With Appendectomy Within 30 Days of Initiating Antibiotic Treatment for Appendicitis. JAMA Surg 2022; 157:e216900. [PMID: 35019975 PMCID: PMC8756360 DOI: 10.1001/jamasurg.2021.6900] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Use of antibiotics for the treatment of appendicitis is safe and has been found to be noninferior to appendectomy based on self-reported health status at 30 days. Identifying patient characteristics associated with a greater likelihood of appendectomy within 30 days in those who initiate antibiotics could support more individualized decision-making. OBJECTIVE To assess patient factors associated with undergoing appendectomy within 30 days of initiating antibiotics for appendicitis. DESIGN, SETTING, AND PARTICIPANTS In this cohort study using data from the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial, characteristics among patients who initiated antibiotics were compared between those who did and did not undergo appendectomy within 30 days. The study was conducted at 25 US medical centers; participants were enrolled between May 3, 2016, and February 5, 2020. A total of 1552 participants with acute appendicitis were randomized to antibiotics (776 participants) or appendectomy (776 participants). Data were analyzed from September 2020 to July 2021. EXPOSURES Appendectomy vs antibiotics. MAIN OUTCOMES AND MEASURES Conditional logistic regression models were fit to estimate associations between specific patient factors and the odds of undergoing appendectomy within 30 days after initiating antibiotics. A sensitivity analysis was performed excluding participants who underwent appendectomy within 30 days for nonclinical reasons. RESULTS Of 776 participants initiating antibiotics (mean [SD] age, 38.3 [13.4] years; 286 [37%] women and 490 [63%] men), 735 participants had 30-day outcomes, including 154 participants (21%) who underwent appendectomy within 30 days. After adjustment for other factors, female sex (odds ratio [OR], 1.53; 95% CI, 1.01-2.31), radiographic finding of wider appendiceal diameter (OR per 1-mm increase, 1.09; 95% CI, 1.00-1.18), and presence of appendicolith (OR, 1.99; 95% CI, 1.28-3.10) were associated with increased odds of undergoing appendectomy within 30 days. Characteristics that are often associated with increased risk of complications (eg, advanced age, comorbid conditions) and those clinicians often use to describe appendicitis severity (eg, fever: OR, 1.28; 95% CI, 0.82-1.98) were not associated with odds of 30-day appendectomy. The sensitivity analysis limited to appendectomies performed for clinical reasons provided similar results regarding appendicolith (adjusted OR, 2.41; 95% CI, 1.49-3.91). CONCLUSIONS AND RELEVANCE This cohort study found that presence of an appendicolith was associated with a nearly 2-fold increased risk of undergoing appendectomy within 30 days of initiating antibiotics. Clinical characteristics often used to describe severity of appendicitis were not associated with odds of 30-day appendectomy. This information may help guide more individualized decision-making for people with appendicitis.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Thea Price
- Rush University Medical Center, Chicago, Illinois
| | | | | | - Callie M Thompson
- Vanderbilt University Medical Center, Nashville, Tennessee.,University of Utah, Salt Lake City
| | - Patricia Ayoung-Chee
- Tisch Hospital NYU Langone Medical Center, New York, New York.,Morehouse School of Medicine, Atlanta, Georgia
| | - Stephen R Odom
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | - Joseph Cuschieri
- Harborview Medical Center, UW Medicine, Seattle, Washington.,University of California, San Francisco
| | - Heather L Evans
- Harborview Medical Center, UW Medicine, Seattle, Washington.,University of South Carolina, Charleston
| | - Mike K Liang
- Lyndon B. Johnson General Hospital, University of Texas, Houston.,University of Houston, HCA Healthcare, Kingwood, Texas
| | | | | | - Jesse Victory
- Bellevue Hospital Center, NYU School of Medicine, New York, New York
| | - Jon Wisler
- Ohio State University Medical Center, Columbus
| | | | | | - Amy Kaji
- Harbor-UCLA Medical Center, West Carson, California
| | | | | | - Hasan B Alam
- University of Michigan Medical Center, Ann Arbor.,Northwestern University, Evanston, Illinois
| | - John Scott
- University of Michigan Medical Center, Ann Arbor
| | - Lillian S Kao
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston
| | - Wesley H Self
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - David A Talan
- Olive View-UCLA Medical Center, Los Angeles, California.,Ronald Reagan UCLA Medical Center, Los Angeles, California
| | | | - Danielle C Lavallee
- University of Washington, Seattle.,BC Academic Health Science Network, Vancouver, Canada
| | | | | | | | | | | | | |
Collapse
|
|
18
|
van Amstel P, M L The SM, Bakx R, Bijlsma TS, Noordzij SM, Aajoud O, de Vries R, Derikx JPM, van Heurn LWE, Gorter RR. Predictive scoring systems to differentiate between simple and complex appendicitis in children (PRE-APP study). Surgery 2022; 171:1150-1157. [PMID: 35067338 DOI: 10.1016/j.surg.2021.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/15/2021] [Accepted: 12/19/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Several clinical prediction rules have been developed for preoperative differentiation between simple and complex appendicitis in children, as potential treatment strategies differ. This study aimed to externally validate applicable clinical prediction rules that could be used to differentiate between simple and complex appendicitis in children. METHODS Potential clinical prediction rules were identified by a scoping review of the literature. Clinical prediction rules applicable in our daily practice were subsequently externally validated in a multicenter historical cohort consisting of 1 tertiary center and 1 large teaching hospital. All children (<18 years old) with histopathologically confirmed acute appendicitis between 2013 and 2020 were included. Test results of clinical prediction rules were compared to the gold standard of either simple or complex appendicitis consisting of predefined perioperative and histopathological criteria. Areas under the receiver operating characteristic curves were determined for the selected clinical prediction rules. Areas under the receiver operating characteristic curve >0.7 were considered acceptable and potentially useful. RESULTS In total, 31 clinical prediction rules were identified, of which 12 could be evaluated in our cohort consisting of 550 children. The main reason to exclude clinical prediction rules was the use of variables that were not routinely measured in our cohort. In our cohort, 208/550 (38%) were diagnosed with complex appendicitis according to the gold standard. Clinical prediction rules with areas under the receiver operating characteristic curve >0.7 were: Gorter (0.81), Bogaard (0.79), Bröker (0.79), Graham (0.77), Hansson (0.76), BADCF (0.76), and Eddama (0.75). CONCLUSION In this study, clinical prediction rules consisting of a combination of clinical and objective variables had the highest discriminative ability. External validation showed that 7 clinical prediction rules were potentially useful. Integration of these clinical prediction rules in daily practice is proposed to guide decision making regarding treatment strategies.
Collapse
Affiliation(s)
- Paul van Amstel
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands.
| | - Sarah-May M L The
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands; Department of Surgery, Northwest Hospital, Alkmaar, The Netherlands
| | - Roel Bakx
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands
| | - Taco S Bijlsma
- Department of Surgery, Northwest Hospital, Alkmaar, The Netherlands
| | | | - Oumaima Aajoud
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands
| | - Ralph de Vries
- Vrije Universiteit Amsterdam, University Library, The Netherlands
| | - Joep P M Derikx
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands
| | - L W Ernest van Heurn
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands
| | - Ramon R Gorter
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands
| |
Collapse
|
|
19
|
Ielpo B, Podda M, Pellino G, Pata F, Caruso R, Gravante G, Di Saverio S, ACIE Appy Study Collaborative. Author response: Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study. Br J Surg 2021; 108:e313. [PMID: 34000031 PMCID: PMC7675377 DOI: 10.1002/bjs.11999] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 02/05/2023]
Abstract
Background Surgical strategies are being adapted to face the COVID‐19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X‐ray plus molecular testing (PCR) being the commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P < 0·001). One‐third changed their approach from laparoscopic to open surgery owing to the popular (but evidence‐lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one‐third felt that patients who did present had more severe appendicitis than they usually observe. Conclusion Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS‐CoV‐2.
Collapse
Affiliation(s)
- B Ielpo
- Department of Surgery, Hepatopancreatobiliary Unit, University Hospital Leon,
Leon, Spain
| | - M Podda
- Department of General and Emergency Surgery, Cagliari University Hospital,
Azienda Ospedaliero‐Universitaria, Cagliari, Italy
| | - G Pellino
- Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona,
Spain
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi
della Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - F Pata
- General Surgery Unit, Nicola Giannettasio Hospital,
Corigliano‐Rossano, Italy
- Department of General Surgery, La Sapienza University, Rome,
Italy
| | - R Caruso
- Hospital Universitario HM Sanchinarro, Madrid, Spain
| | - G Gravante
- Department of General Surgery, Ospedale ‘Francesco Ferrari’,
Casarano, Italy
| | - S Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of
Varese, ASST Sette Laghi, Regione LombardiaVarese, Italy
| | | |
Collapse
|
|
20
|
The effect of the Covid-19 outbreak on the management of acute appendicitis: A retrospective comparative cohort study. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.960850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
|
21
|
Li J. Revisiting delayed appendectomy in patients with acute appendicitis. World J Clin Cases 2021; 9:5372-5390. [PMID: 34307591 PMCID: PMC8281431 DOI: 10.12998/wjcc.v9.i20.5372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/04/2021] [Accepted: 05/19/2021] [Indexed: 02/06/2023] Open
Abstract
Acute appendicitis (AA) is the most common acute abdomen, and appendectomy is the most common nonelective surgery performed worldwide. Despite the long history of understanding this disease and enhancements to medical care, many challenges remain in the diagnosis and treatment of AA. One of these challenges is the timing of appendectomy. In recent decades, extensive studies focused on this topic have been conducted, but there have been no conclusive answers. From the onset of symptoms to appendectomy, many factors can cause delay in the surgical intervention. Some are inevitable, and some can be modified and improved. The favorable and unfavorable results of these factors vary according to different situations. The purpose of this review is to discuss the causes of appendectomy delay and its risk-related costs. This review also explores strategies to balance the positive and negative effects of delayed appendectomy.
Collapse
Affiliation(s)
- Jian Li
- Department of General Surgery, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang 621000, Sichuan Province, China
| |
Collapse
|
|
22
|
Kobayashi T, Hidaka E, Koganezawa I, Nakagawa M, Yokozuka K, Ochiai S, Gunji T, Ozawa Y, Hikita K, Sano T, Tomita K, Tabuchi S, Chiba N, Kawachi S. Prediction Model for Failure of Nonoperative Management of Uncomplicated Appendicitis in Adults. World J Surg 2021; 45:3041-3047. [PMID: 34156478 DOI: 10.1007/s00268-021-06213-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prediction of failure of nonoperative management (NOM) in uncomplicated appendicitis (UA) is difficult. This study aimed to establish a new prediction model for NOM failure in UA. METHODS We included 141 adults with UA who received NOM as initial treatment. NOM failure was defined as conversion to operation during hospitalization. Independent predictors of NOM failure were identified using logistic regression analysis. A prediction model was established based on these independent predictors. Receiver operating characteristic (ROC) curve analysis and the Hosmer-Lemeshow test were used to assess the discrimination and calibration of the model, respectively, and risk stratification using the model was performed. RESULTS Among 141 patients, NOM was successful in 120 and unsuccessful in 21. Male sex, maximal diameter of the appendix, and the presence of fecalith were identified as independent predictors of NOM failure for UA. A prediction model with scores ranging from 0 to 3 was established using the three variables (male sex, maximal diameter of the appendix ≥ 15 mm, and the presence of fecalith). The area under the ROC curve for the new prediction model was 0.778, and the model had good calibration (P = 0.476). A score of 2 yielded a sensitivity of 71.4% and a specificity of 90.8%. Patients were stratified into low (0-1), moderate (2), and high (3) risk categories, which had NOM rates of 5.2%, 47.1%, and 77.8%, respectively. CONCLUSIONS Our prediction model may predict NOM failure in UA with good diagnostic accuracy and help surgeons select appropriate treatments.
Collapse
Affiliation(s)
- Toshimichi Kobayashi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Eiji Hidaka
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Itsuki Koganezawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Masashi Nakagawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Kei Yokozuka
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Sigeto Ochiai
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Takahiro Gunji
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Yosuke Ozawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Kosuke Hikita
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Toru Sano
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Koichi Tomita
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Satoshi Tabuchi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Naokazu Chiba
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan
| | - Sigeyuki Kawachi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo, 193-0998, Japan.
| |
Collapse
|
|
23
|
Di Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, Boermeester M, Sartelli M, Coccolini F, Tarasconi A, De' Angelis N, Weber DG, Tolonen M, Birindelli A, Biffl W, Moore EE, Kelly M, Soreide K, Kashuk J, Ten Broek R, Gomes CA, Sugrue M, Davies RJ, Damaskos D, Leppäniemi A, Kirkpatrick A, Peitzman AB, Fraga GP, Maier RV, Coimbra R, Chiarugi M, Sganga G, Pisanu A, De' Angelis GL, Tan E, Van Goor H, Pata F, Di Carlo I, Chiara O, Litvin A, Campanile FC, Sakakushev B, Tomadze G, Demetrashvili Z, Latifi R, Abu-Zidan F, Romeo O, Segovia-Lohse H, Baiocchi G, Costa D, Rizoli S, Balogh ZJ, Bendinelli C, Scalea T, Ivatury R, Velmahos G, Andersson R, Kluger Y, Ansaloni L, Catena F. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg 2020; 15:27. [PMID: 32295644 PMCID: PMC7386163 DOI: 10.1186/s13017-020-00306-3] [Citation(s) in RCA: 577] [Impact Index Per Article: 115.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy. METHODS This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients. CONCLUSIONS The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.
Collapse
Affiliation(s)
- Salomone Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy.
| | - Mauro Podda
- Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Belinda De Simone
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Marco Ceresoli
- Emergency and General Surgery Department, University of Milan-Bicocca, Milan, Italy
| | - Goran Augustin
- Department of Surgery, University Hospital Centre of Zagreb, Zagreb, Croatia
| | - Alice Gori
- Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Marja Boermeester
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Antonio Tarasconi
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Nicola De' Angelis
- Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, Paris, France
| | - Dieter G Weber
- Trauma and General Surgeon Royal Perth Hospital & The University of Western Australia, Perth, Australia
| | - Matti Tolonen
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Arianna Birindelli
- Department of General Surgery, Azienda Socio Sanitaria Territoriale, di Valle Camonica, Italy
| | - Walter Biffl
- Queen's Medical Center, University of Hawaii, Honolulu, HI, USA
| | - Ernest E Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Michael Kelly
- Acute Surgical Unit, Canberra Hospital, ACT, Canberra, Australia
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Jeffry Kashuk
- Department of Surgery, University of Jerusalem, Jerusalem, Israel
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carlos Augusto Gomes
- Department of Surgery Hospital Universitario, Universidade General de Juiz de Fora, Juiz de Fora, Brazil
| | | | - Richard Justin Davies
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Dimitrios Damaskos
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
| | - Ari Leppäniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas, SP, Brazil
| | - Ronald V Maier
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA, USA
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Gabriele Sganga
- Department of Emergency Surgery, "A. Gemelli Hospital", Catholic University of Rome, Rome, Italy
| | - Adolfo Pisanu
- Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Gian Luigi De' Angelis
- Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Harry Van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Francesco Pata
- Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano, and La Sapienza University of Rome, Rome, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | | | - Andrey Litvin
- Department of Surgery, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Fabio C Campanile
- Department of Surgery, San Giovanni Decollato Andosilla Hospital, Viterbo, Italy
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Gia Tomadze
- Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia
| | - Rifat Latifi
- Section of Acute Care Surgery, Westchester Medical Center, Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Fakri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | | | - Gianluca Baiocchi
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - David Costa
- Hospital universitario de Alicante, departamento de Cirugia General, Alicante, Spain
| | - Sandro Rizoli
- Department of Surgery, St. Michael Hospital, University of Toronto, Toronto, Canada
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Cino Bendinelli
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | | | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
| | - George Velmahos
- Harvard Medical School, Massachusetts General Hospital, Boston, USA
| | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Luca Ansaloni
- Department of General Surgery and Trauma, Bufalini Hospital, Cesena, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| |
Collapse
|
|
24
|
Daldal E, Dagmura H. The Correlation between Complete Blood Count Parameters and Appendix Diameter for the Diagnosis of Acute Appendicitis. Healthcare (Basel) 2020; 8:healthcare8010039. [PMID: 32069909 PMCID: PMC7151080 DOI: 10.3390/healthcare8010039] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/05/2020] [Accepted: 02/11/2020] [Indexed: 12/20/2022] Open
Abstract
Acute appendicitis is one of the most common causes of acute abdominal diseases seen between the ages of 10 and 19, mostly seen in males. The lifetime risk of developing acute appendicitis is 8.6% for males and 6.7% for females. We aimed to investigate the efficacy of the complete blood count parameters, C-reactive protein, and Lymphocyte-C-reactive Protein Ratio laboratory tests in the diagnosis of acute appendicitis, as well as their relationship with appendix diameter. We retrospectively examined all patients who underwent appendectomy between 1 January 2012 and 30 June 2019 in the General Surgery Clinic of Gaziosmanpasa University Faculty of Medicine. Laboratory tests, imaging findings, age, and gender were recorded. Lymphoid hyperplasia is considered as normal appendix—in other words, as negative appendicitis. The distribution of Lymphoid hyperplasia and appendicitis rates were statistically different in the groups formed according to appendix diameter (≤6 and >6 mm) (p < 0.001). We found a significant correlation between appendix diameter and WBC (White blood count), Lymphocyte, Neutrophil, RDW(Red blood cell distribution width), NLR(Neutrophil to lymphocyte ratio), and PLT/L (Platelet to lymphocyte ratio), MPV (Mean platelet volume) and RDW were significantly different in patients with an appendix diameter of ≤6 mm (p = 0.007, p = 0.006, respectively). WBC, Neutrophil, PDW, and NLR values were significantly different between appendicitis and hyperplasia groups in patients with an appendix diameter of >6 mm. The sensitivity of the NLR score (cutoff = 2.6057) in the diagnosis of appendicitis was 86.1% and selectivity was 50% in these patients. Complete blood count parameters evaluation with the clinical findings revealed that NLR is an important parameter that may help the diagnosis of acute appendicitis with an appendix diameter of >6 mm. In patients whose pathological results indicated acute appendicitis but who had a diameter of ≤6 mm, we found an elevated MPV and low RDW values.
Collapse
Affiliation(s)
- Emin Daldal
- General Surgery, Gaziosmanpasa University, Kaleardı mahallesi, 60250 Tokat, Turkey;
| | - Hasan Dagmura
- General Surgery and Surgical Oncology Department, Gaziosmanpasa University, Kaleardı Mahallesi, 60250 Tokat, Turkey
- Correspondence: ; Tel.: +90-532-162-6615
| |
Collapse
|
|
25
|
Antibiotic Treatment and Appendectomy for Uncomplicated Acute Appendicitis in Adults and Children. Ann Surg 2019; 270:1028-1040. [PMID: 30720508 DOI: 10.1097/sla.0000000000003225] [Citation(s) in RCA: 171] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
|
26
|
Felber A, Catalano D, Stafford C, Francone TD, Roberts PL, Marcello PW, Ricciardi R. What is the Long-Term Follow-Up of Nonoperatively Treated Patients with Appendicitis? Am Surg 2019. [DOI: 10.1177/000313481908500520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this study, we determine outcomes after nonoperative treatment of appendicitis. First, we abstracted data for patients discharged with a diagnosis of appendicitis from a tertiary care facility from August 1, 2007, through June 30, 2017. For patients treated nonoperatively, we collected additional medical treatment for appendicitis, future surgical treatment, and date of last follow-up. In our study, we identified 487 patients treated for appendicitis. From this group, 66 patients were successfully treated nonoperatively. Eight patients (12%) had an interval appendectomy at a mean follow-up time of two months. Of the 58 remaining patients, 20 (34%) did not have any further appendicitis-related issues over a mean follow-up period of 25 months. A total of 38 (66%) had recurring or additional concerns requiring further treatment or emergent surgery within a mean time of four months. A large proportion, 76 per cent (n = 29), required unscheduled or emergent appendectomy. There were more patients diagnosed with an abscess (55%) in the group that had further appendicitis issues. In conclusion, nonoperative treatment of appendicitis is associated with significant likelihood of future appendicitis-related treatment or emergency surgery (66%). In addition, patients diagnosed with an abscess are at particularly high risk of future appendicitis-related issues.
Collapse
Affiliation(s)
- Andrew Felber
- Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Deven Catalano
- Division of Colon and Rectal Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Caitlin Stafford
- Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Todd D. Francone
- Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Patricia L. Roberts
- Division of Colon and Rectal Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Peter W. Marcello
- Division of Colon and Rectal Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Rocco Ricciardi
- Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts; and
| |
Collapse
|
|
27
|
Becker P, Fichtner-Feigl S, Schilling D. Clinical Management of Appendicitis. Visc Med 2018; 34:453-458. [PMID: 30675493 DOI: 10.1159/000494883] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Ever since the first appendectomy has been performed, surgery has been the standard of care for acute appendicitis, with antibiotic therapy being reserved for special situations. Recent studies have shown the feasibility of antibiotic therapy for uncomplicated appendicitis. Methods This clinical therapeutic review is based both on author expertise and a selective literature survey in PubMed based on the term 'appendicitis', combined with the terms 'acute', 'complicated', 'conservative', 'non-operative', 'therapy', 'surgery', and 'strategy'. According to these search results as well as to the treatment guidelines from the American College of Surgeons, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, European Association of Endoscopic Surgery, and World Society of Emergency Surgery, we present an interdisciplinary treatment concept. Results Approximately 90% of patients treated with antibiotics are able to avoid surgery during the initial admission. The other 10% that fail to respond to antibiotics require a rescue appendectomy. Recurrence rates of non-operated patients within 1 year are as high as 20-30%. Conclusion In uncomplicated appendicitis without risk factors for failure of non-operative management, a shared decision based on the patient's preferences should be made. In cases with risk factors, appendectomy is still the treatment recommended. If the diagnosis is uncertain or clinical symptoms are rather mild, antibiotic therapy should be started. In complicated appendicitis, management depends on the clinical state, with either immediate surgery or primarily antibiotic therapy and combined with drainage of abscess, being followed by interval appendectomy in some cases.
Collapse
Affiliation(s)
- Peter Becker
- Medizinische Klinik II, Diakonissenkrankenhaus Mannheim, Mannheim, Germany
| | - Stefan Fichtner-Feigl
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, Freiburg i.Br., Germany
| | - Dieter Schilling
- Medizinische Klinik II, Diakonissenkrankenhaus Mannheim, Mannheim, Germany
| |
Collapse
|
|
28
|
Abstract
BACKGROUND Antibiotic treatment of acute appendicitis has gained interest and inquiries. Reports have demonstrated both safety and high resolution of symptoms and inflammation following antibiotic treatment of appendicitis, but information on long-term results is required. Our present aim was therefore to evaluate long-term recurrence rate of initial antibiotics-alone treatment for suspected acute appendicitis. METHODS Patients with favourable response to antibiotics in earlier randomized (RCT, n = 97) and population-based (PBT, n = 342) studies as well as subsequently treated non-randomized (Non-R, n = 271) patients are evaluated for long-term risk to relapse demanding surgical appendectomy; altogether 710 patients. RESULTS Clinical characteristics among randomized and non-randomized patients were similar without any statistical difference according to abdominal symptoms and degree of systemic inflammation (CRP, WCC) when antibiotic treatment started. Females and males showed the same results. The median follow-up time was 2162 days (5.92 years), and the range across highest and lowest follow-up was 3495 days (range 2-3497) for the entire group, without significant differences among subgroups (RCT, PBT, Non-R). The cumulative probability for relapse of appendicitis demanding appendectomy was: 0.09, 0.12, 0.12 and 0.13 at 1-, 2-, 3- and 5-year follow-up, with a probability of 0.86 ± 0.013 without appendectomy after 8 years. This may imply an overall benefit of 60-70% by antibiotics during expected 10-year follow-up accounting for initial treatment failures at 10-23% in our published reports. CONCLUSION Antibiotic treatment is safe and effective as a first-line therapy in unselected adults with acute appendicitis with a risk around 15% for long-term relapse following favourable initial treatment response.
Collapse
|
|
29
|
Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis: Time to change the goal of our research? Int J Surg 2017; 48:264-265. [PMID: 29180069 DOI: 10.1016/j.ijsu.2017.11.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 11/17/2017] [Indexed: 11/23/2022]
|
|
30
|
Poillucci G, Mortola L, Podda M, Di Saverio S, Casula L, Gerardi C, Cillara N, Presenti L. Laparoscopic appendectomy vs antibiotic therapy for acute appendicitis: a propensity score-matched analysis from a multicenter cohort study. Updates Surg 2017; 69:531-540. [PMID: 29101666 DOI: 10.1007/s13304-017-0499-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/25/2017] [Indexed: 12/13/2022]
|
|
31
|
A prospective non-randomized controlled, multicenter trial comparing Appendectomy and Conservative Treatment for Patients with Uncomplicated Acute Appendicitis (the ACTUAA study). Int J Colorectal Dis 2017; 32:1649-1660. [PMID: 28812175 DOI: 10.1007/s00384-017-2878-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Acute appendicitis (AA) is among the most common causes of lower abdominal pain and admissions to the emergency department. Over the past 20 years, there has been a renewed interest in the conservative management of uncomplicated AA, and several studies demonstrated that an antibiotic-first strategy is a viable treatment option for uncomplicated AA. The aim of this prospective non-randomized controlled, multicenter trial is to compare antibiotic therapy and emergency appendectomy as treatment for patients with uncomplicated AA confirmed by US and/or CT or MRI scan. METHODS All adult patients in the age range 18 to 65 years with suspected AA, consecutively admitted to the Surgical Department of the 13 participating Italian Hospitals, will be invited to take part in the study. A multicenter prospective collected registry developed by surgeons, radiologists, and pathologists with expertise in the diagnosis and treatment of uncomplicated acute appendicitis represents the best research method to assess the long-term role of antibiotics in the management of the disease. Comparison will be made between surgical and antibiotic-first approaches to uncomplicated AA through the analysis of the primary outcome measure of complication-free treatment success rate based on 1-year follow-up. Quality of life, length of hospital stay, pain evaluation, and time to return to normal activity will be evaluated as secondary outcome measures. TRIAL REGISTRATION Clinicaltrials.gov ID: NCT03080103.
Collapse
|
|
32
|
Huston JM, Kao LS, Chang PK, Sanders JM, Buckman S, Adams CA, Cocanour CS, Parli SE, Grabowski J, Diaz J, Tessier JM, Duane TM. Antibiotics vs. Appendectomy for Acute Uncomplicated Appendicitis in Adults: Review of the Evidence and Future Directions. Surg Infect (Larchmt) 2017; 18:527-535. [PMID: 28614043 DOI: 10.1089/sur.2017.073] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute appendicitis is the most common abdominal surgical emergency in the United States, with a lifetime risk of 7%-8%. The treatment paradigm for complicated appendicitis has evolved over the past decade, and many cases now are managed by broad-spectrum antibiotics. We determined the role of non-operative and operative management in adult patients with uncomplicated appendicitis. METHODS Several meta-analyses have attempted to clarify the debate. Arguably the most influential is the Appendicitis Acuta (APPAC) Trial. RESULTS According to the non-inferiority analysis and a pre-specified non-inferiority margin of -24%, the APPAC did not demonstrate non-inferiority of antibiotics vs. appendectomy. Significantly, however, the operations were nearly always open, whereas the majority of appendectomies in the United States are done laparoscopically; and laparoscopic and open appendectomies are not equivalent operations. Treatment with antibiotics is efficacious more than 70% of the time. However, a switch to an antimicrobial-only approach may result in a greater probability of antimicrobial-associated collateral damage, both to the host patient and to antibiotic susceptibility patterns. A surgery-only approach would result in a reduction in antibiotic exposure, a consideration in these days of focus on antimicrobial stewardship. CONCLUSION Future studies should focus on isolating the characteristics of appendicitis most susceptible to antibiotics, using laparoscopic operations as controls and identifying long-term side effects such as antibiotic resistance or Clostridium difficile colitis.
Collapse
Affiliation(s)
- Jared M Huston
- 1 Deparment of Surgery, Hofstra Northwell School of Medicine at Hofstra University , Hempstead, New York
| | - Lillian S Kao
- 2 Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston , Houston, Texas
| | - Phillip K Chang
- 3 Department of Surgery, University of Kentucky College of Medicine , Lexington, Kentucky
| | - James M Sanders
- 4 Department of Pharmacy, John Peter Smith Health Network , Fort Worth, Texas
| | - Sara Buckman
- 5 Department of Surgery, Washington University in St. Louis School of Medicine , St. Louis, Missouri
| | - Charles A Adams
- 6 Department of Surgery, Warren Alpert School of Medicine of Brown University , Providence, Rhode Island
| | - Christine S Cocanour
- 7 Department of Surgery, University of California Davis School of Medicine , Sacramento, California
| | - Sarah E Parli
- 8 Department of Pharmacy, University of Kentucky College of Pharmacy , Lexington, Kentucky
| | - Julia Grabowski
- 9 Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Northwestern University , Chicago, Illinois
| | - Jose Diaz
- 10 Department of Surgery, RA Cowley Shock Trauma Center, University of Maryland School of Medicine , Baltimore, Maryland
| | - Jeffrey M Tessier
- 11 Antimicrobial Stewardship, John Peter Smith Health Network , Fort Worth, Texas
| | - Therese M Duane
- 12 Department of Surgery, John Peter Smith Health Network , Fort Worth, Texas
| |
Collapse
|
|
33
|
Foell D, Bahde R, Senninger N. The Non Operative Treatment for Acute Appendicitis (NOTA) Study: Is Less Surgery Better Surgery? Ann Surg 2017; 265:E83-E84. [PMID: 28486302 DOI: 10.1097/sla.0000000000001323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Daniel Foell
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
| | | | | |
Collapse
|
|
34
|
|
|
35
|
Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015; 386:1278-1287. [PMID: 26460662 DOI: 10.1016/s0140-6736(15)00275-5] [Citation(s) in RCA: 669] [Impact Index Per Article: 66.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute appendicitis is one of the most common abdominal emergencies worldwide. The cause remains poorly understood, with few advances in the past few decades. To obtain a confident preoperative diagnosis is still a challenge, since the possibility of appendicitis must be entertained in any patient presenting with an acute abdomen. Although biomarkers and imaging are valuable adjuncts to history and examination, their limitations mean that clinical assessment is still the mainstay of diagnosis. A clinical classification is used to stratify management based on simple (non-perforated) and complex (gangrenous or perforated) inflammation, although many patients remain with an equivocal diagnosis, which is one of the most challenging dilemmas. An observed divide in disease course suggests that some cases of simple appendicitis might be self-limiting or respond to antibiotics alone, whereas another type often seems to perforate before the patient reaches hospital. Although the mortality rate is low, postoperative complications are common in complex disease. We discuss existing knowledge in pathogenesis, modern diagnosis, and evolving strategies in management that are leading to stratified care for patients.
Collapse
Affiliation(s)
- Aneel Bhangu
- Academic Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham UK; College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Salomone Di Saverio
- Emergency and General Surgery Department, CA Pizzardi Maggiore Hospital, Bologna, Italy
| | | | | |
Collapse
|
|
36
|
Atema JJ, van Rossem CC, Leeuwenburgh MM, Stoker J, Boermeester MA. Scoring system to distinguish uncomplicated from complicated acute appendicitis. Br J Surg 2015; 102:979-90. [PMID: 25963411 DOI: 10.1002/bjs.9835] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/04/2015] [Accepted: 03/24/2015] [Indexed: 12/11/2022]
Abstract
Abstract
Background
Non-operative management may be an alternative for uncomplicated appendicitis, but preoperative distinction between uncomplicated and complicated disease is challenging. This study aimed to develop a scoring system based on clinical and imaging features to distinguish uncomplicated from complicated appendicitis.
Methods
Patients with suspected acute appendicitis based on clinical evaluation and imaging were selected from two prospective multicentre diagnostic accuracy studies (OPTIMA and OPTIMAP). Features associated with complicated appendicitis were included in multivariable logistic regression analyses. Separate models were developed for CT and ultrasound imaging, internally validated and transformed into scoring systems.
Results
A total of 395 patients with suspected acute appendicitis based on clinical evaluation and imaging were identified, of whom 110 (27·8 per cent) had complicated appendicitis, 239 (60·5 per cent) had uncomplicated appendicitis and 46 (11·6 per cent) had an alternative disease. CT was positive for appendicitis in 284 patients, and ultrasound imaging in 312. Based on clinical and CT features, a model was created including age, body temperature, duration of symptoms, white blood cell count, C-reactive protein level, and presence of extraluminal free air, periappendiceal fluid and appendicolith. A scoring system was constructed, with a maximum possible score of 22 points. Of the 284 patients, 150 had a score of 6 points or less, of whom eight (5·3 per cent) had complicated appendicitis, giving a negative predictive value (NPV) of 94·7 per cent. The model based on ultrasound imaging included the same predictors except for extraluminal free air. The ultrasound score (maximum 19 points) was calculated for 312 patients; 105 had a score of 5 or less, of whom three (2·9 per cent) had complicated appendicitis, giving a NPV of 97·1 per cent.
Conclusion
With use of novel scoring systems combining clinical and imaging features, 95 per cent of the patients deemed to have uncomplicated appendicitis were correctly identified as such. The score can aid in selection for non-operative management in clinical trials.
Collapse
Affiliation(s)
- J J Atema
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - C C van Rossem
- Department of Surgery, Tergooi Hospital, Hilversum, The Netherlands
| | - M M Leeuwenburgh
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - J Stoker
- Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| |
Collapse
|