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Kupietzky A, Gross M, Dover R, Maden A, Parnasa SY, Shussman N, Mazeh H, Mizrahi I. Operative Outcomes of Patients With Recurrent Uncomplicated Appendicitis are Similar to Patients With Acute Uncomplicated Appendicitis. J Surg Res 2025; 308:209-215. [PMID: 40120525 DOI: 10.1016/j.jss.2025.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2024] [Revised: 02/18/2025] [Accepted: 02/22/2025] [Indexed: 03/25/2025]
Abstract
INTRODUCTION Nonoperative management (NOM) for uncomplicated acute appendicitis (AA) has been gaining popularity in recent years. As so, more patients present with recurrent AA after a successful past episode of NOM. The aim of this study is to assess the outcomes of patients who underwent appendectomy due to recurrent uncomplicated AA after a successful episode of NOM in the past, and to compare their operative and postoperative course to patients operated for uncomplicated AA during their index admission. METHODS A retrospective analysis identified patients who underwent appendectomy in our institution between 2017 and 2022. The study group included all consecutive patients who underwent an appendectomy due to recurrent uncomplicated AA after NOM for uncomplicated AA in the past. Their course and outcomes were compared to a cohort of consecutive patients without any prior episodes of AA, who underwent an appendectomy during their index admission. RESULTS During the study period, 102 patients underwent an appendectomy due to recurrent uncomplicated AA. This group was compared to 107 consecutive patients without prior episodes of AA, who underwent upfront surgery during their index admission. Analysis demonstrated no significant difference between the groups in the operative approach, resection-technique, overall postoperative complication rates, the use of peritoneal drains, and intraoperative findings. However, length of surgery was significantly shorter in the recurrent AA group than in the upfront appendectomy group (mean ± standard deviation, 34 ± 13.7 versus 50.7 ± 18 min; P < 0.001). Pathology analysis revealed a normal appendix in 11.8% of patients presenting with recurrent AA compared to 1.9% of patients in the upfront surgery group (P = 0.007). CONCLUSIONS This study demonstrates that surgery for recurrent uncomplicated AA after a successful episode of NOM appears to be safe and comparable to upfront surgery during the index admission for uncomplicated AA.
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Affiliation(s)
- Amram Kupietzky
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Mika Gross
- Department of Military Medicine and "Tzameret", Faculty of Medicine, Hebrew University of Jerusalem and Medical Corps, Israel Defense Forces, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Roi Dover
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ata Maden
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shani Y Parnasa
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Noam Shussman
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Haggi Mazeh
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ido Mizrahi
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Salö M, Tiselius C, Rosemar A, Öst E, Sohlberg S, Andersson RE. Swedish national guidelines for diagnosis and management of acute appendicitis in adults and children. BJS Open 2025; 9:zrae165. [PMID: 40203150 PMCID: PMC11980984 DOI: 10.1093/bjsopen/zrae165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Revised: 11/19/2024] [Accepted: 12/15/2024] [Indexed: 04/11/2025] Open
Abstract
BACKGROUND Acute appendicitis is one of the most common causes of acute abdominal pain. Differences in the management of this large group of patients has important consequences for the patients and the healthcare system. Controversies regarding the understanding of the natural course of the disease, the utility of new diagnostic methods, and alternative treatments have lead to large variations in practice patterns between centres. These national guidelines present evidence-based recommendations aiming at a uniform, safe and cost-efficient management of this large group of patients. METHOD A working group of six experts with broad clinical and research experience was formed. Additional expertise from outside was consulted during the process. A national survey revealed significant variations in the management of patients with suspicion of appendicitis. The evidence provided in published guidelines and reviews were extracted and systematically graded, according to the GRADE methodology. This was supplemented by additional more recent and more directed search of the literature. Patients treated for appendicitis were involved through interviews. The guidelines were reviewed by external experts before the final version was determined. RESULTS The guidelines cover an extensive number of issues: pathology, epidemiology, aetiology, natural history, clinical and laboratory diagnosis, diagnostic scoring systems, diagnostic imaging, treatment, nursing care, follow-up, quality registers and quality indicators, among others. Special considerations related to children and pregnant women are covered. CONCLUSION These national guidelines present an extensive and thorough review of the current knowledge base related to appendicitis, and provide up-to-date evidence-based recommendations for the management of this large group of patients.
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Affiliation(s)
- Martin Salö
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden
- Department of Pediatric Surgery, Skåne University Hospital, Lund, Sweden
| | - Catarina Tiselius
- Department of Surgery, Västmanland Hospital Västerås, Västerås, Sweden
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
| | - Anders Rosemar
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital Östra, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elin Öst
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Sara Sohlberg
- Department of Women´s and Children´s Health, Uppsala University, Uppsala, Sweden
| | - Roland E Andersson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Futurum Academy for Health and Care, Jönköping County Council, Jönköping, Sweden
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Diaz JJ, Napolitano L, Livingston DH, Costantini T, Inaba K, Biffl WL, Winchell R, Salim A, Coimbra R. Evidence-based, cost-effective management of acute appendicitis: An algorithm of the Journal of Trauma and Acute Care Surgery emergency general surgery algorithms work group. J Trauma Acute Care Surg 2025; 98:368-373. [PMID: 39894950 PMCID: PMC11902600 DOI: 10.1097/ta.0000000000004569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2024] [Revised: 01/22/2025] [Accepted: 12/13/2024] [Indexed: 02/04/2025]
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Diaz JJ, Ceresoli M, Herron T, Coccolini F. Current management of acute appendicitis in adults: What you need to know. J Trauma Acute Care Surg 2025; 98:181-189. [PMID: 39504344 DOI: 10.1097/ta.0000000000004471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2024]
Abstract
ABSTRACT Acute appendicitis is one of the most common acute surgical diseases in the world today. Acute appendicitis can present with a well-recognized clinical presentation with abdominal pain which localize in the right lower quadrant. This presentation is more typical in men than in women of child baring age. Several clinical and laboratory calculations can be used to increase the likelihood of making a correct diagnosis. Various imaging modalities can be used to make the diagnosis which include ultrasound, computer tomography, and magnetic resonance imaging. Each study has well known sensitivity/specificity of positive predictive value of making the diagnosis of appendicitis. The management of acute appendicitis is based on the presentation of the patient and dividing it into uncomplicated and complicated disease. Each requires management with antibiotics and followed with timely appendectomy. Recent studies have demonstrated nonoperative management of uncomplicated appendicitis without no fecalith that can be managed with antibiotics alone. Complicated acute appendicitis should undergo timely surgical intervention. Patients presenting with a large appendiceal abscess or phlegmon should undergo percutaneous drainage and antibiotic management. There are certain patient populations that should be considered for surgical intervention. Pregnant patients as well as immunosuppressed patients should undergo timely surgical intervention to decrease the risk of complications. This review outlines the current principles of the diagnosis, imaging, and treatment of acute appendicitis based on the best available evidence of acute appendicitis in adults.
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Affiliation(s)
- Jose J Diaz
- From the Division of Acute Care Surgery (J.J.D.), Tampa General Hospital, University of South Florida, Tampa, Florida; School of Medicine and Surgery (M.C.), University of Milano-Bicocca; General and Emergency Surgery Department (M.C.), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; Tampa General Hospital (T.H.), University of South Florida, Tampa, Florida; and Department of General Emergency and Trauma Surgery (F.C.), Pisa University Hospital, Pisa, Italy
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Zhang X, Zheng X, Jin H, Li A, Zhang H, Zhang D. Efficacy and safety of different antibiotic treatment versus surgical treatment for acute appendicitis: A network meta-analysis. World J Surg 2024; 48:2843-2854. [PMID: 39500855 DOI: 10.1002/wjs.12382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 08/21/2024] [Indexed: 12/06/2024]
Abstract
OBJECTIVE This systematic review and network meta-analysis compared various antibiotic treatments with surgical treatment for acute appendicitis. METHODS We searched PubMed, Embase, Cochrane Library, and Wanfang databases for randomized controlled trials (RCTs) that met the prespecified inclusion criteria up to July 2023. The interventions included various antibiotics and surgery. The outcomes measured were initial treatment success, treatment success at 1-year follow-up, and treatment-related complications. Meta-analysis was conducted using R software with the gemtc package. Surfaces under the cumulative ranking curves (SUCRA) were used to rank the interventions. RESULTS Thirteen RCTs involving nine treatments (cefotaxime [CTX] + tinidazole [TNZ], CTX + metronidazole [MTZ], ampicillin [AMP] + gentamicin [GEN] + MTZ, amoxicillin/clavulanate [AMC] + GEN, meropenem [MEM] + MTZ, AMC, ertapenem [ETP] + MTZ, ETP, and surgery) were included in this network meta-analysis. In head-to-head comparisons, no statistically significant difference was found between any two interventions for initial treatment success (p > 0.05). The SUCRA indicated that surgery ranked first (SUCRA, 66.5%) for initial treatment success. Surgery was associated with an increased treatment success rate at 1-year follow-up compared to AMC (OR = 0.01, 95% CrI = 0.00-0.14, p < 0.05), MEM + MTZ (OR = 0.06, 95% CrI = 0.00-0.42, p < 0.05), and AMP + GEN + MTZ (OR = 0.02, 95% CrI = 0.00-0.23, p < 0.05). No statistically significant differences were found between any two interventions regarding complications (p > 0.05). CONCLUSION Our network meta-analysis suggests that surgery ranks highest for initial treatment success and treatment success at 1-year follow-up. However, surgery may increase the complication rate.
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Affiliation(s)
- Xianhuan Zhang
- Emergency Department, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
| | - Xiaokang Zheng
- Emergency Department, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
| | - Hongfeng Jin
- Emergency Department, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
| | - Aiming Li
- Emergency Department, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
| | - Hao Zhang
- Emergency Department, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
| | - Dehua Zhang
- Emergency Department, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
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Ferrara F, Peltrini R. Risk of appendiceal neoplasm in patients with appendix disorders. World J Clin Cases 2024; 12:6148-6150. [PMID: 39371555 PMCID: PMC11362891 DOI: 10.12998/wjcc.v12.i28.6148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 06/03/2024] [Accepted: 06/21/2024] [Indexed: 08/13/2024] Open
Abstract
The most common appendicular disease is acute appendicitis, with a lifetime risk of 7%-8%. Complicated cases, which can occur in 2%-7% of patients, can significantly impact the severity of the condition and may require different management approaches. Nonoperative management with possible delayed appendectomy has been suggested for selected patients, however, there is a non-negligible risk of missing an underlying malignancy, which is reported to be as high as 11%. Diagnostic work-up is paramount to achieve optimal treatment with good results.
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Affiliation(s)
- Francesco Ferrara
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me. Pre. C. C.), “Paolo Giaccone” Hospital, University of Palermo, Palermo 90127, Italy
| | - Roberto Peltrini
- Department of Public Health, University of Naples Federico II, Napoli 80131, Italy
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Boström L, Jovic V, Dahlberg M, Holtenius F, Sandblom G, Järnbert-Pettersson H. Survival among 148 patients with an incidentally detected appendiceal tumours at surgery for acute appendicitis: a population-based cohort follow-up study. Eur J Trauma Emerg Surg 2024; 50:2113-2122. [PMID: 39020129 PMCID: PMC11599532 DOI: 10.1007/s00068-024-02580-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 06/11/2024] [Indexed: 07/19/2024]
Abstract
PURPOSE To investigate the long-term prognosis of appendiceal tumours incidentally detected at appendicectomy for suspicion of benign appendicitis. METHODS A retrospective register-based single centre cohort study was carried out, using data from the local acute appendicectomy quality register of cases operated on at the Department of Surgery, South General Hospital, Stockholm, Sweden. The local colorectal cancer register was also used to identify appendix tumours. The study period was between January 2004 and January 2023. Survival was calculated according to the Kaplan-Meier method. RESULTS A total of 11,888 patients were registered in the acute acute appendicectomy register, 54% males and 46% females, median age 32 (Q1 = 21, Q3 = 47) (with 33.7% were 41 years or older). From the appendicectomy and colorectal registers 148 (1.2% of the total cohort) appendiceal tumours were found; 60% in females and 40% in males, median age 56 (Q1 = 43, Q3 = 70) (with 78.4% being 41 years or older). Tumours found were: Low grade Appendiceal Mucinous Neoplasms (LAMN, N = 64); Neuroendocrine Tumours (NET N = 24); adenocarcinomas or other form of carcinomas (N = 57); and adenomas (N = 3). The overall 5-year survival in patients operated for LAMN was 96.8%, for NET 93.3% and for adenocarcinoma 69.7%. The overall 5-year survival for all tumour patients was 85.7%. For the younger patients (< 51 years) with LAMN and NET, almost all survived to the end of follow-up. Survival of patients in the carcinoma group was statistically significantly lower than for the LAMN and NET groups, especially in females 51 years or older. In the group of tumour patients undergoing surgery (n = 146), primary surgery was laparoscopic in 47% and open in 52%. Two patients did not undergo surgery due to widespread disease. In 64% of cases operation was acute, whereas it was delayed and/or planned in 34%. Most procedures were laparoscopic appendicectomy 36%, followed by open appendicectomy 30%, right-sided hemicolectomy 14.6% (open 11.6% and laparoscopic 3%, acute operation 5.5%), ileocaecal resection 5% (acute operation 3.4%), and staging laparoscopy 7%. In 38% of the operated patients the tumour was discovered incidentally at histopathology examination. Two patients had CRS and HIPEC as the initial operation. Forthy-three per cent of the 146 tumour patients operated underwent a second procedure: CRS and HIPEC in 23.3% and right-sided hemicolectomy in 13.6% (laparoscopic 8.2% open 5.4%). CONCLUSION Survival was high for patients with incidentally detected appendiceal LAMN or NET, but not so for carcinoma. Survival was lower in the carcinoma group older than 50 years, especially those sick and females.
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Affiliation(s)
- Lennart Boström
- Department of Surgery, South General Hospital (Södersjukhuset), Sjukhusbacken 10, Stockholm, SE-11883, Sweden.
- Department of Clinical Science and Education, Karolinska Institutet, South General Hospital, Stockholm, Sweden.
| | - Viktor Jovic
- Department of Pathology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Martin Dahlberg
- Department of Surgery, South General Hospital (Södersjukhuset), Sjukhusbacken 10, Stockholm, SE-11883, Sweden
- Department of Clinical Science and Education, Karolinska Institutet, South General Hospital, Stockholm, Sweden
| | - Fredrik Holtenius
- Department of Surgery, South General Hospital (Södersjukhuset), Sjukhusbacken 10, Stockholm, SE-11883, Sweden
| | - Gabriel Sandblom
- Department of Surgery, South General Hospital (Södersjukhuset), Sjukhusbacken 10, Stockholm, SE-11883, Sweden
- Department of Clinical Science and Education, Karolinska Institutet, South General Hospital, Stockholm, Sweden
| | - Hans Järnbert-Pettersson
- Department of Clinical Science and Education, Karolinska Institutet, South General Hospital, Stockholm, Sweden
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Ghandour R, Bardier A, Wagner M, Malgras B, Kaci R, Doat S, Pocard M. Association between preoperative appendiceal histology grade and Pseudomyxoma peritonei grade offers a solution to avoid right hemicolectomy during cytoreductive surgery and HIPEC. Surg Oncol 2024; 56:102123. [PMID: 39163796 DOI: 10.1016/j.suronc.2024.102123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 08/01/2024] [Accepted: 08/16/2024] [Indexed: 08/22/2024]
Abstract
INTRODUCTION & OBJECTIVES Treatment of PMP consists of appendectomy, cytoreductive surgery (CRS) and HIPEC. Right-sided hemicolectomy is necessary only when PMP is high grade, given the lymphatic invasion risk. To date, no single preoperative factor was identified as predictive of PMP grade. MATERIALS & METHODS Preoperative factors of a prospective cohort study on PMP were retrospectively analyzed, in order to identify situations linked with high or low grade appendiceal PMP. The main outcome was PMP grade on definitive histology after CRS. RESULTS n = 105. In univariate analysis, the grade of the appendiceal tumor, systematically reviewed in an expert center, showed an OR of 25.00 (95 % CI: 3.30-189.27; p = 0.001) and an NPV of 93.75 [85.36, 100]. Peritoneal biopsy demonstrated an OR of 19.80 (95 % CI: 2.30-170.71; p = 0.002) and a PPV of 90 [71.41, 100]. In multivariate analysis, these two factors remained significantly associated with PMP grade. CONCLUSION Whenever appendiceal tumor is low grade on preoperative histology, the colon has to be spared unless completeness of CRS is compromised, which is a high-grade feature in fact. In case of high grade appendiceal tumor and/or peritoneal biopsy, right-sided hemicolectomy is warranted. If no histology is available preoperatively, adapt to intraoperative lesions as no preoperative factors seem to be predictive.
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Affiliation(s)
- Richard Ghandour
- Department of Hepato-Biliary and Pancreatic Surgery, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière University Hospital, 47-83 Bd de l'Hôpital,Cedex 13, F-75651, Paris, France.
| | - Armelle Bardier
- Department of Anatomopathology, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière University Hospital, 47-83 Bd de l'Hôpital,Cedex 13, F-75651, Paris, France
| | - Mathilde Wagner
- Department of Radiology, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière University Hospital, 47-83 Bd de l'Hôpital,Cedex 13, F-75651, Paris, France
| | - Brice Malgras
- Department of Surgery, Bégin Army Instruction Hospital, 69, avenue de Paris, 94160, St Mandé, France; Paris Cité University, INSERM U1275, CArcinose Péritoine Paris-Technologies, F-75010, Paris, France
| | - Rachid Kaci
- Paris Cité University, INSERM U1275, CArcinose Péritoine Paris-Technologies, F-75010, Paris, France; Department of Anatomopathology, Lariboisière University Hospital, 2 rue Ambroise Paré, F-75010, Paris, France
| | - Solène Doat
- Department of Hepato-Gastro-Enterology, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière University Hospital, 47-83 Bd de l'Hôpital,Cedex 13, F-75651, Paris, France
| | - Marc Pocard
- Department of Hepato-Biliary and Pancreatic Surgery, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière University Hospital, 47-83 Bd de l'Hôpital,Cedex 13, F-75651, Paris, France; Paris Cité University, INSERM U1275, CArcinose Péritoine Paris-Technologies, F-75010, Paris, France.
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Rashid R, Khalabazyane B, Kadhmawi I, Inteti K, Woodhouse M, Hanna J. Appendiceal Neoplasm in Conservatively Managed Acute Appendicitis: A Retrospective Observational Study. Cureus 2024; 16:e70480. [PMID: 39479054 PMCID: PMC11522839 DOI: 10.7759/cureus.70480] [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: 09/30/2024] [Indexed: 11/02/2024] Open
Abstract
Introduction Appendiceal neoplasms are more prevalent in patients ≥ 40 years old who present with complicated appendicitis, especially if managed conservatively. Routine interval appendicectomy is not recommended. Follow-up bowel screening using both a CT scan and colonoscopy is recommended. Following the COVID-19 pandemic, many units have increased their utilization of non-operative management of acute appendicitis (NOM). This provides an optimal population sample to study the incidence of unexpected appendiceal malignancy compared to a similar cohort that underwent operative management. The primary outcomes of interest include the incidence of appendiceal malignancy following NOM, efficacy of bowel screening, and rates of re-admission. Methods A retrospective, observational study on patients admitted with acute appendicitis from January 2020 to December 2021. All patients diagnosed with acute appendicitis aged 40 years and older were included in the study, while those under 40 or without a diagnosis of acute appendicitis were excluded. Results We had 211 cases of acute appendicitis. 125 (59%) of which were managed operatively, while 86 cases (41%) were managed NOM. We found six cases (7%) of appendiceal malignancy in the NOM cohort, compared to two cases (1.6%) in the operatively-managed cohort. A routine follow-up colonoscopy failed to reveal any sinister pathology. All six cases underwent interval appendicectomy through which the malignancy was detected. 39 cases (45%) of NOM had at least one episode of re-admission, with 32 (37%) of them being in the first year. Conclusion NOM of acute appendicitis in adults ≥ 40 years old is associated with an increase in unexpected appendiceal malignancy, none of which were detected on follow-up colonoscopy. We emphasize the need for closer surveillance and potentially more aggressive follow-up strategies, including routine interval appendicectomy, for older patients undergoing NOM of acute appendicitis.
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Affiliation(s)
- Rahel Rashid
- General and Colorectal Surgery, Arrowe Park Hospital, Wirral, GBR
| | | | - Israa Kadhmawi
- Clinical Research fellow, Arrowe Park Hospital, Wirral, GBR
| | | | | | - Joseph Hanna
- Trauma and Orthopaedics, Wirral University Hospital, Cheshire, GBR
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Hosokawa Y, Moritani M, Makuuchi Y, Nagakawa Y. Indication of conservative treatment by antibiotics for uncomplicated and complicated acute appendicitis. World J Gastrointest Surg 2024; 16:2538-2545. [PMID: 39220069 PMCID: PMC11362944 DOI: 10.4240/wjgs.v16.i8.2538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Acute appendicitis is one of the most common emergency abdominal disease, and recent studies have evaluated conservative treatment using antibiotics for uncomplicated appendicitis. Although the efficacy of conservative treatment for uncomplicated appendicitis is known, its efficacy for complicated appendicitis remains unknown, so are risk factors for the conservative treatment of appendicitis. In our institution, conservative treatment has long been the first choice for most appendicitis cases, except for perforation. Therefore, this novel study investigated the outcomes of conservative treatment for uncomplicated and complicated acute appendicitis and the risk factors associated with conservative treatment. AIM To investigate the indication of conservative treatment by antibiotics for uncomplicated and complicated acute appendicitis. METHODS We investigated 270 patients who received conservative treatment for acute appendicitis at the Nishitokyo Central General Hospital, between April 2011 and February 2022. Twenty-eight (10.3%) patients were resistant to conservative treatment and underwent surgery. We retrospectively investigated the outcomes of conservative treatment for appendicitis and the risk factors for resistance to conservative treatment using the receiver operating characteristic curves and Cox hazard model. RESULTS Two hundred and forty-two (89.7%) patients improved with conservative treatment. The significant and independent predictors of resistance to conservative treatment were body temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid visible on computed tomography (CT). The rate of resistance to conservative treatment was 66.7% (6/9) for patients with the above three factors, 22.9% (8/35) for patients with two factors (appendicolith and body temperature ≥ 37.3 °C), 16.7% (2/12) for patients with two factors (Douglas sinus fluid and appendicolith) and 11.1% (1/9) for patients with two factors (Douglas sinus fluid and body temperature ≥ 37.3 °C). CONCLUSION A temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid on CT might be clinical risk factors of resistance to conservative treatment for acute appendicitis.
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Affiliation(s)
- Yuichi Hosokawa
- Department of Surgery, Nishitokyo Central General Hospital, Tokyo 188-0014, Japan
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo 166-0023, Japan
| | - Masato Moritani
- Department of Surgery, Nishitokyo Central General Hospital, Tokyo 188-0014, Japan
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo 166-0023, Japan
| | - Yosuke Makuuchi
- Department of Surgery, Nishitokyo Central General Hospital, Tokyo 188-0014, Japan
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo 166-0023, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo 166-0023, Japan
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Ramadan S, Olsson Å, Ekberg O, Buchwald P. Predictive factors for recurrent acute appendicitis after conservative treatment. Scand J Gastroenterol 2024; 59:933-938. [PMID: 38814018 DOI: 10.1080/00365521.2024.2359438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/06/2024] [Accepted: 05/19/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Conservative treatment of acute appendicitis is gaining popularity, and identifying patients with a higher risk of recurrence is becoming increasingly important. Previous studies have suggested that older age, male sex, diabetes, appendicolith and abscess formation may be contributing factors, however, results from the adult population are inconsistent. AIM This study aims to identify predictive factors for recurrent appendicitis after conservative treatment. METHODS This retrospective study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and follow-up data were retrieved from medical charts and radiologic images. Uni -and multivariable logistic regression analysis were performed using Stata Statistical Software. RESULTS In total, 379 patients with conservatively treated acute appendicitis were identified, of which 78 (20.6%) had recurrence. All patients were followed-up for a minimum of 41 months after the first diagnosis of acute appendicitis unless appendectomy after successful conservative treatment or death occurred during follow-up. The median time to recurrence was 6.5 (1-17.8) months. After multivariable logistic regression analysis, external appendix diameter >10 mm [OR 2.4 (CI 1.37-4.21), p = .002] and intra-abdominal abscess [OR 2.05 (CI 1.18-3.56), p = .011] on computed tomography were significant independent risk factors for recurrent appendicitis. Appendicolith was not associated with an increased risk of recurrence. CONCLUSION This study suggests abscess formation and appendix distension of >10 mm to be potential risk factors for recurrent acute appendicitis after initial successful conservative treatment.
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Affiliation(s)
- Shaima Ramadan
- Department of Surgery, Colorectal Unit, Skåne University Hospital Malmö, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Åsa Olsson
- Department of Surgery, Colorectal Unit, Skåne University Hospital Malmö, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Olle Ekberg
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Translational Medicine, Division of Medical Radiology, Skåne University Hospital Malmö, Malmö, Sweden
| | - Pamela Buchwald
- Department of Surgery, Colorectal Unit, Skåne University Hospital Malmö, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
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12
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Peltrini R, Schiavo C, Pilone V. Three reasons to consider interval appendectomy for the management of complicated appendicitis. Updates Surg 2024; 76:1121-1122. [PMID: 38460101 DOI: 10.1007/s13304-024-01788-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 02/12/2024] [Indexed: 03/11/2024]
Affiliation(s)
- Roberto Peltrini
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy.
| | - Ciro Schiavo
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Vincenzo Pilone
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
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13
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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.
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Affiliation(s)
- Hani Bendib
- Department of General Surgery, EPH Kouba, Algiers, Algeria
- Faculty of Medicine, Algiers 1 University, Algeria
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14
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Saeed A, Abuzaid Y, Hammad M. Prevalence of, Subtypes of, and the Role of Age in Incidental Appendiceal Neoplasms in Acute Appendicitis: A Single-Institute Study from Bahrain. Cureus 2024; 16:e60150. [PMID: 38864054 PMCID: PMC11166375 DOI: 10.7759/cureus.60150] [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: 05/12/2024] [Indexed: 06/13/2024] Open
Abstract
INTRODUCTION Primary appendiceal neoplasms (ANs) are rare entities that can present with acute appendicitis symptoms. Accurate diagnosis of these diverse subtypes is crucial for prognosis and proper management. AIMS AND OBJECTIVES This descriptive retrospective study aims to determine the prevalence and pathological subtypes of incidental ANs in patients presenting with acute appendicitis symptoms at Salmaniya Medical Center (SMC) in Bahrain between the period of January 2020 and March 2024. Particular focus was placed on investigating whether advanced age is a significant risk factor for these neoplasms. MATERIALS AND METHODS The study included 38,643 patients (aged 15 years and above) who underwent appendectomy for suspected acute appendicitis during the study period. Demographic data, clinical diagnoses, preoperative imaging findings, histopathological reports, and management details were analyzed. Medical records of patients were retrieved from ISEHA system. Statistical analysis was done using Microsoft Excel. RESULTS The results showed that 12 patients (0.04% per year) had different subtypes of appendiceal tumors. Neuroendocrine tumors were the most common, identified in nine patients (75%), including nine cases of well-differentiated neuroendocrine carcinoma (NEC). Other histopathological subtypes included low-grade appendiceal mucinous neoplasm (LAMN), adenocarcinoma, and goblet cell adenocarcinoma, each found in one patient. Additionally, two patients had confirmed appendiceal mucocele. The mean age of patients with ANs was 30 years (range: 19-52 years), and 66.6% were younger than 38 years. Conclusion: These findings highlight the importance of considering ANs in the differential diagnosis of acute appendicitis, especially in older patients. Further research is warranted to confirm the role of age as a risk factor and guide clinical decision-making.
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Affiliation(s)
- Ahmed Saeed
- Surgery, Salmaniya Medical Complex, Manama, BHR
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15
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Yap DRY, Lui RN, Samol J, Ngeow J, Sung JJ, Wong SH. Beyond a vestigial organ: effects of the appendix on gut microbiome and colorectal cancer. J Gastroenterol Hepatol 2024; 39:826-835. [PMID: 38303116 DOI: 10.1111/jgh.16497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/11/2023] [Accepted: 01/07/2024] [Indexed: 02/03/2024]
Abstract
The role of appendectomy in the pathogenesis of colorectal cancer (CRC) is a recent topic of contention. Given that appendectomy remains one of the most commonly performed operations and a first-line management strategy of acute appendicitis, it is inherently crucial to elucidate the association between prior appendectomy and subsequent development of CRC, as there may be long-term health repercussions. In this review, we summarize the data behind the relationship of CRC in post-appendectomy patients, discuss the role of the microbiome in relation to appendectomy and CRC pathogenesis, and provide an appraisal of our current understanding of the function of the appendix. We seek to piece together the current landscape surrounding the microbiome and immunological changes in the colon post-appendectomy and suggest a direction for future research involving molecular, transcriptomic, and immunologic analysis to complement our current understanding of the alterations in gut microbiome.
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Affiliation(s)
- Daniel Ren Yi Yap
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Rashid N Lui
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Faculty of Medicine, State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, SAR, China
- Department of Clinical Oncology, Faculty of Medicine, the Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Jens Samol
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Department of Medical Oncology, Tan Tock Seng Hospital, National Healthcare Group, Singapore, Singapore
- Johns Hospital University, Baltimore, Maryland, USA
| | - Joanne Ngeow
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- National Cancer Centre Singapore, Singapore Health Services, Singapore, Singapore
| | - Joseph Jy Sung
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, National Healthcare Group, Singapore, Singapore
| | - Sunny H Wong
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, National Healthcare Group, Singapore, Singapore
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16
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Fransvea P, Puccioni C, Altieri G, D'Agostino L, Costa G, Tropeano G, La Greca A, Brisinda G, Sganga G. Beyond acute appendicitis: a single-institution experience of unexpected pathology findings after 989 consecutive emergency appendectomy. Langenbecks Arch Surg 2024; 409:87. [PMID: 38441707 DOI: 10.1007/s00423-024-03277-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/27/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Appendiceal neoplasms (ANs) are rare, with an estimated incidence of around 1%: neuroendocrine tumours (NETs) and low-grade appendiceal mucinous neoplasms (LAMNs) comprise most cases. Most tumours are cured by appendectomy alone, although some require right hemicolectomy and intra-operative chemotherapy. The aim of the present study is to evaluate our institution's experience in terms of the prevalence of AN, their histological types, treatment and outcomes in adult patients undergoing emergency appendectomy. MATERIAL AND METHODS Single-centre retrospective cohort analysis of patients treated for acute appendicitis at a large academic medical centre. Patients with a diagnosis of acute appendicitis (AA) where further compared with patients with acute appendicitis and a histologically confirmed diagnosis of appendiceal neoplasm (AN). RESULTS A diagnosis of acute appendicitis was made in 1200 patients. Of these, 989 patients underwent emergency appendectomy. The overall incidence of appendiceal neoplasm was 9.3% (92 patients). AN rate increased with increasing age. Patients under the age of 30 had a 3.8% (14/367 patients) rate of occult neoplasm, whereas patients between 40 and 89 years and older had a 13.0% rate of neoplasm. No difference was found in clinical presentations and type of approach while we found a lower complicated appendicitis rate in the AN group. CONCLUSION ANs are less rare with respect to the literature; however, clinically, there are no specific signs of suspicious and simple appendicectomy appears to be curative in most cases. However, age plays an important role; older patients are at higher risk for AN. ANs still challenge the non-operative management concept introduced into the surgical literature.
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Affiliation(s)
- Pietro Fransvea
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy.
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy.
| | - Caterina Puccioni
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy
| | - Gaia Altieri
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Luca D'Agostino
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Gianluca Costa
- Surgery Center, Colorectal Surgery Clinical and Research Unit - Fondazione Policlinico Universitario Campus Bio-Medico, University Campus Bio-Medico of Rome, Rome, Italy
| | - Giuseppe Tropeano
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Antonio La Greca
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy
| | - Giuseppe Brisinda
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy
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17
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Di Fabio F, Ravi P, Allievi N, Khan KA, Abduelraheim A, Moran B. Occult appendix pathology in patients undergoing colorectal cancer resection and prophylactic appendectomy. World J Surg 2024; 48:211-216. [PMID: 38651600 DOI: 10.1002/wjs.12010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 10/17/2023] [Indexed: 04/25/2024]
Abstract
BACKGROUND The risk-benefit balance of prophylactic appendectomy in patients undergoing left colorectal cancer resection is unclear. The aim of this report is to assess the proportion of histologically abnormal appendices in patients undergoing colorectal cancer resection in a unit where standard of care is appendectomy, with consent, when left-sided resection is performed. METHODS A retrospective study on a prospectively collected database was conducted in a single tertiary-care center. Overall, 717 consecutive patients undergoing colorectal cancer resection between January 2015 and June 2021 were analyzed. The primary outcome was the proportion of histologically abnormal appendix specimens at prophylactic appendectomy. The secondary outcome was complications from prophylactic appendectomy. RESULTS Overall, 576/717 (80%) patients had appendectomy at colorectal cancer surgery. In total, 234/576 (41%) had a right-/extended-right hemicolectomy or subtotal colectomy which incorporates appendectomy, and 342/576 (59%) had left-sided resection (left-hemicolectomy, anterior resection or abdominoperineal excision) with prophylactic appendectomy. At definitive histology, 534/576 (92.7%) had a normal appendix. The remaining 42/576 (7.3%) showed abnormal findings, including: 14/576 (2.4%) inflammatory appendix pathology, 2/576 (0.3%) endometriosis, 8/576 (1.4%) hyperplastic polyp, and 18/576 (3.1%) appendix tumors, which encompassed six low-grade appendiceal mucinous neoplasms (LAMNs), three carcinoids, and nine serrated polyps. In the 342 patients who had prophylactic appendectomy, 10 (2.9%) had a neoplasm (two LAMN, three carcinoids, and five serrated polyps). There were no complications attributable to appendectomy. CONCLUSION Occult appendix pathology in patients undergoing colorectal cancer resection is uncommon when prophylactic appendectomy was performed. However, approximately 3% of patients had a synchronous appendix neoplasm.
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Affiliation(s)
- Francesco Di Fabio
- Colorectal Surgery and Peritoneal Malignancy Unit, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Prabhu Ravi
- Colorectal Surgery and Peritoneal Malignancy Unit, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Niccolo Allievi
- Colorectal Surgery and Peritoneal Malignancy Unit, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Kashuf A Khan
- Colorectal Surgery and Peritoneal Malignancy Unit, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Abu Abduelraheim
- Colorectal Surgery and Peritoneal Malignancy Unit, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Brendan Moran
- Colorectal Surgery and Peritoneal Malignancy Unit, Basingstoke and North Hampshire Hospital, Basingstoke, UK
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18
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Salminen R, Rautio T, Nordström P, Rantanen T, Mällinen J, Grönroos J, Salminen P. Five-year follow-up of appendiceal neoplasm risk in periappendicular abscess in the Peri-Appendicitis Acuta Randomized Clinical Trial. Scand J Surg 2023; 112:265-268. [PMID: 37655682 DOI: 10.1177/14574969231192128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Affiliation(s)
- Roosa Salminen
- Department of Surgery, University of Oulu, Oulu, Finland
| | - Tero Rautio
- Department of Surgery, University of Oulu, Oulu, Finland
- Division of Operative Care, Oulu University Hospital and Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Pia Nordström
- Divison of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - Tuomo Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Jari Mällinen
- Department of Surgery, University of Oulu, Oulu, Finland
- Division of Operative Care, Oulu University Hospital and Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Paulina Salminen
- Paulina Salminen Division of Digestive Surgery and Urology Turku University Hospital P.O. Box 52 Turku 20520 Finland
- Department of Surgery University of Turku Turku Finland
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19
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Nguyen CGT, Hamid A, Chen A, Sood D, Jou J. Low grade appendiceal mucinous neoplasm metastatic to the ovary: A case report and intraoperative assessment guide. Int J Surg Case Rep 2023; 109:108563. [PMID: 37524024 PMCID: PMC10400853 DOI: 10.1016/j.ijscr.2023.108563] [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: 06/19/2023] [Revised: 07/18/2023] [Accepted: 07/23/2023] [Indexed: 08/02/2023] Open
Abstract
INTRODUCTION Incidence of low grade appendiceal mucinous neoplasm is increasing. Preoperatively, it may present similarly to primary ovarian malignancy. This case report describes a case of presumed ovarian malignancy with final pathologic diagnosis of low grade appendiceal mucinous neoplasm. We also propose several surgical strategies to approach this conundrum. PRESENTATION OF CASE A postmenopausal woman with abdominal pain was found to have a 30 cm abdominopelvic mass with elevated CA-125 and CEA presumably a primary ovarian malignancy. During surgical staging, intraoperative findings were notable for an appendiceal mass. Intraoperative surgical oncology consultation recommended appendectomy for diagnostic purposes. Following primary surgery and final pathologic diagnosis, she underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. DISCUSSION Low grade appendiceal mucinous neoplasm should be within the differential diagnosis of gynecologic surgeons when presented with a patient with large volume ascites and biopsy of acellular mucin. Intraoperatively, an abnormal appearing appendix with normal appearing gynecologic structures should trigger suspicion for appendiceal rather than ovarian origin. Preoperative symptoms, imaging studies, tumor markers, and frozen section pathology may not be able to differentiate between appendiceal and epithelial ovarian malignancies. CONCLUSION A recognition of mucinous material and abnormal appearing appendix should prompt the surgeon to consider performing an appendectomy to obtain primary pathologic diagnosis. A high level of suspicion could better optimize the patient for a joint case with the appropriate surgeons. Given the documented disguise of low grade appendiceal mucinous neoplasm as primary ovarian cancer and its increasing incidence, diagnosis and general understanding of treatment should be understood.
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Affiliation(s)
- Christine G T Nguyen
- Oregon Health and Sciences University, Department of Obstetrics and Gynecology, 3182 SW Sam Jackson Park Road, Portland, OR 97239, United States of America.
| | - Anam Hamid
- Oregon Health and Sciences University, Department of Pathology, 3182 SW Sam Jackson Park Road, Portland, OR 97239, United States of America
| | - Athena Chen
- Oregon Health and Sciences University, Department of Pathology, 3182 SW Sam Jackson Park Road, Portland, OR 97239, United States of America
| | - Divya Sood
- Oregon Health and Sciences University, Department of Surgery, Division of Surgical Oncology, 3182 SW Sam Jackson Park Road, Portland, OR 97239, United States of America
| | - Jessica Jou
- Oregon Health and Sciences University, Department of Obstetrics and Gynecology, 3182 SW Sam Jackson Park Road, Portland, OR 97239, United States of America
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Appendiceal Cancer in the National Cancer Database: Increasing Frequency, Decreasing Age, and Shifting Histology. J Am Coll Surg 2022; 234:1082-1089. [PMID: 35703801 DOI: 10.1097/xcs.0000000000000172] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nonoperative management of acute appendicitis is increasingly common. However, small studies have demonstrated high rates of appendiceal cancer in interval appendectomy specimens. Therefore, we sought to identify national trends in appendiceal cancer incidence and histology. STUDY DESIGN The National Cancer Database was queried for patients 18 years or older, diagnosed with a right-sided colon cancer (including appendiceal) from 2004 to 2017 who had undergone surgery. Outcomes included trends in appendiceal cancer compared with right-sided colon cancers and trends in appendiceal cancer histology. Logistic regression was used to assess trends over time while adjusting for patient age, insurance, income, area of residence, and comorbidity. Predicted probabilities of the outcomes were derived from the logistic regression models. RESULTS Of 387,867 patients with right-sided colon cancer, 19,570 had appendiceal cancer and of those 5,628 had a carcinoid tumor. Odds of appendiceal cancer, relative to other right-sided colon cancers, increased from 2004 to 2017 (odds ratio [OR] 2.56, 95% CI 2.35-2.79). The increase occurred in all age groups; however, it was more markedly increased in patients 40-49 years old (2004: 10%, 95% CI 9-12 to 2017: 18%, 95% CI 16-20; pairwise comparisons p < 0.001). Odds of appendiceal carcinoid, relative to other appendiceal histologies, increased from 2004 to 2017 (OR 1.70, 95% CI 1.40-2.07) with the greatest increase in probability of a carcinoid in patients younger than 40 years old (2004: 24%, 95% CI 15-34 to 2017: 45%, 95% CI 37-53; pairwise comparisons p < 0.001). CONCLUSION Appendiceal cancer has increased over time, and the increase appears to be driven by a rise in carcinoids, most prevalent in patients 49 years of age or younger. When nonoperative management of acute appendicitis is undertaken, close follow-up may be appropriate given these findings.
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21
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Kanaka S, Mizutani S, Yokoyama Y, Matsutani T, Chihara N, Katsuno A, Takata H, Nakata R, Mishima K, Wada Y, Shimizu T, Yamagiwa R, Haruna T, Nakamura Y, Hamaguchi A, Taniai N, Yoshida H. Periappendiceal fluid collection on preoperative computed tomography can be an indication for interval appendectomy: a retrospective study. World J Emerg Surg 2022; 17:30. [PMID: 35637469 PMCID: PMC9153096 DOI: 10.1186/s13017-022-00437-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/25/2022] [Indexed: 12/04/2022] Open
Abstract
Background The treatment strategies for acute appendicitis, such as emergency appendectomy (EA), interval appendectomy (IA), and repeating nonoperative management (NOM), are controversial. In this study, we examined the preoperative factors that can be used to distinguish which patients should undergo IA. Methods We retrospectively identified 902 patients who underwent surgery for appendicitis in our hospital from January 2010 to December 2021. Of these patients, 776 were included in this study. The patients were divided into two groups: those with a periappendiceal fluid collection (PAFC) on preoperative computed tomography (PAFC-positive group, n = 170) and those without a PAFC (PAFC-negative group, n = 606). In each group, we compared patients who underwent EA and IA. Results In the PAFC-positive group, patients who underwent EA had a significantly higher postoperative complication rate than those who underwent IA (40.5% vs. 24.0%, p = 0.037). In the multivariate analysis, only the presence of PAFC was significantly associated with an increased risk of postoperative complications (odds ratio, 7.11; 95% confidence interval, 2.73–18.60; p < 0.001). The presence of PAFC alone was not significantly associated with an increased risk of IA or NOM failure (odds ratio, 1.48; 95% confidence interval, 0.19–11.7; p = 0.71). The rate of neoplasia on pathologic examination was significantly higher in the PAFC-positive than PAFC-negative group (7.6% vs. 1.5%, p < 0.001); the rate of carcinoma was also higher in the PAFC-positive group (2.4% vs. 0.17%, p = 0.02). Conclusions The presence of PAFC on preoperative computed tomography was found to be a risk factor for postoperative complications but not IA or NOM failure. It was also correlated with neoplasia as the etiology of appendicitis. Therefore, PAFC positivity is useful as an indication for IA.
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Affiliation(s)
- Shintaro Kanaka
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan.
| | - Satoshi Mizutani
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Yasuyuki Yokoyama
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Takeshi Matsutani
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Naoto Chihara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Akira Katsuno
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Hideyuki Takata
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Ryosuke Nakata
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Keisuke Mishima
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Yudai Wada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Takao Shimizu
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Ryo Yamagiwa
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Takahiro Haruna
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Yuka Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Akira Hamaguchi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Nobuhiko Taniai
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Musashikosugi Hospital, 1-383 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
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22
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Di Nuzzo MM, De Werra C, Pace M, Franca RA, D’Armiento M, Bracale U, Lionetti R, D’Ambra M, Calogero A. Promoting Laparoscopic Anterior Approach for a Very Low Presacral Primary Neuroendocrine Tumor Arising in a Tailgut Cyst. Healthcare (Basel) 2022; 10:healthcare10050805. [PMID: 35627942 PMCID: PMC9141776 DOI: 10.3390/healthcare10050805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/13/2022] [Accepted: 04/25/2022] [Indexed: 02/07/2023] Open
Abstract
Background: Tailgut cysts are rare congenital lesions that develop in the presacral space. As they can potentially conceal primary neuroendocrine tumors, surgical excision is suggested as the treatment of choice. However, specific management guidelines have yet to be developed. A posterior approach is usually preferred for cysts extending to the third sacral vertebral body. Conversely, a transabdominal approach is preferred for lesions extending upward to achieve an optimal view of the surgical field and avoid injuries. Case report: Here, we report a case of a 48-year-old man suffering from perianal pain and constipation. Digital rectal examination and magnetic resonance imaging revealed a presacral mass below the third sacral vertebral body. A laparoscopic transabdominal presacral tumor excision was performed. The final histological diagnosis was a rare primary neuroendocrine tumor arising from a tailgut cyst. The postoperative course was uneventful, and no signs of recurrence were observed at the six-month follow-up. Conclusions: This study may help establish more well-grounded recommendations for the surgical management of rectal tumors, demonstrating that the laparoscopic transabdominal technique is safe and feasible, even for lesions below the third sacral vertebral body. This approach provided an adequate view of the presacral space, facilitating the preservation of cyst integrity, which is essential in cases of malignant pathologies.
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Affiliation(s)
- Maria Michela Di Nuzzo
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
- Correspondence: ; Tel.: +39-33-8936-9828
| | - Carlo De Werra
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
| | - Mirella Pace
- Department of Biomorfological and Functional Sciences, University of Naples Federico II, 80138 Naples, Italy; (M.P.); (R.A.F.)
| | - Raduan Ahmed Franca
- Department of Biomorfological and Functional Sciences, University of Naples Federico II, 80138 Naples, Italy; (M.P.); (R.A.F.)
| | - Maria D’Armiento
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
| | - Umberto Bracale
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
| | - Ruggero Lionetti
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
| | - Michele D’Ambra
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
| | - Armando Calogero
- Department of Public Health, University of Naples Federico II, 80138 Naples, Italy; (C.D.W.); (M.D.); (U.B.); (R.L.); (M.D.); (A.C.)
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23
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Reiter S, Rog CJ, Alassas M, Ong E. Progression to pseudomyxoma peritonei in patients with low grade appendiceal mucinous neoplasms discovered at time of appendectomy. Am J Surg 2021; 223:1183-1186. [PMID: 34879923 DOI: 10.1016/j.amjsurg.2021.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/03/2021] [Accepted: 12/01/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The discovery of a low grade appendiceal mucinous neoplasm (LAMN) during appendectomy is a rare scenario. These neoplasms can progress to pseudomyxoma peritonei (PMP), however the incidence of progression is not well known. METHODS The records of all patients with a diagnosis of localized LAMN found during appendectomy were identified, and demographic, tumor, surveillance, and outcome variables were analyzed. RESULTS Progression to PMP occurred in 20% of patients in an average of 12.4 months after appendectomy with median follow-up of 18 months. Tumor variables such as margin positivity, appendiceal perforation, and presence of extra-appendiceal acellular mucin or mucinous epithelium on the serosal were not significantly associated with progression. CONCLUSIONS During an average follow-up period of 18 months after surgery, progression to PMP occurred in a fifth of patients. It is difficult to predict which patients will progress, therefore cross-sectional imaging surveillance is recommended for all patients.
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Affiliation(s)
- Shelby Reiter
- Department of Surgery, Division of Surgical Oncology, Swedish Medical Center, 747 Broadway, Heath 10, Suite 1003, Seattle, WA, 98122, USA.
| | - Colin J Rog
- Department of Surgery, Division of Surgical Oncology, Swedish Medical Center, 747 Broadway, Heath 10, Suite 1003, Seattle, WA, 98122, USA.
| | - Mohamed Alassas
- Department of Surgery, Division of Surgical Oncology, Swedish Medical Center, 747 Broadway, Heath 10, Suite 1003, Seattle, WA, 98122, USA.
| | - Evan Ong
- Department of Surgery, Division of Surgical Oncology, Swedish Medical Center, 747 Broadway, Heath 10, Suite 1003, Seattle, WA, 98122, USA.
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24
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Teng TZJ, Thong XR, Lau KY, Balasubramaniam S, Shelat VG. Acute appendicitis-advances and controversies. World J Gastrointest Surg 2021; 13:1293-1314. [PMID: 34950421 PMCID: PMC8649565 DOI: 10.4240/wjgs.v13.i11.1293] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/24/2021] [Accepted: 09/29/2021] [Indexed: 02/06/2023] Open
Abstract
Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon's practice. With the recent advancements in AA's management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon's repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic's repercussions on patients and how surgeons' practices have evolved in the context of AA.
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Affiliation(s)
- Thomas Zheng Jie Teng
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | - Xuan Rong Thong
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | - Kai Yuan Lau
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
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25
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Peltrini R, Podda M, Di Saverio S, Bracale U, Corcione F. Interval appendicectomy for complicated appendicitis: do not let your guard down! Br J Surg 2021; 108:e288-e289. [PMID: 33970230 DOI: 10.1093/bjs/znab158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/13/2021] [Indexed: 11/12/2022]
Affiliation(s)
- R Peltrini
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - M Podda
- Department of Emergency Surgery, Cagliari University Hospital 'Duilio Casula', Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - S Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Varese, Italy
| | - U Bracale
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - F Corcione
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
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26
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Guevara-Cuellar CA, Rengifo-Mosquera MP, Parody-Rúa E. Cost-effectiveness analysis of nonoperative management versus open and laparoscopic surgery for uncomplicated acute appendicitis in Colombia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:34. [PMID: 34112179 PMCID: PMC8194214 DOI: 10.1186/s12962-021-00288-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/01/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Traditionally, uncomplicated acute appendicitis (AA) has been treated with appendectomy. However, the surgical alternatives might carry out significant complications, impaired quality of life, and higher costs than nonoperative treatment. Consequently, it is necessary to evaluate the different therapeutic alternatives' cost-effectiveness in patients diagnosed with uncomplicated appendicitis. METHODS We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18-60 years with a diagnosis of uncomplicated AA from the payer´s perspective at the secondary and tertiary health care level. The time horizon was 5 years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed. METHODS We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18-60 years with a diagnosis of uncomplicated AA from the payer's perspective at the secondary and tertiary health care level. The time horizon was five years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed. RESULTS LA presents a lower cost ($363 ± 35) than OA ($384 ± 41) and NOM ($392 ± 44). NOM exhibited higher QALYs (3.3332 ± 0.0276) in contrast with LA (3.3310 ± 0.057) and OA (3.3261 ± 0.0707). LA dominated the OA. The ICER between LA and NOM was $24,000/QALY. LA has a 52% probability of generating the highest NMB versus its counterparts, followed by NOM (30%) and OA (18%). There is a probability of 0.69 that laparoscopy generates more significant benefit than medical management. The mean value of that incremental NMB would be $93.7 per patient. CONCLUSIONS LA is a cost-effectiveness alternative in the management of patients with uncomplicated AA. Besides, LA has a high probability of producing more significant monetary benefits than NOM and OA from the payer's perspective in the Colombian health system.
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Affiliation(s)
| | | | - Elizabeth Parody-Rúa
- Faculty of Health Sciences, Universidad Icesi, Calle 18 No. 122-135 Pance, 70000, Cali, Colombia
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