Risk of Appendiceal Neoplasm in Periappendicular Abscess in Patients Treated With Interval Appendectomy vs Follow-up With Magnetic Resonance Imaging: 1-Year Outcomes of the Peri-Appendicitis Acuta Randomized Clinical Trial

Rate of Neoplasia in Patients with Complicated Acute Appendicitis Managed Nonoperatively: A Prospective Study

BACKGROUND

Recent studies suggest the rate of neoplasia in patients with complicated acute appendicitis initially managed nonoperatively is higher than previously reported.

OBJECTIVE

This study aimed to determine the incidence and predictors of neoplasia in patients with complicated appendicitis treated nonoperatively.

METHODS

We conducted a prospective cohort study of all patients who presented to a tertiary care center with acute appendicitis between 2019 and 2023. Patients with complicated appendicitis treated nonoperatively were included in the study cohort. Patient demographics, clinical course, radiological findings, and pathologic information were collected. The primary outcome was rate of neoplasia. Multivariable logistic regression analysis was performed to identify predictors of appendiceal neoplasia.

RESULTS

In total, we identified 1166 patients with acute appendicitis, of whom 75 patients had complicated appendicitis treated nonoperatively (median age 51 years [interquartile range 38-68]; 36 [48%] were female). Fifty-four (72%) patients had their appendix removed due to failure of nonoperative management, recurrent symptoms, suspicion of neoplasia, or elective surgery. The neoplasia rate among patients with complicated appendicitis initially treated nonoperatively was 16.0% (12/75). Two patients with neoplasia were younger than 40 years of age. Suspicion of malignancy on initial imaging was associated with an increased risk of appendiceal neoplasia (odds ratio 8.13, 95% confidence interval 1.20-55.15; p = 0.03). Age, sex, and appendiceal diameter were not significantly associated with appendiceal neoplasia.

CONCLUSIONS

The high rate of appendiceal neoplasia in patients with complicated appendicitis treated nonoperatively should be a factor in decision making for interval appendectomy for patients of all ages.

Appendiceal Tumor Prevalence in Patients With Periappendicular Abscess

Importance

There are no large prospective cohort studies validating the previously reported high appendiceal tumor rate in patients with periappendicular abscess.

Objective

To confirm the appendiceal neoplasm rate associated with periappendicular abscess.

Design, Setting, and Participants

The Peri-Appendicitis Acuta Tumor prospective multicenter cohort study was conducted at 12 hospitals in Finland. All consecutive adult patients diagnosed with acute appendicitis were included, focusing on patients with imaging confirmed periappendicular abscess undergoing interval appendectomy or emergency appendectomy with available histopathology from December 3, 2020, through December 2, 2022. These data were analyzed from May 2023 to September 2024.

Interventions

Recommended treatment was initial antibiotics and, if needed, drainage, followed by interval appendectomy at 3 months.

Main Outcomes and Measures

The main outcome was appendiceal tumor rate associated with periappendicular abscess. Secondary outcomes included tumor histology and prognostic factors for appendiceal tumor (age, sex, body mass index, duration of symptoms, C-reactive protein level, white blood cell count, computed tomography findings, and tumor markers).

Results

There were 6165 consecutive patients with acute appendicitis. Of these, 396 patients (6.4%) presented with periappendicular abscess, with 9 patients declining to participate and 17 patients without available appendiceal histopathology, leaving 370 patients for the analysis (181 female [48.8%] and 189 male [51.2%]; median age, 58 [range, 18-90] years). Appendiceal tumor rate in patients with periappendicular abscess was 14.3% (53 of 370; 95% CI, 10.8%-17.9%), which was higher compared with uncomplicated acute appendicitis (14.3% vs 1.5%; 48 of 3170; 95% CI, 1.1%-1.9%; P < .001) and complicated acute appendicitis without periappendicular abscess (14.3% vs 2.4%; 63 of 2599; 95% CI, 1.8%-3.0%; P < .001). Patient age (odds ratio, 1.06; 95% CI, 1.04-1.09; P < .001) was the only factor associated with periappendicular abscess tumor prevalence. A cutoff point of age 35 years with high sensitivity was chosen (area under the curve, 0.75; 95% CI, 0.68-0.82) and only 1 patient below this threshold presented with an appendiceal tumor (sensitivity, 98.1%; 95% CI, 94.5-100). Of the 54 tumors on 53 patients, there were 21 low-grade appendiceal mucinous neoplasms, 20 adenocarcinomas, 8 adenomas, and 5 neuroendocrine tumors. The complication rate of emergency appendectomy was higher than after interval appendectomy (31.3% [70 of 224] vs 4.8% [5 of 105], respectively [P < .001]).

Conclusions and Relevance

This large prospective cohort study confirmed a high appendiceal tumor rate associated with periappendicular abscess, especially in patients older than 35 years. At the least, all patients older than 35 years should undergo routine interval appendectomy.

Trial Registration

ClinicalTrials.gov Identifier: NCT04634448.

Clinical outcomes and optimal indications for nonoperative management of acute appendicitis in adult patients: a comprehensive literature review

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.

Swedish national guidelines for diagnosis and management of acute appendicitis in adults and children

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.

A randomized double-blind noninferiority clinical multicenter trial on oral moxifloxacin versus placebo in the outpatient treatment of uncomplicated acute appendicitis: APPAC IV study protocol

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Factors Predicting Incidentally Found Appendiceal Tumors Following Appendectomy: Propensity Score Matching Analysis

PURPOSE

The factors that predict coincidental appendiceal neoplasms in patients who underwent appendectomy due to appendicitis were investigated.

METHODS

5829 patients diagnosed with appendicitis and underwent appendectomy in the department of surgery were examined. Among these patients, patients with appendiceal neoplasia and benign pathology were selected by propensity score matching analysis in a ratio of 1:4. As a result of analysis, 74 and 274 patients were grouped as appendiceal neoplasia and benign pathology, respectively.

RESULTS

The mean age of the 348 appendiceal neoplasia and benign pathology groups included in the study was 45.6 and 46.4, respectively. Appendiceal diameter, contrast enhancement in the appendix wall, and neutrophil count were independent parameters for appendiceal neoplasia pathology. The AUC value of the combination of appendix diameter, lack of enhancement in the appendix wall, and neutrophil count in distinguishing appendiceal neoplasia pathology was 0.787.

CONCLUSION

Appendix diameter, lack of wall enhancement, and neutrophil count are the three predictive indicators useful in helping clinicians suspect appendiceal neoplasms.

Clinical prediction model for gangrenous appendicitis: A retrospective single-center study

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Current management of acute appendicitis in adults: What you need to know

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.

Acute Appendicitis Management in Patients Aged Above 40 Years During the COVID-19 Pandemic: A Retrospective Study With Four Years of Follow-Up

Background The COVID-19 pandemic led many units to increase their utilization of nonoperative management (NOM) of acute appendicitis, with the literature showing its non-inferiority when compared to operative management (OM). Therefore, we compared NOM to OM against standard guidelines in order to ascertain the effectiveness of NOM. Primary outcomes were rates of admission, complications, hospital length of stay (LOS), and the incidence of colonic malignancy following NOM upon subsequent bowel evaluation using colonoscopy and/or computed tomography (CT) scan. Methods This was a retrospective observational study done on patients who were admitted with acute appendicitis from January 2020 to January 2022 at Wirral University Teaching Hospital, UK. Data was electronically collected from medical records. Inclusion criteria were patients aged 40 years and above, admitted with a diagnosis of acute appendicitis using a CT scan, and who underwent either OM or NOM. Exclusion criteria were patients below 40 years old or not diagnosed with acute appendicitis. Results This study included 211 cases of acute appendicitis (female to male: 110:101), with a median age of 60. One hundred and twenty-five (60%) patients were managed operatively, while 86 cases (40%) were managed by NOM. All of the cases were diagnosed using a CT scan. The mean LOS for operative and non-operative cases were 4.77 and 4.89 days, respectively. When readmission days were added over the following three years, adjusted LOS was 5.35 days for operative cases, in comparison to 10.86 days for NOM. Forty-five percent of NOM cases had at least one episode of readmission, with 37% of them being in the first year. We found six cases of malignancy in the NOM cohort, none of which were detected on colonoscopy following discharge. Conclusion NOM is associated with increased LOS and increased readmission rates, and 44% of cases eventually required appendicectomy.

Appendiceal Neoplasm in Conservatively Managed Acute Appendicitis: A Retrospective Observational Study

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.

Predictive factors for recurrent acute appendicitis after conservative treatment

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.

Management of Uncomplicated Appendicitis in Adults: A Nationwide Analysis From 2018 to 2019

INTRODUCTION

Nonoperative management (NOM) of uncomplicated appendicitis (UA) has been increasingly utilized in recent years. The aim of this study was to describe nationwide trends of sociodemographic characteristics, outcomes, and costs of patients undergoing medical versus surgical management for UA.

METHODS

The 2018-2019 National (Nationwide) Inpatient Sample was queried for adults (age ≥18 y) with UA; diagnosis, as well as laparoscopic and open appendectomy, were defined by the International Classification of Diseases, 10th Revision, Clinical Modification codes. We examined several characteristics, including cost of care and length of hospital stay.

RESULTS

Among the 167,125 patients with UA, 137,644 (82.4%) underwent operative management and 29,481 (17.6%) underwent NOM. In bivariate analysis, we found that patients who had NOM were older (53 versus 43 y, P < 0.001) and more likely to have Medicare (33.6% versus 16.1%, P < 0.001), with higher prevalence of comorbidities such as diabetes (7.8% versus 5.5%, P < 0.001). The majority of NOM patients were treated at urban teaching hospitals (74.5% versus 66.3%, P < 0.001). They had longer LOS's (5.4 versus 2.3 d, P < 0.001) with higher inpatient costs ($15,584 versus $11,559, P < 0.001) than those who had an appendectomy. Through logistic regression we found that older patients had up to 4.03-times greater odds of undergoing NOM (95% CI: 3.22-5.05, P < 0.001).

CONCLUSIONS

NOM of UA is more commonly utilized in patients with comorbidities, older age, and those treated in teaching hospitals. This may, however, come at the price of longer length of stay and higher costs. Further guidelines need to be developed to clearly delineate which patients could benefit from NOM.

Is non-operative treatment of acute appendicitis possible: A narrative review

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.

SAGES guideline for the diagnosis and treatment of appendicitis

BACKGROUND

Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis.

METHODS

A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts.

RESULTS

Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty.

CONCLUSIONS

These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.

Controversies and Future Directions in Management of Acute Appendicitis: An Updated Comprehensive Review

Globally, acute appendicitis has an estimated lifetime risk of 7-8%. However, there are numerous controversies surrounding the management of acute appendicitis, and the best treatment approach depends on patient characteristics. Non-operative management (NOM), which involves the utilization of antibiotics and aggressive intravenous hydration, and surgical appendectomy are valid treatment options for healthy adults. NOM is also ideal for poor surgical candidates. Another important consideration is the timing of surgery, i.e., the role of interval appendectomy (IA) and the possibility of delaying surgery for a few hours on index admission. IA refers to surgical removal of the appendix 8-12 weeks after the initial diagnosis of appendicitis. It is ideal in patients with a contained appendiceal perforation on initial presentation, wherein an initial nonoperative approach is preferred. Furthermore, IA can help distinguish malignant and non-malignant causes of acute appendicitis, while reducing the risk of recurrence. On the contrary, a decision to delay appendectomy for a few hours on index admission should be made based on the patients' baseline health status and severity of appendicitis. Post-operatively, surgical drain placement may help reduce postoperative complications; however, it carries an increased risk of drain occlusion, fistula formation, and paralytic ileus. Furthermore, one of the most critical aspects of appendectomy is the closure of the appendiceal stump, which can be achieved with the help of endoclips, sutures, staples, and endoloops. In this review, we discuss different aspects of management of acute appendicitis, current controversies in management, and the potential role of endoscopic appendectomy as a future treatment option.

Tuberculous peritonitis after conservative treatment for acute perforated appendicitis: a case report

BACKGROUND

Interval appendectomy is widely recommended for patients with abscesses due to perforated appendicitis. A concomitant malignancy-related problem was reported after conservative treatment of acute appendicitis with abscess, but perforated appendicitis-associated tuberculous peritonitis was never reported.

CASE PRESENTATION

A 67-year-old male patient with a laryngeal cancer history presented to our hospital with an acute appendicitis-associated ileal abscess. He was scheduled for an interval appendectomy after conservative treatment. Fortunately, the symptoms subsided, and the patient was discharged for a later scheduled appendectomy. However, after 3 months, he was readmitted to our hospital with fever and abdominal pain, and emergency surgery was performed, which was suspected to be peritonitis. Intraoperative results revealed numerous white nodules in the abdominal cavity. The condition was diagnosed as tuberculous peritonitis based on macroscopic results, later pathological findings, and positive T-SPOT.TB. The antituberculosis medications were effective, and the patient recovered and was discharged from the hospital 8 days thereafter.

CONCLUSION

Patients, particularly those immunocompromised, may develop tuberculous peritonitis after conservative treatment for acute perforated appendicitis.

Retrospective analysis of the incidence of appendiceal neoplasm and malignancy in patients treated for suspected acute appendicitis

BACKGROUND

Nonoperative management of uncomplicated appendicitis is currently being promoted as treatment option, albeit 0.7-2.5% of appendectomies performed due to suspected acute appendicitis show histologically malignant findings. The purpose of this study was to investigate the incidence of neoplasm and malignancy of the appendix in patients presenting with suspected acute appendicitis in real world setting.

METHODS

This is a retrospective single-centre investigation of 457 patients undergoing appendectomy between the years 2017-2020. The patients' demographics, symptoms and diagnosis, intraoperative findings, and histopathological results were analysed.

RESULTS

In 3.7% (n = 17) histological analysis revealed neoplasms or malignancies. Median age was 48 years (20-90 years), without sex predominance. Leukocytes (11.3 ± 3.7 G/l) and C-reactive protein (54.2 ± 69.0 mg/l) were elevated. Histological analysis revealed low-grade mucinous appendiceal neoplasia (n = 3), sessile serrated adenoma of the appendix (n = 3), neuroendocrine tumours (n = 7), appendiceal adenocarcinoma of intestinal type (n = 3), and goblet cell carcinoma (n = 1). Additional treatment varied between no treatment or follow-up due to early tumour stage (n = 4), follow-up care (n = 3), additional surgical treatment (n = 8), or best supportive care (n = 2).

CONCLUSIONS

Preoperative diagnosis of appendiceal tumours is difficult. Nonoperative management of patients with acute, uncomplicated appendicitis potentially prevents the correct diagnosis of malignant appendiceal pathologies. Therefore, close follow-up or surgical removal of the appendix is mandatory.

Appendicitis to multivisceral transplantation: a career experience with appendiceal malignancy

John Hunter is regarded as the father of scientific surgery. His principles involved reasoning, observation and experimentation. His most powerful saying was: "Why not try the experiment?" This manuscript charts a career in abdominal surgery ranging from the treatment of appendicitis to the development of the largest appendiceal tumour centre in the world. The journey has led to the first report of a successful multivisceral and abdominal wall transplant for patients with recurrent non-resectable pseudomyxoma peritonei. We all stand on the shoulders of giants and surgery progresses by learning from the past while being prepared to experiment into the future.

Appendiceal adenocarcinoma, diagnosed after acute perforated appendicitis: Potential contribution of HIPEC

INTRODUCTION

Treatment of peritoneal metastasis from appendicular adenocarcinoma consists of cyto-reductive surgery (CRS) and Hyperthermic IntraPEritoneal Chemotherapy (HIPEC). In case of acute appendicular syndrome (AAS) the tumor is likely to be perforated. In that case, there is no treatment recommendation. We propose CRS and HIPEC.

MATERIALS AND METHOD

We listed 21 consecutive patients who were addressed for discovery of appendiceal adenocarcinoma. The emergency surgery was performed in a primary-care hospital. We evaluated the therapeutic algorithms, per operative decision, survival and recurrent rate.

RESULTS

Among the 21 patients, 4 patients were diagnosed as synchronous appendicular peritoneal metastasis, and underwent CRS and HIPEC. The other 17 patients with diagnosis of adenocarcinoma on anatomopathological samples, without peritoneal metastasis during appendectomy, were addressed. Between them 2 patients were denied CRS. Among the 15 operated patients, 8 patients had no peritoneal metastasis discovery during surgery, and therefore underwent prophylactic CRS and HIPEC. Peritoneal metastasis were discovered for the other 7 patients, who also underwent CRS and HIPEC. For the prophylactic group, the recurrence rate is 12,5 %, overall survival (OS) is 100 %. The rate of grade III-IV surgical complications after CRS and HIPEC was 36 % among the 19 patients who underwent surgery.

CONCLUSION

In case of appendectomy in emergency situations for perforated adenocarcinoma, half of the patients may have peritoneal metastasis. In case of non-identified peritoneal metastasis during CRS, performing a prophylactic HIPEC seems to be associated with an encouraging rate of peritoneal disease free situation at 5 years.

[Acute appendicitis in adults]

Acute appendicitis in adults. Clinical guidelines.

Risk of appendiceal malignancy in conservatively treated acute appendicitis

BACKGROUND AND AIMS

Appendectomy has historically been the standard treatment of acute appendicitis, but lately, conservative treatment of uncomplicated acute appendicitis with antibiotics has successfully been used in selected patients. Complicated acute appendicitis is often treated conservatively initially, but may benefit from interval appendectomy due to the higher risk of appendiceal malignancy and recurrence. Recommendations for follow-up after conservatively treated appendicitis vary. Furthermore, the risk of underlying malignancy and the necessity of routine interval appendectomy are unclear. This study aims to evaluate follow-up status, recurrence, and underlying appendiceal malignancy in conservatively treated uncomplicated and complicated acute appendicitis.

METHODS

This study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and data on follow-up, recurrence, number of appendectomies after initial conservative treatment, and underlying malignancy were retrieved from medical charts.

RESULTS

The study cohort included 391 patients, 152 with uncomplicated and 239 with complicated acute appendicitis. Median time of study follow-up was 52 months. The recurrence risk was 23 (15.1%) after uncomplicated and 58 (24.3%) after complicated acute appendicitis (p = 0.030). During follow-up, 55 (23%) patients with complicated acute appendicitis underwent appendectomy. Appendiceal malignancies were found in 12 (5%) patients with previous complicated acute appendicitis versus no appendiceal malignancies after uncomplicated acute appendicitis (p = 0.002).

CONCLUSION

The risk of appendiceal malignancy and recurrent appendicitis was significantly higher in patients with complicated acute appendicitis compared with uncomplicated acute appendicitis.

Comparison of treatment methods in plastron appendicitis: a tertiary center experience

BACKGROUND

It is controversial which treatment method is superior in plastron appendicitis and the research is still going on. The aim of this study is to compare treatment methods for plastron appendicitis in the adult population with our experience.

MATERIALS AND METHODS

The data of 92 patients who were diagnosed with plastron appendicitis in university hospital between 2015 and 2021 were analyzed retrospectively. Data were taken from the hospital database. The patients were divided into three groups: those treated with primary surgery, with interval appendectomy and only with conservative method.

RESULTS

Interval appendectomy resulted in a lower rate of conversion to open surgery compared to primary surgery, shorter operative time, and lower complication rates. Surgical procedures were found to be superior in detecting neoplasms compared to conservative treatment. After conservative treatment, one of three patients was retreated with the diagnosis of acute appendicitis.

CONCLUSION

In plastron appendicitis, routine interval appendectomy can be performed due to its advantages over other treatments such as the frequency of attacks after conservative treatment, the risk of the tumor being overlooked in conservative treatment, and the high rate of complications and conversion to open surgery in the primary surgery group.

Interval appendectomy as a safe and feasible treatment approach after conservative treatment for appendicitis with abscess: a retrospective, single-center cohort study

Emergency appendectomy (EA) is the gold standard management for acute appendicitis (AA). However, whether EA or interval appendectomy (IA) after conservative treatment is the optimal approach in AA with abscess remains controversial. This study compared IA and EA in patients presenting with AA accompanied by abscess. This was a retrospective single-center study including 446 consecutive patients undergoing appendectomy between April 2009 and March 2023. AA with abscess was defined as a pericecal abscess observed by computed tomography or abdominal ultrasonography, and patients with signs of peritoneal irritation were excluded. Perioperative outcomes were compared between the patients who directly underwent EA and those who underwent IA after conservative treatment. Among 42 patients (9.4%) with AA and abscess, 34 and 8 patients underwent IA and EA, respectively. The rates of ileocecal resection and postoperative complications were lower in the IA group than in the EA group (3% vs. 50%, P < 0.001 and 9% vs. 75%, P < 0.001, respectively). Colonoscopy before IA was performed in 16 of the 17 patients aged ≥ 40 years in the IA group, and one patient underwent ileocecal resection because of suspicious neoplasm in the root of the appendix. IA after conservative treatment might be considered as the useful therapeutic option for AA with abscess. Colonoscopy during the waiting period between the initial diagnosis and IA should be considered in patients aged ≥ 40 years who may have malignant changes. Implementing IA as a first-line treatment will be beneficial to both patients and healthcare providers.

Incidence of occult appendiceal neoplasm in patients over 40 years with acute appendicitis: A single-institution review

OBJECTIVE

To investigate the incidence of occult appendiceal neoplasm in patients aged 40 years and over who underwent appendicectomy for appendicitis.

METHODS

The clinical coding electronic database was used to identify patients aged 40 years and over who were diagnosed with appendicitis from September 2010 to September 2022. Patients were included if they were managed operatively.

DESIGN

Retrospective cohort study.

SETTING

Modified Monash category 3 (large rural town).

PARTICIPANTS

Patients aged 40 years and over undergoing appendicectomy for appendicitis.

MAIN OUTCOME MEASURES

Incidence of appendiceal neoplasm within appendicectomy specimen.

RESULTS

A total of 279 patients aged 40 years and over underwent appendicectomy, with a median age of 53 years (range 40-95). Nineteen patients (7%) were found to have a primary neoplastic lesion within the appendix: seven neuroendocrine neoplasms (37%), six sessile serrated lesions (32%), two colonic-type adenocarcinoma (11%), two goblet cell adenocarcinoma (11%) and two appendiceal mucinous neoplasms (11%). Additionally, one patient had a metastatic adenocarcinoma of pancreaticobiliary aetiology.

CONCLUSIONS

Occult appendiceal neoplasm was higher than reported in the literature in our cohort. This would support appendicectomy as the treatment of choice for patients aged 40 years and over with acute appendicitis and caution against nonoperative management in this demographic.

Diagnosis and treatment of appendicitis: systematic review and meta-analysis

BACKGROUND

The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children.

METHODS

Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively.

RESULTS

2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04).

CONCLUSIONS

This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.

Oncological aspect of incidental appendectomy with regard to histopathological findings: A retrospective cohort study

INTRODUCTION

The aim of this retrospective cohort study was to describe the findings on histopathological examination of removed, macroscopically non-diseased, vermicular appendix during another primary surgical procedure (incidental appendectomy (IA)). Previous studies disapproved IA but were based on the possibility of complicated appendicitis. We observed the prevalence of neoplasms of the appendix in IA versus the appendectomy performed due to acute appendicitis (AA).

METHODS

The database of histopathology reports of the Surgery Department, University Hospital of Split was reviewed in the period from January 1, 2017, to December 31, 2021. A total of 2832 histopathology reports were reviewed.

RESULTS

There was no difference in gender distribution between these two groups, but AA had a statistically significantly lower median patient age compared to the group IA (40 vs. 68 years; P < 0.001). In the AA group, there were 84.5% acute appendicitis, 11.1% normal appendiceal reports, 3.2% appendiceal neoplasms, and 1.2% other pathologies. The group IA had 89.5% normal findings of the appendix, 7.2% appendiceal neoplasms, and 0.5% other pathology. The difference in neoplasm prevalence between IA and AA groups was 4.0% (95%CI: 2.2 to 5.8), P < 0.001. The number of incidental appendectomies needed to detect one neoplasm of the appendix is 25.

CONCLUSION

Incidental appendectomies in patients undergoing abdominal surgery revealed a relatively high prevalence of appendiceal neoplasms above the age of 60 years. Prospective studies about incidental appendectomies, their clinical consequences, and impact on prognosis should be performed to define the value of incidental appendectomy in those patients.

High Incidence of Appendiceal Neoplasms in the Elderly: A Critical Concern for Non-Surgical Treatment

OBJECTIVE

Appendiceal neoplasms (ANs) are rare tumors that are often discovered incidentally during histopathological examinations. The increasing incidence of ANs is a critical issue in the non-operative management of acute appendicitis. This study aimed to document the temporal trends over a 12-year period by analyzing the clinical presentation, imaging findings, and histopathological features of ANs.

SUBJECTS AND METHODS

Health records of patients who underwent appendectomy from 2011 to 2022 were examined. Demographic and clinical data, laboratory results, imaging findings, and histopathological features were documented. The characteristics of both ANs and non-neoplastic cases were evaluated.

RESULTS

A total of 22,304 cases were identified, of which 330 (1.5%) were diagnosed with ANs. The odds ratio for ANs increased with age, with the highest odds ratio observed in patients aged 70 or older. Receiver Operating Characteristic analysis showed that age and appendiceal diameter were significant predictors of ANs. An optimal age cut-off point of 28.5 years was determined, yielding a sensitivity of 72% and a specificity of 64%. For appendiceal diameter, the optimal cut-off was found to be 9.5 mm, exhibiting a sensitivity of 77% and a specificity of 56%.

CONCLUSION

Although the incidence of ANs remains relatively low, a steady increase has been observed over the past decade. The increasing rate of ANs raises concerns regarding non-surgical management options. The results of this study highlight the importance of considering ANs as a potential diagnosis in older patients and in patients with an appendix diameter greater than 9.5 mm. These findings may have implications for treatment and management.

Appendiceal Mucinous Neoplasms: From Clinic to Pathology and Prognosis

Appendiceal mucinous neoplasms have been classified differently over time causing confusion when comparing results between working groups in this field and establishing a prognosis of the disease. A historical perspective of the different classification systems of these tumors is essential for the understanding of the evolution of concepts and histopathological definitions that have led up to the present moment. We carried out a systematic review of the pathological classifications of appendiceal mucinous tumors and how they have included the new criteria resulting from clinical and pathological research. The latest classifications by PSOGI and AJCC 8th edition Cancer Staging have made a great effort to incorporate the new pathological descriptions and develop prognostic groups. The introduction of these new classification systems has posed the challenge of verifying how they adapt to our casuistry and which one defines best the prognosis of our patients. We reclassified our series of patients treated for mucinous appendiceal tumors with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy following the PSOGI and the AJCC 8th edition criteria and concluded that both classifications correspond well with the OS and DFS of these patients, with some advantage relative to the PSOGI classification due to a better histopathological description of the different groups.

Factors associated with recurrent appendicitis after nonoperative management

BACKGROUND

The objective of this study is to identify predictors for recurrent appendicitis in patients with appendicitis previously treated nonoperatively.

METHODS

This is a prospective cohort study of all adult patients with appendicitis treated at a tertiary care hospital. Patient demographics, radiographic information, management, and clinical outcomes were recorded. The primary outcome was recurrent appendicitis within 6 months after discharge from the index admission. Given the competing risk of interval appendectomy, a time-to-event competing-risk analysis was performed.

RESULTS

Of the 699 patients presenting with appendicitis, 74 were treated nonoperatively (35 [47%] were women; median [IQR] age, 48 [33,64] years), and 21 patients (29%) had recurrent appendicitis. On univariate and multivariate analysis, presence of an appendicolith on imaging was the only factor associated with a higher risk of recurrent appendicitis (p = 0.02).

CONCLUSIONS

The presence of appendicolith was associated with an increased risk of developing recurrent appendicitis within 6 months.

Infection or Inflammation: Are Uncomplicated Acute Appendicitis, Acute Cholecystitis, and Acute Diverticulitis Infectious Diseases?

Background: It is recognized increasingly that common surgical infections of the peritoneal cavity may be treated with antibiotic agents alone, or source control surgery with short-course antimicrobial therapy. By extension, testable hypotheses have emerged that such infections may not actually be infectious diseases, but rather represent inflammation that can be treated successfully with neither surgery nor antibiotic agents. The aim of this review is to examine extant data to determine which of uncomplicated acute appendicitis (uAA), uncomplicated acute calculous cholecystitis (uACC), or uncomplicated mild acute diverticulitis (umAD) might be amenable to management using supportive therapy alone, consistent with the principles of antimicrobial stewardship. Methods: Review of pertinent English-language literature and expert opinion. Results: Only two small trials have examined whether uAA can be managed with observation and supportive therapy alone, one of which is underpowered and was stopped prematurely because of challenging patient recruitment. Data are insufficient to determine the safety and efficacy of non-antibiotic therapy of uAA. Uncomplicated acute calculous cholecystitis is not primarily an infectious disease; infection is a secondary phenomenon. Even when bactibilia is present, there is no high-quality evidence to suggest that mild disease should be treated with antibiotic agents. There is evidence to indicate that antibiotic prophylaxis is indicated for urgent/emergency cholecystectomy for uACC, but not in the post-operative period. Uncomplicated mild acute diverticulitis, generally Hinchey 1a or 1b in current nomenclature, does not benefit from antimicrobial agents based on multiple clinical studies. The implication is that umAD is inflammatory and not an infectious disease. Non-antimicrobial management is reasonable. Conclusions: Among the considered disease entities, the evidence is strongest that umAD is not an infectious disease and can be treated without antibiotic agents, intermediate regarding uACC, and lacking for uAA. A plausible hypothesis is that these inflammatory conditions are related to disruption of the normal microbiome, resulting in dysbiosis, which is defined as an imbalance of the natural microflora, especially of the gut, that is believed to contribute to a range of conditions of ill health. As for restorative pre- or probiotic therapy to reconstitute the microbiome, no recommendation can be made in terms of treatment, but it is not recommended for prevention of primary or recurrent disease.

Clinicopathologic parameters and outcomes of mucinous neoplasms confined to the appendix: a benign entity with excellent prognosis

Appendiceal mucinous neoplasms (AMNs), characterized by expansile or "pushing" growth of neoplastic epithelium through the appendix wall, are sometimes accompanied by peritoneal involvement, the extent and grade of which largely determine clinical presentation and long-term outcomes. However, the prognosis of tumors entirely confined to the appendix is still debated and confusion remains regarding their biologic behavior and, consequently, their clinical management and even diagnostic nomenclature. We evaluated AMNs limited to the appendix from 337 patients (median age: 58 years, interquartile range (IQR): 47-67), 194 (57.6%) of whom were women and 143 (42.4%) men. The most common clinical indication for surgery was mass or mucocele, in 163 (48.4%) cases. Most cases (N = 322, 95.5%) comprised low-grade epithelium, but there were also 15 (4.5%) cases with high-grade dysplasia. Lymph nodes had been harvested in 102 (30.3%) cases with a median 6.5 lymph nodes (IQR: 2-14) per specimen for a total of 910 lymph nodes examined, all of which were negative for metastatic disease. Histologic slide review in 279 cases revealed 77 (27.6%) tumors extending to the mucosa, 101 (36.2%) to submucosa, 33 (11.8%) to muscularis propria, and 68 (24.4%) to subserosal tissues. In multivariate analysis, deeper tumor extension was associated with older age (p = 0.032; odds ratio (OR): 1.02, 95% confidence intervals (CI): 1.00-1.03), indication of mass/mucocele (p < 0.001; OR: 2.09, CI: 1.41-3.11), and wider appendiceal diameter, grossly (p < 0.001; OR: 1.61, CI: 1.28-2.02). Importantly, among 194 cases with at least 6 months of follow-up (median: 56.1 months, IQR: 24.4-98.5), including 9 high-grade, there was no disease recurrence/progression, peritoneal involvement (pseudomyxoma peritonei), or disease-specific mortality. These data reinforce the conclusion that AMNs confined to the appendix are characterized by benign biologic behavior and excellent clinical prognosis and accordingly suggest that revisions to their nomenclature and staging would be appropriate, including reverting to the diagnostic term mucinous adenoma in order to accurately describe a subset of them.

Demographic trends in the incidence of malignant appendiceal tumours in England between 1995 and 2016: Population-based analysis

AIMS

Recent data suggest that the incidence of malignant appendiceal tumours is increasing. This study aimed to determine temporal trends in the incidence of malignant appendiceal tumours within England and a possible influence by demographic factors.

METHODS

All incident cases of appendiceal tumours in patients aged 20 years and above were identified from the National Cancer Registration and Analysis Service database between 1995 and 2016 using ICD-9/10 codes. Cancers were categorized according to histology. Joinpoint regression analysis was used to investigate changes in age-standardized incidence rates by age, sex, histological subtype and index of multiple deprivation quintiles, based on socioeconomic domains (income, employment, education, health, crime, barriers to housing and services and living environment). Average annual per cent changes (AAPCs) were estimated by performing Monte-Carlo permutation analysis.

RESULTS

A total of 7333 tumours were diagnosed and 7056 patients were analysed, comprising 3850 (54.6 per cent) neuroendocrine tumours (NETs), 1892 (26.8 per cent) mucinous adenocarcinomas and 1314 (18.6 per cent) adenocarcinoma (not otherwise specified). The overall incidence of appendiceal tumours increased from 0.3 per 100 000 to 1.6 per 100 000 over the study interval. Incidence rate increases of comparable magnitude were observed across all age groups, but the AAPC was highest among patients aged 20-29 years (15.6 per cent, 95 per cent c.i 12.7-18.6 per cent) and 30-39 years (14.2 per cent, 12.2-16.2 per cent) and lowest among those aged 70-79 years (6.8 per cent, 5.7-8.0 per cent). Similar incidence rate increases were reported across all socioeconomic deprivation quintiles and in both sexes. Analysis by grade of NET showed that grade 1 tumours accounted for 63 per cent between 2010 and 2013, compared with 2 per cent between 2000 and 2003.

CONCLUSIONS

The incidence rate of malignant appendiceal tumours has increased significantly since 1995 and is mainly attributed to an increase in NETs. The increased diagnosis of low-grade NETs may in part be due to changes in pathological classification systems.

Interval laparoscopic appendectomy after laparotomy drainage for acute appendicitis with abscess: A case report

INTRODUCTION

Immediate appendectomy for acute appendicitis with abscess has a high frequency of ileocecal resection and postoperative complications compared with interval appendectomy after conservative treatment. The optimal approach to acute appendicitis with abscess remains controversial.

PRESENTATION OF CASE

A 69-year-old woman was referred to our hospital for abdominal pain. A computed tomography scan revealed an enlarged abscess around the cecum. The diagnosis was perforated appendicitis with abscess, and conservative treatment was performed. Percutaneous drainage was difficult because the abscess was near the intestinal tract. Because of the persistence of symptoms on the fourth day of hospitalization, laparotomy drainage was performed, and the patient's condition improved afterwards. Colonoscopy was performed on an outpatient follow-up to rule out malignant tumors of the colon. Interval laparoscopic appendectomy was performed 3 months after discharge to prevent appendicitis. The postoperative course was uneventful.

DISCUSSION

For this case of acute appendicitis with abscess, conservative treatment such as antibiotic therapy and laparotomy drainage was performed. Laparotomy drainage enabled us to approach the abscess directly and minimized the risk of its spread into the abdominal cavity compared to the laparoscopic approach. Interval laparoscopic appendectomy was more effective and easier for this case of appendectomy, wherein adhesions to the abdominal wall were expected compared to laparotomy.

CONCLUSION

Conservative treatment approaches, such as drainage and antibiotic therapy, can be first-line for appendicitis with abscesses. Interval laparoscopic appendectomy can be useful to resect the appendix and observe the abdominal cavity.

Appendectomy versus nonoperative management of simple appendicitis: A post hoc analysis of an Eastern Association for the Surgery of Trauma multicenter study using a hierarchical ordinal scale

BACKGROUND

Controversy exists about the preferred initial treatment of appendicitis. We sought to compare the two treatments for initial management of simple appendicitis.

METHODS

In this post hoc analysis of the Multicenter Study for the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, subjects were divided into appendectomy or nonoperative management (NOM; antibiotics only or percutaneous drainage) cohorts. A novel topic-specific hierarchical ordinal scale was created with eight mutually exclusive categories: mortality, reoperation, other secondary interventions, readmission, emergency department visit, wound complication, surgical site infection, and no complication. Pairwise comparisons of American Association for the Surgery of Trauma Imaging Severity Grade 1 (simple appendicitis) patients were compared using win-lose-tie scoring and the sums of appendectomy/NOM groups were compared.

RESULTS

A total 3,591 subjects were included: 3,262 appendectomy and 329 NOM, with significant differences in baseline characteristics between groups. Across 28 sites, the rate of NOM ranged from 0% to 48%, and the loss to follow-up rate was significantly higher for NOM compared with appendectomy (16.5% vs. 8.7%, p = 0.024). In the simple appendicitis hierarchical ordinal scale analysis, 2,319 subjects resulted in 8,714,304 pairwise comparisons; 75% of comparisons resulted in ties. The median (interquartile range) sums for the two groups are as follows: surgical, 400 (400-400), and NOM, 400 (-2,427 to 400) (p < 0.001). A larger proportion of appendectomy subjects (88.1%) had an outcome that was equivalent (or better) than at least half of the subjects compared with NOM subjects (NOM, 70.5%; OR [95% confidence interval], 0.3 [0.2-0.4]).

CONCLUSION

In contemporary American practice, appendectomy (compared with NOM) for simple appendicitis is associated with lower odds of developing clinically important unfavorable outcomes in the first year after illness.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Appendiceal Cancer in the National Cancer Database: Increasing Frequency, Decreasing Age, and Shifting Histology

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.

Survival and prognostic factors for postoperative primary appendiceal cancer: a retrospective cohort study based on the Surveillance, Epidemiology, and End Results database

BACKGROUND

The factors affecting the postoperative survival of patients with primary appendiceal cancer (PAC) have yet to be fully explored. And there are no clear guidelines for adjuvant treatment after appendectomy. Whether chemotherapy can prolong patient survival after appendectomy, is critical in guiding postoperative medications. The majority of studies on appendiceal cancer are single case reports, and they focused on the incidence of appendiceal cancer. The present study aimed to investigate the survival characteristics of patients with primary appendiceal cancer after surgery using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

The data of 2,891 cases of primary appendiceal cancer between 2004 to 2015 were obtained from the SEER database and subjected to survival analysis using the Kaplan-Meier method and Cox proportional-hazards model. The annual percentage change (APC) was calculated using the weighted least squares method.

RESULTS

The overall age-adjusted incidence rate per 100,000 population steadily increased from 0.58 in 2004 to 1.63 in 2015. For patients who received chemotherapy, the median overall survival (OS) was 65 months and the 5-year OS rate was 51.9%, and for patients who did not receive chemotherapy or whose chemotherapy status was unknown, the median OS was not reached and the 5-year OS rate was 78.9%. Age [35< age <69: hazard radio (HR) =2.147; 95% confidence interval (CI): 1.442-3.197, P<0.001; age >69: HR =5.259; 95% CI: 3.485-7.937, P<0.001], race (White race: HR =0.728; 95% CI: 0.590-0.899, P=0.003), histologic type (mucinous neoplasm: HR =0.690; 95% CI: 0.580-0.821, P<0.001; malignant carcinoid: HR =0.657; 95% CI: 0.536-0.806, P<0.001), grade (II: HR =1.794; 95% CI: 1.471-2.187, P<0.001; III: HR =2.905; 95% CI: 2.318-3.640, P<0.001; IV: HR =3.128; 95% CI: 2.159-4.533, P<0.001), and stage (localized: HR =0.236; 95% CI: 0.194-0.287, P<0.001; regional: HR =0.425; 95% CI: 0.362-0.499, P<0.001) were identified as independent predictors of survival. And after adjusting for known factors (age, sex, race, tumor size, marital status, histologic type, grade, stage), chemotherapy (HR =1.220; 95% CI: 1.050-1.417, P=0.009) was revealed to be an independent indicator of poor prognosis.

CONCLUSIONS

There was an increasing trend in the incidence of appendiceal cancer in the United States between 2004 and 2015. Chemotherapy was revealed to be an independent indicator of poor prognosis, which provide valuable insight into the therapy of primary appendiceal cancer. Large clinical trials of chemotherapy and targeted therapy for appendiceal cancer are urgently needed.

Management of Complicated Appendicitis During Pregnancy in the US

IMPORTANCE

Data are sparse regarding the optimal treatment for complicated appendicitis during pregnancy.

OBJECTIVE

To compare nonoperative and operative management in complicated appendicitis during pregnancy.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using National Inpatient Sample data from between January 2003 and September 2015. This database approximates a 20% stratified sample of US inpatient hospital discharges. Included individuals were pregnant women discharged with the diagnosis of complicated appendicitis. Data were analyzed from February 2020 through February 2022.

EXPOSURES

Study patients were categorized into 3 groups: those with successful nonoperative management, failed nonoperative management with delayed operation, or immediate operation for complicated appendicitis.

MAIN OUTCOMES AND MEASURES

Clinical outcomes, including maternal infectious complications and perinatal complications, hospital length of stay, and total hospital charges.

RESULTS

Among 8087 pregnant women with complicated appendicitis (median [IQR] age, 27 [22-32] years), nonoperative management of complicated appendicitis was successful among 954 patients (11.8%) and failed among 2646 patients (32.7%), who underwent delayed operation; 4487 patients (55.5%) underwent immediate operation. In multivariate analysis, successful nonoperative management was associated with higher odds of amniotic infection (odds ratio [OR], 4.35; 95% CI, 2.22-8.53; P < .001) and sepsis (OR, 1.52; 95% CI, 1.10-2.11; P = .01) compared with immediate operation, while there was no significant difference in preterm delivery, preterm labor, or abortion. However, failed nonoperative management that required delayed operation was associated with higher odds of preterm delivery, preterm labor, or abortion compared with immediate operation (OR, 1.45; 95% CI, 1.24-1.68; P < .001). Immediate operation was associated with decreased hospital charges compared with nonoperative management that was successful (regression coefficient [RC], 0.09; 95% CI, 0.07-0.11; P < .001) and that failed (RC, 0.12; 95% CI: 0.11-0.14; P < .001). In subgroup multivariate logistic regression analysis, each day in delay to surgery was associated with an increase in odds of preterm delivery, preterm labor, or abortion by 23% (OR, 1.23; 95% CI, 1.18-1.29; P < .001).

CONCLUSIONS AND RELEVANCE

This study found that immediate operation for complicated appendicitis in pregnant women was associated with lower odds of maternal infectious complications without higher odds of perinatal or other maternal complications compared with successful nonoperative management. Failed nonoperative management was associated with worse clinical outcomes.

The appendix‐mucosal immunity and tolerance in the gut: consequences for the syndromes of appendicitis and its epidemiology

The cause of appendicitis is unknown. A review is presented across diverse sources relating to the biology of the appendix and its perturbations. A mechanistic model of the function of the appendix is presented, and its application to the syndromes and consequences of appendicitis is described.

The association between appendicitis severity and patient age with appendiceal neoplasm histology-a population-based study

PURPOSE

Recent studies have reported alarming appendiceal tumor rates associated with complicated acute appendicitis, especially in patients presenting with a periappendicular abscess. However, the data on histology of appendiceal tumors among acute appendicitis patients is limited, especially in patient cohorts differentiating between uncomplicated and complicated acute appendicitis. We have previously reported the association of increased appendiceal tumor prevalence with complicated acute appendicitis in this population-based study. The objective of this secondary analysis was to evaluate the association of both appendicitis severity and patient age with appendiceal tumor histology.

METHODS

This nationwide population-based registry study (The Finnish Cancer Registry) was conducted from 2007 to 2013. All appendiceal tumors (n = 840) and available medical reports (n = 504) of these patients at eight study hospitals were previously evaluated, identifying altogether 250 patients with both acute appendicitis and appendiceal tumor.

RESULTS

The severity of acute appendicitis was significantly associated with more malignant tumor histology. The risk of adenocarcinoma or pseudomyxoma was significantly higher among patients with periappendicular abscess (OR 15.05, CI 95% 6.98-32.49, p < 0.001) and patients presenting with perforated acute appendicitis (OR 4.09, CI 95% 1.69-9.90, p = 0.0018) compared to patients with uncomplicated acute appendicitis. Similarly, patient age over 40 years was significantly associated with the risk of adenocarcinoma and pseudomyxoma (OR 26.46, Cl 95% 7.95-88.09, p < 0.001). Patient sex was not associated with a more malignant appendiceal tumor histology (p = 0.67).

CONCLUSION

More malignant appendiceal tumor histology of adenocarcinoma or pseudomyxoma was significantly associated with patient age over 40 years and complicated acute appendicitis, especially periappendicular abscess.

OUP accepted manuscript

BACKGROUND

Non-operative management of uncomplicated acute appendicitis is an option, but omission of antibiotics from the regimen has not been tested.

METHODS

A double-blind, placebo-controlled, superiority RCT in adults with CT-confirmed uncomplicated acute appendicitis was designed to compare placebo with antibiotics (intravenous ertapenem followed by oral levofloxacin and metronidazole). The primary endpoint was treatment success (resolution resulting in discharge without appendicectomy within 10 days); secondary outcomes included pain scores, complications, hospital stay, and return to work.

RESULTS

From May 2017 to September 2020, 72 patients with a mean(s.d.) age of 37.5 (11.1) years were recruited at five hospitals. Six were excluded after randomization (5 early consent withdrawals, 1 randomization protocol violation), 35 were assigned to receive antibiotics, and 31 to receive placebo. Enrolment challenges (including hospital pharmacy resources in an acute-care surgery setting) meant that only the lowest sample size of three predefined scenarios was achieved. The 10-day treatment success rate was 87 (95 per cent c.i. 75 to 99) per cent for placebo and 97 (92 to 100) per cent for antibiotics. This clinical difference of 10 (90 per cent c.i. -0.9 to 21) per cent was not statistically different for the primary outcome (1-sided P = 0.142), and secondary outcomes were similar.

CONCLUSION

The lack of antibiotic superiority statistically suggests that a non-inferiority trial against placebo is warranted in adults with CT-confirmed mild appendicitis. Registration number: EudraCT 2015-003634-26 (https://eudract.ema.europa.eu/eudract-web/index.faces), NCT03234296 (http://www.clinicaltrials.gov).

MANAGEMENT OF ILEOCECAL CROHN'S DISEASE DURING SURGICAL TREATMENT FOR ACUTE APPENDICITIS: A SYSTEMATIC REVIEW

BACKGROUND

In many patients, the diagnosis of Crohn's disease (CD) is made during surgery for appendicitis in urgent settings. Intraoperative diagnosis can be challenging in certain cases, especially for less experienced surgeons.

OBJECTIVE

Review of the literature searching for scientific evidence that can guide surgeons through optimal management of ileocecal CD found incidentally in surgery for acute appendicitis (AA).

METHODS

Included studies were identified by electronic search in the PubMed database according to the Preferred Items of Reports for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The quality and bias assessments were performed by Methodological Index for Non-Randomized Studies (MINORS) criteria for non-randomized studies.

RESULTS

A total of 313 studies were initially identified, six of which were selected (all retrospective) for qualitative assessment (two studies were comparative and four only descriptive case series). Four studies identified a high rate of complications when appendectomy or ileocolectomy were performed and in only one, there was no increased risk of postoperative complications with appendectomy. In the sixth study, diarrhea, previous abdominal pain, preoperative anemia and thrombocytopenia were independent predictors for CD in patients previously operated for suspected AA.

CONCLUSION

Despite the paucity of data and low quality of evidence, a macroscopically normal appendix should be preserved in the absence of complicated disease when CD is suspected in surgery for AA. Ileocecal resections should be reserved for complicated disease (inflammatory mass, ischemia, perforation or obstruction). Further prospective studies are needed to confirm these claims.

Progression to pseudomyxoma peritonei in patients with low grade appendiceal mucinous neoplasms discovered at time of appendectomy

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.

Risk of appendiceal neoplasm after interval appendectomy for complicated appendicitis: A systematic review and meta-analysis

BACKGROUND

Non-operative management is often the treatment of choice in cases of complicated appendicitis and routine interval appendectomy is not usually recommended. Actually, recent studies show an alarming number of appendiceal neoplasms following interval appendectomy. The aim of this study is to evaluate the prevalence of appendiceal neoplasms and their histological types after interval appendectomy for complicated appendicitis in adults.

METHODS

A comprehensive literature search of the PubMed, Scopus and Web of Science databases was conducted according to the PRISMA statement. Studies reporting appendiceal neoplasm rates after interval appendectomy and histopathological characteristics were included. The most recent World Health Organization (WHO) classification of malignant tumours was considered. A pooled prevalence analysis for both prevalence and pathology was performed.

RESULTS

A total of eight studies was included: seven retrospective series and one randomized controlled trial. The pooled prevalence of neoplasms after interval appendectomy was 11% (95% CI 7-15; I2 = 37.5%, p = 0.13). Appendiceal mucinous neoplasms occurred in 43% (95% CI 19-68), adenocarcinoma in 29% (95% CI 6-51), appendiceal neuroendocrine neoplasm in 21% (95% CI 6-36), globet cell carcinoma in 13% (95% CI -2-28), adenoma or serrated lesions in 20% (95% CI -0-41) of cases.

CONCLUSION

The risk of appendiceal neoplasm in patients treated with interval appendectomy for complicated appendicitis is 11%; mucinous neoplasm is the most common histopathological type. Further studies should investigate this association in order to clarify the biological pathway and clinical implications.