Outcomes of Nonoperative vs Operative Management of Acute Appendicitis in Older Adults in the US

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.

Predictors and Trends of Hemorrhage After Bariatric Surgery Using Two Large National Datasets: A Retrospective Observational Study

INTRODUCTION

The National Inpatient Sample (NIS) is a comprehensive representative database for inpatient hospitalizations; the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database aggregates surgical outcomes from nationally accredited bariatric surgical programs. There has been no comparison of postoperative hemorrhage rates nor a comparison of predictors of hemorrhage between the two databases. The aim of this study was to compare trends and predictors of significant hemorrhage after bariatric surgery using two national databases.

METHODS

The core NIS files of the Healthcare Cost and Utilization Project and the MBSAQIP Participant Use Data Files from 2016 to 2021 were concatenated, and vertical sleeve gastrectomy and Roux-en-Y gastric bypass procedures were included. Trends in a 3-d postoperative hemorrhage requiring blood transfusion were derived from both datasets. Demographic, comorbidity, and other health factors were analyzed to construct multivariable logistic regression models.

RESULTS

Briefly, 204,866 and 1,029,979 patients were identified in the NIS and MBSAQIP, respectively, and 3-d inpatient blood transfusion rates were 0.48% and 0.64%. Anticoagulants, Black race, diabetes, and increased age were associated with higher risk of a blood transfusion in both datasets. Vertical sleeve gastrectomy had a lower transfusion risk than Roux-en-Y gastric bypass (NIS: odds ratio: 0.62; 95% confidence interval [0.53, 0.71], P < 0.05; MBSAQIP: odds ratio: 0.52 [0.49, 0.55], P < 0.05). The NIS reported consistently lower annual 3-d transfusion rates relative to the MBSAQIP.

CONCLUSIONS

Health care professionals should be aware of the associated risk factors for blood transfusion after bariatric surgery. Most blood transfusions occurred during the initial hospitalization.

High Diagnostic Accuracy but Persistent Risk of Complicated Appendicitis: A Retrospective Analysis from Hail Province, Saudi Arabia

Context

Acute appendicitis is a common surgical emergency. While clinical diagnosis is generally effective, it is not perfect, potentially leading to negative appendectomies or delayed treatment.

Aims

This study investigated the histopathological patterns of appendectomy specimens in King Khalid Hospital, Hail Province, Saudi Arabia, correlating them with preoperative clinical diagnoses to assess diagnostic accuracy and guide optimal management.

Subjects and Methods

A retrospective analysis was conducted on 198 patients who underwent appendectomies between August 2023 and July 2024. Resected appendix specimens underwent histopathological examination and were categorized as inflamed, malignant, or benign. Clinical data and histopathological findings were compared using statistical analyses, including Fisher's exact test, to assess diagnostic accuracy and explore potential associations between patient demographics, appendicitis severity, and clinical presentation.

Results

The study cohort consisted predominantly of young males (78.8%, mean age: 26 ± 9.2 years), with no pediatric cases included. The most common histopathological finding was an inflamed appendix (99.5%), with acute inflammation being most prevalent (86.9%). Perforation (10.1%) and gangrenous changes (2.5%) were also observed. A rare case of negative appendectomy (0.5%) was attributed to a perforated Meckel's diverticulum.

Conclusions

This study demonstrates a high preoperative diagnostic accuracy for acute appendicitis. However, the occurrence of negative appendectomies and complicated cases, particularly in young adult males, highlights the need for continuous vigilance and refinement of diagnostic approaches. Further research exploring age- and sex-specific risk factors for complicated appendicitis is crucial to optimizing patient management strategies and minimizing unnecessary surgical interventions.

Potential risks of nonoperative management of appendicitis in high-risk patients

INTRODUCTION

The popularity of nonoperative management for acute appendicitis is based on the untested assumption that it offers a lower risk alternative to surgery in patients who are at high risk for morbidity and mortality with appendectomy. We hypothesized that patients who were at a high risk with appendectomy would also be at a high risk for complications following nonoperative management.

METHODS

This is a retrospective cohort study of patients with acute, uncomplicated appendicitis in the 2004-2017 National Inpatient Sample. We used a logistic regression model to predict the risk of morbidity or mortality following appendectomy and applied this model to predict the risk of patients managed nonoperatively. High risk was defined as ≥2 standard deviations above the mean predicted risk of morbidity or mortality. We used inverse probability weighting of the propensity score to compare outcomes of nonoperative versus operative management for high-risk patients.

RESULTS

The sample included 21,242 high-risk patients with a median age of 68 years (interquartile range 57-78), and 31% were managed nonoperatively. Compared to surgery, nonoperative management was associated with a 9% decrease in complications (95% confidence interval [CI] 7%-10%), 2% increase in mortality (95% CI 2%-3%), $10,202 increase in hospital costs (95% CI $9,065-$11,339), 3-day increase in length of stay (95% CI 2-3), and 9% greater likelihood of discharge to skilled nursing facilities (95% CI 8%-10%).

CONCLUSION

Nonoperative management of acute appendicitis in high-risk patients may reduce morbidity but increase mortality, duration of hospitalization, discharge to skilled facility, and costs. Surgeons should exercise caution when considering nonoperative management in these vulnerable patients.

Nonoperative Management of Acute Appendicitis in the Geriatric Population: A Review

Appendicitis remains a common cause of acute abdominal pain, particularly challenging to manage in elderly patients due to age-related declines in physiological reserve and the presence of comorbidities. While appendectomy has traditionally been the standard treatment, nonoperative management (NOM) using antibiotics has emerged as a potential alternative for elderly patients, especially those considered frail or at high surgical risk. This review explores the efficacy and outcomes of NOM compared to surgery in this population, with a focus on recurrence rates, postoperative complications, and the impact of frailty on treatment decisions. Recent studies highlight both the benefits and limitations of NOM. While it can effectively manage uncomplicated appendicitis in the short term, recurrence rates are significantly higher in elderly patients, often necessitating delayed surgery, which can lead to worse outcomes. Research also shows that frail patients face elevated risks of complications, including mortality, whether treated surgically or nonoperatively. The review underscores the importance of careful patient selection, close monitoring, and individualized treatment approaches when considering NOM for elderly patients with appendicitis. Long-term risks such as recurrence, antibiotic resistance, and complications further complicate the decision-making process.

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.

Power Has Pitfalls: (In)accuracy of Administrative Data for Nonoperative Management of Appendicitis

INTRODUCTION

Nonoperative management (NOM) of uncomplicated appendicitis is increasingly common. Effectiveness of NOM has been studied by identifying patients via International Classification of Diseases (ICD) 9/ICD-10 codes for uncomplicated appendicitis and no code for appendectomy. We sought to assess the accuracy of such administrative definitions.

METHODS

We retrospectively identified patients with ICD-9/ICD-10 codes for appendicitis at five sites across the United States. Initial management plan and clinical severity were recorded by trained abstractors. We identified a gold standard cohort of patients with surgeon-diagnosed uncomplicated appendicitis and planned NOM. We defined two administrative cohorts with ICD-9/ICD-10 codes for uncomplicated appendicitis and either no surgery during initial admission (definition #1) or no surgery on day 0-1 of admission (definition #2). We compared each definition to the gold standard.

RESULTS

Among 1224 patients with uncomplicated appendicitis, 72 (5.9%) underwent planned NOM. NOM patients were older (median [Q1-Q3] of 37 [27-56] versus 32 [25-44] y) and less frequently male (51.4% versus 54.9%), White (54.1% versus 67.6%), and privately insured (38.9% versus 50.2%) than patients managed operatively. Definition #1 had sensitivity of 0.81 and positive predictive value of 0.87 for NOM of uncomplicated appendicitis. Definition #2 had sensitivity of 0.83 and positive predictive value of 0.72. The gold standard cohort had a true failure/recurrence rate of 23.6%, compared with apparent rates of 25.4% and 39.8%, respectively.

CONCLUSIONS

Administrative definitions are prone to misclassification in identifying planned NOM of uncomplicated appendicitis. This likely impacts outcomes in studies using administrative databases. Investigators should disclose how misclassification may affect results and select an administrative definition that optimally balances sensitivity and specificity for their research question.

Outcomes Following Surgical and Nonsurgical Treatment for Uncomplicated Appendicitis in Older Adults

Importance

The optimal treatment of acute uncomplicated appendicitis in older adults with frailty is not defined.

Objective

To examine outcomes associated with treatment strategies for acute uncomplicated appendicitis in older adults with or without frailty.

Design, Setting, and Participants

This retrospective cohort study used National Inpatient Sample data from adults 65 years or older with a diagnosis of uncomplicated appendicitis from January 1, 2016, to December 31, 2018. Data were analyzed from July to November 2023. The National Inpatient Sample database approximates a 20% stratified sample of all inpatient hospital discharges in the US.

Exposures

Study patients were categorized into 3 groups: nonoperative management, immediate operation, and delayed operation.

Main Outcomes and Measures

Clinical outcomes, including hospital complications and in-hospital mortality, were assessed among older adults with and without frailty, identified using an adapted claims-based frailty index.

Results

A total of 24 320 patients were identified (median [IQR] age, 72 [68-79] years; 50.9% female). Of those, 7290 (30.0%) were categorized as having frailty. Overall, in-hospital mortality was 1.4%, and the incidence of complications was 37.3%. In patients with frailty, multivariable analysis showed both nonoperative management (odds ratio [OR], 2.89; 95% CI, 1.40-5.98; P < .001) and delayed appendectomy (OR, 3.80; 95% CI, 1.72-8.43; P < .001) were associated with increased in-hospital mortality compared with immediate appendectomy. In patients without frailty, immediate appendectomy was associated with increased hospital complications compared with nonoperative management (OR, 0.77; 95% CI, 0.64-0.94; P = .009) and lower hospital complications compared with delayed appendectomy (OR, 2.05; 95% CI, 1.41-3.00; P < .001).

Conclusions and Relevance

In this cohort study of older adults with uncomplicated appendicitis, outcomes differed among management strategies based on frailty status. Routine frailty assessments incorporated in the care of older adult patients may help guide discussions for shared decision-making.

Atypical Presentation and Diagnostic Challenges of Appendicitis in an 85-Year-Old Male: A Case Report

Acute appendicitis in elderly individuals is uncommon and poses a significant challenge due to atypical symptomatology. An 85-year-old male presented to the emergency department (ED) with abdominal pain associated with nausea and reduced oral intake. Physical examination revealed diffuse abdominal tenderness. He was initially treated for constipation with an enema and discharged. Two days later, the patient returned with worsened pain and a new onset of fever. Examination revealed guarding. Lab results showed significant elevation in C-reactive protein (CRP) and white blood count (WBC). A contrast-enhanced computed tomography (CT) scan showed evidence of a perforated appendix. He was admitted into the surgical ward and improved on conservative treatment. This case describes an atypical presentation of acute appendicitis in an elderly patient, emphasizing the importance of recognizing unusual presentations in this population. Early use of contrast-enhanced CT scans is crucial for accurate diagnosis and improving patients outcomes.

The risks of failed nonoperative management of appendicitis in older adults

BACKGROUND

The consequences of failed nonoperative management of appendicitis in older patients have not been described.

METHODS

We used the 2004-2017 National Inpatient Sample to identify acute appendicitis patients managed nonoperatively (<65 years old: 32,469; ≥65 years old: 11,265). Outcomes included morbidity, length of stay (LOS), inpatient costs, and discharge to skilled facilities. Differences were estimated using propensity scores.

RESULTS

For patients <65, nonoperative failure was associated with increased morbidity (7 ​% [95 ​% CI 6.9 ​%-8.1 ​%]), LOS (3 day [95 ​% CI 3-4]), costs ($9015 [95 ​% CI $8216- $9446]), and discharges to skilled facilities (1 ​% [95 ​% CI 0.9 ​%-1.6 ​%]) compared to successful nonoperative treatment. Patients ≥65 had differences in morbidity (14 ​% [95 ​% CI 13.6 ​%-16.2 ​%]), LOS (6 days [95 ​% CI 5-6]), costs ($15,964 [95 ​% CI $15,181- $17,708]), and discharges to skilled facilities (12 ​% [95 ​% CI: 10.0 ​%-13.3]) compared to nonoperative success.

CONCLUSIONS

Nonoperative management of appendicitis should be approached cautiously for older adults.