Decline in admission rates for acute appendicitis in England

[Interdisciplinary surgical spectrum in cooperation of abdominal surgery and gynecology : What must the (general/abdominal) surgeon know?]

AIM

This short overview aims to concisely outline the most important gynecological issues from a predominantly operative point of view, which could also be relevant for general and abdominal surgeons as well as important gynecological aspects of primarily visceral surgical pathologies.

METHOD

Narrative review on the topic of interdisciplinary cooperation in gynecological/general and abdominal surgery through the use of PubMed® as well as the Cochrane Library with search terms, such as "operative profile of abdominal surgery and gynecology", "interdisciplinary surgery aspects of gynecology/abdominal surgery" as well as "interdisciplinary surgical approach-surgical complication".

RESULTS (MAIN POINTS)

As the close anatomical relationship suggests, numerous primarily gynecological pathologies can also occur in abdominal organs. Likewise, predominantly surgical pathologies can result in involvement of gynecological organs. This can make an intraoperative collaboration necessary. In addition, as a result of diagnostic uncertainty or within the context of complications, interdisciplinary collaboration can also be required preoperatively and postoperatively. Multidisciplinary knowledge as well as close cooperation of the involved specialties can improve the outcome of affected patients.

CONCLUSION

Many pathologies extend not only to the boundaries of an individual discipline but can also affect physiological systems exceeding those limits. Therefore, for an optimal treatment it is necessary to be aware of such aspects of the diseases and to establish structured procedures for interdisciplinary cooperation.

Antibiotic treatment for appendicitis in Norway and Sweden: a nationwide survey on treatment practices

Background

Appendicitis is one of the most common causes of acute abdomen. Uncomplicated appendicitis is as an inflamed appendix without perforation, gangrene or abscess formation. Recent trials show that one can safely treat uncomplicated appendicitis with antibiotics, given patient approval and appropriate follow-up. A recent study has also indicated no difference between antibiotic treatment and placebo. Our aim was to investigate if Norwegian and Swedish surgical departments treat uncomplicated appendicitis with antibiotics and to explore their opinions on this treatment practice.

Methods

A questionnaire was distributed to all heads of department in hospitals that treat appendicitis in Norway and Sweden. Answers were collected using a REDCap survey. Answers were compared between centers and nations and the results were presented anonymously.

Results

We sent the questionnaire to 94 eligible recipients and received 61 (65%) answers. In total, 8/61 (13%) departments stated that they have established antibiotic treatment as sole treatment for uncomplicated appendicitis. Almost half of the responders stated that they have used antibiotics sporadically to treat uncomplicated appendicitis. Lack of evidence and guidelines were noted as reasons why antibiotic treatment has not been implemented as sole treatment.

Conclusions

Most Norwegian and Swedish departments have not implemented antibiotic treatment as the sole treatment for uncomplicated appendicitis. Despite several recent large trials on this subject, lack of evidence and guidelines was the most frequently reported reason in our survey.

Is the increased incidence of pathologically proven acute appendicitis more likely seen in elderly patients? A retrospective cohort study

AIM

Although appendicitis is a disease of the young, it has been speculated that its incidence has increased among the elderly people. In this study, it was aimed to evaluate annual changes of appendicitis seen in older patients (≥60 years) throughout a 10-year period.

METHODS

All adult patients who were surgically treated for acute appendicitis were retrospectively analyzed with respect to pathological analysis, gender, age and proportion of the patients aged 60 or over in an annual base. Variability in the mean age and proportion of the older patients aged 60 or over throughout the study years were regarded as the main outcomes.

RESULTS

There were 3296 patients with a mean age of 30.42 ± 12 years. Distribution of gender was similar (p = 0.636). There was a significant positive correlation in the mean age of the patients throughout the study years (p = 0.043). Stratification by the age of 60 yielded a significant increase in percent of the older patients, from 0.93% at 2007 to 4.28% at 2016 (p = 0.019).

CONCLUSIONS

The mean age of the patients with acute appendicitis is going to increase. Therefore, it is expected that all surgeons are more likely to be confronted with elderly patients with appendicitis in the near-future.

Acute Appendicitis: Trends in Surgical Treatment

BACKGROUND

Appendectomy is the gold standard for treatment of acute appendicitis. However, recent studies favor primary antibiotic therapy. The aim of this observational study was to explore changes in the numbers of operations for acute appendicitis in the period 2010-2017, paying special attention to disease severity.

METHODS

Data from diagnosis-related group statistics were used to analyze the trends, mortality, and complication rates in the surgical treatment of appendicitis in Germany between 2010 and 2017. All cases of appendectomy after a diagnosis of appendicitis were included.

RESULTS

Altogether, 865 688 inpatient cases were analyzed. The number of appendectomies went down by 9,8%, from 113 614 in 2010 to 102 464 in 2017, while the incidence fell from 139/100 000 in 2010 to 123/100 000 in 2017 (standardized by age group). This decrease is due to the lower number of operations for uncomplicated appendicitis (79 906 in 2017 versus 93 135 in 2010). Hospital mortality decreased both in patients who underwent surgical treatment of complicated appendicitis (0.62% in 2010 versus 0.42% in 2017) and in those with a complicated clinical course (5.4% in 2010 versus 3.4% in 2017).

CONCLUSION

Decisions on the treatment of acute appendicitis in German hospitals follow the current trend towards non-surgical management in selected patients. At the same time, the care of acute appendicitis has improved with regard to overall hospital morbidity and hospital mortality.

The Worldwide Epidemiology of Acute Appendicitis: An Analysis of the Global Health Data Exchange Dataset

BACKGROUND

This study aims to describe the worldwide epidemiology and changing disease trends of acute appendicitis (AA).

METHODS

Epidemiological data on the incidence of AA and deaths were collected from the Global Health Data Exchange repository from 1990 to 2019. Data were stratified by age, sex and Socio-Demographic Index (SDI).

RESULTS

In 2019, there were an estimated 17.7 million cases (incidence 228/100,000) with over 33,400 deaths (0.43/100,000). Both the absolute number and the incidence had increased from 1990 to 2019 (+ 38.8% and + 11.4%, respectively). The number of deaths and deaths per 100,000 declined during this period (- 21.8% and - 46.2%, respectively). These trends were largely similar in all 5 SDI groups. There was a significant difference in the incidence of AA between the SDI groups, with low SDI group having the lowest and high SDI group having the highest. The high SDI group had the lowest mortality rate (Kruskall-Wallis test, p < 0.001). The peak incidence was in the 15-19-year age group. The mortality rate increased exponentially from the third decade of life.

CONCLUSIONS

The mortality rate of AA is declining worldwide, while the incidence is increasing. The peak incidence is in the 15-19-year group.

Evaluation of role of hyperbilirubinemia as a new diagnostic marker of complicated appendicitis

BACKGROUND

In appendicitis, elevated intra-luminal pressure and ischemic necrosis of mucosa causes tissue gangrene or perforation. This leads to cytotoxin facilitated progressive bacterial invasion or translocation into the hepatic parenchyma through portal system. This phenomenon interferes with the bilirubin excretion into the bile canaliculi. In the present study, establishment of a possible role of hyperbilirubinemia as a marker of gangrenous/perforated appendicitis has been studied.

METHODS

After matching the inclusion and exclusion criteria, all cases of clinically diagnosed acute appendicitis were taken for this prospective, single center, observational study. Per-operative diagnosis was confirmed by histopathological examination.

RESULTS

Out of 110 subjects of acute appendicitis 41 subjects (37.27%) had hyperbilirubinemia. Out of 35 subjects diagnosed as complicated appendicitis 32 subjects (91.42%) had raised total bilirubin levels, while the remaining 03 (8.58%) had normal levels. Among 75 subjects diagnosed as acute simple appendicitis 09 subjects (12%) had raised total bilirubin level, while the remaining 66 subjects (88%) had normal levels. It was Mixed Type of Hyperbilirubinemia in gangrenous/perforated appendicitis. The sensitivity of Total serum bilirubin in predicting complicated appendicitis was found 91.43% (76.942% to 98.196%), where as the specificity of this test was 88.00% (78.439% to 94.363%). positive predictive value and negative predictive value were 78.03% and 95.65% respectively. Positive likelihood ratio and negative likelihood ratio were found to be 7.619 and 0.097 respectively taking prevalence of complicated appendicitis be 31.80%. Receiver Operating Characteristic curve was obtained which shows optimal criterion at Total Bilirubin Level 1.06 mg/dl where sensitivity was 91.43% and specificity was 97.33% at 95% confidence interval with 31.8% disease prevalence.

CONCLUSIONS

This is to conclude that Serum bilirubin level estimation, which is a simple, cheap and easily available laboratory test, can be added to the routine investigations in clinically suspected cases of acute appendicitis for early diagnosis of complications. Trial registration Registered with Clinical Trials Registry-India (ICMR-NIMS) with Registration number CTRI/2019/05/018879 Dated 01/05/2019. This was a prospective trial. Trial URL: http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=33113&EncHid=99780.32960&modid=1&compid=19%27,%2733113det%27 .

Trend of Appendicitis Mortality at National and Provincial Levels in Iran from 1990 to 2015

BACKGROUND

Appendicitis is one of the most preventable causes of death worldwide. We aimed to determine the trend of mortality due to appendicitis by sex and age at national and provincial levels in Iran during 26 years.

METHODS

Data were collected from Iran Death Registration System (DRS), cemetery databanks in Tehran and Esfahan, and the national population and housing censuses of Iran. The estimated population was determined for each group from 1990 to 2015 using a growth model. Incompleteness, misalignment, and misclassification in the DRS were addressed and multiple imputation methods were used for dealing with missing data. ICD-10 codes were converted to Global Burden of Disease (GBD) codes to allow comparison of the results with the GBD study. A Spatio-Temporal model and Gaussian Process Regression were used to predict the levels and trends in child and adult mortality rates, as well as cause fractions.

RESULTS

From 1990 to 2015, 6,982 deaths due to appendicitis were estimated in Iran. The age-standardized mortality rate per 100000 decreased from 0.72 (95% UI: 0.46-1.12) in 1990 to 0.11 (0.07-0.16) in 2015, a reduction of 84.72% over the course of 26 years. The male: female ratio was 1.13 during the 26 years of the study with an average annual percent change of -2.31% for women and -2.63% for men. Among men and women, appendicitis mortality rate had the highest magnitude of decline in the province of Zanjan and the lowest in the province of Hormozgan. In 1990, the lowest age-standardized appendicitis-related mortality was observed in both women and men in the province of Alborz and the highest mortality rate among men were observed in the province of Lorestan. In 2015, the lowest mortality rates in women and men were in the province of Tehran. The highest mortality rates in women were in Hormozgan, and in men were in Golestan province.

CONCLUSION

The mortality rate due to appendicitis has declined at national and provincial levels in Iran. Understanding the causes of differences across provinces and the trend over years can be useful in priority setting for policy makers to inform preventive actions to further decrease mortality from appendicitis.

Disease burden of appendectomy for appendicitis: a population-based cohort study

Background

Few large-scale epidemiologic studies evaluate the clinical and economic burden of appendicitis. These data may impact future research and treatment strategies. In this study, the objective was to determine the burden of appendectomy for appendicitis in terms of incidence rates, length of hospital stay (LOS) and hospital costs on a national level. In addition, outcomes were compared for subgroups based on surgical treatment, age and hospital setting.

Methods

Observational retrospective population-based cohort study using the national Dutch healthcare reimbursement registry, which covers hospital registration and reimbursement for 17 million inhabitants. Patients with a diagnosis of appendicitis who underwent appendectomy between 2006 and 2016 were included. Primary outcomes were incidence rates, LOS and hospital costs.

Results

A total of 135,025 patients were included. Some 53% of patients was male, and 64% was treated in a general hospital. The overall incidence rate of appendectomy was 81 per 100,000 inhabitants and showed a significant decreasing trend across time and age. Mean ± SD LOS per patient was 3.66 ± 3.5 days. LOS showed a significant increase with age and was significantly longer for open versus minimally invasive appendectomy. Mean ± SD hospital costs per patient were €3700 ± 1284. Costs were initially lower for open compared to minimally invasive appendectomy, but were similar from 2012 onward. Compared to non-university hospitals, patients treated in university hospitals had a significantly longer LOS and higher costs.

Conclusions

Appendectomy for appendicitis represents a substantial clinical and economic burden in the Netherlands. A preference for minimally invasive technique seems justified.

Population-based cohort study on the epidemiology of acute appendicitis in children in Sweden in 1987-2013

Background

The long‐term incidence of acute appendicitis has been reported to be declining in Europe and North America. Recent reports, however, indicate stabilized or even increased rates. The aim of this study was to investigate the present epidemiology of acute appendicitis and appendicectomy in a population‐based cohort of Swedish children.

Methods

The Swedish National Patient Register was queried for all children with acute appendicitis and/or appendicectomy in 1987–2013. Population‐based incidence rates were calculated. Rates were age‐ and sex‐adjusted, and analysed for temporal and regional trends.

Results

Some 56 774 children with acute appendicitis were identified, of whom 53 478 (94·2 per cent) underwent appendicectomy. The incidence rate of acute appendicitis declined by 43·7 per cent over 26 years, from 177·7 to 100·1 per 100 000 person‐years between 1987 and 2013. The most significant reduction was for non‐perforated appendicitis, from 138·5 to 68·4 per 100 000 person‐years between 1987 and 2009. The incidence rate of perforated appendicitis decreased from 28·0 to 19·9 per 100 000 person‐years and negative appendicectomies reduced from 48·5 to 3·6 per 100 000 person‐years during the study interval.

Conclusion

The incidence rates of acute appendicitis and negative appendicectomy have reduced markedly in Swedish children over time, with significantly different trends amongst non‐perforated appendicitis and perforated appendicitis. The full explanation for the observed findings is unclear.

Incidence of appendicitis according to region of origin in first- and second-generation immigrants and adoptees in Sweden. A cohort follow-up study

BACKGROUND

Geographic variations in incidence of appendicitis and proportion of perforations suggest environmental or genetic etiological factors. We study incidence of appendicitis and proportion of perforations according to geographical origin in immigrants and international adoptees in Sweden.

METHODS

A cohort of 11,557,566 Swedish residents - 277,104 first- and 377,773 second-generation immigrants and 57,304 adoptees - was followed from 1988 till 2010. Differences in proportion of operation for perforated appendicitis and negative appendectomy and standardized incidence ratios (SIR) of perforated and non-perforated appendicitis associated with geographic origin was analyzed.

RESULTS

High incidence rates are seen in first- and second-generation immigrants from South America for perforated (SIR 1.58 and 1.81, respectively) and non-perforated appendicitis (SIR 1.18 and 1.22, respectively), and in adoptees from South America for non-perforated appendicitis (SIR 1.07). Low incidence rates are seen for perforated appendicitis in first-generation immigrants and adoptees from Asia (SIR 0.74 and 0.56, respectively), and for non-perforated appendicitis in immigrants from Africa and Asia (SIR 0.69 and 0.76 in first-generation, 0.51 and 0.74 in second-generation, respectively) and in adoptees from Asia (SIR 0.71). A high proportion of perforated appendicitis is associated with a low incidence rate of non-perforated appendicitis but no increase in the incidence rate of perforated appendicitis.

CONCLUSIONS

The association of different incidence of appendicitis with geographic origin which remains over generations and is seen in adoptees suggest genetic etiologic factors. The proportion of perforation can be high without an increased incidence rate of perforation and is therefore an imperfect indicator of quality of care.

Risk of acute appendicitis in and around pregnancy: a population-based cohort study from England

OBJECTIVE

To determine the absolute and relative risk of acute appendicitis during the antepartum and postpartum periods compared with the time outside pregnancy among women of childbearing age.

BACKGROUND

Acute appendicitis is the most common nonobstetric surgical emergency during pregnancy. Estimates of the incidence of acute appendicitis in pregnancy remain imprecise and inconsistent.

METHODS

All potential fertile women aged 15 to 44 years registered within Clinical Practice Research Datalink with linkages to the Hospital Episodes Statistics between 1997 and 2012 were identified. Absolute rates of acute appendicitis were calculated during the antepartum and postpartum periods and were compared with the time outside pregnancy in terms of incidence rate ratio (IRR) using a Poisson regression model.

RESULTS

Among 1,624,804 women, there were 362,219 pregnancies resulting in live or stillbirths. Compared with the time outside pregnancy, the rate of acute appendicitis was 35% lower during the antepartum period [IRR, 0.65; 95% confidence interval (CI), 0.55-0.76], with the lowest rate reported during the third trimester (IRR, 0.47; 95% CI, 0.35-0.64) for all ages; no increased risk of acute appendicitis was observed in the postpartum period compared with the time outside pregnancy among women aged 15 to 34 years but an 84% increased risk for women older than 35 years (IRR, 1.84; 95% CI, 1.18-2.86). The highest and lowest rates of negative appendectomy were encountered in the second and the third trimesters, respectively.

CONCLUSIONS

Pregnant women are less likely to be diagnosed with acute appendicitis than nonpregnant women, with the lowest risk reported during the third trimester.

Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy

BACKGROUND

Identification of variation in practice is a key step towards standardization of service and determination of reliable quality markers. This study aimed to investigate variation in provision and outcome of emergency appendicectomy.

METHODS

A multicentre, trainee-led, protocol-driven, prospective observational cohort study was performed during May and June 2012. The main outcome of interest was the normal histopathology rate; secondary outcomes were laparoscopy and 30-day adverse event rates. Analysis included funnel plots and binary logistic regression models to identify patient- and hospital-related predictors of outcome.

RESULTS

A total of 3326 patients from 95 centres were included. An initial laparoscopic approach was performed in 66.3 per cent of patients (range in centres performing more than 25 appendicectomies over the study period: 8.7-100 per cent). A histologically normal appendix was removed in 20.6 per cent of patients (range in centres performing more than 25 procedures: 3.3-36.8 per cent). Funnel plot analysis revealed that 22 centres fell below three standard deviations of the mean for laparoscopy rates. Higher centre volume, consultant presence in theatre and daytime surgery were independently associated with an increased use of laparoscopy, which in turn was associated with a reduction in 30-day morbidity (adjusted for disease severity). Daytime surgery further reduced normal appendicectomy rates. Increasing volume came at the cost of higher negative rates, and low negative rates came at the cost of higher perforation rates.

CONCLUSION

This study reveals the extremely wide variation in practice patterns and outcomes among hospitals. Organizational factors leading to this variation have been identified and should be addressed to improve performance.

Usefulness index in nonspecific abdominal pain--an aid in the diagnosis?

OBJECTIVE

In 1990, Lavelle and Kanagaratnam introduced Usefulness Index (UI) test for assessment of usefulness of clinical observations. Although, nonspecific abdominal pain (NSAP) is the most common diagnosis among secondary care patients with acute abdominal pain, the efficiency of UI test is rarely considered in NSAP.

METHODS

In an extension of the World Organisation of Gastro-Enterology Research Committee (OMGE) acute abdominal pain study, 1333 patients presenting with acute abdominal pain were included in the study. The clinical signs (n = 14) and tests (n = 3) in each patient were recorded in detail, using a predefined structured data collection sheet, and the collected data were compared with the final diagnoses of the patients.

RESULTS

The most significant clinical tests and signs of NSAP in univariate analysis were (UI = Usefulness Index and RR = risk ratio): rigidity (UI = 0.36, RR = 32.2), rebound (UI = 0.33, RR = 6.3), guarding (UI = 0.25, RR = 4.9), Murphy's positive (UI = 0.13, 8.9), bowel sounds (UI = 0.12, RR = 3.3), and renal tenderness (UI = 0.12, RR = 2.2). The sensitivity of the doctors' initial decision in detecting NSAP was 0.70 with a specificity of 0.83 and with the UI = 0.37 and RR = 11.4.

CONCLUSION

The patients with negative test results in rigidity, rebound, guarding, Murphy's, and bowel sounds tended to be at risk for NSAP and in these patients the UI test could be an aid for clinician to differentiate NSAP from other causes of acute abdominal pain.

Accuracy of clinical coding from 1210 appendicectomies in a British district general hospital

AIMS

The primary aim of this study was to assess the accuracy of clinical coding in identifying negative appendicectomies. The secondary aim was to analyse trends over time in rates of simple, complex (gangrenous or perforated) and negative appendicectomies.

METHODS

Retrospective review of 1210 patients undergoing emergency appendicectomy during a five year period (2006-2010). Histopathology reports were taken as gold standard for diagnosis and compared to clinical coding lists. Clinical coding is the process by which non-medical administrators apply standardised diagnostic codes to patients, based upon clinical notes at discharge. These codes then contribute to national databases. Statistical analysis included correlation studies and regression analyses.

RESULTS

Clinical coding had only moderate correlation with histopathology, with an overall kappa of 0.421. Annual kappa values varied between 0.378 and 0.500. Overall 14% of patients were incorrectly coded as having had appendicitis when in fact they had a histopathologically normal appendix (153/1107), whereas 4% were falsely coded as having received a negative appendicectomy when they had appendicitis (48/1107). There was an overall significant fall and then rise in the rate of simple appendicitis (B coefficient -0.239 (95% confidence interval -0.426, -0.051), p = 0.014) but no change in the rate of complex appendicitis (B coefficient 0.008 (-0.015, 0.031), p = 0.476).

CONCLUSIONS

Clinical coding for negative appendicectomy was unreliable. Negative rates may be higher than suspected. This has implications for the validity of national database analyses. Using this form of data as a quality indictor for appendicitis should be reconsidered until its quality is improved.

Appendectomy and diagnosis-related groups (DRGs): patient classification and hospital reimbursement in 11 European countries

Background

As part of the EuroDRG project, researchers from 11 countries (i.e., Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Sweden, and Spain) compared how their diagnosis-related groups (DRG) systems deal with appendectomy patients. The study aims to assist surgeons and national authorities to optimize their DRG systems.

Methods

National or regional databases were used to identify hospital cases with a diagnosis of appendicitis treated with a procedure of appendectomy. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that together comprised at least 97% of cases. Six standardized case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained.

Results

European DRG systems vary widely: they classify appendectomy patients according to different sets of variables (between two and six classification variables) into diverging numbers of DRGs (between two and 11 DRGs). The most complex DRG is valued 5.1 times more resource intensive than an index case in France but only 1.1 times more resource intensive than an index case in Finland. Comparisons of quasi prices for the case vignettes show that hypothetical payments for the most complex case vignette amount to only 1,005€ in Poland but to 12,304€ in France.

Conclusions

Large variations in the classification of appendectomy patients raise concerns whether all systems rely on the most appropriate classification variables. Surgeons and national DRG authorities should consider how other countries’ DRG systems classify appendectomy patients in order to optimize their DRG system and to ensure fair and appropriate reimbursement.

Electronic supplementary material

The online version of this article (doi:10.1007/s00423-011-0877-5) contains supplementary material, which is available to authorized users.

Changing incidence of acute appendicitis and nonspecific abdominal pain between 1987 and 2007 in Finland

BACKGROUND

The incidence of acute appendicitis has declined in many countries. The aim of this study was to determine the trends in incidence of acute appendicitis (AA), appendectomies for AA, and nonspecific abdominal pain (NSAP) in Finland between 1987 and 2007.

METHODS

We carried out a national register study. Demographic features were investigated. Diagnoses and procedures were classified according to the World Health Organization International Classification of Diseases. Data were analyzed for each of all five University Hospital districts (UHD) of Finland.

RESULTS

During the observation period of 21 years, 186,558 appendectomies were performed in Finland, of which 137,528 (74%) cases were reported as AA. The incidence of acute appendicitis declined 32%. The diagnostic accuracy improved from 73 to 82% and was higher in men. The accuracy rate among the male patients was stable throughout the two decades; among the female patients it rose from 63 to 75%. The incidence of appendicitis was highest in patients aged 15-24 years. The average incidence of NSAP was 34/10,000/year, and it was higher in older age groups. There was a large geographical disparity in the incidence of NSAP.

CONCLUSION

The incidence of acute appendicitis as well as the incidence of appendectomies is declining in Finland. The incidence of the NSAP has also been declining but we did not find any correlations between the incidences of the acute appendicitis and NSAP. There were clear geographical differences in the incidence of NSAP but not in the incidence of AA.

An evaluation of the utility of additional tests in the preoperative diagnostics of acute appendicitis

BACKGROUND

Determining the optimum algorithm for diagnostic procedure in suspected acute appendicitis (AA) may not only reduce the number of unnecessary operations, but also the frequency of complications, and may contribute measurably to reducing the costs of treating patients with acute abdominal conditions.

OBJECTIVE

The aim of the study was to assess the value of standard diagnostic methods and measurement of selected biochemical and hematological parameters (C-reactive protein, CRP; interleukin-6, IL-6; procalcitonin, PCT; total count of white blood cell, WBC) in the accuracy of preoperative AA diagnosis.

MATERIAL AND METHODS

The prospective study included 132 patients (female: 52.3%, male: 47.7%) emergency admitted to the Surgical Department, aged 15 to 74 years (mean 36 years), with a suspicion of appendicitis. Measurement of PCT concentration was carried out by immunoluminometric assay, IL-6 concentration by micro enzyme-linked immunosorbent assay and CRP concentration by immunonephelometric assay. Statistical analysis was done by the chi-square test and Fisher's exact test for categorized discrete variables, and the Mann-Whitney U and Kruskal-Wallis tests for continuous variables. In order to assay the diagnostic utility of tests, the receiver operating characteristic model of curve analysis was used.

RESULTS

AA was confirmed in 89 (67.5%) of the patients operated on (group A). Twenty-six (19.7%) of the patients were not operated on and did not require surgery (group C); in 13 patients (9.8%) operated with a preliminary diagnosis of AA, no changes in the appendix were found during the course of the operation (group B). Four (3%) of the patients treated conservatively for periappendicular infiltration were excluded from the following analysis (group D). The mean count of WBC in AA was 13.22 ± 4.45 × 103/μL, with no statistical significance between groups, which does not allow the patients requiring surgery to be distinguished. The highest elevation of IL-6 concentration was observed in the group with the AA and the periappendicular infiltration: 101.5 ± 355.9 vs. 173.6 ± 228.33 pg/mL, respectively; p < 0.05. No surgery patients of group C showed considerably lower CRP concentrations than those of group D: CRP: 2.05 ± 3.6 vs. 6.36 ± 4.74 mg/L; p < 0.05. In cases of advanced forms of AA, the gangrenous with perforation, higher marker values are obtained than those in the phlegmonose form (186.60 ± 541.2 vs. 40.08 ± 48.3 pg/mL; (p < 0.05) for IL-6 and 8.88 ± 7.45 vs. 2.84 ± 3.83 mg/L; (p < 0.001) for CRP, respectively).

CONCLUSIONS

1. AA diagnosis based only on an assessment of clinical status may lead to an increase in the number of people operated with false-positive diagnoses of AA. 2. Applying additional diagnostic methods such as IL-6 determination seems to be useful in reducing the numbers of false-positive diagnoses of AA. 3. Laboratory tests, i.e., CRP, IL-6, and PCT are much more useful in assessing the risk of complications during the course of AA.

An evaluation of the utility of additional tests in the preoperative diagnostics of acute appendicitis

BACKGROUND

Determining the optimum algorithm for diagnostic procedure in suspected acute appendicitis (AA) may not only reduce the number of unnecessary operations, but also the frequency of complications, and may contribute measurably to reducing the costs of treating patients with acute abdominal conditions.

OBJECTIVE

The aim of the study was to assess the value of standard diagnostic methods and measurement of selected biochemical and hematological parameters (C-reactive protein, CRP; interleukin-6, IL-6; procalcitonin, PCT; total count of white blood cell, WBC) in the accuracy of preoperative AA diagnosis.

MATERIAL AND METHODS

The prospective study included 132 patients (female: 52.3%, male: 47.7%) emergency admitted to the Surgical Department, aged 15 to 74 years (mean 36 years), with a suspicion of appendicitis. Measurement of PCT concentration was carried out by immunoluminometric assay, IL-6 concentration by micro enzyme-linked immunosorbent assay and CRP concentration by immunonephelometric assay. Statistical analysis was done by the chi-square test and Fisher's exact test for categorized discrete variables, and the Mann-Whitney U and Kruskal-Wallis tests for continuous variables. In order to assay the diagnostic utility of tests, the receiver operating characteristic model of curve analysis was used.

RESULTS

AA was confirmed in 89 (67.5%) of the patients operated on (group A). Twenty-six (19.7%) of the patients were not operated on and did not require surgery (group C); in 13 patients (9.8%) operated with a preliminary diagnosis of AA, no changes in the appendix were found during the course of the operation (group B). Four (3%) of the patients treated conservatively for periappendicular infiltration were excluded from the following analysis (group D). The mean count of WBC in AA was 13.22 ± 4.45 × 103/μL, with no statistical significance between groups, which does not allow the patients requiring surgery to be distinguished. The highest elevation of IL-6 concentration was observed in the group with the AA and the periappendicular infiltration: 101.5 ± 355.9 vs. 173.6 ± 228.33 pg/mL, respectively; p < 0.05. No surgery patients of group C showed considerably lower CRP concentrations than those of group D: CRP: 2.05 ± 3.6 vs. 6.36 ± 4.74 mg/L; p < 0.05. In cases of advanced forms of AA, the gangrenous with perforation, higher marker values are obtained than those in the phlegmonose form (186.60 ± 541.2 vs. 40.08 ± 48.3 pg/mL; (p < 0.05) for IL-6 and 8.88 ± 7.45 vs. 2.84 ± 3.83 mg/L; (p < 0.001) for CRP, respectively).

CONCLUSIONS

1. AA diagnosis based only on an assessment of clinical status may lead to an increase in the number of people operated with false-positive diagnoses of AA. 2. Applying additional diagnostic methods such as IL-6 determination seems to be useful in reducing the numbers of false-positive diagnoses of AA. 3. Laboratory tests, i.e., CRP, IL-6, and PCT are much more useful in assessing the risk of complications during the course of AA.

Acute appendicitis--a benign disease?

INTRODUCTION

Appendicitis is the most common cause of the acute abdomen and can affect all age groups. Most patients recover quickly but a minority can suffer postoperative complications. This case-note review was undertaken to assess the frequency of these complications.

PATIENTS AND METHODS

Adult patients (> 16 years) undergoing an emergency appendicectomy at a University teaching hospital between February 2004 and January 2005 were identified from pathology records. Details of operative procedure, histology and postoperative complications were noted from the hospital case notes

RESULTS

A total of 199 patients with a median age of 31 years (range, 16-89 years) were identified. Of these, 58 (29%) patients experienced a postoperative complication. Eight (4%) patients were admitted to the surgical high dependency unit or intensive care unit postoperatively and there was one death (0.5%). Re-operation for a postoperative complication was required in 9 (4.5%) patients and there was a 13% re-admission rate (26 patients). Comparison between patients with histologically proven appendicitis (164 patients; 82%) and those patients having a negative appendicectomy (35 patients; 18%) showed no significant difference in the rate of complications as defined (43 of 164, 26% versus 15 of 35, 43%; P = 0.08). However, patients with positive histology were more likely to experience a septic complication (29 of 164, 18% versus 1 of 35, 3%; P = 0.028) and all re-operations came from this group. Despite this, patients with a negative appendicectomy were more likely to be re-admitted (12 of 35, 34% versus 14 of 164, 8.5%; P = 0.0002), predominantly with persistent abdominal pain.

CONCLUSIONS

Appendicectomy is associated with a significant morbidity. Patients with an inflamed appendix were more likely to experience a septic complication but re-admission was more common in patients with a histologically normal appendix because of unresolved abdominal pain.

Dramatic decline of acute appendicitis in Greece over 30 years: index of improvement of socioeconomic conditions or diagnostic aids?

BACKGROUND AND AIMS

There are several reports showing a continuing fall in the incidence of acute appendicitis in the western countries. Our aim was to study the trend of the incidence of acute appendicitis in the Greek population over 30 years.

METHODS

We analyzed the data referring to the years 1970-1999 on the incidence and mortality of acute appendicitis for the entire Greek population. Data were retrieved from the Annual Bulletin for the Social Welfare and Health Statistics of the National Statistics Service of Greece. In this database, acute appendicitis was a hospital discharge diagnosis.

RESULTS

Over the study period, there was a 75% decrease of the age-standardized incidence of acute appendicitis from 652/100,000 to 164/100,000. The median female-to-male ratio of hospitalized patients for appendicitis of the study period (1970-1999) fell progressively from 1.27 in the year 1970 to 0.93 in the year 1999. The case fatality rates remained constant, ranging below 0.09 deaths per 100 appendicitis cases.

CONCLUSION

There is a significant decline of the incidence of acute appendicitis in the Greek population over the years 1970-1999. This time trend is probably related to the improvement of the socioeconomic conditions over the same period and not to the introduction of new diagnostic aids.

Day case emergency laparoscopic appendectomy

BACKGROUND

Laparoscopic appendectomy (LA) is associated with a shorter hospital stay and fewer complications than conventional open appendectomy (OA). This study aimed to examine the safety and efficacy of day case emergency LA.

METHODS

The records of patients undergoing emergency LA under the care of two laparoscopic surgeons over a 3-year period (Februrary 2003 to February 2006) were reviewed to examine hospital length of stay (LOS), complications, histology, grade of the operating surgeon, and time required to perform the procedure.

RESULTS

A total of 104 patients (median age, 25 years; range, 11-72 years; 58 men) underwent LA, with 9 and 66 patients discharged in 8 and 24 hours, respectively (median LOS 22 hours: range 6-170 hours). One patient underwent conversion to OA. Histologically, 86 patients had appendicitis and 18 had normal appendices with another pathology present. The median operative time was 35 min (range, 20-80 min). The complications included three wound infections and two pelvic abscesses not requiring further operative intervention.

CONCLUSION

Day case emergency LA is safe and effective for treating selected patients.

Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management

OBJECTIVE

Appendicitis has been declining in frequency for several decades. During the past 10 years, its preoperative diagnosis has been made more reliable by improved computed tomography (CT) imaging. Thresholds for surgical exploration have been lowered by the increased availability of laparoscopic exploration. These innovations should influence the number of appendectomies performed in the United States. We analyzed nationwide hospital discharge data to study the secular trends in appendicitis and appendectomy rates.

METHODS

All appendicitis and appendiceal operations reported to the National Hospital Discharge Survey (NHDS) 1970-2004 were classified as perforated, nonperforated, negative, and incidental appendectomies and analyzed over time and by various demographic measures. Secular trends in the population-based incidence rates of nonperforated and perforated appendicitis and negative and incidental appendectomy were examined.

RESULTS

Nonperforated appendicitis rates decreased between 1970 and 1995 but increased thereafter. The 25-year decreasing trend was accounted for almost entirely by a decreasing incidence in the 10-19 year age group. The rise after 1995 occurred in all age groups above 5 years and paralleled increasing rates of CT imaging and laparoscopic surgery on the appendix. Since 1995 the negative appendectomy rate has been falling, especially in women, and incidental appendectomies, frequent in prior decades, have been rarely performed. Despite these large changes, the rate of perforated appendicitis has increased steadily over the same period. Although perforated and nonperforated appendicitis rates were correlated in men, they were not significantly correlated in women nor were there significant negative correlations between perforated and negative appendectomy rates.

CONCLUSION

The 25-year decline in nonperforated appendicitis and the recent increase in appendectomies coincident with more frequent use of CT imaging and laparoscopic appendectomies did not result in expected decreases in perforation rates. Similarly, time series analysis did not find a significant negative relationship between negative appendectomy and perforation rates. This disconnection of trends suggests that perforated and nonperforated appendicitis may have different pathophysiologies and that nonoperative management with antibiotic therapy may be appropriate for some initially nonperforated cases. Further efforts should be directed at identifying preoperative characteristics associated with nonperforating appendicitis that may eventually allow surgeons to defer operation for those cases of nonperforating appendicitis that have a low perforation risk.

Appendicectomy: who performs it, when and how?

A comparative review of changing patterns between 1997 and 2002 of who performs appendicectomy and a snapshot of the surgical approaches in use. It also indicates the stage at which competency in appendicectomy may be achieved by contemporary trainees in surgery and anaesthesia.

Acute surgical admissions for abdominal pain in adults in Kumasi, Ghana

BACKGROUND

Abdominal pain of less than a weeks' duration is the presenting complaint in one of every five patients admitted to the surgical Accidents and Emergency Ward of the Komfo Anokye Teaching Hospital in Kumasi. This study is a prospective one, to determine the cause of abdominal pain in a large number of patients.

METHODS

A monthly audit of discharge summaries for all patients admitted with acute abdominal pain was prepared and transferred to a special study pro forma to provide data over the 84-month period from January 1998 to December 2004.

RESULTS

There were 3114 patients, 2070 men and 1044 women. The ages ranged from 15 to 95 years. The seven most common causes of the admissions were acute appendicitis 698 (22.4%), typhoid ileal perforation (506) 16.2%, acute intestinal obstruction 391 (12.6%), gastroduodenal perforations 342 (11.0%), non-specific abdominal pain 306 (9.8%), abdominal injures 260 (8.3%) and acute cholecystitis 102 (3.2%). There were 1976 (63.4%) emergency operations. Appendicectomy was a common operation that was carried out (638 cases or 32.3%). Two hundred and thirty patients (7.4%) died. Thirty-five patients died before and 195 after operation. Of these 230 deaths, 110 (47.8%) reported to the hospital after three or more days of illness. Twenty-six per cent and 23.7% of postoperative deaths occurred after emergency colonic resections and closure of gastroduodenal perforations, respectively.

CONCLUSION

Acute appendicitis, typhoid ileal perforation, acute intestinal obstruction and gastroduodenal perforations were the leading causes of acute admissions for abdominal pain to our hospital. Late presentation was associated with increased mortality.

Acute appendicitis occurring immediately post-renal transplant

A 10-yr-old boy who presented with vomiting and abdominal pain 12 days after an uneventful renal transplant had no identifiable transplant-related cause for these symptoms. Four days later a perforated appendix was diagnosed. His case illustrates that common abdominal pathologies may present differently in immunosuppressed, transplanted patients, causing diagnostic delay.

A description of radical nephrectomy practice and outcomes in England: 1995-2002

OBJECTIVES

To describe national trends in the practice of radical nephrectomy (RN) in England between 1995 and 2002.

METHODS

Data were extracted from the Hospital Episode Statistics database of the Department of Health in England between 1995/1996 and 2001/2002. Patients were included in the study if an International Classification of Diseases diagnosis code (ICD-10) for malignant neoplasm of the kidney, renal pelvis or ureter, and an operative procedure code (OPCS-4) describing total or partial excision of the kidney by either a laparoscopic or open approach, were present in any of the diagnosis or operative procedure fields. Overall, 17 308 patients were included.

RESULTS

Patient age and the proportion who were men did not change over the study period. The proportion of patients admitted as an emergency decreased from 14.0% to 7.5% over this period (P < 0.001). The mean waiting duration increased by almost 6 days (P < 0.001) and length of stay by approximately 1 day, from 11.7 days in 1995 to 10.8 days in 2001 (P < 0.001). In-hospital mortality decreased from 2% to 1.5% (P = 0.134). In-hospital mortality and length of stay were higher in older patients and in those admitted as an emergency. Women had a longer stay than men (11.5 vs 11.1 days), but in-hospital mortality was higher in men (2.3% vs 1.6%). The national number of RNs per year increased by approximately 20%, from 2254 in 1995 to 2671 in 2001. Over the same period the mean annual hospital volume of RN increased by approximately 40%, from 17 in 1995 to 24 in 2001. The annual number of laparoscopic RNs nationally increased from seven in 1995 to 84 in 2002.

CONCLUSIONS

The annual number of RNs in England increased by almost a fifth and this was accompanied by an increase in annual hospital volume of about two-fifths. There was a large proportional increase in the number of laparoscopic RNs. Emergency admission rates and length of stay decreased but this was not accompanied by a significant change in in-hospital mortality rate.