Abscess due to perforated appendicitis: factors associated with successful percutaneous drainage

Non-operative treatment strategy for appendiceal abscess in children under 3 years old: a retrospective observational study

Background

There are few studies on appendiceal abscess with appendicolith in children under 3 years old. This study aims to explore the success rate of non-surgical treatment of appendiceal abscess and assess the potential influence of an appendicolith on non-surgical treatment outcomes in children under 3 years old.

Methods

The clinical data of children under 3 years old who were diagnosed with appendiceal abscess at the Wuhan Children's Hospital, China, from February 2013 to May 2020 were collected. According to the findings of ultrasonography and CT imaging, they were divided into two groups, namely, the appendicolith group and the non-appendicolith group.

Results

A total of 94 children with appendiceal abscess were identified, meeting the specified study criteria, and categorized into two groups, namely, the appendicolith group (n = 51, 54.3%) and the non-appendicolith group (n = 43, 45.7%). Non-surgical treatment was unsuccessful in six out of the 94 children, yielding an overall success rate of 93.6% for non-surgical management of appendiceal abscess in children under 3 years old. The success rate for non-surgical treatment in the appendicolith subgroup was 90.2%, whereas that for the non-appendicolith subgroup was 97.7%. No statistically significant distinction was observed between the two groups (P = 0.292). Likewise, there were no significant differences in gender, age, duration of symptoms, fever, vomiting, diarrhea, rebound pain, white blood cell count, C-reactive protein level, and abscess cross-sectional area between the appendicolith group and the non-appendicolith group. However, there is a statistical difference in tenderness in the right lower abdomen.

Conclusion

Non-surgical treatment of appendiceal abscess has a high success rate and can be considered an effective treatment strategy. In pediatric patients under 3 years old without evidence of complete intestinal obstruction or diffuse peritonitis, non-surgical treatment may be considered for appendiceal abscess.

Image-guided abscess drainage in children with perforated appendicitis - can it wait?

BACKGROUND

Image-guided drainage is the management of choice for perforated appendicitis with intra-abdominal abscess/es. However, there is paucity of data regarding the optimal time for intervention in children.

OBJECTIVE

The purpose of this study is to assess the relationship between the time from diagnosis of a drainable abscess to abscess drainage (delta time) and the clinical outcome in patients with complicated acute appendicitis.

MATERIALS AND METHODS

This is an institutional review board (IRB)-approved retrospective study comprising 80 pediatric patients who had image-guided abscess drainage due to perforated acute appendicitis. Delta time was associated with clinical outcome including length of stay, catheter dwell time, need for additional interventions, and need for tissue plasminogen activator (t-PA). Gamma regression models were used to assess the adjusted effect of delta time on the "length of stay" and "catheter dwell time" using "volume of the largest abscess" and "number of collections" as severity indices. Logistic regression was used to assess the effect of delta time on the "need for the t-PA" and "need for additional interventions."

RESULTS

Mean age (SD) was 10.2 (3.8) years. Mean time between diagnosis and intervention (delta time) was 1.5 (1.2) days. There was no evidence that delta time effects the length of stay, catheter dwell time, need for t-PA, and need for additional interventions (P > 0.05). However, there was an association between the number of collections and volume of the largest abscess with length of stay (P = 0.006; P = 0.058), catheter dwell time (P = 0.029; P < 0.001), and need for additional interventions (P = 0.029; P = 0.016).

CONCLUSIONS

Our results suggest that time between diagnosis of an appendicitis associated abscess and intervention is not significantly associated with need for tPA, need for additional intervention, drain dwell time, or length of stay.

Laparoscopic Drainage Versus Interventional Radiology for Management Of Appendicular Abscess : A Randomized Controlled Trial.. [DOI: 10.21203/rs.3.rs-1975645/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background: Laparoscopic drainage of appendicular abscess has become a novel technique due to its advantages over interventional radiology like complete exploration of the abdomen, exclusion of other pathologies, excision of the appendix at same session, better cosmesis, decrease incidence of wound infection & incisional hernia, better visualization of surgical field, fine handling of edematous tissue and drainage of multiple collections. Methods: This prospective randomized controlled clinical trial included all patients who developed the manifestations of appendicular abscess and referred to the Zagazig University Hospital Emergency Department between January 2020 and February 2022. The study was prospectively approved by Zagazig University Faculty of Medicine Institutional Review Board (Approval Number: 55342/24.1.2020), and was retrospectively submitted in clinicaltrials.gov in 15/6/2022 (ClinicalTrials.gov ID: NCT05419440). The sample size was 172 patients divided into two equal group, laparoscopic group involved 86 patients (group1), interventional radiology group involved 86 patients (group2). Results: “Group 1 (laparoscopic drainage group) included 86 patients: 55.8% were males, with a mean age of 41.2 (± 12.2) years-old, while in group 2 (interventional radiology group) included 86 patients: 51.2% were males, with a mean age of 36.8 (± 10.9) years-old. The reported complications were bowel injury, fecal fistula, recurrence, pelvic collection and mortality with incidence rates of occurrence 1(1.2%), 3 (3.5%), 0 (0%), 0 (0%), 0(0%) respectively in group (1) while in group(2) were 5(5.8%), 0(0%), 3(3.5%), 8(9.3%), 1(1.2%) respectively. Regarding quality of life in both groups were excellent, good, poor with incidence rates of 48(55.8%), 38(44.2%), 0(0%) respectively in group (1), and 12(14%), 59(68.6%), 15(17.4%) respectively in group(2). Conclusion: Laparoscopic management of appendicular abscess can be safely applied in a good experienced hand with no mortality & morbidity, without the need for interval appendectomy.

Clostridioides difficile infection after appendectomy: An analysis of short-term outcomes from the NSQIP database

BACKGROUND

Clostridioides difficile infection can be a significant complication in surgical patients. The purpose of this study was to describe the incidence and impact on outcomes of Clostridioides difficile infection in adult patients after appendectomy.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program data set was used to identify all patients with the primary procedure code of appendectomy between 2016 and 2018. Patient demographics and clinical characteristics were extracted from the database, and descriptive statistics were performed. A multivariate logistic regression was created to identify predictors of Clostridioides difficile infection following appendectomy.

RESULTS

A total of 135,272 patients who underwent appendectomy were identified, and of those, 469(0.35%) developed Clostridioides difficile infection. Patients with Clostridioides difficile infection were more likely to be older (51.23 vs 40.47 years; P < .0001), female (P = .004), American Society of Anesthesiology score >2 (P < .0001), present with septic shock (P < .0001), or lack functional independence (P < .0001). Patients with Clostridioides difficile infection were more likely to have increased operative time (62.9 vs 50.4 minutes; P < .0001), have perforated appendicitis (48.9% vs 23.5%; P < .0001), and underwent open surgery (7.0% vs 4.0%; P = .0006). Postoperatively, patients with Clostridioides difficile infection required a longer length of stay (4.8 vs 1.8 days; P < .0001), had increased mortality (2.1% vs 0.1%; P < .0001), higher incidences of postoperative abscess (14.9% vs 2.9%; P < .0001), postoperative sepsis (15.1% vs 4.0%; P < .0001), and readmission (30.7% vs 3.4%; all P < .0001). On multivariate analysis, older age (P < .0001), female sex (P = .0043), septic shock (P = .0002), open surgery (P = .037), and dirty wound class (P = .0147) were all independently predictive factors of Clostridioides difficile infection after appendectomy.

CONCLUSION

Clostridioides difficile infection is an uncommon postoperative complication of appendectomy and is associated with worse outcomes and higher mortality. Older patients, female sex, those with sepsis, and those undergoing open surgery are at higher risk for developing Clostridioides difficile infection.

From the Base of the Cecum to the Throne of England: King Edward VII’s Appendix

This historical retrospective explores the case of King Edward VII’s appendicitis at the time of his planned coronation in 1902, as well as the contributions of the king’s surgeons Frederick Treves and Joseph Lister, towards his medical care. The history of appendicitis, as well as a view of the king’s medical management in the lens of modern surgical and sociopolitical contexts, is also examined.

Modern Management of the Appendix: So Many Options

Nonoperative management (NOM) of acute appendicitis is becoming more popular, especially in resource-strapped locations, to minimize hospital system costs. In uncomplicated cases of appendicitis, NOM can effectively treat the patient. It does carry a 39.1% risk of recurrence in 5 years, and operative management (OM) does not increase morbidity or risk of complication, so the authors recommend laparoscopic OM for uncomplicated appendicitis. For complicated cases of appendicitis, the authors recommend initial NOM with interval appendectomy in all patients. All appendicitis patients should undergo surveillance endoscopy if older than 40 years to rule out a contributing neoplasm.

Drain Failure in Intra-Abdominal Abscesses Associated with Appendicitis

BACKGROUND

Previous studies have suggested that percutaneous drainage and interval appendectomy is an effective treatment for appendicitis with associated abscess. Few studies to date have analyzed risk factors for failed drain management. We hypothesized that older patients with more co-morbidities would be at higher risk for failing conservative treatment.

METHODS

The 2010-2014 editions of the National Inpatient Sample (NIS) were queried for patients with diagnoses of peri-appendiceal abscesses. Minors and elective admissions were excluded. We identified patients who underwent percutaneous drainage and defined drain failure as undergoing a surgical operation after drainage but during the same inpatient visit to assess for factors associated with failure of drainage alone as a treatment. After univariable analysis, binomial logistic regression was used to assess for independent risk factors. Frequencies were analyzed by χ² and continuous variables by Student's t-test.

RESULTS

A total of 2,209 patients with appendiceal abscesses received drains; 561 patients (25.4%) failed conservative management and underwent operative intervention. On univariable analysis, patients who failed conservative management were younger, more likely to be Hispanic, have more inpatient diagnoses, and to have undergone drainage earlier in the hospital course. Multivariable regression demonstrated that the number of diagnoses, female sex, and Hispanic race were predictive of failure of drainage alone. Older age, West and Midwest census regions, and later drain placement were predictive of successful treatment with drainage alone. Failure was associated with more charges and longer hospital stay but not with a higher mortality rate.

CONCLUSION

Approximately a quarter of patients will fail management of appendiceal abscess with percutaneous drain placement alone. Risk factors for failure are patient complexity, female sex, earlier drainage, and Hispanic race. Failure of drainage is associated with higher total charges and longer hospital stay; however, no change in the mortality rate was noted.

Bad bacteria in acute appendicitis: rare but relevant

PURPOSE

Bacterial infections are a factor for morbidity in patients with acute appendicitis (AA). The spreading of multidrug-resistant (MDR) bacteria is a significant problem in surgery, and the most relevant MDR pathogens are summarized as Enterobacteriaceae, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterococci (ESKAPE) bacteria. Data regarding the species and distribution of bacteria in AA are available, but information about the resistances and their relevance is deficient.

METHODS

In this retrospective study, we analyzed microbiological swabs of patients with AA. The outcome parameters of patients after laparoscopic appendectomy were analyzed against microbiological results, including antibiotic resistance testing. Positive swabs were compared with bacteria cultivated after alternative abdominal emergency surgery (AES).

RESULTS

In total, 584 patients with AA were included and had a mean age of 35.5 years. In 216 patients (36.9%), a swab was taken, and in 128 (59.3%) swabs, bacteria could be cultivated. The most frequent organisms were Escherichia coli, Bacteroides species, and Pseudomonas. In 9.4% of the positive AA swabs, MDR germs were cultivated, and all of them were ESKAPE pathogens. Patients with MDR bacteria in AA suffered more infectious complications (p = 0.006) and needed longer hospitalizations (p < 0.009). In AES, aside from appendicitis, a different spectrum containing more MDR bacteria was cultivated (5.9 vs. 20.9%; p < 0.0001).

CONCLUSIONS

Although they occur less frequently in appendectomy compared to emergency surgeries for other abdominal diseases, MDR bacteria are traceable in this common disease and contribute to additional morbidity.