Recurrent appendicitis following successful drainage of appendicular abscess in adult without interval appendectomy during COVID-19. Prospective cohort study

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.

SAGES guidelines update to laparoscopy in the era of COVID-19

BACKGROUND

Patients requiring cholecystectomy or appendectomy may present with concomitant COVID infection in both the inpatient and outpatient scenarios. It is unclear whether these patients benefit more from operative or nonoperative management in the setting of active COVID infection. These guidelines seek to address urgent and elective clinical scenarios.

METHODS

A systematic review was conducted to address these questions. These results were then presented to an interdisciplinary panel that formulated recommendations based on the best available evidence or utilized expert opinion when the evidence base was lacking.

RESULTS

Conditional recommendations were made in favor of (1) either operative or nonoperative management of COVID-positive patients with appendicitis or cholecystitis and (2) delaying operations by more than six weeks in patients who test positive for COVID in the elective setting.

CONCLUSIONS

These recommendations should provide guidance regarding the management of surgical patients with concomitant COVID infection. This guideline also identifies important areas where future research should focus to strengthen the evidence base.

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.

Acute abdomen in patients with covid-19: an integrative review

INTRODUCTION

upon infection with SARS-CoV-2, patients presented with non-classical symptoms, such as gastrointestinal phenomena including loss of appetite, nausea, vomiting, diarrhea, and abdominal pain abdominal pain. These occurrences, typically, were found in severely affected patients with COVID-19. With this, the aim of this paper is to analyze the available knowledge on the development of acute abdomen in SARS-CoV-2 infected patients.

METHODOLOGY

this is an Integrative Review in PubMed, Web of Science and VHL databases. The following descriptors were used: "Acute abdomen", "COVID-19", "Abdominal pain" and "SARS-CoV-2" with the Boolean operator "AND", and articles relevant to the theme were selected. Initially, 331 articles were selected, all published between 2020 and 2023, in Portuguese and/or English. After analysis, 11 articles matched the proposed objective.

RESULTS

the relationship between tenderness in the right upper region or the presence of Murphy's sign contributed in the association between abdominal pain and the more severe forms of COVID-19 in infected patients. The number of diagnoses for acute conditions such as cholecystitis, appendicitis, diverticulitis and pancreatitis decreased with the pandemic, but at the same time there was an increase in the duration of surgical procedures and in the length of hospital stays. These acute abdominal conditions were the result of delayed demand for hospital care, which also contributed to an increase in the conversion rate to open surgery and in the number of perforative conditions.

CONCLUSION

the development of acute abdomen in SARS-CoV-2 infected patients was predictive of an unfavorable prognosis.

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.