Time to appendectomy for acute appendicitis: A systematic review

The Risk of Adhesive Bowel Obstruction in Children With Appendicitis: A Systematic Review

OBJECTIVE

Complicated appendicitis is associated with a higher risk of postoperative complications, including adhesive bowel obstruction. The aim of this meta-analysis is to investigate the difference in rates of postoperative bowel obstruction in paediatric patients with complicated versus simple appendicitis and whether this is influenced by the surgical approach.

METHODS

A systematic literature search following PRISMA guidelines was conducted using MEDLINE, Embase and Cochrane Library for studies that analysed incidence of adhesive bowel obstruction in paediatric patients after appendicectomy. Studies from 1998 to 2022 were included in analysis. The study protocol was registered on PROSPERO (ID CRD42022309769).

RESULTS

Pooled analysis of 6 studies with low risk of bias and adequate follow up periods, considering 58,962 cases of appendicectomy, revealed complex appendicitis was associated with a near two-fold increase in incidence of SBO (pooled odds ratio 2.02 (95% CI 1.35-2.69)). Interestingly, a similar pooled analysis of 10 studies, considering 62,433 cases of appendicectomy, revealed no significant difference between open and laparoscopic management of complex appendicitis (pooled odds ratio 0.93 (95% CI 0.24 to 1.62)).

CONCLUSION

Complex appendicitis is associated with a two-fold increase in the rates of adhesive bowel obstruction. Whilst there are cosmetic advantages of a laparoscopic approach, surgical expertise should be favoured in decision making relating to surgical approach (laparoscopic versus open) as the evidence for a laparoscopic approach reducing risks of adhesive bowel obstruction is not convincing.

LEVEL OF EVIDENCE

Level II.

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.

Transumbilical laparoscopic-assisted appendectomy <em>versus</em> laparoscopic appendectomy in children: a single center experience

Laparoscopic Appendectomy (LPSA) is the first choice for appendectomy in pediatric surgery. Trans-Umbilical Laparoscopic Assisted Appendicectomy (TULAA) is another used technique. We compared both these procedures used for the treatment of acute appendicitis. The study was conducted between January 2019 to December 2020. Patients were divided into two groups: LPSA and TULAA groups. The collected data were: operative time, number of conversions, time of canalization and hospital stay. A total of 181 patients were included: 73 were kept in the LPSA and 108 in the TULAA group. Mean operative time was 70.9 minutes (range 45-130 min) for LPS and 56.4 (30-145 min) for TULAA group (p <0.0001). Complications rate showed no statistically significant difference between both the two groups. However, conversions showed a statistically significant difference (p=0.04). Both techniques showed similar results. TULAA technique takes a significantly shorter operating time. The selection between LPSA and TULAA techniques depends on the experience of the surgeon's work and the personal laparoscopic learning curve. In our experience LPSA was a useful technique to improve the laparoscopic skill of the pediatric surgery residents.

Defining high-quality care in pediatric surgery: Implications for performance measurement and prioritization of quality and process improvement efforts

Establishing a standardized and comprehensive framework for defining surgical quality is essential for meaningful performance measurement and process improvement efforts. The goal of this chapter is to provide a conceptual framework for defining surgical quality based on the perspectives of relevant stakeholders, and to identify infrastructure and care processes necessary for the delivery of high-quality surgical care. Central to this framework are the complementary approaches for quality assessment as outlined by the Institute of Medicine and Donabedian paradigms, and how these should be used together to develop a robust and granular taxonomy of quality constructs relevant to all surgical conditions. The utility of balancing and composite measures for quality assessment is also reviewed, as are practical considerations for identifying and prioritizing process improvement opportunities based on procedure volume and perioperative risk.

Expedited Surgical Care of Appendicitis is Associated With Improved Resource Utilization

INTRODUCTION

Appendectomy for acute appendicitis is the most common pediatric intra-abdominal operation. Current literature supports the notion that modest in-hospital, preoperative delays are not associated with greater patient morbidity. However, there is less certainty regarding the role that hour-of-presentation plays in determining the timing of surgery. Thus, we aimed to evaluate how after-hours presentation may relate to the timing of surgery and to assess the outcomes and resource utilization associated with expedited appendectomy compared to nonexpedited.

METHODS

Patient records for children who underwent an appendectomy at a freestanding pediatric hospital from 2015 to 2019 were reviewed. Business hour presentations were defined as arrival at the emergency department from 7 AM to 6 PM. Primary outcomes were hospital length of stay (LOS), cost derived from the Pediatric Health Information System database, perforation, surgical complications, and 30-day readmissions.

RESULTS

Nine hundred forty-two patients underwent appendectomy over the study period. The median time to OR was 2.0 h in the expedited cohort and 9.8 h in the nonexpedited group. Presentation during business hours was associated with 4.4 higher odds (P < 0.001) of expedited workflow. Expedited appendectomies were associated with shorter hospital LOS (11.5 h, P < 0.001), less costly admissions ($1,155, P < 0.001); LOS measured in midnights, perforation and readmission rates were similar between groups.

CONCLUSIONS

We found reduced resource utilization associated with expedited appendectomy. Additionally, the demonstrated association between the time of presentation to the emergency department (ED) and the timing of surgery may be utilized to inform staffing and resource deployment decisions. Further research regarding the generalizability and sustainability of an expedited presurgical workflow in pediatric appendectomy is certainly indicated.

Are only a few hours adequate for hospitalisation following mini-incision open appendectomy in paediatric patients?

BACKGROUND

A very short hospital length of stay following an open appendectomy in children with acute simple appendicitis has never been mentioned yet in the literature. The authors reviewed the outcome of these paediatric patients who were treated with the open technique.

MATERIALS AND METHODS

In this analytical cohort observational study, we retrospectively reviewed the medical records of the 115 consecutive patients who underwent open appendectomy from June 2017 to July 2021.

RESULTS

There were 84 patients whose appendices were inflammatory or suppurative and appendectomies were done only through McBurney's point. Of these, the average age was 9.11 ± 2.67 years. The mean length of the incision was 1.95 ± 0.48 cm. Nearly one-third (25/85) were discharged within 3 h following surgery. Of the remaining cases, nine patients were discharged within the same day. There were increased percentages of patients who were eligible for early discharge in each consecutive year.

CONCLUSION

The idea of immediate discharge within 3 h seems to be feasible for children with acute simple appendicitis who were treated with open appendectomy. We believe that the practice will be widely acknowledged and proceed to reduce the resources and the expenses in the hospital.

Time between onset of symptoms and definitive treatment in children with acute appendicitis: How it affects length of hospital stay?

PURPOSE

Any delay in treatment of acute appendicitis (AA) could lead to complications increasing morbidity and length of hospital stay (LHS). The aim of this study was to determine the time interval between onset of symptoms and seeking medical attention and definitive treatment in children with AA and its impact on LHS.

MATERIALS AND METHODS

A prospective study was conducted from December 2017 to March 2018. All patients diagnosed with AA and who underwent surgical procedure were enrolled. A questionnaire leaflet completed by parents was used to collect clinical data and information about seeking medical attention and children's management. Time was divided into six different intervals (1-2 h, 3-6 h, 7-12 h, 13-24 h, >24 h and >48 h) to estimate the time between onset of symptoms and seeking medical attention and time between hospital admission and surgical procedure. LHS was recorded.

RESULTS

During the study period, 125 children were enrolled. Over half of the patients sought for medical assistance relatively soon (3-12 h) after the onset of symptoms, whereas 17.6% sought late healthcare (>24 h). The time between the medical examination and surgical procedure was <24 h in approximately 80% of the children. LHS was affected by time between onset of symptoms and seeking medical attention and time between medical examination and surgical procedure (P = 0.001 and P = 0.017, respectively).

CONCLUSIONS

The majority of the children with AA admitted to hospital were treated relatively soon after the onset of symptoms. However, a significant proportion of children delayed to seek medical advice and undergo appendectomy, increasing LHS.

Time to Surgery Does Not Impact Outcome in Pediatric Appendicitis

Background: Despite the high prevalence of acute appendicitis in children and substantial resource utilization associated with this condition, no consensus has been reached on optimal timing for performing appendectomies. The aim of this study was to examine the association between time to appendectomy and outcomes and assess the feasibility of delayed appendectomy in children. Patients and Methods: We performed a retrospective analysis of all patients younger than 14 years of age undergoing an appendectomy for suspected appendicitis. We divided our patients into two groups based on whether their time to appendectomy was shorter or longer than eight hours: group A, early appendectomy and group B, delayed appendectomy. Then we compared the two study groups regarding demographic, clinical, and radiographic characteristics, peri-operative data, and outcomes. Results: During the eight-year study period, a total of 1,141 patients underwent appendectomies. After applying exclusion criteria, 852 children were included: 544 (63.8%) in group A and 308 (36.2%) in group B. There were no differences in the rate of complicated appendicitis at exploration, post-operative complications, length of post-operative hospital stay, and 30-day re-admission rate between the two study groups. Conclusions: Our study demonstrated that delaying appendectomy within 24 hours of presentation is safe and feasible for pediatric acute appendicitis. Therefore, patients presenting during nighttime hours could be initially treated conservatively with antibiotic agents. This allows the surgeon to delay surgery to the following day.

Delayed Surgery for Perforated Appendicitis is Feasible in Children Without Compromising the Outcome in Selected Cases

BACKGROUND AND AIM

The relationship between time to surgery and risk of postoperative complications and re-intervention has not been conclusively investigated in pediatric perforated appendicitis (PA). The aim of this study was to determine whether time to appendectomy (TTA) is a risk factor for postoperative complications and re-intervention in a cohort of children undergoing appendectomy for PA.

METHODS

A total of 254 children (age: 8.7 ± 3.7 years) undergoing appendectomy for PA were retrospectively evaluated and stratified into Group I-III according to the Clavien-Dindo classification for postoperative complications (Group I n = 218, 86%; Group II n = 7, 3%; Group III n = 29, 11%).

RESULTS

The TTA was comparable between all groups (group I: 8.8 ± 9.2 h; group II: 7.8 ± 5.3 h; group III: 9.5 ± 9.6 h; overall: 8.8 ± 9.1 h; p = 0.885). A C-reactive protein (CRP) value at admission of  ≥128.6 mg/l indicated a higher risk for developing Grade II complications with no need for re-intervention (OR: 3.963; 95% CI: 1.810-8.678; p = 0.001) and Grade III complications with the need for re-intervention (OR: 3.346; 95% CI: 1.456-7.690; p = 0.004). This risk was independent of the TTA (OR: 1.007; 95% CI: 0.980-1.035; p = 0.613).

CONCLUSIONS

Appendectomy can be delayed by an average time delay of about 9 h in children with PA without increasing the risk of postoperative complications and re-intervention, also in patients at high risk defined by the initial CRP level ≥ 128.6 mg/l. This data may support the correct risk-adjusted scheduling of surgical interventions in times of limited capacity.

Patient Outcomes Related to In-Hospital Delays in Appendicectomy for Appendicitis: A Retrospective Study

Background and objective

In many hospitals, the availability of operating theatres and access to senior surgical and anaesthetic support diminish during night hours. Therefore, urgent surgery is sometimes postponed until the following morning rather than performed overnight, if it is judged to be safe. In this study, we aimed to determine if a delay in laparoscopic appendicectomy in cases of acute appendicitis of over 12 hours, analogous to an overnight delay, correlated with worse patient outcomes. Our primary outcome was delayed discharge from the hospital. Our secondary outcomes were appendicitis severity, conversions, and postoperative complications.

Methods

We undertook a retrospective review of the medical records of patients who underwent laparoscopic appendicectomy for appendicitis at a UK district general hospital between 01/01/2018 and 30/08/2019. For each patient, clinical and demographic information, and time of hospital admission, surgery, and discharge were collected. Delayed discharge was defined as "time to discharge" >24 hours after surgery.

Results

A total of 446 patients were included in the study. In 137 patients (30.7%), "time to surgery" was under 12 hours; in 309 patients (69.3%) "time to surgery" was over 12 hours. Of note, 319 patients (71.5%) had a delayed discharge; 303 patients (67.9%) had complicated appendicitis, and 143 patients had severe appendicitis (32.1%). No statistically significant association between "time to surgery" and delayed discharge, appendicitis severity, conversion, or 30-day re-presentations was observed.

Conclusion

Time from admission to the start of appendicectomy did not affect patient outcomes. Short in-hospital delays in appendicectomy, such as an overnight delay, may be safe in certain patients and should be determined based on clinical judgement.

Diagnostic Accuracy of Suspected Appendicitis: A Comparative Analysis of Misdiagnosed Appendicitis in Children

OBJECTIVE

When evaluating suspected appendicitis, limited data support quality benchmarks for negative appendectomy (NA); none exist for delayed diagnosis of appendicitis (DDA). The objectives of this study are the following: (1) to provide preliminary evidence supporting a quality benchmark for DDA and 2) to compare presenting features and diagnostic evaluations of children with NA and DDA with those with pathology-confirmed appendicitis (PCA) diagnosed during initial emergency department (ED) encounter.

METHODS

Secondary analysis of data from a QI project designed to reduce the use computed tomography when evaluating suspected appendicitis using a case-control design. Patients undergoing appendectomy in an academic tertiary care children's hospital system between January 1, 2015, and December 31, 2016 (n = 1,189) were eligible for inclusion in this case-control study. Negative appendectomy was defined as no pathologic change or findings consistent with a different diagnosis. Delayed diagnosis of appendicitis was defined as patients undergoing appendectomy within 7 days of a prior ED visit for a related complaint. Controls of PCA (n = 150) were randomly selected from all cases undergoing appendectomy.

RESULTS

There were 42 NA (3.5%) and 31 DDA (2.6%). Cases of PCA and NA exhibited similar histories, examination findings, and underwent comparable diagnostic evaluations. Cases of PCA more frequently demonstrated a white blood cell count greater than 10 × 103/μL (85% vs 67%; P = 0.01), a left-shift (77% vs 45%; P < 0.001), and an ultrasound interpretation with high probability for appendicitis (73% vs 54%; P = 0.03). Numerous significant differences in history, examination findings, and diagnostic tests performed existed between cases of PCA and DDA.

CONCLUSIONS

Children with PCA and NA present similarly and undergo comparable evaluations resulting in appendectomy. A 3% to 4% NA rate may be unavoidable given these similarities. Presenting features in DDA significantly differ from those of PCA. An irreducible proportion of appendicitis diagnoses may be delayed.

Presurgical time and associated factors as predictors of acute perforated appendicitis: a prospective cohort study in a teaching pediatric hospital in Colombia

Background

We aim to determine the association between out and in-hospital factors with time, from the beginning of the symptoms to the surgery, in patients with acute appendicitis treated at Fundación Hospital Pediatrico La Misericordia (HOMI) in Colombia.

Methods

Eleven month prospective cohort study of pediatric patients at HOMI with acute appendicitis diagnosis taken to surgery. Data from the out-of-hospital phase was collected by surveying parents, and the data regarding the in-hospital phase was completed with medical records. We analyzed the association between the time from the beginning of the symptoms to the surgery, and out and in-hospital factors associated with this time using generalized linear models.

Results

Eight hundred three patients were included in the study. Total pre-surgical time was longer in perforated appendicitis (PA) group (2.65 days, standard deviation (SD) 1.88 vs. 2.04 days, SD 1.45) (p < 0.01). Factors associated with longer total and out-of-hospital presurgical times were age under 4 years old, lower socioeconomic status, father as a caregiver, self-medication, and underestimating disease severity.

Conclusions

Out-of-hospital timing determines the longer pre-surgical time in complicated appendicitis. Younger age and lower socioeconomic status affect time significantly. We suggest the implementation of strategies in order to lower prehospital time, rates, and costs of complicated appendicitis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03121-8.

Impact of the COVID-19 pandemic and the restrictions on pediatric appendicitis in Turkey: A single-center experience

BACKGROUND

In this study we investigated how the incidence and course of acute appendicitis (AA) changed in children during the pandemic.

METHODS

Children diagnosed with AA during the 1-year pandemic period after the first COVID-19 case in Turkey and the previous 1 year were included in the study. Children were divided into two groups: those hospitalized during the pandemic (group A) and those hospitalized in the year before the pandemic (group B). Furthermore, we compared the findings obtained for COVID-19-positive and COVID-19-negative children in the whole study group and within group A.

RESULTS

A significant difference was found between the two groups in terms of gender, the rate of vomiting and the number of days of vomiting. Complicated AA was more frequent in group B than in group A. In addition, the hospital stay was significantly longer, the mean number of days with fever was significantly higher, and mean body temperature was significantly higher in COVID-19-positive patients in the whole study group and within group A.

CONCLUSIONS

Contrary to most studies in the literature, in the present study the patients in the pre-pandemic period were admitted to hospital later, and this may have been associated with the higher frequency of complicated AA in these patients. During the pandemic, however, the arrangements and warnings of health authorities might have reduced the anxiety and the hesitancy of families to go to the hospital, and hence this may have been associated with the lower rate of complicated AA in this period.

The use of the ratio of C-reactive protein to albumin for the diagnosis of complicated appendicitis in children

PURPOSE

No reliably specific marker for complicated appendicitis has been identified. The ratio of serum C-reactive protein (CRP) to albumin (ALB) (CRP/ALB ratio) is a new inflammation-based prognostic score that is associated with the severity of inflammation. The aim of this study was to evaluate the predictive value of CRP/ALB ratio for the diagnosis of complicated appendicitis in children.

METHODS

A retrospective study of 296 children with acute appendicitis was conducted with assessments of demographic data, clinical symptoms, pre-operative laboratory results, abdominal ultrasound examinations and clinical outcomes. According to the postoperative pathological results, patients were divided into a simple appendicitis group (169 patients) and a complicated appendicitis group (127 patients). SPSS version 22.0 was used to analyse the data.

RESULTS

Of the 296 patients, CRP/ALB ratio was higher in complicated appendicitis than in simple appendicitis (P < 0.05). Logistic regression analysis showed that higher levels of white blood cell count (WBC), CRP, CRP/ALB ratio, and increased incidence in submucosal layer loss and appendicolith were independent risk factors for complicated appendicitis in children. Receiver operating characteristic curve analysis showed that the area under the curve of the CRP/ALB ratio (0.883) was larger than that of WBC (0.702), CRP (0.802), ALB (0.835), submucosal layer loss (0.633) and appendicolith (0.673). A CRP/ALB ratio ≥ 1.39 was found to be a significant marker in the prediction of complicated appendicitis, with 86.61% sensitivity and 84.62% specificity. Patients with a CRP/ALB ratio ≥ 1.39 had a 31.263 times higher chance of having complicated appendicitis (95% CI: 16.449-59.418) than those with a CRP/ALB ratio < 1.39.

CONCLUSION

The admission CRP/ALB ratio was significantly higher in children with complicated appendicitis. The CRP/ALB ratio is a novel but promising haematological marker that aids in the differentiation of acute complicated and simple appendicitis.

Prehospital barriers for rural New Zealand parents in paediatric appendicitis: a qualitative analysis

BACKGROUND

Appendicitis is the most common reason children undergo emergency general surgery. Worse appendicitis outcomes have been demonstrated in rural, lower socioeconomic, and indigenous populations. These findings are hypothesised to be a result of differential access and delay in presentation to hospital. However, no qualitative study has investigated why prehospital delay may exist.

METHODS

We conducted individual, semi-structured interviews with the parents of 11 rural children who presented with acute appendicitis between June 2019-January 2020. Utilising grounded theory methodology, we created an exploratory framework.

RESULTS

Participating families travelled a mean distance of 50.4 km to access hospital, and the median prehospital symptom duration was 42 h. Families with reduced financial or social resources were more likely to 'watch and wait' due to the increased relative burden of access. Key considerations were travel, organising childcare and parental income loss in a rural environment. Structural healthcare barriers further dissuaded prompt access and subsequent engagement. These included poor cultural safety, maldistribution of rural health services, and contradictory public health messages. Several families sought informal community-based health advice to mitigate these barriers, leading to earlier hospital presentation.

CONCLUSION

Prehospital delay in rural families occurred most frequently due to an extended decision-making phase where families evaluated the costs and benefits of accessing hospital-level care. The utilisation of informal community expertise and whānau advocacy helped circumvent reduced access to health facilities. Cultural safety remains problematic and hinders engagement with Māori families.

Revisiting delayed appendectomy in patients with acute appendicitis

Acute appendicitis (AA) is the most common acute abdomen, and appendectomy is the most common nonelective surgery performed worldwide. Despite the long history of understanding this disease and enhancements to medical care, many challenges remain in the diagnosis and treatment of AA. One of these challenges is the timing of appendectomy. In recent decades, extensive studies focused on this topic have been conducted, but there have been no conclusive answers. From the onset of symptoms to appendectomy, many factors can cause delay in the surgical intervention. Some are inevitable, and some can be modified and improved. The favorable and unfavorable results of these factors vary according to different situations. The purpose of this review is to discuss the causes of appendectomy delay and its risk-related costs. This review also explores strategies to balance the positive and negative effects of delayed appendectomy.

Acute Appendicitis in Childhood and Adulthood

BACKGROUND

Acute appendicitis is the most common cause of the acute abdomen, with an incidence of 1 per 1000 persons per year. It is one of the main differential diagnoses of unclear abdominal conditions.

METHODS

This review is based on pertinent publications that were retrieved by a selective search in the PubMed and Cochrane Library databases.

RESULTS

In addition to the medical history, physical examination and laboratory tests, abdominal ultrasonography should be performed to establish the diagnosis (and sometimes computed tomography [CT] or magnetic resonance imaging [MRI], if ultrasonography is insufficient). Before any treatment is provided, appendicitis is classified as either uncomplicated or complicated. In both types of appendicitis, the decision to treat surgically or conservatively must be based on the overall clinical picture and the patient's risk factors. Appendectomy is the treatment of choice for acute appendicitis in all age groups. In Germany, appendectomy is mainly performed laparoscopically in patients with low morbidity. Uncomplicated appendicitis can, alternatively, be treated conservatively under certain circumstances. A meta-analysis of five randomized, controlled trials has revealed that ca. 37% of adult patients treated conservatively undergo appendectomy within one year. Complicated appendicitis is a serious disease; it can also potentially be treated conservatively (with antibiotics, with or without placement of a drain) as an alternative to surgical treatment.

CONCLUSION

Conservative treatment is being performed more frequently, but the current state of the evidence does not justify a change of the standard therapy from surgery to conservative treatment.

Timeliness of pediatric surgical appendicitis care is associated with time of hospital admission

BACKGROUND

Despite the frequency of acute appendicitis in children, there is no evidence-based consensus surrounding the urgency of the operation if a diagnosis is made after regular business hours. Although a modest delay in time to operation does not increase disease severity, postponing cases to the next calendar day may be associated with higher resource utilization. We aimed to evaluate the trend of delaying appendectomies to the next calendar day and its associated outcomes.

METHODS

We queried the Pediatric Health Information System to analyze appendectomy patients younger than 18 y of age from 2010 to 2018. Same-day appendectomy and next-day appendectomy cohorts were created using admission hour and operative day. Healthcare cost, length of stay, surgical complications, and 30-day readmission rates were collected. Bivariate analyses and multivariable regressions were used to evaluate groups stratified by time of presentation.

RESULTS

During the study period, 113,662 appendectomies were performed, comprising 88,715 (78.1%) same-day appendectomies and 24,947 (21.9%) next-day appendectomies. A higher proportion of same-day appendectomies (80.5%) were performed during hours 12:00am to 5:00pm and 19.5% were performed during hours 6:00pm to 11:00pm. The trend of next-day appendectomies increased during the study period from 13.9% to 20.2%. This was primarily evident in the 6:00pm to 11:00pm period. The 5:00pm cutoff was most predictive of a next-day appendectomy. Next-day appendectomies had similar rates of surgical complications; however, they were associated with higher costs, longer lengths of stay, and higher readmission rates.

CONCLUSION

As the understanding of appendicitis urgency has changed, a more tempered approach of delivering surgical care has trended. Although short delays appear safe, postponement to the next calendar day is associated with higher resource utilization.

Acute Appendicitis in Pregnancy: How to Manage?

Objectives

Acute appendicitis during pregnancy may be associated with severe maternal and fetal complications. The clinical, laboratory and radiological parameters used in diagnosis and the effects of the surgical method and timing on the results are controversial. The present study aims to reveal the relationship between clinical approach, surgical treatment methods and complications in pregnant women with suspected acute appendicitis.

Methods

Between December 2007 and August 2019, 21 pregnant women who underwent appendectomy were included in this study. Age, gestational age, complaints at admission, leukocyte count, radiological examination results, type of surgery (conventional or laparoscopic), histopathology results, time from admission to operation, maternal and fetal complications were retrospectively evaluated.

Results

The number of patients who developed complications was six (28.6%). Three (14.3%) of these patients had preterm birth and three (14.3%) had an abortion. There was no statistically significant relationship between trimester and complication (p=0.747). Fourteen patients (66.7%) underwent laparoscopic surgery and seven patients (33.3%) underwent conventional surgery. Although the complication rate was higher in the laparoscopic group, there was no statistically significant difference (p=0.306). The fetal loss rate in the series was 14.3% and all were in the laparoscopic group. However, there was no statistically significant difference between the groups (p=0.158).

Conclusion

Pregnancy-related limiting factors may complicate the diagnosis of acute appendicitis. These patients definitely need a more skeptical assessment and additional diagnostic tools beyond the standard clinical approach. Although laparoscopic appendectomy appears to be a safe option in treatment, its relationship with a higher risk of fetal loss should be kept in mind.

Low intra-operative diagnostic accuracy does not affect postoperative treatment of acute appendicitis

BACKGROUND

The intra-operative classification of appendicitis defines postoperative treatment. The correct designation can influence patient recovery, complications and hospital costs. Recent research has shown that intra-operative classification criteria varies among surgeons, and is not always the same as the pathologist's report. Classification accuracy can lower costs by preventing unnecessary treatment or sub-optimal interventions.

METHODS

During a period of 4 months, N = 133 appendix specimens were received and evaluated by the pathology department of a single teaching hospital. Five surgeons extracted the specimens and one experienced pathologist drew the histopathology reports. A comparison between the surgeons' classifications and the pathologist's was made. Classification accuracy was determined and statistical analyses was performed using chi-square, and p values were obtained. A p < 0.05 was considered significant.

RESULTS

A total of N = 133 specimens were obtained, 127 belonged to patients following emergency surgery due to acute abdominal pain; the other six were from elective hemi-colectomies for right colonic adenocarcinomas, and were not included. Of the 127 specimens analyzed, 14 (11%) were negative, 21 (16.5%) were edematous, 81 (63.7%) were phlegmonous and 11 (8.6%) were gangrenous. A total of 18 (14%) perforated appendices were also reported. Surgical accuracy was 60.6% (N = 67) with a statistically significant p < 0.001. Only five patients with incorrect intraoperative classifications received unnecessary or lacked treatment.

CONCLUSIONS

An overall accuracy of 60.6% is seen when the surgical classification is compared to the pathological classification. Although the surgeons' accuracy is low when comparing intra-operative versus histopathological classification, this variation in designation does not affect postoperative treatment significantly.

Did the COVID-19 Pandemic Cause a Delay in the Diagnosis of Acute Appendicitis?

BACKGROUND

Appendectomy for acute appendicitis remains one of the most common surgical procedures. This study aims to assess the clinical presentation and delays in diagnosing acute appendicitis during the COVID-19 pandemic.

METHODS

We evaluated data of all adult patients who underwent an appendectomy at our hospital between June 1, 2019 and June 1, 2020. Demographic data, admission type to the emergency room, radiological findings, pathological findings, and hospitalization time were noted. Patients were divided into four groups of 3-month periods, pre (Groups 5, 4, 3, 2) and during the pandemic (Group 1). Hospitalization time and perforation status of each group were compared. The hospital admission type and their effect on perforation were also evaluated.

RESULTS

Two hundred and fourteen patients were included; 135 patients were male, and 57 were female. The median age was 39 years. In Group 1 (pandemic period), 28.8% of patients were referred to us from pandemic hospitals. The median hospitalization time was 7.3 h before pandemics (Group 2-5), 5 h in the pandemic period (Group 1). Perforation rates were 27.8% in Group 1, 23.3% in Group 2, 16.3% in Group 3, 14.0% in Group 4, and 18.6% in Group 5 (0 = 0.58). There was no difference in the patients in Group 1 in the rate of perforated appendicitis in patients who were referred from other pandemic hospitals (29.4) and those admitted via our own emergency room (16.6%) (p = 0.27) during the pandemic period.

CONCLUSION

We did not observe any clear increase in the diagnosis of perforated appendicitis during the pandemic period, even in patients who were transferred from other hospitals.

Outcomes after appendectomy in children with acute appendicitis treated at a tertiary paediatric centre: results from a retrospective cohort study

PURPOSE

In general, an appendectomy is presumed to have a limited burden of disease. However, in current literature, reported complication rates vary. This study aims to provide additional insights in the incidence of post-appendectomy complications in children with acute appendicitis.

METHODS

This retrospective cohort study included children (0-17 years old) that underwent appendectomy at our tertiary referral centre for suspected acute appendicitis (January 2011-December 2018). Children referred to our centre, and those that underwent non-operative treatment were excluded. Post-appendectomy complications were recorded from electronic medical charts using predefined definitions and classified as severe (Clavien-Dindo III-IV) or less severe (Clavien-Dindo I-II).

RESULTS

A total of 131 children were included. Simple and complex appendicitis was diagnosed in 66 (50%) and 60 (46%) children, respectively. A non-inflamed appendix was seen in five (4%) children. One or more complications were identified in 33 (25%) patients. Eight (12%) children with simple appendicitis developed a complication, three of these were severe. In children with complex appendicitis, 23 (38%) children developed a complication, 14 of these were severe.

CONCLUSION

This study shows a high rate of complications compared with current literature, both in children with simple and complex appendicitis. This is probably the result of our definition of complications and being a tertiary referral centre receiving more severe appendicitis cases. However, these results still show that appendectomy is not always a routine procedure with only few complications. Substantiating the need to keep optimizing treatment for children with appendicitis.

A clinical prediction model for complicated appendicitis in children younger than five years of age

Background

No reliably specific method for complicated appendicitis has been identified in children younger than five years of age. This study aimed to analyze the independent factors for complicated appendicitis in children younger than five years of age, develop and validate a prediction model for the differentiation of simple and complicated appendicitis.

Methods

A retrospective study of 382 children younger than five years of age with acute appendicitis from January 2007 to December 2016 was conducted with assessments of demographic data, clinical symptoms and signs, and pre-operative laboratory results. According to intraoperative findings and postoperative pathological results, acute appendicitis was divided into simple and complicated appendicitis. Univariate and multivariate analyses were used to screen out the independent factors of complicated appendicitis, and develop a prediction model for complicated appendicitis. Then 156 such patients from January 2017 to December 2019 were collected as validation sample to validate the prediction model. Test performance of the prediction model was compared with the ALVARADO score and Pediatric Appendicitis Score (PAS).

Results

Of the 382 patients, 244 (63.9%) had complicated appendicitis. Age, white blood cell count, and duration of symptoms were the independent factors for complicated appendicitis in children younger than five years of age. The final predication model for complicated appendicitis included factors above. In validation sample, the prediction model exhibited a high degree of discrimination (area under the curve [AUC]: 0.830; 95% confidence interval [CI]: 0.762–0.885) corresponding to a optimal cutoff value of 0.62, and outperformed the PAS (AUC: 0.735; 95% CI: 0.658–0.802), ALVARADO score (AUC: 0.733; 95% CI: 0.657–0.801).

Conclusion

Age, white blood cell count, and duration of symptoms could be used to predict complicated appendicitis in children younger than five years of age with acute appendicitis. The prediction model is a novel but promising method that aids in the differentiation of acute simple and complicated appendicitis.

Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines

BACKGROUND AND AIMS

Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.

METHODS

This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.

CONCLUSIONS

The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.

In-hospital perforation risk in acute appendicitis: Age matters

BACKGROUND

Controversy exists regarding how quickly an adult with appendicitis requires surgery to prevent perforation, and recent literature on antibiotic use as definitive treatment has complicated this question further. Since perforation is associated with worse outcomes, particularly in the elderly, efforts to prevent this complication are warranted. We studied risk factors for in-hospital perforation in patients diagnosed by admission CT with non-perforated acute appendicitis.

METHODS

We evaluated baseline demographics, symptom duration, and time from admission to antibiotics and surgery. Outcome measure was perforation diagnosed intra-operatively by attending surgeon.

RESULTS

Of 700 patients, 84 (12%) sustained in-hospital perforation; time from admission to operation or antibiotics were not associated. Duration of symptoms >24 h (aOR = 2.23, 95% CI = 1.33-3.72, p < 0.001) increased perforation risk. Patient age over 46 years (aOR = 4.54, 95% CI = 2.04-10.06, p < 0.001) was also associated with higher risk that increased with increasing age.

CONCLUSION

Time to operation and antibiotic timing were not associated with in-hospital perforation in a general adult population. However, these findings suggest a possible benefit to expedient surgery in older patients.