The effect of appendectomy in future tubal infertility and ectopic pregnancy: a systematic review and meta-analysis

The body mass index and the risk of ectopic pregnancy: a 5-year retrospective case-control study

PURPOSE

Acknowledging the associated risk factors may have a positive impact on reducing the incidence of ectopic pregnancy (EP). In recent years, body mass index (BMI) has been mentioned in research. However, few studies are available and controversial on the relationship between EP and BMI.

METHODS

We retrospectively studied the EP women as a case group and the deliveries as a control group in the central hospital of Wuhan during 2017 ~ 2021. χ2 test of variables associated with ectopic pregnancy was performed to find differences. Univariate and multivariate binary logistic regression analysis was conducted to analyze the association of the variables of age, parity, history of induced abortion, history of ectopic pregnancy, history of spontaneous abortion, history of appendectomy surgery and BMI (< 18.5 kg/m2, 18.5 ~ 24.9 kg/m2, 25 kg/m2 ~ 29.9 kg/m2, ≥ 30 kg /m2) with EP.

RESULTS

They were 659 EP and 1460 deliveries. The variables of age, parity, history of induced abortion, history of ectopic pregnancy and BMI were different significantly(P < 0.05). Multivariate analysis showed that the variables of age > 35 years old [(OR (Odds Ratio), 5.415; 95%CI (Confidence Interval), 4.006 ~ 7.320, P < 0.001], history of ectopic pregnancy (OR, 3.944; 95%CI, 2.405 ~ 6.467; P < 0.001), history of induced abortion(OR, 3.365; 95%CI, 2.724 ~ 4.158, P < 0.001) and low BMI (< 18.5 kg/m2) (OR, 1.929; 95%CI, 1.416 ~ 2.628, P < 0.001])increased the risk of EP.

CONCLUSION

The history of ectopic pregnancy, history of induced abortion and age > 35 years old were the risk factors with EP. In addition to these traditional factors, we found low BMI (< 18.5 kg/m2) with women may increase the risk to EP.

Does an Ileoanal Anastomosis Decrease the Rate of Successful Pregnancy Compared With an Ileorectal Anastomosis? A National Study of 1491 Patients

OBJECTIVE

Report the rate of successful pregnancy in a national cohort of women with either an ileal pouch anal (IPAA) or ileorectal (IRA) anastomosis constructed after colectomy for inflammatory bowel disease (IBD) or polyposis.

BACKGROUND

Fertility after IPAA is probably impaired. All available data are corroborated by only small sample size studies. It is not known whether construction of IPAA versus IRA influences the odds of subsequently achieving a successful pregnancy, especially with increased utilization of the laparoscopic approach.

METHODS

All women (age: 12-45 y) undergoing IRA or IPAA in France for polyposis or IBD, between 2010-2020, were included. A control population was defined as women aged from 12 to 45 years undergoing laparoscopic appendicectomy during the same period. The odds of successful pregnancy were studied using an adjusted survival analysis.

RESULTS

A total of 1491 women (IPAA=872, 58%; IRA=619, 42%) were included. A total of 220 deliveries (15%) occurred during the follow-up period of 71 months (39-100). After adjustment, the odds of successful pregnancy was not significantly associated with type of anastomosis (after IPAA: Hazard Ratio [HR]=0.79, 95% confidence interval=0.56-1.11, P =0.17). The laparoscopic approach increased the odds of achieving successful pregnancy (HR=1.79, 95% confidence interval=1.20-2.63, P =0.004). IRA and IPAA significantly impacted fertility when compared with the control population ( P <0.001).

CONCLUSIONS

In this large cohort study, total colectomy for polyposis or IBD was associated with reduced fertility compared with the general population. No difference in odds of achieving successful pregnancy was found between IRA and IPAA after adjustment. This analysis suggests laparoscopic surgery may be associated with greater likelihood of pregnancy.

Diagnostic Accuracy Rates of Appendicitis Scoring Systems for the Stratified Age Groups

BACKGROUND

Many scoring systems have been developed for acute appendicitis, which is the most common emergent disorder in surgical practice. Considering the physiological changes and chronic diseases occurring with advancing age, an applied scoring system may not produce the same score in similar patients in all age groups.

OBJECTIVES

We aimed to compare the predictive values of scoring systems in different age groups.

METHODS

In this prospective study, the patients operated on in our clinic with a prediagnosis of acute appendicitis between March 2020 and March 2021 were included. We divided them into three age groups as 18-45 years (group 1), 46-65 years (group 2), and >65 years (group 3). We compared the scores of the nine acute appendicitis scoring systems most commonly used in the literature for these age groups.

RESULTS

A total of 203 patients were included in our study. The Alvarado scoring system yielded the most accurate results for group 1, whereas the Fenyo-Linberg scoring system was the most accurate system for group 2 and the Eskelinen scoring system for group 3.

CONCLUSION

Age should be considered as a major parameter during the selection of the scoring system to be applied for patients with prediagnosis of acute appendicitis. Our study revealed the Alvarado and the Fenyo-Lindberg scoring systems as the most accurate systems for the differential diagnosis of appendicitis in the 18-45 and 46-65 years age groups, respectively. Although we found the Eskelinen scoring system as the most accurate one in the >65 years age group, the confidence intervals indicated that it may not be appropriate for use alone in this group.

Suspected and Confirmed Acute Appendicitis During the COVID-19 Pandemic: First and Second Quarantines—a Prospective Study

Purpose

COVID-19 posed an unprecedented modern global healthcare crisis affecting both elective and urgent surgeries. The aim of this study is to evaluate the difference in the presentation of acute appendicitis (AA) before and during the COVID-19 era, the first and second quarantines.

Methods

We performed a prospective study from December 2018 to May 2021. Two cohorts were analysed, one with patients who presented to the emergency department (ED) with suspected AA and the second with confirmed AA. Both cohorts were divided into four groups: before COVID-19, during the first quarantine, between the first and second quarantine, and during the second quarantine. Data such as demographics, the time to first contact with the healthcare provider and time to operation, laboratory tests, clinical stage of AA, length of stay, and COVID-19 status were collected. A total of 469 patients were enrolled.

Results

A total of 209 patients were male (45%) and 260 were female (55%), with the median age being 33 years (24–45). In the first cohort of suspected AA, there was no difference in sex; however, more older patients presented to the ED during the first quarantine (41 years) compared with other groups (28.5, 36, and 32.5 years), p &lt; 0.000. Before the pandemic, there was a shorter duration of symptoms to first contact with the healthcare provider (13 h) compared with other groups, p = 0.001. In the second cohort of confirmed AA, there was a shorter period of time to operation from first symptoms before the pandemic (22 h) compared with other groups (30, 35, 30.5 h), p &lt; 0.000. There were more complicated gangrenous, perforated appendicitis or periappendicular abscess in Group 2 and 3 (26, 22 and 10%, and 26, 22 and 2%, respectively) compared with Group 1 (20, 4 and 3%) and Group 4 (22, 12, and 2%), p = 0.009. Hospital stay was longer during the first quarantine (3 days) compared with other groups (2 days), p = 0.009. Six patients were COVID-19 positive: one from Group 3 and five from Group 4 (p &gt; 0.05).

Conclusions

Our study suggests that during the first quarantine of the COVID-19 pandemic, there was delayed presentation to the ED with suspected AA and there was a greater proportion of complicated appendicitis and longer hospitalization in confirmed cases as well.

Pelvic Health Assessment in Adult Females Following Pediatric Appendicitis: A Monocentric Retrospective Case-Control Study

Background: The anatomical location of the appendix in females determines its close contact with the internal genitalia, involving the latter in case of acute appendicitis (AA). The aim of this study was to evaluate the incidence of pelvic health impairment in adult women who underwent appendicectomy during childhood. Materials and Methods: A retrospective observational study was conducted including all female patients who underwent appendicectomy for acute appendicitis at our Center between January 1985 and December 1995. The patients were divided into two groups, i.e., complicated AA (Group A) and not complicated AA (Group B), and were asked to respond to a questionnaire investigating their general health status, fertility impairment, ectopic pregnancies, miscarriages, endometriosis, and chronic pelvic pain. The same questionnaire was administered to female volunteers with past medical history (PMH) negative for AA. The data were compared using chi-square test and Fisher exact test (a p value < 0.05 was considered for statistical significance). Results: In total, 75 patients operated for AA during childhood (22 in Group A and 53 in group B) and 44 female volunteers with PMH negative for AA (group C) were enrolled in the study. Seventeen patients (77.3%) in group A, 40 (75.4%) in group B, and 29 (65.9%) in group C (p > 0.05) had pregnancies. The number of miscarriages among women who became pregnant in their life was 5 in group A, 13 in group B, and 12 in group C (p > 0.05). Chronic pelvic pain was reported by 7 out of 22 (31.8%) patients in group A, 7 out of 53 (13.2%) in group B, and 5 out of 44 (11.4%) in group C (A vs. C: p = 0.04, OR = 3.64; A vs. B: p = 0.06 and B vs. C: p = 0.52). Conclusions: In our series, AA, complicated or not, neither determined repercussions on fertility, risk of miscarriages, and ectopic pregnancies nor increased the risk of developing endometriosis. However, women who experienced complicated AA showed a higher prevalence of chronic pelvic pain onset in adulthood compared to healthy women.

Association of complicated appendicitis on the risk of later in vitro fertilization treatment requirement and ectopic pregnancy: a nationwide cohort study

INTRODUCTION

A population-based register study utilizing three Finnish National Registers was carried out to determine whether uncomplicated appendicitis, complicated appendicitis and appendectomy without appendicitis are associated with a subsequent risk of requiring in vitro fertilization (IVF) treatment or a risk of ectopic pregnancy among reproductive-age women.

MATERIAL AND METHODS

A total of 23 997 women who underwent appendectomy for uncomplicated or complicated appendicitis or for nonspecific abdominal pain or who had nonspecific abdominal pain without surgical procedures between 2000 and 2012 were included in the study. The later risks of IVF treatment requirement and ectopic pregnancy were assessed after uncomplicated appendicitis, complicated appendicitis and appendectomy without appendicitis. Women with nonspecific abdominal pain without surgical procedures served as the reference group.

RESULTS

The rates of later IVF treatment after uncomplicated appendicitis, complicated appendicitis and appendectomy without appendicitis were low (2.1%, 2.5% and 2.3%, respectively; p = 0.681). Neither appendicitis nor appendectomy was associated with the risk of requiring IVF treatment. The rate of ectopic pregnancy after uncomplicated and complicated appendicitis was very low (0.8%). Women with uncomplicated appendicitis had a significantly lower risk of ectopic pregnancy compared with patients with nonspecific abdominal pain.

CONCLUSIONS

Appendicitis, whether complicated or uncomplicated, and appendectomy without appendicitis does not increase the risk of requiring later IVF treatment or the risk of ectopic pregnancy.

Conditional CT Strategy-An Effective Tool to Reduce Negative Appendectomy Rate and the Overuse of the CT

(1) Background: Diagnosis of acute appendicitis (AA) remains challenging; either computed tomography (CT) is universally used or negative appendectomy rates of up to 30% are reported. Transabdominal ultrasound (TUS) as the first-choice imaging modality might be useful in adult patients to reduce the need for CT scans while maintaining low negative appendectomy (NA) rates. The aim of this study was to report the results of the conditional CT strategy for the diagnosis of acute appendicitis. (2) Methods: All patients suspected of acute appendicitis were prospectively registered from 1 January 2016 to 31 December 2018. Data on their clinical, radiological and surgical outcomes are presented. (3) Results: A total of 1855 patients were enrolled in our study: 1206 (65.0%) were women, 649 (35.0%) were men, and the median age was 34 years (IQR, 24.5–51). TUS was performed in 1851 (99.8%) patients, and CT in 463 (25.0%) patients. Appendices were not visualized on TUS in 1320 patients (71.3%). Furthermore, 172 (37.1%) of 463 CTs were diagnosed with AA, 42 (9.1%) CTs revealed alternative emergency diagnosis and 249 (53.8%) CTs were normal. Overall, 519 (28.0%) patients were diagnosed with AA: 464 appendectomies and 27 diagnostic laparoscopies were performed. The NA rate was 4.2%. The sensitivity and specificity for TUS and CT are as follows: 71.4% and 96.2%; 93.8% and 93.6%. (4) Conclusion: A conditional CT strategy is effective in reducing NA rates and avoids unnecessary CT in a large proportion of patients. Observation and repeated TUS might be useful in unclear cases.

Appendectomy and women’s reproductive outcomes: a review of the literature

Background

The most frequent abdominal surgery performed for benign disease in females of fertile age is appendectomy, which remains among the most common surgeries and is a possible cause of peritoneal adhesions. The fact that appendectomy can cause adhesions may lead one to think that this may be a relevant risk factor for infertility; however, there is no universal agreement regarding the association between appendectomy and fertility. The aim of this review is to evaluate weather appendectomy may have a relevant impact on female fertility.

Methods

The search was conducted in PubMed and there was no limitation set on the date of publication. All studies regarding populations of female patients who had undergone appendectomy for inflamed appendix, perforated appendix, or negative appendix between childhood and the end of the reproductive period were included.

Results

Some authors believe that pelvic surgery can cause adhesions which can potentially lead to tubal infertility by causing tubal obstruction or by altering motility of fimbriae, tubal fluid secretion, and embryo transport. On the other hand, the most recent evidence reported that removal of the appendix seems to be associated with an increased pregnancy rate in large population studies.

Conclusion

Despite the existence of contrasting opinions concerning fertility after appendectomy, the most recent evidence suggests that appendectomy may actually lead to improved fertility and decreased time to pregnancy. Appendectomy seems to be correlated with improved fertility and higher pregnancy rates.

A Unique Presentation of an Ectopic Pregnancy After Appendectomy

Ectopic pregnancies account for the majority of deaths in early pregnancy. A 27-year-old woman with unexplained infertility and a history of an appendectomy was referred to the reproductive endocrinology clinic. She was initially diagnosed with a pregnancy of unknown location and was later found to have an ectopic pregnancy. Final pathology found a surgical staple likely present from a previous appendectomy within the fallopian tube proximal to the ectopic site. The surgical staple is postulated to have entered the tube through ciliary action and caused the ectopic pregnancy. This rare case highlights physicians' need to carefully monitor and remove visible loose staples after using automated stapling devices.

Risk profile of Qatari women treated for infertility in a tertiary hospital: a case-control study

BACKGROUND

Female infertility is a multifactorial condition constituting a worldwide public health problem. The ability to reproduce is an important product of any marriage, hence infertility may exert a negative impact on physical, financial, social and emotional wellbeing of affected couples. The cornerstone to the management of any disease, including infertility, is prevention. Identifying the modifiable risk factors of female infertility will aid at prevention, early detection, and treatment of medical conditions that can threaten fertility as well as promoting healthy behaviours that can preserve it.

AIM

To explore the risk profile of infertility among Qatari women and compare risk factors distribution among primary vs. secondary infertility.

METHODOLOGY

A hospital-based case control study was conducted from September 17th, 2017- February 10th, 2018. Cases (n = 136) were enrolled from infertility clinic and controls (pregnant women, n = 272), were enrolled from antenatal clinic, Women Hospital, Hamad Medical Corporation (HMC). Interview questionnaire was utilized to collect data about sociodemographic, risk factors related to infertility and patient health Questionnaire (PHQ)-2. Body Mass Index (BMI) was calculated. Logistic regression was used to identify the associated factors to infertility. Statistical significance was set at 0.05.

RESULTS

Forty three primary and ninety three secondary infertility cases were included. Risk factors were age >  35 years (OR = 3.7, 95% CI: 1.41-9.83), second-hand smoking (OR = 2.44, 95% CI:1.26-4.73), steady weight gain (OR = 4.65,, 95% CI: 2.43-8.91), recent weight gain (OR = 4.87, 95% CI: 2.54-9.32), menstrual cycle irregularities (OR = 4.20, 95% CI:1.14-15.49), fallopian tube blockage (OR = 5.45, 95% CI: 1.75-16.95), and symptoms suggestive of sexually transmitted infections (STIs) including chronic lower abdominal/pelvic pain (OR = 3.46, 95% CI: 1.57-7.63), abnormal vaginal discharge (OR = 3.32, 95% CI:1.22-9.03) and dyspareunia (OR = 7.04, 95% CI: 2.76-17.95). Predictive factors for secondary infertility were; longer time from previous conception (OR = 5.8, 95% CI: 3.28-10.21), history of stillbirth (OR = 2.63, 95% CI: 1.04-6.67) or miscarriage (OR = 2.11, 95% CI: 1.21-3.68) and postpartum infection (OR = 3.75, 95% CI: 1.27-11.06). Protective factors were higher education level (OR = 0.44, 95% CI: 0.25-0.78), higher income (OR = 0.17, 95% CI: 0.06-0.49), and awareness/loyalty to fertility window (OR = 0.33, 95% CI: 0.21-0.52 and OR = 0.29, 95% CI: 0.19-0.44, consequently).

CONCLUSION

This study highlighted the opportunities to strengthen public health as well as hospital-based health promotion programs importantly toward behavioural-related risk factors (e.g. smoking, obesity, STIs etc.). Moreover, detecting, preventing, and managing modifiable risk factors through awareness, screening and early management of chronic diseases, may contribute at reduction of incidence and severity of infertility. Such interventions can be delivered at premarital, family planning, post-natal and antenatal clinics at primary health care with early referral to secondary care if required.

Suboptimal endometrial-embryonal synchronization is a risk factor for ectopic pregnancy in assisted reproduction techniques

RESEARCH QUESTION

What are the main risk factors associated with ectopic pregnancy and what is the true incidence of ectopic pregnancies in an IVF programme?

DESIGN

Retrospective single-centre study of 12,429 blastocyst transfers (8182 fresh and 4247 frozen embryo transfers) conducted between January 2010 and December 2017. IVF outcome was analysed, and ectopic pregnancy risk evaluated according to patient's characteristics and assisted reproductive technology treatment factors.

RESULTS

Of 5061 patients reporting a positive pregnancy test, 43 were diagnosed with ectopic pregnancy (0.85%). Neither female age (36.7 versus 35.8 years), body mass index, quality of transfer nor stimulation protocol affected the ectopic pregnancy rate, but history of previous ectopic pregnancy (OR 3.26; P = 0.0080), tubal surgery, or both (OR 6.20; P < 0.0001) did. The incidence of ectopic pregnancy was increased in women with uterine malformations (OR 3.85; P = 0.0052), uterine pathologies (OR 5.35; P = 0.0001), uterine surgeries (OR 2.29; P = 0.0154) or sub-optimal endometrial build-up (OR 4.46 to 5.31; P < 0.0001). Transfer of slow-developing blastocysts (expressed by expansion) significantly increased the risk of ectopic pregnancy (OR 2.59; P = 0.0102).

CONCLUSIONS

Unfavourable uterine environment, including uterine pathologies, uterine or tubal surgery and suboptimal endometrial build-up were related to ectopic pregnancy. Low expansion grade of blastocysts was identified as an additional putative risk factor for ectopic pregnancy, indicating the importance of proper embryonal-maternal synchronization. The overall ectopic pregnancy rate after blastocyst transfer was low, comparable with reported ectopic pregnancy rates in spontaneous conceptions. Proper evaluation of tubal and uterine pathologies, optimizing endometrial preparation and the transfer of expanded blastocysts in a frozen embryo transfer cycle, might be beneficial.

Risk factors of tubal infertility in a tertiary hospital in a low-resource setting: a case-control study

BACKGROUND

Infertility is the inability to sustain a pregnancy in a woman with regular (2-3 times per week) unprotected sexual intercourse for a period of 1 year. This is a major public health problem that remains under-recognised in Cameroon and most countries in sub-Saharan Africa. This study aimed at identifying the risk factors associated with tubal infertility in a tertiary hospital in Douala, Cameroon.

METHODS

We conducted a case-control study at the Obstetrics, Gynaecology and Radiology Departments of the Douala Referral Hospital from October 1, 2016, to July 30, 2017. We recruited 77 women with tubal infertility diagnosed using hysterosalpingography and 154 unmatched pregnant women served as controls. Data on socio-demographic, reproductive and sexual health, and radiologic assessments were collected using a pretested questionnaire. The data were analysed using the Statistical Package for the Social Sciences (SPSS) software version 24.0. Logistic regression models were fitted to identify demographic, reproductive health factors, surgical, medical and toxicological factors associated with tubal infertility. The adjusted odds ratios (AOR) and their 95% confidence interval were interpreted. Statistical significance set at p < 0.05.

RESULTS

Sixty-one per cent of respondents had secondary infertility. Following multivariate logistic regression analysis, respondents who were housewives (AOR 10.7; 95% CI: 1.68-8.41, p = 0.012), self-employed (AOR 17.1; 95% CI: 2.52-115.8, p = 0.004), with a history of Chlamydia trachomatis infection (AOR 17.1; 95% CI: 3.4-85.5, p = 0.001), with Mycoplasma infection (AOR 5.1; 95% CI: 1.19-22.02, p = 0.03), with ovarian cyst (AOR 20.5; 95% CI: 2.5-168.7, p = 0.005), with uterine fibroid (AOR 62.4; 95% CI: 4.8-803.2, p = 0.002), have undergone pelvic surgery (AOR 2.3; 95% CI: 1.0-5.5, p = 0.05), have undergone other surgeries (AOR 49.8; 95% CI: 6.2-400, p = 0.000), diabetic patients (AOR 10.5; 95% CI 1.0-113.4, p = 0.05) and those with chronic pelvic pain (AOR 7.3; 95% CI: 3.2-17.1, p = 0.000) were significantly associated with tubal infertility while the young aged from 15 to 25 (AOR 0.07; 95% CI: 0.01-0.67, 0.021), those in monogamous marriages (AOR 0.05; 95% CI: 0.003-1.02, p = 0.05), as well as those with a history of barrier contraceptive methods (condom) (AOR 0.17; 95% CI: 0.03-1.1, p = 0.06) were less likely to have tubal infertility.

CONCLUSION

The following factors were independently associated with tubal infertility: being a housewife, self-employed, history of Chlamydia trachomatis, Mycoplasma infection, and uterine fibroid. Furthermore, a history of pelvic surgery and other surgeries, diabetes mellitus, and chronic pelvic pain were also associated with tubal infertility. Young age, persons in monogamous marriages and users of barrier methods of contraception (condom) were less likely to have tubal infertility. Identification of these factors will be a target of intervention to avoid tubal infertility.

The Association of Appendectomy, Adhesions, Tubal Pathology, and Female Infertility

Background and Objectives

The aim of the study was to investigate a potential association between previous childhood appendectomy, tube pathology, and female infertility.

Methods

We reviewed patients seeking care at the fertility clinic of our university medical center between 2006 and 2016. The history of previous appendectomy was extracted from hospital documentation and by telephone follow-up. Tubal patency was assessed by diagnostic laparoscopy and chromopertubation.

Results

In our study cohort (N = 237), 24.9% (n = 59) had a history of previous appendectomy. Previous appendectomy, therefore, was about 3-fold more prevalent in women seeking fertility treatment than in the general population. Patients with previous appendectomy had more intra-abdominal adhesions (P < .001) and patients with adhesions tended to have compromised tubal patency (P = .05). However, there was no direct correlation between a previous appendectomy and tube pathology (P = .727).

Conclusion

Because previous appendectomy was associated with intra-abdominal adhesions, and these were in turn associated with tube pathology, but appendectomy was not directly associated with compromised tubal patency, previous appendectomy may indirectly affect female fertility through mechanisms other than direct tubal obstruction. This is one of the largest study analyzing laparoscopic chromopertubation in association with previous childhood appendectomy.

Bilateral hydrosalpinx in patients with Hirschsprung's disease

PURPOSE

Hirschsprung's disease (HD) is uncommon in females. There are very few reports on the patients' obstetric and gynecological outcome. Hydrosalpinx causes pain and infertility. It is rare in nonsexually active teenagers. It may be because of an intrinsic disease of the fallopian tubes or secondary to surgery.

AIM

to describe the relationship between hydrosalpinx and HD or its surgical approach; to report the impact of bilateral hydrosalpinx on fertility in HD.

METHODS

The records of all females with HD since 1980 were reviewed. Only patients who reached menarche were included. Prevalence of hydrosalpinx and hydrosalpinx-free survival were compared after abdominoperineal (A) or transanal (T) surgery. Treatment for hydrosalpinx was reviewed.

RESULTS

Seventeen out of 27 patients had reached menarche (Group A: 13 patients; Group T: 4 patients). Five patients in group A and none in group T presented bilateral hydrosalpinx (p=0.261). There were no statistical differences in hydrosalpinx-free survival between groups (p=0.344). Hydrosalpinx treatment: two bilateral and one unilateral salpingectomy, one pyosalpinx evacuation and one untreated. Three patients had conception desire: one has children; two are on IVF program.

CONCLUSION

An association between hydrosalpinx and HD was observed. The development of hydrosalpinx was not associated with surgical approach in our study. Females with HD should have a gynecological follow-up for the development of hydrosalpinx, which can impair fertility.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Long-Term Complications of Appendectomy: A Systematic Review

BACKGROUND AND AIMS

Appendectomy is a common surgical procedure, but no overview of the long-term consequences exists. Our aim was to systematically review the long-term complications of appendectomy for acute appendicitis.

MATERIALS AND METHODS

This systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol was registered on PROSPERO (CRD42017064662). The databases PubMed and EMBASE were searched for original reports on appendectomy with n ≥ 500 and follow-up >30 days. The surgical outcomes were ileus and incisional hernia; other outcomes were inflammatory bowel disease, cancer, fertility, and mortality.

RESULTS

We included 37 studies. The pooled estimate of the ileus prevalence was 1.0% over a follow-up period of 4.6 (range, 0.5-15) years. Regarding incisional hernia, we found a pooled estimate of 0.7% prevalence within a follow-up period of 6.5 (range, 1.9-10) years. Ulcerative colitis had a pooled estimate of 0.15% prevalence in the appendectomy group and 0.19% in controls. The opposite pattern was found regarding Crohn's disease with a pooled estimate of 0.20% prevalence in the appendectomy group and 0.12% in controls. No clear pattern was found regarding most of the examined cancers in appendectomy groups compared with background populations. Pregnancy rates increased after appendicitis compared with controls in most studies. Mortality was low after appendectomy.

CONCLUSION

Appendectomy had a low prevalence of long-term surgical complications. We did not find any significant other long-term complications, though the prevalence of Crohn's disease was higher and the prevalence of ulcerative colitis was lower after appendectomy than in controls. Appendectomy did not impair fertility.

Risk of Ectopic Pregnancy in Women With Inflammatory Bowel Disease: A 22-Year Nationwide Cohort Study

BACKGROUND & AIMS

Few data are available on adverse events of pregnancy in women with inflammatory bowel diseases (IBD), such as ectopic pregnancy. We assessed the risk of ectopic pregnancy in pregnancies of women in Denmark with IBD compared with those without IBD over a 22-year period. We also examined the disease-specific risks of ectopic pregnancies in pregnancies of women with ulcerative colitis (UC) or Crohn's disease (CD) who underwent IBD-related surgical procedures.

METHODS

We performed a retrospective study of all women of child-bearing age (ages, 15-50 y) registered in the Danish National Patient Registry with at least 1 pregnancy during the period from January 1994 through December 31, 2015. We collected data on all women with an ectopic pregnancy, hydatidiform mole, miscarriages (spontaneous and other abortions, including abnormal pregnancy products, missed abortion, and pregnancy without a fetus), induced abortions, and births in women with and without IBD. Our study population included 7548 pregnancies in women with UC, 6731 pregnancies in women with CD, and 1,832,732 pregnancies in women without IBD. We controlled for multiple covariates, including pelvic and abdominal surgery.

RESULTS

Women with CD had a greater risk of ectopic pregnancy, per pregnancy, than women without IBD (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.01-1.49), whereas women with UC did not (OR, 0.98; 95% CI, 0.80-1.20). In pregnancies of women with CD and UC who underwent IBD-related surgery before pregnancy, there was a nonsignificant increase in risk of ectopic pregnancy compared with pregnancies in women with IBD who did not have surgery (OR, 1.49; 95% CI, 0.91-2.44 for CD, and OR, 1.17; 95% CI, 0.54-2.52 for UC).

CONCLUSIONS

We found a statistically significant increased risk of ectopic pregnancy in pregnancies of women with CD compared with pregnancies of women without IBD. Surgery for IBD before pregnancy increased the risk of ectopic pregnancy, although this increase was not statistically significant.

SUCCESSFUL MANAGEMENT OF CECAL PERFORATION AND FOCAL PERITONITIS IN A GORILLA (GORILLA GORILLA GORILLA)

An 18-yr-old female Western lowland gorilla ( Gorilla gorilla gorilla) presented with acute-onset severe lethargy, bloody vaginal discharge, decreased appetite, and an abnormal posture. The gorilla was diagnosed with a ruptured cecal blind sac with severe adhesions to the right ovary. A typhlectomy and unilateral ovariectomy were performed. Histologic examination identified a severe transmural circumferential typhlitis with rupture and adhesions to the infundibulum and chronic typhlitis. Postoperative management included antibiotics, analgesics, short-term dietary modifications, and probiotics for suspect oral candidiasis. The gorilla made a full clinical recovery and was pregnant within 1 yr of surgery. To the authors' knowledge, this is the first case of successful management of typhlitis in a gorilla. Typhlitis and intestinal rupture should be considered as a differential diagnosis for acute onset severe abdominal pain in gorillas.