A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis

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.

Visual Endoscopic Retrograde Appendicitis Therapy Vs Antibiotic Therapy for Treatment of Uncomplicated Acute Appendicitis

INTRODUCTION

Visual endoscopic retrograde appendicitis therapy (V-ERAT) involves a single-use video scope, allowing for real-time visualization of the appendiceal lumen during the procedure to treat uncomplicated acute appendicitis (AA). This study aims to compare V-ERAT to antibiotic therapy in treating uncomplicated AA.

METHODS

This multicenter, retrospective cohort study was conducted at 9 hospitals in China from August 2021 to July 2023. Propensity score matching was performed to minimize selection bias. A total of 692 uncomplicated AA patients were included, with 188 undergoing V-ERAT and 504 receiving antibiotic therapy. The primary outcome was treatment success rate. The secondary outcomes included recurrent appendicitis rate, the appendectomy rate during the initial hospitalization, length of initial hospitalization, time to disease recurrence, and overall adverse events.

RESULTS

The treatment success rate did not differ between the V-ERAT and antibiotic groups (93.6%; 95% confidence interval [CI] 89.1%-96.7% vs 90.5%; 95% CI, 87.6%-92.9%) ( P = 0.225). However, V-ERAT demonstrated a significantly lower risk of appendicitis recurrence compared with antibiotic therapy during the follow-up (log-rank P < 0.001), with a hazard ratio of 0.14 (95% CI, 0.07-0.29, P < 0.001). V-ERAT was associated with a lower appendectomy rate during the initial hospitalization (4.3%; 95% CI, 1.9%-8.2% vs 9.5%; 95% CI, 7.1%-12.4%) ( P = 0.027), a shorter length of initial hospitalization (3 [interquartile range (IQR), 3-4] vs 4 [IQR, 4-6] days, P < 0.001), and a longer time to recurrence (269 [IQR, 210-318] vs 70 [IQR, 21-103] days, P < 0.001). The overall adverse event rates did not differ between the 2 groups (log-rank P = 0.064).

DISCUSSION

V-ERAT seems to be a safe and effective alternative to antibiotic therapy in treating uncomplicated AA, significantly reducing the risk of appendicitis recurrence.

Impact analysis of expanding antibiotic use for treatment of uncomplicated appendicitis without appendicolith

Aim: Approximately 20% of patients with uncomplicated appendicitis receive antibiotics as a first-line treatment; this study explores the impacts of expanding patient uptake of first-line antibiotics for appendicitis treatment. Materials & methods: We model the impacts on the patient, caregiver, payer and total societal costs associated with expanding antibiotics use from 20 to 50% for patients with appendicitis through use of a decision-tree model. Results: Increasing antibiotics uptake to 50% of eligible appendicitis patients is expected to decrease overall societal economic costs by $192 million, and these savings are driven by a $493 million reduction in initial treatment costs. For patients and their caregivers, out-of-pocket costs are expected to decrease by $18 million, appendectomies by 27,410 and missed work hours by 639,682. Conclusion: Increasing national uptake of antibiotics for the treatment of appendicitis may reduce patient, payer and total societal costs with minimal impact to patient health outcomes. An expansion may also decrease the total number of appendectomies, appendectomy-related medical complications, and lost wages for patients and caregivers, with minimal decreases in the number of appendiceal cancer cases treated early.

Cost utility analysis of antibiotics compared with operative treatment in uncomplicated acute appendicitis

Appendicitis is the most common acute abdominal condition affecting general surgical practice. Recently, conservative treatment with antibiotics has been considered as an alternative. Therefore, this study was conducted to evaluate if antibiotics could be cost-effective compared to laparoscopic appendectomy or open appendectomy. A prospective study was undertaken to estimate health-related quality of life for antibiotic and operative treatment, and to ascertain costs in a cohort. A societal perspective incremental cost-effectiveness ratio (ICER) at 1 year after surgery was estimated. A probabilistic sensitivity analyses was performed. ICERs were estimated comparisons between individual antibiotics, laparoscopic appendectomy, and open appendectomy in uncomplicated acute appendicitis. Antibiotics showed improved cost savings compared to operative treatments with an ICER of -113,973.09 USD per quality adjusted life year at 1 year. Based on one year findings, antibiotics represent a lower cost treatment option with better cost-utility compared to operative treatment options in uncomplicated acute appendicitis patients. As such, antibiotic treatment can be initially considered as an alternative option where resources are limited to minimize complication rates associated with operative treatments.

Gastrointestinal Behҫet's disease mimicking appendicitis

A woman in her 40s of Chinese and African American ancestry with medical history of severe Behҫet's disease on immunosuppressive therapy presented with right lower quadrant abdominal pain. CT of the abdomen and pelvis suggested appendicitis. General surgery recommended bowel rest and antibiotics for treatment, considering her a high surgical risk due to her history of Behҫet's disease and immunosuppression. She again presented 2 weeks later with nausea, vomiting, worsening pain, fever, leucocytosis and elevated inflammatory markers. Colonoscopy was pursued with concern for appendicitis versus possible Behҫet's disease flare, which revealed colonic aphthous ulcers and a large caecal ulcer with associated oedema and ulceration of the appendiceal orifice, consistent with ileocaecal Behҫet's disease. Antibiotics were discontinued, and she was treated with systemic glucocorticoids with complete resolution of her presenting symptoms. Behҫet's disease may convincingly mimic appendicitis, and colonoscopy may prevent unnecessary appendectomy in patients with such a presentation.

Safety of in-hospital delay of appendectomy - a propensity score-matched analysis of 4900 consecutive patients undergoing surgery for suspected appendicitis

BACKGROUND

Historically, urgent surgery was advocated in patients with suspected appendicitis because of the risk of perforation and possible complications. Although recent studies have shown that it is safe to delay surgery under certain circumstances, many studies do not report adjusted data and exclude patients based on risk factors. Furthermore, it is unclear whether an ultrasound-based diagnostic workup is sufficient to safely delay surgery. This large retrospective study aimed to analyze the risk-adjusted association between delayed appendectomy and perforation and complication rates.

METHODS

Data from consecutive patients who underwent appendectomy for suspected appendicitis at a single institution were reviewed and analyzed. The investigated outcomes were perforation and complication rates. Propensity score (PS) matching was used to create equal groups regarding confounding factors, and multivariate analysis was performed to control for risk factors and to calculate adjusted odds ratios (ORs) for in-hospital delay.

RESULTS

Between January 2008 and June 2023, 4900 patients underwent appendectomy for suspected appendicitis. Ultrasound imaging was performed in 4754 patients. Multivariate analysis of PS-matched data showed no association between a waiting time of >12 h and perforation rate (OR, 0.93; 95% CI, 0.67-1.31; P =.69) or complication rate (OR, 0.90; 95% CI, 0.62-1.30; P =.56). Similar results were obtained for a waiting time of 18 h and perforation rate (OR, 0.96; 95% CI, 0.48-1.56; P =.88) or complication rate (adjusted OR, 0.97; 95% CI, 0.57-1.68; P =.93).

CONCLUSION

This large PS-matched analysis showed that it is safe to delay surgery by 12 and 18 h, even when the diagnostic workup is based on ultrasound. In patients with risk factors for complications, postponement of the procedure can be considered if it can improve overall conditions or allow the procedure to be performed with a higher level of expertise.

Clinical outcomes and optimal indications for nonoperative management of acute appendicitis in adult patients: a comprehensive literature review

Appendectomy as the standard treatment for acute appendicitis has been challenged by accumulating evidence supporting nonoperative management with antibiotics as a potential primary treatment. This review aimed to summarize the clinical outcomes and the optimal indications for nonoperative management of acute appendicitis in adults. Current evidence suggests that uncomplicated and complicated appendicitis have different pathophysiologies and should be treated differently. Nonoperative management for uncomplicated appendicitis was not inferior to appendectomy in terms of complications and length of stay, with less than a 30% failure rate at 1 year. The risk of perforation and postoperative complications did not increase even if nonoperative management failed. Complicated appendicitis with localized abscess or phlegmon could also be treated conservatively, with a success rate of more than 80%. An interval appendectomy following successful nonoperative management is recommended only for patients over the age of 40 years to exclude appendiceal malignancy. The presence of appendicoliths increased the risk of treatment failure and complications; thus, it may be an indication for appendectomy. Nonoperative management is a safe and feasible option for both uncomplicated and complicated appendicitis. Patients should be informed that nonoperative management may be a safe alternative to surgery, with the possibility of treatment failure.

Sepsis management of the acute care surgery patient: What you need to know

ABSTRACT

Increasingly, acute care surgeons have taken over the management of general surgery consult patients in the hospital, many of whom present with sepsis and/or in septic shock. In this article, we will discuss the intricacies of sepsis management for acute care surgery. The underlying tenants of sepsis management will be outlined with specific attention to the nuances associated with surgical patients. Ultimately, when a surgical problem is identified, this management will culminate with the need for specific source control - the unique aspect when a surgical as opposed to a medical disease process is the cause of sepsis. However, surgeons must also be competent in the other components of sepsis management including antimicrobial therapy and hemodynamic support. This article is designed for the surgeon or for any provider caring for patients with a potential acute care surgical problem, recognizing that different practice settings will vary with regard to resource availability for laboratory tests, invasive monitoring, diagnostics, and surgeon availability.

Identification of predictors for complicated acute appendicitis: A retrospective cohort study from a high-volume hospital

BACKGROUND

Acute appendicitis (AA) is the most prevalent cause of acute abdominal pain, with an incidence rate ranging from 96.5 to 100 per 100,000 adults. The rapid and accurate identification of the type and risk level of AA continues to pose a significant challenge. We aimed to develop a model for preoperative differentiation between complicated and uncomplicated AA.

METHODS

In this retrospective study, 1196 AA patients were selected. The preoperative and postoperative clinicopathological characteristics were analyzed retrospectively. Both univariate analysis and multivariate analyses were conducted using binary logistic regression to identify the predictive factor associated with complicated AA.

RESULTS

Among a total of 1196 AA patients, 465 (38.9 ​%) were identified as having complicated AA. Approximately 10 ​% of AA patients experienced postoperative complications. Multivariate logistic regression analysis indicated that several factors were associated with an increased risk of complicated AA, including male (P ​< ​0.001, OR ​= ​2.178), age (P ​< ​0.001, OR ​= ​1.028), days of abdominal pain before operation ​= ​3 (P ​< ​0.001, OR ​= ​3.616), days of abdominal pain before operation ​= ​4 (P ​< ​0.001, OR ​= ​7.528), temperature (P ​< ​0.001, OR ​= ​2.121), abdominal tension (P ​< ​0.001, OR ​= ​2.242), neutrophil (P ​< ​0.001, OR ​= ​1.053), fluid accumulates around the appendix (P ​= ​0.002, OR ​= ​2.010), appendiceal fecalith (P ​< ​0.001, OR ​= ​2.122), and the diameter of the appendix (P ​= ​0.002, OR ​= ​1.083).

CONCLUSIONS

The results of this study significantly advance the understanding of preoperative differentiation between complicated and uncomplicated AA. The predictive nomogram offers a valuable tool for clinicians, enhancing decision-making and improving patient outcomes.

Non-operative management of uncomplicated appendicitis in children, why not? A meta-analysis of randomized controlled trials

BACKGROUND

This study aims to provide a meta-analysis of randomized controlled trials (RCTs) comparing non-operative management (NOM) and operative management (OM) in a pediatric population with uncomplicated acute appendicitis.

METHODS

A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines. A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL from inception to June 2024. Only randomized controlled trials (RCTs) were included, excluding studies involving adult patients and/or participants with complicated appendicitis. The variables considered were treatment complications, treatment efficacy during index admission and one-year follow-up, length of hospital stay (LOS), quality of life, and presence of appendicoliths.

RESULTS

Three RCTs involving 269 participants (134 antibiotics/135 appendectomy) were included. There was no statistically significant difference between the two treatments in terms of complication risk (combined RD = - 0.03; 95% CI - 0.11; 0.06, p = 0.54), even including complications related to NOM failure. The risk of complication-free treatment success rate in the antibiotic group is lower than in the surgery group (combined RD = - 0.05; 95% CI - 0.13; - 0.04; p = 0.29). In patients without appendicolith, the combined risk difference of treatment success between NOM and OM was not statistically significant - 0.01 (IC - 0.17; 0.16; p value: 0.93). There is no statistical difference in terms of efficacy at 1 year, between NOM and OM (combined RD = - 0.06; 95% CI - 0.21; 0.09), p = 0.44). The LOS in the NOM group is significantly longer than in the OM group (difference of median = - 19.90 h; 95% CI - 29.27; - 10.53, p < .0001).

CONCLUSIONS

This systematic review and meta-analysis provide evidence that NOM is safe and feasible for children with uncomplicated appendicitis and, in the group of patients without appendicolith, it is associated with a similar success rate to OM. However, more high-quality studies with adequate power and construction are still needed.

Generalized Pairwise Comparisons to Support Shared Decision-Making in the CODA Trial

Importance

Shared decision-making (SDM) can be made difficult by the multifaceted nature of outcome assessment. A rigorous method for analyzing results from multiple outcomes is called generalized pairwise comparisons (GPC), which could assist in SDM.

Objective

To examine whether GPC can be useful in SDM by using individual-patient data from the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial.

Design, Setting, and Participants

This comparative effectiveness study used data from participants in the multicenter US CODA trial (conducted between May 2016 and March 2020). All possible pairs of patients (one from each arm) were formed to analyze each of 7 outcomes of interest sequentially. Data were analyzed between February 2020 and early 2024.

Exposures

Three scenarios of priorities related to a different order of outcomes were considered. The first scenario came from a consensus exercise with patients that favored antibiotics, whereas the other 2 were arbitrarily chosen to illustrate the range of possible outcomes depending on prioritizations. Scenario 2 favored neither treatment, and scenario 3 favored appendectomy.

Main Outcomes and Measures

The primary outcome was the net treatment benefit (NTB), a formal measure of benefit-risk, which is the net probability that a randomly selected patient from the antibiotic-assigned arm would have a more favorable outcome than a randomly selected patient from the appendectomy-assigned arm.

Results

A total of 1552 patients were included in the CODA trial, with 776 (mean [SD] age, 38.3 [13.4] years; 286 [37%] female) in the antibiotic arm and 776 (mean [SD] age, 37.8 [13.7] years; 290 [37%] female) in the appendectomy arm. The NTB of antibiotic treatment was 12.8% (95% CI, 7.1% to 18.3%; P < .001) for the first scenario, 3.2% (95% CI -2.4% to 8.7%; P = .27) for the second, and -14.5% (95% CI. -20.2% to -8.8%; P < .001) for the third. These results respectively favored antibiotics, neither treatment, or appendectomy, thus illustrating that benefit-risk varies considerably according to individual priorities.

Conclusions and Relevance

This comparative effectiveness study of antibiotics and appendectomy illustrates that the GPC method is a flexible yet mathematically rigorous quantitative analysis of benefit-risk balance. This method provides a more exhaustive and nuanced quantitative assessment of the differences between 2 treatment modalities in terms of prioritized outcomes. Furthermore, GPC could support SDM by considering individual prioritizations of the multiple outcomes.

A randomized double-blind noninferiority clinical multicenter trial on oral moxifloxacin versus placebo in the outpatient treatment of uncomplicated acute appendicitis: APPAC IV study protocol

BACKGROUND

Antibiotic therapy is currently considered a safe and effective treatment alternative for computed tomography (CT)-confirmed uncomplicated acute appendicitis with recent studies reporting good results on both oral antibiotics only and outpatient management. Furthermore, there are promising pilot results on uncomplicated acute appendicitis management with symptomatic treatment (placebo). This trial aims to assess whether both antibiotics and hospitalization can be safely omitted from the treatment of uncomplicated acute appendicitis.

METHODS

The APPAC IV (APPendicitis Acuta IV) trial is a randomized, double-blind, multicenter noninferiority clinical trial comparing oral moxifloxacin with oral placebo in an outpatient setting with a discharge directly from the emergency room (ER). Adult patients (18-60 years) with CT-confirmed uncomplicated acute appendicitis (absence of appendicolith, abscess, perforation, tumor, appendiceal diameter ⩾15 mm on CT, or body temperature >38 °C) will be enrolled in nine Finnish hospitals. Primary outcome is treatment success at 30 days, that is, the resolution of acute appendicitis resulting in discharge from the hospital without appendectomy during the 30-day follow-up evaluated using a noninferiority design with a noninferiority margin of 6 percentage points. Noninferiority will be evaluated using one-sided 95% confidence interval of proportion difference between groups. Secondary endpoints include postintervention complications, recurrent appendicitis after the 30-day follow-up, duration of hospital stay, admission to hospital and reason for admission, readmissions to emergency department or hospitalization, VAS pain scores, quality of life, sick leave, and treatment costs. The follow-up after discharge from the ER includes a phone call at day 1, and at 3-4 days, 30 days, and 1, 3, 5, 10, and 20 years. Those eligible patients, who decline to undergo randomization, will be invited to participate in a concurrent observational cohort study with follow-up at 30 days, and 1 and 5 years.

DISCUSSION

To our knowledge, APPAC IV trial is the first large randomized, double-blind, noninferiority multicenter clinical trial aiming to compare oral antibiotics and placebo for CT-diagnosed uncomplicated acute appendicitis in an outpatient setting. The study aims to bridge the major knowledge gap on whether antibiotics and hospitalization or both can be omitted in the treatment of uncomplicated acute appendicitis.

TRIAL REGISTRATION

The study protocol has been approved by the Clinical Trials Information System (CTIS) of the European Medicines Agency (EMA), study number: 2023-506213-21-00 and the trial has been registered in ClinicalTrials.gov, NCT06210269.

Impact of gestational age on the management of acute appendicitis during pregnancy: A nationwide observational study

OBJECTIVE

To compare conservative management and appendectomy for acute appendicitis during pregnancy by trimester.

METHODS

This retrospective cohort study used data from a national inpatient database from July 2010 to March 2022. Pregnant women diagnosed with acute appendicitis were included. Multivariable analysis using generalized estimating equations was performed to compare outcomes between conservative management and appendectomy across trimesters. The main outcomes were preterm labor, preterm delivery, or abortion; antepartum hemorrhage; duration of hospitalization; and duration of antibiotic use.

RESULTS

A total of 3158 individuals from 632 acute-care hospitals were eligible. The proportion of conservative management versus appendectomy by trimester were 507 (49.1%) versus 525 (50.9%) in the first, 690 (44.6%) versus 856 (55.4%) in the second, and 337 (58.1%) versus 243 (41.9%) in the third. In the second trimester, appendectomy was associated with a higher rate of preterm delivery, preterm labor, or abortion (odds ratio [OR], 2.91 [95% confidence interval (CI), 1.62-5.25]). Antepartum hemorrhage occurred more frequently for appendectomy in the first (OR, 2.12 [95% CI, 1.31-3.43]) and third (OR, 2.43 [95% CI, 1.79-3.31]) trimesters. Appendectomy was associated with a longer duration of hospitalization in the second (2.15 days; 95% CI, 1.14-3.17 days) and third (3.97 days; 95% CI, 2.22-5.71 days) trimesters. Antibiotic use duration was shorter for appendectomy in the first (-1.20 days [95% CI -1.51 to -0.90 days]) and second (-0.61 days [95% CI -0.90 to -0.32 days]) trimesters.

CONCLUSIONS

Clinical outcomes of acute appendicitis during pregnancy vary by trimester. Considering the appendectomy risks, conservative management may be viable depending on the clinical context and trimester.

Antibiotic treatment versus appendicectomy for acute appendicitis in adults: an individual patient data meta-analysis

BACKGROUND

Randomised controlled trials (RCTs) have found antibiotics to be a feasible and safe alternative to appendicectomy in adults with imaging-confirmed acute appendicitis. However, patient inclusion criteria and outcome definitions vary greatly between RCTs. We aimed to compare antibiotics with appendicectomy for the treatment of acute appendicitis using individual patient data and uniform outcome definitions.

METHODS

In this individual patient data meta-analysis, we searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials without language restrictions between database inception and June 6, 2023, for RCTs comparing appendicectomy with antibiotics for the treatment of adults (≥18 years) with imaging-confirmed acute appendicitis. Studies without 1-year follow-up data on complications were excluded, as were patients. Corresponding authors of eligible studies were contacted and invited to share data; individual patient data were merged after validation. One-stage meta-analyses were conducted using a generalised, mixed-effects linear regression model, accounting for clustering of patients within studies. The primary outcome was the complication rate at 1-year follow-up, uniformly harmonised across trials using the Clavien-Dindo classification. Complications were further divided into minor (grade 1-2 or equivalent) and major (grade 3-5 or equivalent) complications. Appendicectomy rate during 1 year was a key secondary outcome but not considered a complication for the antibiotics group. Outcomes were described separately for patients with and without an appendicolith. This study is registered with PROSPERO, CRD42023391676.

FINDINGS

Of 887 potentially relevant articles, eight were eligible for inclusion, of which six RCTs could provide data for 2101 eligible patients (1050 assigned to antibiotics and 1051 assigned to appendicectomy; 830 [39·5%] women and 1271 [60·5%] men). All studies raised some bias concerns due to absence of blinding. One study was judged to have a high risk of bias due to the exclusion of eligible patients after randomisation, but these patients were eligible for inclusion in our meta-analysis. At 1 year, 57 (5·4%) of 1050 patients randomly assigned to antibiotics had a complication compared with 87 (8·3%) of 1051 patients randomly assigned to appendicectomy (odds ratio [OR] 0·49 [95% CI 0·20 to 1·20]; risk difference -4·5 percentage points [95% CI -11·6 to 2·6]). At 1 year, 1025 (97·5%) patients in the appendicectomy group had undergone appendicectomy compared with 356 (33·9%) patients in the antibiotics group. In patients with an appendicolith at pre-interventional imaging, there were more complications at 1 year among patients who received antibiotic treatment than among those who underwent appendicectomy (29 [15·0%] of 193 patients vs 12 [6·3%] of 190 patients; OR 2·82 [95% CI 1·11 to 7·18]; risk difference 13·2 percentage points [95% CI 2·3 to 24·2]). In the antibiotics group, 94 (48·7%) of 193 patients with an appendicolith underwent appendicectomy within 1 year versus 262 (30·6%) of 857 patients without an appendicolith.

INTERPRETATION

This meta-analysis showed that antibiotic treatment in adults with imaging-confirmed acute appendicitis was a safe alternative to surgery and resulted in around two-thirds of patients avoiding appendicectomy during the first year. In patients with an appendicolith, initial antibiotic treatment increased the risk of complications compared with appendicectomy, and around half of these patients assigned to antibiotics underwent step-up appendicectomy within 1 year. These data should be key components in shared decision making.

FUNDING

None.

C-reactive protein and digestive pathologies: A narrative review for daily clinical use

The aim of this narrative review is to familiarize clinicians, especially digestive surgeons, to adequately use of serum C-reactive protein as a reliable noninvasive biomarker in diverse practical clinical situations. We hope that the review will help clinicians for their decision-making when facing various digestive diseases including operative and nonoperative pathologies such as anastomotic leakage, pancreatitis, emergency situation, and digestive cancer management and prognosis.

Appendicolith as a Sign of Complicated Appendicitis: A Myth or Reality? A Retrospective Study

INTRODUCTION

Appendicolith can be incidentally detected on abdominal computer tomography (CT) without any signs of appendicitis. However, it has also been found to be a risk factor for failure of nonoperative management in acute appendicitis. The present retrospective study aimed to evaluate whether appendicolith predicts complicated appendicitis in patients with any appendicitis.

METHODS

A retrospective chart review was conducted for patients undergoing appendectomy from January 2016 to December 2018. Appendicolith was considered to be present when it was described in a CT scan.

RESULTS

Of the 267 patients, appendicolith was found in 120 cases, while there were no in 147 cases in preoperative CT scans. In the case of complicated appendicitis (gangrenous or gangrenous perforated appendicitis), appendicolith was visible in CT scans in 57.7% of the patients. Of the patients with uncomplicated appendicitis, 38.3% had appendicolith in CT scan (p = 0.002). In univariate logistic regression analysis, based on the finding of the histological specimen, appendicolith was associated with complicated appendicitis (OR: 2.12; 95% CI: 1.28-3.51; p = 0.004). When adjusting for sex, age group (age ≤50 vs. >50 years), and duration of symptoms (≤24 vs. >24 h), the odds ratio was 3.52 (95% CI: 1.88-6.58; p < 0.001).

CONCLUSION

Our study found that appendicolith can be considered an independent risk factor for complicated appendicitis. Therefore, in the presence of appendicolith, surgical treatment should probably be preferred over nonsurgical treatment in acute appendicitis.

Routine colonoscopy with a surprise in the cecum: It's a giant appendicolith! A Case report and review of the literature

Giant appendicoliths (defined as appendiceal stones larger than 2 cm in size) are rare findings, with less than 20 well-documented reported cases. Appendicoliths, in general, are linked to an increased risk of appendicitis and associated complications. However, little information is available on the clinical impact of giant appendicoliths. We present a case of a giant appendicolith accidentally discovered during screening colonoscopy. With more than 4 cm, this appendicolith is one of the largest of the few reported so far. In contrast to all other cases of giant appendicoliths, the patient did not exhibit any symptoms. Additionally, we provide an overview of giant appendicolith cases, discussing their clinical features, diagnosis, and treatment.

Current management of acute appendicitis in adults: What you need to know

ABSTRACT

Acute appendicitis is one of the most common acute surgical diseases in the world today. Acute appendicitis can present with a well-recognized clinical presentation with abdominal pain which localize in the right lower quadrant. This presentation is more typical in men than in women of child baring age. Several clinical and laboratory calculations can be used to increase the likelihood of making a correct diagnosis. Various imaging modalities can be used to make the diagnosis which include ultrasound, computer tomography, and magnetic resonance imaging. Each study has well known sensitivity/specificity of positive predictive value of making the diagnosis of appendicitis. The management of acute appendicitis is based on the presentation of the patient and dividing it into uncomplicated and complicated disease. Each requires management with antibiotics and followed with timely appendectomy. Recent studies have demonstrated nonoperative management of uncomplicated appendicitis without no fecalith that can be managed with antibiotics alone. Complicated acute appendicitis should undergo timely surgical intervention. Patients presenting with a large appendiceal abscess or phlegmon should undergo percutaneous drainage and antibiotic management. There are certain patient populations that should be considered for surgical intervention. Pregnant patients as well as immunosuppressed patients should undergo timely surgical intervention to decrease the risk of complications. This review outlines the current principles of the diagnosis, imaging, and treatment of acute appendicitis based on the best available evidence of acute appendicitis in adults.

The risk of preterm delivery after appendectomy during pregnancy is higher in the face of a negative appendectomy

BACKGROUND

Reported outcomes after appendectomy during pregnancy remain inconclusive, and the risk for preterm delivery is not necessarily procedure-related.

METHODS

This retrospective cohort study included 185 pregnant women who underwent appendectomy during pregnancy and gave birth between 2005 and 2022, compared using a 3:1 ratio to 555 parturients who did not undergo surgery. clinical, obstetrical and neonatal outcomes were analyzed.

RESULTS

Laparoscopic appendectomy was the most common procedure (117/185; 63.2 ​%) whereas 68/185 (36.8 ​%) had open appendectomy. Pathological findings revealed that 141/185 cases (76.2 ​%) had an inflamed appendix, while 44/185 (23.8 ​%) were classified as having a "white appendix" (negative appendectomy). Preterm delivery occurred more frequently in the appendectomy group [22/185 (11.9 ​%) vs 30/555 (5.4 ​%), p ​= ​0.003] with even higher incidence in negative appendectomies compared to inflamed appendix cases [9/44 (20.5 ​%) vs 13/141 (9.2 ​%), p ​= ​0.044]. Multivariate analysis identified appendectomy (but not an inflamed appendix) as the sole significant risk factor for preterm birth (odds ratio 2.3, CI 1.26-4.15, p ​= ​0.006).

CONCLUSION

Preterm delivery correlates with negative appendectomies. Careful assessment is essential to avoid unnecessary surgical interventions during pregnancy.

Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomised, non-inferiority trial

BACKGROUND

Support for the treatment of uncomplicated appendicitis with non-operative management rather than surgery has been increasing in the literature. We aimed to investigate whether treatment of uncomplicated appendicitis with antibiotics in children is inferior to appendicectomy by comparing failure rates for the two treatments.

METHODS

In this pragmatic, multicentre, parallel-group, unmasked, randomised, non-inferiority trial, children aged 5-16 years with suspected non-perforated appendicitis (based on clinical diagnosis with or without radiological diagnosis) were recruited from 11 children's hospitals in Canada, the USA, Finland, Sweden, and Singapore. Patients were randomly assigned (1:1) to the antibiotic or the appendicectomy group with an online stratified randomisation tool, with stratification by sex, institution, and duration of symptoms (≥48 h vs <48 h). The primary outcome was treatment failure within 1 year of random assignment. In the antibiotic group, failure was defined as removal of the appendix, and in the appendicectomy group, failure was defined as a normal appendix based on pathology. In both groups, failure was also defined as additional procedures related to appendicitis requiring general anaesthesia. Interim analysis was done to determine whether inferiority was to be declared at the halfway point. We used a non-inferiority design with a margin of 20%. All outcomes were assessed in participants with 12-month follow-up data. The trial was registered at ClinicalTrials.gov (NCT02687464).

FINDINGS

Between Jan 20, 2016, and Dec 3, 2021, 936 patients were enrolled and randomly assigned to appendicectomy (n=459) or antibiotics (n=477). At 12-month follow-up, primary outcome data were available for 846 (90%) patients. Treatment failure occurred in 153 (34%) of 452 patients in the antibiotic group, compared with 28 (7%) of 394 in the appendicectomy group (difference 26·7%, 90% CI 22·4-30·9). All but one patient meeting the definition for treatment failure with appendicectomy were those with negative appendicectomies. Of those who underwent appendicectomy in the antibiotic group, 13 (8%) had normal pathology. There were no deaths or serious adverse events in either group. The relative risk of having a mild-to-moderate adverse event in the antibiotic group compared with the appendicectomy group was 4·3 (95% CI 2·1-8·7; p<0·0001).

INTERPRETATION

Based on cumulative failure rates and a 20% non-inferiority margin, antibiotic management of non-perforated appendicitis was inferior to appendicectomy.

FUNDING

None.

Machine-learning-assisted Preoperative Prediction of Pediatric Appendicitis Severity

PURPOSE

This study evaluates the effectiveness of machine learning (ML) algorithms for improving the preoperative diagnosis of acute appendicitis in children, focusing on the accurate prediction of the severity of disease.

METHODS

An anonymized clinical and operative dataset was retrieved from the medical records of children undergoing emergency appendectomy between 2014 and 2021. We developed an ML pipeline that pre-processed the dataset and developed algorithms to predict 5 appendicitis grades (1 - non-perforated, 2 - localized perforation, 3 - abscess, 4 - generalized peritonitis, and 5 - generalized peritonitis with abscess). Imputation strategies were used for missing values and upsampling techniques for infrequent classes. Standard classifier models were tested. The best combination of imputation strategy, class balancing technique and classification model was chosen based on validation performance. Model explainability was verified by a pediatric surgeon. Our model's performance was compared to another pediatric appendicitis severity prediction tool.

RESULTS

The study used a retrospective cohort including 1980 patients (60.6 % males, average age 10.7 years). Grade of appendicitis in the cohort was as follows: grade 1-70 %; grade 2-8 %; grade 3-7 %; grade 4-7 %; grade 5-8 %. Every combination of 6 imputation strategies, 7 class-balancing techniques, and 5 classification models was tested. The best-performing combined ML pipeline distinguished non-perforated from perforated appendicitis with 82.8 ± 0.2 % NPV and 56.4 ± 0.4 % PPV, and differentiated between severity grades with 70.1 ± 0.2 % accuracy and 0.77 ± 0.00 AUROC. The other pediatric appendicitis severity prediction tool gave an accuracy of 71.4 %, AUROC of 0.54 and NPV/PPV of 71.8/64.7.

CONCLUSION

Prediction of appendiceal perforation outperforms prediction of the continuum of appendicitis grades. The variables our models primarily rely on to make predictions are consistent with clinical experience and the literature, suggesting that the ML models uncovered useful patterns in the dataset. Our model outperforms the other pediatric appendicitis prediction tools. The ML model developed for grade prediction is the first of this type, offering a novel approach for assessing appendicitis severity in children preoperatively. Following external validation and silent clinical testing, this ML model has the potential to enable personalized severity-based treatment of pediatric appendicitis and optimize resource allocation for its management.

LEVEL OF EVIDENCE: 3

Diagnostic value of the MZXBTCH scoring system for acute complex appendicitis

The objective of this study was to develop a novel scoring model, assess its diagnostic value for complex appendicitis, and compare it with existing scoring systems. A total of 1,241 patients with acute appendicitis were included, comprising 868 patients in the modeling group (mean age, 35.6 ± 14.2 years; 52.4% men) and 373 patients in the validation group (mean age, 36.2 ± 13.8 years; 53.1% men). Among them, 28.4% (346/1,241) were diagnosed with complex appendicitis. The distribution of clinical features, laboratory results, and imaging findings was comparable between the two groups. The data from the modeling group were used to develop the MZXBTCH scoring system, which subsequently validated using the validation group data. Based on postoperative pathological diagnoses, the validation group (n = 373) was scored using the Alvarado, Raja Isteri Pengiran Anak Saleha (RIPASA), Appendicitis Inflammatory Response (AIR), and MZXBTCH scoring systems. Receiver operating characteristic (ROC) curves were plotted to compare the diagnostic efficacy of these scoring systems for complex appendicitis. Multivariate logistic regression analysis identified preoperative body temperature (odds ratio (OR) = 1.104; 95% confidence interval (CI) 1.067-1.143; P < 0.001), preoperative C-reactive protein (CRP) level (OR = 1.002; 95% CI 1.001-1.002; P < 0.001), lymphocyte percentage (OR = 0.994; 95% CI 0.990-0.996; P < 0.001), appendiceal fecal stones (OR = 1.127; 95% CI 1.068-1.190; P < 0.001), periappendiceal fat stranding (OR = 1.133; 95% CI 1.072-1.198; P < 0.001), and appendix diameter (OR = 1.013; 95% CI 1.004-1.022; P < 0.001) as independent risk factors for complex appendicitis. Using R programming, a nomogram based on these independent risk factors was constructed to derive MZXBTCH scores. ROC curve analysis of the MZXBTCH model indicated an area under the curve (AUC) of 0.773. ROC curve analysis revealed that the AUC values of the Alvarado, RIPASA, AIR, and MZXBTCH scoring systems were 0.66, 0.68, 0.76, and 0.82, respectively. Sensitivities were 64.29%, 66.33%, 68.37%, and 74.49%, and specificities were 55.64%, 60%, 75.64%, and 76.36%, respectively. Positive predictive values were 0.34, 0.37, 0.5, and 0.53, while negative predictive values were 0.81, 0.83, 0.87, and 0.89. Accuracy rates were 0.58, 0.62, 0.74, and 0.76, respectively. The MZXBTCH scoring system demonstrated higher sensitivity, specificity, and accuracy compared with the Alvarado, RIPASA, and AIR scoring systems in distinguishing complex appendicitis.

Non-Operative Management of Uncomplicated Appendicitis in Children: Can Patients Be Discharged From the Emergency Department?

INTRODUCTION

Non-operative management of uncomplicated appendicitis in children is a safe alternative to laparoscopic appendectomy. The purpose of this study is to determine the feasibility of nonoperative outpatient management of uncomplicated appendicitis in pediatric patients.

METHODS

A standardized pathway for non-operative outpatient management of uncomplicated appendicitis in children (NOMA-C) was implemented in a university pediatric surgery practice starting October 2021. Those who met criteria would be considered for discharge from the emergency department (ED) with oral antibiotics and close followup over the following year. A quality improvement project started concurrently to monitor patients for recurrent symptoms of appendicitis.

RESULTS

A total of 121 patients were diagnosed with acute appendicitis during the study period (October 2021 to April 2023). Forty-five children (38%) met criteria for the NOMA-C protocol, and 11 patients/families chose appendectomy. Of the 34 patients who pursued nonoperative management, 14 patients were admitted to the hospital and 20 patients were discharged from the ED. Total time in the ED/hospital was significantly shorter for patients discharged from the ED (7 hours versus 23 hours; p<0.001). At one year follow up only 4 (12%) had undergone appendectomy. There were no adverse events for patients who underwent nonoperative management.

CONCLUSION

A protocol offering non-operative management of appendicitis with an option for outpatient management was feasible and safe. Outpatient management was associated with shorter ED/hospital stays than those admitted. Future studies should evaluate whether this protocol can be adopted by EDs without pediatric surgery services to avoid the need for transfer.

Patient reported outcomes after laparoscopic appendectomy for acute appendicitis

PURPOSE

The purpose of this study is to establish more evidence to provide the clinicians with a greater knowledge on the patient reported outcomes and quality of life (QoL) after laparoscopic appendectomy (LA).

METHOD

105 patients who had undergone LA for acute appendicitis regardless of severity, were included prospectively at Odense University Hospital, Svendborg. The patient reported consequence of surgery were assessed through the validated electronic survey from European-QoL questionnaire (5Q-5D-5L) including a self-reported VAS-score (0-100). The first survey was sent out the first day after surgery and the subsequent surveys at 7, 30 and 90 days. The replies was converted into an index-score expressing the QoL from 0 (death) to 1 (full health).

RESULTS

All patients experienced pain/discomfort at day 1. At day 7, 30 and 90 it was 95%, 45% and 25%, respectively. The median index-score at day 1, 7, 30 and 90 was 0.778, 0.840, 0.984 and 1.00, respectively.

Efficacy and safety of different antibiotic treatment versus surgical treatment for acute appendicitis: A network meta-analysis

OBJECTIVE

This systematic review and network meta-analysis compared various antibiotic treatments with surgical treatment for acute appendicitis.

METHODS

We searched PubMed, Embase, Cochrane Library, and Wanfang databases for randomized controlled trials (RCTs) that met the prespecified inclusion criteria up to July 2023. The interventions included various antibiotics and surgery. The outcomes measured were initial treatment success, treatment success at 1-year follow-up, and treatment-related complications. Meta-analysis was conducted using R software with the gemtc package. Surfaces under the cumulative ranking curves (SUCRA) were used to rank the interventions.

RESULTS

Thirteen RCTs involving nine treatments (cefotaxime [CTX] + tinidazole [TNZ], CTX + metronidazole [MTZ], ampicillin [AMP] + gentamicin [GEN] + MTZ, amoxicillin/clavulanate [AMC] + GEN, meropenem [MEM] + MTZ, AMC, ertapenem [ETP] + MTZ, ETP, and surgery) were included in this network meta-analysis. In head-to-head comparisons, no statistically significant difference was found between any two interventions for initial treatment success (p > 0.05). The SUCRA indicated that surgery ranked first (SUCRA, 66.5%) for initial treatment success. Surgery was associated with an increased treatment success rate at 1-year follow-up compared to AMC (OR = 0.01, 95% CrI = 0.00-0.14, p < 0.05), MEM + MTZ (OR = 0.06, 95% CrI = 0.00-0.42, p < 0.05), and AMP + GEN + MTZ (OR = 0.02, 95% CrI = 0.00-0.23, p < 0.05). No statistically significant differences were found between any two interventions regarding complications (p > 0.05).

CONCLUSION

Our network meta-analysis suggests that surgery ranks highest for initial treatment success and treatment success at 1-year follow-up. However, surgery may increase the complication rate.

Appendicitis in the Neutropenic Patient: A Systematic Review

Neutropenia increases the complexity of surgical decision-making in cases of acute appendicitis. In this systematic review, we discuss medical vs surgical management and timing of appendectomy in the neutropenic adult patient. We queried databases utilizing the key words "neutropenia" and "appendicitis." The search identified 999 articles of which 481 articles were reviewed after duplicates were removed. Studies with pediatric patients, single case studies, and abdominal pain in neutropenic patients not caused by appendicitis were excluded. Seven studies remained in this review accounting for 130 patients, of which 28 were diagnosed with neutropenic appendicitis, and were included for final analysis. Four of the 7 articles were case reports, demonstrating the relative paucity of literature on this subject. Studies referred to the high risk of morbidity and mortality after surgical intervention in the neutropenic population, and attempting medical management first was common but not universal, reserving appendectomy for failure of medical management. Three studies suggested medical therapy as first-line management while 2 studies suggested surgical management and 2 studies did not distinguish a precedence. Both medical and surgical management have been successfully used in treating appendicitis in neutropenic patients. In most patients, medical management was attempted first (n = 16/28) vs immediate appendectomy (n = 7/28). Appendectomy was performed when medical management failed (n = 2/28) or after correction of neutropenia (n = 1/28). Timing or performance of appendectomy was unclear in 2 patients. With the increasing use of immunosuppressive medications, broad-spectrum antibiotics, and recent data from the CODA (Comparison of Outcomes of Antibiotic Drugs and Appendectomy) trial, medical management as a first-line treatment for most patients with neutropenia and appendicitis is warranted, and identifying a protocol for such patients would be of value.

An Unusual Approach to Diagnosing Stump Appendicitis Using Colonoscopy

Stump appendicitis is a known post-appendectomy entity causing right lower quadrant abdominal pain. Usually, a patient with a prior history of appendectomy presents to the emergency room with right lower quadrant abdominal pain and stump appendicitis, which is visualized on computed tomography of the abdomen pelvis. We report a case of stump appendicitis diagnosed by colonoscopy and subsequently confirmed by surgery.

Potential risks of nonoperative management of appendicitis in high-risk patients

INTRODUCTION

The popularity of nonoperative management for acute appendicitis is based on the untested assumption that it offers a lower risk alternative to surgery in patients who are at high risk for morbidity and mortality with appendectomy. We hypothesized that patients who were at a high risk with appendectomy would also be at a high risk for complications following nonoperative management.

METHODS

This is a retrospective cohort study of patients with acute, uncomplicated appendicitis in the 2004-2017 National Inpatient Sample. We used a logistic regression model to predict the risk of morbidity or mortality following appendectomy and applied this model to predict the risk of patients managed nonoperatively. High risk was defined as ≥2 standard deviations above the mean predicted risk of morbidity or mortality. We used inverse probability weighting of the propensity score to compare outcomes of nonoperative versus operative management for high-risk patients.

RESULTS

The sample included 21,242 high-risk patients with a median age of 68 years (interquartile range 57-78), and 31% were managed nonoperatively. Compared to surgery, nonoperative management was associated with a 9% decrease in complications (95% confidence interval [CI] 7%-10%), 2% increase in mortality (95% CI 2%-3%), $10,202 increase in hospital costs (95% CI $9,065-$11,339), 3-day increase in length of stay (95% CI 2-3), and 9% greater likelihood of discharge to skilled nursing facilities (95% CI 8%-10%).

CONCLUSION

Nonoperative management of acute appendicitis in high-risk patients may reduce morbidity but increase mortality, duration of hospitalization, discharge to skilled facility, and costs. Surgeons should exercise caution when considering nonoperative management in these vulnerable patients.

Diagnostic Value of Serum Sodium Level and Neutrophil-to-Lymphocyte Ratio in Predicting Severity of Acute Appendicitis: A Retrospective Cross-Sectional Two-Center Study

Background and Objectives: The best way to distinguish complicated acute appendicitis (CAA) from uncomplicated acute appendicitis (UCAA) is still under debate. The aim of this study was to investigate the potential use of the serum sodium (Na+) level and the neutrophil-to-lymphocyte ratio (NLR) to distinguish CAA from UCAA and to evaluate whether CAA is more reliably diagnosed using these two variables together. Materials and Methods: This was a retrospective, cross-sectional, two-center study of patients diagnosed with AA between 1 January 2016 and 31 December 2023. The demographic and analytical variables were analyzed. The NLR was defined as the quotient between the absolute values of neutrophils and lymphocytes. Hyponatremia was defined as a serum Na+ level of ≤135 mmol/L. The sensitivity and specificity of the NLR and the serum Na+ level in the diagnosis of CAA were determined by assessing the receiver operating characteristic curves. Results: Among the patients who underwent an appendectomy, 3066 histologically confirmed AA cases were identified and included in this study. The registered data revealed that 348 (11.3%) patients had CAA, and the remaining 2718 (88.7%) patients had UCAA. The mean ages were 49.47 ± 18.97 and 38.16 ± 14.50, respectively (p < 0.001). The analysis revealed an exponential correlation between the NLR and the serum Na+ level with a moderate degree of agreement with CAA (Cohen's Kappa: 0.461, p < 0.001). For CAA, using the NLR and the serum Na+ level, the areas under the curve and the cutoffs were 0.664, 4.2 with a confidence interval (CI) of 0.647-0.681 and 0.727, 135 mmol/L with a CI of 0.711-0.742, respectively; all these values were significant with a p-value of <0.001. Conclusions: Although the serum Na+ level is a more effective marker than the NLR, using these two variables together can help detect high-risk patients who may benefit from early management by limiting delays in surgery.

Clinical significance of appendicoliths in conservative treatment of acute complicated appendicitis patients with peri-appendiceal abscess: a single-center retrospective study

Background

This study aimed to analyze the clinical data of patients who received conservative treatment for acute complicated appendicitis with peri-appendiceal abscess, identify factors influencing the success rate, and improve treatment strategies.

Methods

The clinical data of acute complicated appendicitis patients with peri-appendiceal abscess who received conservative treatment at the Department of Emergency Surgery, Zhongshan Hospital, Fudan University, from January 2016 to March 2023, were retrospectively analyzed.

Results

A total of 80 patients were included in our study. Patients were divided into two groups based on the outcomes of ultrasound-guided drainage: The Drainage group (n=28) and the Antibiotic group (n=52). The baseline characteristics of the two groups were comparable. In the Antibiotic group, the surgery rate was 30.4% for patients with an appendicolith and 6.9% for those without. In the Drainage group, the surgery rate was 33.3% for patients with an appendicolith and 27.3% for those without. The presence of an appendicolith significantly correlated with the need for surgery in the Antibiotic group (P=0.026), but not in the Drainage group (P=0.771). For patients who underwent surgery, the incidence of surgical site infections did not differ significantly (P=0.656), and the median length of postoperative hospital stay was similar between the groups (4.0 days vs. 3.0 days, P=0.337).

Conclusion

The presence of an appendicolith is a risk factor for the failure of antibiotic therapy alone in acute complicated appendicitis patients with peri-appendiceal abscess. However, it does not affect the surgical rate in those who underwent successful drainage.

Acute Appendicitis Management in Patients Aged Above 40 Years During the COVID-19 Pandemic: A Retrospective Study With Four Years of Follow-Up

Background The COVID-19 pandemic led many units to increase their utilization of nonoperative management (NOM) of acute appendicitis, with the literature showing its non-inferiority when compared to operative management (OM). Therefore, we compared NOM to OM against standard guidelines in order to ascertain the effectiveness of NOM. Primary outcomes were rates of admission, complications, hospital length of stay (LOS), and the incidence of colonic malignancy following NOM upon subsequent bowel evaluation using colonoscopy and/or computed tomography (CT) scan. Methods This was a retrospective observational study done on patients who were admitted with acute appendicitis from January 2020 to January 2022 at Wirral University Teaching Hospital, UK. Data was electronically collected from medical records. Inclusion criteria were patients aged 40 years and above, admitted with a diagnosis of acute appendicitis using a CT scan, and who underwent either OM or NOM. Exclusion criteria were patients below 40 years old or not diagnosed with acute appendicitis. Results This study included 211 cases of acute appendicitis (female to male: 110:101), with a median age of 60. One hundred and twenty-five (60%) patients were managed operatively, while 86 cases (40%) were managed by NOM. All of the cases were diagnosed using a CT scan. The mean LOS for operative and non-operative cases were 4.77 and 4.89 days, respectively. When readmission days were added over the following three years, adjusted LOS was 5.35 days for operative cases, in comparison to 10.86 days for NOM. Forty-five percent of NOM cases had at least one episode of readmission, with 37% of them being in the first year. We found six cases of malignancy in the NOM cohort, none of which were detected on colonoscopy following discharge. Conclusion NOM is associated with increased LOS and increased readmission rates, and 44% of cases eventually required appendicectomy.

Clinical significance of peri-appendiceal abscess and phlegmon in acute complicated appendicitis patients undergoing emergency appendectomy

BACKGROUND

Although antibiotic therapy has become the primary treatment for acute uncomplicated appendicitis, the management of acute complicated appendicitis necessitates careful consideration of various treatment options.

AIM

To analyze the clinical data of patients who underwent emergency appendectomy for acute complicated appendicitis with peri-appendiceal abscess or phlegmon, identify factors influencing the postoperative length of hospital stay (LOS), and improve treatment strategies.

METHODS

The clinical data of acute complicated appendicitis patients with peri-appendiceal abscess or phlegmon who underwent emergency appendectomy at The Department of Emergency Surgery, Zhongshan Hospital, Fudan University from January 2016 to March 2023 were retrospectively analyzed.

RESULTS

A total of 234 patients were included in our study. The duration of symptoms and the presence of an appendicolith were significantly correlated with the occurrence of peri-appendiceal abscess in patients with acute complicated appendicitis (P < 0.001 and P = 0.015, respectively). Patients with symptoms lasting longer than 72 h had a significantly longer postoperative LOS compared to those with symptoms lasting 72 h or less [hazard ratio (HR), 1.208; 95%CI: 1.107-1.319; P < 0.001]. Additionally, patients with peri-appendiceal abscesses had a significantly longer postoperative LOS compared to those with phlegmon (HR, 1.217; 95%CI: 1.095-1.352; P < 0.001). The patients with peri-appendiceal abscesses were divided into two groups based on the median size of the abscess: Those with abscesses smaller than 5.0 cm (n = 69) and those with abscesses 5.0 cm or larger (n = 82). Patients with peri-appendiceal abscesses measuring 5.0 cm or larger had a significantly longer postoperative LOS than those with abscesses smaller than 5.0 cm (P = 0.038).

CONCLUSION

The duration of symptoms and the presence of an appendicolith are significant risk factors for the formation of peri-appendiceal abscesses in patients with acute complicated appendicitis. Patients with peri-appendiceal abscesses experience a significantly longer postoperative LOS compared to those with peri-appendiceal phlegmon.

Feasibility of GPT-3.5 versus Machine Learning for Automated Surgical Decision-Making Determination: A Multicenter Study on Suspected Appendicitis

Background: Nonsurgical treatment of uncomplicated appendicitis is a reasonable option in many cases despite the sparsity of robust, easy access, externally validated, and multimodally informed clinical decision support systems (CDSSs). Developed by OpenAI, the Generative Pre-trained Transformer 3.5 model (GPT-3) may provide enhanced decision support for surgeons in less certain appendicitis cases or those posing a higher risk for (relative) operative contra-indications. Our objective was to determine whether GPT-3.5, when provided high-throughput clinical, laboratory, and radiological text-based information, will come to clinical decisions similar to those of a machine learning model and a board-certified surgeon (reference standard) in decision-making for appendectomy versus conservative treatment. Methods: In this cohort study, we randomly collected patients presenting at the emergency department (ED) of two German hospitals (GFO, Troisdorf, and University Hospital Cologne) with right abdominal pain between October 2022 and October 2023. Statistical analysis was performed using R, version 3.6.2, on RStudio, version 2023.03.0 + 386. Overall agreement between the GPT-3.5 output and the reference standard was assessed by means of inter-observer kappa values as well as accuracy, sensitivity, specificity, and positive and negative predictive values with the “Caret” and “irr” packages. Statistical significance was defined as p < 0.05. Results: There was agreement between the surgeon’s decision and GPT-3.5 in 102 of 113 cases, and all cases where the surgeon decided upon conservative treatment were correctly classified by GPT-3.5. The estimated model training accuracy was 83.3% (95% CI: 74.0, 90.4), while the validation accuracy for the model was 87.0% (95% CI: 66.4, 97.2). This is in comparison to the GPT-3.5 accuracy of 90.3% (95% CI: 83.2, 95.0), which did not perform significantly better in comparison to the machine learning model (p = 0.21). Conclusions: This study, the first study of the “intended use” of GPT-3.5 for surgical treatment to our knowledge, comparing surgical decision-making versus an algorithm found a high degree of agreement between board-certified surgeons and GPT-3.5 for surgical decision-making in patients presenting to the emergency department with lower abdominal pain.

Feasibility of a novel unassisted single-channel transcolonic endoscopic appendectomy for the treatment of appendiceal lesions (with video)

BACKGROUND

Transcolonic endoscopic appendectomy (TEA) is rapidly evolving and has been reported as a minimally invasive alternative to appendectomy. We aimed to characterize the feasibility and safety of a novel unassisted single-channel TEA.

METHOD

We retrospectively investigated 23 patients with appendicitis or appendiceal lesions who underwent TEA from February 2016 to December 2022. We collected clinicopathological characteristics, procedure‑related parameters, and follow‑up data and analyzed the impact of previous abdominal surgery and traction technique.

RESULTS

The mean age was 56.0 years. Of the 23 patients with appendiceal lesions, fourteen patients underwent TEA and nine underwent traction-assisted TEA (T-TEA). Eight patients (34.8%) had previous abdominal surgery. The En bloc resection rate was 95.7%. The mean procedure duration was 91.1 ± 45.5 min, and the mean wound closure time was 29.4 ± 18.6 min. The wounds after endoscopic appendectomy were closed with clips (21.7%) or a combination of clip closure and endoloop reinforcement (78.3%), and the median number of clips was 7 (range, 3-15). Three patients (13.0%) experienced major adverse events, including two delayed perforations (laparoscopic surgery) and one infection (salvage endoscopic suture). During a median follow-up of 23 months, no residual or recurrent lesions were observed, and no recurrence of abdominal pain occurred. There were no significant differences between TEA and T-TEA groups and between patients with and without abdominal surgery groups in each factor.

CONCLUSION

Unassisted single-channel TEA for patients with appendiceal lesions has favorable short- and long-term outcomes. TEA can safely and effectively treat appendiceal disease in appropriately selected cases.

Power Has Pitfalls: (In)accuracy of Administrative Data for Nonoperative Management of Appendicitis

INTRODUCTION

Nonoperative management (NOM) of uncomplicated appendicitis is increasingly common. Effectiveness of NOM has been studied by identifying patients via International Classification of Diseases (ICD) 9/ICD-10 codes for uncomplicated appendicitis and no code for appendectomy. We sought to assess the accuracy of such administrative definitions.

METHODS

We retrospectively identified patients with ICD-9/ICD-10 codes for appendicitis at five sites across the United States. Initial management plan and clinical severity were recorded by trained abstractors. We identified a gold standard cohort of patients with surgeon-diagnosed uncomplicated appendicitis and planned NOM. We defined two administrative cohorts with ICD-9/ICD-10 codes for uncomplicated appendicitis and either no surgery during initial admission (definition #1) or no surgery on day 0-1 of admission (definition #2). We compared each definition to the gold standard.

RESULTS

Among 1224 patients with uncomplicated appendicitis, 72 (5.9%) underwent planned NOM. NOM patients were older (median [Q1-Q3] of 37 [27-56] versus 32 [25-44] y) and less frequently male (51.4% versus 54.9%), White (54.1% versus 67.6%), and privately insured (38.9% versus 50.2%) than patients managed operatively. Definition #1 had sensitivity of 0.81 and positive predictive value of 0.87 for NOM of uncomplicated appendicitis. Definition #2 had sensitivity of 0.83 and positive predictive value of 0.72. The gold standard cohort had a true failure/recurrence rate of 23.6%, compared with apparent rates of 25.4% and 39.8%, respectively.

CONCLUSIONS

Administrative definitions are prone to misclassification in identifying planned NOM of uncomplicated appendicitis. This likely impacts outcomes in studies using administrative databases. Investigators should disclose how misclassification may affect results and select an administrative definition that optimally balances sensitivity and specificity for their research question.

Direct visualization endoscopic retrograde appendicitis therapy for treatment of acute uncomplicated appendicitis

OBJECTIVE

To investigate the diagnostic and therapeutic value of direct visualization (single-use eyeMax subscope) endoscopic management of acute uncomplicated appendicitis.

METHODS

Thirty-six patients diagnosed with acute uncomplicated appendicitis, confirmed by computed tomography or ultrasonography, from Jan 2023 to Feb 2024 were enrolled in this study. We collected demographics, colonoscopy findings, subscope findings, clinical outcomes of endoscopic retrograde appendicitis therapy (ERAT), and adverse events associated with ERAT.

RESULTS

Appendiceal intubation was successful for all 36 patients. Thirty-five patients (97.2%) were definitely confirmed as having acute uncomplicated appendicitis. One patient with negative appendicitis was diagnosed as having cecal diverticulitis with fecalith incarceration. The mean procedure time was 13.1 ± 13.6 min. One patient presented with worsening abdominal pain, and a computed tomography scan suggested a perforated appendix. The mean length of hospitalizations was 1.78 ± 2 days. The mean follow-up was 158 days; during this period, two patients (5.6%) experienced recurrent abdominal pain after 23 and 88 days and subsequently underwent laparoscopic appendectomy.

CONCLUSION

Direct visualization ERAT may be effective for diagnosing and treating acute uncomplicated appendicitis and seems to have a low complication rate.

The Use and Impact of a Decision Support Tool for Appendicitis Treatment

OBJECTIVE

Since introducing new and alternative treatment options may increase decisional conflict, we aimed to describe the use of the decision support tool (DST) and its impact on treatment preference and decisional conflict.

BACKGROUND

For the treatment of appendicitis, antibiotics are an effective alternative to appendectomy, with both approaches associated with a different set of risks (eg, recurrence vs surgical complications) and benefits (eg, more rapid return to work vs decreased chance of readmission). Patients often have limited knowledge of these treatment options, and DSTs that include video-based educational materials and questions to elicit patient preferences about outcomes may be helpful. Concurrent with the Comparing Outcomes of Drugs and Appendectomy trials, our group developed a DST for appendicitis treatment ( www.appyornot.org ).

METHODS

A retrospective cohort including people who self-reported current appendicitis and used the AppyOrNot DST between 2021 and 2023. Treatment preferences before and after the use of the DST, demographic information, and Ottawa Decisional Conflict Scale (DCS) were reported after completing the DST.

RESULTS

A total of 8243 people from 66 countries and all 50 U.S. states accessed the DST. Before the DST, 14% had a strong preference for antibiotics and 31% for appendectomy, with 55% undecided. After using the DST, the proportion in the undecided category decreased to 49% ( P < 0.0001). Of those who completed the Ottawa Decisional Conflict Score (DCS; n = 356), 52% reported the lowest level of decisional conflict (<25) after using the DST; 43% had a DCS score of 25 to 50, 5.1% had a DCS score of >50 and 2.5% had and DCS score of >75.

CONCLUSIONS

The publicly available DST appyornot.org reduced the proportion that was undecided about which treatment they favored and had a modest influence on those with strong treatment preferences. Decisional conflict was not common after use. The use of this DST is now a component of a nationwide implementation program aimed at improving the way surgeons share information about appendicitis treatment options. If its use can be successfully implemented, this may be a model for improving communication about treatment for patients experiencing emergency health conditions.

Nonoperative Management of Boerhaave Syndrome: A Case Study

Spontaneous esophageal rupture, also known as Boerhaave syndrome, represents an unusual yet clinically significant condition characterized by the rupture of the esophageal wall due to a sudden increase in intraluminal pressure, typically induced by vomiting, concomitant with negative intrathoracic pressure dynamics. This condition poses a challenging clinical entity, presenting high mortality rates, especially when treatment is delayed. Surgical intervention is frequently employed as the primary management strategy, while non-surgical approaches, including stent placement and endoluminal vacuum therapy, are less commonly utilized. This study aims to provide insights into the efficacy of non-operative management strategies by examining a clinical case. A 20-year-old male patient presented with fever, epigastric pain, excessive vomiting, and diarrhea over the past four days. A week prior, he had been examined at a private clinic, diagnosed with acute appendicitis, and managed conservatively with oral antibiotics. On the current admission, a contrast-enhanced thoracoabdominal CT scan revealed pneumomediastinum without fluid collection and portal vein thrombosis evidently due to acute appendicitis. Given the patient's favorable clinical status and the absence of collections in the mediastinum, a nonoperative approach was decided upon and was eventually successful. This case study concerns the sensible application of conservative modalities in selected patients with esophageal rupture.

Endoscopic retrograde appendicitis therapy

Endoscopic retrograde appendicitis therapy (ERAT) is a novel and minimally invasive technological alternative for the management of acute or chronic appendicitis. Through endoscopic appendiceal intubation, obstructions such as appendiceal feces and parasites within the appendiceal lumen can be effectively eliminated, leading to patient recovery. Additionally, in cases where the orifices are swollen or complicated appendicitis is present, a stent may be inserted following appendiceal flushing. Due to the utilization of endoscopy for accessing the orifices of the appendix in order to alleviate appendiceal obstruction, patients were able to avoid undergoing appendectomy and experienced a reduced likelihood of recurrence when compared to antibiotic therapy. Additionally, the ERAT provided alternative options for individuals with appendicitis and comorbidities. Recent advancements in techniques, such as the "mother-baby" endoscopic system and the use of microbubble contrast agents, have expanded the range of indications and the eligible patient populations. The objective of this review is to present a comprehensive overview of the development, procedural aspects, therapeutic principles, treatment efficacy, therapeutic applications, and potential complications associated with ERAT.

SAME day amBulatory c (SAMBA): a multicenter, prospective, randomized clinical trial protocol

BACKGROUND

A recent meta-analysis concluded that outpatient appendectomy appears feasible and safe, but there is a lack of high-quality evidence and a randomized trial is needed. The aim of this trial is to demonstrate that outpatient appendectomy is non-inferior to conventional inpatient appendectomy in terms of overall morbi-mortality on the 30th postoperative day (D30).

METHODS

SAMBA is a prospective, randomized, controlled, multicenter non-inferiority trial. We will include 1400 patients admitted to 15 French hospitals between January 2023 and June 2025. Inclusion criteria are patients aged between 15 and 74 years presenting acute uncomplicated appendicitis suitable to be operated by laparoscopy. Patients will be randomized to receive outpatient care (day-surgery) or conventional inpatient care with overnight hospitalization in the surgery department. The primary outcome is postoperative morbi-mortality at D30. Secondary outcomes include time from diagnosis to appendectomy, length of total hospital stay, re-hospitalization, interventional radiology, re-interventions until D30, conversion from outpatient to inpatient, and quality of life and patient satisfaction using validated questionnaires.

DISCUSSION

The SAMBA trial tests the hypothesis that outpatient surgery (i.e., without an overnight hospital stay) of uncomplicated acute appendicitis is a feasible and reliable procedure in establishments with a technical platform able to support this management strategy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05691348. Registered on 20 January 2023.

Modified endoscopic retrograde appendicitis therapy vs. laparoscopic appendectomy for uncomplicated acute appendicitis in children

OBJECTIVES

Modified endoscopic retrograde appendicitis therapy (mERAT) has been proposed as an alternative to laparoscopic appendectomy for the treatment of appendicitis. However, data from children in large samples are lacking. The aim of this article is to evaluate the efficacy between mERAT and laparoscopic appendectomy (LA) in children with uncomplicated appendicitis.

METHOD

We retrospectively analyzed 594 patients with suspected uncomplicated appendicitis from October 2018 to May 2021. A pool of 294 consecutive patients who met the inclusion criteria were ultimately enrolled in this study (228 and 66 patients in mERAT and LA, respectively). Given the differences in baseline clinical data (gender, age), the regression equation including differences in clinical baseline, grouping factor, and white blood cell count was established to address the influence of potential confounding factors.

RESULT

The initial success rate of mERAT management was 96.9%, and the recurrence rate was 6.9% in the mERAT group and 1.7% in the LA group within 1 year, which was no significant difference. But the mERAT group had a lower rate of adverse events. Finally, those results indicated that the treatment modalities, LA or mERAT, had no significant effect on initial success rate (P = 0.99) or recurrence rate (P = 0.17) within 1 year, but a significant effect on the adverse events rate during hospitalization (P = 0.01) in the multivariate regression analysis.

CONCLUSION

Among children with uncomplicated appendicitis, an initial mERAT management strategy had a success rate of 96.9%, which was similar to the LA group at 1 year. This follow-up supports the feasibility of mERAT alone as an alternative to surgery for uncomplicated appendicitis.

Patient Perspectives on Evolving Diverticulitis Treatment: An Assessment of Patient Willingness to Enroll in a Randomized Controlled Trial

Objective

The objective of the study was to assess patients' attitudes regarding participation in a randomized trial of antibiotics versus placebo for acute diverticulitis.

Background

Despite evidence that antibiotics may not be necessary to treat acute uncomplicated diverticulitis, they remain the mainstay of treatment in the United States. A randomized trial in the United States evaluating antibiotic effectiveness could accelerate the implementation of antibiotic-free treatment, but providers maintain concerns that patients may be unwilling to participate.

Methods

This mixed-methods study conducted semi-structured interviews of patients presenting to a quaternary care emergency department with acute diverticulitis and a web-based survey of a larger cohort. The interviews assessed patients' experiences with diverticulitis and perceptions of participation in a trial comparing antibiotics versus placebo. The survey quantified patients' willingness to participate in such a study and the relative importance of factors influencing the process.

Results

Thirteen patients completed an interview. Reasons to participate included a desire to help others or contribute to scientific knowledge. Doubts about the efficacy of observation as a treatment method were the main barrier to participation. In a survey of 218 subjects, 62% of respondents reported willingness to participate in a randomized clinical trial. "What my doctor thinks," followed by "What I have experienced in the past" were the most important decision-making factors.

Conclusion

Patients with acute uncomplicated diverticulitis maintain complex and varying perceptions of antibiotic use. Most surveyed patients would be willing to participate in a trial of antibiotics versus placebo. Our findings support the trial's feasibility and may facilitate an informed approach to recruitment and consent.

Trends and levels of the global, regional, and national burden of appendicitis between 1990 and 2021: findings from the Global Burden of Disease Study 2021

BACKGROUND

Appendicitis is a common surgical emergency that poses a large clinical and economic burden. Understanding the global burden of appendicitis is crucial for evaluating unmet needs and implementing and scaling up intervention services to reduce adverse health outcomes. This study aims to provide a comprehensive assessment of the global, regional, and national burden of appendicitis, by age and sex, from 1990 to 2021.

METHODS

Vital registration and verbal autopsy data, the Cause of Death Ensemble model (CODEm), and demographic estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) were used to estimate cause-specific mortality rates (CSMRs) for appendicitis. Incidence data were extracted from insurance claims and inpatient discharge sources and analysed with disease modelling meta-regression, version 2.1 (DisMod-MR 2.1). Years of life lost (YLLs) were estimated by combining death counts with standard life expectancy at the age of death. Years lived with disability (YLDs) were estimated by multiplying incidence estimates by an average disease duration of 2 weeks and a disability weight for abdominal pain. YLLs and YLDs were summed to estimate disability-adjusted life-years (DALYs).

FINDINGS

In 2021, the global age-standardised mortality rate of appendicitis was 0·358 (95% uncertainty interval [UI] 0·311-0·414) per 100 000. Mortality rates ranged from 1·01 (0·895-1·13) per 100 000 in central Latin America to 0·054 (0·0464-0·0617) per 100 000 in high-income Asia Pacific. The global age-standardised incidence rate of appendicitis in 2021 was 214 (174-274) per 100 000, corresponding to 17 million (13·8-21·6) new cases. The incidence rate was the highest in high-income Asia Pacific, at 364 (286-475) per 100 000 and the lowest in western sub-Saharan Africa, at 81·4 (63·9-109) per 100 000. The global age-standardised rates of mortality, incidence, YLLs, YLDs, and DALYs due to appendicitis decreased steadily between 1990 and 2021, with the largest reduction in mortality and YLL rates. The global annualised rate of decline in the DALY rate was greatest in children younger than the age of 10 years. Although mortality rates due to appendicitis decreased in all regions, there were large regional variations in the temporal trend in incidence. Although the global age-standardised incidence rate of appendicitis has steadily decreased between 1990 and 2021, almost half of GBD regions saw an increase of greater than 10% in their age-standardised incidence rates.

INTERPRETATION

Slow but promising progress has been observed in reducing the overall burden of appendicitis in all regions. However, there are important geographical variations in appendicitis incidence and mortality, and the relationship between these measures suggests that many people still do not have access to quality health care. As the incidence of appendicitis is rising in many parts of the world, countries should prepare their health-care infrastructure for timely, high-quality diagnosis and treatment. Given the risk that improved diagnosis may counterintuitively drive apparent rising trends in incidence, these efforts should be coupled with improved data collection, which will also be crucial for understanding trends and developing targeted interventions.

FUNDING

Bill and Melinda Gates Foundation.

Indication of conservative treatment by antibiotics for uncomplicated and complicated acute appendicitis

BACKGROUND

Acute appendicitis is one of the most common emergency abdominal disease, and recent studies have evaluated conservative treatment using antibiotics for uncomplicated appendicitis. Although the efficacy of conservative treatment for uncomplicated appendicitis is known, its efficacy for complicated appendicitis remains unknown, so are risk factors for the conservative treatment of appendicitis. In our institution, conservative treatment has long been the first choice for most appendicitis cases, except for perforation. Therefore, this novel study investigated the outcomes of conservative treatment for uncomplicated and complicated acute appendicitis and the risk factors associated with conservative treatment.

AIM

To investigate the indication of conservative treatment by antibiotics for uncomplicated and complicated acute appendicitis.

METHODS

We investigated 270 patients who received conservative treatment for acute appendicitis at the Nishitokyo Central General Hospital, between April 2011 and February 2022. Twenty-eight (10.3%) patients were resistant to conservative treatment and underwent surgery. We retrospectively investigated the outcomes of conservative treatment for appendicitis and the risk factors for resistance to conservative treatment using the receiver operating characteristic curves and Cox hazard model.

RESULTS

Two hundred and forty-two (89.7%) patients improved with conservative treatment. The significant and independent predictors of resistance to conservative treatment were body temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid visible on computed tomography (CT). The rate of resistance to conservative treatment was 66.7% (6/9) for patients with the above three factors, 22.9% (8/35) for patients with two factors (appendicolith and body temperature ≥ 37.3 °C), 16.7% (2/12) for patients with two factors (Douglas sinus fluid and appendicolith) and 11.1% (1/9) for patients with two factors (Douglas sinus fluid and body temperature ≥ 37.3 °C).

CONCLUSION

A temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid on CT might be clinical risk factors of resistance to conservative treatment for acute appendicitis.

Appendicolith classification: physical and chemical properties of appendicoliths in patients with CT diagnosed acute appendicitis - a prospective cohort study

OBJECTIVE

Appendicoliths are associated with a more complicated course of acute appendicitis and failure of non-operative treatment. We aimed to update the appendicolith classification originally described in 1966 and to assess the association of appendicolith characteristics with appendicitis severity.

DESIGN

This prospective predefined MAPPAC-trial (ClinicalTrials.gov NCT03257423) substudy included patients with CT diagnosed appendicitis presenting with an appendicolith. CT visible appendicoliths were harvested at surgery, measured and characterised by morphological examination complemented with micro-CT and micro-X-ray fluorescence spectroscopy. Patients were categorised into two groups: appendicolith appendicitis without other complications and appendicolith appendicitis with complications (appendiceal gangrene, perforation and/or abscess). The association of appendicolith classification and characteristics with appendicitis severity was evaluated.

RESULTS

Of 78 patients with a CT appendicolith, 41 appendicoliths were collected and classified based on the degree of hardness into three classes. The hardest appendicoliths (class 3) were less common (19.5%) presenting with a stone-hard outer layer and concentrically layered inner structure around a core. The layered inner structure was also observed in class 2 appendicoliths, but was absent in soft, class 1 appendicoliths. Appendicolith hardness or measures (maximum length, diameter and weight) were not associated with appendicitis severity. The spatial distribution of the main inorganic elements of calcium and phosphorus varied within most appendicoliths.

CONCLUSION

This updated classification confirms categorisation of CT visible appendicoliths into three classes based on their physical and chemical characteristics. The data on clinical and aetiopathological characteristics of appendicoliths is scarce and using this systematic classification would add to this understanding.

Why Evidence Generation Should Matter to Payers and How They Can Help

Importance

The US leads the world in bringing new medical products to market, but the ability to generate evidence to inform clinical practice in postmarket settings needs improvement. Although a diverse group of stakeholders is working to improve postmarket evidence generation, the role of private payers has been underappreciated.

Observations

Payers are crucial allies in improving evidence generation because better data would better inform coverage decisions, their policies and practices influence the conduct of care and research, and their claims data are a source of real-world evidence used in medical product evaluation. In addition, payers have a stake in improving evidence generation because the kinds of evidence needed to inform health care and coverage decisions are often not available when a product enters the market and may not be generated without their involvement. Here, we describe several key steps payers could take to improve evidence generation, including participating in efforts to reduce administrative and financial barriers to the conduct of clinical trials, directly incentivizing evidence generation on high-priority questions by funding potential cost-saving trials, increasing engagement with the medical products industry on evidentiary needs for coverage decisions, and improving usability of claims data by reducing data lags and routinely recording unique device identifiers. Broad payer engagement with US Food and Drug Administration recommendations regarding evidence generation will ensure that the opportunities to participate in clinical research are extended to all communities and that evidence needed to inform care is generated in trials and surveillance systems that reflect the clinical reality across the US.

Conclusions and Relevance

Increasing payer involvement in evidence generation can benefit all participants in the medical innovation ecosystem. The importance of payers in these efforts will continue to grow in response to imperatives to increase integration of care and research, engage a diverse set of communities in clinical research, and move toward alternative payment models.

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.

The impact of surgical timing on outcome in acute appendicitis in adults: a retrospective observational population-based cohort study

BACKGROUND

Acute appendicitis is a global disease with high incidence. The main objective was to assess the association between time from admission to surgery (TAS) and surgery during emergency hours with operative outcome in light of conflicting evidence.

METHODS

This is a retrospective population-wide analysis of hospital billing data (2010-2021) of all adult patient records of surgically treated cases of acute appendicitis in Germany by TAS. The primary outcome was a composite clinical endpoint (CCE; prolonged length of stay, surgical site infection, interventional draining after surgery, revision surgery, ICU admission and/or in-hospital mortality). Cases of complicated appendicitis were identified using diagnosis (ICD-10) and procedural codes (resection beyond appendectomy).

RESULTS

855 694 patient records were included, of which 27·6% (236,481) were complicated cases of acute appendicitis. 49·0% (418,821) were females and median age was 37 (interquartile range 22·5-51·5). Age, male sex, and comorbidity were associated with an increased proportion of CCE and in-hospital mortality. TAS was associated with a clinically relevant increase of CCE after 12 h in complicated appendicitis [Odd's ratio (OR), 1·19, 95% CI: 1·14-1·21] and after 24 h in uncomplicated appendicitis (OR 1·10, 95% CI: 1·02-1·19). Beyond the primary endpoint, the proportion of complicated appendicitis increased after TAS of 72 h. Surgery during emergency hours (6 pm-6.59 am) was associated with an increase of CCE and mortality (OR between 1·14 and 1·49). Age, female sex, night-time admission, weekend admission, a known previous surgery, obesity, and therapeutic anticoagulation were associated with delayed performance of surgery.

CONCLUSION

This work found an increase of a CCE after TAS of 12 h for complicated appendicitis and an increase of the CCE after TAS of 24 h for uncomplicated appendicitis with a stable proportion of complicated appendicitis in these time windows. Both CCE and mortality were increased if appendectomy was performed during emergency hours.

Does delayed operation increase morbidity and mortality? An analysis of emergency general surgery procedures

BACKGROUND

Early operation is assumed to improve outcomes after emergency general surgery (EGS) procedures; however, few data exist to inform this opinion. We aimed to (1) characterize time-to-operation patterns among EGS procedures and (2) test the association between timing and patient outcomes. We hypothesize that patients receiving later operations are at greater risk for mortality and morbidity.

METHODS

We performed a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program data for adults aged 18 to 89 years who underwent nonelective intra-abdominal operations (appendectomy, cholecystectomy, small bowel resection, lysis of adhesions, and colectomy) from 2015 to 2020. The primary outcome was 30-day postoperative mortality. Secondary outcomes were serious morbidity and all morbidity. Admission-to-operation timing was calculated and classified as early (≤48 hours) or late (>48 hours). A multivariable logistic regression model adjusted risk estimates for age, comorbidities, frailty (Modified Frailty Index, 5-item score), and other confounders.

RESULTS

Of 269,959 patients (mean age, 47.0 years; 48.0% male, 61.6% White), 88.7% underwent early operation, ranging from 70.36% (lysis of adhesions) to 98.67% (appendectomy). Unadjusted 30-day mortality was higher for late versus early operation (6.73% vs. 1.96%; p < 0.0001). After risk adjustment, late operation significantly increased risk for 30-day mortality (odds ratio [OR], 1.545; 95% confidence interval [CI], 1.451-1.644), serious morbidity (OR, 1.464; 95% CI, 1.416-1.514), and all morbidity (OR, 1.468; 95% CI, 1.417-1.520). This mortality risk persisted for all EGS procedures; risk of serious and any morbidity persisted for all procedures except cholecystectomy.

CONCLUSION

Late operation significantly increased risk for 30-day mortality, serious morbidity, and all morbidity across a variety of EGS procedures. We believe that these findings will inform decisions regarding timing of EGS operations and allocation of surgical resources.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.