Antibiotic Treatment and Appendectomy for Uncomplicated Acute Appendicitis in Adults and Children: A Systematic Review and Meta-analysis

Economic Evaluation of Acute Appendicitis Therapeutic Interventions: A Systematic Review

Background and Aims

Acute appendicitis (AA) is a prevalent cause of lower abdominal pain, often leading patients to seek emergency department care, particularly among young individuals. The present study aimed to systematically review cost-effectiveness studies focusing on therapeutic interventions for AA.

Method

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically reviewed economic evaluations of AA treatments published between 2000 and 2020. We searched multiple databases, including Cochrane, PubMed, Scopus, and Web of Science. The studies included in this review were assessed using the Quality of Health Economic Studies (QHES) checklist, and cost data were standardized to 2022 US dollars.

Results

Out of the 53 screened studies, 11 fulfilled the inclusion criteria. The studies' average QHES score was of high quality (0.87). Most studies were from the payer's perspective and the health system (four studies each). Five studies were based on the decision tree model, and three were based on the Markov model. Four studies were conducted on children. Of the 11 studies reviewed, five support the cost-effectiveness of laparoscopy, five support the cost-effectiveness of antibiotic therapy, and one supports the cost-effectiveness of open appendectomy.

Conclusions

Based on the findings of this study, laparoscopic therapeutic intervention, compared to open appendectomy, can be more cost-effective for the treatment of patients with AA.

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.

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.

Appendectomy followed by two-stage right-sided colectomy with lymph node dissection for appendiceal cancer and risk factors for peritoneal recurrence: a single high-volume cancer center study in Japan

PURPOSE

Few studies have evaluated whether the timing of colectomy affects the prognosis of appendiceal cancer. This study compared long-term outcomes and recurrence patterns between initial appendectomy followed by two-stage colectomy and one-stage colectomy for appendiceal cancer.

METHODS

We retrospectively evaluated 65 patients who underwent 2-stage (n = 17) or 1-stage (n = 48) right-sided colectomy with lymph node dissection for stage 0-III appendiceal cancer between August 2005 and December 2022. The recurrence types and risk factors were compared.

RESULTS

The 2-stage colectomy group had a more advanced disease stage than the 1-stage group (stage III cases: 29.4% vs. 14.6%, P = 0.03). The 5-year overall recurrence rates were similar between the groups (29.4% vs. 19.2%, P = 0.39). All peritoneal recurrence cases (n = 9) had pT3 or T4 depth. Among pT3 and T4 cases (n = 46), the peritoneal recurrence rates did not differ significantly (31.2% vs. 13.8%, P = 0.17). A multivariate analysis identified preoperative serum CA19-9 level of > 37 ng/mL (hazard ratio [HR], 35.4; 95% confidence interval [CI], 3.08-406.8; P = 0.004) and lymph node metastasis (HR, 42.6; 95% CI, 9.90-183.6; P < 0.001) as independent risk factors for peritoneal recurrence.

CONCLUSIONS

Serum CA19-9 levels and lymph node metastasis are risk factors for peritoneal recurrence. The effect of colectomy timing on recurrence was not definitive.

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.

Swedish national guidelines for diagnosis and management of acute appendicitis in adults and children

BACKGROUND

Acute appendicitis is one of the most common causes of acute abdominal pain. Differences in the management of this large group of patients has important consequences for the patients and the healthcare system. Controversies regarding the understanding of the natural course of the disease, the utility of new diagnostic methods, and alternative treatments have lead to large variations in practice patterns between centres. These national guidelines present evidence-based recommendations aiming at a uniform, safe and cost-efficient management of this large group of patients.

METHOD

A working group of six experts with broad clinical and research experience was formed. Additional expertise from outside was consulted during the process. A national survey revealed significant variations in the management of patients with suspicion of appendicitis. The evidence provided in published guidelines and reviews were extracted and systematically graded, according to the GRADE methodology. This was supplemented by additional more recent and more directed search of the literature. Patients treated for appendicitis were involved through interviews. The guidelines were reviewed by external experts before the final version was determined.

RESULTS

The guidelines cover an extensive number of issues: pathology, epidemiology, aetiology, natural history, clinical and laboratory diagnosis, diagnostic scoring systems, diagnostic imaging, treatment, nursing care, follow-up, quality registers and quality indicators, among others. Special considerations related to children and pregnant women are covered.

CONCLUSION

These national guidelines present an extensive and thorough review of the current knowledge base related to appendicitis, and provide up-to-date evidence-based recommendations for the management of this large group of patients.

Cost-Effectiveness of Nonoperative Management vs Upfront Laparoscopic Appendectomy for Pediatric Uncomplicated Appendicitis for 1 Year

BACKGROUND

Nonoperative management (NOM) with antibiotics alone for pediatric uncomplicated appendicitis is accepted to be safe and effective. However, the relative cost-effectiveness of this approach compared with appendectomy remains unknown. We aimed to evaluate the cost-effectiveness of nonoperative vs operative management for pediatric uncomplicated acute appendicitis.

STUDY DESIGN

A trial-based real-world economic evaluation from the healthcare sector perspective was performed using data collected from a multi-institutional nonrandomized controlled trial investigating NOM vs surgery. The time horizon was 1 year, with costs in 2023 US dollars. Ratio of costs-to-charges-based data for the initial hospitalization, readmissions, and unplanned emergency department visits were extracted from the Pediatric Health Information System. Utility data were derived from patient-reported disability days and health-related quality-of-life scores. Multiple scenarios and 1-way deterministic and probabilistic sensitivity analyses accounted for parameter uncertainty. Willingness-to-pay threshold was set at $100,000 per quality-adjusted life year (QALY) or disability-adjusted life year. Primary outcome measures included total and incremental mean costs, QALY, disability-adjusted life year, and incremental cost-effectiveness ratios.

RESULTS

Of 1,068 participants, 370 (35%) selected NOM and 698 (65%) selected urgent laparoscopic appendectomy. Operative management cost an average of $9,791 per patient and yielded an average of 0.884 QALYs, whereas NOM cost an average of $8,044 per patient and yielded an average of 0.895 QALYs. NOM was both less costly and more effective in base case and scenario analyses using disability days and alternate methods of calculating uses.

CONCLUSIONS

NOM is cost-effective compared with laparoscopic appendectomy for pediatric uncomplicated appendicitis for 1 year.

Discriminatory Value and Validation of a Risk Prediction Model Based on Serum Cytokines in Pediatric Acute Appendicitis: A Single-Center Experience of 483 Cases

Objectives: Pediatric acute appendicitis (AA) is one of the most prevalent acute abdominal conditions in pediatric surgery. Children with complicated acute appendicitis (CA) may need timely surgical decisions and have a worse prognosis. In this study, we explored the risk factors and developed a predictive model for complicated AA in children. Methods: A retrospective analysis was conducted on patients data from those hospitalized for acute appendicitis, confirmed by post-surgery pathological results, at Children's Hospital of Chongqing Medical University between September 2022 and October 2023. Lasso regression was performed to identify risk factors, and multivariate logistic regression analysis was used for model establishment. Results: Serum levels of IFN-γ, IL-5, IL-6, IL-8, and IL-10 before surgery were useful in classifying acute appendicitis in children. IL-6, IL-8, and IL-10, on their own, had high predictive values for CA in children. Independent risk factors for CA were age, IL-10, and IFN-γ. A multifactorial logistic regression prediction model was established, demonstrating good predictive efficacy. Its predictive sensitivity was 70.0%, specificity 73.9%, with an AUC of 0.7949. Furthermore, the results of the external validation indicated that the model's accuracy was good, with an AUC of 0.8567. Conclusions: Early identification of CA is imperative for timely clinical decision-making. Prediction models based on age, IL-10, and IFN-γ may be reliable and accurate in predicting the incidence of CA, which may lead to better clinical outcomes for children with AA.

Phlegmonous appendicitis as a variant of uncomplicated appendicitis

Acute appendicitis is the most common cause of surgical acute abdomen, and its classification into uncomplicated, phlegmonous, and complicated forms is crucial for guiding treatment strategies. This study aims to compare the preoperative laboratory findings and postoperative outcomes of phlegmonous appendicitis with uncomplicated and complicated appendicitis. This retrospective cohort study included 1,441 patients who underwent appendectomy between January 2019 and March 2021 at Ankara Bilkent City Hospital. Patients were classified based on histopathological findings into four groups: normal appendix, uncomplicated appendicitis, phlegmonous appendicitis, and complicated appendicitis. Preoperative laboratory values, postoperative complications, and length of hospital stay were analyzed. The distribution of patients was as follows: Group A (normal appendix, 7.6%), Group B (uncomplicated appendicitis, 59.8%), Group C (phlegmonous appendicitis, 17.6%), and Group D (complicated appendicitis, 15%). Phlegmonous appendicitis exhibited significantly higher leukocyte counts and appendix diameters compared to uncomplicated appendicitis but had lower CRP values than complicated appendicitis. The median hospital stay was similar for Groups A, B, and C (1 day) but significantly longer for Group D (2.1 days, p < 0,001). Complication rates were highest in Group D (24.1%) compared to the other groups. While phlegmonous appendicitis shares some clinical and laboratory characteristics with complicated appendicitis, its postoperative outcomes align more closely with those of uncomplicated appendicitis. This suggests that phlegmonous appendicitis may be more accurately classified as a variant of uncomplicated appendicitis, emphasizing the need for consistent classification to improve treatment strategies and patient outcomes.

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.

Acute appendicitis and its treatment: a historical overview

PURPOSE

Acute appendicitis (AA) is the leading cause of acute abdomen worldwide, with an incidence of 90-100 cases per 100,000 individuals annually and a lifetime risk of 7-12%. Despite its prevalence, historical accounts of AA are limited, particularly when compared to conditions like haemorrhoids, likely due to the appendix's internal location. This article traces the historical evolution of AA treatment from ancient times to the present, highlighting key contributions.

METHODS

A review of common research databases and relevant literature on AA was conducted.

RESULTS

Evidence from ancient Egypt suggests early recognition of the appendix, referring to it as the "worm of the bowel." However, detailed anatomical descriptions and treatment approaches for AA did not emerge until the Renaissance, particularly with contributions from Leonardo da Vinci and Berengario da Carpi. The article traces the progression of AA management, including the first autopsies and surgeries, the development of surgical techniques predating anaesthesia and antisepsis, and advancements achieved from the nineteenth to the twenty-first century. The shift from conservative to surgical approaches is discussed, alongside innovations such as laparoscopic appendicectomy, single-incision laparoscopic surgery (SILS), natural orifice transluminal endoscopic surgery (NOTES), and endoscopic retrograde appendicitis therapy (ERAT). The impact of the COVID-19 pandemic on AA treatment, including adaptations in medical practices, is also explored.

CONCLUSIONS

This review highlights the significant historical developments in AA treatment and its pivotal role in advancing abdominal surgery.

Operative and non-operative management of acute appendicitis during pregnancy: a population-based study

PURPOSE

Acute appendicitis during pregnancy poses unique challenges due to altered anatomical and physiological dynamics and concern about foetal well-being. This study aimed to assess management strategies and outcomes of acute appendicitis during pregnancy, focusing on non-operative management versus surgical intervention.

METHODS

The study is based on the computerized healthcare utilization database of Lombardy.

RESULTS

In Lombardy, a total of 1,231,040 deliveries were identified. Acute appendicitis during pregnancy occurred in 0.03% of cases, with 74.49% of these cases classified as uncomplicated. Appendicitis during pregnancy was associated with worse maternal and perinatal outcomes. Among uncomplicated cases, 38.46% were treated with non-operative management. Perinatal outcomes did not significantly differ between non-operative management and surgery groups. Additionally, a declining trend in surgical treatment over the study period was observed (P = 0.0477), possibly indicating a shift towards conservative management.

CONCLUSION

The findings suggest that non-operative management may be a viable option for selected pregnant patients with uncomplicated appendicitis, potentially avoiding surgical complications and allowing for faster recovery. Further research is warranted to validate these findings, explore evolving trends, and refine clinical guidelines for managing acute appendicitis during pregnancy.

Evaluation of the ability of laboratory, ultrasonography, and Doppler ultrasonography findings to distinguish between simple and complicated appendicitis

OBJECTIVE

To evaluate the utility of laboratory ultrasonographic and Doppler ultrasonographic findings in the differentiation of simple and complicated appendicitis.

METHODS

A prospective study was conducted, including pediatric patients who underwent surgery with the diagnosis of appendicitis.

RESULTS

Fifty patients, who were found to have appendicitis on ultrasonographic examination, were included. The mean age was found to be 12.80 ± 3.67 years, with 30% female and 70% male. The patients were histopathologically divided into two groups: simple appendicitis (Group 1, 41 patients, 82%) and complicated appendicitis (Group 2, 9 patients, 18%). CRP (C-reactive protein) levels (p = 0.004) and periappendiceal fatty tissue thickness (PFI) (p < 0.005) were found to be statistically significantly higher in Group 2 compared to Group 1. The portal vein (PV) diameter and peak systolic velocity (PSV) values were significantly higher in the study group compared to the control group (p = 0.033, p = 0.001).

CONCLUSION

Doppler ultrasonographic examination did not significantly differentiate complicated from simple appendicitis. The CRP value is an independent risk factor in the diagnosis of complicated appendicitis, and the presence of a significant increase in mesenteric tissue thickness is one of the important criteria for differentiating complicated appendicitis from simple appendicitis.

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.

No genetic causality between appendectomy and gastrointestinal cancers: a Mendelian randomization study and meta-analysis in European population

The impact of appendectomy on the risk of gastrointestinal cancers remains unknown. We aimed to systematically estimate the causal relationship between appendectomy and gastrointestinal cancers in the European population using two-sample Mendelian randomization (TSMR) study methods and meta-analysis. As part of the discovery cohort analysis, we identified independent genetic variants strongly associated with appendectomy from the UK Biobank (50,105 cases) to serve as instrumental variables (IVs). Summary-level data for gastrointestinal cancers were obtained from the FinnGen study. As the replication cohort, IVs associated with appendectomy were extracted in the FinnGen study (28,601 cases). The data for gastrointestinal cancers were obtained from the UK Biobank. Finally, meta-analyses were conducted to evaluate the combined causal effects of the MR results. We found no causal relationship between appendectomy and gastrointestinal cancers in both the discovery and replication cohorts. Finally, the meta-analysis revealed no causal association between appendectomy and gastrointestinal cancers. Our findings suggest no causal relationship exists between appendectomy and gastrointestinal cancers in the European population. This genetic evidence supports the conclusion from other observational studies that appendectomy does not affect the risk of gastrointestinal cancers in the European population.

A Decade-Long Retrospective Clinicopathological Study of Appendiceal Neoplasms

INTRODUCTION

 Appendiceal neoplasms (ANs) are uncommon, representing less than 1% of all gastrointestinal tumors. They are most often discovered incidentally during appendectomies performed for suspected acute appendicitis. Recent studies have reported an increase in the incidence of AN. Our study aimed to analyze the spectrum of AN and determine the cases discovered incidentally.

MATERIAL AND METHODS

 This retrospective descriptive study was performed over 10 years, from March 2014 to March 2024, at Saveetha Medical College and Hospital in Chennai, India. Complete enumeration sampling was performed, and tumor registries were reviewed to identify all cases of AN received during the study period. The corresponding clinical and radiological data were obtained from the hospital database, whereas histopathology records were used to evaluate tumor characteristics. Descriptive statistical analysis was employed, and the spectrum of AN was analyzed.

RESULTS

 During the study period, 12 cases of AN were identified. Eleven cases (91.7%) were diagnosed from appendicectomy specimens, while one was from a right hemicolectomy specimen. Of these 12, nine cases (75%) were incidental findings. In our study, we found that there was a higher number of female cases, with nine out of twelve cases (75%) being female. Most patients presented with abdominal pain, and acute appendicitis was the most frequent preoperative diagnosis. Low-grade appendiceal mucinous neoplasm was the most common type encountered followed by other appendiceal tumors.

CONCLUSION

 The incidence of AN has increased in recent years, with most cases being found incidentally. Given the increasing rate of incidental AN, it is vital to maintain vigilance in specimen analysis including comprehensive examination and precise grossing to ensure malignancies are not overlooked.

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.

An FUO patient diagnosed as appendicitis: a case report

BACKGROUND

The diagnosis and management of fever of unknown origin pose significant challenges in the field of infectious diseases, as it is influenced by various factors. Infectious diseases have long been recognized as the primary etiology of fever of unknown origin. However, not all infectious diseases can definitively identify the causative pathogen and infection sites.

CASE PRESENTATION

we present a case report of an individual with fever, nausea, and anorexia but did not report any abdominal pain. Physical examination revealed no signs of abdominal tenderness. Repeated imaging studies including enhanced CT and color US of the appendix, only one color US suggested the possibility of appendicitis. Despite effective anti-infective treatment, the patient continued to experience low-grade fever, leading to the decision for laparoscopic exploration and subsequent appendectomy. Pathological findings confirmed the presence of appendicitis. After the surgical procedure, the patient's temperature and infectious markers returned to within normal range, ultimately leading to a diagnosis of appendicitis.

CONCLUSIONS

The atypical symptoms and signs, along with the negative imaging results, contribute to the under diagnosis of appendicitis and the progression of fever of unknown origin, thereby exacerbating the physical, mental, and economic burden on patients. Consequently, there are valuable insights to be gained regarding the management of both appendicitis and fever of unknown origin.

Appendectomy: Cross-sectional study of the effects of COVID-19 in a hospital in South Brazil

Background

COVID-19 has further burdened the Brazilian healthcare system, especially emergencies. Patients may have delayed seeking care for surgical abdominal pain. Delays in the approach may have impacted clinical evolution and outcomes. This study evaluated appendectomies and their complications performed by the public system during one-year follow-up of COVID-19 in a hospital in southern Brazil.

Materials and methods

In this hospital-based cross-sectional study, we included adult patients who underwent appendectomy from March 2019 to April 2021 (n = 162). Patients were divided into pre-pandemic (n = 78) and pandemic (n = 84) groups based on the surgery date. The analyzed variables included hospitalization duration, intensive care unit (ICU) admission, surgical approach, histopathological findings, COVID-19 testing, patient outcomes, and 30-day survival rate.

Results

The cohorts exhibited similar epidemiology, with the sex ratio and average age being maintained. No statistical difference was found in the 30-day survival rate and clinical outcomes. Of the four patients admitted to the ICU, three belonged to the pandemic cohort and tested negative for COVID-19. Only 47.6 % of the patients in the pandemic cohort underwent COVID-19 polymerase chain reaction examination; one tested positive (2.5 %).

Conclusion

This study demonstrated that there was no increased risk for appendectomies during the first wave of the pandemic. Surgeries were safe during this period. Patients continued to access the emergency service despite surgical abdominal pain and restrictive measures imposed by health authorities. The similar results observed across cohorts are attributed to the readiness of the teams and the availability of medical surgical equipment in safe quantities.

Acute Appendicitis in Children in the Era of Covid-19

BACKGROUND

Abdominal pain is a common complaint encountered by paediatric surgeons. This complaint could be related to surgical or non-surgical causes. With coronavirus disease 2019 (COVID-19), the incidence of abdominal pain has increased and mimicked acute appendicitis in paediatric patients.

OBJECTIVE

The objective of this study was to assess the impact of the COVID-19 pandemic on paediatric acute appendicitis in terms of demographic data (age and sex), and operative findings, specifically, the complicated appendicitis and negative appendectomy rates.

MATERIALS AND METHODS

This retrospective cohort study reviewed the records of children aged 5-15 years, who were diagnosed with acute appendicitis and underwent surgery between January 2018 and December 2021. The patients were divided into pre-pandemic and pandemic groups. Demographic, operative and histopathological findings were compared between the two groups.

RESULTS

A significant increase in the incidence of acute abdominal pain amongst the admitted children (39.8% vs. 32.7%, P < 0.0001) and a significant decrease in the incidence of acute appendicitis (27% vs. 33%, P < 0.013) were observed in the pandemic group. An associated non-significant increase in the rates of complicated appendicitis (30% vs. 26%, P = 0.299) and negative appendectomy (5.8% vs. 3.8%, P = 0.359) was noted. During the pandemic period, no statistically significant differences were found between polymerase chain reaction (PCR)-positive and PCR-negative patients in complicated appendicitis or negative appendectomy rates (30% vs. 29.7%, P = 0.841, and 6.7% vs. 4.2%, P = 0.424, respectively).

CONCLUSION

COVID-19 is associated with an increased incidence of acute abdominal pain in children but a decreased rate of acute appendicitis. The latter tends to present at a younger age than usual. The rates of complicated appendicitis and negative appendectomy increased but were not significantly affected by the pandemic or severe acute respiratory syndrome coronavirus 2 infection status.

Single-port laparoscopic appendectomy using new surgical procedure versus conventional three-port laparoscopic appendectomy

The aim of this study was to compare the clinic outcomes between new single-port laparoscopic appendectomy (NSLA) and conventional three-port laparoscopic appendectomy (CTLA) for patients with acute appendicitis. Patients who were diagnosed with acute appendicitis and underwent appendectomy were retrospectively collected from a single clinical center from September 2021 to June 2023. Baseline characteristics, surgical information, and postoperative information were compared between the NSLA group and the CTLA group. Univariate and multivariate logistic regression analyses were used to find out the predictors of overall complications. A total of 296 patients were enrolled from a single clinical medical center. There were 146 (49.3%) males and 150 (50.7%) females. There were 54 (18.2%) patients in the NSLA group and 242 (81.8%) patients in the CTLA group. After data analysis, we found the patients in the NSLA group had a shorter postoperative hospital stay (P < 0.01) than the CTLA group. The other outcomes including intraoperative blood loss (P = 0.167), operation time (P = 0.282), nature of the appendix (P = 0.971), and overall complications (P = 0.543) were not statistically different. After univariate and multivariate logistic regression analysis, we found that age (P = 0.018, OR = 1.039, 95% CI = 1.007-1.072), neutrophil percentage (P = 0.018, OR = 1.070, 95% CI = 1.011-1.132), and fever (P = 0.019, OR = 6.112, 95% CI = 1.340-27.886) were the predictors of overall complications. However, the surgical procedure (NSLA versus CTLA) was not a predictor of overall complications (P = 0.376, OR = 1.964, 95% CI = 0.440-8.768). Compared with CTLA, there was no significant increase in postoperative overall complications with NSLA, making it a safe and feasible new surgical procedure. More studies are needed to evaluate the long-term results.

The impact of timing on outcomes in appendicectomy: a systematic review and network meta-analysis

INTRODUCTION

Appendicectomy remains the standard treatment for appendicitis. There is a lack of clarity on the timeframe in which surgery should be performed to avoid unfavourable outcomes.

AIM

To perform a systematic review and network meta-analysis to evaluate the impact the (1)time-of-day surgery is performed (2), time elapsed from symptom onset to hospital presentation (patient time) (3), time elapsed from hospital presentation to surgery (hospital time), and (4)time elapsed from symptom onset to surgery (total time) have on appendicectomy outcomes.

METHODS

A systematic review was performed as per PRISMA-NMA guidelines. The time-of-day which surgery was done was divided into day, evening and night. The other groups were divided into < 24 h, 24-48 h and > 48 h. The rate of complicated appendicitis, operative time, perforation, post-operative complications, surgical site infection (SSI), length of stay (LOS), readmission and mortality rates were analysed.

RESULTS

Sixteen studies were included with a total of 232,678 patients. The time of day at which surgery was performed had no impact on outcomes. The incidence of complicated appendicitis, post-operative complications and LOS were significantly better when the hospital time and total time were < 24 h. Readmission and mortality rates were significantly better when the hospital time was < 48 h. SSI, operative time, and the rate of perforation were comparable in all groups.

CONCLUSION

Appendicectomy within 24 h of hospital admission is associated with improved outcomes compared to patients having surgery 24-48 and > 48 h after admission. The time-of-day which surgery is performed does not impact outcomes.

Current use of artificial intelligence in the diagnosis and management of acute appendicitis

INTRODUCTION

Acute appendicitis is a common and time-sensitive surgical emergency, requiring rapid and accurate diagnosis and management to prevent complications. Artificial intelligence (AI) has emerged as a transformative tool in healthcare, offering significant potential to improve the diagnosis and management of acute appendicitis. This review provides an overview of the evolving role of AI in the diagnosis and management of acute appendicitis, highlighting its benefits, challenges, and future perspectives.

EVIDENCE ACQUISITION

We performed a literature search on articles published from 2018 to September 2023. We included only original articles.

EVIDENCE SYNTHESIS

Overall, 121 studies were examined. We included 32 studies: 23 studies addressed the diagnosis, five the differentiation between complicated and uncomplicated appendicitis, and 4 studies the management of acute appendicitis.

CONCLUSIONS

AI is poised to revolutionize the diagnosis and management of acute appendicitis by improving accuracy, speed and consistency. It could potentially reduce healthcare costs. As AI technologies continue to evolve, further research and collaboration are needed to fully realize their potential in the diagnosis and management of acute appendicitis.

Usefulness of extended inflammatory parameters related to neutrophil activation reported by Sysmex XN-1000 hematology analyzer for predicting complicated acute appendicitis. Comparison with canonical inflammatory laboratory tests

AIM

Accurate diagnosis of complicated appendicitis is of importance to ensure that patients receive early and effective treatment, minimizing the risk of postoperative complications to promote successful recovery. Biochemical markers are a promising tool to identify complicated appendicitis. We aimed to evaluate the potential role of novel parameters related with neutrophil activation, known as "Extended Inflammation Parameters" (EIP), included in blood cell count reported by Sysmex XN-Series analyzers, compared to other canonical biomarkers in identifying complicated appendicitis.

METHOD

Prospective observational study including patients with confirmed diagnosis of acute appendicitis. C-reactive protein (CRP), procalcitonin, cell blood count, including white blood cell (WBC), absolute neutrophil (ANC) and immature granulocyte (IG) count and EIP (neutrophil reactivity [NEUT-RI] and granularity intensity [NEUT-GI]) were analyzed before surgery. Their accuracy to diagnose complicated appendicitis was tested in an ROC curve analysis.

RESULTS

Our population study included 119 patients, and appendicitis was complicated in 58 (48.7%). NLR, CRP and procalcitonin levels, ANC and IG count and NEUT-RI and NEUT-GI were higher in patients with complicated appendicitis. Regarding accuracy for complicated appendicitis, CRP was the biomarker with the highest performance (ROC AUC: 0.829), with an optimal cutoff of 73.1 mg/L (sensitivity: 63.8%, specificity: 88.5%). NEUT-RI and NEUT-GI achieved both significant but poor accuracy, with ROC AUC of 0.606 and 0.637, respectively.

CONCLUSIONS

Novel laboratory tests reported by Sysmex XN-Series analyzers have poor accuracy for identifying complicated appendicitis. In this study, CRP was the biomarker with the highest performance and may be useful as predictor of the severity of acute appendicitis.

Is non-operative treatment of acute appendicitis possible: A narrative review

Introduction

Acute appendicitis (AA) represents the most frequent surgical emergency. Perforation was long considered the ultimate outcome of AA, prompting appendectomy; which remains the standard treatment. New data have clarified the role of the appendix, justifying conservative treatment. This narrative review aims to summarize the evidence regarding the non-operative treatment (NOT) of AA in adults.

Methods

The literature search was performed via the PubMed Medline database. Our criteria-based selection resulted in a total of 48 articles for review.

Results

Recent trials and meta-analyses have assessed NOT, which support primary antibiotic treatment of uncomplicated AA. Although it has a significant recurrence and failure rate, NOT does not appear to increase the risk of appendicular perforation. Moreover, NOT compared with appendectomy, seems to be associated with less morbidity, lower cost of care and preserved quality of life.

Conclusion

First-line NOT seems to be a reasonable approach for the treatment of uncomplicated CT-confirmed AA. Careful patient screening would definitely enhance the success rate.

Beyond a vestigial organ: effects of the appendix on gut microbiome and colorectal cancer

The role of appendectomy in the pathogenesis of colorectal cancer (CRC) is a recent topic of contention. Given that appendectomy remains one of the most commonly performed operations and a first-line management strategy of acute appendicitis, it is inherently crucial to elucidate the association between prior appendectomy and subsequent development of CRC, as there may be long-term health repercussions. In this review, we summarize the data behind the relationship of CRC in post-appendectomy patients, discuss the role of the microbiome in relation to appendectomy and CRC pathogenesis, and provide an appraisal of our current understanding of the function of the appendix. We seek to piece together the current landscape surrounding the microbiome and immunological changes in the colon post-appendectomy and suggest a direction for future research involving molecular, transcriptomic, and immunologic analysis to complement our current understanding of the alterations in gut microbiome.

Appendectomy versus antibiotic treatment for acute appendicitis

BACKGROUND

Acute appendicitis is one of the most common emergency general surgical conditions worldwide. Uncomplicated/simple appendicitis can be treated with appendectomy or antibiotics. Some studies have suggested possible benefits with antibiotics with reduced complications, length of hospital stay, and the number of days off work. However, surgery may improve success of treatment as antibiotic treatment is associated with recurrence and future need for surgery.

OBJECTIVES

To assess the effects of antibiotic treatment for uncomplicated/simple acute appendicitis compared with appendectomy for resolution of symptoms and complications.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trial registers (World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov) on 19 July 2022. We also searched for unpublished studies in conference proceedings together with reference checking and citation search. There were no restrictions on date, publication status, or language of publication.

SELECTION CRITERIA

We included parallel-group randomised controlled trials (RCTs) only. We included studies where most participants were adults with uncomplicated/simple appendicitis. Interventions included antibiotics (by any route) compared with appendectomy (open or laparoscopic).

DATA COLLECTION AND ANALYSIS

We used standard methodology expected by Cochrane. We used GRADE to assess the certainty of evidence for each outcome. Primary outcomes included mortality and success of treatment, and secondary outcomes included number of participants requiring appendectomy in the antibiotic group, complications, pain, length of hospital stay, sick leave, malignancy in the antibiotic group, negative appendectomy rate, and quality of life. Success of treatment definitions were heterogeneous although mainly based on resolution of symptoms rather than incorporation of long-term recurrence or need for surgery in the antibiotic group.

MAIN RESULTS

We included 13 studies in the review covering 1675 participants randomised to antibiotics and 1683 participants randomised to appendectomy. One study was unpublished. All were conducted in secondary care and two studies received pharmaceutical funding. All studies used broad-spectrum antibiotic regimens expected to cover gastrointestinal bacteria. Most studies used predominantly laparoscopic surgery, but some included mainly open procedures. Six studies included adults and children. Almost all studies aimed to exclude participants with complicated appendicitis prior to randomisation, although one study included 12% with perforation. The diagnostic technique was clinical assessment and imaging in most studies. Only one study limited inclusion by sex (male only). Follow-up ranged from hospital admission only to seven years. Certainty of evidence was mainly affected by risk of bias (due to lack of blinding and loss to follow-up) and imprecision. Primary outcomes It is uncertain whether there was any difference in mortality due to the very low-certainty evidence (Peto odds ratio (OR) 0.51, 95% confidence interval (CI) 0.05 to 4.95; 1 study, 492 participants). There may be 76 more people per 1000 having unsuccessful treatment in the antibiotic group compared with surgery, which did not reach our predefined level for clinical significance (risk ratio (RR) 0.91, 95% CI 0.87 to 0.96; I2 = 69%; 7 studies, 2471 participants; low-certainty evidence). Secondary outcomes At one year, 30.7% (95% CI 24.0 to 37.8; I2 = 80%; 9 studies, 1396 participants) of participants in the antibiotic group required appendectomy or, alternatively, more than two-thirds of antibiotic-treated participants avoided surgery in the first year, but the evidence is very uncertain. Regarding complications, it is uncertain whether there is any difference in episodes of Clostridium difficile diarrhoea due to very low-certainty evidence (Peto OR 0.97, 95% CI 0.24 to 3.89; 1 study, 1332 participants). There may be a clinically significant reduction in wound infections with antibiotics (RR 0.25, 95% CI 0.09 to 0.68; I2 = 16%; 9 studies, 2606 participants; low-certainty evidence). It is uncertain whether antibiotics affect the incidence of intra-abdominal abscess or collection (RR 1.58, 95% CI 0.61 to 4.07; I2 = 19%; 6 studies, 1831 participants), or reoperation (Peto OR 0.13, 95% CI 0.01 to 2.16; 1 study, 492 participants) due to very low-certainty evidence, mainly due to rare events causing imprecision and risk of bias. It is uncertain if antibiotics prolonged length of hospital stay by half a day due to the very low-certainty evidence (MD 0.54, 95% CI 0.06 to 1.01; I2 = 97%; 11 studies, 3192 participants). The incidence of malignancy was 0.3% (95% CI 0 to 1.5; 5 studies, 403 participants) in the antibiotic group although follow-up was variable. Antibiotics probably increased the number of negative appendectomies at surgery (RR 3.16, 95% CI 1.54 to 6.49; I2 = 17%; 5 studies, 707 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Antibiotics may be associated with higher rates of unsuccessful treatment for 76 per 1000 people, although differences may not be clinically significant. It is uncertain if antibiotics increase length of hospital stay by half a day. Antibiotics may reduce wound infections. A third of the participants initially treated with antibiotics required subsequent appendectomy or two-thirds avoided surgery within one year, but the evidence is very uncertain. There were too few data from the included studies to comment on major complications.

Retrospective analysis of the incidence of appendiceal neoplasm and malignancy in patients treated for suspected acute appendicitis

BACKGROUND

Nonoperative management of uncomplicated appendicitis is currently being promoted as treatment option, albeit 0.7-2.5% of appendectomies performed due to suspected acute appendicitis show histologically malignant findings. The purpose of this study was to investigate the incidence of neoplasm and malignancy of the appendix in patients presenting with suspected acute appendicitis in real world setting.

METHODS

This is a retrospective single-centre investigation of 457 patients undergoing appendectomy between the years 2017-2020. The patients' demographics, symptoms and diagnosis, intraoperative findings, and histopathological results were analysed.

RESULTS

In 3.7% (n = 17) histological analysis revealed neoplasms or malignancies. Median age was 48 years (20-90 years), without sex predominance. Leukocytes (11.3 ± 3.7 G/l) and C-reactive protein (54.2 ± 69.0 mg/l) were elevated. Histological analysis revealed low-grade mucinous appendiceal neoplasia (n = 3), sessile serrated adenoma of the appendix (n = 3), neuroendocrine tumours (n = 7), appendiceal adenocarcinoma of intestinal type (n = 3), and goblet cell carcinoma (n = 1). Additional treatment varied between no treatment or follow-up due to early tumour stage (n = 4), follow-up care (n = 3), additional surgical treatment (n = 8), or best supportive care (n = 2).

CONCLUSIONS

Preoperative diagnosis of appendiceal tumours is difficult. Nonoperative management of patients with acute, uncomplicated appendicitis potentially prevents the correct diagnosis of malignant appendiceal pathologies. Therefore, close follow-up or surgical removal of the appendix is mandatory.

Impact of COVID-19 on acute appendicitis presentation, management and pathology findings in adult and paediatric populations

BACKGROUND

We investigated the impact of the COVID-19 pandemic on trends of presentation, management and pathology findings in patients who underwent an appendicectomy for suspected acute appendicitis.

METHOD

The retrospective study reviewed patients (n = 939 adults and n = 329 children) who had an appendicectomy performed for suspected acute appendicitis and histopathology assessment in the Belfast Health and Social Care Trust, Northern Ireland. Pre-COVID-19 (March 2019 to February 2020) and COVID-19 Year 1 (March 2020 to February 2021) data were compared. Chi-squared tests were applied to compare timeframes.

RESULTS

513 adult appendicectomies were performed in the immediate year pre-COVID-19, compared to 426 in COVID-19 Year 1, representing a 17% reduction. No such reduction was seen within the paediatric population, likely related to a change in regional paediatric referral criteria during the pandemic. When comparing COVID-19 Year 1 with pre-pandemic, fewer patients presented with <24 hours of symptoms (45% v 53%, p = 0.005), and there was greater use of pre-operative computed tomography imaging in adults (63.2% v 48.7%, p<0.001). Fewer adult and paediatric cases of simple acute appendicitis and non-diagnostic specimens, with relative increased proportions of perforated acute appendicitis, were observed in COVID-19 Year 1 compared with pre-pandemic. No absolute increase in perforated acute appendicitis cases was observed in adults.

CONCLUSION

Year 1 of the COVID-19 pandemic was associated with delayed presentation of acute appendicitis in adults and children. In adults, an overall reduction in appendicectomy operations, increased use of pre-operative diagnostic imaging, and fewer specimens showing simple acute appendicitis or non-diagnostic features, collectively support appropriate restriction of surgery for those patients with a more certain acute appendicitis diagnosis.

Nonoperative Treatment of Diverticulitis and Appendicitis: Which Antibiotic Regimen Fails?

INTRODUCTION

Diverticulitis and appendicitis are common emergency general surgical conditions. Both can be treated with antibiotics alone; however, no antibiotic regimen has been identified as superior to others. In this study, we review different antibiotic regimens and their rates of failure.

METHODS

Retrospective cohort study of patients treated empirically with antibiotics for diverticulitis or appendicitis from January 1, 2018, to December 31, 2020, at an independent academic hospital in the Midwest.

RESULTS

A total of 587 (appendicitis, n = 43; diverticulitis, n = 544) patients were included in the cohort. They were equally male (49%) and female (51%) with a median age of 59 y. Three major antibiotic classes were compared: cephalosporin + metronidazole (C + M), penicillins, and quinolone + metronidazole. Appendicitis patients were more likely to receive C + M for empiric treatment (73%, P < 0.001), while diverticulitis patients were more likely to receive quinolone + metronidazole (45%, P < 0.001). Patients empirically treated with antibiotics for appendicitis were more likely than those treated for diverticulitis to require additional antibiotics or procedure within 90 d (33% versus 13%, respectively; P = 0.005). Empiric treatment with C + M for diverticulitis was more likely to be associated with the need for additional antibiotics or procedures within 90 d than treatment with other regimens (P = 0.003). Choice of antibiotic for empiric treatment did not correlate with death at 90 d for appendicitis or diverticulitis. Diverticulitis patients who were initially treated as inpatients and were prescribed C + M at hospital discharge had a higher rate of death than those who were prescribed the other antibiotics (P = 0.04).

CONCLUSIONS

Empiric antibiotic treatment of appendicitis is more likely to be associated with additional antibiotics or procedure when compared with diverticulitis; however, antibiotic choice did not correlate with any of the other outcomes. Empiric treatment with a C + M for diverticulitis was more likely to be correlated with the need for additional antibiotics or procedure within 90 d.

Misdiagnosis of Acute Appendicitis Cases in the Emergency Room

Acute appendicitis (AA) is one of the most frequent surgical emergencies, especially in pediatric populations, with its misdiagnosis in emergency settings presenting significant health risks. This misdiagnosis leads to various complications, such as delayed treatment or unnecessary surgeries. Factors such as age, gender, and comorbidities contribute to diagnostic errors, leading to complications such as peritonitis and increased negative appendectomy rates. This underscores the importance of accurate clinical assessment and awareness of common pitfalls, such as cognitive biases and over-reliance on laboratory tests. This review delves into the prevalence of AA misdiagnosis, its health burden, and the challenges inherent in the diagnostic process. It scrutinizes the effectiveness of different diagnostic approaches, including clinical assessment and imaging techniques. The treatment paradigms for AA are also explored, focusing on surgical interventions and the potential of conservative treatments using antibiotics. The review underscores the criticality of precise diagnosis in preventing adverse outcomes and ensuring effective treatment.

Impact of preoperative factors and waiting time on post-appendectomy complications: a retrospective study

BACKGROUND

Several factors are associated with increased postoperative complications after appendectomies. However, few studies combined these potential factors for comprehensive prediction of surgical outcomes. Whether high-risk patients benefit from a shorter waiting time for surgery remains unclear. This study aimed to explore the impact of surgical waiting time and potential risk factors on postoperative complications.

METHODS

A total of 1343 patients diagnosed with acute appendicitis requiring an emergent appendectomy were included from 2013 to 2018. The preoperative risk factors associated with postoperative complications were selected and the probability of postoperative complications was calculated by multivariate logistic regression model. Patients were divided into four groups based on the risk (high & low) and time to surgery (> 12 & ≤12 hours). The odds ratios for complications were evaluated between groups.

RESULTS

The selected risk factors included age, neutrophil-lymphocyte ratio, systemic inflammatory response syndrome and abdominal pain duration. Compared with low-risk patients with time to surgery ≤12 hours, high-risk patients with time to surgery > 12 hours had significant increased overall postoperative complication rate (16.85% vs. 8.16%, p = 0.002) and a trend toward increased surgical site infection rate (10.99% vs. 6.46%, p = 0.058). When operated within 12 hours, there was no difference in outcomes between high- and low-risk patients. On the other hand, time to surgery > 12 hours did not increase complication rate in low-risk patients.

CONCLUSIONS

The surgical outcome may be affected by preoperative factors and time to surgery. It is suggested that high-risk patients receive appendectomy within 12 hours to avoid increased postoperative complications.

A meta-analysis and trial sequential analysis comparing nonoperative versus operative management for uncomplicated appendicitis: a focus on randomized controlled trials

BACKGROUND

The aim of this study is to provide a meta-analysis of randomized controlled trials (RCT) comparing conservative and surgical treatment in a population of adults with uncomplicated acute appendicitis.

METHODS

A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL. We have exclusively incorporated randomized controlled trials (RCTs). Studies involving participants with complicated appendicitis or children were excluded. The variables considered are as follows: treatment complications, complication-free treatment success at index admission and at 1 year follow-up, length of hospital stay (LOS), quality of life (QoL) and costs.

RESULTS

Eight RCTs involving 3213 participants (1615 antibiotics/1598 appendectomy) were included. There was no significant difference between the two treatments in terms of complication rates (RR = 0.66; 95% CI 0.61-1.04, P = 0.07, I2 = 69%). Antibiotics had a reduced treatment efficacy compared with appendectomy (RR = 0.80; 95% CI 0.71 to 0.90, p < 0.00001, I2 = 87%) and at 1 year was successful in 540 out of 837 (64.6%, RR = 0.69, 95% confidence interval 0.61 to 0.77, p < 0.00001, I2 = 81%) participants. There was no difference in LOS (mean difference - 0.58 days 95% confidence interval - 1.59 to 0.43, p = 0.26, I2 = 99%). The trial sequential analysis has revealed that, concerning the three primary outcomes, it is improbable that forthcoming RCTs will significantly alter the existing body of evidence.

CONCLUSIONS

As further large-scale trials have been conducted, antibiotic therapy proved to be safe, less expensive, but also less effective than surgical treatment. In order to ensure well-informed decisions, further research is needed to explore patient preferences and quality of life outcomes.

[Acute appendicitis in adults]

Acute appendicitis in adults. Clinical guidelines.

Conservative Versus Surgical Management of Acute Appendicitis: A Systematic Review

Recent studies have discussed the role of antibiotic treatment in the conservative management of acute appendicitis and whether antibiotics are a safe option to replace appendicectomy, which has been the gold standard treatment of acute appendicitis for many years. The bibliographic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, Medline, and PubMed comparing conservative versus surgical treatment of acute appendicitis were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty-one studies consisting of systematic reviews and meta-analyses involving 44,699 participants were identified. At least 17,865 participants were treated with antibiotics. Our studies compare antibiotic versus appendicectomy among acute appendicitis patients ranging from 7 to 94 years of age. In most studies, patients received parenteral antibiotics for a total of one to three days, and oral antibiotics such as oral cephalosporin plus metronidazole, oral amoxicillin/clavulanate, oral fluoroquinolones plus Tinidazole upon hospital discharge for a total of 7 to 10 days. The total course of antibiotics for both parenteral and oral regimes ranged from 2 to 16 days, with 10 days being the commonest duration. The recurrence rate following initial antibiotic treatment at one-year follow-up ranged from 13% to 38%, while the mean duration of recurrence ranged from three to eight months. The majority of the patients with recurrence underwent appendicectomy, while some patients were either given a repeat or different course of antibiotics due to the possible presence of antibiotic resistance; however, only 2.4% of the patients were successfully treated upon completion of the second course of antibiotics. Most of the studies concluded that appendicectomy remains the gold standard treatment for uncomplicated acute appendicitis, given its higher efficacy and lower complication rates. Although antibiotic treatment cannot be routinely recommended, it can be considered an appropriate alternative in selected patients with uncomplicated appendicitis who wish to avoid surgery and also acknowledge the risk of recurrence and the potential need for subsequent surgery at the same time.

Causal effects of gut microbiota on appendicitis: a two-sample Mendelian randomization study

Background

Previous research has posited a potential correlation between the gut microbiota and the onset of appendicitis; however, the precise causal connection between appendicitis and the gut microbiota remains an unresolved and contentious issue.

Methods

In this investigation, we performed a Mendelian randomization (MR) analysis employing publicly accessible summary data extracted from genome-wide association studies (GWAS) to elucidate the potential causal nexus between the gut microbiota and the development of appendicitis. We initially identified instrumental variables (IVs) through a comprehensive array of screening methodologies, subsequently executing MR analyses using the Inverse Variance Weighted (IVW) technique as our primary approach, supplemented by several alternative methods such as MR Egger, weighted median, simple mode, and weighted mode. Additionally, we implemented a series of sensitivity analysis procedures, encompassing Cochran's Q test, MR-Egger intercept test, Mendelian Randomized Polymorphism Residual and Outlier (MR-PRESSO) test, and a leave-one-out test, to affirm the robustness and validity of our findings.

Results

Our investigation indicates that an elevated prevalence of Deltaproteobacteria, Christensenellaceae, Desulfovibrionaceae, Eubacterium ruminantium group, Lachnospiraceae NK4A136 group, Methanobrevibacter, Desulfovibrionales, and Euryarchaeota is inversely associated with the risk of appendicitis. Conversely, we observed a positive correlation between an increased abundance of Family XIII, Howardella, and Veillonella and the susceptibility to appendicitis. Sensitivity analyses have corroborated the robustness of these findings, and Mendelian randomization analyses provided no indications of reverse causality.

Conclusion

Our Mendelian randomization (MR) analysis has unveiled potential advantageous or detrimental causal associations between the gut microbiota and the occurrence of appendicitis. This study offers novel theoretical and empirical insights into the understanding of appendicitis pathogenesis, along with its implications for preventive and therapeutic strategies.

Outcomes in COVID-19 patients undergoing laparoscopic cholecystectomy/appendectomy in the pre-vaccine era

Background

We hypothesized that COVID-19 positive patients requiring laparoscopic cholecystectomy (lap chole) or appendectomy (lap appy) would have increased inpatient mortality rates compared to all COVID-19 patients.

Methods

Retrospective cohort analysis including COVID-19 patients from 1/1/20 to 9/30/20. 82,574 cases identified. Patients excluded if <18 years old or underwent surgery other than lap chole or lap appy. Control groups were patients without surgery (N = 82,145). Exposure groups underwent lap chole (N = 323) or lap appy (N = 106). Primary outcome was inpatient mortality. Secondary outcomes included hospital length of stay (LOS) and complications such as bacterial pneumonia, deep venous thrombosis (DVT), pulmonary embolism (PE), urinary tract infection (UTI), acute myocardial infarction (MI), acute respiratory distress syndrome (ARDS), and respiratory failure (RF).

Results

Overall inpatient mortality rate was 32.8% in COVID-19 patients undergoing lap chole (p-value <0.0001), 2.8 % lap appy (p-value 0.93), and 1.2 % in control group. ARDS complication rate was 11.2 % in lap chole (p-value <0.0001), 1.9 % lap appy (p-value 0.71), and 0.2 % in control.

Conclusion

COVID-19 patients during the initial wave of the pandemic who underwent lap chole during hospital admission had significantly higher risk of mortality and ARDS while lap appy did not.

Endoscopic retrograde appendicitis therapy versus appendectomy or antibiotics in the modern approach to uncomplicated acute appendicitis: A systematic review and meta-analysis

INTRODUCTION

Endoscopic retrograde appendicitis therapy has been proposed as an alternative strategy for treating appendicitis, but debate exists on its role compared with conventional treatment.

METHODS

This systematic review was performed on MEDLINE, Cochrane Central Register of Controlled Trials, and EMBASE. The last search was in April of 2023. The risk ratio with a 95% confidence interval was calculated for dichotomous variables, and the mean difference with a 95% confidence interval for continuous variables. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool (randomized controlled trials) and the Risk of Bias in Non-Randomized Studies of Intervention tool (non-randomized controlled trials).

RESULTS

Six studies met the eligibility criteria. Four studies compared endoscopic retrograde appendicitis therapy (n = 236 patients) and appendectomy (n = 339) and found no differences in technical success during index admission (risk ratio 0.97, 95% confidence interval [0.92,1.02]). Appendectomy showed superior outcomes for recurrence at 1-year follow-up (risk ratio 11.28, 95% confidence interval [2.61,48.73]). Endoscopic retrograde appendicitis therapy required shorter procedural time (mean difference -14.38, 95% confidence interval [-20.17, -8.59]) and length of hospital stay (mean difference -1.19, 95% confidence interval [-2.37, -0.01]), with lower post-intervention abdominal pain (risk ratio 0.21, 95% confidence interval [0.14,0.32]). Two studies compared endoscopic retrograde appendicitis therapy (n = 269) and antibiotic treatment (n = 280). Technical success during admission (risk ratio 1.11, 95% confidence interval [0.91,1.35]) and appendicitis recurrence (risk ratio 1.07, 95% confidence interval [0.08,14.87]) did not differ, but endoscopic retrograde appendicitis therapy decreased the length of hospitalization (mean difference -1.91, 95% confidence interval [-3.18, -0.64]).

CONCLUSION

This meta-analysis did not identify significant differences between endoscopic retrograde appendicitis therapy and appendectomy or antibiotics regarding technical success during index admission and treatment efficacy at 1-year follow-up. However, a high risk of imprecision limits these results. The advantages of endoscopic retrograde appendicitis therapy in terms of reduced procedural times and shorter lengths of stay must be balanced against the increased risk of having an appendicitis recurrence at one year.

Clinical efficacy and safety of endoscopic retrograde appendicitis treatment for acute appendicitis: A systematic review and meta-analysis

OBJECTIVES

To assess the efficacy and safety of endoscopic retrograde appendicitis treatment (ERAT) for acute appendicitis (AA) by conducting a meta-analysis of clinical randomized trials (RCTs).

METHODS

Eight electronic databases were searched. Study quality was assessed using the Cochrane risk of bias tool. RevMan5.3 and STATA14 software were used to for statistical analysis.

RESULTS

Twenty-six RCTs with 2236 subjects were analyzed. First, operative time, length of hospital stay and duration of bed rest were shorter in the ERAT groups than in the control groups, with the pooled MD and 95 % CI being -13.22(-20.09, -6.35)(p = 0.0002), -2.13 (-2.47, -1.80)(p < 0.00001) and -3.15 (-3.76, -2.53)(p < 0.00001), respectively. Second, patients in the ERAT groups had a lower incidence of complications than the control groups, with a pooled RR and 95 % CI of 0.25(0.18, 0.35)(p < 0.00001). Third, patients who received ERAT returned to normal temperature faster than the control groups, the pooled MD and 95 % CI was -3.39(-4.36, -2.42)(p<0.00001). Finally, the result showed that the recurrence rate in the ERAT groups was approximately twice that of control groups, with the pooled RR and 95 % CI being 2.10(1.02, 4.32)(p < 0.00001).

CONCLUSIONS

ERAT results in fewer complications and shorter recovery time. And compared to appendectomy, ERAT reduces operative time and intraoperative bleeding. However, the recurrence of acute appendicitis after ERAT remains a concern. And more multicenter and large-scale RCTs are needed to confirm the benefits of ERAT.

SYSTEMATIC REVIEW REGISTRATION

We have registered on the PROSPERO [https://www.crd.york.ac.uk/PROSPERO/], and the registration number is CRD42023420171.

Incidence of occult appendiceal neoplasm in patients over 40 years with acute appendicitis: A single-institution review

OBJECTIVE

To investigate the incidence of occult appendiceal neoplasm in patients aged 40 years and over who underwent appendicectomy for appendicitis.

METHODS

The clinical coding electronic database was used to identify patients aged 40 years and over who were diagnosed with appendicitis from September 2010 to September 2022. Patients were included if they were managed operatively.

DESIGN

Retrospective cohort study.

SETTING

Modified Monash category 3 (large rural town).

PARTICIPANTS

Patients aged 40 years and over undergoing appendicectomy for appendicitis.

MAIN OUTCOME MEASURES

Incidence of appendiceal neoplasm within appendicectomy specimen.

RESULTS

A total of 279 patients aged 40 years and over underwent appendicectomy, with a median age of 53 years (range 40-95). Nineteen patients (7%) were found to have a primary neoplastic lesion within the appendix: seven neuroendocrine neoplasms (37%), six sessile serrated lesions (32%), two colonic-type adenocarcinoma (11%), two goblet cell adenocarcinoma (11%) and two appendiceal mucinous neoplasms (11%). Additionally, one patient had a metastatic adenocarcinoma of pancreaticobiliary aetiology.

CONCLUSIONS

Occult appendiceal neoplasm was higher than reported in the literature in our cohort. This would support appendicectomy as the treatment of choice for patients aged 40 years and over with acute appendicitis and caution against nonoperative management in this demographic.

Preoperative scoring system for prediction of extended resection during emergency surgery for acute appendicitis

PURPOSE

Appendicectomy is the primary treatment for acute appendicitis. However, extended resection (ER) may be required in difficult cases. Preoperative prediction of ER may identify challenging cases but remains difficult. We aimed to establish a preoperative scoring system for ER prediction during emergency surgery for acute appendicitis.

METHODS

This was a single-center retrospective study. Patients who underwent emergency surgery for acute appendicitis between January 2014 and December 2022 were included and divided into ER and appendicectomy groups. Independent variables associated with ER were identified using multivariate logistic regression analysis. A new scoring system was established based on these independent variables. The discrimination of the new scoring system was assessed using the area under the receiver operating characteristic curve (AUC). The risk categorization of the scoring system was also analyzed.

RESULTS

Of the 179 patients in this study, 12 (6.7%) underwent ER. The time interval from symptom onset to surgery ≥ 4 days, a retrocecal or retrocolic appendix, and the presence of an abscess were identified as independent preoperative predictive factors for ER. The new scoring system was established based on these three variables, and the scores ranged from 0 to 6. The AUC of the scoring system was 0.877, and the rates of ER among patients in the low- (score, 0-2), medium- (score, 4), and high- (score, 6) risk groups were estimated to be 2.5%, 28.6%, and 80%, respectively.

CONCLUSION

Our scoring system may help surgeons identify patients with acute appendicitis requiring ER and facilitate decision-making regarding treatment options.

Higher Rates of Complicated Appendicitis During the COVID-19 Pandemic: A Year-to-Year Analysis

INTRODUCTION

The COVID-19 pandemic impacted presentation, management strategies, and patient outcomes of numerous medical conditions. The aim of this study is to perform a year-to-year comparison of clinical outcomes of patients with acute appendicitis (AA) before and during the pandemic.

METHODS

Patients treated for AA during the initial 12-mo period of the pandemic at our institute were compared to those treated for AA during the 12-mo period before. Clinical and laboratory parameters, treatment strategies, intraoperative findings, pathology reports, and postoperative outcomes were compared.

RESULTS

During the study period, 541 patients presented with AA. The median (interquartile range) age was 28 (21-40) y and 292 (54%) were males. 262 (48%) patients presented during the pre-COVID-19 period, while 279 patients (52%) presented during the COVID 19 pandemic. The groups were comparable for baseline clinical data and imaging results upon index admission. There was no significant difference in rate of nonoperative treatment between the Pre-COVID-19 and During-COVID-19 eras (51% versus 53%, P = 0.6) as well as the success rate of such treatment (95.4% versus 96.4%, P = 0.3). Significantly more patients presented with a periappendicular abscess during COVID-19 (4.6% versus 1.1%, P = 0.01) and median (interquartile range) operative time was significantly longer (78 (61-90) versus 32.5 (27-45) min, P < 0.001). Pathology reports revealed a higher rate of perforated appendicitis during COVID-19 (27.4% versus 10.2%, P < 0.001).

CONCLUSIONS

Patients with AA present with higher rates of perforated and complicated appendicitis during the COVID-19 pandemic. The success rates of nonoperative management in selected patients with noncomplicated AA did not change during the pandemic and is a safe, feasible, option.

Outpatient Non-operative Management of Uncomplicated Acute Appendicitis: A Non-inferiority Study

INTRODUCTION

Non-operative management (NOM) of uncomplicated acute appendicitis is a well-established alternative to upfront surgery. The administration of intravenous broad-spectrum antibiotics is usually performed in hospital, and only one study described outpatient NOM. The aim of this multicentre retrospective non-inferiority study was to evaluate both safety and non-inferiority of outpatient compared to inpatient NOM in uncomplicated acute appendicitis.

METHODS

The study included 668 consecutive patients with uncomplicated acute appendicitis. Patients were treated according to the surgeon's preference: 364 upfront appendectomy, 157 inpatient NOM (inNOM), and 147 outpatient NOM (outNOM). The primary endpoint was the 30-day appendectomy rate, with a non-inferiority limit of 5%. Secondary endpoints were negative appendectomy rate, 30-day unplanned emergency department (ED) visits, and length of stay.

RESULTS

30-day appendectomies were 16 (10.9%) in the outNOM group and 23 (14.6%) in the inNOM group (p = 0.327). OutNOM was non-inferior to inNOM with a risk difference of-3.80% 97.5% CI (- 12.57; 4.97). No difference was found between inNOM and outNOM groups for the number of complicated appendicitis (3 vs. 5) and negative appendectomy (1 vs. 0). Twenty-six (17.7%) outNOM patients required an unplanned ED visit after a median of 1 (1-4) days. In the outNOM group, the mean cumulative in-hospital stay was 0.89 (1.94) days compared with 3.94 (2.17) days in the inNOM group (p < 0.001).

CONCLUSIONS

Outpatient NOM was non-inferior to inpatient NOM with regard to the 30-day appendectomy rate, while a shorter hospital stay was found in the outNOM group. Further, studies are required to confirm these findings.

The appendix and ulcerative colitis - an unsolved connection

The appendix is thought to have a role in the pathogenesis of ulcerative colitis, but the nature and basis of this association remains unclear. In this Perspective, we consider the biology of the appendix with respect to its immunological function and the microbiome, and how this relates to evidence that supports the involvement of the appendix in ulcerative colitis. In experimental models, removal of the inflamed appendix prevents colitis, and in human observational studies, appendectomy is associated with protection against ulcerative colitis. Further, among people who develop ulcerative colitis, appendectomy before diagnosis might influence the course and outcomes of the disease - some evidence suggests that it protects against colectomy but could increase the risk of colorectal cancer. Appendectomy after onset of ulcerative colitis seems to have disparate consequences. Clinical trials to understand whether appendectomy has a role in the treatment of ulcerative colitis are ongoing. Major questions about the role of the appendix in the pathogenesis of ulcerative colitis remain unanswered, and further research is needed to establish whether the connection is clinically relevant.

Appendicitis in Children

The management of pediatric appendicitis continues to advance with the development of evidence-based treatment algorithms and a recent shift toward patient-centered treatment approaches. Further research should focus on development of standardized institution-specific diagnostic algorithms to minimize rates of missed diagnosis and appendiceal perforation and refinement of evidence-based clinical treatment pathways that reduce complication rates and minimize health care resource utilization.

Machine Learning for Decision-Support in Acute Abdominal Pain - Proof of Concept and Central Considerations

Acute abdominal pain is a common presenting symptom in the emergency department and represents heterogeneous causes and diagnoses. There is often a decision to be made regarding emergency surgical care. Machine learning (ML) could be used here as a decision-support and relieve the time and personnel resource shortage.Patients with acute abdominal pain presenting to the Department of Surgery at Bonn University Hospital in 2020 and 2021 were retrospectively analyzed. Clinical parameters as well as laboratory values were used as predictors. After randomly splitting into a training and test data set (ratio 80 to 20), three ML algorithms were comparatively trained and validated. The entire procedure was repeated 20 times.A total of 1357 patients were identified and included in the analysis, with one in five (n = 276, 20.3%) requiring emergency abdominal surgery within 24 hours. Patients operated on were more likely to be male (p = 0.026), older (p = 0.006), had more gastrointestinal symptoms (nausea: p < 0.001, vomiting p < 0.001) as well as a more recent onset of pain (p < 0.001). Tenderness (p < 0.001) and guarding (p < 0.001) were more common in surgically treated patients and blood analyses showed increased inflammation levels (white blood cell count: p < 0.001, CRP: p < 0.001) and onset of organ dysfunction (creatinine: p < 0.014, quick p < 0.001). Of the three trained algorithms, the tree-based methods (h2o random forest and cforest) showed the best performance. The algorithms classified patients, i.e., predicted surgery, with a median AUC ROC of 0.81 and 0.79 and AUC PRC of 0.56 in test sets.A proof-of-concept was achieved with the development of an ML model for predicting timely surgical therapy for acute abdomen. The ML algorithm can be a valuable tool in decision-making. Especially in the context of heavily used medical resources, the algorithm can help to use these scarce resources more effectively. Technological progress, especially regarding artificial intelligence, increasingly enables evidence-based approaches in surgery but requires a strictly interdisciplinary approach. In the future, the use and handling of ML should be integrated into surgical training.

The Vermiform Appendix and Its Pathologies

The vermiform appendix is a muscular cylindrical structure originating near the junction of the cecum and ileum, averaging 9 cm (5-35 cm) in size. As the most mobile viscera, it can adopt several positions, the most common being the retrocecal position. Perceived as an atavistic organ lacking physiological relevance, the vermiform appendix appears to be involved in immune function, serving in the maturation of B lymphocytes and the production of immunoglobulin A, in endocrine function, excreting amines and hormones in the 2-3 mL of mucus secreted daily, and in digestive function, by storing beneficial bacteria from where they can recolonize the colon. With a lumen of about 6 mm, the vermiform appendix has a reduced storage capacity, so any blockage of the appendix with fecoliths (fecaliths), seeds derailed from the colon, or enlarged lymph nodes prevents drainage and intraluminal accumulation of secreted mucus. Unable to relax, the appendix wall severely limits its intraluminal volume, so mucus accumulation leads to inflammation of the appendix, known generically as appendicitis. In addition, the vermiform appendix may be the site of the development of neoplastic processes, which may or may not involve mucus production, some of which can significantly affect the standard of living and ultimately lead to death. In general, mucinous tumors may have a better prognosis than non-mucinous tumors. This review takes a comprehensive path, starting by describing the anatomy and embryology of the vermiform appendix and further detailing its inflammatory pathologies, pathologies related to congenital anomalies, and appendix tumors, thus creating an up-to-date framework for better understanding, diagnosis, and treatment of these health problems.