Superior outcomes (but at higher costs) of non-operative management with interval appendectomy over immediate surgery in appendicitis with abscess: Results from a large adult population cohort

Effect of Plastic Bag Extraction in Minimally Invasive Appendectomy

BACKGROUND

Evidence regarding the effects of plastic bag use for appendix removal during minimally invasive appendectomy remains scarce and conflicting.

OBJECTIVE

This study aimed to analyze the effects of plastic bag use during minimally invasive appendectomy on preoperative infection risk, morbidity and mortality.

DESIGN

This retrospective analysis of the prospective National Surgical Quality Improvement Program (NSQIP) cohort program.

SETTING

This study included data from the NSQIP database between the years of 2016 and 2019.

PATIENT

Adult patients undergoing minimally invasive (laparoscopic or robotic) without unplanned conversion to open surgery.

INTERVENTION

Use of plastic bag for specimen removal during appendectomy.

MAIN OUTCOME MEASURES

Risk ratios for the incidence of superficial surgical site infection, intra-abdominal abscess, overall medical morbidity, and overall mortality.

RESULTS

There were 43 783 cases of minimally invasive appendectomy in the NSQIP database between the years of 2016 and 2019. Among those who reported information regarding use of plastic bag, 28 589 (91.87%) reported use of plastic bag for specimen removal. Use of plastic bag was associated with a significant decrease in superficial surgical site infection (RR .39 (95% CI: .31-.49), P < .001), and in the risk of postoperative intra-abdominal abscess (RR: 0.66 (.57-.77), P < .001)). We also observed a robust reduction in overall medical-related morbidity and overall mortality, even after adjusting for multiple confounders.

LIMITATIONS

Observational nature of the study cannot exclude residual bias. Also, there was a significant rate of missing values for plastic bag use, which may bias results.

CONCLUSIONS

In this global prospective cohort using NSQIP database, use of plastic bag for appendix removal during minimally invasive appendectomy was associated with a significant improvement in surgical related outcomes and reduction in morbidity and overall mortality.

Development of a scoring model based on objective factors to predict gangrenous/perforated appendicitis

BACKGROUND

The mortality rate of gangrenous/perforated appendicitis is higher than that of uncomplicated appendicitis. However, non-operative management of such patients is ineffective. This necessitates their careful exam at presentation to identify gangrenous/perforated appendicitis and aid surgical decision-making. Therefore, this study aimed to develop a new scoring model based on objective findings to predict gangrenous/perforated appendicitis in adults.

METHODS

We retrospectively analyzed 151 patients with acute appendicitis who underwent emergency surgery between January 2014 and June 2021. We performed univariate and multivariate analyses to identify independent objective predictors of gangrenous/perforated appendicitis, and a new scoring model was developed based on logistic regression coefficients for independent predictors. Receiver operating characteristic (ROC) curve analysis and the Hosmer-Lemeshow test were performed to assess the discrimination and calibration of the model. Finally, the scores were classified into three categories based on the probability of gangrenous/perforated appendicitis.

RESULTS

Among the 151 patients, 85 and 66 patients were diagnosed with gangrenous/perforated appendicitis and uncomplicated appendicitis, respectively. Using the multivariate analysis, C-reactive protein level, maximal outer diameter of the appendix, and presence of appendiceal fecalith were identified as independent predictors for developing gangrenous/perforated appendicitis. Our novel scoring model was developed based on three independent predictors and ranged from 0 to 3. The area under the ROC curve was 0.792 (95% confidence interval, 0.721-0.863), and the Hosmer-Lemeshow test showed a good calibration of the novel scoring model (P = 0.716). Three risk categories were classified: low, moderate, and high risk with probabilities of 30.9%, 63.8%, and 94.4%, respectively.

CONCLUSIONS

Our scoring model can objectively and reproducibly identify gangrenous/perforated appendicitis with good diagnostic accuracy and help in determining the degree of urgency and in making decisions about appendicitis management.

Delayed Operative Management in Complicated Acute Appendicitis-Is Avoiding Extended Resection Worth the Wait ? Results from a Global Cohort Study

BACKGROUND

The optimal management of complicated acute appendicitis remains undefined. According to current guidelines, a trial of non-operative management with delayed appendectomy may be associated with better outcomes for patients, including a reduced rate of extended resection appendectomy.

METHODS

We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement program to analyze the outcomes of hemodynamically stable patients presenting with complicated (abscess, perforation, or both) appendicitis submitted to early (less than 24 h) or delayed (24 h or more) operative management.

RESULTS

Delayed operative management was associated with a significant reduction of the rate of extended resection appendectomy (RR: 2.15, 95% CI: 1.59 - 2.81, p < 0.001). Delayed operative management was associated with a non-significant trend towards reduced mortality (RR: 2.17; 95% CI: 0.98-2.85, p = 0.05). Delayed operative management was also associated with a significant decrease in total operative time and a significant reduction in the rate of postoperative abscess. There was no association between delayed intervention and medical related morbidity (RR: 1.01; 95% CI 0.91-1.11, p 0.811). However, delayed operative management was associated with a significant increase in total length of stay (coefficient 1.10; 95% CI: 1.02 to 1.18, p < 0.001).

CONCLUSION

Delayed operative management may be associated with a reduction in the need of extended resection appendectomy, shorter operative time, and a trend towards reduced mortality. On the other hand, it may also be associated with an increased length of in-hospital stay and short-term morbidity.

The feasibility of interval laparoscopic appendectomy and appropriate patient selection: A retrospective study of adult appendiceal masses

INTRODUCTION

We examined the safety and effectiveness of interval laparoscopic appendectomy (ILA) for adult appendiceal mass (AAM) and then used a novel white blood cell (WBC) parameter to identify the types of AAM cases for which nonsurgical treatment followed by ILA is effective.

METHODS

We reviewed the cases of 956 patients who had undergone appendectomy between April 2012 and March 2018 at our facility. Of these patients, 49 had AAM, including 34 who underwent ILA. We examined the safety and effectiveness of ILA by comparing it with laparoscopic appendectomy (LA); specifically, the 34 cases treated with ILA were compared with 477 cases of adult uncomplicated appendicitis treated with LA from the same patient cohort. We then examined the factors associated with not successfully completing the planned nonsurgical treatment and interval before ILA. Patient demographics and clinical variables were reviewed.

RESULTS

Patients who had undergone ILA had longer operative times than those who had undergone LA (P = .0059), but they also had shorter postoperative hospital stays (P < .001). There were no significant differences in other perioperative variables. Multivariate analysis showed that a ratio of WBC count on day 3 and day 0 from the start of nonsurgical treatment (WBC day3/day0) of 0.906 or higher was significantly associated with not completing the nonsurgical treatment and interval before ILA (P = .045).

CONCLUSION

A comparison of the procedures found that ILA for AAM was almost as safe and effective as LA for adult uncomplicated appendicitis. The WBC day3/day0 ratio can be an objective parameter to assess the effectiveness of the nonsurgical treatment before ILA earlier in the course of treatment.

Interval laparoscopic appendectomy after antibiotic therapy for appendiceal abscess in elderly patients

INTRODUCTION

The aim of this study was to evaluate the safety and efficacy of interval laparoscopic appendectomy after antibiotic therapy in elderly patients with appendiceal abscess.

METHODS

We retrospectively analyzed data for 50 patients with appendiceal abscess aged ≥18 years who had initially planned to undergo interval laparoscopic appendectomy after antibiotic therapy and 50 patients with appendicitis aged ≥70 years who had undergone early laparoscopic appendectomy. All patients were treated at the National Hospital Organization Kumamoto Medical Center between 2012 and 2018. We compared perioperative outcomes after interval appendectomy between patients aged <70 years and ≥70 years.

RESULTS

Clinical progression of appendicitis during antibiotic therapy developed in one patient (2.0%), and recurrent appendicitis after antibiotic therapy for appendiceal abscess occurred in two patients (4.0%). Pathological findings confirmed appendiceal neoplasms in four patients (8.0%). Postoperative infectious complications occurred in 1 of 47 patients (2.1%) who had undergone successful interval laparoscopic appendectomy, and the median length of postoperative hospital stay was 4 days (interquartile range, 3-5 days). There were no significant differences in outcomes after interval appendectomy between patients aged <70 years and ≥70 years. In the secondary analysis, the median length of postoperative hospital stay after interval laparoscopic appendectomy for appendiceal abscess (4 days) was significantly shorter than that after early laparoscopic appendectomy for uncomplicated appendicitis (7 days; P < .001).

CONCLUSIONS

Interval laparoscopic appendectomy for appendiceal abscess may be safe and effective in elderly patients without severe comorbidities. Interval appendectomy may be necessary for determining the underlying cause of appendiceal abscess in adults.