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Rafique U, Elfeky MA, Bhatti K, Siddique K. Does Diagnostic Laparoscopy Still Have a Role in the Evaluation of Right Iliac Fossa Pain Versus Imaging Techniques or Experience? Cureus 2022; 14:e30678. [PMID: 36439602 DOI: 10.7759/cureus.30678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
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Lee S, Connelly TM, Ryan JM, Power-Foley M, Neary PM. Outcomes of the Macroscopically Normal Appendix Left in Situ in Patients with Suspected Appendicitis. World J Surg 2022; 46:1353-1358. [PMID: 35274182 DOI: 10.1007/s00268-022-06497-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Right iliac fossa (RIF) pain is a common indication for laparoscopy to diagnose and treat appendicitis. When a macroscopically normal appendix is found, there is no standard consensus regarding excision. Some surgeons remove the appendix due to the risk of microscopic inflammation and to avoid a future, repeat laparoscopy for possible appendicitis. Alternatively, others leave the appendix in situ to avoid morbidity from a potentially unnecessary procedure. We aimed to evaluate the outcomes of patients with macroscopically normal appendices left in situ. METHODS All emergency laparoscopies without appendicectomy between January 1st 2010- December 31st 2020 were identified from theatre records. All operative notes were individually evaluated and comments on the macroscopic appearance of the appendix and any intra-operative pathology were recorded. Only patients undergoing laparoscopy for suspected appendicitis with macroscopically normal appendices were included. RESULTS A total of 120 patients [median age 21.68 (range 9-90.8) years] were included. The cohort was predominantly female (n=105, 87.5%). Forty-eight patients (40.0%) had a positive finding during index laparoscopy. During a median duration of 94.5 (range 8-131) months' follow-up, 16 patients (13.33%) underwent a repeat laparoscopy for recurrent RIF pain. Thirteen (10.8% of total cohort) subsequently underwent an appendicectomy. Histology confirmed acute appendicitis in six cases (4.17% of entire cohort). On subanalysis of smaller cohort, index laparoscopies with no positive findings (n=72), nine patients (12.5%) underwent appendicectomy with two (2.7%) appendices demonstrating appendicitis on histological examination. CONCLUSION 87% of the total cohort with a normal appendix at laparoscopy for RIF pain did not undergo further laparoscopy. Less than 5% of the total cohort and 2.7% of subanalysis cohort had an appendicectomy for histologically-proven appendicitis within the follow-up period. From the evidence in this study, we conclude that leaving the appendix in situ unless macroscopically inflamed is a viable alternative to excision.
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Affiliation(s)
- Sara Lee
- Department of Academic Surgery, University Hospital Waterford, University College Cork, Dunmore Road, Waterford, Ireland.
| | - Tara M Connelly
- Department of Academic Surgery, University Hospital Waterford, University College Cork, Dunmore Road, Waterford, Ireland
| | - Jessica M Ryan
- Department of Academic Surgery, University Hospital Waterford, University College Cork, Dunmore Road, Waterford, Ireland
| | - Megan Power-Foley
- Department of Academic Surgery, University Hospital Waterford, University College Cork, Dunmore Road, Waterford, Ireland
| | - Peter M Neary
- Department of Academic Surgery, University Hospital Waterford, University College Cork, Dunmore Road, Waterford, Ireland
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Hryn VH, Drabovskiy VS, Sytnik DA, Ryabuschko RM, Riabuschko MM, Bilash SM, Gonzhak BI. PECULIARITIES OF MORPHOETIOPATHOGENESIS OF ACUTE APPENDICITIS AND CONSEQUENCES AFTER APPENDECTOMY. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:1492-1499. [PMID: 35907222 DOI: 10.36740/wlek202206112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The aim: To study the features of morphoethiopathogenesis of acute appendicitis and the consequences after appendectomy. PATIENTS AND METHODS Materials and methods: 10 preparations of human appendix were studied, from which 5 appendixes were normal in people who died in adulthood and old age and 5 processes were taken intraoperatively during appendectomy. Morphometric characteristics of the tissue structures of the preparations were compared with the systematic review data, the literature search by the following keywords: morphoethiopathy", "vermiform process", "lymphoepithelial formations", "digestive system", "lymphoid nodule", "Peyer's patches", "mucous membrane". RESULTS Results: Pathogenesis of acute appendicitis - it is a consistent, staged process that is completely subject to the laws of exudative inflammation in response to microbial aggression. Removal of the appendicular process should be approached carefully and based on possible immunological consequences. Removal of the appendix as an immunocompetent organ Unreasonable removal of pathohistological unchanged appendix has medical consequences (can lead to consequences such as colon cancer) and not only. CONCLUSION Conclusions: Our results suggest that the vermiform appendix retains its active function throughout human life. The study provides an overview with current knowledge about the etiology, pathogenesis and possible consequences of appendectomy as the main method of treatment of acute appendicitis. The search for ways to prevent appendicitis can be successful only by finding out the causes and factors that in some individuals cause the inability of the appendix to resist bacterial invasion. Appendix is necessary to fully support the immune responses of the digestive tract, but it belongs to the category of those organs, the loss of which during forced surgery does not cause significant damage to the body.
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Harris J, Fleming CA, Stassen PN, Mullen D, Mohan H, Foley J, Heeney A, Nugent E, Schmidt K, Mealy K. A comparison of intra-operative diagnosis to histopathological diagnosis of acute appendicitis in paediatric and adult cohorts: an analysis of over 1000 patients. Ir J Med Sci 2021; 191:1809-1813. [PMID: 34515986 PMCID: PMC9308595 DOI: 10.1007/s11845-021-02770-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 08/28/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Appendicitis is a common general surgical emergency. The role of removing a normal appendix is debated. However, this relies on accurate intra-operative diagnosis of a normal appendix by the operating surgeon. This study aimed to compare surgeon's intra-operative assessment to final histological result acute appendicitis in paediatric and adult patients. METHODS All patients who underwent appendicectomy over a 14-year period in a general surgical department were identified using the prospective Lothian Surgical Audit system and pathology reports retrieved to identify final histological diagnosis. Open appendicectomy was selected to examine, as the routine practise at our institution is to remove a normal appendix at open appendicectomy. RESULTS A total of 1035 open appendicectomies were performed for clinically suspected appendicitis. Sensitivity of intra-operative diagnosis of appendicitis with operating surgeon was high at 95.13% with no difference between trainee and consultant surgeon or between adult and paediatric cases. Specificity of intra-operative diagnosis was lower in the paediatric group (32.58%) than in the adult group (40.58%). Women had a higher rate of negative appendicectomy than men. CONCLUSION The results of this study highlight some discordance between histological evidence of acute appendicitis and intra-operative impression. Therefore other clinical variables and not just macroscopic appearance alone should be used when deciding to perform appendicectomy.
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Affiliation(s)
- Johnathon Harris
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland.
| | | | - Paul N Stassen
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Daniel Mullen
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Helen Mohan
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - James Foley
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Anna Heeney
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Emmeline Nugent
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Karl Schmidt
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Ken Mealy
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
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Logie K, Robinson T, VanHouwelingen L. Management of the normal-appearing appendix during laparoscopy for clinically suspected acute appendicitis in the pediatric population. J Pediatr Surg 2020; 55:893-898. [PMID: 32081356 DOI: 10.1016/j.jpedsurg.2020.01.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/25/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE The widespread use of laparoscopy has brought forth the question of how to manage a macroscopically normal-appearing appendix in cases of clinically suspected appendicitis. This study aimed to determine the current practices of pediatric general surgeons in Canada regarding this matter. METHODS An online survey was created following the American Pediatric Surgical Association (APSA) guidelines and distributed via email to the Canadian Association of Pediatric Surgeons (CAPS) staff surgeons. The questions assessed clinician characteristics, standard practice, and rationale. Results were analyzed using descriptive statistics. RESULTS A total of 54/72 (75%) CAPS members practicing in Canada completed the survey. All (100%) agreed they would remove a normal-appearing appendix during laparoscopy for suspected acute appendicitis. The most common reasons were: possibility of microscopic appendicitis (39/54, 72.2%), avoiding future diagnostic confusion (28/54, 51.9%), and patient preference/consent discussion (21/54, 38.9%). Most (53/54, 98.1%) had performed a negative appendectomy and 49/54 (90.7%) agreed there were no sufficient guidelines. CONCLUSIONS The majority of pediatric surgeons agree sufficient guidelines do not exist to support decision making when a normal-appearing appendix is found during laparoscopy for suspected acute appendicitis. This survey shows that removal of the appendix in this case would be supported by the majority of Canadian pediatric surgeons. TYPE OF STUDY Survey LEVEL OF EVIDENCE: VII (Expert Opinion).
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Affiliation(s)
- Kathleen Logie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tessa Robinson
- Division of Pediatric Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada
| | - Lisa VanHouwelingen
- Division of Pediatric Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada.
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Rud B, Vejborg TS, Rappeport ED, Reitsma JB, Wille‐Jørgensen P. Computed tomography for diagnosis of acute appendicitis in adults. Cochrane Database Syst Rev 2019; 2019:CD009977. [PMID: 31743429 PMCID: PMC6953397 DOI: 10.1002/14651858.cd009977.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Diagnosing acute appendicitis (appendicitis) based on clinical evaluation, blood testing, and urinalysis can be difficult. Therefore, in persons with suspected appendicitis, abdominopelvic computed tomography (CT) is often used as an add-on test following the initial evaluation to reduce remaining diagnostic uncertainty. The aim of using CT is to assist the clinician in discriminating between persons who need surgery with appendicectomy and persons who do not. OBJECTIVES Primary objective Our primary objective was to evaluate the accuracy of CT for diagnosing appendicitis in adults with suspected appendicitis. Secondary objectives Our secondary objectives were to compare the accuracy of contrast-enhanced versus non-contrast-enhanced CT, to compare the accuracy of low-dose versus standard-dose CT, and to explore the influence of CT-scanner generation, radiologist experience, degree of clinical suspicion of appendicitis, and aspects of methodological quality on diagnostic accuracy. SEARCH METHODS We searched MEDLINE, Embase, and Science Citation Index until 16 June 2017. We also searched references lists. We did not exclude studies on the basis of language or publication status. SELECTION CRITERIA We included prospective studies that compared results of CT versus outcomes of a reference standard in adults (> 14 years of age) with suspected appendicitis. We excluded studies recruiting only pregnant women; studies in persons with abdominal pain at any location and with no particular suspicion of appendicitis; studies in which all participants had undergone ultrasonography (US) before CT and the decision to perform CT depended on the US outcome; studies using a case-control design; studies with fewer than 10 participants; and studies that did not report the numbers of true-positives, false-positives, false-negatives, and true-negatives. Two review authors independently screened and selected studies for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently collected the data from each study and evaluated methodological quality according to the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate random-effects model to obtain summary estimates of sensitivity and specificity. MAIN RESULTS We identified 64 studies including 71 separate study populations with a total of 10,280 participants (4583 with and 5697 without acute appendicitis). Estimates of sensitivity ranged from 0.72 to 1.0 and estimates of specificity ranged from 0.5 to 1.0 across the 71 study populations. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.93 to 0.96), and summary specificity was 0.94 (95% CI 0.92 to 0.95). At the median prevalence of appendicitis (0.43), the probability of having appendicitis following a positive CT result was 0.92 (95% CI 0.90 to 0.94), and the probability of having appendicitis following a negative CT result was 0.04 (95% CI 0.03 to 0.05). In subgroup analyses according to contrast enhancement, summary sensitivity was higher for CT with intravenous contrast (0.96, 95% CI 0.92 to 0.98), CT with rectal contrast (0.97, 95% CI 0.93 to 0.99), and CT with intravenous and oral contrast enhancement (0.96, 95% CI 0.93 to 0.98) than for unenhanced CT (0.91, 95% CI 0.87 to 0.93). Summary sensitivity of CT with oral contrast enhancement (0.89, 95% CI 0.81 to 0.94) and unenhanced CT was similar. Results show practically no differences in summary specificity, which varied from 0.93 (95% CI 0.90 to 0.95) to 0.95 (95% CI 0.90 to 0.98) between subgroups. Summary sensitivity for low-dose CT (0.94, 95% 0.90 to 0.97) was similar to summary sensitivity for standard-dose or unspecified-dose CT (0.95, 95% 0.93 to 0.96); summary specificity did not differ between low-dose and standard-dose or unspecified-dose CT. No studies had high methodological quality as evaluated by the QUADAS-2 tool. Major methodological problems were poor reference standards and partial verification primarily due to inadequate and incomplete follow-up in persons who did not have surgery. AUTHORS' CONCLUSIONS The sensitivity and specificity of CT for diagnosing appendicitis in adults are high. Unenhanced standard-dose CT appears to have lower sensitivity than standard-dose CT with intravenous, rectal, or oral and intravenous contrast enhancement. Use of different types of contrast enhancement or no enhancement does not appear to affect specificity. Differences in sensitivity and specificity between low-dose and standard-dose CT appear to be negligible. The results of this review should be interpreted with caution for two reasons. First, these results are based on studies of low methodological quality. Second, the comparisons between types of contrast enhancement and radiation dose may be unreliable because they are based on indirect comparisons that may be confounded by other factors.
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Affiliation(s)
- Bo Rud
- Copenhagen University Hospital HvidovreGastrounit, Surgical DivisionKettegaards Alle 30HvidovreDenmark2650
| | - Thomas S Vejborg
- Bispebjerg Hospital, University of CopenhagenDepartment of Radiology R23 Bispebjerg BakkeCopenhagenDenmarkDK 2400 NV
| | - Eli D Rappeport
- Bispebjerg Hospital, University of CopenhagenDepartment of Radiology R23 Bispebjerg BakkeCopenhagenDenmarkDK 2400 NV
| | - Johannes B Reitsma
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 GA Utrecht
| | - Peer Wille‐Jørgensen
- Bispebjerg HospitalDepartment of Surgical Gastroenterology KBispebjerg Bakke 23Copenhagen NVDenmarkDK‐2400
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Gee KM, Jones RE, Babb JL, Preston SC, Beres AL. Clinical and Imaging Correlates of Pediatric Mucosal Appendicitis. J Surg Res 2019; 242:111-117. [PMID: 31075655 DOI: 10.1016/j.jss.2019.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/20/2019] [Accepted: 04/09/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Mucosal appendicitis is a controversial entity that is histologically distinct from transmural appendicitis. There is mixed opinion regarding mucosal inflammation as a spectrum of appendicitis versus a negative appendectomy. The ability to distinguish these diagnoses preoperatively is of importance to prevent unnecessary surgery. We hypothesize that patients with mucosal appendicitis can be discriminated from those with transmural disease based on specific preoperative clinical and imaging findings. MATERIALS AND METHODS After IRB approval, all patients who underwent laparoscopic appendectomy at our institution during 2015 were reviewed in the electronic medical record. Patients with mucosal appendicitis were identified and matched 2:1 to a random cohort of nonperforated transmural appendicitis cases. Demographic and clinical data were collected, including history, examination, laboratory, and imaging findings. Preoperative factors associated with mucosal appendicitis were modeled using binomial logistic regression analysis. RESULTS Of 1153 appendectomies performed during 2015, 103 patients had pathologic diagnosis of mucosal appendicitis. When compared with patients with mucosal infection, leukocytosis >10,000 per microliter led to 5.9 times higher likelihood of transmural pathology (P = 0.000). Noncompressibility on ultrasound was associated with 7.3 times higher likelihood of transmural disease (P = 0.015). Echogenic changes were predictive of transmural appendicitis, conferring 3.9 times the risk (P = 0.007). Presence of free fluid led to 2.3 times the rate of transmural pathology (P = 0.007). Finally, for every millimeter decrease in appendiceal diameter, patients were half as likely to exhibit transmural disease (P = 0.000). Together, these variables can successfully predict presence of mucosal appendicitis on final pathology report at a rate of 82.1%, and explain 60% of the variance in diagnosis of mucosal versus transmural appendicitis (P = 0.000). CONCLUSIONS Mucosal appendicitis remains a controversial pathologic entity, but is not associated with greater complications compared with transmural appendicitis when treated with laparoscopic appendectomy. Transmural disease can be predicted by leukocytosis, noncompressible appendix, presence of free fluid, larger appendiceal diameter and echogenicity.
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Affiliation(s)
- Kristin M Gee
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ruth Ellen Jones
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jacqueline L Babb
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stephanie C Preston
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alana L Beres
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Surgery, Children's Health, Dallas, Texas.
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Sørensen AK, Bang-Nielsen A, Levic-Souzani K, Pommergaard HC, Jørgensen AB, Tolstrup MB, Rud B, Kovacevic B, Bulut O. Readmission and reoperation rates following negative diagnostic laparoscopy for clinically suspected appendicitis: The "normal" appendix should not be removed - A retrospective cohort study. Int J Surg 2019; 64:1-4. [PMID: 30769215 DOI: 10.1016/j.ijsu.2019.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 01/30/2019] [Accepted: 02/04/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND In cases with clinically suspected appendicitis, there is controversy regarding the decision to remove a macroscopically normal appearing appendix during laparoscopy when no other intra-abdominal pathology is found. The aim of this study was to examine the rate of appendicitis, along with readmission and reoperation rates following diagnostic laparoscopy of clinically suspected appendicitis in patients where the appendix was not removed. METHODS We performed a retrospective cohort analysis of patients who underwent a diagnostic laparoscopy due to clinical suspicion of appendicitis where no other pathology was found and the appendix was not removed. The study period was from 2008 to 2013 and involved patients from two university hospitals in the Copenhagen area. RESULTS Of the 271 patients included (81.6% women, median age 27), 56 (20.7%) were readmitted with right iliac fossa pain after a median time of 10 months (range 1-84). Twenty-two patients (8.1%) underwent a new laparoscopic procedure. Appendix was removed in 18 patients, of which only one showed histological signs of inflammation. The median follow-up time was 5.6 years (range 1-109 months). CONCLUSION There was a low rate of appendicitis after a previous negative diagnostic laparoscopy. Therefore, based on results from the current study, we do not consider that it is necessary to remove a macroscopic normal appendix during laparoscopy for clinically suspected appendicitis. The high readmission rate warrants the need for further investigation or follow-up.
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Affiliation(s)
| | - Anders Bang-Nielsen
- Gastrounit - Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Denmark
| | - Katarina Levic-Souzani
- Gastrounit - Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Denmark
| | | | | | | | - Bo Rud
- Gastrounit - Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Denmark
| | - Bojan Kovacevic
- Department of Surgery, Copenhagen University Hospital, Herlev, Denmark
| | - Orhan Bulut
- Gastrounit - Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Denmark; Institute of Clinical Medicine, University of Copenhagen, Denmark
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Guthrie GJ, Johnston T, Ewing A, Mullen R, Suttie SA, Patil PV. A prospective observational study of the utility of early diagnostic laparoscopy for right lower abdominal pain: a safe and effective diagnostic and therapeutic tool. Scott Med J 2019; 64:49-55. [PMID: 30630393 DOI: 10.1177/0036933016649869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Diagnostic laparoscopy is commonly performed for diagnosis of right lower abdominal pain and its use is increasing in the emergency setting. Some studies have reported that diagnostic laparoscopy and laparoscopic appendicectomy have advantages over conventional surgery. Many emergency surgeons now perform diagnostic laparoscopy for both clinically diagnosed appendicitis and when the diagnosis is in doubt. The aim of the present study was to assess whether the use of diagnostic laparoscopy is justified and safe for those admitted with right lower abdominal pain. METHODS AND RESULTS Data were collected prospectively on consecutive patients attending the acute surgical receiving unit with right iliac fossa pain or a suspected diagnosis of acute appendicitis. A total of 284 patients underwent diagnostic laparoscopy. Of them 233 (82%) had a positive finding at laparoscopy, 207 (88%) underwent appendicectomy, the majority of which were carried out laparoscopically. Surgical trainees performed the majority of operations and this did not have a negative impact on operative findings (p 0.856), operation performed (0.642), or operative duration (0.831). No intra-operative complications were sustained. Ultrasound examination was carried out in 49 patients, while CT was carried out in 24. CONCLUSION The results of the present study highlight the utility of early diagnostic laparoscopy as both a diagnostic and therapeutic tool in the acute setting.
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Affiliation(s)
- Graeme Jk Guthrie
- 1 Specialty Registrar General Surgery, Department of General Surgery, Ninewells Hospital, UK
| | - Thomas Johnston
- 2 Foundation Doctor General Surgery, Department of General Surgery, Ninewells Hospital, UK
| | - Anne Ewing
- 3 Foundation Doctor General Surgery, Department of General Surgery, Ninewells Hospital, UK
| | - Russell Mullen
- 4 Specialty Registrar General Surgery, Department of General Surgery, Ninewells Hospital, UK
| | - Stuart A Suttie
- 5 Specialty Registrar General Surgery, Department of General Surgery, Ninewells Hospital, UK
| | - Pradeep V Patil
- 6 Consultant General Surgeon, Department of General Surgery, Ninewells Hospital, UK
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Gómez López JR, Martín Del Olmo JC, Montenegro Martín MA, Concejo Cutoli P, Martín Esteban ML, Toledano Trincado M, López Mestanza IC, Vaquero Puerta C. Laparoscopic Appendectomy in the Setting of Clinical Prediction Rules. J Laparoendosc Adv Surg Tech A 2018; 29:184-191. [PMID: 30585754 DOI: 10.1089/lap.2018.0707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Acute appendicitis (AA) is the most frequent surgical entity in the emergency department, but its correct diagnosis remains challenging. To improve diagnosis, clinical prediction rules (CPRs) have been created to establish objective scores for the probability of suffering AA. In this study, we establish scores indicating whether laparoscopy would be superior to clinical observation or repeat diagnostic test. METHODS A retrospective observational study was conducted with 433 patients submitted to surgery for suspected AA using a laparoscopic approach. The Alvarado, Raja Isteri Pengiran Anak Saleha Appendicitis, appendicitis inflammatory response, and adult appendicitis score scales were applied in each case to establish a high, medium, or low probability of suffering AA. RESULTS Of the 433 patients analyzed, 381 (88.0%) had AA. Twelve (2.8%) were converted to open surgery, and complications were observed in 54 (12.5%) cases. The CPRs studied showed statistically significant differences between AA and negative appendectomies. However, in patients with intermediate probability scores, the diagnostic accuracy of the CPRs evaluated was not adequate. CONCLUSIONS Laparoscopic surgery can serve as a diagnostic tool for patients with intermediate AA probability scores because of its low associated morbidity and mortality and because it affords a direct diagnosis of the problem, allowing determination of the appropriate treatment.
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11
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Allaway MGR, Eslick GD, Cox MR. The Unacceptable Morbidity of Negative Laparoscopic Appendicectomy. World J Surg 2018; 43:405-414. [PMID: 30209573 DOI: 10.1007/s00268-018-4784-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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12
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Sensibilidad, especificidad y fiabilidad de la escala RIPASA en el diagnóstico de apendicitis aguda en relación con la escala de Alvarado. Cir Esp 2018; 96:149-154. [DOI: 10.1016/j.ciresp.2017.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 11/10/2017] [Accepted: 11/25/2017] [Indexed: 11/19/2022]
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13
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de Burlet KJ, Crane G, Cullinane R, Larsen PD, Dennett ER. Review of appendicectomies over a decade in a tertiary hospital in New Zealand. ANZ J Surg 2017; 88:1253-1257. [PMID: 28994178 DOI: 10.1111/ans.14203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 07/23/2017] [Accepted: 07/26/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute appendicectomy is the most common emergency operation for patients with abdominal pain. In the last decade, computed tomography (CT) scans have increasingly been used to aid in the diagnosis in order to reduce the negative appendicectomy rate. The aim of this study was to evaluate our institution's negative appendicectomy rate and the use of pre-operative imaging. METHODS A retrospective review was undertaken for all adult patients (>16 years), who underwent an appendicectomy on emergency basis in the years 2004, 2009 and 2014. Cases were identified from the hospital electronic theatre record system. Data were also obtained from the patients records and laboratory reports. RESULTS A total of 874 patients were included, 227 in 2004, 308 in 2009 and 339 in 2014. The negative appendicectomy rate was 29.1% in 2004, 20.1% in 2009 and 19.5% in 2014 (P = 0.014). Negative appendicectomies were more common in women (P = <0.001), patients between the ages of 16-30 years (P = <0.001) and were associated with low inflammatory markers (median white cell count of 10.2, C-reactive protein of 8, P = <0.001). The use of CT scan prior to operation increased between 2009 and 2014 (34 (11.0%) versus 64 (18.9%), P = <0.001). CONCLUSION Though the number of appendicectomies being performed in our institution has increased over the last decade, the negative appendicectomy rate remains fairly static and the increased use of CT scans did not further decrease the proportion of negative appendicectomies between 2009 and 2014.
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Affiliation(s)
- Kirsten J de Burlet
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Grant Crane
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Ruth Cullinane
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Peter D Larsen
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Elizabeth R Dennett
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
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van Rossem CC, Bolmers MDM, Schreinemacher MHF, van Geloven AAW, Bemelman WA. Prospective nationwide outcome audit of surgery for suspected acute appendicitis. Br J Surg 2015; 103:144-51. [PMID: 26509648 DOI: 10.1002/bjs.9964] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 06/16/2015] [Accepted: 09/04/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Studies comparing laparoscopic and open appendicectomy are difficult to interpret owing to several types of bias, and the results often seem of limited clinical importance. National audits can be valuable to provide insight into outcomes following appendicectomy at a population level. METHODS A prospective, observational, resident-led, nationwide audit was carried out over a period of 2 months, including all consecutive adult patients who had surgery for suspected acute appendicitis. Complications after laparoscopic and open appendicectomy were compared by means of logistic regression analysis; subgroup analyses were performed for patients with complicated appendicitis. RESULTS A total of 1975 patients were included from 62 participating Dutch hospitals. A normal appendix was seen in 3·3 per cent of patients. Appendicectomy was performed for acute appendicitis in 1378 patients, who were analysed. All but three patients underwent preoperative imaging. Laparoscopy was used in 79·5 per cent of patients; the conversion rate was 3·4 per cent. A histologically normal appendix was found in 2·2 per cent. Superficial surgical-site infection was less common in the laparoscopic group (odds ratio 0·25, 95 per cent c.i. 0·14 to 0·44; P < 0·001). The rate of intra-abdominal abscess formation was not significantly different following laparoscopic or open surgery (odds ratio 1·71, 0·80 to 3·63; P = 0·166). Similar findings were observed in patients with complicated appendicitis. CONCLUSION Management of acute appendicitis in the Netherlands is preferably performed laparoscopically, characterized by a low conversion rate. Fewer superficial surgical-site infections occurred with laparoscopy, although the rate of abscess formation was no different from that following open surgery. A low normal appendix rate is the presumed effect of a mandatory preoperative imaging strategy.
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Affiliation(s)
- C C van Rossem
- Departments of Surgery, Tergooi Hospital, Hilversum, The Netherlands
| | - M D M Bolmers
- Departments of Surgery, Tergooi Hospital, Hilversum, The Netherlands
| | | | - A A W van Geloven
- Departments of Surgery, Tergooi Hospital, Hilversum, The Netherlands
| | - W A Bemelman
- Academic Medical Centre, Amsterdam, The Netherlands
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Pham H, Devadas M, Howle J. Effect of surgical experience on the macroscopic diagnosis of appendicitis: A retrospective cohort study. Int J Surg 2015; 16:78-82. [DOI: 10.1016/j.ijsu.2015.02.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 02/13/2015] [Accepted: 02/24/2015] [Indexed: 11/28/2022]
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Laparoscopic appendectomy for chronic right lower quadrant abdominal pain. Int J Colorectal Dis 2014; 29:1199-202. [PMID: 25060220 DOI: 10.1007/s00384-014-1978-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE The appendix can be a rare cause for chronic right lower quadrant abdominal pain (RLQAP), even though no objective disorder can be determined to the appendix. This condition can be described as chronic appendicitis or (neurogenic) appendicopathy. After careful selection, elective appendectomy is performed in our centre for this group of patients. METHODS All patients that underwent an elective appendectomy between 2006 and 2013 were prospectively analysed. Inclusion criterion was chronic RLQAP without abnormalities seen on imaging. Exclusion criterion was pain after conservative treatment of (complicated) appendicitis or an abnormal appendix on imaging like a mass, mucocoele or faecolith. Primary outcome was the effect on the pain postoperatively. RESULTS In the period of the study, ten patients met the inclusion criteria and underwent an appendectomy for chronic RLQAP. Average preoperative pain score assessed with visual analogue scale (VAS) was 8.6. Preoperative work-up showed no abnormalities. No macroscopic abnormalities were seen during surgery in any of the patients. Histopathological analysis was obtained and showed limited abnormalities in eight of ten patients, mostly suspicion of previous inflammation. Postoperatively, no complications occurred, and at revision after 3 weeks, average VAS was 1.0. Long-term follow-up showed that patients remained free of symptoms; average VAS after a median of 33 months was 1.0. CONCLUSIONS A significant reduction of pain was achieved after an appendectomy in all patients suffering from chronic RLQAP in this series. Seven out of ten patients were completely free of pain.
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Gaitán HG, Reveiz L, Farquhar C, Elias VM. Laparoscopy for the management of acute lower abdominal pain in women of childbearing age. Cochrane Database Syst Rev 2014; 2014:CD007683. [PMID: 24848893 PMCID: PMC10843248 DOI: 10.1002/14651858.cd007683.pub3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This is an updated version of the original review, published in Issue 1, 2011, of The Cochrane Library. Acute lower abdominal pain is common, and making a diagnosis is particularly challenging in premenopausal women, as ovulation and menstruation symptoms overlap with symptoms of appendicitis, early pregnancy complications and pelvic infection. A management strategy involving early laparoscopy could potentially provide a more accurate diagnosis, earlier treatment and reduced risk of complications. OBJECTIVES To evaluate the effectiveness and harms of laparoscopy for the management of acute lower abdominal pain in women of childbearing age. SEARCH METHODS The Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, LILACS and CINAHL were searched (October 2013). The International Clinical Trials Registry Platform (ICTRP) was also searched. No new studies were included in this updated version. SELECTION CRITERIA Randomised controlled trials (RCTs) that included women of childbearing age who presented with acute lower abdominal pain, non-specific lower abdominal pain or suspected appendicitis were included. Trials were included if they evaluated laparoscopy with open appendicectomy, or laparoscopy with a wait and see strategy. Study selection was carried out by two review authors independently. DATA COLLECTION AND ANALYSIS Data from studies that met the inclusion criteria were independently extracted by two review authors and the risk of bias assessed. We used standard methodological procedures as expected by The Cochrane Collaboration. A summary of findings table was prepared using GRADE criteria. MAIN RESULTS A total of 12 studies including 1020 participants were incorporated into the review. These studies had low to moderate risk of bias, mainly because allocation concealment or methods of sequence generation were not adequately reported. In addition, it was not clear whether follow-up was similar for the treatment groups. The index test was incorporated as a reference standard in the laparoscopy group, and differential verification or partial verification bias may have occurred in most RCTs. Overall the quality of the evidence was low to moderate for most outcomes, as per the GRADE approach.Laparoscopy was compared with open appendicectomy in eight RCTs. Laparoscopy was associated with an increased rate of specific diagnoses (seven RCTs, 561 participants; odds ratio (OR) 4.10, 95% confidence interval (CI) 2.50 to 6.71; I(2) = 18%), but no evidence was found of reduced rates for any adverse events (eight RCTs, 623 participants; OR 0.46, 95% CI 0.19 to 1.10; I(2) = 0%). A meta-analysis of seven studies found a significant difference favouring the laparoscopic procedure in the rate of removal of normal appendix (seven RCTs, 475 participants; OR 0.13, 95% CI 0.07 to 0.24; I(2) = 0%).Laparoscopic diagnosis versus a 'wait and see' strategy was investigated in four RCTs. A significant difference favoured laparoscopy in terms of rate of specific diagnoses (four RCTs, 395 participants; OR 6.07, 95% CI 1.85 to 29.88; I(2) = 79%), but no evidence suggested a difference in rates of adverse events (OR 0.87, 95% CI 0.45 to 1.67; I(2) = 0%). AUTHORS' CONCLUSIONS We found that laparoscopy in women with acute lower abdominal pain, non-specific lower abdominal pain or suspected appendicitis led to a higher rate of specific diagnoses being made and a lower rate of removal of normal appendices compared with open appendicectomy only. Hospital stays were shorter. No evidence showed an increase in adverse events when any of these strategies were used.
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Affiliation(s)
- Hernando G Gaitán
- National University of ColombiaDepartment of Obstetrics & Gynecology and Clinical Research Institute, Faculty of MedicineCarrera 30 No. 45‐03BogotaColombia
| | - Ludovic Reveiz
- Free time independent Cochrane reviewer7838 Heatherton LanePotomacUSA20854
| | - Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
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Negative Appendectomy: an Audit of Resident-Performed Surgery. How Can Its Incidence Be Minimized? Indian J Surg 2014; 77:913-7. [PMID: 27011482 DOI: 10.1007/s12262-014-1063-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 03/27/2014] [Indexed: 12/29/2022] Open
Abstract
Negative appendectomy remains a concern in current surgical practice. Data from the developing world is scarce. Data of appendectomies during the last 5 years were analyzed. Interval and incidental appendectomies were excluded. The demographic details, presenting complaints, clinical signs, and investigations performed were recorded in a predesigned proforma. The data were critically analyzed. Six hundred eighty-five appendectomies were performed during the period. One hundred eighty-five patients with a normal appendix were identified on histopathology. Sixty-seven patients with incidental or interval appendectomies were excluded. Thus, 118 patients had appendectomies performed erroneously. All these patients with presumed diagnosis of acute appendicitis were operated on by resident surgeons. Records of 17 patients could not be retrieved. The most common symptom was abdominal pain (100 %), and the commonest sign was right iliac fossa tenderness (93 %). Most of the patients underwent USG to supplement the diagnosis. CT scan and diagnostic laparoscopy were not performed. The negative appendectomy rate was 17.2 % (12.4 % in males; 33.3 % in females). The highest incidence of negative appendectomy was in females aged 11-20 years (66.7 %). The rate of negative appendectomy at our institute is comparable with the world statistics. More diligence is required in making the clinical diagnosis of acute appendicitis, especially in young females. The use of C-reactive protein and CT scan may decrease the negative appendectomy rate.
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Liese J, Halbinger TM, Ulrich F, Bechstein WO, Strey CW. Appendicitis—the balance between cost effectiveness and safety remains challenging. Langenbecks Arch Surg 2014; 399:493-501. [DOI: 10.1007/s00423-014-1179-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 02/21/2014] [Indexed: 01/07/2023]
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A preclustering-based ensemble learning technique for acute appendicitis diagnoses. Artif Intell Med 2013; 58:115-24. [DOI: 10.1016/j.artmed.2013.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 03/03/2013] [Accepted: 03/17/2013] [Indexed: 12/29/2022]
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Roosinovich E, Reay-Jones N. Use of blood tests in the diagnosis of acute appendicitis. Br J Hosp Med (Lond) 2013; 73:C183-5. [PMID: 23519065 DOI: 10.12968/hmed.2012.73.sup12.c183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Jaunoo SS, Hale AL, Masters JPM, Jaunoo SR. An international survey of opinion regarding investigation of possible appendicitis and laparoscopic management of a macroscopically normal appendix. Ann R Coll Surg Engl 2012; 94:476-80. [PMID: 23031764 PMCID: PMC3954241 DOI: 10.1308/003588412x13373405385377] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION The use of imaging and laparoscopy in patients with right iliac fossa pain as tools to make or exclude a diagnosis of appendicitis is at the discretion of the clinician. We sought to establish a consensus of opinion on this matter by surveying professional bodies for laparoscopic surgery in France, Italy and the US. METHODS A survey was sent to members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), as well as the French Society for Endoscopic Surgery (SFCE) and the Italian Society for Endoscopic Surgery (SICE). The survey asked about management of both male and female patients presenting with right iliac fossa pain and what operative strategy the respondents would pursue should they find a macroscopically normal appendix at laparoscopy. RESULTS A total of 364 responses were returned from the three groups. The responses from SAGES showed computed tomography to be the preferred modality for investigating patients with right iliac fossa pain, irrespective of sex. Both SFCE and SICE preferred the use of diagnostic laparoscopy, especially in the female patient group. The majority of all respondents stated that they would remove a macroscopically normal appendix at laparoscopy. CONCLUSIONS Laparoscopy remains a potent tool in the management of appendicitis. However, the dilemma of when to remove a macroscopically normal appendix remains. Our study shows that removal of the appendix in this instance would be supported by an international consensus.
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Affiliation(s)
- S S Jaunoo
- Warwickshire Surgical Research Group, University Hospitals Coventry & Warwickshire NHS Trust, UK.
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Evaluation of the appendix during diagnostic laparoscopy, the laparoscopic appendicitis score: a pilot study. Surg Endosc 2012; 27:1594-600. [PMID: 23073690 DOI: 10.1007/s00464-012-2634-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 09/25/2012] [Indexed: 12/25/2022]
Abstract
BACKGROUND Diagnostic laparoscopy is the ultimate diagnostic tool to evaluate the appendix. Still, according to the literature, this strategy results in a negative appendectomy rate of approximately 12-18 % and associated morbidity. Laparoscopic criteria for determining appendicitis are lacking. The goal of this study is to define clear and reliable criteria for appendicitis during diagnostic laparoscopy that eventually may safely reduce the negative appendectomy rate. METHODS From December 2009 through April 2011, 134 patients were included and analysed in a single-centre prospective pilot study. Intraoperatively, the appendix was evaluated by the surgeon according to nine criteria for appendicitis. The operating surgeon decided whether it should be removed or not. Immediately after the operation the surgeon had to complete a questionnaire on nine criteria for appendicitis. All removed appendices were examined by a pathologist. In case the appendix was not removed, the clinical postoperative course was decisive for the (missed) presence of appendicitis. RESULTS In 109 cases an inflamed appendix was removed; in 25 patients the appendix was normal, 3 of which had been removed. After univariate analysis and clinical judgement six variables were included in the Laparoscopic APPendicitis score (LAPP score). In this study, use of the LAPP score would have led to a positive predictive value of 99 % and a negative predictive value of 100 %. CONCLUSIONS This study presents the LAPP score. The LAPP score is an easily applicable score that can be used by surgeons to evaluate the appendix during diagnostic laparoscopy. The score has high positive and negative predictive value. The LAPP score needs to be validated in a multicentre validation study.
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Rud B, Olafsson L, Vejborg TS, Wilhelmsen M, Reitsma JB, Rappeport ED, Wille-Jørgensen P. Diagnostic accuracy of Computed Tomography for Appendicitis in Adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009977] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Bo Rud
- Bispebjerg Hospital; Department of Surgical Gastroenterology K; 23 Bispebjerg Bakke Copenhagen NV Denmark DK 2400
| | - Lydur Olafsson
- Bispebjerg Hospital; Department of Surgical Gastroenterology K; 23 Bispebjerg Bakke Copenhagen NV Denmark DK 2400
| | - Thomas S Vejborg
- Bispebjerg Hospital, University of Copenhagen; Department of Radiology R; 23 Bispebjerg Bakke Copenhagen Denmark DK 2400 NV
| | - Michael Wilhelmsen
- Bispebjerg Hospital; Department of Surgical Gastroenterology K; 23 Bispebjerg Bakke Copenhagen NV Denmark DK 2400
| | - Johannes B Reitsma
- University Medical Center Utrecht; Julius Center for Health Sciences and Primary Care; PO Box 85500 Utrecht Netherlands 3508 GA Utrecht
| | - Eli D Rappeport
- Bispebjerg Hospital, University of Copenhagen; Department of Radiology R; 23 Bispebjerg Bakke Copenhagen Denmark DK 2400 NV
| | - Peer Wille-Jørgensen
- Bispebjerg Hospital; Department of Surgical Gastroenterology K; 23 Bispebjerg Bakke Copenhagen NV Denmark DK 2400
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Jones GE, Kreckler S, Shah A, Stechman MJ, Handa A. Increased use of laparoscopy in acute right iliac fossa pain - is it good for patients? Colorectal Dis 2012; 14:237-42. [PMID: 21689285 DOI: 10.1111/j.1463-1318.2011.02576.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM The use of laparoscopy, with or without appendicectomy, is becoming more common in the management of acute right iliac fossa (RIF) pain, but little is known of the 'unintended' consequences of this change. This study aimed to evaluate the impact of increased use of laparoscopy on the number and type of patients treated surgically and on the rate of negative appendicectomy. METHOD A prospective audit was carried out of admissions to a teaching hospital over two, 3-month periods during 2007 and 2008. The management, investigations and outcome of patients presenting with RIF pain were studied. RESULTS Admissions were stable over the two time-periods. There was a significant increase in the number of laparoscopic operations performed, from 22.5% (14/62) in 2007 to 85.7% (72/84) in 2008 (P < 0.0001), and the percentage of patients undergoing surgery rose from 55.4% (n = 62) in 2007 to 71.2% (n = 84) in 2008 (P < 0.01). In 2008, female patients were more likely to have surgery, an increase from 37.1% to 66.2% (P < 0.001), and were more likely to have a laparoscopic procedure, an increase from 50% to 98% (P < 0.0001). The rate of histologically confirmed appendicitis did not increase significantly (50/122 vs 57/118; P = 0.25), but the number of patients with a normal appendix either left in situ because it was macroscopically normal or found to be histologically normal following excision, increased significantly, from 9.01% in 2007 to 21.2% in 2008 (P < 0.01). The diagnostic value of pelvic ultrasound decreased from 75.6% of examinations in 2007 to 54.5% in 2008 (P = 0.039). CONCLUSION An increase in laparoscopic procedures has resulted in more operations in women, an associated higher negative appendicectomy rate and decreased usefulness of pelvic ultrasound. Increased use of laparoscopy needs to be balanced against the diagnostic benefits of 'negative' laparoscopy.
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Affiliation(s)
- G E Jones
- Department of Surgery, John Radcliffe Hospital, Oxford, UK.
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Raman SP, Fishman EK. Imaging: Multidetector CT in the diagnosis of suspected appendicitis. Nat Rev Gastroenterol Hepatol 2011; 8:607-9. [PMID: 21931366 DOI: 10.1038/nrgastro.2011.171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
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Gaitán HG, Reveiz L, Farquhar C. Laparoscopy for the management of acute lower abdominal pain in women of childbearing age. Cochrane Database Syst Rev 2011:CD007683. [PMID: 21249692 DOI: 10.1002/14651858.cd007683.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute lower abdominal pain is common and making a diagnosis is particularly challenging in premenopausal woman as ovulation and menstruation symptoms overlap with the symptoms of appendicitis and pelvic infection. A management strategy involving early laparoscopy could potentially provide a more accurate diagnosis, earlier treatment and reduced risk of complications. OBJECTIVES To evaluate the effectiveness and harms of laparoscopy for the management of acute lower abdominal pain in women of childbearing age. SEARCH STRATEGY The Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, LILACS and CINHAL were searched (to April 2010). SELECTION CRITERIA Randomised controlled trials (RCTs) that included women of childbearing age who presented with acute lower abdominal pain, nonspecific lower abdominal pain or suspected appendicitis were included. DATA COLLECTION AND ANALYSIS Data from studies that met the inclusion criteria were independently extracted by two authors and the risk of bias assessed. MAIN RESULTS Laparoscopy was compared with open appendicectomy in eight RCTs. Laparoscopy was associated with an increased rate of specific diagnoses (7 RCTs, 561 participants; OR 4.10, 95% CI 2.50 to 6.71; I(2) 18%) but there was no evidence of reduced rate for any adverse event (8 RCTs, 623 participants; OR 0.46, 95% CI 0.19 to 1.10; I(2) 0%).Laparoscopic diagnosis versus a 'wait and see' strategy was investigated in four RCTs. There was a significant difference favouring laparoscopy in the rate of specific diagnoses (4 RCTs, 395 participants; OR 6.07, 95% CI 1.85 to 29.88; I(2) 79%) but there was no evidence of a difference in the rates of adverse events (OR 0.87, 95% CI 0.45 to 1.67; I(2) 0%). AUTHORS' CONCLUSIONS The advantages of laparoscopy in women with nonspecific abdominal pain and suspected appendicitis include a higher rate of specific diagnoses being made and a lower rate of removal of normal appendices compared to open appendicectomy only. Hospital stays were shorter. There was no evidence of an increase in adverse events with any of the strategies.
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Affiliation(s)
- Hernando G Gaitán
- Universidad Nacional de Colombia, Calle 119a # 18-14 (502), Bogota, Colombia
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Toorenvliet BR, Wiersma F, Bakker RFR, Merkus JWS, Breslau PJ, Hamming JF. Routine ultrasound and limited computed tomography for the diagnosis of acute appendicitis. World J Surg 2011; 34:2278-85. [PMID: 20582544 PMCID: PMC2936677 DOI: 10.1007/s00268-010-0694-y] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Acute appendicitis continues to be a challenging diagnosis. Preoperative radiological imaging using ultrasound (US) or computed tomography (CT) has gained popularity as it may offer a more accurate diagnosis than classic clinical evaluation. The optimal implementation of these diagnostic modalities has yet to be established. The aim of the present study was to investigate a diagnostic pathway that uses routine US, limited CT, and clinical re-evaluation for patients with acute appendicitis. Methods A prospective analysis was performed of all patients presenting with acute abdominal pain at the emergency department from June 2005 until July 2006 using a structured diagnosis and management flowchart. Daily practice was mimicked, while ensuring a valid assessment of clinical and radiological diagnostic accuracies and the effect they had on patient management. Results A total of 802 patients were included in this analysis. Additional radiological imaging was performed in 96.3% of patients with suspected appendicitis (n = 164). Use of CT was kept to a minimum (17.9%), with a US:CT ratio of approximately 6:1. Positive and negative predictive values for the clinical diagnosis of appendicitis were 63 and 98%, respectively; for US 94 and 97%, respectively; and for CT 100 and 100%, respectively. The negative appendicitis rate was 3.3%, the perforation rate was 23.5%, and the missed perforated appendicitis rate was 3.4%. No (diagnostic) laparoscopies were performed. Conclusions A diagnostic pathway using routine US, limited CT, and clinical re-evaluation for patients with acute abdominal pain can provide excellent results for the diagnosis and treatment of appendicitis.
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Affiliation(s)
- Boudewijn R Toorenvliet
- Department of Surgery, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
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Rodríguez Cuellar E, Gutiérrez Andreu M, Gómez Rodríguez P, Alcalde Escribano J, De La Cruz Vigo F. [Impact of imaging tests on the negative appendectomy rate]. ACTA ACUST UNITED AC 2010; 25:188-92. [PMID: 20227901 DOI: 10.1016/j.cali.2009.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Revised: 11/16/2009] [Accepted: 12/23/2009] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Negative appendectomies and perforated appendectomies have traditionally been quality indicators in surgery. The aim of this study is to analyze the emergency appendectomies in our hospital regarding the use of imaging tests and a review of the literature to analyze the quality of diagnosis in acute appendicitis. MATERIAL AND METHODS Retrospective study including all patients operated on for suspected acute appendicitis at a single institution for one year (2007). Data gathered from histology and imaging tests reports. Analysis of the histology results, imaging test used and its diagnostic accuracy. Comparison with quality levels published in the international literature. RESULTS A total of 394 patients were included in the study, the overall rate of negative appendectomy was 9.6%. Abdominal ultrasound (AU) was performed on 54.6% of patients and abdominal CT-scan on 10.2% of them, and 4.2% of the patients had both tests. AU positive predictive value was 82%. CT-scan positive predictive value was 97%. CONCLUSION The negative appendectomy rate (9.6%) in our centre shows values lower than the published ones in historical series but superior to the one published recently in the USA. The use of imaging tests in our hospital is lower than the one published in the USA, although similar to data reported in other European countries.
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Affiliation(s)
- E Rodríguez Cuellar
- Servicio de Cirugía General A, Hospital Universitario 12 de Octubre, Madrid, España.
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Kao LS, Tsao KJ. Serum markers in acute appendicitis. J Surg Res 2009; 164:69-71. [PMID: 20189591 DOI: 10.1016/j.jss.2009.11.716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 11/04/2009] [Accepted: 11/18/2009] [Indexed: 11/15/2022]
Affiliation(s)
- Lillian S Kao
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas 77026, USA.
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Beltran MA, Mendez PE, Barrera RE, Contreras MA, Wilson CS, Cortes VJ, Cruces KS. Is hyperbilirubinaemia in appendicitis a better predictor of perforation than C-reactive protein? - a prospective study. Indian J Surg 2009; 71:265-72. [PMID: 23133170 DOI: 10.1007/s12262-009-0074-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 03/25/2009] [Indexed: 12/26/2022] Open
Abstract
PURPOSE To compare the performance for the prediction of perforated appendicitis of total bilirubin versus C-reactive protein (CRP), white blood cell count, the time period of symptoms' evolution, and systemic inflammatory response syndrome (SIRS). METHODS Prospective observational study, applying receiver operating characteristics curve analysis to compare the sensitivity and specificity of the tested variables. RESULTS The period of symptom's evolution was prolonged (105.2 ± 79.3 hours vs. 38.6 ± 17.5 hours), and CRP levels were higher in perforated appendicitis (176 ± 82.6 mg/l vs. 80 ± 76 mg/l). Most patients with perforated appendicitis had a SIRS score higher than 3 points. CRP (>76.7 mg/l), the time period of symptoms' evolution (>34.5 hours), and SIRS (3 points or more), were the best cutoff values to predict perforated appendicitis. CONCLUSIONS Perforated appendicitis may be suspected based on CRP, SIRS and the time period of symptoms' evolution. We do not recommend the use of total bilirubin to predict perforation in appendicitis.
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Affiliation(s)
- Marcelo A Beltran
- Department of Surgery, Emergency Unit, Universidad Catolica Del Norte, Hospital De La Serena, La Serena, Chile
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COBBEN LP, BAKKER OJ, PUYLAERT JB, KINGMA LM, BLICKMAN JG. Imaging of patients with clinically suspected appendicitis in the Netherlands: conclusions of a survey. Br J Radiol 2009; 82:482-5. [DOI: 10.1259/bjr/31522537] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Cobben L, Groot I, Kingma L, Coerkamp E, Puylaert J, Blickman J. A simple MRI protocol in patients with clinically suspected appendicitis: results in 138 patients and effect on outcome of appendectomy. Eur Radiol 2009; 19:1175-83. [PMID: 19137303 DOI: 10.1007/s00330-008-1270-9] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2008] [Accepted: 10/26/2008] [Indexed: 02/07/2023]
Abstract
To establish the value of breathhold magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis. Over a 14-month period, 138 patients clinically suspected of having appendicitis were evaluated prospectively with MRI and comprised the study group. Fast turbo spin-echo breathhold T1, T2 and T2 fat suppression sequences were used in coronal and axial planes. The imaging results were recorded separately and subsequently correlated with clinical, radiological and histopathological follow-up. The effect of imaging strategies in patients suspected of appendicitis on hospital resources was calculated. Sixty-two of the 138 patients had a histopathologically proven appendicitis. MRI determined appendicitis in 63 patients, with one examination being false positive. The resulting sensitivity and specificity were 100% and 99%, respectively. MRI showed an alternative diagnosis in 41 of the 75 remaining patients. In 22 of the remaining 34 patients, a normal appendix was depicted with MRI. In two patients, where MRI showed no appendicitis, an alternative diagnosis or normal appendix, an unnecessary appendectomy was performed. The overall effect of using MRI in patients suspected of appendicitis on the use of hospital resources could have been a net saving between 55,746 euros and 72,534 euros. MRI has a high accuracy in detecting and excluding appendicitis, an alternative diagnosis or showing the normal appendix, and can be a valuable and cost-effective tool in the workup of patients clinically suspected of having appendicitis.
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Affiliation(s)
- Lodewijk Cobben
- Department of Radiology, Medisch Centrum Haaglanden, Burgemeester Banninglaan 1, 2262BA Leidschendam, The Netherlands.
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Konstantinidis KM, Anastasakou KA, Vorias MN, Sambalis GH, Georgiou MK, Xiarchos AG. A Decade of Laparoscopic Appendectomy: Presentation of 1026 Patients with Suspected Appendicitis Treated in a Single Surgical Department. J Laparoendosc Adv Surg Tech A 2008; 18:248-58. [PMID: 18373452 DOI: 10.1089/lap.2006.0209] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
| | - Kornilia A. Anastasakou
- Department of General, Laparoscopic, and Robotic Surgery, Athens Medical Center, Athens, Greece
| | - Michael N. Vorias
- Department of General, Laparoscopic, and Robotic Surgery, Athens Medical Center, Athens, Greece
| | - George H. Sambalis
- Department of General, Laparoscopic, and Robotic Surgery, Athens Medical Center, Athens, Greece
| | - Michael K. Georgiou
- Department of General, Laparoscopic, and Robotic Surgery, Athens Medical Center, Athens, Greece
| | - Anastasios G. Xiarchos
- Department of General, Laparoscopic, and Robotic Surgery, Athens Medical Center, Athens, Greece
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Garbarino S, Shimi SM. Routine diagnostic laparoscopy reduces the rate of unnecessary appendicectomies in young women. Surg Endosc 2008; 23:527-33. [DOI: 10.1007/s00464-008-9855-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Revised: 01/17/2008] [Accepted: 02/02/2008] [Indexed: 12/22/2022]
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Puig S, Staudenherz A, Felder-Puig R, Paya K. Imaging of Appendicitis in Children and Adolescents: Useful or Useless? A Comparison of Imaging Techniques and a Critical Review of the Current Literature. Semin Roentgenol 2008; 43:22-8. [DOI: 10.1053/j.ro.2007.08.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Liu K, Ahanchi S, Pisaneschi M, Lin I, Walter R. Can Acute Appendicitis be Treated by Antibiotics Alone? Am Surg 2007. [DOI: 10.1177/000313480707301118] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Emergency appendectomy at presentation has been the standard of care for acute appendicitis. We examined the use of antibiotics as an alternative treatment. From September 2002 to August 2003, 170 consecutive patients diagnosed with acute appendicitis without abscess were reviewed retrospectively. Patients were divided into two groups: Group I (n = 151) underwent emergency appendectomy and Group II (n = 19) received antibiotics alone. The mode of treatment was at the attending surgeon's discretion. The overall complication rate was eight per cent for Group I and 10 per cent for Group II patients ( P = 0.22). Group II patients suffered no complications during antibiotic treatment, and any complications that did occur developed after subsequent appendectomy. One Group II patient had recurrent appendicitis (5%). The length of stay was 2.61 ± 0.21 days for Group I and 2.95 ± 0.38 days for Group II patients ( P = 0.57). Patients with acute appendicitis may be treated safely with antibiotics alone without emergency appendectomy.
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Affiliation(s)
- Katherine Liu
- Hospital of Cook County, Chicago, Illinois
- Rush University Medical Center, Chicago, Illinois
| | - Sadie Ahanchi
- Chicago Medical School at Rosalind Franklin University, Chicago, Illinois; and, Chicago, Illinois
| | - Mark Pisaneschi
- Hospital of Cook County, Chicago, Illinois
- University of Illinois at Chicago, Chicago, Illinois
| | - Irene Lin
- Hospital of Cook County, Chicago, Illinois
| | - Robert Walter
- Hospital of Cook County, Chicago, Illinois
- Rush University Medical Center, Chicago, Illinois
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Musunuru S, Chen H, Rikkers LF, Weber SM. Computed tomography in the diagnosis of acute appendicitis: definitive or detrimental? J Gastrointest Surg 2007; 11:1417-21; discussion 1421-2. [PMID: 17701439 DOI: 10.1007/s11605-007-0268-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Accepted: 07/19/2007] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Utilization of computed tomography (CT) scans in patients with presumed appendicitis was evaluated at a single institution to determine the sensitivity of this diagnostic test and its effect on clinical outcome. METHODS Adult patients (age > 17 years) with appendicitis were identified from hospital records. Findings at surgery, including the incidence of perforation, were correlated with imaging results. RESULTS During a 3-year period, 411 patients underwent appendectomy for presumed acute appendicitis at our institution. Of these patients, 256 (62%) underwent preoperative CT, and the remaining 155 (38%) patients did not have imaging before the surgery. The time interval between arrival in the emergency room to time in the operating room was longer for patients who had preoperative imaging (8.2 +/- 0.3 h) compared to those who did not (5.1 +/- 0.2 h, p < 0.001). Moreover, this possible delay in intervention was associated with a higher rate of appendiceal perforation in the CT group (17 versus 8%, p = 0.017). CONCLUSIONS Preoperative CT scanning in patients with presumed appendicitis should be used selectively as widespread utilization may adversely affect outcomes. The potential negative impact of CT imaging includes a delay in operative intervention and a potentially higher perforation rate.
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Affiliation(s)
- Sandeepa Musunuru
- Department of Surgery, University of Wisconsin, H4/752 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
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Beltrán MA, Almonacid J, Vicencio A, Gutiérrez J, Cruces KS, Cumsille MA. Predictive value of white blood cell count and C-reactive protein in children with appendicitis. J Pediatr Surg 2007; 42:1208-14. [PMID: 17618882 DOI: 10.1016/j.jpedsurg.2007.02.010] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Few studies have addressed the predictive value of white blood cells (WBCs) and C-reactive protein (CRP) at different cutoff values in appendicitis. Our purpose was to determine the cutoff values for WBC and CRP at different periods during clinical evolution of appendicitis and to establish their use for the diagnosis of appendicitis and differentiation of simple from perforated appendicitis. METHODS We studied 198 patients operated on for appendicitis, which were further divided into 4 subgroups according to the time from the onset of symptoms to diagnosis. Receiver operating characteristic curves were constructed for CRP and WBC; the best cutoff points were used to calculate the sensitivity and specificity to discriminate patients with and without appendicitis and patients with simple and perforated appendicitis. RESULTS White blood cell and CRP individually and together had a high sensitivity to differentiate patients with and without appendicitis. The specificity of WBC and CRP taken individually and together to differentiate patients with simple and perforated appendicitis was high, but the sensitivity was low. CONCLUSIONS White blood cell and CRP could be used to support the clinical diagnosis of appendicitis, and, depending on the time from the onset of symptoms to diagnosis, to differentiate patients with and without appendicitis and discriminate simple from perforated appendicitis.
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Affiliation(s)
- Marcelo A Beltrán
- Department of Surgery and Emergency Unit, Hospital de Ovalle, Ovalle IV Region, Chile.
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Livingston EH, Woodward WA, Sarosi GA, Haley RW. Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management. Ann Surg 2007; 245:886-92. [PMID: 17522514 PMCID: PMC1876946 DOI: 10.1097/01.sla.0000256391.05233.aa] [Citation(s) in RCA: 278] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Appendicitis has been declining in frequency for several decades. During the past 10 years, its preoperative diagnosis has been made more reliable by improved computed tomography (CT) imaging. Thresholds for surgical exploration have been lowered by the increased availability of laparoscopic exploration. These innovations should influence the number of appendectomies performed in the United States. We analyzed nationwide hospital discharge data to study the secular trends in appendicitis and appendectomy rates. METHODS All appendicitis and appendiceal operations reported to the National Hospital Discharge Survey (NHDS) 1970-2004 were classified as perforated, nonperforated, negative, and incidental appendectomies and analyzed over time and by various demographic measures. Secular trends in the population-based incidence rates of nonperforated and perforated appendicitis and negative and incidental appendectomy were examined. RESULTS Nonperforated appendicitis rates decreased between 1970 and 1995 but increased thereafter. The 25-year decreasing trend was accounted for almost entirely by a decreasing incidence in the 10-19 year age group. The rise after 1995 occurred in all age groups above 5 years and paralleled increasing rates of CT imaging and laparoscopic surgery on the appendix. Since 1995 the negative appendectomy rate has been falling, especially in women, and incidental appendectomies, frequent in prior decades, have been rarely performed. Despite these large changes, the rate of perforated appendicitis has increased steadily over the same period. Although perforated and nonperforated appendicitis rates were correlated in men, they were not significantly correlated in women nor were there significant negative correlations between perforated and negative appendectomy rates. CONCLUSION The 25-year decline in nonperforated appendicitis and the recent increase in appendectomies coincident with more frequent use of CT imaging and laparoscopic appendectomies did not result in expected decreases in perforation rates. Similarly, time series analysis did not find a significant negative relationship between negative appendectomy and perforation rates. This disconnection of trends suggests that perforated and nonperforated appendicitis may have different pathophysiologies and that nonoperative management with antibiotic therapy may be appropriate for some initially nonperforated cases. Further efforts should be directed at identifying preoperative characteristics associated with nonperforating appendicitis that may eventually allow surgeons to defer operation for those cases of nonperforating appendicitis that have a low perforation risk.
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Affiliation(s)
- Edward H Livingston
- Department of Surgery, Divisions of Gastrointestinal and Endocrine Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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Ekeh AP, Wozniak CJ, Monson B, Crawford J, McCarthy MC. Laparoscopy in the contemporary management of acute appendicitis. Am J Surg 2007; 193:310-3; discussion 313-4. [PMID: 17320525 DOI: 10.1016/j.amjsurg.2006.09.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2006] [Revised: 09/20/2006] [Accepted: 09/20/2006] [Indexed: 01/07/2023]
Abstract
BACKGROUND We sought to compare laparoscopic appendectomy (LA) with open appendectomy (OA) focusing on the negative appendectomy rate (NAR), emergency department (ED) to operating room (OR) time, procedure length, and histopathological correlation. METHODS All appendectomies for appendicitis over a 6-year period at a single hospital were reviewed. Open and laparoscopic procedures were compared. RESULTS There were 1,312 appendectomies (54.6% OA and 45.4% LA) Mean ED to OR time was as follows: LA 10.8 hours (standard deviation [SD] +/- 9.0) versus 9.8 hours (SD +/- 8.5) OA (P = .0333). Mean OR time was 61.2 minutes (SD +/- 29.1) LA versus 57.7 minutes (SD +/- 28) OA (P = .0293). NAR was 18.3%, LA 23.3% versus 14.0% OA (P < .0001). Postoperative correlation with histopathology was 86% for LA versus 92% OA (P = .0003). In the LA group, 9.9% with a "normal" appendix had appendicitis by histopathology. CONCLUSIONS LA is associated with increased presentation to procedure time, operative time, and negative appendectomy rate. Removing a "normal" appendix during LA in the absence of alternate pathology is recommended.
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Affiliation(s)
- Akpofure Peter Ekeh
- Department of Surgery, Wright State University, CHE 7000, Miami Valley Hospital, 1 Wyoming Street, Dayton, OH 45459, USA.
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Influence of ultrasonography on clinical decision making in suspected acute appendicitis in adults. Eur Surg 2006. [DOI: 10.1007/s10353-006-0286-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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