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Bolmers MDM, de Jonge J, Bom WJ, van Rossem CC, van Geloven AAW, Bemelman WA. In-hospital Delay of Appendectomy in Acute, Complicated Appendicitis. J Gastrointest Surg 2022; 26:1063-1069. [PMID: 35048258 DOI: 10.1007/s11605-021-05220-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 10/14/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Present theory is that uncomplicated and complicated appendicitis are different entities. Recent studies suggest it is safe to delay surgery in patients with uncomplicated appendicitis. We hypothesize that patients with complicated appendicitis are at higher risk for postoperative complications when surgery is delayed. METHODS Data was used from the multicenter, prospective SNAPSHOT appendicitis study of 1975 patients undergoing surgery for suspected appendicitis. Adult patients (≥ 18 years) who underwent appendectomy for appendicitis were included in this study. The primary outcome was the difference in postoperative complications between patients with complicated appendicitis who were operated within and after 8 h after hospital presentation. Secondary outcomes were the incidence of both uncomplicated and complicated appendicitis in relationship to delay of appendectomy. Follow-up was 30 days. A multivariable analysis was performed. RESULTS Of 1341 adult patients with appendicitis, 34.3% had complicated appendicitis. In patients with complicated appendicitis, 22.8% developed a postoperative complication compared to 8.2% for uncomplicated appendicitis (P < 0.001). Delay in surgery (> 8 h) increased the complication rate in patients with complicated appendicitis (28.1%) compared to surgery within 8 h (18.3%; P = 0.01). Multivariate analysis showed a delay in surgery as an independent predictor for a postoperative complication in patients with complicated appendicitis (OR 1.71; 95%CI 1.01-2.68, P = 0.02). CONCLUSION In-hospital delay of surgery (> 8 h) in patients with complicated appendicitis is associated with a higher risk of a postoperative complication. It is important that we recognize and treat these patients early.
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Affiliation(s)
- M D M Bolmers
- Department of Surgery, Dijklander Hospital, Hoorn, The Netherlands. .,Department of Surgery, Tergooi Hospital, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands.
| | - J de Jonge
- Department of Surgery, Tergooi Hospital, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands
| | - W J Bom
- Department of Surgery, Tergooi Hospital, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands
| | - C C van Rossem
- Department of Surgery, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - A A W van Geloven
- Department of Surgery, Tergooi Hospital, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Moekotte J, Bos ME, Bolmers MDM. [A woman with an abdominal swelling after coughing]. Ned Tijdschr Geneeskd 2022; 166:D6698. [PMID: 35499610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
We present the case of a 79-year old woman with acute abdominal swelling and pain after coughing. She was in hemorrhagic shock and received blood transfusion after which hemodynamic stabilization occured. This case illustrates that a rectus sheath hematoma can be the (uncommon) cause of acute abdominal pain and shock.
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Affiliation(s)
- Jiri Moekotte
- Dijklander Ziekenhuis, Hoorn. Afd. Spoedeisende Hulp
- Contact: Jiri Moekotte
| | - Marly E Bos
- Dijklander Ziekenhuis, Hoorn. Afd. Spoedeisende Hulp
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Bolmers MDM, Bom WJ, Scheijmans JCG, van Geloven AAW, Boermeester MA, Bemelman WA, van Rossem CC. Accuracy of imaging in discriminating complicated from uncomplicated appendicitis in daily clinical practice. Int J Colorectal Dis 2022; 37:1385-1391. [PMID: 35583564 PMCID: PMC9167165 DOI: 10.1007/s00384-022-04173-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Radiologic imaging can accurately diagnose acute appendicitis, but little is known about its discriminatory capacity between complicated and uncomplicated appendicitis. OBJECTIVE This study aims to investigate the accuracy of imaging in discriminating complicated from uncomplicated appendicitis. METHODS Data was used from the prospective, nationwide, observational SNAPSHOT appendicitis database, including patients with suspected acute appendicitis who were planned for an appendectomy. Usage of ultrasound (US), CT, MRI or a combination was recorded. Radiological reports were used to group for complicated or uncomplicated appendicitis. The reference standard was based on operative and pathological findings. Primary outcomes were sensitivity and specificity in discriminating complicated from uncomplicated appendicitis. Secondary outcomes were diagnostic accuracy results per imaging modality and for the subgroups age, BMI, and sex. RESULTS Preoperative imaging was performed in 1964 patients. In 1434 patients (73%), only US was used; in 109 (6%) patients, only CT was used; and 421 (21%) patients underwent US followed by CT or MRI. Overall, imaging workup as practiced, following the national guideline, had a poor sensitivity for complicated appendicitis of only 35%, although specificity was as high as 93%. For US, accuracy for complicated appendicitis was higher in children than in adults; sensitivity 41.2% vs. 26.4% and specificity 94.6% vs. 93.4%, respectively, p = 0.003. For relevant subgroups such as age, sex and BMI, no other differences in the discriminatory performance were found. CONCLUSION A diagnostic workup with stepwise imaging, using a conditional CT or MRI strategy, poorly discriminates between complicated and uncomplicated appendicitis in daily practice.
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Affiliation(s)
| | - Wouter J. Bom
- Department of Surgery, UMC, Location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands ,Department of Surgery, Tergooi MC, Hilversum, The Netherlands
| | - Jochem C. G. Scheijmans
- Department of Surgery, UMC, Location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marja. A. Boermeester
- Department of Surgery, UMC, Location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - Willem A. Bemelman
- Department of Surgery, UMC, Location AMC, Amsterdam Gastroenterology & Metabolism, University of Amsterdam, Amsterdam, The Netherlands
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Bolmers MDM, de Jonge J, van Rossem CC, van Geloven AAW, Bemelman WA. Discrepancies between Intraoperative and Histological Evaluation of the Appendix in Acute Appendicitis. J Gastrointest Surg 2020; 24:2088-2095. [PMID: 31410818 DOI: 10.1007/s11605-019-04345-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 07/24/2019] [Indexed: 01/31/2023]
Abstract
PURPOSE To identify discrepancies between intraoperative and histological evaluations of the appendix in acute appendicitis and to evaluate the effect on surgical outcome. METHODS Data was used from our previous multicentre, prospective, cohort study of patients with suspected acute appendicitis. Appendices were scored during intraoperative and histological evaluation as uncomplicated or complicated appendicitis. Primary outcome was percentage of concordance between intraoperative and histological evaluation. Secondary outcomes were (infectious) postoperative complications, length of hospital stay, hospital re-admission and re-intervention rate, all within 30 days of surgery. RESULTS A total of 1850 patients were included. In 65.7% (1215/1850) of the appendices, the intraoperative evaluation was uncomplicated and in 34.3% (635/1850), complicated appendicitis. Patients with uncomplicated appendicitis had a postoperative course with significantly less postoperative complications (7.2% vs 24.3%), a shorter length of hospital stay (2 vs 5 days) and a lower re-admission (4.2% vs 9.6%) and re-intervention rate (1.1% vs 4.3%) than intraoperative complicated appendicitis (p < 0.001). In 93.5% (1136/1215) of the intraoperative uncomplicated patients and in 46.6% (296/635) of the intraoperative complicated patients, there was an agreement with pathology (Kappa 0.45). In 23.9% (81/339) of patients with intraoperative complicated and histological uncomplicated appendicitis, a postoperative complication was observed, which was similar to the postoperative complication rate of complicated appendicitis both on intraoperative and histological evaluation (24.7% (73/296)). CONCLUSIONS There is a moderate agreement between a surgeon and pathologist in diagnosing patients with complicated appendicitis. However, the intraoperative diagnosis of complicated appendicitis was significantly associated with postoperative complications. Routine histological evaluation should be preserved for excluding malignancies in suspect appendices.
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Affiliation(s)
- Matthijs D M Bolmers
- Department of Surgery, Tergooi Hospital Hilversum, 10016, 1213 XZ, Hilversum, The Netherlands
| | - Joske de Jonge
- Department of Surgery, Tergooi Hospital Hilversum, 10016, 1213 XZ, Hilversum, The Netherlands.
| | - Charles C van Rossem
- Department of Surgery, Maasstad Hospital Rotterdam, 9100, 3007 AC, Rotterdam, The Netherlands
| | - Anna A W van Geloven
- Department of Surgery, Tergooi Hospital Hilversum, 10016, 1213 XZ, Hilversum, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, 22660, 1105 AZ, Amsterdam, The Netherlands
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de Jonge J, Bolmers MDM, Musters GD, van Rossem CC, Bemelman WA, van Geloven AAW. Predictors for interval appendectomy in non-operatively treated complicated appendicitis. Int J Colorectal Dis 2019; 34:1325-1332. [PMID: 31175422 DOI: 10.1007/s00384-019-03303-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE To determine the incidence rate and identify predictive factors for interval appendectomy after non-operatively treated complicated appendicitis. METHODS Single-center retrospective cohort study conducted between January 2008 and June 2017. Adult patients with acute appendicitis were identified. Patients with complicated appendicitis initially treated non-operatively were included. Outcomes included abscess rate on imaging, results of additional imaging during follow-up, incidence rate of and surgical indications for interval appendectomy, and outcomes of histological reports. RESULTS Of all adult patients with acute appendicitis (n = 1839), 9% (170/1839) was initially treated non-operatively. Median age of these patients was 55 years (IQR 42-65) and 48.8% (83/170) were men. In 36.4% (62/170) of the patients, an appendicular abscess was diagnosed. 62.4% (106/170) did not require subsequent surgery (no interval appendectomy group) and in 37.6% (64/170), an interval appendectomy was performed (interval appendectomy group). Median follow-up was 80 weeks (17-192) and 113 weeks (34-246), respectively. Most frequent reason to perform subsequent surgery was recurrent appendicitis (45% (29/64)). Increasing age was significantly associated with a lower risk of undergoing interval appendectomy (OR 0.7; CI 0.6-0.89); p = 0.002). In the interval appendectomy group, appendicular neoplasm was found in 11% (7/64) of the patients, in contrast to 1.5% (25/1669) of the patients that had acute surgery (p < 0.001). CONCLUSIONS One out of three patients non-operatively treated for complicated appendicitis required an interval appendectomy. The incidence of appendicular neoplasms was high in these patients compared with those that had acute surgery. Therefore, additional radiological imaging following non-operatively treated complicated appendicitis is recommended.
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Affiliation(s)
- J de Jonge
- Department of Surgery, Tergooi Hospital Hilversum, P.O. Box 10016, 1201DA, Hilversum, The Netherlands.
| | - M D M Bolmers
- Department of Surgery, Tergooi Hospital Hilversum, P.O. Box 10016, 1201DA, Hilversum, The Netherlands
| | - G D Musters
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, 22660, 1105AZ, Amsterdam, The Netherlands
| | - C C van Rossem
- Department of Surgery, Maasstad Hospital Rotterdam, 9100, 3007AC, Rotterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, 22660, 1105AZ, Amsterdam, The Netherlands
| | - A A W van Geloven
- Department of Surgery, Tergooi Hospital Hilversum, P.O. Box 10016, 1201DA, Hilversum, The Netherlands
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van Rossem CC, Bolmers MDM, Schreinemacher MHF, Bemelman WA, van Geloven AAW, Pinkney TD, Bhangu A. Diagnosing acute appendicitis: surgery or imaging? Colorectal Dis 2016; 18:1129-1132. [PMID: 27454191 DOI: 10.1111/codi.13470] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 06/08/2016] [Indexed: 02/08/2023]
Abstract
AIM Investigation of suspected appendicitis varies widely across different countries, which creates variation in outcome for patients. Use of imaging drives much of this variation, with concerns over delay of imaging and radiation exposure of computed tomography being balanced against the risks of unnecessary surgery. METHOD Two national, prospective snapshot audits (UK n = 3326 and Netherlands n = 1934) reported investigation, management and outcome of appendicectomy and can be compared to generate treatment recommendations. RESULTS Preoperative imaging was conducted in 32.8% of UK patients in contrast to 99.5% of patients in the Netherlands. A large difference in the normal appendicectomy rate was observed (20.6% in the UK vs 3.2% in the Netherlands) and the connection between these two outcome differences cannot be neglected. CONCLUSION This article discusses the role of imaging in the diagnostic work-up of patients who are suspected of acute appendicitis, comparing national snapshot studies as a model to do so.
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Affiliation(s)
- C C van Rossem
- Department of Surgery, Tergooi Hospital, Hilversum, The Netherlands
| | - M D M Bolmers
- Department of Surgery, Tergooi Hospital, Hilversum, The Netherlands
| | | | - W A Bemelman
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - T D Pinkney
- Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - A Bhangu
- Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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