Can Salmonella typhi Cause Acute Appendicitis?

Salmonella typhi, commonly known for causing typhoid fever, is recognized as a bacterium responsible for a wide range of gastrointestinal and systemic infections. While its systemic manifestations have been well-documented, its association with localized gastrointestinal complications, such as appendicitis, remains relatively rare and less explored. This case report presents a compelling clinical case of a 55-year-old patient who presented with symptoms of gastrointestinal distress and was diagnosed with S. typhi-induced appendicitis. The patient's history, clinical presentation, laboratory investigations, radiological findings, management, and outcomes are thoroughly discussed. The report also touches upon the broader context of appendicitis etiology and highlights the significance of prompt diagnosis and intervention in cases of Salmonella-induced appendicitis.

Incidental appendicectomy in pancreas transplantation: A single-center study

BACKGROUND

Appendicitis in pancreatic transplant recipients can be challenging to diagnose and manage. Incidental appendicectomy (IA) during pancreas transplantation obviates the risk of appendicitis but potentially at the cost of increased operating time or early post-operative complications. This study reviewed the value of IA at a single center.

METHODS

This was a retrospective study of patients who underwent a pancreas transplant in our unit from January 1st, 2012 to December 31st, 2020, with end of follow-up on May 21st, 2023; recipients were grouped by whether or not an IA was performed during pancreas transplantation. Donor, recipient, operative, and graft outcomes were compared between the two groups. Post-transplant complications related to appendiceal pathology (or IA) were recorded and classified.

RESULTS

Two hundred forty-three patients underwent a pancreas transplant; 227 (93%) patients had an appendix in situ at transplantation, and of these 53 (23%) underwent an IA and 174 (77%) did not. There were no statistically significant differences in operative time (p = .06) or hospital stay (p = .50) between the two groups. In the IA cohort, there were no Clavien-Dindo Grade III-V complications relating to the appendicectomy. In those that did not undergo an IA, two patients (1%) subsequently required appendicectomy due to appendicitis. Comparison of pancreatic graft survival showed no statistically significant difference between the groups (p = .44).

CONCLUSIONS

This study suggests that IA is effective at reducing risks of post-transplant appendiceal complications without significantly prolonging inpatient stay or impairing graft survival. These data support the consideration of undertaking an IA for all patients undergoing a pancreas transplant.

Conservative Versus Surgical Management of Acute Appendicitis: A Systematic Review

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

The appendix in endometriosis

BACKGROUND

In the most severe stage of endometriosis, Stage IV, intestinal involvement is common. The true prevalence of endometriotic disease of the appendix in this population is not well described. A macroscopically normal looking appendix may harbour endometriosis.

AIMS

Our study aims to assess the role of routinely performing appendicectomy in Stage IV endometriosis surgery, and the histopathological prevalence of true appendiceal endometriosis in this population.

METHODS

This is a retrospective study of women undergoing surgery for Stage IV endometriosis between 2018 to 2022 in a tertiary public hospital in New South Wales, Australia. Patient demographics, age and post-operative complications were retrospectively retrieved from hospital medical records. Inclusion criteria were women with Stage IV endometriosis who underwent routine appendicectomy as part of their endometriosis surgery. Exclusion criteria were women who did not have Stage IV endometriosis, those who had cancer surgery or emergency surgery for endometriosis. The primary outcome of this study was to determine the incidence of appendiceal endometriosis. Secondary outcomes included post-operative complications and length of stay.

RESULTS

Sixty-seven patients were included. The mean age was 36 years. All patients also underwent bowel resection for colorectal endometriosis. There were 35.8% who had confirmed appendiceal endometriosis on histopathology. Post-operative complications included port site infections, colitis, urinary tract infection and ureteric injury. There were no complications related to appendicectomy. Mean length of stay was 4.4 days.

CONCLUSION

Laparoscopic appendicectomy can be safely performed at time of laparoscopic surgical excision of Stage IV endometriosis and should be routinely considered in a subset of Stage IV endometriosis patients with colorectal involvement undergoing surgery.

Prevalence of Neuroendocrine Tumours (NET) in Patients Undergoing Appendicectomy for Acute Appendicitis: A Tertiary Care Study

Introduction Acute appendicitis is one of the common causes of acute abdomen in adults, which is managed widely with appendicectomy. Neuroendocrine tumours are the most common appendiceal tumours diagnosed incidentally on appendicectomy specimens.  Methods  Demographic data, presenting complaints, indications for appendicectomy, and the histology findings based on histopathological reports of the patients who have undergone appendicectomy for appendicitis at surgical units of Teaching Hospital, Jaffna, from 1st of January 2019 to 31st of December 2022 were retrospectively analyzed.  Results Of the 1341 histopathology reports, 0.2% (n=3) were neuroendocrine tumours (NET). The mean age of the patients with NET was 48.6, and 66.6% of them were females. All three NETs identified in appendicectomy specimens were well differentiated and smaller than 2 cm. All three had negative resection margins and were managed only with appendicectomy.  Conclusion  NETs of the appendix are the commonest appendiceal neoplasms. The majority of them are diagnosed incidentally in appendicectomy specimens. Surgical management of the tumours is either by appendicectomy or hemicolectomy, which depends mainly on tumor size. Surgical decisions should be tailor-made to the patients based on multi-disciplinary team decisions.

Significance of Histopathology of Appendectomy Specimens: Analysis From a Teaching Hospital of Pakistan

Background Histopathology of a tissue specimen plays a crucial role in formulating the final diagnosis of any disease. It confirms whether the histopathological findings are in correspondence with the clinical diagnosis and thus suggests an optimal management plan. Standard surgical practices guide that every human tissue specimen must undergo postoperative tissue analysis unless indicated otherwise. Objective To determine the significance of histopathology in determining the final diagnosis of appendectomy specimens. Materials and methods This retrospective clinical study conducted in May 2022 included 100 patients operated for appendectomy from January 1, 2021, to December 31, 2021, in the emergency room of the Department of General Surgery, Unit-III, Lahore General Hospital, Lahore. Data were retrieved from patients' records and the picture archiving and communication system (PACS). A Google Forms-based pro forma (Google, Mountain View, CA) was generated to include the demographic details, clinical manifestations, and histopathology reports of the patients. Descriptive analysis was completed using a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA). Results Fifty-two patients were females out of the total 100. The mean age at presentation was 23.02 ± 12.02 years. Of the samples, 54% were not sent for histopathology. Among the remaining ones, 27% of cases were proven to be acute appendicitis. Alvarado score was 7-10 in 50% of patients. Other lesions proven by histopathology were appendiceal phlegmon (4%), perforated appendix (4%), mucocele (1%), carcinoid tumor (1%), tuberculosis (1%), and adenocarcinoma (1%). Conclusions Histopathological analysis is the gold standard for the tissue diagnosis of a disease. The high percentage of the samples not sent for histopathology is alarming since the appendix is not only a site for inflammatory pathologies but for neoplastic lesions as well. This practice depicts that the incidence of non-inflammatory pathologies is being ignored by healthcare professionals and there is a dire need to emphasize the significance of acquiring histopathology reports for the specimens of appendectomy in all circumstances.

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

OBJECTIVE

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

METHODS

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

DESIGN

Retrospective cohort study.

SETTING

Modified Monash category 3 (large rural town).

PARTICIPANTS

Patients aged 40 years and over undergoing appendicectomy for appendicitis.

MAIN OUTCOME MEASURES

Incidence of appendiceal neoplasm within appendicectomy specimen.

RESULTS

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

CONCLUSIONS

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

Is It Worth Considering Colonic Evaluation After Appendicectomy?

Introduction The association of acute appendicitis with caecal or colorectal cancer is known. One of the proposed theories for acute appendicitis is luminal blockage by mass at the base of the appendix. There have been no national recommendations or guidelines for follow-up with patients aged 40 and older after an emergency appendicectomy. The purpose of this study was to evaluate the prevalence of caecal and colonic cancer or polyps in patients over the age of 40 who have undergone an appendicectomy. This shall enable us to develop the necessary strategies to investigate and diagnose associated caecal and colonic pathology in acute appendicitis to prevent delayed diagnosis of colon cancer. Methods All patients who underwent appendicectomy between October 2011 and October 31, 2021, and who were 40 years of age or older were included in this retrospective cohort study. Patients aged 40 to 54 years old and patients 55 years or older underwent subgroup analyses. We looked at any investigations of the colon (CT pneumocolon or colonoscopy) within three years before the appendicectomy or three years after an appendicectomy. All colorectal cancers diagnosed within five years of the index episode of appendicitis were included in the analysis. Results A total of 1076 appendicectomies were performed on patients aged 40 and older during the study period of 10 years. A total of 769 patients were confirmed to have appendicitis on histology. One hundred and fifty-seven patients had colonic investigations within three years of the diagnosis of acute appendicitis. In our study, 51 of the 769 patients (6.63%) were found to have colorectal neoplasms. Eight patients (8/769, 1.04%) were diagnosed with colorectal cancers, and the occurrence of caecal cancer was 0.26% (2/769). The mortality rate was 75% (6/8) in these patients diagnosed with colorectal cancer. Four out of six died due to advanced metastatic colonic cancer. In comparison to patients aged 40 to 54, patients over the age of 55 had a statistically significant increased risk of caecal pathology (polyp and cancer) (p = 0.07). Conclusion There seems to be an increased risk of significant colorectal neoplasm in patients over the age of 55 who are admitted with acute appendicitis, and there appears to be an increased severity with a poor prognosis of cancer in these individuals. We recommend the use of routine colonoscopy or CT pneumocolon, particularly for those over the age of 55 who present with acute appendicitis or the histology of appendicular neoplasms.

A Case Report of Rare and Lethal Methicillin-Resistant Staphylococcus aureus (MRSA) Peritonitis in Infancy

Peritoneal inflammation without a discernible intraperitoneal source is referred to as primary peritonitis. Only 2% of pediatric acute abdominal crises are diagnosed preoperatively. Association with other infections is uncommon and is often limited to hepatic and urinary pathogens. Here, we describe a case of primary peritonitis in a one-month-old child who had laparotomy and appendicectomy as per the recommended treatment plan. There were no accompanying hepatic and urinary diseases. In this instance, methicillin-resistant Staphylococcus aureus (MRSA) was the responsible bacteria. The use of linezolid, as per the culture sensitivity report of intraperitoneal pus, ensured a smooth recovery in this case.

Paediatric negative appendicectomy rates at a regional Western Australian Centre: a five-year cohort study

BACKGROUND

In acute appendicitis, decision-making around operative intervention for paediatric patients differs from adults due to a higher weight placed on clinical assessment and reduced rates of cross-sectional imaging. In regional settings, non-paediatric emergency doctors, general surgeons, and radiologists usually assess and manage this patient group. Differences have been observed in paediatric negative appendicectomy rates between general and paediatric centres.

METHODS

A retrospective cohort study was performed, identifying paediatric patients undergoing emergency appendicectomy at the Southwest Health Campus (Bunbury, Western Australia) from 2017 to 2021. The primary outcome measure was histopathology confirming the absence of transmural inflammation of the appendix. In addition, clinical, biochemical and radiological data were collected to identify predictors of negative appendicectomy (NA). Secondary outcome measures were hospital length-of-stay and post-operative complication rates.

RESULTS

Four hundred and twenty-one patients were identified, of which 44.9% had a negative appendicectomy. Statistically significant associations between female gender, white cell count less than 10 × 109 , neutrophil ratio less than 75%, low CRP and NA were observed. NA was not associated with a lower risk of re-admission or complications compared with appendicectomy for appendicitis.

CONCLUSIONS

Our centre's NA rate is higher than that observed in the literature at both non-paediatric and paediatric surgical centres. NA has similar morbidity risk to appendicectomy for uncomplicated appendicitis and offers a timely reminder that diagnostic laparoscopy in children is not benign.

Management of acute appendicitis during COVID-19 pandemic. Single center data from a tertiary care hospital in Germany

Objectives

The unexpected global overload of the health system during COVID-19 pandemic has caused changes in management of acute appendicitis worldwide. Whereas conservative treatment was widely recommended, the appendicectomy remained standard therapy in Germany. We aimed to investigate the impact of COVID-19 pandemic on treatment routine for acute appendicitis at University Hospital of Magdeburg.

Methods

Adult patients with clinical and/or radiological diagnosis of acute appendicitis were included in the single center retrospective study. Data was collected to patient demographics, treatment modality and outcomes including morbidity and length of stay. The patient data related to COVID-19 period from March 22, 2020 to December 31, 2021 (649 days) were compared to the Non-COVID-19 period from June 12, 2018 to March 21, 2020 (649 days). Subgroup analysis related to conservative or surgical treatment has been performed.

Results

A total of 385 patients was included in the study, 203 (52.73 %) during Non-COVID-19 period and 182 (47.27 %) during COVID-19 period. Mean age of entire collective was 43.28 years, containing 43.9 % female patients (p=0.095). Conservative treatment was accomplished in 49 patients (12.7 % of entire collective), increasing from 9.9 % to 15.9 % during COVID-19 period (p=0.074). Laparoscopic appendicectomy was performed in 99.3 % (n=152) of operated patients during COVID-19 period (p=0.013), followed by less postoperative complications compared to reference period (23.5 % vs. 13.1 %, p=0.015). The initiation of antibiotic therapy after the diagnosis increased from 37.9 % to 53.3 % (p=0.002) during COVID-19 period regardless the following treatment modality. Antibiotic treatment showed shorter duration during pandemic period (5.57 days vs. 3.16 days, p<0.001) and it was given longer in the conservative treatment group (5.63 days vs. 4.26 days, p=0.02). The overall length of stay was shorter during COVID-19 period (4.67 days vs. 4.12 days, p=0.052) and in the conservative treatment group (3.08 days vs. 4.47 days, p<0.001). However, the overall morbidity was lower during the COVID-19 period than before (17.2 % vs. 7.7 %, p=0.005) and for conservative therapy compared to appendicectomy (2 % vs. 14.3 %, p=0.016). There was no mortality documented.

Conclusions

According to our findings the COVID-19 pandemic had a relevant impact on treatment of acute appendicitis, but it was possible to maintain the traditional diagnostic and treatment pathway. Although laparoscopic appendicectomy remains a recommended procedure, the conservative treatment of uncomplicated appendicitis with excellent short-term outcome can be a safe alternative to surgery during potential new wave of COVID-19 pandemic and in the daily routine.

The Rate of Negative Appendicectomy and Perforated Appendicitis As Quality Indicators of the General Surgical Service in a District General Hospital in Cavan, Republic of Ireland

Introduction Appendicitis is a common surgical condition that can be difficult to diagnose due to its varied clinical presentations. Surgical removal of the inflamed appendix is often necessary, and the appendix is sent for histopathological assessment to confirm the diagnosis. However, in some cases, the analysis may return a negative result for acute inflammation, known as a negative appendicectomy (NA). The definition of NA varies among experts. While negative appendicectomies are not ideal, they are accepted by surgeons to reduce the rate of perforated appendicitis, which can have severe consequences for patients. A study was conducted to investigate the rates of negative appendicectomies and their impact at a local district general hospital in Cavan, Republic of Ireland. Methods The study was conducted retrospectively from January 2014 to December 2019 on patients who were admitted with suspected appendicitis and underwent appendicectomy for appendicitis, regardless of age and sex. The researchers excluded patients who underwent elective, interval, and incidental appendicectomies. Data were collected on patient demographics, duration of symptoms prior to presentation, the intraoperative appearance of the appendix, and the histology results of the appendix specimens. Descriptive statistics and the Chi-squared test were used for data analysis with the help of IBM Statistical Package for the Social Sciences (SPSS) Version 26. Results The study retrospectively reviewed 876 patients who underwent an appendicectomy for suspected appendicitis between January 2014 and December 2019. The age distribution of patients was non-uniform, with 72% presenting before the third decade. The overall perforated appendicitis rate was 7.08%, and the overall negative appendicectomy (NA) rate was 21.3%. A subset analysis showed a statistically significant lower NA rate in females than in males. The NA rate decreased significantly over time and has been sustained since 2014 at around 10%, which is consistent with other published studies. The majority of the histology findings were uncomplicated appendicitis. Discussion This article discusses the challenges of diagnosing appendicitis and the need to reduce unnecessary surgeries. Laparoscopic appendectomy is the standard treatment, with an average cost of £2222.53 per patient in the UK. However, patients with negative appendicectomies (NA) have longer hospital stays and higher morbidity than uncomplicated cases, making it crucial to reduce unnecessary surgeries. The clinical diagnosis of appendicitis is not always straightforward, and the rate of perforated appendicitis increases with a longer duration of symptoms, particularly pain. The selective use of imaging in suspected appendicitis could reduce NA rates, but a statistical difference has not been proven. Scoring systems like the Alvarado score have limitations and cannot be relied upon alone. Retrospective studies have limitations, and biases and confounding variables must be considered. Conclusion The study found that a thorough investigation of patients, particularly with preoperative imaging, can decrease the rate of unnecessary appendectomies without increasing the rate of perforation. This could save costs and reduce harm to patients.

When Precision Meets Penmanship: ChatGPT and Surgery Documentation

ChatGPT (Chatbot Generative Pre-Trained Transformer) is an artificial intelligence with several potential applications in the field of medicine. As a large language model, it is particularly good at generating text. This study investigates the use of ChatGPT in constructing operation notes for laparoscopic appendicectomy, one of the most common surgical procedures in the UK. We prompted ChatGPT-4, the latest generation of ChatGPT, to produce operation notes for laparoscopic appendicectomy, which were then evaluated against 'Getting It Right First Time' (GIRFT) recommendations. GIRFT is an organisation that has collaborated with the National Health Service (NHS) to improve surgical documentation guidelines. Excluding certain items documented elsewhere in patient records, the generated notes were assessed against 30 key points in GIRFT recommendations. This process was repeated three times to obtain an average score. Our results showed that ChatGPT generated operation notes in seconds, with an average coverage of 78.8% (23.66 out of 30 points) of the GIRFT guidelines, surpassing average compliance with similar guidelines from the Royal College of Surgeons (RCS). However, the quality of ChatGPT's output was found to be dependent on the quality of the prompt, highlighting the need for verification of the generated content. Additionally, secure integration with electronic health records is required before ChatGPT can be adopted into the NHS.

Dr Google - assessing the reliability and readability of information on general surgical procedures found via search engines

BACKGROUND

The most common general surgical emergency operations are laparoscopic appendicectomy, laparoscopic cholecystectomy, hernia repair, hemorrhoidectomy and colectomy. Patients commonly perform an internet search for more information prior to undergoing surgery, which can lead to an inappropriate understanding of their procedure. The aim is to assess the quality of information available on three of the most used search engines.

METHODS

A search was conducted on Google.com, Bing.com and Yahoo.com using the terms related to laparoscopic appendicectomy, laparoscopic cholecystectomy, hemorrhoidectomy, hernia repair and colectomy. First 20 results from each search engine were collected for evaluation. Results were excluded if they were sponsored, duplicates, academic publications, advertisements, forums, audiovisual tools, social media or any non-English information. Included results were assessed for reliability using DISCERN and JAMA benchmark score. Readability was assessed using Flesch Reading Ease (FRE) Score and Simple Measure of Gobbledygook (SMOG).

RESULTS

Hundred and ninety-seven websites were analysed, 44.7% were published by institutions, 34.5% by health websites and 20.8% by independent surgeons. Mean DISCERN scores for Institutions was 54.6 ± 11.3, independent surgeons 45.9 ± 11.4 and health websites 58.7 ± 10.3. Mean JAMA score for Institutions was 1.0 ± 1.0, independent surgeons 0.1 ± 0.4 and health websites 1.7 ± 1.1. FRE scores for institutions was 51.6 ± 10.3, independent surgeons 40.9 ± 10.2, and health websites 45.7 ± 12.3. SMOG scores were 9.8 ± 1.5 for institutions, 11.4 ± 1.6 for independent surgeons and 10.6 ± 1.7 for health websites.

CONCLUSION

Health information on common general surgical procedures found on search engines are generally fair to good quality but still above the suggested reading level of the population. Information on surgical procedures should be written at recommended reading level of 13-14 years old.

Ultrasound-Guided Quadratus Lumborum Block Versus Transversus Abdominis Plane Block for Laparoscopic Inguinal Hernia Repair and Appendicectomy Using Ropivacaine With Dexmedetomidine

Background The present study aims to investigate the efficacy of ultrasound-guided quadratus lumborum (QL) block versus transversus abdominis plane (TAP) block for laparoscopic inguinal hernia repair and appendicectomy using ropivacaine with dexmedetomidine for quality and duration of postoperative analgesia. Settings and design This was a prospective, randomized, single-blind study conducted for one year (September 2020-August 2021) in the Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow, after obtaining ethical clearance from the institutional ethics committee. Methods A total of 64 patients of American Society of Anesthesiologists (ASA) grades I-II and ages between 20 and 50 years undergoing laparoscopic inguinal hernia repair and appendicectomy were randomly allocated into two groups of 32 each; group A received ultrasonography (USG)-guided quadratus lumborum block using 0.5% ropivacaine 20 ml with dexmedetomidine 0.5 mcg/kg of body weight, and group B was given USG-guided transversus abdominis plane block using 0.5% ropivacaine 20 ml with dexmedetomidine 0.5 mcg/kg of body weight after the induction of general anesthesia and before surgical incision. Data were analyzed using Student's t-test, Mann-Whitney U test, and chi-square test as applicable. Results The duration of analgesia was statistically higher (P<0.001) in group A (21.00±3.73 hours) as compared to group B (14.44±2.99 hours). Group A had significantly less analgesic (P<0.001) at 12, 18, and 24 hours postoperatively. The visual analog scale (VAS) was significantly decreased in group A at rest and movement. The range of percentage changes in heart rate (HR) was significantly higher in group B as compared to group A at 12, 18, and 24 hours (group A: 7.23%-14.70%; group B: 6.41%-28.01%). The mean blood pressure (MBP) was significantly increased in group B at 12, 18, and 24 hours as compared to group A. The range of changes in baseline MBP in group A was less than in group B (group A: 0.73%-8.34%; group B: 0.73%-18.20%). Conclusion Quadratus lumborum block is effective and better than transversus abdominis plane block for providing postoperative analgesia during laparoscopic inguinal hernia repair and appendicectomy.

Telemedicine versus face-to-face follow up in general surgery: a randomized controlled trial

BACKGROUND

Telemedicine provides healthcare to patients at a distance from their treating clinician. There is a lack of high-quality evidence to support the safety and acceptability of telemedicine for postoperative outpatient follow-up. This randomized controlled trial-conducted before the COVID-19 pandemic-aimed to assess patient satisfaction and safety (as determined by readmission, reoperation and complication rates) by telephone compared to face-to-face follow-up after uncomplicated general surgical procedures.

METHODS

Patients following laparoscopic appendicectomy or cholecystectomy and laparoscopic or open umbilical or inguinal hernia repairs were randomized to a telephone or face-to-face outpatient clinic. Patient demographics, perioperative details and postoperative outcomes were compared. Patient satisfaction was assessed via a standardized Likert-style scale.

RESULTS

One hundred and twenty-three patients were randomized over 12 months. Mean consultation times were significantly shorter for telemedicine than face-to-face clinics (telemedicine 10.52 ± 7.2 min, face-to-face 15.95 ± 9.96 min, P = 0.0021). There was no difference between groups in the attendance rates, nor the incidence or detection of postoperative complications. Of the 58 patients randomized to the telemedicine arm, 40% reported high, and 60% reported very high satisfaction with the method of clinic follow-up.

CONCLUSION

Telemedicine postoperative follow-up is safe and acceptable to patients and could be considered in patients undergoing uncomplicated benign general surgery.

Diverticulitis and Diverticulosis of the Appendix: A Case Series

Introduction Diverticula of the appendix is a rare entity, may be complicated by inflammation/infection, and clinically mimics acute appendicitis. The reported associated risk factors include male gender, Hirschprung's disease, cystic fibrosis and adult age, where some reports claim that they are also associated with an increased risk of appendiceal malignancy. Imaging has a place in pre-operative diagnosis, however, most of the cases were diagnosed during a pathological examination after surgery. They are associated with a higher rate of perforation (more than four times compared with classical acute appendicitis). In this review, we present a case series of five patients diagnosed with diverticulitis and one with diverticulosis of the appendix that were managed at a single centre. Our aim is to explore the common clinical, radiological, and intra-operative findings associated with this disease as well as the outcome of management. Materials and methods A total number of six cases of diverticular disease of the appendix diagnosed and managed at Basildon University hospital in the period between 2016 and 2020 were studied. The demographic details and clinical data including presenting symptoms, laboratory results, radiological characteristics, intraoperative findings and histopathological features were analysed. Results The study group included four males and two females, with an age range of 20-84 years. The most common presenting clinical symptoms were right iliac fossa abdominal pain, nausea, anorexia, and diarrhoea. Half of the cases showed a thickened appendix in the pre-operative CT scan. An inflamed or perforated appendix was seen in five cases as well as inflammation of the diverticula. Conclusion Appendiceal diverticulitis is an uncommon pathology that imitates acute appendicitis, and appendicectomy is the standard treatment. Prophylactic appendicectomy is recommended for non-inflamed diverticula - this is due to the potential risk of inflammation, perforation, and the risk of developing an appendiceal neoplasm.

The Role of Appendicectomy in Ulcerative Colitis: Systematic Review and Meta-Analysis

BACKGROUND

This updated systematic review and meta-analysis investigates the putative role of the appendix in ulcerative colitis as a therapeutic target.

METHODS

Ovid Medline, Embase, PubMed and CENTRAL were searched with MeSH terms ("appendectomy" OR "appendicitis" OR "appendix") AND ("colitis, ulcerative") through October 2020, producing 1469 references. Thirty studies, including 118 733 patients, were included for qualitative synthesis and 11 for quantitative synthesis. Subgroup analysis was performed on timing of appendicectomy. Results are expressed as odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

Appendicectomy before UC diagnosis reduces the risk of future colectomy (OR, 0.76; 95% CI, 0.65-0.89; I2 = 5%; P = .0009). Corresponding increased risk of colorectal cancer and high-grade dysplasia are identified (OR, 2.27; 95% CI, 1.11-4.66; P = .02). Significance is lost when appendicectomy is performed after disease onset. Appendicectomy does not affect hospital admission rates (OR, 0.87; 95% CI, 0.68-1.12; I2 = 93%; P = .27), steroid use (OR, 1.08; 95% CI, 0.78-1.49; I2 = 36%; P = .64), immunomodulator use (OR, 1.04; 95% CI, 0.76-1.42; I2 = 19%; P = .79), or biological therapy use (OR, 0.76; 95% CI, 0.44-1.30; I2 = 0%; P = .32). Disease extent and risk of proximal progression are unaffected by appendicectomy. The majority (71% to 100%) of patients with refractory UC avoid colectomy following therapeutic appendicectomy at 3-year follow-up.

CONCLUSIONS

Prior appendicectomy reduces risk of future colectomy. A reciprocal increased risk of CRC/HGD may be due to prolonged exposure to subclinical colonic inflammation. The results warrant further research, as consideration may be put toward incorporating a history of appendicectomy into IBD surveillance guidelines. A potential role for therapeutic appendicectomy in refractory left-sided UC is also identified.

Reduced number of admissions with acute appendicitis but not severe acute appendicitis at two Sydney hospitals during the first COVID-19 lockdown period

Background

This study investigated whether there was a change in acute appendicitis, appendicectomy admissions or disease severity during the 2020 lockdown period in NSW.

Methods

A retrospective before‐and‐after study was undertaken of patients admitted to two Sydney hospitals (St. Vincent's and Liverpool Hospitals) who had appendicectomy for presumed acute appendicitis and patients who had confirmed appendicitis but did not undergo surgery. Study periods were the 2020 lockdown period (15 March–15 May 2020), the corresponding period in the previous year, and the 1‐month after these periods. Patients were classified as having no, mild or severe appendicitis using operation and histopathological reports.

Results

(Thirty‐six percent) fewer patients were admitted with acute appendicitis during the lockdown period compared with the previous year with a substantial reduction in normal/mild appendicitis presentations (OR 0.56, 95% CI 0.34–0.93, P = 0.03). There were 46% fewer patients with mild appendicitis during lockdown (56) compared with the previous year (103); numbers of patients with severe appendicitis were very similar (46 vs. 51). There was no increase in number of admissions with severe appendicitis, or in the time from onset of symptoms to admission, in the month following lockdown.

Conclusion

Compared with the previous year, there were markedly fewer admissions with appendicitis during lockdown, with no evidence of a shift to more cases of severe appendicitis nor delayed presentation in the post‐lockdown period. It is plausible that some patients with mild appendicitis may have recovered without hospitalization, supporting the importance of implementing trials on non‐surgical management of appendicitis.

During COVID‐19 lockdown in Sydney we noted a reduction in hospital presentations with acute appendicitis but not severe acute appendicitis. Mild appendicitis may be able to be successfully managed in the outpatient setting.

Appendicitis in Far North Queensland: a new take on an old story

BACKGROUND

Appendicitis is a leading cause of surgical hospital admission. To date, there have been no published epidemiological studies describing appendicitis in tropical and remote Australia and none specifically documenting appendicitis in Indigenous Australians. This descriptive study used available state data to investigate appendicitis across Far North Queensland (FNQ).

METHODS

Queensland Health hospital admission data for FNQ was analysed to explore appendicitis epidemiology and outcomes in FNQ, 2012-2018. Population data for the same time period provided rates.

RESULTS

Over the study period, 3458 hospital presentations for appendicitis were available for analysis. Mean incidence was 178 per 100 000/yr. Median age was 27 years with 50.1% female patients. The annual rate of appendicitis was higher in the Indigenous population. Most patients had a laparoscopic procedure with a low rate of conversion to open surgery (2.6%). More than 80% of patients were discharged from hospital in less than 3 days. Intensive care (ICU) admission rate was low overall (1.1%) although higher for Indigenous people (2.4%). Following discharge, the hospital re-admission rate was 3.8% and all-cause mortality was 0.03%.

CONCLUSION

The incidence of appendicitis in FNQ is higher than that reported in the rest of Australia in both Indigenous and non-Indigenous populations. Despite logistical challenges of health care, clinical outcomes are in line with best practice across the country. Clinicians in FNQ should maintain a high index of suspicion for diagnosing appendicitis in rural and remote settings.

Prevalence of Carcinoma in Appendectomy Specimens for Patients Presenting With Acute Appendicitis: A Single-Center Study

Introduction Acute appendicitis is the most common general surgical emergency globally. Its etiology includes the presence of luminal obstruction by faecoliths, lymphoid hyperplasia, impacted stool, and rarely by appendiceal or caecal cancer. Malignancy related to acute appendicitis is usually seen in the older age group. Aim To identify the subset rate of patients operated for acute appendicitis who have appendiceal carcinoma and analyze the outcome of their post-operative management. Material and methods A retrospective study of a cohort of 529 patients aged > 40 diagnosed with acute appendicitis with subsequent appendectomy in the period between 1 January 2014 and 31 December 2019 at Basildon and Thurrock University Hospital, Essex, United Kingdom was conducted. We analyzed the clinical data of the cohort including demographic information, diagnosis, pre-operative imaging, histological diagnosis as well as post-operative management where indicated. Results The median age of patients was 54.5 years (range 40-92). The male to female ratio in the appendicectomy cohort was 1:1.1. About 45% were aged 40-49 years, 24.8% were aged 50-59 and 30.2% were ≥60 years. Post-operative histology revealed acute appendicitis in 82.4% of the group. In 11% of the patients, the histology revealed the presence of other benign pathology as mucocele of the appendix, acute diverticulitis, follicular hyperplasia, and fibrous obliteration. The diagnosis of appendicular malignancy was seen in 1.9%. Conclusion Incidental appendiceal cancers in the resected specimens after acute appendicitis are rare but may be associated with a poor prognosis. It is recommended to consider such diagnosis in particular when dealing with acute appendicitis in older patients with longer symptom history, and in presence of peri-appendicular mass.

Cost-Utility Analysis of Antibiotic Therapy versus Appendicectomy for Acute Uncomplicated Appendicitis

BACKGROUND

Current UK National Health Service (NHS) guidelines recommend appendicectomy as gold standard treatment for acute uncomplicated appendicitis. However, an alternative non-surgical management involves administrating antibiotic-only therapy with significantly lower costs. Therefore, a UK-based cost-utility analysis (CUA) was performed to compare appendicectomy with an antibiotic-only treatment from an NHS perspective.

METHODS

This economic evaluation modelled health-outcome data using the ACTUAA (2021) prospective multicentre trial. The non-randomised control trial followed 318 patients given either antibiotic therapy or appendicectomy, with quality of life (QOL) assessed using the SF-12 questionnaires administered 1-year post-treatment. A CUA was conducted over a 1-year time horizon, measuring benefits in quality adjusted life years (QALYs) and costs in pound sterling using a propensity score-matched approach to control for selection based on observable factors.

RESULTS

The CUA produced an incremental cost-effectiveness ratio (ICER) of -GBP 23,278.51 (-EUR 27,227.80) per QALY. Therefore, for each QALY gained using antibiotic-only treatment instead of appendicectomy, an extra GBP 23,278.51 was saved. Additionally, two sensitivity analyses were conducted to account for post-operative or post-treatment complications. The antibiotic-only option remained dominant in both scenarios.

CONCLUSION

While the results do not rely on a randomized sample, the analysis based on a 1-year follow-up suggested that antibiotics were largely more cost-effective than appendicectomy and led to improved QOL outcomes for patients. The ICER value of -GBP 23,278.51 demonstrates that the NHS must give further consideration to the current gold standard treatment in acute uncomplicated appendicitis.

Risk prediction score and appendicectomy in the elderly: A single centre 5-year retrospective cohort study

BACKGROUND

Appendicitis is a common surgical emergency that can be a challenging entity to manage. In the elderly, it is associated with significant morbidity and mortality. Risk prediction is not routinely performed prior to surgery.

METHODS

All patients aged >65 years undergoing appendicectomy over 5 years from one NHS Trust were included. Age, American Society of Anesthesiologists physical status classification system (ASA grade), Rockwood score, type of surgery, length of stay, morbidity and 90-day mortality were recorded. ACS NSQIP was retrospectively calculated. Spearman's Rank correlation coefficient and linear regression analysis were conducted, assessing correlation between ASA, Age, Rockwood Score and ACS NSQIP with length of stay and post-operative complications.

RESULTS

A total of 225 patient cases were reviewed. A complication rate of 29.3% was recorded, with a 6.7% serious complication rate. Two mortalities occurred. ASA, Age, Rockwood and NSQIP scoring systems all showed low degree positive correlation with length of stay (+0.16-+0.34). As predictors of length of stay, ASA was superior. Rockwood and age showed low degree positive correlation (+0.25-+0.33) with post-operative complications. NSQIP and ASA demonstrated a greater degree of correlation (+0.38-+0.40).

CONCLUSION

Both ASA and ACS NSQIP appear superior indicators for outcomes compared to age and Rockwood score. However, caution is warranted when interpreting the superiority of ASA over validated risk stratification tools. Therefore, we advocate the use of pre-operative risk stratification for elderly patients undergoing low-risk surgery such as appendicectomy. Validated tools are not routinely applied in many centres currently. Utilisation of scores such as ACS NSQIP may help improve consent, patient selection, outcomes and expectations.

Procedure of choice in a patient initially operated for a suspected epithelial appendiceal neoplasm

In patients operated for a suspected appendiceal neoplasm, radical appendectomy is the procedure of choice because it provides definitive treatment in most of appendiceal neoplasms, except from mucinous or colonic-type adenocarcinoma and NET>2 cm.

Johan Forceps As a Knot Pusher for Extracorporeal Roeder Knot: An Inexpensive Alternative to an Endoloop Ligature in Laparoscopic Appendicectomy

Background: Securing of the appendix stump is one of the key steps in performing laparoscopic appendicectomy (LA). This can be achieved by a variety of methods including endoloops, stapler, and clips. An alternative technique, previously described by authors, is the use of Johan forceps as a knot pusher, to deploy an extracorporeal Roeder knot at the base of appendix. We aimed to evaluate the safety and cost-effectiveness of our technique. Patients and Methods: A single surgeon's, prospective cohort, and multicenter study was undertaken at three different hospitals in the United Kingdom. We collected data of all patients, who underwent LA by this technique between 2014 and 2019. Demographics, operative findings, postoperative complications and readmissions were recorded and analyzed. Results: In total, 227 appendicectomies were performed. Median age was 24 years (interquartile range [IQR]: 16-58) with 58% male preponderance. Operative findings were 57% (n = 130) acutely inflammatory appendicitis, 16.74% (n = 38) were complicated appendicitis (perforated, gangrenous). Rest of the operative findings were macroscopically normal appendix (with no other pathology in 18.06% (n = 41), and macroscopically normal appendix but with gynecological pathologies in 7.9% (n = 18). Postoperatively, there were no cases to report complication of blow out stumps neither clinically nor radiologically. Surgical site infections rate has been 3.5% (n = 8). One patient had small intra-abdominal abscess (0.4%), treated by IV antibiotics. Mean hospital stay was 1.89 days (standard deviation [SD] 1-5 days). Thirty days readmissions rate was 4.8%. None of the complications or readmissions was related to the surgical technique. There were no deaths recorded in this series. Cost of handmade endoloop was $0.69. Conclusion: Use of Johan forceps as knot pusher for extracorporeal Roeder knot is a safe, feasible, cost-effective, and easily reproducible technique for carrying out LA.

Open Appendicectomy under Spinal Anesthesia-A Valuable Alternative during COVID-19

Introduction  Concerns relating to coronavirus disease 2019 (COVID-19) and general anesthesia (GA) prompted our department to consider that open appendicectomy under spinal anesthesia (SA) avoids aerosolization from intubation and laparoscopy. While common in developing nations, it is unusual in the United Kingdom. We present the first United Kingdom case series and discuss its potential role during and after this pandemic. Methods  We prospectively studied patients with appendicitis at a British district general hospital who were unsuitable for conservative management and consequently underwent open appendicectomy under SA. We also reviewed patient satisfaction after 30 days. This ran for 5 weeks from March 25th, 2020 until the surgical department reverted to the laparoscopic appendicectomy as the standard of care. Main outcomes were 30-day complication rates and patient satisfaction. Results  None of the included seven patients were COVID positive. The majority (four-sevenths) had complicated appendicitis. There were no major adverse (Clavien-Dindo grade III to V) postoperative events. Two patients suffered minor postoperative complications. Two experienced intraoperative pain. Mean operative time was 44 minutes. Median length of stay and return to activity was 1 and 14 days, respectively. Although four stated preference in hindsight for GA, the majority (five-sevenths) were satisfied with the operative experience under SA. Discussion  Although contraindications, risk of pain, and specific complications may be limiting, our series demonstrates open appendicectomy under SA to be safe and feasible in the United Kingdom. The technique could be a valuable contingency for COVID-suspected cases and patients with high-risk respiratory disease.

Emergency appendicectomy during COVID-19 pandemic - A single UK centre experience

Background - In December 2019 following an outbreak of Novel coronavirus infection (COVID-19) in Wuhan, China, it spread rapidly overwhelming the healthcare systems globally. With little knowledge of COVID-19 virus, very few published reports on surgical outcomes; hospitals stopped elective surgery, whilst emergency surgery was offered only after exhausting all conservative treatment modalities. This study presents our experience of outcomes of emergency appendectomies performed during the pandemic. Methods - Prospectively we collected data on 132 patients in peak pandemic period from 1st March to 5th June 2020 and data compared with 206 patients operated in similar period in 2019. Patient demographics, presenting symptoms, pre-operative events, investigations, surgical management, postoperative outcomes and complications were analysed. Results - Demographics and ASA grades of both cohorts were comparable. In study cohort 84.4% and 96.7% in control cohort had laparoscopic appendicectomy. Whilst the study cohort had 13.6% primary open operations, control cohort had 5.3%. Mean length of stay and early post-operative complications (&lt;30 days) were similar in both cohorts apart from surgical site infections (p = 0.02) and one mortality in study cohort. Conclusion - In these overwhelming pandemic times, although conservative treatment of acute appendicitis is an option, a proportion of patients will need surgery. Our study shows that with careful planning and strict theatre protocols, emergency appendicectomy can be safely offered with minimal risk of spreading COVID-19 infection. These observations warrant further prospective randomised studies. Keywords - appendicectomy, COVID-19, Coronavirus, emergency surgery, laparoscopy.

Surgical Versus Conservative Management of Acute Appendicitis During the COVID-19 Pandemic: A Single-Centre Retrospective Study

Introduction The COVID-19 pandemic provoked a change to normal surgical practice in the United Kingdom and led to an increase in acute appendicitis (AA) patients being treated conservatively with antibiotics. We aim to analyse the management of patients presenting with AA to our institution during the first wave of the pandemic, comparing surgically and conservatively managed patients. Method All patients presenting to our centre with AA between March and July 2020 were included. Six-month follow-up data were collected retrospectively using electronic records. Patients were categorised into surgically and conservatively managed groups. The primary outcome was the complication rate (post-operative complications vs failure of antibiotic treatment) and the secondary outcomes were length of hospital stay and Alvarado score. Results  Fifty-seven patients (n=57) were admitted with AA, 45.6% (n=26) managed conservatively compared to 54.4% (n=31) treated surgically. Higher complication rates were observed amongst the conservatively managed group, although not found to be statistically significant (16% vs 35%; p=0.131). There was no significant difference in length of hospital stay observed between the two groups (surgical: median, 2; interquartile range, 2-3 vs conservative: median, 3; interquartile range, 2-4). White cell count (WCC) and Alvarado score were higher on admission in the surgical group with statistical significance (p=0.012 and p=0.028, respectively). Conclusions COVID-19 has led to a significant cohort of conservatively managed AA patients in the United Kingdom. We propose a stratification pathway based on clinical severity, Alvarado score and imaging to facilitate safe selection for conservative management of AA, in order to reduce failure of treatment rates in this patient group. Further UK-based studies will add to the evidence-based surrounding safe management of AA with conservative treatment.

Duration of post-operative antibiotic treatment in acute complicated appendicitis: systematic review and meta-analysis

BACKGROUND

Appendicitis is the most frequent aetiology of acute abdominal pain requiring surgical treatment, with an estimated lifetime risk between 7% and 8%. Antibiotics play a substantial role in treatment, and there is considerable debate regarding the duration of antibiotics in treating appendicitis.

METHODS

We searched multiple databases from inception until June 2019 for peer-reviewed studies that compared different durations of antibiotic treatment after appendicectomy for acute complicated appendicitis in adults. We dichotomized reported data into short- and extended-term antibiotic use and controlled for different definitional thresholds in the meta-analysis. We generated risk ratios using restricted maximum likelihood methods and mixed effects modelling for each outcome of interest.

RESULTS

Four observational studies involving 847 participants were included in the meta-analysis. For the primary outcomes of intra-abdominal infection, we did not find a statistically significant difference between extended- and short-term antibiotic strategies for intra-abdominal infection (Risk ratio 0.92, 95% confidence interval (CI) 0.49-1.74). Three randomized controlled trials involving 291 participants were included in a separate meta-analysis. We found that extended antibiotic usage was not associated with a statistically significant reduced risk for intra-abdominal infection (RR 0.52, 95% CI 0.21-1.29) or surgical site skin infection (RR 1.44, 95% CI 0.43-4.81).

CONCLUSION

This systematic review and meta-analysis found that extended post-operative antibiotic treatment may not be associated with a reduced risk of intra-abdominal infection; however, meta-analysis was significantly limited by heterogeneity between studies and underpowered trials. Further large randomized controlled trials are needed to confirm these findings.

Comparative analysis of emergency general surgery on-call structure and its impact on emergency appendicectomy outcomes

BACKGROUND

In Australia, there has been a shift from the traditional 'on-call' surgical model to the 'acute surgical unit' (ASU) model to improve outcomes in acute general surgery. Using emergency appendicectomy as a standardized procedure, we aimed to identify the different patterns of care between these on-call structures by comparing two metropolitan district hospitals; one that employs a traditional on-call model and the other, which employ the ASU model.

METHODS

Data on consecutive patients undergoing emergency appendectomies at the two hospitals (traditional and ASU model) between July 2018 and December 2018 were retrieved for retrospective review. Patient factors, preoperative factors, operative factors and post-operative outcomes were collected and tabulated for comparative analysis between the traditional versus ASU model of care.

RESULTS

Univariate analysis demonstrated that there were a greater proportion of consultant-led cases (P < 0.001), a shorter time to theatre (P = 0.047) and a greater number of out-of-hours operations (P < 0.001) in the ASU model compared to the traditional model. A larger proportion of patients from the traditional model underwent a computed tomography scan as part of their diagnostic workup compared to the ASU model (P < 0.001). There was no difference in negative appendicectomy rates, intraoperative conversion rates, post-operative complication rates or mean lengths of hospital stay between the two on-call models.

CONCLUSION

The ASU and traditional on-call model appears to achieve equivalent care outcomes for patients with acute appendicitis.

Surgery in pregnancy: Identifying factors contributing to variation and delay in diagnosis and management of appendicitis in pregnancy

BACKGROUND

Suspected appendicitis is the most common indication for surgery for non-obstetric conditions during pregnancy. Delay in management increases the risk of appendiceal perforation and pregnancy loss. Stand-alone specialty obstetric hospitals often don't have surgical teams on site. It has been suspected that this may be a factor that leads to delayed diagnosis and management of non-obstetric surgical conditions in pregnancy.

AIMS

To assess the differences in time to diagnosis, imaging, surgical management and outcomes between a stand-alone tertiary obstetric hospital and a tertiary general hospital for pregnant patients presenting with suspected appendicitis who underwent an appendicectomy.

MATERIALS AND METHODS

A retrospective study of all women who underwent appendicectomy in pregnancy for suspected appendicitis over a four-year period.

RESULTS

Women who attended the specialist hospital were later in gestation (medians 29 weeks vs 18 weeks, P = 0.004) and less likely to have imaging (84% vs 56%, P = 0.047) with no difference in the rates of confirmation of diagnosis of appendicitis using imaging. Women who presented to the specialist hospital were more likely to be managed with a laparotomy, admitted to high dependency unit, have a longer hospital stay and tended to be later in gestation. There was no difference in rates of positive appendicectomies, appendiceal perforation or management in under the recommended 24 h.

CONCLUSIONS

The specialty obstetric hospital has a much higher rate of laparotomy and longer length of stay. The majority of patients presenting to both hospitals did not undergo surgery within 24 h and delay in imaging was a major contributor.

A Comparative Study Between Single-Incision Laparoscopic Appendicectomy Using Conventional Instruments and Glove-Port (SILACIG) and Conventional Multiport Laparoscopic Appendicectomy (CMLA)

Introduction

Appendicectomy is the most common surgical procedure. Conventional laparoscopic appendicectomy being time-tested, attempts were made to make it less invasive. Single-incision laparoscopic appendicectomy is the most recent trend. The present study is conducted with the aim to compare surgical outcomes between single-incision laparoscopic appendicectomy using conventional instruments and glove-port (SILACIG) with conventional multiport laparoscopic appendicectomy (CMLA).

Materials and methods

A total of 80 patients with appendicitis were recruited and underwent SILACIG (n=40) and CMLA (n=40). They were monitored for operative time, time of oral intake, pain on the second postoperative day, day of discharge, return to work, and scar size after two months.

Results

There was no significant difference between SILACIG and CMLA in terms of the time of oral intake, day of discharge, and return to work. Operative time was significantly more in the SILACIG group as compared to CMLA. Pain on the second postoperative day was less than CMLA, and the size of the operative scar was significantly smaller than 2 cm in the SILACIG group as compared to the CMLA group.

Conclusion

SILACIG is a feasible, safe, and cost-effective technique. It is comparable with CMLA in terms of preoperative diagnosis, postoperative oral intake, hospitalization period, and return to work. It shows less pain on the second postoperative day and cosmetic benefit but requires more operative time than CMLA. 

Enterobius Vermicularis: A Parasitic Cause of Appendicular Colic

Enterobius vermicularis is the most commonly identified parasite incidentally found within the appendix of a clinically diagnosed appendicitis. This parasitic cause of appendicular colic, primarily affecting children, is an important cause of negative appendicectomy. We report an unusual and interesting case of a young female who presented with clinical features of acute appendicitis. Laparoscopic appendicectomy revealed the presence of an Enterobius vermicularis infestation originating from the lumen of her vermiform appendix. Our case report is supplemented with a review of the literature, an overview of the parasitology, and discussion of pertinent symptomatology and peri-operative management strategies.

Synchronous Acute Appendicitis and Cholecystitis in a Paediatric Patient with Salmonella Enteritis

We present the case of a 13-year-old male who presented with right upper quadrant pain and diarrhoea after recently travelling from Bali, Indonesia. He had a normal white cell count of 8x10^9/L and elevated c-reactive protein (CRP) of 205 mg/L with normal liver function tests. Originally thought to be appendicitis, given the rarity of cholecystitis in a child, he was commenced on broad-spectrum antibiotics and was taken to the operating theatre based on his clinical presentation. Diagnostic laparoscopy revealed inflammatory change in both the gallbladder and appendix and a laparoscopic cholecystectomy and appendicectomy were performed simultaneously. Histopathology results confirmed cholecystitis and appendicitis and a stool culture confirmed the presence of Salmonella serotype B. Synchronous cholecystitis and appendicitis is an exceedingly rare phenomenon with only a handful of cases reported in the literature. This is the first case in the literature of this phenomenon occurring in the paediatric population; surgeons need to be aware of this rare possibility even in the paediatric population and especially in those patients with an atypical presentation or in recent travellers experiencing gastroenteritis.

A simple classification of peritoneal contamination in perforated appendicitis predicts surgery-related complications

AIM

Perforated appendicitis has poorer clinical outcomes compared to non-perforated appendicitis. However, accurate outcome comparisons in research and clinical audits are challenged by its wide spectrum of manifestation. Previous attempts at the classification of severity have been complex and difficult to reproduce. In our study, we used another institution's (Jones et al., TX, USA) previously described simple classification system of peritoneal contamination and examined its usefulness in predicting outcomes.

METHODS

With ethical approval, we retrospectively reviewed the records of all paediatric patients operated at our institution for perforated appendicitis from 2016 to 2017. Patient demographics, intra-operative and histological findings, post-operative outcomes and length of stay were collected. Patients were categorised into group 1 (purulence in right lower quadrant only) and group 2 (contamination in two or more quadrants). Post-operative complications were defined as procedure-related (e.g. post-operative ileus, intra-abdominal abscess, visceral injury) and non-procedure-related (e.g. bronchospasm). Statistical analysis using χ² tests for categorical data and Mann-Whitney U-tests for non-parametric continuous variables was performed, with a significance of P < 0.05.

RESULTS

There were 134 eligible patients. We excluded 19 with incomplete data, leaving 115 for analysis, of which 69 (60%) were in group 2. Those in group 2 had a longer stay (P = 0.005) and more post-operative complications (P = 0.001), particularly procedure-related events (P = 0.006). There were no differences in age (P = 0.182), gender (P = 0.876), readmission rate (P = 0.317) and non-procedure-related post-operative complications (0.152).

CONCLUSION

This simple classification of perforated appendicitis appears to differentiate clinical outcomes well, particularly for iatrogenic morbidity, making it useful for operative preparation and outcomes research.

Validation of a cost-effective appendicectomy model for surgical training

BACKGROUND

Appendicitis is a commonly occurring condition worldwide. The gold standard treatment is appendicectomy. Although training models are commercially available for this procedure, they are often associated with high cost. Here we present a cost-effective model.

AIM

To establish construct validity of a cost-effective laparoscopic appendicectomy simulation model.

METHODS

Three groups of surgeons were recruited; novices (n = 31), of intermediate expertise (n = 13) and experts (n = 5) and asked to perform a simulated laparoscopic appendicectomy using the new model. Their performance was assessed by a faculty member and compared between the three groups using a validated scoring system (Global Operative Assessment of Laparoscopic Skills [GOALS] score).

RESULTS

One-way ANOVA test showed a significant difference in task performance between groups (p < 0.0001). Post-hoc comparisons after the application of Bonferroni correction (statistically significant p value <0.017) demonstrate a significant difference in performance between all groups for all GOALS categories as well as the total score. Effect size calculations showed that experience level had moderate (Eta-squared >0.5 and <0.8) and significant (>0.8) impact on the performance of the simulated procedure.

CONCLUSION

The model described in this study is cost-effective, valid and can adequately simulate appendicectomy. The authors recommend inclusion of this model to postgraduate surgical training.

Outcomes of an acute care surgery model: a 10-year follow-up study

BACKGROUND

Many hospitals across Australia and New Zealand have implemented acute care surgery (ACS) models over the past decade, often with improved outcomes such as reductions in wait time to surgery, complications and length of stay. The aim of this study was to evaluate the outcomes of patients who underwent non-elective appendicectomy and cholecystectomy and compare these with the results observed shortly after the implementation of an ACS model at our institution 10 years earlier.

METHODS

A retrospective review of contemporary patients who underwent non-elective appendicectomy and cholecystectomy compared with historical data was performed. Primary outcomes were wait time to surgery, surgical complications and length of stay.

RESULTS

In the contemporary cohort, 263 patients underwent non-elective appendicectomy over a 1-year period compared with 226 patients in the historical cohort. The median wait time to surgery had increased (17.7 versus 9.6 h, P < 0.001). There was no significant difference in a composite end-point of complications and readmissions (8.0% versus 9.3%, P = 0.61). The length of stay was unchanged. There was greater use of preoperative imaging and reduced overnight operating. For non-elective cholecystectomies, 132 patients underwent this procedure in the contemporary cohort over a 2-year period compared with 115 patients in the historical cohort. There were no significant differences in wait time to surgery (2 versus 1 day, P = 0.13) or complications (9.8% versus 8.7%, P = 0.75). The length of stay was unchanged.

CONCLUSION

The majority of improvements seen shortly following the implementation of an ACS model have been sustained after 10 years.

South Coast appendicular mass management (SCAM) survey

Background

Management of appendicular mass and interval appendicectomy remains a controversial issue. Recent publication of a randomized controlled trial (RCT) reported the incidence of around 20% neoplastic lesions in the age group of more than forty years among the interval appendicectomy group against magnetic resonance imaging (MRI) surveillance only which led to trial termination. The objective of this study is to evaluate the current practice of the management of appendicular mass in five major hospitals of South Coast of the England.

Methods

A proforma was designed and emailed to the general surgical department of five hospitals in the South Coast of England. The proforma completion rate and compliance were improved by direct telephone call to the on-call registrars and consultants to collect data.

Results

Fifty-three surgeons (22 consultants, 27 ST3-ST8 grade surgical trainees and 4 SAS grades) completed the proforma. The clinical, hematological and computerized tomography (CT) based diagnostic criteria, and in-patient intravenous antibiotics (IV ABTXs) in addition to the radiological drainage in amenable cases for appendicular mass/abscess were mostly agreed initial management plan among surgeons. Normalization of inflammatory markers and radiological resolution were agreed discharge indicators. Agreed follow up investigations were CT scan (by 23%), Colonoscopy (by 13%), and both CT and colonoscopy (by 57%) after discharging patients. Only 17% surgeons offered planned interval appendicectomy and 62% surgeons offered interval appendectomy in selective cases of appendicular mass within 6 weeks to 6 months after discharge.

Conclusions

South Coast appendicular mass management (SCAM) survey confirms diverse practice to manage appendicular mass/abscess among surgeons working in South Coast hospitals. A substantial percentage of surgeons do not offer interval appendectomy to patients potentially leaving neoplastic lesions in situ.

Comparative Study of Alvarado Score and its Modifications in the Preoperative Diagnosis of Acute Appendicitis at a Tertiary Center in Sokoto, Nigeria

BACKGROUND

Decision-making in patients suspected of having acute appendicitis has remained a diagnostic challenge worldwide despite the advances in imaging and appendiceal surgery. There have been efforts to improve the diagnosis of appendicitis using clinical scoring systems.

AIM

We evaluated and compared the diagnostic accuracy and role of Alvarado score (AS) and two of its modification (Kalan and Al-Fallouji) in the preoperative diagnosis of acute appendicitis.

MATERIALS AND METHODS

This was a prospective study conducted at the Usmanu Danfodiyo University Teaching Hospital, Sokoto, of all adult patients operated for acute appendicitis from July 2014 to June 2017. The results were analyzed on computer using Statistical Package for the Social Science version 15.

RESULTS

One hundred and eleven patients were studied. Sixty-six (59.5%) patients were males and 45 (40.5%) were females. The male-to-female ratio was 1.5:1. The mean age was 23.89 ± 4.93 years. The AS sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 90.3%, 83.3%, 96.6%, 62.2%, and 89.2%, respectively, were similar to the findings of Kalan score (90.3%, 83.3%, 96.6%, 62.5%, and 89.2%, respectively) and Al-Fallouji score (96.8%, 66.7%, 93.8%, 80%, and 91.9%, respectively). The receiver operating curve and area under the curve show that Alvarado, Kalan, and Al-Fallouji are accurate scores in the preoperative diagnosis of acute appendicitis with an area under the curve of 0.88, 0.86, and 0.85, respectively.

CONCLUSION

Kalan and Al-Fallouji scores have comparably good diagnostic accuracy as the AS among our patients. Any of these scores can be used as an adjunct in the preoperative diagnosis of acute appendicitis.

Efficacy and Safety of Intraperitoneal Local Anesthetics in Laparoscopic Appendectomy: A Systematic Review and Meta-Analysis

Intraperitoneal local anesthetics have been increasingly used nowadays. However, they are not routinely given in laparoscopic appendectomy and a lot of controversies are found about their administration in this procedure. The goal of this study is to review effectiveness and safety of intraperitoneal local anesthetics in laparoscopic appendectomy. We conducted a computer search of four authentic databases. We included randomized controlled trials (RCTs) which compared intraperitoneal local anesthetics versus control group in laparoscopic appendectomy. Data were extracted from eligible studies and pooled in a meta-analysis model using RevMan software. We evaluated post-operative pain in different periods and safety outcomes including postoperative nausea and vomiting (PONV) and shoulder pain. Furthermore, we assessed the length of hospital stay and postoperative opioid consumption within 24 hours. Seven RCTs were included with a total of 579 patients in this review. Our analysis indicated a significant difference in postoperative pain at different durations preferring intraperitoneal local anesthetics compared to control. Moreover, intraperitoneal local anesthetics were significantly linked to fewer patients experienced PONV and shoulder pain respectively (RR= 0.28, 95% CI [0.16, 0.50], p < 0.0001), (RR= 0.32, 95% CI [0.17, 0.58], p = 0.0002). We found less hospital stay duration in intraperitoneal local anesthetics group after removal of the heterogeneity (MD= -0.39, 95% CI [-0.63, -0.16], p = 0.001). Intraperitoneal local anesthetics were significantly linked to less postoperative opioid consumption (SMD = -0.60, 95% CI [-0.96, -0.24], p = 0.001). Intraperitoneal local anesthetics can be routinely used in laparoscopic appendectomy as it is associated with less postoperative pain and reduction in different adverse events postoperatively.

Appendicectomy mortality: an Australian national audit

BACKGROUND

Appendicectomy is a safe surgical procedure with minimal risks. Low mortality rates (0.04-0.24%) have been reported from a number of countries. Appendicectomy mortality rates have not been reported in Australia in recent years. The aim of the study was to conduct an appendicectomy mortality audit, to identify clinical management issues and to calculate the mortality rate of appendicectomy in Australia.

METHODS

This study analysed data from a peer review of appendicectomy deaths in Australian hospitals of all states and territories, from 2006 to 2017. Additional procedural data were obtained from the Australian Institute of Health and Welfare for the calculation of mortality rates.

RESULTS

The final analysis included 82 patients of whom 62 were elderly (age >65 years) with 47 males and 35 females. Two or more comorbidities were present in 68 patients. Open operation was performed in 62 patients, with complicated appendicitis found in 50 cases. The majority of management issues were non-surgical. Of the 16 surgical management issues identified, 11 issues occurred post-operatively in the elderly, which were potentially preventable. The overall mortality was 0.02% with 0.01% in the young (age <65 years) and 0.20% in the elderly.

CONCLUSION

Australia's appendicectomy mortality rate was very low and comparable to international figures. Surgical management of appendicectomy was satisfactory in general. However, post-operative care in the elderly was found to be poor at times, with room for improvement. Further research is needed whether improvements in post-operative care could alter the clinical course to death in the elderly.

Prospective Cohort Study of Haptic Virtual Reality Laparoscopic Appendicectomy Learning Curve Trajectory

Background: Simulation training is strongly advocated by 24/7 risk-rich professions because swift learning curve inflection point attainment delivers earlier competence; the left-shift effect. The aim of this study was to determine the value of haptic laparoscopic virtual reality simulation, by iterative benchmark exercise (n = 8), before simulated laparoscopic appendicectomy (SLA); the hypothesis was that favorable benchmark learning curve trajectories would be associated with improved SLA competence when compared with consultant expert performance. Methods: A 28-trainee cohort completed 1349 Laparoscopic Haptic Virtual Reality Skills (LHVRS) tasks, during which 19 ergonomic variables were assessed by virtual interface, including force feedback (Surgicalscience.com), before 153 SLAs. Primary outcome measure was SLA composite competence score related to six consultant trainer experts. Results: Of the eight LHVRS tasks, the three with the steepest learning curve trajectories correlated with better median overall SLA competence scores, namely tissue grasping/lifting (rho = 0.362, P = .049), fine dissection (rho = 0.388, P = .028), and camera navigation (rho = 0.518, P = .007); fine dissection was the only haptic laparoscopic virtual reality simulation task that predicted a SLA score within a Youden index defined, 70% of the consultant expert level (area under curve [AUC] = 0.803, P = .028). A significant SLA learning curve emerged, with a learning curve trajectory inflection point at the fourth SLA attempt (first SLA 30.5% versus fourth SLA score 76.0%, gradient 76°, P = .010). Conclusion: Learning curve trajectory can be measured, influenced, and accelerated significantly; a pronounced left-shift effect, with translational potential for enhanced shorter training time and improved patient safety.

RIFT Study Group On behalf of the West Midlands Research Collaborative. Right Iliac Fossa Pain Treatment (RIFT) Study: protocol for an international, multicentre, prospective observational study

INTRODUCTION

Patients presenting with right iliac fossa (RIF) pain are a common challenge for acute general surgical services. Given the range of potential pathologies, RIF pain creates diagnostic uncertainty and there is subsequent variation in investigation and management. Appendicitis is a diagnosis which must be considered in all patients with RIF pain; however, over a fifth of patients undergoing appendicectomy, in the UK, have been proven to have a histologically normal appendix (negative appendicectomy). The primary aim of this study is to determine the contemporary negative appendicectomy rate. The study's secondary aims are to determine the rate of laparoscopy for appendicitis and to validate the Appendicitis Inflammatory Response (AIR) and Alvarado prediction scores.

METHODS AND ANALYSIS

This multicentre, international prospective observational study will include all patients referred to surgical specialists with either RIF pain or suspected appendicitis. Consecutive patients presenting within 2-week long data collection periods will be included. Centres will be invited to participate in up to four data collection periods between February and August 2017. Data will be captured using a secure online data management system. A centre survey will profile local policy and service delivery for management of RIF pain.

ETHICS AND DISSEMINATION

Research ethics are not required for this study in the UK, as determined using the National Research Ethics Service decision tool. This study will be registered as a clinical audit in participating UK centres. National leads in countries outside the UK will oversee appropriate registration and study approval, which may include completing full ethical review. The study will be disseminated by trainee-led research collaboratives and through social media. Peer-reviewed publications will be published under corporate authorship including 'RIFT Study Group' and 'West Midlands Research Collaborative'.

Five lessons in uncomplicated appendicitis: Can we remove the surgery?

Appendicectomy has remained the treatment of choice for appendicitis for over a century and is the most commonly performed emergency operation in children. However, emerging evidence suggests that appendicectomy may not always be necessary in uncomplicated appendicitis, with early paediatric trials demonstrating that antibiotic-only therapy can be safe and effective. Further rigorously designed and appropriately powered studies are necessarily to establish the place of non-operative management of uncomplicated appendicitis in the future.

Review of appendicectomies over a decade in a tertiary hospital in New Zealand

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.

Emergency appendicectomy in Australia: findings from a multicentre, prospective study

BACKGROUND

Emergency appendicectomy is the most common emergency surgical procedure performed in Australia. Despite this frequency, there is a relative paucity of contemporary, broad-based, local data that examine how emergency appendicectomies are currently performed and what are the outcomes from these operations.

METHODS

A multicentre, prospective, observational study was performed. Patients were recruited by local investigators for a period of 2 months with 30-day follow-up. Patients were eligible for study inclusion if they underwent an emergency appendicectomy for suspected acute appendicitis. The primary outcome of the study was the negative appendicectomy rate (NAR), with secondary outcomes including 30-day complication rates, method of operation and conversion rates.

RESULTS

A total of 1189 patients were recruited across 27 centres. The NAR across all centres was 19.0%. 98.2% of appendicectomies were performed with a laparoscopic-first approach. The rate of conversion from laparoscopy to open operation was 2.4%. 9.4% of patients were recorded as having one or more of the following complications: readmission (6.6%), surgical site infection (1.9%), intra-abdominal abscess (2.7%) or further intervention (1.5%). Patients who had an open operation had higher rates of readmission and surgical site infection.

CONCLUSION

The NAR found in this study is within the traditional measures of acceptance; however, this rate is high when measured against modern international benchmarks.

Derivation and validation of the APPEND score: an acute appendicitis clinical prediction rule

BACKGROUND

Although many clinical prediction rules (CPRs) for appendicitis exist, none have been developed for a New Zealand population presenting with right iliac fossa (RIF) pain. The aim of this study was to derive and validate an appendicitis CPR for our population.

METHOD

This is a retrospective review of all patients from December 2010 to February 2012 of at least 15 years of age presenting to the general surgery service with RIF pain. Patient data were divided into derivation and validation groups. Univariate and multiple regression analyses identified significant predictors of appendicitis which were used to construct a CPR. A retrospective validation study was then performed and the CPR was refined accordingly. Finally, the accuracy of the CPR was tested.

RESULTS

The final components of the new CPR, the APPEND score, were Anorexia, migratory Pain, local Peritonism, Elevated C-reactive protein, Neutrophilia and male gender (Dude). This CPR has an area under the receiver operating characteristic curve of 0.84. The CPR can stratify patients into low, intermediate and high-risk groups which may standardize patient care and reduce the negative appendicectomy rate.

CONCLUSION

A new CPR for predicting appendicitis, in patients presenting with RIF pain, has been derived and validated for use in our population. A prospective study to further evaluate its performance is required.