Do surgical emergencies stay at home? Observations from the first United States Coronavirus epicenter

BACKGROUND

During the coronavirus disease 2019 pandemic, New York instituted a statewide stay-at-home mandate to lower viral transmission. While public health guidelines advised continued provision of timely care for patients, disruption of safety-net health care and public fear have been proposed to be related to indirect deaths because of delays in presentation. We hypothesized that admissions for emergency general surgery (EGS) diagnoses would decrease during the pandemic and that mortality for these patients would increase.

METHODS

A multicenter observational study comparing EGS admissions from January to May 2020 to 2018 and 2019 across 11 NYC hospitals in the largest public health care system in the United States was performed. Emergency general surgery diagnoses were defined using International Classification Diseases, Tenth Revision, codes and grouped into seven common diagnosis categories: appendicitis, cholecystitis, small/large bowel, peptic ulcer disease, groin hernia, ventral hernia, and necrotizing soft tissue infection. Baseline demographics were compared including age, race/ethnicity, and payor status. Outcomes included coronavirus disease (COVID) status and mortality.

RESULTS

A total of 1,376 patients were admitted for EGS diagnoses from January to May 2020, a decrease compared with both 2018 (1,789) and 2019 (1,668) (p < 0.0001). This drop was most notable after the stay-at-home mandate (March 22, 2020; week 12). From March to May 2020, 3.3%, 19.2%, and 6.0% of EGS admissions were incidentally COVID positive, respectively. Mortality increased in March to May 2020 compared with 2019 (2.2% vs. 0.7%); this difference was statistically significant between April 2020 and April 2019 (4.1% vs. 0.9%, p = 0.045).

CONCLUSION

Supporting our hypothesis, the coronavirus disease 2019 pandemic and subsequent stay-at-home mandate resulted in decreased EGS admissions between March and May 2020 compared with prior years. During this time, there was also a statistically significant increase in mortality, which peaked at the height of COVID infection rates in our population.

LEVEL OF EVIDENCE

Epidemiological, level IV.

A Nationwide Cohort Study of Outcome after Pediatric Appendicitis

INTRODUCTION

 Children with appendicitis often present with complicated disease. The aim of this study was to describe the clinical management of pediatric appendicitis, and to report how disease severity and operative modality are associated with short- and long-term risks of adverse outcome.

MATERIALS AND METHODS

 A nationwide retrospective cohort study of all Swedish children (<18 years) diagnosed with appendicitis, 2001 to 2014 (n = 38,939). Primary and secondary outcomes were length of stay, surgical site infections, readmissions, 30-day mortality, and long-term risk of surgery for small bowel obstruction (SBO). Implications of complicated disease and operative modality were assessed with adjustment for age, gender, and trends over time.

RESULTS

 Complicated appendicitis was associated with longer hospital stay (4 vs. 2 days, p < 0.001), increased risk of surgical site infection (5.9 vs. 2.3%, adjusted odds ratio [aOR]: 2.64 [95% confidence interval, CI: 2.18-3.18], p < 0.001), readmission (5.5 vs. 1.2, aOR: 4.74 [95% CI: 4.08-5.53], p < 0.001), as well as long-term risk of surgery for SBO (0.7 vs. 0.2%, adjusted hazard ratio [aHR]: 3.89 [95% CI: 2.61-5.78], p < 0.001). Intended laparoscopic approach was associated with reduced risk of surgical site infections (2.3 vs. 3.1%, aOR: 0.74 [95% CI: 0.62-0.89], p = 0.001), but no overall reduction in risk for SBO; however, successful laparoscopic appendectomy was associated with less SBO during follow-up compared with open appendectomy (aHR: 0.27 [95% CI: 0.11-0.63], p = 0.002).

CONCLUSION

 Children treated for complicated appendicitis are at risk of substantial short- and long-term morbidities. Fewer surgical site infections were seen after intended laparoscopic appendectomy, compared with open appendectomy, also when converted procedures were accounted for.

Appendicitis Mortality in a Resource-Limited Setting: Issues of Access and Failure to Rescue

BACKGROUND

Appendicitis is one of the most common emergency surgery conditions worldwide, and the incidence is increasing in low- and middle-income countries. Disparities in access to care can lead to disproportionate morbidity and mortality in resource-limited settings; however, outcomes following an appendectomy in low- and middle-income countries remain poorly described. Therefore, we aimed to describe the characteristics and outcomes of patients with appendicitis presenting to a tertiary care center in Malawi.

METHODS

We conducted a retrospective analysis of the Kamuzu Central Hospital (KCH) Acute Care Surgery database from 2013 to 2020. We included all patients ≥13 years with a postoperative diagnosis of acute appendicitis. We performed bivariate analysis by mortality, followed by a modified Poisson regression analysis to determine predictors of mortality.

RESULTS

We treated 214 adults at KCH for acute appendicitis. The majority experienced prehospital delays to care, presenting at least 1 week from symptom onset (n = 99, 46.3%). Twenty (9.4%) patients had appendiceal perforation. Mortality was 5.6%. The presence of a postoperative complication the only statistically significant predictor of mortality (RR 5.1 [CI 1.13-23.03], P = 0.04) when adjusting for age, shock, transferring, and time to presentation.

CONCLUSIONS

Delay to intervention due to inadequate access to care predisposes our population for worse postoperative outcomes. The increased risk of mortality associated with resultant surgical complications suggests that failure to rescue is a significant contributor to appendicitis-related deaths at KCH. Improvement in barriers to diagnosis and management of complications is necessary to reduce further preventable deaths from this disease.

Managing acute uncomplicated appendicitis in frail geriatric patients: A second hit may be too much

INTRODUCTION

Studies have proposed the use of antibiotics only in cases of acute uncomplicated appendicitis (AUA). However, there remains a paucity of data evaluating this nonoperative approach in the vulnerable frail geriatric population. The aim of this study was to examine long-term outcomes of frail geriatric patients with AUA treated with appendectomy compared with initial nonoperative management (NOP).

METHODS

We conducted a 1-year (2017) analysis of the Nationwide Readmissions Database and included all frail geriatric patients(age, ≥65 years) with a diagnosis of AUA. Frailty was assessed using the five-factor modified frailty index. Patients were stratified into those undergoing appendectomy at index admission (operative management) versus those receiving antibiotics only without operative intervention (NOP). Propensity score matching in a 1:1 ratio was performed adjusting for patient- and hospital-related factors.

RESULTS

A total of 5,562 frail geriatric patients with AUA were identified from which a matched cohort of 1,320 patients in each group was obtained. Patients in the NOP and operative management were comparable in terms of age (75.5 ± 7.7 vs. 75.5 ± 7.4 years; p = 0.882) and modified frailty index (0.4 [0.4-0.6] vs. 0.4 [0.4-0.6]; p = 0.526). Failure of NOP management was reported in 18% of patients, 95% of which eventually underwent appendectomy. Over the 6-month follow-up period, patients in the NOP group had significantly higher rates of Clostridium difficile enterocolitis (3% vs. 1%; p < 0.001), greater number of overall hospitalized days (5 [3-9] vs. 4 [2-7] days; p < 0.001), and higher overall costs (US $16,000 [12,000-25,000] vs. US $11,000 [8,000-19,000]; p < 0.001). Patients undergoing appendectomy after failed NOP had significantly higher rates of complications (20% vs. 11%; p < 0.001), mortality (4% vs. 2%; p = 0.019), and appendiceal neoplasm (3% vs. 1%; p = 0.027).

CONCLUSION

One in six patients failed NOP within 6 months and required appendectomy with subsequent more complications and higher mortality. Appendectomy may offer better outcomes in managing AUA in the frail geriatric population.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Trends in Appendicitis Among Pregnant Women, the Risk for Cardiac Arrest, and Maternal-Fetal Mortality

Background

Appendicitis is the most common extra-uterine surgical emergency requiring immediate intervention during pregnancy. However, risks for mortality and morbidity among pregnant women with appendicitis remain poorly understood. This study was conducted to determine the temporal trends of appendicitis in pregnant women, and to calculate the risk of maternal–fetal mortality and near-miss marker (i.e., cardiac arrest) among pregnant women in general, and by race/ethnicity.

Methods

We conducted this retrospective study using data from the Nationwide Inpatient Sample (NIS) from January 1, 2002, through December 31, 2015. Joinpoint regression was used to estimate and describe temporal changes in the rates of all and acute appendicitis during the 14-year study period. We also estimated the risk of cardiac arrest, maternal, and fetal mortality among mothers of various racial/ethnic groups with a diagnosis of acute appendicitis. Within each group, patients without acute appendicitis were the referent category.

Results and conclusions

Out of the 58 million pregnancy hospitalizations during the study period, 63,145 cases (10.74 per 10,000 hospitalizations) were for acute appendicitis. There was a 5% decline (95% CI: − 5.1, − 5.0) in the rate of appendicitis hospitalizations over the period of the study. After adjusting for covariates, pregnant mothers with acute appendicitis had increased likelihood when compared to those without acute appendicitis to suffer fetal loss (OR: 2.05, 95% CI: 1.85–2.28) and nearly fivefold increase for inpatient maternal death. In conclusion, appendicitis during pregnancy remains an important cause of in-hospital maternal–fetal mortality overall and regardless of race/ethnicity.

Management and Outcomes of Acute Appendicitis in the Presence of Cirrhosis: A Nationwide Analysis

Best management for acute appendicitis (AA) in adults with liver cirrhosis is controversial and needs more investigation. We aimed to examine the impact of different treatment modalities on outcomes in this complex patient population. The Nationwide Inpatient Sample database from 2012 to 2014 was queried to identify AA patients with no cirrhosis, compensated cirrhosis (CC), and decompensated cirrhosis (DC). Each cohort was further stratified according to the treatment type: nonoperative management, open appendectomy, and laparoscopic appendectomy (LA). Chi-square, ANOVA, and binary regression analyses were used to determine differences between groups and risk factors for mortality and complications, with P < 0.05 considered statistically significant. A total of 108,289 AA patients were analyzed; of those, 304 with CC and 134 with DC were identified. Compared with CC and no cirrhosis, DC patients had significantly higher mortality, higher cost, and longer hospital length of stay. LA is accompanied by higher survival, lower cost, shorter duration of hospitalization, and lower incidence of complications across all groups. We conclude that LA is the best management strategy for AA in cirrhotic patients. Even in decompensated cirrhotics, which are associated with worse clinical outcomes, LA is still a favorable option over open appendectomy and nonoperative management.

Emergency General Surgery-A Misnomer?

Emergency general surgery (EGS) is defined as the urgent assessment and treatment of nontrauma, general surgical emergencies involving adults. Acute surgical emergencies often represent the most common reason for hospital admission with diagnoses, including bowel obstruction and appendicitis. EGS is a growing surgical subspecialty that includes both operative and nonoperative management of acutely ill patients. We sought to assess the burden of nonoperative care in EGS patients at our academic medical center. This study was conducted by retrospective analysis of prospectively collected data from patients entered into the Duke EGS Registry between July 1, 2016 and September 10, 2017. Fifty-six per cent (n = 771) of patients in the Duke EGS Registry (n = 1377) were managed nonoperatively as compared with 44 per cent (n = 606) who were managed operatively. Nonoperative management of disease represents a large subset of EGS and, therefore, needs further investigation to improve processes, outcomes, and standardization of care.

Early versus delayed appendicectomy for appendiceal phlegmon or abscess

BACKGROUND

Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms and avoid complications. The timing of appendicectomy for appendiceal phlegmon or abscess is controversial.

OBJECTIVES

To assess the effects of early versus delayed appendicectomy for appendiceal phlegmon or abscess, in terms of overall morbidity and mortality.

SEARCH METHODS

We searched the Cochrane Library (CENTRAL; 2016, Issue 7), MEDLINE Ovid (1950 to 23 August 2016), Embase Ovid (1974 to 23 August 2016), Science Citation Index Expanded (1900 to 23 August 2016), and the Chinese Biomedical Literature Database (CBM) (1978 to 23 August 2016). We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform search portal (23 August 2016) and ClinicalTrials.gov (23 August 2016) for ongoing trials.

SELECTION CRITERIA

We included all individual and cluster-randomised controlled trials, irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

We included two randomised controlled trials with a total of 80 participants in this review. 1. Early versus delayed open appendicectomy for appendiceal phlegmonForty participants (paediatric and adults) with appendiceal phlegmon were randomised either to early appendicectomy (appendicectomy as soon as appendiceal mass resolved within the same admission) (n = 20), or to delayed appendicectomy (initial conservative treatment followed by interval appendicectomy six weeks later) (n = 20). The trial was at high risk of bias. There was no mortality in either group. There is insufficient evidence to determine the effect of using either early or delayed open appendicectomy onoverall morbidity (RR 13.00; 95% CI 0.78 to 216.39; very low-quality evidence), the proportion of participants who developed wound infection (RR 9.00; 95% CI 0.52 to 156.91; very low quality evidence) or faecal fistula (RR 3.00; 95% CI 0.13 to 69.52; very low quality evidence). The quality of evidence for increased length of hospital stay and time away from normal activities in the early appendicectomy group (MD 6.70 days; 95% CI 2.76 to 10.64, and MD 5.00 days; 95% CI 1.52 to 8.48, respectively) is very low quality evidence. The trial reported neither quality of life nor pain outcomes. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscessForty paediatric participants with appendiceal abscess were randomised either to early appendicectomy (emergent laparoscopic appendicectomy) (n = 20) or to delayed appendicectomy (initial conservative treatment followed by interval laparoscopic appendicectomy 10 weeks later) (n = 20). The trial was at high risk of bias. The trial did not report on overall morbidity or complications. There was no mortality in either group. We do not have sufficient evidence to determine the effects of using either early or delayed laparoscopic appendicectomy for outcomes relating to hospital stay between the groups (MD -0.20 days; 95% CI -3.54 to 3.14; very low quality of evidence). Health-related quality of life was measured with the Pediatric Quality of Life Scale-Version 4.0 questionnaire (a scale of 0 to 100 with higher values indicating a better quality of life). Health-related quality of life score measured at 12 weeks after appendicectomy was higher in the early appendicectomy group than in the delayed appendicectomy group (MD 12.40 points; 95% CI 9.78 to 15.02) but the quality of evidence was very low. This trial reported neither the pain nor the time away from normal activities.

AUTHORS' CONCLUSIONS

It is unclear whether early appendicectomy prevents complications compared to delayed appendicectomy for people with appendiceal phlegmon or abscess. The evidence indicating increased length of hospital stay and time away from normal activities in people with early open appendicectomy is of very low quality. The evidence for better health-related quality of life following early laparoscopic appendicectomy compared with delayed appendicectomy is based on very low quality evidence. For both comparisons addressed in this review, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy.Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities, quality of life and the length of hospital stay.

[APPROACH TO ESTABLISHMENT OF INDICATIONS FOR PROGRAMMED SANATION OF ABDOMINAL CAVITY IN DIFFUSE PERITONITIS]

The results of treatment of 33 patients, suffering diffuse peritonitis, with postoperatively applied tactics of the programmed surgical sanation of abdominal cavity were analyzed. Indications for relaparotomy were established, based on the estimation scale for the enteral insufficiency severity. The patients death and the complications causes were analyzed, depending on terms and rates of relaparotomy conduction.

Pediatric appendicitis: pathophysiology and appropriate use of diagnostic imaging

Evaluating children for appendicitis can be extremely difficult, and various strategies have been developed to improve the precision of preoperative diagnosis. Among these, ultrasound and computed tomography (CT) are now widely used but remain controversial. Although CT scanning is superior to ultrasound in terms of diagnostic accuracy for appendicitis, the large dose of ionizing radiation from CT and the risk of subsequent radiation-induced malignancy (RIM) are of particular concern in pediatric patients. This article reviews the literature on the pathophysiology, morbidity and mortality of appendicitis, summarizes the data regarding pediatric imaging in appendicitis, provides a practical approach to imaging for clinicians who evaluate pediatric patients, and makes recommendations for reducing the risk of RIM in pediatric patients.

Ethnic variations in five lower gastrointestinal diseases: Scottish health and ethnicity linkage study

OBJECTIVES

Our objective was to augment the limited evidence mainly from local, clinical studies of ethnic differences in gastrointestinal disorders. Our question was: are there ethnic variations in hospitalisation/death for lower gastrointestinal disorders in Scotland?

SETTING

Scotland.

POPULATION

This retrospective-cohort linked 4.65 (of 4.9) million people in the 2001 census of Scotland (providing data on ethnicity, country of birth and indicators of socioeconomic deprivation) to 9 years of National Health Service hospitalisation and death records.

PRIMARY AND SECONDARY OUTCOME MEASURES AND ANALYSIS

For appendicitis, we studied all ages; for irritable bowel syndrome, ulcerative colitis, Crohn's disease and diverticular disease, we included those ≥20 years. Using Poisson regression (robust variance) we calculated, by ethnic group and sex, first-hospitalisation/death age-adjusted rates per 100,000 person-years, and relative risks (RRs) with 95% CIs multiplied by 100, so the White Scottish reference population had an RR=100.

RESULTS

There were ethnic variations; for example, for irritable bowel syndrome, RRs (95% CIs) were comparatively high in Other White British women (128.4 (111.0 to 148.6)), and low in Pakistani women (75.1 (60.6 to 93.1)). For appendicitis, RRs were high in men in Other White British (145.2 (127.8 to 164.9)), and low in most non-White groups, for example, Pakistanis (73.8 (56.9 to 95.6)). For ulcerative colitis, RRs were high in Indian (169.8 (109.7 to 262.7)) and Pakistani (160.8 (104.2 to 248.2)) men. For Crohn's disease, the RR was high in Pakistani men (209.2 (149.6 to 292.6)). For diverticular disease, RRs were high in Irish men (176.0 (156.9 to 197.5)), and any Mixed background women (144.6 (107.4 to 194.8)), and low in most non-White groups, for example, Chinese men (47.1 (31.0 to 71.6) and women (46.0 (30.4 to 69.8)).

CONCLUSIONS

Appendicitis and diverticular disease were comparatively low in most non-White groups, while ulcerative colitis and Crohn's disease were mostly higher in South Asians. Describing and understanding such patterns may help clinical practice and research internationally.

Laparoscopic appendectomy trends and outcomes in the United States: data from the Nationwide Inpatient Sample (NIS), 2004-2011

Laparoscopic appendectomy (LA) is becoming the standard procedure of choice for appendicitis. We aimed to evaluate the frequency and trends of LA for acute appendicitis in the United States and to compare outcomes of LA with open appendectomy (OA). Using the Nationwide Inpatient Sample database, we examined patients who underwent appendectomy for acute appendicitis from 2004 to 2011. A total of 2,593,786 patients underwent appendectomy during this period. Overall, the rate of LA was 60.5 per cent (children: 58.1%; adults: 63%; elderly: 48.7%). LA rate significantly increased from 43.3 per cent in 2004 to 75 per cent in 2011. LA use increased 66 per cent in nonperforated appendicitis versus 100 per cent increase in LA use for perforated appendicitis. The LA rate increased in all age groups. The increased LA use was more significant in male patients (84%) compared with female patients (62%). The overall conversion rate of LA to OA was 6.3 per cent. Compared with OA, LA had a significantly lower complication rate, a lower mortality rate, a shorter mean hospital stay, and lower mean total hospital charges in both nonperforated and perforated appendices. LA has become an established procedure for appendectomy in nonperforated and perforated appendicitis in all rates exceeding OA. Conversion rate is relatively low (6.3%).

Pattern of acute appendicitis in Mekelle, Ethiopia

BACKGROUND

Acute appendicitis is one of the commonly encountered emergencies in the practice of general surgery but there are no much study regarding the magnitude and its pattern in Ethiopia and in Mekelle hospital in particular.

OBJECTIVE

This study was aimed at assessing the magnitude, pattern and outcomes of acute appendicitis.

METHODS

Between September 2008 to August 2010, 196 patients with acute appendicitis were admitted to Mekelle hospital. In this descriptive retrospective audit, case notes were obtained from medical records office and information entered included patient demographics, clinical symptoms, white blood cell count level and operative funding. Post-operative complications and operative outcomes were also recorded. Adequate records have been maintained in the hospital on patients undergoing appendectomy.

RESULTS

There were 196 patients during the study period from all age groups with clinical suspicion of acute appendicitis who underwent appendectomy. The age ranged from 4 to 80 years (mean - 22 years). There were 143 (73%) males and females accounting for 53 (27%). The sex ratio was (M: F; 2.9:1). Majority of patients with acute appendicitis were between 20 - 29 years of age, accounting for 76 (38.7%), predominantly males affected than females. The other age group affected was between 10-19 years of age accounting for 56 (28.5%), again with male predominance. The frequent clinical presentation's of acute appendicitis were abdominal pain 196 (100.0%), vomiting 107 (54.6%) and anoxia 97 (49.5%). The duration of presentation ranged from 12 hours to 5 days (Mean- 3.5 days).

CONCLUSION

This study has depicted that acute appendicitis is the commonest emergency surgical condition affecting the young in the study area. Early presentation, early diagnosis and prompt treatment have shown to attribute to lower rate of complications, likewise decreasing mortality. The other observed fact was the negative appendectomy which was more frequent in females in their reproductive age group. Additional modern imaging is fundamental to support diagnostic accuracy to significantly reduce or avoid negative explorations.

[The nature of postoperative complications in patients with peritonitis]

We studied the postoperative period in patients with peritonitis. The structure of the most important factors that slow down the healing process and lead to mortality. Among the factors that affect the healing process is the most important character of fluid, and the prevalence of peritonitis (causative factor), which causes complications on the part of the internal organs and wounds.

Pure transvesical NOTES appendectomy using a 5-mm rigid laparoscope: a feasibility and survival study with porcine models

BACKGROUND

Previously, the authors demonstrated the feasibility of a pure transvesical natural orifice translumenal endoscopic surgery (NOTES) for uterine horn resection (UHR) using a rigid ureteroscope in swine as an appendectomy model. However, visualization was poor, and there was room for improvement. The authors have assessed the feasibility and safety of a revised technique that uses a 5-mm rigid laparoscope.

METHODS

Eight operations on four female pigs (35-40 kg) were performed as a proof of concept study. Four right-side operations were performed in a survival model. The surgical procedure was similar to the original technique. However, the rigid ureteroscope was replaced by a 5-mm laparoscope after modification of the access system. In addition, the clipped metal threads used for bladder closure were easily placed with a long 13-gauge needle. In the survival model, a Foley catheter was placed for 1 day.

RESULTS

The new technique provided considerably better visualization and operability than the original technique. The mean total operative time was 96.6 ± 18.2 min, and the mean estimated blood loss was 15.0 ± 13.5 ml. On postoperative day 3, pig 2 in the survival study died of peritonitis resulting from a small bowel injury. The lab results for the other pigs demonstrated no adverse events and tolerable immune responses. Necropsy showed complete healing of the vesicotomy.

CONCLUSIONS

The revised transvesical NOTES UHR technique improved the outcomes and feasibility of the original technique. This approach may be translatable to human appendectomy procedures in the future.

A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon)

BACKGROUND

No standardized approach is available for the management of complicated appendicitis defined as appendiceal abscess and phlegmon. This study used meta-analytic techniques to compare conservative treatment versus acute appendectomy.

METHODS

Comparative studies were identified by a literature search. The end points evaluated were overall complications, need for reoperation, duration of hospital stay, and duration of intravenous antibiotics. Heterogeneity was assessed and a sensitivity analysis was performed to account for bias in patient selection.

RESULTS

Seventeen studies (16 nonrandomized retrospective and 1 nonrandomized prospective) reported on 1,572 patients: 847 patients received conservative treatment and 725 had acute appendectomy. Conservative treatment was associated with significantly less overall complications, wound infections, abdominal/pelvic abscesses, ileus/bowel obstructions, and reoperations. No significant difference was found in the duration of first hospitalization, the overall duration of hospital stay, and the duration of intravenous antibiotics. Overall complications remained significantly less in the conservative treatment group during sensitivity analysis of studies including only pediatric patients, high-quality studies, more recent studies, and studies with a larger group of patients.

CONCLUSION

The conservative management of complicated appendicitis is associated with a decrease in complication and reoperation rate compared with acute appendectomy, and it has a similar duration of hospital stay. Because of significant heterogeneity between studies, additional studies should be undertaken to confirm these findings.

Acute appendicitis--open or minimally-invasive approach?

BACKGROUND

Although laparoscopy has become the standard approach in other procedures, this technique is not generally accepted for acute appendicitis.

AIM

To evaluate the results after minimally invasive appendectomies.

METHODS

All medical records of patients operated for acute appendicitis during the last year were retrospectively reviewed. We considered only patients with diagnosis of acute appendicitis confirmed by histopathology. We designed two groups: operated by open approach (OA) and operated by minimally-invasive approach (MIA). The two groups were compared for differenced in homogeneity and main end results: morbidity, mortality, hospital stay.

RESULTS

The men/women ratio was 112/88 (1.27), with a mean age of 31.83 +/- 1.06 years. There were more women in the MIA and more men in the OA group, p = 0.001. The Alvarado score was significant lower in MIA group (5.69 +/- 0.24 versus 6.57 +/- 0.23, p = 0.009). Comorbidities were noted in 51% from the patients, most of them in MIA group: 58.8%; N = 60, p = 0.016. Mean operation time was similar in both groups: 36.96 +/- 1.48 in OA versus 37.03 +/- 1.39 minutes in MIA. The postoperative mortality rate was 0.5%. The postoperative morbidity rate was 12%. Even though the number of cases with postoperative complications were double in OA group (16 cases versus 8 cases in MIA group) it did not reach statistical significance, p = 0.073. Histopathological examinations revealed early acute appendicitis in 45.5% cases (N = 91), suppurative appendicitis in 46.5% (N = 93) and gangrenous appendicitis in 8% (N = 16); early acute appendicitis was more frequent in MIA group and suppurative appendicitis in OA group: p = 0.017. The hospital stay was similar in both groups: 4.34 +/- 0.39 in OA versus 3.58 +/- 0.25 days in MIA group; p = 0.103.

CONCLUSIONS

MIA is a safe procedure and can be performed even in the patients with comorbidities. We didn't find any statistical significant difference from point of view of postoperative morbidity; however more postoperative complications were find in OA vs MIA group. The postoperative hospital stay was similar in both groups.

Position and susceptibility to inflammation of vermiform appendix in Accra, Ghana

OBJECTIVES

To determine the normal (non-inflamed) position of the vermiform appendix in Ghana and carry out a pilot study to test the hypothesis "The retrocaecal appendix is less prone to inflammation".

DESIGN

Retrospective autopsy study.

SETTING

The pathology department and the department of surgery theatres of the Korle Bu Teaching hospital in Accra, Ghana

SUBJECTS

Consecutive autopsies and inflamed appendices at appendicectomy. Deaths occurring from untreated appendicitis were excluded from the autopsy study. Conversely non-inflamed appendices and appendices from interval appendicectomy were excluded from the appendicitis study.

RESULTS

There were 1358 autopsies and 323 inflamed appendices. In the autopsy study the retrocaecal position was the most common (914 [67.3%]). Other positions were pelvic (294 [21.6%]), preileal (66 [4.9%]), postileal (51 [3.8%]) and paracaecal (33 [2.4%]). These positions were similar in males and females. The positions of 323 inflamed appendices were: retrocaecal (183 [56.7%]), pelvic (66 [20.4%]), preileal (20 [6.2%]), postileal (15 [4.6%]) and paracaecal (39 [12.1%]). Comparing the nonretrocaecal to the retrocaecal position by chi square, the non-retrocaecal position was more prone to inflammation (p<0.001).

CONCLUSION

The position of the normal appendix in Ghana differs from Western literature. The retrocaecal position appears less prone to inflammation in Ghanaians.

Appendicitis in the elderly: a change in the laparoscopic era

BACKGROUND

Appendicitis in elderly patients is associated with significant morbidity and mortality. Early and correct diagnosis together with minimally invasive surgery can lead to more favorable outcomes than occurred in the prelaparoscopic era.

METHODS

A retrospective review of 116 elderly patients (age > 60) from 1999 to 2004 is compared with the authors' previously published studies from 1978 to 1988 (n = 96) and from 1988 to 1998 (n = 113), respectively.

RESULTS

In our current series (1999-2004), more cases were managed laparoscopically (n = 68) than with open surgery (n = 48). Perforated appendicitis cases resulted in significantly longer hospital stays, more complications, and longer operating time than nonperforated cases. The laparoscopic cases had significantly shorter lengths of hospital stay and fewer complications than open cases, and comparable operating times. As compared with our previous studies from 1978 to 1988) and from 1988 to 1998, the current series (1999-2004) consists of patients presenting with fewer classical symptoms. Computed tomography (CT) scanning was more accurate in the current study and more routinely used. The patients in the current series had more correct preoperative diagnoses. Perforated appendicitis was encountered less frequently and associated with fewer complications. The 4% mortality rate in the previous two series decreased to less than 1% in this series.

CONCLUSION

Minimally invasive surgery combined with increased use and accuracy of preoperative CT scans has changed the clinical management of acute appendicitis in elderly patients, leading to decreased lengths of stay, decreased mortality, and more favorable outcomes.

[Septic complications in acute appendicitis. Problems of diagnosis and treatment]

AIM

diagnostic improvement in complicated acute appendicitis (AA) by implementing the new sepsis concepts and modern imaging procedures; optimization of treatment with decreasing postoperation morbidity and mortality and improving the cost-efficiency indicator. 1495 cases of AA admitted between 2000 and 2004 have been assessed retrospectively and among them 306 (20.46%) had complications. On admission 80.43% patients were diagnosed with AA, 17.50% with acute abdominal syndrome and 2.07% with chronic appendicitis. On discharge there were 1158 (77.45%) cases of inflammatory AA and 306 (20.46%) cases of complicated AA (perforation, gangrene, peritonitis, plastron abscess).

TREATMENT

98.26% of patients under-went operation and 1.73% did not.

SURGICAL PROCEDURES

standard appendicectomy in 1407 (95.77%) cases; laparoscopic appendicectomy in 30 (2.04%) cases; extraperitoneal approach in 15 (1.02%) cases; associated with surgical interventions on other organs in 75 (5.10%) cases. POST-OPERATORY MORBIDITY:128 (41.08%) cases out of 306; septic parietal complications in 102 (33.33%) cases; intraperitoneal complications in 26 (8.49%) cases. POST-OPERATORY MORTALITY: 6 deaths in patients aged over 68.

AVERAGE LENGTH OF STAY IN HOSPITAL

4 days for uncomplicated AA and 14.6 days for complicated ones. Perioperative septic complications are the result of evolution of late diagnosed disease, unjustified postponing of operation, surgical technique, patient health condition.

Racial disparities in the management of pediatric appenciditis

BACKGROUND

Our objective was to compare the racial differences in incidence and management of pediatric appendicitis.

MATERIALS AND METHODS

Data for this study come from two large national hospital discharge databases from the Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project: The Nationwide Inpatient Sample (NIS) and the Kids' Inpatient Database (KID). Analysis was restricted to age less than 18 years with an ICD-9 diagnosis of either simple (540.9) or complex (540.0 and 540.1) appendicitis. Data were weighted to represent national estimates. Incidence was defined as the number of new disease cases divided by the number of at risk hospitalized children.

RESULTS

The data for this study contained an estimated 428,463 [95% confidence interval (CI) = 414, 672-442, 253] cases of appendicitis, representing approximately 65,000 to 75,000 cases annually. Multi-variant analysis suggests that African-Americans, as compared to Caucasians, were less prone to develop appendicitis [odds ratio (OR) = 0.39, 95% CI (0.38, 0.41)], but less frequently underwent laparoscopic treatment [OR = 0.78, 95% CI (0.74, 0.87)], and were more likely to have complex appendicitis [OR = 1.39, 95% CI (1.30, 1.49)]. In contrast, Hispanics were more likely than Caucasians to both develop appendicitis [OR = 1.48, 95% CI (1.41, 1.56)] and to have complex disease [OR = 1.10, 95% CI (1.05, 1.16)]. The incidence of appendicitis was less frequent in females versus males [OR = 0.69, 95% CI (0.68, 0.70)] but the likelihood of laparoscopic exploration was higher [OR = 1.39, 95% CI (1.34, 1.43)]. Finally, children with public insurance [OR = 1.25, 95% CI (1.21, 1.29)] and uninsured children [OR = 1.10, 95% CI (1.04, 1.16)] were more likely to have complex appendicitis when compared to children with private insurance.

CONCLUSIONS

African-American children with appendicitis have lower overall hospitalization rates, higher rates of perforation, a greater delay to surgical management, and lower laparoscopic rates. In contrast, Hispanic children more frequently had appendicitis and complex disease. The treatment of African-American and Hispanic children overall was associated with a longer hospital stay and higher charges. The lower incidence of appendicitis in African-American children is incompletely understood and the disparity in surgical management among minority children remains troubling.

[Legal aspects of deadly acute appendicitis]

Appendicitis is diagnosed by synoptic evaluation of typical symptoms, laboratory tests and sonography. The only therapy is a prompt operation. The main reason for appendicitis mortality is the condition not detected or not detected in time. The case of a 50 year old male who died from a non-detected perityphlitic appendicitis with abscesses in the liver is presented. Only if appendicitis can be reliably ruled out an operation is not indicated. The not performed surgical intervention is often interpreted as a treatment error by the courts. In doubt, an operation should therefore be performed.

Morbidity of laparoscopic surgery for complicated appendicitis: an international study

BACKGROUND

Although laparoscopic appendectomy has some advantages over open appendectomy, some reports do show more postoperative intraabdominal abscesses.

METHODS

A retrospective review of complicated appendicitis managed surgically by eight surgical groups from six countries was undertaken. Among 3,433 patients with appendicitis, 1,017 (29.5%) had complicated appendicitis, which included perforated or gangrenous appendicitis with or without localized or disseminated peritonitis. There were 74 preoperative abscesses (7.4%) and 5 small bowel obstructions.

RESULTS

One patient died. There were 29 postoperative intraabdominal abscesses (2.8%) and 112 mostly minor complications. Conversion to laparotomy was necessary for 28 patients (2.7%). The surgical time ranged from 32 to 132 min (mean, 62 min), and the hospital stay ranged from 1 to 18 days (mean, 3.5 days).

CONCLUSIONS

The morbidity rates, particularly for intraabdominal abscesses, were less for laparoscopic appendectomy in complicated appendicitis than those reported in the literature for open appendectomy, whereas operating times and hospital stays were similar.

[Laparoscopic appendectomy--considerations in about 1000 cases]

Laparoscopic appendectomy (LA) is a well spread method today, but not as largely accepted as cholecystectomy, the cure of gastro-esophageal reflux and some other procedures (relatively small in number) for which the laparoscopic approach is the golden standard. Otherwise it is improbable that LA will gain such a status, at least in the near future. On the other hand it is obvious that LA offers important advantages for some special situations: the right iliac area syndrome, obesity, professional sportsmen, abnormal localization of the appendix, as well for the cases when localized and especially diffuse peritonitis is associated. Our paper analyses the experience of General Surgery Department at the "St.John" Emergency Hospital Bucharest on laparoscopic appendectomy. The retrospective study includes 996 cases that were treated laparoscopic between 1996-2004. Of these 745 cases were catarrhal, 166 cases were phlegmonous and 76 gangrenous appendicitis. In 93 cases localized or diffuse peritonitis was associated. There were recorded also 3 cases of each of the following: chronic appendicitis, appendicular mass and mucocele. The number of conversions was 28 (2.81%). There were also 10 reinterventions (1.004%), 7 because of intraperitoneal abscess and we also recorded one death.

The Burden of Appendicitis-Related Hospitalizations in the United States in 1997

BACKGROUND

Acute appendicitis is among the most frequent causes of surgical abdominal disease worldwide.

METHODS

Data from the Nationwide Inpatient Sample of the Healthcare Utilization Project were used to estimate the prevalence and disease burden of appendicitis-related hospitalizations in the United States in 1997. The data are a representative sample of discharge records from community hospitals drawn from 22 states in the United States.

RESULTS

In the United States in 1997, there were an estimated 252,682 (95% CI: 242,957-262,407) appendicitis-related hospitalizations. The mean length of stay and total charges for appendicitis-related hospitalizations were four days (95% CI: 3.4-4.6) and $11,645 (95% CI: $11,299-$11,992) per hospitalization, respectively. Appendicitis-related hospitalizations associated with post-operative infection, peritoneal abscess, or peritonitis had longer average lengths of stay and higher average costs when compared to hospitalizations associated with local appendicitis without post-operative infection. Appendicitis cases among very young and older patients were more likely to be associated with peritoneal abscess, peritonitis, or post-operative infection.

CONCLUSIONS

In 1997, appendicitis-related hospitalizations accounted for 0.6% of all hospitalizations in the United States, resulting in approximately one million hospital days and $3 billion in hospital charges. Between 1984 and 1997, the rate of appendicitis hospitalizations in the U. S. population declined slightly, whereas the total number of hospital days remained unchanged.

Decline in admission rates for acute appendicitis in England

BACKGROUND

The incidence of acute appendicitis declined in western countries between the 1930s and the early 1990s. The aim of this study was to determine time trends in hospital admissions for acute appendicitis in England between 1989-1990 and 1999-2000, and in population mortality rates for appendicitis from 1979 to 1999.

METHODS

: Hospital Episode Statistics for admissions were obtained from the Department of Health and mortality data from the Office for National Statistics.

RESULTS

Between 1989-1990 and 1999-2000, age-standardized hospital admission rates for acute appendicitis decreased by 12.5 per cent in male patients and by 18.8 per cent in female patients. The proportions of admissions that resulted in operation remained stable. Admission rates for non-specific mesenteric lymphadenitis fell. Admission rates for abdominal pain increased between 1989-1990 and 1995-1996, at which time the International Classification of Diseases codes changed. Between 1995-1996 and 1999-2000, admission rates for abdominal pain declined. Analysis of age-specific admission rates for acute appendicitis and abdominal pain from 1989-1990 to 1995-1996 showed that the decline in acute appendicitis could not be accounted for by a change in diagnostic practice. Mortality rates for acute appendicitis remained stable over the study period.

CONCLUSION

Admission rates for acute appendicitis declined over the study period. This decline cannot be explained by reclassification.

Implications of removing a normal appendix

BACKGROUND

The diagnosis of acute appendicitis remains difficult, and therefore 15-30% of the removed appendices appear to be normal. The aim of this study is to investigate the morbidity, mortality and costs of removing a normal appendix in patients with suspected appendicitis.

PATIENTS AND METHODS

A retrospective study was performed on patients who underwent a negative appendectomy for suspected appendicitis in the period 1991-1999 with a median follow-up of 4.4 years. Patients who underwent an elective appendectomy or appendectomy for other reasons were excluded.

RESULTS

In 285 patients (70% women, 30% men) a normal appendix was removed. In 192 (67%) patients a muscle-splitting incision was performed, in 6 (2%) a median laparotomy, and in 51 (18%) the normal appendix was removed by laparoscopy. In 36 patients (13%) a diagnostic laparoscopy was converted to a muscle-splitting incision. Complications occurred in 16 (6%) patients, in 5 (2%) a reoperation was needed. The mean hospital stay was 4.4 (SE 2.8) days, in case of complication 7.4 (SE 4.2) days. The mean extra hospital costs of a negative appendectomy were EUR 2,712.

CONCLUSION

The removal of a normal appendix has considerable complications and costs. In an attempt to prevent these costs, extra diagnostic tools should be considered. Expensive diagnostic tools as diagnostic laparoscopy should be used selectively in order to not further exceed costs.

Acute appendicitis in the elderly. An analysis of 47 patients over 80 years of age

OBJECTIVE

To correlate the preoperative findings, perforation rate and the mortality rate after appendicectomy in the elderly age.

DESIGN

Retrospective study.

SETTING

Teaching hospital, Sweden.

SUBJECTS

Forty-seven patients over 80 years of age who have undergone acute appendicectomy.

MAIN OUTCOME MEASURES

Operative and postoperative outcome after acute appendicectomy in the elderly.

RESULTS

The complication rate after appendicectomy was statistically significantly increased to 28% as well as the mortality increased to 8.5% in the elderly patients when compared to the other age group. The perforation rate was also statistically significantly increased to 64% when compared to the same group.

CONCLUSIONS

Our study shows that at the time of clinical symptoms, inflammatory parameters in acute appendicitis in the elderly do not differ from the young patient, but patients older than 80 years of age have a high risk of perforation, morbidity and mortality.

[Possibilities in diagnostic laparoscopy of acute appendicitis]

Results of diagnostic laparoscopy in acute appendicitis suspects are presented. Laparoscopy allowed examination of the appendix in 96.5% cases, to make final diagnosis in 92.5% and to avoid surgery in 31.2% cases. Larger application of diagnostic laparoscopy in patients suspected of acute appendicitis will reduce significantly rate of diagnostic mistakes, complications and unwarranted appendectomies.

Abdominal pain among children re-evaluation of a diagnostic algorithm

AIM: To re-evaluate the algorithm that has been used for over 40 years for diagnosis of acute abdominal pain among children.

METHODS: Among the 937 cases admitted to the surgical emergency ward in 2000, 656 cases of acute appendicitis were studied to evaluate the usefulness of the present algorithm for its calculated accuracy, false positive and false negative rates, the sensitivity and specificity in the instant diagnosis of various types of acute appendicitis in different age groups. The algorithm used was established in 1958 and revised for this study in 1999. It includes a 3-step analysis of clinical presentations, i.e.: firstly, a diagnosis of surgical pain by definite organic abdominal signs; then a diagnosis of the subgroup of surgical condition by special signs; and finally the diagnosis of the present disease by specific signs. A footnote describes a "comparative technique" of abdominal examination in non-cooperative children.

RESULTS: The general accuracy of diagnosis was 92.8%, overall mortality 0.1% among 973 cases of abdominal pain in 2000.373 attending surgeons and 241 residents including trainees joined the diagnosis and treatment with no remarkable difference in the results. The incidence of acute appendicitis, 656 in 973 cases, was 67.4% representing the majority of abdominal pain. In the series of 656 cases, the accuracy of diagnosis of acute appendicitis was 93.6%, false positive 6.4%, false negative 0.9%, sensitivity at first visit 82.7%, specificity for appendicitis 98.0%, no death or documentary complication.

CONCLUSION: The present algorithm used for diagnosis of acute abdominal pain is effective and preferable in reducing misdiagnosis and maltreatment at emergency. The use of some modern technology should be further explored.

[Therapy of diffuse suppurative peritonitis with continuous peritoneal lavage]

Peritonitis is a severe illness with a high mortality rate and different treatment modalities. Over a time period of 12 years 510 patients with peritonitis treated with continuous peritoneal lavage (CPL) were retrospectively analyzed. 315 of 510 patients with a mean age of 57.4 and a mean APACHE-II-Score of 10.2 on admission had a diffuse four quadrant peritonitis. 195 had a local and diffuse peritonitis due to perforation of the appendix. 232 of 315 patients with diffuse peritonitis (73.7%) had a secondary peritonitis, mostly due to organ perforation. The most frequent comorbidities were congestive heart failure (36.8%), pulmonary diseases (26%), diabetes mellitus (18.7%), chronic renal failure (16.8%), chronic liver diseases (9.5%) and a history of alcohol abuse (12.4%). On admission 18.7% had pulmonary insufficiency, 18.4% renal failure, 14.3% congestive heart failure and 13.3% hepatic insufficiency. 14% had one organ-, 6.7% two organ-, 2.5% three organ- and 5% four organ failure. The mean duration of lavage was 5.1 days with a fluid amount of 8-24 l/day. 81.3% of all patients could be treated successfully. 46 patients were reoperated due to persistent peritonitis. The mortality rate of the primarily treated patients was 15.6% compared to 37.0% of patients who had to be reoperated. The mortality rate of all patients was 18.7%. The prognosis of the clinical outcome was significantly influenced by preexisting organ failure and by the duration of the peritonitis on admission. Our results on CPL for diffuse peritonitis are in accordance with results from other treatment modalities; a direct comparison was not possible due to the different patient groups.

[Current therapy of complicated appendicitis]

A significant number of complications in acute appendicitis develop due to delayed or even missed diagnosis. Potentially every patient can be affected due to a distinct feature of appendicitis--the rapidity with which the inflammation passes through the different stages. Even after a few hours, gangrenous appendicitis with impending overt perforation can have developed. In many cases, the term complicated appendicitis may be less significant than implied because, e.g., the rapidly developed perforation can be treated by appendectomy, which rarely presents a surgical challenge. However, every perforation of a hollow viscus in the abdomen leads to peritonitis of different degrees, which untreated can end lethally. The often cited statement of Dieu la Foy from the last but one century "no patient has to die from appendicitis" remains a surgical dream not quite fulfilled. Occasionally even today, patients with comorbidity die from the sequelae of appendicitis, i.e., high-risk groups including the very young and the very old and immunosuppressed patients. These patients should receive special attention when the diagnosis of appendicitis is considered. By definition, complicated appendicitis includes perforation of the appendix, empyema or abscess formation, and finally fecal peritonitis. The surgical procedure chosen and when to add supportive measures will depend on the specific complication present. Early or immediate appendectomy, i.e., the urgent indication to operate, is a generally accepted concept in the therapy of acute appendicitis. Even in complicated cases, the aim is just one operative procedure or if need be only the application of antibiotics.

[Insidious and often fatal. Appendicitis with few symptoms in the elderly patient]

The age peak for acute appendicitis is between 10 and 20 years. Although older persons more rarely develop appendicitis, in the group of over-45-year-olds the perforation and mortality rates are appreciably higher. The reason for this is the fact that in the elderly, the symptoms are often veiled, so that the diagnosis is delayed. A particular role in this connection is played by pain killers and non-specific findings. In particular, however, the commonly present co-morbidity in older patients with appendicitis often leads to recalcitrant infections, and not infrequently to sepsis with a potentially fatal outcome. For the establishment of the diagnosis, therefore, a careful physical examination and thorough history-taking, together with a comprehensive laboratory work-up is essential. Imaging procedures such as X-rays of the abdomen, ultrasonography and, where indicated, such further measures as a barium enema or a CT scan may help establish the diagnosis in patients with unclear clinical symptoms, and thus prevent perforation.

Acute appendicitis in Yirgalem Hospital, southern Ethiopia

The prevalence of appendicitis shows a marked variation between populations. The aim of this study is to determine the rate of prevalence of acute appendicitis in Yirgalem Hospital, in Southern Ethiopia. A retrospective analysis was undertaken on 200 cases of acute appendicitis surgically managed at Yirgalem Hospital from January 1997 to December 1999. During this period the disease accounted for 27.9% of the operations for acute abdominal emergencies and for 1.1% of total hospital admissions. There were 159 males and 41 females giving a male to female ratio of 3.9:1. The mean age was 25.6 +/- 10.9 years (range 4-90 years). The average duration of illness at presentation and hospital stay were 3.4 +/- 1.7 and 7.1 +/- 5.3 days, respectively. All the cases presented with abdominal pain and a shift of the periumbilical abdominal pain to the right lower quadrant was found in the majority. Right lower quadrant tenderness was the leading physical finding. The rate of simple and perforated appendicitis were 45.5% and 44%, respectively. Thirty-two per cent of the patients had postoperative wound infection. Out of the 200 patients operated upon for acute appendicitis 8 (4%) died. The study showed that the prevalence of acute appendicitis was low in Yirgalem Hospital and the results of the study were compared with those from elsewhere.

Mortality after appendectomy in Sweden, 1987-1996

OBJECTIVE

To study mortality after appendectomy.

SUMMARY BACKGROUND DATA

The management of patients with suspected appendicitis remains controversial, with advocates of early surgery as well as of expectant management. Mortality is not known.

METHODS

The authors conducted a complete follow-up of deaths within 30 days after all appendectomies in Sweden (population 8.9 million) during the years 1987 to 1996 (n = 117,424) by register linkage. The case fatality rate (CFR) and the standardized mortality ratio (SMR) were analyzed by discharge diagnosis.

RESULTS

The CFR was 2.44 per 1,000 appendectomies. It was strongly related to age (0.31 per 1,000 appendectomies at 0-9 years of age, decreasing to 0.07 at 20-29 years, and reaching 164 among nonagenarians) and diagnosis at surgery (0.8 per 1,000 appendectomies after nonperforated appendicitis, 5.1 after perforated appendicitis, 1.9 after appendectomies for nonsurgical abdominal pain, and 10.0 for those with other diagnoses). The SMR showed a sevenfold excess rate of deaths after appendectomy compared with the general population. The relation to age was less marked (SMR of 44.4 at 0-9 years, decreasing to 2.4 in patients aged 20-29 years. and reaching 8.1 in nonagenarians). The SMR was doubled after perforation compared with nonperforated appendicitis (6.5 and 3.5, respectively). Nonsurgical abdominal pain and other diagnoses were associated with a high excess rate of deaths (9.1 and 14.9, respectively). The most common causes of deaths were appendicitis, ischemic heart diseases and tumors, followed by gastrointestinal diseases.

CONCLUSIONS

The CFR after appendectomy is high in elderly patients. The excess rate of death for patients with nonperforated appendicitis and nonsurgical abdominal pain suggests that the deaths may partly be caused by the surgical trauma. Increased diagnostic efforts rather than urgent appendectomy are therefore warranted among frail patients with an equivocal diagnosis of appendicitis.

Effectiveness of imaging studies in acute appendicitis: a simplified decision model

Computed tomography (CT) and ultrasonography (US) have been proposed as non-invasive diagnostic aids in patients with suspected acute appendicitis. Currently, clear guidelines about the indications to use these techniques are lacking. Using the concepts of decision analysis, a model was created to calculate the effectiveness of US and CT in patients with clinically suspected appendicitis. The perspective chosen was the health of individual patients. The model makes use of published data and provides a critical threshold probability (ctp). Decisions in individual cases can be made by comparing ctp with the clinical probability of disease. The calculated ctp-values for US and CT were 0.58 and 0.74, respectively. In other words, on average, US (CT) is indicated only if the expert clinician considers the probability of disease to be smaller than 58% (74%). It is concluded that in patients with suspected acute appendicitis, selective rather than routine use of imaging studies is recommended. The exact value of the decision threshold should be determined in function of the local situation.

[Appendicitis in Niger: current prognosis]

Acute appendicitis remains one of the most frequent emergencies in abdominal surgery. Surgery is usually straightforward and prognosis excellent. However, outcome depends essentially on how soon diagnosis is made. In Niger, the 1990s were marked by the development of private medicine and the deterioration of services in state health structures (health centres and hospitals). The goal of this prospective study, carried out over 24 months (March 1997-March 1999) was to analyse existing appendicitis prognosis in our country. The study population was made up of 362 patients and we based our survey on a number of factors found in the medical literature, and in particular on a similar study conducted in the same hospital in 1989 by another group of surgeons. Delays in diagnosis and thus therapy still today tends to transform prognosis for simple acute appendicitis into that of peritonitis. The numerous and varied post-operative complications keep the mortality rate at 4%.

[Relaparotomy after an appendectomy]

The analysis covers 2555 appendectomies, performed on an emergency and scheduled surgery basis in the clinic of emergency surgery.--State University Hospital "Queen Giovanna", Sofia, over the period 1985-1997. Relaparotomy is necessitated in 28 cases (1.09 per cent) because of various postoperative complications. Data are presented on the number of relaparotomies, done under conditions of emergency and scheduled surgery, and with a special reference to the pathoanatomical character of appendicitis. The underlying causes of undertaking relaparotomy and postoperative lethality are analyzed. As shown by the obtained results post-relaparotomy mortality rate is the highest after primary operation for destructive form of appendicitis and advanced form of peritonitis.

[Characteristics of appendicitis in patients over 70 years of age]

Chart review of our patients who were operated for acute appendicitis was performed to characterize the appendicitis in the elder patients. Celiotomy revealed perforation of the appendix in almost 40%, frequently in patients with unspecific symptoms and no leucocytosis. While mortality was 9.2% in the ninteeneighties, non of our patients died during the last 5.5 years. This might be attributed to emergency operation, improved anaesthesia and intensive medical care.

Laparoscopic versus open appendicectomy: a comparative study

There are many questions regarding the advantages and disadvantages a videolaparoscopic approach in the treatment of acute appendicitis. The authors present the results of a non-randomized, prospective study with 496 patients admitted between January 1992 and March 1998 by the General Surgery Service of São Rafael Hospital Salvador-BA-Brazil. The patients were submitted for appendicectomy by video laparoscopy or by the traditional open method, and variables such as surgery duration, morbidity, mortality, costs, and length of stay (LOS) were compared. The results demonstrate that laparoscopic appendicectomy is a safe alternative for treatment of acute appendicitis; however, there are several disadvantages that gradually must be overcome.

Impact an anatomical site on bacteriological and clinical outcome in the management of intra-abdominal infections

The clinical and bacteriological results of treatment for 429 patients who had intra-abdominal infection were analyzed to determine whether the anatomical origin of peritonitis influenced outcome. All patients had received effective broad spectrum antimicrobial therapy and operation in four multicenter trials. The diagnoses of infection were categorized into three sites: upper gastrointestinal tract, complicated appendicitis, and lower gastrointestinal tract. Clinical response rates were excellent for complicated appendicitis and were lowest for infections related to the upper gastrointestinal tract. Bacteriological response rates were also lower for upper gastrointestinal tract organisms and were highest for isolates associated with complicated appendicitis. There were no deaths in the 213 patients who had infection associated with appendicitis. Seven deaths occurred in the 86 patients (81%) with an upper gastrointestinal site of infection, and nine deaths occurred in the 130 patients (6.5%) with lower gastrointestinal site of infection. Mortality was related to recurrent intra-abdominal infection after an unsuccessful primary operation and a serum albumin less than 25 g/l. Clinical trails of antimicrobials for intra-abdominal infection should consider stratification of patients according to these three levels of alimentary tract perforation when the site is known preoperatively. Patients who have infection secondary to previous surgery or who are malnourished represent a higher risk group even with appropriate antibiotics.

Acute abdominal pain in children: an analysis of admissions over a three year period

A quality audit was performed of the case records of 1313 children admitted with acute abdominal pain over a three year period under the care of paediatric surgeons at the Princess Margaret Hospital for Children, Perth. Fifty-four per cent (n = 714) of the patients were discharged without surgical intervention; in this group the most frequent (70%, n = 503) diagnosis was non-specific abdominal pain (NSAP). Of those children having surgery, 74% (n = 443) had appendicitis proven on histopathology; the remaining appendices (n = 134) were reported as normal and no other surgical cause for the patients symptoms were identified. Only 3.7% (n = 22) of children having surgery had another surgical cause for their pain. Of this group, 11 had adnexal pathology, eight had complications of a Meckel's diverticulum and three had torsion of the omentum. There were no deaths in this series, and 39 patients (3%) had wound infections. Based on these results, only 35% of children referred to a surgeon with abdominal pain will actually require surgical intervention, although as a consequence of concern over clinical status an additional 10% will have a laparotomy with normal findings.

Acute appendicitis in Ethiopia

Over a five year period, appendectomy comprised 17.32% of emergency abdominal operations at Gondar College of Medical Hospital, Ethiopia. The mortality rate was 4.5% and the annual incidence was uniform (nineteen to twenty two cases per year) during the study period.

[Mortality in acute appendicitis--an analysis of a ten-year period]

This is a retrospective study covering 11,142 acute appendicitis patients, operated in the emergency surgery section of the Emergency Medicine Institute "Pirogov" over the period 1986 through 1995. Overall mortality amounts to 0.29 per cent (32 deceased). The dynamic patterns of mortality undergo regression analysis. The basic factors having an impact on thanatogenesis are comprehensively discussed, namely advanced age, premorbidity background, form of appendicitis and postoperative complications. Late diagnosis is the most important factor leading to peritonitis development. Also, peritonitis against the background of concomitant diseases and advanced age proves to be the underlying cause of the fatal outcome of patients--in 24 (75 per cent) of the total number of deaths. The necessary measures contributing to make prompt diagnosis in acute appendicitis, and undertaking more effective treatment of appendicular peritonitis and postoperative complications are outlined.