Pediatric perforated appendicitis diagnosis based on the C-reactive protein/prealbumin ratio

Pediatric perforated appendicitis, prone to multiple complications, necessitates identifying potential serum biomarkers for early diagnosis and intervention. A cross-sectional study was conducted on patients under 16 with acute appendicitis, admitted to Hainan Women and Children's Medical Center from January 2019 to July 2023. The patients were categorized into perforated and non-perforated groups. Among the 313 included patients, 106 (33.87%, 95% CI 28.59-39.14%) developed perforation. The C-reactive protein to prealbumin ratio (CPA) showed a significant difference between the perforated and non-perforated groups [6.63 (2.9-13.02) vs. 0.7 (0.11-2.18), p < 0.001]. The AUC of CPA on the ROC curve was 0.691 (95% CI 0.513-0.869, p = 0.084) in patients under 4. In patients aged 4-9, the sensitivity of CPA > 3 predicting perforation was 76.2%, with a specificity of 81.6%, and an AUC of 0.816 (95% CI 0.747-0.886, p < 0.001). For patients aged 9-16, the sensitivity of CPA > 2.2 predicting perforation was 85%, with a specificity of 85.7%, and an AUC of 0.919 (95% CI 0.859-0.979, p < 0.001). CPA > 3 and CPA > 2.2 can predict perforated appendicitis in patients aged 4-9 and 9-16, respectively.

Lack of Routine Postoperative Labs Not Associated With Complications in Pediatric Perforated Appendicitis

INTRODUCTION

Postoperative (postop) management of pediatric perforated appendicitis varies significantly, and postop intra-abdominal abscesses (IAA) remain a significant issue. Between 2019 and 2020, our standardized protocol included routine postop labs after an appendectomy for perforated appendicitis. However, given the lack of predictive utility of these routine labs, we discontinued this practice in 2021. We hypothesize that discontinuing routine postop labs will not be associated with an increase in complication rates after an appendectomy for pediatric perforated appendicitis.

METHODS

A single-institution, retrospective review of all pediatric appendectomies for perforated appendicitis from January 2019 to December 2021 was conducted at University Hospitals Rainbow Babies and Children's Hospital in Cleveland, Ohio. Data were collected on rate of complications (IAA development, re-admissions, bowel obstructions, superficial surgical site infections, intensive care unit transfers, Clostridium difficile infections, allergic reactions, and transfusions), postop imaging, postop interventions, and length of stay. Statistical analysis was completed using Fisher's exact test and Mann-Whitney U-test.

RESULTS

A total of 109 patients (2019-2020 n = 61, 2021 n = 48) were included in the study. All 61 patients from 2019 to 2020 had postop labs compared to only eight patients in 2021. There was no statistically significant difference between the two groups in overall complication rates, but there was a decrease in IAAs reported in 2021 (P = 0.03). There were no statistically significant differences in other complications, postop imaging usage, or postop interventions. The median length of stay was 4.5 d in 2021 compared to 6.0 d in 2019-2020 (P = 0.009).

CONCLUSIONS

Discontinuing routine postop labs is not associated with an increase in overall complications rates. Further studies are needed to determine whether routine postop labs can be safely removed in pediatric patients with perforated appendicitis, which would reduce patient discomfort and care costs.

A recurrent retrohepatic abscess secondary to a dropped appendicolith

Appendicoliths can drop into the peritoneal cavity during the course of an appendicectomy, or more commonly as a result of perforated appendicitis. We report the case of a patient with a history of recurrent retrohepatic abscesses over 7-year period due to a retained appendicolith and review the literature on perihepatic abscesses caused by retained appendicoliths. The abscess had been drained percutaneously 4 times without retrieval of the appendicolith and eventually the patient needed a laparotomy, drainage of the abscess, and extraction of the appendicolith. Treatment of abscesses secondary to dropped appendicoliths may be percutaneous, laparoscopic, or via conventional open surgery, but it is important to retrieve the appendicolith if recurrent abscess formation is to be avoided.

Povidone-iodine intra-abdominal irrigation versus no irrigation in pediatric perforated appendicitis: A secondary economic analysis of a Bayesian randomized controlled trial

BACKGROUND

A pilot randomized controlled trial (RCT) conducted in children (2-17 ​y) with perforated appendicitis demonstrated an 89% probability of reduced intra-abdominal abscess (IAA) rate with povidone-iodine (PVI) irrigation, compared with no irrigation (NI). We hypothesized that PVI also reduced 30-day hospital costs.

METHODS

We conducted a retrospective economic analysis of a pilot RCT. Hospital costs, inflated to 2019 U.S. dollars, were obtained for index admissions and 30-day emergency visits and readmissions. Cost differences between groups were assessed using frequentist and Bayesian generalized linear models.

RESULTS

We observed a 95% Bayesian probability that PVI reduced 30-day mean total hospital costs ($16,555 [PVI] versus $18,509 [NI]; Bayesian cost ratio: 0.90, 95% CrI, 0.78-1.03). The mean absolute difference per patient was $1,954 less with PVI (95% CI, -$4,288 to $379).

CONCLUSIONS

PVI likely reduced the IAA rate and 30-day hospital costs, suggesting the intervention is both clinically superior and cost saving.

Association between bacterial resistance profile and the development of intra-abdominal abscesses in pediatric patients with perforated appendicitis: cohort study

PURPOSE

The objective of this study was to determine the association between the presence of a microorganism resistant to the antibiotic used in empirical therapy and the development of intra-abdominal abscesses in children with perforated appendicitis.

METHODS

A prospective cohort study was conducted in patients under 18 years of age who underwent laparoscopic appendectomy between November 1, 2019, and September 30, 2020, in whom perforated appendicitis was documented intraoperatively. Peritoneal fluid samples were taken for bacteria culture purposes, and clinical and microbiological data were collected from all patients.

RESULTS

A total of 232 patients were included in the study. The most isolated microorganisms were Escherichia coli (80.14%) and Pseudomonas aeruginosa (7.45%). In addition, 5.31% of E. coli isolates were classified as ESBL-producing organisms. No association was found between a germ resistant to empiric antimicrobial therapy and the development of a postoperative intra-abdominal abscess. Multivariate analysis showed that being a high-risk patient on admission (OR 2.89 (p = 0.01)) was associated with the development of intra-abdominal abscesses postoperatively.

CONCLUSION

E. coli was the most commonly isolated microorganism, with a low rate of ESBL-producing isolates. No association between resistance and risk of postoperative intra-abdominal abscess was found. However, it was identified that being a high-risk patient on admission was associated with this complication.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level I.

Addressing health equity in pediatric surgical care in the United States- Progress and challenges

There are notable inequities in health outcomes for children based on their social determinants of health (SDOH), including where they are born and live, their primary language, their race and ethnicity, socioeconomic status, and more. These health inequities are not restricted to resource limited settings; here we highlight three broad topics that are relevant to pediatric surgeons in the United States (US): access to care and disparities, and examples of inequities in firearm-related injuries and appendicitis. Most of our patients will at some point require operative interventions, yet there can be significant challenges in accessing this care and navigating our health systems, particularly around complex perioperative care. There are significant opportunities to improve equitable care by helping patients navigate our health systems and connecting them with additional resources, including screening for primary care services. Firearm-related injuries are now the leading cause of death in children in the US, with significant associated morbidity for non-fatal injuries. There are notable inequities in the risk of injury and types of injuries experienced by children based on their SDOH. Appendicitis is one of the most common pathologies managed by pediatric surgeons, with similar inequities in the rates of perforated appendicitis based on a child's SDOH. For both issues, addressing the inequities our patients experience requires moving upstream and working towards prevention. Key opportunities include better research and data to understand the drivers for observed inequities, multidisciplinary collaboration, community engagement, and public health advocacy among others. As a profession, we have a responsibility to work to address the health inequities our patients experience.

Amyand's hernia with a perforated appendix and an enterocutaneous fistula: A case report

INTRODUCTION

Amyand's hernia is a rare finding accounting for less than 1 % of inguinal hernias. The appendix with its pathology within the hernia sac may become isolated from the gastrointestinal tract, which can cause further confusion in clinical diagnosis. Awareness of the possibility of such appendiceal isolation could aid in clinical diagnosis. We report a rare case of Amyand's hernia complicated with a perforated appendix and an enterocutaneous fistula.

PRESENTATION OF CASE

A 64-year-old gentleman with diabetes mellitus type II and hypertension presented with a right inguinal swelling associated with a malodorous discharge without features of intestinal obstruction. Ultrasonography revealed a right inguinal hernia with features of partial strangulation. He underwent a right inguinal exploration with subsequent debridement, appendicectomy and a herniorraphy. The patient had complete recovery and histopathology revealed acute appendicitis.

DISCUSSION

Amyand's hernia is rare and difficult to diagnose pre-operatively. Appendicitis in Amyand's hernia is rarer still and may be caused by intraluminal or extraluminal obstruction. Clinical presentation is variable and ultrasonography and computed tomography (CT) scan aid in diagnosis. Appendicectomy is regarded as unnecessary when the appendix is normal. Synthetic mesh should be avoided when the appendix is inflamed or perforated.

CONCLUSION

Amyand's hernia is rare and difficult to diagnose. Ultrasonography and CT scan are valuable tools for pre-operative diagnosis. Isolation of the appendix with its pathology within the hernia sac can add to the confusion in clinical diagnosis. Management of Amyand's hernia should be tailored according to the pathology encountered and treatment should not be delayed.

Image-guided abscess drainage in children with perforated appendicitis - can it wait?

BACKGROUND

Image-guided drainage is the management of choice for perforated appendicitis with intra-abdominal abscess/es. However, there is paucity of data regarding the optimal time for intervention in children.

OBJECTIVE

The purpose of this study is to assess the relationship between the time from diagnosis of a drainable abscess to abscess drainage (delta time) and the clinical outcome in patients with complicated acute appendicitis.

MATERIALS AND METHODS

This is an institutional review board (IRB)-approved retrospective study comprising 80 pediatric patients who had image-guided abscess drainage due to perforated acute appendicitis. Delta time was associated with clinical outcome including length of stay, catheter dwell time, need for additional interventions, and need for tissue plasminogen activator (t-PA). Gamma regression models were used to assess the adjusted effect of delta time on the "length of stay" and "catheter dwell time" using "volume of the largest abscess" and "number of collections" as severity indices. Logistic regression was used to assess the effect of delta time on the "need for the t-PA" and "need for additional interventions."

RESULTS

Mean age (SD) was 10.2 (3.8) years. Mean time between diagnosis and intervention (delta time) was 1.5 (1.2) days. There was no evidence that delta time effects the length of stay, catheter dwell time, need for t-PA, and need for additional interventions (P > 0.05). However, there was an association between the number of collections and volume of the largest abscess with length of stay (P = 0.006; P = 0.058), catheter dwell time (P = 0.029; P < 0.001), and need for additional interventions (P = 0.029; P = 0.016).

CONCLUSIONS

Our results suggest that time between diagnosis of an appendicitis associated abscess and intervention is not significantly associated with need for tPA, need for additional intervention, drain dwell time, or length of stay.

Early surgery for perforated appendicitis: Are we moving the needle on postoperative abscess?

BACKGROUND

Perforated appendicitis is often managed nonoperatively though upfront surgery is becoming more common. We describe postoperative outcomes for patients undergoing surgery at their index hospitalization for perforated appendicitis.

METHODS

We used the 2016-2020 National Surgical Quality Improvement Program database to identify patients with appendicitis who underwent appendectomy or partial colectomy. The primary outcome was surgical site infection (SSI).

RESULTS

132,443 patients with appendicitis underwent immediate surgery. Of 14.1% patients with perforated appendicitis, 84.3% underwent laparoscopic appendectomy. Intra-abdominal abscess rates were lowest after laparoscopic appendectomy (9.4%). Open appendectomy (OR 5.14, 95% CI 4.06-6.51) and laparoscopic partial colectomy (OR 4.60, 95% CI 2.38-8.89) were associated with higher likelihoods of SSIs.

CONCLUSIONS

Upfront surgical management of perforated appendicitis is now predominantly approached by laparoscopy, often without bowel resection. Postoperative complications occurred less frequently with laparoscopic appendectomy compared to other approaches. Laparoscopic appendectomy during the index hospitalization is an effective approach to perforated appendicitis.

Labs Do Not Predict Postoperative Intra-abdominal Abscess in Pediatric Perforated Appendicitis

INTRODUCTION

We aim to evaluate the utility of postoperative labs in predicting the development of an intra-abdominal abscess (IAA) in pediatric patients with perforated appendicitis. We hypothesize that postoperative labs are not predictive of IAA development.

METHODS

This was a single-institution retrospective cohort study that included pediatric patients (n = 61) who underwent surgery for perforated appendicitis from January 1, 2019 to December 1, 2020. Patients were stratified into those who developed a postoperative IAA (n = 22) and those who did not (n = 39). Postoperative labs (white blood cell [WBC] count, absolute neutrophil count, platelet count, C-reactive protein) were examined. Mann-Whitney U tests and chi-square tests were used to assess for differences between groups.

RESULTS

There was extensive heterogeneity and overlap in postoperative lab values between patients who developed an IAA and those who did not. Almost all patients who developed an IAA had clinical signs that were indicative of abscess formation regardless of their postoperative WBC count or change in WBC count. While patients who developed an IAA had a higher postoperative median WBC count (10.8 versus 8.4, P = 0.003) and a smaller WBC count decrease (-4.9 versus -7.4, P = 0.01), no cutoff value for any of the examined lab values specifically predicted abscess formation. Postoperative median absolute neutrophil count (7.4 versus 4.0, P = 0.15), platelet count (360 versus 353, P = 0.98), and C-reactive protein (8.20 versus 5.32, P = 0.06) did not differ significantly.

CONCLUSIONS

We conclude that postoperative labs have limited clinical utility in evaluating IAA development in children with perforated appendicitis.

Drain placement in paediatric complicated appendicitis: a systematic review and meta-analysis

Children undergoing appendicectomy for complicated appendicitis are at an increased risk of post-operative morbidity. Placement of an intra-peritoneal drain to prevent post-operative complications is controversial. We aimed to assess the efficacy of prophylactic drain placement to prevent complications in children with complicated appendicitis. A systematic review was performed in accordance with PRISMA guidelines. Cochrane, MEDLINE and Web of Science databases were searched from inception to November 2022 for studies directly comparing drain placement to no drain placement in children ≤ 18 years of age undergoing operative treatment of complicated appendicitis. A total of 5108 children with complicated appendicitis were included from 16 studies; 2231 (44%) received a drain. Placement of a drain associated with a significantly increased risk of intra-peritoneal abscess formation (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.16-2.24, p = 0.004) but there was no significant difference in wound infection rate (OR 1.46, 95% CI 0.74-2.88, p = 0.28). Length of stay was significantly longer in the drain group (mean difference 2.02 days, 95% CI 1.14-2.90, p < 0.001). Although the quality and certainty of the available evidence is low, prophylactic drain placement does not prevent intra-peritoneal abscess following appendicectomy in children with complicated appendicitis.

Nationwide management of perforated pediatric appendicitis: Interval versus same-admission appendectomy

PURPOSE

Although conservative management followed by readmission for interval appendectomy is commonly used to manage perforated appendicitis, many studies are limited to individual or noncompeting pediatric hospitals. This study sought to compare national outcomes following interval or same-admission appendectomy in children with perforated appendicitis.

METHODS

The Nationwide Readmission Database was queried (2010-2014) for patients <18 years old with perforated appendicitis who underwent appendectomy using ICD9-CM Diagnosis codes. A propensity score-matched analysis (PSMA) utilizing 33 covariates between those with (Interval Appendectomy) and without a prior admission (Same-Admission Appendectomy) was performed to examine postoperative outcomes.

RESULTS

There were 63,627 pediatric patients with perforated appendicitis. 1014 (1%) had a prior admission for perforated appendicitis within one calendar year undergoing interval appendectomy compared to 62,613 (99%) Same-Admission appendectomy patients. The Interval Appendectomy group was more likely to receive a laparoscopic (87% vs. 78% same-admission) than open (13% vs. 22% same-admission; p < 0.001) operation. Patients receiving interval appendectomy were more likely to have their laparoscopic procedure converted to open (5% vs. 3%) and receive more concomitant procedures. PSMA demonstrated a higher rate of small bowel obstruction in those receiving Same-Admission appendectomy while all other complications were similar. Although those receiving Interval Appendectomy had a shorter index length of stay (LOS) and lower admission costs, they incurred an additional $8044 [$5341-$13,190] from their prior admission.

CONCLUSION

Patients treated with interval appendectomy experienced more concomitant procedures and incurred higher combined hospitalization costs while still having a similar postoperative complication profile compared to those receiving same-admission appendectomy for perforated appendicitis.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Retrospective Comparative Study.

Hyperfibrinogenemia and hyponatremia as predictors of perforated appendicitis in children: A retrospective cohort study

PURPOSE

The aim of this study was to investigate the predictive value of hyperfibrinogenemia and hyponatremia for perforated appendicitis in children.

METHODS

A retrospective review of 521 pediatric patients (≤ 15 years) with acute appendicitis confirmed by histopathology from January 2017 to December 2020 was performed. Patients were divided in two groups, those with non-perforated (n = 379; 73%) and perforated appendicitis (n = 142; 27%). The serum values of sodium and fibrinogen were taken before surgery. We performed the receiver operating characteristic analysis for the two biochemical markers. The sensitivity, specificity, positive and negative predictive values for perforated appendicitis in the presence of hyponatremia and hyperfibrinogenemia were calculated.

RESULTS

Hyperfibrinogenemia (≥ 4.0 g/L) was found in 58.45% of perforated appendicitis and 104 of 142 (73.34%) children with perforated appendicitis had hyponatremia (≤ 135 mmol/L). The perforated appendicitis group had a higher mean fibrinogen concentration (P = 0.001). There was a statistically significant difference in mean serum sodium levels between the perforated appendicitis and non-perforated appendicitis groups (P = 0.016). Receiver operating characteristic curve analysis for fibrinogen, sodium and combination of the both markers shown the combination had the largest area under the curve in identifying children with perforated acute appendicitis (0.858) (95% CI, 0.82-0.90) compared with fibrinogen (0.815) (95% CI, 0.77-0.86) and sodium 0.818 (95% CI, 0.78-0.86) alone. Furthermore, the combination of both markers had the best positive and negative predictive value for appendix perforation compared to fibrinogen and sodium.

CONCLUSION

Hyponatremia and/or hyperfibrinogenemia are excellent markers for predicting perforated appendicitis in children. We propose that plasma sodium and/or fibrinogen concentrations be utilized as a supplementary to guide individual treatment decisions in children with appendicitis, such as surgery timing and nonoperative management options.

Complete common mesentery revealed by acute perforated appendicitis: case report and review of the literature

Intestinal malrotation in children is a rare aberration, due to a halt in the rotation and attachment of the primitive gut, it can be asymptomatic if the rotation terminates at 90 degrees, which manifests itself in unusual forms of appendicitis as in our observation, or dangerous in cases of inadequate common mesentery and worsened by small intestine volvulus. This 12-year-old boy experienced abdominal discomfort in the hypogastrium and left iliac fossa 4 days before admission. The pain had been developing in a feverish setting, and the clinical examination had revealed abdominal sensitivity. A biological inflammatory syndrome was detected throughout the biological workup, the CT scan allowed the diagnosis of acute appendicitis on a complete common mesentery, and the patient underwent a laparotomy appendectomy. Even though children frequently experience acute appendicitis in its conventional form, it is nevertheless highly challenging to identify in its atypical forms when intestinal malrotation is involved. An abdominopelvic CT scan is used to make the diagnosis, and appendectomy, preferably with laparoscopy, is the recommended course of action.

Effect of the COVID-19 pandemic on patients with presumed diagnosis of acute appendicitis

BACKGROUND

Acute appendicitis (AAp) is the most frequent cause of acute abdominal pain, and appendectomy is the most frequent emergency procedure that is performed worldwide. The coronavirus disease 2019 (COVID-19) pandemic has caused delays in managing diseases requiring emergency approaches such as AAp and trauma.

AIM

To compare the demographic, clinical, and histopathological outcomes of patients with AAp who underwent appendectomy during pre-COVID-19 and COVID-19 periods.

METHODS

The demographic, clinical, biochemical, and histopathological parameters were evaluated and compared in patients who underwent appendectomy with the presumed diagnosis of AAp in the pre-COVID-19 (October 2018-March 2020) and COVID-19 (March 2020-July 2021) periods.

RESULTS

Admissions to our tertiary care hospital for AAp increased 44.8% in the COVID-19 period. Pre-COVID-19 (n = 154) and COVID-19 (n = 223) periods were compared for various parameters, and we found that there were statistically significant differences in terms of variables such as procedures performed on the weekdays or weekends [odds ratio (OR): 1.76; P = 0.018], presence of AAp findings on ultrasonography (OR: 15.4; P < 0.001), confirmation of AAp in the histopathologic analysis (OR: 2.6; P = 0.003), determination of perforation in the appendectomy specimen (OR: 2.2; P = 0.004), the diameter of the appendix (P < 0.001), and hospital stay (P = 0.003). There was no statistically significant difference in terms of interval between the initiation of symptoms and admission to the hospital between the pre-COVID-19 (median: 24 h; interquartile range: 34) and COVID-19 (median: 36 h; interquartile range: 60) periods (P = 0.348). The interval between the initiation of symptoms until the hospital admission was significantly longer in patients with perforated AAp regardless of the COVID-19 or pre-COVID-19 status (P < 0.001).

CONCLUSION

The present study showed that in the COVID-19 period, the ultrasonographic determination rate of AAp, perforation rate of AAp, and duration of hospital stay increased. On the other hand, negative appendectomy rate decreased. There was no statistically significant delay in hospital admissions that would delay the diagnosis of AAp in the COVID-19 period.

Postoperative hyperlipasemia in perforated appendicitis in children

OBJECTIVE

The objective of this study was to assess the hyperlipasemia cases detected in the postoperative period of perforated appendicitis.

MATERIALS AND METHODS

A retrospective analysis of the perforated appendicitis cases occurred in our institution over a 7-year period (2013-2019) was carried out. Only cases where preoperative and postoperative serum lipase levels were available were included. The variables collected were statistically assessed by means of a descriptive, univariate analysis.

RESULTS

A total of 88 patients were studied. They were divided into 3 groups according to postoperative lipase levels - 57 were allocated to Group 1 (lipase: 70-194.0 U/L, normal range), 20 were allocated to Group 2 (lipase: 195-582 U/L), and 11 were allocated to Group 3 (lipase: > 582 U/L, which triples normal levels). Statistically significant differences were found in the following variables: sex, postoperative abscess, postoperative subocclusion/intestinal occlusion, preoperative lipase levels, days of parenteral nutrition, days of ICU stay, and days of hospital stay. Postoperative lipase had a moderate correlation with preoperative lipase, and none of the cases met acute pancreatitis diagnostic criteria.

CONCLUSIONS

Hyperlipasemia in the postoperative period of perforated appendicitis is not associated with developing clinical pancreatitis, but it is associated with worse progression in terms of increased complications, such as subocclusion/intestinal occlusion and intra-abdominal abscess, and longer ICU stay, hospital stay, and parenteral nutrition. There is a moderate correlation between preoperative and postoperative lipase, which means they could both prove useful as prognostic markers.

Medications and the risk of perforated appendicitis: an adverse event report system (FAERS) database analysis

OBJECTIVE

Different classes of medication have been reported in the literature to be associated with an increased risk of gastrointestinal perforation. However, little is known about the risk of drug-induced perforated appendicitis.

METHODS

We analyzed the Food and Drug Administration Adverse Event Reporting System (FAERS), a large national database of reported adverse events associated with post-market FDA-approved medications from January 2011 to October 2021. Patients of any age group with appendiceal perforation were included. Duplicated reports and other anatomical areas of gastrointestinal tract perforation outside the appendix were excluded.

RESULTS

During the study period, 474 event cases met inclusion criteria, of which 284 were females. Most reports of perforation occurred in patients 40-49 years (n = 110) and 50-59 years (n = 144). Cases of perforated appendicitis occurred in patients being treated for multiple sclerosis (31.5%) and rheumatoid arthritis (17.1%). Perforation occurred in patients receiving interferon beta 1a (23.6%), adalimumab (17.9%), etanercept (14.1%), natalizumab (12.2%), clozapine (10.1%), infliximab (9.9%), bevacizumab (7.2%), and calcium chloride (4.9%). Sixteen fatal outcomes were reported.

CONCLUSION

Findings from the FAERS database highlight the risk of appendiceal perforation in the context of different classes of drugs. Larger pharmacovigilance studies are needed to confirm these observations.

[The importance of microbiological results for the treatment of complicated appendicitis-a monocentric case-control study]

BACKGROUND

Patients with complicated appendicitis frequently develop postoperative septic complications. There are no uniform standards for the choice of perioperative antibiotic prophylaxis and the duration of postoperative antibiotic treatment. The purpose of this study was to investigate associations between microbiological samples and postoperative complications.

METHODS

Patients with appendectomy and positive intraoperative swabs during 2013-2018 were included in this case-control study. Pathogen classes and their resistance patterns were evaluated in initial and follow-up swabs and compared in each of the groups with and without complications.

RESULTS

A total of 870 patients underwent surgery during the period studied. Pathogen detection succeeded in 102 of 210 cases (48.6%) with suspected bacterial peritoneal contamination. Conversion from laparoscopic to open intra-abdominal perforation and the presence of an abscess were independent risk factors for wound infections in the multivariate analysis. The combination of different classes of pathogens resulted in significantly increased overall resistance to ampicillin/sulbactam in both the initial swabs (57%) and the follow-up swabs (73%). Resistant E. coli strains combined with certain anaerobes were also regularly detected in postoperative intra-abdominal abscesses. Piperacillin/tazobactam was effective against 83% of positive swabs in our resistance tests.

CONCLUSION

Surgical treatment for complicated appendicitis remains the central therapeutic column. A regular review of the existing resistance patterns in perforated appendicitis can help to adjust and improve antibiotic treatment. Piperacillin/tazobactam should be used cautiously as a reserve antibiotic. A valid alternative is second or third generation cephalosporins in combination with metronidazole.

Utility of Pentraxin-3 as a biomarker for diagnosis of acute appendicitis: a systematic review and meta-analysis

PURPOSE

To systematically summarize all relevant data and to define the current evidence on the utility of Pentraxin-3 (PTX3) as a biomarker for acute appendicitis (AA) in children.

METHODS

This review was conducted in accordance with the PRISMA guidelines. PubMed, Embase, Scopus, and Web of Science databases were systematically searched for studies comparing the levels of PTX3 in patients with AA vs healthy controls or non-specific abdominal pain (NSAP). Mean differences were calculated for all outcomes and the inverse variance method was used for weighted mean difference. The methodological quality of the included studies was assessed using the Downs and Black scale.

RESULTS

Five comparative studies were included. Significantly elevated levels of PTX3 in cases with AA vs healthy controls (WMD: 9.56, 95% CI 7.24-11.88, p < 0.00001), and patients with AA vs NSAP (WMD: 8.05, 95% CI 6.81-9.29, p < 0.00001) were demonstrated. Similarly, in separate meta-analyses, the levels of PTX3 were significantly elevated in children with AA vs healthy controls (WMD: 11.18, 95% CI 10.03-12.34, p < 0.00001), and children with AA vs NSAP (WMD: 8.35, 95% CI 6.88-9.82, p < 0.00001).

CONCLUSIONS

PTX3-levels are elevated in AA, but differentiation between perforated and non-perforated appendicitis demands other methods.

The Utility of Discharge Antibiotics in Pediatric Perforated Appendicitis Without Leukocytosis

INTRODUCTION

Optimal management of pediatric perforated appendicitis remains a topic of active investigation. Our institutional clinical practice guidelines (CPGs) were modified to discontinue antibiotics on discharge for patients with normal white blood cell count (WBC) without left shift. We hypothesized that patients would receive fewer antibiotics without increased complications.

METHODS

Patients <18 y old with perforated appendicitis who underwent laparoscopic appendectomy between November 1, 2016 and May 31, 2021 at a tertiary care children's hospital were included. Primary outcome was adverse events: postdischarge surgical site infection (SSI), 30-day emergency department (ED) visits, or readmissions. Outcomes were compared before and after CPG modification. Multivariable regression was performed to identify factors associated with SSI.

RESULTS

There were 113 patients pre- and 97 patients post-CPG modification. 23.1% of patients in the pre-cohort had an elevated discharge WBC or left shift compared to 18.9% of patients in the post-cohort (P = 0.48). Significantly fewer patients were prescribed antibiotics on discharge in the post-cohort (70.8% pre versus 14.4% post, P < 0.0001) and for fewer days (2 pre versus 0 post, P < 0.0001). Total antibiotic days decreased significantly (6.1 pre versus 4.6 post, P < 0.0001). There was an increase in postdischarge SSIs on univariate analysis (1.8% pre versus 9.3% post, P = 0.03), ED visits (9.7% pre versus 19.6% post, P = 0.04), and readmissions (5.3% pre versus 11.3% post, P = 0.13). On multivariable analysis, being in the post-cohort was not significantly associated with post-discharge SSIs after adjusting for sex, symptom duration, initial WBC, and discharge antibiotic duration (OR 0.25, 95% CI 0.04-1.4, P = 0.11).

CONCLUSIONS

Modification of a pediatric perforated appendicitis clinical practice guideline to discontinue antibiotics on discharge with a normal WBC without left shift was effective in decreasing antibiotic duration. This was associated with an increase in SSIs on univariate analysis, which did not persist on multivariable analysis and requires further investigation.

Evaluation of radiological and temporal characteristics of acute appendicitis on the non-enhanced computed tomography images

PURPOSES

To investigate the relationships and interactions between temporal and radiological features of gangrene and perforation of inflamed appendices.

METHODS

A total of 402 patients were included who underwent laparoscopic appendectomies between January 1, 2016 and March 30, 2020 and had pathologically proved acute appendicitis and preoperative non-enhanced CT examinations. The radiological features (appendix diameter, appendicolith, appendiceal intraluminal gas, periappendiceal gas, periappendiceal fat stranding/fluid, and short axial diameter of the mesenteric lymph nodes) were obtained from the preoperative CT images of 382 patients with visible appendices. Clinical parameters and temporal variables (pre-CT delay, preoperative delay, estimated complication delay, symptom delay, and system delay) were recorded.

RESULTS

Among simple/suppurative, gangrenous, and perforated appendicitis, the radiological characteristics except for short axial diameters of lymph nodes, and the temporal variables other than system delay were significantly different. The Cox regression analysis identified the appendicolith as the independent risk factor for both gangrene and perforation of inflamed appendices by using the preoperative delay or estimated complication delay. By the preoperative delay, the median time for gangrene and perforation was 76.23 (95%CI 73.89-78.58) h and 77.55 (95%CI 74.12-80.98) h, respectively, if appendicolith was present. If estimated complication delay was used as the elapsed time and the appendicolith was perceptible, the median time for gangrene and perforation and was 72.33 (95%CI 62.93-81.74) h and 75.07 (95%CI 69.48-80.65) h, respectively.

CONCLUSION

There were interactions between the time evolution and radiological features of acute appendicitis. The evaluation of gangrene and perforation rate of acute appendicitis could be benefitted from combining the preoperative delay/estimated complication delay with CT characteristics in the preoperative urgent radiological analysis.

Laparoscopic versus open appendicectomy for complicated appendicitis in children: A systematic review and meta-analysis

BACKGROUND

Laparoscopic appendectomy (LA) is the preferred approach in uncomplicated appendicitis. However, in patients with complicated appendicitis (CA), the best approach is still unclear though laparoscopy is being increasingly preferred over open appendicectomy (OA) nowadays.

AIM

To comprehensively review the current literature and compare the associations of LA and OA concerning various postoperative outcomes in order to determine the best approach for children with CA.

METHODS

The PRISMA guidelines were adhered to and an electronic database search was extensively performed. Data analysis, including subgroup analysis of randomized-control trials, was performed using RevMan 5.3. Methodological and statistical heterogeneity, as well as publication bias of the included studies, were assessed.

RESULTS

Four randomized controlled trials (266 LA versus 354 OA) and thirty-six case-controlled trials (2580 LA versus 3043 OA) were included in the analysis. Compared to OA, LA has a shorter length of stay, a lower rate of surgical site infection as well as a significantly lower overall complication rate. The rates of intraabdominal abscess formation, post-operative fever, pneumonia and ileus are similar in the two groups. So are the rates of readmissions and reoperations. LA was also shown to have a shorter time taken to oral intake and a lesser requirement of analgesics as well as intravenous antibiotics. Operative time for OA was found to be significantly shorter than that for LA.

CONCLUSION

This meta-analysis objectively demonstrates that laparoscopy has a better overall complication profile compared to OA and should be the procedure of choice in children with complicated appendicitis.

Machine learning prediction model for postoperative outcome after perforated appendicitis

Purpose

Appendectomy for acute appendicitis is one of the most common operative procedures worldwide in both children and adults. In particular, complicated (perforated) cases show high variability in individual outcomes. Here, we developed and validated a machine learning prediction model for postoperative outcome of perforated appendicitis.

Methods

Retrospective analyses of patients with clinically and histologically verified perforated appendicitis over 10 years were performed. Demographic and surgical baseline characteristics were used as competing predictors of single-patient outcomes along multiple dimensions via a random forest classifier with stratified subsampling. To assess whether complications could be predicted in new, individual cases, the ensuing models were evaluated using a replicated 10-fold cross-validation.

Results

A total of 163 patients were included in the study. Sixty-four patients underwent laparoscopic surgery, whereas ninety-nine patients got a primary open procedure. Interval from admission to appendectomy was 9 ± 12 h and duration of the surgery was 74 ± 38 min. Forty-three patients needed intensive care treatment. Overall mortality was 0.6 % and morbidity rate was 15%. Severe complications as assessed by Clavien-Dindo > 3 were predictable in new cases with an accuracy of 68%. Need for ICU stay (> 24 h) could be predicted with an accuracy of 88%, whereas prolonged hospitalization (greater than 7–15 days) was predicted by the model with an accuracy of 76%.

Conclusion

We demonstrate that complications following surgery, and in particular, health care system-related outcomes like intensive care treatment and extended hospitalization, may be well predicted at the individual level from demographic and surgical baseline characteristics through machine learning approaches.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02456-1.

An incidental finding of ANET in a patient with perforated appendix: A case report

Introduction and importance

Appendiceal neuroendocrine tumors (ANETs) are incidentally found in 0.2–0.7% of appendectomies for suspected appendicitis.

Case presentation

A 29-year-old female presented with pain in the right lower quadrant of her abdomen for the past 48 h. On emergency appendectomy for suspected acute appendicitis, a perforated appendix was found. Histopathological examination showed grade 1 (low) ANET.

Clinical discussion

Appendiceal neuroendocrine neoplasms (ANENs) are commonly found at the tip of the appendix and are treated with appendectomy alone. For few ANENs located at the base, or small tumors (≤2 cm) infiltrating the submucosa, the muscularis, the subserosa layer or the mesoappendix, right hemicolectomy is recommended. However, no guidelines have been established concerning patients with appendiceal perforation in case of ANENs.

Conclusion

Although rare, ANETs should be considered in the differential diagnosis of acute appendicitis. Since, ANETs are rarely diagnosed preoperatively, subsequent patient evaluation after appendectomy is crucial for management of the patient.

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Appendiceal Neuroendocrine tumor (ANET) are incidentally found in 0.2–0.7% of appendectomies for suspected appendicitis.

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ANETs are commonly found at the tip of the appendix and are treated with appendectomy alone.

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Although rare, ANETs should be considered in the differential diagnosis of acute appendicitis.

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Since, ANETs are rarely diagnosed preoperatively, subsequent patient evaluation after appendectomy is crucial.

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The best management of ANETs in case of perforated appendicitis remains unclear.

Anaesthetic challenges in a child with perforated appendicitis and COVID-19 Co-Infection: A case report

Background

The deadly coronavirus disease 2019 (COVID-19) wreaked havoc globally in early 2020 and caused lives to a standstill. Healthcare workers (HCW) handling patients infected with COVID-19 wore protective equipment to defend themselves from cross infection and curbing further spread. Nevertheless, these do hamper their dexterity, especially during surgical procedures.

Case presentation

A child presented to our centre needing an emergency open appendicectomy during the coronavirus disease 2019 (COVID-19) pandemic in June 2021. Prior to the surgery, her initial test for COVID-19 was negative but subsequently became positive on the second test. Fortunately, all HCW during the care for the patient, donned full personal protective equipment (PPE), and avoided cross-infection.

Discussion

HCW handling patients with COVID-19 should wear adequate PPE to. However, these pose detrimental effects to their dexterity during routine care of such patients. Good teamwork and communication among HCW and parents are important during the safe management of a young child with COVID-19.

Conclusion

HCW should have low index of suspicion of COVID-19 in children with upper respiratory tract infection. Prompt and pro-active measures should be rapidly taken to prevent exposure and co-infection. Wearing multi layers of PPE do negatively affect the mood and agility of HCW handling young children with COVID-19. Thus, they should practice good team work, receive regular simulation and scenario-based training to be better prepared for pressurised situations.

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Challenges faced during management of a child in a resource limited nation during COVID-19 pandemic.

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Healthcare workers are at risks of contracting COVID-19 infections from patients.

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Various methods were implemented to curb the spread of COVID-19 in the operating theatre and hospital.

When to take it out? Optimal timing of interval appendectomy in 500 consecutive children

PURPOSE

While interval appendectomy following nonoperative management of perforated appendicitis is delayed until several weeks after presentation, the optimal time from presentation to interval appendectomy is unknown.

METHODS

The data warehouse of a large children's hospital was queried for interval appendectomies from 2006 to 2019. Data extracted included demographics, initial and operative hospitalization details, and pathology findings. Student's t-test and logistic regression were used where appropriate.

RESULTS

500 patients were identified with a mean age of 10 years, 53% male. Mean time to operation was 12.7 weeks. Operation prior to 12 weeks was associated with increased odds of acute inflammation on pathology (OR = 2, p < 0.01). Acute inflammation was associated with increased mean operative time (101 vs 84 min, p < 0.01). Presence of an appendicolith, initial hospitalization length, drain placement, readmission prior to operation, age and gender were all non-predictive of acute inflammation. Only 11% of appendices had an occluded lumen and 17% an appendicolith. Carcinoid tumors were identified in 6 patients (1.2%).

CONCLUSION

Acute inflammation is found many weeks after perforation and is associated with increased operative time. Acute inflammation is more likely to be present in operations performed prior to 12 weeks.

Accuracy of ultrasonography for differentiating between simple and complex appendicitis in children

PURPOSE

Accurate differentiation between simple and complex appendicitis is important since differences in treatment exist. This study aimed to assess the accuracy of ultrasonography in differentiating between simple and complex appendicitis.

METHODS

Data from children aged < 18 years who underwent appendectomy between the 1st of January 2013 and the 1st of January 2018 were analyzed retrospectively. Ultrasonography reports of eligible children were divided into simple (test negative) and complex appendicitis (test positive) based on predefined criteria and compared to a gold standard (a combination of predefined perioperative and histopathological criteria). Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were calculated to measure ultrasonographic accuracy in differentiating between simple and complex appendicitis.

RESULTS

176 children were eligible for inclusion. The mean age at the time of operation was 10.1 ± SD 4.6 years. 84 (47.7%) children had simple appendicitis and 92 (52.3%) had complex appendicitis. The use of ultrasonography yielded a sensitivity: 46%, specificity: 90%, PPV: 84%, and NPV: 60%.

CONCLUSION

Ultrasonography as standalone modality is not suitable for differentiating between simple and complex appendicitis in children. To improve preoperative differentiation, other variables such as clinical signs and laboratory data are necessary in conjunction with ultrasonography findings.

Comparison of non-invasive physiological assessment tools between simple and perforated appendicitis in children

PURPOSE

The role of non-invasive measures of physiologic reserve, specifically the Compensatory reserve index (CRI) and the Shock index pediatric age-adjusted (SIPA), is unknown in the management of children with acute appendicitis. CRI is a first-in-class algorithm that uses pulse oximetry waveforms to continuously monitor central volume status loss. SIPA is a well-validated, but a discontinuous measure of shock that has been calibrated for children.

METHODS

Children with suspected acute appendicitis (2-17 years old) were prospectively enrolled at a single center from 2014 to 2015 and monitored with a CipherOx CRI™ M1 pulse oximeter. CRI values range from 1 (normovolemia) to 0 (life-threatening hypovolemia). SIPA is calculated by dividing heart rate by systolic blood pressure and categorized as normal or abnormal, based on age-specific cutoffs. Univariate and multivariable regression models were developed with simple versus perforated appendicitis as the outcome.

RESULTS

Almost half the patients (45/94, 48%) had perforated appendicitis. On univariate analysis, the median admission CRI value was significantly higher (0.60 versus 0.33, p < 0.001) and the ED SIPA values were significantly lower (0.90 versus 1.10, p = 0.002) in children with simple versus perforated appendicitis. In a multivariable model, only CRI significantly detected differences in the physiologic state between patients with simple and perforated appendicitis.

CONCLUSIONS

CRI is a non-invasive measure of physiologic reserve that may be used to accurately guide early management of children with acute simple versus perforated appendicitis.

The predictors of perforated appendicitis in the pediatric emergency department: A retrospective observational cohort study

OBJECTIVE

Appendiceal perforation has significant effects on perioperative morbidity and postoperative outcome. The present study aimed to identify possible predictive factors associated with perforated appendicitis (PA) in children at admission in the emergency department (ED).

METHODS

In this retrospective observational cohort study, consecutive medical records of children <18 years old with surgically and histopathologically confirmed acute appendicitis (AA) over three years (2013-2015) were analyzed. Patients were divided into two groups: PA and non-perforated appendicitis (NPA). The differences between the two groups and potential predictors of PA were explored using univariate and multivariate analyses.

RESULTS

During the study period, 295 patients underwent an appendectomy and had confirmatory AA diagnoses. Ninety-two patients had a PA (31.2%). In the univariate analysis, male gender, vomiting, diarrhea, fever, elevated white blood cell count (WBC) levels, and high C-reactive protein (CRP) were identified as predictors of PA. In the multivariate analysis, male gender (odds ratio [OR]: 3.133; 95% confidence interval [CI]: 1.610-6.096); vomiting (OR: 2.346; 95% CI: 1.141-4.822); diarrhea (OR: 4.549; 95% CI: 1.850-11.181); fever (OR: 3.429; 95% CI: 1.765-6.663); elevated WBC (OR: 2.962; 95% CI: 1.491-5.884) and elevated CRP (OR: 3.061; 95% CI: 1.267-7.396) were variables that predicted the PA in children.

CONCLUSION

Our data indicate that several clinical and biochemical parameters can reliably distinguish between pediatric PA and NPA at admission in the emergency department.

Irrigation during laparoscopic appendectomy for complicated appendicitis increases the operative time and reoperation rate: a meta-analysis of randomized clinical trials

This meta-analysis of randomized clinical trials (RCT) aimed to compare peritoneal irrigation followed by suction with aspiration only during laparoscopic surgery for complicated appendicitis (LA). PRISMA guidelines with the random-effects model were adopted using Review Manager Version 5.3 for pooled estimates. We retained six eligible RCT published between 2012 and 2019. They involved a total of 1019 patients (541 patients in the aspiration group and 478 patients in the irrigation group). Aspiration only during LA is associated with shorter operative time (MD = 8.50 min, 95% CI [- 12.97 to - 4.02], p = 0.0002) and lower reoperation rate (OR = 0.37 95% CI [0.14-0.96], p = 0.04). There was no difference between aspiration group and irrigation group in terms of Intraperitoneal abscess (IPA) (OR = 0.99 95% CI [0.54-1.81], p = 0.95), morbidity rate (OR = 1.14 95% CI [0.44-2.98], p = 0.79), wound infection (OR = 0.94 95% CI [0.20-4.40], p = 0.94), and hospital stay (MD = 0.65 day, 95% CI [- 0.52 to 1.82], p = 0.27). Irrigation during LA prevents post-appendectomy IPA in neither adults nor pediatric patients. However, it lengthens the operative time and involves a higher reoperation rate.

Prophylactic intraabdominal drains do not confer benefit in pediatric perforated appendicitis: Results from a quality improvement initiative

BACKGROUND/PURPOSE

Prophylactic, intraabdominal drains have been used to prevent intraabdominal abscess (IAA) after perforated appendicitis. We hypothesized that routine drain placement would reduce the IAA rate in pediatric perforated appendicitis.

METHODS

A 27-month quality improvement (QI) initiative was conducted: closed-suction, intraabdominal drains were placed intraoperatively in pediatric (age < 18) perforated appendicitis patients. QI patients were compared to controls admitted during the preceding 8 months and following 4 months. The primary outcome was 30-day IAA rate. Univariate and multivariate analyses were performed.

RESULTS

Two hundred seventy QI patients were compared to 109 controls. There was 100% compliance during 21 of 27 months of the QI initiative; only 7 QI patients did not receive drains. IAA occurred in 20.0% of QI patients and 22.9% of control (p = 0.52). After adjustment, the QI initiative was not associated with reduced odds of IAA (OR 0.83, 95% CI 0.48-1.44). Median length of stay was longer in QI patients during the index admission (p = 0.03) and over 30 postoperative days (p = 0.03), but these relationships did not persist after adjustment.

CONCLUSIONS

A QI initiative investigating prophylactic, intraabdominal drain placement in perforated appendicitis did not reduce the IAA rate. We recommend against routine drain placement in pediatric perforated appendicitis.

LEVEL OF EVIDENCE

Level III.

Distilling the Key Elements of Pediatric Appendicitis Clinical Practice Guidelines

BACKGROUND

Use of clinical practice guidelines (CPGs) have been shown to reduce care delays, optimize resource utilization, and improve patient outcomes. We conducted a systematized review to identify key elements that should be included in an evidence-based CPG for pediatric appendicitis.

METHODS

We characterized key decision points and content areas from CPGs developed from 2000 to 2019 that were identified using publicly available platforms and manual search/personal communications.

RESULTS

Twenty-seven CPGs were reviewed with content saturation achieved after reviewing eight. We found 16 key elements spanning from triage to postoperative care. Elements with high accord among CPGs included use of laparoscopy and delay of postoperative imaging for abscess screening until postoperative day seven. For simple appendicitis, all CPGs endorsed antibiotic cessation, diet advancement, and early activity, and 11 CPGs included same-day discharge. Elements with heterogeneity in decision-making included antibiotic selection/duration for perforated appendicitis, criteria defining perforation, and utility of postoperative laboratory evaluations.

CONCLUSIONS

Development of an evidence-based CPGs for pediatric appendicitis requires attention to a finite number of key decision points and content areas. Existing literature demonstrates improved patient outcomes with CPG implementation.

Reducing Piperacillin and Tazobactam Use for Pediatric Perforated Appendicitis

BACKGROUND

Although perforated appendicitis is associated with infectious complications, the choice of antibiotic therapy is controversial. We assess the effectiveness and safety of an intervention to reduce piperacillin and tazobactam (PT) use for pediatric acute perforated appendicitis.

METHODS

This is a single-center, retrospective cohort study of children 18 y of age or younger who underwent primary appendectomy for perforated appendicitis between January 01, 2016 and June 30, 2019. An intervention to decrease PT use was implemented: the first phase was provider education (April 19, 2017) and the second phase was modification of electronic antibiotic orders to default to ceftriaxone and metronidazole (July 06, 2017). Preintervention and postintervention PT exposure, use of PT ≥ half of intravenous antibiotic days, and clinical outcomes were compared.

RESULTS

Forty children before and 109 after intervention were included and had similar baseline characteristics. PT exposure was 31 of 40 (78%) and 20 of 109 (18%) (P < 0.001), and use ≥ half of intravenous antibiotic days was 31 of 40 (78%) and 14 of 109 (13%) (P < 0.001), in the preintervention and postintervention groups, respectively. There was no significant difference in mean duration of antibiotic therapy (10.8 versus 9.8 d), mean length of stay (6.2 versus 6.5 d), rate of surgical site infection (10% versus 11%), or rate of 30-d readmission and emergency department visit (20% versus 20%) between the preintervention and postintervention periods, respectively.

CONCLUSIONS

Provider education and modification of electronic antibiotic orders safely reduced the use of PT for pediatric perforated appendicitis.

The usefulness and positive predictive value of ultrasonography and computed tomography in the diagnosis of acute appendicitis in adults: a retrospective study

OBJECTIVE

To analyze the evolution of the use of imaging tests (ultrasonography and computed tomography (CT)) in the diagnosis of acute appendicitis. To determine the positive predictive value of these tests and the percentage of negative and complicated appendectomies.

MATERIAL AND METHODS

This retrospective study compared adults who underwent appendectomy for suspected acute appendicitis at our tertiary hospital during 2015 versus similar patients at our center during 2007.

RESULTS

A total of 278 patients were included. The rate of negative appendectomies descended to 5%. The positive predictive value of ultrasonography increased to 97.4% in 2015, and the positive predictive value of CT and combined CT and ultrasonography was 100%. The rate of complicated appendicitis increased (23% in 2015).

CONCLUSIONS

The use of imaging tests increased, and the rate of "blind" laparotomies decreased. Nevertheless, the rate of complicated appendicitis increased.

Early versus interval appendicectomy for localised perforated appendicitis in children: A best evidence review

A best evidence topic in general surgery was written according to a structured protocol. The question addressed was whether early or interval appendicectomy provides a superior clinical outcome for children presenting with localised perforated appendix. Altogether 204 papers were found using the search strategy reported below; of which 5 were identified to provide the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We concluded that for children presenting with localised perforated appendix without abscess formation, early appendicectomy provides better clinical outcome in terms of lower complication and re-admission rate and shorter length of hospital stay.

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There is controversy in the management of perforated appendicitis in children.

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Limited studies focus on analysing free perforated appendicitis separately from appendicular abscess, mass and phlegmon.

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Localised perforated appendicitis treated with early appendectomy have lower complication and re-admission rate.

Managing acute appendicitis during the COVID-19 pandemic in Jiaxing, China

BACKGROUND

Coronavirus disease 19 (COVID-19) is a global pandemic and has had a profound impact on our routine surgical activities. Acute appendicitis is the most common abdominal emergency worldwide. Therefore, it is highly essential to assess the influence the pandemic has on acute appendicitis.

AIM

To assess the efficacy of the management of acute appendicitis during the COVID-19 pandemic.

METHODS

We retrospectively analyzed 90 patients who presented with acute appendicitis during the outbreak of COVID-19 in Jiaxing, China. Clinical data regarding appendectomies patients were also collected for the corresponding time frame from 2019. Preoperative management, intraoperative protective measures, and postoperative management were conducted.

RESULTS

After screening, six patients were identified as unqualified due to fever and were then referred to the COVID-19 expert group. The results of the nucleic acid test were negative. Of the 76 patients enrolled in the simple group, nine patients received medication therapy, and all others underwent surgery. From this same group, 66 patients were diagnosed with suppurative appendicitis, and one patient was diagnosed with perforated appendicitis after surgery. There were 14 patients in the complex group, for which the postoperative diagnosis indicated perforated appendicitis. The proportion of men with perforated appendicitis was higher than that in 2019 (P < 0.05). The chief complaint duration for perforated appendicitis patients in 2020 was longer than that in 2019 (P < 0.05). The routine blood test showed that white blood cell counts and neutrophil ratios were higher in perforated appendicitis patients in 2020 than in 2019 (P < 0.05). The ratio of open appendectomies to the amount of mean blood loss during surgery was greater in 2020 than in 2019 (P < 0.05). Online consultation after discharge was selected in 59 cases (65.6%). No perioperative infection with COVID-19 or long-term postoperative complications were found.

CONCLUSION

The management of acute appendicitis from Jiaxing effectively reduced the influence of the pandemic and minimized the risk of nosocomial infection.

Identification of perforated appendicitis within a right inguinal hernia sac (Amyand's hernia) by emergency abdominal CT scan: A case report

Amyand's hernia (AH) is a rare condition in which the vermiform appendix is herniated into the inguinal sac regardless of whether the appendix appears normal or is inflamed. Most cases of AH are diagnosed intraoperatively at the time of inguinal hernia repair as its clinical diagnosis is difficult, and the role of computed tomography (CT) and other diagnostic imaging has not been described well in the literature.

We report the case of a 79-year-old female who presented to the emergency department with nonspecific symptoms of nausea, vomiting, and constipation. Her symptoms were nonspecific, and physical examination suggested that she did not have a strangulated hernia or appendicitis, but the emergency CT scan of the abdomen showed a perforated appendix trapped in the sac of a right-sided inguinal hernia.

Complicated appendicitis in an AH is a surgical emergency, and an accurate diagnosis is necessary for proper triage of patients and appropriate management. CT plays a significant role in revealing an unsuspected diagnosis of AH. Radiologists must be aware of this rare presentation of the appendix in an inguinal hernia sac and be familiar with AH subtypes.

Standardized Discharge Antibiotics May Reduce Readmissions in Pediatric Perforated Appendicitis

BACKGROUND

Based on limited evidence, the American Pediatric Surgical Association recommends 5-7 d of postoperative antibiotics in perforated appendicitis for preventing intra-abdominal abscess (IAA). In 2015, our institutional clinical practice guideline was modified to standardize prescription for 7 additional days of oral antibiotics after discharge. We hypothesized that prescribing oral antibiotics after discharge would be associated with fewer complications in perforated appendicitis.

MATERIALS AND METHODS

A retrospective cohort study was conducted of pediatric (younger than 18 y) patients who underwent laparoscopic appendectomy for perforated appendicitis (August 1, 2012-April 30, 2019). Patients diagnosed with IAA before discharge or with a postoperative length of stay ≥8 d were excluded. Patient outcomes were compared prestandardization and poststandardization of discharge antibiotics.

RESULTS

Of 617 patients, 212 (34.5%) were admitted prestandardization and 404 (65.5%) poststandardization. Overall, 409 patients (66.3%) received discharge antibiotics. The median total postoperative antibiotic duration was 4 d (interquartile range, 3-5) prestandardization versus 11 d (interquartile range, 10-12) poststandardization (P < 0.001). Prestandardization patients had a higher rate of IAA (8.9% versus 4.5%, P = 0.03) and were readmitted more frequently (13.1% versus 6.4%, P = 0.005). On adjusted analysis, admission poststandardization was associated with reduced odds of IAA (odds ratio, 0.51; 95% confidence interval, 0.25-1.06), but the relationship was imprecise. Admission poststandardization was significantly associated with reduced adjusted odds of readmission (odds ratio, 0.46; 95% confidence interval, 0.25-0.85).

CONCLUSIONS

Prescription for seven additional days of oral antibiotics after discharge was associated with reduced odds of readmission in pediatric perforated appendicitis. This population may benefit from a longer postoperative antibiotic course than currently recommended.

Intra-abdominal Abscess After Appendectomy-Are Drains Necessary in All Patients?

BACKGROUND

Research has shown that patients who develop a postoperative intra-abdominal abscess (PIAA) after appendectomy have a greater number of health care visits with drain placement. Our institution developed an algorithm to limit drain placement for only abscesses with a size >20 cm². We sought to determine the adherence to and effectiveness of this algorithm.

METHODS

This prospective observational study included patients aged 2-18 y old who developed a PIAA from September 2017 to June 2019. Outcomes were compared between patients with a small or large abscess. Analysis was performed in STATA; P < 0.05 was significant.

RESULTS

Thirty patients were included. The median age was 10.6 y (7, 11.7); 60% were men, and 60% were Caucasian. The median duration of symptoms before diagnosis of appendicitis was 3 d (2, 6). Thirteen patients (43%) were diagnosed with a PIAA while still inpatient, and 17 (57%) were readmitted at a later date. After algorithm implementation, 95% (n = 19) of patients with a large abscess had aspiration ± drain placement, whereas 30% (n = 3) with a small abscess underwent drainage. Length of stay after abscess diagnosis, total duration of antibiotics, and number of health care visits were the same between groups. One patient with a small abscess required reoperation for an obstruction, whereas one patient with a large abscess that was drained was readmitted for a recurrent abscess.

CONCLUSIONS

Small PIAA can be successfully managed without intervention. Our proposed algorithm can assist in determining which patients can be treated with antibiotics alone.

Comparison of Appendectomy for Perforated Appendicitis With and Without Abscess: A National Surgical Quality Improvement Program Analysis

BACKGROUND

Outcomes of appendectomy stratified by type of complicated appendicitis (CA) features are poorly researched, and the evidence to guide operative versus nonoperative management for CA is lacking. This study aimed to determine laparoscopic-to-open conversion risk, postoperative abscess risk, unplanned readmission risk, and length of hospital stay (LOS) associated with appendectomy in patients with perforated appendicitis without abscess (PA) and perforated appendicitis with abscess (PAWA) compared with a control cohort of nonperforated appendicitis (NPA).

METHODS

The 2016-2017 National Surgical Quality Improvement Program Appendectomy-targeted database identified 12,537 (76.1%) patients with NPA, 2142 (13.0%) patients with PA, and 1799 (10.9%) patients with PAWA. Chi-squared analysis and analysis of variance were used to compare categorical and continuous variables. Binary logistic and linear regression models were used to compare risk-adjusted outcomes.

RESULTS

Compared with NPA, PA and PAWA had higher rates of conversion (0.8% versus 4.9% and 6.5%, respectively; P < 0.001), postoperative abscess requiring intervention (0.6% versus 4.8% and 7.0%, respectively; P < 0.001), readmission (2.8% versus 7.7% and 7.6%, respectively; P < 0.001), and longer median LOS (1 day versus 2 days and 2 days, respectively; P < 0.001). PA and PAWA were associated with increased odds of postoperative abscess (odds ratio [OR]: 7.18, 95% confidence interval [CI]: 5.2-9.8 and OR: 9.94, 95% CI: 7.3-13.5, respectively), readmission (OR: 2.70, 95% CI: 2.1-3.3 and OR: 2.66, 95% CI: 2.2-3.3, respectively), and conversion (OR: 5.51, 95% CI: 4.0-7.5 and OR: 7.43, 95% CI: 5.5-10.1, respectively). PA was associated with an increased LOS of 1.7 days and PAWA with 1.9 days of LOS (95% CI: 1.5-1.8 and 1.7-2.1, respectively).

CONCLUSIONS

Individual features of CA were independently associated with outcomes. Further research is needed to determine if surgical management is superior to nonoperative management for CA.

Assessing surgical care delivery at facilities caring for higher volumes of minority children utilizing the pediatric quality indicator for perforated appendicitis: a propensity-matched analysis

INTRODUCTION

The pediatric quality indicator (PDI) measures released by the Agency for Healthcare Research and Quality (AHRQ) provide an impetus for benchmarking quality of care in children. The PDI-17, aimed at studying perforation in appendicitis, is one such measure that this study aims to utilize to assess surgical care delivery and outcomes in children managed at majority-minority hospitals.

METHODS

The Kid Inpatient Database (2000-2012) was queried for pediatric patients (< 18 years) with a diagnosis of appendicitis, with and without perforation. Facilities were categorized into tertiles based on rates of perforation (PDI-17). Similarly, tertiles were generated based on volume of minority patients (Black and Hispanic) treated at each facility. Multivariable regression analysis adjusted for demographic parameters, hospital-level characteristics, propensity score quintiles, clinically relevant outcomes, and tertiles of minority patients treated.

RESULTS

Of the 322,805 patients with appendicitis 28.7% had perforated appendicitis. Patients presenting to facilities caring for a higher volume of perforated appendicitis were younger with public insurance or no insurance and, however, these patients were less likely to belong to a minority group (p < 0.05). Additionally, these patients were less likely to belong to the highest income quartile (OR [95% CI] 0.45 [0.39-0.52]). Hospitals treating the highest volume of minority patients [majority-minority hospitals (MMHs)] had an 87% (OR [95% CI] 1.87 [1.77-1.98]) increased likelihood of also treating the highest rates of perforated appendicitis.

CONCLUSION

Hospitals treating a high volume of complicated appendicitis are less likely to care for minority groups. Additionally, MMHs lacking experience and volume in caring for complicated appendicitis have an increased likelihood of patients with perforations which is indicative of poor healthcare access.

Is a nasogastric tube necessary after transumbilical laparoscopic-assisted appendectomy in children with perforated appendicitis?

BACKGROUND

This study assessed the necessity of postoperative nasogastric tube (NGT) use in acute pediatric cases of perforated appendicitis.

METHODS

All cases of acute pediatric perforated appendicitis managed with transumbilical laparoscopic-assisted appendectomy at our hospital from 2011 to 2017 were retrospectively reviewed. Sixty-two cases were selected and divided into two groups based on NGT placement.

RESULTS

There were no significant differences between the two groups in most parameters of patient demographics, or surgical data. Notably, the mean time to first oral intake and to regular diet was significantly shorter in no-NGT group (1 day vs 3 days, P < 0.0001; and 4 days vs 7 days, P = 0.003, respectively). Postoperative length of stay was significantly shorter in no-NGT group (7 days vs 9 days, P < 0.0001).

CONCLUSION

Considering the results of our analysis, we believe that routine NGT placement is not always necessary in these situations.

Intravenous versus intravenous/oral antibiotics for perforated appendicitis in pediatric patients: a systematic review and meta-analysis

Background

The use of oral (PO) antibiotics following a course of certain intravenous (IV) antibiotics is proposed in order to avoid the complications of IV medications and to decrease the cost. However, the efficacy and safety of sequential IV/PO antibiotics is unclear and requires further study.

Methods

The databases, including PubMed, EMBASE and Cochrane Library, were searched. Studies comparing outcomes in patients with perforated appendicitis receiving sequential IV/PO and PO antibiotics therapy were screened. The Newcastle-Ottawa Scale (NOS) and the Jadad score were used to evaluate the quality of the cohort and the randomized controlled portions of the trial, respectively. Statistical heterogeneity was assessed using the I² value. A fixed or random-effect model was applied according to the I² value.

Results

Five controlled studies including a total of 580 patients were evaluated. The pooled estimates revealed that sequential IV/PO antibiotic therapy did not increase the risk of complications, with a risk ratio (RR) of 0.97 (95% CI 0.51–1.83, P = 0.93) for postoperative abscess, 1.04 (95% CI 0.25–4.36, P = 0.96) for wound infection and 0.62 (95% CI 0.33–1.16, P = 0.13) for readmission.

Conclusions

Our study demonstrates that sequential IV/PO antibiotic therapy is noninferior to IV antibiotic therapy regarding postoperative abscess, wound infection and readmission.

Early appendectomy vs. conservative management in complicated acute appendicitis in children: A meta-analysis

BACKGROUND

No consensus exists among surgeons regarding the optimal treatment of complicated acute appendicitis in children (CAA). Existing studies present heterogeneity of data and only few studies analyzed free perforated appendicitis (FPA) separately from appendicular abscess (AAb) and appendicular phlegmon (AP).

METHOD

Studies which have been judged eligible for this systematic review and consequent meta-analysis are those comparing non-operative management (NOM) with operative management (OM) in children with CAA. Studies were subgrouped between those analyzing mixed patients with CAA, those focusing on patients with AAb/AP and those focusing on patients with FPA.

RESULTS

Fourteen studies fulfilled the inclusion criteria and were included in the meta-analysis with a total of 1288 patients. In the fixed-effects model the complication rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.07, 95%CI = 0.02-0.27) and to the OM arm for the FPA subgroup (RR = 1.86, 95%CI = 1.20-2.87); the re-admission rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.35, 95%CI = 0.13-0.93) and to the OM arm for the FPA subgroup (RR = 1.49, 95%CI = 1.49-7.44). There was no statistical heterogeneity for the two subgroups of patients. The costs weren't significantly different between NOM and OM. The length of stay was favorable to OM. The pooled proportion rate of NOM success was 90%, the pooled relapse rate of appendicitis was 15.4%.

CONCLUSIONS

Children with AAb/AP reported better results in terms of complication rate and re-admission rate if treated with NOM. Conversely children with FPA showed lower complication rate and re-admission rate if treated with OM.

LEVEL OF EVIDENCE

II.

Geographic and socioeconomic predictors of perforated appendicitis: A national Canadian cohort study

BACKGROUND/PURPOSE

Appendiceal perforation significantly impacts the outcomes of pediatric appendicitis. While socioeconomic status affects perforation risk in the United States, these effects should dissipate in a universal healthcare system. The specific spatial patterns associated with perforation have also never been delineated. This study examined the effect of geography and SES on appendiceal perforation in Canada's universal healthcare system.

METHODS

Using administrative databases, Canadian children with appendicitis from 2008 to 2015 were identified. Perforation rates were examined based on rurality, distance from treating hospital, and SES. A spatial analysis identified neighborhoods with high perforation rates. Predictors of high perforation clusters were determined using logistic regression.

RESULTS

Over the study period, 43,055 children with appendicitis were identified. The overall perforation rate was 31.5%. Rural neighborhoods and those >125 km from the treating hospital were more likely to be within a high perforation cluster (OR 2.39, 95%CI 1.31-4. 02, p = 0.001; and OR 2.55, 95%CI 1.35-4.47, p = 0.001, respectively). Children in high perforation clusters were more likely to suffer complications. SES was not associated with perforation rates.

CONCLUSIONS

In this population-based study, appendiceal perforation was not a function of SES, but a spatial phenomenon. These findings highlight disparities in access to surgical care in Canada.

LEVEL OF EVIDENCE

Prognosis study, level II.

Laparoscopic versus open appendectomy for perforated appendicitis in adults: randomized clinical trial

BACKGROUND

The advantages of laparoscopic appendectomy did not meet the same acceptance in the setting of perforated appendicitis as in uncomplicated appendicitis in the general surgical community. The aim of this study was to compare the clinical outcome of laparoscopic and open appendectomy in perforating appendicitis.

METHODS

A randomized controlled study was conducted on 126 patients presenting with perforated appendicitis. Sixty patients were subjected to laparoscopic appendectomy (LA) and 66 patients underwent traditional open appendectomy (OA).

RESULTS

65 (51.6%) patients were female, and 61 (48.4%) patients were male in whom the mean age was 37.6 + 8.5 years. A significant difference was calculated in the domains of postoperative pain, less need for analgesics, hospital stay, and return to daily activities. The mean operative time was shorter in OA 94 ± 10.4 min than LA 120.6 ± 17.7 min. No statistically significant difference between both groups was detected as regard occurrence of intra-abdominal collection.

CONCLUSION

In view of its clinical outcomes, laparoscopy should be considered in the context of perforated appendicitis. The possibility of intra-abdominal collection should not be a barrier against the widespread practice of this surgical procedure amidst laparoscopic surgeons if adequate precautions are employed.

Non-Operative Management is More Cost-Effective than Immediate Operation in Perforated Appendicitis Patients with Seven or More Days of Symptoms

BACKGROUND

Management of perforated appendicitis in children remains controversial. Nonoperative (NO) and immediate operative (IO) strategies are used with varying outcomes. We hypothesized that IO intervention for patients with perforated appendicitis would be more cost-effective than NO management.

METHODS

A retrospective chart review of all patients with appendicitis from 2012 to 2015 was performed. Patients with perforated appendicitis were defined by evidence of perforation on imaging. We excluded patients who presented with sepsis, organ failure, and ventriculoperitoneal shunts. NO management was determined by surgeon preference. Univariate and multivariate analyses were performed.

RESULTS

IO was performed on 145 patients with perforated appendicitis, whereas 83 were treated with NO management. Compared to IO patients, NO patients incurred higher overall costs, greater length of stay, more readmissions, complications, peripherally inserted central venous catheter lines, interventional radiology drains, and unplanned clinic and emergency department visits (P < 0.0001 for all). Multivariate analysis adjusting for age, days of symptoms, admission C-reactive protein and white blood cell count revealed that NO management was independently associated with increased costs (OR 1.35, 1.12-1.62, 95% CI). Cost curves demonstrated that total cost for IO surpasses that of NO management when patients present with greater than 6.3 d of symptoms (P = 0.01).

CONCLUSIONS

Our data suggest that IO is more cost-effective than NO management for patients with perforated appendicitis who present with less than 6.3 d of symptoms, after which point, NO management is more cost-effective.

LEVEL OF EVIDENCE

IV.

Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis

BACKGROUND

Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis.

METHODS

A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case-control studies (CCS) that compared LA with OA for complicated appendicitis.

RESULTS

Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71-1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31-0.59, p < 0.0001), wound infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19-0.36, p < 0.001), respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13-0.49, p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%; OR = 0.65, 95% CI: 0.42-1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%; OR = 0.15, 95% CI: 0.04-0.61, p = 0.008). LA has a significantly shorter hospital stay (6.4 days vs. 8.9 days, p = 0.02) and earlier resumption of solid food (2.7 days vs. 3.7 days, p = 0.03).

CONCLUSION

These results clearly demonstrate that LA for complicated appendicitis has the same incidence of IAA but a significantly reduced morbidity, mortality and length of hospital stay compared with OA. The finding of complicated appendicitis at laparoscopy is not an indication for conversion to open surgery. LA should be the preferred treatment for patients with complicated appendicitis.

Risk Factors for Perforated Appendicitis in the Acute Care Surgery Era-Minimizing the Patient's Delayed Presentation Factor

BACKGROUND

Numerous factors contribute to advanced disease or increased complications in patients with acute appendicitis (AA). This study aimed to identify risk factors associated with AA perforation, including the effect of system time (ST) delay, after controlling for patient time (PT) delay. In this study, PT was controlled (to less than or equal to 24 h) to better understand the effect of ST delay on AA perforation.

METHODS

Medical records of patients who underwent surgery for AA at a tertiary referral hospital from October 2009 through September 2013 were reviewed. Data collected included demographics, body mass index, presence of fecalith, PT (i.e., duration of time from symptom onset to arrival in emergency department), and ST (i.e., duration of time from arrival in emergency department to operating room). AA was classified as simple (acute, nonperforated) versus advanced (gangrenous, perforated).

RESULTS

Seven hundred forty-seven patients underwent surgery for AA. After excluding patients with PT > 24 h, 445 patients fit the study criteria, of which 358 patients with simple AA and 87 patients with advanced disease. Advanced appendicitis patients were older and had higher body mass index, longer PT, higher WBC, and higher incidence of fecaliths. Both groups had similar ST. Risk factors for advanced appendicitis after multiple regression analysis are age >50 y old, WBC >15,000, the presence of fecaliths, and PT delay >12 h.

CONCLUSIONS

Once PT delay was limited to ≤24 h, the ST delay of >12 h did not adversely affect the incidence of advanced AA. Age >50 y, WBC >15,000, PT delay >12 h, and the presence of fecaliths were identified as risk factors associated with advanced AA.

Hyperbilirubinemia as a Predictor of Appendiceal Perforation: A Systematic Review and Diagnostic Test Meta-Analysis

Background

Misdiagnosis of the severity of acute appendicitis may lead to perforation and can consequently result in increased morbidity and mortality. In this study, the role of hyperbilirubinemia as a predictor of perforation is assessed by performing a meta-analysis of diagnostic accuracy.

Methods

A systematic search of the literature published over the past 20 years was performed using the EMBASE, PubMed, Cochrane library, and Google Scholar databases.

Results

Low values of sensitivity, specificity, and diagnostic odds ratio (DOR) were detected: 0.21 (95% confidence interval (CI): 0.13 - 0.30, standard error (SE) = 0.43), 0.27 (95% CI: 0.15 - 0.43, SE = 0.73), and 0.10 (95% CI: 0.3 - 0.28, SE = 0.05), respectively. The positive likelihood ratio (PLR) was low (0.29 (95% CI: 0.27 - 0.91, SE = 0.76)), whereas the negative likelihood ratio (NLR) was high (2.88 (95% CI: 1.66 - 5.14, SE = 0.10)). The hierarchical summary receiver operating characteristic curve was positioned towards the lower right corner, and the area under the curve was 0.19, both indicating a low level of overall accuracy and discrimination. Compared with the PLR, the negative inverse likelihood ratio (1/LR^-) indicated that a positive result has a greater impact on the odds of disease than does a negative result.

Conclusions

Hyperbilirubinemia alone is not a reliable tool to predict perforation. Future studies should investigate whether the combined predictive values of bilirubin, C-reactive protein (CRP), and white blood cells are a more effective diagnostic tool.