Management of Uncomplicated Appendicitis in Adults: A Nationwide Analysis From 2018 to 2019

INTRODUCTION

Nonoperative management (NOM) of uncomplicated appendicitis (UA) has been increasingly utilized in recent years. The aim of this study was to describe nationwide trends of sociodemographic characteristics, outcomes, and costs of patients undergoing medical versus surgical management for UA.

METHODS

The 2018-2019 National (Nationwide) Inpatient Sample was queried for adults (age ≥18 y) with UA; diagnosis, as well as laparoscopic and open appendectomy, were defined by the International Classification of Diseases, 10th Revision, Clinical Modification codes. We examined several characteristics, including cost of care and length of hospital stay.

RESULTS

Among the 167,125 patients with UA, 137,644 (82.4%) underwent operative management and 29,481 (17.6%) underwent NOM. In bivariate analysis, we found that patients who had NOM were older (53 versus 43 y, P < 0.001) and more likely to have Medicare (33.6% versus 16.1%, P < 0.001), with higher prevalence of comorbidities such as diabetes (7.8% versus 5.5%, P < 0.001). The majority of NOM patients were treated at urban teaching hospitals (74.5% versus 66.3%, P < 0.001). They had longer LOS's (5.4 versus 2.3 d, P < 0.001) with higher inpatient costs ($15,584 versus $11,559, P < 0.001) than those who had an appendectomy. Through logistic regression we found that older patients had up to 4.03-times greater odds of undergoing NOM (95% CI: 3.22-5.05, P < 0.001).

CONCLUSIONS

NOM of UA is more commonly utilized in patients with comorbidities, older age, and those treated in teaching hospitals. This may, however, come at the price of longer length of stay and higher costs. Further guidelines need to be developed to clearly delineate which patients could benefit from NOM.

Validation and comparison of two new scoring systems for the prediction of complicated versus uncomplicated appendicitis

OBJECTIVES

To validate the Atema and APSI scoring systems in the diagnosis of complicated vs uncomplicated appendicitis. To compare these scoring systems with computed tomography (CT) imaging alone to establish which method provides most accurate prediction of complicated vs uncomplicated appendicitis.

METHODS

This was a retrospective review of a sample of 160 patients that underwent appendicectomy and CT imaging for suspected appendicitis between 2018 and 2021 in a tertiary university teaching hospital. Each scoring system was applied to all patients and results analysed and compared with the effectiveness of CT imaging, RESULTS: 32.5% (n = 52) were found to have complicated appendicitis and 67.5% (n = 108) uncomplicated appendicitis. Application of the Atema score to our cohort of patients resulted in a sensitivity 76.9% [CI (64.2, 87.5), specificity 58.7% [CI (48.9, 68.1)], PPV 47.1% [CI (40.5, 53.8) and NPV 84.2% [CI (76.0, 89.9)]. By comparison, the APSI yielded a sensitivity 50.9% [CI (36.6, 65.4)], specificity 76.1% [CI (67.0, 87.8)], PPV 50% [CI (39.2, 60.6)] and NPV 76% [CI (71.1, 81.7)]. Radiology prediction of complicated vs uncomplicated appendicitis with CT imaging showed sensitivity 46% [CI (32.2, 60.5)], specificity 79%; [CI (69.8, 86)], PPV 51% [CI (39.6, 62.5)] and NPV 75% [CI (69.8, 79.9)].

CONCLUSION

By comparing the APSI and Atema et al. scoring systems with CT reporting in our hospital, it appears that the Atema may confer some benefit in stratifying patient risk of complicated versus uncomplicated appendicitis. Further larger scale prospective studies are required.

The role of intraoperative swab during appendectomy in patients with uncomplicated and complicated appendicitis

INTRODUCTION

Bacteria play an important role not only in pathogenesis of appendicitis but also in the postoperative course of patients. However, the usefulness of an intraoperative swab during appendectomy is controversial. The primary aim of this study was to investigate the impact of intraoperative swab during appendectomy on the postoperative outcome in patients with uncomplicated and complicated appendicitis.

METHODS

A retrospective analysis was conducted on a consecutive series of 1570 adult patients who underwent appendectomy for acute appendicitis at the University Hospital Erlangen between 2010 and 2020. Data regarding the intraoperative swab were collected and analyzed for the entire cohort as well as for patients with uncomplicated and complicated appendicitis.

RESULTS

An intraoperative swab was taken in 29% of the cohort. The bacterial isolation rate in the obtained intraoperative swabs was 51%, with a significantly higher rate observed in patients with complicated appendicitis compared to those with uncomplicated appendicitis (79% vs. 35%, p < 0.001). The presence of a positive swab was significantly associated with worse postoperative outcomes, including higher morbidity, increased need for re-surgery, and longer hospital stay, when compared to patients without a swab or with a negative swab. A positive swab was an independent risk factor for postoperative morbidity (OR 9.9 (95% CI 1.2-81.9), p = 0.034) and the need for adjustment of postoperative antibiotic therapy (OR 8.8 (95% CI 1.1-72.5), p = 0.043). However, a positive swab resulted in postoperative antibiotic therapy adjustment in only 8% of the patients with bacterial isolation in the swab.

CONCLUSION

The analysis of swab samples obtained during appendectomy for acute appendicitis can help identify patients at a higher risk of a worse postoperative outcome. However, the frequency of antibiotic regime changes based on the swab analysis is low.

Therapeutic strategy for acute appendicitis based on laparoscopic surgery

PURPOSE

The treatment strategies for acute appendicitis differ depending on the facility, and various studies have investigated the usefulness of conservative treatment with antibiotics, laparoscopic surgery, and interval appendectomy (IA). However, although laparoscopic surgery is widely used, the clinical strategy for acute appendicitis, especially complicated cases, remains controversial. We assessed a laparoscopic surgery-based treatment strategy for all patients diagnosed with appendicitis, including those with complicated appendicitis (CA).

METHODS

We retrospectively analysed patients with acute appendicitis treated in our institution between January 2013 and December 2021. Patients were classified into uncomplicated appendicitis (UA) and CA groups based on computed tomography (CT) findings on the first visit, and the treatment course was subsequently compared.

RESULTS

Of 305 participants, 218 were diagnosed with UA and 87 with CA, with surgery performed in 159 cases. Laparoscopic surgery was attempted in 153 cases and had a completion rate of 94.8% (145/153). All open laparotomy transition cases (n = 8) were emergency CA surgery cases. No significant differences were found in the incidence of postoperative complications in successful emergency laparoscopic surgeries. In univariate and multivariate analyses for the conversion to open laparotomy in CA, only the number of days from onset to surgery ≥ 6 days was an independent risk factor (odds ratio: 11.80; P < 0.01).

CONCLUSION

Laparoscopic surgery is preferred in all appendicitis cases, including CA. Since laparoscopic surgery is difficult for CA when several days from the onset have passed, it is necessary that surgeons make an early decision on whether to operate.

Usefulness of Preoperative Predictors of Pathological Complicated Appendicitis

INTRODUCTION

Complicated appendicitis (CA) is often indicated for emergency surgery; however, preoperative predictors of pathological CA (pCA) remain unclear. Furthermore, characteristics of CA that can be treated conservatively have not yet been established.

METHODS

305 consecutive patients diagnosed with acute appendicitis were reviewed. The patients were divided into two groups: an emergency surgery and a conservative treatment group. The emergency surgery group was pathologically classified as having uncomplicated appendicitis (pUA) and pCA, and the preoperative predictors of pCA were retrospectively assessed. Based on the preoperative pCA predictors, a predictive nomogram whether conservative treatment would be successful or not was created. The predictors were applied to the conservative treatment group, and the outcomes were investigated.

RESULTS

In the multiple logistic regression analysis of the factors contributing to pCA, C-reactive protein ≥3.5 mg/dL, ascites, appendiceal wall defect, and periappendiceal fluid collection were independent risk factors. Over 90% of cases without any of the above four preoperative pCA predictors were pUA. The accuracy of the nomogram was 0.938.

CONCLUSION

Our preoperative predictors and nomogram are useful to aid in distinguishing pCA and pUA and to predict whether or not conservative treatment will be successful. Some CA can be treated with conservative treatment.

Covid-19 Pandemic Strategy for Treatment of Acute Uncomplicated Appendicitis with Antibiotics- Risk Categorization and Shared Decision-Making

BACKGROUND

During the Coronavirus disease 2019 (COVID-19) pandemic, a protocol was adopted by our department on antibiotics treatment for Acute Uncomplicated Appendicitis (AUA). Our study aimed to determine the feasibility and safety of non-operative treatment (NOT), compared to upfront laparoscopic appendectomy (LA), for AUA in children during the pandemic.

METHOD

Our prospective comparative study was conducted from May 1, 2020 to January 31, 2021. Patient selection criteria included: age ≥5 years, abdominal pain duration ≤48 h, ultrasound (US)/Computered Tomography scan confirmation of AUA, US appendiceal diameter 6-11 mm with no features of perforation/abscess collection and no faecolith. For NOT patients, intravenous antibiotics were administered for 24-48 h followed by oral for 10-day course. Comparison was performed between patients whose parents preferred NOT to those who opted for up-front appendectomy. Primary outcomes were NOT success at index admission, early and late NOT failure rates till 27 months. Secondary outcomes were differences in complication rate, hospital length of stay (LOS) and cost between groups.

RESULTS

77 patients were recruited: 43 (55.8%) underwent NOT while 34 (44.2%) patients opted for LA. Success of NOT at index admission was 90.7% (39/43). Overall, NOT failure rate at 27 months' follow-up was 37.2% (16/43). Of the NOT failures, 1 appendix was normal on histology while only 1 was perforated. There were no significant differences in secondary outcomes between both groups except for LOS of late NOT failure. Cost for upfront LA was nearly thrice that of NOT.

CONCLUSION

Our stringent COVID protocol together with shared decision-making with parents is a safe and feasible treatment option during a crisis situation.

LEVEL OF EVIDENCE

Treatment study, Level II.

Predicting complicated appendicitis based on clinical findings: the role of Alvarado and Appendicitis Inflammatory Response scores

PURPOSE

The pre-interventional differentiation between complicated and uncomplicated appendicitis is decisive for treatment. In the context of conservative therapy, the definitive diagnosis of uncomplicated appendicitis is mandatory. This study investigates the ability of clinical scoring systems and imaging to differentiate between the two entities.

METHODS

This is a retrospective analysis of two cohorts from two tertiary referral centers in Switzerland and Germany. All consecutive patients underwent appendectomy between January 2008 and April 2013 (in the first cohort) or between January 2017 and June 2019 (the second cohort). Exclusion criteria did not apply as all patients found by the database search and received an appendectomy were included. Diagnostic testing and calculation of a receiver operating curve were performed to identify a cutoff for clinical scores that resulted in a minimum sensitivity of 90% to detect complicated appendicitis. The cutoff was combined with additional diagnostic imaging criteria to see if diagnostic properties could be improved.

RESULTS

Nine hundred fifty-six patients were included in the analysis. Two hundred twenty patients (23%) had complicated appendicitis, and 736 patients (77%) had uncomplicated appendicitis or no inflammation. The complicated appendicitis cohort had a mean Alvarado score of 7.03 and a mean AIR of 5.21. This compared to a mean Alvarado of 6.53 and a mean AIR of 4.07 for the uncomplicated appendicitis cohort. The highest Alvarado score with a sensitivity of > 90% to detect complicated appendicitis was ≧ 5 (sensitivity = 95%, specificity 8.99%). The highest AIR score with a sensitivity of > 90% to detect complicated appendicitis was ≧ 3 (sensitivity 91.82%, specificity 18.53). The analysis showed that additional CT information did not improve the sensitivity of the proposed cut-offs.

CONCLUSION

AIR and Alvarado scores showed limited capability to distinguish between complicated and uncomplicated appendicitis even with additional imaging in this retrospective cohort. As conservative management of appendicitis needs to exclude patients with complicated disease reliably, appendectomy seems until now to remain the safest option to prevent undertreatment of this mostly benign disease.

Social Vulnerability and Appendicitis: Single-Institution Study in a High Insurance State

INTRODUCTION

Multiple factors signifying higher social vulnerability, including lower socioeconomic status and minority race, have been associated with presentation with complicated appendicitis (CA). In this study, we compared the Social Vulnerability Index (SVI) of our population by appendicitis severity (uncomplicated appendicitis [UA] versus CA). We hypothesized that SVI would be similar between patients with UA and CA presenting to our institution, a safety-net hospital in a state with high healthcare insurance coverage.

METHODS

We included all patients at our hospital aged 18 y and older who underwent appendectomy for acute appendicitis between 2012 and 2016. SVI values were determined based on the 2010 census data using ArcMap software. We used nonparametric univariate statistics to compare the SVI of patients with CA versus UA and multivariable regression to model the likelihood of operative CA.

RESULTS

A total of 997 patients met inclusion criteria, of which 177 had CA. The median composite SVI score for patients with CA was lower than for patients with UA (80% versus 83%, P = 0.004). UA was associated with higher socioeconomic (83% versus 80%, P = 0.007), household/disability (68% versus 55%, P = 0.037), and minority/language SVI scores (91% versus 89%, P = 0.037). On multivariable analysis controlling for age, sex, ethnicity, insurance status, relevant comorbidities, and chronicity of symptoms, there was an inverse association between SVI and the likelihood of CA (odds ratio 0.59, 95% confidence interval 0.4-0.87, P = 0.008).

CONCLUSIONS

In the setting of high healthcare insurance and a medical center experienced in caring for vulnerable populations, patients presenting with UA have a higher composite SVI, and thus greater social vulnerability, than patients presenting with CA.

Accuracy of imaging in discriminating complicated from uncomplicated appendicitis in daily clinical practice

BACKGROUND

Radiologic imaging can accurately diagnose acute appendicitis, but little is known about its discriminatory capacity between complicated and uncomplicated appendicitis.

OBJECTIVE

This study aims to investigate the accuracy of imaging in discriminating complicated from uncomplicated appendicitis.

METHODS

Data was used from the prospective, nationwide, observational SNAPSHOT appendicitis database, including patients with suspected acute appendicitis who were planned for an appendectomy. Usage of ultrasound (US), CT, MRI or a combination was recorded. Radiological reports were used to group for complicated or uncomplicated appendicitis. The reference standard was based on operative and pathological findings. Primary outcomes were sensitivity and specificity in discriminating complicated from uncomplicated appendicitis. Secondary outcomes were diagnostic accuracy results per imaging modality and for the subgroups age, BMI, and sex.

RESULTS

Preoperative imaging was performed in 1964 patients. In 1434 patients (73%), only US was used; in 109 (6%) patients, only CT was used; and 421 (21%) patients underwent US followed by CT or MRI. Overall, imaging workup as practiced, following the national guideline, had a poor sensitivity for complicated appendicitis of only 35%, although specificity was as high as 93%. For US, accuracy for complicated appendicitis was higher in children than in adults; sensitivity 41.2% vs. 26.4% and specificity 94.6% vs. 93.4%, respectively, p = 0.003. For relevant subgroups such as age, sex and BMI, no other differences in the discriminatory performance were found.

CONCLUSION

A diagnostic workup with stepwise imaging, using a conditional CT or MRI strategy, poorly discriminates between complicated and uncomplicated appendicitis in daily practice.

Classification of acute appendicitis (CAA): treatment directed new classification based on imaging (ultrasound, computed tomography) and pathology

PURPOSE

Acute appendicitis (AA) is amongst the most common causes of acute abdominal pain. In spite of progress based on risk stratifications, "negative" appendectomies are performed in up to 30% of patients whilst the appendix perforates in others. Preoperative classification of AA based on imaging is therefore recommended. The aim was to classify AA based on imaging (ultrasound/US, computed tomography/CT), surgical pathology, and/or histopathology in order to differentiate between complicated and uncomplicated AA. A new classification of acute appendicitis (CAA) shall be illustrated by typical US and CT images and be employed in a diagnostic and therapeutic algorithm.

METHODS

Medline, Embase, and the Cochrane Library were searched. Any study after 1970, which investigated clinical scores, pathology, US, CT, magnetic resonance imaging, and treatment of AA, was included. Typical images were taken from the author's image database.

RESULTS

Five main types of AA are defined, normal appendix (type 0), nonvisualised appendix (type X), uncomplicated AA (type 1), complicated AA without perforation (type 2), and complicated AA with perforation (type 3). The imaging modality is indicated by an additional letter, e.g., type p3b for free perforation on pathology. Standardised reporting of the appendix evaluation by US and CT is presented, as well as algorithms for AA management. Imaging features indicating imminent perforation, as well as likely recurrence, were both classified as complicated AA.

CONCLUSION

Imaging is mandatory in suspected AA. The CAA clearly separates uncomplicated from complicated forms of AA allowing nonoperative management in selected patients with uncomplicated forms of AA.

Non-operative treatment versus appendectomy for acute uncomplicated appendicitis: A randomized controlled trial

Objectives:

To compare the outcome of non-operative treatment (NOT) with antibiotics versus surgical management of uncomplicated appendicitis in children.

Methods:

This randomized clinical trial (NCT 04030741) was carried out in Pediatric Surgery Department, Mayo Hospital from September 2018 to September 2019. Total sample size was 180, and after informed consent patients were randomly allocated in two groups. All children between 5 and 15 years of age and having pediatric appendicitis score (PAS) >7 were included. Patients with previous abdominal surgery, peritonitis, appendicular mass, or intra-abdominal abscess were excluded. Children in NOT group (Group A) were given intravenous Meropenem and Metronidazole for 48 hours and after starting oral, antibiotics were continued orally for 7 days. In Group B, children underwent appendectomy. Failure of NOT was labeled if there was abscess formation or peri-appendiceal fluid collection on ultrasound, development of peritonitis or recurrence of appendicitis.

Results:

In Group A, mean age was 9.56±1.8 years and in Group B 10.11±1.8 years. There were 123 male and 57 female patients. Group B had 100% successful outcome. NOT (Group A) had successful outcome in 75 patients (83.3%) and failure was noted in 15 (16.7%). Five needed operation within 48 hours, all had appendicolith, and 10 patients presented within 6 months. Raised total leukocyte count (p value < 0.0001) and C reactive protein (p value < 0.04) levels were noted with failure of NOT.

Conclusions:

In this study, success of NOT was 84% so a trial of NOT in cases of uncomplicated appendicitis should be considered in children.

Does speed matter? A look at NSQIP-P outcomes based on operative time

BACKGROUND

Appendicitis is a common pediatric surgical condition, comprising a large burden of healthcare costs. We aimed to determine if prolonged operative times were associated with increased 30-day complication rates when adjusting for pre-operative risk factors.

METHODS

Patients <18 years old, diagnosed intraoperatively with acute uncomplicated appendicitis and undergoing laparoscopic appendectomy were identified from the NSQIP-P 2012-2018 databases. The primary outcome, "infectious post-operative complications", is a composite of sepsis, deep incisional surgical site infections, wound disruptions, superficial, and organ space infections within 30-days of the operation. Secondary outcomes included return to the operating room and unplanned readmissions within 30 days. Logistic regression models were used to assess associations between operative time and each outcome. A Receiver Operating Characteristic (ROC) curve was generated from the predicted probabilities of the multivariate model for infectious post-operative complications to examine operative times.

RESULTS

Between 2012 and 2018, 27,763 pediatric patients with acute uncomplicated appendicitis underwent a laparoscopic appendectomy. Over half the population was male (61%) with a median operative time of 39 min (IQR 29-52 min). Infectious post-operative complication rate was 2.8% overall and was highest (8%) among patients with operative time ≥ 90 min (Fig. 1). Unplanned readmission occurred in 2.9% of patients, with 0.7% returning to the operating room. Each 30-min increase in operating time was associated with a 24% increase in odds of an infectious post-operative complication (OR=1.24, 95% CI=1.17-1.31) in adjusted models. Operative time thresholds predicted with ROC analysis were most meaningful in younger patients with higher ASA class and pre-operative SIRS/Sepsis/Septic shock. Longer operative times were also associated with higher odds of unplanned readmission (OR=1.11, 95% CI=1.05-1.18) and return to the operating room (OR=1.13, 95% CI=1.02-1.24) in adjusted models.

CONCLUSION

There is a risk-adjusted association between prolonged operative time and the occurrence of infectious post-operative complications. Infectious postoperative complications increase healthcare spending and are currently an area of focus in healthcare value models. Future studies should focus on addressing laparoscopic appendectomy operative times longer than 60 min, with steps such as continuation of antibiotics, shifting roles between attending and resident surgeons, and simulation training.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Defining treatment strategy for uncomplicated appendicitis based on patient satisfaction feedback: A cross-sectional study

BACKGROUND

Two surgical strategies are available for appendicitis: emergency laparoscopic appendectomy and interval laparoscopic appendectomy. However, timing of surgical intervention remains debatable. This study aimed to compare the surgical outcomes of emergency laparoscopic appendectomy and interval laparoscopic appendectomy and conduct a questionnaire survey to investigate the use of emergency laparoscopic appendectomy and patient satisfaction with regard to treatment.

METHODS

We included 162 patients who underwent laparoscopic appendectomy at our hospital. Outcomes were assessed by operation time, blood loss, postoperative fasting time, length of hospital stay, and complication rate. Patient satisfaction was measured by questionnaire addressing degree of satisfaction, presurgery anxiety, and length of hospital stay.

RESULTS

Of 162 patients, 74 (46%) and 88 (54%) received emergency and interval laparoscopic appendectomy, respectively. No significant difference was observed in the operation time, blood loss, length of hospital stay, or complication rate. Among 66 patients who responded to the questionnaire (28 emergency, 38 interval), a significant difference was observed only in the degree of satisfaction regarding the timing of the surgical intervention (p = 0.04).

CONCLUSION

Surgical outcomes of emergency and interval appendectomy were equivalent; however, patient satisfaction favored emergency appendectomy, suggesting it is a preferable approach for the treatment of uncomplicated appendicitis.

A single centre evaluation of risk prediction models and imaging modalities in acute appendicitis

INTRODUCTION

Patients with suspected appendicitis remain a diagnostic challenge. The aim of this study was to validate risk prediction models, and to investigate diagnostic accuracy of ultrasonography and computed tomography (CT) in adults undergoing appendicectomy.

METHODS

A retrospective case review was performed of patients aged 16-45 years having an appendicectomy between January 2019 and January 2020 at a tertiary referral centre. Primary outcomes were the accuracy of a high risk appendicitis risk score and ultrasonography and CT imaging modalities compared with histological reports following appendicectomy.

RESULTS

A total of 206 patients (52% female) were included in the study. Removal of a histologically normal appendix was equally likely in men and women (13.1% vs 11.2% respectively, relative risk: 1.17, 95% confidence interval: 0.56-2.44, p=0.674). A high risk appendicitis score correctly identified 84.0% (79/94) of cases in men and 85.9% (67/78) of cases in women. Ultrasonography was reported as equivocal in 85.7% (18/21) of low risk women and 59.0% (23/39) of high risk women. CT correctly detected or excluded appendicitis in 75.0% (6/8) of low risk women and 88.5% (23/26) of high risk women.

CONCLUSIONS

This study suggests that risk prediction models may be useful in both women and men to identify appendicitis. Ultrasonography gave high rates of equivocal results and should not be relied on for the diagnosis of appendicitis. CT is a highly accurate diagnostic tool and could be considered in those at low risk where clinical suspicion remains to reduce negative appendicectomy rates.

Appendectomy versus conservative treatment with antibiotics for patients with uncomplicated acute appendicitis: a propensity score-matched analysis of patient-centered outcomes (the ACTUAA prospective multicenter trial)

PURPOSE

The aim of this prospective multicenter study was to compare antibiotic therapy and appendectomy as treatment for patients with uncomplicated appendicitis confirmed by ultrasound and/or computed tomography.

METHODS

The study was conducted from January 2017 to January 2018. Data regarding all patients discharged from the participating centers with a diagnosis of uncomplicated appendicitis were collected prospectively.

RESULTS

Of the 318 patients enrolled in the study, 27.4% underwent antibiotic-first therapy, and 72.6% underwent appendectomy. The matched group was composed of 87 patients in both study arms. Of the 87 patients available of 1-year follow-up in the antibiotic-first group, 64 (73.6%) did not require appendectomy. The complication-free treatment success in the antibiotic-first group was 64.4%. A statistically significant higher complication-free treatment success was found in the appendectomy group: 81.8% in the pre-matching sample and 83.9% in the post-matching sample. Patients in the antibiotic-first group reported lower VAS scores compared to those treated with an appendectomy, both at discharge (2.0 ± 1.7 vs 3.6 ± 2.3) and at 30-day follow-up (0.3 ± 0.6 vs 2.1 ± 1.7). The mean of the days of absence from work was higher in the appendectomy group (β 0.63; 95% CI 0.08-1.18).

CONCLUSION

Although laparoscopic appendectomy remains the gold standard of treatment for uncomplicated appendicitis, conservative treatment with antibiotics is a safe option in most cases. Approximately 65% of patients treated with antibiotics are symptom-free at 1 year, without increased risk of adverse events should symptoms recur, and better outcomes in terms of less pain and shorter period of absence from work compared to patients undergoing an appendectomy.

TRIAL REGISTRATION

Clinicaltrials.gov identifier (NCT number): NCT03080103.

The role of postoperative antibiotics in preventing surgical site infections in uncomplicated appendicitis

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In patients who underwent appendicectomy for uncomplicated appendicitis is the use of postoperative antibiotics associated with lower rates of surgical site infections? The search has been devised and 6 studies were deemed to be suitable to answer the question. The outcome assessed was the efficiency of postoperative antibiotic therapy in decreasing the rate of surgical site infections in uncomplicated appendicitis. Authors recommend against the use of postoperative antibiotics based on the supported evidence. Hence, its usage was not associated with lower rates of surgical site infections. On the contrary, it might increase the cost, postoperative morbidity and length of stay.

Reducing resource utilization for patients with uncomplicated appendicitis through use of same-day discharge and elimination of postoperative antibiotics

BACKGROUND

There is controversy over certain aspects of post-appendectomy care for children with uncomplicated appendicitis. Some institutions have embraced the practice of same-day discharge after appendectomy, while others are hesitant due to concerns about increased readmissions or emergency department (ED) visits. Similarly, some surgeons have transitioned to treating gangrenous appendicitis with a single perioperative dose, while others are concerned about increased risk of infection in this population.

METHODS

We developed a pathway for the management of patients undergoing appendectomy for uncomplicated acute appendicitis which included same-day discharge and elimination of postoperative antibiotics for patients with gangrenous appendicitis. We compared outcomes for children treated at our institution before and after implementation of the protocol.

RESULTS

We identified 575 patients undergoing appendectomy for uncomplicated appendicitis (307 pre- and 268 post-protocol). We observed a significant decrease in postoperative length-of stay (10.6 to 2.6 h, p < 0.0001). There were no increases in postoperative complications, such as superficial (2.6% vs 1.1%, p = 0.19) or organ-space surgical-site infection (1.6% vs 0.4%, p = 0.14), percutaneous drain placement (1.3% vs 0%, p = 0.06), postoperative ED visits (5.5% vs 5.2%, p = 0.87) or readmission (3.3% vs 1.5%, p = 0.17).

CONCLUSIONS

These findings suggest that incorporating same-day discharge for simple appendicitis and eliminating postoperative antibiotics for children with gangrenous appendicitis does not increase complication rates. Implementation of similar pathways across institutions has the potential to significantly reduce resource utilization for children undergoing appendectomy for uncomplicated appendicitis.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Validation of a Scoring System to Distinguish Uncomplicated From Complicated Appendicitis

BACKGROUND

Studies have shown that uncomplicated appendicitis can be treated conservatively with antibiotics. It is important to select only those patients with uncomplicated appendicitis when considering conservative management. Recently, a scoring system based on clinical evaluation and ultrasound was developed to improve this selection and aid in shared decision making when considering an antibiotics-first strategy. The aim of this study was to externally validate the scoring system.

MATERIALS AND METHODS

A retrospective cohort study of all adult patients presenting to the emergency department between January 2014 and January 2017 with suspected acute appendicitis based on clinical evaluation and ultrasound was performed. For every patient, a score was calculated using the previously described scoring system. A final diagnosis, subdivided into complicated appendicitis, uncomplicated appendicitis, complicated alternative disease, and uncomplicated alternative disease, was assigned to every patient based on operative findings.

RESULTS

A total of 678 patients with suspected acute appendicitis based on clinical and ultrasonography findings were identified, of whom 175 (25.8%) had complicated appendicitis, 491 (72.4%) had uncomplicated appendicitis, and 12 (1.8%) had an alternative disease. Of the 678 patients, 272 had a score of five points or less, of whom 17 (6.2%) had complicated appendicitis, giving a negative predictive value of 93.8%.

CONCLUSIONS

With the scoring system based on clinical and ultrasonography features, 93.8% of patients predicted to have uncomplicated appendicitis were correctly identified. The scoring system could help identify patients suitable for conservative management in future studies.

Single-port laparoscopic appendectomy using a needle-type grasping forceps for acute uncomplicated appendicitis in children: Case series

•

Acute appendicitis is the most common between the ages of 10 and 20 years.

•

Our centre performed a new technology of single-port laparoscopic appendectomy using a needle-type grasping forceps (SLAN).

•

SLAN has advantages of favourable cosmetic results, minimal trauma, and enhanced postoperative recovery.

Introduction

Single-port laparoscopy has been used in any areas of surgery, including appendectomy, to reduce the operative stress and enhance postoperative recovery procedure. This paper introduces our attempt to perform single-port laparoscopic appendectomy using conventional laparoscoopic instruments and a needle-type grasping forceps (SLAN), which has dominant advantage in cosmetic appearance.

Methods

We report six pediatric patients who underwent SLAN for uncomplicated appendicitis from April to November 2019. SLAN was performed transumbilically, while conventional laparoscopic instruments and needle-type grasping forceps were both used. After routine intracorporeal appendectomy was completed, the pathological appendix was extracted through the single-port site, while a 10 mm trocar was used to avoid incision infectious. Clinical data and postoperative follow-up data were collected and analyzed to evaluate the feasibility, safety, and clinical outcomes of this novel technique.

Results

SLAN was successfully performed in all six pediatric patients. The median operative time, first exhaust time after surgery, pain score of postoperative day 1, and postoperative hospital stay were 69 (range, 50−85) min, 1.33 (range, 1–2) d, 0.83 (range, 0–3) score, 1.5 (range, 1–2) d, respectively. Neither intraoperative nor postoperative complications were noted, while no incision infectious, adhesive intestinal obstruction, and abdominal abscess were observed with 2–9 months follow up.

Discussion

Though there are many methods to perform single-port laparoscopic appendectomy, the use of needle grasping forceps in laparoscopic appendectomy has been confirmed a new choice for uncomplicated appendicitis in children.

Conclusion

SLAN is a feasible and safe technique to treat acute uncomplicated appendicitis in children. To be emphasized, surgeons must strictly grasp the indications for this surgery.

Successful surgical management of non-perforating acute appendicitis with septic disseminated intravascular coagulation: A case report and review of the literature

•

Non-perforating acute appendicitis with septic DIC is extremely rare.

•

Nowadays, interval appendectomy has become popular.

•

However, judging the limit of conservative treatment for acute appendicitis is a critically important matter.

•

Appendectomy should be performed for non-perforating acute appendicitis with septic DIC.

Introduction

Perforating appendicitis and abscess-forming appendicitis may cause septic disseminated intravascular coagulation (DIC). However, non-perforating acute appendicitis with septic DIC is extremely rare.

Presentation of case

A 67-year-old man was referred to our hospital one day after starting oral antibiotic treatment for acute appendicitis. Physical examination revealed only slight spontaneous abdominal pain without tenderness and peritoneal irritation. Contrast-enhanced computed tomography demonstrated an enlarged appendix (10 mm in diameter) without fecalith, ascites, intraperitoneal free air, and abscess. There was no evidence of perforating appendicitis. Laboratory analysis revealed septic DIC. The patient was diagnosed with non-perforating acute appendicitis with septic DIC. The patient was distressed regarding whether he should be treated conservatively with an antibiotics-first strategy or undergo an appendectomy. Ultimately, a laparoscopic appendectomy was performed. Histopathological examination showed non-perforating gangrenous appendicitis. He required DIC therapy for 2 days postoperatively. He was discharged on postoperative day 9, and remained in good health 1 month after surgery.

Discussion

There is no absolute index of conversion to surgery with an antibiotics-first strategy of appendicitis treatment. Judging the limit of conservative treatment and determining the best moment to perform surgery is a critically important matter for patients with acute appendicitis.

Conclusions

The incidence of conservative treatment preceding an antibiotics-first strategy for acute appendicitis is increasing. However, it is thought that appendectomy should be performed when acute appendicitis is complicated with septic DIC, even if it is a non-perforating appendicitis in which improvement with conservative treatment is anticipated.

Clinical recovery in children with uncomplicated appendicitis undergoing non-operative treatment: secondary analysis of a prospective cohort study

Non-operative treatment of uncomplicated appendicitis in children is gaining ground. Pending definitive evidence regarding its effectiveness, there is a call to evaluate clinical recovery after non-operative treatment. In this study, we analyzed data collected during initial admission of a multicenter prospective cohort in which children, 7-17 year, were treated non-operatively for uncomplicated appendicitis. During admission clinical parameters (pain and gastro-intestinal symptoms), inflammation parameters and sequential abdominal ultrasound were recorded. In total, 45 children were included, 42(93%) were discharged without the need for appendectomy; median [IQR] pain scores on admission were 5 [4-7], decreasing to 2 [0-3] after 1 day of treatment. Initially, 28/42 (67%) reported nausea and 19/42 (45%) vomiting; after 1 day, this was 3/42 (7%) and 1/42 (2%), respectively. White blood cell count declined from a median [IQR] of 12.9 [10.7-16.7] 10E9/L on admission to 7.0 [5.8-9.9] 10E9/L on day 1. Median [IQR] C-reactive protein levels increased from 27.5 [9-69] mg/L on admission to 48 [22-80] mg/L on day 1, declining to 21.5 [11-42] mg/L on day 2. Follow-up ultrasound showed no signs of complicated appendicitis in any of the patients.Conclusion: Clinical symptoms resolved in most children after 1 day of non-operative treatment. This suggests that non-operative treatment is a viable alternative to appendectomy regarding clinical recovery.Trail registration: NCT01356641 What is Known: • Non-operative treatment of uncomplicated appendicitis in children is safe and its use around the world is gaining ground, however high quality evidence from adequately designed randomized trials is still lacking. • Concerns have been raised regarding the potentially prolonged clinical recovery associated with non-operative treatment. What is New: • Most clinical symptoms resolve after 1 day of non-operative treatment in the majority of children.

Optimising the antibiotic treatment of uncomplicated acute appendicitis: a protocol for a multicentre randomised clinical trial (APPAC II trial)

BACKGROUND

Based on epidemiological and clinical data acute appendicitis can present either as uncomplicated (70-80%) or complicated (20-30%) disease. Recent studies have shown that antibiotic therapy is both safe and cost-effective for a CT-scan confirmed uncomplicated acute appendicitis. However, based on the study protocols to ensure patient safety, these randomised studies used mainly broad-spectrum intravenous antibiotics requiring additional hospital resources and prolonged hospital stay. As we now know that antibiotic therapy for uncomplicated acute appendicitis is feasible and safe, further studies evaluating optimisation of the antibiotic treatment regarding both antibiotic spectrum and shorter hospital stay are needed to evaluate antibiotics as the first-line treatment for uncomplicated acute appendicitis.

METHODS

APPAC II trial is a multicentre, open-label, non-inferiority randomised controlled trial comparing per oral (p.o.) antibiotic monotherapy with intravenous (i.v.) antibiotic therapy followed by p.o. antibiotics in the treatment of CT-scan confirmed uncomplicated acute appendicitis. Adult patients with CT-scan diagnosed uncomplicated acute appendicitis will be enrolled in nine Finnish hospitals. The intended sample size is 552 patients. Primary endpoint is the success of the randomised treatment, defined as resolution of acute appendicitis resulting in discharge from the hospital without the need for surgical intervention and no recurrent appendicitis during one-year follow-up. Secondary endpoints include post-intervention complications, late recurrence of acute appendicitis after one year, duration of hospital stay, pain, quality of life, sick leave and treatment costs. Primary endpoint will be evaluated in two stages: point estimates with 95% confidence interval (CI) will be calculated for both groups and proportion difference between groups with 95% CI will be calculated and evaluated based on 6 percentage point non-inferiority margin.

DISCUSSION

To our knowledge, APPAC II trial is the first randomised controlled trial comparing per oral antibiotic monotherapy with intravenous antibiotic therapy continued by per oral antibiotics in the treatment of uncomplicated acute appendicitis. The APPAC II trial aims to add clinical evidence on the debated role of antibiotics as the first-line treatment for a CT-confirmed uncomplicated acute appendicitis as well as to optimise the non-operative treatment for uncomplicated acute appendicitis.

TRIAL REGISTRATION

Clinicaltrials.gov , NCT03236961, retrospectively registered on the 2nd of August 2017.

Conservative antibiotic treatment for acute uncomplicated appendicitis is feasible

PURPOSE

Appendectomy versus conservative antibiotic treatment (CAT) for children with acute uncomplicated appendicitis (AUA) remains unresolved, with concerns regarding the practicality of CAT. We analyzed our center's experience with CAT for AUA, using a protocol with strict inclusion, exclusion and treatment criteria.

METHODS

Non-randomized, prospective cohort study included all children admitted betwee 2014 and 2016, with clinical and laboratory tests suspicious for AUA. Data collected included clinical signs and symptoms; laboratory, ultrasound and pathology results. Follow-up was conducted through clinic visits, telephone conversations and national registry analysis.

RESULTS

Included in CAT: 362 children, 19 underwent appendectomy within 1-2 days. Overall, 75 were readmitted for recurrent acute appendicitis during 22 months (6-43) follow-up. Thirty were treated successfully with antibiotics a second time. The remaining 45 had appendectomy. Overall, 86.8% underwent CAT with no surgery. Histology of all recurrent AUA revealed no perforations.

CONCLUSION

We confirm the feasibility of conservative management of AUA in children. A rigorous diagnostic plan with strict inclusion and exclusion criteria will lead to high success rate of CAT with a strong safety profile. CAT does not compete with surgery or render appendectomy unnecessary. It is a safe alternative to surgery in selected cases.

A prospective non-randomized controlled, multicenter trial comparing Appendectomy and Conservative Treatment for Patients with Uncomplicated Acute Appendicitis (the ACTUAA study)

PURPOSE

Acute appendicitis (AA) is among the most common causes of lower abdominal pain and admissions to the emergency department. Over the past 20 years, there has been a renewed interest in the conservative management of uncomplicated AA, and several studies demonstrated that an antibiotic-first strategy is a viable treatment option for uncomplicated AA. The aim of this prospective non-randomized controlled, multicenter trial is to compare antibiotic therapy and emergency appendectomy as treatment for patients with uncomplicated AA confirmed by US and/or CT or MRI scan.

METHODS

All adult patients in the age range 18 to 65 years with suspected AA, consecutively admitted to the Surgical Department of the 13 participating Italian Hospitals, will be invited to take part in the study. A multicenter prospective collected registry developed by surgeons, radiologists, and pathologists with expertise in the diagnosis and treatment of uncomplicated acute appendicitis represents the best research method to assess the long-term role of antibiotics in the management of the disease. Comparison will be made between surgical and antibiotic-first approaches to uncomplicated AA through the analysis of the primary outcome measure of complication-free treatment success rate based on 1-year follow-up. Quality of life, length of hospital stay, pain evaluation, and time to return to normal activity will be evaluated as secondary outcome measures.

TRIAL REGISTRATION

Clinicaltrials.gov ID: NCT03080103.

Diagnosis and management of acute appendicitis. EAES consensus development conference 2015

Unequivocal international guidelines regarding the diagnosis and management of patients with acute appendicitis are lacking. The aim of the consensus meeting 2015 of the EAES was to generate a European guideline based on best available evidence and expert opinions of a panel of EAES members. After a systematic review of the literature by an international group of surgical research fellows, an expert panel with extensive clinical experience in the management of appendicitis discussed statements and recommendations. Statements and recommendations with more than 70 % agreement by the experts were selected for a web survey and the consensus meeting of the EAES in Bucharest in June 2015. EAES members and attendees at the EAES meeting in Bucharest could vote on these statements and recommendations. In the case of more than 70 % agreement, the statement or recommendation was defined as supported by the scientific community. Results from both the web survey and the consensus meeting in Bucharest are presented as percentages. In total, 46 statements and recommendations were selected for the web survey and consensus meeting. More than 232 members and attendees voted on them. In 41 of 46 statements and recommendations, more than 70 % agreement was reached. All 46 statements and recommendations are presented in this paper. They comprise topics regarding the diagnostic work-up, treatment indications, procedural aspects and post-operative care. The consensus meeting produced 46 statements and recommendations on the diagnostic work-up and management of appendicitis. The majority of the EAES members supported these statements. These consensus proceedings provide additional guidance to surgeons and surgical residents providing care to patients with appendicitis.

Long-term outcomes of operative versus nonoperative treatment for uncomplicated appendicitis

PURPOSE

Although nonoperative treatment for uncomplicated appendicitis is now an accepted approach, there are few reports in children. The aim of this study was to compare long-term outcomes between operative and nonoperative treatment in children.

METHODS

Between April 2007 and December 2013, all uncomplicated appendicitis patients were asked to select either operative (laparoscopic surgery) or nonoperative treatment on admission. For nonoperative treatment, intravenous injection of antibiotics was continued until serum C-reactive protein concentration decreased to below 0.5mg/dL. A questionnaire survey on satisfaction with treatment was added afterwards and performed more than 1year after treatment.

RESULTS

Eighty-six patients chose operative treatment, and 78 chose nonoperative treatment. The success rate of nonoperative treatment was 98.7%. There was no difference in the length of hospital stay between the two groups. Ileus occurred in two operatively-treated patients, while recurrence of appendicitis occurred in 22 nonoperatively-treated patients (28.6 %) after an average of 4.3years of follow-up. The overall nonoperative treatment failure including both early failure and recurrence occurred more frequently among those with appendicoliths than without appendicoliths. Satisfaction levels were higher for operative treatment.

CONCLUSIONS

Although the success rate of nonoperative treatment was very high, a considerable number of patients experienced recurrence.

The outcome of antibiotic therapy for uncomplicated appendicitis with diameters ≤ 10 mm

PURPOSE

Although many patients receive antibiotic therapy for uncomplicated appendicitis, the relatively high treatment failure and recurrence rates are problematic. We assumed that patients with appendicitis and appendiceal diameters ≤ 10 mm, have better outcomes. The purpose of this prospective non-randomized study was to assess the outcomes of antibiotic therapy in patients with uncomplicated appendicitis and appendiceal diameters ≤ 10 mm.

METHODS

Over 2 years, we enrolled 119 patients who initially received antibiotic therapy. The failure of antibiotic therapy was defined as the need for appendectomy and true appendicitis. Peritonitis was defined as either complicated appendicitis or intra-abdominal abscess postoperatively. We evaluated the rates of treatment failure, peritonitis, and recurrence.

RESULTS

Nine patients (7.6%) failed to respond to initial antibiotic therapy, and 6 had true appendicitis after subsequent surgery. Two patients had complicated appendicitis (peritonitis), but no patient displayed intra-abdominal abscess postoperatively. During a median follow-up period months of 14 months, 14 patients (12.7%) experienced recurrence.

CONCLUSIONS

Antibiotic therapy without surgery may be a safe treatment for uncomplicated appendicitis in select patients with appendiceal diameters ≤ 10 mm.