Appendicitis

See Article on Page 192-197 Acute appendicitis is the most common indication for surgery in patients admitted to hospital due to an acute abdomen. Although most are uncomplicated, about 20% of all acute appendicitis cases are complicated, leading to local or diffuse peritonitis. An urgent appendectomy is the recommended treatment for both complicated and uncomplicated appendicitis. The appendectomy, which has been the first choice for the treatment of acute appendicitis for over 120 years, is a classic surgical procedure [1]. Nowadays, a laparoscopic appendectomy is widely practiced for its benefits, such as significantly shorter operative time, lower incidence of wound infection, and reduced length of hospital stay [2]. Although an appendectomy is generally well tolerated, it is still considered a major surgical intervention and can be associated with postoperative morbidity in about 2%-23% of patients [3]. According to a study that followed patients for over a decade, 3% of the patients undergoing appendectomy were readmitted for intestinal obstruction related to postoperative adhesion [4,5]. Therefore, physicians are taking higher interest in noninvasive interventions, such as antibiotic therapy, as a primary treatment. Although the appendectomy remains the standard approach for treating appendicitis [6], several studies have already suggested that appendicitis can be treated with antibiotics [5]. Two well-studied appendicitis scoring systems based on clinical symptoms were used to diagnose appendicitis: the Alfredo Alvarado system for adults and the Madan Samuel system for children. The Alvarado score was developed in Philadelphia in the mid-1980s and has a sensitivity of 81% and a specificity of 74% [7]. The Pediatric Appendicitis Score was developed to diagnose appendicitis in children and has a high sensitivity of 100% and specificity of 92% [8]. Although these scoring systems were widely used to diagnose appendicitis in the past, they are no longer practically implicated. Recently, various diagnostic tools, such as computed tomography (CT) and ultrasound, have been developed to diagnose appendicitis. With the improvement of such radiologic tools, determining the severity of and diagnosing appendicitis have become more accurate. The development of radiologic tools has provided many advantages for diagnosing appendicitis and determining its severity. The increased use of CT has reduced the rate of negative (unnecessary) appendectomies [9]. A meta-analysis consisting of data from 31 studies revealed that both the sensitivity and the specificity of CT for appendicitis were as high as 94% [10]. The development of a precise scoring system based on CT to distinguish between complicated and uncomplicated appendicitis has led to an improvement in diagnostic accuracy [11]. This system provides the physician with the evidence needed to decide on a treatment strategy for appendicitis patients. A meta-analysis [12] of randomized controlled trials comparing antibiotics with appendectomies has shown that although antibiotic treatment alone can be successful in 77%-95% of the cases, patients should be made aware of the fact that the failure rate during the first year, with a need for readmission or surgery, is around 25%-30%. However, recently conducted research proposed the use of antibiotics as the single treatment for uncomplicated appendicitis. However, one should note that more accurate selection criteria, based on combinations of clinical risk scores and imaging, are required for patients or subgroups of patients in whom primary antibiotic treatment is more likely to succeed in the long-term, and CT could be of assistance in the process of selecting patients suitable for antibiotics therapy. Although the appendectomy is the best treatment for the appendicitis, studies on the use of antibiotics therapy to treat patients with uncomplicated appendicitis are still meaningful; thus, efforts for such research should be supported.

An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children

Demographic changes associated with the aging population mean that surgeons increasingly have contact and make decisions about treating patients from the oldest age groups. The aim of the study was to review the literature concerning the treatment of acute appendicitis in patients over the age of 60 years old. A review of the literature published in the years 2000-2015 has been carried out using the PubMed database. The initial number of results corresponding to the query in English, "appendicitis (MeSH) AND elderly (MeSH)" was 260. Selection based on the titles, abstracts, and eventually whole articles, ultimately resulted in 11 papers concerning the treatment of appendicitis in patients above 60 years of age. Nine papers were retrospective and 2 were prospective. In total, the studies included 82,852 patients. Laparoscopic appendectomy was associated with a lower mortality rate, a smaller number of postoperative complications and a shorter length of hospital stay, which led to it being recommended by most authors. Four of the ten papers demonstrated that the patients who were qualified for laparoscopic surgery had less comorbidity and were in a lower ASA (American Society of Anaesthesiology) category. Antibiotic therapy as an independent method was assessed in one study in a group of elderly people, on a selected group of 26 patients, and its effectiveness was shown to be 70%. Most studies, however, are highly heterogeneous which significantly hindered comparisons. Currently, laparoscopic appendectomy seems to be the treatment of choice in the elderly with acute appendicitis. Antibiotic therapy, as an independent method of treatment of acute appendicitis, cannot currently be recommended. However, further, prospective, and better-designed studies are needed, involving a larger number of patients, and primarily dedicated to the elderly.

Acute appendicitis is one of the most common urgent abdominal interventions.Open appendectomy has been a standard procedure for acute appendicitis for more than 100 years.However, in the last 20 years, after many studies, laparoscopic appendectomy has become a gold standard in solving acute appendicitis.The main goal of our study was to compare results of open and laparoscopic appendectomies with regard to in-hospital stay, time of operation, postoperative complications and postoperative pain.All patients underwent open or laparoscopic appendectomy in the Center of Minimally Invasive Surgery and Emergency Center of the University Clinical Center Ni, Serbia in the period of one year.A total of 126 patients were enrolled and submitted to retrospective analysis.One hundred and twenty-six patients who underwent laparoscopic or open appendectomy surgery were retrospectively analysed.A laparoscopic appendectomy was performed in 58 patients, while 68 patients underwent an open appendectomy.Groups were demographically similar and there was no significant difference between the age structure and gender distribution (t = 0.927; p = 0.057).Average height (p = 0.123), weight (p = 0.200) and BMI (p = 0.425) were mostly similar.Previous surgical operations were more common in patients with open appendectomy, but with no statistical significance (p = 0.141).Percentage of patients with WBC > 10 were the same in both groups (p = 0.927).Diabetes mellitus was more common in patients with open appendectomy, but with no statistical significance (p = 0.563).Acute and perforated appendicitis were similar in both groups (p = 0.490).Average time of operation was the same in both groups (p = 0.751).Number of days of in-hospital stay was shorter in patients who underwent laparoscopic appendectomy (p < 0.001).The analysis of administration of parenteral and oral analgesics showed that postoperative pain was less in the group of patients who underwent laparoscopic appendectomy than in the group of patients with open appendectomy.There was no statistically significant difference with respect to postoperative complications between two groups (p < 0.001).The treatment of appendicitis by using laparoscopic surgery in comparison to open approach provides a better result in terms of duration of hospital stay, recovering time, postoperative complications and postoperative pain.

&lt;p dir="ltr"&gt;Acute appendicitis is a clinical term for inflammation of the vermiform appendix with a sudden onset. Symptoms depend both on the age of a patient and on the position of appendix intraabdominally. The aetiology remains unknown, although, there are multiple theories. The lifetime risk of acute appendicitis in Western countries has been established as 7-8%, with 8.6% for males and 6.7% for females. The standard treatment has been surgery for many decades, but non-operative treatment, in the form of antibiotics, has more recently come to light as a feasible alternative to appendectomies.&lt;/p&gt;&lt;p dir="ltr"&gt;Aims: The aim of this thesis was to assess intermediate and long-term outcomes of non- operative treatment in both children and adults. This included assessing safety and feasibility of non-operative treatment and its complications. An additional aim was to ascertain the failure rate of non-operative treatment and recurrence of acute uncomplicated appendicitis in children and try to establish the reasons for the treatment failure.&lt;/p&gt;&lt;p dir="ltr"&gt;Methods: Study I was a 5-year follow-up of all participants who underwent surgery or non- operative treatment with antibiotics in a previous randomised controlled pilot trial. Data was extracted from the hospital notes and telephone interviews.&lt;/p&gt;&lt;p dir="ltr"&gt;Study II was a long-term follow-up of adults with acute appendicitis who were involved in two randomised controlled trials, which compared non-operative treatment with appendectomy. The first trial consisted of 40 patients (13 female) and second trial was a multicentre study with 252 male patients. National registers were used to retrieve data at follow up, including the Swedish National Patient Register, the Cancer Register, the Cause of Death Register and Statistics Sweden.&lt;/p&gt;&lt;p dir="ltr"&gt;Study III was a systematic review that was registered in PROSPERO (CRD42024592607) and done according to PRISMA statement. We searched three databases (PubMed, Medline, Web of Science). Eligible studies were randomised controlled trials or prospective cohort studies with children aged &lt;18 years that received non-operative treatment for uncomplicated appendicitis and reporting at least 30 days follow-up. We carried out a meta- analysis.&lt;/p&gt;&lt;p dir="ltr"&gt;Results: In Study I, we followed up all 50 children (26 children in the appendectomy group, 24 children in the nonoperative group) for at least 5 years. The surgical group was without failures and in the nonoperative group there were 11 failures and recurrences. In the first year there were nine failures, two of them had an appendicitis on the histopathology. Another two recurrences, that were histopathologically confirmed appendicitis occurred one to five years after the initial trial. At the 5-year follow-up, 54% of children had been successfully treated nonoperatively with antibiotics alone.&lt;/p&gt;&lt;p dir="ltr"&gt;In Study II, in total, we were able to trace down 259 patients in the Patient Register, 137 patients in the non-operative group and 122 in the surgical group. At the end of follow-up, 82 (60%) patients had had successful non-operative treatment without an appendectomy. In the non-operative group there were 21 (15%) failures during the first admission. Thirty-four recurrences happened after discharge, all with a diagnostic code of acute appendicitis. After successful initial treatment, 82/116 (71%) remained without appendectomy.&lt;/p&gt;&lt;p dir="ltr"&gt;In Study III, through a systematic search we were able to identify 2343 abstracts. Thirty studies were eligible, 8 randomised controlled trials and 22 prospective cohort studies reporting 27 different patient cohorts. An early failure rate occurred in 10% (95% CI 7-14%) and the recurrence rate was 29% (95% CI 24-34%) at the end of follow-up. When analysing studies with faecalith, a failure rate was higher (17% versus 6.4%) with P-value &lt;0.0001.&lt;/p&gt;&lt;p dir="ltr"&gt;Conclusions: Studies I and II demonstrated intermediate- and long-term safety of non- operative treatment alone in children and adults. This treatment does not increase the risk of malignancy and other complications and patients avoid surgery. Study III demonstrated a low initial failure rate and the recurrence rate was 29%. Non-operative treatment was less successful in children with a faecalith, particularly during first admission. These results can be used for discussion about treatment options of uncomplicated appendicitis with child patients and their caregivers.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. &lt;b&gt;Patkova B&lt;/b&gt;, Svenningsson A, Almström M, Eaton S, Wester T, Svensson JF. Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial. Ann Surg. 2020 Jun;271(6):1030-1035. &lt;a href="https://doi.org/10.1097/SLA.0000000000003646"&gt;https://doi.org/10.1097/SLA.0000000000003646&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. &lt;b&gt;Pátková B,&lt;/b&gt; Svenningsson A, Almström M, Svensson JF, Eriksson S, Wester T, Eaton S. Long-Term Outcome of Nonoperative Treatment of Appendicitis. JAMA Surg. 2023 Oct 1;158(10):1105-1106. &lt;a href="https://doi.org/10.1001/jamasurg.2023.2756"&gt;https://doi.org/10.1001/jamasurg.2023.2756&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. &lt;b&gt;Patková B&lt;/b&gt;, Svenningsson A, Jumah S, Wester T, Eaton S. Failure and recurrence of non-operative treatment of uncomplicated appendicitis in children; a systematic review and meta-analysis. [Manuscript]&lt;/p&gt;

&lt;p dir="ltr"&gt;Acute appendicitis is a clinical term for inflammation of the vermiform appendix with a sudden onset. Symptoms depend both on the age of a patient and on the position of appendix intraabdominally. The aetiology remains unknown, although, there are multiple theories. The lifetime risk of acute appendicitis in Western countries has been established as 7-8%, with 8.6% for males and 6.7% for females. The standard treatment has been surgery for many decades, but non-operative treatment, in the form of antibiotics, has more recently come to light as a feasible alternative to appendectomies.&lt;/p&gt;&lt;p dir="ltr"&gt;Aims: The aim of this thesis was to assess intermediate and long-term outcomes of non- operative treatment in both children and adults. This included assessing safety and feasibility of non-operative treatment and its complications. An additional aim was to ascertain the failure rate of non-operative treatment and recurrence of acute uncomplicated appendicitis in children and try to establish the reasons for the treatment failure.&lt;/p&gt;&lt;p dir="ltr"&gt;Methods: Study I was a 5-year follow-up of all participants who underwent surgery or non- operative treatment with antibiotics in a previous randomised controlled pilot trial. Data was extracted from the hospital notes and telephone interviews.&lt;/p&gt;&lt;p dir="ltr"&gt;Study II was a long-term follow-up of adults with acute appendicitis who were involved in two randomised controlled trials, which compared non-operative treatment with appendectomy. The first trial consisted of 40 patients (13 female) and second trial was a multicentre study with 252 male patients. National registers were used to retrieve data at follow up, including the Swedish National Patient Register, the Cancer Register, the Cause of Death Register and Statistics Sweden.&lt;/p&gt;&lt;p dir="ltr"&gt;Study III was a systematic review that was registered in PROSPERO (CRD42024592607) and done according to PRISMA statement. We searched three databases (PubMed, Medline, Web of Science). Eligible studies were randomised controlled trials or prospective cohort studies with children aged &lt;18 years that received non-operative treatment for uncomplicated appendicitis and reporting at least 30 days follow-up. We carried out a meta- analysis.&lt;/p&gt;&lt;p dir="ltr"&gt;Results: In Study I, we followed up all 50 children (26 children in the appendectomy group, 24 children in the nonoperative group) for at least 5 years. The surgical group was without failures and in the nonoperative group there were 11 failures and recurrences. In the first year there were nine failures, two of them had an appendicitis on the histopathology. Another two recurrences, that were histopathologically confirmed appendicitis occurred one to five years after the initial trial. At the 5-year follow-up, 54% of children had been successfully treated nonoperatively with antibiotics alone.&lt;/p&gt;&lt;p dir="ltr"&gt;In Study II, in total, we were able to trace down 259 patients in the Patient Register, 137 patients in the non-operative group and 122 in the surgical group. At the end of follow-up, 82 (60%) patients had had successful non-operative treatment without an appendectomy. In the non-operative group there were 21 (15%) failures during the first admission. Thirty-four recurrences happened after discharge, all with a diagnostic code of acute appendicitis. After successful initial treatment, 82/116 (71%) remained without appendectomy.&lt;/p&gt;&lt;p dir="ltr"&gt;In Study III, through a systematic search we were able to identify 2343 abstracts. Thirty studies were eligible, 8 randomised controlled trials and 22 prospective cohort studies reporting 27 different patient cohorts. An early failure rate occurred in 10% (95% CI 7-14%) and the recurrence rate was 29% (95% CI 24-34%) at the end of follow-up. When analysing studies with faecalith, a failure rate was higher (17% versus 6.4%) with P-value &lt;0.0001.&lt;/p&gt;&lt;p dir="ltr"&gt;Conclusions: Studies I and II demonstrated intermediate- and long-term safety of non- operative treatment alone in children and adults. This treatment does not increase the risk of malignancy and other complications and patients avoid surgery. Study III demonstrated a low initial failure rate and the recurrence rate was 29%. Non-operative treatment was less successful in children with a faecalith, particularly during first admission. These results can be used for discussion about treatment options of uncomplicated appendicitis with child patients and their caregivers.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. &lt;b&gt;Patkova B&lt;/b&gt;, Svenningsson A, Almström M, Eaton S, Wester T, Svensson JF. Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial. Ann Surg. 2020 Jun;271(6):1030-1035. &lt;a href="https://doi.org/10.1097/SLA.0000000000003646"&gt;https://doi.org/10.1097/SLA.0000000000003646&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. &lt;b&gt;Pátková B,&lt;/b&gt; Svenningsson A, Almström M, Svensson JF, Eriksson S, Wester T, Eaton S. Long-Term Outcome of Nonoperative Treatment of Appendicitis. JAMA Surg. 2023 Oct 1;158(10):1105-1106. &lt;a href="https://doi.org/10.1001/jamasurg.2023.2756"&gt;https://doi.org/10.1001/jamasurg.2023.2756&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. &lt;b&gt;Patková B&lt;/b&gt;, Svenningsson A, Jumah S, Wester T, Eaton S. Failure and recurrence of non-operative treatment of uncomplicated appendicitis in children; a systematic review and meta-analysis. [Manuscript]&lt;/p&gt;

The objective was to identify a set of clinical features that can rule out appendicitis in patients with suspected acute appendicitis and nondiagnostic ultrasound (US) results, allowing safe discharge and next-day reevaluation without initial computed tomography (CT) or magnetic resonance imaging (MRI). Data on clinical and US evaluation, including a number of prespecified variables potentially associated with acute appendicitis, were prospectively collected in two diagnostic accuracy studies of imaging. These studies included patients with suspected appendicitis seen in the emergency department (ED). For development and validation of the clinical decision rule (CDR), only patients with inconclusive or negative US results were included. There were 199 (of 422) patients in the development cohorts and 120 (of 211) patients in the validation cohort. Logistic regression analysis was used for data from patients with inconclusive or negative US results, and profiles were created of all possible combinations of predictors retained in the multivariable model. A final diagnosis was assigned by an expert panel based on perioperative data, histopathology, and clinical follow-up of at least 3 months. The CDR selected patients after negative or inconclusive US for discharge and next-day reevaluation without initial CT or MRI if fewer than two of the following predictors were present: male sex, migration of pain to the right lower quadrant, vomiting, and white blood cell (WBC) count higher than 12.0 × 10(9) /L. Applying the CDR in the development set selected 126 of 199 (63%) patients with negative or inconclusive US results for discharge without further imaging. This rule reduced the probability of appendicitis from 26% (51 of 199) in the total group of patients with negative or inconclusive US results to 12% (15 of 126) in the group that would be discharged based on the rule (p = 0.001). In the validation set (n = 120), the decision rule selected 72 (60%) patients for discharge and next-day reevaluation and reduced the probability of appendicitis from 20% (24 of 120) in the total group to 6% (4 of 72) in the patients selected on the rule (p = 0.001). The negative predictive value of the decision rule in the validation set was 94% (95% confidence interval [CI] = 87% to 98%). In comparison, the negative predictive value of CT in the same group was 99% (95% CI = 93% to 100%, p = 0.14), and that of MRI was 99% (95% CI = 94% to 100%, p = 0.12). Alternative decision rules based on combinations of the present decision rule with C-reactive protein (CRP) results did not improve selection. This newly developed CDR significantly reduces the probability of appendicitis in a large subgroup of patients with negative or inconclusive US results. These patients can be safely discharged for outpatient reevaluation without further initial imaging if proper follow-up is available. This could assist in lowering the number of ED imaging investigations in patients with suspected appendicitis.

Acute appendicitis is one of the most common emergency abdominal disease, and recent studies have evaluated conservative treatment using antibiotics for uncomplicated appendicitis. Although the efficacy of conservative treatment for uncomplicated appendicitis is known, its efficacy for complicated appendicitis remains unknown, so are risk factors for the conservative treatment of appendicitis. In our institution, conservative treatment has long been the first choice for most appendicitis cases, except for perforation. Therefore, this novel study investigated the outcomes of conservative treatment for uncomplicated and complicated acute appendicitis and the risk factors associated with conservative treatment. To investigate the indication of conservative treatment by antibiotics for uncomplicated and complicated acute appendicitis. We investigated 270 patients who received conservative treatment for acute appendicitis at the Nishitokyo Central General Hospital, between April 2011 and February 2022. Twenty-eight (10.3%) patients were resistant to conservative treatment and underwent surgery. We retrospectively investigated the outcomes of conservative treatment for appendicitis and the risk factors for resistance to conservative treatment using the receiver operating characteristic curves and Cox hazard model. Two hundred and forty-two (89.7%) patients improved with conservative treatment. The significant and independent predictors of resistance to conservative treatment were body temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid visible on computed tomography (CT). The rate of resistance to conservative treatment was 66.7% (6/9) for patients with the above three factors, 22.9% (8/35) for patients with two factors (appendicolith and body temperature ≥ 37.3 °C), 16.7% (2/12) for patients with two factors (Douglas sinus fluid and appendicolith) and 11.1% (1/9) for patients with two factors (Douglas sinus fluid and body temperature ≥ 37.3 °C). A temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid on CT might be clinical risk factors of resistance to conservative treatment for acute appendicitis.

Pain in Right Fossa Iliac, Anorexia and Fever as the Only Data in Acute Appendicitis

To investigate the clinical outcome in patients with a diagnosis of appendicitis at computed tomography (CT) in whom treatment is deemed unnecessary after clinical evaluation. After institutional review board approval, 2283 patients (856 men, 1427 women; mean age, 46 years; age range, 18-99 years) who underwent CT because they were suspected of having appendicitis between 2002 and 2007 were retrospectively identified. CT reports were reviewed, and the likelihood of appendicitis was assigned a score on a five-point scale: score 1, definitely absent; score 2, nonvisualized appendix with no secondary signs of inflammation; score 3, equivocal; score 4, probable; and score 5, definitely present. Diagnosis of appendicitis at CT was considered a false-positive result if the CT report was classified as probable or definite appendicitis but the patient was not treated within 4 days. Cases with false-positive results were reviewed by two readers blinded to patient outcome, supporting clinical data, and prospective scan interpretation, and a grade was assigned by using the same scale. Medical records were reviewed to determine outcomes. Descriptional statistics were used. Overall, 516 (23%) of 2283 patients had CT findings of probable or definite appendicitis. Thirteen (3%) of 516 patients did not receive immediate treatment for appendicitis. Of these, five (38%; 95% confidence interval: 18%, 65%) underwent later appendectomy with proved appendicitis after a mean interval of 118 days (range, 5-443 days). Seven (54%) of 13 patients never developed appendicitis across a mean follow-up of 583 days (range, 14-1460 days). One (8%) of 13 had a normal appendix at eventual surgery. Five of 13 patients with CT findings of appendicitis and reassuring clinical evaluation results in whom immediate treatment was deferred ultimately returned with appendicitis. In patients with CT results positive for appendicitis and benign or atypical clinical findings, a diagnosis of chronic or recurrent appendicitis may be considered.

To the Editor,We have read the article that is published by Kirkil et al. (1) with a great deal and interest. They have brought up nonoperative treatment of uncomplicated appendicitis versus appendectomy. Although nonsurgical treatment of acute appendicitis is an unsatisfied method for sur-geons we have analyzed the article particularly. We want to emphasize some subjects that must be explained.Appendicitis is one of the most common surgical dis-eases. The lifetime risk of the acute appendicitis is re-ported nearly 7% (2). Although nonoperative treatment of acute appendicitis looks like alternative to surgery it is not recognized by majority of surgeons. Nowadays laparoscopic appendectomy even single vs. multiple port is investigated.Apurva et al. reported the rate of diagnosis of appen-diceal adenocarcinoma who had previous diagnose as 3.1%. Although authors performed colonoscopy in suspected patients that must be in mind the success of colonoscopy with appendiceal malignancy is low. Also the criteria to perform colonoscopy are not well de-fined. As authors underlined; there is not enough data and study about this. In our opinion there must be cost analyze of operative versus nonoperative treatment of noncomplicated ap-pendicitis to support nonoperative treatment as an ef-fective method. Preoperative diagnosis, medical treat-ment, hospital charges during follow up period and in case of need unavoidable surgery compose the cumu-lative cost of nonoperative treatment of noncompli-cated appendicitis (3). Early noncomplicated acute ap-pendicitis has lower cost according to the complicated appendicitis. Effective surgery could prevent increase of hospital cost (4). However Kirkil et al. indicated that nonoperative treat-ment of noncomplicated acute appendicitis is an effec-tive treatment method we believe that a diagnostic al-gorithm must be used during diagnosis and treatment of acute appendicitis.

Acute Appendicitis in Infants: Still a Diagnostic Dilemma

BackgroundAppendectomy is considered the gold standard treatment for acute appendicitis. Recently the need for surgery has been challenged in both adults and children. In children there is growing clinician, patient...

Appendectomy is the gold standard for treatment of acute appendicitis. However, recent studies favor primary antibiotic therapy. The aim of this observational study was to explore changes in the numbers of operations for acute appendicitis in the period 2010-2017, paying special attention to disease severity. Data from diagnosis-related group statistics were used to analyze the trends, mortality, and complication rates in the surgical treatment of appendicitis in Germany between 2010 and 2017. All cases of appendectomy after a diagnosis of appendicitis were included. Altogether, 865 688 inpatient cases were analyzed. The number of appendectomies went down by 9,8%, from 113 614 in 2010 to 102 464 in 2017, while the incidence fell from 139/100 000 in 2010 to 123/100 000 in 2017 (standardized by age group). This decrease is due to the lower number of operations for uncomplicated appendicitis (79 906 in 2017 versus 93 135 in 2010). Hospital mortality decreased both in patients who underwent surgical treatment of complicated appendicitis (0.62% in 2010 versus 0.42% in 2017) and in those with a complicated clinical course (5.4% in 2010 versus 3.4% in 2017). Decisions on the treatment of acute appendicitis in German hospitals follow the current trend towards non-surgical management in selected patients. At the same time, the care of acute appendicitis has improved with regard to overall hospital morbidity and hospital mortality.

Acute appendicitis is a common surgical emergency. It is commonly caused by obstruction of the appendiceal lumen due to fecaliths, tumors, or lymphoid hyperplasia. For over a century, appendectomy has been the primary treatment for acute appendicitis. Abraham Groves performed the first open appendectomy in 1883. In 1983, Kurt Semm completed the first laparoscopic appendectomy, heralding a new era in appendectomy. However, appendectomy is associated with certain complications and a rate of negative appendectomies. Studies have suggested controversy over the impact of appendectomy on the development of inflammatory bowel disease and Parkinson's disease, but an increasing number of studies indicate a possible positive correlation between appendectomy and colorectal cancer, gallstones, and cardiovascular disease. With the recognition that the appendix is not a vestigial organ and the advancement of endoscopic te-chnology, Liu proposed the endoscopic retrograde appendicitis therapy. It is an effective minimally invasive alternative for treating uncomplicated acute appendicitis. Our team has developed an appendoscope with a disposable digital imaging system operated through the biopsy channel of a colonoscope and successfully applied it in the treatment of appendicitis. This article provides an overview of the progress in endoscopic treatment for acute appendicitis and offers a new perspective on the future direction of appendiceal disease treatment.