Ayurvedic Management of Acute Appendicitis: A Case Report.

Background: Identification of complicated and uncomplicated acute appendicitis is important in children. In acute appendicitis, along with clinical evaluation and staging, many laboratory tests have been used. The aim of the study was to compare total leucocyte count in children with uncomplicated and complicated acute appendicitis in different age groups.Methods: Retrospective cohort study was performed in children who underwent appendicectomy, in a Government tertiary care institution between January 2017 and December 2018. 206 patients were divided into complicated and uncomplicated appendicitis. Total leucocyte count at time of admission was compared according to age. Unpaired t test and Chi-square test were used for statistical analysis.Results: There were 136 males and 70 females. 107 patients (51.94%) had complicated and 99 (48.06%) had uncomplicated appendicitis. Mean leucocyte count per µl in uncomplicated appendicitis was 18993±3540 in <5 years, 17155±3386 in 5-10 years and 15833±3613 in 10-15 years. The mean leucocyte count for complicated appendicitis was 19974±3658 in <5 years, 17727±4487 in 5-10 years and 17220±3411 in 10-15 years age group. In 10-15 years group, patients with complicated acute appendicitis had statistically significant higher values of mean total leucocyte count.Conclusions: Total leucocyte count can be used as marker of severity of acute appendicitis in children older than 10 years. In children with clinical suspicion of acute appendicitis, total leucocyte count >20000 per µl signifies complicated appendicitis in all age groups.

Appendiceal tumors are rare, but high neoplasm rates have been reported at interval appendectomy after periappendicular abscess. Non-operative management of uncomplicated acute appendicitis has shown promising results. The data on appendiceal tumor incidence and presentation among acute appendicitis patients is limited, especially in patient cohorts differentiating between uncomplicated and complicated acute appendicitis. Objective was to assess appendiceal tumor incidence and tumor association to appendicitis in patients with uncomplicated and complicated acute appendicitis. This nationwide population-based registry study was conducted from 2007 to 2013. The Finnish Cancer Registry and the National Institute for Health Registry were used to combine data on all appendiceal tumors and acute appendicitis diagnosis with medical reports evaluated at eight study hospitals. Altogether, 840 appendiceal tumors were identified, and out of these, 504 patient reports were reviewed, including 472 patients in this study. Tumor was diagnosed at appendectomy for suspected acute appendicitis in 276 patients (58%). In the whole study, histologically acute appendicitis and tumor were both present in 53% (n= 250), and out of these, 41% (n= 102) were complicated and 59% (n= 148) uncomplicated acute appendicitis. The associated tumor risk was significantly higher in complicated acute appendicitis compared with uncomplicated cases (3.24% vs. 0.87%, p< 0.001). Overall tumor prevalence among acute appendicitis patients was 1.24%. Appendiceal tumor prevalence in acute appendicitis was low. Tumor risk was significantly higher in complicated acute appendicitis compared with uncomplicated acute appendicitis. The risk of missed appendiceal tumors related to antibiotic therapy of uncomplicated acute appendicitis is very low.

Objectives: Acute appendicitis is the most common non-obstetric pathology requiring emergency surgery on pregnant women. The aim of the study is to show the effect of uncomplicated and complicated acute appendicitis on pregnancy. Methods: This study was conducted retrospectively at the Department of General Surgery of Konya City Hospital. Pregnant patients who underwent surgery for acute appendicitis from January 1, 2020, through December 31, 2021, were included in the study. The cases were divided into two groups as complicated and uncomplicated appendicitis and compared. The demographic, clinical, and laboratory findings of the patients were obtained by screening the patient files. The cases were divided into two groups as complicated and uncomplicated appendicitis and compared. Results: The study included 46 pregnant patients with a mean age of 25.9 years. The mean gestational age of the patients at the time of surgery was 16.5 weeks. Of the patients, 47.8% were in the first trimester. Open appendectomy was performed in 35 (76.1%) patients, and laparoscopic appendectomy in eight (17.4%). Seven (15.2%) appendicitis cases were complicated. A negative appendectomy was performed in two (4.3%) patients. Preterm labor was seen at a rate of 28.6% in the complicated appendicitis group and 5.1% in the uncomplicated appendicitis group (p = 0.04), and the mean operative times were 65.8 and 46.1 minutes, respectively (p &amp;lt; 0.001). Conclusions: Both postoperative complications due to surgery and obstetric complications increase in patients with complicated appendicitis; therefore, it is particularly important to closely follow up these cases.

Operative Outcomes of Patients With Recurrent Uncomplicated Appendicitis are Similar to Patients With Acute Uncomplicated Appendicitis.

Is preoperative distinction between complicated and uncomplicated acute appendicitis feasible without imaging?

Treatment strategies for acute uncomplicated appendicitis have evolved and now conservative antibacterial treatment is recommended over surgical treatment, especially for paediatric patients. The aim of this study was to evaluate microbiota in paediatric patients with acute uncomplicated and complicated appendicitis, and antibacterial susceptibility of the causative microorganisms. Bacteriological identification was conducted using the VITEK2 analyser. Antibacterial susceptibility tests were performed and the results were evaluated in accordance with the recommendations of the European Committee on Antimicrobial Susceptibility Testing (EUCAST) “Clinical breakpoints and dosing of antibiotics” (Version 7.0, January 2019). Serodiagnosis of Yersinia enterocolitica was performed using indirect haemagglutination. The results revealed differences in microbiota in cases of acute complicated and acute uncomplicated appendicitis. Pseudomonas aeruginosa was identified more frequently in cases of acute complicated appendicitis. Mixed culture was prevalent in cases of both acute complicated and acute uncomplicated appendicitis. Very few positive extended spectrum beta-lactamase (ESBL) Escherichia coli cultures were identified. Most of strains of Pseudomonas aeruginosa were resistant to amoxicillin with clavulanic acid, ertapenem, ampicillin and cefotaxime. Some of E. coli isolates were resistant to ampicillin and to amoxicillin with clavulanic acid.

Uncomplicated acute appendicitis has been managed traditionally by early appendicectomy. However, recently, there has been increasing interest in the potential for primary treatment with antibiotics, with studies finding this to be associated with fewer complications than appendicectomy. The aim of this study was to compare outcomes of antibiotic therapy with appendicectomy for uncomplicated acute appendicitis. This meta-analysis of randomised controlled trials included adult patients presenting with uncomplicated acute appendicitis treated with antibiotics or appendicectomy. The primary outcome measure was complications. Secondary outcomes included treatment efficacy, hospital length of stay (LOS), readmission rate and incidence of complicated appendicitis. Five randomised controlled trials with a total of 1430 participants (727 undergoing antibiotic therapy and 703 undergoing appendicectomy) were included. There was a 39% risk reduction in overall complication rates in those treated with antibiotics compared with those undergoing appendicectomy (RR 0.61, 95% CI 0.44-0.83, p=0.002). There was no significant difference in hospital LOS (mean difference 0.25days, 95% CI -0.05 to 0.56, p=0.10). In the antibiotic cohort, 123 of 587 patients initially treatedsuccessfully with antibiotics were readmitted with symptoms suspicious of recurrent appendicitis. The incidence of complicated appendicitis was not increased in patients who underwent appendicectomy after "failed" antibiotic treatment (10.8%) versus those who underwent primary appendicectomy (17.9%). Increasing evidence supports the primary treatment of acute uncomplicated appendicitis with antibiotics, in terms of complications, hospital LOS and risk of complicated appendicitis. Antibiotics should be prescribed once a diagnosis of acute appendicitis is made or considered.

This study aimed to investigate the predictive power of serum systemic inflammatory markers including neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-eosinophil ratio (MER), and C-reactive protein (CRP) levels for distinguishing uncomplicated and complicated acute appendicitis in adult patients admitted to the emergency department (ED). This retrospective, cross-sectional, observational, and single-center study enrolled 212 consecutive adult patients with acute appendicitis who were admitted to the ED of our tertiary care university hospital between January 1, 2019 and December 31 2021. Patients were divided into two groups (Group I, uncomplicated acute appendicitis; Group II, complicated appendicitis) according to their surgical findings and histopathological examination. Systemic inflammatory markers measured on admission were compared among patients to identify factors associated with complicated acute appendicitis. A total of 132 patients, 83 male (62.9%) and 49 female (37.1%), were included in the study. The mean age was 34.7±13.40 years. Based on the histopathological examination, the number of patients in Group I was 103 (78.03%) and 29 (21.96%) in Group II. Laboratory findings on admission revealed no significant differences between Groups I and II patients in terms of mean serum NLR, MER, and CRP values (p=0.096, p=0.248, and p=0.297, respectively). However, the mean serum PLR in Group II patients was statistically significantly higher than those in Group I (p=0.032). The mean serum monocyte and monocyte fraction (%) values were significantly lower, and the mean serum neutrophil fraction (%) value was higher in Group II patients compared to those with Group I. Receiving operator characteristic (ROC) analysis identified a serum PLR cutoff value of ≥133.73 for distinguishing uncomplicated and complicated acute appendicitis in adult patients, with 60% sensitivity and 58.4% specificity. In addition, ROC analysis revealed a cutoff monocyte fraction (%) level of ≤6, with 72% sensitivity and 64% specificity, for distinguishing uncomplicated and complicated acute appendicitis in adult patients. Our findings indicate that the mean serum NLR, MER, and CRP values measured on admission to ED in adult patients with acute appendicitis could not predict complicated acute appendicitis. However, mean serum PLR and neutrophil and monocyte counts can be useful in distinguishing complicated cases.

While patients with acute uncomplicated appendicitis may be treated conservatively, those who suffer from complicated appendicitis require surgery. We describe a logistic regression equation to calculate the likelihood of acute uncomplicated appendicitis and complicated appendicitis in patients presenting to the emergency department with suspected acute appendicitis. A cohort of 895 patients who underwent appendicectomy were analysed retrospectively. Depending on the final histology, patients were divided into three groups; normal appendix, acute uncomplicated appendicitis and complicated appendicitis. Normal appendix was considered the reference category, while acute uncomplicated appendicitis and complicated appendicitis were the nominal categories. Multivariate and univariate regression models were undertaken to detect independent variables with significant odds ratio that can predict acute uncomplicated appendicitis and complicated appendicitis. Subsequently, a logistic regression equation was generated to produce the likelihood acute uncomplicated appendicitis and complicated appendicitis. Pathological diagnosis of normal appendix, acute uncomplicated appendicitis and complicated appendicitis was identified in 188 (21%), 525 (59%) and 182 patients (20%), respectively. The odds ratio from a univariate analysis to predict complicated appendicitis for age, female gender, log2 white cell count, log2 C-reactive protein and log2 bilirubin were 1.02 (95% confidence interval, CI, 1.01, 1.04), 2.37 (95% CI 1.51, 3.70), 9.74 (95% CI 5.41, 17.5), 1.57 (95% CI 1.40, 1.74), 2.08 (95% CI 1.56, 2.76), respectively. For the same variable, similar odds ratios were demonstrated in a multivariate analysis to predict complicated appendicitis and univariate and multivariate analysis to predict acute uncomplicated appendicitis. The likelihood of acute uncomplicated appendicitis and complicated appendicitis can be calculated by using the reported predictive equations integrated into a web application at www.appendistat.com. This will enable clinicians to determine the probability of appendicitis and the need for urgent surgery in case of complicated appendicitis.

2412 Cost effectiveness analysis of operative Versus antibiotic management for uncomplicated appendicitis

Appendectomy has historically been the standard treatment of acute appendicitis, but lately, conservative treatment of uncomplicated acute appendicitis with antibiotics has successfully been used in selected patients. Complicated acute appendicitis is often treated conservatively initially, but may benefit from interval appendectomy due to the higher risk of appendiceal malignancy and recurrence. Recommendations for follow-up after conservatively treated appendicitis vary. Furthermore, the risk of underlying malignancy and the necessity of routine interval appendectomy are unclear. This study aims to evaluate follow-up status, recurrence, and underlying appendiceal malignancy in conservatively treated uncomplicated and complicated acute appendicitis. This study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and data on follow-up, recurrence, number of appendectomies after initial conservative treatment, and underlying malignancy were retrieved from medical charts. The study cohort included 391 patients, 152 with uncomplicated and 239 with complicated acute appendicitis. Median time of study follow-up was 52 months. The recurrence risk was 23 (15.1%) after uncomplicated and 58 (24.3%) after complicated acute appendicitis (p = 0.030). During follow-up, 55 (23%) patients with complicated acute appendicitis underwent appendectomy. Appendiceal malignancies were found in 12 (5%) patients with previous complicated acute appendicitis versus no appendiceal malignancies after uncomplicated acute appendicitis (p = 0.002). The risk of appendiceal malignancy and recurrent appendicitis was significantly higher in patients with complicated acute appendicitis compared with uncomplicated acute appendicitis.

More than a century after its introduction, appendectomy has remained the gold standard treatment for acute appendicitis. In adults with acute uncomplicated appendicitis, nonoperative management (NOM) has been shown to be a viable treatment option. To date, there has been relatively limited data on the nonoperative management of acute appendicitis in the pediatric population. The primary objective of this study was to systematically review the available literature in the pediatric population and compare the efficacy and recurrence between initial nonoperative treatment strategy and appendectomy in children with uncomplicated appendicitis. In July 2021, we conducted systematic searches of the PubMed and Google Scholar databases. We only included full-text comparative original studies published within the last decade, and we excluded articles that solely examined NOM without comparing it to appendectomy. Two writers worked independently on the data collection and analysis. It was found that NOM had a high initial success rate and a low rate of recurrent appendicitis. After months of follow-up, the vast majority of patients with uncomplicated acute appendicitis who received initial nonoperative treatment did not require surgical intervention. Furthermore, the rate of complication was comparable in both treatment groups, and NOM did not appear to be associated with an increased risk of complications. The most significant drawback stemmed from the fact that the included articles in this study had a wide range of study designs and inclusion criteria. According to current evidence, NOM is feasible and cost-effective. Antibiotic therapy can be given safely in a small subset of individuals with uncomplicated appendicitis. To optimize outcomes, physicians should evaluate the clinical presentation and the patient's desire when selecting those to be managed nonoperatively. Again, more research, preferably large randomized trials, is required to compare the long-term clinical efficacy of NOM with appendicectomy. Finally, additional research is required to establish the characteristics of patients who are the best candidates for nonoperative treatment.

There is still controversy regarding the ideal technique to close the appendicular stump in laparoscopic appendectomy (LA). The objective of this study was to determine the safety and efficiency of the use of an endoloop (EL) and endostapler (ES) in complicated and uncomplicated acute appendicitis. Retrospective cohort study of patients undergoing LA from February 2013 to December 2019. Acute uncomplicated and complicated appendicitis were analysed separately, establishing two groups according to the stump closure technique: EL or ES. Seven hundred-nine patients were included (535 uncomplicated and 174 complicated). In uncomplicated appendicitis, an EL was used in 447 of the patients (83.55%) and an ES was used in 88 patients (16.45%). In complicated appendicitis, an EL was used in 85 patients (48.85%) and an ES was used in 89 patients (51.15%). An analysis of effectiveness and a cost analysis of each technique were performed. In uncomplicated appendicitis, we found no differences with respect to global complications, although there were significant differences in the total mean hospital stay (EL group 1.55 (SD 1.48) days; ES group 2.21 (SD 1.69) days; p = 0.046). This meant a savings of 514.12€ per patient using the EL p < 0.001). In complicated appendicitis, the reoperations classified as Clavien-Dindo IIIB in the EL group (6.4%) were greater than in the ES group (0%) (p = 0.012), although the rate of postoperative abscesses (p = 0.788) and the mean volume of abscesses (p = 0.891) were similar. The systematic use of an EL could reduce costs in uncomplicated appendicitis, while in complicated cases, both options are valid. Prospective studies with a greater number of patients are needed to observe differences in postoperative complications.

An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis. To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography (CT). The Appendicitis Acuta (APPAC) multicenter, open-label, noninferiority randomized clinical trial was conducted from November 2009 until June 2012 in Finland. The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan. Patients were randomly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period. Patients randomized to antibiotic therapy received intravenous ertapenem (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day). Patients randomized to the surgical treatment group were assigned to undergo standard open appendectomy. The primary end point for the surgical intervention was the successful completion of an appendectomy. The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period. There were 273 patients in the surgical group and 257 in the antibiotic group. Of 273 patients in the surgical group, all but 1 underwent successful appendectomy, resulting in a success rate of 99.6% (95% CI, 98.0% to 100.0%). In the antibiotic group, 70 patients (27.3%; 95% CI, 22.0% to 33.2%) underwent appendectomy within 1 year of initial presentation for appendicitis. Of the 256 patients available for follow-up in the antibiotic group, 186 (72.7%; 95% CI, 66.8% to 78.0%) did not require surgery. The intention-to-treat analysis yielded a difference in treatment efficacy between groups of -27.0% (95% CI, -31.6% to ∞) (P = .89). Given the prespecified noninferiority margin of 24%, we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery. Of the 70 patients randomized to antibiotic treatment who subsequently underwent appendectomy, 58 (82.9%; 95% CI, 72.0% to 90.8%) had uncomplicated appendicitis, 7 (10.0%; 95% CI, 4.1% to 19.5%) had complicated acute appendicitis, and 5 (7.1%; 95% CI, 2.4% to 15.9%) did not have appendicitis but received appendectomy for suspected recurrence. There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients randomized to antibiotic treatment. Among patients with CT-proven, uncomplicated appendicitis, antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy. Most patients randomized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period, and those who required appendectomy did not experience significant complications. clinicaltrials.gov Identifier: NCT01022567.

Importance An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis. Objective To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography (CT). Design, Setting, and Participants The Appendicitis Acuta (APPAC) multicenter, open-label, noninferiority randomized clinical trial was conducted from November 2009 until June 2012 in Finland. The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan. Patients were randomly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period. Interventions Patients randomized to antibiotic therapy received intravenous ertapenem (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day). Patients randomized to the surgical treatment group were assigned to undergo standard open appendectomy. Main Outcomes and Measures The primary end point for the surgical intervention was the successful completion of an appendectomy. The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period. Results There were 273 patients in the surgical group and 257 in the antibiotic group. Of 273 patients in the surgical group, all but 1 underwent successful appendectomy, resulting in a success rate of 99.6% (95% CI, 98.0% to 100.0%). In the antibiotic group, 70 patients (27.3%; 95% CI, 22.0% to 33.2%) underwent appendectomy within 1 year of initial presentation for appendicitis. Of the 256 patients available for follow-up in the antibiotic group, 186 (72.7%; 95% CI, 66.8% to 78.0%) did not require surgery. The intention-to-treat analysis yielded a difference in treatment efficacy between groups of −27.0% (95% CI, −31.6% to ∞) ( P = .89). Given the prespecified noninferiority margin of 24%, we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery. Of the 70 patients randomized to antibiotic treatment who subsequently underwent appendectomy, 58 (82.9%; 95% CI, 72.0% to 90.8%) had uncomplicated appendicitis, 7 (10.0%; 95% CI, 4.1% to 19.5%) had complicated acute appendicitis, and 5 (7.1%; 95% CI, 2.4% to 15.9%) did not have appendicitis but received appendectomy for suspected recurrence. There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients randomized to antibiotic treatment. Conclusions and Relevance Among patients with CT-proven, uncomplicated appendicitis, antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy. Most patients randomized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period, and those who required appendectomy did not experience significant complications. Trial Registration clinicaltrials.gov Identifier:NCT01022567