True Incidence of Appendiceal Neoplasms in Patients Presenting with Complicated Appendicitis: A Call for a Revised Management Algorithm.

Appendiceal neoplasms (ANs) are rare, with an estimated incidence of around 1%: neuroendocrine tumours (NETs) and low-grade appendiceal mucinous neoplasms (LAMNs) comprise most cases. Most tumours are cured by appendectomy alone, although some require right hemicolectomy and intra-operative chemotherapy. The aim of the present study is to evaluate our institution's experience in terms of the prevalence of AN, their histological types, treatment and outcomes in adult patients undergoing emergency appendectomy. Single-centre retrospective cohort analysis of patients treated for acute appendicitis at a large academic medical centre. Patients with a diagnosis of acute appendicitis (AA) where further compared with patients with acute appendicitis and a histologically confirmed diagnosis of appendiceal neoplasm (AN). A diagnosis of acute appendicitis was made in 1200 patients. Of these, 989 patients underwent emergency appendectomy. The overall incidence of appendiceal neoplasm was 9.3% (92 patients). AN rate increased with increasing age. Patients under the age of 30 had a 3.8% (14/367 patients) rate of occult neoplasm, whereas patients between 40 and 89years and older had a 13.0% rate of neoplasm. No difference was found in clinical presentations and type of approach while we found a lower complicated appendicitis rate in the AN group. ANs are less rare with respect to the literature; however, clinically, there are no specific signs of suspicious and simple appendicectomy appears to be curative in most cases. However, age plays an important role; older patients are at higher risk for AN. ANs still challenge the non-operative management concept introduced into the surgical literature.

Interval appendectomy or non-operative management is commonly performed for complicated appendicitis in adult patients. However, these treatments are still controversial because the incidence rate of appendiceal tumors recognized after interval appendectomy is reportedly higher than that after emergency appendectomy. Thus, this study aimed to compare the appendiceal tumor rates between uncomplicated and complicated appendicitis. This study was a retrospective review of patients with appendicitis who underwent surgical removal at a single institution over 7.5years. The primary objective was the comparison of the incidence rate of appendiceal tumors using propensity score matching, and the secondary objective was the same comparison among older patients, defined as patients aged ≥ 60years. A total of 1277 patients were included. Of these patients, 297 (23.3%) were preoperatively diagnosed with complicated appendicitis. Moreover, 22 (1.7%) patients, including 14 cases of complicated appendicitis and 8 cases of uncomplicated appendicitis, were diagnosed with appendiceal tumors based on pathological examination. No significant difference was found in the incidence rate of appendiceal tumors between the two groups after matching for patients' background, including age, sex, and history of appendicitis by propensity score matching (P = 0.073). However, among patients aged ≥ 60years, the incidence of appendiceal tumors was significantly higher in complicated than in uncomplicated appendicitis (P = 0.006). Although the overall risk of appendiceal tumors did not differ between complicated and uncomplicated appendicitis when analyzed by the propensity score matching, in older patients aged ≥ 60years, the risk increased among those with complicated appendicitis. Therefore, although the incidence is low, complicated appendicitis, particularly, among older patients, should be examined carefully and be performed IA when unusual findings exist.

Non-operative management of acute uncomplicated appendicitis has shown promising results but might carry the risk of delayed diagnosis of premalignant or malignant appendiceal tumors found by chance in 0.7-2.5% of appendiceal specimen after appendectomy. Purpose of this study was to analyze whether appendiceal tumors are associated with a complicated appendicitis and to determine risk factors for appendiceal neoplasm and malignancy in patients with acute appendicitis. We performed a retrospective analysis of 1033 adult patients, who underwent appendectomy for acute appendicitis from 2010 to 2016 at the University hospital Erlangen. Data included patients' demographics; comorbidities; pre-, intra- and postoperative findings; and histopathological results. Complicated appendicitis was defined in the presence of perforation or abscess. Appendiceal neoplasm respectively malignancy rate was 2.8% respectively 1.5%. Using univariate analysis, we identified seven risk factors at least for appendiceal neoplasm or malignancy: age, ASA, C-reactive protein, appendiceal diameter, perforation, intraoperative perithyphilitic abscess, and complicated appendicitis. Risk for appendiceal neoplasm or malignancy was 4.4% respectively 2.7% in complicated acute appendicitis compared to 2.0% respectively 1.0% in uncomplicated appendicitis (p = 0.043 respectively p = 0.060). In multivariate analysis, age ≥ 50years and a diameter of the appendix in the sonography ≥ 13mm were independent risk factors predicting the presence of appendiceal neoplasm and malignancy. Among patients with appendicitis, there are relevant risk factors predicting appendiceal tumors, especially age and appendiceal diameter in sonography. But the identified risk factors have a low sensitivity and specificity, so obtaining a confident preoperative diagnosis is challenging.

IntroductionStudies evaluating the rate and histology of appendiceal neoplasms between complicated and uncomplicated appendicitis include a small number of patients. Therefore, we sought a meta-analysis and systematic review comparing the rates and types of appendiceal neoplasm between complicated and uncomplicated appendicitis.MethodsWe included articles published from the time of inception of the datasets to September 30, 2022. The electronic databases included English publications in Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, and Scopus.ResultsA total of 4962 patients with appendicitis enrolled in 4 comparative studies were included. The mean age was 43.55 years (16- 94), and half were male (51%). Based on intra-operative findings, 1394 (38%) had complicated appendicitis, and 3558 (62%) had uncomplicated appendicitis. The overall incidence rate of neoplasm was 1.98%. No significant difference was found in the incidence rate of appendiceal neoplasm between complicated (3.29%) and uncomplicated (1.49%) appendicitis (OR 0.44, 95% CI 0.16- 1.23; p < 0.087; I2 = 54.9%). The most common appendiceal neoplasms were Neuroendocrine Tumors (NET) (49.21%), Nonmucinous Adenocarcinoma (24.24%), Mixed Adeno-Neuroendocrine Tumor (MANEC) (11.40%), Mucinous Adenocarcinoma (4.44%). There was a significant difference between complicated and uncomplicated appendicitis in rates of adenocarcinoma (50% vs. 13%), NET (31% vs. 74%), MANEC (19% vs. 13%) (P < 0.001).ConclusionWhile there was no significant difference in the overall neoplasm rate between complicated and uncomplicated appendicitis, the NET rate was significantly higher in uncomplicated appendicitis. In comparison, the Adenocarcinoma rate was considerably higher in Complicated appendicitis. These findings emphasize the importance of evaluating risk factors for neoplasm when considering appendectomy in patients with appendicitis.

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.

Introduction The purpose of this study is to evaluate the diagnostic value of C-reactive protein (CRP) to identify complicated appendicitis (defined as perforation, abscess or gangrenous appendicitis) versus simple appendicitis. Methods A retrospective study was performed in the emergency department (ED) of Prince of Wales Hospital in the New Territories of Hong Kong. The clinical records of patients admitted to the surgical wards via the ED over 17 months were reviewed by a research assistant. We included all patients aged &gt;13 years who had a provisional diagnosis of “acute appendicitis” or “right lower quadrant pain”. We excluded patients with pregnancy, previous appendicectomy, incomplete medical records or no CRP levels determined before operation and those who discharged themselves from hospital against medical advice after admission. The outcome of this study was the CRP level in relation to the presence of complicated appendicitis. ROC curve analysis was employed to identify the optimum cut-off level of CRP which had the best sensitivity and specificity to identify complicated appendicitis compared to simple appendicitis. Results Forty-two patients were diagnosed to have acute appendicitis, 31 of whom had complicated appendicitis. CRP level was higher in the group of complicated appendicitis (p&lt;0.05). We identified an optimum cut-off value for CRP of 40.1 mg/L to discriminate between complicated and non-complicated appendicitis. The sensitivity and specificity of CRP to identify complicated appendicitis were 71.0% and 100% respectively at this cut-off level. Conclusion High CRP levels could possibly predict the diagnosis of complicated appendicitis and facilitate more appropriate surgical care. This finding needs to be confirmed in prospective and larger multicentre studies. (Hong Kong j.emerg.med. 2014;21:354-360)

Introduction Acute appendicitis is the most common surgical emergency. Early detection of patients with complicated appendicitis leads to prompt surgical management and better outcome. This study investigated the relationship between the severity of acute appendicitis and the presence of preoperative hyponatremia. Materials and Methods We retrospectively reviewed the medical files of adult patients operated on for acute appendicitis over a 6-year period. Hyponatremia was defined as serum sodium level of ≤135 mEq/L. Patients were classified into complicated appendicitis and noncomplicated appendicitis according to operative findings and/or histopathology reports. Results A total of 129 patients were identified and included in this study. Complicated appendicitis was found more frequently in female patients and older patients. Hyponatremia was found significantly more frequently in patients with complicated appendicitis (p < 0.001) and also in patients with perforation than without perforation (p=0.047). Conclusions The present study demonstrated that preoperative hyponatremia is associated with complicated appendicitis. Serum sodium levels, a routine, low-cost laboratory test, could act as an accessory marker aiding surgeons in earlier identification of gangrenous or perforated acute appendicitis.

PurposeAppendicoliths are one of the important causes of acute appendicitis. Currently, there is no consensus on the relationship between appendicoliths and complicated appendicitis, and opinions on the treatment of appendicolith-associated appendicitis vary. This study aims to determine the significance of appendicolith in acute complicated appendicitis and to assess the characteristics of appendicoliths and Computed tomography (CT) features associated with complicated appendicitis.MethodsA retrospective analysis was conducted on patients who underwent surgical treatment for acute appendicitis at the affiliated hospital of Qingdao University from January 2016 to October 2023. Acute appendicitis was classified into two groups with and without appendicolith based on CT findings, intraoperative observations, and postoperative pathology. The clinical data of the two groups were analyzed and compared. Further subgroup analysis was performed within the appendicolith group based on pathological findings, comparing the location, size, and number of appendicoliths, as well as the length, diameter, and CT features of the appendix.ResultsAmong 331 patients with acute appendicitis, 179 had appendicolith, of which 106 were complicated appendicitis and 73 were uncomplicated appendicitis. Among 152 patients without appendicolith, 44 had complicated appendicitis and 108 had uncomplicated appendicitis. appendicoliths were independently associated with complicated appendicitis (OR = 1.88, 95% CI: 1.04–3.40, p = 0.036). In patients with appendicolith appendicitis, three factors were independently associated with complicated appendicitis: appendiceal diameter (OR = 1.20; 95% CI: 1.03–1.40), moderate-severe fat stranding (OR = 17.61; 95% CI: 3.19–97.33), and periappendiceal air (OR = 9.78; 95% CI: 1.17–81.46).ConclusionAppendiceal appendicoliths are closely related to acute complicated appendicitis. The diameter of the appendix and moderate-severe fat stranding, periappendiceal air on CT are significant indicators for identifying complicated appendicitis in acute appendicitis with appendicolith.

Background: Acute appendicitis in the pediatric population remains a diagnostic challenge for clinicians. Despite many biochemical markers, imaging modalities and scoring systems, initial misdiagnosis and complication rates are high in children. This suggests the need for investigations directed towards new diagnostic tools to aid in the diagnosis. Recent studies have shown a correlation between serum sodium levels and complicated appendicitis. Although the exact reasons for hyponatremia in patients with complicated appendicitis are not known, there is persuasive data to support the role of pro-inflammatory cytokines such as IL-6 in the non-osmotic release of antidiuretic hormone. This meta-analysis aims to investigate all available data on hyponatremia as a diagnostic marker of complicated appendicitis in the pediatric population. Methods: The literature search was conducted by two independent investigators according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The scientific databases (PubMed, EMBASE, Web of Science, and Scopus) were systematically searched for relevant studies using the keywords (hyponatremia) AND (appendicitis) AND (children). The methodological quality was assessed using a validated scale, and RevMan 5.4 software was utilized for pooled analysis. Results: Seven studies were included in the final meta-analysis, five of which were retrospective. A total of 1615 and 2808 cases were distributed into two groups: group A with complicated appendicitis and group B with uncomplicated acute appendicitis, respectively. The studies compared serum sodium levels of patients among the groups. Pooling the data demonstrated significantly lower serum sodium levels in children with complicated appendicitis vs. the non-complicated appendicitis (WMD: −3.29, 95% CI = −4.52 to −2.07, p < 0.00001). The estimated heterogeneity among the included studies was substantial and statistically significant (I2 = 98%, p < 0.00001). Conclusion: The results of the present meta-analysis indicate that hyponatremia has potential to be utilized as a biochemical marker in the diagnosis of complicated appendicitis in the pediatric population. However, well designed prospective diagnostic efficiency studies are essential to consolidate the association between hyponatremia and complicated acute appendicitis.

IntroductionIt is important to promptly assess the severity of appendicitis since late diagnosis can proceed towards perforation, peritonitis and sepsis. The main objective of this study is to decipher the ability of CRP, TLC and neutrophils in acute appendicitis to predict complications and perforation in pediatric age group. MethodsThis cohort study was conducted in the Pediatric Surgery Department of Liaquat National Hospital, Karachi. It included all the patients diagnosed and operated on for acute appendicitis within the pediatric age group. ResultsThe median (IQR) age of study population was 9 (7–11) years, the majority of which fell into 6–12 years of age group with 70% males. Histopathology came out positive in 127 individuals. Out of those 127 patients, 45.9% (n = 62) had simple appendicitis and 48.1% (n = 65) had complicated appendicitis (n = 65), while 37 (27.4%) had shown perforation. The majority of individuals had suppurative appendicitis on histopathology (35.6%). On receiver operating characteristic (ROC) analysis, CRP has the highest specificity for complicated appendicitis and the highest positive likelihood ratio for both complicated and perforated appendicitis. ConclusionCRP was observed in our study to be an independent marker of severity in acute appendicitis.

The purpose of this study is to investigate the role of serum calprotectin (CP), lactoferrin (LF), and high-mobility group protein B1 (HMGB-1) levels and fecal CP and LF levels in differential diagnosis of acute uncomplicated appendicitis from other causes of abdominal pain and further from complicated appendicitis. Totally, 120 children were included grouped into 4 as: healthy controls, patients with right lower quadrant pain with other than surgical causes, patients with uncomplicated appendicitis, and patients with complicated appendicitis. Serum CP, LF, HMGB-1, C-reactive protein (CRP) levels, and white blood cell (WBC) count were studied as well as the fecal CP and LF levels. There was a statistically significant difference between control group and both uncomplicated and complicated acute appendicitis groups, regarding all parameters. In diagnosis of complicated acute appendicitis, area under curve (AUC) for fecal LF, serum CP, and serum HMGB-1 were determined as 1.00 and the cutoff level was determined as 25μg/g feces, 670ng/mL, and 30ng/mL, respectively. In differential diagnosis of uncomplicated and complicated AA, the most accurate parameter was fecal LF with an AUC of 0.977. At a 60μg/g cutoff value for this variable, sensitivity, specificity, and accuracy were 96.7, 93.3, and 95.0%, respectively. In conclusion, HMGB-1, calprotectin, and lactoferrin constitute novel markers in diagnosis of AA. Moreover, their levels may be helpful for the clinicians to judge about the severity of the condition. Larger studies are warranted to determine the diagnostic potential of HMGB-1, LF, and CP in AA diagnosis.

Fibrinogen as a Marker of Overall and Complicated Acute Appendicitis: A Systematic Review and Meta-Analysis

PurposeRecent studies have reported alarming appendiceal tumor rates associated with complicated acute appendicitis, especially in patients presenting with a periappendicular abscess. However, the data on histology of appendiceal tumors among acute appendicitis patients is limited, especially in patient cohorts differentiating between uncomplicated and complicated acute appendicitis. We have previously reported the association of increased appendiceal tumor prevalence with complicated acute appendicitis in this population-based study. The objective of this secondary analysis was to evaluate the association of both appendicitis severity and patient age with appendiceal tumor histology.MethodsThis nationwide population-based registry study (The Finnish Cancer Registry) was conducted from 2007 to 2013. All appendiceal tumors (n = 840) and available medical reports (n = 504) of these patients at eight study hospitals were previously evaluated, identifying altogether 250 patients with both acute appendicitis and appendiceal tumor.ResultsThe severity of acute appendicitis was significantly associated with more malignant tumor histology. The risk of adenocarcinoma or pseudomyxoma was significantly higher among patients with periappendicular abscess (OR 15.05, CI 95% 6.98–32.49, p < 0.001) and patients presenting with perforated acute appendicitis (OR 4.09, CI 95% 1.69–9.90, p = 0.0018) compared to patients with uncomplicated acute appendicitis. Similarly, patient age over 40 years was significantly associated with the risk of adenocarcinoma and pseudomyxoma (OR 26.46, Cl 95% 7.95–88.09, p < 0.001). Patient sex was not associated with a more malignant appendiceal tumor histology (p = 0.67).ConclusionMore malignant appendiceal tumor histology of adenocarcinoma or pseudomyxoma was significantly associated with patient age over 40 years and complicated acute appendicitis, especially periappendicular abscess.

Background: To research the perioperative significance of the simple laboratory test values on differentiating complicated acute appendicitis. Methods: The medical records of 216 acute appendicitis patients were examined retrospectively. Patients were divided into two groups according to pathological results (non-complicated (n=157) and complicated (n=59)). The demographic and clinical data, laboratory findings, length of hospital stay, and pathological results were compared between the two groups. Receiver operating characteristics (ROC) curves were performed to analyze the optimal cutoff value of numerical variables which were significantly differed between the group comparisons. Results: The preoperative data were similar in two groups except for age. The length of hospital stay (LOHS) was longer and total/direct bilirubin levels higher in the complicated group (p=0.002, p=0.002, and p=0.002, respectively. The lymphocyte level and amylase level were lower in the complicated group (p=0.02 and p=0.004, respectively). ROC curve analysis showed a cutoff values as follows: total bilirubin ≥0.89 mg/dL, direct bilirubin ≥0.43 mg/dL, lymphocyte≤1.63%, and amylase ≤46.5 U/L. Conclusion: Preoperative higher total and direct bilirubin levels are able to predict complicated appendicitis. Preoperative higher serum amylase levels should not have a place in the differential diagnosis of complicated appendicitis. This means that if serum amylase is elevated in a patient with doubted acute appendicitis, it does not suggest acute complicated appendicitis.

Background: Clinical care may be influenced by the ability to predict whether a patient has complicated appendicitis at the time of presentation. However, it is unclear whether prehospital or in-hospital factors are associated with complicated appendicitis. We also want to know if C-reactive protein (CRP) and procalcitonin (PCT) can be used as supporting factors for Alvarado Score associated with complex appendicitis. Objectives: The aim of this study is to know the possibility of adding CRP and PCT to support the diagnostic protocol for differentiating between complicated acute appendicitis and noncomplicated acute appendicitis by knowing the sensitivity and specificity of each of them, as well as knowing which is more acceptable to add to the diagnostic protocol. Materials and Methods: A cross-sectional study was carried out in the Emergency Unit at AL-Hilla Teaching Hospital in Babylon province, Hilla city, between October 2021 and January 2022. There were a total of 90 patients; CRP and PCT were measured for patients by enzyme-linked immunosorbent assay method, in addition to knowing their Alvarado score. SPSS software was used to conduct the statistical analysis. Results: At the time of surgery, 34 (40%) of the 90 patients had complicated appendicitis, whereas 54 (60%) without complication. The age and gender of the groups did not show any significant difference. The Alvarado score, CRP, and PCT levels all showed a significant difference (P &lt; 0.05). The correlation between Alvarado score and biochemical parameters (CRP and PCT) show a significant positive correlation. Conclusions: CRP and PCT support Alvarado score to differentiate between complicated acute appendicitis and noncomplicated acute appendicitis, and this is evident from the significantly higher concentrations of both in patients with complicated acute appendicitis than in patients with noncomplicated acute appendicitis.