Appendicoliths are recognized risk factors for complicated appendicitis and adverse surgical outcomes. However, current preoperative assessments lack a standardized method to evaluate appendicoliths beyond simply documenting their presence. This study aimed to develop and validate a CT-based appendicolith scoring system incorporating both location and morphological characteristics to predict postoperative outcomes in patients with acute appendicitis. We retrospectively analyzed 241 adult patients with acute appendicitis and radiologically confirmed to have appendicoliths who underwent appendectomy between August 2021 and December 2023. Two researchers, blinded to clinical outcomes, independently scored appendicoliths based on location (root = 3, mid-section = 2, tip = 1) and morphology (granular = 3, rod-shaped = 2, sediment-like = 1). Total scores (range 2-6) were calculated as the sum of the location score and the morphology score (Location + Morphology=Total), and inter-observer agreement was assessed. Patients were stratified into three groups: low-risk (2-3 points), intermediate-risk (4 points), and high-risk (5-6 points). Clinical characteristics, operative outcomes, and postoperative complications were compared across groups. Univariate regression and receiver operating characteristic (ROC) curve analyses were performed to evaluate the scoring system's predictive performance. The cohort comprised 130 males and 111 females (median age 35 years). Inter-observer agreement for the total score was excellent (κ = 0.937). High-risk patients (n = 129) demonstrated significantly larger appendiceal diameters compared with low-risk (n = 41) and intermediate-risk (n = 71) groups (P < 0.001), with a positive correlation between score and diameter (γ = 0.298, P = 0.003). High-risk patients also exhibited significantly longer hospital stays (median 7.0 vs. 6.0 days, P = 0.003), higher rates of prolonged flatus (> 48h, 58.9% vs. 40.9-43.9%, P = 0.030), and increased postoperative complications (14.7% vs. 4.2-4.9%, P = 0.043). Univariate analysis showed that the appendicolith severity grade was significantly associated with postoperative complications (Crude OR = 2.164, 95% CI: 1.014-4.617, P = 0.046). ROC analysis demonstrated moderate predictive utility for postoperative complications (AUC = 0.641, 95% CI: 0.533-0.748) and prolonged hospitalization (AUC = 0.636, 95% CI: 0.558-0.714), with an optimal cutoff of ≥ 4.5 points. This CT-based appendicolith scoring system provides a simple, reproducible, and clinically useful tool for preoperative risk stratification in acute appendicitis. Higher scores correlate with increased inflammatory severity, prolonged recovery, and an increased risk of postoperative complications, potentially guiding perioperative management decisions.

Child Opportunity and Severity of Pediatric Acute Appendicitis: A Statewide Analysis.

Acute appendicitis (AA) is a common cause of acute abdomen. Appendiceal base gangrene or perforation represents a severe form of complicated appendicitis, in which secure closure of the appendiceal stump is crucial for surgical management, and no standardized optimal strategy has yet been established. This study aimed to evaluate the safety and feasibility of laparoscopic endostapler partial cecal resection in patients with complicated appendicitis involving appendiceal base gangrene or perforation. A retrospective study was conducted on consecutive patients who underwent surgical treatment for appendicitis at our center between January 2021 and January 2025. Patients classified as Gomes grade 3B (appendiceal base gangrene or perforation) were identified based on intraoperative findings. Baseline characteristics and perioperative outcomes were collected. Exploratory analyses across appendicitis subtypes were performed to provide contextual information. A single-arm descriptive analysis was conducted in the Gomes grade 3B cohort. The primary outcomes were postoperative complications and readmission assessed over a 3-month follow-up period. A total of 785 patients were included in the analysis, including 484 with uncomplicated appendicitis and 301 with complicated appendicitis, of whom 277 did not involve the appendiceal base and 24 were classified as Gomes grade 3B. In the Gomes grade 3B cohort, all patients successfully underwent laparoscopic surgery without conversion to open surgery or intraoperative complications. The mean operative time was 123.33 ± 16.59min. The median time to oral intake was 3.0 days (2.5-3.0), and the median length of hospital stay was 5.0 days (5.0-5.0). Postoperative complications occurred in three patients (12.50%), all classified as Clavien-Dindo grade I-II. No severe complications (Clavien-Dindo grade III-V) or readmissions were observed during the 3-month follow-up period. Laparoscopic endostapler partial cecal resection showed technical feasibility and acceptable short-term safety in patients with complicated appendicitis with appendiceal base involvement. This technique may represent a potential surgical option for this specific patient population, although further studies are required.

The clinical presentation of acute appendicitis in elderly patients is often atypical, leading to delayed diagnosis and a substantially elevated risk of complicated appendicitis. This progression complicates treatment strategies and negatively impacts prognostic outcomes. Currently, there is a lack of simple and practical tools to help identify complicated appendicitis at presentation in elderly patients. The objective of this study was to investigate admission-time factors associated with complicated appendicitis in the elderly and to develop a model for admission-time identification/risk stratification. Clinical data from 288 elderly patients with acute appendicitis admitted to the General Surgery Department of Jiangsu Province (Suqian)Hospital, between January 2016 and December 2024 were retrospectively analyzed. Patients were categorized into a complicated appendicitis (CA) group (n = 117) and an uncomplicated appendicitis (UCA) group (n = 171) based on postoperative pathology. Univariate and multivariate logistic regression analyses were performed to identify independent predictors and to develop a risk-stratification model. Model performance was evaluated using the Hosmer-Lemeshow (H-L) test, calibration curves, and receiver operating characteristic (ROC) curves. Multivariate analysis showed that white blood cell count (WBC) ≥ 12.81 × 10⁹/L (OR = 2.78), lymphocyte count ≤ 0.955 × 10⁹/L (OR = 0.27), and C-reactive protein (CRP) ≥ 56.085mg/L (OR = 20.42) were independently associated with complicated appendicitis at admission. The constructed risk-stratification model exhibited an area under the curve (AUC) of 0.85, with a sensitivity of 81.2%, and a specificity of 84.8%. The H-L test indicated satisfactory model calibration (P = 0.933). The model based on admission WBC, lymphocyte count, and CRP showed good discriminatory ability for identifying complicated appendicitis in elderly patients at presentation. As an admission-time risk-stratification tool, it may assist clinical assessment and triage.

BACKGROUNDThis study aimed to investigate the role of the HALP (hemoglobin, albumin, lymphocyte, platelet) score and inflammatory biomarkers C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) in distinguishing between complicated and uncomplicated acute appendicitis.METHODSThis retrospective study was conducted between May and August 2024 at Ankara Etlik State Hospital and included patients diagnosed with acute appendicitis who were treated surgically. HALP score, CRP, NLR, and PLR were calculated using preoperative laboratory results. Patients were categorized into complicated and uncomplicated appendicitis groups based on intraoperative and histopathological findings. Statistical analyses included the independent samples t-test, Mann–Whitney U test, and chi-square test. A p-value <0.05 was considered statistically significant.RESULTSA total of 208 patients were analyzed. HALP scores were significantly lower in the complicated appendicitis group (4.6 vs. 5.8, p=0.002), while CRP levels were significantly higher (84.9 vs. 38.7 mg/L, p<0.001). NLR (7.0 vs. 6.9, p=0.091) and PLR (165 vs. 170, p=0.767) did not differ significantly between the groups.CONCLUSIONCRP and HALP score are useful parameters for predicting complicated appendicitis. The HALP score, reflecting both systemic inflammation and nutritional status, may serve as a novel and cost-effective tool in clinical assessment.

Preoperative prediction of complicated acute appendicitis using the appendicitis inflammatory response (AIR) score.

CRP/Albumin index as a predictor of complicated appendicitis: beyond clinical signs.

Non-operative management (NOM) of complicated appendicitis is increasingly accepted, but the role of interval appendicectomy (IA) remains contentious. Contemporary evidence has shifted decision-making from recurrence risk alone toward age-linked neoplasm risk and radiological features. To synthesise contemporary randomised trials, prospective cohorts, and meta-analyses on recurrence after NOM of periappendiceal abscess, appendiceal tumour prevalence, and the diagnostic performance and harms of surveillance strategies (cross-sectional imaging and colonoscopy), to inform a pragmatic risk-stratified framework. Recurrence after successful NOM is commonly reported at 12-24% and is concentrated within the first six months. In adults presenting with periappendiceal abscess, appendiceal tumour prevalence rises with age, reaching approximately 5-10% in patients aged 35-39 and 14-20% in cohorts of patients aged ≥40 years. Interval CT/MRI findings identify higher-risk patients in whom IA should be prioritised. Colonoscopy is best used selectively, particularly when caecal pathology is suspected, imaging is equivocal, or IA is not planned in older patients. Interval appendicectomy should generally be considered for patients aged ≥40 years and for any patient with persistent symptoms or concerning radiological findings, while recognising that decisions must be individualised with shared decision making. Younger patients with complete radiological resolution and no red-flag features can usually be observed with structured imaging follow-up. A risk-stratified clinical algorithm is proposed to guide post-NOM management.

Interval appendectomy practices for complicated appendicitis in children: a systematic review from the APSA Outcomes and Evidence-Based Practice Committee.

Background: Acute appendicitis is a common surgical emergency, and delay in presentation is a key factor contributing to disease progression and complications. The duration of symptoms plays an important role in determining whether appendicitis remains uncomplicated or progresses to a complicated form. Aim: To assess the prevalence of complicated and uncomplicated appendicitis based on the duration of symptoms at presentation. Materials and Methods: This hospital-based cross-sectional study was conducted at Meenakshi Medical College Hospital, Kanchipuram, over one year. A total of 50 patients with suspected acute appendicitis who underwent appendectomy were included. Patients were categorized based on duration of symptoms into &lt;24 hours, 24–48 hours, and &gt;48 hours. Intraoperative findings were used to classify appendicitis as uncomplicated or complicated. Statistical analysis was performed using SPSS, and a p value &lt; 0.05 was considered statistically significant. Results: Uncomplicated appendicitis was more common overall (56%), while 44% had complicated appendicitis. Patients presenting within 24 hours predominantly had uncomplicated appendicitis (88.9%), whereas those presenting after 48 hours had a significantly higher proportion of complicated appendicitis (83.3%) (p = 0.001). The mean duration of symptoms was significantly higher in complicated cases (46.8 ± 12.6 hours vs 22.6 ± 8.4 hours; p = 0.001). Postoperative complications were also more frequent in complicated cases (p = 0.03). Conclusion: Delayed presentation is strongly associated with complicated appendicitis. Early diagnosis and timely surgical intervention are essential to reduce complications and improve patient outcomes.

Background: Acute appendicitis is one of the most common surgical emergencies worldwide. This study aimed to evaluate the impact of disease severity and age on outcomes after laparoscopic versus open appendectomy and to identify predictors of prolonged hospitalization. Methods: A single-center retrospective cohort study was conducted at a tertiary emergency hospital, including 311 adult patients who underwent appendectomy between January 2020 and December 2024. The primary outcome was length of hospital stay (LOS), with prolonged hospitalization defined as LOS &gt; 7 days. Results: The study included 311 patients (mean age 43.3 ± 18.0 years; 58.5% male), of whom 38.6% had complicated appendicitis. Complicated appendicitis was associated with older age and longer hospitalization. The laparoscopic approach was associated with a significantly shorter LOS compared with the open approach (4.43 ± 2.62 vs. 5.68 ± 3.11 days, p &lt; 0.001). Increasing age independently predicted complicated appendicitis and prolonged hospitalization, while laparoscopy remained independently associated with reduced LOS after adjustment for measured confounders. No significant interaction was observed between surgical approach and disease severity. Conclusions: Disease severity and age are the main determinants of postoperative outcomes in acute appendicitis. Laparoscopic appendectomy was independently associated with shorter hospital stay after adjustment, although this association may be attenuated in more severe disease.

Optimal management of patients with acute complicated appendicitis remains debated. Traditional management often emphasized nonoperative treatment using antibiotics and, when necessary, percutaneous drainage. Growing evidence indicates that operative management may be safe in select patients. This study aimed to evaluate whether appendiceal stump size ≥2cm on preoperative CT scan is predictive of intraoperative complexity and postoperative outcomes. A multicenter retrospective review evaluated operative outcomes in patients with acute complicated appendicitis identified on preoperative imaging that were managed operatively from January 2018 to May 2024. Appendiceal stump length was measured on computed tomography (CT) by an attending acute care surgeon. The primary outcome was the need for extended resection. Secondary outcomes included conversion to open, readmission, length of stay (LOS), postoperative abscess, and mortality. One hundred fifty-two patients met the inclusion criteria: 98 had stump size ≥2cm, and 54 had stump length <2cm. Patients with stump size ≥2cm were more likely to have chronic kidney disease (0.0% vs. 9.9%, p=0.002). There were no other differences in baseline characteristics. Patients with stump size <2cm had a significantly increased risk of need for extended resection (OR=20.2, 95% CI: 4.43-92.15, p<0.001). They also had a significantly increased odds of conversion to open surgery (OR=5.9, 95% CI: 1.97-17.63, p<0.001). LOS was longer in patients with appendiceal stumps <2cm (mean 4.6±3.7d) compared with those with appendiceal stumps ≥2cm (3.0±2.3d, p=0.01). There was no difference in readmissions, postoperative abscess, or mortality. Appendiceal stump length ≥2cm was associated with significantly reduced risk of conversion to open and extended resection. These patients also had shorter LOS. Stump length on preoperative imaging may serve as a useful adjunct in operative planning for patients with acute complicated appendicitis. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). Original Research-Therapeutic/Care Management; Level III.

Two for One? Safety and Efficacy of Concomitant Hernia Repair During Pediatric Appendectomy.

Modified enhanced recovery after surgery protocol for pediatric complicated appendicitis in a Mexican tertiary hospital: a randomized clinical trial.

BackgroundAcute appendicitis ranges from mild inflammation to perforation. A clinically important subset of cases harbors an occult appendiceal neoplasm that is often indistinguishable from routine appendicitis preoperatively. Blood-derived inflammatory indices have been proposed as predictors of disease severity and malignancy. We evaluated the diagnostic value of platelet-to-lymphocyte ratio (PLR), systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), and CRP/SII for predicting complicated appendicitis and identifying neoplasms.MethodsWe conducted a 5-year retrospective study of 837 appendectomies at a tertiary surgical center. Preoperative clinical, laboratory, imaging, and histopathologic findings were analyzed. Appendicitis severity was classified according to WSES criteria. Diagnostic performance was assessed using logistic regression and receiver-operating characteristic (ROC) analysis.ResultsAppendiceal neoplasms were found in 1.1% of patients and were uniformly unsuspected intraoperatively. Neoplastic patients were significantly older (P < 0.001) and had higher PLR and SII (P < 0.001 and P = 0.005). PLR (AUC 0.868) and SII (AUC 0.770) showed the strongest discrimination between benign and malignant pathology. CRP/SII showed the best performance for complicated appendicitis (AUC 0.703). Age, PLR, and CRP/SII were independent predictors of neoplasm, while SII, PLR, and CRP/SII were independently associated with complicated disease.DiscussionAppendiceal neoplasms may present as clinically uncomplicated appendicitis. Simple inflammatory indices-particularly PLR and SII-were associated with both disease severity and hidden malignancy. These inexpensive and widely available markers may support early surgical decision-making in older or high-risk patients. Prospective validation is needed to define optimal thresholds and refine their role in preoperative triage.

Abstract Introduction: Acute appendicitis is among the most common surgical emergencies, with timely differentiation between simple and complicated forms being critical for management. Conventional diagnostic tools have limitations, prompting interest in inflammatory biomarkers such as the neutrophil-to-lymphocyte ratio (NLR). The aim of the study was to evaluate the diagnostic performance of neutrophil count, lymphocyte count and NLR in differentiating complicated from simple appendicitis and to correlate these findings. Subjects and Methods: This analytical cross-sectional study was conducted on 53 patients undergoing appendectomy at a tertiary care centre. Intraoperative findings and histopathology reports were recorded. Pre-operative complete blood counts were used to calculate neutrophil counts, lymphocyte counts and NLR. Patients were grouped into complicated and simple appendicitis for comparison. Descriptive statistics, independent samples t- test and receiver operating characteristic (ROC) analysis were applied. Results: Of 53 patients, 26 (49.1%) had complicated appendicitis, whereas 27 (50.9%) had simple appendicitis. Histopathology most frequently revealed acute perforative appendicitis with peritonitis (17%). Complicated cases demonstrated higher neutrophils (10,387.5 vs. 8572.9/μL), lower lymphocytes (1164.2 vs. 1656.2/μL; P = 0.005) and a significantly elevated NLR (9.51 vs. 5.59; P &lt; 0.001). ROC analysis showed fair discrimination for neutrophils (area under the curve [AUC] = 0.769), poor for lymphocytes (AUC = 0.231–0.766) and excellent for NLR (AUC = 0.920). Conclusion: The NLR demonstrated superior diagnostic performance over neutrophil or lymphocyte counts alone, emerging as a rapid, cost-effective biomarker for distinguishing complicated from simple appendicitis. Its incorporation into routine evaluation can improve early risk stratification and guide timely surgical intervention.

Short-course antibiotic (SCA) therapy after appendectomy for complicated appendicitis (CA) has gained increasing attention, but its safety and efficacy remain insufficiently supported by meta-analyses. This study aimed to evaluate whether SCA therapy is as safe and effective as conventional long-course antibiotic (LCA) therapy following appendectomy for CA. A comprehensive literature search was conducted to identify randomized controlled trials (RCTs) and observational studies comparing different durations of postoperative antibiotic therapy for CA. Data were analyzed using RevMan 5.3 for meta-analysis, and the GRADE approach was applied to assess the quality of evidence for key outcomes. Four RCTs and nine observational studies involving 3,251 patients were included. The meta-analysis revealed no significant increase in the risk of surgical site infection (SSI) (RR = 1.19, 95% CI: 0.52 to 2.73, P = 0.67, low-quality evidence) or intra-abdominal abscess (IAA) (RR = 1.18, 95% CI: 0.92 to 1.51, P = 0.19, moderate-quality evidence) with less than 3-day SCA therapy compared to LCA therapy. Secondary outcomes showed no significant differences between the two regimens (moderate to very-low quality evidence). However, SCA therapy was associated with a shorter length of hospital stay (low-quality evidence). For patients with CA, less than 3-day SCA therapy does not increase the risk of SSI or IAA. Moreover, reducing the duration of antibiotic use may help minimize unnecessary antibiotic consumption.

Abstract Introduction Acute appendicitis is a common surgical emergency, with complicated cases associated with higher risks of infection and morbidity. While preoperative antibiotics are well established, the optimal postoperative antibiotic regimen remains unclear, with significant variability in choice, route, and duration. This review evaluates recent evidence on postoperative antibiotic stewardship in complicated appendicitis. Methods This systematic review followed PRISMA guidelines and was registered with PROSPERO. A comprehensive search of PubMed and the Cochrane Library identified studies on postoperative antibiotic use following appendicectomy. Two independent reviewers screened studies, including RCTs, cohort studies, and observational studies. Data on study characteristics, interventions, and outcomes were extracted. Risk of bias was assessed using RoB 2 and ROBINS-I tools, and evidence certainty was graded using GRADE. Results Eleven studies involving 8361 participants were included. Short-course intravenous antibiotics were non-inferior to prolonged regimens in preventing infections and reducing hospital stays. Factors such as disease severity and surgical complexity influenced the need for extended antibiotic use. In selected cases, oral antibiotics were as effective as intravenous therapy. Conclusions Shorter intravenous antibiotic courses and early transition to oral antibiotics are effective in managing complicated appendicitis, leading to shorter hospital stays and reduced healthcare costs without increasing complications. Individualised treatment based on patient risk factors and intraoperative findings is essential. These findings support antimicrobial stewardship initiatives and highlight the need for further research, especially in high-risk populations.

Preoperative differentiation between uncomplicated and complicated paediatric appendicitis remains challenging. This study aimed to evaluate the diagnostic performance of routine admission biomarkers and blood cell count-derived inflammatory indices for severity stratification and to determine whether fibrinogen provides additional predictive value beyond commonly used markers. We conducted a retrospective single-centre study (2018-2025) using electronically recorded clinical data. Patients with suspected appendicitis were identified through appendicitis-related ICD-10 codes and diagnostically validated. The final analytical cohort required complete admission laboratory data, including C-reactive protein (CRP), fibrinogen, and complete blood count parameters. Derived inflammatory indices included the neutrophil-to-lymphocyte ratio (NLR) and the systemic immune-inflammation index (SII). Diagnostic discrimination and multivariable prediction models were evaluated to assess the ability of these markers to distinguish complicated from uncomplicated appendicitis. Of 1518 screened records, 1132 patients met inclusion criteria (620 complicated; 512 uncomplicated). Complicated appendicitis was associated with higher inflammatory markers and longer hospital stay (all p < 0.001). CRP demonstrated the strongest univariable discrimination (area under the curve [AUC] 0.785), while fibrinogen showed lower performance (AUC 0.744). A combined model including CRP, NLR, and SII achieved good discrimination (AUC 0.812), with minimal improvement after adding fibrinogen (AUC 0.813). In multivariable analysis, log-transformed CRP and SII remained independently associated with complicated appendicitis (both p < 0.001). A rule-out probability threshold of 0.303 achieved 90% sensitivity (negative predictive value 0.803), whereas a CRP cut-off ≥92.24 mg/L showed high specificity (0.943) and positive predictive value (0.900). Routine admission biomarkers and inflammatory indices derived from complete blood counts can support severity stratification in paediatric appendicitis. CRP and SII provide meaningful predictive information, whereas fibrinogen contributes little additional discriminatory value beyond CRP-based models. These findings suggest that a small set of routinely available laboratory markers may assist early risk stratification, although external validation is required before clinical implementation.

Acute appendicitis (AA) is a frequent cause of acute abdominal pain in emergency departments.We aimed to evaluate the association and discriminatory performance of the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) for identifying complicated acute appendicitis. In this retrospective study, we analyzed 483 patients treated at the General Hospital of Carapicuiba from January 2018 to June 2024. Normality was assessed using the Shapiro-Wilk test, and bivariate comparisons were performed using the Mann-Whitney test. Multivariate logistic regression was used to investigate the association of complicated AA with NLR, PLR, age, and sex. A receiver operating characteristic (ROC) curve was constructed to determine sensitivity, specificity, and the area under the curve (AUC). Statistical significance was set at P < 0.05. Of 483 patients, 273 (56.5%) had complicated appendicitis. Median NLR and PLR were higher in complicated versus uncomplicated cases (P< 0.001). The optimal ROC-derived cutoffs were NLR 8.84 (sensitivity 43.6%, specificity 79.5%; AUC 0.694; 95% confidence interval (CI), 0.645-0.742) and PLR 170.6 (sensitivity 40.7%, specificity 73.3%; AUC 0.600; 95% CI, 0.550-0.651). In unadjusted analysis, NLR >8.84 was associated with complicated appendicitis (odds ratio (OR) 3.00; 95% CI, 1.99-4.53). In the multivariable model including age and sex, PLR remained independently associated with complicated appendicitis. NLR and PLR were associated with complicated appendicitis in unadjusted analyses. After adjustment for age and sex, only PLR remained independently associated. Given their low cost and wide availability, these ratios may complement clinical assessment to support risk stratification and timely management, particularly in resource-limited settings.