Early Acute Appendicitis Research Articles

Construction of a clinical prediction model for complicated appendicitis based on machine learning techniques

Acute appendicitis is a typical surgical emergency worldwide and one of the common causes of surgical acute abdomen in the elderly. Accurately diagnosing and differentiating acute appendicitis can assist clinicians in formulating a scientific and reasonable treatment plan and providing high-quality medical services for the elderly. In this study, we validated and analyzed the different performances of various machine learning models based on the analysis of clinical data, so as to construct a simple, fast, and accurate estimation method for the diagnosis of early acute appendicitis. The dataset of this paper was obtained from the medical data of elderly patients with acute appendicitis attending the First Affiliated Hospital of Anhui University of Chinese Medicine from January 2012 to January 2022, including 196 males (60.87%) and 126 females (39.13%), including 103 (31.99%) patients with complicated appendicitis and 219 (68.01%) patients with uncomplicated appendicitis. By comparing and analyzing the prediction results of the models implemented by nine different machine learning techniques (LR, CART, RF, SVM, Bayes, KNN, NN, FDA, and GBM), we found that the GBM algorithm gave the optimal results and that sensitivity, specificity, PPV, NPV, precision, recall, F1 and brier are 0.9167, 0.9739, 0.9429, 0.9613, 0.9429, 0.9167, 0.9296, and 0.05649, respectively. The GBM model prediction results are interpreted using the SHAP technology framework. Calibration and Decision curve analysis also show that the machine learning model proposed in this paper has some clinical and economic benefits. Finally, we developed the Shiny application for complicated appendicitis diagnosis to assist clinicians in quickly and effectively recognizing patients with complicated appendicitis (CA) and uncomplicated appendicitis (UA), and to formulate a more reasonable and scientific clinical plan for acute appendicitis patient population promptly.

The Histopathological Findings in Appendectomy Specimens in an Iranian Population.

Appendicitis is one of the most common causes of acute abdominal surgeries. The importance of parasitic etiologies in the pathogenesis of appendicitis is not well known in appendectomy specimens on a large scale in southwestern Iran. The current study aimed to retrospectively assess the demographic data and histopathological records of appendicitis in a 28-year period in Fars province, southwestern Iran. Histopathological records of 13,013 patients who had undergone surgeries for appendicitis at Dr. Ali Shariati Hospital, affiliated with the Fasa University of Medical Sciences from December 1993 to January 2021 were reviewed and data concerning the patients' demographic data and histopathological records were retrieved from each record. More than 6800 archived microscopic glass slides were also reviewed. From a total of 13,013 histopathological records of surgical excisions of appendicitis that were reviewed over a 28-year period, 8,189 (62.9%) were male and 4,842 (37.1%) were female. Patients' age ranged from 2 to 98 years, with a mean age of 24.68±19.87 years. The most common inflammatory changes were 5,687 (43.7%), 1,228 (9.4%), 670 (5.1%), 522 (4%), and 363 (2.8%) cases of acute appendicitis, suppurative appendicitis, early acute appendicitis, gangrenous appendicitis, and perforated appendicitis respectively. Microscopically, no viral inclusions, fungal elements, and histopathologic findings of bacterial causes were found. Parasitic infections such as helminthiasis were detected in 74 (0.6%) cases aged from 6 to 63. Enterobiasis (Syn. oxyuriasis, pinworm infection) accounted for 73 (98.6%) of the 74 helminthiases, while ascariasis accounted for 1 (1.4%). Out of 74 cases, 29 (39.2%) showed evidence of appendicitis. The results suggest that although parasitic agents are minor causes of appendicitis, these agents should be kept in mind during differential diagnosis. However, whether every parasitic infection leads to appendicitis is controversial.

Endometriosis ofthe Appendix: When Appendicitis Is Less Than Straightforward.

We present a case report of a 49-year-old female with a history of ulcerative colitis who originally presented to the general surgery clinic after an incidental finding on computed tomography was concerning for a dilated, fluid-filled appendix. She ultimately underwent a laparoscopic appendectomy. The pathology returned consistent with early acute appendicitis, with endometrial tissue along the outer wall of the appendix. We then performed a literature review regarding appendiceal masses and the occurrence of endometriomas and/or endometriosis of the appendix. A PubMed search was performed using the key words of appendix and appendicitis and endometrioma. Specific articles were examined mentioning the occurrence of endometriomas of the appendix and isolated endometriosis of the appendix. Between 2% and 6% of cases of appendicitis present due to an appendiceal mass, usually an inflammatory phlegmon. A variety of other causes, including primary malignancy, secondary malignancy, and combinations of pathologies, may lead to the eventual removal of the appendix. Specifically, endometriosis of the appendix is reported in less than 1% of females on post-appendectomy pathologic analysis. Although specific symptoms may guide a provider, there are few distinguishing symptoms that would point a provider toward a different etiology, to include malignancy, for appendicitis. Further information is needed to determine when a patient has an increased risk for an underlying pathology when presenting with appendicitis. This information will help drive continued treatment and lead to improved screening for appendiceal masses.

STUDY ON DIAGNOSTIC EFFICACY OF COMBINED USE OF ALVARADO SCORE AND ULTRASOUND FOR PREOPERATIVE DIAGNOSIS OF ACUTE APPENDICITIS

Background and Aim: This study set out to determine whether or not the use of Alvarado scoring and Ultrasonography together improved the accuracy of diagnosing acute appendicitis and whether or not it decreased the number of false-positive appendicectomy outcomes without increasing their associated morbidity and mortality. Study design: Cross-sectional study, conducted in the Department of Surgery at Government Medical College Haldwani Nainital. Patients and Methods: The participants were recruited from an emergency department or surgical ward and presented with symptoms suggestive of acute appendicitis, including abdominal pain, rebound tenderness, nausea, vomiting, or elevated temperature. Results: The study found that those between the ages of 21 and 40 had the highest rate of developing acute appendicitis. Evidently, the incidence is highest in the second, third, and fourth decades of life, Males outweigh females by a factor of two to one in this series, on correlating the Alvarado score to appendix histopathology data, and discovered that it had a sensitivity of 96.39 percent. On the correlation between ultrasonography and histopathological examination showed a sensitivity of 100% and a PPV of 86.46 percent. Conclusion: Combined use of the Alvarado score and USG in appendectomy decision-making has high sensitivity and accuracy, allowing patients to be diagnosed in the early acute appendicitis stage, and reducing morbidity and postoperative complications.

Role of Conservative Management in the Treatment of Acute Non-Complicated Appendicitis

Objective: The purpose of this study was to assess the efficiency of non-operative management of acute non-complicated appendicitis in terms of cost effectiveness, as well as related morbidity and mortality. Study Design: A prospective observational research. Place and duration: In the Surgical Unit of Islam Medical College and Teaching Hospital Sialkot for one-year duration from January 2021 to December 2021. Methodology: The study included 110 patients with early acute non-complicated appendicitis who were identified by clinical history, physical, and laboratory testing. 110 patients were given intravenous antibiotics for two days, followed by oral antibiotics for seven days. A proforma was used to collect the data. Several morbidities were recognized and tracked in patients. Results: There were 72 men and 38 women, with an average age of 20 years. Right iliac fossa pain, nausea, vomiting, and anorexia were the most frequent symptoms, whereas fever, tachycardia, and rebound tenderness in the right iliac fossa were the most common signs. Patients were randomly assigned to one of two groups. After an uneventful stay of 2 to 4 days. Patients in Group 1 (36.4 percent) who were treated conservatively had no problems and were discharged after a hospital stay of 2 to 4 days. Within four months, 5 patients (12.5%) and three patients (3%) experienced recurrence within six months. They had appendicectomies done in the traditional way. Wound infection was the sole postoperative complication in one patient (5%). Their hospital stay lasted anywhere from three to six days. Two (2.9%) patients with perforated/gangrenous appendix with appendicolith was found in Group-2 patients who had standard appendicectomy. Wound infection occurred in 4 individuals (5.7 percent), pelvic collection in 3 (4.3 percent), and subsequently small intestinal obstruction (adhesive) in two patients (2.8 percent). Their hospital stay lasted anywhere from four to nine days. Conclusion: Patients who were treated conservatively with antibiotics had minor discomfort and required fewer analgesics. Although surgery-related morbidity, death, and costs were averted, the recurrence rate was not insignificant. Keywords: Acute appendicitis, Conservative management, Recurrence

Acute appendicitis in an elderly patient treated with choyoto in combination with conservative antibiotic therapy

ABSTRACTCaseA male patient in his 70s was brought to the hospital with as chief complaint fever and difficulty in moving. Abdominal computed tomography revealed early acute appendicitis with fecaliths, and conservative treatment with antibiotics was started. On day 4, the patient started taking choyoto.OutcomeAlthough his symptoms did not exacerbate, contrast‐enhanced computed tomography showed that the lumen of the appendix remained slightly enlarged, suggesting an appendiceal tumor. The patient refused further examination and was discharged on day 34 while continuing as an outpatient.ConclusionConservative treatment without surgery for acute appendicitis is risky in the elderly because of the possibility of a malignancy and because the severity of the disease tends to be underestimated. On the other hand, the risk of postoperative complications is high due to comorbidities. Therefore, In order to solve this dilemma, the effectiveness of the combination of Kampo medicines with conservative antibiotic therapy in improving symptoms and preventing recurrence should be verified.

Accuracy Score on Raja Isteri Pengiran Anak Saleha (RIPASA) and Pediatric Appendicitis (PAS) for Diagnosing Acute Appendicitis in Children

Abstract
 Introduction. Acute appendicitis is the most common case of acute abdomen. Diagnosis of acute appendicitis is still difficult and is one of the problems in the surgical field. The Clinical Scoring System (CSS) has been developed to help doctors classify risk categories. PAS has been widely evaluated in the pediatric population. In another study it was found that RIPASA had better sensitivity, specificity, and accuracy than PAS in pediatric patients.
 Methods. This study is a cross sectional study to assess the level of concordance between RIPASA and PAS scores in diagnosing acute appendicitis, with the gold standard of Histopathological examination. Samples were taken by consecutive method, in 30 patients aged <18 years for 1 year.
 Results. This study had an average age of 10.10 ± 3.745 years. Histopathologically early acute appendicitis 3.3%, acute suppurative appendicitis as much as 20%, acute gangrenous appendicitis 73.3% and others 3.3%. Using a cut-off point value of 9.5 for RIPASA and 7 for PAS, the sensitivity, Specificity, Accuracy of 82.75%, 100%, 80% for RIPASA, and 75.8%, 100%, 73.3% for PAS.
 Conclusion. The RIPASA score on the cut-off treshold 9.5 has better sensitivity and accuracy than PAS in diagnosing acute appendicitis in pediatric patients and can be used as CSS to assist in making decisions regarding the diagnosis of acute appendicitis in children.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

The Use of Machine Learning Approaches for the Diagnosis of Acute Appendicitis.

Acute appendicitis is one of the most common emergency diseases in general surgery clinics. It is more common, especially between the ages of 10 and 30 years. Additionally, approximately 7% of the entire population is diagnosed with acute appendicitis at some time in their lives and requires surgery. The study aims to develop an easy, fast, and accurate estimation method for early acute appendicitis diagnosis using machine learning algorithms. Retrospective clinical records were analyzed with predictive data mining models. The predictive success of the models obtained by various machine learning algorithms was compared. A total of 595 clinical records were used in the study, including 348 males (58.49%) and 247 females (41.51%). It was found that the gradient boosted trees algorithm achieves the best success with an accurate prediction success of 95.31%. In this study, an estimation method based on machine learning was developed to identify individuals with acute appendicitis. It is thought that this method will benefit patients with signs of appendicitis, especially in emergency departments in hospitals.

Endoscopic Diagnosis of Early Acute Appendicitis in an Asymptomatic Patient.

Endoscopic Diagnosis of Early Acute Appendicitis in an Asymptomatic Patient.

Clinical and radiographic factors associated with appendectomy in pediatric patients with abdominal pain and equivocal imaging findings for appendicitis.

Background and Hypothesis 
 Acute appendicitis is a common surgical emergency in children. The diagnosis requires physicians to rely on clinical, radiographic and laboratory factors. The nonoperative management of appendicitis is becoming more frequent. This requires an accurate diagnosis prior to initiating therapy to prevent unnecessary antibiotic administration for abdominal pain unrelated to appendicitis. We hypothesize clinical and radiographic factors are associated with appendicitis in patients with abdominal pain and inconclusive imaging studies. 
 Methods 
 The DORIS (Dig Our RIS) interactive data-mining tool was utilized to identify patients<18 years of age presenting to the emergency department in 2016 with abdominal pain who obtained abdominal imaging suggestive of early acute appendicitis. Relevant clinical and radiographic information was obtained from the medical record for univariate analysis looking for associations with appendectomy. 
 Results 
 One hundred patients were identified with 21 excluded due to imaging for other reasons or with clear non-appendicitis etiologies for pain (e.g. trauma cases, ovarian cyst). Seventy-nine patients were included with 49 (62%) undergoing surgery and 30 who were observed and/or discharged from the ED. Important differences between surgical and nonsurgical patients included: white blood cell count (13.81±0.68 vs. 10.29±0.90, p=0.002), neutrophil percentage (78.31±1.90 vs. 67.78±2.65, p=0.002), appendiceal diameter on CT scan (9.37±0.53 vs. 7.58±0.30, p=0.013). 
 Conclusion and Potential Impact 
 In a group of patients with concern for appendicitis and imaging suggestive of early acute appendicitis, distinct clinical and radiographic characteristics are associated with appendicitis. Within a paradigm of nonoperative management of appendicitis, accurate diagnosis will prevent the overutilization of antibiotics.

Case of Cystic Fibrosis with Distal Intestinal Obstruction Syndrome Mimicking Acute Appendicitis

Cystic Fibrosis (CF) is a genetic disease affecting multiple organs. Improved life expectancy amongst adult CF patients have given rise to extra-pulmonary and gastrointestinal manifestations. Distal Intestinal Obstruction Syndrome (DIOS) continues to be a rising complication in adult CF patients presenting with acute abdominal pain mimicking abdominal appendicitis. A 22-year-old Turkish Male with history of CF presented with progressively worsening right lower quadrant abdominal pain and constipation for two days. He reported nausea, decreased appetite for three days and his last bowel movement was two days prior to admission. He was diagnosed with CF at the age of four and his disease progressed to an exocrine pancreas insufficiency, which was treated with pancreatic enzymes and other medical therapies. Abdominal exam showed tenderness on right lower quadrant with no rebound tenderness, guarding or peritoneal signs. Laboratory analysis showed leukocytosis with no electrolyte imbalances. CT scan of abdomen showed thickening and inflammation around the terminal ileum and extraluminal free fluid. Since early acute appendicitis cannot be excluded, patient underwent open appendectomy that showed non-inflamed appendix, micro-perforation of the lateral wall of the cecum requiring partial cecectomy. Post operatively he was started on Polyethylene Glycol. Patient had a complete recovery and did not have a recurrence of symptoms on follow up. DIOS is described by the collection of viscid fecal material within the lumen combined with sticky mucoid intestinal content adherent to intestinal wall of the terminal ileum and cecum. Patients characteristically present with right lower quadrant pain, nausea, abdominal distension and failure to pass stools. Though the abdominal X-rays are recommended to aid in diagnosis of DIOS, they are inadequate to differentiate ileus from other causes of abdominal pathologies presenting in CF. Osmotic laxatives are administered to achieve the passage of stool (consisting of clear fluid) along with resolution of abdominal pain and constipation. With increasing migration of patient populations around America, inner-city or community hospitals may not be equipped with CF care centers or programs, which provide expertise in patient management and patient care. Therefore, our case highlights the importance of DIOS to be a differential diagnosis in a patient presenting with history of CF and complaints of abdominal pain and constipation.2513_A Figure 1. Axial view depicting thickening around the terminal ileum (Yellow arrows) along with extraluminal fluid and reactive lymph nodes2513_B Figure 2. Coronal view with thickening of ileum with distended appendix (Yellow arrows)

Non-operative treatment of acute appendicitis in selected patients

Background: Surgical approach for acute appendicitis (AA) is a standard live saving treatment method. The purpose of this study was to assess the feasibility, initial safety and success rate of non-operative treatment of AA in selected patients.Methods: Selected AA patients were enrolled in this prospective study (non-operative treatment). This was based on IV antibiotic therapy and followed up with oral antibiotic. Patients who declined to participate or excluded were managed with appendectomy and considered as controls. The primary goal of the study was to determine the feasibility, initial safety, early and late success rates of non-operative management. Secondary outcomes include hospital length of stay and charge, days of missed works and return to normal activity at home of patients treated non-operatively in comparison to appendectomy group.Results: In non-operative group (36 patients), 7 patients failed to response and managed by appendectomy with early success rate of 80.5%. Three patients experienced recurrent attacks of AA were managed with appendectomy. Late success rate was 72.2%. In appendectomy group (53 patients) one patient with adenocarcinoma of the colon detected during surgery and in ten patients the appendix was perforated. One patient died due to generalized peritonitis. In non-operative group length of stay and hospital charge were lower but only days to resume home activities and days of missed work were shorter and statistically significant as compared to appendectomy group.Conclusions: This study confirms the feasibility, safety and optimum success rate of non-operative treatment of early AA in selected patients.

TWO-PORT LAPAROSCOPIC APPENDECTOMY IS MORE BENEFECIAL THAN OPEN APPENDECTOMY IN EARLY ACUTE APPENDICITIS

Open appendectomy has already commonly been performed to treat acute appendicitis, but the relatively more painful and longer incision scar becomes a cosmetical problem. Two port laparoscopic appendectomy can be performed safely, less painful and leaving only two small incision scars. The aim of the study was to evaluate the benefit of two-port laparoscopic appendectomy and that of with open appendectomy in the case of early acute appendicitis. An observational study was conducted from 2012 to 2014; to compare the operating time, post operative pain and wound infection in early acute appendicitis, performed with two-port laparoscopic appendectomy and with open appendectomy. The statistical analysis in this study uses t-test. There were 114 patients (73 men and 41 women) divided into two groups based on the choice made by the patients themselves. The number of samples performed with two-port laparoscopic appendectomy was 64 and that with open appendectomy was 46. Four patients were excluded from this study. In analysis using t-test, we found that the two-port laparoscopic appendectomy was more beneficial than open appendectomy. There was a significant difference between the two groups, the length of operation time was 37.22 minute in two-port laparoscopic appendectomy and 43.83 minute in open appendectomy (p=0.00), VAS pain score was 1.58 in two-port laparoscopic appendectomy and 2.30 in open appendectomy (p=0.00) and no post operative wound infection in both two groups. The conclusion is two-port laparoscopic appendectomy technique is faster and less painful and the same risk of wound infection than open appendectomy in early acute appendicitis.

P066: Outcomes of non-operative versus operative management in pediatric acute uncomplicated appendicitis

Introduction: The purpose of this study was to look at outcomes of pediatric patients with early, acute appendicitis who were treated with non-operative management (NOM) with antibiotics. Primary outcomes were subsequent appendectomy or Emergency Department (ED) visits. Methods: The method used for this study was a retrospective chart review of children under the age of 18, looking at outcomes of those who received non-operative management (NOM) for early acute appendicitis between April 2014-April 2015. The inclusion criteria included: (a) Age 0-17, (b) US or CT suggested acute uncomplicated appendicitis (c) Final diagnosis of appendicitis during April 2014-2015. Outcomes that were investigated were repeat ED visits and need for subsequent appendectomy. Results: Data extracted from the EMR found 209 charts with an ED diagnosis of appendicitis. Two charts (.9%) were excluded as they were duplicates. Sixty-seven patients (32%) were excluded after appendicitis was ruled out. One hundred and forty patients (67%) had a final diagnosis of appendicitis, 124 patients (88.6%) were taken directly to the operating room for appendectomy, 16 patients (11.4%) were treated with antibiotics instead of operative management. Three patients who received non-operative management had complex appendicitis, 13 had acute uncomplicated appendicitis. Six patients out of 13 (46%) were successfully treated with antibiotics with no repeat visits to the ED or Pediatric Surgery for appendectomy, 7 patients (54%) required appendectomy after initial treatment with antibiotics. Two patients who underwent appendectomy after initial NOM had no evidence of clinical appendicitis, one patient was taken to the OR based on parent preference and one patient had an episode of abdominal pain that prompted an interval appendectomy four weeks post the episode of abdominal pain. Conclusion: Treatment of acute uncomplicated appendicitis with NOM remains a management option in the pediatric population. Further studies and long term follow up are required to better identify appropriate patients for non-operative management versus operative management.

Appendectomy Performed Routinely in the Laparoscopic Treatment of Endometriosis

INTRODUCTION: Our aim was to evaluate the relevance of performing concomitant appendectomy for patients undergoing laparoscopic surgical treatment of endometriosis by assessment of appendiceal pathology. METHODS: Laparoscopic appendectomy was performed on 79 sequential women undergoing laparoscopic treatment of endometriosis between January 2011 and December 2013. The same surgeon performed all appendectomies. Patients undergoing excision and treatment of endometriosis received simultaneous appendectomy at the time of laparoscopic surgery as part of a comprehensive management of endometriosis. All appendectomies were performed using the Altrus thermal device (ConMed). RESULTS: Abnormal pathology of the appendix included fibrosis, fecalith, follicular lymphoid hyperplasia and fecal impaction in addition to the diagnoses designated as significant pathology. Significant pathology was defined as endometriosis, acute focal inflammation, early acute appendicitis or carcinoid tumor. 38/79 (48.1%) of patients had abnormal pathology and 11/79 (13.9%) demonstrated significant pathology. Average age for patients with normal pathology was 34.8 years and for patients with abnormal pathology the average age was 35.02 years. In this cohort, there were no surgical complications related to appendectomy. 3/79 (3.8%) of patients had a complication of surgery related to the extent of endometriosis. CONCLUSION: Pathology of the appendix is seen in a surprisingly high proportion of patients with surgically diagnosed endometriosis. Patients should be counseled that appendectomy performed at the time of laparoscopic surgical treatment of endometriosis may concomitantly treat benign or significant pathology of the appendix and should be considered as an important component of management.

Primary peritonitis caused by Raoultella ornithinolytica in a 53‐year‐old man

Introduction: Raoultella ornithinolytica is a Gram‐negative bacillus. This bacillus was until recently often confused with Klebsiella spp. It is known primarily for causing histamine fish poisoning or scombroid syndrome, and rarely causes human infections. This case report discusses a patient who presented with generalized primary peritonitis due to R. ornithinolytica. Case presentation: A 53‐year‐old Scandinavian man resident in Botswana, sub‐Saharan Africa, presented to the emergency department shortly after onset of lower abdominal pain and dysuria. He was treated for urinary tract infection and discharged. He came back after 16 h with more severe, generalized abdominal pain and a fever of 38 °C. Abdominal sonography was unremarkable. Examination confirmed peritonitis, particularly marked in the right iliac fossa. He had mild leukocytosis 13.1×109 l−1, a C‐reactive protein level of 372.7 mg l−1 and his serum albumin level was 31 g l−1. He was admitted for parenteral antibiotics, laparoscopic peritoneal lavage and appendectomy. He had 500 ml of free pus in the abdomen with no evident focal source. A pus swab grew R. ornithinolytica. The pathology showed mild early acute appendicitis with severe periappendicitis and suppurative peritonitis. He was discharged home after 7 days of parenteral antibiotics. Conclusion: R. ornithinolytica infections are rare in humans, but they can be life‐threatening.

Limited added utility of performing follow-up contrast-enhanced CT in patients undergoing initial non-enhanced CT for evaluation of flank pain in the emergency department

In our emergency department (ED), patients with flank pain often undergo non-enhanced computed tomography (NECT) to assess for nephroureteral (NU) stone. After immediate image review, decision is made regarding need for subsequent contrast-enhanced CT (CECT) to help assess for other causes of pain. This study aimed to review the experience of a single institution with this protocol and to assess the utility of CECT. Over a 6 month period, we performed a retrospective analysis on ED patients presenting with flank pain undergoing CT for a clinical diagnosis of nephroureterolithiasis. Patients initially underwent abdominopelvic NECT. The interpreting radiologist immediately decided whether to obtain a CECT to evaluate for another etiology of pain. Medical records, CT reports and images, and 7-day ED return were reviewed. CT diagnoses on NECT and CECT were compared. Additional information from CECT and changes in management as documented in the patient's medical record were noted. Three hundred twenty-two patients underwent NECT for obstructing NU stones during the study period. Renal or ureteral calculi were detected in 143/322 (44.4 %). One hundred fifty-four patients (47.8 %) underwent CECT. CECT added information in 17/322 cases (5.3 %) but only changed management in 6/322 patients (1.9 %). In four of these patients with final diagnosis of renal infarct, splenic infarct, pyelonephritis and early acute appendicitis in a thin patient, there was no abnormality on the NECT (4/322 patients, 1.2 %). In the remaining 2 patients, an abnormality was visible on the NECT. In patients presenting with flank pain with a clinical suspicion of nephroureterolithiasis, CECT may not be indicated. While CECT provided better delineation of an abnormality in 5.3 % of cases, changes in management after CECT occurred only in 2 %. This included 1 % of patients in whom a diagnosis of organ infarct, pyelonephritis or acute appendicitis in a thin patient could only be made on CECT.

Two-port laparoscopic appendectomy as transition to laparoendoscopic single site surgery

BACKGROUND:According to the precepts of reduced surgical trauma and better cosmesis, an intermediate laparoscopic appendectomy technique between the conventional three-trocar procedure and Laparoendoscopic Single Site Surgery (LESS) was performed, based on literature review and experience of the surgical team.PATIENTS AND METHODS:Patients with early stage acute appendicitis and a favourable anatomical presentation were selected. The procedure was performed with two ports: A 10 mm trocar at the umbilicus site for laparoscope and a 5 mm one just above the pubic bone for grasper. The appendix was secured by external wire traction through a right iliac fossa puncture with 14-gauge intravenous catheter.RESULTS:From August 2009 to December 2012, we performed 42 cases; two required conversion to a conventional laparoscopic technique. There were no complications in the remaining, no wound infections and a mean operation time of 64.5 minutes.CONCLUSION:The use of two-port laparoscopic appendectomy can act as a LESS intermediate step procedure, without loss of instrumental triangulation and maintenance of appropriate counter-traction. This technique can be used as an alternative to the three-port laparoscopic procedure in patients with initial presentation of appendicitis and a favourable anatomical position.

Management Strategies of Appendix with Mild Inflammation

Ozet Abstract Amac: Akut apandisit tedavisi halen klinik bir tartismadir. Bu calismada, erken akut apandisit tanisi alan hastalarda degisik tedavi yaklasimlarini ve bunlarin takiplerini tartismayi amacladik. Yontem: Agustos 2008 ve Ocak 2010 tarihleri arasinda erken donem akut apandisit tanisi konulan 45 hasta calismaya dahil edildi ve bu hastalarin 1 yillik takip sonuclari incelendi. Bu hastalar 3 gruba randomize edildi. Birinci gruba apendektomi yapildi, ikinci gruba antibiyotik tedavisi uygulandi ve ucuncu grup ise sadece izlendi. Bulgular: 45 hastanin ortanca yasi 25 (18-52) idi. 34 hasta kadin (%75.6) ve 11 hasta (%24.4) erkek idi. Ortalama beyaz kure sayisi 7952±1698 /uL (4800-10700) olarak izlendi. Ultrasonografide ortalama apendiks duvar kalinligi 5.46±0.35 (5,0-6,0) mm olarak tespit edildi. Gruplar arasinda yas, cinsiyet, beyaz kure sayisi ve ultrasonografi sonuclari acisindan farklilik yoktu (p=0.361, 0.894, 0.708 ve 0.867). Cerrahi yapilan grubun hepsinde patoloji sonuclari akut apandisit olarak geldi. Antibiyotik tedavi grubundan 2 hasta daha sonra tekrarlayan karin agrisi sikayeti ile, biri 2 hafta sonra, digeri ise 2 gun sonra tekrar hastaneye basvurdu ve bu hastalara apendektomi yapildi, ancak patoloji raporlarinda kronik apandisit bulgusu saptanmadi. Sonuc: Apendektomi erken akut apandisit dusunulen hastalarin cogunda gerekli degildir. Objective: In this study, we examined the cases with mild acute appendicitis and their treatments with different modalities and their follow up. Method: 45 patients were studied between August 2008 and January 2010, with further follow-up for 1 year. The patients were randomly allocated into three groups by systematic random sampling with an equal size of 15 to maintain balance. First group was appendectomy group, second was antibiotic group and third group was follow up (no treatment) group. Results: The median age of the patients was 25 (18-52) years. 34 (75.6%) were women and 11 (24.4%) were men. The mean white blood cell count was 7952±1698 /uL (480010700). The mean appendix wall thickness at ultrasonography was 5.46±0.35 (5,0-6,0) mm. There were no statistical difference detected between groups in age of patients, sex, white blood cell count and ultrasonography results (p=0.361, 0.894, 0.708 and 0.867). Of the patients who underwent surgery had proven appendicitis at histological examination. Two patients treated with antibiotics were readmitted with recurrent appendicitis, one patients after 2 weeks of treatment and one patient after 2 days of treatment and were subsequently operated in the second admission. However, no chronic findings were noted at histopathological examination. Conclusion: Most of the early acute appendicitis, there is no need for appendectomy. Anahtar Kelimeler: Akut apandisit, hafif inflamasyon, antibiyotikler, takip, konservatif tedavi.