Emergency Appendectomy Research Articles

764 Paediatric Emergency Appendicectomy in a District General Hospital: A Review of Current Practice

Abstract Aim Appendicitis is one of the most common surgical pathologies amongst children, with approximately 80% in the UK admitted and managed in district general hospitals. The Royal college of Surgeons paediatric emergency appendicectomy commissioning guidelines state a negative appendicectomy rate should be <15% and <1% should be admitted following a prior discharge with no intervention. We aimed to review current practice and adherence to guidelines. Method A retrospective review was carried out of all paediatric patients admitted with suspected appendicitis, in a single centre over a 1-year period. Demographics, pre-operative investigations, technique, histology, length of stay, readmissions, complications, and transfers to tertiary centres were recorded. Results Total of 101 patients admitted within audit window with a median age of 9.5 years, 50.5% male. Average length of stay was 2 days. Total of 30 appendicectomies performed (63.3% laparoscopic). Negative appendicectomy rate 23.3% (n=7). Seventeen underwent a pre-operative ultrasound, 2 of which confirmed appendicitis and proceeded to an appendicectomy. The remaining 15 were successfully discharged. 28-day readmission rate returned at 5.94%. 1 (0.99%) patient was readmitted following a prior discharge with no intervention and subsequently underwent an appendicectomy, revealing acute appendicitis. No patients were transferred to a tertiary centre. Conclusions Overall, favourable comparison to published guidelines, however higher than optimal negative appendicectomy rate. Utilisation of preoperative ultrasound may aid towards the reduction of this figure. Guideline also states patients should be taken to theatre within 12 hours of decision to operate. Further review of patient's notes should be performed to determine this.

A prospective comparative study of TZANAKIS score versus ALVARADO score in the effective diagnosis of acute appendicitis

: Multiple scoring systems have been addressed to identify those patients who need emergency appendicectomy as the risk of delay could be avoided. Of these, the consideration of both sore related to the Alvarado and Tzanakis is essential for the study to understand the effective diagnose of acute appendicitis. The study aims to compare and evaluate Alvarado and Tzanakis score for diagnosing the acute appendicitis. This study was conducted in the department of General Surgery associated with the M.K.C.G, Medical College and Hospital, Berhampur from August, 2018 to July, 2020. A total of 96 patients were being considered for carrying out a systematic study after carefully verifying a variety of the inclusion and exclusion criteria. To conduct the study in a systematic manner, the doctor has analyzed and given the score of Alvarado and Tzanakis. On the basis of score of these two approaches, the medical team has provided the treatment to these patients. The proper identification of score has helped to select the method of operation and surgery. In addition to this, the comparison of score focusing on the NPV and PPV has also allowed for identifying the sensitivity. The Alvarado and Tzanakis score was found to have sensitivity along with the specificity of 94.44% and 83.33% respectively. However, the PPV and NPV was found to be 98.84% and 50.00% respectively as compared to Alvarado score where sensitivity, specificity, PPV and NPV was found out to be 77.77%, 66.66%, 97.22% and 16.66% respectively. From the study, it has carried out that the Tzanakis scoring system has been addressed a more reliable for analyzing the condition of patients and offering the treatment. Diagnostic. Alvarado score, with the former achieving higher sensitivity and PPV.

TH5.2 Gender differences in patients undergoing emergency appendicectomy

Abstract Aims Although appendicectomy is common, there exists minimal published literature exploring whether there are differences between adult males and females undergoing appendicectomy. This study aimed to investigate the demographics, pre-operative investigation, intra-operative findings and clinical outcomes between both genders having an emergency appendicectomy (EA). Methods A multicentre retrospective observational study was carried out across four hospitals who had an EA between August 2018 and November 2020. Patients were identified through pathology records. Data was extracted from electronic records for demographics, pre-operative (peak) blood results, pre and post-operative imaging, operative details, and the clinical outcomes. Patients were dichotomised by gender and results compared. Data was analysed using unpaired Student t test or Chi-squared test as appropriate with p < 0.05 considered statistically significant. Results 1,128 emergency appendicectomies (57.5% male) were included. Males undergoing EA were younger (median age: 34 vs 40 years, p<0.001). There was no difference in peak pre-operative white cell or neutrophil count; however, C-reactive protein was lower in male patients (median 72 vs 97, p<0.001). Pre-operative imaging was performed more often in females: ultrasound (20.7 vs 1.5%, p<0.001) and CT scan (61.8 vs 54.9%, p=0.020). Male patients underwent more open surgery (14.0 vs 6.5%, p<0.001). There was no difference in the severity of appendicitis, rate of negative appendicectomy, median total hospital stay, post-operative complication or 30-day readmission rates. Conclusions This study demonstrates that differences exist between males and females who have EA in terms of age, use of pre-operative imaging and operative approach, however, clinical outcomes are similar.

SP10.1.9 Routine preoperative group and save is not necessary for emergency appendectomy in adults – A retrospective multicentre study

Abstract Aims The use of routine Group and Save (G&S) for appendectomy is practised commonly with little evidence behind this practise. Our aim was to assess whether routine pre-operative G&S before appendectomy is required by identifying rate of perioperative blood transfusion. Methods A multicentre retrospective observational study of all adult patients who had emergency appendectomy across four hospitals between August 2018 and November 2020. Patients were identified through pathology records. Data was extracted for demographics, pre and post-operative imaging and operative details, G&S, cross matching and peri-operative blood transfusion. Results 1,105 patients were identified, 635 (57.4%) were male. Median age was 37 years (IQR 26–52). 1,012 (91.6%) were ASA 1 or 2. Surgical approach: 890 (80.5%) laparoscopic, 79 (7.1%) converted to open, 119 (10.8%) open and 17 (1.5%) laparotomy. Severity of appendicitis: 804 (72.8%) inflamed, 56 (5.1%) gangrenous, 235 (21.3%) perforated and 10 (0.9%) were normal. 921 (83.3%) patients had pre-operative G&S. 42 (3.8%) patients also had cross match (36 patients had 1 unit and 6 patients had 2 units). None of the patients required blood transfusion in 30 days post appendectomy. The total cost of G&S is estimated to be £56,733 in this cohort. Conclusions The need for peri-operative blood transfusion is rare in patients undergoing appendectomy via any surgical approach. It has significant cost impact as well as it causes unnecessary delays if not done in timely manner. Our study suggests that routine G&S policy is not necessary and we suggest a more ‘selective’ G&S policy.

EP-148 Acute appendicitis complicated by COVID-19: an unexpected postsurgical sequela, Case Presentation

BackgroundThis is a case in which we explore the presentation and management of a 62-year-old gentleman, who attended a UK based surgical unit with appendicitis and a positive COVID-19 on admission. Following an urgent appendicectomy, he suffered a morbid and protracted postoperative period, complicated by an upper gastrointestinal bleed and prolonged ileus. The virus has been recognised to increase the risk of micro-thromboembolic events and gastrointestinal complications. We discuss the possibility of COVID-19 causing the patient's presentation and his post-surgical recovery. We aim to demonstrate our experience of the relationship between acute appendicitis and the morbidity associated with COVID-19.DiscussionThe case demonstrates a unique sequela following an otherwise routine emergency appendicectomy. In concurrence with a radiologically and microbiologically evident COVID-19 infection, it raises the question of whether the appendicitis was caused or at least complicated by the virus. This hypothesis is supported by a similar discovery in a case series carried out in Wuhan, in which a paediatric patient acutely presented with a perforated appendix in parallel with a SARSCoV-2 infection, which required urgent surgery. Contrastingly, a case which involved a COVID-19 positive adult male with a non-perforated and non-suppurative appendix demonstrated no complications post-operatively.ConclusionIt is possible to postulate that the severe presentation outlined in our case could also have been caused by a delayed COVID-19 presentation. However, there is currently no formal research to support this and the approach has not been exemplified in a complex case such as ours.

Clinical Profileof Patients having Acute Appendicitis: A Cross-Sectional Study

Aim: To examine the clinical characteristics of patients with acute appendicitis Study design: A cross-sectional study Place and Duration: This study was conducted at Liaquat University Hospital Jamshoro / Hyderabad from March 2021 to March 2022. Methodology: Presentstudy included 118 patients who went through emergency appendectomy for acute appendicitis. The study evaluated the patient’s clinical profile who presented with acute appendicitis. A detailed history was taken, a clinical examination was performed, and tests such as a complete blood test and ultrasonography were performed. Patients of either gender, above 10 years of age, and with clinical diagnoses of acute appendicitis were incorporated in the study. Patients having an appendicular mass or right ureteric/renal colic were excluded from the study. Results: In the current study themean age of patients was 27.56 ± 9.8 years. Out of 118 patients, 71 (60.1%) were males, and 47 (39.83%) were females. We observed thepredominance of malesin the current study. Majority of the patients presented with complaints of right iliac fossa pain (98.3%) and migration of pain (67.8%). Nausea and anorexia were present in 86.4% of cases, and vomiting was present in 84.7% of cases.Tenderness was observed in right iliac fossa in all patients while Dunphy sign (59.3%), guarding (63.5%), rebound tenderness (69.4%), rigidity (5.9%), Psoas sign (45.7%), Rovsing sign (35.5%)and Obturator sign (21.1%). Conclusion: Males are more likely to have acute appendicitis than females between 10 and 30 years of age. The most common signs and symptoms were discomforts, anorexia, nausea/vomiting, and abdominal pain. Tenderness, guarding, and rebound tenderness were the most prevalent symptoms. Keywords: Appendicectomy, emergency department, Abdomen pain, Acute appendicitis

Negative Appendicectomy Rates in Females of Childbearing Age: A Retrospective Analysis and Literature Review.

IntroductionA negative appendicectomy rate (NAR) is defined as the portion of pathologically normal appendices removed surgically in patients suspected of having acute appendicitis. The lifetime risk of acute appendicitis is 8.6% for males and 6.7% for females; contrarily, the lifetime risk of appendicectomy is 12% for males and 23.1% for females. This study aims primarily to evaluate the true NAR in females of childbearing age to offer insight into potential strategies to reduce the number of unnecessary operative procedures carried out, along with their associated morbidity and mortality.MethodsAll emergency appendicectomies over a one-year period were retrospectively identified and collected from a single tertiary care centre. Preoperative clinical, laboratory and postoperative histopathological data were collected. The negative appendicectomy rate in subgroups divided by biomarkers and radiological imaging findings were analysed. The diagnostic value of these modalities in the context of acute appendicitis was found by calculating the sensitivity, specificity, positive predictive values, and negative predictive values.ResultsA total of 417 patients were included (median age 26; M:F, 0.7:1.0). The overall negative appendicectomy rate was 35.0% (146/417). Two-hundred sixty-one patients underwent an appendicectomy in the child-bearing age group. The NAR was significantly higher in those females with raised WBC and C-reactive protein (CRP) compared to their male counterparts (p-value -<0.001).ConclusionWomen of childbearing age have a higher NAR of 43% when compared to the general population of 35%. Preoperative tests, including ultrasound scans, computed tomography and inflammatory markers in blood tests, help direct those who would benefit from surgery to the operating theatre, however, no test alone is suitably sensitive or specific. To reduce the NAR, management options include a return to observation and serial examination, increased use of low-dose CT or a commitment to improving the performance of ultrasonography.

O043 The outcomes after emergency appendicectomy in patients with liver cirrhosis: a population-based cohort study from England

Abstract Introduction The mortality risk after appendicectomy in patients with liver cirrhosis is predicted to be higher than in the general population given the associated risk of perioperative bleeding, infections, and liver decompensation. This population-based cohort study aimed to determine the 90-day mortality risk following emergency appendicectomy in patients with cirrhosis. Methods Adult patients undergoing emergency appendicectomy in England between January 2001 and December 2018 were identified from two linked primary and secondary electronic healthcare databases, the clinical practice research datalink, and hospital episode statistics data. Length of stay, re-admission, Case fatality, and the odds ratio of 90-day mortality were calculated for patients with and without cirrhosis, adjusting for age, sex, and co-morbidity using logistic regression. Results A total of 40353 patients underwent appendicectomy and of these 75(0.19%) had cirrhosis. Patients with cirrhosis were more likely to be older (p &amp;lt;0.0001) and have comorbidities (p&amp;lt;0.0001). Proportionally, more patients with cirrhosis underwent an open appendicectomy (76%) compared with 64% of those without cirrhosis (p = 0.03). The 90-day case fatality rate was 6.67% in patients with cirrhosis compared with 0.56% in patients without cirrhosis. Patients with cirrhosis had longer hospital length of stay (4 (IQR 3–9) days versus 3 (IQR 2–4) days and higher readmission rates at 90-days (20% vs 11%, p=0.019). Most importantly, their odds of death at 90-days were 3 times higher than patients without cirrhosis, adjusted odds ratio 3.75 (95% CI 1.35–10.49) Conclusion Patients with cirrhosis have a 3-fold increased odds of 90-day mortality after emergency appendicectomy compared to those without cirrhosis. Take-home message Patients with cirrhosis have a 3-fold increased mortality risk than those without cirrhosis. They also have longer hospital stays and higher risk of readmissions.

Systematic review and meta-analysis comparing perioperative outcomes of pediatric emergency appendicectomy performed by trainee vs trained surgeon.

Appendicectomy is a common pediatric surgical procedure performed by trainees and surgeons with varying reported outcomes. It is a benchmark procedure for trainee progression and training benefits should be weighed against patient safety and perioperative outcomes. This systematic review and meta-analysis investigated any differential perioperative outcomes dependent on the grade of the operating surgeon. A systematic literature review and meta-analysis were performed comparing outcomes of pediatric appendicectomy performed by trainees versus trained surgeons. Of 2,086 articles screened, 5 retrospective non-randomized comparative studies reporting on 10,019 participants were analyzed. There was no difference in overall complications (OR 0.92; 95% CI 0.76, 1.12; P = 0.42), major complications [Clavien-Dindo (CD) III/IV] (OR 1.18; 95% CI 0.71, 1.97; P = 0.52), minor complications (CD I/II) (OR 1.13; 95% CI 0.57, 2.27; P = 0.72), post-op ileus (OR 0.74; 95% CI 0.10, 5.26; P = 0.76), wound infections (OR 0.87; 95% CI 0.62, 1.21; P = 0.41), abscess formation (OR 0.58; 95% CI 0.28, 1.22; P = 0.15), operation times [Mean Difference (MD) 2.31min; 95% CI -4.94, 9.56; P = 0.53] and reoperation rate (OR 1.22; 95% CI 0.23, 6.42; P = 0.81). Trainees had fewer conversions to open appendicectomy (OR 0.14; 95% CI 0.02, 0.88; P = 0.04). Appendicectomy performed on pediatric patients by trainees did not compromise patient safety. LEVEL OF EVIDENCE: III.

Systematic review and meta-analysis comparing perioperative outcomes of emergency appendectomy performed by trainee vs trained surgeon

BackgroundAppendectomy is a benchmark operation for trainee progression, but this should be weighed against patient safety and perioperative outcomes. MethodsSystematic literature review and meta-analysis comparing outcomes of appendectomy performed by trainees versus trained surgeons. ResultsOf 2086 articles screened, 29 studies reporting on 135,358 participants were analyzed. There was no difference in mortality (Odds ratio [OR] 1.08, P = 0.830), overall complications (OR 0.93, P = 0.51), or major complications (OR 0.56, P = 0.16). There was no difference in conversion from laparoscopic to open surgery (OR 0.81, P = 0.12) and in intraoperative blood loss (Mean Difference [MD] 5.58 mL, P = 0.25). Trainees had longer operating time (MD 7.61 min, P < 0.0001). Appendectomy by trainees resulted in shorter duration of hospital stay (MD 0.16 days, P = 0.005) and decreased reoperation rate (OR 0.78, P = 0.05). ConclusionsAppendectomy performed by trainees does not compromise patient safety. Due to statistical heterogeneity, further randomized controlled trials, with standardized reported outcomes, are required.

Requirement of preoperative blood typing for cholecystectomy and appendectomy: a systematic review

PurposeBlood typing, or group and save (G&S) testing, is commonly performed prior to cholecystectomy and appendectomy in many hospitals. In order to determine whether G&S testing is required prior to these procedures, we set out to evaluate the relevant literature and associated rates of perioperative blood transfusion.MethodsStudies from January 1990 to June 2021 assessing the requirement of preoperative G&S testing for elective or emergency cholecystectomy and appendectomy were retrieved from MEDLINE, EMBASE and CINAHL databases. The search was performed on 6th July 2021 (PROSPERO registration number CRD42021267967). Number of patients, co-morbidities, operation performed, number of patients that underwent preoperative G&S testing, perioperative transfusion rates and financial costs were extracted.ResultsWe initially screened 194 studies of which 15 retrospective studies, a total of 477,437 patients, specifically met the inclusion criteria. Ten studies reported on cholecystectomy, two studies on appendectomy and three studies included both procedures. Where reported, a total of 177,539/469,342 (37.8%) patients underwent preoperative G&S testing with a perioperative transfusion rate of 2.1% (range 0.0 to 2.1%). The main preoperative risk factors associated with perioperative blood transfusion identified include cardiovascular co-morbidity, coagulopathy, anaemia and haematological malignancy. All 15 studies concluded that routine G&S is not warranted.ConclusionThe current evidence suggests that G&S is not necessarily required for all patients undergoing cholecystectomy or appendectomy. Having a targeted G&S approach would reduce delays in elective and emergency lists, reduce the burden on the blood transfusion service and have financial implications.

Safety of Laparoscopic Appendectomy in the Setting of Coagulopathy: An ACS-NSQIP Study.

Patients with coagulopathy requiring emergent appendectomy constitute a challenging patient population. It is unclear whether laparoscopic appendectomy (LA) is as safe as open appendectomy (OA) in these patients. We queried the ACS-NSQIP database for adults with coagulopathy undergoing emergent appendectomy from 2014 to 2017. Demographic characteristics and operative outcomes were compared between the two groups. Propensity weighting for LA versus OA was estimated using augmented inverse probability of treatment weights (AIPW). A total of 137,429 patients were included, of which 7049 (5%) had coagulopathy. In patients with coagulopathy, LA was the most common approach (89%). After AIPW, there was no difference in the adjusted risk of either postoperative transfusion or 30-day reoperation between OA and LA. LA was associated with reduced operative time (56 versus 75min), length of stay (3.5 versus 7.0d), and surgical site infection rate (6% versus 13%) compared to OA. Patients with coagulopathy represent a significant proportion of those undergoing an appendectomy. The majority of patients with coagulopathy who require appendectomy undergo LA, and this approach appears to be safe with regard to transfusion requirement and reoperation.

Laparoscopy uptake for paediatric appendicectomy: a comparison of general surgeons versus specialist paediatric surgeons in England from 1997 to 2015.

Laparoscopy is used in as many as 95% of adult appendicectomies. There is level I evidence showing that it reduces wound infection, postoperative ileus and length of inpatient stay in children compared with the open approach. The aim of this study was to report the uptake of laparoscopy for paediatric appendicectomy in England and to determine whether this was similar for general surgeons (GS) and specialist paediatric surgeons (SPS). Hospital Episode Statistics data were obtained for all children aged <16 years who had an OPCS 4.6 code for emergency appendicectomy from 1997 to 2015 (18 years). Data are analysed to compare rate of laparoscopic vs open procedures for GS and SPS over time and to investigate factors associated with the use of laparoscopy. There were 196,987 appendicectomies and where specialty was available, 133,709 (79%) cases were undertaken by GS and 35,141 (21%) by SPS. The rate of cases undertaken with laparoscopy for both specialties combined increased from 0.8% in 1998 to 50% in 2014 (p<0.0001). In 2014, this rate was 41% for GS compared with 71% for SPS (p<0.0001). Female gender (odds ratio (OR)=1.84, 95% confidence interval (CI) 1.80-1.90), increasing age (OR=1.18, 95% CI 1.18-1.19 per year) and treatment by SPS (OR=3.71, 95% CI 3.60-3.82) were all factors positively associated with use of laparoscopy in multivariate analysis. There has been a vast increase in the proportion of appendicectomies undertaken laparoscopically in children. Despite adjusting for patient factors, laparoscopy was used significantly less by GS when compared with SPS. This difference is most apparent in younger children.

Acute Abdomen as a Manifestation of Multisystem Inflammatory Syndrome in Children Associated With COVID-19 and Report of Cardiac Involvement: A Case Series

Background and Aim: Following the prevalence of severe acute respiratory syndrome-coronavirus (SARS-CoV2) in the world, a type of severe involvement in children was reported as multisystem inflammatory syndrome in children (MIS-C) involving various organs, such as lung, skin, heart, kidney, gastrointestinal tract, and eyes, acute abdomen as a manifestation of this syndrome is rarely reported. To introduce children with MIS-C with fever and acute abdomen who underwent appendectomy. Case Report: Six children between the ages of 8 to 12 years (3 boys and 3 girls) presented with acute abdominal pain, fever, and vomiting, due to obvious tenderness and rebound tenderness in the right lower quadrant of the abdomen and other clinical and laboratory symptoms, 4 of them underwent emergency appendectomy. Materials and Methods: Due to the lack of improvement in abdominal pain and the symptoms and problems in various organs in patients, such as heart (three cases of myocarditis, one case of pericardial effusion), kidneys (two cases of increased urea and creatinine), skin (four cases of skin rash), lung (six cases of pulmonary involvement and two cases of pleural effusion), gastrointestinal tract (abdominal pain and vomiting and three cases of diarrhea), and laboratory symptoms in the form of increased acute phase reactors and (D dimer ) and most cases of lymphopenia (six cases) and evidence of COVID-19 infection (positive polymerase chain reaction [PCR] or COVID-19 positive serology, or compatible imaging and laboratory symptoms), MIS-C was diagnosed and treated for these patients. Patients were treated with corticosteroids and intravenous immune globulin (IVIG) and enoxaparin and other medications and fortunately, all cases improved. In addition, the pathology report after appendectomy was appendicitis in most cases. Results: Four cases that showed clinical manifestations of acute abdomen underwent surgery without overall complications. In some of these patients, appendicitis was the cause of abdominal pain, and in some patients, inflammatory response to COVID-19 (e.g. mesenteric adenitis) was the cause of pain and no mortality was reported. In most patients, inflammatory markers, such as CRP and ESR were elevated, and albumin levels were mildly decreased during admission and ferritin and D-dimer levels were abnormal in most patients. Four cases had cardiac involvement and all MIS-C patients were treated with steroids and IVIG, respectively. Also, no mortality was reported in patients treated with corticosteroids. Conclusion: Therefore, it is essential to note that in children with a complaint of abdominal pain and have symptoms in favor of an acute abdomen; attention should be paid to the symptoms of the involvement of other body systems due to (MIS-C).

Amoxicillin Plus Clavulanic Acid Versus Appendicectomy for Treatment of Acute Uncomplicated Appendicitis

Acute appendicitis is the most common indication for surgery in patients admitted to hospital for acute abdominal pain. In about 20% of cases, acute appendicitis is complicated, leading to local or diffuse peritonitis mostly. Although urgent appendicectomy is still the recommended treatment for acute uncomplicated appendicitis and also antibiotic treatment can cure acute appendicitis or can be the first line of treatment. In the Current study we assessed the efficacy of amoxicillin plus clavulanic acid by comparison with emergency appendicectomy for treatment of patients with uncomplicated acute appendicitis. In this Study open-label, non-inferiority, randomized trial, adult patients (aged 18–68 years) with uncomplicated acute appendicitis, as assessed by CT scan, were enrolled at Pakistan Instiute of Medical Sciences (PIMS) Hospital Islamabad Pakistan. A computer-generated randomization sequence was used to allocate patients randomly in a 1:1 ratio to receive amoxicillin plus clavulanic acid (3 g per day) for 8–15 days or emergency appendicectomy. The primary endpoint was occurrence of post intervention peritonitis within 30 days of treatment initiation. Non-inferiority was shown if the upper limit of the two-sided 95% CI for the difference in rates was lower than 10 percentage points. Both intention-to-treat and per-protocol analyses were done. The Current research Result show that Of 243 patients randomised, 123 were allocated to the antibiotic group and 120 to the appendicectomy group. Four were excluded from analysis because of early dropout before receiving the intervention, leaving 239 (antibiotic group, 120; appendicectomy group, 119) patients for intention-to-treat analysis. 30-day post intervention peritonitis was significantly more frequent in the antibiotic group (8%, n=9) than in the appendicectomy group (2%, n=2; treatment difference 5•8; 95% CI 0•3–12•1). In the appendicectomy group, despite CT-scan assessment, 21 (18%) of 119 patients were unexpectedly identified at surgery to have complicated appendicitis with peritonitis. In the antibiotic group, 14 (12% [7•1–18•6]) of 120 underwent an appendicectomy during the first 30 days and 30 (29% [21•4–38•9]) of 102 underwent appendicectomy between 1 month and 1 year, 26 of whom had acute appendicitis (recurrence rate 26%; 18•0–34•7).The Current result conclude that Amoxicillin plus clavulanic acid was not non-inferior to emergency appendicectomy for treatment of acute appendicitis. Identification of predictive markers on CT scans might enable improved targeting of antibiotic treatment. Keywords: Amoxicillin, clavulanic acid versus appendicectomy

Dilemma Behind Post-Spinal Tetraplegia: Is Conversion Disorder Really the Culprit?

The occurrence of intra-operative conversion disorder with tetraplegia in a patient undergoing emergency appendectomy under spinal anaesthesia has been described in this case report. A 19-year-old female patient was given spinal anaesthesia for an emergency appendectomy. She had a block up to the T10 level as per assessment. Following confirmation of sensory and motor blockade level, the patient became apnoeic and appeared to stop responding abruptly. Her vitals remained constant except for tachycardia. She was taken on bag and mask ventilation and preparation for endotracheal intubation was underway. The patient began to respond again after a few minutes of continual stimulation and bag mask ventilation. Rest of the perioperative period was uneventful. Postoperative psychiatry consultation was done, and she was diagnosed as a case of conversion disorder.International Journal of Human and Health Sciences Vol. 06 No. 03 July’22 Page: 332-334

Emergency appendectomy versus elective appendectomy following conservative treatment for acute appendicitis: a multicenter retrospective clinical study by the Japanese Society for Abdominal Emergency Medicine

To establish the best treatment strategy for acute appendicitis. We collected data on 2142 appendectomies performed in 2017 and compared the backgrounds and surgical outcomes of patients who underwent early surgery (ES) (< 48h) with those managed with non-ES (> 48h). We performed a risk factor analysis to predict postoperative complications and subgroup analysis to propose a standard treatment strategy. The incidence of postoperative complications was significantly higher in the ES group than in the non-ES group, and significantly lower in the laparoscopic surgery group than in the laparotomy group. Surgical outcomes, including the incidence of postoperative complications, were comparable after acute surgery (< 12h) and subacute surgery (12-48h), following antibiotic treatment. The risk factors for postoperative complications in the ES group were a higher age, history of abdominal surgery, perforation, high C-reactive protein level, histological evidence of gangrenous or perforated appendicitis, a long operation time, and intraoperative complications. The risk factors for postoperative complications in the non-ES group were perforation and unsuccessful conservative treatment. Non-early appendectomy is feasible for acute appendicitis but should be applied with care in patients with risk factors for postoperative complications or failure of pretreatment, including diabetes mellitus, abscess formation, and perforation.

Clinical Experience of Emergency Appendectomy under the COVID-19 Pandemic in a Single Institution in South Korea.

Background and Objectives: The COVID-19 pandemic has brought serious changes in healthcare systems worldwide, some of which have affected patients who need emergency surgery. Acute appendicitis is the most common surgical disease requiring emergency surgery. This study was performed to determine how the COVID-19 pandemic has changed the treatment of patients with acute appendicitis in South Korea. Materials and Methods: We retrospectively reviewed a medical database that included patients who underwent surgery for acute appendicitis in our hospital from January 2019 to May 2021. We classified the patients into two groups according to whether they were treated before or after the COVID pandemic and 10 March 2020 was used as the cutoff date, which is when the World Health Organization declared the COVID pandemic. Results: A total of 444 patients were included in the “Pre-COVID-19” group and 393 patients were included in the “COVID-19” group. In the “COVID-19” group, the proportion of patients with severe morbidity was significantly lower. The time that the patients spent in the emergency room before surgery was significantly longer in the ”COVID-19” group (519.11 ± 486.57 min vs. 705.27 ± 512.59 min; p-value < 0.001). There was no difference observed in the severity of appendicitis or in the extent of surgery between the two groups. Conclusions: During the COVID-19 pandemic, a statistically significant time delay (186.16 min) was needed to confirm COVID-19 infection status. However, there was no clinical difference in the severity of appendicitis or in the extent of surgery. To ensure the safety of patients and medical staff, a COVID-19 PCR test should be performed.

Periappendiceal fluid collection on preoperative computed tomography can be an indication for interval appendectomy: a retrospective study

BackgroundThe treatment strategies for acute appendicitis, such as emergency appendectomy (EA), interval appendectomy (IA), and repeating nonoperative management (NOM), are controversial. In this study, we examined the preoperative factors that can be used to distinguish which patients should undergo IA.MethodsWe retrospectively identified 902 patients who underwent surgery for appendicitis in our hospital from January 2010 to December 2021. Of these patients, 776 were included in this study. The patients were divided into two groups: those with a periappendiceal fluid collection (PAFC) on preoperative computed tomography (PAFC-positive group, n = 170) and those without a PAFC (PAFC-negative group, n = 606). In each group, we compared patients who underwent EA and IA.ResultsIn the PAFC-positive group, patients who underwent EA had a significantly higher postoperative complication rate than those who underwent IA (40.5% vs. 24.0%, p = 0.037). In the multivariate analysis, only the presence of PAFC was significantly associated with an increased risk of postoperative complications (odds ratio, 7.11; 95% confidence interval, 2.73–18.60; p < 0.001). The presence of PAFC alone was not significantly associated with an increased risk of IA or NOM failure (odds ratio, 1.48; 95% confidence interval, 0.19–11.7; p = 0.71). The rate of neoplasia on pathologic examination was significantly higher in the PAFC-positive than PAFC-negative group (7.6% vs. 1.5%, p < 0.001); the rate of carcinoma was also higher in the PAFC-positive group (2.4% vs. 0.17%, p = 0.02).ConclusionsThe presence of PAFC on preoperative computed tomography was found to be a risk factor for postoperative complications but not IA or NOM failure. It was also correlated with neoplasia as the etiology of appendicitis. Therefore, PAFC positivity is useful as an indication for IA.

Accuracy of C-reactive protein and leukocyte count in the diagnosis of acute appendicitis compared to histopathological examination

Background. One of the most common causes of acute surgical abdomen is acute appendicitis. The aim of this study was to compare the accuracy of C-reactive protein (CRP) and the total leukocyte count (TLC) with the postoperative histopathological examination in the diagnosis of acute appendicitis. Methods. It is a prospective observational study over a period of 18 months, on patients who underwent emergency appendectomy. Purposive sampling method and Chi square test were used for the study to find significant association between the variables. Results. The mean age of the participants was 24.06 ± 8.61 years (74.7% men and 25.3% women). All cases had abdominal pain, and 86.7% anorexia, 57.3% migraine, 49.3% vomiting, 38.7% fever. In the case of the normal appendix, TLC was positive in 31% of cases; in cases with inflamed appendix 65% of cases were positive for TLC, while in cases with gangrenous and/or perforated appendix all cases were positive for TLC. CRP had a sensitivity of 88.7%, 69.23% specificity, 93.22% PPV and 56.25% NPV for diagnosis. When both TLC and CRP were used, they have a high sensitivity (90.32%) compared to single use and reported to histopathological findings, and a high PPV value (93.33%). Conclusions. The combined sensitivity and specificity values of TLC and CRP were higher in the diagnosis of acute appendicitis, thus reducing the number of negative appendicectomies and the need for a CT scan, which is generally expensive and associated with the risk of radiation.