Incidence Of Complicated Appendicitis Research Articles

Impact of the COVID-19 Pandemic on the Incidence of Complicated Appendicitis in a Tertiary Medical Center, Amman, Jordan. A retrospective cohort.

Abstract
 Objective: To assess the incidence of complicated appendicitis during the COVID-19 pandemic in Jordan University Hospital.
 Materials and Methods: in this cohort study, we retrospectively investigated data on acute appendicitis cases, two groups were established, the first group was the pandemic group, which includes patients who presented to the hospital during the period of acute restrictions and shutdowns extending from the 17th of March to the 6th of June 2020, and the pre-pandemic group which represents the same period in the previous year. These two groups were compared in terms of clinical characteristics and the prevalence of complicated appendicitis.
 Results: A total of 45 patients were included in the study, 24 in the pandemic group and 21 in the pre-pandemic group. Gender distribution was not significant between the two periods (P-value>0.05). Rates of occurrence of overall complications, preoperative complications, and intraoperative complications were similar indicating no significant difference between the two groups (P-value=0.526, 0.835, and 0.547, respectively). The duration between symptoms and admission and ALVARADO score were not significantly different between the two study groups. Also, the duration of in-hospital stay was numerically but not significantly lower in the 2019 (March-June) group compared to 2020 (March-June).
 Conclusion: In our study, there was no significant difference in the incidence of complicated appendicitis between pandemic and pre-pandemic groups.

Acute Appendicitis in the Epicenter of the COVID-19 Pandemic: A New York City Single-Center Experience.

Appendectomy is the gold standard for simple appendicitis. During the coronavirus-19 pandemic, it was estimated that appendectomies in the United States decreased by 24%. We aimed to describe trends in acute appendicitis management at a center located in one of the largest epicenters of the pandemic. This is a retrospective cohort study in a single institution located in Queens, New York, of patients who presented with acute appendicitis. A pre-COVID time period, March-June 2019, was compared to peak-COVID, March-June 2020, and late-COVID, March-June 2021. Of the 382 patients admitted with appendicitis during the time periods, 164 were admitted pre-COVID. Appendicitis presentations decreased by 44% during peak-COVID and 23% in late-COVID. Patients were younger during peak-COVID compared to pre-COVID (39 vs 34years old, P = .036). Incidence of complicated appendicitis in pre-, peak-, and late-COVID was equivalent (41% vs 46% vs 45%) and operative management was similar (85% vs 76% vs 79%). Non-operative patients had shorter lengths of stay (pre- vs peak-COVID: 4.6 vs 2.9days, P = .006). Readmission rates were similar between the cohorts across time periods. During peak-COVID, there was a significant decrease in presentation of acute appendicitis but clinical presentation and outcomes remained similar between the cohorts. Patients who were managed non-operatively may be discharged earlier without increased rates of readmissions.

Acute Appendicitis Following COVID-19 Infection in Pediatric Patients: A Single Center's Study in Greece.

This study investigated the potential association between the previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive infection, as well as vaccination, and the presentation of acute appendicitis in pediatric patients. It has been three years since the World Health Organization (WHO) declared the SARS-CoV-2 pandemic, and city lockdowns and self-protective measures have been applied worldwide. In an effort to contribute to the research on the probable long-term complications of the COVID-19 infection as well as the vaccination against SARS-CoV-2, the current study was designed and investigated patients' health records in the post-quarantine era. A retrospective analysis of patients admitted and treated surgically for acute appendicitis from January 2022 to June 2022 was conducted. Demographic and personal data, as well as the COVID-19 infection history of each child, were recorded. The patients who were negative for a previous COVID-19 infection were excluded. For the rest of the sample, the time-to-onset of acute appendicitis, the severity of appendicitis (complicated or uncomplicated), and the vaccination status of the patients were examined. Regarding the time-to-onset of appendicitis, we divided the patients into three groups: group A with a time-to-onset < 3 months, group B with a time-to-onset of 3-6 months, and group C with a time-to-onset of >6 months. Statistical analysis followed and was considered significant if p < 0.05. Sixty-six children with a mean age of 10.5 years (range 1-15 years) were admitted for acute appendicitis during the determined period. After excluding 30 children that were negative for previous COVID-19 infection, we divided the patients into three groups: group A-23 children, group B-7 children, and group C-6 children. A statistically significant incidence of acute appendicitis diagnosis in <3 months after laboratory-confirmed COVID-19 infection (p < 0.01) was found. The incidence of complicated appendicitis was greater in patients with a positive SARS-CoV-2 history, with an estimated odds ratio of 1.8 (p > 0.05). The majority of the children (92%) had not received a COVID-19 vaccination. For the vaccinated children, the relative risk for complicated appendicitis was equal to 1.5 (p > 0.05). The results of our study demonstrate a potential positive relationship between COVID-19 infection and subsequent acute appendicitis in pediatric patients. There are also some speculations on the presentation of complicated cases of appendicitis following COVID-19 infection or vaccination, but these need to be further proven. Further data are required to better understand this potential complication of COVID-19 infection as well as the role of vaccines in the current post-vaccine era.

Patient and Process Outcomes Among Pediatric Patients Undergoing Appendectomy During the COVID-19 Pandemic - an International Retrospective Cohort study.

COVID-19 forced healthcare systems to make unprecedented changes in clinical care processes. We hypothesized that the COVID-19 pandemic adversely impacted timely access to care, perioperative processes, and clinical outcomes for pediatric patients undergoing primary appendectomy. We conducted a retrospective, international, multicenter study using matched cohorts within participating centers of the international PEdiatric Anesthesia COVID-19 Collaborative (PEACOC). Patients < 18 years old were matched using age, ASA-PS status, and sex. The primary outcome was the difference in hospital length of stay of patients undergoing primary appendectomy during a 2-month period early in the COVID-19 pandemic (April-May 2020) compared to pre-pandemic (April-May 2019). Secondary outcomes included time to appendectomy and the incidence of complicated appendicitis. 3351 cases from 28 institutions were available with 1684 cases in the pre-pandemic cohort matched to 1618 in the pandemic cohort. Hospital length of stay was statistically significantly different between the two groups: 29 hours (IQR: 18, 67) in the pandemic cohort versus 28 hours (IQR: 18, 79) in the pre-pandemic cohort (adjusted coefficient, 1; 95% CI 0.39 to 1.61, P<0.001), but this difference was small. Eight centers demonstrated a statistically significantly longer hospital length of stay in the pandemic period compared to the pre-pandemic period, while 13 were shorter and 7 did not observe a statistically significant difference. During the pandemic period, there was a greater occurrence of complicated appendicitis, pre-pandemic 313 (18.6%) versus pandemic 389 (24.1%), absolute difference of 5.5% (adjusted OR, 1.32; [95% CI 1.1 to 1.59]; P=0.003). Preoperative SARS CoV-2 testing was associated with significantly longer time-to-appendectomy, 720 minutes (IQR: 430, 1112) with testing versus 414 minutes (IQR: 231, 770) without testing, adjusted coefficient, 306 minutes, (95% CI 241 to 371, P <0.001), and longer hospital length of stay, 31 hours (IQR: 20, 83) with testing versus 24 hours (IQR: 14, 68) without testing, adjusted coefficient, 7.0, (95% CI 2.7 to 11.3, P=0.002). For children undergoing appendectomy, the COVID-19 pandemic did not significantly impact hospital length of stay.

Prospective study of laparoscopic management of appendicitis during the COVID pandemic in a single paediatric centre.

The coronavirus (COVID-19) pandemic affected the presentation of many conditions. This study analyses and describes the impact of the COVID-19 pandemic on the management of appendicitis in children and the role of laparoscopy. We performed a prospective (during the pandemic) and retrospective (historic control) review of the management of appendicitis in a tertiary paediatric surgical unit. Preoperative data, operative findings and patient outcomes were compared between groups to identify differences between the study periods and to identify any factors predictive of outcomes. Sixty-two patients were identified in the pre-pandemic cohort, 72 in the pandemic cohort. There was no significant difference in patient demographics, length of admission or time between admission and surgery between groups. There was however a significantly longer time to presentation to hospital in the pandemic group. Clinical outcomes were comparable between the two groups, with no difference in the presence of surgical complications or histologically advanced appendicitis between the two groups. Laparoscopic surgery was safely used to manage appendicitis in the pandemic cohort through utilisation of a COVID-19 pathway that included guidance on testing, and use of personal protective equipment (PPE). Conservative management in the pandemic cohort was reserved for patients with appendicitis with the presence of mass formation. Despite a delayed presentation to hospital, there was no rise in the incidence of complicated appendicitis, complications of surgery or length of stay during the COVID-19 pandemic. Laparoscopic appendicectomy was also shown to be a safe and effective standard for the management of appendicitis during the pandemic. III, treatment.

Determination of risk factors for conversion from laparoscopic to open appendectomy in patients with acute appendicitis.

Acute appendicitis is the most common cause of surgical emergencies. It can be difficult to distinguish cases of acute appendicitis that should be managed by laparoscopic appendectomy (LA) from those that should be managed by open surgery. This study aimed to prevent the inappropriate choice of technique and associated complications by identifying potential risk factors for conversion from laparoscopic to open appendectomy (OA) at the time of initial surgical assessment. This is a retrospective analysis of patients who underwent laparoscopic exploration for acute appendicitis. The study included patients over 18 years of age between January 2016 and July 2021. Patients were divided into two groups according to the surgical approach: those who underwent a LA and those who initially underwent laparoscopic exploration first and then converted to OA. Demographics, perioperative factors, and outcomes were compared between groups. The study included 634 adults undergoing laparoscopic exploration for an appendectomy. About 80.8% had LA, and 19.2% (n=122) required COA. COA patients' average age was significantly higher than LA patients' (48.5 years vs. 37.8 years, P<0.001). The conversion rate for patients over 65 was 63.8%, compared to 15.6% for those under 65 (P<0.001). COA patients had higher bilirubin levels (36.1% vs. 13.5%, P<0.001), higher American Society of Anesthesiologists (ASA) scores (ASA >2, COA 52.5% vs. LA 7.8%, P<0.001), and a higher need for CT imaging (84.4% vs. 67.6%, P<0.001) than LA patients. An Alvarado score >6 significantly differenti-ated LA from COA (62.6% vs. 39.4%, P< p<0.001). COA patients experienced significantly increased periods until starting oral intake (31.6 vs. 9.9 h, P<0.001) and higher rates of complicated appendicitis (40.9% vs. 0.6%, P<0.001). After surgery, COA had higher rates of complications compared to LA: surgical site infections (8.2% vs. 2.7%, P=0.004), reoperation (13.1% vs. 0%, P<0.001), hospital re-admission (14.7% vs. 2.3%, P<0.001), and mortality (1.6% vs. 0%, P<0.004). Advanced age, especially over 65 years, elevated bilirubin levels, an ASA >2 score, and an increased need for pre-operative diagnostics using CT scans were found to be significant predictors of conversion to OA. In the conversion group, operative time, time to oral intake, and the incidence of complicated appendicitis were significantly higher. The conversion group had significantly higher rates of postoperative complications, surgical site infections, hospital readmissions, and mortality. To avoid the increased rate of complications associated with conversion to open surgery, the initial evaluation of a patient with prospective risk factors may be beneficial.

The Impact of the COVID-19 Pandemic on the Incidence, Severity, and Management of Acute Appendicitis: A Single Center Experience in Thailand.

For more than two years since the COVID-19 pandemic, human lives have changed, including the healthcare system. Management of acute appendicitis, the most common emergency surgical disease, has been inevitably affected. This study aimed to assess the effect of the COVID-19 pandemic on the incident rate of complicated appendicitis, management, outcome, and complication of acute appendicitis. Patients and Methods. This study was a retrospective cohort study comparing 574 patients diagnosed with acute appendicitis before the COVID-19 outbreak and 434 patients diagnosed with acute appendicitis during the COVID-19 outbreak. Patient demographic data, type of appendicitis, type of treatment, time to surgery, length of stay, cost, and complications were collected and analyzed. During the COVID-19 pandemic, the number of patients diagnosed with acute appendicitis was reduced. CT scan usage for diagnosis was increased compared to pre-COVID-19. Most patients diagnosed with acute appendicitis received operative treatment in both groups. Median time to surgery was significantly longer during the COVID-19 pandemic, 11.93 hours compared to 9.62 hours pre-COVID-19, p-value <0.001 (relative risk 1.5, 95% CI 1.29-1.76, p value 0.041). The incidence of complicated appendicitis was not higher during COVID-19. Compared to pre-COVID-19, ICU admission rate, the use of a mechanical ventilator, length of stay, and cost increased in the univariate analysis but were not statistically significant in the multivariate analyses. Other treatment complications had no statistically significant difference. The incidence of complicated appendicitis did not increase during the COVID-19 pandemic. The operation waiting time significantly increased but did not increase the rate of treatment complications in a well-prepared hospital system.

The effect of climate and air pollution on the development of complicated appendicitis

&lt;b&gt;Aim:&lt;/b&gt; The aim of this study was to examine whether there is a relationship between complicated appendicitis and seasons, weekends, and air pollution. &lt;/br&gt;&lt;/br&gt; &lt;b&gt; Materials and methods:&lt;/b&gt; Patients who had undergone appendectomy in the last three years due to acute appendicitis were filtered from the database. Patients’ demographic features, date of the surgery, pathology reports, data on atmospheric temperatures, atmospheric pressure, relative humidity, and air pollution on the date of the surgery were collected and compared between complicated and non-complicated appendicitis groups. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Results:&lt;/b&gt; Out of 360 patients, 238 were men. The median age was 39 years for women and 29 years for men. Complicated appendicitis was seen in 78 (21.7%) patients, and the incidence rates were similar between the sexes (p = 0.69); this rate increased with increasing age (p = 0.001). The day of the week in which the surgery was performed (p = 0.55) and weekdays versus weekends (p = 0.16) did not change the complicated appendicitis incidence rate. This rate was similar among seasons (p = 0.44), temperature (p = 0.81), humidity (p = 0.62), and atmospheric pressure (p = 0.95). There was no difference between the groups for all noxious gases or PM2.5 levels, but for PM10 levels there was a significant difference (p = 0.045). In multivariate analysis, age (p = 0.001) and PM10 air pollution (p = 0.045) significantly affected the development of complicated appendicitis. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusions:&lt;/b&gt; Air pollution of PM10 may have a real effect on the incidence of complicated appendicitis.

Effect of the Movement Control Order on the Incidence of Complicated Appendicitis During the COVID-19 Pandemic: A Cross-Sectional Study.

BackgroundAppendicitis is common and delayed presentation results in complicated appendicitis with increased morbidity. This study investigates the effect of the Movement Control Order (MCO) during the COVID-19 pandemic on the presentation and severity of appendicitis.MethodsA cross-sectional study including 193 patients diagnosed with appendicitis was conducted at four hospitals in Pahang, Malaysia. Those who presented between 1 February 2020 and 17 March 2020 were included in the pre-MCO group and those between 18 March 2020 and 30 April 2020 in the MCO group. The definitions of simple and complicated appendicitis were based on the Sunshine Appendicitis Grading Score. The primary outcome was the incidence of complicated appendicitis, and the secondary outcomes were length of stay, a composite of surgical morbidities and a composite of organ failure.ResultsA total of 105 patients in the pre-MCO group and 88 in the MCO group were analysed. The incidence of complicated appendicitis was 33% and it was higher in the MCO than in the pre-MCO group (44% versus 23%, P = 0.002). The MCO period was independently associated with complicated appendicitis in the logistic regression (P = 0.001). It was also associated with prolonged length of stay (3.5 days versus 2.4 days, P < 0.001) and higher overall surgical morbidity (19% versus 5%, P = 0.002).ConclusionThe MCO imposed during the COVID-19 pandemic was associated with a higher incidence of complicated appendicitis and surgical morbidity.

Increased incidence of complicated acute appendicitis after the first COVID-19 pandemic peak: Have patients a different attitude towards COVID-hospitals?

ObjectiveThe 11 March 2020 the World Health Organisation considered the COVID-19 Infection a pandemic disease. Between March and May 2020, the region of southern Switzerland was affected by the first pandemic peak, which was managed by dividing hospitals in Covid and non Covid facilities and by reducing elective surgery. At the end of the pandemic peak hospitals returned to their original structure but there was concern as to possible avoidance of former COVID facilities by patients because of fear of contracting of COVID-19 infection. For acute situations such as acute appendicitis, this could imply a delay of treatment. The aim of this retrospective study is to analyse the increment in incidence of complicated appendicitis in the post-pandemic period at our institution.MethodsClinical data of patients who underwent appendectomies in the period before and after the COVID-19 pandemic were analysed and compared. Diagnosis was based histopathological examination and/or on intra-operative or CT findings. Complicated appendicitis was defined as the presence of perforated or gangrenous appendicitis on histopathology or the presence of an abscess on CT scan. The incidence of complicated appendicitis, the time between onset of symptoms and patient admission (TOSA), the initial inflammatory blood tests and the complication rate was compared between the two periods.Results79 patients were included in the study, 31 in the post-COVID-19 peak group (A), April - October 2020, and 48 in the pre-pandemic group (B), April - October 2019. Incidence of complicated appendicitis was significantly higher in group A (55% vs 14% p = 0.02). These findings correlate with a greater TOSA (mean time 35 hours vs 17 hours, p = 0.01) and higher inflammatory values in the initial blood test, (mean WBC count 14.8 G/l vs 12.9 G/l, p = 0.08 and mean CRP value 73 mg/l vs 43 mg/l, p = 0.01) in group A.ConclusionOur data show a clear increase of incidence of complicated acute appendicitis after the pandemic peak in our hospital. Indeed patients tended to wait longer to visit our emergency department after the pandemic peak. One explanation is a possible fear by the patients of contracting COVID-19 infection in a former COVID hospital. Management of surgical emergencies during and after a pandemic peak phase should take into account the fact that patients may wait longer to visit a doctor thus aggravating the degree of their disease.

Incidence of Complicated Appendicitis as a Metric of Health Care Delivery.

Complicated acute appendicitis (CAA) has been linked to extremes of age, racial and socioeconomic disparities, public insurance, and remote residency. CAA rate has been used from 2005 to 2018 as a health care quality metric, with the assumption that delay in treatment was a main cause of perforation. We studied factors that could contribute to CAA focusing on modifiable factors which could be altered as part of a health care delivery system. All primary admissions for acute appendicitis (AA) from the 2010 Nationwide Inpatient Sample were linked to 2010 state-level physician density data. CAA was distinguished by codes for perforation, generalized peritonitis, or intra-abdominal abscess. A multivariable logistic regression model for CAA prediction was built. A total of 288556 patients were admitted with AA and 86272 (29.9%) had CAA. Independent factors, linked to CAA, included age outside the 10-39 range (odds ratio (OR) = 2.1-2.4 and all P < .001), male gender (OR = 1.2), malnutrition (OR = 6.2), diabetes mellitus (OR = 2.1), chronic anemias (OR = 1.9), nonprivate insurances (OR 1.2-1.5), nonmetropolitan patient's residence (OR = 1.15), and Midwest region (OR = 1.2). Patient income and physician coverage were not significant factors after adjustment for all other covariates. Highest CAA fraction of 39.6% was noted in rural patients admitted to urban teaching facilities. Although provider coverage at the state level may seem adequate and not related to increased CAA rates, the distance patients traveled for their definitive surgical care correlated with higher rates of CAA. Adjusting physician distribution into nonurban settings closer to patients could decrease rates of CAA by diminishing time to definitive care.

Demographics of paediatric patients presenting with acute appendicitis: A 5-year retrospective review of hospitals served by the Department of Paediatric Surgery at the University of the Witwatersrand

Background. There are no recently published data on the incidence and demographics or perforation rates of paediatric patients from our local population presenting with acute appendicitis. Objective. To show the age and gender distribution of paediatric patients presenting with acute appendicitis within our communities, as well as demonstrating the incidence of perforated acute appendicitis in our paediatric population. Method. The study is a retrospective record review of all paediatric patients who presented with acute appendicitis to the Department of Paediatric Surgery at both Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), and Chris Hani Baragwanath Academic Hospital (CHBAH) from June 2010 to September 2015. Data collected included all demographic data as well as histology results of patients who underwent appendectomies. Results. The total numbers of patients included in the study were 544; 234 at CHBAH, and 311 at CMJAH. The male-to-female ratio was 1.58:1. The mean age for presentation at both hospitals combined was 8.76 years. We found that 13.41% of paediatric patients with acute appendicitis in this cohort were under the age of 6 years. A histological review showed that 50.1% of patients in our cohort presented with complicated appendicitis, and we had a negative appendectomy rate of 8.4%. Histological results of patients under the age of 6 years revealed a higher negative appendicectomy rate of 11.4%. However, the incidence of complicated appendicitis in this age group was only 45.7%, which is lower than that reported in the literature. Three patients were found to have Enterobius vermicularis in the lumen of the appendix, and Ascaris ova were identified in one patient. Histology revealed a low-grade mucinous neoplasm in one patient. Conclusion. Acute appendicitis occurred at a median age of 8.76 years in our study population, with a male-to-female ratio of 1.58:1. We found that acute appendicitis occurred relatively more frequently in our patients under the age of 6 years compared with the incidence of acute appendicitis in this age group published elsewhere. Complicated appendicitis occurred in 50.1% of our patient population, with an increased frequency of perforated appendicitis occurring in our male population. However, complicated appendicitis occurred in only 44.7% of our patients below the age of 6 years, which is in stark contrast to published literature. Helminthic infections were rare associated pathogens in our study, and an unlikely underlying pathogen of acute appendicitis in our population.

Complicated appendicitis during pregnancy

To analyze incidence, diagnosis and treatment of complicated appendicitis in pregnant women and to determine the optimal surgical approach. Retrospective cohort analysis included 338 pregnant women who underwent appendectomy in 2012-2016. Complicated appendicitis (abscess, local or common peritonitis and their combinations) was diagnosed in 22 cases. The main perioperative variables (duration of the disease, time of surgery, length of hospital-stay, incidence of wound complications, etc.), clinical and laboratory symptoms, results of ultrasound diagnosis and pregnancy outcomes were analyzed. Statistical analysis was carried out in Stata 14.2. Fisher's exact test, Mann-Whitney-Wilcoxon's U-test and multivariate regression analysis were used to compare data. The incidence of complicated appendicitis in pregnant women was 6.51%. There are no clinical symptoms which would be significantly more common in complicated appendicitis during pregnancy. Complicated course prolongs surgery and hospital-stay, however duration of postoperative analgesia depends on surgical technique as a rule. There were 27% of laparoscopic interventions that is lower compared with women with uncomplicated appendicitis. The percentage of conversions was higher too. Clinical diagnosis of complicated appendicitis during pregnancy even by using of ultrasound is not satisfactory and requires the involvement of other objective methods, such as MRI. Laparoscopic intervention is not contraindicated in pregnant women with complicated appendicitis and determine better treatment outcomes than open surgery.

Diagnostic value of serum bilirubin in appendicular perforation

Background: Hyperbilirubinemia has been well documented in relation to acute appendicitis. This study tries to establish the diagnostic value of this parameter in determining the severity of acute appendicitis.Methods: This is a prospective analytical study conducted on 100 patients with acute appendicitis. All patients were subjected to clinical evaluation and investigations; including liver function tests. The diagnosis was confirmed peri-operatively and postoperatively by histopathological examination. The data was compiled and analysed.Results: The incidence of complicated appendicitis was found to be 18%, defined as evidence of gangrene, or microscopic or gross perforation on histopathological examination. Among these total serum bilirubin (TSB) was raised in 17 cases (17%) and statistically significant correlation was established by p-value &lt;0.001. The mean of TSB level was higher in perforated appendicitis than in cases of acute appendicitis (0.57±0.26 mg/dL; range 0.1-1.2 versus 1.68±1.09 mg/dL; range 0.8-4.8 mg/dL). TSB was shown to have specificity of 96.4%, sensitivity 88.2%, PPV 83.3% and NPV was 97.6%. The diagnostic accuracy of raised bilirubin for diagnosis of appendicular perforation was calculated to be 95.0%. The rise in bilirubin was mixed in type (both indirect and direct). There could not be established any correlation between the liver enzymes and appendicitis or its complications.Conclusions: This study ascertains the predictive value of serum bilirubin in acute appendicitis patients as an indicator of severity. Raised bilirubin in the setting of acute appendicitis identifies higher probability of appendicular perforation.

Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis.

Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe, but overall effectiveness is determined by combining medical outcomes with the patient's and family's perspective, goals, and expectations. To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children. Prospective patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1, 2012, through March 6, 2013. Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy. Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and, on demonstrating improvement of symptoms, completion of 10 days of treatment with oral antibiotics. The primary outcome was the 1-year success rate of nonoperative management. Successful nonoperative management was defined as not undergoing an appendectomy. Secondary outcomes included comparisons of the rates of complicated appendicitis, disability days, and health care costs between nonoperative management and surgery. A total of 102 patients were enrolled; 65 patients/families chose appendectomy (median age, 12 years; interquartile range [IQR], 9-13 years; 45 male [69.2%]) and 37 patients/families chose nonoperative management (median age, 11 years; IQR, 10-14 years; 24 male [64.9%]). Baseline characteristics were similar between the groups. The success rate of nonoperative management was 89.2% (95% CI, 74.6%-97.0%) at 30 days (33 of 37 children) and 75.7% (95% CI, 58.9%-88.2%) at 1 year (28 of 37 children). The incidence of complicated appendicitis was 2.7% in the nonoperative group (1 of 37 children) and 12.3% in the surgery group (8 of 65 children) (P = .15). After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days (median [IQR], 8 [5-18] vs 21 [15-25] days, respectively; P < .001) and lower appendicitis-related health care costs (median [IQR], $4219 [$2514-$7795] vs $5029 [$4596-$5482], respectively; P = .01). When chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, incurring less morbidity and lower costs than surgery. clinicaltrials.gov Identifier: NCT01718275.

Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials

Objective To compare the safety and efficacy of antibiotic treatment versus appendicectomy for the primary treatment of uncomplicated acute appendicitis.Design Meta-analysis of randomised controlled trials.Population Randomised controlled trials of adult...

Clinical versus sonographic evaluation of acute appendicitis in children: A comparison of patient characteristics and outcomes

Purpose: Abdominal sonography has gained popularity in establishing the diagnosis of appendicitis in children with equivocal clinical presentations. However, no clear outcome benefits have been demonstrated to date. The authors conducted a retrospective study to compare the characteristics and outcomes of patients undergoing appendectomy after clinical evaluation only with those undergoing the procedure after sonography. Methods: The charts of 454 consecutive patients undergoing appendectomy for acute appendicitis between January 1, 1998 and December 4, 1999 were reviewed. Patients operated on after clinical evaluation only were compared with patients operated on after abdominal sonography. Results: Forty-two percent of patients (n = 191) constituted the sonography group. When compared with the clinical group, these patients had higher prevalence of female gender (52% v 38%; P =.004), longer symptom duration (2.2 ± 2.5 v 1.6 ± 1.6 days; P =.003), higher incidence of preoperative in-patient observation (19% v 4%; P <.001), longer duration between evaluation and operation (8.0 ± 3.9 v 4.9 ± 2.9 hours; P <.001), higher incidence of normal appendices on pathologic examination (13% v 6%; P =.006), and higher incidence of postoperative abscesses or phlegmons (4.4% v 1.2%; P =.04). The groups did not differ significantly in age, hospital stay, incidence of complicated appendicitis, or incidence of wound infection. Conclusions: Patients undergoing sonography before appendectomy have a longer delay before operation, a higher rate of misdiagnosis, and more postoperative complications. Limiting sonography to truly equivocal cases and using it early in the diagnostic workup may improve outcomes in this group of patients. J Pediatr Surg 36:780-783. Copyright © 2001 by W.B. Saunders Company.

Acute and perforated appendicitis: Current experience with ultrasound‐aided diagnosis

The clinical value of high-resolution real-time sonography for the diagnosis of acute and complicated appendicitis was prospectively investigated in 857 patients admitted with suspected appendicitis. The ultrasound findings were correlated with history and physical examination on admission. Sonography was able to make the diagnosis of appendicitis with a sensitivity of 89.7%, a specificity of 98.2%, an overall accuracy of 96.3%, and a positive and negative predictive value of 93.6% and 97%, respectively. Routine use of ultrasound before making therapeutic decisions has reduced the rate of unnecessary laparotomies from 20.3% to 11.3%. In 48 (24.7%) of 194 patients with proven appendicitis, the disease had progressed to perforation at laparotomy. History and clinical findings on admission classified 30 (62.5%) of these patients as "highly suspect;" however, 9 (18.8%) were classified as "equivocal" and 9 (18.8%) as "very unlikely." Only half (48%) of the patients with appendiceal rupture had white blood cell counts higher than 13,000/mm3 or fever above 38 degrees C (50%). Sonography enabled the visualization of the inflamed appendix and/or appendicular abscess in 44 (91.7%) patients with perforation. In 47 of 48 patients with appendiceal rupture, the ultrasound-aided diagnosis was made on hospital admission. Thus, the incidence of complicated appendicitis (24.7%) in our study population must be attributed to disease progression before admission and preclinical diagnostic delay.