Laparoscopic Appendectomy Research Articles

Using Consumer Wearable Devices to Profile Postoperative Complications After Pediatric Appendectomy

IntroductionMarkers of postoperative recovery in pediatric patients are difficult for parents to evaluate after hospital discharge, who use subjective proxies to assess recovery and the onset of complications. Consumer-grade wearable devices (e.g., Fitbit) generate objective recovery data in near real time and thus may provide an opportunity to remotely monitor postoperative patients and identify complications beyond the initial hospitalization. The aim of this study was to use daily step counts from a Fitbit to compare recovery in patients with complications to those without complications after undergoing appendectomy for complicated appendicitis. MethodsChildren ages 3-17 years old undergoing laparoscopic appendectomy for complicated appendicitis were recruited. Patients wore a Fitbit device for 21 d after operation. After collection, patient data were included in the analysis if minimum wear-time criteria were achieved. Postoperative complications were identified through chart review, and step count trajectories for patients recovering with and without complications were compared. Additionally, to account for the patients experiencing a complication on different postoperative days, median daily step count for pre- and post-complication were analyzed. ResultsEighty-six patients with complicated appendicitis were enrolled in the study, and fourteen children developed a postoperative complication. Three patients were excluded because they did not meet the minimum wear time requirements. Complications were divided into abscesses (n = 7, 64%), surgical site infections (n = 2, 18%), and other, which included small bowel obstruction and Clostridioides difficile infection (n = 2, 18%). Patients presented with a complication on mean postoperative day 8, while deviation from the normative recovery trajectory was evident 4 d prior. When compared to children with normative recovery, the patients with surgical complications experienced a slower increase in step count postoperatively, but the recovery trajectory was specific to each complication type. When corrected for day of presentation with complication, step count remained low prior to the discovery of the complication and increased after treatment resembling the normative recovery trajectory. ConclusionsThis study profiled variations from the normative recovery trajectory in patients with complication after appendectomy for complicated appendicitis, with distinct trajectory patterns by complication type. Our findings have potentially profound clinical implications for monitoring pediatric patients postoperatively, particularly in the outpatient setting, thus providing objective data for potentially earlier identification of complications after hospital discharge.

The importance of accuracy in consenting in Laparoscopic Appendicectomies and Cholecystectomies in Emergency General Surgery

Abstract Background Emergency General Surgery frequently necessitates expediting the consent due to clinic pressure often reducing the time for extensive and accurate consents. New recommendations from GIRFT, RCS and ASGBI advise the best practice for laparoscopic appendicectomy and cholecystectomies documentation to ensure that clinicians are adhering to safe practice with focus on consenting and informing patients accurately. Aim The aim of this study is to look at the accuracy of the documentation of consent in emergency general surgery laparoscopic appendicectomies and cholecystectomies to ensure and promote best practice. Method A retrospective analysis of 75 patients from the emergency general surgical take requiring laparoscopic appendicectomy or cholecystectomy from 08/09/23-14/9/23 in the Royal infirmary of Edinburgh, a tertiary trauma centre. The consent forms were analysed for scribed operation, legibility, abbreviations, and risks/ complications. The patients’ notes were then analysed to find out the operation carried out and any operative or immediate post operative complications. The consents forms were then compared to the post operative notes looking at the immediate operative complications to assess their accuracy. Conclusion The retrospective study demonstrated that there is scope for improvement within the consenting process to ensure the accuracy of the predicted operation and subsequent risks thus to improve true informed consent. The areas which could easily be improved on as such is the legibility, use of abbreviations and complete documentation of risks/complications the use of Procedure specific consent forms (PSCF) may be beneficial in creating standardisation.

Reducing Unnecessary Group and Screen Sampling for Laparoscopic Appendicectomy: A retrospective single centre analysis.

Abstract Aims Blood transfusion is rarely required for patients undergoing laparoscopic appendicectomies (LA) however some NHS trusts still require group and screen (G&S) sampling. This study aimed to assess G&S sampling for LA, rate of transfusion and the cost of G&S sampling at our hospital. It re-assessed these parameters after introduction of a guideline specifying that G&S are not needed routinely and should only be considered in case of high-risk patients (including those with deranged clotting, anticoagulation or profound anaemia). Methods A retrospective observational study was conducted in our centre from 01/02/2022-01/06/2022 (cycle one) and 20/04/23- 20/08/2023 (cycle two post, guideline introduction). All patients undergoing emergency LA were included. Laboratory costs of G&S sampling was estimated at £18.37 excluding consumables, CO2 emissions estimated at 116g/ test. Results The first cycle included 48 patients for which 85 G&S samples were sent costing £1561.45. 21 samples were rejected / not required and estimated CO2 emissions were 9.86kg. In second cycle, 32 G&S samples were sent for 52 patients, only 2 samples were rejected. No patients required blood transfusion. £973.61 and an estimated 6.1kg CO2 emissions were saved. Conclusions We established a guideline which negates the need for routine G&S sampling in patients undergoing LA in our hospital. Projected savings are approximately £30,000 per annum excluding theatre delay costs, personnel and other consumables. We recommend other NHS trusts should look to implement similar guidelines in order to reduce cost and CO2 impact of unnecessary testing in EGS.

Pain Management Throughout Pediatric Laparoscopic Appendectomy: A Systematic Review.

Opioid-related fatalities are a leading cause of accidental death in the United States. Appendicitis is a common cause of abdominal pain in children and adolescents. The management of pain throughout the laparoscopic appendectomy (LA) in the pediatric population is a critical concern. This study aimed to evaluate trends in analgesic use and patient satisfaction following LA, with a focus on reducing the reliance on opioids for pain management. From 2003 to 2023, 18258 articles were filtered for all types of analgesic use with LA. The publications were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 19 studies were included for analysis and review. The study included peer-reviewed experimental and observational studies involving individuals under 18 years. Pain management strategies varied across studies, involving a combination of analgesics, nerve blocks, and wound infiltrations. Analgesics such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids were administered before and after surgery. Some studies implemented patient-controlled analgesia (PCA) pumps. Other studies explored non-pharmacological interventions like magnetic acupuncture. The results showed a reduction in the need for postoperative analgesics in patients treated with LA, particularly when using non-opioid medications and novel analgesic techniques. Pediatric patients who received gabapentin reported lower opioid use, shorter hospital stays, and high satisfaction rates. However, the reliance on opioids remained significant in some cases, particularly among patients with peritonitis who required more morphine. Pain management in pediatric patients is multifaceted, involving preoperative and postoperative analgesics, nerve blocks, and PCA pumps. Efforts to improve pain management following pediatric LA while reducing opioid reliance are essential in the context of the ongoing opioid epidemic. The findings from this study highlight the potential benefits of non-opioid analgesics, nerve blocks, and alternative methods for managing postoperative pain in <18 appendectomy patients. Further research and standardization of pain management protocols are needed to ensure optimal patient outcomes and minimize the risk of opioid-related complications.

A randomised controlled trial to study the analgesic efficacy of transversus abdominis plane block for adult undergoing elective laparoscopic appendectomy

Background: Laparoscopic appendectomy has evolved over the years as a minimally invasive approach for appendicitis. Routinely opioids are used for pain control postoperatively, however, its widespread use has numerous side effects and delays postoperative recovery. More recent studies have shown that transversus abdominis plane block reduces postoperative pain and analgesic drug usage. This study aims to evaluate the impact of transversus abdominis plane block in managing postoperative pain following elective laparoscopic appendectomy. Methods: A prospective, randomized, double-blind trial was performed on patients undergoing elective laparoscopic appendectomy. Patients were randomized to receive a TAP block with 0.25% bupivacaine and a control group receiving a TAP block with normal saline infusion. Laparoscopic port sites were infiltrated with bupivacaine in the control group and normal saline in the TAP block intervention group before starting the surgery. Postoperative pain scores were recorded using the visual analog scale scores at dedicated time points. Results: A total of 20 patients were included in the control group and 19 in the TAP block group. Visual analog scale scores were significantly reduced in the TAP block group at 6 hours, 12 hours, and 18 hours (p&lt;0.001 in each). However, there was no significant reduction in the visual analog scale score at 24 hours (p=0.015). There was no significant difference between postoperative nausea (p=0.18), and length of postoperative hospital stay (p=0.93) between the two groups. Consumption of rescue analgesics and antiemetics in the first 24 hours postoperatively between both groups was statistically significant (p=0.005). Conclusions: Bilateral TAP block is safe and effective in reducing the need for analgesics and antiemetics in patients undergoing laparoscopic appendectomy in the postoperative period. In addition, there is a significant improvement in visual analog scale scores in patients after TAP block.

Laparoscopic appendectomy in complicated appendicitis with compromised appendix base: a retrospective cohort study

Laparoscopic appendectomy in complicated appendicitis with compromised appendix base: a retrospective cohort study

Pre-Anesthesia Transfusion and Peri-Procedure Complications in Patients with Sickle Cell Disease on Hydroxyurea

Introduction Patients with sickle cell disease (SCD) are at increased risk of perioperative complications following general anesthesia including acute chest syndrome (ACS), vaso-occlusive pain episodes (VOE), and infection. The 2013 Transfusion Alternatives Preoperatively in SCD (TAPS) study found preoperative transfusion of patients with SCD, type SS or SB 0 thalassemia, prior to low- or medium-risk surgeries was associated with decreased perioperative complications. The American Society of Hematology 2020 guidelines for transfusion support for SCD suggest preoperative transfusion for those requiring general anesthesia (GA) lasting &amp;gt; 1 hour; however, it was noted that this should be individualized based on factors such as risk of surgery, baseline hemoglobin (Hb), and disease severity. With more broad use of Hydroxyurea (HU) that improves baseline Hb and decreases ACS and VOE frequency, we lack equipoise for when pre-anesthesia transfusion is indicated. We performed a chart review on pediatric patients with SCD at a large SCD center to determine clinician practice of pre-anesthesia transfusion versus no transfusion for patients on HU and the incidence of post-anesthesia complications with and without pre-anesthesia transfusion. Methods We performed an institutional review board approved retrospective chart review of patients with SCD (all genotypes) aged 0 to 22 years who underwent procedures or imaging studies with GA between the years 2019 and 2022 at our institution. Surgical risk score was assigned to all procedures per the TAPS study criteria. We examined the incidence of post-anesthesia complications occurring in the emergency department or hospital within 30 days post-anesthesia. Complications such as VOE, ACS, transfusion-related effects, and infection were recorded as categorical variables. Results We identified 165 patients with SCD who underwent GA at our center between 2019 and 2022: 56 of these patients were on hydroxyurea and 41 were not on hydroxyurea. We excluded 52 patients on chronic transfusion and 16 who had not consented for participation or had anesthesia encounters during a stem cell transplant admission. Among the 56 patients on HU, 34 received pre-anesthesia transfusion (2 by exchange transfusion) and 22 did not. The average Hb of those on HU who received pre-anesthesia transfusion was 8.64 g/dl (SD 1.1 g/dl) and of those who did not receive transfusion it was 9.4 g/dl (SD 1.33 g/dl) (p = 0.03, unpaired t-test). Among patients on HU who received transfusion, 4/34 (12%) had post-anesthesia complications and of those who did not receive transfusion, 6/22 (27%) had complications (p = 0.17, Fisher exact test) (Table). Among the transfused cohort, complications occurred after 2 low-risk procedures (ACS after an electrophysiology study with radiofrequency ablation and streptococcal infection after an abdominal exploratory laparoscopy), 1 medium-risk procedure (hematuria/abdominal pain after laparoscopic cholecystectomy) and 1 high-risk procedure (respiratory failure after coarctation of the aorta repair). Among patients who were not transfused, complications occurred after 2 imaging studies (ACS in the setting of parainfluenza infection after brain MRI and VOE after shoulder MRI), 2 low-risk procedures (ACS after laparoscopic appendectomy and VOE after adenoidectomy), and 2 medium-risk procedures (ACS after laparoscopic cholecystectomy and multiple admissions for 1 patient for ACS and VOE after endoscopic retrograde cholangiopancreatography). Conclusions In patients with SCD -SS or -SB 0 thalassemia on hydroxyurea undergoing procedures with anesthesia at our center, clinicians continued to prescribe pre-anesthesia transfusion for those with a Hb &amp;lt; 9 g/dl. The incidence of complications was higher in patients on HU who did not receive pre-anesthesia transfusion despite an average pre-procedure Hb of &amp;gt; 9 g/dL, but this was not statistically significant in our small sample size. However, these numbers are comparable to the findings of the TAPS study which found that 5/33 (15%) patients in the preoperative transfusion group had clinically important complications compared with 13/33 (39%) patients in the no transfusion group. These findings suggest that despite higher baseline Hb levels in the setting of HU use, patients with sickle cell disease may continue to benefit from pre-anesthesia transfusion but a randomized controlled trial is necessary.

Stump Appendicitis: A Rare Late Complication of Appendectomy, a Retrospective Analysis of 9082 Appendectomy Cases

Objective: Appendectomy for appendicitis is one of the most common surgical procedures performed worldwide. The remnant of the appendix stump after the first appendectomy carries the risk of developing stump appendicitis. Stump appendicitis is a rare late complication of appendectomy; inflammation occurs in the remaining appendicular stump. Delayed diagnosis of this condition can cause serious complications. Stump appendicitis is indeed a recognized clinical picture, but is often overlooked when evaluating patients with right lower quadrant abdominal pain, especially those with a history of appendectomy. It remains a clinical challenge because of its often delayed diagnosis and effective treatment, and possible accompanying morbidity or mortality. Material and Methods: Materials and Methods: We retrospectively screened the patients who were hospitalized in our general surgery clinic and diagnosed with stump appendicitis in the hospital for 12 years. There were 11 patients between January 2011 and 2023 Results: The mean age of all 11 patients described was 55 years (range: 20 to 66). 72% of the patients were male (8/11 males and 3/11 females). 63% of the patients had their first operations open, and 36% of them were laparoscopic. The mean white blood cell count on presentation of all reported 11 cases was 11,996 cells/mm3 (range: 5930 to 18,740), the mean fever was 37.82°C (range: 36.8 to 38.6), and the mean CRP count on presentation of all cases was 36.7 (range: 0.4 to 142.91). The most commonly performed radiographic examination used to diagnose stump appendicitis is the abdominal computerized tomography (CT) scan. It was used in 100% (11 cases). Ultrasound was also used in 100% (11 cases). Conclusion: The appendicular base must be accessed prior to undertaking an appendectomy, irrespective of the chosen strategy or technique. It is noteworthy that, apart from open or laparoscopic appendectomy, antibiotic therapy should also be considered as part of the treatment regimen, as documented in the literature series.

Using Wearable Devices to Profile Demographic-Specific Recovery After Pediatric Appendectomy

IntroductionCounseling patients and parents about the postoperative recovery expectations for physical activity after pediatric appendectomy varies significantly and is not specific to patients' demographic characteristics. Consumer wearable devices (CWD) can be used to objectively assess patients’ normative postoperative recovery of physical activity. This study aimed to develop demographic-specific normative physical activity recovery trajectories using CWD in pediatric patients undergoing appendectomy. MethodsChildren ages 3-18 y old undergoing laparoscopic appendectomy for acute appendicitis were recruited. Patients wore a Fitbit device for 21 d postoperatively and daily step counts were measured. Patients with postoperative complications were excluded. Segmented regression models were fitted and time-to-plateau was estimated for patients with simple and complicated appendicitis separately for each age group, sex, race/ethnicity, and body mass index category. ResultsAmong 147 eligible patients; 76 (51.7%) were female, 86 (58.5%) were in the younger group, and 79 (53.7%) had complicated appendicitis. Patients 3-11 y old demonstrated a faster trajectory to a physical activity plateau compared to those 12-18 in both simple (postoperative day [POD] 9 versus POD 17) and complicated appendicitis (POD 17 versus POD 21). Males and females had a similar postoperative recovery trajectory in simple and complicated appendicitis. There was no clear pattern differentiating trajectories based on race/ethnicity. Overweight/obese patients demonstrated a slower recovery trajectory in simple appendicitis. ConclusionsThis study demonstrates that factors other than the disease itself, such as age, may affect recovery, suggesting the need for more tailored discharge instructions. CWDs can improve our understanding of recovery and allow for better data-driven counseling perioperatively.

EGS P39 The first cycle of an audit assessing the quality of documentation of emergency laparoscopic appendicectomies at Birmingham Heartlands Hospital, a District General Hospital

Abstract Background Laparoscopic appendicectomy is a common general surgical procedure. Poor documentation can a) result in misunderstandings between healthcare workers looking after patients and b) limit fair investigation of incidents. The Get It Right First Time (GIRFT) guidance was produced to advise on the information that should be available in patient records to reduce risk of both of the above. Aims and objectives To assess how well laparoscopic appendicectomies are documented in accordance with the GIRFT criteria. To then develop interventions to improve documentation and ultimately improve communication with other healthcare workers and allow defence of good medical practice. Methods Three people collected data on 100 laparoscopic appendicectomies that took place in 2022-2023 at Heartlands Hospital. Data was collected based on the 34 GIRFT recommendations and the sources were: electronic patient notes (adults); scanned patient notes (children); electronic operation notes (all); and theatre logbooks. It was then analysed and grouped into factors that were documented well (&amp;gt;75% of the cases), moderately well (&amp;gt;50% but £75%), poorly (&amp;gt;25% but £50%) or very poorly (£25%). Results Factors that that were documented well (23%) included use of a sterile bag for appendix removal (83%), details of closure (96%), and instructions for post-operative antibiotics (88%) and recovery (97%). Those documented moderately well (19%) included port location and size (70%) and achievement of haemostasis (62%). Those documented poorly (23%) included whether ports were inserted under direct vision (38%) and whether any residual appendix was left behind (39%). Those documented very poorly (36%) included sending a sample to histology and grade of doctors. Several of these were documented primarily in paper records that are not scanned - hence not readily accessible). Conclusions While there are several aspects of documentation which we are currently doing well, there is still much scope to improve documentation as a whole. The current format of the operation note itself limits the information which can be communicated. This in combination with the documentation of some important information on paper – which is largely inaccessible outside of theatre or once a patient has been discharged – produces unnecessary ambiguity. Discussion is ongoing with electronic records teams to alter the operation note format to improve documentation quality. These findings will be discussed at a departmental audit meeting to specify changes before re-auditing.

Analysis of the Effectiveness of Laparoscopic Appendectomy Compared to Laparotomy in the Treatment of Acute Appendicitis

Objective: To analyze the clinical effects of laparoscopic appendectomy compared to traditional laparotomy in treating acute appendicitis. Methods: 90 patients with acute appendicitis were selected as research subjects. They were divided into a control group and an observation group, with 45 cases in each group. The control group underwent traditional laparotomy, while the observation group underwent laparoscopic appendectomy. The intraoperative indicators, postoperative recovery indicators, postoperative stress indicators, and postoperative omplications of the two groups were compared. Results: The operative time of the observation group was longer, but the incision length was shorter and the blood loss was lesser (P &lt; 0.05); the observation group had shorter postoperative first gas-passing time, recovery of gastrointestinal function, ambulation time, and lower postoperative pain score. The bservation group had lower postoperative stress index levels (P &lt; 0.05); the observation group had a lower postoperative complication rate (P &lt; 0.05). Conclusion: Aside from prolonging the operative time, laparoscopic appendectomy is more ideal than traditional laparotomy in all other indicators and has better therapeutic effects in treating acute ppendicitis.

Carcinoid tumor of the appendix with clinical picture of acute appendicitis, urgently operated on by laparoscopic appendectomy. Presentation of clinical case

Carcinoid tumor of the appendix with clinical picture of acute appendicitis, urgently operated on by laparoscopic appendectomy. Presentation of clinical case

Management of acute appendicitis during COVID-19 pandemic. Single center data from a tertiary care hospital in Germany.

The unexpected global overload of the health system during COVID-19 pandemic has caused changes inmanagement of acute appendicitis worldwide. Whereas conservative treatment was widely recommended, the appendicectomy remained standard therapy in Germany. We aimed to investigate the impact of COVID-19 pandemic ontreatment routine for acute appendicitis at University Hospital of Magdeburg. Adult patients with clinical and/or radiological diagnosis of acute appendicitis were included in the single center retrospective study. Data was collected to patient demographics, treatment modality and outcomes including morbidity and length of stay. The patient data related to COVID-19 period from March 22, 2020 to December 31, 2021 (649days) were compared to the Non-COVID-19 period from June 12, 2018 to March 21, 2020 (649days). Subgroup analysis related to conservative or surgical treatment has been performed. A total of 385 patients was included in the study, 203 (52.73%) during Non-COVID-19 period and 182 (47.27%) during COVID-19 period. Mean age of entire collective was43.28 years, containing 43.9% female patients (p=0.095). Conservative treatment was accomplished in 49 patients (12.7% of entire collective), increasing from 9.9 % to 15.9% during COVID-19 period (p=0.074). Laparoscopic appendicectomy was performed in 99.3% (n=152) of operated patients during COVID-19 period (p=0.013), followed by less postoperative complications compared to reference period (23.5% vs. 13.1%, p=0.015). The initiation of antibiotic therapy after the diagnosis increased from 37.9 % to 53.3% (p=0.002) during COVID-19 period regardless the following treatment modality. Antibiotic treatment showed shorter duration during pandemic period (5.57days vs. 3.16days, p<0.001) and it was given longer in the conservative treatment group (5.63days vs. 4.26days, p=0.02). The overall length of stay was shorter during COVID-19 period (4.67days vs. 4.12 days, p=0.052) and in the conservative treatment group (3.08days vs. 4.47days, p<0.001). However, the overall morbidity was lower during the COVID-19 period than before (17.2% vs. 7.7%, p=0.005) and for conservative therapy compared toappendicectomy (2 % vs. 14.3%, p=0.016). There was no mortality documented. According to our findings the COVID-19 pandemic had a relevant impact on treatment of acute appendicitis, but it was possible to maintain the traditional diagnostic and treatment pathway. Although laparoscopic appendicectomy remains a recommended procedure, the conservative treatment of uncomplicated appendicitis with excellent short-term outcome can be a safe alternative to surgery during potential new wave of COVID-19 pandemic and in the daily routine.

Hem-o-Lok clip versus extracorporeal sliding knot during Laparoscopic appendectomy, A prospective randomized clinical trial.

Hem-o-Lok clip versus extracorporeal sliding knot during Laparoscopic appendectomy, A prospective randomized clinical trial.

Neuroendocrine Tumor of The Appendix: Retrospective 7266 analysis of Appendectomy Patients in a single center

Objective: We aim to identify appendiceal neuroendocrine tumors (NETs) seen after acute appendicitis and investigate their incidence in patients with laparoscopic or open appendectomy surgery. Here we have shaped the characteristic features of the tumor according to the 2010 classification rating of The World Health Organization (WHO) (surgical margin, invasion, grading, TNM stages) and also explored the disease-free survival in these patients. Material and Methods: This is the medical record of the patient with 7266 appendectomy retrospectively evaluated, and with these examples in histopathological analysis, a total of 43 patients were diagnosed with appendicitis NETs and included in the study. Age, gender, prediction of the surgical team during the operation, location of the tumor, WHO grade, depth of invasion, positive surgical margin, tumor size, TNM stage, and postoperative survival of these patients were analyzed retrospectively. Results: In this study, the incidence of appendiceal (NETs) was found to be 0.59% among 7,266 patients. Out of the 42 patients with appendiceal NETs, 27 were female and 16 were male. The mean age of the patients was 33.65 years (range: 11–78). The diagnosis was aided by clinical examination, ultrasound, and abdominal computerized tomography (CT) imaging. Most patients were initially diagnosed with appendicitis, and surgical interventions, including laparoscopic and conventional appendectomy, were performed. The pathological analysis confirmed appendicitis with NETs, classified according to the WHO 2010 recommendation. The majority of patients had well-differentiated NETs (G1 or G2). Surgical resection achieved negative radial margins, and no pathological signs were detected during follow-up colonoscopies. At a median follow-up of 70.2 months, all patients remained disease-free and alive. Conclusion: Appendiceal neuroendocrine tumors are rare but distinct entities that require a multidisciplinary approach for diagnosis and management. Surgical resection is the primary treatment, with systemic therapies reserved for advanced cases. The prognosis is generally favorable, with better outcomes seen in well-differentiated tumors. Long-term follow-up is crucial. Further research is needed to improve understanding and optimize treatment strategies for these tumors.

A Rare Case of Cecostomy Tube in Complicated Acute Appendicitis Leading to Fecal Peritonitis

The most common abdominal surgical emergency in the world in acute appendicitis. Most common age group involved is between first to second decades but patients at extreme age have higher mortality rate due to late presentation. We are presenting a case of appendicitis which was complicated as long history at time of first surgery which led to caecal injury which was managed with ceacostomy. 62 years gentleman was referred from private hospital with fecal discharge from the open appendectomy wound and cecostomy tube insitu. Patient was diagnosed as phlegmon sequelae of acute appendicitis. Patient underwent emergency laparotomy, peritoneal lavage, removal of cecostomy tube, primary repair of caecal perforation and diversion loop ileostomy. Patient recuperated well. This case report highlights the challenges faced and complexities associated with failure of cecostomy in managing caecal perforation following laparoscopic appendectomy. The conversion from a laparoscopic approach to an emergency open appendectomy followed with cecostomy proved to be a vital decision in the face of phlegmon sequelae of acute appendicitis. The phlegmonous nature of acute appendicitis should be managed conservatively otherwise leading to a more aggressive surgical intervention. Keywords: Acute appendicitis, cecostomy, ileostomy, fecal discharge, phlegmon, complicated appendicitis.

Appendiceal and bowel endometriosis mimicking acute appendicitis with small bowel obstruction: case report and brief review of the literature

Endometriosis is defined as the presence of endometrium-like tissue outside the uterine cavity. This disease can have a variable presentation with symptoms that range from asymptomatic to non-menstrual pelvic pain, dysmenorrhea, dyspareunia, bowel symptoms, infertility, among others. We hereby present the case of a 39-year old female that presented to emergency room complaining of abdominal pain in right iliac fossa. Acute appendicitis was suspected, even though CT scan was inconclusive. Diagnostic laparoscopy was scheduled and laparoscopic appendectomy was performed and pathology examination reported acute appendicitis due to appendiceal endometriosis.

The burden of the knowledge-to-action gap in acute appendicitis

BackgroundThe burden of emergency general surgery (EGS) is higher compared to elective surgery. Acute appendicitis (AA) is one of the most frequent diseases and its management is dictated by published international clinical practice guidelines (CPG). Adherence to CPG has been reported as heterogeneous. Barriers to clinical implementation were not studied. This study explored barriers to adherence to CPG and the clinico-economic impact of poor compliance.MethodsData were extracted from the three-year data lock of the REsiDENT-1 registry, a prospective resident-led multicenter trial. We identified 7 items from CPG published from the European Association of Endoscopic Surgery (EAES) and the World Society of Emergency Surgery (WSES). We applied our classification proposal and used a five-point Likert scale (Ls) to assess laparoscopic appendectomy (LA) difficulty. Descriptive analyses were performed to explore compliance and group comparisons to assess the impact on outcomes and related costs. We ran logistic regressions to identify barriers and facilitators to implementation of CPG.ResultsFrom 2019 to 2022, 653 LA were included from 24 centers. 69 residents performed and coordinated data collection. We identified low compliance with recommendations on peritoneal irrigation (PI) (25.73%), abdominal drains (AD) (34.68%), and antibiotic stewardship (34.17%).Poor compliance on PI and AD was associated to higher infectious complications in uncomplicated AA. Hospitalizations were significantly longer in non-compliance except for PI in uncomplicated AA, and costs significantly higher, exception made for antibiotic stewardship in complicated AA. The strongest barriers to CPG implementation were complicated AA and technically challenging LA for PI and AD. Longer operative times and the use of PI negatively affected antibiotic stewardship in uncomplicated AA. Compliance was higher in teaching hospitals and in emergency surgery units.ConclusionsWe confirmed low compliance with standardized items influenced by environmental factors and non-evidence-based practices in complex LA. Antibiotic stewardship is sub-optimal. Not following CPG may not influence clinical complications but has an impact in terms of logistics, costs and on the non-measurable magnitude of antibiotic resistance. Structured educational interventions and institutional bundles are required.

WBC Count vs. CRP Level in Laboratory Markers and USG vs. CT Abdomen in Imaging Modalities: A Retrospective Study in the United Arab Emirates to Determine Which Are the Better Diagnostic Tools for Acute Appendicitis.

Introduction Acute Appendicitis (AA) is the most common surgical emergency. Despite the use of variousdiagnostic parameters, the rate of negative appendectomy remains high (30%). Thus, through our retrospective study, we aim to analyse whether white blood cell (WBC) count or C-reactive protein (CRP) level is more indicative in the confirmation of AA. We also analysed imaging modalities ultrasonography (USG) and computed tomography (CT) of the abdomen to find out which is better for diagnosing AA. Methods Patients with suspected AA admitted for laparoscopic appendectomy in Saqr Hospital, Ras Al Khaimah, United Arab Emirates, during 2019-2020 were included in the study. Patients who had either or bothWBC and CRP values were included in the study and their diagnosis was confirmed based on histological appendectomy findings. Data analysis was done using IBM SPSS Statistics for Windows, Version 23.0 (Released 2015; IBM Corp., Armonk, New York, United States), receiver operating characteristic (ROC) curve, and chi-square test as required. p-value of <0.05 was considered statistically significant. Results Out of the 320 patients with suspected AA, WBC had a p-value of 0.8 (insignificant). A total of 228 patients who had elevated WBChad confirmed histological diagnosis of AA, and 152 patients who were tested for CRP and had elevated levels had confirmed histological diagnosis of AA. CRP had a p-value of 0.04 (significant). However, when the ROC curve was used as evidence to see which was a better test, WBC and CRP both had a low area under the curve (AUC), which proved that they were not the most accurate diagnostic marker in diagnosing AA. However, CRP was slightly better than WBC. A total of 266 patients underwent USG abdomen and it had a p-value of 0.4 (insignificant), while 118 patients underwent CT scan, which had a p-value of0.01 (significant). CT abdomen was statistically proven as a better radiological investigation.Also, when the ROC curve was used to compare USG and CT abdomen, CT again proved to be a better radio diagnostic method for AA. Conclusions From our study, it can be concluded that CRP is better than WBC in ruling in appendicitis and CT abdomen is better than USG in diagnosing appendicitis, but CT abdomen is only next to histological diagnosis in confirming AA.Hence, we recommend doing CRP as the primary laboratory marker for suspected cases of AA.CT abdomen is the ideal imaging modality in cases of suspected AA where clinical examination, laboratory values, and ultrasound examination are inconclusive.

The impact of enhanced recovery after surgery on inflammatory indicators and prognosis related to complex appendicitis in children

ObjectiveTo explore the application effect of enhanced recovery after surgery (ERAS) perioperative plan in the treatment of complex appendicitis in children, and further enrich the implementation plan of ERAS in the field of pediatric surgery.MethodThis study selected 122 children who underwent laparoscopic complex appendectomy at Inner Mongolia Maternal and Child Health Hospital and Baotou Fourth Hospital from August 2018 to July 2022, and randomly divided them into a traditional surgery group (TS) and an enhanced recovery surgery group (ERAS). The changes of white blood cell (WBC), hypersensitive C-reactive protein (CRP), pro Calcitonin (PCT) and interleukin 6 (IL-6) before and after surgery were compared. The degree of pain, recovery time of intestinal function, length of hospital stay, hospital costs, postoperative complications and parental satisfaction were compared between the two groups.ResultThe WBC and CRP levels in the ERAS group at 6 h after surgery, as well as the IL-6 levels on the 3rd day after surgery, were lower than those in the TS group. Meanwhile, the analgesic effect of ERAS group at 3 h and 6 h after surgery was better than that of TS group. And the ERAS group had a shorter postoperative first exhaust time, fewer overall hospital stays, and lower hospitalization costs. In addition, the ERAS group had high parental satisfaction during hospitalization. There was no statistically significant difference in postoperative complications between the two groups of children.ConclusionERAS can promote postoperative recovery of children, reduce surgical stress, save family medical expenses, alleviate the pain of children, and improve parental satisfaction. It is a safe and effective method for treating complex appendicitis in children.