Management Of Acute Appendicitis Research Articles

Outcomes of Conservative Management of Acute Appendicitis during COVID-19 Pandemic.

To measure the outcomes of conservative treatment of acute appendicitis. Observational study. Fauji Foundation Hospital, Rawalpindi from April to July 2020. Methodology:All 58 patients (n=58) presenting with acute appendicitis (AA) were included. Assessment was done with Alvarado score (AS) and ultrasound. Treatment was initiated according to the algorithm corresponding with AS. Those with AS score of 4 or less were started on outpatient oral antibiotics. Patients with AS score of 5 or more were admitted for IV antibiotics. If the symptoms and signs resolved, they were sent home on oral antibiotics to complete a course of 5 days. If their condition did not improve in 72 hours or deteriorated at any time, appendectomy was done. Outcomes were recorded and analysed on SPSS. Out of 58 patients, 16 were treated with oral, while 42 with IV antibiotics. This yielded a statistically significant difference on the course of disease (p=0.028). Resolution of symptoms was seen in 27.6% (n=16) with conservative management; whereas, 72.4% (n=42) patients needed a subsequent appendectomy. The difference in operative findings between patients, who had been given oral or IV antibiotics was statistically insignificant (p=0.536). Diagnostic value of leukocyte count (TLC), ultrasound and AS was not found to be significant. Non-operative management is successful in about a quarter of the patients of AA. There is very limited value of sonography, laboratory parameters, or AS in confirming the diagnosis of AA. Key Words: Appendicitis, Conservative treatmen, COVID-19.

Outcomes of Conservative Management of Acute Appendicitis during COVID-19 Pandemic.

To measure the outcomes of conservative treatment of acute appendicitis. Observational study. Fauji Foundation Hospital, Rawalpindi from April to July 2020. All 58 patients (n=58) presenting with acute appendicitis (AA) were included. Assessment was done with Alvarado score (AS) and ultrasound. Treatment was initiated according to the algorithm corresponding with AS. Those with AS score of 4 or less were started on outpatient oral antibiotics. Patients with AS score of 5 or more were admitted for IV antibiotics. If the symptoms and signs resolved, they were sent home on oral antibiotics to complete a course of 5 days. If their condition did not improve in 72 hours or deteriorated at any time, appendectomy was done. Outcomes were recorded and analysed on SPSS. Out of 58 patients, 16 were treated with oral, while 42 with IV antibiotics. This yielded a statistically significant difference on the course of disease (p=0.028). Resolution of symptoms was seen in 27.6% (n=16) with conservative management; whereas, 72.4% (n=42) patients needed a subsequent appendectomy. The difference in operative findings between patients, who had been given oral or IV antibiotics was statistically insignificant (p=0.536). Diagnostic value of leukocyte count (TLC), ultrasound and AS was not found to be significant. Non-operative management is successful in about a quarter of the patients of AA. There is very limited value of sonography, laboratory parameters, or AS in confirming the diagnosis of AA. Key Words: Appendicitis, Conservative treatmen, COVID-19.

Appendicitis and COVID-19: yet another clinical dilemma

Acute appendicitis is the most common general surgery encountered in the emergency room worldwide. Management of acute appendicitis in patients who are tested positive for SARS-CoV-2 is still under debate as the full course of this novel disease is not yet mapped out. Here, we report three patients who presented with symptoms of acute appendicitis without any respiratory complaints. Three patients presented to surgical emergency room with classical symptoms and signs of acute appendicitis with modified Alvarado score of more than 6/9. Though they did not have any respiratory symptoms, they tested positive for SARS-CoV-2 by RT-PCR method. All patients underwent open appendicectomy. Open appendicectomy was preferred procedure to minimize aerosol generation and for safety of operating health care workers. Histopathology was suggestive of inflamed appendix and post-operative course was uneventful. Gastrointestinal symptoms like appendicitis could be a varied and sole presentation in patients suffering from COVID-19 infection. Conservative approach can be considered in all patients suffering from acute appendicitis and surgery can be reserved for those not responding to conservative line of management or having complications in form of perforated or gangrenous appendix and appendicular abscess. Further research may elaborate the correlation between COVID-19 and acute appendicitis.

Antibiotic Management for Acute Appendicitis in Children: Is it Worth it?

Antibiotic Management for Acute Appendicitis in Children: Is it Worth it?

Differences in treatment strategies in the management of acute appendicitis in a county hospital in Guatemala and an academic teaching institution in the United States.

Laparoscopy and antibiotic-first (NOM) strategies have been introduced in the management of acute appendicitis in industrialised countries. Data regarding the feasibility of these strategies in low-income nations are sparse. A retrospective analysis of adult patients undergoing appendicectomy at a county non-teaching hospital in San Benito, Guatemala (Hospital Nacional (HNSB)) was compared to an academic, teaching institution in Dallas, USA (Veterans Medical Centre). Most patients at the VA (92%) underwent computed tomography prior to being operated upon while none did so at HNSB. Whilst all patients at HNSB underwent an open approach, 95% of VA patients underwent a laparoscopic appendicectomy with a 4.7% conversion rate. General anaesthesia was universally used at Veterans Medical Centre, whilst spinal anaesthesia was utilised in 88% of cases at HNSB. NOM of acute appendicitis was undertaken only rarely at the Veterans Medical Centre and never at HNSB, where it was not thought expedient.

COMPARİSON OF ALVARADO AND RIPASA SCORES İN PATİENTS WİTH ACUTE APPENDİCİTİS

Objective: Acute appendicitis management delays results in perforation and increases the morbidity and mortality. Studies have reported a 20% perforation rate, and 2-30% negative laparotomy whose diagnoses are made by symptoms and physical examination. By using anamnesis, clinical signs-symptoms and inflammatory parameters to reduce the diagnosis time, complications, and morbidity-mortality of AA, various scoring methods have been developed. The first scoring system defined for this purpose is Alvarado scoring system. The RIPASA scoring system was developed for patients in Asia. In this study, we aimed to determine which scoring is more suitable for our population by comparing Alvarado and RIPASA scoring methods in patients who underwent an appendectomy. Method: The Alvarado and RIPASA scores of each patient were calculated by the scoring system parameters after the 182 patient files were analyzed retrospectively. At cut-off value of 7.5 for RIPASA score and 7 for Alvarado score, patients were divided into high and low-risk groups. The positive predictive value, negative predictive value, sensitivity, and specificity were calculated and the two scoring systems' effectivity were compared with Chi-square and area under curve analysis. Results: According to the histological examination 42(23%) patients were not considered as acute appendicitis. RIPASA scoring systems high-risk group classification was better by predicting the acute appendicitis patients (p = 0.001, p <0.05). The area under the curve for RIPASA score calculated as 0.738 and this is statistically significant (p = 0.001; p <0.05). The result was better then the Alvarado AUC score (0,633). Alvarado scoring systems' negative predictive value was higher than the RIPASA score, respectively (58,14%, 32.56%). Conclusions: It is beneficial to use the RIPASA scoring system for patients in our region to reduce the rate of negative laparotomy and unnecessary surgical procedures in patients admitted to emergency services with the suspicion of acute appendicitis.

Retrospective analysis of laparoscopic versus open appendectomy for the treatment of acute appendicitis

Background: Acute appendicitis is one of the most commonly encountered emergency by the general surgeons and appendectomy is the most common surgery performed in the world. Although open appendectomy is preferred by many surgeons, yet the laparoscopic approach is gradually replacing open surgery for treatment of acute appendicitis.Methods: A total of 400 patients of acute appendicitis were operated, 200 by laparoscopic appendectomy and 200 by open method by a single surgeon at various private hospitals in Jammu (Jammu and Kashmir), India over a period of three years from July 2017 to July 2020. The two groups were compared with respect to operative time, duration of hospital stay, post-operative pain, complication rate and time taken to resume routine activity and cosmetic satisfaction of the patients.Results: Results were found to be better with the laparoscopic technique. There was significantly less pain in the postoperative period with faster recovery, early resumption to work, reduced postoperative complications and better cosmetic satisfaction of the patients operated by the laparoscopic appendectomy technique as compared to open surgery.Conclusions: Laparoscopic appendectomy is safe and feasible technique in expert hands, for treatment of acute appendicitis with results comparable to the open appendectomy, with no obvious increase in complications and is definitely a procedure of choice for the management of acute appendicitis.

National trends in the presentation of surgically resected appendiceal adenocarcinoma over a decade.

Rates of nonoperative management of acute appendicitis and appendiceal adenocarcinoma have increased over a decade, but the presentation and outcomes of appendiceal adenocarcinoma over this period is not well-characterized. Patients with surgically resected Stage I-III appendiceal adenocarcinoma were identified from the 2006 to 2015 National Cancer Data Base and classified into two cohorts, 2006-2010 and 2011-2015, based on year of diagnosis. Three-year overall survival (OS) was analyzed using Cox proportional hazards regression and Kaplan-Meier survival estimates. Of 4233 patients, 1369 (32.3%) and 2864 (67.7%) were diagnosed in 2006-2010 and 2011-2015, respectively. Following multivariable analysis, patients in 2011-2015 were more likely to be<40 years of age (6.4% vs. 4.7%, odds ratio [OR] 1.53, p.015), present with pT4 tumors (40.2% vs. 34.4%, OR 1.46, p.004), and undergo hyperthermic intraperitoneal chemotherapy (4.4% vs. 2.4%, OR 1.97, p.001). Comparing patients diagnosed in 2011-2015 to 2006-2010, adjusted 3-year OS was no different among all patients (81.1% vs. 79%, p .778). There has been an increase in the proportion of patients with pT4 appendix tumors over time, primarily among older (≥60 years) patients. Even so, these shifts in presentation have not resulted in differences in survival outcomes.

Non-operative Management for Acute Appendicitis During the COVID-19 Pandemic Does Not Increase the Rate of Complications

Non-operative Management for Acute Appendicitis During the COVID-19 Pandemic Does Not Increase the Rate of Complications

Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study.

Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P < 0·001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2.

Managing acute appendicitis during the COVID-19 pandemic in Jiaxing, China.

BACKGROUNDCoronavirus disease 19 (COVID-19) is a global pandemic and has had a profound impact on our routine surgical activities. Acute appendicitis is the most common abdominal emergency worldwide. Therefore, it is highly essential to assess the influence the pandemic has on acute appendicitis.AIMTo assess the efficacy of the management of acute appendicitis during the COVID-19 pandemic.METHODSWe retrospectively analyzed 90 patients who presented with acute appendicitis during the outbreak of COVID-19 in Jiaxing, China. Clinical data regarding appendectomies patients were also collected for the corresponding time frame from 2019. Preoperative management, intraoperative protective measures, and postoperative management were conducted.RESULTSAfter screening, six patients were identified as unqualified due to fever and were then referred to the COVID-19 expert group. The results of the nucleic acid test were negative. Of the 76 patients enrolled in the simple group, nine patients received medication therapy, and all others underwent surgery. From this same group, 66 patients were diagnosed with suppurative appendicitis, and one patient was diagnosed with perforated appendicitis after surgery. There were 14 patients in the complex group, for which the postoperative diagnosis indicated perforated appendicitis. The proportion of men with perforated appendicitis was higher than that in 2019 (P < 0.05). The chief complaint duration for perforated appendicitis patients in 2020 was longer than that in 2019 (P < 0.05). The routine blood test showed that white blood cell counts and neutrophil ratios were higher in perforated appendicitis patients in 2020 than in 2019 (P < 0.05). The ratio of open appendectomies to the amount of mean blood loss during surgery was greater in 2020 than in 2019 (P < 0.05). Online consultation after discharge was selected in 59 cases (65.6%). No perioperative infection with COVID-19 or long-term postoperative complications were found.CONCLUSIONThe management of acute appendicitis from Jiaxing effectively reduced the influence of the pandemic and minimized the risk of nosocomial infection.

Evaluation of a new scoring system for early diagnosis and management of acute appendicitis in pediatric patients

Background Acute appendicitis is a common surgical emergency among infants and children. The diagnosis of acute appendicitis in young children remains a big challenge, as most of such patients present late, with complications. However, unnecessary surgery should be avoided. Over years, many scoring systems have been introduced for helping the diagnosis of acute appendicitis such as Alvarado score, the Pediatric Appendicitis Score (PAS), and Appendicitis Inflammatory Response score. Patients and methods In the period between 3/2018 and 9/2019, 130 infants and children till the age of 16 years, with acute right iliac pain, were included in this study. These patients were evaluated using three diagnostic scores: Acute Pediatric Appendicitis Score (APAS), PAS, and Alvarado scores. Results Logistic regression analysis yielded a model comprising nine variables, all being statistically significant (P Conclusion APAS score is a significant diagnostic tool for diagnosis of acute appendicitis in pediatrics. The study also provides a solid comparison among APAS, PAS, and Alvarado scores. APAS score is the first score in well-known literature to introduce ultrasound examination as a routine investigation among the suspected children with acute appendicitis with an accuracy of ∼95.38%.

What Information are Patients Receiving from the Internet about the Operative and Nonoperative Management of Acute Appendicitis?

Journal of the American College of Surgeons 231(4):p e143, October 2020. | DOI: 10.1016/j.jamcollsurg.2020.08.377

What Information Are Patients Receiving from the Internet about the Operative and Nonoperative Management of Acute Appendicitis?

Introduction: Recent studies suggest that nonoperative management of appendicitis (NOMA) may be a reasonable option for managing uncomplicated acute appendicitis. We examined the Internet to see if patients are likely to find the information they need to make an informed decision between the 2 options. Methods: A list of 29 search terms was established by a focus group and then entered into Google, resulting in 49 unique webpages, each reviewed by 3 reviewers. Consensus was obtained for bias (surgery, NOMA, or balanced), webpage type, JAMA score, reading grade, and DISCERN score, a measure of quality of written information for patients. Results: Thirty of the 49 websites (61%) favored surgery, while 13 (27%) favored NOMA, and 6 sites (12%) provided balanced information. Twelve of 49 sites (24%) did not list NOMA as an option. The majority of patient-directed (11/12 = 92%) and physician-directed (7/9 = 78%) webpages favored surgery, whereas academic webpages presented a more balanced distribution. Academic and physician-directed webpages ranked higher than commercial and news webpages (median ranks 3 and 4 vs. 7.5 and 8). Only 8/49 sites (16%) mentioned that the presence of a fecalith predicts the failure of NOMA. Reading grades were almost all well above the recommended grade 8 level. Conclusion: Most of the webpages available on the Internet do not provide enough information, nor are they sufficiently understandable to allow most patients to make an informed decision about the current options for the management of acute appendicitis.

Changes in Incidence and Management of Acute Appendicitis in Children-A Population-Based Study in the Period 2000-2015.

Recent studies suggest that the epidemiology and management of appendicitis have changed during the last decades. The purpose of this population-based study was to examine this in the pediatric population in Denmark. Data were retrieved from the Danish National Patient Registry, the Danish Civil Registration System, and the Statbank Denmark. Patients aged 0 to 17 years diagnosed with appendicitis and appendectomized during the period 2000 to 2015 were included. The primary outcome was the annual incidences of appendicitis. Secondary outcomes were the annual percent of patients with appendicitis having a laparoscopic appendectomy, delay from admission to surgery, length of postoperative hospital stay, and 30-day postoperative mortality. A total of 24,046 pediatric cases of appendicitis were identified. The annual incidence steadily declined until 2008 (-29%, all ages) and then remained stable. The surgical approach of choice changed from being open appendectomy in 2000 (97%) to laparoscopic appendectomy in 2015 (94%). Simultaneously, the duration of postoperative hospital stay declined from 41 hours (median) to 17 hours. Delay from admission until surgery did not change during the period. Only one child died within the 30-day postoperative period. In accordance with other recent studies from Western countries, we found significant changes in the incidence of acute appendicitis including a decline in all age groups except those below 5 years of age, a shift toward laparoscopic appendectomy, and decreasing time spent in the hospital during the years 2000 to 2015.

Current opinions and practices for the management of acute appendicitis: an international survey.

BackgroundIn recent decades the management of acute appendicitis has evolved significantly. Improved access to early imaging and better clinical scoring algorithms have resulted in less negative appendicectomy rates. In addition, non-operative management has become increasingly utilized. The aim of this study was to assess the variability of management of acute appendicitis globally.MethodsThis was a multi-national targeted survey of general surgeons across 39 countries. A structured set of questions was utilized to delineate nuances between management styles of consultants and trainees. Opinions on the pathological diagnosis of appendicitis, acceptable negative appendicectomy rates, and the role of non-operative treatment of appendicitis (NOTA) were surveyed.ResultsA total of 304 general surgeons responded to this survey, 42% of which were consultants/attendings. Sixty-nine percent advocated that a histologically normal appendix was the most appropriate definition of a negative appendicectomy, while 29% felt that anything other than inflammation, necrosis, gangrene, or perforation was more appropriate. Forty-three percent felt that negative appendicectomy rates should be less than 10%, with 41% reporting that their own negative appendicectomy rate was < 5%. Interestingly, only 17% reported routinely using NOTA for uncomplicated appendicitis, with one-fifth stating that they would undergo NOTA if they themselves had uncomplicated appendicitis.ConclusionThis study represents the largest sampling of management strategies for acute appendicitis. It shows substantial global heterogeneity between clinicians regarding what constitutes a negative appendicectomy as well as the appropriateness of non-operative management.

Management of Acute Appendicitis in Covid Pandemic- A Prospective Study of 25 Cases

Acute Appendicitis is a surgical emergency. Patients present with pain in right lower abdomen, with other symptoms like nausea/vomiting, fever, diarrhoea, urinary symptoms. Diagnosis is based on a multimodality approach that includes, clinical, radiological and pathological findings. Alvarado Score helps determine the severity of infection, confirm diagnosis and guide further management. Management is either conservative with antibiotics or surgical depending on severity. However approach to surgical management has changed with the ongoing Covid-19 pandemic. It has necessitated categorisation of surgical procedures into essential and non essential to limit risk to both patient and surgical team and also for prioritization of resources to the rising, continued spread of Covid-19. We present a prospective study of 25 cases of appendicitis presenting during the Covid Pandemic between 15th March and 30th May to our hospital, with an intent to try conservative management for all patients except in the presentations with complications like perforation, abscess or the presence of fecolith or poor response to conservative management.Patients not amenable to conservative management were treated by Open appendicectomy.

The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study

BackgroundAcute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK).MethodsPatients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up.ResultsThe patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26–49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1–4] days vs. 3 [2–4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive.ConclusionCOVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.

Encuesta nacional sobre el tratamiento de la apendicitis aguda en España durante la fase inicial de la pandemia por COVID-19

IntroductionThe COVID-19 pandemic has had a significant impact on Spanish hospitals, which have had to allocate all available resources to treat these patients, reducing the ability to attend other common pathologies. The aim of this study is to analyze how the treatment of acute appendicitis has been affected. MethodsA national descriptive study was carried out by a online voluntary distribution of a specific questionnaire with Google Drive™ distributed by email by the Spanish Association of Surgeons (AEC) to all affiliated surgeons actually working in Spain (5203) opened from April 14th to April 24th. ResultsWe received 337 responses from 170 centers. During the first month of the pandemic the incidence of acute appendicitis has decreased. Although conservative management has increased, surgical option has been the most used in both simple and complicated appendicitis. Despite the fact that the laparoscopic approach continues to be the most widely used in our services, the open approach has increased during this pandemic period. ConclusionHighlight the contribution of this study in terms of knowledge of the status of the treatment of acute appendicitis during this first month of the pandemic, being able to serve for a better possible organization in future waves of the pandemic and a reorganization of current protocols and management of acute appendicitis in a pandemic situation.

The Unintended Consequences of Nonoperative Management of Acute Appendicitis

BackgroundAppendicitis has traditionally been treated surgically. Recently, nonoperative management is emerging as a viable alternative to the traditional operative approach. This raises the question of what are the unintended consequences of nonoperative management of appendicitis with respect to cost and patient burden. MethodsNational Readmissions Database was queried between 2010 and 2014. Patients who were admitted with acute appendicitis between January and June of each year were identified. Patients who underwent appendectomy were compared with those treated nonoperatively. Six-month all-cause readmission rates and aggregate costs between index hospitalization and readmissions were calculated. ResultsWe identified 438,995 adult admissions for acute appendicitis. Most cases were managed with appendectomy (93.2%). There was a significant increase in the rate of nonoperative management, from 3.6% in 2010 to 6.8% in 2014 (P value for trend <0.01). Discharges receiving nonoperative management tended to be older and have more comorbidities. There was a 59% decreased adjusted odds of readmission within 6 mo among patients receiving appendectomy in comparison to those managed nonoperatively. Despite this, in multivariable linear regression, there was an adjusted $2900 cost increase associated with surgical management (P < 0.01). ConclusionsThis study shows that nonoperative management is increasing. Patients treated nonoperatively may have an increased risk of readmission within 6 mo but incur a decreased average adjusted total cost. Given this, it is important that surgeons critically assess patients who are being considered for nonoperative management of appendicitis.