Non-complicated Acute Appendicitis Research Articles

Composite Criteria for Non‐Operative Management of Acute Non‐Complicated Appendicitis Result in Low Failure Rates

The aim of this study is to investigate the outcomes of conservative management of non-complicated acute appendicitis (AA) using our unique institutional protocol, and to compare between these and the outcomes of operative management. Patients admitted to our institution between March 2016 and October 2019 with non-complicated AA were grouped according to their initial management: non-operative versus surgical. Our unique protocol for non-operative management includes: pain< 3days; afebrile upon admission; non-gravid; WBC<15,000 (× 109/L); CRP< 5mg/dl; appendix diameter < 1cm; no appendicolith on imaging; no prior episode of AA; no history of Inflammatory Bowel Disease; no evidence of peritonitis on physical examination. The primary outcome measured was failure of non-surgical management during the index admission. Secondary outcomes included recurrence rate, readmissions, complications, length of antibiotic treatment and length of stay (LOS). A total of 695 patients were included, 436 in the operative group and 259 in the non-surgical treatment group. The mean follow-up time was 1004.9 ± 205.7days. Patients initially treated conservatively rarely required surgery during their index admission (6.9%). Recurrence rate was 19.1% after a mean follow up of 33.4months. The overall failure rate of conservative management was documented in 20.8% of the patients. The complication rate was higher in those treated with upfront surgery (1.6% vs. 0.4%, p < 0.001). The overall LOS was not statistically different between the groups. Our composite protocol for non-surgical management of non-complicated AA results in a low failure rate. A well calculated patient treatment allocation in non-complicated AA can advocate for wide-spread use of the conservative approach.

The predictors of complicated acute appendicitis: large unstained cells, gamma-glutamyl transferase, monocyte to platelet ratio, age and gender

Aim: In this study, we sought to investigate possible biomarkers markers that can preoperatively distinguish complicated and non-complicated acute appendicitis.&#x0D; Material and Method: Patients who underwent appendectomy between February and December 2019 were screened retrospectively. Patients with pathology findings other than appendicitis were excluded. Patients with a confirmed diagnosis of acute appendicitis were categorized as complicated and non-complicated appendicitis for analysis of sociodemographic characteristics, comorbidities and preoperative laboratory parameters.&#x0D; Results: A total of 575 patients were included in the study. Among these, 432 (75.1%) were diagnosed with non-complicated appendicitis and 143 (24.9%) were diagnosed with complicated appendicitis. The mean (SD) age was 34.2±14.2 years. Hypertension, diabetes mellitus and hypothyroidism were the most frequent comorbidities. Age (OR, 1.026; p=0.010), male gender (OR, 1.837; p=0.044), LUC (OR: 19.868; p=0.034) and GGT (OR: 1.013; p=0.013) were associated with a higher risk of complicated appendicitis. An increase in monocyte to platelet ratio (MPR) (OR: 0.920; p=0.047) was associated with a lower risk of complicated appendicitis.&#x0D; Conclusion: In patients with acute appendicitis, parameters including age, gender, as well as LUC, GGT and MPR, which are easily available and relatively cheap biomarkers, can be useful to distinguish non-complicated and complicated cases preoperatively.

The decrease of non-complicated acute appendicitis and the negative appendectomy rate during pandemic

BackgroundDuring pandemic, admissions for surgical emergencies dropped down dramatically. Also acute appendicitis decreased. The aim of the present study was to evaluate the change in volume and clinical presentation of patients with acute appendicitis during pandemic and the variation in treatment.MethodsThis is a retrospective study of patients admitted in 11 Italian hospital for acute appendicitis during the lockdown period (March–April 2020) compared with the same period of the previous 2 years (2018–2019). The number and the rate of complicated and non-complicated acute appendicitis were recorded and compared between the two study periods; non-operative vs operative treatment and negative appendectomy rate were also recorded.ResultsThe study included 532 patients, 112 in the study period and 420 in the control period; Hospital admission for acute appendicitis dropped by 46% (OR 0.516 95% CI 0.411–0.648 p < 0.001) during the 2020 lockdown. The number of complicated acute appendicitis did not change (− 18%, OR 0.763 95% CI 0.517–1.124 p = 0.1719), whereas the number of non-complicated acute appendicitis significantly decreased (− 56%, OR 0.424 95% CI 0.319–0.564 p < 0.001). Non-operative treatment rate remained similar (12.1% vs. 11.6% p = 0.434). The negative appendectomy rate also significantly decreased (6.1% vs. 17.3%, p = 0.006).ConclusionsThe present study found a significant reduction of both admissions for non-complicated acute appendicitis and negative appendectomy rate during the pandemic period. Conversely, admissions for complicated acute appendicitis did not change.Trial registration: NCT04649996.

PREOPERATIVE EVALUATION OF THE SCORING SYSTEM DEVELOPED BY ATEMA TO DISTINGUISH COMPLICATED FROM UNCOMPLICATED ACUTE APPENDICITIS

Background: The diagnosis of acute appendicitis is purely based on history, clinical examination and some laboratory investigations (e.g. WBC count). Certain diagnosis can only be obtained at surgery and after pathological examination of surgical specimen. The Atema scoring system can distinguish complicated from non-complicated appendicitis preoperatively. Objective: To evaluate the validity and diagnostic accuracy of the Atema scoring system in differentiating complicated from non- complicated appendicitis before surgery. Patients and Methods: A prospective study was carried out on 60 patients complaining of acute abdominal pain, diagnosed as acute appendicitis using the Alvarado score and undergoing open appendectomy operation in the Emergency Department, Faculty of Medicine, Al-Azhar University from December 2019 to July 2020. Routine clinical and laboratory work up were done, the Atema Score was calculated to every patient in the study preoperatively. The decision to operate was made by a senior surgeon (consultant). The intraoperative finding whether the acute appendicitis was complicated or not was recorded. Post operatively, the histo-pathological examination results were recorded for each patient. The ROC curve was done, the cut-off point of the Atema scoring system was detected based on the ROC curve. The area under the ROC curve and the p-value were calculated. The sensitivity, specificity, positive predictive value and negative predictive value of the Atema scoring system above the level of the cut-off point were calculated. Results: In total of 60 patients, 37 patients (61.7%) had complicated appendicitis and 23 patients (38.3%) had non-complicated appendicitis. The sensitivity of the Atema score has a diagnostic accuracy of 0.944 (Area under the curve) with sensitivity 86.96% and specificity 89.19% with positive predictive value 83.3% and negative predictive value 91.7%. Conclusion: The Atema score can significantly differentiate between complicated and non-complicated acute appendicitis. A higher score denotes increased probability of the presence of complications as perforation and gangrene.

The Effect of Environmental Factors on the Incidence of Complicated Appendicitis in Mongolian Paediatric Population

Introduction: Acute appendicitis (AA) in children is the primary cause of urgent surgery in pediatric patients. Diagnosis of AA continues to be a challenge, especially in the youngest children, who often present with abdominal pain accompanied by nonspecific signs. As epidemiological data on the relationship between acute appendicitis and environmental factors are relatively few and the issue is still controversial, we conducted this study which compared two groups of patients with complicated and noncomplicated appendicitis in a sample of patients admitted to a MNCMCH. The aim of this study was to determine the risk factors for complications in acute appendicitis in the paediatric population. Methods: Our study was performed on 1003 children admitted for suspected acute appendicitis and underwent appendectomy at the MNCMCH, Ulaanbaatar Mongolia, between January 2019 and December 2019. The diagnosis was based on the results of pathological examination. The two groups of complicated (gangrenous and perforated) and noncomplicated (catarrhal and phlegmonous) acute appendicitis were compared. Results: 1003 pediatric patients (≤18 years old) were suspected of having acute appendicitis and subsequently underwent surgery. From a total of 967 patients, 56% (n = 542) were male, 44% (n = 425) were female (gender ratio was 1.3:1). The histological examination noted that 33.1% were uncomplicated, 66.9% were complicated. While the incidence of acute appendicitis was higher during winter, the highest incidence of complicated appendicitis was observed equally in winter and autumn without significant association (p = 0.541). The months of December and March were marked by the highest incidence of AA. The highest incidence of complicated appendicitis was observed during the month of December (45%) with statistically significant difference (p < 0.001). Our study of the incidence of family history, allergy and family members was noted in complicated and noncomplicated group with statistically significant difference (p < 0.001). Conclusions: Pediatric acute appendicitis incidence is increased in winter months in Mongolia. Preventive measures to decrease morbidity and mortality associated with this disease can be taken during the winter seasons from December to March. However, further large-scale studies are needed to support this conclusion.

Manejo de apendicitis aguda no complicada en adultos: antibioticoterapia versus manejo quirúrgico

Introducción: La apendicitis aguda es la emergencia quirúrgica abdominal más prevalente en EEUU. El diagnóstico se realiza en base al cuadro clínico y hallazgos de laboratorio e imagen. El tratamiento gold estándar es la apendicectomía, que conlleva un alto costo, riesgo de complicaciones quirúrgicas y de anestesia, por lo que en recientes estudios se ha planteado el uso de antibioticoterapia como estrategia efectiva de manejo médico no invasivo de apendicitis aguda no complicada. Objetivo: describir los métodos diagnósticos más sensibles para diferenciar la apendicitis complicada de la no complicada, y comparar la efectividad del manejo médico versus el manejo quirúrgico de la apendicitis no complicada en adultos, en cuanto a la tasa de recurrencia y las compilaciones asociadas al manejo. Materiales y métodos: estudio descriptivo cualitativo de revisión bibliográfica de artículos obtenidos de las bases de datos de Pub Med, Google Scholar y Science Direct, utilizando los descriptores “apendicitis” AND “diagnóstico” AND “antibióticos”. Se obtuvieron 90 artículos que incluyen ensayos clínicos, estudios de caso, revisiones bibliográficas y estudios observacionales. Se excluyeron aquellos artículos basados en población pediátrica, y se seleccionaron aquellos publicados entre el año 2015 y 2020, en idioma inglés y español, que utilizan al menos dos pruebas diagnósticas, y comparan la terapéutica antibiótica contra la apendicectomía. Se obtuvieron finalmente 26 artículos como referencia para esta revisión. Resultados: el método diagnostico predominante es la clínica, asociado a los siguientes signos positivos: Mac Burney, Rovsing y signo de Psoas. Los métodos diagnósticos de imagen, con mayor sensibilidad, incluyen la tomografía axial computarizada y la resonancia magnética, el Score con mayor sensibilidad y especificidad es el de RIPASA. El esquema de antibioticoterapia más utilizado es ertapenem (1 g/día) intravenoso por tres días, seguido por antibioticoterapia oral por siete días con levofloxacina (500 mg/día) y metronidazol (500 mg/cada ocho horas). El uso de antibioticoterapia para el manejo de apendicitis aguda no complicada es efectivo y seguro; se demostró que no es inferior, respecto al manejo quirúrgico; sin embargo, los resultados sobre una disminución de complicaciones y fallo terapéutico es controversial. El paciente ideal para ser sometido a esta terapéutica es aquel que tiene bajo riesgo de complicaciones, por lo que se deben excluir todos aquellos pacientes con clínica de apendicitis complicada, o que utilicen de forma crónica esteroides o anticoagulantes o aquellos que asocien comorbilidades como diabetes mellitus, síndrome coronario agudo, insuficiencia cardíaca, renal o hepática. Los resultados deben ser interpretados con cautela dada la falta de evidencia científica de nivel 1. Conclusión: En la mayoría de los estudios analizados se concluye que la apendicetomía sigue siendo el método terapéutico de elección; sin embargo, el manejo conservador es una alternativa que no es inferior a la invasiva y se puede ofrecer como opción de tratamiento.

Acute appendicitis is associated with appendiceal microbiome changes including elevated Campylobacter jejuni levels

ObjectivesTo compare the appendiceal microbiomes and examine the prevalence of Campylobacter species in the appendices of adult subjects with confirmed acute non-perforated appendicitis and controls with healthy appendices.DesignArchived samples of...

Perforation in pediatric non-complicated appendicitis treated by antibiotics: the real incidence.

The incidence of perforation during antibiotic therapy (AT) of children triaged as non-complicated acute appendicitis (NC-Ap) was investigated. Abdominal ultrasonography (US) and/or computed tomography (CT) scans from cases of perforation identified at appendectomy for failed AT were reassessed blindly by a panel of board-certified specialists for any evidence of pre-AT morbidity suggestive of perforation. Of 521 cases triaged as NC-Ap, symptoms resolved with AT in 452 cases (86.8%). All 69/521 (13.2%) cases with persistent symptoms had urgent appendectomy, and 12/521 (2.3%) were found to have perforated. Blind reassessment of US and/or CT scans from these cases identified seven with evidence of perforation when they were triaged as NC-Ap. Thus, the actual incidence of perforation during AT for NC-Ap was actually 12-7 = 5/521 (0.95%). Perforation is generally believed to be a complication of AT, but inappropriate triaging of cases for AT can bias results by artificially inflating the number of perforations, in this study, by more than double. We are the first to assess the unbiased incidence of perforation during AT for NC-Ap, by reassessing pre-AT US and/or CT scans. The incidence of perforation during AT is actually negligible.

Are endoscopic loop ties safe even in complicated acute appendicitis? A systematic review and meta-analysis.

Appendectomy is amongst the most common general surgical procedures and the laparoscopic approach is recognized and recommended by international guidelines as a valid option. The different closure techniques of the appendicular stump constitute a matter of debate since their possible implication in determining postoperative infectious complications. The aim of the present meta-analysis is to compare endostapler versus endoscopic loop ties for stump closure during laparoscopic appendectomy. This is a systematic review with meta-analysis of randomized trials and cohort studies comparing endostapler with endoscopic loop ties for the closure of appendicular sump in laparoscopy appendectomy. Subgroup analysis of pediatric patients and patients with complicated appendicitis were performed when data were available. Complicated acute appendicitis was defined as in case of gangrenous/necrotic appendix or perforated appendix. Main outcomes were wound infection rate, intra-abdominal infection rate, length of stay, readmission and reoperation rates. a total of 5934 patients from 14 studies were included in the analysis. Endostapler was associated with a similar intra-abdominal abscess rate (RR 0.88, 95%C.I. 0.54-1.43) but a lower incidence of wound infection (RR 0.54, 95%C.I. 0.22-0.97) Length of stay, readmission and reoperation rates were similar. In subgroups analysis endostapler reduces significantly the wound infection rate in pediatric patients; no differences in main outcomes were observed in patients with complicated acute appendicitis. In complicated acute appendicitis the stump closure technique did not affect outcomes; the use of endostapler seems to be associated to a reduction of wound infection rate in pediatric patients with non-complicated acute appendicitis.

Outcomes of appendectomy in elderly veteran patients

BackgroundSome studies indicate that noncomplicated acute appendicitis might be treated exclusively with antibiotics instead of an appendectomy. This study was undertaken to assess outcomes in elderly veterans and to determine if operative intervention would lead to substantial complications such that a nonoperative strategy should be investigated. MethodsA retrospective, single-institution analysis was conducted of patients who underwent an appendectomy at the VA North Texas Health Care System over a period of 12 years (from July 2005 to June 2017). Patients who underwent an appendectomy for cancer, interval appendectomy, exploratory laparotomy for perforated appendicitis, or appendectomy as part of another major operation were excluded from the study. Patients were then grouped as elderly (≥60 years old) and young (<60 years old), and differences in outcome were assessed. Univariate and multivariate analyses were also performed to determine if age and comorbid conditions were independent predictors of complications in both cohorts. ResultsOf patients who underwent an appendectomy for acute appendicitis (n = 257, male = 90.7%, age = 45.4 ± standard deviation 15.6 years, body mass index = 30.3 ± 6.3 kg/m2), 195 were young (38.7 ± 11.2 years old) and 62 elderly (66 ± 5 years old). More patients were male in the elderly cohort (98.4% vs 88%; P = .01). The incidence of gangrenous and perforated appendicitis was greater in elderly patients (11.3% and 14.4% vs 24 % and 40%, P < .01 each). Diabetes and hypertension, as well as a history of cardiac, pulmonary, and renal diseases, were more than 2-fold greater in older patients. Complications and 30-day readmission rates were similar in both groups (young vs elderly: 7.2% and 9% vs 9.7% and 11%, P > .5 each). Logistic regression analysis showed that age and American Society of Anesthesia level were not independent predictors of complications. A history of cardiac disease and open operation independently predicted complications regardless of age. Unexpected malignancy was 3% in the elderly and 1.5% in the young cohort (P = .6) ConclusionComplicated appendicitis is more common in elderly patients. Appendectomy in elderly veteran patients has a low rate of complications similar to younger patients and the private sector. Operative intervention in this group of patients is not prohibitive. Further studies are needed to determine if nonoperative intervention is noninferior to an appendectomy in this high-risk patient population.

Is the appendix length/diameter ratio an early-indicator for the perforation in acute appendicitis?

Objective: Acute appendicitis is the most frequent reason for the stomachaches resulting in the surgery. The acute appendicitis perforation might create complications that are of vital importance. In this study, it is aimed to examine the relationship of appendix length/diameter ratio with acute appendicitis perforation. Methods: Using the pathology results of appendectomy materials of 144 patients that applied to emergency service between March 2013 and May 2014 and were operated due to the suspicion of acute appendicitis, the length/diameter ratios were calculated. The patients were divided into 2 groups as perforated appendicitis and non-perforated appendicitis. The number of patients and the length/diameter ratios were calculated and recorded for both groups. PearsonÂ’s Chi-Square test was used for statistical analysis. Results: In pathological examination of 144 patients involved in this study, non-complicated acute appendicitis was diagnosed in 123 (85.4%) patients, while 21(14.6%) patients were found to have perforation. In present study, the results indicating that the length/diameter ratio might be used as early indicator for the perforation were achieved. When the appendix length/diameter ratio declined below 10, then the perforation frequency significantly increased (p

A case of asymptomatic ileal duplication cyst associated with acute appendicitis

Abstract Duplications of the alimentary tract are infrequent anomalies. They are most frequently located in the terminal ileum, and majority of them became symptomatic before the age of 2. Presenting symptoms may include abdominal mass, intestinal obstruction, intussusception, rectal bleeding, and abdominal pain. Preoperative diagnosis is usually difficult, intra-abdominal duplications are usually diagnosed during surgical explorations of above complications. We presented a 12-year-old girl with asymptomatic ileal duplication cyst associated with non-complicated acute appendicitis, whose imaging studies at admission were compatible with complicated perforated appendicitis.

Evaluation of Platelet Indices and Red Cell Distribution Width as New Biomarkers for the Diagnosis of Acute Appendicitis

ABSTRACTBackground: Debate around the value of laboratory tests in establishing the diagnosis of acute appendicitis (AA) still continues. This prospective study aimed to investigate the changes in mean platelet volume (MPV), platelet distribution width (PDW), and red cell distribution width (RDW) with the diagnosis of acute appendicitis. Method: 200 patients who underwent emergency appendectomy were included. According to postoperative histology, patients were divided into three groups: acute non-complicated, acute complicated appendicitis (positive appendicectomy groups), and negative appendectomy group. White blood cell (WBC), neutrophil, lymphocyte count, neutrophil-to-lymphocyte ratio (NLR), platelets (PLT) count, MPV, PDW, RDW, and C-reactive protein (CRP) were compared among the groups. Results: One hundred twenty-five (62.5%) patients had non-complicated acute appendicitis, 20 (10%) had complicated acute appendicitis, while 55 (27.5%) had normal appendix. WBC (p <.001), neutrophil (p <.001), NLR (p <.001), PDW (p =.003), and CRP (p =.001) were higher, while lymphocyte (p <.001) and PLT counts (p =.020) were lower in positive appendectomy compared with negative appendectomy patients. MPV levels were insignificantly different across the groups. RDW level was significantly higher in complicated compared with non-complicated acute appendicitis (p =.006); however, no significant difference was found between positive and negative appendectomy groups. Using receiver operating characteristic analysis, sensitivity, specificity, and diagnostic accuracy respectively were 44.83, 100.0, and 72.415% for WBC count, 72.41, 81.82, and 77.115% for neutrophil count, 48.28, 90.91, and 69.595% for PDW, 89.66, 63.64, and 76.65% for CRP. Conclusions: Increased PDW combined with elevated WBC and neutrophil counts maybe used as diagnostic tests in the cases of acute appendicitis, while MPV and RDW levels were not useful diagnostic markers.

Non-Complicated Acute Appendicitis in Adults Treated Successfully by Conservative Treatment without Recurrences

AA = Acute Appendicitis, un-AA = Uncomplicated AA, cAA = Complicated Acute Appendicitis, WBC = White Blood Cells, CRP = C-Reactive Protein, U/S = Ultrasound, CT = Computed Tomography, MRI = Magnetic Resonance Imaging, pts = Patients, NET = Neuroendocrine Tumor.

Risk factors for the development of complicated appendicitis in adults.

To investigate the patient's history and physical examination information to find out risk factors associated with complicated appendicitis. Two hundred patients who were admitted with complicated appendicitis (including abscess, phlegmon, and generalized peritonitis) were retrieved from our database. Two hundred patients with non-complicated acute appendicitis were randomly selected from the same period. These two groups were compared in terms of demographic characteristics, past medical history, and presenting symptoms. We made a multivariate analysis model using binary logistic regression and backward stepwise elimination. Based on multivariate analysis, risk factors for complicated appendicitis included presenting with epigastric pain (OR=3.44), diarrhea (OR=23.4) or malaise (OR=49.7), history of RLQ pain within the past 6 months (OR=4.93), older age (OR=1.04), being married (OR=2.52), lack of anorexia (OR=4.63) and longer interval between onset of symptoms and admission (OR=1.46). Conversely, higher (academic) education was associated with decreased odds for complicated appendicitis (OR=0.26). Our findings suggest that a surgeon's clinical assessment is more reliable to make a judgment. "Bedside evaluation" is a useful, cheap, quick and readily available method for identifying those at risk for developing complicated acute appendicitis.

How to avoid negative appendectomies: Can US achieve this?

Clinical diagnosis of acute appendicitis is based primarily on symptoms and physical findings. However, diagnosis of appendicitis is not always straightforward. The aim of this study was to demonstrate the diagnostic effectiveness of ultrasonography (US) in these cases in combination with white blood cell count (WBC) and C-reactive protein (CRP) level. Retrospective analysis of data collected on 470 consecutive patients who underwent appendectomy at the same institution between January 2014 and January 2016 was conducted. Data included demographic features, preoperative WBC and CRP levels, and US measurement of diameter of appendix. Patients were divided into 3 groups: lymphoid hyperplasia (LH), non-complicated acute appendicitis (NCAA), and complicated acute appendicitis (CAA), according to postoperative histopathological examination results. There were 331 male and 139 female patients with mean age of 32.29±11.44 years included in the study. Mean WBC level was 12.31103/µL (±4.47 103/µL), 13.3 103/µL (±3.87 103/µL) and 14.08 103/µL (±4.11 103/µL) in LH, NCAA, and CAA groups, respectively (p=0.016). Mean CRP level was 14.2±19 mg/L, 36.9±59 mg/L, and 40.8±66 mg/L in LH, NCAA, and CAA groups, respectively (p=0.008). Mean outer diameter of the vermiform appendix on US was 4.8 mm (±3.9 mm), 6.9 mm (±4.08 mm) and 7.6 mm (±3.92 mm) in LH, NCAA, and CAA groups, respectively (p<0.01). When all variables were compared with each other, there were statistically significant differences in US findings according to group. WBC count and CRP level were higher in patients with acute appendicitis, but these findings alone were insufficient for definitive diagnosis. US findings were effectual both in diagnosis and demonstration of severe inflammation. US should be combined with laboratory tests and used as standard initial imaging in diagnostic pathway of patients with clinically suspected appendicitis. The authors of this study believe that this diagnostic pathway will reduce negative appendectomy rate.

Evaluation of Handmade Extra-Corporeal Loop versus Metallic Clips in Securing the Appendicular Stump in Laparoscopic Appendicectomy

Introduction: Laparoscopic appendicectomy has gained popularity due to the advantages of minimal-access surgery. Inadequate closure of the appendix stump leads to intra-abdominal surgical site infection or even fecal fistula. The base of the appendix can be secured with endostapler, endoloops, metallic clips or intracorporeal ligature. Aim: To evaluate the handmade extra-corporeal loop versus endoclip in securing the base of the appendix in non-complicated acute appendicitis. Methods: During the period from April 2014 to February 2016, in South Valley University, Aswan University and Sohag University hospitals (these are tertiary hospitals), 400 laparoscopic appendicectomy patients were included in this prospective study. In total, 240 patients were female and the overall average age was 25.6 years old. Patients were divided into two equal groups (group L and group C): in group L, handmade extracorporeal loop was used to secure the base of the appendix, the metallic clip was used in group C.Results: The mean operative time was 49 min in group L and 35.4 min in group C (P 0.05). Complications varied between port- site wound infection and delayed intestinal sounds, fecal fistula and there were no statistically significant differences. Conclusion: Using extracorporeal handmade loop or the metallic clips to secure the appendicular stump is safe, feasible, easy and inexpensive methods. The loop takes a little more time in its preparation. Metallic clips are inappropriate for edematous wide base appendix.

The diagnostic value of C-reactive protein and white blood cell count in diagnosis of acute appendicitis

Introduction Appendectomy is one of the commonest operations performed annually. Despite the advancement in the laboratory tests and radiological tests, still the rate of negative appendectomies is 15-30%. This study was designed to assess the diagnostic value of quantitative C-reactive protein (CRP) and white blood cell count (WCC) in patients suspected to have acute appendicitis. Patients and methods Our study is a prospective study that was conducted between December 2012 and March 2013 after approval of the ethical committee. Inclusion criteria Patients with clinically diagnosed acute appendicitis without generalized peritonitis. Exclusion criteria Patients with generalized peritonitis All patients were subjected to the following Clinical examination Routine bloods immediately after decision to admit including full blood count and CRP. Urine test Pregnancy test for all females Ultra sound scan to rule out other causes of abdominal pain All the patients were operated upon via open approach and the appendix was sent for histopathological analysis and the results were compared with C-Reactive protein (CRP) and the WBC (White blood cell count) and the results were compared using t-tests. Results Our study recruited 100 patients, 60 males (60%) and 40 females (40%), in the age range 20-55 years. The histopathological analysis showed acute appendicitis in 85 patients (85%), the operative notes showed 60 patients with noncomplicated appendicitis, 25 patients with complicated appendicitis; the WCC alone has a sensitivity of 85%, specificity of 75%, CRP alone has a sensitivity of 93.3% and specificity of 86.6%, WCC alone had positive predictive value of 44% and it improves to 70% when both parameters are combined together, whereas the negative predictive value of the WCC was 100%. In patients with normal appendix the mean CRP level was 10.6 mg/l, the median level was 10.6 mg/l, and the mean WCC was 8 Χ 10 9 cells/l, the median WCC 7 Χ 10 9 cells/l, whereas in patients with noncomplicated acute appendicitis (n = 60) the mean CRP was 40 mg/l, the median was 20 mg/l; in patients with complicated appendicitis (n = 25) the mean CRP was 90 mg/l and the median was CRP 60 mg/l. Conclusion We suggest that patients experiencing lower abdominal pain, with normal CRP values and normal WCC are unlikely to have acute appendicitis and need further investigations before embarking onto surgery.

Can abdominal surgical emergencies be treated in an ambulatory setting?

The performance of emergency abdominal surgery in an outpatient setting is increasingly the order of the day in France. This review evaluates the feasibility and reliability of ambulatory surgical treatment of the most common abdominal emergencies: appendectomy for acute appendicitis and cholecystectomy for acute complications of gallstone disease (acute cholecystitis and gallstone pancreatitis). This study evaluates surgical procedures performed on an ambulatory basis according to the international definition (admission in the morning, discharge in the evening with a hospital stay of less than 12 hours). Just as for elective surgery, eligibility of patients for an ambulatory approach depends on the capacities of the surgical and anesthesia team: to manage the risks, particularly the risk of deferring surgery until the morning); to prevent or treat post-operative symptoms like pain, nausea, vomiting, re-ambulation in order to permit rapid post-operative discharge. Recent studies have shown that appendectomy for non-complicated acute appendicitis can be deferred for up to 12 hours without any increase in danger. Many other studies have shown that early discharge after appendectomy for acute non-complicated appendicitis is feasible and safe. Nonetheless, there is only one published series of truly ambulatory appendectomies. The results were excellent. Patients who presented in the afternoon were brought back for operation the following morning. The appropriate timing for performance of cholecystectomy in patients with acute calculous cholecystitis or gallstone pancreatitis has not been well defined, but is always somewhat delayed relative to the onset of symptoms. To minimize operative complications, cholecystectomy for acute calculous cholecystitis should probably be performed between 24 and 72 hours after diagnosis. Cholecystectomy for gallstone pancreatitis should probably not be delayed longer than a week; the need to keep the patient hospitalized during the interval has not been demonstrated. Early discharge after cholecystectomy was usually possible, even in series where acute cholecystitis was diagnosed intra-operatively. Cholecystectomy for acute cholecystitis and gallstone pancreatitis seems to be feasible but no reports specifically support this approach. Emergency abdominal surgery seems to be feasible on an ambulatory setting for non-complicated acute appendicitis, acute calculous cholecystitis and gallstone pancreatitis. Only a single French series on ambulatory appendectomy for acute appendicitis has been reported.

Hyperbilirubinemia as a predictive factor in acute appendicitis.

Our aim was to establish the role of hyperbilirubinemia as a predictive parameter for the prediction of either acute, or gangrenous/perforated appendicitis as well as to compare other parameters in a similar role. Medical files of the patients who underwent appendectomies between September 2013 and September 2014 were evaluated. Age, gender, preoperative white blood cell count (WBC), neutrophil count (NEU), neutrophil percentage (NEU%), C-reactive protein (CRP), total/direct/indirect bilirubin levels, and the postoperative histopathological findings were recorded. The Fisher's exact, Pearson's χ (2), ANOVA, and Kruskal-Wallis tests while logistic regression for multivariate analysis was performed. p<0.05 was accepted as statistically significant. The study group of 162 patients consisted of 97 (60%) men and 65 (40%) women with a median age of 36 (18-90). Histopathological examinations revealed normal appendix in 21 (13%) patients, non-complicated acute appendicitis in 100 (62%), and appendiceal gangrene/perforation in 41 (25%) patients. WBC, NEU, NEU%, and CRP levels were significantly higher in cases of acute and gangrenous/perforated appendicitis (p<0.01). Total and direct bilirubin levels were also significantly elevated in patients with acute and gangrenous/perforated appendicitis (p<0.01). According to multivariate analysis, elevated CRP levels were associated with 14 times, elevated total bilirubin levels were associated with five times, and elevated direct bilirubin levels were associated with 36 times greater risk for appendiceal gangrene/perforation (p<0.01, p<0.05, p<0.01, respectively). Hyperbilirubinemia, especially with elevated direct bilirubin levels, may be considered as an important marker for the prediction of appendiceal gangrene/perforation.