Nonperforated Appendicitis Research Articles

Trends and outcomes in pediatric laparoscopic appendectomy: a NSQIP-P analysis of same-day discharge and readmission rates.

Practice patterns of same-day discharge for pediatric laparoscopic appendectomy for non-perforated appendicitis are not well-analyzed. Our aim is to evaluate current practice patterns and outcomes of same-day discharge for these patients. NSQIP-P retrospective registry identified patients (2017-2021) who underwent laparoscopic appendectomy for non-perforated appendicitis. Annual same-day discharge (SDD) rate was determined. SDD patients were compared to those discharged postoperative days 1-2 (non-SDD). Sub-group analysis was performed on ICD-10 code K35.30. Regression was performed. Overall, 67,214 patients were identified. The SDD rate increased from 33.3% (2017) to 52.5% (2021) with decreased 30-day readmissions between SDD and non-SDD (1.3% vs 2.1%, p < 0.001). Sub-group analysis identified 7,330 patients with SDD rates from 50.7% (2019) to 60.4% (2021) with decreased 30-day readmissions (1.3% vs 2.1%, p < 0.001) for SDD versus non-SDD. No increase in adverse events for SDD occurred in either analysis. Regression identified esophageal/gastric/intestinal diseases increased odds of early readmission or reoperation (OR 1.85, p = 0.042). Same-day discharge after pediatric laparoscopic appendectomy for non-perforated acute appendicitis continues to increase in frequency without a significant increase in adverse outcomes. SDD rates are 20-30% lower than previously published single-center studies, indicating there is a likely a larger percentage of patients that could discharge same-day. Level III.

5-Hydroxyindoleacetic acid as a biomarker for revealing perforation in acute appendicitis

BackgroundThe present study investigated the level of 5-hydroxyindoleacetic acid (5-HIAA) in perforated and nonperforated appendicitis patients. This issue is important for timely diagnosis of acute appendicitis complications and making decision about the surgical plan and type of incision.MethodsThis prospective study was conducted on patients with acute appendicitis. 5-HIAA levels were measured in urine spot sample of every patient before the surgery. The patients were finally included based on result of pathology for presence of appendicitis or not and sorted by direct surgical detection for exist of perforation or not. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 5-HIAA were investigated. The data were statistically analyzed by SPSS v.27.ResultsA total of 150 patients were included in two groups as 40 patients in the perforated appendicitis group and 110 patients in the noncomplicated acute appendicitis group. The average age of patients in the perforated appendicitis group was 28.8 ± 6.07 years, and that of patients in the acute appendicitis group was 29.6 ± 6.96 years. 94 patients (63%) were male, and 56 (37%) were female. No significant difference was observed in terms of age or sex between the two groups. The difference in the 5-HIAA concentration between the acute appendicitis group (0.3 ± 0.04 mg/dl) and the perforated appendicitis group (0.5 ± 0.03 mg/dl) was significant (P < 0.001). The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were 82%, 62%, 75%, 77%, and 88% respectively.ConclusionThis study shows that the 5-HIAA concentration in patients with perforated appendicitis can potentially increased significantly more than that in patients in the early stages of acute appendicitis. further studies with larger sample sizes are needed to prove the present results.

Comparative Outcomes of Immediate and Delayed Wound Closure Techniques in Appendectomies for Gangrenous Appendicitis

Background: Post-operative medical complications are very common in patients with gangrenous nonperforated appendicitis, especially surgical site infections (SSIs). Currently no conclusive answers on the relative benefits of immediate vs delayed wound clear therefore a comparison is essential. Objectives: In order to compare the results of immediate versus delayed wound closure in patients with gangrenous appendicitis who underwent appendectomy, SSIs, wound healing, and general postoperative recovery will be assessed. Methodology: The present study is a retrospective cohort study, using data from 185 patients, operated for gangrenous appendicitis during the period between from January 2023 to February, 2024. Total patients were categorized into two groups based on the wound closure technique employed, immediate wound closure (IWC, n=105) and delayed wound closure (DWC, n=80). Specific dependent variables were the overall SSI rate, days to wound healing and days of hospitalization. Secondary endpoints included a return of symptoms and overall postoperative morbidity. Results: The study also revealed that the incidence of SSIs was relatively low in the DWC group at 8. 0% compared to the (22.0± 0.01) % in the IWC group, which was statistically significant (p&lt;0. 001). The overall IWC time was significantly shorter in the IWC group (11 days) as compared to the DWC group (15 days) (P value = 0. 02). In our study, the DWC group was found to have a lower median LOS of 6 days as compared to IWC group that had a LOS of 8 days. When compared the two groups regarding readmission rates, the difference was not statistically significant (p-value = 0. 05). Conclusion: These delayed wound closure strategies in appendectomy for gangrenous appendicitis are a safe means of decreasing SSIs and hospital stay without a predisposing effect on wound healing and readmission. Based on these findings, it is recommended that DWC is the better approach in the management of such high-risk surgical patients.

Balancing Costs and Care: Nonoperative Appendicitis Treatment Outcomes in Pakistan.

Dear Respected Editor, In Pakistan, approximately 110,000 cases of appendicitis are reported annually [1], highlighting the condition's prevalence and significance. Traditional management predominantly revolves around widely practiced surgical intervention, such as appendectomy. [2]. Immediate appendectomy has become the standard treatment due to the significant morbidity and mortality difference between perforated and non-perforated acute appendicitis. However, the country's healthcare landscape presents a complex challenge due to varying regional access to medical resources. This variation in healthcare infrastructure exacerbates the difficulty of effectively managing appendicitis and underscores the need for solutions that strike a balance between clinical outcomes and economic considerations. While appendectomy remains a standard surgical procedure, it comes with inherent disadvantages, chief among them being the cost burden it places on patients and healthcare systems [3]. For patients in a low- to middle-income nation like Pakistan, the financial strain associated with surgery—which includes preoperative evaluations, surgical costs, hospital stays, and postoperative care—can be challenging [4]. Furthermore, the ripple effects affect the whole healthcare system, diverting resources that may otherwise be used for other urgent medical needs. A study by Siddiqui et al. emphasizes the need for a comprehensive analysis of economic factors in appendicitis management, particularly in low- and middle-income countries like Pakistan. The challenges in countries such as Pakistan require the exploration of alternative approaches that can optimize clinical outcomes while effectively managing healthcare costs without compromising patient care. [2] The recent study by Lee et al. introduces a promising alternative to conventional appendicitis management [5]. The research focuses on nonoperative treatment approaches, such as antibiotic therapy and observation, which have gained traction for their potential benefits Further, the study shows that the majority of the patients who had nonoperative treatment did not encounter a recurrence of appendicitis and were able to avoid surgical intervention for a period of around 20 years. Furthermore, there is a lack of data indicating any long-term dangers associated with nonoperative care. One of the prominent advantages lies in the reduction of immediate healthcare expenses, which can alleviate the financial burden on both patients and healthcare systems. By presenting evidence on the effectiveness and safety of nonoperative approaches, this study opens avenues for a paradigm shift in appendicitis management in Pakistan. The potential to achieve comparable clinical outcomes while minimizing the economic burden is a compelling proposition that warrants further exploration and consideration within Pakistan's healthcare challenges.

Predictive Value of Neutrophil-to-Lymphocyte Ratio in Differentiating Perforated from Non-perforated Appendicitis: A Cross-Sectional Study in a Tertiary Care Hospital, Tamil Nadu.

Introduction Acute appendicitis is a common reason for acute abdominal pain.It has a high perforation rate of 20%. Diagnosis of acute appendicitis is usually through well-known clinical signs and symptoms.Radiologic imaging is by and large carried out in peculiar cases with indistinct signs and symptoms.Although various scoring methods are available for screening and diagnosis, those have inadequate validity to accurately predict the severity of acute appendicitis.From the differential counts, the neutrophil-to-lymphocyte ratio (NLR) is an economical and straightforward measure of subclinical inflammation. NLR may be a useful marker for predicting the onset and severity of appendicitis because of the insight it gives into immunological and inflammatory pathways. In this study, we aimed to determine the association between NLR and acute appendicitis among adult patients to differentiate between perforated and non-perforated appendicitis in a tertiary care hospital in Tamil Nadu, India. Methods This was a cross-sectional study conducted in the Department of General Surgery of a deemed university in Chennai, Tamil Nadu.The study was conducted from March 2022 to December 2022. Patients aged 18 years and above undergoing appendicectomy surgery were included in the study.Patients with hematology disorders, chronic kidney disease, chronic liver disease, chronic obstructive pulmonary disease, asthma, cancer, or auto-immune diseases, and any viral, bacterial, or parasitic infections were excluded.Pregnant women were also excluded from the study.After obtaining informed consent from the patients, blood samples were collected as and when they were diagnosed as acute appendicitis.Laboratory analysis for complete hemogramincluding white blood cell (WBC) count, neutrophil, and lymphocyte count was carried out using an automated hematology analyzer.Prevalence of perforated appendicitis was reported as a percentage.The receiver-operating characteristic (ROC) curve was developed for NLR in differentiating perforated and non-perforated appendicitis.Data were entered in Microsoft Excel 2023.These analyses were carried out in STATA 12.0 (StataCorp, College Station, Texas, USA). Results A total of 212 patients aged 18 years and above were included in the study.Among them 93 (43.9%) were male and 119 (56.1%) were female.Prevalence of perforated appendicitis observed intra-operatively was 29.7% and non-perforated appendicitis was 70.3%. The mean (SD) of NLR among patients with perforated appendicitis was 8.8 (5.1) and non-perforated appendicitis was 3.2 (2.4) with a statistically significant difference (p-value < 0.0001).ROC curve with a cut-off value of 3.78 NLR, had sensitivity of 65.9% and specificity of 93.1% in differentiating perforated and non-perforated appendicitis.The positive predictive value (PPV) and negative predictive values (NPV) were reported as 85.7% and 81.2%, respectively. Conclusion NLR has a reasonable validity in differentiating perforated and non-perforated appendicitis.NLR may be useful in low-resource settings where routine confirmatory radiological procedures like computed tomography scans are not available.

Changes in Levels of Serum Cytokines and Chemokines in Perforated Appendicitis in Children.

Appendicitis is primarily diagnosed based on intraoperative or histopathological findings, and few studies have explored pre-operative markers of a perforated appendix. This study aimed to identify systemic biomarkers to predict pediatric appendicitis at various time points. The study group comprised pediatric patients with clinically suspected appendicitis between 2016 and 2019. Pre-surgical serum interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), intercellular cell-adhesion molecule-1 (ICAM-1), and endothelial selectin (E-selectin) levels were tested from day 1 to day 3 of the disease course. The biomarker values were analyzed and compared between children with normal appendices and appendicitis and those with perforated appendicitis (PA) and non-perforated appendicitis. Among 226 pediatric patients, 106 had non-perforated appendicitis, 102 had PA, and 18 had normal appendices. The levels of all serum proinflammatory biomarkers were elevated in children with acute appendicitis compared with those in children with normal appendices. In addition, the serum IL-6 and TNF-α levels in children with PA were significantly higher, with an elevation in TNF-α levels from days 1 and 2. In addition, serum IL-6 levels increased significantly from days 2 and 3 (both p < 0.05). Serum ICAM-1 and E-selectin levels were elevated in the PA group, with consistently elevated levels within the first three days of admission (all p < 0.05). These results indicate that increased serum levels of proinflammatory biomarkers including IL-6, TNF-α, ICAM-1, and E-selectin could be used as parameters in the prediction and early diagnosis of acute appendicitis, especially in children with PA.

THE OUTCOME OF ANTIBIOTICS VS OPEN APPENDECTOMY FOR ACUTE NON-PERFORATED APPENDICITIS

Acute appendicitis is a common surgical emergency. While appendectomy has been the conventional treatment for this condition, recent advancements in antibiotic therapy have led to exploring the use of antibiotics as a non-surgical alternative for treating non-complicated acute appendicitis. Objective: The objective of the present study was to compare the outcomes of administering antibiotics and performing emergency appendicectomy in a cohort of individuals diagnosed with non-perforated acute appendicitis based on CT evaluation. Methods: After the ethical approval from the institutional review board, this randomised control trial was conducted at Combined Military Hospital Jhelum from July 2022 to December 2023. The patients were randomly assigned, using a closed envelope method, to either have open appendectomy (Group A, n=60) or receive antibiotic therapy (Group B, n=60) with intravenous ertapenem. Open appendectomy was conducted utilising the McBurney technique. The patient’s outcomes were assessed during their hospitalization period, specifically on days 0, 1, and 2, and by telephone interviews one week and two months following the intervention. Pain scores were collected at two specific time points, one week and two months after randomisation, utilising a visual analogue scale (VAS). Results: No significant differences were observed in the baseline characteristics in both groups. Mean± S.D of the pain experience of the study participants in both groups was 4.16±1.04 and 3.68±1.02 (days) (P value=0.008). Mean± S.D of the hospital stay of the study participants in both groups was 3.13±0.87 and 3.16±0.83 (days) (P value=0.843). A significant difference in the VAS score was observed (p &lt;0.0001) in the participants of both groups at discharge and after a one-week follow-up period. Conclusion: The findings of the study indicate that a significant proportion of individuals who received antibiotic therapy for non-perforated acute appendicitis did not necessitate the surgical procedure of appendectomy within the two-month post-treatment observation period.

Postoperative Antibiotics, Outcomes, and Resource Use in Children With Gangrenous Appendicitis

Gangrenous, suppurative, and exudative (GSE) findings have been associated with increased surgical site infection (SSI) risk and resource use in children with nonperforated appendicitis. Establishing the role for postoperative antibiotics may have important implications for infection prevention and antimicrobial stewardship. To compare SSI rates in children with nonperforated appendicitis with GSE findings who did and did not receive postoperative antibiotics. This was a retrospective cohort study using American College of Surgeons' National Surgical Quality Improvement Program (NSQIP)-Pediatric Appendectomy Targeted data from 16 hospitals participating in a regional research consortium. NSQIP data were augmented with operative report and antibiotic use data obtained through supplemental medical record review. Children with nonperforated appendicitis with GSE findings who underwent appendectomy between July 1, 2015, and June 30, 2020, were identified using previously validated intraoperative criteria. Data were analyzed from October 2022 to July 2023. Continuation of antibiotics after appendectomy. Rate of 30-day postoperative SSI including both incisional and organ space infections. Complementary hospital and patient-level analyses were conducted to explore the association between postoperative antibiotic use and severity-adjusted outcomes. The hospital-level analysis explored the correlation between postoperative antibiotic use and observed to expected (O/E) SSI rate ratios after adjusting for differences in disease severity (presence of gangrene and postoperative length of stay) among hospital populations. In the patient-level analysis, propensity score matching was used to balance groups on disease severity, and outcomes were compared using mixed-effects logistic regression to adjust for hospital-level clustering. A total of 958 children (mean [SD] age, 10.7 [3.7] years; 567 male [59.2%]) were included in the hospital-level analysis, of which 573 (59.8%) received postoperative antibiotics. No correlation was found between hospital-level SSI O/E ratios and postoperative antibiotic use when analyzed by either overall rate of use (hospital median, 53.6%; range, 31.6%-100%; Spearman ρ = -0.10; P = .71) or by postoperative antibiotic duration (hospital median, 1 day; range, 0-7 days; Spearman ρ = -0.07; P = .79). In the propensity-matched patient-level analysis including 404 patients, children who received postoperative antibiotics had similar rates of SSI compared with children who did not receive postoperative antibiotics (3 of 202 [1.5%] vs 4 of 202 [2.0%]; odds ratio, 0.75; 95% CI, 0.16-3.39; P = .70). Use of postoperative antibiotics did not improve outcomes in children with nonperforated appendicitis with gangrenous, suppurative, or exudative findings.

Incidence and Management of Appendiceal Neuroendocrine Tumors in Pediatric Population: A Bicentric Experience with 6285 Appendectomies.

Neuroendocrine tumors (NETs) are rare tumors that arise from neuroendocrine cells and are the most common tumors of the appendix. NETs of the appendix usually cause no symptoms and often go unnoticed until they cause acute appendicitis or are discovered during an accidental appendectomy. As the trend towards the conservative treatment of acute appendicitis increases in the pediatric population, the question arises as to whether the majority of NETs go undetected and are only discovered at an advanced stage. The purpose of the proposed study is to review the incidence and outcomes of treatment for NETs of the appendix in children and include the data presented in the data pool for further review. From 1 January 2009 to 1 November 2023, a total of 6285 appendectomies were performed in two large pediatric centers in Croatia. After a retrospective review of the case records and histopathologic findings, a total of 31 children (0.49%) were diagnosed with NET of the appendix and included in the further analysis. The primary outcome of this study was the incidence and treatment outcome of pediatric patients diagnosed with NET of the appendix. Secondary outcomes included the patients' demographic, clinical, and laboratory data and the histopathologic characteristics of tumor species. The overall incidence of NETs of the appendix was stable over the study years, with minor fluctuations. The median age of patients was 14 (interquartile range-IQR: 12, 16) years, with a female predominance (64.5%). The majority of patients (96.8%) presented with acute abdominal pain and underwent appendectomy because acute appendicitis was suspected. Acute appendicitis was confirmed by histopathology in 18 (58%) cases. NETs of the appendix were not detected preoperatively in any of the patients. Among patients with confirmed acute appendicitis, most (n = 14; 77.8%) were found to have non-perforated acute appendicitis. In most children, the tumor was located at the tip of the appendix (n = 18; 58.1%), and the majority of tumors had a diameter of less than 1 cm (n = 21, 67.7%). The mitotic count (n = 25, 80.6%) and Ki-67 proliferation index (n = 23, 74.2%) were low in most patients, so most tumors were classified as NET G1 (n = 25, 80.6%), while NET G2 and NET G3 were found in four (12.9%) and two (6.5%) patients, respectively. All children were treated with appendectomy only. The median follow-up time was 54 (IQR: 24, 95) months. The incidence of appendiceal NET among pediatric patients is very low. NET occurs most frequently in adolescents, with a female predominance. Most tumors are less than 1 cm in diameter, located at the tip, and associated with non-perforated appendicitis. Appendectomy is the treatment of choice, and major surgery was not necessary in our cohort.

Predictors of in-hospital appendiceal perforation in patients with non- perforated acute appendicitis with appendicolithiasis at presentation

IntroductionAppendicolithiasis is a risk factor for perforated acute appendicitis. There is limited inpatient data on predictors of progression in appendicolithiasis-associated non-perforated acute appendicitis.MethodsWe identified adults presenting with appendicolithiasis-associated non-perforated acute appendicitis (on computed tomography) who underwent appendectomy. Logistic regression was used to investigate predictors of in-hospital perforation (on histopathology).Results296 patients with appendicolithiasis-associated non-perforated acute appendicitis were identified; 48 (16.2%) had perforation on histopathology. Mean (standard deviation [SD]) age was 39 (14.9) years. The mean (SD) length of stay (LOS) was 1.5 (1.8) days. LOS was significantly longer with perforated (mean [SD]: 3.0 [3.1] days) vs. non-perforated (mean [SD]: 1.2 [1.2] days) appendicitis (p < 0.001). On multivariate analysis, in-hospital perforation was associated with age > 65 years (OR 5.4, 95% CI: 1.4- 22.2; p = 0.015), BMI > 30 kg/m2 (OR 3.5, 95% CI: 1.3–8.9; p = 0.011), hyponatremia (OR 3.6, 95% CI: 1.3–9.8; p = 0.012). There was no significant association with age 25–65 years, gender, race, steroids, time-to- surgery, neutrophil percentage, or leukocyte count.ConclusionGeriatric age, obesity, and hyponatremia are associated with progression to perforation in appendicolithiasis-associated non-perforated acute appendicitis.

Efficacy and Safety of Three Doses of Ceftriaxone and Metronidazole as Prophylactic Uses during Acute Non-Perforated Appendicitis Surgical Operation: A Randomized Control Trial

Background: This study compared the efficacy of prophylactic antibiotics with seven days of conventional antibiotics. Objective: This present study was carried out to evaluate the effectiveness of three doses of prophylaxis with ceftriaxone and metronidazole. Methodology: This parallel arm, randomized control trial was conducted among fifty patients, consisting of 25 cases and 25 controls, with acute appendicitis admitted at Dhaka Medical College Hospital, Popular Medical College Hospital, Dhaka, and Ad-din Barrister Rafique Ul-Haq Hospital, Dhaka, during the period of November 2021 to April 2022. This study was done to evaluate the efficacy of three doses of combined prophylactic antibiotics, ceftriaxone and metronidazole, in acute non-perforated appendicitis cases. The patients in the control group were treated with seven days of conventional antibiotic therapy to compare the efficacy with three doses of prophylactic antibiotics. Results: Among 9 wound infections (15%), 4 patients were in the control group (36.5%), and 5 (40.5%) were in the case group in the study group with combined surgical prophylaxis of ceftriaxone and metronidazole (P=0.001). One patient develops both a wound infection and an intra-abdominal abscess. The study also found that amount to patient (3.3%) with intra-abdominal abscess formation 01 (50%) in control group and 01(50.0%) in combined prophylaxis group (ceftriaxone and metronidazole) (P&gt;0.3). Conclusion: In conclusion no significant difference could be found between the patients who received combined three doses of ceftriaxone and metronidazole and the control groups with regard to age, sex, distribution of symptoms before admission, preoperative temperature, duration of surgery, hospital stay, and concomitant diseases both overall and within each of the three groups of appendiceal examination. Bangladesh Journal of Infectious Diseases, June 2023;10(1):11-15

Appendicitis and its associated mortality and morbidity in infants up to 3 months of age: A systematic review.

Although appendicitis is rare in young infants, the reported mortality is high. Primary aim of this systematic review was to provide updated insights in the mortality and morbidity (postoperative complications, Clavien-Dindo grades I-IV) of appendicitis in infants ≤3 months of age. Secondary aims comprised the evaluation of patient characteristics, diagnostic work-up, treatment strategies, comorbidity, and factors associated with poor outcome. This systematic review was reported according to the PRISMA statement with a search performed in Pubmed, Embase and Web of Science (up to September 5th 2022). Original articles (published in English ≥1980) reporting on infants ≤3 months of age with appendicitis were included. Both patients with abdominal appendicitis and herniated appendicitis (such as Amyand's hernia) were considered. Data were provided descriptively. In total, 131 articles were included encompassing 242 cases after identification of 4294 records. Overall, 184 (76%) of the 242 patients had abdominal and 58 (24%) had herniated appendicitis. Two-hundred (83%) of the patients were newborns (≤28 days) and 42 (17%) were infants between 29 days and ≤3 months of age. Either immediate, or after initial conservative treatment, 236 (98%) patients underwent surgical treatment. Some 168 (69%) patients had perforated appendicitis. Mortality was reported in 20 (8%) patients and morbidity in an additional 18 (8%). All fatal cases had abdominal appendicitis and fatal outcome was relatively more often reported in newborns, term patients, patients with relevant comorbidity, nonperforated appendicitis and those presented from home. Mortality was reported in 20 (8%) infants ≤3 months of age and additional morbidity in 18 (8%). All patients with fatal outcome had abdominal appendicitis. Several patient characteristics were relatively more often reported in infants with poor outcome and adequate monitoring, early recognition and prompt treatment may favour the outcome.

Clinical scores (Alvarado and AIR scores) versus imaging (ultrasound and CT scan) in the diagnosis of equivocal cases of acute appendicitis: a randomized controlled study.

A total of 286 consecutive adult patients with suspected acute appendicitis were included. The clinical scores, including Alvarado and AIR scores and ultrasound, were done for all patients. Abdominal and pelvic CT scans were done for 192 patients to resolve the diagnosis of acute appendicitis. The sensitivity, specificity, positive and negative predictive values, and accuracy rate of both clinical scores and imaging (ultrasound and CT scan) were compared. The final histopathology was used as the gold standard for which the diagnostic feasibility of the clinical score and imaging were compared. Out of 286 total patients who presented with right lower quadrant abdominal pain, a presumptive diagnosis of acute appendicitis was made in 211 patients (123 males and 88 females) after thorough clinical evaluation, clinical scores, and imaging, and they were submitted to appendicectomy. The overall prevalence of acute appendicitis proved by histopathology as a gold standard was 89.1% (188 patients) with a negative appendectomy rate of 10.9%. Simple acute appendicitis was reported in 165 (78.2%) patients and perforated appendicitis in 23 (10.9%) patients. For patients with equivocal clinical scores (≥4 to ≤6), the sensitivity, specificity, predictive values, and accuracy rate of CT scan were significantly higher than those of Alvarado and AIR scores. Patients with low clinical scores (≤4) and high clinical scores (≥7), the sensitivity, specificity, predictive values, and accuracy rate of clinical scores and imaging were comparable. The diagnostic feasibility of AIR scores was significantly higher than the Alvarado score, and the clinical scores were associated with significantly higher diagnostic accuracy than ultrasound. CT scan is unlikely to be needed and will add little to the diagnosis of acute appendicitis for patients with high clinical scores (≥7). The sensitivity of the CT scan for perforated appendicitis was lower than that for nonperforated appendicitis. The use of CT scans for query cases did not change the negative appendectomy rate. CT scan evaluation is beneficial only for patients with equivocal clinical scores. For patients with high clinical scores, surgery is recommended. AIR score was superior to the Alvarado score in terms of sensitivity, specificity, and predictive values. A CT scan is usually not required for patients with low scores since acute appendicitis is unlikely; in such cases, ultrasound could be of help to exclude other diagnoses.

Study of outcomes of perforated appendicitis in adults: a prospective cohort study.

The aim was to study the intraoperative features and postoperative outcomes of appendicular perforation in adults. First, to study the incidence, clinical presentation, and complications of perforated appendicitis in a tertiary care hospital. Second, to study morbidity and mortality in an operated case of perforated appendicitis. This prospective observational study was conducted at a tertiary care centre in a government setup from August 2017 to July 2019. Data were collected from patients (N=126) who had an intraoperative finding of perforated appendicitis. The inclusion criteria are as follows: patients over the age of 12 with a perforated appendix, as well as any patients with intraoperative findings like perforated appendicitis, gangrenous perforated appendicitis, or a disintegrated appendix. The exclusion criteria are as follows: all patients with appendicitis below 12 years of age with perforated appendicitis; all patients with appendicitis with intraoperative findings of acute nonperforated appendicitis; and all patients with intraoperative findings of an appendicular lump or mass. Perforation was found in 13.8% of the cases of acute appendicitis in this study. With a mean age of 32.5 years, the most common age of presentation in perforated appendicitis was 21-30 years. The most prevalent presenting symptom in all patients (100%) was abdominal pain, followed by vomiting (64.3%) and fever (38.9%). Patients with perforated appendicitis had a 72.2% complication rate. Peritoneal pollution of more than 150ml was linked to a 100% increase in morbidity and mortality (54.5%). The mean duration of the hospital stay in patients with a perforated appendix was 7.28±5 days. Surgical site infection (42%) was the most common early complication, followed by wound dehiscence (16.6%), intestinal obstruction (1.6%), and faecal fistula (1.6%). The most common late complications were intestinal obstruction (2.4%), intra-abdominal abscess (1.6%), and incisional hernia (1.6%). The mortality rate in patients with perforated appendicitis was 4.8%. To conclude, prehospital delay was an important factor contributing to appendicular perforation and leading to adverse outcomes. A higher rate of morbidity and prolonged duration of hospital stay were seen in patients with delayed presentation, with features of generalised peritonitis and perforation of the base of the appendix. Delayed presentations in as elderly population with underlying co-morbid conditions associated with severe peritoneal contamination were associated with higher mortality (26%) in perforated appendicitis. Conventional surgery and open procedures remain the preferred approach in a government setup like ours where laparoscopy may not be available during odd hours. Since this study was done over a short duration, certain long-term outcomes could not be assessed. Hence, there is still a need for further studies.

Satisfaction With Same-Day Discharge After Laparoscopic Appendectomy for Nonperforated Appendicitis

IntroductionSame-day discharge (SDD) after laparoscopic appendectomy for acute nonperforated appendicitis is safe, without an increased rate of postoperative complications, emergency department visits, or readmissions. We aimed to evaluate caregiver satisfaction with this protocol. MethodsPatients discharged on the day of laparoscopic appendectomy for nonperforated acute appendicitis were identified between January 2022 and August 2022. Surveys to evaluate satisfaction with the protocol were distributed to the caregivers via email or text message 96 h after discharge. Telephone surveys were conducted if there were no responses to the initial online survey. The surveys assessed comfort with SDD, postoperative pain control adequacy, postoperative provider contact, and overall satisfaction. The protocol focused on avoidance of narcotics in the postoperative period and immediate return to a regular diet. ResultsA total of 255 cases of nonperforated acute appendicitis underwent SDD. The survey response rate was 50.6% (n = 129). Most respondents were Caucasian (69.0%, n = 89) and male (51.9%, n = 67) with a median age of 12.0 y (IQR 8.9,14.7). The median postoperative length of hospital stay was 3.8 h (interquartile range [IQR] 3.2,4.8). The overall satisfaction rate was 91.5%, with 118 caregivers feeling satisfied with SDD. Most caregivers felt comfortable with the SDD protocol (89.9%, n = 116), with 22.5% (n = 29) calling a medical provider postoperatively. Approximately nine out of 10 caregivers reported that pain was adequately controlled (91.5%, n = 118). In contrast, those that were dissatisfied reported issues with pain control and anxiety with SDD after a surgical procedure. ConclusionsCaregiver satisfaction and comfort with same-day discharge following laparoscopic appendectomy is high with appropriate anticipatory guidance and preoperative education.

Prediction of Perforated and Nonperforated Acute Appendicitis Using Machine Learning-Based Explainable Artificial Intelligence

The primary aim of this study was to create a machine learning (ML) model that can predict perforated and nonperforated acute appendicitis (AAp) with high accuracy and to demonstrate the clinical interpretability of the model with explainable artificial intelligence (XAI). A total of 1797 patients who underwent appendectomy with a preliminary diagnosis of AAp between May 2009 and March 2022 were included in the study. Considering the histopathological examination, the patients were divided into two groups as AAp (n = 1465) and non-AAp (NA; n = 332); the non-AAp group is also referred to as negative appendectomy. Subsequently, patients confirmed to have AAp were divided into two subgroups: nonperforated (n = 1161) and perforated AAp (n = 304). The missing values in the data set were assigned using the Random Forest method. The Boruta variable selection method was used to identify the most important variables associated with AAp and perforated AAp. The class imbalance problem in the data set was resolved by the SMOTE method. The CatBoost model was used to classify AAp and non-AAp patients and perforated and nonperforated AAp patients. The performance of the model in the holdout test set was evaluated with accuracy, F1- score, sensitivity, specificity, and area under the receiver operator curve (AUC). The SHAP method, which is one of the XAI methods, was used to interpret the model results. The CatBoost model could distinguish AAp patients from non-AAp individuals with an accuracy of 88.2% (85.6-90.8%), while distinguishing perforated AAp patients from nonperforated AAp individuals with an accuracy of 92% (89.6-94.5%). According to the results of the SHAP method applied to the CatBoost model, it was observed that high total bilirubin, WBC, Netrophil, WLR, NLR, CRP, and WNR values, and low PNR, PDW, and MCV values increased the prediction of AAp biochemically. On the other hand, high CRP, Age, Total Bilirubin, PLT, RDW, WBC, MCV, WLR, NLR, and Neutrophil values, and low Lymphocyte, PDW, MPV, and PNR values were observed to increase the prediction of perforated AAp. For the first time in the literature, a new approach combining ML and XAI methods was tried to predict AAp and perforated AAp, and both clinical conditions were predicted with high accuracy. This new approach proved successful in showing how well which demographic and biochemical parameters could explain the current clinical situation in predicting AAp and perforated AAp.

Hyperfibrinogenemia and hyponatremia as predictors of perforated appendicitis in children: A retrospective cohort study

The aim of this study was to investigate the predictive value of hyperfibrinogenemia and hyponatremia for perforated appendicitis in children. A retrospective review of 521 pediatric patients (≤ 15years) with acute appendicitis confirmed by histopathology from January 2017 to December 2020 was performed. Patients were divided in two groups, those with non-perforated (n = 379; 73%) and perforated appendicitis (n = 142; 27%). The serum values of sodium and fibrinogen were taken before surgery. We performed the receiver operating characteristic analysis for the two biochemical markers. The sensitivity, specificity, positive and negative predictive values for perforated appendicitis in the presence of hyponatremia and hyperfibrinogenemia were calculated. Hyperfibrinogenemia (≥ 4.0g/L) was found in 58.45% of perforated appendicitis and 104 of 142 (73.34%) children with perforated appendicitis had hyponatremia (≤ 135mmol/L). The perforated appendicitis group had a higher mean fibrinogen concentration (P = 0.001). There was a statistically significant difference in mean serum sodium levels between the perforated appendicitis and non-perforated appendicitis groups (P = 0.016). Receiver operating characteristic curve analysis for fibrinogen, sodium and combination of the both markers shown the combination had the largest area under the curve in identifying children with perforated acute appendicitis (0.858) (95% CI, 0.82-0.90) compared with fibrinogen (0.815) (95% CI, 0.77-0.86) and sodium 0.818 (95% CI, 0.78-0.86) alone. Furthermore, the combination of both markers had the best positive and negative predictive value for appendix perforation compared to fibrinogen and sodium. Hyponatremia and/or hyperfibrinogenemia are excellent markers for predicting perforated appendicitis in children. We propose that plasma sodium and/or fibrinogen concentrations be utilized as a supplementary to guide individual treatment decisions in children with appendicitis, such as surgery timing and nonoperative management options.

Comparative Role of Different Antibiotics for Non‐Perforated Acute Appendicitis a Meta-Base Histopathological Study

Background: The preferred method of treating appendicitis for more than a century has been appendectomy. Recent trials have challenged this theory. In patients with non-perforated appendicitis, this study evaluated the advantages and disadvantages of antibiotic treatment against appendectomy. Aims and objectives: Surgery vs. non-operative antibiotic treatment for acute non-perforated appendicitis. Study design: A meta-base histopathological study. Methodology: By using inclusion and exclusion criteria, all matched patients were chosen for the study and divided into two groups, group A and group B, using the closed envelop technique. All patients received an injection of injectable ceftriaxone 1 g and metronidazole 500 mg as part of an antibiotic prophylaxis regimen prior to surgery, while group A, patients received a single dosage of the same medications. Intravenous and oral antibiotic regimens, a second- or third-generation cephalosporin or ceftriaxone plus metronidazole injectable. The statistical software for the social science system (SPSS) version 17.0 was used for the statistical analysis. A (p≤0.05) value was used to denote a significant difference for all statistical tests. Antibiotics: Intravenous and oral antibiotic regimens (i) A second- or third-generation cephalosporin, or ceftriaxone plus metronidazole injectable (ii) single-agent regimens of amoxicillin-clavulanate. (iii) Fluoroquinolone or an advanced generation cephalosporin plus metronidazole, and amoxicillin-clavulanate. Practical Implications: In patients with non-perforated appendicitis, this study evaluated the advantages and disadvantages of antibiotic treatment against appendicectomy. In patients with clinically uncomplicated appendicitis, the decision between medicinal and surgical care is value and preference-dependent, indicating the need for a shift in practice towards collaborative decision-making. Results: Seroma was present in (12±0.01) of patients in group A and (20±0.02) of patients in group B; the (p≤0.05) value is very higher than Group-A, which is statistically insignificant. That implies that post-operative antibiotic medication does not lessen seroma development. In table-2 intra-abdominal abscess formation levels in group-A and Group- B were (7.2±0.02, 15±0.02) which indicated that antibacterial postoperative therapy was not effective as pre past- operative. That implies that antibacterial postoperative therapy does not lessen local site edema. People in both groups (16.2±0.01, 19±0.02) experienced pus discharge from the stitch line, and the p value is uncertain. Fever was seen in (6.5±0.01) of patients in group A and (10.2±0.02) of patients in group B; their p values were (P≤0.01 and P≤0.02) occasionally. Patients' length of hospital stays were shown that pre and post-surgery treatment was statistically significant than only post-surgery treatment. Conclusion: As a result, we can draw the conclusion from our study that, in cases of non-perforated appendicitis, carefully chosen and appropriately timed pre-operative antibiotics are sufficient in preventing Seroma formation, Intra-abdominal abscess formation, Local site edema, pus discharge from the stitch line, fever and stay in hospital. Post-operative antibiotics were not affect the rate of occurrence of the above mentioned variables. Keywords: Seroma formation, Intra-abdominal abscess formation, Local site edema, Pus discharge from the stitch line, Antibiotics. Appendicitis.

Role of Metronidazole after Appendicectomy in Simple Cases of Acute Appendicitis

Background: Simple cases of acute appendicitis are usually dealt with appendicectomy and post-operative antibiotics. Causative organisms include both aerobes as well as anaerobes. The antibiotic spectrum to cover aerobes varies from hospital to hospital but the drug Metronidazole is used to cover anaerobes which is fairly common Aim: To determine the role of metronidazole after appendicectomy in simple cases of acute appendicitis Study design: Randomized, controlled, multicenter trial. Place and duration of study: Department of Surgery, Central Park Teaching Hospital Lahore, Noor Hospital, Kot Radha Kishan and Bilquees Hospital, Kasur from 1st January 2020 to 31st December 2021 Methodology: One hundred and thirty patients were included in the study divided into 2 groups (65 in each group). Inclusion criteria included all patients of simple acute appendicitis from age 13 to 70 years. Exclusion criteria were patients with complications of acute appendicitis. Patients receiving Metronidazole were allocated group A, while those not receiving this drug were allocated group B. Open appendicectomy was done in all cases. Variables of interest were post-operative wound infection, hospital stay and nausea/vomiting. Results: Mean age of patients of group A was 29.39±16.32 years while mean age of patients in group B was 34.18±18.05 years. 44.6% patients of group A were male and 55.4% were females. On the other hand 50.8% patients of group B were male and 49.2% were females. In group A, 6 patients got wound infection (9.2%) while 59 patients had uneventful recovery (90.8%). In group B, 4 patients got wound infection making it 6.2% while rest of the 61 patients had uneventful recovery (93.8%). The difference between the 2 groups was not statistically significant (p-value 0.11). Mean hospital stay in group A patients was 2.28±0.89 days while in group B it was 2.12±0.73 days. Conclusion: Metronidazole is an effective drug against anaerobes but in simple cases of non-perforated appendicitis this drug does not decreases the wound infection rate after appendicectomy. Keywords: Metronidazole, Appendicitis, Appendicectomy

A RANDOMISED CONTROL TRIAL TO ASCERTAIN IF POSTOPERATIVE ANTIBIOTICS ARE NECESSARY FOLLOWING LAPAROSCOPIC APPENDICECTOMY IN NONPERFORATED APPENDICITIS

Background: The most frequent cause of severe abdominal discomfort is acute appendicitis. Prophylactic antibiotics should be used as directed to reduce the risk of postoperative surgical site infections (SSIs). There is no denitive recommendation, though, for how long to use antibiotics. There has only been one preoperative prophylactic dose several randomised control trials strongly suggest. Therefore, the goal of the study was to ascertain if postoperative antibiotics were necessary following laparoscopic appendix surgery for nonperforated appendicitis. Methods: A total of 52 nonperforated appendicitis patients were separated into two groups and underwent laparoscopic appendectomy. Patients in group B (n=26) received three postoperative doses of antibiotics in addition to the one preoperative dose given to group A's (n=26) patients. Regular investigations, such as Complete blood count, blood urea, serum creatinine, and other tests like an abdominal ultrasound were also carried out. After a laparoscopic appendicectomy, the surgical incision was examined to check for any evidence of postoperative SSI after 48, 72, and 7 days. Results: Group A had a mean age of 30.6± 10.5 years compared to group B's mean age of 30.7 ±9.5 years (p=0.75). Right iliac fossa pain was the initial complaint of every subject in the research. Grade III SSIs occurred in 0ne patient in group A (4%) and one patient in group B (4%) and were treated conservatively. The difference in the incidence of SSIs between the two groups was statistically negligible (p=1.000). Conclusions: After a laparoscopic appendicectomy, prophylactic postoperative doses of antibiotics offer no additional advantage over a single preoperative dosage in terms of preventing postoperative SSIs