Outcomes Of Appendicitis Research Articles

189 Outcomes in Appendicitis During The COVID-19 Pandemic: A Single Center Report Of 36 Cases

Abstract Introduction Surgical management of acute appendicitis(AA) during the first peak of COVID-19 was modified somewhat in order to mitigate concurrent infection. Early in the pandemic an open approach was preferable. The management of AA at a single surgical unit over three months during the COVID-19 outbreak is presented. Method Data on patients diagnosed with AA (3rd March 2020 to 4th May 2020) were analysed. Management strategies, morbidity, length of stay and readmissions were evaluated. Results Median age was 45 years (range 6-75) with a male: female ratio of 2.7:1. The mean white cell count and CRP were 14.7(5.4-25) and 121.6(1- 545), respectively. Appendicectomy (28/36;77.8%) was performed laparoscopically in 23(82.1%) and open in 4(14.3%); 13.9%(5/36) of AA, were managed conservatively. Among the COVID-19 positive patients(5/36), 4 were managed laparoscopically, one needed a laparotomy. Considering COVID-19 positive vs negative/not done status, conversion was seen 50%(2/4) and 5.3%(1/19) respectively. A difference in mean length of stay was noted (positive vs negative/not done = 10.4 days vs 3.43 days). Morbidity was 16.7%(6/36) with a re-admission rate of 11%(4/36). Conclusions Surgical units need to be flexible to modify their management plans as the COVID-19 pandemic evolves. Awaiting USS/CECT, wait and watch policy related delays should be avoided when possible. A higher conversion rate, morbidity and readmission rate were noted in this cohort of patients, potentially the result of more complicated inflammation, as patients may present late owing to apprehensions regarding their safety while attending hospital.

Prehospital barriers for rural New Zealand parents in paediatric appendicitis: a qualitative analysis

Appendicitis is the most common reason children undergo emergency general surgery. Worse appendicitis outcomes have been demonstrated in rural, lower socioeconomic, and indigenous populations. These findings are hypothesised to be a result of differential access and delay in presentation to hospital. However, no qualitative study has investigated why prehospital delay may exist. We conducted individual, semi-structured interviews with the parents of 11 rural children who presented with acute appendicitis between June 2019-January 2020. Utilising grounded theory methodology, we created an exploratory framework. Participating families travelled a mean distance of 50.4 km to access hospital, and the median prehospital symptom duration was 42 h. Families with reduced financial or social resources were more likely to 'watch and wait' due to the increased relative burden of access. Key considerations were travel, organising childcare and parental income loss in a rural environment. Structural healthcare barriers further dissuaded prompt access and subsequent engagement. These included poor cultural safety, maldistribution of rural health services, and contradictory public health messages. Several families sought informal community-based health advice to mitigate these barriers, leading to earlier hospital presentation. Prehospital delay in rural families occurred most frequently due to an extended decision-making phase where families evaluated the costs and benefits of accessing hospital-level care. The utilisation of informal community expertise and whānau advocacy helped circumvent reduced access to health facilities. Cultural safety remains problematic and hinders engagement with Māori families.

Prevalence of Postoperative Unfavorable Outcome and Associated Factors in Patients with Appendicitis: A Cross-Sectional Study.

PurposeAppendicitis is surgical emergency that might need removal of the inflamed appendix. Unless treated, appendicular abscess, perforation, and even death might be the unfavorable outcomes. Hence, this study was aimed to investigate the unfavorable outcomes and associated factors among appendicitis operated patients.Patients and MethodsA total of 300 patients who operated for appendicitis from September 1 2019 to August 30 2020 were studied using a retrospective cross-sectional study. Data were collected by using a checklist. Epi-data and SPSS version 25 were used for data entry and analysis, respectively. Binary logistic regression model was used to identify independent factors. A p<0.05 was used to set the statistical significance of factors.ResultsAmong 300 patients who were operated for acute appendicitis, 36 (12%) developed unfavorable outcomes. Though one death because of sepsis was recorded, wound infection was the main postoperative disorder. Female (AOR=0.49; 95% CI: 0.13–0.074), living outside the hospital setting (AOR= 0.49; 95% CI: 0.13–0.074), duration of illness before arrival at the hospital (1–3 days (AOR= 1.67; 95% CI: 1.34–8.37) and ≥4 days (AOR=5.38; 95% CI: 1.63–7.69)), more than 3 days hospital stay (AOR= 3.21; 95% CI: 2.06–8.10), and mass in the right lower quadrant (AOR= 6.01; 95% CI: 2.11–14.50) were the independent predictors of unfavorable outcomes of appendicitis treatment.ConclusionIn this study, unfavorable outcome of acute appendicitis was high. More than one-tenth of appendicitis cases developed unfavorable outcomes. Living outside the hospital setting area, long duration of illness before arrival at the Hospital, more than 3 days hospital stay, and mass in the right lower quadrant were the risk factors, while females were less likely to have unfavorable outcomes of appendicitis. Therefore, closely working with patients who have abdominal pain and increasing their awareness about acute appendicitis will improve the operation outcome.

Factors Affecting Patient Outcomes in Acute Appendicitis in Rural Areas: An Observational Cohort Study

The most common surgical emergency both in developed and non-developed countries is acute appendicitis and it has a time-dependent clinical course. In this observational cohort study, we aim to investigate the factors affecting patient outcomes in acute appendicitis at a rural hospital. This observational cohort study was held between November 2012 and May 2014 at a rural hospital. Patients' pre-operative, perioperative, and post-operative data were collected prospectively. Patients were followed-up for 12-months. A total of 151 patients were recorded. Factors significantly associated with complicated cases (abscess/perforation) were referral region as remote towns (OR:7.94, 95%CI [3.46-18.23]; p < 0.001), referral season as winter (OR:2.47, %95CI [1.14-5.36]; p = 0.022), pre-operative hospital delay (OR:6.52, 95%CI [3.49-12.20]; p < 0.001), and duration of referral (OR:1.01, 95%CI [1.00-1.01]; p < 0.001). In the multivariate analysis, only pre-operative hospital delay remained as a significant factor (OR:5.87, 95%CI [2.85 - 12.07]; p < 0.001). Factors affecting length of hospital stay (LoHS) were referral region as remote towns (95%CI, β = 3.10 [2.28-3.93], t = 1.91; p < 0.001), abscess/perforation (95%CI, β = 4.70 [4.04-5.36], t = 14.05; p < 0.001), pre-operative hospital delay (95%CI, β = 1.25 [0.87-1.62], t = 6.58; p < 0.001), and duration of referral (95%CI, β = 0.011 [0.01-0.14], t = 7.34; p < 0.001). In the multivariate analysis, all four factors stayed significant. The rate of complicated appendicitis was significantly high in winter than other seasons for patients referring from remote towns (75% vs 33%, p < 0.001). This observational cohort study is the only study specifically focused on the effect of season and region on abscess/perforation rates, LoHS, and accessibility to hospital in patients with acute appendicitis.

Where Did All the Appendicitis Go? Impact of the COVID-19 Pandemic on Volume, Management, and Outcomes of Acute Appendicitis in a Nationwide, Multicenter Analysis.

The study objective was to evaluate effects of the COVID-19 pandemic on rates of emergency department (ED) acute appendicitis presentation, management strategies, and patient outcomes. Acute appendicitis is the most commonly performed emergency surgery in the United States and is unlikely to improve without medical or surgical intervention. Dramatic reductions in ED visits prompted concern that individuals with serious conditions, such as acute appendicitis, were deferring treatment for fear of contracting COVID-19. Patients from 146 hospitals with diagnosed appendicitis and arrival between March 2016 and May 2020 were selected. Electronic medical records data were retrospectively reviewed to retrieve patient data. Daily admissions were averaged from March 2016 through May 2019 and compared with March 2020. April-specific admissions were compared across the 5-year pre-COVID-19 period to April 2020 to identify differences in volume, demographics, disease severity, and outcomes. Appendicitis patient admissions in 2020 decreased throughout March into April, with April experiencing the fewest admissions. April 2020 experienced a substantial decrease in patients who presented with appendicitis, dropping 25.4%, from an average of 2030 patients (2016-2019) to 1516 in 2020. An even greater decrease of 33.8% was observed in pediatric patients (age <18). Overall, 77% of the 146 hospitals experienced a reduction in appendicitis admissions. There were no differences between years in percent of patients treated nonoperatively (P = 0.493) incidence of shock (P = 0.95), mortality (P = 0.24), or need for postoperative procedures (P = 0.81). Acute appendicitis presentations decreased significantly during the COVID-19 pandemic, while overall management and patient outcomes did not differ from previous years. Further research is needed focusing on putative explanations for decreased hospital presentations unrelated to COVID-19 infection and possible implications for surgical management of uncomplicated acute appendicitis.Keywords: acute appendicitis, COVID-19, decreasing volumes, multicenter study.

Clinical Outcomes of Acute Appendicitis During Pregnancy: Conservative Management and Appendectomy.

We have described the epidemiology, diagnostic modality, treatment patterns, and outcomes of acute appendicitis during pregnancy. Using a nationwide claim-based database in Japan, we analyzed the data of pregnant patients who were diagnosed with appendicitis between January 2005 and May 2019. Patient characteristics, imaging studies, length of hospital stay, proportion of fetal losses, complications, and type of antibiotics were examined. The study included 169 patients, of whom 113 patients (67%) underwent conservative management, and appendectomies were performed on 56 patients (open 25% and laparoscopic 8%). The proportion of ultrasonography, computed tomography, and magnetic resonance imaging were 97%, 17%, and 5% (for conservative management); 88%, 39%, and 13% (for appendectomy); 86%, 38%, and 21% (for open appendectomy); and 93%, 43%, and 14% (for laparoscopic appendectomy), respectively. The proportion of complicated appendicitis was 6% in conservative management and 41% in appendectomy (40% in open appendectomy and 43% in laparoscopic appendectomy), respectively. The incidence of fetal loss was 4% in conservative management, 5% in appendectomy (2% in open appendectomy, and 14% in laparoscopic appendectomy). However, there was only one fetal loss (in laparoscopic appendectomy) in the same case of hospitalization. There were no maternal deaths or serious complications after any treatment. All treatments showed acceptable outcomes in appendicitis during pregnancy. Conservative management is considered an acceptable option, especially in uncomplicated cases of appendicitis in pregnant women.

Impact of the COVID-19 pandemic on management and outcomes in acute appendicitis: Should these new practices be the norm?

BackgroundIn early 2020, the COVID-19 pandemic significantly altered management of surgical patients globally. International guidelines recommended that non-operative management be implemented wherever possible (e.g. in proven uncomplicated appendicitis) to reduce pressure on healthcare services and reduce risk of peri-operative viral transmission. We sought to compare our management and outcomes of appendicitis during lockdown vs a non-pandemic period. MethodsAll presentations to our department with a clinical diagnosis of acute appendicitis between 12/03/2020 and 30/06/2020 were compared to the same 110-day period in 2019. Quantity and severity of presentations, use of radiological investigations, rate of operative intervention and histopathological findings were variables collected for comparison. ResultsThere was a reduction in appendicitis presentations (from 74 to 56 cases), and an increase in radiological imaging (from 70.27% to 89.29%) (P = 0.007) from 2019 to 2020. In 2019, 93.24% of patients had appendicectomy, compared to 71.42% in 2020(P < 0.001). This decrease was most pronounced in uncomplicated cases, whose operative rates dropped from 90.32% to 62.5% (P = 0.009). Post-operative histology confirmed appendicitis in 73.9% in 2019, compared to 97.5% in 2020 (P = 0.001). Normal appendiceal pathology was reported for 17 cases (24.64%) in 2019, compared to none in 2020 (P < 0.001) – a 0% negative appendicectomy rate (NAR). DiscussionThe 0% NAR in 2020 is due to a combination of increased CT imaging, a higher threshold to operate, and is impacted by increased disease severity due to delayed patient presentation. This study adds to growing literature promoting routine use of radiological imaging to confirm appendicitis diagnosis. As we enter a second lockdown, patients should be encouraged to avoid late presentations, and surgical departments should continue using radiological imaging more liberally in guiding appendicitis management.

A local experience of non-operative management for an appendicitis cohort during COVID-19

BackgroundDuring the first United Kingdom COVID-19 wave, the Royal Colleges of Surgeons initially recommended conservative management with antibiotics instead of surgery for appendicitis. This study compared local outcomes of appendicitis during this period with a pre-COVID-19 cohort. MethodsAn observational study was conducted in a district general hospital. All episodes of appendicitis were prospectively studied from 25th March 2020 until 26th May 2020 and compared with a retrospective pre-COVID cohort from 27th November 2019 until 29th January 2020. Primary outcome was 30-day treatment failure of simple appendicitis for conservatively managed cases during COVID-19 compared to surgically managed cases pre-pandemic. Treatment failure was defined as any unplanned radiological or surgical intervention. ResultsOver nine weeks, there were 39 cases of appendicitis during COVID-19 and 50 cases pre-COVID-19. Twenty-six and 50 cases underwent appendicectomy during and pre-COVID-19 respectively. There was no difference in 30-day postoperative complication rates and nor were there any peri-operative COVID-19 infections.Twelve cases of simple appendicitis underwent conservative management during COVID-19 and were compared with 23 operatively managed simple cases pre-pandemic. There was a higher failure rate in the conservative versus operative group (33.3 vs 0% OR = 24.88, 95% CI 1.21 to 512.9, p=0.0095). Length of stay was similar (1.5 vs 2.0 p=0.576). DiscussionLocally, conservative management was more likely to fail than initial appendicectomy. We suggest that surgery should remain first line for appendicitis, with conservative management reserved for those with suspected or proven COVID-19 infection.

Is Pseudomonas infection associated with worse outcomes in pediatric perforated appendicitis?

BackgroundThere is little information on the effects of Pseudomonas infection on outcomes in perforated appendicitis. As Pseudomonas is not covered by many empiric appendicitis antibiotic regiments, we hypothesized that children with Pseudomonas would have worse outcomes. MethodsPatients <18 years old undergoing appendectomy for perforated appendicitis at a tertiary children's hospital 2015–2019 were included and were stratified by presence of Pseudomonas on intraoperative culture. The primary outcome was post-operative organ-space infection (SSI). ResultsIntraoperative cultures were collected in 58.4% of patients (n = 149/255) with 22.2% (n = 33) positive for Pseudomonas. SSIs occurred in 21.2% of children with Pseudomonas compared to 20.7% of children without Pseudomonas (p = 0.9). Children with Pseudomonas had longer antibiotic duration (9.1 vs. 6.7 days, p = 0.03) and LOS (6.7 vs. 5.9 days, p = 0.03) than those without, but a similar rate of post-operative interventions (12.2% vs. 19.0%, p = 0.4), hospital costs ($28,860 vs. $23,945, p = 0.3), ED visits (9.1% vs. 19.9%, p = 0.3), and readmissions (9.1% vs. 9.5%, p = 1). ConclusionPseudomonas was identified in 22% children with perforated appendicitis and was associated with longer antibiotic durations and LOS, but similar rates of SSI, post-operative interventions, and readmissions compared to children without Pseudomonas. Empiric coverage of Pseudomonas may not be necessary.

DIAGNOSIS, MANAGEMENT AND CLINICOPATHOLOGICAL FEATURES OF ACUTE APPENDICITIS IN PREGNANT WOMEN AND ITS IMPACT ON FETAL OUTCOMES

Objective: To evaluate the clinicopathological features and feto-maternal outcomes of appendicitis during pregnancy. Material and Method: This study involved comparisons of laboratory findings, preoperative ultrasonography (US), pathology and clinical outcomes of 17 pregnant and 59 age-matched non-pregnant women undergoing appendectomy. Results: The total number of US scans, rates of non-visualized appendix on US, and length of hospital stay were higher in pregnant women than in non-pregnant subjects (p&lt;0.001, p=0.035, and p=0.014; respectively). The rate of negative appendectomy was 1.5-times higher and the rate of complicated appendicitis was 7-times higher in pregnant compared with non-pregnant patients. The diagnostic accuracy of US was higher in the non-pregnant group (72.9% vs. 64.7%). In terms of the hematological parameters, no significant difference was found between the pregnant patients with and without appendicitis. There was one premature birth and one abortus in the second trimester, and one premature birth followed by a negative appendectomy in the third trimester. Conclusion: The diagnosis of acute appendicitis in pregnancy may remain inconclusive despite comprehensive evaluation with clinical examination, laboratory studies, and US. We recommend that clinicians consider additional imaging scans when they suspect appendicitis during pregnancy to avoid unnecessary surgical interventions. Both complicated appendicitis and negative appendectomy can cause a non-negligible rate of fetal morbidity and mortality.&nbsp;&nbsp;

Does the time from symptom onset to surgery affect the outcomes of patients with acute appendicitis? A prospective cohort study of 255 patients.

The objective of this study was to evaluate the impact of operative timing on outcomes of acute appendicitis. This study examined adult patients who had presented to the hospital with acute appendicitis and had undergone appendectomy from December 2017 to February 2019. Time delay and outcomes of perforated and non-perforated appendicitis were compared. Patients were classified into five groups based on the period from symptom onset to operation: group 1, <24 hours; group 2, ≥24 and <48 hours; group 3, ≥48 and <72 hours; group 4, ≥72 and <96 hours; and group 5, ≥96 hours. The five groups were compared, with risk of perforation assessed in particular. A total of 255 patients were included in the analysis. Symptom duration, operative time, and length of postoperative hospital stay (P< .001) were significantly longer in the perforated group (n=49) than in the non-perforated group (n=206). The perforated group also had a higher conversion rate to open procedures (P= .002) and a higher rate of wound infection (P= .034). Group 1 had 53 patients, group 2 had 95 patients, group 3 had 57 patients, group 4 had 32 patients, and group 5 had 18 patients. The incidence of appendiceal perforation and median operative time progressively increased along with symptom duration in the five groups. In multivariate analyses, independent risk factors for appendiceal perforation were male gender (odds ratio=2.33, 95% confidence interval [CI]: 1.07-5.08) and symptom duration ≥48 hours (relative to ≥24 and <48 hours) (odds ratio=4.64, 95%CI: 1.76-12.27). Patients with symptom duration ≥72 hours had a significantly longer operative time than those with symptom duration ≥48 and <72 hours (β=21.38, 95%CI: 5.66-37.11, P= .008). The risk of perforation increased significantly 48 hours after the onset of appendicitis. Symptoms duration ≥72 hours was associated with a longer operative time.

Treatment outcomes of acute appendicitis and associated factors among admitted patients with a diagnosis of acute abdomen in Debre Markos Referral Hospital, Amhara Region, North West Ethiopia.

Appendicitis is an inflammation of the vermiform appendix and is one of the most common causes of an acute abdomen in young adults. If left untreated, it can lead to appendiceal abscess, perforation and peritonitis. To assess treatment outcomes of acute appendicitis and associated factors among admitted patients with a diagnosis of acute abdomen.Methods and materials: A cross sectional study was employed among 169 patients using a census. Data were collected from patient medical records by using a checklist. Data were entered using Epi-data and analysed by statistical product and service solution. Logistic regression analysis was employed. Among 303 patients with a diagnosis of acute abdomen, 169 (55.7%) developed acute appendicitis; of whom, 45 (26.6%) developed unfavourable treatment outcomes. Patients who had elevated white blood cell count at the time of presentation (adjusted odds ratio = 4.7; 95% confidence interval (1.95, 11.35)) and intraoperative appendiceal abscess (adjusted odds ratio = 3.8; 95% confidence interval (1.61, 9.07)) were significantly associated with an unfavourable appendicitis treatment outcome.Conclusion and recommendation: Nearly a quarter of the patients developed unfavourable treatment outcomes. Elevated white blood cell count and intraoperative appendiceal abscess were significantly associated with unfavourable appendicitis treatment outcome. Therefore, early detection and treatment of appendiceal abscess is crucial for a better outcome.

Current management of pediatric appendicitis: A Central European survey.

Appendicitis is one of the most common diagnoses in pediatric populations. Although new recommendations for the treatment of pediatric appendicitis were published, management varies among different institutions. To determine current practices in 4 (n = 4) representative pediatric surgical departments in Central Europe. One department from each of the 4 countries was surveyed using an online questionnaire. Questions focused on preoperative, operative and postoperative practices in 2018, particularly those related to antibiotic (ATB) therapy and laparoscopy. A total of 519 appendectomies were performed, among which 413 (79.6%) were laparoscopic appendectomies (LAs), with a conversion rate of 5.1%. Appendectomy, as an elective procedure, was performed in 43 (8.3%) patients. One-quarter (129 patients) had complex appendicitis and 72.3% of these were operated laparoscopically. In 3 departments, ATB prophylaxis was administered, based on the decisions of the operating surgeon. One department used standard ATB prophylaxis (metronidazole). Whenever phlegmonous appendicitis was detected, ATB were administered therapeutically in 2 departments. Two other departments administered ATB based on surgeon decision. The choice of ATB was not standardized. If complex appendicitis was detected, all sites administered ATB therapeutically. The type of ATB treatment was standardized in complex cases in 2 departments. Thirty-four complications (6.6%) at surgical sites were recorded - 4.1% (16/390) after uncomplicated and 14% (18/129) after complex appendicitis. Thirty-two occurred after acute surgeries and 26 of these followed laparoscopic procedures. Postoperatively, intra-abdominal abscesses occurred in 3.5% of laparoscopic and in 2.9% of open appendectomy (OA) cases. This questionnaire study showed that treatment outcomes for appendicitis in children in Central Europe are comparable with data reported in the literature. Laparoscopic appendectomy is the predominant surgical method, but there is a little consensus for ATB treatment in the management of appendicitis at our 4 pediatric surgical departments.

Complications of appendectomy and cholecystectomy in acute care surgery: A systematic review and meta-analysis.

Acute care surgery (ACS) was initiated two decades ago to address timeliness and quality in emergency general surgery. We hypothesized that ACS has improved the management of acute appendicitis and biliary disease. A comprehensive systematic review and meta-analysis of outcome studies for emergent appendectomy and cholecystectomy from 1966 to 2017, comparing studies prior to and following ACS implementation, were performed. Of 1,704 studies, 27 were selected for analysis (appendicitis, 16; biliary pathology, 7; both, 4). Following ACS introduction, the complication rate was significantly reduced in both appendectomy and cholecystectomy (risk ratios, 0.70; 95% confidence interval [CI], 0.57-0.85; I = 9.2% and relative risk, 0.62; 95% CI, 0.41-0.94; I = 63.5%) respectively. There was a significant reduction in the time from arrival in emergency until admission and from admission to operation (-1.37 hours: 95% CI, -1.93 to -0.80; -2.51 hours: 95% CI, -4.44 to -0.58) in the appendectomy cohort. Time to operation was shorter in the cholecystectomy group (-6.46 hours; 95% CI, -9.54 to -3.4). Length of hospital stay was reduced in both groups (appendectomy, -0.9 day; cholecystectomy, -1.09 day). There was a reduction in overall cost in cholecystectomy group (-US $854.37; 95% CI, -1,554.1 to -154.05). No statistical significance was detected for wound infection, abscess, conversion of laparoscopy to open technique, rate of negative appendectomy, after hours, readmission, and cost. The implementation of ACS models in general surgery emergency care has significantly improved system and patient outcomes for appendicitis and biliary pathology. Systematic review and meta-analysis of a retrospective study, level III.

Day Care Appendectomy Is Safe in Young Patients with Uncomplicated Early Presentation

We analyzed the surgical outcomes of uncomplicated appendicitis in patients treated with conventional or laparoscopic appendectomy on an ambulatory basis compared with those who stayed overnight. Demographics, clinical course, surgery type, length of stay, and surgical outcomes of patients who underwent conventional or laparoscopic appendectomy for uncomplicated appendicitis were measured. Comparisons were performed using Student t test and chi square analysis. A total of 197 patients were enroll in the study, 69 (35%) patients were discharged within 12 h after their surgery with a mean age of 26.1 years ± 10.23, and the rest of the patients (n = 128,65%) were hospitalized, with a mean age of 27.0 years ± 12.2 (p < 0.608). Open treatment was practice on 124 (62.9%) patients, laparoscopic approach was achieved on 73 (37%) patients, and three (1.5%) patients underwent conversion due to difficult dissection. There was a 14-h mean difference between groups, from the initial time of abdominal pain until arrival to the emergency room, with a mean time in the ambulatory group of 27.7 h ± 19.7 and hospitalized group of 42.4 h ± 39.7 (p < 0.001). Five (7.2%) patients on the ambulatory group presented post-surgical complications, with no significant difference from the patients of the inpatient group (n = 6, 4.7%) (p < 0.456). Overall, mortality rate was 0%, and all patients are well and alive with a mean follow-up of 8 months (range, 6–18 months). This study confirms suitability of conventional appendectomy as an outpatient procedure for uncomplicated appendicitis’ management.

Validation of the American Association for the Surgery of Trauma grading system for acute appendicitis severity.

The American Association for the Surgery of Trauma (AAST) developed an anatomic grading system to assess disease severity through increasing grades of inflammation. Severity grading can then be utilized in risk-adjustment and stratification of patient outcomes for clinical benchmarking. We sought to validate the AAST appendicitis grading system by examining the ability of AAST grade to predict clinical outcomes used for clinical benchmarking. Surgical quality program data were prospectively collected on all adult patients undergoing appendectomy for acute appendicitis at our institution between December 2013 and May 2018. The AAST acute appendicitis grade from 1 to 5 was assigned for all patients undergoing open or laparoscopic appendectomy. Primary outcomes were occurrence of major complications, any complications, and index hospitalization length of stay. Multivariable models were constructed for each outcome without and with inclusion of the AAST grade as an ordinal variable. We also developed models using International Classification of Diseases, 9th or 10th Rev.-Clinical Modification codes to determine presence of perforation for comparison. A total of 734 patients underwent appendectomy for acute appendicitis. The AAST score distribution included 561 (76%) in grade 1, 49 (6.7%) in grade 2, 79 (10.8%) in grade 3, 33 (4.5%) in grade 4, and 12 (1.6%) in grade 5. The mean age was 35.3 ± 14.7 years, 47% were female, 20% were nonwhite, and 69% had private insurance. Major complications, any complications, and hospital length of stay were all positively associated with AAST grade (p < 0.05). Risk-adjustment model fit improved after including AAST grade in the major complications, any complications, and length of stay multivariable regression models. The AAST grade was a better predictor than perforation status derived from diagnosis codes for all primary outcomes studied. Increasing AAST grade is associated with higher complication rates and longer length of stay in patients with acute appendicitis. The AAST grade can be prospectively collected and improves risk-adjusted modeling of appendicitis outcomes. Prospective/Epidemiologic, Level III.

Appendicitis in Low-Resource Settings.

Background: Acute appendicitis is one of the most common surgical emergencies globally. Its incidence is increasing in low- and middle-Human Development Index countries (LMHDICs). Although a proportion of patients can be treated successfully with non-operative management consisting of antibiotics, supportive therapy, and close observation, current diagnostic algorithms lack the granularity to identify these patients accurately. Methods: We reviewed published literature describing practice patterns and clinical outcomes for appendicitis in LMHDICs and compared them with studies from high-Human Development Index countries, as well as guidelines published by international surgical societies. Results: We identified shortcomings in current diagnostic and therapeutic strategies used in LMHDICs. Delays in obtaining surgical care inherent in many LMHDIC healthcare systems make prompt surgical care the mainstay for the treatment of acute appendicitis. Laparoscopic appendectomy leads to better outcomes than open appendectomy in resource-constrained settings and when available should be the surgical technique of choice. Conclusions: Acute appendicitis is common in LMHDICs, and if possible, laparoscopic appendectomy should be the procedure of choice.

Impact of a dedicated emergency surgical service on appendicitis outcomes.

AimThe Emergency Surgery and Trauma (ESAT) team is a dedicated consultant‐led service to streamline the emergency surgical workload in Singapore. As acute appendicitis is one of the most common acute surgical conditions, we aim to compare outcomes of patients with appendicitis in the ESAT model as compared to the traditional on‐call model.MethodsA retrospective review of patients admitted to Khoo Teck Puat Hospital, Singapore, with acute appendicitis between two periods: May–October 2014 (6 months pre‐ESAT) versus January–June 2017 (post‐ESAT). Patient demographics, operative details, efficiency, clinical outcomes, and hospital bill savings were evaluated.ResultsThere were 192 patients in the pre‐ESAT period and 179 patients in the post‐ESAT period. Patient demographics and comorbidities were comparable (P > 0.05). Time from emergency department referral to surgical review was significantly reduced in the ESAT period: 77.8 ± 46.9 min versus 127 ± 102 in the pre‐ESAT period (P = 0.002). Time from case booking to operating theatre was significantly shorter in the ESAT period: 72.4 ± 55.2 min compared to 157.3 ± 209.1 (P < 0.01). More cases were carried out in the daytime during the ESAT period, 50.2% versus 39.1% (P = 0.029). The majority underwent laparoscopic appendectomy 156/179 (87.2%) in the ESAT period, with fewer open appendectomies 3/179 (1.7%) as compared to the pre‐ESAT period (P = 0.062). There were higher intraoperative consultant supervision rates during the ESAT period, 38/166 (22.9%) as compared to 12/166 (6.7%) in the pre‐ESAT period (P = 0.001). There were fewer complications (Clavien–Dindo grade II and above) in the ESAT period, 1 (0.6%) as compared to 6 (3.4%) pre‐ESAT (P = 0.07).ConclusionThe ESAT service is associated with better efficiency outcomes for patients with acute appendicitis.

Appendicitis in Pregnancy: A Post-Hoc Analysis of an EAST Multicenter Study.

Objective: To compare the presentation, management, and outcomes of appendicitis in pregnant and non-pregnant females of childbearing age (18-45 years). Methods: This was a post-hoc analysis of a prospectively collected database (January 2017-June 2018) from 28 centers in America. We compared pregnant and non-pregnant females' demographics, clinical presentation, laboratory data, imaging findings, management, and clinical outcomes. Results: Of the 3,597 subjects, 1,010 (28%) were of childbearing age, and 41 were pregnant: The mean age of the pregnant subjects was 30 ± 8 years at a median gestational age of 15 (range 10-23) weeks. The two groups had similar demographics and clinical presentation, but there were differences in management and outcomes. For example, in pregnant subjects, abdominal ultrasound scans (US) plus magnetic resonance imaging (MRI) was the most frequently used imaging method (41%) followed by MRI alone (29%), US alone (22%), computed tomography (CT) (5%), and no imaging (2%). Despite similar American Association for the Surgery of Trauma Emergency General Surgery Clinical and Imaging Grade at presentation, pregnant subjects were more likely to be treated with antibiotics alone (15% versus 4%; p = 0.008). Pregnant subjects were less likely to have simple appendicitis and were more likely to have complicated (perforated or gangrenous) appendicitis or a normal appendix. With the exception of index hospital length of stay, there were no significant differences between the groups in clinical outcomes at index hospitalization or at 30 days. Conclusion: Almost 1 in 20 women of childbearing age presenting with appendicitis is pregnant. Appendicitis most commonly affects women in early to mid-pregnancy. Compared with non-pregnant women of childbearing age, pregnant women presenting with appendicitis undergo non-operative management more often and are less likely to have simple appendicitis. Compared with non-pregnant patients, they have similar clinical outcomes at both index hospitalization and 30 days after discharge.

Management and Outcomes of Acute Appendicitis in the Presence of Cirrhosis: A Nationwide Analysis

Best management for acute appendicitis (AA) in adults with liver cirrhosis is controversial and needs more investigation. We aimed to examine the impact of different treatment modalities on outcomes in this complex patient population. The Nationwide Inpatient Sample database from 2012 to 2014 was queried to identify AA patients with no cirrhosis, compensated cirrhosis (CC), and decompensated cirrhosis (DC). Each cohort was further stratified according to the treatment type: nonoperative management, open appendectomy, and laparoscopic appendectomy (LA). Chi-square, ANOVA, and binary regression analyses were used to determine differences between groups and risk factors for mortality and complications, with P < 0.05 considered statistically significant. A total of 108,289 AA patients were analyzed; of those, 304 with CC and 134 with DC were identified. Compared with CC and no cirrhosis, DC patients had significantly higher mortality, higher cost, and longer hospital length of stay. LA is accompanied by higher survival, lower cost, shorter duration of hospitalization, and lower incidence of complications across all groups. We conclude that LA is the best management strategy for AA in cirrhotic patients. Even in decompensated cirrhotics, which are associated with worse clinical outcomes, LA is still a favorable option over open appendectomy and nonoperative management.