Perforated Appendix Research Articles

Reduction in perforated appendicitis incidence between rural and urban populations after introducing social health insurance in Vietnam: A population-based study.

Over the years, Vietnam has expanded its social health insurance (SHI) coverage to reduce health disparities. In this population-based study, we examined the differences in incidences of perforated appendix between rural and urban populations in Vietnam since the expansion of SHI coverage in 2015. We also identified risk factors for perforated appendix in these populations. The 2015-2019 SHI inpatient claims data from the Social Security Agency of Dong Thap Province were used to elaborate the final sample of 6863 patients aged 18years or above who underwent an appendectomy. Multivariable probit and logistic regression model were employed to obtain adjusted estimates. An overall rate of 22.9% for perforated appendix among adults in Dong Thap was revealed. After the expansion of SHI, rural residents consistently had lower rates of perforated appendix than urban residents, but the differences between rural and urban residents were small and decreased over time, that is from 4.4% in 2015 to 3.4% in 2019. Older, male, and poor residents were at a higher risk of perforated appendix in both urban and rural areas. In rural areas, patients with comorbidities, patients who resided in remote communes bordering Cambodia, and patients who had district hospitals or commune facilities as their primary assigned providers were significantly more likely to develop perforated appendix. Under the SHI in Vietnam, no significant difference was observed in perforated appendicitis incidence between urban and rural residents. Additional efforts are required to reduce poorer outcomes among other high-risk residents.

Delayed primary skin closure reduce surgical site infection following surgery for gastrointestinal perforation: A systematic review and meta-analysis.

Following surgery for Gastrointestinal (GI) perforation, there is an increased occurrence of Surgical Site Infections (SSI). The beneficial effect of employing delayed primary skin closure (DPC) on severely contaminated incisions subsequent to surgery for GI perforation remains unverified. To systematically evaluate the advantages of the DPC management in surgery for GI perforation. A literature search was performed using ClinicalTrials.gov, Pubmed, Embase, Cocharane, and Web of Science identified all eligible English-language studies related to surgery for GI perforation through October 2023. Randomized clinical trials (RCTs) comparing DPC with primary skin closure (PC) in surgery for GI perforation were included. Two investigators independently performed the inclusion work, and a third investigator was consulted for resolving conflicts. Data were extracted by multiple independent investigators and pooled in a random-effects model. The primary outcome was SSI, defined in accordance with the original studies. The secondary outcome was the length of stay (LOS). Final analysis included 12 RCTs which included a total of 903 patients were randomizing divided into either DPC or PC, including 289 patients with gastroduodenal perforation (32%), 144 patients with small intestine perforation (15.96%), 60 patients with colon perforation (6.64%), and 410 patients with appendix perforation (45.4%). The rates of SSI was significantly decreased after DPC management (OR:0.31, 95%CI:0.15-0.63, p < 0.01), no significant differences were observed between the DPC group and PC group in terms of LOS (MD: - 0.37, 95% CI: - 1.91-1.16, p = 0.63). These results point to the efficacy of DPC management in reducing SSI in patients under surgery for GI perforation, and this strategy did not increase the LOS. This systematic review and meta-analysis may contribute to informed decision-making in the management of severely contaminated wounds associated with GI perforation.

FP7.3 - Acute Appendicitis and Lung Metastasis – A rare combination

Abstract Background Lung cancer is the third most common cancer in the UK. Although widespread metastasis is common, metastasis to the appendix is rare. Here we present a case of acute appendicitis secondary to lung metastasis. Case Presentation An 84-year-old man was admitted with a two-day history of right iliac fossa and suprapubic pain. He was known to have previous lung cancer treated with radical radiotherapy. Bloods on admission revealed elevated inflammatory markers with WCC 14.73 x 109/L and CRP 71.1mg/L. A Computed tomography was performed which showed acute appendicitis with perforation. An emergency laparoscopic appendicectomy was performed which showed a mid-appendiceal perforation with a localized abscess cavity. His recovery was uneventful, and the patient was discharged on postoperative day 2. Histological analysis revealed an adenocarcinoma in the appendicular lumen and within the muscle wall extending to the serosal surface. Immunochemistry profile was positive for CK, CK-19, TTF1 and Napsin A favoring a diagnosis of lung adenocarcinoma which was rationalized in the lung MDT. The patient remains under the respiratory physicians for close follow up. Discussion Lung metastasis to the appendix causing acute appendicitis is uncommon, with only twelve cases of appendiceal metastasis reported in the literature, ten of which presented with a perforated appendix. It may be considered as a differential for the cause of perforated acute appendicitis especially in patients with background of lung cancer.

FP7.17 - Appendiceal Foreign Bodies in Adults: A Systematic Review of Case Reports

Abstract Adults can accidentally swallow foreign bodies (FBs) with food. In rare occasions, these can lodge in the appendix lumen causing inflammation. This is known as foreign body appendicitis. We conducted this study to review different types and management of appendiceal FBs. A comprehensive search on PubMed, MEDLINE, Embase, Cochrane Library and Google Scholar was performed to detect appropriate case reports for this review. Case reports eligible for this review included patients above 18 years of age with all types of FB ingestion causing appendicitis. A total of 64 case reports were deemed to be eligible for inclusion in this systematic review. The patient mean age was 44.3 ± 16.7 years (range, 18-77). Twenty-four foreign bodies were identified in the adult appendix. They were mainly lead shot pellet, fishbone, dental crown or filling, toothpick, and others. Forty-two percent of the included patients presented with classic appendicitis pain, while 17% were asymptomatic. Moreover, the appendix was perforated in 11 patients. Regarding modalities used for diagnosis, computed tomography (CT) scans confirmed the presence of FBs in 59% of cases while X-ray only managed to detect 30%. Almost all of the cases (91%) were treated surgically with appendicectomy and only six were managed conservatively. Overall, lead shot pellets were the most common foreign body found. Fishbone and toothpick accounted for most of the perforated appendix cases. This study concludes that prophylactic appendicectomy is recommended for the management of foreign bodies detected in the appendix, even if the patient is asymptomatic.

Direct visualization endoscopic retrograde appendicitis therapy for treatment of acute uncomplicated appendicitis.

To investigate the diagnostic and therapeutic value of direct visualization (single-use eyeMax subscope) endoscopic management of acute uncomplicated appendicitis. Thirty-six patients diagnosed with acute uncomplicated appendicitis, confirmed by computed tomography or ultrasonography, from Jan 2023 to Feb 2024 were enrolled in this study. We collected demographics, colonoscopy findings, subscope findings, clinical outcomes of endoscopic retrograde appendicitis therapy (ERAT), and adverse events associated with ERAT. Appendiceal intubation was successful for all 36 patients. Thirty-five patients (97.2%) were definitely confirmed as having acute uncomplicated appendicitis. One patient with negative appendicitis was diagnosed as having cecal diverticulitis with fecalith incarceration. The mean procedure time was 13.1 ± 13.6 min. One patient presented with worsening abdominal pain, and a computed tomography scan suggested a perforated appendix. The mean length of hospitalizations was 1.78 ± 2 days. The mean follow-up was 158 days; during this period, two patients (5.6%) experienced recurrent abdominal pain after 23 and 88 days and subsequently underwent laparoscopic appendectomy. Direct visualization ERAT may be effective for diagnosing and treating acute uncomplicated appendicitis and seems to have a low complication rate.

Factors prolonging the operative time for transumbilical laparoscopic-assisted appendectomy in pediatric patients: a retrospective single-center study.

Transumbilical laparoscopic-assisted appendectomy (TULAA) is one of the first endoscopic surgeries performed by trainee pediatric surgeons. While the operative time is generally shorter than for conventional laparoscopic appendectomy, the indications for this procedure are unclear and many unknown factors can prolong the operative time. We conducted this study to identify the factors that may prolong the operative time for TULAA. This retrospective, single-center study was conducted between 2015 and 2023. We performed multivariate analysis to identify the factors associated with prolonged operative time by analyzing TULAA procedures performed by trainees. The study included 243 patients. The median operative time was 84min (interquartile range, 69-114min). Multivariate analysis revealed that an increased body mass index, elevated C-reactive protein level, a history of conservative treatment for acute appendicitis, and appendix perforation, for the patient; < 6years' experience since graduation for the operating surgeon; and lack of board certification as a supervisor from the Japanese Society of Pediatric Surgeons for the attending surgeon were independent risk factors for prolonging the operative time. Having an attending surgeon with board certification as a supervisor by the Japanese Society of Pediatric Surgeons contributes to reducing the operative time required for TULAA.

Factors associated with early inhospital adverse outcome following surgery for acute appendicitis in Uganda: a multicenter cohort

IntroductionSurgery for acute appendicitis has been associated with significant morbidity. This study aimed to determine the factors associated with early inhospital adverse outcomes following surgery for acute appendicitis in Uganda.MethodsThis was a multicentre, prospective cohort in which early inhospital outcome following surgery for acute appendicitis was assessed at 4 regional referral hospitals in Uganda. The occurrence of complications during the admission period was documented as well as the length of hospital stay. Factors associated with adverse outcomes were determined using Poisson regression.ResultsOf the 102 patients who underwent surgery for acute appendicitis, the majority were males 79(77.5%) with a mean age of 23.8(SD = 12.5) years. The perforated appendix was seen in 26 (25.5%) patients. Post-operative complications occurred in 21(20.6%) with the commonest being surgical site infection in 19(18.6%) patients. The median length of hospital stay was 3(IQR = 3–4) days with 43(42.2%) staying in hospital for more than 3 days. The presence of anemia (Hb < 8) (aRR = 1.376, CI = 1.159–1.634, P = < 0.001) and having a perforated appendix (aRR = 1.263, CI = 1.026–1.555, P = 0.027) were independently associated with occurrence of complications while being HIV positive (aRR = 1.379, CI = 1.105–1.721, P = 0.005) and having a perforated appendix (aRR = 1.258, CI = 1.019–1.554, P = 0.033) were independently associated with prolonged hospital stay.ConclusionCommunity education about early presentation is still required in order to reduce the number of patients that present late which should, in turn, reduce the risk of complications and length of hospital stay.

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.

Is Appendectomy During Late Stages of Pregnancy Associated with an Increased Cesarean Delivery Rate? - a Retrospective Analysis of One Center During 10 Years.

About one in 500 pregnant women requires a surgical intervention that is not pregnancy-related. One of the most common surgical interventions during pregnancy is appendectomy. The primary aim of this study was to assess surgical access of appendectomy during pregnancy and pregnancy outcome. Secondary outcomes were clinical symptoms and diagnostics as well as histopathological analysis. This is a single-center retrospective data analysis conducted at a tertiary perinatal center. A digital search of the hospital record archive was conducted focusing on pregnant women beyond 24 0/7 weeks of pregnancy encoding appendectomy. Descriptive statistical analysis was performed. Between January 2013 and January 2023, a total of 20 appendectomies were performed during pregnancy with gestational age beyond 24 0/7 weeks of pregnancy. All of them were performed as lower midline laparotomy. The rate of appendix perforation was 3/20 (15.0%). 19/20 patients (95.0%) delivered via cesarean. In 7/20 patients (35.0%) appendectomy was performed during cesarean delivery due to incidental finding of irritated or abnormal vermiform appendix. In the pathological work-up, only 2/7 (28.6%) of these subjects had inflammation. In this small monocentric cohort, only open appendectomies were performed. Our data indicate that it is safe to perform open appendectomy during pregnancy if necessary. In this small patient group, there was an increase in simultaneous cesarean deliveries.

Appendicular Perforation in Pregnancy

In this case study, a third-trimester primigravida faced the rare challenge of a perforated appendix followed by successful perinatal outcome. Despite inconclusive imaging results from ultrasound and MRI, clinical progression guided the diagnosis. Timely intervention via emergency laparotomy, involving obstetric and gastro-surgical teams, averted further complications, ensuring a favorable outcome for both mother and baby. The complexities of diagnosing appendicitis during pregnancy, particularly when perforated, were emphasized. This instance underscored the pivotal role of a multidisciplinary approach, meticulous surgical planning, and attentive postoperative care, showcasing how prompt intervention and holistic management are paramount in navigating such intricate scenarios during pregnancy.

Amyand&amp;apos;s hernia unveiled: a case report on perforated appendix within the inguinal hernia sac

Background: Acute appendicitis (AA) is still a common cause of lower abdominal pain, which frequently leads to emergency room (ER) visits. A case of perforated appendix within the inguinal hernia sac was presented. Case presentation: The clinical journey of a 30-year-old male patient with acute right iliac fossa pain suggestive of recurrent appendicitis was detailed in this case report. The patient\&amp;apos;s complicated medical history, which included dostinex-treated hyperprolactinemia and a previous episode of conservatively managed appendicitis in 2017, sets the stage for complex diagnostic challenges. The patient complained of acute localized tenderness and pain in the right iliac fossa, but no gastrointestinal symptoms, fever, or diarrhea were present. The admission laboratory results showed elevated white blood cells (WBC) (15.2), hemoglobin (Hb) (15.8), and platelet (PLT) (191) levels. Computed tomography scans exposed a perforated appendix within the right inguinal hernial sac surrounded by inflammatory changes. Laparoscopic appendectomy revealed a perforated appendix within the inguinal hernial sac, necessitating omental dissection and drainage. The postoperative course was uneventful, with a 7-day hospital stay and subsequent OPD follow-up. Microscopic examination confirmed acute suppurative appendicitis with periappendicitis aligning with clinical and radiological assessments. Conclusions: Amyand\&amp;apos;s hernia is a rare type of hernia that involves the appendix. A perforated appendix within a groin hernia is unusual and necessitates immediate source control to manage infection and prevent sepsis.

Retroperitoneal Abscess as an Extension of Ischiorectal Abscess: A Rare Case Report

Infections of the retroperitoneum can result from primary haematogenous spread of microbes or secondary infections originating from the retroperitoneal area or nearby organs. These abscesses can be caused by a perforated retrocaecal appendix, diverticulitis, perforated duodenal ulcers, iatrogenic gastrointestinal tract perforations, pancreatic cancer, inflammatory bowel diseases, genitourinary extravasation due to obstruction, osteomyelitis, postoperative duodenal ulcer perforations, and infections related to pelvic and puerperal conditions, as well as trauma. However, the occurrence of a retroperitoneal abscess as an extension of an ischiorectal abscess is exceedingly rare. Hereby, the authors present a case report of 27-year-old male who presented with persistent lower right quadrant abdominal pain, high-grade fever, and pus discharge from the perianal region for the last five days. He experienced difficulty passing stools and flatus for three days. Contrast-enhanced Computed Tomography (CECT) revealed a perforated appendix with fluid collection in the preperitoneal space on the right-side. Surgery revealed a significant amount of purulent discharge below the rectus muscle, extending along the right abdomen to the psoas muscle and connecting with the ischiorectal fossa. Retroperitoneal abscesses can originate from the perianal or ischiorectal region through various anatomical spaces.

Amyand hernia with perforated appendix simulating as testicular torsion in a neonate: A case report

Background: Amyand hernia is defined as the presence of the vermiform appendix within the hernial sac. A perforated appendix is an uncommon complication of Amyand hernia. Rarely it may simulate a testicular torsion. Case Presentation: A twenty-five-day-old male infant presented with right-sided scrotal swelling, exhibiting symptoms of crying, irritability, and poor feeding over a two-day duration. The swelling was non-reducible, confined to the scrotum, and the spermatic cord showed thickening with erythematous scrotal skin. Following preparation, an inguinal incision was made, and an appendectomy and herniotomy were performed. Conclusion: Amyand hernia, a rare type of inguinal hernia, poses challenges in preoperative diagnosis. The occurrence of a perforated appendix is especially rare in neonates with Amyand hernia. Surgical management entails appendectomy through an inguinal incision coupled with meticulous hernia repair.

Perforated Subhepatic Appendix Presenting as a Gas under Diaphragm: Clinical Diagnostic Challenges for Surgical Residents: A Case Report

This study addresses the rarity of the subhepatic location of the appendix, found in only 0.08% of cases, and the infrequent occurrence of perforated appendicitis presenting with gas under the diaphragm. When these two uncommon conditions coincide in the context of one of the common causes of acute abdomen, namely acute appendicitis, it poses a diagnostic challenge for surgical residents in training. The case presented involves a patient with generalized abdominal pain, soft abdomen, and tenderness over all quadrants, particularly the right upper quadrant. Her chest x-ray findings indicated free gas under the right hemi-dome of the diaphragm and an inconclusive ultrasound for acute appendicitis, computed tomography confirmed the subhepatic appendix and pneumoperitoneum. Operative intervention revealed a perforated subhepatic appendix, and the patient recovered well, being discharged on the 4th postoperative day. The clinical discussion emphasizes the ability of surgical residents to safely perform appendectomies but highlights the crucial role of experienced surgeons in managing cases with atypical presentations. The conclusion underscores the diagnostic challenges posed by atypical presentations of acute appendicitis in a clinical setting.

Value of ultrasound in the assessment of acute abdomen in the pediatric age group

Background &amp; objectives: Acute abdominal pain in pediatric age groups is the most common presentation in an emergency room. The study aimed to diagnose cases of pediatric acute abdomen based on the ultrasound findings and determine the value of ultrasound in decision-making. Methods: A cross-sectional prospective study was conducted in the Raparin Hospital in Erbil City/Iraq from Feb 2021 to June 2022. A convenience sampling method was used, and 200 patients who complained of acute abdominal pain were included in the study. The questionnaire was designed for data collection. A specialist pediatrician clinically examined the children; investigations were done then referred to the radiology department for an ultrasound examination. Results: The ages of the involved cases ranged from one month to 15 years. Among them, 56.0% were males compared to 44.0% females, with a male-to-female ratio of 1.27:1. Regarding provisional clinical diagnosis of the patients, 60.0% presented with gastrointestinal problems among them, 39.2% had Gastroenteritis, 28.3% had appendicitis, 5.8% intestinal obstruction, 4.2% appendicular mass, 1.7% perforated appendix with the same percentage for intussusception, 23.0% suffered from mesenteric lymphadenitis, 7.0% had genitourinary symptoms and 6.0% were presented with non-specific symptoms. There was a highly significant association between the management plan and the surgical outcome of the cases, where the ultrasound was diagnostic among the majority (95.3%) of the operated patients. Conclusions: Ultrasound helped in earlier diagnoses of acute abdominal conditions and reduced radiation exposure to the pediatric age group.

Appendicitis on Pediatric Patients: Current Evidence in Diagnosis and Treatment

Appendicitis is a common surgical condition in pediatric patients, with a higher prevalence among males by 55 – 60%. The etiology is not definitively established, but luminal obstruction caused by stool, lymphoid hyperplasia, or parasites is a commonly cited cause. The classic presentation includes the gradual onset of periumbilical abdominal pain with migration to the right lower quadrant within 24 hours, fever, anorexia, nausea, and vomiting. However, infants and young children may present differently. Risk scores have been developed to improve the accuracy of diagnosis by using clinical symptoms, physical examination, and laboratory results. Ultrasound is the recommended imaging modality due to its low cost and avoidance of radiation, with reported sensitivity ranging from 72.5% to 94.8% and specificity of 95% to 99%, depending on the operator's experience. In young preschool-age children, acute appendicitis carries a higher risk of complications, including surgical site infections and abscesses. The risk of appendix perforation increases with delayed diagnosis. Treatment involves fluid resuscitation, pain control, antibiotics, and appendectomy. In cases of perforation, percutaneous drainage may be necessary. Hospital readmissions are often due to infection, bowel obstruction, or abdominal pain.

Appendicular peritonitis and pregnancy: About two cases

Appendicular peritonitis and pregnancy is a rare and serious association. The clinical presentation is sometimes misleading because of the anatomical and physiological changes associated with pregnancy, often responsible for diagnostic hesitation and therapeutic delay that are detrimental to the mother and the unborn child. The maternal-fetal prognosis depends on the severity of the abdominal pathology. We report the case of two patients aged 25 and 34, Admitted to gyneco-obstetrical emergencies for abdominal pain, postprandial vomiting and occlusive syndrome all on an evolving pregnancy of 12 and 18 SA. Clinical examination found on palpation a generalized contracture in one case, defense of the right hypochondrium. Fetal heart sounds were positive. Abdominopelvic ultrasound revealed intraperitoneal effusion in both cases without associated obstetric lesion. The abdomino-pelvic scan done in emergency allowed an individualization of a stercorite at the level of the FID, without clear visualization of the appendic . All patients were operated on within 24 hours of admission. Laparotomy found in both cases a gangrenous and perforated appendix associated with an intraperitoneal effusion which was removed and then aspirated. Retrograde appendectomy, peritoneal cleansing plus drainage was performed in all cases. Tocolysis and antibiotic therapy were instituted , The postoperative follow-up was simple.

Low-Grade Appendiceal Mucinous Neoplasm: What Is the Best Treatment?

Low-grade appendiceal mucinous neoplasm (LAMN) is an uncommon tumor of the appendix that is usually diagnosed incidentally after surgery. Although LAMN may be asymptomatic, it can rupture and seed mucin and neoplastic epithelium into the peritoneum, causing pseudomyxoma peritonei (PMP). Data from 53 patients were retrospectively analyzed. Age, sex, tumor size, margin status, peritoneal carcinomatosis index, surgical procedures, postoperative results with histologic diagnosis, T stage, recurrence, and mortality of the patients were evaluated. Appendectomy was performed in 37 patients, right hemicolectomy in nine patients, cytoreductive surgery in one patient, and cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in six patients. Recurrence occurred in four patients. Of the patients who developed recurrence, one patient had stage T4a disease, and the other three patients had T4b disease (p<0.001). Eighteen patients had acellular mucin in the serosa and four of these patients developed recurrence (p=0.004). Twelve patients had appendix perforation, and three of these patients had PMP on exploration (p<0.001). The mean survival time was 93.3 months in patients without recurrence and 32 months in patients with recurrence (p=0.021). Low-grade appendiceal mucinous neoplasms are rare appendiceal tumors. The appropriate management of this tumor is controversial. T stage, appendix perforation, presence of acellular mucin on the serosa, and surgical margins are risk factors for the development of PMP. Appendectomy is considered sufficient when there are no risk factors for Tis (LAMN) and T3 disease. Right hemicolectomy may be sufficient if there are no risk factors for T4a disease, but cytoreductive surgery and hyperthermic intraperitoneal chemotherapy seem to be the most appropriate treatments in the presence of the stated risk factors for T4b disease.

Surgical site infiltration using ketamine versus bupivacaine for postoperative analgesia following appendicectomy

Background Appendicectomy is the standard surgery to remove an inflamed appendix and prevent peritonitis and other serious complication of a perforated appendix. Relieving postappendicectomy pain can help in early mobility and rehabilitation. The study compares the efficacy of using ketamine versus bupivacaine for surgical site infiltration for postoperative analgesia following appendicectomy. Methods We enrolled 60 patients aged between 14 and 50 with ASA status class I and II undergoing uncomplicated appendicectomy under general anesthesia. Patients were randomly divided into two equal groups where group 1 received surgical site infiltration using plain bupivacaine at the end of the operation while group 2 received surgical site infiltration using ketamine. The visual analog scale (VAS) was estimated at zero, 1, 2, 6, 12, and 24 h after surgery. The time until the first need for analgesia and the overall analgesic consumption were recorded in both groups. Any adverse effects in the recovery room were recorded. Postoperative hemodynamics were also recorded every 2 h for up to 24 h. Results The VAS score at 1, 2, 6, and 12 h was significantly lower in the ketamine group than in the bupivacaine group (P &lt; 0.001). The time until the first need for analgesia was significantly prolonged in the ketamine group than in the bupivacaine group (P value &lt; 0.001). The total ketorolac and morphine consumption in the first 24 h postoperatively was significantly lower in the ketamine group than in the bupivacaine group (P value &lt; 0.001). Postoperative nausea and vomiting (PONV) occurred in five (16.667%) patients in the bupivacaine group and in six (20%) patients in the ketamine group. Conclusions Surgical site infiltration using either ketamine or bupivacaine can be used safely and efficiently to control acute postoperative pain and decrease the total consumption of systemic analgesics; however, ketamine infiltration seems superior in this field.

508 Appendicoliths – Time to Operate: The Temporal Relationship Between Pre-Operative CT Confirmed Appendicolith and Time to Develop Complicated Appendicitis

Abstract Aim Evidence suggests delaying an appendicectomy for up to 24 hours does not increase the risk of complicated appendicitis. Appendicoliths are a risk factor for perforation. However, no study has explored the temporal relationship between appendicolith presence and time to perforation. This study aims to review pre-operative Computer Tomography (pCT) confirmed appendicoliths and their correlation with a shorter time to complicated appendicitis. Method Retrospective single centre study of patients admitted between 2018-2020. Inclusion criteria: age ≥18 years, appendicitis on histopathology following an operation and pCT scan. Complicated appendicitis was defined intra-operatively as an appendicular abscess, gangrenous or perforated appendix. Results 310 patients were included in the study (45.5% with complicated appendicitis). Appendicoliths were present in 79 (25.5%) patients. Multivariate logistic regression identified an appendicolith as a significant risk factor for perforation (Odds Ratio 4.2, 95% Confidence Interval [CI] 1.3-13.6, p = 0.018). Within the first 12 hours of admission, those with an appendicolith accounted for a significantly greater proportion of patients with complicated appendicitis intra-operatively than those without (57.7% vs 42.3% respectively, p = 0.039). Within 12 hours of admission, those with an appendicolith were 2.2 times more likely to suffer from complicated appendicitis than those without (95% CI 1.4-3.7). Conclusions Patients with an appendicolith found on CT should be prioritised for theatre within 12 hours of admission.