Acute Perforated Appendicitis Research Articles

Appendiceal adenocarcinoma, diagnosed after acute perforated appendicitis: Potential contribution of HIPEC

IntroductionTreatment of peritoneal metastasis from appendicular adenocarcinoma consists of cyto-reductive surgery (CRS) and Hyperthermic IntraPEritoneal Chemotherapy (HIPEC). In case of acute appendicular syndrome (AAS) the tumor is likely to be perforated. In that case, there is no treatment recommendation. We propose CRS and HIPEC. Materials and methodWe listed 21 consecutive patients who were addressed for discovery of appendiceal adenocarcinoma. The emergency surgery was performed in a primary-care hospital. We evaluated the therapeutic algorithms, per operative decision, survival and recurrent rate. ResultsAmong the 21 patients, 4 patients were diagnosed as synchronous appendicular peritoneal metastasis, and underwent CRS and HIPEC.The other 17 patients with diagnosis of adenocarcinoma on anatomopathological samples, without peritoneal metastasis during appendectomy, were addressed. Between them 2 patients were denied CRS. Among the 15 operated patients, 8 patients had no peritoneal metastasis discovery during surgery, and therefore underwent prophylactic CRS and HIPEC. Peritoneal metastasis were discovered for the other 7 patients, who also underwent CRS and HIPEC.For the prophylactic group, the recurrence rate is 12,5 %, overall survival (OS) is 100 %.The rate of grade III-IV surgical complications after CRS and HIPEC was 36 % among the 19 patients who underwent surgery. ConclusionIn case of appendectomy in emergency situations for perforated adenocarcinoma, half of the patients may have peritoneal metastasis. In case of non-identified peritoneal metastasis during CRS, performing a prophylactic HIPEC seems to be associated with an encouraging rate of peritoneal disease free situation at 5 years.

Impact of COVID-19 on acute appendicitis presentation, management and pathology findings in adult and paediatric populations.

We investigated the impact of the COVID-19 pandemic on trends of presentation, management and pathology findings in patients who underwent an appendicectomy for suspected acute appendicitis. The retrospective study reviewed patients (n = 939 adults and n = 329 children) who had an appendicectomy performed for suspected acute appendicitis and histopathology assessment in the Belfast Health and Social Care Trust, Northern Ireland. Pre-COVID-19 (March 2019 to February 2020) and COVID-19 Year 1 (March 2020 to February 2021) data were compared. Chi-squared tests were applied to compare timeframes. 513 adult appendicectomies were performed in the immediate year pre-COVID-19, compared to 426 in COVID-19 Year 1, representing a 17% reduction. No such reduction was seen within the paediatric population, likely related to a change in regional paediatric referral criteria during the pandemic. When comparing COVID-19 Year 1 with pre-pandemic, fewer patients presented with <24 hours of symptoms (45% v 53%, p = 0.005), and there was greater use of pre-operative computed tomography imaging in adults (63.2% v 48.7%, p<0.001). Fewer adult and paediatric cases of simple acute appendicitis and non-diagnostic specimens, with relative increased proportions of perforated acute appendicitis, were observed in COVID-19 Year 1 compared with pre-pandemic. No absolute increase in perforated acute appendicitis cases was observed in adults. Year 1 of the COVID-19 pandemic was associated with delayed presentation of acute appendicitis in adults and children. In adults, an overall reduction in appendicectomy operations, increased use of pre-operative diagnostic imaging, and fewer specimens showing simple acute appendicitis or non-diagnostic features, collectively support appropriate restriction of surgery for those patients with a more certain acute appendicitis diagnosis.

Intra-abdominal hemorrhage from an ileocolic vessel as a complication of acute appendicitis perforation

This is an extremely rare complicated presentation of acute appendicitis perforation, which was accompanied by an intra-abdominal hemorrhage from an ileocolic vessel. A 61-year-old man visited an emergency department complaining of abdominal pain. Tenderness &amp; rebound tenderness at the right lower quadrant and muscle guarding were noticed. Computed tomography showed perforated appendicitis with peritonitis. Also, an intra-abdominal hemorrhage of the ileocolic vessel was suggested. An emergent laparoscopic exploration was performed and found a gangrenous retrocecal appendix, peri-lesional adhesion, and substantial hematoma. Finally, a partial cecectomy was performed. A pathologic test confirmed the acute gangrenous appendicitis. Physicians should be aware that appendicitis could complicate an intra-abdominal hemorrhage even though it is extremely rare.ackground.

Management of Acute Appendicitis in Children in a University Hospital.

Little is known about the positive predictive value of diagnostic tools for severe acute appendicitis (AA). Our objective was to study a retrospective cohort of patients with AA, emphasizing its laboratory and radiologic features, to establish risk factors for more severe cases of AA. A retrospective cohort study with patients with AA confirmed by biopsy was performed. In each case, examinations were reviewed, data were compared, and laboratory and radiologic findings were established to identify risk factors for severe AA. During the studied period, 405 children, with a mean age of 120 months, were evaluated. Most of the patients were boys (63.2%). C-reactive protein was the best parameter for the diagnosis of perforated AA, with a sensitivity of 88% for values above 173 mg/dL. A total of 64.4% of the patients underwent abdominal ultrasound, and 26% had normal results. Acute appendicitis is a disease with a wide spectrum of complications; thus, it is important to recognize the markers associated with severe cases of AA. High levels of C-reactive protein were the best markers associated with perforated appendicitis, and ultrasound was requested in most of the cases but was not helpful in most of them.

Acute perforated appendicitis after colonoscopy. A case of a rare clinical entity

Acute perforated appendicitis after colonoscopy. A case of a rare clinical entity

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.

Comparison of Clinical, Pathological, and Procedural Characteristics of Adult and Pediatric Acute Appendicitis before and during the COVID-19 Pandemic

Aims: This study aims to examine the impact of the COVID-19 pandemic on the clinical, pathological, and surgical features of acute appendicitis (AA) in a tertiary referral center - Clinical Hospital Centre Zagreb, through a patient data comparison before and during the pandemic. Methods: Demographic (age, gender), clinical (duration of hospitalization), pathological (gangrenous AA, perforated AA, complications), and surgical data (type of appendectomy, negative appendectomy, conversion, revision) were retrospectively collected from an electronic database for all consecutive patients admitted for AA before and during the COVID-19 pandemic. Results: Demographic data were comparable between groups. There was statistically no significant difference in the type of appendectomy (p=0.331). The median hospital length of stay was 3 (2-5) days (p=0.078). There was an increase in the conversion rate (4.2% to 7.7%, p=0.031). The negative appendectomy rate did not differ significantly (5.6% vs. 4.2%, p=0.338). There was no significant difference in the incidence of perforated AA (13.3% vs. 15.7%, p=0.339). Conclusion: We did not observe a significant increase in the rate of AA complications during the COVID-19 pandemic at the Clinical Hospital Centre Zagreb. This could be because AA is typically diagnosed and treated in emergency care, which remained available during the pandemic. Additionally, diagnostic and therapeutic protocols remained unchanged despite the pandemic.

The Histopathological Findings in Appendectomy Specimens in an Iranian Population

Background: Appendicitis is one of the most common causes of acute abdominal surgeries. The importance of parasitic etiologies in the pathogenesis of appendicitis is not well known in appendectomy specimens on a large scale in southwestern Iran. The current study aimed to retrospectively assess the demographic data and histopathological records of appendicitis in a 28-year period in Fars province, southwestern Iran. Materials and Methods: Histopathological records of 13,013 patients who had undergone surgeries for appendicitis at Dr. Ali Shariati Hospital, affiliated with the Fasa University of Medical Sciences from December 1993 to January 2021 were reviewed and data concerning the patients' demographic data and histopathological records were retrieved from each record. More than 6800 archived microscopic glass slides were also reviewed. Results: From a total of 13,013 histopathological records of surgical excisions of appendicitis that were reviewed over a 28-year period, 8,189 (62.9%) were male and 4,842 (37.1%) were female. Patients' age ranged from 2 to 98 years, with a mean age of 24.68±19.87 years. The most common inflammatory changes were 5,687 (43.7%), 1,228 (9.4%), 670 (5.1%), 522 (4%), and 363 (2.8%) cases of acute appendicitis, suppurative appendicitis, early acute appendicitis, gangrenous appendicitis, and perforated appendicitis respectively. Microscopically, no viral inclusions, fungal elements, and histopathologic findings of bacterial causes were found. Parasitic infections such as helminthiasis were detected in 74 (0.6%) cases aged from 6 to 63. Enterobiasis (Syn. oxyuriasis, pinworm infection) accounted for 73 (98.6%) of the 74 helminthiases, while ascariasis accounted for 1 (1.4%). Out of 74 cases, 29 (39.2%) showed evidence of appendicitis. Conclusion: The results suggest that although parasitic agents are minor causes of appendicitis, these agents should be kept in mind during differential diagnosis. However, whether every parasitic infection leads to appendicitis is controversial. 

Left side perforated appendicitis with intestinal non-rotation: a case report

BackgroundAcute appendicitis is the most common cause of acute abdominal pain, requiring emergency surgery. Symptoms and signs of acute appendicitis usually occur in the right lower quadrant. However, approximately one-third of cases have pain unexcepted location due to its various anatomical locations. Acute appendicitis is a very rare cause of left lower quadrant pain; if it occurs, situs inversus (SI) and midgut malrotation (MM) are uncommon anatomic anomalies that complicate its diagnosis and management.Clinical presentationHere we present a 23-year-old Ethiopian male patient who presented with epigastric and left paraumbilical abdominal pain, fever, and vomiting of a day duration. On examination at admission, the patient had left lower quadrant tenderness. Later, with the help of imaging studies, the patient was diagnosed with left-side acute perforated appendicitis with intestinal nonrotation, and he was operated on and discharged improved after 6 days of hospital stay.ConclusionPhysicians should be aware that acute appendicitis in patients with intestinal mal-rotation may be present with left-side abdominal pain. Although it is extremely rare, acute appendicitis should always be considered in the differential diagnosis of left-side abdominal pain. An increase in awareness of this anatomical variant is essential for physicians.

P-011 OPEN PREPERITONEAL APPROACH IN AN INCARCERATED ABSCESSIFIED GARENGEOT HERNIA

Abstract Aim The Garengeot hernia is a a rare entity (incidence 0.15–5%) that appears more frequently in elderly women and contents the vermiform appendix. Different surgical approaches are available but the most appropriate one is unknown. Association or conversion to laparotomy may be needed in complicated cases entailing higher morbimortality. Results 82-year-old female with hypertension, dyslipidemia and left inguinal hernioplasty. She presented acute right inguinal pain with a 1 month of evolution mass associated extended to the limb. Blood tests were normal but CT scan was performed reporting a right incarcerated inguinal hernia with acute perforated and abscessified appendicitis. Besides antibiotics, an open preperitoneal approach was performed. An incarcerated crural hernia was found: the sac was opened, the perforated appendix was reduced and the abscess was debrided. Appendicectomy was performed and after aseptic measures and critical view, a 15×15cm gentamicin impregnated large-pore light-weight polypropylene mesh was placed in the preperitoneal space covering the myopectineal orifice. Patient was successfully discharged 4 days after surgery with no complications after two years of follow-up. Conclusion The treatment of a complicated crural hernia in a septic environment in the emergency room represents a challenge. In an incarcerated and abscessified Garangeot hernia, an open preperitoneal approach (modified Nyhus technique) can be safely performed to confront both pathologies. Not only it allows access to the abdominal cavity through a small incision, avoiding the need for a laparotomy, but also favours an optimal exploration and repair of the myopectineal orifice.

Metastasis of small cell lung carcinoma to the appendix: A case report and literature review

Small cell lung cancer (SCLC) is an aggressive tumor with rapid growth and metastasis. Common sites of metastasis include lymph nodes, adrenal glands, liver, bone, and brain, while gastrointestinal metastasis is less and appendicular metastasis is much rarer. Here, we reported a rare case of appendiceal metastasis from small cell lung cancer presented with acute gangrenous perforated appendicitis, periappendiceal abscess and retroperitoneal abscess. The patient, a 63-year-old male, was diagnosed as small-cell lung cancer due to cough, expectoration and blood in sputum. After chemotherapy, local radiotherapy and whole brain prophylactic radiotherapy, the disease progressed continuously and recurred 1 year later, then presented with acute gangrenous perforated appendicitis combined with periappendiceal abscess and retroperitoneal abscess 2 years later. Histopathological and immunohistochemical findings after appendectomy suggested malignant metastasis of small cell lung cancer. Therefore, in the diagnosis and treatment of SCLC cases, SCLC metastasis occurs not only in the common lymph nodes, kidney, adrenal gland, brain, liver, etc., but also in the appendix. This report is expected to provide new guidance for the diagnosis and treatment of such cases.

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.

Metastatic Small Cell Lung Cancer Presenting as Acute Appendicitis: A Case-Report

Introduction and Importance: We present a case of extensive stage small cell lung cancer presenting as perforated appendicitis secondary to an appendiceal metastasis. This is a rare presentation with only 6 reported cases in the literature. Surgeons must be aware of unusual causes for perforated appendicitis as in our case the prognosis can be dire. Case Presentation: A 60-year-old man presented with an acute abdomen and septic shock. Computed tomography demonstrated perforated appendicitis and a widespread malignant process initially suspected as colonic origin malignancy. Urgent laparotomy and a subtotal colectomy was performed. Further imaging suggested the malignancy was secondary to a primary lung cancer. Histopathology demonstrated a ruptured small cell neuroendocrine carcinoma in the appendix with TTF1 positive immunohistochemistry. Unfortunately, the patient deteriorated due to respiratory compromise and was palliated on day 6 postoperatively. Discussion: The appendix is a rare site for metastasis of lung cancer and these metastases usually present as acute perforated appendicitis. Distinguishing the site of the primary tumor can be difficult when there is extensive metastatic disease, and this differentiation relies on immunohistochemistry. In our case the patient was managed surgically, however rapidly deteriorated post operatively from multi-organ metastatic disease. This demonstrates the diagnostic challenges in metastatic small cell lung carcinoma presenting as an acute appendicitis as well as the poor prognosis with advanced disease. Conclusion: Surgeons should consider a broad differential diagnosis for the cause of acute perforated appendicitis as this can rarely be due to a secondary metastatic deposit from a widespread malignant process.

Appendiceal adenocarcinoma, diagnosed after acute perforated appendicitis : potential contribution of CHIP for 22 patients

Appendiceal adenocarcinoma, diagnosed after acute perforated appendicitis : potential contribution of CHIP for 22 patients

Hyperbillirubinemia as a Predictive Factor for Appendiceal Perforation in Acute Appendicitis: A Prospective Study

Hyperbillirubinemia as a Predictive Factor for Appendiceal Perforation in Acute Appendicitis: A Prospective Study

Perforated appendicitis after blunt abdominal trauma: a case report

Cases of acute appendicitis due to blunt abdominal trauma (BAT) are rare, and usually regarded as two separate entities. Although the exact mechanism of acute appendicitis after BAT is unknown, several literatures reported their causal relationship. Suspicion of appendicitis should be raised in presentation of abdominal pain after BAT. We present a case report of two patients who developed acute perforated appendicitis following BAT.

Predictive value of sphericity index and other multidetector computed tomography findings in perforated acute appendicitis.

Early radiological prediction and diagnosis of perforated acute appendicitis remain controversial. In the current study, it was aimed to examine the predictive value of multidetector computed tomography (MDCT) findings in perforated acute appendicitis. The patients (n=542) who underwent appendectomy between January 2019 and December 2021 were retrospectively evaluated. The patients were divided into two groups as non-perforated appendicitis and perforated appendicitis. Preoperative abdom-inal MDCT findings, appendix sphericity index (ASI) scores, and laboratory findings were evaluated. The sample consisted of 427 cases in the non-perforated group and 115 cases in the perforated group, with a mean age of 33.88±12.84 years. The mean time until admission was 2.06±1.43 days. Appendicolith, free fluid, wall defect, abscess, free air, and retroperitoneal space (RPS) involvement were all found to be significantly higher in the perforated group (P<0.001). The mean long axis, short axis, and ASI values were found to be higher in the perforated group (P<0.001; P=0.004; and P<0.001, respectively). C-reac-tive protein (CRP) was found to be significantly higher in the perforated group (P=0.008), but the mean white blood count was found to be similar between the groups (P=0.613). Among MDCT findings, free fluid, wall defect, abscess, high CRP, long axis, and ASI were observed to be predictive values for perforation. According to receiver operating characteristic analysis, ASI had a cut-off value of 1.30, a sensitivity of 80.87%, and a specificity of 93.21%. MDCT findings, namely, appendicolith, free fluid, wall defect, abscess, free air, and RPS involvement are significant findings for perforated appendicitis. With a high sensitivity and specificity, the ASI appears to be a key predictive parameter for perfo-rated acute appendicitis.

Acute promyelocytic leukemia with acute perforating appendicitis: A rare occurrence of medical and surgical emergency

Acute promyelocytic leukemia with acute perforating appendicitis: A rare occurrence of medical and surgical emergency

Apendicite necrosante como complicação da varicela: relato de caso e revisão da literatura

In immunocompetent children, complications of varicella are rare. Acute appendicitis (AA) is one of the most exceptional complications of chickenpox. In this report we describe a case of a 6-year-old girl with a perforated AA in the course of varicella. We intend with this clinical case to remember an extremely rare complication of varicella, which is at the same time the most common cause of abdominal surgery in children.

Single-port laparoscopic appendectomy for perforated appendicitis using ArtiSential® wristed articulated instrument.

Single-port laparoscopic appendectomy (SPLA) was firstly introduced in 1998 and has been suggested potential advantages including better cosmetic outcome, less post-operative pain and avoidance of possible haemorrhagic complications from injuring epigastric vessels. However, single-port laparoscopic approach using conventional straight instruments may lead to internal and external conflicts and ergonomic discomfort, and new laparoscopic articulating instruments were developed to overcome these limitations of straight instruments. The ArtiSential® (LIVSMED Inc., Republic of Korea) is an 8-mm diameter pistol-handle instrument that has complete articulating function like human wrist and intuitive controllability. We present a technical report of SPLA for perforated appendicitis using ArtiSential® wristed articulated instrument. A 78-year-old female with a body mass index of 23.5 was referred to our emergency room with right lower quadrant abdominal pain. Abdominal computed tomography scan showed a distended tubular structure in the right lower quadrant (1.2 cm in diameter) with periappendiceal fluid collection. The patient's clinical presentation was highly indicative of perforated acute appendicitis. We performed SPLA with ArtiSential® grasper with the left hand, and this instrument helped us to allow greater manoeuvrability and dexterity with double triangulation technique. The total operation time was 40 min, and the patient was discharged without complications on the 1st day after surgery.