Severe Appendicitis Research Articles

Ovarian cyst mimicking acute appendicitis in children: a case report

Pediatric acute appendicitis is common; however, it is different from torsion ovarian cysts. The estimated incidence of ovarian torsion in children is 5 per 100,000 girls. Herein, we report two cases of ovarian torsion mimicking pediatric acute appendicitis mimicking ovarian cyst. In the first case, a girl who was being assessed for acute appendicitis was identified to have torsion of the ovarian cyst during the surgery. In the second case, a girl experienced a ruptured ovarian cyst but then got severe appendicitis following the surgical procedure. The simultaneous occurrence of appendicitis and ovarian cysts is rare. These two patients' acute gastrointestinal complaints and symptoms exhibit similarities and may coincide. Both patients underwent salpingo-oopherectomy and appendectomy. Both patients were healthy on hospital discharge in a healthy condition. Female patients with severe abdominal pain and amenorrhea should be evaluated for ovarian torsion. Diagnosing the condition may be challenging due to non-specific clinical signs.

Appendiceal neoplasms derived from appendiceal tip remnants following appendectomy: a report of two cases

BackgroundNeoplasms derived from remnant appendix are rarely described, with most cases arising from the appendiceal “stump”. Here, we present two surgical cases of appendiceal neoplasms derived from appendiceal “tip” remnants.Case presentationThe first patient was a 71-year-old man who had undergone laparoscopic appendectomy for acute appendicitis 12 years prior. During appendectomy, the appendiceal root was ligated, but the appendix was not completely removed due to severe inflammation. At the most recent presentation, computed tomography (CT) was performed to examine choledocholithiasis, which incidentally revealed a cystic lesion of approximately 90 mm adjacent to the cecum. A retrospective review revealed that the cystic lesion had increased in size over time, and laparoscopic ileocecal resection was performed. Pathology revealed no continuity from the appendiceal orifice to the cyst, and a diagnosis of low-grade appendiceal mucinous neoplasm (LAMN) was made from the appendiceal tip remnant. The patient was discharged without complications. The second patient was a 65-year-old man who had undergone surgery for peritonitis due to severe appendicitis 21 years prior. During this operation, the appendix could not be clearly identified due to severe inflammation; consequently, cecal resection was performed. He was referred to our department with a chief complaint of general fatigue and loss of appetite and a cystic lesion of approximately 85 mm close to the cecum that had increased over time. CT showed irregular wall thickening, and malignancy could not be ruled out; therefore, laparoscopic ileocecal resection with D3 lymph node dissection was performed. The pathological diagnosis revealed mucinous adenocarcinoma (TXN0M0) arising from the remnant appendiceal tip. The patient is undergoing follow-up without postoperative adjuvant chemotherapy, with no evidence of pseudomyxoma peritonei or cancer recurrence for 32 months postoperatively.ConclusionsIf appendicitis-associated inflammation is sufficiently severe that accurate identification of the appendix is difficult, it may remain on the apical side of the appendix, even if the root of the appendix is ligated and removed. If the appendectomy is terminated incompletely, it is necessary to check for the presence of a residual appendix postoperatively and provide appropriate follow-up.

A case of multidrug-resistant intractable pylephlebitis and intra-abdominal abscess due to perforated appendicitis successfully treated with open abdominal management

BackgroundPylephlebitis, a rare and lethal form of portal venous septic thrombophlebitis, often arises from infections in regions drained by the portal vein. Herein, we report a case of peritonitis with portal vein thrombosis due to acute severe appendicitis, managed with intensive intraperitoneal drainage via open abdominal management (OAM).Case presentationA 19-year-old male with severe appendicitis, liver abscesses, and portal vein thrombosis developed septic shock and multi-organ failure. After emergency interventions, the patient was admitted to the intensive care unit. Antibiotic treatment based on cultures revealing multidrug-resistant Escherichia coli and Bacteroides fragilis and anticoagulation therapy (using heparin and edoxaban) was initiated. Despite continuous antibiotic therapy, the laboratory results consistently showed elevated levels of inflammatory markers. On the 13th day, open abdominal irrigation was performed for infection control. Extensive intestinal edema precluded wound closure, necessitating open-abdominal management in the intensive care unit. Anticoagulation therapy was continued, and intra-abdominal washouts were performed every 5 days. On the 34th day, wound closure was achieved using the anterior rectus abdominis sheath turnover method. The patient recovered successfully and was discharged on the 81st day.ConclusionsAlongside appropriate antibiotic selection, early surgical drainage and OAM are invaluable. This case underscores the potential of anticoagulation therapy in facilitating safe surgical procedures.

Gene Expression Profiling in Pediatric Appendicitis

Appendicitis is the most common indication for urgent surgery in the pediatric population, presenting across a range of severity and with variable complications. Differentiating simple appendicitis (SA) and perforated appendicitis (PA) on presentation may help direct further diagnostic workup and appropriate therapy selection, including antibiotic choice and timing of surgery. To provide a mechanistic understanding of the differences in disease severity of appendicitis with the objective of developing improved diagnostics and treatments, specifically for the pediatric population. The Gene Expression Profiling of Pediatric Appendicitis (GEPPA) study was a single-center prospective exploratory diagnostic study with transcriptomic profiling of peripheral blood collected from a cohort of children aged 5 to 17 years with abdominal pain and suspected appendicitis between November 2016 and April 2017 at the Alberta Children's Hospital in Calgary, Alberta, Canada, with data analysis reported in August 2023. There was no patient follow-up in this study. SA, PA, or nonappendicitis abdominal pain. Blood transcriptomics was used to develop a hypothesis of underlying mechanistic differences between SA and PA to build mechanistic hypotheses and blood-based diagnostics. Seventy-one children (mean [SD] age, 11.8 [3.0] years; 48 [67.6%] male) presenting to the emergency department with abdominal pain and suspected appendicitis were investigated using whole-blood transcriptomics. A central role for immune system pathways was revealed in PA, including a dampening of major innate interferon responses. Gene expression changes in patients with PA were consistent with downregulation of immune response and inflammation pathways and shared similarities with gene expression signatures derived from patients with sepsis, including the most severe sepsis endotypes. Despite the challenges in identifying early biomarkers of severe appendicitis, a 4-gene signature that was predictive of PA compared to SA, with an accuracy of 85.7% (95% CI, 72.8-94.1) was identified. This study found that PA was complicated by a dysregulated immune response. This finding should inform improved diagnostics of severity, early management strategies, and prevention of further postsurgical complications.

Severity of Acute Appendicitis is Predicted by Hyperbilirubinemia: A Clinical Clue

Background: One of the most frequent abdominal emergencies requiring emergency surgery is acute appendicitis, and appendectomy is the most common emergency procedure performed globally. There is an urgent need for a predictor of the severity of acute appendicitis since delayed identification and treatment of severe appendicitis are linked to higher risks of perforation and postoperative morbidity, mortality, and prolong hospital stay. Objectives: The aim of this study was to assess how the severity of acute appendicitis is predicted by hyperbilirubinemia. Methods: This descriptive cross-section study was carried out in the Department of Surgery at Combined Military Hospital (CMH), Cumilla, during March 2021 to Feb 2023. A total of 80 patients purposing were included in this study. Among them 30 were diagnosed as complicated appendicitis and rest 50 were simple appendicitis patients. Patients diagnosed with complicated appendicitis and simple appendicitis irrespective of age and sex were included in the study. Patients who were not given consent to participate in the study were excluded from the study. After taking consent and matching eligibility criteria, data were collected from patients on variables of interest using the predesigned structured questionnaire by interview, observation, clinical examination and hematological investigation of the patients. Statistical analyses of the results were obtained by using window based Microsoft Excel and Statistical Packages for Social Sciences (SPSS-26), where required. Results: In complicated appendicitis 40% were male and 60% were female. In simple appendicitis 40% were male and 60% were female. The mean T-Bil in complicated appendicitis was 1.187mg/dL and 1.00 mg/dL in simple appendicitis. About 46.0% patients had hyperbilirubinemia in complicated appendicitis and 32.5% in simple appendicitis. Here, 58.0% had fever >37.30C in complicated appendicitis and 33.5% in simple appendicitis. About 69.7% had positive ..........

EARLY OPERATIVE MANAGEMENT OF COMPLICATED APPENDICITIS IS ASSOCIATED WITH IMPROVED SURGICAL OUTCOMES IN ADULTS: A SYSTEMATIC REVIEW

Introduction: Appendectomy is one of the most common surgeries in the US, with over 300,000 performed annually. In addition, 20% of adults may have complex appendicitis with extensive peritonitis, perforation, abscess, or phlegmon. In severe appendicitis patients, there is no unanimity on whether to operate or when. Statistics contradict each other. Non-operative care and radiologically guided percutaneous drainage have become prominent treatments. The aim: This article demonstrated an association between early surgical management of complicated appendicitis and enhanced surgical outcomes in adults. Methods: By comparing itself to the standards set by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, this study was able to show that it met all of the requirements. So, the experts were able to make sure that the study was as up-to-date as it was possible to be. For this search approach, publications that came out between 2013 and 2023 were taken into account. Several different online reference sources, like Pubmed and SagePub, were used to do this. It was decided not to take into account review pieces, works that had already been published, or works that were only half done. Result: In the PubMed database, the results of our search brought up 68 articles, whereas the results of our search on SagePub brought up 51 articles. The results of the search conducted for the last year of 2013 yielded a total 19 articles for PubMed and 13 articles for SagePub. In the end, we compiled a total of 11 papers, 7 of which came from PubMed and 4 of which came from SagePub. We included three study that met the criteria. Conclusion: The benefits of immediate surgery for patients with complicated appendicitis include a reduction in hospitalization time, subsequent infections, and short-term mortality, according to research.

Invasive Aggregatibacter infection: shedding light on a rare pathogen in a retrospective cohort analysis.

Introduction. Aggregatibacter are Gram-negative, facultatively anaerobic rods or coccobacilli that are infrequently encountered as pathogens causing infection.Hypothesis/Gap Statement. The range of invasive infection that Aggregatibacter cause is poorly described. The pathogenicity of species such as Aggregatibacter segnis is debated.Aim. To identify invasive infection due to Aggregatibacter species in a large healthcare organization and to characterize clinical syndromes, co-morbidities and risk factors.Methodology. All microbiological samples positive for Aggregatibacter species were identified by conventional culture or 16S rRNA PCR between October 2017 and March 2021. Electronic records for all patients with positive samples were reviewed and the infection syndrome classified for patients with invasive disease.Results. Twenty-seven patients with invasive infection were identified, with a statistically significant difference in species-specific patterns of invasive infection (P=0.02) and a statistically significant association with residence in the 30 % most deprived households in the UK by postcode (P<0.01). The three most common co-morbidities were periodontitis or recent dental work (29.6%), cardiovascular disease (25.9%) and diabetes (18.5 %).Conclusion. We describe a novel association of Aggregatibacter segnis with skin and soft tissue infection. The propensity of the Aggregatibacter species to cause invasive infection at different body sites and be associated with deprivation is reported. Aggregatibacter actinomycetemcomitans bacteraemia was associated with infective endocarditis, and Aggregatibacter aphrophilus was implicated in severe appendicitis and noted to cause brain abscess. Areas warranting future research include exploring the risk-factors required for invasive infection and those that may determine the species-specific differences in patterns of invasive disease.

Our Experience with Laparoscopic Appendectomy at the Department of Pediatric Surgery LRH Peshawar

Aim and Objective: This study aims to determine the effectiveness of laparoscopic appendectomy for children performed as emergency or emergency surgery at MTI/LRH in Peshawar, Pakistan. Material &amp; Methods: From January 2020 to December 2022, the Department of Pediatric Surgery, Medical Teaching Institute, Lady Reading Hospital Peshawar studied acute appendicitis in children. This study comprised children with clinically confirmed acute appendicitis as indicated by blood complete, HBs Ag, HCV, ultrasound, and primary assessment. The pediatric surgical unit maintained direct resuscitation of patients' NPO for at least 6 hours, began antibiotics, and performed laparoscopic surgery under general anesthesia. This strategy avoids additional treatment, saves time and money, reduces hospital-acquired infections and other hospital dangers, and allows for excellent local infection control without pus spreading throughout the peritoneal cavity. Laparoscopic surgery makes cholecystectomy a few-day procedure instead of a week. Laparoscopic appendectomy reduces hospital stays for children. Thus, we examined our data to determine whether children may have an emergency or same-day laparoscopic appendectomy (24-hour postoperative stay). We reviewed all three-year-olds who underwent laparoscopic appendectomy for suspected appendicitis. Results: Acute appendicitis afflicted 79 children, 4/1 male-to-female. 79 2- to 16-year-olds underwent laparoscopic appendectomy surgeries. 5% of children after laparoscopic appendectomy developed perforated appendicitis and needed an open appendectomy. Forty-one (64.5%) had severe appendicitis before surgery. 22 (27.2%) had perforated appendicitis, (5%) had ovarian cyst rupture, and 2.5% had no pathology. Surgery averaged 54 minutes. 14 of 79 primary wound closure patients had their right lower quadrant peritoneal cavity emptied. All 79 patients underwent successful appendectomy operations. Wound infection (6 patients) and stomach pain (4 patients) were the most prevalent sequelae managed conservatively. Four patients required readmission and laparotomy due to intestinal obstruction and other issues. Thirty-two children were released within 24 hours after laparoscopic appendectomy. The control group had no significant morbidity (drug rash,1: fever, 3). Practical implication: This study will provide the data on the effectiveness of the laparoscopic appendectomy for the treatment of Appendicitis. Conclusion: Our study shows that the current laparoscopic appendectomy method for treating adorable appendicitis in children is safe and may be performed as a fast-track or same-day operation with a postoperative stay of fewer than 24 hours in some children who do not have perforated appendicitis. Keywords: Laparoscopic appendectomy, Pediatric Laparoscopy, fast-track same-day surgery

WE5.2 Safety of in-hospital delay to appendicectomy in acute appendicitis: a retrospective study

Abstract Aims In many hospitals the availability of operating theatres and access to senior surgical and anaesthetic support diminishes during night hours. Therefore urgent surgery is sometimes postponed until the following morning rather than performed overnight, if judged to be safe. We aim to determine if a delay to laparoscopic appendicectomy in cases of acute appendicitis of over 12 hours, analogous to an overnight delay, is correlated to worse patient outcomes. Our primary outcome was delayed discharge from hospital. Our secondary outcomes were appendicitis severity, conversion, and post-operative complications. Methods We undertook a retrospective review of the medical records of patients who underwent laparoscopic appendicectomy at a UK district general hospital between 01/01/2018 and 30/08/2019. For each patient clinical and demographic information; and times of hospital admission, surgery, and discharge; were collected. Delayed discharged was defined as ‘time to discharge’ &amp;gt;24 hours. Results 506 patients were included. In 144 patients (28.5%) ‘time to surgery’ was under 12 hours; in 362 patients (71.5%) ’time to surgery’ was over 12 hours. 362 patients (71.5%) had a delayed discharge. 303 patients (59.9%) had simple appendicitis; 143 patients had severe appendicitis (28.3%); 60 patients had a macroscopically normal appendix (11.9%). No statistically significant association between ‘time to surgery’ and delayed discharge, appendicitis severity, conversion or 30 day re-presentations was observed. Conclusions Time from admission to start of appendicectomy did not affect patient outcomes. Short in-hospital delays to appendicectomy, for example an overnight delay, may be safe in certain patients, taking account of clinical judgement.

Ripasa versus Alvarado as a Scoring System in Diagnosis of Acute Appendicitis in Al-Yarmouk Teaching Hospital

Background: Appendicitis is one of the most frequent diagnoses for emergency department visits resulting in hospitalization. A number of scoring systems have been developed to try to identify people who are likely to have appendicitis and are eligible for surgery. Aim of study: is to compare the accuracy of RIPASA to Alvarado score in the diagnosis of acute appendicitis. Methods: A prospective comparative study that was conducted at Al-Yarmouk Teaching Hospital / Baghdad during the period of one year from 1st of Feb. 2019 till 1st of Feb. 2020. It included 200 patients attended the outpatient clinic or the emergency department in Al-Yarmouk Teaching Hospital complaining from lower abdominal and/or right iliac fossa pain suggestive of acute appendicitis. Scoring was done to diagnose appendicitis by two scoring systems (Alvarado and RIPASA) using the data for each patient. The individual scores were then compared to the final diagnosis made by the clinician and to the recommendations of each scoring system. Results: In this study, most of the patients (172 patients, 86%) underwent appendectomy. We noticed that 44.8% of the operated cases were diagnosed as catarrhal appendicitis. Incidences of rebound tenderness, leukocytosis, migratory pain, ROVSING sign, and right iliac fossa guarding were significantly higher in patients diagnosed with appendicitis than those in patients diagnosed as normal appendix. Means of ALVARADO and RIPASA scores were significantly increased with severity to reach the highest level in patients diagnosed with severe appendicitis than other findings. ALVARADO score was 69.7% sensitive, 87.5% specific, and 74% accurate. RIPASA score was 94.1% sensitive, 62.5% specific, and 86.5% accurate. Conclusion: RIPASA score is more accurate and more sensitive than Alvarado score, in spite of the lower specificity, so that it can be effectively conducted for the better evaluation of acute appendicitis. RIPASA score is simple, non-invasive, and cost effective way to be used in resource limited conditions.

Reduced number of admissions with acute appendicitis but not severe acute appendicitis at two Sydney hospitals during the first COVID-19 lockdown period.

BackgroundThis study investigated whether there was a change in acute appendicitis, appendicectomy admissions or disease severity during the 2020 lockdown period in NSW.MethodsA retrospective before‐and‐after study was undertaken of patients admitted to two Sydney hospitals (St. Vincent's and Liverpool Hospitals) who had appendicectomy for presumed acute appendicitis and patients who had confirmed appendicitis but did not undergo surgery. Study periods were the 2020 lockdown period (15 March–15 May 2020), the corresponding period in the previous year, and the 1‐month after these periods. Patients were classified as having no, mild or severe appendicitis using operation and histopathological reports.Results(Thirty‐six percent) fewer patients were admitted with acute appendicitis during the lockdown period compared with the previous year with a substantial reduction in normal/mild appendicitis presentations (OR 0.56, 95% CI 0.34–0.93, P = 0.03). There were 46% fewer patients with mild appendicitis during lockdown (56) compared with the previous year (103); numbers of patients with severe appendicitis were very similar (46 vs. 51). There was no increase in number of admissions with severe appendicitis, or in the time from onset of symptoms to admission, in the month following lockdown.ConclusionCompared with the previous year, there were markedly fewer admissions with appendicitis during lockdown, with no evidence of a shift to more cases of severe appendicitis nor delayed presentation in the post‐lockdown period. It is plausible that some patients with mild appendicitis may have recovered without hospitalization, supporting the importance of implementing trials on non‐surgical management of appendicitis.

Are We Hitting the Target?: The Effectiveness of Distinct Antibiotic Regimens in Pediatric Appendectomies.

Currently, a range of different antibiotics are administered perioperatively during appendectomy surgery in the pediatric population. One reason for the lack of a uniform treatment regimen is the paucity of large studies on microbiologic data and susceptibility patterns. A retrospective, monocentric study on antibiotic susceptibility, including 1258 pediatric patients undergoing appendectomy from 2012 to 2020 was performed. Predictors for prolonged length of stay (LOS) and complications were determined using regression analysis, and objective criteria for broad-spectrum antibiotic regimens were identified. Simulations of the effectiveness of different antibiotic regimens against identified bacterial susceptibility results were conducted. The most important predictors for prolonged LOS and an increased incidence of infectious complications are elevated preoperative C-reactive protein levels, high intraoperative severity gradings and insufficient primary antibiotic treatment. Based on our results, a simple antibiotic treatment, consisting of cefuroxime-metronidazole (C-M) or ampicillin-sulbactam (AS), is sufficient in around 85% of all patients; both options being equally efficient. In severe appendicitis, the likelihood of resistance is 31% and 32% for C-M and AS, respectively. For piperacillin-tazobactam and C-M-tobramycin, the incidence of bacterial resistance decreases to 12%. Resistance is reduced to 8% for AS-tobramycin treatment. The patient populations benefiting most from an extended antibiotic regimen are those with a high intraoperative severity grading. Evidence suggests that an insufficient antibiotic regimen is associated with a prolonged LOS and a higher rate of infectious complications, justifying the expansion of a simple antibiotic regimen in cases of severe intraabdominal findings. In all other cases, a simple antibiotic treatment with AS is recommended.

Mast Cell Essential Roles: Will it be a Novel Tool for Differentiating the Severity of Pediatric Appendicitis?

BACKGROUND: Appendicitis is an undesirable diagnosis, and the Alvarado score (AS) alone is insufficient in recognizing it. Many novel laboratory indicators, such as leukocytes and mast cells, differentiate. AIM: Our objective was to demonstrate that mast cells had a greater influence on appendicitis severity than the AS, neutrophils, and platelets. MATERIALS AND METHODS: An observational research in which 35 individuals with acute appendicitis at our institutions were identified for the appendix grade and allocated to one of two groups: Complicated or non-complicated. The AS and white blood cell count were calculated using the neutrophil-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), thrombocyte-to-neutrophil ratio (TNR), and total leukocyte. Mast cell count and granulation are evaluated using pathological anatomy. RESULTS: TLR could not distinguish between severe appendicitis and others, but some showed potential. NLR, TNR, total leukocyte, ASs, mast cell count, and degranulation demonstrated good sensitivity-specificity values. CONCLUSIONS: Mast cells have the potential to become a promising approach for predicting complicated pediatric appendicitis.

Laparoscopic Appendectomy Using the Surgical-Glove Port Through an Umbilical Incision: A Single-Center Retrospective Study.

BackgroundSingle-incision laparoscopic appendectomy (SILA) has recently emerged as a promising alternative for the management of acute appendicitis. This study aimed to compare the surgical outcomes of the SILA with those of three laparoscopic appendectomies (TLA) procedures using the existing equipment, the 10-mm laparoscope, and the surgical-glove port method.MethodologyBetween February 2021 and February 2022, this single-center retrospective study examined 68 patients who underwent laparoscopic appendectomy by a single surgeon. The study excluded patients with severe appendicitis, grade IV-V, following the American Association for the Surgery of Trauma classification. Clinical outcomes were analyzed, including operation time, hospital stay, postoperative pain, and postoperative morbidity.ResultsThere were no statistically significant differences between SILA and TLA patients, respectively, in operation time (37.5 minutes vs. 35 minutes, p = 0.261) and the median duration of hospitalization (three days vs. three days, p = 0.929). There was no difference in the mean visual analog scale score between the two groups on the first day (p = 0.852), second day (p = 0.540), and the day of discharge from the hospital (p = 0.686), as well as return to diet (two days vs. two days, p = 0.053). Two (10%) cases of short-term complications in the SILA group and one (2.1%) case in the TLA group were noted.ConclusionsSILA performed through a handmade surgical-glove port is a safe and viable therapy option for mild-to-moderate appendicitis. When the hospital lacks a specialized laparoscopic single-incision surgical system, this technique should be used on patients.

Patient Outcomes Related to In-Hospital Delays in Appendicectomy for Appendicitis: A Retrospective Study.

Background and objectiveIn many hospitals, the availability of operating theatres and access to senior surgical and anaesthetic support diminish during night hours. Therefore, urgent surgery is sometimes postponed until the following morning rather than performed overnight, if it is judged to be safe. In this study, we aimed to determine if a delay in laparoscopic appendicectomy in cases of acute appendicitis of over 12 hours, analogous to an overnight delay, correlated with worse patient outcomes. Our primary outcome was delayed discharge from the hospital. Our secondary outcomes were appendicitis severity, conversions, and postoperative complications.MethodsWe undertook a retrospective review of the medical records of patients who underwent laparoscopic appendicectomy for appendicitis at a UK district general hospital between 01/01/2018 and 30/08/2019. For each patient, clinical and demographic information, and time of hospital admission, surgery, and discharge were collected. Delayed discharge was defined as "time to discharge" >24 hours after surgery.ResultsA total of 446 patients were included in the study. In 137 patients (30.7%), "time to surgery" was under 12 hours; in 309 patients (69.3%) "time to surgery" was over 12 hours. Of note, 319 patients (71.5%) had a delayed discharge; 303 patients (67.9%) had complicated appendicitis, and 143 patients had severe appendicitis (32.1%). No statistically significant association between "time to surgery" and delayed discharge, appendicitis severity, conversion, or 30-day re-presentations was observed.ConclusionTime from admission to the start of appendicectomy did not affect patient outcomes. Short in-hospital delays in appendicectomy, such as an overnight delay, may be safe in certain patients and should be determined based on clinical judgement.

Metabolomics and Inflammatory Mediator Profiling for the Differentiation of Life-Threatening and Non-Severe Appendicitis in the Pediatric Population.

While children with appendicitis often have excellent clinical outcomes, some develop life-threatening complications including sepsis and organ dysfunction requiring pediatric intensive care unit (PICU) support. Our study applied a metabolomics and inflammatory protein mediator (IPM) profiling approach to determine the bio-profiles of children who developed severe appendicitis compared with those that did not. We performed a prospective case-control study of children aged 0–17 years with a diagnosis of appendicitis. Cases had severe disease resulting in PICU admission. Primary controls had moderate appendicitis (perforation without PICU); secondary controls had mild appendicitis (non-perforated). Serum samples were analyzed using Proton Nuclear Magnetic Resonance (1H NMR) Spectroscopy and Gas Chromatography-Mass Spectrometry (GC-MS); IPM analysis was performed using plasma bead-based multiplex profiling. Comparisons were made using multivariate data statistical analysis. Fifty-three children were included (15 severe, 38 non-severe). Separation between severe and moderate appendicitis demonstrated excellent sensitivity and specificity (100%, 88%; 14 compounds), separation between severe and mild appendicitis also showed excellent sensitivity and specificity (91%, 90%; 16 compounds). Biomarker patterns derived from metabolomics and IPM profiling are capable of distinguishing children with severe appendicitis from those with less severe disease. These findings provide an important first step towards developing non-invasive diagnostic tools for clinicians in early identification of children who are at a high risk of developing severe appendicitis.

Elevated C-reative protein (CRP) as a surgical indication for appendicitis

Objective: Role of C-reactive protein value in the diagnosis of appendicitis by correlating with severity of appendicitis on histopathological findings.&#x0D; Methodology: This descriptive study was conducted at the department of general surgery Unit-IV, Liaquat University Hospital Hyderabad from March 2016 to February 2017.&#x0D; All cases above 12 years of age with severe appendicitis based on presenting signs and symptoms were included. The patient underwent routine laboratory investigations including abdominal plain x-ray in an erect position and ultrasound abdomen. The blood sample was taken from each patient for C-reactive protein and was send to Hospital diagnostic laboratory. During surgery, a specimen of each patient was sent to a diagnostic laboratory for histopathology. All the data were record on Performa.&#x0D; Results: A total of 305 patients were studied; their mean age was 35.7+9.7 years. Males were found in the majority (73%). 75.41% of patients had leukocytosis. C-reactive protein was raised among 26.22% of patients. On histopathological findings, 04.91% of patients had a normal appendix, while 69.83% had gross inflammation of the appendix, 19.67% patients had gangrenous appendix, and 05.57% patients had perforation and peritonitis. Elevated C reactive protein (CRP) and leukocytosis were significantly associated with the severity of appendicitis, p value 0.001.&#x0D; Conclusion: C-reactive protein is a non-invasive and reliable indicator for surgical treatment of appendicitis. C-reactive protein and white blood cells (WBCs) were significantly associated with the severity of appendicitis.

Appendectomy during the COVID-19 pandemic in Italy: a multicenter ambispective cohort study by the Italian Society of Endoscopic Surgery and new technologies (the CRAC study)

Major surgical societies advised using non-operative management of appendicitis and suggested against laparoscopy during the COVID-19 pandemic. The hypothesis is that a significant reduction in the number of emergent appendectomies was observed during the pandemic, restricted to complex cases. The study aimed to analyse emergent surgical appendectomies during pandemic on a national basis and compare it to the same period of the previous year. This is a multicentre, retrospective, observational study investigating the outcomes of patients undergoing emergent appendectomy in March–April 2019 vs March–April 2020. The primary outcome was the number of appendectomies performed, classified according to the American Association for the Surgery of Trauma (AAST) score. Secondary outcomes were the type of surgical technique employed (laparoscopic vs open) and the complication rates. One thousand five hundred forty one patients with acute appendicitis underwent surgery during the two study periods. 1337 (86.8%) patients met the inclusion criteria: 546 (40.8%) patients underwent surgery for acute appendicitis in 2020 and 791 (59.2%) in 2019. According to AAST, patients with complicated appendicitis operated in 2019 were 30.3% vs 39.9% in 2020 (p = 0.001). We observed an increase in the number of post-operative complications in 2020 (15.9%) compared to 2019 (9.6%) (p < 0.001). The following determinants increased the likelihood of complication occurrence: undergoing surgery during 2020 (+ 67%), the increase of a unit in the AAST score (+ 26%), surgery performed > 24 h after admission (+ 58%), open surgery (+ 112%) and conversion to open surgery (+ 166%). In Italian hospitals, in March and April 2020, the number of appendectomies has drastically dropped. During the first pandemic wave, patients undergoing surgery were more frequently affected by more severe appendicitis than the previous year's timeframe and experienced a higher number of complications. Trial registration number and date: Research Registry ID 5789, May 7th, 2020

ARROSIVE BLEEDING FROM THE APPENDICULAR ARTERY IN ACUTE DESTRUCTIVE APPENDICITIS

Summary. Objective of the study: to present to the surgical community a rather rare complication of severe destructive appendicitis – arrosive bleeding and the cause of its development.&#x0D; Material and methods. Published a rare clinical case from prac-tice — the development of perforation of the appendix and arrosive bleeding from the appendicular artery in a patient with acute gangrenous appendicitis.&#x0D; Results and its discussion. The atypical course of acute appendicitis of undulating nature under the mask of acute adnexitis and antibacterial therapy has led to a prolonged delay with surgery in the surgical department. Only the appendicular abscess, which spontaneously opened into the abdominal cavity, made it possible to diagnose acute appendicitis and determine indications for emergency surgery, during which arrosive bleeding was diagnosed. The favorable outcome of the disease is due to the local purulent-necrotic process and small hemoperitoneum.&#x0D; Findings. Timely diagnosis of acute appendicitis, with the involvement of additional research methods in unclear cases, and subsequent appendectomy, are the prevention of a rather rare complication — arrosive bleeding from the appendicular artery in the development of severe complicated forms of acute destructive appendicitis.

Clinicopathological characteristics of De Garengeot hernia: six case reports and literature review

BackgroundDe Garengeot hernia, wherein the appendix is present within a femoral hernia, is a rare disease; therefore, the clinicopathological features remain to be clarified. This study aimed to reveal the clinicopathological characteristics of De Garengeot hernia.Case presentationSix patients who underwent appendectomy and herniorrhaphy between 1999 and 2018 were included. The incidence of De Garengeot hernia was 3.2% among the 182 femoral hernias that required surgery during the study period. The median age of the patients was 78 years, and five patients were women. The median body mass index was 20.1. Patients frequently had fever or elevated CRP level. Preoperative diagnoses based on computed tomography were femoral (n = 3), inguinal (n = 2), and De Garengeot (n = 1) hernias. Emergency and elective surgeries were performed in four and two patients, respectively. Histopathological examination of the resected appendix showed gangrenous appendicitis (n = 3), perforated appendicitis (n = 2), and appendiceal ischemia (n = 1) in the patients. Postoperatively, one patient developed sepsis.ConclusionsPreoperative diagnosis of De Garengeot hernia is often difficult, and patients frequently have severe appendicitis. Precise diagnosis is required, and emergency surgery should be considered depending on the severity of appendicitis.