Treatment Of Uncomplicated Acute Appendicitis Research Articles

THE EFFICACY OF ANTIBIOTICS IN ACUTE APPENDICITIS TREATMENT : A COMPREHENSIVE SYSTEMATIC REVIEW

Background: Acute appendicitis has been the most common cause of lower abdominal pain leading to emergency visits worldwide. To avoid major complications, appendectomy has remained the standard treatment for uncomplicated acute appendicitis for over a century. The aim: The aim of this study to show about the efficacy of antibiotics in acute appendicitis treatment. Methods: 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. This search approach, publications that came out between 2014 and 2024 were taken into account. Several different online reference sources, like Pubmed, SagePub, and Sciencedirect 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: Five publications were found to be directly related to our ongoing systematic examination after a rigorous three-level screening approach. Subsequently, a comprehensive analysis of the complete text was conducted, and additional scrutiny was given to these articles. Conclusion: The therapeutic effects of antibiotics and appendicectomy were comparable for the treatment of acute appendicitis.

Interval Appendectomy After Successful Antibiotic Treatment?

This Viewpoint discusses the pros and cons of performing interval appendectomy in patients who have recovered from successful antibiotic treatment of acute uncomplicated appendicitis.

Three-Year Outcomes of Oral Antibiotics vs Intravenous and Oral Antibiotics for Uncomplicated Acute Appendicitis

Current short-term evidence has shown that uncomplicated acute appendicitis can be treated successfully with oral antibiotics alone, but longer-term results are lacking. To assess the treatment effectiveness of oral antibiotic monotherapy compared with combined intravenous (IV) and oral antibiotics in computed tomography-confirmed uncomplicated acute appendicitis at a longer-term follow-up. This secondary analysis of a predefined year 3 follow-up of the Appendicitis Acuta II (APPAC II) noninferiority, multicenter randomized clinical trial compared oral moxifloxacin with combined IV ertapenem plus oral levofloxacin and metronidazole for the treatment of uncomplicated acute appendicitis. The trial was conducted at 9 university and central hospitals in Finland from April 2017 to November 2018, with the last follow-up in November 2022. Participants included patients aged 18 to 60 years, who were randomized to receive either oral antibiotics monotherapy (n = 301) or combined IV and oral antibiotics (n = 298). Antibiotics monotherapy consisted of oral moxifloxacin, 400 mg/d, for 7 days. Combined IV and oral antibiotics consisted of IV ertapenem sodium, 1 g/d, for 2 days plus oral levofloxacin, 500 mg/d, and metronidazole, 500 mg 3 times/d, for 5 days. The primary end point was treatment success, defined as the resolution of acute appendicitis and discharge from hospital without the need for surgical intervention and no appendicitis recurrence at the year 3 follow-up evaluated using a noninferiority design. The secondary end points included late (after 1 year) appendicitis recurrence as well as treatment-related adverse events, quality of life, length of hospital stay, and length of sick leave, which were evaluated using a superiority design. After exclusions, 599 patients (mean [SD] age, 36 [12] years; 336 males [56.1%]) were randomized; after withdrawal and loss to follow-up, 582 patients (99.8%) were available for the year 3 follow-up. The treatment success at year 3 was 63.4% (1-sided 95% CI, 58.8% to ∞) in the oral antibiotic monotherapy group and 65.2% (1-sided 95% CI, 60.5% to ∞) in the combined IV and oral antibiotics group. The difference in treatment success rate between the groups at year 3 was -1.8 percentage points (1-sided 95% CI, -8.3 percentage points to ∞; P = .14 for noninferiority), with the CI limit exceeding the noninferiority margin. There were no significant differences between groups in treatment-related adverse events, quality of life, length of hospital stay, or length of sick leave. This secondary analysis of the APPAC II trial found a slightly higher appendectomy rate in patients who received oral antibiotic monotherapy; however, noninferiority of oral antibiotic monotherapy compared with combined IV and oral antibiotics could not be demonstrated. The results encourage future studies to assess oral antibiotic monotherapy as a viable treatment alternative for uncomplicated acute appendicitis. ClinicalTrials.gov Identifier: NCT03236961.

Optimizing antibiotic management for patients with acute appendicitis: A quality improvement study

BackgroundTo decrease surgical site infections after appendectomy for acute appendicitis, preoperative broad-spectrum antibiotics are often used in clinical practice. However, this treatment strategy has come under scrutiny because of increasing rates of antibiotic-resistant infections. MethodsThe aim of this multisite quality improvement project was to decrease the treatment of uncomplicated acute appendicitis with piperacillin-tazobactam without increasing the rate of surgical site infections. Our quality improvement intervention had 2 distinct components: (1) updating electronic health record orders to encourage preoperative administration of narrow-spectrum antibiotics and (2) educating surgeons and emergency department clinicians about selecting appropriate antibiotic therapy for acute appendicitis. Patient demographics, clinical characteristics, and outcomes were compared 6 months before and after implementation of the quality improvement intervention. ResultsA total of 352 laparoscopic appendectomies were performed during the 6-month preintervention period, and 369 were performed during the 6-month postintervention period. The preintervention period and postintervention period groups had similar baseline demographics, vital signs, and laboratory test values. The rate of preoperative piperacillin-tazobactam administration significantly decreased after the intervention (51.4% preintervention period vs 20.1% postintervention period, P < .001). The rate of surgical site infections was similar in both groups (superficial surgical site infections = 1.4% preintervention period vs 0.8% postintervention period, P = .50; deep surgical site infections = 1.1% preintervention period vs 0.0% postintervention period, P = .06; and organ space surgical site infections = 3.1% preintervention period vs 3.0% postintervention period, P > .99). Rates of 30-day readmission, reoperation, and Clostridioides difficile infection also did not differ between groups. ConclusionOur quality improvement intervention successfully decreased piperacillin-tazobactam administration without increasing the rate of surgical site infections in patients with acute appendicitis.

Conservative Versus Surgical Management of Acute Appendicitis: A Systematic Review.

Recent studies have discussed the role of antibiotic treatment in the conservative management of acute appendicitis and whether antibiotics are a safe option to replace appendicectomy, which has been the gold standard treatment of acute appendicitis for many years. The bibliographic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, Medline, and PubMed comparing conservative versus surgical treatment of acute appendicitis were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty-one studies consisting of systematic reviews and meta-analyses involving 44,699 participants were identified. At least 17,865 participants were treated with antibiotics. Our studies compare antibiotic versus appendicectomy among acute appendicitis patients ranging from 7 to 94 years of age. In most studies, patients received parenteral antibiotics for a total of one to three days, and oral antibiotics such as oral cephalosporin plus metronidazole, oral amoxicillin/clavulanate, oral fluoroquinolones plus Tinidazole upon hospital discharge for a total of 7 to 10 days. The total course of antibiotics for both parenteral and oral regimes ranged from 2 to 16 days, with 10 days being the commonest duration. The recurrence rate following initial antibiotic treatment at one-year follow-up ranged from 13% to 38%, while the mean duration of recurrence ranged from three to eight months. The majority of the patients with recurrence underwent appendicectomy, while some patients were either given a repeat or different course of antibiotics due to the possible presence of antibiotic resistance; however, only 2.4% of the patients were successfully treated upon completion of the second course of antibiotics. Most of the studies concluded that appendicectomy remains the gold standard treatment for uncomplicated acute appendicitis, given its higher efficacy and lower complication rates. Although antibiotic treatment cannot be routinely recommended, it can be considered an appropriate alternative in selected patients with uncomplicated appendicitis who wish to avoid surgery and also acknowledge the risk of recurrence and the potential need for subsequent surgery at the same time.

Evaluation of Factors Predicting Successful Outcome in Patients Undergoing Expectant Management of Uncomplicated Acute Appendicitis.

Expectant management, or non-operative management (NOM), with standalone intravenous antibiotic therapy, has emerged as an effective alternative to appendectomy for the treatment of uncomplicated acute appendicitis. Various clinical, biochemical, and radiological factors have been implicated in predicting the success or failure of outcomes. Therefore, it is important to identify patients at the onset who are likely to have successful outcomes for conservative management of uncomplicated acute appendicitis. We prospectively enrolled 85 surgical patients diagnosed with uncomplicated acute appendicitis in our study. On admission, clinical features such as duration of symptoms, pulse rate (PR), history of fever within 24 hours of admission, modified Alvarado score and adult appendicitis score, biochemical parameters such as C-reactive protein (CRP), and hematological parameters such as total leukocyte count (TLC) were recorded. Radiological imaging of patients, namely ultrasonography and contrast-enhanced CT abdomen to evaluate appendix diameter and mural enhancement, was also undertaken. The outcome of expectant management for these patients (success or failure) was recorded, and the above-mentioned factors were evaluated to find a possible correlation with successful expectant management. We found that among 85 patients, 77.6% had a successful NOM of appendicitis, whereas 22.4% had a failed NOM of appendicitis. The duration of symptoms, pulse rate, fever within 24 hours of admission, TLC, percentage of neutrophils, CRP level, appendix diameter, modified Alvarado score, and adult appendicitis scorewere found to be statistically significant predictors of successful NOM of appendicitis according to univariate analysis. According to multivariable analysis, pulse rate and appendix diameter value were found to be statistically significant predictors of successful NOM of appendicitis. With each beat per minute (bpm) increase in pulse rate, there was a 0.30% decrease in the probability of a successful NOM of appendicitis. With each mm increase in appendix diameter, there was an 82% decrease in the probability of a successful NOM of appendicitis. From our study, it can be concluded that patients who met the following criteria, i.e., duration of symptoms before presenting to surgical emergency less than two days, presence of fever within 24 hours of presenting to surgical emergency, pulse rate >90 bpm, TLC >12000 cells/dL, CRP >20 mg/L, appendix diameter >10 mm, modified Alvarado score ≥ 9, and adult appendicitis score ≥ 18, have a higher probability of failure of NOM and hence should be excluded from expectant management.

Frequency of Appendectomy in Children after Conservative Treatment of Uncomplicated Acute Appendicitis

Background: Acute appendicitis, frequently seen in children, involves an inflamed appendix. Conventionally, surgical removal (appendectomy) has been the go-to treatment. Recently, interest in a conservative approach, utilizing antibiotics and close monitoring, has grown, particularly for uncomplicated cases. This shift aims to reduce surgical intervention, reflecting a changing understanding of the condition. Aim of the study: The aim of the study was to assess the frequency of appendectomy in children after conservative treatment of uncomplicated acute appendicitis. Methods: This prospective observational study spanned from July 2017 to March 2019, conducted at the Department of Paediatric Surgery, Dhaka Medical College Hospital, Bangladesh. It involved 62 children admitted for uncomplicated acute appendicitis. Data collection employed purposive sampling, and MS Office tools were used for data analysis. Results: In this study, the mean age of the total participants was 8.95±2.10 years within a range from 4 years to 12 years. The male-female ratio was 1.6:1. The frequency of appendectomy among the total participants was 4.9% (n=3). After taking conservative treatment, 95.1% (n=59) of patients were successfully discharged. Within six months, 13.0% (n=8) experienced recurrence, and the average hospital stay was 5.26±0.63 days. Conclusion: The frequency of appendectomy in children after conservative treatment of uncomplicated acute appendicitis. So, by using conservative treatment physicians can save a huge number of paediatric patients from the hassles and sufferings of surgery for uncomplicated acute appendicitis.

Outcomes of Conservative Treatment of Uncomplicated Acute Appendicitis in Children

Background: Pediatric healthcare is evolving, with acute appendicitis being a common issue. Traditionally, appendectomy has been the standard treatment. However, recent literature suggests that conservative antibiotic treatment could be a viable option, particularly for uncomplicated cases in children. Aim of the study: The aim of the study was to evaluate the outcomes of conservative treatment for uncomplicated acute appendicitis in children. Methods: From July 2017 to March 2019, a prospective observational study was conducted at Dhaka Medical College Hospital, Bangladesh, involving 62 children with uncomplicated acute appendicitis. They received conservative treatment, including supportive care, for five days. Patients who responded positively within 24 hours continued for at least five days before discharge and underwent a 6-month follow-up. Results: The study encompassed 62 patients, with a mean age of 8.95 years, and a slight male predominance (61.3% male, 38.7% female). Clinical findings revealed a notable decrease in pain intensity (9.42 to 0.77), temperature (101.02º to 98.90º), and inflammatory markers (CRP: 28.13 ± 11.56 mg/L to 9.78 ± 7.50 mg/L) from admission to day 5. The mean duration of hospital stay was 5.26 ± 0.63 days. Remarkably, 95.1% of patients successfully recovered with conservative treatment, while 4.9% required surgery as part of their treatment course. Conclusion: This study found some potential benefits of conservative treatment for uncomplicated acute appendicitis in children. Significant improvements in clinical parameters and a high success rate emphasize its potential as a viable alternative to surgery in select cases, warranting further exploration in pediatric healthcare practices.

Laparoscopic Appendectomy Combined with an "Antimicrobial-Free" Strategy for Acute Uncomplicated Appendicitis.

Objective: To explore the efficacy and safety of enhanced recovery protocol (ERP) combined with laparoscopic appendectomy (LA) in the treatment of acute uncomplicated appendicitis (AUA) without antibiotics. Methods: In this study, a total of 160 patients with AUA who underwent LA between January 2018 and December 2021 were included and divided into the antibiotic group (n = 80) or the no-antibiotic group (n = 80). The patients in the antibiotic group received the ERP combined with antimicrobials during the perioperative period, while those in the no-antibiotic group only received the ERP during the perioperative period. The clinical data of these patients were collected to compare the inflammation level and stress state before and after surgery. In addition, the incidence of postoperative complications and the recovery speed of the patients were compared between groups. Results: There were no significant differences in the inflammation level and stress state before or after surgery, the incidence of postoperative complications or the recovery speed between the antibiotic group and the no-antibiotic group (P > .05). Conclusion: The use of ERP combined with LA as an antimicrobial-free treatment scheme in the perioperative period was found to be safe and effective for patients with AUA. Therefore, this approach is clinically valuable.

Risk of appendiceal malignancy in conservatively treated acute appendicitis.

Appendectomy has historically been the standard treatment of acute appendicitis, but lately, conservative treatment of uncomplicated acute appendicitis with antibiotics has successfully been used in selected patients. Complicated acute appendicitis is often treated conservatively initially, but may benefit from interval appendectomy due to the higher risk of appendiceal malignancy and recurrence. Recommendations for follow-up after conservatively treated appendicitis vary. Furthermore, the risk of underlying malignancy and the necessity of routine interval appendectomy are unclear. This study aims to evaluate follow-up status, recurrence, and underlying appendiceal malignancy in conservatively treated uncomplicated and complicated acute appendicitis. This study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and data on follow-up, recurrence, number of appendectomies after initial conservative treatment, and underlying malignancy were retrieved from medical charts. The study cohort included 391 patients, 152 with uncomplicated and 239 with complicated acute appendicitis. Median time of study follow-up was 52 months. The recurrence risk was 23 (15.1%) after uncomplicated and 58 (24.3%) after complicated acute appendicitis (p = 0.030). During follow-up, 55 (23%) patients with complicated acute appendicitis underwent appendectomy. Appendiceal malignancies were found in 12 (5%) patients with previous complicated acute appendicitis versus no appendiceal malignancies after uncomplicated acute appendicitis (p = 0.002). The risk of appendiceal malignancy and recurrent appendicitis was significantly higher in patients with complicated acute appendicitis compared with uncomplicated acute appendicitis.

Comparison of the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis: a systematic review and meta-analysis

ObjectiveThis meta-analysis aimed to compare the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis.MethodsWe searched the randomized controlled studies (RCTs) comparing appendectomy with antibiotic treatment for uncomplicated acute appendicitis in the electronic database including Pubmed, Embase, Cochrane, Web of Science, CNKI, VIP, and WanFang. The primary outcomes included complication-free treatment success at 1 year, complications, surgical complications, and the complicated appendicitis rates. Secondary outcomes included negative appendicitis, length of hospital stay, the quality of life at 1 month, and the impact of an appendicolith on antibiotic therapy.ResultsTwelve randomized controlled studies were included. Compared with surgery group, the antibiotic group decreased the complication-free treatment success at 1 year (RR 0.81; 95% CI 0.73–0.91; z = 3.65; p = 0.000). Statistically significance was existed between antibiotic group and surgical group with both surgical types(open and laparoscopic) (RR 0.43; 95% CI 0.31–0.58; z = 5.36; p = 0.000), while no between the antibiotic treatment and laparoscopic surgery (RR 0.72; 95% CI 0.41–1.24; z = 1.19; p = 0.236). There was no statistically significant differences between two groups of surgical complications (RR 1.38; 95% CI 0.70–2.73; z = 0.93; p = 0.353), the complicated appendicitis rate (RR 0.71; 95% CI 0.36–1.42; z = 0.96; p = 0.338), negative appendectomy rate (RR 1.11; 95% CI 0.69–1.79; z = 0.43; p = 0.670), duration of hospital stay (SMD 0.08; 95%CI -0.11-0.27; z = 0.80; p = 0.422), and quality of life at 1 month (SMD 0.09; 95%CI -0.03-0.20; z = 1.53; p = 0.127). However, in the antibiotic treatment group, appendicolith rates were statistically higher in those whose symptoms did not improve (RR 2.94; 95% CI 1.28–6.74; z = 2.55; p = 0.011).ConclusionsAlthough the cure rate of antibiotics is lower than surgery, antibiotic treatment is still a reasonable option for patients with uncomplicated acute appendicitis who do not want surgery without having to worry about complications or complicating the original illness.

Invited Commentary: Low-Impact Laparoscopy Could Become the New Standard for Treatment of Uncomplicated Acute Appendicitis.

Invited Commentary: Low-Impact Laparoscopy Could Become the New Standard for Treatment of Uncomplicated Acute Appendicitis.

Assessing micro- vs macro-costing approaches for treating appendicitis in children with appendicectomy or non-operatively

ObjectivesWe conducted a health economic sub-study within a feasibility RCT comparing a non-operative treatment pathway as an alternative to appendicectomy for the treatment of uncomplicated acute appendicitis in children. The objectives were to understand and assess data collection tools and methods and to determine indicative costs and benefits assessing the feasibility of conducting a full economic evaluation within the definitive trial.MethodsWe compared different methods of estimating treatment costs including micro-costing, hospital administrative data (PLICS) and health system (NHS) reference costs. We compared two different HRQoL instruments (CHU-9D and EQ-5D-5L) in terms of data completeness and sensitivity to change over time, including potential ceiling effects. We also explored how the timing of data collection and duration of the analysis could affect QALYs (Quality Adjusted Life Years) and the results of the cost-utility analysis (CUA) within the future RCT.ResultsUsing a micro-costing approach, the total per treatment costs were in alignment with hospital administrative data (PLICS). Average health system reference cost data (macro-costing using NHS costs) could potentially underestimate these treatment costs, particularly for non-operative treatment. Costs incurred following hospital discharge in the primary care setting were minimal, and limited family borne costs were reported by parents/carers. While both HRQoL instruments performed relatively well, our results highlight the problem of ceiling effect and the importance of the timing of data collection and the duration of the analysis in any future assessment using QALYs and CUA.ConclusionsWe highlighted the importance of obtaining accurate individual-patient cost data when conducting economic evaluations. Our results suggest that timing of data collection and duration of the assessment are important considerations when evaluating cost-effectiveness and reporting cost per QALY.Clinical trial registrationCurrent Controlled Trials ISRCTN15830435.

Covid-19 Pandemic Strategy for Treatment of Acute Uncomplicated Appendicitis with Antibiotics- Risk Categorization and Shared Decision-Making

BackgroundDuring the Coronavirus disease 2019 (COVID-19) pandemic, a protocol was adopted by our department on antibiotics treatment for Acute Uncomplicated Appendicitis (AUA). Our study aimed to determine the feasibility and safety of non-operative treatment (NOT), compared to upfront laparoscopic appendectomy (LA), for AUA in children during the pandemic. MethodOur prospective comparative study was conducted from May 1, 2020 to January 31, 2021. Patient selection criteria included: age ≥5 years, abdominal pain duration ≤48 h, ultrasound (US)/Computered Tomography scan confirmation of AUA, US appendiceal diameter 6–11 mm with no features of perforation/abscess collection and no faecolith. For NOT patients, intravenous antibiotics were administered for 24–48 h followed by oral for 10-day course. Comparison was performed between patients whose parents preferred NOT to those who opted for up-front appendectomy. Primary outcomes were NOT success at index admission, early and late NOT failure rates till 27 months. Secondary outcomes were differences in complication rate, hospital length of stay (LOS) and cost between groups. Results77 patients were recruited: 43 (55.8%) underwent NOT while 34 (44.2%) patients opted for LA. Success of NOT at index admission was 90.7% (39/43). Overall, NOT failure rate at 27 months’ follow-up was 37.2% (16/43). Of the NOT failures, 1 appendix was normal on histology while only 1 was perforated. There were no significant differences in secondary outcomes between both groups except for LOS of late NOT failure. Cost for upfront LA was nearly thrice that of NOT. ConclusionOur stringent COVID protocol together with shared decision-making with parents is a safe and feasible treatment option during a crisis situation. Level of EvidenceTreatment study, Level II.

Management of uncomplicated acute appendicitis during the COVID-19 pandemic: Appendectomy or non-surgical treatment?

This study aims to compare medical treatment and appendectomy in patients diagnosed with uncomplicated acute appendicitis during the COVID-19 pandemic. Retrospectively analyzed were the data of 80 patients who received medical or surgical treatment for uncomplicated acute appendicitis between March 15, 2020, and August 31, 2020. The demographic characteristics of the patients, length of hospital stay, physical examination and radiology findings, laboratory results, and any complications were recorded. Patients were divided into two groups depending on the mode of treatment, as surgical and non-surgical. Forty patients were given medical treatment and 40 patients were directly operated on for appendicitis. Of the 40 patients who received medical treatment, 8 (20%) ended up requiring an operation due to recurrence. The mean duration of hospitalization was 2 days (range: 1-3), and the mean follow-up duration was 285.35±65.66 days (range: 101-379). The white blood cell count was significantly higher in the surgical group (p=0.004), and the length of hospital stay was longer in the non-surgical group (p<0.001). The prevalence of post-operative complications was similar for patients who underwent appendectomy directly on admission or after recurrence (p=1.000). Among the patients who received medical treatment, the most important predictors of requiring surgery were the red cell distribution width and increased appendix diameter in computed tomography (p<0.05). Medical treatment is an effective alternative in patients with uncomplicated appendicitis. Even in the case of a recurrence in follow-up, surgery due to a potential recurrence is not associated with an increased rate of complication compared to direct surgery.

Comparison of conservative and operative treatment of uncomplicated appendicitis in the pediatric population

Introduction/Objective. Studies about possibilities of conservative, i.e., non-operative management of acute uncomplicated appendicitis in adult and pediatric population have been published lately, considering benefits of preserving appendix and potential complications related to appendectomy. Methods. In this retrospective study, medical data of 76 patients treated at the Institute for Child and Youth Health Care of Vojvodina in Novi Sad for acute uncomplicated appendicitis in 2015 and 2016 have been analyzed, comparing length of stay, antibiotic therapy use, complications occurrence, as well as the financial burden depending of the type of therapy applied. Results. During this period, 76 patients (55 operated on and 21 treated conservatively) were treated for acute uncomplicated appendicitis. Conservatively treated children spent statistically significantly shorter period of time at the hospital compared to the ones operated on (4.24 vs. 5.76 days; p &lt; 0.001). Early surgical complications occurred in 10.91% of those operated on and in 9.52% conservatively treated children, which was not a statistically significant difference (p = 0.863). The total cost of hospital stay was significantly lower in those who underwent non-operative management (10,340 RSD vs. 54,281 RSD; p &lt; 0.001). The difference was significant even when analyzing costs related to rehospitalization and operative treatment of children initially treated conservatively (p &lt; 0.001). Conclusion. Non-operative, i.e., conservative treatment of acute uncomplicated appendicitis in the pediatric population is safe and effective compared to the operative one, and it is not associated with more frequent occurrence of early surgical complications. Total costs for the non-operative treatment are significantly lower, even considering costs related to re-hospitalization of children initially treated conservatively.

＜Editors' Choice＞ Advantages of gasless single-port transumbilical extracorporeal laparoscopic-assisted appendectomy in the treatment of uncomplicated acute appendicitis in children in China: a multi-institutional retrospective study.

Gasless transumbilical extracorporeal laparoscopic-assisted appendectomy is an approach used increasingly to treat uncomplicated acute appendicitis (UAA). However, there is limited information on its clinical effects and value in the Chinese pediatric population. This study retrospectively reviewed patients with UAA treated in two pediatric institutions from January 2018 through October 2021. Enrolled patients were divided into two groups by operative technique: gasless transumbilical laparoscopic-assisted appendectomy (gasless-TULAA, n=142) and conventional laparoscopic appendectomy (CLA, three-port, n=126). The perioperative clinical data, including age, sex, body mass index (BMI), operation time, time to postoperative ambulation, time to first postoperative exhaust, hospitalization expenses, and postoperative complications (incision infection, intestinal obstruction, and residual abdominal abscess), were compared between the two groups. Operations in both groups were successfully conducted without converting to open surgery. There were no significant differences (p > 0.05) in age and BMI in the two groups. Compared with CLA, gasless-TULAA showed significantly shorter operation time, earlier postoperative ambulation, shorter postoperative exhaust time, and lower hospital cost (p < 0.001). All patients were followed for 3 months, and postoperative complications were observed in three patients: two patients in the gasless-TULAA group (one with surgical wound effusion, one with intra-abdominal abscess), and one patient in the CLA group (surgical wound infection); there was no significant difference between the groups. Notably, 38 patients initially treated by gasless-TULAA were converted because of intraoperative factors. The gasless-TULAA technique had potential benefits: shortened operation time, better outcome, and greater cost-efficiency. These superiorities are worthy of future large-scale prospective study.

Follow-up ultrasonographic findings among children treated conservatively for uncomplicated acute appendicitis.

BackgroundUltrasound is an accurate tool for diagnosing acute appendicitis. Conservative treatment for uncomplicated acute appendicitis is feasible and safe in children. However, no sonographic follow-up results from children with nonoperatively managed acute appendicitis have been reported.ObjectiveTo describe the sonographic appearance of the appendix at follow-up ultrasound and to attempt to identify signs predictive of recurrent acute appendicitis.Materials and methodsChildren diagnosed with uncomplicated acute appendicitis and treated conservatively in our hospital from 2014 to 2019, and who presented for follow-up ultrasound at 3, 6 and 9 months, were included in our study. Clinical, laboratory and ultrasound data were recorded.ResultsBy the end of follow-up, 29 (14.2%) of 204 children in the cohort had developed recurrent acute appendicitis and 175 had recovered uneventfully. On follow-up ultrasound, appendiceal diameter measured > 6 mm in 56/204 (27.5%) cases at 3 months and in 9/26 (34.5%) at 6 months. After 3 months, 102/204 (50%) children had normal appendiceal diameter on ultrasound. Appendiceal diameter > 6 mm was associated with intraluminal fluid or sludge in the appendiceal lumen at 3- and 6-month follow-up (P < 0.001, P = 0.002, respectively). Comparing cases with and without recurrence, at 3-month follow-up, appendiceal diameter > 6 mm was found in 17/29 (58.6%) cases vs. 39/175 (22.3%), respectively (P < 0.001). Appendiceal diameter returned to normal in 12/19 (63.2%) cases in the nonrecurrent acute appendicitis group compared with 2/7 (28.6%) in the recurrent acute appendicitis group (P = 0.05) at the 6-month follow-up. Intraluminal fluid or sludge was detected more frequently in the recurrent acute appendicitis versus the nonrecurrent acute appendicitis group at 3- (P < 0.001) and 6-month (P = 0.001) follow-up.ConclusionProgressive normalization of appendiceal diameter was noted on follow-up ultrasound. The prevalence of both appendiceal diameter > 6 mm and intraluminal fluid or sludge were found to be increased in children who later developed recurrent acute appendicitis. Ultrasound appears to be a useful tool for follow-up in children with conservatively treated uncomplicated acute appendicitis and possibly might help predict recurrence.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00247-022-05497-2.

Blood culture positivity in patients with acute appendicitis: A propensity score-matched prospective cohort study.

The prevalence of bacteremia in acute appendicitis is unknown. We aimed to assess prevalence and predictive factors of bacteremia in adult patients with appendicitis. In this prospective propensity score-matched cohort study, patients were recruited as part of one single-center prospective observational study assessing appendicitis microbiology in concurrence with two randomized controlled trials on non-operative treatment of uncomplicated acute appendicitis. All patients evaluated for enrollment in these three trials between April 2017 and December 2018 with both a confirmed diagnosis of appendicitis and available blood culture on admission were included in this study. Potential predictive factors of bacteremia (age, sex, body mass index (BMI), body temperature, C-reactive protein (CRP), leukocyte count, comorbidities, symptom duration, and appendicitis severity) were assessed. Prevalence of bacteremia was determined by all available blood cultures followed by propensity score matching using sex, age, BMI, CRP, leukocyte count, and body temperature of the patients without available blood culture. Out of the 815 patients with appendicitis, 271 patients had available blood culture and the prevalence of bacteremia was 12% (n = 33). Based on propensity score estimation, the prevalence of bacteremia in the whole prospective appendicitis cohort was 11.1%. Bacteremia was significantly more frequent in complicated acute appendicitis (15%; 29/189) compared with uncomplicated acute appendicitis (5%; 4/82) (p = 0.015). Male sex (p = 0.024) and higher body temperature (p = 0.0044) were associated with bacteremia. Estimated prevalence of bacteremia in patients with acute appendicitis was 11.1%. Complicated appendicitis, male sex, and higher body temperature were associated with bacteremia in acute appendicitis.

Endoscopic Retrograde Appendicitis Therapy: Is it Really a Need of the Hour?

Endoscopic retrograde appendicitis therapy (ERAT) has emerged as a promising, non-invasive treatment for acute uncomplicated appendicitis (AUA). ERAT involves cannulation, appendicography, appendiceal stone extraction, appendiceal lumen irrigation, and stent deployment. Recent randomized trials comparing ERAT to laparoscopic appendectomy (LA) have provided promising results in terms of safety and efficacy of ERAT. If the current trajectory of research and development is maintained, ERAT will likely become a strong contender for the standard of care for AUA. Standardized training and credentialing for ERAT, akin to procedures established for endoscopic retrograde cholangiopancreatography, will be pivotal to global adoption of this modality.