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"Appendicitis"
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Madeline
Madeline, smallest and naughtiest of the twelve little charges of Miss Clavel, wakes up one night with an attack of appendicitis.
Book
Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines
Background and aims
Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide.
In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.
Methods
This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.
Conclusions
The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.
Journal Article
Madeline
Madeline, smallest and naughtiest of the twelve little charges of Miss Clavel, wakes up one night with an attack of appendicitis.
Book
A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis
In a randomized trial comparing antibiotic therapy with appendectomy in patients with appendicitis, antibiotics were noninferior on the basis of EQ-5D scores. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days, and complications were more common, especially in those with an appendicolith.
Journal Article
Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomised, non-inferiority trial
Support for the treatment of uncomplicated appendicitis with non-operative management rather than surgery has been increasing in the literature. We aimed to investigate whether treatment of uncomplicated appendicitis with antibiotics in children is inferior to appendicectomy by comparing failure rates for the two treatments.
In this pragmatic, multicentre, parallel-group, unmasked, randomised, non-inferiority trial, children aged 5–16 years with suspected non-perforated appendicitis (based on clinical diagnosis with or without radiological diagnosis) were recruited from 11 children's hospitals in Canada, the USA, Finland, Sweden, and Singapore. Patients were randomly assigned (1:1) to the antibiotic or the appendicectomy group with an online stratified randomisation tool, with stratification by sex, institution, and duration of symptoms (≥48 h vs <48 h). The primary outcome was treatment failure within 1 year of random assignment. In the antibiotic group, failure was defined as removal of the appendix, and in the appendicectomy group, failure was defined as a normal appendix based on pathology. In both groups, failure was also defined as additional procedures related to appendicitis requiring general anaesthesia. Interim analysis was done to determine whether inferiority was to be declared at the halfway point. We used a non-inferiority design with a margin of 20%. All outcomes were assessed in participants with 12-month follow-up data. The trial was registered at ClinicalTrials.gov (NCT02687464).
Between Jan 20, 2016, and Dec 3, 2021, 936 patients were enrolled and randomly assigned to appendicectomy (n=459) or antibiotics (n=477). At 12-month follow-up, primary outcome data were available for 846 (90%) patients. Treatment failure occurred in 153 (34%) of 452 patients in the antibiotic group, compared with 28 (7%) of 394 in the appendicectomy group (difference 26·7%, 90% CI 22·4–30·9). All but one patient meeting the definition for treatment failure with appendicectomy were those with negative appendicectomies. Of those who underwent appendicectomy in the antibiotic group, 13 (8%) had normal pathology. There were no deaths or serious adverse events in either group. The relative risk of having a mild-to-moderate adverse event in the antibiotic group compared with the appendicectomy group was 4·3 (95% CI 2·1–8·7; p<0·0001).
Based on cumulative failure rates and a 20% non-inferiority margin, antibiotic management of non-perforated appendicitis was inferior to appendicectomy.
None.
Journal Article
Antibiotics versus Appendectomy for Acute Appendicitis — Longer-Term Outcomes
In this randomized trial comparing antibiotic treatment with appendectomy in patients with appendicitis, the percentage of patients in the antibiotics group who later underwent appendectomy was 40% at 1 year and 46% at 2 years and was higher in patients with an appendicolith. Videos present information on treatment options for use in shared decision making between clinicians and patients.
Journal Article
Cost analysis of antibiotic therapy versus appendectomy for treatment of uncomplicated acute appendicitis: 5-year results of the APPAC randomized clinical trial
The efficacy and safety of antibiotic treatment for uncomplicated acute appendicitis has been established at long-term follow-up with the majority of recurrences shown to occur within the first year. Overall costs of antibiotics are significantly lower compared with appendectomy at short-term follow-up, but long-term durability of these cost savings is unclear. The study objective was to compare the long-term overall costs of antibiotic therapy versus appendectomy in the treatment of uncomplicated acute appendicitis in the APPAC (APPendicitis ACuta) trial at 5 years.
This multicentre, non-inferiority randomized clinical trial randomly assigned 530 adult patients with CT-confirmed uncomplicated acute appendicitis to appendectomy or antibiotic treatment at six Finnish hospitals. All major costs during the 5-year follow-up were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis. Between November 2009 and June 2012, 273 patients were randomized to appendectomy and 257 to antibiotics. The overall costs of appendectomy were 1.4 times higher (p<0.001) (€5716; 95% CI: €5510 to €5925) compared with antibiotic therapy (€4171; 95% CI: €3879 to €4463) resulting in cost savings of €1545 per patient (95% CI: €1193 to €1899; p<0.001) in the antibiotic group. At 5 years, the majority (61%, n = 156) of antibiotic group patients did not undergo appendectomy.
At 5-year follow-up antibiotic treatment resulted in significantly lower overall costs compared with appendectomy. As the majority of appendicitis recurrences occur within the first year after the initial antibiotic treatment, these results suggest that treating uncomplicated acute appendicitis with antibiotics instead of appendectomy results in lower overall costs even at longer-term follow-up.
Journal Article
Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management
Acute appendicitis is one of the most common abdominal emergencies worldwide. The cause remains poorly understood, with few advances in the past few decades. To obtain a confident preoperative diagnosis is still a challenge, since the possibility of appendicitis must be entertained in any patient presenting with an acute abdomen. Although biomarkers and imaging are valuable adjuncts to history and examination, their limitations mean that clinical assessment is still the mainstay of diagnosis. A clinical classification is used to stratify management based on simple (non-perforated) and complex (gangrenous or perforated) inflammation, although many patients remain with an equivocal diagnosis, which is one of the most challenging dilemmas. An observed divide in disease course suggests that some cases of simple appendicitis might be self-limiting or respond to antibiotics alone, whereas another type often seems to perforate before the patient reaches hospital. Although the mortality rate is low, postoperative complications are common in complex disease. We discuss existing knowledge in pathogenesis, modern diagnosis, and evolving strategies in management that are leading to stratified care for patients.
Journal Article
Parasitic Appendicitis in 14.797 Cases: A Retrospective Cohort Study/On Dort Bin Yedi Yuz Doksan Yedi Olguda Parazitik Apandisit: Retrospektif Bir Kohort Calismasi
Objective: This study aimed to determine the frequency of Enterobius vermicularis in appendectomy specimens and evaluate the histopathological characteristics of adult and pediatric cases with E. vermicularis infection. Methods: Appendectomies examined from 1 January 2010, to 1 December 2020, were analysed retrospectively. Cases were divided into two groups: under 18 years (children) and 18 and over (adults). Demographic and histopathological characteristics of patients were also examined. Results: Out of 14.797 patients that underwent appendectomy, 6.130 were children and 8.667 were adults. E. vermicularis was detected in 268 patients, wherein 64.2% were children and 35.8% were adults. In the detection of E. vermicularis in appendectomy specimens, the frequency was higher in children compared to that in adults (2.85%, 1.1%, respectively) (p<0.001). Histopathologically, acute appendicitis was defined in 31.7% (n=85) of 268 cases, and E. vermicularis was found to cause a higher rate of acute appendicitis in adults (p<0.001). Conclusion: The frequency of E. vermicularis in appendectomy specimens is higher in children. However, E. vermicularis causes acute appendicitis more frequently in adults. Keywords: Appendectomy, Enterobius vermicularis, parasites Amaç: Bu çalismada, Enterobius vermicularis'in apandektomi spesmenlerinde görülme sikligini bulmayi ve E. vermicularis enfeksiyonu saptanan yetiskin ve çocuk olgularin histopatolojik özelliklerini degerlendirmeyi amaçladik. Yöntemler: 1 Ocak 2010 ile 1 Aralik 2020 tarihleri arasinda yapilan apendektomiler geriye dönük olarak degerlendirildi. Olgular 18 yas alti (çocuk) ve 18 ve üstü (yetiskin) olmak üzere iki gruba ayrildi. Hastalarin demografik ve histopatolojik özellikleri incelendi. Bulgular: Apendektomi yapilan 14,797 hastanin 6,130'u çocuk, 8,667'si yetiskindi. Toplam 268 hastada E. vermicularis tespit edildi ve bunlarin %64,2'si çocuk; %35,8'i yetiskindi. Çocuklarin apendektomi spesmenlerinde E. vermicularis saptanma sikligi yetiskinlere göre daha yüksekti (sirasiyla: %2,85, %1,1) (p<0,001). Histopatolojik olarak akut apandisit, 268 olgunun %31,7'sinde (n=85) tanimlandi ve E. vermicularis'nin yetiskinlerde daha yüksek oranda akut apandisite neden oldugu saptandi (p<0,001). Sonuç: Apendektomi spesmenlerinde E. vermicularis sikligi çocuklarda daha yüksektir. Buna karsin E. vermicularis eriskinlerde daha sik akut apandisite neden olur. Anahtar Kelimeler: Apendektomi, Enterobius vermicularis, parazit
Journal Article
Prospective Observational Study on acute Appendicitis Worldwide (POSAW)
Background
Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments.
Methods
This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016–September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study.
Results
A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%.
Conclusions
The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.
Journal Article