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Danish Medical Journal Aug 2014The treatment strategy for appendiceal mass is controversial, ranging from operation or image-guided drainage to conservative treatment with or without antibiotics. The... (Review)
Review
INTRODUCTION
The treatment strategy for appendiceal mass is controversial, ranging from operation or image-guided drainage to conservative treatment with or without antibiotics. The aim of this study was to assess the various treatment modalities with respect to complications and treatment failure.
METHODS
The analysis was based on the principles of a qualitative systematic review. The literature was searched in PubMed for the period from 1966 to March 2014. The articles were reviewed with respect to complications, treatment failure and hospital stay. Papers on post-operative intra-abdominal abscesses and abscesses of any cause other than appendicitis were excluded as were also studies only describing recurrent appendicitis and/or interval appendectomy. Sub-analyses were performed in children, adults, and in mixed populations.
RESULTS
A total of 48 studies were found eligible; they included in total 3,772 patients. Operation for appendiceal mass was beset with a moderate to high risk of complications of up to 57% and a risk of intestinal resection of up to 25%. Major complications were observed in up to 18% of cases. Conservative treatment with or without antibiotics was associated with a treatment failure rate of 8-15%. Drainage was beset with a risk of complications of 2-15% and a risk of treatment failure of 2-13%.
CONCLUSION
Operation with appendectomy for appendiceal mass carries a high risk of complications compared with conservative treatment or drainage. Drainage may lower the risk of treatment failure but entails a risk of complications. Based on the best evidence, we propose a step-down treatment strategy.
FUNDING
Not relevant.
TRIAL REGISTRATION
Not relevant.
Topics: Abdominal Abscess; Anti-Bacterial Agents; Appendectomy; Appendicitis; Drainage; Humans; Treatment Failure; Watchful Waiting
PubMed: 25162440
DOI: No ID Found -
ANZ Journal of Surgery Jul 2021Appendicitis is the most frequent aetiology of acute abdominal pain requiring surgical treatment, with an estimated lifetime risk between 7% and 8%. Antibiotics play a... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Appendicitis is the most frequent aetiology of acute abdominal pain requiring surgical treatment, with an estimated lifetime risk between 7% and 8%. Antibiotics play a substantial role in treatment, and there is considerable debate regarding the duration of antibiotics in treating appendicitis.
METHODS
We searched multiple databases from inception until June 2019 for peer-reviewed studies that compared different durations of antibiotic treatment after appendicectomy for acute complicated appendicitis in adults. We dichotomized reported data into short- and extended-term antibiotic use and controlled for different definitional thresholds in the meta-analysis. We generated risk ratios using restricted maximum likelihood methods and mixed effects modelling for each outcome of interest.
RESULTS
Four observational studies involving 847 participants were included in the meta-analysis. For the primary outcomes of intra-abdominal infection, we did not find a statistically significant difference between extended- and short-term antibiotic strategies for intra-abdominal infection (Risk ratio 0.92, 95% confidence interval (CI) 0.49-1.74). Three randomized controlled trials involving 291 participants were included in a separate meta-analysis. We found that extended antibiotic usage was not associated with a statistically significant reduced risk for intra-abdominal infection (RR 0.52, 95% CI 0.21-1.29) or surgical site skin infection (RR 1.44, 95% CI 0.43-4.81).
CONCLUSION
This systematic review and meta-analysis found that extended post-operative antibiotic treatment may not be associated with a reduced risk of intra-abdominal infection; however, meta-analysis was significantly limited by heterogeneity between studies and underpowered trials. Further large randomized controlled trials are needed to confirm these findings.
Topics: Acute Disease; Adult; Anti-Bacterial Agents; Appendectomy; Appendicitis; Humans; Randomized Controlled Trials as Topic; Surgical Wound Infection
PubMed: 33576567
DOI: 10.1111/ans.16615 -
Inflammatory Bowel Diseases Apr 2023This updated systematic review and meta-analysis investigates the putative role of the appendix in ulcerative colitis as a therapeutic target. (Meta-Analysis)
Meta-Analysis
BACKGROUND
This updated systematic review and meta-analysis investigates the putative role of the appendix in ulcerative colitis as a therapeutic target.
METHODS
Ovid Medline, Embase, PubMed and CENTRAL were searched with MeSH terms ("appendectomy" OR "appendicitis" OR "appendix") AND ("colitis, ulcerative") through October 2020, producing 1469 references. Thirty studies, including 118 733 patients, were included for qualitative synthesis and 11 for quantitative synthesis. Subgroup analysis was performed on timing of appendicectomy. Results are expressed as odds ratio (OR) with 95% confidence intervals (CIs).
RESULTS
Appendicectomy before UC diagnosis reduces the risk of future colectomy (OR, 0.76; 95% CI, 0.65-0.89; I2 = 5%; P = .0009). Corresponding increased risk of colorectal cancer and high-grade dysplasia are identified (OR, 2.27; 95% CI, 1.11-4.66; P = .02). Significance is lost when appendicectomy is performed after disease onset. Appendicectomy does not affect hospital admission rates (OR, 0.87; 95% CI, 0.68-1.12; I2 = 93%; P = .27), steroid use (OR, 1.08; 95% CI, 0.78-1.49; I2 = 36%; P = .64), immunomodulator use (OR, 1.04; 95% CI, 0.76-1.42; I2 = 19%; P = .79), or biological therapy use (OR, 0.76; 95% CI, 0.44-1.30; I2 = 0%; P = .32). Disease extent and risk of proximal progression are unaffected by appendicectomy. The majority (71% to 100%) of patients with refractory UC avoid colectomy following therapeutic appendicectomy at 3-year follow-up.
CONCLUSIONS
Prior appendicectomy reduces risk of future colectomy. A reciprocal increased risk of CRC/HGD may be due to prolonged exposure to subclinical colonic inflammation. The results warrant further research, as consideration may be put toward incorporating a history of appendicectomy into IBD surveillance guidelines. A potential role for therapeutic appendicectomy in refractory left-sided UC is also identified.
Topics: Humans; Colitis, Ulcerative; Appendectomy; Colectomy; Colitis
PubMed: 35766795
DOI: 10.1093/ibd/izac127 -
Pediatric Radiology May 2016Magnetic resonance imaging for the evaluation of appendicitis in children has rapidly increased recently. This change has been primarily driven by the desire to avoid CT... (Meta-Analysis)
Meta-Analysis Review
Magnetic resonance imaging for the evaluation of appendicitis in children has rapidly increased recently. This change has been primarily driven by the desire to avoid CT radiation dose. This meta-analysis reviews the diagnostic performance of MRI for pediatric appendicitis and discusses current knowledge of cost-effectiveness. We used a conservative Haldane correction statistical method and found pooled diagnostic parameters including a sensitivity of 96.5% (95% confidence interval [CI]: 94.3-97.8%), specificity of 96.1% (95% CI: 93.5-97.7%), positive predictive value of 92.0% (95% CI: 89.3-94.0%) and negative predictive value of 98.3% (95% CI: 97.3-99.0%), based on 11 studies. Assessment of patient outcomes associated with MRI use at two institutions indicates that time to antibiotics was 4.7 h and 8.2 h, time to appendectomy was 9.1 h and 13.9 h, and negative appendectomy rate was 3.1% and 1.4%, respectively. Alternative diagnoses were present in ~20% of cases, most commonly adnexal cysts and enteritis/colitis. Regarding technique, half-acquisition single-shot fast spin-echo (SSFSE) pulse sequences are crucial. While gadolinium-enhanced T1-weighted pulse sequences might be helpful, any benefit beyond non-contrast MRI has not been confirmed. Balanced steady-state free precession (SSFP) sequences are generally noncontributory. Protocols do not need to exceed five sequences; four-sequence protocols are commonly utilized. Sedation generally is not indicated; patients younger than 5 years might be attempted based on the child's ability to cooperate. A comprehensive pediatric cost-effectiveness analysis that includes both direct and indirect costs is needed.
Topics: Appendicitis; Appendix; Child; Humans; Magnetic Resonance Imaging
PubMed: 27229509
DOI: 10.1007/s00247-016-3557-3 -
World Journal of Surgery Mar 2017To determine the diagnostic accuracy of abdominal ultrasound (US) for the diagnosis of acute appendicitis (AA), in terms of sensitivity, specificity and post-test... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
To determine the diagnostic accuracy of abdominal ultrasound (US) for the diagnosis of acute appendicitis (AA), in terms of sensitivity, specificity and post-test probabilities for positive and negative result.
METHODS
A systematic search of MEDLINE, Embase, The Cochrane library and Science Citation Index Expanded from January 1994 to October 2014 was performed. Two authors independently evaluated studies for inclusion, extracted data and performed analyses. The reference standard for evaluation of final diagnosis was pathohistological report on tissue obtained at appendectomy. Summary sensitivity, specificity and post-test probability of AA after positive and negative result of US with corresponding 95% confidence intervals (CI) were calculated.
RESULTS
Out of 3306 references identified through electronic searches, 17 reports met the inclusion criteria, with 2841 included participants. The summary sensitivity and specificity of US for diagnosis of AA were 69% (95% CI 59-78%) and 81% (95% CI 73-88%), respectively. At the median pretest probability of AA of 76.4%, the post-test probability for a positive and negative result of US was 92% (95% CI 88-95%) and 55% (95% CI 46-63%), respectively.
CONCLUSIONS
Abdominal ultrasound does not seem to have a role in the diagnostic pathway for diagnosis of AA in suspected patients. The summary sensitivity and specificity of US do not exceed that of physical examination. Patients that require additional diagnostic workup should be referred to more sensitive and specific diagnostic procedures, such as computed tomography.
Topics: Appendicitis; Appendix; Humans; Sensitivity and Specificity; Ultrasonography
PubMed: 27864617
DOI: 10.1007/s00268-016-3792-7 -
Cureus Sep 2022Acute appendicitis is one of the most commonly encountered surgical emergencies worldwide. The laparoscopic approach for managing acute appendicitis is gaining... (Review)
Review
Acute appendicitis is one of the most commonly encountered surgical emergencies worldwide. The laparoscopic approach for managing acute appendicitis is gaining popularity over open appendicectomy in the current surgical practice. The advantages of laparoscopic appendectomy are early recovery, fewer wound complications, less pain and better cosmesis. One of the most critical steps in laparoscopic appendicectomy is a secure appendicular stump closure. Life-threatening postoperative complications are often encountered following the breakdown of appendicular stump closure. There are several methods to achieve appendicular stump closure such as intra-corporeal knotting, endoloops, external corporeal knotting and pushing knot inside, endoscopic linear cutting stapler (endo GIA), and endoclips. A meta-analysis on the technique of appendicular stump closure in laparoscopic appendicectomy failed to demonstrate the superiority of one method over the other. In the last few years, many authors have evaluated the outcome of sutureless appendicectomy performed using devices like a harmonic scalpel. This systematic review and meta-analysis is aimed to summarise the current evidence regarding the utility and safety of harmonic scalpel in sutureless appendicectomy. This systematic review and meta-analysis was conducted as per the preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. A systematic, detailed search was carried out by the authors in the electronic database, including Medline, Embase, CENTRAL, Scopus, Google scholar and clinical trial registry. Studies were selected and compared based on outcomes such as operative time, hospital stay, postoperative paralytic ileus, wound infection, and total complications. Statistical analysis was performed using the random effect model, fixed-effect model, pooled risk ratio, pooled mean difference and I heterogeneity. Four comparative studies with a total of 642 patients (376 male and 266 females) were included in the analysis. There were 359 patients in the conventional technique of appendicular stump closure group and 283 patients in the harmonic scalpel for appendicular stump closure group. Pooled analysis of the outcome measure of total complications showed that the use of harmonic scalpel for closure of appendiceal stump does not result in an increased incidence of complications as compared to the conventional technology of appendiceal stump closure. Pooled analysis of the outcome measure of mean operative time revealed a statistically significant reduction in the operative time in the patients where harmonic scalpel has been used for the management of appendiceal stump as compared to conventional methods (pooled mean difference of -12.96 with 95% CI -15.42, -10.50). Appendiceal stump closure during laparoscopic appendectomy by harmonic scalpel (HS) is comparable with the conventional techniques in terms of hospital stay, wound infection, postoperative paralytic ileus, and total complications. The use of a harmonic scalpel for closure of appendicular stump is associated with a reduction of the mean operative time of laparoscopic appendicectomy.
PubMed: 36159348
DOI: 10.7759/cureus.28759 -
The Journal of Surgical Research Feb 2022Yersinia infection affects terminal ileum and lymph nodes and could therefore mimic the symptoms of appendicitis. We aimed to systematically characterise the suspected... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Yersinia infection affects terminal ileum and lymph nodes and could therefore mimic the symptoms of appendicitis. We aimed to systematically characterise the suspected or confirmed abdominal diseases and/or surgeries associated with Yersinia infection.
MATERIALS AND METHODS
This systematic review and meta-analysis was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol (CRD42016053252) was uploaded to PROSPERO. The searches were conducted in PubMed and EMBASE on October 2, 2020. Original reports on patients with abdominal surgical diseases were included. The primary outcome was to characterise suspected or confirmed abdominal surgical diseases and/or surgeries associated with Yersinia infection, while the secondary outcomes were the positive rate of Yersinia species for each disease and surgery, and to investigate the rate of Yersinia spp. in different geographic regions. We calculated the weighted mean prevalence of positive tests for Yersinia spp. for the different diseases and surgeries according to the detection method and for subgroups based on geographic region.
RESULTS
From the search, 33 studies were included in the systematic review and 18 in the meta-analysis. Across geographic regions, the weighted mean prevalence for Yersinia spp. was 51% (95% CI 34%-69%) in mesenteric lymphadenitis, 65% (95% CI 45%-85%) in terminal ileitis, and 8% (95% CI 2%-15%) in normal appendices.
CONCLUSIONS
Around half of the patients with mesenteric lymphadenitis and terminal ileitis were serologically positive for infections with Yersinia spp. Yersinia infection may cause unnecessary surgery for suspected appendicitis due to symptoms from mesenteric lymphadenitis or terminal ileitis.
Topics: Appendicitis; Appendix; Crohn Disease; Humans; Mesenteric Lymphadenitis; Yersinia Infections
PubMed: 34628159
DOI: 10.1016/j.jss.2021.08.027 -
Annals of Emergency Medicine Oct 2014The objective of this study is to systematically review the accuracy of the Alvarado score and Pediatric Appendicitis Score and to identify optimal cutoffs for low- and... (Meta-Analysis)
Meta-Analysis Review
STUDY OBJECTIVE
The objective of this study is to systematically review the accuracy of the Alvarado score and Pediatric Appendicitis Score and to identify optimal cutoffs for low- and high-risk populations.
METHODS
We performed a systematic review of the literature and identified 26 studies of the accuracy of the Alvarado score and Pediatric Appendicitis Score. Data were abstracted in parallel, and only prospective, cohort studies that avoided verification bias were included. We calculated summary likelihood ratios for low-, moderate-, and high-risk groups, using all possible cutoffs based on available data, even if not reported in the original study.
RESULTS
The pretest probability of appendicitis was approximately 33% in studies of children and approximately 66% in studies of adults. Likelihood ratios at different cutoffs for the Alvarado score in adults were as follows: 0.03 (<4 points), 0.42 (4 to 6 points), and 3.4 (≥ 7 points); and 0.01 (<5 points), 0.98 (5 to 8 points), and 6.7 (≥ 9 points). Likelihood ratios for the Alvarado score in children were as follows: 0.02 (<4 points), 0.27 (4 to 6 points), and 4.2 (≥ 7 points); and 0.04 (<5 points), 1.2 (5 to 8 points), and 8.5 (≥ 9 points). For the Pediatric Appendicitis Score, likelihood ratios were 0.13 (<4 points), 0.70 (4 to 7 points), and 8.1 (≥ 8 points).
CONCLUSION
For children with a pretest probability of acute appendicitis of 60% or less, an Alvarado score below 4 rules out the diagnosis; this is also true for a score less than 5 if the pretest probability is up to approximately 40%. In adults with a pretest probability greater than or equal to 60%, an Alvarado score of 8 or higher rules in the diagnosis, whereas one of 9 or higher rules in the diagnosis at pretest probabilities greater than or equal to 40%. The Pediatric Appendicitis Score did not identify clinically useful low- or high-risk groups at typical pretest probabilities.
Topics: Adult; Appendicitis; Child; Diagnosis, Differential; Humans; Severity of Illness Index
PubMed: 24731432
DOI: 10.1016/j.annemergmed.2014.02.025 -
Journal of Gastroenterology and... Dec 2020Appendicitis after colonoscopy is an exceedingly rare complication. It remains to be explored if this entity is truly a complication of colonoscopy or a coincidental...
BACKGROUND AND AIM
Appendicitis after colonoscopy is an exceedingly rare complication. It remains to be explored if this entity is truly a complication of colonoscopy or a coincidental occurrence of appendicitis post-colonoscopy. The aim of this study was to systematically review all the available evidence since it was first described in 1988.
METHODS
The literature on post-colonoscopy appendicitis was searched using PubMed, EMBASE, and Cochrane databases. Additional manual search was performed and cross-checked for additional references. The search was performed up to November 2019. Data collected included demographics, reason for colonoscopy, time to diagnosis, imaging performed, management, and outcome.
RESULTS
Fifty-three cases were found in the systematic review with a median age of 55 years (24-84 years). The time to diagnosis post-colonoscopy was mostly within 24-48 h. Clinical features mimicked those of common acute appendicitis. In the past decade, computed tomography scan has been the imaging choice to investigate abdominal pain after colonoscopy, mainly to rule out perforation. The mainstay of management was appendectomy (open or laparoscopy). Four of the 12 cases (33.3%) were treated successfully with antibiotics alone. There has been a twofold increase in cases reported in the past decade (2009-2019, n = 31 vs 1999-2008, n = 15).
CONCLUSION
There is a considerable variation in the definition of post-colonoscopy appendicitis in the current literature. Regardless of whether post-colonoscopy appendicitis is a true entity, it should be considered as a differential diagnosis in any patient presenting with acute abdomen following colonoscopy.
Topics: Abdomen, Acute; Acute Disease; Adult; Aged; Aged, 80 and over; Anti-Bacterial Agents; Appendectomy; Appendicitis; Colonoscopy; Diagnosis, Computer-Assisted; Female; Humans; Laparoscopy; Male; Middle Aged; Postoperative Complications; Time Factors; Young Adult
PubMed: 32503089
DOI: 10.1111/jgh.15130 -
Cureus Nov 2022This meta-analysis aims to evaluate the comparative outcomes of drain insertion versus no drain after appendicectomy for complicated appendicitis. A systematic search... (Review)
Review
This meta-analysis aims to evaluate the comparative outcomes of drain insertion versus no drain after appendicectomy for complicated appendicitis. A systematic search of PubMed, Cochrane Library and Scopus was conducted, and all studies comparing drain versus no drain after appendicectomy for complicated appendicitis were included. Abdominal collection, surgical site infection (SSI), bowel obstruction, faecal fistula, paralytic ileus, length of hospital stay (LOS) and mortality were the evaluated outcome parameters for the meta-analysis. Seventeen studies reporting a total number of 4,255 patients who underwent appendicectomy for complicated appendicitis with (n=1,580) or without (n=2,657) drain were included. There was no significant difference between the two groups regarding abdominal collection (odds ratio (OR)=1.41, P=0.13). No-drain group was superior to the drain group regarding SSI (OR=1.93, P=0.0001), faecal fistula (OR=4.76, P=0.03), intestinal obstruction (OR=2.40, P=0.04) and paralytic ileus (OR=2.07, P=0.01). There was a difference regarding mortality rate between the two groups (3.4% in the drain group vs 0.5% in the no-drain group, risk difference (RD)=0.01, 95% CI (-0.01, 0.04), P=0.36). In conclusion, this meta-analysis has shown that drains have no effect on the development of intra-abdominal collections in complicated appendicitis, but it can significantly increase the risk of postoperative complications such as fistula, surgical site infection (SSI), bowel obstruction, ileus and length of hospital stay.
PubMed: 36600842
DOI: 10.7759/cureus.32018