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Surgical Infections Aug 2022Despite the high prevalence of acute appendicitis in children and substantial resource utilization associated with this condition, no consensus has been reached on...
Despite the high prevalence of acute appendicitis in children and substantial resource utilization associated with this condition, no consensus has been reached on optimal timing for performing appendectomies. The aim of this study was to examine the association between time to appendectomy and outcomes and assess the feasibility of delayed appendectomy in children. We performed a retrospective analysis of all patients younger than 14 years of age undergoing an appendectomy for suspected appendicitis. We divided our patients into two groups based on whether their time to appendectomy was shorter or longer than eight hours: group A, early appendectomy and group B, delayed appendectomy. Then we compared the two study groups regarding demographic, clinical, and radiographic characteristics, peri-operative data, and outcomes. During the eight-year study period, a total of 1,141 patients underwent appendectomies. After applying exclusion criteria, 852 children were included: 544 (63.8%) in group A and 308 (36.2%) in group B. There were no differences in the rate of complicated appendicitis at exploration, post-operative complications, length of post-operative hospital stay, and 30-day re-admission rate between the two study groups. Our study demonstrated that delaying appendectomy within 24 hours of presentation is safe and feasible for pediatric acute appendicitis. Therefore, patients presenting during nighttime hours could be initially treated conservatively with antibiotic agents. This allows the surgeon to delay surgery to the following day.
Topics: Acute Disease; Appendectomy; Appendicitis; Child; Humans; Laparoscopy; Length of Stay; Postoperative Complications; Retrospective Studies; Treatment Outcome
PubMed: 35704046
DOI: 10.1089/sur.2022.056 -
Journal of Pediatric Surgery Aug 2017To compare the risk of complications between initial nonoperative treatment and appendectomy of uncomplicated (simple) appendicitis in children. (Comparative Study)
Comparative Study Review
BACKGROUND
To compare the risk of complications between initial nonoperative treatment and appendectomy of uncomplicated (simple) appendicitis in children.
METHODS
Systematic literature search. Eligible for inclusion were both and randomized controlled trials and cohort studies including children in which the outcome of nonoperative treatment of uncomplicated appendicitis was reported with a minimum follow-up period of one year. Two authors extracted data independently and assessed quality. Primary outcome parameter was the percentage of children experiencing complications. Secondary outcomes were early failures, recurrent appendicitis and appendectomies, for all indications and on request.
RESULTS
Five of the 2051 articles screened were eligible for inclusion, including 147 children (nonoperative treatment) and 173 children (appendectomy) with one year follow-up. Percentage of children experiencing complications ranged from 0 to 13% versus 0-17% for nonoperative and appendectomy, respectively. Nonoperative treatment avoided an appendectomy in 62-81% of the children after one year follow-up.
CONCLUSION
The evidence base for initial nonoperative treatment of acute uncomplicated appendicitis in children is by far insufficient. It suggests that the percentage of patients experiencing complications in the initial nonoperative treatment group is comparable to the appendectomy group, and it may avoid an appendectomy in the large majority of children after one year follow-up.
TYPE OF STUDY
Systematic review.
LEVEL OF EVIDENCE
1.
Topics: Acute Disease; Anti-Bacterial Agents; Appendectomy; Appendicitis; Child; Female; Humans; Male; Postoperative Complications; Treatment Outcome
PubMed: 28449821
DOI: 10.1016/j.jpedsurg.2017.04.005 -
Annals of the Royal College of Surgeons... Apr 2021The COVID-19 pandemic stimulated a national lockdown in the UK. The public were advised to avoid unnecessary hospital attendances and health professionals were advised... (Observational Study)
Observational Study
INTRODUCTION
The COVID-19 pandemic stimulated a national lockdown in the UK. The public were advised to avoid unnecessary hospital attendances and health professionals were advised to avoid aerosol-generating procedures wherever possible. The authors hypothesised that these measures would result in a reduction in the number of patients presenting to hospital with acute appendicitis and alter treatment choices.
METHODS
A multicentred, prospective observational study was undertaken during April 2020 to identify adults treated for acute appendicitis. Searches of operative and radiological records were performed to identify patients treated during April 2018 and April 2019 for comparison.
RESULTS
A total of 190 patients were treated for acute appendicitis pre-lockdown compared with 64 patients treated during lockdown. Patients treated during the pandemic were more likely to have a higher American Society of Anesthesiology (ASA) score ( = 0.049) and to have delayed their presentation to hospital (2 versus 3 days, = 0.03). During the lockdown, the use of computed tomography (CT) increased from 36.3% to 85.9% ( < 0.001), the use of an antibiotic-only approach increased from 6.2% to 40.6% ( < 0.001) and the rate of laparoscopic appendicectomy reduced from 85.3% to 17.2% ( < 0.001). The negative appendicectomy rate decreased from 21.7% to 7.1% during lockdown (< 0.001).
CONCLUSIONS
The COVID-19 lockdown was associated with a decreased incidence of acute appendicitis and a significant shift in the management approach. The increased use of CT allows the identification of simple appendicitis for conservative treatment and decreases the negative appendicectomy rate.
Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Anti-Bacterial Agents; Appendectomy; Appendicitis; COVID-19; Conservative Treatment; Delayed Diagnosis; Female; Health Services Accessibility; Humans; Incidence; Male; Middle Aged; Pandemics; Patient Acceptance of Health Care; Practice Patterns, Physicians'; Prospective Studies; Severity of Illness Index; United Kingdom
PubMed: 33682449
DOI: 10.1308/rcsann.2020.7128 -
The Journal of Surgical Research Mar 2019Single-incision laparoscopic appendectomy (SILA) in the pediatric population has been well described. Our children's hospital has adopted this modality for nearly all... (Comparative Study)
Comparative Study
BACKGROUND
Single-incision laparoscopic appendectomy (SILA) in the pediatric population has been well described. Our children's hospital has adopted this modality for nearly all appendectomies. From our center's experience, we hoped to identify factors that portend conversion from SILA to multiport appendectomy. We compared our cohort of conventional three-port laparoscopic appendectomy (CLA) for outcomes including operative time, postop length of stay (LOS), complications, and readmission.
MATERIALS AND METHODS
A retrospective chart review of patients who underwent appendectomy from 2012 to 2017 at our children's hospital was performed. The type of appendectomy performed, if the case required conversion to multiple ports, and perforation status were recorded. Demographic data identified included age, sex, and body mass index. Outcomes analyzed were operative time, LOS, and postoperative complication/readmission rate.
RESULTS
Of 1001 appendectomies performed, 959 (95.9%) were initiated with plan for SILA, and 35 (3.5%) were initiated CLA. Of those initiated SILA, 884/959 (92.2%) were completed without additional port placement. Cases which were not able to be completed SILA were statistically significantly more likely to be male patients, have increased body mass index, or perforated appendicitis. When compared to cases initiated CLA, SILA remained statistically similar for readmission and LOS but had significantly faster operative time.
CONCLUSIONS
SILA appears to be a safe and efficient modality for the treatment of appendicitis in pediatric populations with no increased morbidity. Parents of children who are obese, males, or present with perforation should be counseled regarding the possibility of additional port placement or considered for initiating conventional three-port laparoscopic appendectomy.
Topics: Adolescent; Appendectomy; Appendicitis; Child; Female; Humans; Laparoscopy; Male; Retrospective Studies
PubMed: 30691799
DOI: 10.1016/j.jss.2018.08.050 -
Journal of Pediatric Surgery May 2023Appendectomy is the most common pediatric emergency surgery performed to date. This study compared outcomes between laparoscopic appendectomy (LA) and transumbilical...
PURPOSE
Appendectomy is the most common pediatric emergency surgery performed to date. This study compared outcomes between laparoscopic appendectomy (LA) and transumbilical laparoscopic assisted appendectomy (TULAA) for 1154 uncomplicated patients across 5 years at a single institution. Primary outcomes include length of stay (LOS), post-operative complications, pain score, and operating room (OR) time.
METHODS
Demographic and clinical data was collected for 1154 eligible patients treated for uncomplicated appendicitis between August 2014-October 2019, with 830 patients in the LA group, and 324 in the TULAA group. Mixed effects modeling procedure using logistic and linear regression examined the effect of surgery type on the four primary outcomes after adjustment for potential clustering effect of surgeon and confounding factors.
RESULTS
Of 1154 patients, 62.7% were male, and mean (SD) age was 10.9 (3.6) years. Median [IQR] LOS was 28.0 h [22.0, 36.0], mean (SD) OR time was 29.0 (10.0) minutes, and median [IQR] pain at maximum level was 5.5 (2.7). The complication rate overall was <5.0% and did not differ between TULAA and LA groups (p > 0.05). OR time was reduced by an average of 5.2 min in the TULAA group (p < 0.001), pain did not differ between groups overall (p > 0.05), and patients were more likely to be discharged within 24 h in patients who underwent TULAA (OR = 5.3 [1.6, 17.4], p = 0.007).
CONCLUSION
Retrospective analysis of 1154 pediatric appendectomies, found no difference in complications between single- and three-incision laparoscopic procedures (TULAA vs. LA). Findings suggest TULAA is a safe procedure for acute appendicitis in pediatrics.
LEVEL OF EVIDENCE
IV.
Topics: Humans; Child; Male; Female; Appendectomy; Appendicitis; Retrospective Studies; Treatment Outcome; Umbilicus; Laparoscopy; Length of Stay; Pain
PubMed: 36805141
DOI: 10.1016/j.jpedsurg.2023.01.033 -
Journal of Pediatric Surgery Feb 2018The perfect balance between safety, cosmesis, and cost effectiveness in a world with ever growing healthcare costs has yet to be found for nonperforated appendicitis....
AIM OF THE STUDY
The perfect balance between safety, cosmesis, and cost effectiveness in a world with ever growing healthcare costs has yet to be found for nonperforated appendicitis. The aim is to present our data regarding safety and cost effectiveness of the transumbilical extracorporeal laparoscopic-assisted appendectomy technique.
METHODS
A retrospective review was performed for all laparoscopic appendectomies for acute appendicitis from October 2014 to October 2016. All cases of perforated appendicitis were excluded (visible hole/abscess/free pus). Included cases were divided into two groups by operative technique: transumbilical (TU) or laparoscopic 3-port (L3P). Operating room charges were billed in 30-min intervals, and hospital charges billed per night in-house. The technique was that the appendix is identified with the laparoscope, grabbed with a grasper that is inserted parallel to the laparoscope, and exteriorized through the umbilicus. The appendectomy is completed extracorporeally.
RESULTS
A total of 494 cases of nonperforated appendicitis were included in the study. One surgeon attempted all cases with the TU technique (n=161), and all other surgeons used the L3P technique (n=333), which required an endostapler and a vascular sealing device. The TU technique was successful in 99 of the attempted cases. The mean operative time of the TU cases and the L3P cases was 21 (8-43) and 37 (12-73) min, respectively (P<0.001). The mean hospital stay for the TU and the L3P cases was 1.6 (1-5) days (one-night admission) and 2.4 (1-14) days (two-night admission), respectively (P<0.001). There were no operative complications or readmissions in either group. The overall cost of the L3P cases was 30% higher than the cost of the TU cases.
CONCLUSION
The transumbilical extracorporeal laparoscopic-assisted technique was as safe as the laparoscopic 3-port technique. It offered all the advantages of a minimally invasive procedure, was associated with a significantly shorter hospital stay, and was remarkably more cost effective than the standard laparoscopic 3-port technique.
LEVEL OF EVIDENCE
III.
Topics: Acute Disease; Adolescent; Appendectomy; Appendicitis; Child; Child, Preschool; Cost-Benefit Analysis; Female; Hospital Costs; Humans; Laparoscopy; Length of Stay; Male; Operative Time; Pennsylvania; Retrospective Studies; Treatment Outcome; Umbilicus; Young Adult
PubMed: 29223668
DOI: 10.1016/j.jpedsurg.2017.11.012 -
Scandinavian Journal of Surgery : SJS :... Jun 2021Although it is controversial whether appendectomy can be safely delayed, it is often unnecessary to postpone operation as a shorter delay may increase patient comfort,...
INTRODUCTION
Although it is controversial whether appendectomy can be safely delayed, it is often unnecessary to postpone operation as a shorter delay may increase patient comfort, enables quicker recovery, and decreases costs. In this study, we sought to study whether the time of day influences the outcomes among patients operated on for acute appendicitis.
MATERIALS AND METHODS
Consecutive patients undergoing appendectomy at Tampere University Hospital between 1 September 2014 and 30 April 2017 for acute appendicitis were included. Primary outcome measures were postoperative morbidity, mortality, length of hospital stay, and amount of intraoperative bleeding. Appendectomies were divided into daytime and nighttime operations.
RESULTS
A total of 1198 patients underwent appendectomy, of which 65% were operated during daytime and 35% during nighttime. Patient and disease-related characteristics were similar in both groups. The overall morbidity and mortality rates were 4.8% and 0.2%, respectively. No time categories were associated with risk of complications or complication severity. Neither was there difference in operation time and clinically significant difference in intraoperative bleeding. Patients undergoing surgery during night hours had a shorter hospital stay. In multivariate analysis, only complicated appendicitis was associated with worse outcomes.
DISCUSSION
We have shown that nighttime appendectomy is associated with similar outcomes than daytime appendectomy. Subsequently, appendectomy should be planned for the next available slot, minimizing delay whenever possible.
Topics: Appendectomy; Appendicitis; Humans; Laparoscopy; Length of Stay; Postoperative Complications; Retrospective Studies; Treatment Outcome
PubMed: 32662330
DOI: 10.1177/1457496920938605 -
The British Journal of Surgery Oct 2023As more patients with appendicitis are treated with antibiotics, factors associated with recurrence may help inform individualized prognostication and decision-making.
BACKGROUND
As more patients with appendicitis are treated with antibiotics, factors associated with recurrence may help inform individualized prognostication and decision-making.
METHODS
This cohort study, using data from the Comparison of Outcomes of Antibiotic Drugs and Appendectomy trial, examined patients treated with antibiotics who did not undergo appendicectomy in the first 30 days. Patients who had appendicectomy between 30 days and 1 year were compared with those who did not. Marginalized logistic regression models were used to calculate adjusted risk differences (RDs) to estimate the association between baseline patient factors and the risk of undergoing an appendicectomy between 30 days and 1 year.
RESULTS
Of 601 patients treated with antibiotics who did not undergo appendicectomy within 30 days (mean age 38.0 years; 217 women (36.1 per cent)), 144 had an appendicectomy and 56 were lost to follow-up between 30 days and 1 year. The estimated rate of appendicectomy between 30 days and 1 year was 28.6 (95 per cent c.i. 25.0 to 32.8) per cent. After adjustment for other factors, nausea, vomiting, or anorexia at baseline presentation was associated with an increased rate of appendicectomy between 30 days and 1 year (adjusted RD 17.52, 95 per cent c.i. 8.64 to 26.40). The presence of an appendicolith (adjusted RD 3.64, -6.08 to 13.36), or an abscess, perforation, or fat stranding on initial imaging (adjusted RD -7.23, -17.41 to 2.95) was not strongly associated with appendicectomy between 30 days and 1 year.
CONCLUSION
Most factors commonly associated with appendicitis severity were not strongly associated with an increased risk of undergoing appendicectomy in the longer term after treatment with antibiotics.
Topics: Humans; Female; Adult; Anti-Bacterial Agents; Appendicitis; Cohort Studies; Length of Stay; Appendectomy
PubMed: 37459231
DOI: 10.1093/bjs/znad218 -
Journal of Korean Medical Science Jan 2022Advances in medicine and changes in the medical environment can affect the diagnosis and treatment of diseases. The main purpose of the present study was to investigate...
BACKGROUND
Advances in medicine and changes in the medical environment can affect the diagnosis and treatment of diseases. The main purpose of the present study was to investigate whether the difference in accessibility to diagnosis and treatment facilities influenced the occurrence of appendectomy in Korea.
METHODS
We collected data on 183,531 appendectomy patients between 2003 and 2017 using the National Health Insurance Services claims. Retrospective analysis of relationship between the age-standardized rate (ASR) of appendectomy and clinical variables affecting medical accessibility was performed. Pearson's correlation analyses were used.
RESULTS
The incidence of appendectomy decreased from 30,164 cases in 2003 to 7,355 cases in 2017. The rate of computerized tomography (CT) scans for diagnosis of appendicitis increased from 4.73% in 2003 to 86.96% in 2017. The ASR of appendectomy in uncomplicated and complicated appendicitis decreased from 48.71 in 2005 to 13.40 in 2010 and 8.37 in 2005 to 2.96 in 2009, respectively. The ASR of appendectomy was higher in the high-income group. The proportion and ASR of appendectomy in older age group increased steadily with years. The total admission days continued to decrease from 6.02 days in 2003 to 4.96 days in 2017.
CONCLUSION
The incidence of appendectomy was seemingly associated with the rate of CT scan. In particular, the incidence of appendectomy in uncomplicated appendicitis was markedly reduced. Through enhanced accessibility to CT scans, accurate diagnosis and treatment of appendicitis can be facilitated.
Topics: Adolescent; Adult; Aged; Appendectomy; Female; Humans; Incidence; Male; Middle Aged; Registries; Republic of Korea; Retrospective Studies; Tomography, X-Ray Computed
PubMed: 35075826
DOI: 10.3346/jkms.2022.37.e27 -
The Journal of Trauma and Acute Care... Jan 2021The impact of laparoscopic appendectomy (LA) on the incidence of intra-abdominal abscess (IAA) remains controversial. We aimed to identify risk factors for...
BACKGROUND
The impact of laparoscopic appendectomy (LA) on the incidence of intra-abdominal abscess (IAA) remains controversial. We aimed to identify risk factors for postappendectomy IAA and assess the impact of appendectomy approach in postoperative morbidity.
METHODS
A retrospective single-center study including consecutive patients who underwent appendectomy for acute appendicitis between 2015 and 2018 was performed. Demographic, clinical, intraoperative, and perioperative variables were collected. Univariate and multivariate analyses was performed to detect independent risk factors for IAA. Comparison of LA and open appendectomy was conducted, and propensity score model (PSM) was used to overcome differences between groups. Independent risk factors for IAA were identified by univariate and multivariate analyses in the PSM cohort.
RESULTS
A total of 532 appendectomies were included. The median age was 35 years. Three hundred two patients (56.7%) underwent LA. The most frequent operative finding was American Association for the Surgery of Trauma (AAST) grade 1 appendicitis in 303 patients (57%). Peritonitis was found in 109 patients (20.5%). Postoperative morbidity and mortality were 14.4% and 0%, respectively. Intra-abdominal abscess rate was 6.2%. An AAST grade of ≥2, a preoperative C-reactive protein level of >100 mg/dL, and diabetes mellitus were identified as independent risk factors for IAA in the multivariate analysis. Comparing LA and open appendectomy, there were no differences in IAA rates. After PSM, LA showed lower morbidity and shorter hospital stay.
CONCLUSIONS
Laparoscopic appendectomy is a safe approach and not related to a higher risk of IAA. Patients with an AAST grade of ≥2, a preoperative C-reactive protein level of >100, and diabetes mellitus have higher risk for postappendectomy IAA.
LEVEL OF EVIDENCE
Therapeutic/care management, level IV.
Topics: Abdominal Abscess; Adult; Appendectomy; Appendicitis; Female; Humans; Laparoscopy; Logistic Models; Male; Middle Aged; Postoperative Care; Retrospective Studies; Risk Factors; Young Adult
PubMed: 33003018
DOI: 10.1097/TA.0000000000002957