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Surgical Infections Apr 2018Acute appendicitis is a common surgical emergency worldwide. Early intervention is associated with better outcomes. In low and middle Human Development-Index Countries... (Review)
Review
BACKGROUND
Acute appendicitis is a common surgical emergency worldwide. Early intervention is associated with better outcomes. In low and middle Human Development-Index Countries (LMHDICs), late presentation and poor access to healthcare facilities can contribute to greater illness severity and higher complication rates, such as post-operative surgical site infections (SSIs). The current rate of SSIs post-appendectomy in low- and middle-index settings has yet to be described.
METHODS
We performed a systemic review of the literature describing the incidence and management of SSIs after appendectomy in LMHDICs. We conducted qualitative and quantitative analysis of the data in manuscripts describing patients undergoing appendectomy to establish a baseline SSI rate for this procedure in these settings.
RESULTS
Four hundred twenty-three abstracts were initially identified. Of these, 35 studies met the criteria for qualitative and quantitative analysis. The overall weighted, pooled SSI rated were 17.9 infections/100 open appendectomies (95% confidence interval [CI] 10.4-25.3 infections/100 open appendectomies) and 8.8 infections/100 laparoscopic appendectomies (95% CI 4.5-13.2 infections/100 laparoscopic appendectomies). The SSI rates were higher in complicated appendicitis and when pre-operative antibiotic use was not specified.
CONCLUSIONS
Observed SSI rates after appendectomy in LMHDICs are dramatically higher than rates in high Human Development-Index Countries. This is particularly true in cases of open appendectomy, which remains the most common surgical approach in LMHDICs. These findings highlight the need for SSI prevention in LMHDICs, including prompt access to medical and surgical care, routine pre-operative antibiotic use, and implementation of bundled care packages and checklists.
Topics: Appendectomy; Developed Countries; Female; Humans; Laparoscopy; Male; Surgical Wound Infection
PubMed: 29058569
DOI: 10.1089/sur.2017.188 -
ANZ Journal of Surgery May 2017
Topics: Abdominal Pain; Appendectomy; Appendicitis; Australia; Female; Fetal Death; Humans; Laparoscopy; Meta-Analysis as Topic; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Retrospective Studies
PubMed: 28470703
DOI: 10.1111/ans.13936 -
Cancer Epidemiology Apr 2022The appendix, an organ of immunological and microbiological importance, could be involved in the pathogenesis of cancers, but results are inconclusive. Our objective was...
BACKGROUND
The appendix, an organ of immunological and microbiological importance, could be involved in the pathogenesis of cancers, but results are inconclusive. Our objective was to assess the association between appendectomy and the subsequent risk of cancer.
METHODS
Data were obtained from the Rotterdam Study; a long-term prospective population-based study of individuals aged 55 years and older, of which the first cohort started in 1990 and included 7983 participants. Information on appendectomy was obtained through either medical interview at baseline or linkage with the national automated pathology center (PALGA). Cancer cases were pathology based. End of follow-up was January 1st, 2015. The association between appendectomy and risk of cancer was assessed using Cox proportional hazard models, adjusted for known confounders.
RESULTS
Of 7135 included participants, 1373 (19.2%) had undergone an appendectomy and 1632 individuals developed cancer. After adjustment for age, sex, socioeconomic status, BMI, smoking, prevalent diabetes mellitus and alcohol intake, a history of appendectomy was associated with a significantly lower risk of cancer [hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.75-0.98]. Subgroup analyses showed similar results for gastrointestinal cancer (HR 0.75, 95% CI 0.56-0.99), in particular colon cancer (HR 0.65, 95% 0.43-0.97), and cancer of the female reproductive organs (HR 0.35, 95% CI 0.15-0.80).
CONCLUSION
Participants who underwent an appendectomy had a reduced risk of cancer in general after adjustment for potential confounders. Therefore, these results contradict earlier studies suggestive of an increased risk. Further research is necessary to replicate these results and reveal its underlying mechanism.
Topics: Appendectomy; Appendicitis; Cohort Studies; Female; Follow-Up Studies; Humans; Neoplasms; Prospective Studies; Risk Factors
PubMed: 35228019
DOI: 10.1016/j.canep.2022.102120 -
Surgical Infections Dec 2019Sepsis is an uncommon occurrence after appendectomy, but the morbidity and mortality of patients who develop sepsis after appendectomy remains exceedingly high. The...
Sepsis is an uncommon occurrence after appendectomy, but the morbidity and mortality of patients who develop sepsis after appendectomy remains exceedingly high. The purpose of this study is to identify risk factors and adverse post-operative outcomes associated with sepsis after appendectomy in adults. The American College of Surgery National Surgical Quality Improvement Program participant user database was queried from 2012 to 2015. Patients who underwent appendectomy were identified and demographic data, intra-operative variables, and post-operative outcomes were collected. The primary outcome was post-operative sepsis after appendectomy, which was defined as the development of sepsis or septic shock post-operatively. Patients with a diagnosis of systemic inflammatory response syndrome (SIRS), sepsis, or septic shock within 48 hours prior to surgery or present at the time of surgery were excluded. Multivariable analyses (logistic and linear regression) were performed to assess for risk factors and adverse outcomes associated with sepsis. Of the 72,538 patients who had appendectomies, 311 patients (0.43%) were identified as having post-operative sepsis. Of these, 17 patients (5.47%) died within 30 days. Age 60 years or more (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.129-2.02), African American race (OR 1.951, 95% CI 1.399-2.722), morbid obesity (OR 1.784, 95% CI 1.264-2.516), acute renal failure or dialysis (OR 4.642, 95% CI 2.17-9.929), disseminated malignancy (OR 4.089, 95% CI 1.719-9.726), and open appendectomy (OR 2.607, 95% CI 2.003-3.393) were found to be associated with increased risk of post-operative sepsis; patients were also less likely to be female (OR 0.650, 95% CI 0.517-0.817). Patients who developed sepsis after appendectomy were more likely to return to the operating room (24.76 vs. 0.77%, p < 0.001), be re-admitted for any cause (53.38% vs. 2.70%, p < 0.0001), and die within 30 days of surgery (5.47% vs. 0.05%, p < 0.001). Patients who become septic after appendectomy are at risk for adverse post-operative morbidity and mortality. Age 60 years or more, African American race, morbid obesity, acute renal failure or dialysis, disseminated malignancy, and open appendectomy increase the risk for sepsis after appendectomy and sepsis-related morbidity and mortality. Given the remarkably large number of appendectomies that are performed each year, the findings of this study can assist in identifying at-risk patients, facilitate physician-patient discussion and shared decision-making, and guide appropriate care to further reduce the incidence of sepsis after appendectomy.
Topics: Adult; Aged; Aged, 80 and over; Appendectomy; Demography; Female; Humans; Incidence; Male; Middle Aged; Retrospective Studies; Risk Factors; Sepsis; Survival Analysis; United States
PubMed: 31009326
DOI: 10.1089/sur.2019.003 -
Cirugia Pediatrica : Organo Oficial de... Apr 2022Acute appendicitis is the most frequent cause of acute abdomen in children. The objective of this study was to analyze the causes, approach, and results of complications...
INTRODUCTION
Acute appendicitis is the most frequent cause of acute abdomen in children. The objective of this study was to analyze the causes, approach, and results of complications requiring surgery following appendectomy.
MATERIAL AND METHODS
A retrospective study of the appendectomies conducted in three third-level institutions from 2015 to 2019 was carried out. Complications, causes, and number of re-interventions, time from one surgery to another, surgical technique used, operative findings at baseline appendectomy according to the American Association for the Surgery of Trauma (AAST) classification, and hospital stay were collected.
RESULTS
3,698 appendicitis cases underwent surgery, 76.7% of which laparoscopically, with 37.2% being advanced (grades II-V of the AAST classification). Mean operating time was 50.4 minutes (49.8 ± 20.1 for laparoscopy vs. 49.9 ± 20.1 for open surgery, p > 0.05), and longer in patients requiring re-intervention (68.6 ± 27.2 vs. 49.1 ± 19.3, p < 0.001). 76 re-interventions (2.05%) were carried out. The causes included postoperative infection (n = 46), intestinal obstruction (n = 20), dehiscence (n = 4), and others (n = 6). Re-intervention risk was not impacted by the baseline approach used (open surgery or laparoscopy, OR: 1.044, 95% CI: 0.57-1.9), but it was by appendicitis progression (7.8% advanced vs. 0.7% incipient, OR: 12.52, 95% CI: 6.18-25.3). There was a tendency to use the same approach both at baseline appendectomy and re-intervention. This occurred in 72.2% of laparoscopic appendectomies, and in 67.7% of open appendectomies. The minimally invasive approach (50/76) was more frequent than the open one (27 laparoscopies and 23 ultrasound-guided drainages vs. 26 open surgeries) (p < 0.05). 55% of obstruction patients underwent re-intervention through open surgery (p > 0.05).
CONCLUSION
Re-intervention rate was higher in advanced appendicitis cases. In this series, the minimally invasive approach (laparoscopic or ultrasound-guided drainage) was the technique of choice for re-interventions.
Topics: Appendectomy; Appendicitis; Child; Humans; Laparoscopy; Length of Stay; Retrospective Studies
PubMed: 35485754
DOI: 10.54847/cp.2022.02.14 -
The Journal of Surgical Research Nov 2022While complication rates have been well described using the National Surgical Quality Improvement Program (NSQIP) and National Surgical Quality Improvement...
INTRODUCTION
While complication rates have been well described using the National Surgical Quality Improvement Program (NSQIP) and National Surgical Quality Improvement Program-Pediatric registries, there have been no direct comparisons of outcomes between adults and children. Our objective was to describe differences in postoperative outcomes between children and adults undergoing common surgical procedures.
METHODS
Using data from 2013 to 2017, we identified patients undergoing laparoscopic appendectomy, laparoscopic cholecystectomy, thyroidectomy, and colectomy. Propensity score matching on gender, race, American Society of Anesthesiologists class, surgical indication, and procedure type was performed. Outcomes included surgical site infection (SSI), readmission rates, mortality/serious morbidity, and hospital length of stay and were analyzed using χ and student's t-test with statistical significance defined as P < 0.05.
RESULTS
We matched 79,866 patients from 812 hospitals. Compared to adults, children had higher rates of SSI following appendectomy (4.12% versus 1.40%, P < 0.01) and cholecystectomy (0.96% versus 0.66%, P = 0.04), readmission following appendectomy (4.26% versus 2.47%, P < 0.01), and longer length of stay in all procedures. In adults, 30-day mortality/serious morbidity was higher for all procedures.
CONCLUSIONS
Compared to adults, children demonstrate unique surgical complication and outcome profiles. Quality improvement efforts such as SSI prevention bundles and enhanced recovery protocols used in adults should be expanded to children.
Topics: Adult; Appendectomy; Child; Colectomy; Humans; Postoperative Complications; Quality Improvement; Retrospective Studies; Surgical Wound Infection; Treatment Outcome
PubMed: 35926308
DOI: 10.1016/j.jss.2022.06.012 -
Surgical Endoscopy Sep 2017Appendectomy is the most common emergency surgery performed in the USA. Removal of a non-inflamed appendix during unrelated abdominal surgery (prophylactic or incidental...
BACKGROUND
Appendectomy is the most common emergency surgery performed in the USA. Removal of a non-inflamed appendix during unrelated abdominal surgery (prophylactic or incidental appendectomy) can prevent the downstream risks and costs of appendicitis. It is unknown whether such a strategy could be cost saving for the health system.
METHODS
We considered hypothetical patient cohorts of varying ages from 18 to 80, undergoing elective laparoscopic abdominal and pelvic procedures. A Markov decision model using cost per life-year as the main outcome measure was constructed to simulate the trade-off between cost and risk of prophylactic appendectomy and the ongoing risk of developing appendicitis, with downstream costs and risks. Rates, probabilities, and costs of disease, treatment, and outcomes by patient age and gender were extracted from the literature. Sensitivity analyses were conducted using complications and costs of prophylactic appendectomy.
RESULTS
With our base-case assumptions, including added cost of prophylactic appendectomy of $660, we find that prophylactic removal of the appendix is cost saving for males aged 18-27 and females aged 18-28 undergoing elective surgery. The margin of cost savings depends on remaining life-years and increases exponentially with age: a 20-year-old female undergoing elective surgery could save $130 over a lifetime by undergoing prophylactic appendectomy, while a 40-year-old female would lose $130 over a lifetime. When the risk of the prophylactic appendectomy exceeds the risk of laparoscopic appendectomy for appendicitis or the cost exceeds $1080, it becomes more cost saving to forego the prophylactic procedure.
CONCLUSIONS
Prophylactic appendectomy can be cost saving for patients younger than age thirty undergoing elective laparoscopic abdominal and pelvic procedures.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Appendectomy; Appendicitis; Cost Savings; Cost-Benefit Analysis; Female; Humans; Male; Markov Chains; Middle Aged; Models, Economic; United States; Young Adult
PubMed: 28078461
DOI: 10.1007/s00464-016-5391-y -
South African Journal of Surgery.... Dec 2022TThis study is a survey amongst surgical trainees in South Africa (SA) designed to document their exposure to laparoscopic appendicectomy (LA) and their perceptions...
BACKGROUND
TThis study is a survey amongst surgical trainees in South Africa (SA) designed to document their exposure to laparoscopic appendicectomy (LA) and their perceptions about the procedure and to identify possible barriers to its uptake.
METHODS
A structured survey was developed using a combination of quantitative and qualitative questions designed to determine the clinical exposure of surgical trainees to laparoscopic appendectomy and then probe possible factors limiting their access to the procedure. A questionnaire was created online, and a link was distributed to various surgical trainees in Southern Africa. A list of trainees was obtained from the Surgreg Training Association of South Africa (STA).
RESULTS
One hundred and thirty-two (47%) trainees completed the survey out of an estimated 280 general surgery registrars. Ninety-five (72%) were male and 37 (28%) were female respondents. Their median age was 31 years (25-36). There were 14 (11%) year-1 and 21 (16%) year-2, 32 (24%) year-3, 37 (28%) year-4 and 28 (21%) year-5 trainees. The breakdown according to region was area 1 (inland and central) 47 (36%), area 2 (western seaboard) 12 (9%) and area 3 (eastern seaboard) 73 (55%). Forty-three (33%) respondents experienced face-to-face teaching on how to perform a LA. Forty-two (32%) had exposure to laparoscopic simulators. Respondents reported a general lack of experience in performing this procedure. Sixty-nine (52%) had performed this procedure without a senior (i.e., solo) and 13 (10%) had only assisted a senior to perform this procedure. Seventy-four (56%) respondents felt confident performing a LA independently. One hundred and thirteen (86%) respondents expected to be taught this procedure. One hundred and five respondents (80%) were keen to learn to perform LA. One hundred and five respondents (80%) stated that they would be interested in attending an online course on LA. The respondents felt that the following were the significant barriers to performing LA: resource constraints 49 (37%) and time constraints 46 (35%). Thirty per cent of respondents (22) in area 3 reported a reluctance by seniors to teach the procedure.
CONCLUSION
There appears to be a lack of exposure to and confidence with LA amongst South African surgical trainees. This implies a deficiency in formal surgical training programmes. Addressing this deficiency will require innovative solutions.
Topics: Adult; Female; Humans; Male; South Africa; Appendectomy; Laparoscopy
PubMed: 36477062
DOI: 10.17159/2078-5151/SAJS3739 -
African Journal of Paediatric Surgery :... 2020In our institution, we avoid emergency nighttime appendectomies, instead performing the surgery during daylight hours the following day. We examined whether emergency or...
BACKGROUND
In our institution, we avoid emergency nighttime appendectomies, instead performing the surgery during daylight hours the following day. We examined whether emergency or early appendectomies affect the outcome of patient morbidity.
MATERIALS AND METHODS
Medical records of children treated for appendicitis between 2010 and 2012 were retrospectively reviewed. Outcomes were compared between Group 1, defined as those patients who presented to the hospital during the day and underwent appendectomy on the same day and Group 2, defined as those patients who presented to the hospital at night and underwent appendectomy the next day. Incidences of perforation at surgery, operative time, complications and length of stay were analysed. Cases with perforation were also analysed to determine if the perforations could have been identified preoperatively.
RESULTS
A total of 74 patients met the study criteria, including 41 and 33 in Groups 1 and 2, respectively. There were no significant differences in the incidence of perforation at surgery, operative time, complications and length of stay. A total of nine cases of perforation were identified during surgery, and there were no significant differences in the pre-operative characteristics between perforated and non-perforated cases.
CONCLUSIONS
The results of this study indicate that early appendectomy is safe and did not increase patient morbidity. We, therefore, recommend performing appendectomies in the daytime.
Topics: Appendectomy; Appendicitis; Child; Emergencies; Emergency Service, Hospital; Female; Humans; Japan; Length of Stay; Male; Morbidity; Operative Time; Retrospective Studies; Time Factors
PubMed: 33106449
DOI: 10.4103/ajps.AJPS_122_16 -
Langenbeck's Archives of Surgery Aug 2023Incidental appendiceal neoplasms are identified in approximately 1% of the specimens of suspected appendicitis. The current institutional policy is to perform en bloc... (Review)
Review
PURPOSE
Incidental appendiceal neoplasms are identified in approximately 1% of the specimens of suspected appendicitis. The current institutional policy is to perform en bloc mesoappendix resection during routine laparoscopic appendicectomy allowing for staging, reducing the need for oncological right hemicolectomy (ORH). Herein, we review en bloc mesoappendicectomy in clinical practice and its effects on the rate of ORH.
METHODS
We reviewed all cases of appendicectomy performed at the Auckland City Hospital between 1 May 2014 and 31 May 2019. Clinical notes and histopathological reports were reviewed. All neoplasms, surgical techniques and the need for further surgery were analysed.
RESULTS
A total of 2455 appendicectomies were performed with an approximately similar number of procedures between the sexes and an overall median age of 31 years. Overall, 86% (n = 2098) of the specimens included resection of the mesoappendix, and 58 (2.4%) appendiceal neoplasms were identified. Of them, 33 (1.3%) specimens included neuroendocrine appendiceal neoplasms. Eleven (33%) patients with appendiceal neuroendocrine neoplasms were recommended ORH. One of these patients may have avoided additional surgery, whereas 3 (9.1%) patients with tumours of 10-20 mm avoided ORH because their mesoappendix was resected.
CONCLUSION
At our centre, there has been a significant change in the practice of mesoappendix resection, and we support resection of the mesoappendix during appendicectomy. The procedure is technically straightforward and safe, incurs no increases in costs or time, allows for accurate tumour staging and guides decisions regarding further surgical interventions.
Topics: Humans; Adult; Appendiceal Neoplasms; Retrospective Studies; Neuroendocrine Tumors; Appendectomy; Appendicitis
PubMed: 37535180
DOI: 10.1007/s00423-023-03019-8