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International Journal of Colorectal... Oct 2021Over the last years, laparoscopic appendectomy has progressively replaced open appendectomy and become the current gold standard treatment for suspected, uncomplicated...
BACKGROUND
Over the last years, laparoscopic appendectomy has progressively replaced open appendectomy and become the current gold standard treatment for suspected, uncomplicated appendicitis. At the same time, though, it is an ongoing discussion that antibiotic therapy can be an equivalent treatment for patients with uncomplicated appendicitis. The aim of this systematic review was to determine the safety and efficacy of antibiotic therapy and compare it to the laparoscopic appendectomy for acute, uncomplicated appendicitis.
METHODS
The PubMed database, Embase database, and Cochrane library were scanned for studies comparing laparoscopic appendectomy with antibiotic treatment. Two independent reviewers performed the study selection and data extraction. The primary endpoint was defined as successful treatment of appendicitis. Secondary endpoints were pain intensity, duration of hospitalization, absence from work, and incidence of complications.
RESULTS
No studies were found that exclusively compared laparoscopic appendectomy with antibiotic treatment for acute, uncomplicated appendicitis.
CONCLUSIONS
To date, there are no studies comparing antibiotic treatment to laparoscopic appendectomy for patients with acute uncomplicated appendicitis, thus emphasizing the lack of evidence and need for further investigation.
Topics: Acute Disease; Anti-Bacterial Agents; Appendectomy; Appendicitis; Humans; Laparoscopy; Length of Stay; Treatment Outcome
PubMed: 33852068
DOI: 10.1007/s00384-021-03927-5 -
JAMA Surgery Mar 2022Use of antibiotics for the treatment of appendicitis is safe and has been found to be noninferior to appendectomy based on self-reported health status at 30 days.... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Use of antibiotics for the treatment of appendicitis is safe and has been found to be noninferior to appendectomy based on self-reported health status at 30 days. Identifying patient characteristics associated with a greater likelihood of appendectomy within 30 days in those who initiate antibiotics could support more individualized decision-making.
OBJECTIVE
To assess patient factors associated with undergoing appendectomy within 30 days of initiating antibiotics for appendicitis.
DESIGN, SETTING, AND PARTICIPANTS
In this cohort study using data from the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial, characteristics among patients who initiated antibiotics were compared between those who did and did not undergo appendectomy within 30 days. The study was conducted at 25 US medical centers; participants were enrolled between May 3, 2016, and February 5, 2020. A total of 1552 participants with acute appendicitis were randomized to antibiotics (776 participants) or appendectomy (776 participants). Data were analyzed from September 2020 to July 2021.
EXPOSURES
Appendectomy vs antibiotics.
MAIN OUTCOMES AND MEASURES
Conditional logistic regression models were fit to estimate associations between specific patient factors and the odds of undergoing appendectomy within 30 days after initiating antibiotics. A sensitivity analysis was performed excluding participants who underwent appendectomy within 30 days for nonclinical reasons.
RESULTS
Of 776 participants initiating antibiotics (mean [SD] age, 38.3 [13.4] years; 286 [37%] women and 490 [63%] men), 735 participants had 30-day outcomes, including 154 participants (21%) who underwent appendectomy within 30 days. After adjustment for other factors, female sex (odds ratio [OR], 1.53; 95% CI, 1.01-2.31), radiographic finding of wider appendiceal diameter (OR per 1-mm increase, 1.09; 95% CI, 1.00-1.18), and presence of appendicolith (OR, 1.99; 95% CI, 1.28-3.10) were associated with increased odds of undergoing appendectomy within 30 days. Characteristics that are often associated with increased risk of complications (eg, advanced age, comorbid conditions) and those clinicians often use to describe appendicitis severity (eg, fever: OR, 1.28; 95% CI, 0.82-1.98) were not associated with odds of 30-day appendectomy. The sensitivity analysis limited to appendectomies performed for clinical reasons provided similar results regarding appendicolith (adjusted OR, 2.41; 95% CI, 1.49-3.91).
CONCLUSIONS AND RELEVANCE
This cohort study found that presence of an appendicolith was associated with a nearly 2-fold increased risk of undergoing appendectomy within 30 days of initiating antibiotics. Clinical characteristics often used to describe severity of appendicitis were not associated with odds of 30-day appendectomy. This information may help guide more individualized decision-making for people with appendicitis.
Topics: Adult; Anti-Bacterial Agents; Appendectomy; Appendicitis; Appendix; Cohort Studies; Female; Humans; Male; Treatment Outcome
PubMed: 35019975
DOI: 10.1001/jamasurg.2021.6900 -
The British Journal of Surgery May 2022Non-operative management of uncomplicated acute appendicitis is an option, but omission of antibiotics from the regimen has not been tested. (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Non-operative management of uncomplicated acute appendicitis is an option, but omission of antibiotics from the regimen has not been tested.
METHODS
A double-blind, placebo-controlled, superiority RCT in adults with CT-confirmed uncomplicated acute appendicitis was designed to compare placebo with antibiotics (intravenous ertapenem followed by oral levofloxacin and metronidazole). The primary endpoint was treatment success (resolution resulting in discharge without appendicectomy within 10 days); secondary outcomes included pain scores, complications, hospital stay, and return to work.
RESULTS
From May 2017 to September 2020, 72 patients with a mean(s.d.) age of 37.5 (11.1) years were recruited at five hospitals. Six were excluded after randomization (5 early consent withdrawals, 1 randomization protocol violation), 35 were assigned to receive antibiotics, and 31 to receive placebo. Enrolment challenges (including hospital pharmacy resources in an acute-care surgery setting) meant that only the lowest sample size of three predefined scenarios was achieved. The 10-day treatment success rate was 87 (95 per cent c.i. 75 to 99) per cent for placebo and 97 (92 to 100) per cent for antibiotics. This clinical difference of 10 (90 per cent c.i. -0.9 to 21) per cent was not statistically different for the primary outcome (1-sided P = 0.142), and secondary outcomes were similar.
CONCLUSION
The lack of antibiotic superiority statistically suggests that a non-inferiority trial against placebo is warranted in adults with CT-confirmed mild appendicitis. Registration number: EudraCT 2015-003634-26 (https://eudract.ema.europa.eu/eudract-web/index.faces), NCT03234296 (http://www.clinicaltrials.gov).
Topics: Acute Disease; Adult; Anti-Bacterial Agents; Appendectomy; Appendicitis; Ertapenem; Humans; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 35576384
DOI: 10.1093/bjs/znac086 -
BMJ Clinical Evidence Dec 2014Appendicitis is an inflammation of the appendix that may lead to an abscess, ileus, peritonitis, or death if untreated. Appendicitis is the most common abdominal... (Review)
Review
INTRODUCTION
Appendicitis is an inflammation of the appendix that may lead to an abscess, ileus, peritonitis, or death if untreated. Appendicitis is the most common abdominal surgical emergency. The current standard treatment of uncomplicated appendicitis is usually surgery, but there has been increasing evidence published on the use of antibiotics.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of surgery compared with antibiotics for acute appendicitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found four studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of surgery (including laparoscopic and open appendicectomy) compared with antibiotics.
Topics: Acute Disease; Appendectomy; Appendicitis; Appendix; Humans; Laparoscopy
PubMed: 25486014
DOI: No ID Found -
World Journal of Emergency Surgery :... Dec 2023To assess the efficacy of artificial intelligence (AI) models in diagnosing and prognosticating acute appendicitis (AA) in adult patients compared to traditional... (Review)
Review
BACKGROUND
To assess the efficacy of artificial intelligence (AI) models in diagnosing and prognosticating acute appendicitis (AA) in adult patients compared to traditional methods. AA is a common cause of emergency department visits and abdominal surgeries. It is typically diagnosed through clinical assessments, laboratory tests, and imaging studies. However, traditional diagnostic methods can be time-consuming and inaccurate. Machine learning models have shown promise in improving diagnostic accuracy and predicting outcomes.
MAIN BODY
A systematic review following the PRISMA guidelines was conducted, searching PubMed, Embase, Scopus, and Web of Science databases. Studies were evaluated for risk of bias using the Prediction Model Risk of Bias Assessment Tool. Data points extracted included model type, input features, validation strategies, and key performance metrics.
RESULTS
In total, 29 studies were analyzed, out of which 21 focused on diagnosis, seven on prognosis, and one on both. Artificial neural networks (ANNs) were the most commonly employed algorithm for diagnosis. Both ANN and logistic regression were also widely used for categorizing types of AA. ANNs showed high performance in most cases, with accuracy rates often exceeding 80% and AUC values peaking at 0.985. The models also demonstrated promising results in predicting postoperative outcomes such as sepsis risk and ICU admission. Risk of bias was identified in a majority of studies, with selection bias and lack of internal validation being the most common issues.
CONCLUSION
AI algorithms demonstrate significant promise in diagnosing and prognosticating AA, often surpassing traditional methods and clinical scores such as the Alvarado scoring system in terms of speed and accuracy.
Topics: Adult; Humans; Artificial Intelligence; Appendicitis; Prognosis; Algorithms; Machine Learning; Acute Disease
PubMed: 38114983
DOI: 10.1186/s13017-023-00527-2 -
Archives of Pathology & Laboratory... May 2022Patients with perforated appendicitis are often managed with antibiotic therapy followed by a delayed appendectomy. Histologic features of such specimens have been...
CONTEXT.—
Patients with perforated appendicitis are often managed with antibiotic therapy followed by a delayed appendectomy. Histologic features of such specimens have been incompletely described, especially in the recent literature.
OBJECTIVE.—
To describe the histomorphology of interval appendicitis with a focus on features that could mimic important conditions, such as infections, Crohn disease, and mucinous neoplasms.
DESIGN.—
Histologic evaluation of 100 interval appendectomy specimens with clinical and radiologic correlation.
RESULTS.—
A total of 54 of the 100 patients (54%) had radiologic evidence of appendiceal perforation, and 97% were treated with intravenous and/or oral antibiotic therapy prior to appendectomy. Percutaneous drains were placed in 34 cases (34%). Common histologic findings included mural eosinophilic infiltration (54%), periappendiceal fibrosis (54%), and xanthogranulomatous inflammation (31%). Periappendiceal fibrosis was frequent among patients with radiologic evidence of perforation. Nine cases (9%) featured pulse granulomata associated with fecal material. Epithelioid granulomata were detected in 6% of cases and were confined to mucosal lymphoid follicles in all cases. Only 4 of these were accompanied by mural lymphoid aggregates that raised the possibility of Crohn disease. Changes mimicking mucinous neoplasms were more common: 14% of cases (14 of 100) displayed goblet cell hyperplasia, 15% (15 of 100) contained diverticula, and 16% (16 of 100) showed mural or periappendiceal mucin pools.
CONCLUSIONS.—
Although interval appendectomy specimens occasionally contain inflammatory infiltrates that mimic infections and/or Crohn disease, changes that can be confused with mucinous neoplasms are more frequently encountered.
Topics: Humans; Appendectomy; Crohn Disease; Retrospective Studies; Appendix; Appendicitis; Granuloma; Fibrosis
PubMed: 36084245
DOI: 10.5858/arpa.2021-0485-OA -
Journal of Medical Radiation Sciences Sep 2022Appendiceal diverticulitis, a frequently underdiagnosed entity, differs from typical appendicitis by the presence of an inflamed appendiceal diverticulum. Appendiceal...
Appendiceal diverticulitis, a frequently underdiagnosed entity, differs from typical appendicitis by the presence of an inflamed appendiceal diverticulum. Appendiceal diverticulitis is a surgical emergency which has an increased risk of perforation compared to typical appendicitis. We will discuss a surgically and pathologically confirmed case of complicated appendiceal diverticulitis and its management implications.
Topics: Appendicitis; Appendix; Diagnosis, Differential; Diverticulitis; Humans
PubMed: 35194966
DOI: 10.1002/jmrs.573 -
European Journal of Trauma and... Feb 2023Acute appendicitis is a common surgical emergency, and the standard approach to diagnosis and management has been codified in several practice guidelines. Adherence to... (Observational Study)
Observational Study
INTRODUCTION
Acute appendicitis is a common surgical emergency, and the standard approach to diagnosis and management has been codified in several practice guidelines. Adherence to these guidelines provides insight into independent surgical practice patterns and institutional resource constraints as impediments to best practice. We explored data from the recent ESTES SnapAppy observational cohort study to determine guideline compliance in contemporary practice to identify opportunities to close evidence-to-practice gaps.
METHODS
We undertook a preplanned analysis of the ESTES SnapAppy observational cohort study, identifying, at a patient level, congruence with, or deviation from WSES Jerusalem guidelines for the diagnosis and management of acute appendicitis and the Surviving Sepsis Campaign in our cohort. Compliance was then correlated with the incidence of postoperative complications.
RESULTS
Four thousand six hundred and thirteen (4613) consecutive adult and adolescent patients with acute appendicitis were followed from date of admission (November 1, 2020, and May 28, 2021) for 90 days. Patient-level compliance with guideline elements allowed patients to be grouped into those with full compliance (all 5 elements: 13%), partial compliance (1-4 elements: 87%) or noncompliance (0 elements: 0.2%). We identified an excess postoperative complication rate in patients who received noncompliant and partially compliant care, compared with those who received fully guideline-compliant care (36% and 16%, versus 7.3%, p < 0.001).
CONCLUSIONS
The observed diagnostic and treatment practices of the participating institutions displayed variability in compliance with key recommendations from existing guidelines. In general, practice was congruent with recommendations for preoperative antibiotic surgical site infection prophylaxis administration, time to surgery, and operative approach. However, there remains opportunities for improvement in the choice of diagnostic imaging modality, postoperative antibiotic stewardship to timely discontinue prophylactic antibiotics, and the implementation of ambulatory treatment pathways for uncomplicated appendicitis in the healthy young adult.
Topics: Adolescent; Young Adult; Humans; Appendicitis; Appendectomy; Anti-Bacterial Agents; Surgical Wound Infection; Antibiotic Prophylaxis
PubMed: 36719428
DOI: 10.1007/s00068-022-02208-2 -
Journal of Ayub Medical College,... 2022The most frequent cause of paediatric acute abdomen is acute appendicitis. If acute appendicitis is not treated promptly, one third of cases progress to complicated... (Observational Study)
Observational Study
BACKGROUND
The most frequent cause of paediatric acute abdomen is acute appendicitis. If acute appendicitis is not treated promptly, one third of cases progress to complicated appendicitis. Complicated appendicitis is associated with significant morbidity and its management protocol differs significantly from that of uncomplicated appendicitis. In this study, we assessed the relationship between serum sodium levels and complicated appendicitis.
METHODS
We conducted a prospective observational study from July to December 2020 at the Department of Neonatal and Paediatric Surgery, The Children Hospital, Pakistan Institute of Medical Sciences, Islamabad, on a sample size of 140 patients who met inclusion and exclusion criteria. For this study, we divided the patients into two groups. Group 1 had uncomplicated appendicitis and Group 2 had complicated appendicitis. These findings were then compared to preoperative serum sodium (Na) levels.
RESULTS
The median serum sodium level in group 1 (uncomplicated appendicitis) was 137.81 mg/dl, while in group 2 it was 131.35 mg/dl (Complicated Appendicitis). The sensitivity and specificity of serum sodium levels at a cut-off point of less than 135 mg/dl were 84.80% and 89.40%, respectively.
CONCLUSION
Hyponatremia is currently thought to be a new marker for differentiating between complicated and uncomplicated appendicitis. It is a low-cost, high efficiency predictive marker for diagnosing and differentiating complicated appendicitis in children.
Topics: Infant, Newborn; Humans; Child; Appendicitis; Hyponatremia; Sensitivity and Specificity; Leukocyte Count; Acute Disease; Sodium; Appendectomy
PubMed: 36550656
DOI: 10.55519/JAMC-04-S4-9982 -
Frontiers in Cellular and Infection... 2023Appendicitis is a frequent condition, with peak incidences in the second decade of life. Its pathogenesis is under debate, but bacterial infections are crucial, and... (Review)
Review
BACKGROUND
Appendicitis is a frequent condition, with peak incidences in the second decade of life. Its pathogenesis is under debate, but bacterial infections are crucial, and antibiotic treatment remains essential. Rare bacteria are accused of causing complications, and various calculated antibiotics are propagated, yet there is no comprehensive microbiological analysis of pediatric appendicitis. Here we review different pre-analytic pathways, identify rare and common bacterial pathogens and their antibiotic resistances, correlate clinical courses, and evaluate standard calculated antibiotics in a large pediatric cohort.
METHOD
We reviewed 579 patient records and microbiological results of intraoperative swabs in standard Amies agar media or fluid samples after appendectomies for appendicitis between May 2011 and April 2019. Bacteria were cultured and identified VITEK 2 or MALDI-TOF MS. Minimal inhibitory concentrations were reevaluated according to EUCAST 2022. Results were correlated to clinical courses.
RESULTS
Of 579 analyzed patients, in 372 patients we got 1330 bacterial growths with resistograms. 1259 times, bacteria could be identified to species level. 102 different bacteria could be cultivated. 49% of catarrhal and 52% of phlegmonous appendices resulted in bacterial growth. In gangrenous appendicitis, only 38% remained sterile, while this number reduced to 4% after perforation. Many fluid samples remained sterile even when unsterile swabs had been taken simultaneously. 40 common enteral genera were responsible for 76.5% of bacterial identifications in 96.8% of patients. However, 69 rare bacteria were found in 187 patients without specifically elevated risk for complications.
CONCLUSION
Amies agar gel swabs performed superior to fluid samples and should be a standard in appendectomies. Even catarrhal appendices were only sterile in 51%, which is interesting in view of a possible viral cause. According to our resistograms, the best antibiotic was imipenem with 88.4% susceptible strains, followed by piperacillin-tazobactam, cefuroxime with metronidazole, and ampicillin-sulbactam to which only 21.6% of bacteria were susceptible. Bacterial growths and higher resistances correlate to an elevated risk of complications. Rare bacteria are found in many patients, but there is no specific consequence regarding antibiotic susceptibility, clinical course, or complications. Prospective, comprehensive studies are needed to further elicit pediatric appendicitis microbiology and antibiotic treatment.
Topics: Humans; Child; Appendicitis; Retrospective Studies; Prospective Studies; Agar; Anti-Bacterial Agents; Bacteria
PubMed: 37228669
DOI: 10.3389/fcimb.2023.1027769