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Surgical Endoscopy Jun 2024Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop...
BACKGROUND
Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis.
METHODS
A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts.
RESULTS
Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty.
CONCLUSIONS
These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.
Topics: Appendicitis; Humans; Appendectomy; Anti-Bacterial Agents; Evidence-Based Medicine
PubMed: 38740595
DOI: 10.1007/s00464-024-10813-y -
Health Science Reports Sep 2023Although appendicitis is rare in young infants, the reported mortality is high. Primary aim of this systematic review was to provide updated insights in the mortality...
BACKGROUND AND AIMS
Although appendicitis is rare in young infants, the reported mortality is high. Primary aim of this systematic review was to provide updated insights in the mortality and morbidity (postoperative complications, Clavien-Dindo grades I-IV) of appendicitis in infants ≤3 months of age. Secondary aims comprised the evaluation of patient characteristics, diagnostic work-up, treatment strategies, comorbidity, and factors associated with poor outcome.
METHODS
This systematic review was reported according to the PRISMA statement with a search performed in Pubmed, Embase and Web of Science (up to September 5th 2022). Original articles (published in English ≥1980) reporting on infants ≤3 months of age with appendicitis were included. Both patients with abdominal appendicitis and herniated appendicitis (such as Amyand's hernia) were considered. Data were provided descriptively.
RESULTS
In total, 131 articles were included encompassing 242 cases after identification of 4294 records. Overall, 184 (76%) of the 242 patients had abdominal and 58 (24%) had herniated appendicitis. Two-hundred (83%) of the patients were newborns (≤28 days) and 42 (17%) were infants between 29 days and ≤3 months of age. Either immediate, or after initial conservative treatment, 236 (98%) patients underwent surgical treatment. Some 168 (69%) patients had perforated appendicitis. Mortality was reported in 20 (8%) patients and morbidity in an additional 18 (8%). All fatal cases had abdominal appendicitis and fatal outcome was relatively more often reported in newborns, term patients, patients with relevant comorbidity, nonperforated appendicitis and those presented from home.
CONCLUSION
Mortality was reported in 20 (8%) infants ≤3 months of age and additional morbidity in 18 (8%). All patients with fatal outcome had abdominal appendicitis. Several patient characteristics were relatively more often reported in infants with poor outcome and adequate monitoring, early recognition and prompt treatment may favour the outcome.
PubMed: 37680208
DOI: 10.1002/hsr2.1435 -
Journal of Clinical Medicine Aug 2023Acute appendicitis is a frequently encountered surgical emergency. Despite several scoring systems, the possibility of delayed diagnosis persists. In addition, a delayed... (Review)
Review
BACKGROUND
Acute appendicitis is a frequently encountered surgical emergency. Despite several scoring systems, the possibility of delayed diagnosis persists. In addition, a delayed diagnosis leads to an increased risk of complicated appendicitis. Hence, there is a need to identify biological markers to help clinicians rapidly and accurately diagnose and prognosticate acute appendicitis with a high sensitivity and specificity. Although several markers have been evaluated, the pressing concern is still the low specificity of these markers. One such marker is serum ischemia-modified albumin (IMA), which can be a novel biomarker for accurately diagnosing and prognosticating acute appendicitis.
METHODS
The authors conducted a systematic search of the PubMed, EMBASE, Web of Science, and Scopus databases through February 2023 as per the PRISMA guidelines. The difference in the levels of IMA between patients with acute appendicitis vs. healthy controls, and the difference in the levels of IMA between patients with complicated vs. non-complicated acute appendicitis were taken as the outcome measures. Statistical analysis was performed using a random effects model and mean difference (MD) was calculated. The methodological quality of the studies was assessed by utilizing the Newcastle-Ottawa scale.
RESULTS
A total of six prospective comparative studies were included in the meta-analysis. The analysis revealed that the mean level of serum IMA was significantly raised in the acute appendicitis group (MD 0.21, 95% CI 0.05 to 0.37, = 0.01). Similarly, the mean serum IMA levels were also raised in the complicated appendicitis group compared to the non-complicated appendicitis group (MD 0.05, 95% CI 0.01 to 0.10, = 0.02). Three of the studies included were, however, of poor methodological quality.
CONCLUSIONS
Serum IMA is a viable potential marker for diagnosing and prognosticating acute appendicitis. However, due to the limited methodological quality of available studies, further prospectively designed and adequately powered studies are needed.
PubMed: 37685553
DOI: 10.3390/jcm12175486 -
Cureus Jan 2024Recent studies have discussed the role of antibiotic treatment in the conservative management of acute appendicitis and whether antibiotics are a safe option to replace... (Review)
Review
Recent studies have discussed the role of antibiotic treatment in the conservative management of acute appendicitis and whether antibiotics are a safe option to replace appendicectomy, which has been the gold standard treatment of acute appendicitis for many years. The bibliographic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, Medline, and PubMed comparing conservative versus surgical treatment of acute appendicitis were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty-one studies consisting of systematic reviews and meta-analyses involving 44,699 participants were identified. At least 17,865 participants were treated with antibiotics. Our studies compare antibiotic versus appendicectomy among acute appendicitis patients ranging from 7 to 94 years of age. In most studies, patients received parenteral antibiotics for a total of one to three days, and oral antibiotics such as oral cephalosporin plus metronidazole, oral amoxicillin/clavulanate, oral fluoroquinolones plus Tinidazole upon hospital discharge for a total of 7 to 10 days. The total course of antibiotics for both parenteral and oral regimes ranged from 2 to 16 days, with 10 days being the commonest duration. The recurrence rate following initial antibiotic treatment at one-year follow-up ranged from 13% to 38%, while the mean duration of recurrence ranged from three to eight months. The majority of the patients with recurrence underwent appendicectomy, while some patients were either given a repeat or different course of antibiotics due to the possible presence of antibiotic resistance; however, only 2.4% of the patients were successfully treated upon completion of the second course of antibiotics. Most of the studies concluded that appendicectomy remains the gold standard treatment for uncomplicated acute appendicitis, given its higher efficacy and lower complication rates. Although antibiotic treatment cannot be routinely recommended, it can be considered an appropriate alternative in selected patients with uncomplicated appendicitis who wish to avoid surgery and also acknowledge the risk of recurrence and the potential need for subsequent surgery at the same time.
PubMed: 38384640
DOI: 10.7759/cureus.52697 -
The American Surgeon May 2024Epiploic appendagitis (EA) is an essential cause of abdominal pain that can be confused with more typical causes such as acute diverticulitis and appendicitis. Epiploic... (Review)
Review
Epiploic appendagitis (EA) is an essential cause of abdominal pain that can be confused with more typical causes such as acute diverticulitis and appendicitis. Epiploic appendagitis accounts for 1% of all cases of abdominal pain in adults. The scarcity of information has limited its recognition as an essential nonsurgical cause of acute abdominal pain. We performed a systematic review of all EA cases published. We searched Scopus, Medline, Web of Science, and Google Scholar to retrieve all available studies from January 2000 to November 2023. 196 case reports and case series were analyzed, with 371 patients with EA included. The mean age at the time of diagnosis was 39 years. Most patients were male (59%). The primary presenting symptoms were pain (100%), tenderness (59.5%), and rebound tenderness (27.4%). The left abdomen was the most common localization of pain (53%). The most frequently identified differential diagnoses were acute appendicitis (26.4%) and acute diverticulitis (16.1%). Most patients (53%) were treated conservatively, and 98 (26.4%) underwent surgical treatment. A significant difference in the choice of treatment was found for signs and symptoms such as rebound tenderness, nausea, anorexia, and diarrhea. Acute EA is an essential clinical condition of rare occurrence that might present a diagnostic challenge, as it can masquerade as another acute abdominal pain etiology. The optimal management of EA is conservative, so a higher recognition by surgeons and emergency physicians is essential to avoid unnecessary surgical interventions and their associated consequences.
PubMed: 38756087
DOI: 10.1177/00031348241256062 -
World Journal of Surgery Aug 2023Reports of an increased proportion of complicated appendicitis during the Covid-19 pandemic suggest a worse outcome due to delay secondary to the restrained access to... (Meta-Analysis)
Meta-Analysis Review
Spontaneous Resolution of Uncomplicated Appendicitis may Explain Increase in Proportion of Complicated Appendicitis During Covid-19 Pandemic: a Systematic Review and Meta-analysis.
BACKGROUND
Reports of an increased proportion of complicated appendicitis during the Covid-19 pandemic suggest a worse outcome due to delay secondary to the restrained access to health care, but may be explained by a concomitant decrease in uncomplicated appendicitis. We analyze the impact of the pandemic on the incidences of complicated and uncomplicated appendicitis.
METHOD
We did a systematic literature search in the PubMed, Embase and Web Of Science databases on December 21, 2022 with the search terms (appendicitis OR appendectomy) AND ("COVID" OR SARS-Cov2 OR "coronavirus"). Studies reporting the number of complicated and uncomplicated appendicitis during identical calendar periods in 2020 and the pre-pandemic year(s) were included. Reports with indications suggesting a change in how the patients were diagnosed and managed between the two periods were excluded. No protocol was prepared in advance. We did random effects meta-analysis of the change in proportion of complicated appendicitis, expressed as the risk ratio (RR), and of the change in number of patients with complicated and uncomplicated appendicitis during the pandemic compared with pre-pandemic periods, expressed as the incidence ratio (IR). We did separate analyses for studies based on single- and multi-center and regional data, age-categories and prehospital delay.
RESULTS
The meta-analysis of 100,059 patients in 63 reports from 25 countries shows an increase in the proportion of complicated appendicitis during the pandemic period (RR 1.39, 95% confidence interval (95% CI 1.25, 1.53). This was mainly explained by a decreased incidence of uncomplicated appendicitis (incidence ratio (IR) 0.66, 95% CI 0.59, 0.73). No increase in complicated appendicitis was seen in multi-center and regional reports combined (IR 0.98, 95% CI 0.90, 1.07).
CONCLUSION
The increased proportion of complicated appendicitis during Covid-19 is explained by a decrease in the incidence of uncomplicated appendicitis, whereas the incidence of complicated appendicitis remained stable. This result is more evident in the multi-center and regional based reports. This suggests an increase in spontaneously resolving appendicitis due to the restrained access to health care. This has important principal implications for the management of patients with suspected appendicitis.
Topics: Humans; COVID-19; Pandemics; Appendicitis; RNA, Viral; SARS-CoV-2; Appendectomy; Retrospective Studies; Acute Disease
PubMed: 37140609
DOI: 10.1007/s00268-023-07027-z -
Alternative Therapies in Health and... Nov 2023Acute appendicitis (AA) is a prevalent abdominal emergency in children, and there has been growing interest in the use of endoscopic retrograde appendicitis treatment... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Acute appendicitis (AA) is a prevalent abdominal emergency in children, and there has been growing interest in the use of endoscopic retrograde appendicitis treatment (ERAT) over the past two decades. A meta-analysis of published retrospective studies was conducted to investigate the clinical characteristics and therapeutic efficacy of ERAT for AA in children.
METHODS
A systematic review and meta-analysis of retrospective studies were carried out, encompassing data from PUBMED, MEDLINE, Cochrane, China National Knowledge Infrastructure (CNKI), WanFang, and VIP Database. The search was limited to studies published between January 1, 2012, and June 31, 2022, with the final search conducted on October 31, 2022. No restrictions were imposed regarding publication or study design filters. The registration number in PROSPERO was CRD42022377739.
RESULTS
Seven retrospective cohort studies with 423 patients were included. The majority of children who underwent ERAT were male (57.6%, 95% CI 52.8%-62.4%). The ERAT procedure had a high success rate (99.5%, 95% CI 98.2%-100.0%) and averaged around 49 minutes. ERAT's efficacy for treating acute appendicitis was high (99.0%, 95% CI 96.5%-100.0%), with a low recurrence rate (4.2%, 95% CI 2.2%-6.7%). Patients typically stayed in the hospital for about 4.3 days, and the rate of postoperative complications was around 3.9% (95% CI 2.0%-6.2%).
CONCLUSIONS
Despite the heterogeneity among studies, ERAT appears to be an effective treatment for acute uncomplicated appendicitis in children. It has a high success rate, a low recurrence rate, preserves the appendix's function, and causes minimal damage. ERAT could be considered a safe and effective treatment option for pediatric appendicitis.
Topics: Humans; Male; Child; Female; Appendicitis; Retrospective Studies; Treatment Outcome; Acute Disease; Postoperative Complications
PubMed: 37632960
DOI: No ID Found -
Cureus Nov 2023Opioid-related fatalities are a leading cause of accidental death in the United States. Appendicitis is a common cause of abdominal pain in children and adolescents. The... (Review)
Review
Opioid-related fatalities are a leading cause of accidental death in the United States. Appendicitis is a common cause of abdominal pain in children and adolescents. The management of pain throughout the laparoscopic appendectomy (LA) in the pediatric population is a critical concern. This study aimed to evaluate trends in analgesic use and patient satisfaction following LA, with a focus on reducing the reliance on opioids for pain management. From 2003 to 2023, 18258 articles were filtered for all types of analgesic use with LA. The publications were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 19 studies were included for analysis and review. The study included peer-reviewed experimental and observational studies involving individuals under 18 years. Pain management strategies varied across studies, involving a combination of analgesics, nerve blocks, and wound infiltrations. Analgesics such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids were administered before and after surgery. Some studies implemented patient-controlled analgesia (PCA) pumps. Other studies explored non-pharmacological interventions like magnetic acupuncture. The results showed a reduction in the need for postoperative analgesics in patients treated with LA, particularly when using non-opioid medications and novel analgesic techniques. Pediatric patients who received gabapentin reported lower opioid use, shorter hospital stays, and high satisfaction rates. However, the reliance on opioids remained significant in some cases, particularly among patients with peritonitis who required more morphine. Pain management in pediatric patients is multifaceted, involving preoperative and postoperative analgesics, nerve blocks, and PCA pumps. Efforts to improve pain management following pediatric LA while reducing opioid reliance are essential in the context of the ongoing opioid epidemic. The findings from this study highlight the potential benefits of non-opioid analgesics, nerve blocks, and alternative methods for managing postoperative pain in <18 appendectomy patients. Further research and standardization of pain management protocols are needed to ensure optimal patient outcomes and minimize the risk of opioid-related complications.
PubMed: 38156159
DOI: 10.7759/cureus.49581 -
International Journal of Colorectal... Nov 2023This study aimed to analyze the diagnostic performance of urinary 5-Hydroxyindoleacetic Acid (5-HIAA) in acute appendicitis (AA). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
This study aimed to analyze the diagnostic performance of urinary 5-Hydroxyindoleacetic Acid (5-HIAA) in acute appendicitis (AA).
METHODS
This review was registered in PROSPERO (CRD42023399541). We included prospective or retrospective original clinical studies evaluating the diagnostic performance of 5-HIAA in AA. A search was conducted in PubMed, Web of Science, Scopus and OVID. Search terms and keywords were: (appendicitis OR acute appendicitis) AND (5-HIAA OR 5-Hydroxyindoleacetic acid OR serotonin metabolite). Two independent reviewers selected the articles and extracted relevant data. Methodological quality was assessed using the QUADAS2 index. A synthesis of the results, standardization of the metrics, and a random-effect meta-analysis were performed. Additionally, a coupled forest plot and a diagnostic test accuracy meta-analysis (DTA) were performed.
RESULTS
Twelve studies with data from 1467 participants (724 patients with a confirmed diagnosis of AA and 743 controls) were included in this review. The random-effect meta-analysis of urinary 5-HIAA (AA vs controls) included 7 articles (352 AA and 258 controls) and resulted in a significant mean difference [95% CI] of 23.30 [15.82-30.77] μmol/L (p < 0.001). The DTA meta-analysis of urinary 5-HIAA included 8 articles and resulted in a pooled sensitivity [95% CI] of 68.6 [44.1-85.9]% and a pooled specificity [95% CI] of 82 [54.7-94.5]%.
CONCLUSIONS
Although the evidence is heterogeneous and limited, urinary 5-HIAA emerges as a potential non-invasive diagnostic tool for AA. Urinary 5-HIAA does not seem to be a useful biomarker to distinguish between NCAA and CAA. Future prospective studies with a large sample size and a rigorous design are necessary to validate these findings.
TRIAL REGISTRATION
PROSPERO (CRD42023399541).
Topics: Humans; Appendicitis; Hydroxyindoleacetic Acid; Prospective Studies; Retrospective Studies; Acute Disease; Diagnostic Tests, Routine
PubMed: 37982905
DOI: 10.1007/s00384-023-04556-w -
Journal of Pediatric Surgery Oct 2023Relevant guidelines recommend the use of the Alvarado score (AS) to assist in the diagnosis of acute appendicitis (AA) in children. To provide reference evidence for the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Relevant guidelines recommend the use of the Alvarado score (AS) to assist in the diagnosis of acute appendicitis (AA) in children. To provide reference evidence for the clinical application of AS, we performed a meta-analysis of studies related to the diagnostic accuracy of AS in children with AA.
METHODS
We searched the relevant literature from databases including CNKI, WanFangdata, VIP, CBM, the Cochrane Library, PubMed, Embase, and Web of Science databases from the date of database creation to April 30, 2022, and screened them according to nadir criteria, followed by data extraction and then combined effect sizes to assess the accuracy of AS for diagnosis in children.
RESULTS
Twenty-six studies involving 2579 cases were finally included, including 19 studies with Alvarado score and 8 studies with modified Alvarado Score (1 study included both Alvarado Score and modified Alvarado Score). The combined sensitivity (SE) of AS for diagnosing AA in children was 76.0% (95% CI 74.0-78.0%; I = 95.1%); combined specificity (SP) was 71.0% (95% CI 68.0-74.0%; I = 86.4%); combined positive likelihood ratio (LR+) was 2.43 (95% CI 1.92- 3.07; I = 78.7%); combined negative likelihood ratio (LR-) was 0.28 (95% CI 0.20-0.41; I = 94.2%); combined AUC = 0.8092, Q∗ = 0.7439; combined diagnostic ratio (DOR) was 8.96 (95% CI 5.65 -14.21; I = 76.2%). The combined effect size I was greater than 50% for all children with a modified AS diagnosis of AA, so all analyses used a random-effects model, which showed a combined SE of 87.0% (95% CI 85.0 - 88.0%; I = 85.5%); the combined SP was 47.0% (95% CI 43.0 - 51.0%. I = 88.7%); combined LR+ was 1.68 (95% CI 1.31-2.17; I = 85.9%); combined LR-was 0.28 (95% CI 0.20-0.39; I = 74.3%); combined AUC = 0.8672 and Q∗ = 0.7978. The combined DOR was 6.43 (95% CI 3.38-12.26; I = 80.0%).
CONCLUSION
The results of this meta-analysis suggest that the accuracy of AS in diagnosing AA in children is moderate, and AS can be an auxiliary tool for the diagnosis of AA in children, relying on AS alone for the diagnosis of AA is not recommended; AS can be further improved scientifically to increase its diagnostic value.
Topics: Humans; Child; Appendicitis; Acute Disease; Databases, Factual; Sensitivity and Specificity
PubMed: 36966018
DOI: 10.1016/j.jpedsurg.2023.02.060