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JAMA Surgery Sep 2022Appendectomy remains the standard of care for uncomplicated acute appendicitis despite several randomized clinical trials pointing to the safety and efficacy of... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Appendectomy remains the standard of care for uncomplicated acute appendicitis despite several randomized clinical trials pointing to the safety and efficacy of nonoperative management of this disease. A meta-analysis of randomized clinical trials may contribute to the body of evidence and help surgeons select which patients may benefit from surgical and nonsurgical treatment.
OBJECTIVE
To assess the efficacy and safety of nonoperative management vs appendectomy for acute uncomplicated appendicitis.
DATA SOURCES
A systematic review was conducted using indexed sources (Embase and PubMed) to search for published randomized clinical trials in English comparing nonoperative management with appendectomy in adult patients presenting with uncomplicated acute appendicitis. To increase sensitivity, no limits were set for outcomes reported, sex, or year of publication. All nonrandomized or quasi-randomized trials were excluded, and validated primers were used.
STUDY SELECTION
Among 1504 studies imported for screening, 805 were duplicates, and 595 were excluded for irrelevancy. A further 96 were excluded after full-text review, mainly owing to wrong study design or inclusion of pediatric populations. Eight studies met the inclusion criteria and were selected for the meta-analysis.
DATA EXTRACTION AND SYNTHESIS
Meta-extraction was conducted with independent extraction by multiple reviewers using the Covidence platform for systematic reviews and in accordance with PRISMA guidelines. Data were pooled by a random-effects model.
MAIN OUTCOMES AND MEASURES
Treatment success and major adverse effects at 30 days' follow-up.
RESULTS
The main outcome (treatment success proportion at 30 days of follow-up) was not significantly different in the operative and nonoperative management cohorts (risk ratio [RR], 0.85; 95% CI, 0.66-1.11). Likewise, the percentage of major adverse effects was similar in both cohorts (RR, 0.72; 95% CI, 0.29-1.79). However, in the nonoperative management group, length of stay was significantly longer (RR, 1.48; 95% CI, 1.26-1.70), and a median cumulative incidence of 18% of recurrent appendicitis was observed.
CONCLUSIONS AND RELEVANCE
These results point to the general safety and efficacy of nonoperative management of uncomplicated acute appendicitis. However, this strategy may be associated with an increase in duration of hospital stay and a higher rate of recurrent appendicitis. This meta-analysis may help inform decision-making in nonoperative management of uncomplicated acute appendicitis.
Topics: Acute Disease; Adult; Anti-Bacterial Agents; Appendectomy; Appendicitis; Child; Humans; Treatment Outcome
PubMed: 35895073
DOI: 10.1001/jamasurg.2022.2937 -
Surgery Dec 2023Endoscopic retrograde appendicitis therapy has been proposed as an alternative strategy for treating appendicitis, but debate exists on its role compared with... (Meta-Analysis)
Meta-Analysis Review
Endoscopic retrograde appendicitis therapy versus appendectomy or antibiotics in the modern approach to uncomplicated acute appendicitis: A systematic review and meta-analysis.
INTRODUCTION
Endoscopic retrograde appendicitis therapy has been proposed as an alternative strategy for treating appendicitis, but debate exists on its role compared with conventional treatment.
METHODS
This systematic review was performed on MEDLINE, Cochrane Central Register of Controlled Trials, and EMBASE. The last search was in April of 2023. The risk ratio with a 95% confidence interval was calculated for dichotomous variables, and the mean difference with a 95% confidence interval for continuous variables. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool (randomized controlled trials) and the Risk of Bias in Non-Randomized Studies of Intervention tool (non-randomized controlled trials).
RESULTS
Six studies met the eligibility criteria. Four studies compared endoscopic retrograde appendicitis therapy (n = 236 patients) and appendectomy (n = 339) and found no differences in technical success during index admission (risk ratio 0.97, 95% confidence interval [0.92,1.02]). Appendectomy showed superior outcomes for recurrence at 1-year follow-up (risk ratio 11.28, 95% confidence interval [2.61,48.73]). Endoscopic retrograde appendicitis therapy required shorter procedural time (mean difference -14.38, 95% confidence interval [-20.17, -8.59]) and length of hospital stay (mean difference -1.19, 95% confidence interval [-2.37, -0.01]), with lower post-intervention abdominal pain (risk ratio 0.21, 95% confidence interval [0.14,0.32]). Two studies compared endoscopic retrograde appendicitis therapy (n = 269) and antibiotic treatment (n = 280). Technical success during admission (risk ratio 1.11, 95% confidence interval [0.91,1.35]) and appendicitis recurrence (risk ratio 1.07, 95% confidence interval [0.08,14.87]) did not differ, but endoscopic retrograde appendicitis therapy decreased the length of hospitalization (mean difference -1.91, 95% confidence interval [-3.18, -0.64]).
CONCLUSION
This meta-analysis did not identify significant differences between endoscopic retrograde appendicitis therapy and appendectomy or antibiotics regarding technical success during index admission and treatment efficacy at 1-year follow-up. However, a high risk of imprecision limits these results. The advantages of endoscopic retrograde appendicitis therapy in terms of reduced procedural times and shorter lengths of stay must be balanced against the increased risk of having an appendicitis recurrence at one year.
Topics: Humans; Anti-Bacterial Agents; Appendectomy; Appendicitis; Hospitalization; Length of Stay; Abdominal Pain; Acute Disease
PubMed: 37806859
DOI: 10.1016/j.surg.2023.08.029 -
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 -
Annals of Surgery Dec 2019The aim of this meta-analysis was to summarize the current available evidence on nonoperative management (NOM) with antibiotics for uncomplicated appendicitis, both in... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The aim of this meta-analysis was to summarize the current available evidence on nonoperative management (NOM) with antibiotics for uncomplicated appendicitis, both in adults and children.
SUMMARY BACKGROUND DATA
Although earlier meta-analyses demonstrated that NOM with antibiotics may be an acceptable treatment strategy for patients with uncomplicated appendicitis, evidence is limited by conflicting results.
METHODS
Systematic literature search was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE databases for randomized and nonrandomized studies comparing antibiotic therapy (AT) and surgical therapy-appendectomy (ST) for uncomplicated appendicitis. Literature search was completed in August 2018.
RESULTS
Twenty studies comparing AT and ST qualified for inclusion in the quantitative synthesis. In total, 3618 patients were allocated to AT (n = 1743) or ST (n = 1875). Higher complication-free treatment success rate (82.3% vs 67.2%; P < 0.00001) and treatment efficacy based on 1-year follow-up rate (93.1% vs 72.6%; P < 0.00001) were reported for ST. Index admission antibiotic treatment failure and rate of recurrence at 1-year follow-up were reported in 8.5% and 19.2% of patients treated with antibiotics, respectively. Rates of complicated appendicitis with peritonitis identified at the time of surgical operation (AT: 21.7% vs ST: 12.8%; P = 0.07) and surgical complications (AT: 12.8% vs ST: 13.6%; P = 0.66) were equivalent.
CONCLUSIONS
Antibiotic therapy could represent a feasible treatment option for image-proven uncomplicated appendicitis, although complication-free treatment success rates are higher with ST. There is also evidence that NOM for uncomplicated appendicitis does not statistically increase the perforation rate in adult and pediatric patients receiving antibiotic treatment. NOM with antibiotics may fail during the primary hospitalization in about 8% of cases, and an additional 20% of patients might need a second hospitalization for recurrent appendicitis.
Topics: Adult; Anti-Bacterial Agents; Appendectomy; Appendicitis; Child; Humans
PubMed: 30720508
DOI: 10.1097/SLA.0000000000003225 -
American Journal of Surgery Jan 2020to investigate whether Neutrophil-to-lymphocyte ratio (NLR) can predict acute appendicitis and whether it can distinguish between uncomplicated and complicated... (Comparative Study)
Comparative Study Meta-Analysis
OBJECTIVES
to investigate whether Neutrophil-to-lymphocyte ratio (NLR) can predict acute appendicitis and whether it can distinguish between uncomplicated and complicated appendicitis.
METHODS
A search of electronic information sources was conducted to identify all studies reporting NLR in patients with clinical suspicion or confirmed diagnosis of acute appendicitis. We considered two comparisons:1) appendicitis versus no appendicitis; 2) uncomplicated appendicitis versus complicated appendicitis. ROC curve analysis was performed to determine cut-off values of NLR for appendicitis and complicated appendicitis.
RESULTS
Seventeen studies, enrolling 8,914 patients were included. NLR of 4.7 was cut-off value for appendicitis with sensitivity of 88.89% and specificity of 90.91% with AUC of 0.96. NLR of 8.8 was cut-off value for complicated appendicitis with sensitivity of 76.92% and specificity 100% with AUC of 0.91. NLR >4.7 was predictor of acute appendicitis (OR:128,P < 0.0001) and, NLR >8.8 was predictor of complicated appendicitis (OR:43,P < 0.0001).
CONCLUSIONS
NLR predicts both diagnosis and severity of appendicitis. This may have implications for prioritising cases for surgery, for monitoring conservatively treated patients and for patients who do not routinely undergo CT scan (pregnant or paediatric patients).
Topics: Acute Disease; Appendicitis; Diagnosis, Differential; Humans; Leukocyte Count; Lymphocytes; Neutrophils; Predictive Value of Tests
PubMed: 31056211
DOI: 10.1016/j.amjsurg.2019.04.018 -
The Cochrane Database of Systematic... Nov 2019Diagnosing acute appendicitis (appendicitis) based on clinical evaluation, blood testing, and urinalysis can be difficult. Therefore, in persons with suspected... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Diagnosing acute appendicitis (appendicitis) based on clinical evaluation, blood testing, and urinalysis can be difficult. Therefore, in persons with suspected appendicitis, abdominopelvic computed tomography (CT) is often used as an add-on test following the initial evaluation to reduce remaining diagnostic uncertainty. The aim of using CT is to assist the clinician in discriminating between persons who need surgery with appendicectomy and persons who do not.
OBJECTIVES
Primary objective Our primary objective was to evaluate the accuracy of CT for diagnosing appendicitis in adults with suspected appendicitis. Secondary objectives Our secondary objectives were to compare the accuracy of contrast-enhanced versus non-contrast-enhanced CT, to compare the accuracy of low-dose versus standard-dose CT, and to explore the influence of CT-scanner generation, radiologist experience, degree of clinical suspicion of appendicitis, and aspects of methodological quality on diagnostic accuracy.
SEARCH METHODS
We searched MEDLINE, Embase, and Science Citation Index until 16 June 2017. We also searched references lists. We did not exclude studies on the basis of language or publication status.
SELECTION CRITERIA
We included prospective studies that compared results of CT versus outcomes of a reference standard in adults (> 14 years of age) with suspected appendicitis. We excluded studies recruiting only pregnant women; studies in persons with abdominal pain at any location and with no particular suspicion of appendicitis; studies in which all participants had undergone ultrasonography (US) before CT and the decision to perform CT depended on the US outcome; studies using a case-control design; studies with fewer than 10 participants; and studies that did not report the numbers of true-positives, false-positives, false-negatives, and true-negatives. Two review authors independently screened and selected studies for inclusion.
DATA COLLECTION AND ANALYSIS
Two review authors independently collected the data from each study and evaluated methodological quality according to the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate random-effects model to obtain summary estimates of sensitivity and specificity.
MAIN RESULTS
We identified 64 studies including 71 separate study populations with a total of 10,280 participants (4583 with and 5697 without acute appendicitis). Estimates of sensitivity ranged from 0.72 to 1.0 and estimates of specificity ranged from 0.5 to 1.0 across the 71 study populations. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.93 to 0.96), and summary specificity was 0.94 (95% CI 0.92 to 0.95). At the median prevalence of appendicitis (0.43), the probability of having appendicitis following a positive CT result was 0.92 (95% CI 0.90 to 0.94), and the probability of having appendicitis following a negative CT result was 0.04 (95% CI 0.03 to 0.05). In subgroup analyses according to contrast enhancement, summary sensitivity was higher for CT with intravenous contrast (0.96, 95% CI 0.92 to 0.98), CT with rectal contrast (0.97, 95% CI 0.93 to 0.99), and CT with intravenous and oral contrast enhancement (0.96, 95% CI 0.93 to 0.98) than for unenhanced CT (0.91, 95% CI 0.87 to 0.93). Summary sensitivity of CT with oral contrast enhancement (0.89, 95% CI 0.81 to 0.94) and unenhanced CT was similar. Results show practically no differences in summary specificity, which varied from 0.93 (95% CI 0.90 to 0.95) to 0.95 (95% CI 0.90 to 0.98) between subgroups. Summary sensitivity for low-dose CT (0.94, 95% 0.90 to 0.97) was similar to summary sensitivity for standard-dose or unspecified-dose CT (0.95, 95% 0.93 to 0.96); summary specificity did not differ between low-dose and standard-dose or unspecified-dose CT. No studies had high methodological quality as evaluated by the QUADAS-2 tool. Major methodological problems were poor reference standards and partial verification primarily due to inadequate and incomplete follow-up in persons who did not have surgery.
AUTHORS' CONCLUSIONS
The sensitivity and specificity of CT for diagnosing appendicitis in adults are high. Unenhanced standard-dose CT appears to have lower sensitivity than standard-dose CT with intravenous, rectal, or oral and intravenous contrast enhancement. Use of different types of contrast enhancement or no enhancement does not appear to affect specificity. Differences in sensitivity and specificity between low-dose and standard-dose CT appear to be negligible. The results of this review should be interpreted with caution for two reasons. First, these results are based on studies of low methodological quality. Second, the comparisons between types of contrast enhancement and radiation dose may be unreliable because they are based on indirect comparisons that may be confounded by other factors.
Topics: Acute Disease; Adult; Appendicitis; Humans; Randomized Controlled Trials as Topic; Tomography, X-Ray Computed
PubMed: 31743429
DOI: 10.1002/14651858.CD009977.pub2 -
Surgical Endoscopy Dec 2023The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children.
METHODS
Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively.
RESULTS
2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04).
CONCLUSIONS
This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.
Topics: Adult; Humans; Child; Appendicitis; Anti-Bacterial Agents; Appendectomy; Treatment Outcome; Drainage
PubMed: 37914953
DOI: 10.1007/s00464-023-10456-5 -
Minerva Chirurgica Jun 2020Abdominal pain (AP) is one of the most frequent clinical condition observed in elderly patients. The differential diagnosis is wide and definitive diagnosis is often...
INTRODUCTION
Abdominal pain (AP) is one of the most frequent clinical condition observed in elderly patients. The differential diagnosis is wide and definitive diagnosis is often difficult due to delayed symptoms, altered laboratory parameters, pre-existing medical disorders, abuse of drugs and in absence of an accurate medical history.
EVIDENCE ACQUISITION
A systematic literature review was carried out through PubMed database for studies published in the last ten years. The following search string was used: {("geriatric"[Title] OR "older"[Title] OR "aged"[Title] OR "elderly"[Title]) AND ((("abdomen"[Title] AND "acute"[Title]) OR "acute abdomen"[Title] OR ("acute"[Title] AND "abdomen"[Title])) OR ("abdominal"[Title] AND "pain"[title]) OR "abdominal pain"[Title])}. Full articles and abstracts were included. Case reports, commentaries, editorials and letters were excluded from the analysis.
EVIDENCE SYNTHESIS
As the age of people presenting AP advances, both rates of surgical procedures and mortality rate increase.
CONCLUSIONS
A systematic approach based on the organization of differential diagnoses into categories, may provide a helpful framework by the combined use of history-taking, physical examination, and results of diagnostic studies. In elderly patients admitted to the emergency department, a crucial role is played by a prompt use of radiological investigations in order to discriminate between older subjects admitted to the emergency department with abdominal pain and pathological cases requiring immediate surgical treatment.
Topics: Abdomen, Acute; Abdominal Pain; Acute Disease; Aged; Aged, 80 and over; Aneurysm, Ruptured; Aortic Aneurysm, Abdominal; Appendicitis; Diagnosis, Differential; Emergency Service, Hospital; Female; Humans; Intestinal Obstruction; Male; Mesenteric Ischemia; Sex Factors
PubMed: 32550726
DOI: 10.23736/S0026-4733.20.08266-8 -
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 -
European Journal of Medical Research Feb 2023Acute appendicitis is one of the most frequent intra-abdominal diseases requiring emergency surgical consult and treatment. The diagnosis of this condition is based on... (Review)
Review
INTRODUCTION
Acute appendicitis is one of the most frequent intra-abdominal diseases requiring emergency surgical consult and treatment. The diagnosis of this condition is based on clinical features and radiologic findings. One-third of patients with acute appendicitis present unusual symptoms. There are several circumstances that may cause misdiagnosis and unclear prognostic prediction. Among these, situs viscerum inversus totalis and midgut malrotation can be challenging scenarios, leading to a delay in treatment, especially when these conditions are unknown. We decided to carry on a systematic review of published cases of acute appendicitis in the context of anatomical anomalies.
METHODS
We used the MESH terms "appendicitis" AND "situs inversus" AND/OR "gut malrotation" to search for titles and abstracts. Inclusion criteria were patients with clinical and/or radiological diagnosis of acute appendicitis, with conservative or surgical management and with preoperative/intraoperative findings of situs viscerum inversus or gut malrotation. Additionally, previous reviews were examined. Exclusion criteria of the studies were insufficient patient clinical and demographic data.
RESULTS
We included in this review 70 articles concerning 73 cases of acute appendicitis with anatomical anomaly. Patients were aged from 8 to 86 years (median: 27.0 years). 50 were male and 23 were female. 46 patients (63%) had situs viscerum inversus, 24 (33%) had midgut malrotation, 2 (2.7%) had Kartagener's syndrome, one of them (1.4%) had an undetermined anomaly In 61 patients the anatomical anomaly was unknown previously (83.6%), while 16,4% already were aware of their condition.
CONCLUSION
Acute appendicitis can occur in association of rare anatomical anomalies and in these cases diagnosis can be challenging. Situs viscerum inversus and midgut malrotation should always be considered in the differential diagnosis of a patient with left lower quadrant pain, especially in younger population. Besides clinical features, it is fundamental to implement the diagnostic progress with radiological examination. Laparoscopic approach is useful to identify and treat acute surgical emergency and it is also a diagnostic tool and can be tailored in order to offer the best exposition of the operatory field for each single case.
Topics: Humans; Female; Male; Child; Adolescent; Young Adult; Adult; Middle Aged; Aged; Aged, 80 and over; Radiography; Acute Disease; Diagnosis, Differential
PubMed: 36805741
DOI: 10.1186/s40001-023-01059-w