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The Cochrane Database of Systematic... Aug 2021This is the second update of a Cochrane Review first published in 2015 and last updated in 2018. Appendectomy, the surgical removal of the appendix, is performed... (Review)
Review
BACKGROUND
This is the second update of a Cochrane Review first published in 2015 and last updated in 2018. Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. Patients who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer postoperative complications. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial.
OBJECTIVES
To assess the safety and efficacy of abdominal drainage to prevent intraperitoneal abscess after appendectomy (irrespective of open or laparoscopic) for complicated appendicitis; to compare the effects of different types of surgical drains; and to evaluate the optimal time for drain removal.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, Web of Science, the World Health Organization International Trials Registry Platform, ClinicalTrials.gov, Chinese Biomedical Literature Database, and three trials registers on 24 February 2020, together with reference checking, citation searching, and contact with study authors to identify additional studies.
SELECTION CRITERIA
We included all randomised controlled trials (RCTs) that compared abdominal drainage versus no drainage in people undergoing emergency open or laparoscopic appendectomy for complicated appendicitis. We also included RCTs that compared different types of drains and different schedules for drain removal in people undergoing appendectomy for complicated appendicitis.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We used the GRADE approach to assess evidence certainty. We included intraperitoneal abscess as the primary outcome. Secondary outcomes were wound infection, morbidity, mortality, hospital stay, hospital costs, pain, and quality of life.
MAIN RESULTS
Use of drain versus no drain We included six RCTs (521 participants) comparing abdominal drainage and no drainage in participants undergoing emergency open appendectomy for complicated appendicitis. The studies were conducted in North America, Asia, and Africa. The majority of participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open appendectomy. None of the trials was assessed as at low risk of bias. The evidence is very uncertain regarding the effects of abdominal drainage versus no drainage on intraperitoneal abscess at 30 days (risk ratio (RR) 1.23, 95% confidence interval (CI) 0.47 to 3.21; 5 RCTs; 453 participants; very low-certainty evidence) or wound infection at 30 days (RR 2.01, 95% CI 0.88 to 4.56; 5 RCTs; 478 participants; very low-certainty evidence). There were seven deaths in the drainage group (N = 183) compared to one in the no-drainage group (N = 180), equating to an increase in the risk of 30-day mortality from 0.6% to 2.7% (Peto odds ratio 4.88, 95% CI 1.18 to 20.09; 4 RCTs; 363 participants; low-certainty evidence). Abdominal drainage may increase 30-day overall complication rate (morbidity; RR 6.67, 95% CI 2.13 to 20.87; 1 RCT; 90 participants; low-certainty evidence) and hospital stay by 2.17 days (95% CI 1.76 to 2.58; 3 RCTs; 298 participants; low-certainty evidence) compared to no drainage. The outcomes hospital costs, pain, and quality of life were not reported in any of the included studies. There were no RCTs comparing the use of drain versus no drain in participants undergoing emergency laparoscopic appendectomy for complicated appendicitis. Open drain versus closed drain There were no RCTs comparing open drain versus closed drain for complicated appendicitis. Early versus late drain removal There were no RCTs comparing early versus late drain removal for complicated appendicitis.
AUTHORS' CONCLUSIONS
The certainty of the currently available evidence is low to very low. The effect of abdominal drainage on the prevention of intraperitoneal abscess or wound infection after open appendectomy is uncertain for patients with complicated appendicitis. The increased rates for overall complication rate and hospital stay for the drainage group compared to the no-drainage group are based on low-certainty evidence. Consequently, there is no evidence for any clinical improvement with the use of abdominal drainage in patients undergoing open appendectomy for complicated appendicitis. The increased risk of mortality with drainage comes from eight deaths observed in just under 400 recruited participants. Larger studies are needed to more reliably determine the effects of drainage on morbidity and mortality outcomes.
Topics: Abscess; Appendectomy; Appendicitis; Drainage; Humans; Peritonitis; Postoperative Complications
PubMed: 34402522
DOI: 10.1002/14651858.CD010168.pub4 -
Frontiers in Surgery 2021To explore the updated evaluation about the obstetrical and perioperative outcomes of laparoscopic appendicectomy (LA) for pregnancy appendicitis compared with open...
To explore the updated evaluation about the obstetrical and perioperative outcomes of laparoscopic appendicectomy (LA) for pregnancy appendicitis compared with open appendicectomy (OA). Two reviewers independently searched the PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, and Web of Science databases to screen eligible studies up to December 2020. Only clinical researches, no < 10 cases for LA and OA group were included. Twenty retrospective studies with 7,248 pregnant women, evaluating LA and OA in surgical and obstetrical outcomes, were included. The weighted mean difference (WMD) with 95% CI and odds ratio (OR) was used to compare continuous and dichotomous variables. It seems LA was connected with significantly shorter hospital time and lower wound infection [mean difference (MD), -0.57 days; 95% CI, -0.96 to -0.18; = 0.004 and OR, 0.34; 95% CI, 0.18 to 0.62; = 0.0005, respectively]. The incidence of fetal loss after LA was higher than OA (OR,1.93; 95% CI, 1.39-2.69; < 0.0001). It was almost similar in the rate of preterm delivery (OR, 0.80; 95% CI, 0.48 to 1.34; = 0.40) and other perioperative and obstetrical complications ( > 0.05). Our results indicated that the occurrence of fetal loss after LA should not be ignored. Caution, skillful operation, and thoroughly informed consent about the advantages and disadvantages of laparoscopy are necessary. https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier: CRD42021233150.
PubMed: 34631781
DOI: 10.3389/fsurg.2021.720351 -
Pediatric Surgery International Nov 2023The COVID-19 pandemic has changed the way to manage the emergencies, as people faced fear of the hospitals, with possible delay in the diagnosis. Moreover, clinicians... (Meta-Analysis)
Meta-Analysis Review
The COVID-19 pandemic has changed the way to manage the emergencies, as people faced fear of the hospitals, with possible delay in the diagnosis. Moreover, clinicians had to rearrange protocols for diagnosis and treatment. We aimed to assess whether COVID-19 pandemic influenced severity of inflammation, management, and outcomes of acute appendicitis (AA), when compared to the pre-COVID era. Using defined search strategy, two independent investigators identified those studies comparing pediatric AA during COVID-19 pandemic versus the pre-COVID-19 period. Meta-analysis was performed using RevMan 5.3. Data are mean ± SD. Of 528 abstracts, 36 comparative studies were included (32,704pts). Time from symptoms onset to surgery was longer during the pandemics compared to the pre-COVID-19 (1.6 ± 0.9 versus 1.4 ± 0.9 days; p < 0.00001). Minimally Invasive Surgery was similar during COVID-19 (70.4 ± 30.2%) versus control period (69.6 ± 25.3%; p = ns). Complicated appendicitis was increased during the pandemics (35.9 ± 14.8%) compared to control period (33.4 ± 17.2%; p < 0.0001). Post-operative complications were comparable between these two groups (7.7 ± 6.5% versus 9.1 ± 5.3%; p = ns). It seems that the COVID-19 pandemic influenced the time of diagnosis, severity of inflammation, and type of surgery. However, the number of post-operative complications was not different between the two groups, leading to the conclusion that the patients were correctly managed. LEVEL OF EVIDENCE: Level 3 Meta-analysis on Level 3 studies.
Topics: Humans; Child; Appendicitis; Pandemics; COVID-19; Inflammation; Acute Disease; Postoperative Complications; Appendectomy; Retrospective Studies
PubMed: 38017246
DOI: 10.1007/s00383-023-05594-9 -
The American Surgeon Sep 2023Both general surgeons (GS) and pediatric surgeons (PS) perform a high volume of appendectomies in pediatric patients, but there is a paucity of data on these outcomes... (Meta-Analysis)
Meta-Analysis
Both general surgeons (GS) and pediatric surgeons (PS) perform a high volume of appendectomies in pediatric patients, but there is a paucity of data on these outcomes based on surgeon training. We performed a systematic review and meta-analysis to compare postoperative outcomes and perioperative resource utilization for pediatric appendectomies. We searched PubMed to identify articles examining the association between surgeon specialization and outcomes for pediatric patients undergoing appendectomies. Study selection, data extraction, risk of bias assessment, and quality assessment were performed by one reviewer, with another reviewer to resolve discrepancies. We identified 4799 articles, with 98.4% (4724/2799) concordance after initial review. Following resolution of discrepancies, 16 studies met inclusion criteria. Of the studies that reported each outcome, GS and PS demonstrated similar rates of readmission within 30 days (pooled RR 1.61 95% CI 0.66, 2.55) wound infections (pooled RR 1.07, 95% CI .55, 1.60), use of laparoscopic surgery (pooled RR 1.87, 95% CI .21, 3.53), postoperative complications (pooled RR 1.40, 95% CI .83, 1.97), use of preoperative imaging (pooled RR .98,95% CI .90, 1.05), and intra-abdominal abscesses (pooled RR .80, 95% CI .03, 1.58). Patients treated by GS did have a significantly higher risk of negative appendectomies (pooled RR 1.47, 95% CI 1.10, 1.84) when compared to PS. This is the first meta-analysis to compare outcomes for pediatric appendectomies performed by GS compared to PS. Patient outcomes and resource utilization were similar among PS and GS, except for negative appendectomies were significantly more likely with GS.
Topics: Humans; Child; Surgeons; Postoperative Complications; Appendectomy; Abdominal Abscess; Specialization
PubMed: 37150834
DOI: 10.1177/00031348231173943 -
Cureus Oct 2022Acute appendicitis (AA) is one of the most common surgical pathologies. Its diagnosis is often carried out based on clinical signs and symptoms, with additional... (Review)
Review
BACKGROUND
Acute appendicitis (AA) is one of the most common surgical pathologies. Its diagnosis is often carried out based on clinical signs and symptoms, with additional minimally invasive tests (i.e., blood testing) done to support the diagnosis. Procalcitonin (PCT) is a relatively novel biomarker that is starting to be used by clinicians for patients admitted into hospitals with a variety of infections. Its level can be used to identify the presence of infection. The aim of this review is to assess how useful PCT is as a biomarker in supporting clinicians' assessment of patients with suspected appendicitis.
METHODS
A systematic literature search was carried out, yielding a total of 16 primary research papers deemed appropriate for appraisal.
RESULTS
The usefulness of PCT in aiding the diagnosis of AA depends on the severity of appendicitis. Patients who experience complicated appendicitis (CAA) such as perforation, gangrene, or necrosis have a significantly raised PCT level (p<0.05) compared to those with uncomplicated appendicitis (UAA) and a variety of other non-appendiceal intra-abdominal pathologies.
CONCLUSIONS
The use of PCT in UAA is weak, however, PCT was deemed useful in helping predict CAA, thus helping portray the severity of infection. This, in turn, will help ensure patients are taken to the operating theatre in a timely and safe manner for subsequent appendicectomy.
PubMed: 36407148
DOI: 10.7759/cureus.30292 -
Langenbeck's Archives of Surgery Nov 2023Studies evaluating the rate and histology of appendiceal neoplasms between complicated and uncomplicated appendicitis include a small number of patients. Therefore, we... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Studies evaluating the rate and histology of appendiceal neoplasms between complicated and uncomplicated appendicitis include a small number of patients. Therefore, we sought a meta-analysis and systematic review comparing the rates and types of appendiceal neoplasm between complicated and uncomplicated appendicitis.
METHODS
We included articles published from the time of inception of the datasets to September 30, 2022. The electronic databases included English publications in Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, and Scopus.
RESULTS
A total of 4962 patients with appendicitis enrolled in 4 comparative studies were included. The mean age was 43.55 years (16- 94), and half were male (51%). Based on intra-operative findings, 1394 (38%) had complicated appendicitis, and 3558 (62%) had uncomplicated appendicitis. The overall incidence rate of neoplasm was 1.98%. No significant difference was found in the incidence rate of appendiceal neoplasm between complicated (3.29%) and uncomplicated (1.49%) appendicitis (OR 0.44, 95% CI 0.16- 1.23; p < 0.087; I2 = 54.9%). The most common appendiceal neoplasms were Neuroendocrine Tumors (NET) (49.21%), Nonmucinous Adenocarcinoma (24.24%), Mixed Adeno-Neuroendocrine Tumor (MANEC) (11.40%), Mucinous Adenocarcinoma (4.44%). There was a significant difference between complicated and uncomplicated appendicitis in rates of adenocarcinoma (50% vs. 13%), NET (31% vs. 74%), MANEC (19% vs. 13%) (P < 0.001).
CONCLUSION
While there was no significant difference in the overall neoplasm rate between complicated and uncomplicated appendicitis, the NET rate was significantly higher in uncomplicated appendicitis. In comparison, the Adenocarcinoma rate was considerably higher in Complicated appendicitis. These findings emphasize the importance of evaluating risk factors for neoplasm when considering appendectomy in patients with appendicitis.
Topics: Humans; Male; Adult; Female; Appendiceal Neoplasms; Appendicitis; Incidence; Risk Factors; Appendectomy; Neuroendocrine Tumors; Adenocarcinoma; Retrospective Studies
PubMed: 37940770
DOI: 10.1007/s00423-023-03164-0 -
Frontiers in Surgery 2021Acute appendicitis (AA) is a common cause of abdominal pain encountering unnecessary surgeries in emergency departments. The present meta-analysis aims to assess the...
Acute appendicitis (AA) is a common cause of abdominal pain encountering unnecessary surgeries in emergency departments. The present meta-analysis aims to assess the accuracy of abdominal ultrasound in suspected acute appendicitis cases in terms of sensitivity, specificity, and post-test odds for positive and negative results. An extensive and systematic search was conducted in Medline ( PubMed), Cinahl ( Ebsco), Scopus, and Web of Sciences from 2010 till the end of March 2021. Two authors analyzed studies for inclusion, collected results, and conducted analyses separately. Examination of the histopathological tissue collected during appendectomy served as a gold standard for determining the final diagnosis of appendicitis. The accuracy was determined by evaluating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic odds ratio. Out of 3,193 references, a total of 18 studies were selected. Overall sensitivity of 77.2% (95% CI - 75.4-78.9%) and specificity of 60% (95% CI - 58-62%) were observed. The diagnostic odds ratio of 6.88(95% CI 1.99-23.82) was obtained. Abdominal ultrasound shows significant accuracy of diagnosis in patients with suspected acute appendicitis.
PubMed: 34262936
DOI: 10.3389/fsurg.2021.707160 -
Pediatric Surgery International Mar 2020Acute appendicitis is the most common surgical emergency in children. Nonoperative treatment of nonperforated acute appendicitis in children is an alternative to... (Meta-Analysis)
Meta-Analysis
Acute appendicitis is the most common surgical emergency in children. Nonoperative treatment of nonperforated acute appendicitis in children is an alternative to appendectomy. The purpose of this systematic review and meta-analysis was to determine the outcomes of nonoperative treatment of nonperforated acute appendicitis in children in the literature. Databases were searched to identify abstracts, using predefined search terms. The abstracts were reviewed by two independent reviewers and articles were selected according to inclusion and exclusion criteria. Data were extracted by the two reviewers and analyzed. The literature search yielded 2743 abstracts. Twenty-one articles were selected for analysis. The study design was heterogenous, with only one randomized controlled study. The symptoms resolved in 92% [95% CI (88; 96)] of the nonoperatively treated patients. Meta-analysis showed that an additional 16% (95% CI 10; 22) of patients underwent appendectomy after discharge from initial hospital stay. Complications and length of hospital stay was not different among patients treated with antibiotics compared with those who underwent appendectomy. Nonoperative treatment of nonperforated acute appendicitis children is safe and efficient. There is a lack of large randomized controlled trials to compare outcomes of nonoperative treatment with appendectomy.
Topics: Acute Disease; Anti-Bacterial Agents; Appendicitis; Child; Conservative Treatment; Emergency Service, Hospital; Humans; Treatment Outcome
PubMed: 31838546
DOI: 10.1007/s00383-019-04610-1 -
World Journal of Emergency Surgery :... Jun 2024Appendicectomy remains the standard treatment for appendicitis. There is a lack of clarity on the timeframe in which surgery should be performed to avoid unfavourable... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Appendicectomy remains the standard treatment for appendicitis. There is a lack of clarity on the timeframe in which surgery should be performed to avoid unfavourable outcomes.
AIM
To perform a systematic review and network meta-analysis to evaluate the impact the (1)time-of-day surgery is performed (2), time elapsed from symptom onset to hospital presentation (patient time) (3), time elapsed from hospital presentation to surgery (hospital time), and (4)time elapsed from symptom onset to surgery (total time) have on appendicectomy outcomes.
METHODS
A systematic review was performed as per PRISMA-NMA guidelines. The time-of-day which surgery was done was divided into day, evening and night. The other groups were divided into < 24 h, 24-48 h and > 48 h. The rate of complicated appendicitis, operative time, perforation, post-operative complications, surgical site infection (SSI), length of stay (LOS), readmission and mortality rates were analysed.
RESULTS
Sixteen studies were included with a total of 232,678 patients. The time of day at which surgery was performed had no impact on outcomes. The incidence of complicated appendicitis, post-operative complications and LOS were significantly better when the hospital time and total time were < 24 h. Readmission and mortality rates were significantly better when the hospital time was < 48 h. SSI, operative time, and the rate of perforation were comparable in all groups.
CONCLUSION
Appendicectomy within 24 h of hospital admission is associated with improved outcomes compared to patients having surgery 24-48 and > 48 h after admission. The time-of-day which surgery is performed does not impact outcomes.
Topics: Humans; Appendectomy; Appendicitis; Length of Stay; Network Meta-Analysis; Time Factors; Postoperative Complications; Time-to-Treatment; Treatment Outcome; Operative Time
PubMed: 38877592
DOI: 10.1186/s13017-024-00549-4 -
Journal of Pediatric Surgery Jun 2024Non-operative management (NOM) of simple appendicitis is becoming an increasingly researched treatment option. This systematic review aims to describe the short and... (Meta-Analysis)
Meta-Analysis Comparative Study
Systematic Review and Meta-analysis to Compare the Short- and Long-term Outcomes of Non-operative Management With Early Operative Management of Simple Appendicitis in Children After the COVID-19 Pandemic.
BACKGROUND
Non-operative management (NOM) of simple appendicitis is becoming an increasingly researched treatment option. This systematic review aims to describe the short and long-term failure rates of NOM and the complication rate of appendicectomy in children with simple appendicitis.
METHODS
The systematic review was registered a priori (CRD42022322149). Study inclusion criteria are: participants aged ≤ 18 years of age; groups undergoing both NOM and appendicectomy for simple appendicitis; outcomes including one or more of: NOM failure rate at 30 days or 1 year and beyond; study design: RCT or case control study. Four databases were searched and 3 reviewers determined study eligibility and data extraction. Risk of bias was assessed and meta-analysis was performed using Stata.
RESULTS
The database search identified 2731 articles, 14 studies met the inclusion criteria; 4 RCTs and 10 case controlled studies. All studies had moderate-serious risk of bias. There were no deaths in either group in any study. Meta-analysis demonstrated a 30 day failure rate of 20 % (95 % CI 11-29 %) and 11 studies reported failure rate at 1 year or beyond at 32 % (95 % CI 25-38 %). Rates of significant complications of appendicectomy was 1 % (95 % CI 0-1 %).
CONCLUSIONS
Non-operative management of simple appendicitis in children is safe, with moderate early success. The failure rate increases over time, resulting in eventual appendicectomy in a third of the children diagnosed with appendicitis. These data will enable clinicians to have an informed discussion with children and their parents about their treatment options for simple appendicitis.
LEVEL OF EVIDENCE
II.
Topics: Humans; Appendicitis; Appendectomy; COVID-19; Child; Conservative Treatment; Postoperative Complications; Treatment Outcome; Treatment Failure
PubMed: 38158255
DOI: 10.1016/j.jpedsurg.2023.12.021