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Langenbeck's Archives of Surgery May 2023Appendicitis is a common cause of acute abdominal pain, and treatment with laparoscopy has become increasingly common during the past two decades. Guidelines recommend... (Meta-Analysis)
Meta-Analysis
PURPOSE
Appendicitis is a common cause of acute abdominal pain, and treatment with laparoscopy has become increasingly common during the past two decades. Guidelines recommend that normal appendices are removed if operated for suspected acute appendicitis. It is unclear how many patients are affected by this recommendation. The aim of this study was to estimate the rate of negative appendectomies in patients undergoing laparoscopic surgery for suspected acute appendicitis.
METHODS
This study was reported following the PRISMA 2020 statement. A systematic search was conducted in PubMed and Embase for retrospective or prospective cohort studies (with n ≥ 100) including patients with suspected acute appendicitis. The primary outcome was the histopathologically confirmed negative appendectomy rate after a laparoscopic approach with a 95% confidence interval (CI). We performed subgroup analyses on geographical region, age, sex, and use of preoperative imaging or scoring systems. The risk of bias was assessed using the Newcastle-Ottawa Scale. Certainty of the evidence was assessed using GRADE.
RESULTS
In total, 74 studies were identified, summing up to 76,688 patients. The negative appendectomy rate varied from 0% to 46% in the included studies (interquartile range 4-20%). The meta-analysis estimated the negative appendectomy rate to be 13% (95% CI 12-14%) with large variations between the individual studies. Sensitivity analyses did not change the estimate. The certainty of evidence by GRADE was moderate due to inconsistency in point estimates.
CONCLUSION
The overall estimated negative appendectomy rate after laparoscopic surgery was 13% with moderate certainty of evidence. The negative appendectomy rate varied greatly between studies.
Topics: Humans; Appendectomy; Appendicitis; Prospective Studies; Retrospective Studies; Laparoscopy
PubMed: 37219616
DOI: 10.1007/s00423-023-02935-z -
Pediatric Surgery International May 2023Stump appendicitis is a rare complication after primary appendectomy and is often not considered in the differential diagnosis of patients who have undergone an... (Review)
Review
BACKGROUND
Stump appendicitis is a rare complication after primary appendectomy and is often not considered in the differential diagnosis of patients who have undergone an appendectomy. With this systematic review, the aim was to identify all cases of stump appendicitis in children in order to gain a better insight into the risk factors, clinical presentation, diagnostics, and treatment.
METHODS
Scopus and PubMed databases were searched. The search combinations used the following MeSH and free text terms: [(stump) OR (residual) OR (remaining) OR (retained) OR (recurrent)] AND (append*). Neither search filters nor text analysis tools were used. To be included, the report had to contain information about a patient between the age of 0 and 18 who was treated for stump appendicitis as a result of an inadequately performed appendectomy.
RESULTS
Out of the 19,976 articles, 29 of them, with a total of 34 cases, met the inclusion criteria. The mean age at the time of stump appendectomy was 13.32 ± 3.57 years, while the median time between primary and stump appendectomy was 7.5 (2.3 - 24.0) months. The ratio between boys and girls was 3.2: 1. Primary appendectomy was performed laparoscopically in a greater number of cases compared to the open approach (1.5: 1), and according to the available data, no higher proportion of complicated appendicitis was recorded during a primary appendectomy. The median duration of symptoms during stump appendicitis was 2 days, and in most cases, the pain was localized. Stump appendectomy in most cases was performed with an open approach, and in relation to the type of appendicitis, most of them were complicated. The mean value of the length of the stump was 2.79 ± 1.22 cm, and the smallest recorded length was 0.6 cm.
CONCLUSIONS
A non-specific clinical presentation with a history of appendectomy usually makes the diagnosis of stump appendicitis challenging for uninformed physicians, and due to untimely treatment, it usually results in complicated forms of stump appendicitis. Complete appendectomy remains the gold standard in the treatment of stump appendicitis.
Topics: Male; Female; Humans; Child; Infant; Appendicitis; Appendectomy; Postoperative Complications; Pain; Diagnosis, Differential; Laparoscopy
PubMed: 37188869
DOI: 10.1007/s00383-023-05475-1 -
European Journal of Pediatrics Jul 2023The aim of this study was to analyze the diagnostic performance of Leucine-Rich Alpha-2-Glycoprotein (LRG1) in pediatric acute appendicitis (PAA). We conducted a... (Meta-Analysis)
Meta-Analysis
The aim of this study was to analyze the diagnostic performance of Leucine-Rich Alpha-2-Glycoprotein (LRG1) in pediatric acute appendicitis (PAA). We conducted a systematic review of the literature in the main databases of medical bibliography. 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 4 random-effect meta-analyses were performed. Eight studies with data from 712 participants (305 patients with confirmed diagnosis of PAA and 407 controls) were included in this review. The random-effect meta-analysis of serum LRG1 (PAA vs control) resulted in a significant mean difference (95% CI) of 46.76 μg/mL (29.26-64.26). The random-effect meta-analysis for unadjusted urinary LRG1 (PAA vs control) resulted in a significant mean difference (95% CI) of 0.61 μg/mL (0.30-0.93). The random-effect meta-analysis (PAA vs control) for urinary LRG1 adjusted for urinary creatinine resulted in a significant mean difference (95% CI) of 0.89 g/mol (0.11-1.66). Conlusion: Urinary LRG1 emerges as a potential non-invasive biomarker for the diagnosis of PAA. On the other hand, due to the high between-study heterogeneity, the results on serum LRG1 should be interpreted with caution. The only study that analyzed salivary LRG1 showed promising results. Further prospective studies are needed to confirm these findings. What is Known: • Pediatric acute appendicitis continues to be a pathology with a high rate of diagnostic error. • Invasive tests, although useful, are a source of stress for patients and their parents. What is New: • LRG1 emerges as a promising urinary and salivary biomarker for the noninvasive diagnosis of pediatric acute appendicitis.
Topics: Child; Humans; Acute Disease; Appendicitis; Biomarkers; Glycoproteins
PubMed: 37148275
DOI: 10.1007/s00431-023-04978-2 -
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 -
Journal of Gastrointestinal Surgery :... Jul 2023To perform a systematic review on the use of magnetic resonance imaging (MRI) of the abdomen to evaluate clinically suspected appendicitis in the general adult... (Review)
Review
OBJECTIVES
To perform a systematic review on the use of magnetic resonance imaging (MRI) of the abdomen to evaluate clinically suspected appendicitis in the general adult population. We examined the diagnostic accuracy, the reported trends of MRI use, and the factors that affect the utility of MRI abdomen, including study duration and cost-benefits.
METHODS
We conducted a systematic literature search on PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library databases. We enrolled primary studies investigating the use of MRI in diagnosing appendicitis in the general adult population, excluding studies that predominantly reported on populations not representative of typical adult appendicitis presentations, such as those focusing on paediatric or pregnant populations.
RESULTS
Twenty-seven eligible primary studies and 6 secondary studies were included, totaling 2,044 patients from eight countries. The sensitivity and specificity of MRI for diagnosing appendicitis were 96% (95% CI: 93-97%) and 93% (95% CI: 80-98%), respectively. MRI can identify complicated appendicitis and accurately propose alternative diagnoses. The duration of MRI protocols in each primary study ranged between 2.26 and 30 minutes, and only one study used intravenous contrast agents in addition to the non-contrast sequences. Decision analysis suggests significant benefits for replacing computed tomography (CT) with MRI and a potential for cost reduction. Reported trends in MRI usage showed minimal utilisation in diagnostic settings even when MRI was available.
CONCLUSIONS
MRI accurately diagnoses appendicitis in the general adult population and improves the identification of complicated appendicitis or alternative diagnoses compared to other modalities using a single, rapid investigation.
Topics: Female; Pregnancy; Humans; Adult; Child; Appendicitis; Magnetic Resonance Imaging; Tomography, X-Ray Computed; Acute Disease; Sensitivity and Specificity; Abdomen
PubMed: 37081221
DOI: 10.1007/s11605-023-05626-8 -
International Journal of Colorectal... Apr 2023There have been debates about the human appendix function, and while previous research suggested it might be a vestigial organ with no functional significance, recent... (Review)
Review
BACKGROUND
There have been debates about the human appendix function, and while previous research suggested it might be a vestigial organ with no functional significance, recent studies have pointed out that it might have an important role in the immune system. Acute appendicitis (AA) is a common cause of emergency abdominal surgery in the world. Some epidemiologic investigations have found an association between appendicitis and viral infections. In this study, we have reviewed systematically articles to discover viral infections that cause appendicitis and find any possible correlations between the two.
METHODS
This systematic review was performed by searching among electronic databases including Web of Science, PubMed, Scopus, and EMBASE on viruses and appendicitis topics.
RESULTS
Conducted search leads to 983 results in all databases after the duplicate removal and screening by title, abstract, and full-text based on inclusion criteria lead to 19 studies. There were several assays to detect the viruses, which are thought to be AA causative agents. RT-PCR and immunoassays were the mainstay methods to detect the probable cause.
CONCLUSION
Investigations suggested that some viruses including measles virus (MV), influenza virus, dengue fever virus (DFV), human immunodeficiency virus (HIV), human herpesviruses, rotavirus, and adenovirus are associated with acute appendicitis. Despite the available reports, the specific mechanisms behind the relationship between acute appendicitis and viral infections are yet to be understood. Therefore, further investigations are necessary to find out the pathogenesis and pathophysiology of viral complications in appendicitis.
Topics: Humans; Appendicitis; Appendix; Viruses; Appendectomy; Virus Diseases; Acute Disease
PubMed: 37069433
DOI: 10.1007/s00384-023-04391-z -
Pediatric Surgery International Apr 2023Children undergoing appendicectomy for complicated appendicitis are at an increased risk of post-operative morbidity. Placement of an intra-peritoneal drain to prevent... (Meta-Analysis)
Meta-Analysis Review
Children undergoing appendicectomy for complicated appendicitis are at an increased risk of post-operative morbidity. Placement of an intra-peritoneal drain to prevent post-operative complications is controversial. We aimed to assess the efficacy of prophylactic drain placement to prevent complications in children with complicated appendicitis. A systematic review was performed in accordance with PRISMA guidelines. Cochrane, MEDLINE and Web of Science databases were searched from inception to November 2022 for studies directly comparing drain placement to no drain placement in children ≤ 18 years of age undergoing operative treatment of complicated appendicitis. A total of 5108 children with complicated appendicitis were included from 16 studies; 2231 (44%) received a drain. Placement of a drain associated with a significantly increased risk of intra-peritoneal abscess formation (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.16-2.24, p = 0.004) but there was no significant difference in wound infection rate (OR 1.46, 95% CI 0.74-2.88, p = 0.28). Length of stay was significantly longer in the drain group (mean difference 2.02 days, 95% CI 1.14-2.90, p < 0.001). Although the quality and certainty of the available evidence is low, prophylactic drain placement does not prevent intra-peritoneal abscess following appendicectomy in children with complicated appendicitis.
Topics: Humans; Child; Abscess; Appendicitis; Length of Stay; Abdominal Abscess; Drainage; Postoperative Complications; Peritonitis; Appendectomy; Laparoscopy
PubMed: 37031267
DOI: 10.1007/s00383-023-05457-3 -
Surgical Infections May 2023The aim of this study was to analyze the diagnostic performance of total platelet count (PC), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR)... (Meta-Analysis)
Meta-Analysis
Diagnostic Performance of Total Platelet Count, Platelet-to-Lymphocyte Ratio, and Lymphocyte-to-Monocyte Ratio for Overall and Complicated Pediatric Acute Appendicitis: A Systematic Review and Meta-Analysis.
The aim of this study was to analyze the diagnostic performance of total platelet count (PC), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) in pediatric acute appendicitis (PAA). We conducted a systematic review of the literature in the main databases of medical bibliography. Two independent reviewers selected the articles and extracted relevant data. Methodological quality was assessed using the QUADAS2 index. A synthesis of the results, a standardization of the metrics, and four random effect meta-analyses were performed. Thirteen studies including data from 4,373 participants (2,767 patients with confirmed diagnosis of PAA and 1,606 controls) were included. Five studies compared PC, and the meta-analysis including three of them showed a non-significant mean difference of -34.47 platelets/1 × 10/L (95% confidence interval [CI], -88.10 to 19.16). Seven publications compared PLR and the meta-analysis of those studies showed significant mean differences between patients with PAA and controls (dif: 49.84; 95% CI, 25.82-73.85) as well as between patients with complicated and uncomplicated PAA (dif: 49.42; 95% CI, 25.47-73.37). Four studies compared LMR and the meta-analysis including 3 of them showed a non-significant mean difference of -1.88 (95% CI, -3.86 to 0.10). Although existing evidence is heterogeneous and limited, PLR appears to be a promising biomarker for the diagnosis of PAA and for the discrimination between complicated and uncomplicated PAA. Our results do not support the use of PC or LMR as biomarkers in PAA.
Topics: Humans; Child; Platelet Count; Monocytes; Appendicitis; Blood Platelets; Lymphocytes; Biomarkers; Neutrophils; Retrospective Studies
PubMed: 37022749
DOI: 10.1089/sur.2023.013 -
Pediatric Surgery International Apr 2023Ladd's Procedure has been the surgical intervention of choice in the management of congenital intestinal malrotation for the past century. Historically, the procedure... (Review)
Review
BACKGROUND
Ladd's Procedure has been the surgical intervention of choice in the management of congenital intestinal malrotation for the past century. Historically, the procedure included performing an appendectomy to prevent future misdiagnosis of appendicitis, since the location of the appendix will be shifted to the left side of the abdomen. This study consists of two parts. A review of the available literature on appendectomy as part of Ladd's procedure and then a survey sent to pediatric surgeons about their approach (to remove the appendix or not) while performing a Ladd's procedure and the clinical reasoning behind their approach.
METHODS
The study consists of 2 parts: (1) a systematic review was performed to extract articles that fulfill the inclusion criteria; (2) a short online survey was designed and sent by email to 168 pediatric surgeons. The questions in the survey were centered on whether a surgeon performs an appendectomy as part of the Ladd's procedure or not, as well as their reasoning behind either choice.
RESULTS
The literature search yielded five articles, the data from the available literature are inconsistent with performing appendectomy as part of Ladd's procedure. The challenge of leaving the appendix in place has been briefly described with minimal to no focus on the clinical reasoning. The survey demonstrated that 102 responses were received (60% response rate). Ninety pediatric surgeons stated performing an appendectomy as part of the procedure (88%). Only 12% of pediatric surgeons are not performing appendectomy during Ladd's procedure.
CONCLUSION
It is difficult to implement a modification in a successful procedure like Ladd's procedure. The majority of pediatric surgeons perform an appendectomy as part of its original description. This study has identified gaps in the literature pertaining to analyze the outcomes of performing Ladd's procedure without an appendectomy which should be explored in future research.
Topics: Child; Humans; Appendectomy; Laparoscopy; Intestinal Volvulus; Digestive System Surgical Procedures
PubMed: 37010655
DOI: 10.1007/s00383-023-05437-7 -
European Journal of Pediatrics Jun 2023The hospital landscape is shifting to new care models to meet current challenges in demand, technology, available budgets and staffing. These challenges also apply to...
The hospital landscape is shifting to new care models to meet current challenges in demand, technology, available budgets and staffing. These challenges also apply to the paediatric population, leading to a reduction in paediatric hospital beds and occupancy rates. Paediatric hospital-at-home (HAH) care is used to substitute hospital care in an attempt to bring hospital services closer to children's homes. In addition, these models attempt to avoid fragmentation of care between hospitals and the community. An important prerequisite for this paediatric HAH care is that it is safe and at least as effective as standard hospital care. The aim of this systematic review is to analyse the evidence on the impact of paediatric HAH care on hospital utilisation, patient outcomes and costs. Four bibliographic databases (Medline, Embase, Cinahl and Cochrane Library) were systematically searched for RCTs and pseudo-RCTs that studied the effectiveness and safety of short-term paediatric HAH care with a focus on models as an alternative to acute hospital admissions. Pseudo-RCTs are defined as observational studies that mimic the design of an RCT, but without randomisation. Outcomes of interest were the length of stay, acute (re)admissions, adverse health outcomes, therapy adherence, parental satisfaction or experience and costs. Only articles written in English, Dutch and French conducted in upper-middle and high-income countries and published between 2000 and 2021 were included. Quality assessment was carried out by two assessors using the Cochrane Collaboration's tool for assessing the risk of bias. Reporting is done in accordance with the PRISMA guidelines. We identified 18 (pseudo) RCTs and 25 publications of low to very low quality. Most of the included RCTs focused on the neonatal population: phototherapy for neonatal jaundice, early discharge after birth combined with outpatient neonatal care. Other RCTs focused on chemotherapy for acute lymphoblastic leukaemia, diabetes type 1 education, oxygen therapy for acute bronchiolitis, an outpatient service for children with infectious diseases and antibiotic treatment for low-risk febrile neutropenia, cellulitis and perforated appendicitis. The identified study results show that paediatric HAH care is not associated with more adverse events or hospital readmissions. The impact of paediatric HAH care on costs is less clear. Conclusions: This review suggests that paediatric HAH care is not associated with more adverse events or hospital readmissions for various clinical indications compared to a standard hospital. Because of the low to very low level of evidence, it is worthwhile to further investigate safety, efficacy and cost effects under strict and well-controlled conditions. This systematic review provides guidance on the essential elements that should be included in HAH care programmes for each type of indication and/or intervention. What is Known: • The hospital landscape is shifting new models of care to meet current challenges in demand, technology, staffing and models of care. Paediatric HAH care is one of these models. Previous literature reviews are inconclusive whether this is a safe and effective way of providing care. What is New: • New evidence suggests that paediatric HAH care for various clinical indications is not associated with adverse events or hospital readmissions compared to a standard hospital. Current evidence is characterised by a low level of quality. • The current review provides guidance on the essential elements that should be included in HAH care programmes for each type of indication and/or intervention.
Topics: Child; Infant, Newborn; Humans; Hospitals, Pediatric; Hospitalization; Patient Readmission; Home Care Services; Patient Discharge
PubMed: 37010537
DOI: 10.1007/s00431-023-04916-2