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The Cochrane Database of Systematic... Dec 2021Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children.
OBJECTIVES
The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective.
SELECTION CRITERIA
We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies.
DATA COLLECTION AND ANALYSIS
We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity.
MAIN RESULTS
We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains.
AUTHORS' CONCLUSIONS
MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.
Topics: Adult; Appendicitis; Child; Female; Humans; Magnetic Resonance Imaging; Pregnancy; Retrospective Studies; Sensitivity and Specificity; Tomography, X-Ray Computed
PubMed: 34905621
DOI: 10.1002/14651858.CD012028.pub2 -
Medicine Aug 2015The aim of this study is to assess the influence of surgeon specialization on outcomes following appendicectomy in children.General surgeons and pediatric surgeons... (Meta-Analysis)
Meta-Analysis Review
The aim of this study is to assess the influence of surgeon specialization on outcomes following appendicectomy in children.General surgeons and pediatric surgeons manage appendicitis in children; however, the influence of subspecialization on outcomes remains unclear.Two authors searched Medline and Embase to identify relevant studies. Eligible studies were comparative and provided data on children who had appendicectomy while under the care of general or pediatric surgical teams. Two authors initially screened titles and abstracts and then full text manuscripts were evaluated. Data were extracted by 2 authors using an electronic spreadsheet. Pooled risk ratios and pooled mean differences were used in analyses.We identified 9 relevant studies involving 50,963 children who were managed by general surgery teams and 15,032 children who were managed by pediatric surgery teams. A normal appendix was removed in 4660/48,105 children treated by general surgery units and in 889/14,760 children treated by pediatric units (pooled risk ratio 1.79; 95% confidence interval [CI] 1.26-2.54; P = 0.001). Children managed in general units had shorter mean hospital stays compared with children managed in pediatric units (pooled mean difference -0.70 days; 95%CI -1.09 to -0.30; P = 0.0005). There were no significant differences regarding wound infections, intra-abdominal abscesses, readmissions, or mortality.We found that children who were managed by specialized pediatric surgery teams had lower rates of negative appendicectomy although mean length of stay was longer. Our article is based upon a group of heterogeneous and mostly retrospective studies and therefore there is little external validity. Further studies are needed.
Topics: Adolescent; Appendectomy; Appendicitis; Child; Child, Preschool; Humans; Infant; Length of Stay; Medicine; Pediatrics; Retrospective Studies
PubMed: 26266388
DOI: 10.1097/MD.0000000000001352 -
Colorectal Disease : the Official... Oct 2021Caecal diverticulitis (CD) is an uncommon condition which can be misdiagnosed as acute appendicitis due to similar clinical presentations. Further, its management varies... (Review)
Review
AIM
Caecal diverticulitis (CD) is an uncommon condition which can be misdiagnosed as acute appendicitis due to similar clinical presentations. Further, its management varies among medical centres. The aim of this study was to review cases of patients with CD, to identify the factors differentiating CD from acute appendicitis and to provide a summary of existing diagnostic methods and therapeutic alternatives regarding its management.
METHODS
This systematic review was conducted in accordance with the PRISMA guidelines and the AMSTAR2 checklist. We searched MEDLINE and Embase from inception until 1 October 2018 for original publications reporting cases of CD.
RESULTS
Out of the 560 identified studies, 146 publications (988 patients) were included in the qualitative synthesis. Most frequent symptoms of CD were right iliac fossa pain (93.2%), nausea and/or vomiting (35.4%) and fever (26.9%). A total of 443 patients (44.8%) underwent radiological imaging, which reported CD in 225 patients (22.8%). For the other patients, the diagnosis was obtained by surgical exploration (73.9%). Among patients diagnosed with CD by imaging, 67 (29.8%) underwent surgery and 158 (70.2%) were treated conservatively. Among patients who underwent surgical exploration, treatment consisted most frequently of right hemi-colectomy (33%), appendectomy (18.8%) and diverticulectomy with appendectomy (16.3%).
CONCLUSION
CD can be misdiagnosed as acute appendicitis, therefore resulting in unnecessary surgical exploration. The review of the literature starting from 1930 highlights the critical role of medical imaging in supporting the clinician to diagnose this condition and administer adequate treatment.
Topics: Appendectomy; Appendicitis; Cecal Diseases; Diagnosis, Differential; Diagnostic Errors; Diverticulitis; Humans
PubMed: 34272795
DOI: 10.1111/codi.15818 -
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 -
The Lancet. Global Health Mar 2016Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well... (Review)
Review
Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data.
BACKGROUND
Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures--caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair--to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety.
METHODS
We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates.
FINDINGS
From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs.
INTERPRETATION
All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care.
FUNDING
None.
Topics: Adult; Appendectomy; Appendicitis; Cesarean Section; Developing Countries; Female; Groin; Hernia; Herniorrhaphy; Humans; Male; Postoperative Period; Pregnancy
PubMed: 26916818
DOI: 10.1016/S2214-109X(15)00320-4 -
Journal of Robotic Surgery Apr 2023Robotically assisted operations are the state of the art in laparoscopic general surgery. They are established predominantly for elective operations. Since laparoscopy... (Review)
Review
Robotically assisted operations are the state of the art in laparoscopic general surgery. They are established predominantly for elective operations. Since laparoscopy is widely used in urgent general surgery, the significance of robotic assistance in urgent operations is of interest. Currently, there are few data on robotic-assisted operations in urgent surgery. The aim of this study was to collect and classify the existing studies. A two-stage, PRISMA-compliant literature search of PubMed and the Cochrane Library was conducted. We analyzed all articles on robotic surgery associated with urgent general surgery resp. acute surgical diseases of the abdomen. Gynecological and urological diseases so as vascular surgery, except mesenterial ischemia, were excluded. Studies and case reports/series published between 1980 and 2021 were eligible for inclusion. In addition to a descriptive synopsis, various outcome parameters were systematically recorded. Fifty-two studies of operations for acute appendicitis and cholecystitis, hernias and acute conditions of the gastrointestinal tract were included. The level of evidence is low. Surgical robots in the narrow sense and robotic camera mounts were used. All narrow-sense robots are nonautonomous systems; in 82%, the Da Vinci system was used. The most frequently published emergency operations were urgent cholecystectomies (30 studies, 703 patients) followed by incarcerated hernias (9 studies, 199 patients). Feasibility of robotic operations was demonstrated for all indications. Neither robotic-specific problems nor extensive complication rates were reported. Various urgent operations in general surgery can be performed robotically without increased risk. The available data do not allow a final evidence-based assessment.
Topics: Humans; Robotic Surgical Procedures; Robotics; Laparoscopy; Cholecystectomy; Hernia
PubMed: 35727485
DOI: 10.1007/s11701-022-01425-6 -
World Journal of Emergency Surgery :... Jan 2024The aim of this study is to provide a meta-analysis of randomized controlled trials (RCT) comparing conservative and surgical treatment in a population of adults with... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The aim of this study is to provide a meta-analysis of randomized controlled trials (RCT) comparing conservative and surgical treatment in a population of adults with uncomplicated acute appendicitis.
METHODS
A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL. We have exclusively incorporated randomized controlled trials (RCTs). Studies involving participants with complicated appendicitis or children were excluded. The variables considered are as follows: treatment complications, complication-free treatment success at index admission and at 1 year follow-up, length of hospital stay (LOS), quality of life (QoL) and costs.
RESULTS
Eight RCTs involving 3213 participants (1615 antibiotics/1598 appendectomy) were included. There was no significant difference between the two treatments in terms of complication rates (RR = 0.66; 95% CI 0.61-1.04, P = 0.07, I = 69%). Antibiotics had a reduced treatment efficacy compared with appendectomy (RR = 0.80; 95% CI 0.71 to 0.90, p < 0.00001, I = 87%) and at 1 year was successful in 540 out of 837 (64.6%, RR = 0.69, 95% confidence interval 0.61 to 0.77, p < 0.00001, I = 81%) participants. There was no difference in LOS (mean difference - 0.58 days 95% confidence interval - 1.59 to 0.43, p = 0.26, I = 99%). The trial sequential analysis has revealed that, concerning the three primary outcomes, it is improbable that forthcoming RCTs will significantly alter the existing body of evidence.
CONCLUSIONS
As further large-scale trials have been conducted, antibiotic therapy proved to be safe, less expensive, but also less effective than surgical treatment. In order to ensure well-informed decisions, further research is needed to explore patient preferences and quality of life outcomes.
Topics: Adult; Humans; Anti-Bacterial Agents; Appendectomy; Appendicitis; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 38218862
DOI: 10.1186/s13017-023-00531-6 -
Diagnostics (Basel, Switzerland) Jan 2023Pylephlebitis, defined as infective thrombophlebitis of the portal vein, is a rare condition with an incidence of 0.37-2.7 cases per 100,000 person-years, which can... (Review)
Review
Pylephlebitis, defined as infective thrombophlebitis of the portal vein, is a rare condition with an incidence of 0.37-2.7 cases per 100,000 person-years, which can virtually complicate any intra-abdominal or pelvic infections that develop within areas drained by the portal venous circulation. The current systematic review aimed to investigate the etiology behind pylephlebitis in terms of pathogens involved and causative infective processes, and to report the most common symptoms at clinical presentation. We included 220 individuals derived from published cases between 1971 and 2022. Of these, 155 (70.5%) were male with a median age of 50 years. There were 27 (12.3%) patients under 18 years of age, 6 (2.7%) individuals younger than one year, and the youngest reported case was only 20 days old. The most frequently reported symptoms on admission were fever (75.5%) and abdominal pain (66.4%), with diverticulitis (26.5%) and acute appendicitis (22%) being the two most common causes. Pylephlebitis was caused by a single pathogen in 94 (42.8%) cases and polymicrobial in 60 (27.2%) cases. However, the responsible pathogen was not identified or not reported in 30% of the included patients. The most frequently isolated bacteria were (25%), spp. (17%), and spp. (15%). The treatment of pylephlebitis consists initially of broad-spectrum antibiotics that should be tailored upon bacterial identification and continued for at least four to six weeks after symptom presentation. There is no recommendation for prescribing anticoagulants to all patients with pylephlebitis. However, they should be administered in patients with thrombosis progression on repeat imaging or persistent fever despite proper antibiotic therapy to increase the rates of thrombus resolution or decrease the overall mortality, which is approximately 14%.
PubMed: 36766534
DOI: 10.3390/diagnostics13030429 -
International Journal of Environmental... May 2021Laparoscopy is a procedure that ultimately reduces hospital stay time and speeds up post-operative recovery. It is mainly performed in high-income countries but its... (Review)
Review
Laparoscopy is a procedure that ultimately reduces hospital stay time and speeds up post-operative recovery. It is mainly performed in high-income countries but its implementation in many low- and middle-income countries (LMICs) is increasing. However, no aggregate data exist regarding the outcomes of this procedure in resource-limited settings. We retrospectively reviewed all cases of laparoscopy recorded from January 2007 to March 2017 at the Department of Surgery of Beira to assess the related outcomes. Moreover, we performed a systematic review of the laparoscopic practices and outcomes in low-income countries. Data from the Department of Surgery of Beira identified 363 laparoscopic procedures, mainly relating to gynecological diseases, cholelithiasis, and appendicectomy with only a 1.6% complication rate (6 cases) and a 1.9% conversion rate (7 cases) to open surgery. The systematic review showed a pooled risk of overall complications significantly lower in laparoscopic vs. open appendicectomy (OR = 0.43; 95% CI 0.19-0.97; I = 85.7%) and a significantly lower risk of infection (OR = 0.53; 95% CI 0.43-0.65; I = 0.00%). The pooled SMD in operation duration in laparoscopic vs. open appendectomy was 0.58 (95% CI -0.00; 1.15; I = 96.52), while the pooled SMD in hospitalization days was -1.35 (95% CI -1.87; -0.82; I = 96.41). Laparoscopy is an expensive procedure to adopt as it requires new equipment and specialized trained health workers. However, it could reduce post-operative costs and complications, especially in terms of infections. It is crucial to increase its accessibility, acceptability, and quality particularly in LMICs, especially during this COVID-19 era when the reduction of patient hospitalization is essential.
Topics: Appendicitis; COVID-19; Humans; Laparoscopy; Length of Stay; Retrospective Studies; SARS-CoV-2; Treatment Outcome
PubMed: 34071312
DOI: 10.3390/ijerph18115796 -
European Journal of Surgical Oncology :... Feb 2023This study systematically reviewed the literature to investigate the value of secondary surgery for children with a high-risk neuroendocrine tumor (NET) of appendix. A... (Review)
Review
This study systematically reviewed the literature to investigate the value of secondary surgery for children with a high-risk neuroendocrine tumor (NET) of appendix. A systematic search was performed in PubMed, Embase and Web of Science. All randomized controlled trials, cohort studies, and case series reporting on the management and outcomes of patients (<20 years) with a histopathologically proven NET of the appendix were eligible for inclusion. Two authors independently selected eligible articles, assessed risk of bias, and extracted data. The outcomes of patients with a high-risk NET treated with secondary surgery were compared to those treated without secondary surgery. Primary outcomes were recurrence rate and disease-free survival. The literature search yielded 667 articles, of which 29 were included. These studies reported on 1112 patients, of whom 145 (13%) had high-risk NET. Heterogeneity between studies was large and risk of bias was serious in 26 and moderate in three studies. Secondary surgery after primary appendectomy was performed in 64 of 145 patients (44%). Length of follow-up ranged between 0 and 612 months. In both treatment groups no recurrences were reported, and thus disease-free survival was 100%. Based on current literature, the value of secondary surgery for pediatric high-risk NET of the appendix may be questioned. However, evidence is scarce, of low-quality, and heterogeneity between studies is large. Large international studies with adequate follow-up are needed to generate high-quality evidence on this topic.
Topics: Humans; Child; Appendix; Appendiceal Neoplasms; Neuroendocrine Tumors
PubMed: 36372617
DOI: 10.1016/j.ejso.2022.10.021