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PubMed2002

Transumbilical laparoscopic-assisted appendectomy (TULAA): a safe and useful alternative for uncomplicated appendicitis.

AIM: To compare transumbilical laparoscopic-assisted appendectomy (TULAA) and open appendectomy (OA) in cases of acute uncomplicated appendicitis. METHODS: 58 TULAA and 65 OA in patients with a preoperative diagnosis of acute uncomplicated appendicitis are compared. Pneumoperitoneum was obtained with a transumbilical 10 mm trocar (telescope access) and a 5 mm operative channel introduced in the left iliac fossa. Appendectomy was performed outside the abdomen, after the exteriorisation of the appendix through the transumbilical incision. RESULTS: In the TULAA group, operative time and hospital stay were reduced. Conversion was necessary in one case (1.7 %), and in one case (1.7 %), an additional 5 mm operative channel was introduced. Neither intra- or postoperative complications were found in the TULAA group, with excellent cosmetic results. In the OA group we had a wound infection (1.5 %) and in 8 cases (12.3 %) an enlargement of the incision was necessary. CONCLUSIONS: TULAA is the best approach in uncomplicated appendicitis. It is less invasive and traumatic, permits a complete evaluation of the peritoneal cavity with superior cosmetic results, especially in obese patients and in cases of ectopic appendicitis.

Acute Disease↗
PubMed2005

[Open versus laparoscopic operation for perforated appendicitis--a comparative study].

INTRODUCTION: Laparoscopic therapy of complicated appendicitis is still discussed controversially. This retrospective study compared the clinical results of open and laparoscopic appendectomy in a single centre. PATIENTS AND METHODS: Within a period of three years (1999 to 2001) 493 patients with suspected acute appendicitis were operated prospectively at a German district hospital (250 open appendectomies, 243 laparoscopic appendectomies). Twenty percent of the patients in every group had a complicated appendicitis (48 open, 44 laparoscopic appendectomies) and were analysed retrospectively considering demographic data, operative time, body mass index, preoperative inflammatory parameters (white blood cell count, C-reactive protein and body temperature) and postoperative complication rate. RESULTS: Both groups were comparable with regard to demographic data. One patient of the laparoscopic group needed an open operation (conversion rate 2.3 %). The body mass index of the laparoscopic group was significantly higher (26.3 vs. 24.1 kg/m(2)). Preoperative white blood cell count, C-reactive protein, body temperature as well as postoperative antibiotic therapy and analgesics requirement were comparable in both groups. There was no significant difference between the length of operative time (open 48 min, laparoscopic 53.5 min). The postoperative hospital stay was significantly shorter in the laparoscopic group (8 vs. 9 days, p = 0.032). Complication rate was significantly lower in the laparoscopic group (11.5 vs. 35 %, p = 0.014). CONCLUSION: Laparoscopic appendectomy is a safe procedure for the treatment of complicated appendicitis with a significantly decreased complication rate and shorter postoperative stay.

Adolescent↗
PubMed2005

[Legal aspects of deadly acute appendicitis].

Appendicitis is diagnosed by synoptic evaluation of typical symptoms, laboratory tests and sonography. The only therapy is a prompt operation. The main reason for appendicitis mortality is the condition not detected or not detected in time. The case of a 50 year old male who died from a non-detected perityphlitic appendicitis with abscesses in the liver is presented. Only if appendicitis can be reliably ruled out an operation is not indicated. The not performed surgical intervention is often interpreted as a treatment error by the courts. In doubt, an operation should therefore be performed.

Abdomen, Acute↗
PubMed1986

Neonatal appendicitis: case report and a revised review of the English literature.

A case of perforated neonatal appendicitis in a surviving premature infant is presented. An up-dated review of the English literature on this subject is included. Of 111 cases with adequate documentation, 29 neonates had the inflamed appendix located within the inguinal hernial sac and survived after operation. In contrast only 24 (29%) of the remaining 82 patients with intra-abdominal acute appendicitis survived. The operative mortality rate in this review since 1901 with and without appendiceal perforation was 61% and 41% respectively. The diagnosis of acute appendicitis since 1976 was made at laparotomy in all patients except one, whereas it was made at necropsy in 57% of the cases of abdominal appendicitis that were reported previously.

Appendectomy↗
PubMed1995

Prophylactic antibiotics in uncomplicated appendicitis during childhood--a prospective randomised study.

544 children operated upon for uncomplicated appendicitis were randomised into three groups. Group I received no antibiotics, patients in Group II were administered one single pre-operative dose of metronidazole (10 mg/kg) and patients in Group III received both both metronidazole (20 mg/kg) and cefuroxime (50 mg/kg) in a single preoperative dose. The rate of infectious complications in Group I was 6.3% but only 2.1 and 2.3 in Groups II and III, respectively. Among patients with a normal appendix or patients with simple appendicitis there was no difference in the rate of post-operative infections between the three different groups. However, in patients with gangrenous appendicitis the rate of postoperative infections was significantly lower in the two groups who received preoperative antibiotics (1.8% and 3.0% respectively) than in the group receiving no prophylactic antibiotics (infection rate 14%). It is concluded that a single preoperative dose of metronidazole significantly decreases the rate of postoperative infectious complications in children with appendicitis. No further improvement could be demonstrated if cefuroxime against aerobic organisms was added.

Adolescent↗
PubMed1998

Perforated appendicitis in children: risk factors for the development of complications.

BACKGROUND: Many aspects of the management of perforated appendicitis in children remain controversial. The objective of this study was to define risk factors associated with the development of postoperative complications in children undergoing treatment for perforated appendicitis. METHODS: We reviewed all children (age < 16 years) who were treated for perforated appendicitis at Cardinal Glennon Children's Hospital between 1988 and 1997. Inclusion criteria included either gross or microscopic evidence of appendiceal perforation. RESULTS: Of 285 children with perforated appendicitis, 279 underwent immediate operative treatment. Mean patient age was 7.7 years and there were no deaths. Major postoperative complications included intra-abdominal abscess (n = 17), ileus (n = 7), mechanical intestinal obstruction (n = 6), and wound infection (n = 4). All children who had a postoperative abscess had more than 5 days of symptoms before operation. Within this subgroup, drain placement was associated with not only decreased postoperative abscess formation and but also shorter duration of fever and length of hospitalization. The incidence of mechanical obstruction or ileus was not increased and the rate of wound infection was actually lower after drainage. CONCLUSIONS: Drain placement appears to be helpful in children with late diagnosis but is of little benefit when the duration of symptoms is less than 5 days. Thus it is likely that drains are most useful in patients with well-established and localized abscess cavities.

Abdominal Abscess↗
PubMed2000

Gangrenous and perforated appendicitis: a meta-analytic study of 2532 patients indicates that the incision should be closed primarily.

BACKGROUND: Surgical incisions after appendectomy for complicated (gangrenous or perforated) acute appendicitis are often managed with delayed closure (DC) rather than primary closure (PC). This study synthesizes the results of other studies in the surgical literature and supports the routine use of PC. METHODS: Studies dealing with complicated appendicitis were reviewed to assess the results of PC in comparison with DC. The rate of incision (wound) infection in groups of patients managed by PC and DC were compared with the use of a statistical technique that defined the probability of expected results by incorporating data derived from all of the various study groups. RESULTS: Of the 2532 patients who had been treated for complicated appendicitis and who were assessed, 1724 patients underwent PC and 808 patients underwent DC. The rate of incision infection was 4.7% and 4.6% in the PC and DC groups, respectively. With a 95% confidence interval, there was no demonstrable difference between the 2 types of operative site management (P < .01). CONCLUSIONS: PC of the skin and subcutaneous tissue after appendectomy for gangrenous or perforated appendicitis, combined with the use of antibiotic therapy in the perioperative period, is not associated with an increased risk of incision infection when compared with DC.

Acute Disease↗
PubMed2006

The SLAPPA (significance of lower abdominal/periumbilical piercing as a predictor of acute appendicitis) audit.

BACKGROUND: Anecdotal observations among medical staff suggest that young women with periumbilical piercing presenting with right iliac fossa pain are more likely to have pelvic inflammatory disease than acute appendicitis because of an unconventional lifestyle. This audit was performed to test the validity of this prejudice. METHODS: The clinical data of all female patients aged 16-45 years admitted to a teaching hospital with suspected acute appendicitis were collected prospectively over six months. Patients who had undergone previous appendicectomy or gynaecological surgery, those with known Crohn's disease, or those on antibiotics at the time of admission were excluded. RESULTS: 107 patients with a median age of 29.7 years (range 15-45 years) were studied. Thirty-two patients had periumbilical piercing (Group A) and 75 patients did not (Group B). Fifty-nine out of 107 (55.14%) were operated upon. Ten (31.2%) patients in Group A had histologically confirmed acute appendicitis compared with 25 (33.3%) in Group B. Other diagnoses in Group A included non-specific abdominal pain (n = 13, 40.6%), urinary tract infection (4, 12.5%), pelvic inflammatory disease (4, 12.5%) and ovarian cyst (1, 3.1%). Corresponding figures for patients in Group B were 30 (40.0%), 8 (10.7%), 7 (9.3%) and 4 (5.3%) respectively. None of the differences between the two groups were statistically significant. CONCLUSIONS: There was no difference in the frequency of a final diagnosis of acute appendicitis or pelvic inflammatory disease in female patients with and without periumbilical piercing. Health care professionals should not allow their clinical judgment to be prejudiced by the presence of body piercing.

Abdominal Pain↗
PubMed2000

Fiber intake and childhood appendicitis.

In order to investigate the possible role of fiber in the etiology of acute appendicitis, 203 consecutive appendectomized children with histologically proved appendicitis and 1922 controls were studied by the diet history method. Statistics were performed by multivariate analysis of variance, discriminant analysis and chi 2. Appendectomized children had statistically significant lower mean daily intake of fiber (17.4 g versus 20.4 g, P < 0.001) including all fiber fractions: cellulose, uronic acid, pentose, exose and lignin. No statistical difference was found for energy, protein, carbohydrate and fat intake. Discriminant analysis proved that only cellulose and exose are independently correlated to appendicitis and lower fiber intake is thought to be the cause in 70% of the cases. Recurrent abdominal pain, chronic constipation and positive family history of appendectomy were more frequent in appendectomized children (P < 0.001). This study gives evidence that low fiber intake could play an important role in the pathogenesis of appendicitis.

Abdominal Pain↗
PubMed2002

Scoring and diagnostic laparoscopy for suspected appendicitis.

OBJECTIVE: To develop a reproducible scoring system to identify patients who present with a doubtful diagnosis of appendicitis and who would benefit from diagnostic laparoscopy. DESIGN: Prospective observational study. SETTING: Regional teaching hospital, The Netherlands. SUBJECTS: 577 consecutive patients during the period 1994-5, and 343 who presented during the period 1996-7. INTERVENTIONS: The variables that seemed to be predictive of acute appendicitis were abstracted from the earlier group. a logistic regression analysis applied, and score created. The score was validated on the 343 patients who presented during 1996-7, and then the groups were combined for further analysis. MAIN OUTCOME MEASURES: Reproducibility of the scoring system obtained by comparing odds ratios (OR) of the two groups; its effectiveness judged by comparing the delayed and normal appendicectomy rates. RESULTS: The following variables were significantly correlated with the presence of acute appendicitis: white cell count 10 x 10(9)/L or more (score 3), rebound tenderness and male sex (score 2 each); and symptoms present for < 48 hrs and temperature 38 degrees C or more (score 1 each). The OR for the two groups were 1.80 and 1.76, respectively, indicating that score was reproducible. With a sensitivity of 93% and a specificity of 83% it would be at least as accurate as clinical judgment. The normal appendicectomy rate would be 7% instead of 9%. and the negative exploration rates (laparoscopy and primary appendicectomy) would both be 22%. The score would also result in a lower perforation rate (2% compared with 17%). CONCLUSION: The score can indicate when there is an indication for laparoscopy in patients with suspected appendicitis.

Adult↗
PubMed1999

Diagnostic accuracy of inflammatory markers in patients operated on for suspected acute appendicitis: a receiver operating characteristic curve analysis.

OBJECTIVE: To analyse the diagnostic accuracy of inflammatory variables in patients operated on for suspected acute appendicitis. DESIGN: Open prospective population based study. SETTING: Teaching hospital, Norway. INTERVENTIONS: Appendicectomy in 544 patients with clinically suspected acute appendicitis. MAIN OUTCOME MEASURES: Diagnostic accuracy of inflammatory variables using receiver operating characteristic (ROC) curve analysis. Logistic regression model of inflammatory variables using results of ROC-analysis. RESULTS: A small area under the ROC curve (AUC) (between 0.56 and 0.69) indicated less diagnostic accuracy. The best cut-off values were associated with low sensitivity and specificity, varying from 46% to 88%. Age, duration of history, and histological grade of inflammation significantly influenced the test results (AUC >0.5). The white cell count (WCC) and C-reactive protein (CRP) concentration were independent predictors of acute appendicitis with cut-off values of >12.3x10(9)/L and >0 mg/L, respectively, but AUC values of over 0.5 were observed only in patients between 13 and 40 years of age. CONCLUSION: Inflammatory variables added information of limited value in the diagnosis of suspected acute appendicitis. The test results should be interpreted differently in different groups of patients.

Acute Disease↗
PubMed2003

Monotherapy versus multi-drug therapy for the treatment of perforated appendicitis in children.

BACKGROUND: Children with perforated appendicitis often have a prolonged hospital course complicated by surgical site or intra-abdominal infections. Treatment with multiple intravenous (IV) antibiotics after appendectomy has been the standard of care for these patients. We have recently adopted a protocol using piperacillin-tazobactam (PT) as a single agent in lieu of the standard multi-drug regimen (MD). We hypothesized that PT would be as effective as MD in reducing postoperative complications and would result in decreased resource utilization. METHODS: We reviewed the medical records of all children admitted to our hospital between January 1, 1998 and December 31, 2001 with the diagnosis of perforated appendicitis. Patients who underwent operation within the first 24 h of admission were divided into two groups based on their antibiotic regimen: PT versus MD. Demographic data, duration of presenting symptoms, initial WBC, length of stay, and infectious complications were abstracted. Categorical data were compared using Chi square analysis; continuous variables were compared using Student's t-test when the data were normally distributed and the Mann-Whitney U test when the data were skewed. RESULTS: There was no difference between the PT (n = 51) and MD (n = 43) groups with respect to age, duration of presenting symptoms, initial WBC, or length of hospital stay. However, patients in the MD group had a significantly higher overall complication rate than those in the PT group (14/43 vs. 4/51, p = 0.002). Antibiotic-related complications including surgical site infections, venous catheter-related infections, intra-abdominal abscesses, and drug reactions were also higher in the MD group (10/43 vs. 4/51, p = 0.04). The outpatient charges for each patient based on an average of seven days of home antibiotics were $2,460 for the PT group and $4,349 for the MD group. CONCLUSIONS: Children with perforated appendicitis can be managed effectively with a single broad-spectrum antibiotic after appendectomy. Monotherapy is not only more efficacious than multi-drug therapy, but may be more cost effective. The use of monotherapy for children with perforated appendicitis after adequate source control should be considered the treatment of choice.

Ampicillin↗
PubMed2006

Two-trocar laparoscopic-assisted appendectomy versus conventional laparoscopic appendectomy in patients with acute appendicitis.

BACKGROUND: In order to reduce abdominal trauma and operative costs we have adopted a two-trocar laparoscopic-assisted appendectomy for patients with acute appendicitis. In the current study, the proposed technique is prospectively evaluated against conventional laparoscopic appendectomy with respect to feasibility, safety, and postoperative outcome. MATERIALS AND METHODS: Between July 2001 and July 2003, 83 consecutive patients were admitted with clinically diagnosed acute appendicitis and were randomly assigned to two-trocar laparoscopic-assisted appendectomy (n = 40, 48.2%) or conventional laparoscopic appendectomy (n = 43, 51.8%). RESULTS: Two-trocar laparoscopic-assisted appendectomy was successfully completed in 30 patients (80.1%). Four patients initially scheduled for two-trocar laparoscopic-assisted appendectomy (10.8%) were converted to laparotomy due to excessive body weight (BMI > or = 40), while an additional 5-mm infraumbilical trocar was inserted in another 3 patients (8.1%). The procedure was associated with decreased operative time and more rapid return to normal activity compared to laparoscopic appendectomy (P < 0.001 and P = 0.038, respectively). There was no statistically significant difference regarding the duration of hospitalization or the morbidity rate between the two groups. Conversion of the initial procedure was associated with increased wound infection rate and higher morbidity (P = 0.032 and P = 0.018, respectively). CONCLUSION: Two-trocar laparoscopic-assisted appendectomy represents a promising minimally invasive procedure for the treatment of acute appendicitis. It is fast and easy to perform, and it is expected to decrease the overall cost of laparoscopic appendectomy. Its only contraindication is excessive body weight; it remains to be evaluated in the setting of perforated appendicitis and retrocecally located appendices.

Adolescent↗
PubMed2003

Histopathology of interval (delayed) appendectomy specimens: strong association with granulomatous and xanthogranulomatous appendicitis.

Patients who present with a ruptured acute appendicitis are often treated with antibiotic therapy and drainage followed by a delayed or interval appendectomy. We noticed interval appendectomy specimens with granulomatous inflammation and postulated that interval appendectomy may lead to granulomatous appendicitis. To test this hypothesis, we reviewed the histopathology of all interval appendectomy specimens within a 4-year period and compared them with a control group of patients who had acute appendicitis and underwent routine acute appendectomy. All slides were randomized and reviewed blindly to assess the inflammatory patterns, with special attention given to the presence of granulomas and other Crohn-like features. Twenty-two cases of interval appendectomy were found. The interval between symptom onset and appendectomy ranged from 30 to 95 days with a mean of 58 days, whereas all 44 control patients had surgery within 72 hours of symptoms onset. Thirteen (59.1%) of the 22 interval appendectomy cases contained granulomas compared with only 3 of 44 controls (P < 0.0001). Eight (36.4%) of the interval appendectomy cases had xanthogranulomatous inflammation compared with none in the acute appendicitis group (P < 0.0001). A Crohn-like appearance was seen in 11 (50.0%) of the interval appendectomy cases and 1 of the controls (P < 0.0001). Follow-up data were available in 8 of 11 cases with Crohn-like features; none developed Crohn disease during an average follow-up period of 23 months. Delayed or interval appendectomy specimens often have a characteristic inflammatory pattern that includes granulomas, xanthogranulomatous inflammation, mural fibrosis/thickening, and transmural chronic inflammation. Without the appropriate clinical history, these changes may be misinterpreted as Crohn disease.

Adolescent↗
PubMed1984

The bacteriology and septic complication of patients with appendicitis.

A detailed bacteriologic study was done on 161 patients operated for appendicitis. Aerobic and anaerobic cultures were taken from the blood, the appendicular lumen, mucosa, serosa, fossa, and from the wound after closure of the peritoneum. There is no correlation between the degree of appendicitis and the incidence of positive blood culture. The infection spread through the appendicular wall as the disease progressed. Aerobic infection was common in early appendicitis but a mixed aerobic and anaerobic infection was predominant in late cases. Late appendicitis, a positive wound culture at the end of the operation, the duration of symptoms of over 36 hours before operation and the age of the patient over 50 years were all associated with an increased incidence of septic complication. From the antibiotic sensitivity on the bacteria isolated, the most effective agent against anaerobes was metronidazole. Effective agents against the aerobes were aminoglycosides and cephalosporins. The best single agent against both anaerobes and aerobes was moxalactum.

Anti-Bacterial Agents↗
PubMed1991

The epidemiology of acute appendicitis in California: racial, gender, and seasonal variation.

The incidence of acute appendicitis has been reported to vary substantially by country, geographic region, race, sex, season, and occupation, but the reasons for this variation are unknown. We evaluated several risk factors for appendicitis by analyzing data from hospital discharge abstracts on all cases of acute appendicitis treated surgically in nonfederal hospitals in California from 1983 to 1986 (N = 102,546). Comparison of age and sex-specific incidence rates for four racial/ethnic groups (white, Hispanic, black, and Asian/other) revealed rates in blacks and the Asian/other group one-half or less of the rates for whites and Hispanics between the ages of 5 and 29 years. Incidence rates in males were higher than rates in females in all racial/ethnic groups for most ages (RR = 1.1-1.7). Seasonal variation in incidence was modest. Peak rates occurred in July, August, and September, and the lowest rates occurred in December. Hypotheses about the etiology of appendicitis must account for substantial racial/ethnic, gender, age variation, and modest seasonal variation in the incidence.

Acute Disease↗
PubMed1993

Tc-99m labeled monoclonal antibodies against granulocytes (BW 250/183) in the detection of appendicitis.

Scintigraphy with Tc-99m labeled antigranulocyte antibodies (BW 250/183 MoABs) was performed in 32 patients with suspected appendicitis. Abdominal imaging (planar/SPECT) was performed 2 hours after injection of the tracer. All patients also had surgery and a histologic examination of the resected tissue. Of the patients, 17 suffered from "acute appendicitis" and 12 had right positive scans (sensitivity = 70.6%). In 15 patients, acute appendicitis could have been ruled out, and in 11 of these cases the scan was true negative (specificity = 73.3%). The overall accuracy was 71.8% (23/32 cases). The use of Tc-99m antigranulocyte MoABs may overcome the problems associated with the Tc-99m HMPAO granulocyte and In-111 oxine approaches, which include nonspecific intestinal activity or the lack of timeliness. The use of Tc-99m labeled antigranulocyte antibodies is suitable as an emergency procedure and may play a role in the management of patients with suspected appendicitis.

Adolescent↗
PubMedDate not supplied

Imaging findings in patients with-right lower quadrant pain: alternative diagnoses to appendicitis.

Patients with right lower quadrant (RLQ) pain referred for imaging studies with a clinical diagnosis of appendicitis may have other pathologic conditions mimicking appendicitis. Appropriate diagnostic imaging may establish other specific diagnoses and thereby play a significant role in determining proper medical or surgical treatment. In this pictorial essay, we present a spectrum of imaging findings in patients whose clinical features were suggestive of appendicitis, but the diagnoses of a broad spectrum of other diseases were established with the imaging studies. The differential diagnoses of diseases mimicking appendicitis are reviewed.

Abdominal Pain↗