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PubMed2007

Laparoscopic appendectomy: differences between male and female patients with suspected acute appendicitis.

BACKGROUND: The role of laparoscopy in the management of patients with suspected acute appendicitis remains controversial. It has been suggested that laparoscopy is useful mainly in young women of reproductive age because of the high incidence of wrong diagnosis in these patients. METHODS: Different management protocols for patients with suspected acute appendicitis were prospectively used in male and female patients; women of reproductive age were treated laparoscopically, while men were randomised to open or laparoscopic appendectomy. RESULTS: From September 2002 to September 2005, 132 patients-54 women and 78 men-with suspected acute appendicitis were treated according to the protocol. The incidence of wrong diagnosis in female patients was high (26% and the conversion rate low (5.5%). In contrast, in the laparoscopic male subgroup, these rates showed a reverse relationship (5.2% and 18.5%, respectively). Morbidity did not differ between female and male patients or between the 2 arms of the male group. Laparoscopic appendectomy took longer to perform without affecting significantly the needs for postoperative analgesia, the duration of hospital stay and the time to return to normal activities when compared with open appendectomy in men. CONCLUSION: Laparoscopic appendectomy is at least as safe as the open procedure in the male population, although it does not appear to offer any obvious advantage over the open procedure. The diagnostic advantage that laparoscopy offers to fertile women makes the procedure attractive for this population.

Adolescent↗
PubMed2004

Imaging strategies in children with suspected appendicitis.

Appendicitis is the commonest acute surgical emergency of childhood, and occurs in approximately 2-4 per 1000 infants. It is usually seen in infants older than 5 years but can occur at any age. Atypical clinical findings are seen in 30-50% of children, especially the younger ones, and often leads to a delayed diagnosis. Preoperative clinical assessment alone has yielded an accuracy ranging between 70 and 90% but is associated with a normal appendectomy rate of 13-25%. Preoperative imaging using the graded compression US technique and/or different helical CT techniques has been able to reduce this rate to 3-7% without an increase in perforation rate. An extensive review of the literature revealed several papers examining the accuracy of different imaging modalities and strategies of acute appendicitis in children. The reported sensitivity of US varied between 87 and 95%, vs 95-97% for helical CT, while the specificity ranged between 85 and 98% for US and 94 and 97% for helical CT. Only one truly randomised study was found, showing that compared with US alone, a combination of US and helical CT increased the sensitivity from 86 to 99%, while the specificity decreased from 95 to 89%. We conclude that imaging should be performed in all children with suspected appendicitis and that US should be the initial procedure with CT as a complementary tool.

Abdomen, Acute↗
PubMed2006

Acute appendicitis: diagnostic value of nonenhanced CT with selective use of contrast in routine clinical settings.

The purposes of this study were to determine the (1) frequency with which nonenhanced computed tomography (CT) (NECT) permits conclusive diagnosis of acute appendicitis, (2) accuracy of NECT when findings are conclusive, and (3) overall accuracy of a CT protocol consisting of NECT with selective use of contrast. Five hundred and thirty-six patients underwent a NECT protocol with selective use of contrast. Diagnostic accuracy was then determined separately for (1) patients with conclusive initial NECT, (2) patients with inconclusive initial NECT, and (3) all patients. NECT was conclusive on initial interpretation in 404/536 patients and inconclusive in 132/536. Of 132 inconclusive studies, 126 were repeated with contrast (intravenous, oral or rectal). Sensitivity, specificity, and positive and negative predictive value for diagnosis of acute appendicitis were (1) 90%, 96.0%, 84.8%, and 97.4% in patients with conclusive NECT (n = 404); (2) 95.6%, 92.3%, 73%, and 99% in patients with inconclusive NECT followed by repeat CT with contrast; and (3) 91.3%, 95%, 82%, and 98% in all patients. The initial diagnosis of appendicitis may be made by NECT in 75% of patients, with contrast administration reserved for inconclusive NECT studies.

Adolescent↗
PubMed2003

Seven cases of neonatal appendicitis with a review of the English language literature of the last century.

Neonatal appendicitis (NA) is a very rare surgical condition. The aim of this study is to once again draw attention to this subject by collecting our cases with NA and cases of NA reported separately in English-language literature over the period from 1901 to 2000. We performed a retrospective chart review of patients admitted to our hospital, with the clinical diagnosis of NA from 1990 to 2000. A survey of the English-language literature together with our own 7 cases revealed a total of 141 cases of NA during the period of 1901-2000. 128 cases had sufficient information for analysis. The patients are grouped and discussed according to these 3 time- periods: 1901-1975, 1976-1984 and 1985-2000. The incidence, etiology, and presenting signs and symptoms of appendicitis in newborns are discussed. Despite the similar perforation rates in the 3 time- periods (73%, 70%, 82%), mortality rate in NA has decreased from 78% in the 1901-1975 period, to 33% in the 1976-1984 period, and to 28% in the 1985-2000 period. A newborn baby presenting with continuous vomiting, refusal to feed, and, showing signs of pain through irritability, restlessness, sleep disturbance, and a distended abdomen; one should strongly suspect an abdominal disorder, perhaps appendicitis.

Appendicitis↗
PubMed2004

Minimum postoperative antibiotic duration in advanced appendicitis in children: a review.

The suitable duration of antibiotic use following appendectomy for advanced appendicitis in children is still debated. A systematic review was performed, including published experimental and observational data of antibiotic use in children who had undergone appendectomy for advanced appendicitis. Data were extracted and analyzed according to predefined criteria. Twenty-eight studies were selected that included 2,284 patients. There was no consistency among the protocols regarding length of antibiotic use, discharge criteria, or use of home antibiotics following discharge. Limiting duration of antibiotic use to 3 days did not appear to be associated with higher rates of intraabdominal abscess or wound infection. In the absence of higher-level evidence, shortening of antibiotic regimens following surgery for pediatric complicated appendicitis appears to be safe.

Anti-Bacterial Agents↗
PubMed2005

Peritoneal taurolidine lavage in children with localised peritonitis due to appendicitis.

Despite aggressive surgical treatment, rational antibiotic therapy, and modern intensive care, generalised peritonitis remains a major threat in the paediatric age group. Several adjuvant strategies such as peritoneal saline lavage and peritoneal drainage have been utilised. Taurolidine, derived from the amino acid taurine, has bactericidic, antiendotoxic, and antiinflammatory properties. It has been introduced previously for intraoperative peritoneal lavage in treating peritonitis in adults. The aim of our study was to evaluate the effect of peritoneal taurolidine lavage on the clinical course and serological inflammation markers in children with perforated appendicitis and localised peritonitis. A series of 27 children presenting with appendicitis between January 1999 and July 2001 were included in the study after parental informed consent. All patients underwent open appendectomy. Taurolidine peritoneal lavage was applied in 15 randomly selected children (eight girls and seven boys; mean age 10 years and 10 months). Twelve children received saline peritoneal lavage and served as the control group (six girls and six boys; mean age 9 years and 7 months). Blood was taken preoperatively and on postoperative days 1, 3, 7, and 14. Full blood cell count, C-reactive protein, endotoxin, interleukin-1, interleukin-6, soluble interleukin-2 receptor, tumour necrosis factor alpha, and procalcitonin were investigated to evaluate the serological course of inflammation. Both groups initially presented with severe inflammation as evidenced clinically and serologically. The clinical postoperative course was uneventful in 13/15 patients in the treatment group and 10/12 patients in the control group. The remaining patients presented complications: intraperitoneal abscess or early postoperative bowel obstruction. With regard to the serological inflammatory parameters, no significant differences were found between the two groups except for the soluble interleukin-2-receptor on the 7th postoperative day. In conclusion, the expected reduction of endotoxin levels and inflammatory activity in the treatment group was not evident. A significant advantage of adjuvant peritoneal taurolidine lavage in the surgical therapy of children with localised peritonitis due to appendicitis could not be shown in our study.

Anti-Infective Agents↗
PubMed2005

Primary versus delayed wound closure in complicated appendicitis: an international systematic review and meta-analysis.

The purpose of this study was to determine, by means of a systematic review, whether the method of wound closure in complicated appendicitis affects the incidence of wound infection. A comprehensive literature search of multiple databases including MEDLINE (1980-2003), was performed, using the Cochrane search strategy, for articles on wound closure and complicated appendicitis. Clinical trials examining the method of wound closure were selected for systematic review and all quasi-randomized and randomized trials underwent meta-analysis. Failure to close the wound as planned in delayed closure (DC) was considered indicative of a wound infection. Purulent drainage requiring wound opening indicated an infection in the wounds closed primarily. Six randomized trials were considered adequate for meta-analysis. None independently showed a statistically significant difference in the risk of developing a wound infection with primary closure (PC). When pooled data were subjected to meta-analysis, PC achieved a statistically significant reduction in the relative risk of treatment failure and did not lead to an increase in wound infections. Primary closure does not increase the risk of developing a wound infection after operation for perforated appendicitis. Given the lack of benefit of DC, and the less traumatic, less painful, and less costly nature of PC; primary closure is a safe and practical treatment option.

Appendicitis↗
PubMed1998

Is acute appendicitis different in patients with sickle cell disease?

Nine patients with sickle cell disease (SCD) were operated upon at our hospital for acute appendicitis, comprising only 0.43% of the total appendicectomies performed at our institution. Three appendices were acutely inflamed and six (66.7%) were perforated. Histologic evaluation of the six perforated specimens revealed congestion and haemorrhage by sickled erythrocytes (RBCs) in addition to acute transmural inflammatory cell infiltrates. The mucosa was extensively ulcerated, with haemorrhage both within the lumen and in the appendiceal wall. The blood vessels were dilated and packed with sickled RBCs. Two of the three acutely inflamed appendices showed features of acute transmural appendicitis, with marked congestion and haemorrhage by sickled RBCs. The third did not show any acute inflammatory cell infiltrate, however, the mucosa was partly ulcerated with both mucosal and intraluminal haemorrhage. These findings suggest that acute appendicitis is different in patients with SCD: while it is not common, when it does develop it has a rapid course with a high incidence of perforation due to blockage of appendiceal vessels by sickled RBCs, leading to transmural necrosis.

Adolescent↗
PubMed2006

Live birth after laparotomy for concurrent heterotopic pregnancy and appendicitis in a 6 weeks IVF pregnancy.

BACKGROUND: A term delivery after concurrent appendectomy and salpingectomy at 6 weeks in an appendicitis coexisting with a heterotopic pregnancy after in vitro fertilization (IVF) treatment is reported. METHODS: Case report. RESULTS: The patient presented with severe low abdominal pain at 6 weeks of pregnancy after IVF and had explorative laparotomy for appendicitis, during which she had appendectomy and salpingectomy for an undiagnosed concurrent heterotopic pregnancy. The patient delivered a 3,960 g healthy infant at 38 weeks. CONCLUSION: In patients with severe abdominal pain after IVF, appendicitis and heterotopic pregnancy should be included in the differential diagnosis. A dual pathology is possible and when treated appropriately it can result in survival of the precious intrauterine pregnancy. This is the second and earliest ever reported case of that resulted in live birth. It shows that explorative surgery must be performed timely in acute abdomen in pregnancy.

Adult↗
PubMed2004

Acute appendicitis in preschool-age children.

UNLABELLED: During the last 11 years, 122 children aged less than 5 years underwent appendectomy with a preoperative diagnosis of acute appendicitis. At surgery, 29 children (24%) presented with acute suppurative appendicitis, 64 children (52%) perforated appendices and 26 children (21%) with appendiceal abscess. In three cases (2%) there was no acute intra-abdominal process. In this study the following data were analysed: age, gender, symptoms, duration of symptoms, whether seen by a physician prior to admission and surgery, physical findings, stage of the disease at operation, histology, postoperative complications and mortality. CONCLUSION: The accurate diagnosis in early childhood appendicitis is still a difficult matter. The responsibility of the paediatric surgeon is mainly the clinical examination with all his clinical skills and facilities and if serious doubt still exists, to proceed with a laparotomy in order to reach a definite diagnosis.

Abdominal Abscess↗
PubMed1997

Evaluation of 99mTc-citrate, 67Ga-citrate and 99mTc(V) dimercaptosuccinic acid for the scintigraphic visualization of acute appendicitis.

An experimental study was planned to evaluate 99mTc-citrate, 67Ga-citrate and 99mTc(V) dimercaptosuccinic acid (DMSA) as agents for the visualization of acute appendicitis. Appendiceal ligation was performed through a midline incision in 24 rabbits. Twenty-four hours later the animals were divided into three equal groups. The rabbits were injected through the aurical vein with 1 mCi (37 MBq) 99mTc-citrate in group I, 0.5 mCi (18.5 MBq) 67Ga-citrate in group II and 1 mCi (37 MBq) 99mTc(V) DMSA in group III. After 3 h, static images of the rabbits were obtained with a gamma camera. There were positive images in seven, six and five rabbits in groups I, II and III respectively. The image quality was better in group I than in the other groups. Also, the mean uptake in group I was significantly higher than those of other two groups (P < 0.05). There was no significant difference between groups II and III (P > 0.05). All rabbits had appendicitis confirmed histologically. In conclusion, these results show that 99mTc-citrate is preferable to 67Ga-citrate and 99mTc(V) DMSA for the differential diagnosis of acute abdominal inflammations such as appendicitis, because of higher concentration ratios, simple and rapid preparation, low cost, excretion mainly through the kidneys and fast blood clearance.

Acute Disease↗
PubMed2003

Late-presenting appendicitis: a laparoscopic approach to a complicated problem.

BACKGROUND: Acute appendicitis is the most common abdominal condition necessitating urgent surgical intervention in the United States. The objective of this study was to determine if interval laparoscopic appendectomy after initial nonoperative treatment for late appendicitis presenting as an appendiceal mass is a safe alternative to immediate appendectomy. METHODS: Thirty two consecutive patients (aged 16-74 years) during a 5-year period presented with appendiceal mass. Seventeen received initial nonsurgical treatment followed by interval laparoscopic appendectomy (aged 16-60 years; group 1). Fifteen underwent immediate appendectomy (aged 16-74 years; group 2). RESULTS: All patients in the interval laparoscopic appendectomy group improved with initial therapy and underwent surgery an average of 4.9 months later. Although the operative time and the complication rate were similar between groups 1 and 2, the time to return to baseline activities was significantly less in group 1 after adjusting for age (p = 0.02 or less). CONCLUSIONS: Interval laparoscopic appendectomy is safe in patients with chronic appendicitis and allows for judicious diagnostic evaluation of the appendiceal mass and planned surgery under controlled conditions.

Acute Disease↗
PubMed2003

Pediatric laparoscopic appendectomy for acute appendicitis.

BACKGROUND: The benefit of laparoscopy in the treatment of pediatric acute appendicitis continues to be controversial, particularly as it relates to operative time and costs. METHODS: We reviewed the charts of 200 children who underwent appendectomy for acute appendicitis concurrently over 35 months at a large teaching children's hospital. RESULTS: Laparoscopic ( n = 105) [corrected] and open ( n = 95) appendectomies were performed. The operative times and postoperative lengths of hospital stay were similar for the two groups. The mean total hospital cost for the laparoscopic group (5,572 dollars) was significantly higher than for the open group (4,472 dollars); ( p < 0.01). CONCLUSIONS: Notably, the results show similar operative times for laparoscopic and open appendectomy. The cost of laparoscopic appendectomy for acute appendicitis is higher than for the open procedure. This study challenges health care providers to reduce costs and develop new ways to measure beneficial outcomes in a pediatric population that may reveal laparoscopic benefits.

Acute Disease↗
PubMed2003

A prospective, randomized, unicenter study comparing laparoscopic and open treatments of acute appendicitis.

BACKGROUND: Appendectomy in the course of acute appendicitis is one of the most frequently performed surgical procedure in general surgery. The aim of this study was to compare the results of laparoscopic and conventional treatments for acute appendicitis in a prospective, randomized, unicenter study. METHODS: The study involved 200 patients treated for acute appendicitis in the Department of General and Vascular Surgery at Ceynowa Hospital in Wejherowo, Poland. RESULTS: The mean operative time for open surgery was 36.99 min. For laparoscopic method the operation was longer, requiring 47.75 min. Suction drainage was applied in 23 patients treated conventionally and 50 patients treated laparoscopically ( p < 0.05). The requirement for analgesia, measured by the number of metamizole ampules, was significantly higher in the conventional group. Pain on postoperative days 2 and 7 measured using a visual analog scale, was significantly more severe for the patients treated conventionally. The hospital stay in both groups did not differ significantly: 5.03 days for the conventional group and 4.71 days for the laparoscopic group. The time until return to work and social activities in the laparoscopic group (15.85 days) and was significantly shorter than in the conventional group (19.65 days). Seven complications occurred in the conventional group (6.7%) and nine (9.4%) in the laparoscopic group. The difference was not statistically significant. No deaths occurred. CONCLUSIONS: On the basis of the conducted study, it may be assumed that laparoscopic appendectomy is a safe procedure, and that postoperative morbidity is comparable with that for a conventional operation. There was less postoperative pain and shorter recovery time after laparoscopic surgery than after the open procedure.

Acute Disease↗
PubMed2003

Laparoscopy for appendicitis and cholelithiasis during pregnancy: a new standard of care.

BACKGROUND: Subsequent to a report from the authors' institution, the laparoscopic management of symptomatic cholelithiasis and appendicitis during pregnancy has become the standard of care at LDS Hospital using institutional guidelines. For comparison with previous outcomes described by the authors, 59 additional laparoscopic cases are reported. METHODS: Medical records of all pregnant patients at LDS Hospital who underwent open or laparoscopic cholecystectomy or appendectomy between 1998 and 2002 were reviewed. The outcomes were compared with the authors' previous data. RESULTS: The laparoscopic management of symptomatic cholelithiasis and appendicitis during pregnancy increased from 54% to 97%. No significant differences in preterm delivery rates, birth weights, or 5-min Apgar scores were found between the two periods. No birth defects or uterine injuries occurred. CONCLUSIONS: With the use of the authors' guidelines, laparoscopy has become the standard of care for managing symptomatic cholelithiasis and appendicitis during pregnancy at LDS Hospital without significant increase in morbidity or mortality.

Adult↗
PubMed2004

The Fenyö-Lindberg scoring system for appendicitis increases positive predictive value in fertile women--a prospective study in 455 patients randomized to either laparoscopic or open appendectomy.

BACKGROUND: Suspected appendicitis is one of the most common indications for acute laparotomy or laparoscopy. The negative laparotomy and laparoscopy rates are high, often in the range of 15-30%, and especially high in some groups of patients such as women of child-bearing age and young patients. Different scoring systems have been introduced in order to improve diagnostic accuracy. The aim of the present study was to analyse the outcome of the Fenyö-Lindberg scoring system in a prospectively randomized multicenter trial and to analyze how well the score performed in stratified subgroups. METHODS: The variables of the Fenyö-Lindberg scoring system were collected in a prospective study comparing laparoscopic and open surgery in suspected appendicitis and with four participating centers. None of the hospitals had used the scoring system previously. Since surgeons were unfamiliar with the score, they could not use it as a diagnostic aid. When comparing the score with the clinical outcome, retrospectively, the investigators interpreting the score were blinded regarding the surgical outcome. RESULTS: Positive predictive value (PPV) of the Fenyö-Lindberg score was higher than that of the surgeon's clinical diagnosis in the patient cohort [0.90 vs 0.79 (p < 0.001)]. The score demonstrated an improvement of PPV in women [0.83 vs 0.70 (p < 0.01)]. PPV was increased in women between 15 and 50 years of age. In women aged 15-30 years and 31-50 years PPV increased from 0.69 to 0.82 and 0.68 to 0.86, respectively (p < 0.01). Both the sensitivity (0.77) and the specificity (0.69) of the score were, however, low. CONCLUSION: The Fenyö-Lindberg score is an inexpensive clinical tool that may improve the diagnostic accuracy for acute appendicitis in women of childbearing age, which is a group of patients where the diagnostic accuracy usually is low and where the arsenal of diagnostic tools such as computed tomography is limited because of radiation. The low specificity of the score in women of childbearing age must, however, be kept in mind.

Adolescent↗
PubMed2006

Impact of previous abdominal surgery on laparoscopic appendectomy for acute appendicitis.

BACKGROUND: Laparoscopic appendectomy is one of the most commonly performed laparoscopic procedures. Impact of previous abdominal surgery on laparoscopic appendectomy has not been previously reported. METHODS: From January 2001 to December 2005, 2029 patients with clinically suspected acute appendicitis underwent laparoscopic surgery in our hospital. Of these, 234 patients (11.5%) were found to have other pathology by intraoperative or histologic findings and were excluded from the study. The 1795 patients who underwent laparoscopic appendectomy for acute appendicitis were divided into three groups: group 1, patients without a history of previous abdominal surgery (n = 1652, 92%); group 2, patients with a history of upper abdominal surgery (n = 20, 1.1%); group 3, patients with a history of lower abdominal surgery (n = 123, 6.8%). Data were collected retrospectively by chart review and analyzed for conversion rate, operative time, intraoperative and postoperative complications, and hospital stay. RESULTS: Of the 1795 patients, 13 (0.7%) were converted to open appendectomy because of technical difficulty. Overall mean operative time was 57.2 (range, 20-225) min. There was no mortality or intraoperative complications. Overall postoperative complication rate was 10.7% (n = 193): rate of surgical wound infection was 8.2% (n = 147), surgical wound seroma 1.3% (n = 24), and intra-abdominal abscess 0.8% (n = 14). Overall postoperative hospital stay averaged 3.2 (range, 0-39) days. There were no significant differences between the three groups regarding the conversion rate (0.8% vs. 0% vs. 0%, p = 0.567), operative time (57.3 vs. 55.8 vs. 56.9 min, p = 0.962), postoperative complication rates (10.7 vs. 10 vs. 12.2%, p = 0.863), and hospital stay (3.2 vs. 3.6 vs. 3.1 days, p = 0.673). CONCLUSIONS: Previous abdominal surgery, whether upper or lower abdominal, has no significant impact on laparoscopic appendectomy for acute appendicitis.

Acute Disease↗
PubMed2005

Clear peritoneal effluent in a child on CCPD with a phlegmonous appendicitis.

Peritonitis as a result of a perorated appendicitis is a rare but life-threatening situation in a patient on peritoneal dialysis (PD). As far as we are aware, the combination of clear dialysate effluent and phlegmonous appendicitis in a patient on PD has not previously been described. We report a 16-year-old girl with acute onset of abdominal pain and vomiting who turned out to have phlegmonous appendicitis, despite having a clear dialysate effluent with normal cell count, and who subsequently developed E coli peritonitis after surgery.

Abdominal Pain↗