Is it possible to predict the severity of acute appendicitis? Reliability of predictive models based on easily available blood variables.

INTRODUCTION: Recent evidence confirms that the treatment of acute appendicitis is not necessarily surgical, and selected patients with uncomplicated appendicitis can benefit from a non-operative management. Unfortunately, no cost-effective test has been proven to be able to effectively predict the degree of appendicular inflammation as yet, therefore, patient selection is too often left to the personal choice of the emergency surgeon. Our paper aims to clarify if basic and readily available blood tests can give reliable prognostic information to build up predictive models to help the decision-making process. METHODS: Clinical notes of 2275 patients who underwent an appendicectomy with a presumptive diagnosis of acute appendicitis were reviewed, taking into consideration basic preoperative blood tests and histology reports on the surgical specimens. Variables were compared with univariate and multivariate analysis, and predictive models were created. RESULTS: 18.2% of patients had a negative appendicectomy, 9.6% had mucosal only inflammation, 53% had transmural inflammation and 19.2% had gangrenous appendicitis. A strong correlation was found between degree of inflammation and lymphocytes count and CRP/Albumin ratio, both at univariate and multivariate analysis. A predictive model to identify cases of gangrenous appendicitis was developed. CONCLUSION: Low lymphocyte count and high CRP/Albumin ratio combined into a predictive model may have a role in the selection of patients who deserve appendicectomy instead of non-operative management of acute appendicitis.

Outcomes in High Perianal Fistula Repair Using Video-Assisted Anal Fistula Treatment Compared With Seton Use: A Randomized Controlled Trial.

Background Anal fistula, or fistula-in-ano, is a chronic abnormal communication between the epithelialized surface of the anal canal and the perianal skin. Video-assisted anal fistula treatment (VAAFT) is a novel, minimally invasive, and sphincter-saving alternative to traditional seton use. This study aimed to determine the short-term and long-term outcomes of VAAFT compared with seton treatment. Material and methods This randomized control trial was conducted at the Department of Surgery, Services Hospital, Lahore, from August 2014 to July 2020. Patients were randomly assigned to either the VAAFT group or the seton group, and postoperative outcomes were assessed for up to three years. Results The study included 80 patients (64 men and 16 women) with a mean age of 39.1 ± 11.2 years. The most common type of fistula was a transsphincteric fistula (n=36, 45%). The mean duration of surgery was significantly longer in the VAAFT group (78.6 minutes) compared with the seton group (36.97 minutes; p=0.000). The mean pain score was significantly higher in the VAAFT group (4.22) compared to the seton group (2.82, p=0.000). The mean time to return to work was shorter in the VAAFT group (7.4 days) than in the seton group (9.2 days, p=0.000). The mean healing time was significantly shorter for patients treated with VAAFT (5.75 weeks) than for those treated with a seton (9.7 weeks; p=0.000). Fistula recurrence after one, two, or three years was not significantly different between groups, and neither group had incidences of anal incontinence. Conclusions VAAFT is associated with earlier healing time and earlier return to work than the traditional seton technique, with no significant difference in fistula recurrence. VAAFT is minimally invasive and, when used in patients where indicated, allows for a prompter return to routine life for the patients, which is an optimal outcome for both patients and physicians.

Role of Laparoscopy in Diagnosing and Treating Acute Nonspecific Abdominal Pain.

Background Nonspecific abdominal pain (NSAP) is a pain for which no immediate cause is evident on acute admission and does not necessitate emergency surgical intervention. NSAP is a frequent reason for presentation in the emergency department (ED). Laparoscopy is a well-established technique that allows a surgeon to visualize the abdominal cavity after insufflation through a few small incision ports. Despite the increasing availability of laparoscopic investigation, the availability of a laparoscope in the ED settings in Pakistan is low due to the expense and maintenance needs of the system. Objective This study aimed to evaluate the role of laparoscopy in diagnosing the cause of acute NSAP and its role in treating the pathology of disease in patients presenting to the emergency department (ED) of Services Hospital, which is a government sector hospital in Lahore, Pakistan. Materials and methods This study was conducted in Services Hospital Lahore, Pakistan, from January 1, 2016 to December 31, 2019. The study included patients aged 12 to 70 years of either sex who presented to the ED with abdominal pain for whom no diagnosis could be achieved on clinical assessment, laboratory findings, and radiological findings (x-ray abdomen, ultrasonography, and computed tomography scan). All study participants underwent diagnostic laparoscopy under general anesthesia. Patients were monitored weekly via follow-up postoperatively for the first month and then monthly for 12 months. All study data were recorded on a predesigned proforma. The data were analyzed using IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. Results A total of 122 patients diagnosed with acute NSAP were enrolled in our study (mean age, 46.4 ± 20.3 years). The study population consisted of 52 male patients (42.6%) and 70 female patients (57.4%). Our study participants had a mean body mass index of 24.2 ± 3.3 kg/m2. The most common ED presentation was lower abdominal pain. One hundred sixteen patients (95.1%) had positive findings on laparoscopy, while six patients (4.9%) had no identified pathology on laparoscopy. The most frequent pathology was appendicular in origin, followed by pelvic inflammatory disease. Surgical management of patients through laparoscopy was performed in 97 patients (79.5%). Conversion to laparotomy was done in 12 patients (9.8%). Definite diagnosis was established in 118 patients (96.7%). Port site infection occurred in four patients (3.3%), chest infection in five patients (4.1%), deep venous thrombosis in one patient (0.8%), and anastomotic leakage in one (0.8%) patient. Four patients (3.3%) developed recurrence of symptoms. Conclusions This study explored the role of laparoscopy in diagnosing and treating patients presenting to the ED with acute NSAP. According to our results, laparoscopy is a safe and effective method for diagnosing and treating acute NSAP with low postoperative morbidity and potentially decreased risk of postoperative complications. Physicians should consider laparoscopy as a first-line invasive investigation for patients presenting with undiagnosed acute abdominal pain.