Índice neutrófilos-linfocitos en el diagnóstico de apendicitis aguda. Una evaluación de su precisión diagnóstica / Neutrophil-to-lymphocyte ratio in the diagnosis of acute appendicitis. Assessment of its diagnostic accuracy

Introducción. La apendicitis aguda (AA) en pacientes pediátricos requiere de un diagnóstico certero. El índice neutrófilos-linfocitos (INL) es un parámetro accesible que puede ser útil en su diagnóstico. Objetivo. Determinar la precisión del INL para diagnosticar AA en pacientes con dolor abdominal. Población y métodos. Estudio de prueba diagnóstica. Se incluyeron 520 pacientes atendidos en el servicio de urgencias pediátricas. Para cuantificar la precisión diagnóstica, se estimó la sensibilidad, la especificidad, los valores predictivos (VP) y los cocientes de probabilidad (CP). Se utilizó un modelo de regresión logística múltiple para evaluar el efecto de las potenciales variables confusoras en la relación entre el INL y la AA. Resultados. La prevalencia de AA fue del 49 %. Para un punto de corte de 5, la sensibilidad fue del 85,1 %, especificidad: 78,9 %, VP+: 79,5 % y VP-: 84,6 %. Sin embargo, basándose en los cocientes de probabilidad, el INL es una prueba poco potente para el diagnóstico de AA (CP+ = 4,03 y CP- = 0,18) y resultó una prueba sin utilidad diagnóstica en el caso de apendicitis complicada (CP+ = 1,57 y CP- = 0,55). Después del ajuste por edad, sexo, obesidad, tiempo de evolución y uso de analgésicos, el INL fue una variable explicativa de la presencia de AA (odds ratio = 23,53; IC95 % 13,14-42,15). Conclusiones. El INL no es lo suficientemente preciso aisladamente para confirmar o descartar la presencia de AA. No obstante, el INL puede emplearse junto con otras pruebas para seleccionar a los pacientes en los cuales es necesario un mayor estudio.

Introduction. Acute appendicitis (AA) in pediatric patients requires an accurate diagnosis. The neutrophil-to-lymphocyte ratio (NLR) is an accessible parameter useful for its diagnosis. Objective. To determine NLR accuracy to diagnose AA in patients with abdominal pain. Population and methods. Diagnostic test study. A total of 520 patients seen at the Pediatric Emergency Department were included. Diagnostic accuracy was estimated based on sensitivity, specificity, predictive values, and likelihood ratios. A multiple logistic regression model was used to assess the effect of potentially confounding variables in the relationship between NLR and AA. Results. The prevalence of AA was 49%. For a cutoff point of 5, sensitivity was 85.1%, specificity: 78.9%; positive predictive value: 79.5%; and negative predictive value: 84.6%. However, based on likelihood ratios, the NLR is not powerful enough to diagnose AA (positive likelihood ratio = 4.03 and negative likelihood ratio = 0.18) and did not exhibit diagnostic usefulness in complicated appendicitis (positive likelihood ratio = 1.57 and negative likelihood ratio = 0.55). Following adjustment for age, sex, obesity, time since symptom onset, and analgesic use, the NLR was an explanatory variable for the presence of AA (odds ratio = 23.53; 95% confidence interval: 13.14­42.15). Conclusions. The NLR alone is not sufficiently accurate to confirm or rule out the presence of AA. However, the NLR can be used together with other tests to select patients in whom further study is necessary.

Impacto de la pandemia por COVID-19 en la población pediátrica con apendicitis aguda: experiencia en un hospital general de tercer nivel / Impact of the COVID-19 pandemic on the pediatric population with acute appendicitis: Experience at a general, tertiary care hospital

Introducción. La apendicitis constituye la principal causa de abdomen agudo quirúrgico en pediatría. Durante la pandemia por COVID-19, se replantearon las estrategias de manejo ydisminuyeron las consultas en las guardias, lo que podría asociarse a diagnósticos tardíos y complicaciones. El objetivo de este estudio fue analizar el impacto de la pandemia en los niños con apendicitis aguda. Métodos. Estudio analítico retrospectivocomparativo de pacientes pediátricos conapendicitis aguda durante los cinco meses del confinamiento por COVID-19 versus los meses equivalentes del año previo. Se analizaron la incidencia, la clínica, el estadio, el abordajequirúrgico y las complicaciones. Resultados. Los casos totales de apendicitisse redujeron un 25 % (n = 67 versus n = 50 en 2020). El tiempo medio hasta la consulta fue de 24 horas en ambos períodos (p = 0,989). La incidencia de peritonitis fue del 44 % (n = 22) versus el 37 % (n = 22) (p = 0,22) en 2019. No se evidenció diferencia en los estadios deenfermedad de acuerdo con lo informado en los partes quirúrgicos. En 2019, todas las cirugías se realizaron por vía laparoscópica; en 2020, solo un42 % (n = 21). La incidencia de complicaciones fue del 6 %, contra 7,5 % en el período previo (p = 0,75). Un paciente fue COVID-19 positivo. Conclusión. A pesar de la reducción en el númerode casos de apendicitis, no se evidenció una demora en la consulta en nuestra población. El mayor impacto se asoció a la readecuación del manejo, evitando el abordaje laparoscópico para reducir la diseminación del virus.

Introduction. Appendicitis is the leading cause of surgical acute abdomen in pediatrics. During the COVID-19 pandemic, management strategies were reassessed and the number of visits to the emergency department dropped down, which may be associated with delayed diagnoses and complications. The objective of this study was to analyze the impact of the pandemic on children with acute appendicitis. Methods. Analytical, retrospective, comparative study of pediatric patients with acute appendicitis in the 5 months of COVID-19 lockdown versus the same period in the previous year. Incidence, clinical data, stage, surgical approach, and complications were analyzed. Results. The total number of appendicitis cases went down by 25 % (n = 67 versus n = 50 in 2020). The mean time to consultation was 24 hours in both periods (p = 0.989). The incidence of peritonitis was 44 % (n = 22) versus 37 % (n = 22) (p = 0.22) in 2019. No differences were  observed in terms of appendicitis stage based on surgery reports. In 2019, all surgeries were laparoscopic; while in 2020, only 42 % (n = 21). The incidence of complications was 6 % versus 7.5 % in the previous period (p = 0.75). One patient was COVID-19 positive. Conclusion. Although in our population the number of appendicitis cases dropped down, consultation was not delayed. The greater impact was associated with the reformulation of management strategies, in which the laparoscopic approach is avoided to reduce virus transmission.

Management of acute appendicitis during the COVID-19 pandemic: Views of two Brazilian surgical societies / Análise descritiva do tratamento dos doentes com apendicite aguda durante a pandemia de COVID-19: A visão dos cirurgiões de duas sociedades nacionais

ABSTRACT Acute appendicitis (AA) is a frequent cause of abdominal pain requiring surgical treatment. During the COVID-19 pandemic, surgical societies considered other therapeutic options due to uncertainties in the evolution of the disease. The purpose of this study is to assess the treatment of AA by members of two Brazilian surgical societies in this period. A common questionnaire was sent in 2020. There were 382 responses. Most surgeons had more than 15 years of profession (68.3%) and treated more than five cases per month (44.8%). About 72.5% would indicate chest CT to investigate COVID-19 in patients with AA. For those patients sustaining uncomplicated AA, without COVID-19, 60.2% would indicate laparoscopic appendectomy (VLA), followed by open appendectomy (OA) (31.7%) and non-operative management (NOM) (1.3%). For those with mild COVID-19, OA was suggested by 51.0%, followed by VLA (29.6%) and NOM (6.0%). For those with severe COVID-19, OA was proposed by 35.3%, followed by NOM (19.9%) and VLA (18.6%). For patients with periappendiceal abscesses, without COVID-19, VLA was suggested by 54.2%, followed by OA (33.2%) and NOM (4.4%). For those with mild COVID-19, OA was proposed in 49.5%, followed by VLA (29.3%) and NOM (8.9%). In those with severe COVID-19, OA was proposed in 36.6%, followed by NOM (25.1%) and VLA (17.3%). This information, based on two recognized Brazilian surgical societies, can help the surgeon to select the best approach individually.

RESUMO A apendicite aguda (AA) é causa frequente de abdome agudo cirúrgico. Durante a pandemia de COVID-19, devido às incertezas na evolução da doença, sociedades consideraram outras opções terapêuticas. Nosso objetivo é descrever o tratamento da AA por membros do CBC e SBAIT neste período. O questionário foi enviado em 2020. Houve 382 respostas. A maioria dos profissionais tinha mais de 15 anos de profissão (68,3%) e atendia mais de cinco casos por mês (44,8%). Cerca de 72,5% realizariam TC de tórax para investigação de COVID-19 em pacientes com AA. Nos com AA não complicada, sem COVID-19, 60,2% optariam pela apendicectomia videolaparoscópica (AVL), seguido de apendicectomia aberta (AAB) (31,7%) e tratamento não operatório (TNO) (1,3%). Nos com COVID-19 leve, AAB foi proposta por 51,0%, seguido da AVL (29,6%) e TNO (6,0%). Nos com COVID-19 grave, a AAB foi proposta por 35,3%, seguido de TNO (19,9%) e AVL (18,6%). Nos com AA complicadas com abscesso, sem COVID-19, AVL foi sugerida por 54,2%, seguida da AAB (33,2%) e TNO (4,4%). Nos com COVID-19 leve, a AAB foi proposta em 49,5%, seguidos da AVL (29,3%) e TNO (8,9%). Nos com COVID-19 grave, a AAB foi proposta em 36,6%, seguido de TNO (25,1%) e AVL (17,3%). Estas são opções de cirurgiões de duas sociedades cirúrgicas reconhecidas e podem auxiliar o colega que está na linha de frente a definir a melhor conduta individualmente.

Apendicitis aguda en el niño: guía de práctica clínica / Acute appendicitis in children. Clinical Pratice Guide

En las últimas décadas se ha prestado mayor atención a los resultados de la actividad quirúrgica debido al peso económico que esta actividad genera en los servicios de salud, el avance ocurrido en la mejora de los cuidados perioperatorios y la creciente ocupación institucional por la calidad de la asistencia y la satisfacción de la población. A este propósito han contribuido el desarrollo y aplicación de guías de práctica clínica. Estas guías reducen la variación en los cuidados del paciente quirúrgico y aumentan su eficiencia, lo que permite que los pacientes se beneficien de iniciativas institucionales encaminadas a mejorar la calidad de la asistencia sanitaria. La apendicitis aguda es sin dudas la enfermedad que tipifica la atención quirúrgica de urgencia en la mayoría de los centros dedicados a la atención sanitaria de niños y adolescentes. Su frecuencia, variación en las características clínicas en los diferentes grupos de edad y los crecientes reportes sobre la posibilidad de tratarse por métodos no quirúrgicos, hizo necesaria una revisión del tema. En el IV Simposio Nacional de Cirugía Pediátrica (Varadero, Matanzas, 1- 3 de julio de 2019), fue presentada, discutida y aprobada una Guía de Práctica Clínica de Apendicitis Aguda en el niño. Compartir la guía a través de su publicación, permitiría a servicios de cirugía pediátrica emplearla como referencia, aplicarla en sus propias instituciones y beneficiar a un gran número de pacientes(AU)

In the last decades, it has been paied attention to the results of the surgical activity due to the economic weight this activity yields in the health services, the advances in the improvement of perioperative cares and the growing institutional occupation due to the quality in the care and the population´s satisfaction. The development and implementation of clinical practice guides have contributed to that purpose. These guides reduce the variation in the cares of surgical patients and increase their efficiency, which allows patients to be benefited by institutional initiatives aimed to improve health care´s quality. Acute appendicitis is, with no doubts, the disease that characterizes emergencie´s surgical care in most of the facilities devoted to children and adolescents´health care. Its frequency, the variation of clinical characteristics in the different age groups and the increasing reports on the possibility of being treated by non-surgical approaches makes necessary a review on the topic. At the IV National Symposium on Pediatric Surgery (Varadero, Matanzas, 2019 July 1-3), a Clinical Practice Guide for Acute Appendicitis was presented, discussed and approved. Sharing the guideline through publication would allow similar services to use it as a reference for applying the model in their own institutions, benefiting a greater number of patients(AU)

Appendectomy: prognostic factors in the brazilian unified health system

SUMMARY INTRODUCTION: Acute appendicitis (AA) is the most common cause of surgical acute abdomen. Postoperative complications in emergency care are reflections of the surgical procedure and pre- and postoperative factors. OBJECTIVE: Define prognostic factors for patients who underwent appendectomy, comparing them with the literature. METHODS: Descriptive observational study with a cross-sectional design based on data from the emergency/urgency appendectomy records between September 2018 and April 2019. Variables of interest were considered based on intrinsic patient data, clinical status, and perioperative management factors. Primary outcomes considered: postoperative complications from hospital admission discharge and prolonged hospital stay for > 2 days. Secondary outcome: death. The results were evaluated by Fisher's exact test (p <0.05). RESULTS: We identified 48 patients undergoing an appendectomy. Young adults accounted for 68.7%. From the total, 58.3% were males, 6 (12.5%) had hospitalization> 2 days, 4 (8.3%) had complications and no deaths. Among the variables, the stage of AA, the time of complaint up until seeking care, and advanced age were correlated with worse prognosis during hospitalization (p <0.05). The emergence of immediate postoperative complications was correlated with longer hospital stay (p <0.05). DISCUSSION: The descriptive data of the sample converge with the epidemiological profile of patients with AA in the literature, corroborating the applicability of conventional guidelines. The results strengthen the hypothesis that the patient's flow with abdominal manifestations is complicated from the first contact with SUS to the resolution of the condition. CONCLUSION: Knowledge of the epidemiological profile and perioperative predictors that are most related to complications favor the appropriate management of patients.

RESUMO INTRODUÇÃO: Apendicite aguda (AA) é causa mais comum de abdome agudo cirúrgico. Complicações pós-operatórias na emergência são reflexos do ato cirúrgico e fatores pré e pós-operatórios. OBJETIVO: Definir fatores prognósticos para paciente pós apendicectomia, comparando com a literatura. MÉTODOS: Estudo observacional descritivo e analítico com formação de base transversal de dados dos prontuários de apendicectomias de emergência/urgência entre setembro de 2018 e abril de 2019. Variáveis de interesse foram consideradas a partir dos dados intrínsecos ao paciente, quadro clínico e manejo perioperatório. Desfechos primários combinados considerados foram complicações pós-operatórias da internação até alta hospitalar e prolongamento da internação > dois dias. Desfecho secundário foi óbito. Resultados avaliados pelo teste exato de Fisher (p<0,05). RESULTADOS: Identificaram-se 48 pacientes submetidos à apendicectomia. Adultos jovens corresponderam a 68,7%. Do total, sexo masculino (58,3%), seis (12,5%) tiveram internação > dois dias, quatro (8,3%) cursaram com complicação e nenhum óbito. Dentre as variáveis consideradas, fase de apresentação da AA tempo de queixa até procura do atendimento e idade avançada correlacionaram com pior prognóstico durante internação (p<0,05). Surgimento de complicações pós-operatórias imediatas correlacionou-se com maior tempo de internação (p<0,05). DISCUSSÃO: Dados descritivos da amostra convergem com perfil epidemiológico de pacientes com AA na literatura, corroborando aplicabilidade das diretrizes convencionais. Resultados fortalecem a hipótese de que o fluxo do paciente com manifestações abdominais é complicado desde o primo-contato com o SUS até a resolução do quadro. CONCLUSÃO: Conhecimento do perfil epidemiológico e dos preditores perioperatórios que mais se relacionam com complicações favorecem manejo adequado dos pacientes.

Desempeño diagnóstico de la escala de Alvarado para la apendicitis aguda en el niño / Diagnostic performance of Alvarado score for acute appendicitis in children

Introducción: El diagnóstico de la apendicitis aguda en niños, no por frecuente, deja de ser aún desafiante a pesar de la mayor experiencia clínica y los mejores estudios complementarios. Objetivo: Determinar el desempeño diagnóstico de la escala de Alvarado para la apendicitis aguda en el niño. Métodos: Estudio observacional, analítico y prospectivo en 452 pacientes de 5 a 18 años de edad que ingresaron en el Servicio de Cirugía Pediátrica del Hospital Pediátrico Docente Centro Habana, con diagnóstico de dolor abdominal o apendicitis aguda, entre enero de 2016 y enero de 2017. Resultados: El 77,0 por ciento de los casos presentaron apendicitis. La especificidad y el valor predictivo positivo de la escala, con el punto de corte en 7, fueron de 0,90 y 0,95, respectivamente; sin embargo, la sensibilidad, el valor predictivo negativo y la precisión diagnóstica tuvieron valores bajos. El punto de corte de la escala más equilibrado se determinó en 6. Solamente 3 casos con apendicitis obtuvieron un puntaje menor de 4. El área bajo la Curva de Características Operativas del Receptor fue de 0,85. Conclusiones: La escala tiene una buena especificidad y valor predictivo positivo, así como un desempeño discriminativo general aceptable. No resulta apropiada como herramienta única para el diagnóstico de la apendicitis aguda en el escenario clínico real. No obstante, sería útil para descartar la enfermedad con un elevado nivel de certeza(AU)

Introduction: The diagnosis of acute appendicitis in children is although frequent still challenging and in despite of the higher clinical experience and the more effective laboratory and imaging studies. Objective: To determine the diagnostic performance of Alvarado score for acute appendicitis in children. Methods: An observational, analytic and prospective study was conducted on 452 patients aged from 5 to 18 years old whom were admitted to the Pediatric Surgery service of Centro Habana Pediatric Hospital from January 2016 to January 2017 with a diagnosis of abdominal pain or acute appendicitis, Results: 77.0 percent of admitted patients had diagnosis of appendicitis. The specificity and positive predictive value of the score were 0.90 and 0.95, respectively, considering 7 as the cutoff point; however, the sensitivity, the negative predictive value and the diagnostic accuracy had low values. The most balanced cutoff point was determined to be 6. Only 3 positive cases had scores under 4. The area under the Receiver Operating Characteristics Curve was 0.85. Conclusions: The score had good specificity and positive predictive value, as well as an acceptable general discriminative performance. However, it didn't result appropriate as a unique tool for diagnosing acute appendicitis in the clinical setting. Nevertheless, it would be useful for ruling out the condition with a high level of certainty(AU)

Impact of the appendiceal position on the diagnosis and treatment of pediatric appendicitis / Impacto da posição do apêndice sobre o diagnóstico e tratamento de apendicite da infância

ABSTRACT Objective: To investigate how symptoms vary according to the appendiceal position in pediatric patients and to demonstrate that the laparoscopic approach is safe and effective in any appendiceal location by comparing each location to another. Methods: The medical records of 1,736 children aged 14 or younger who underwent laparoscopic appendectomy over a period of 14 years were analyzed retrospectively. Patients were divided according to the position of the appendiceal tip into four groups: anterior, pelvic, retrocecal and subhepatic. The Kruskal-Wallis and chi-square tests were used with the Bonferroni correction, with a significant p<0.05. Results: The appendiceal location was anterior in 1,366 cases, retrocecal in 248 cases, pelvic in 66 cases and subhepatic in 56 cases. There were no significant differences between the groups in terms of patient age and gender. Abdominal pain was the only symptom with statistically significant differences between the groups. The rate of perforated appendicitis was higher in the subhepatic and pelvic positions. Intraoperative complications and conversions were not statistically significant. Technical difficulties and operative time were higher in subhepatic position. The rate of postoperative complications was similar between the different locations, except for bowel obstruction, which was higher in pelvic appendicitis. Conclusions: The clinical symptoms of appendicitis hardly ever change with the position of the appendix. The laparoscopic approach is safe and effective, regardless the appendiceal location.

RESUMO Objetivo: Investigar como os sintomas variam de acordo com a posição do apêndice em pacientes pediátricos e demonstrar que a laparoscopia é segura e eficaz em qualquer posição do apêndice, comparando-as. Métodos: Os prontuários de 1.736 pacientes pediátricos com idade ≤14 anos submetidos à apendicectomia laparoscópica em um período de 14 anos foram analisados retrospectivamente. Os pacientes foram divididos de acordo com a posição do apêndice: anterior, pélvica, retrocecal e sub-hepático. Os testes de Kruskal-Wallis e do qui-quadrado foram usados com a correção de Bonferroni, sendo significante p<0,05. Resultados: A posição do apêndice era anterior em 1.366 casos, retrocecal em 248 casos, pélvica em 66 casos e sub-hepática em 56 casos. Não houve diferenças significativas entre os grupos quanto às variáveis idade e sexo. A dor abdominal foi a única variável com diferenças estatisticamente significantes entre os grupos. A taxa de apêndice perfurado foi superior nas posições sub-hepática e pélvica. As complicações intraoperatórias e a taxa de conversão não foram estatisticamente significativas. As dificuldades técnicas e o tempo cirúrgico foram superiores em posição sub-hepática. A taxa de complicações pós-operatórias foi semelhante entre as diferentes posições, exceto a obstrução intestinal, que foi superior em posição pélvica. Conclusões: Os sintomas da apendicite dificilmente variam com a posição do apêndice. A laparoscopia é segura e eficaz, independentemente da posição do apêndice.

Clinical-epidemiological profile of acute appendicitis: retrospective analysis of 638 cases / Perfil clínico-epidemiológico da apendicite aguda: análise retrospectiva de 638 casos

ABSTRACT Objective: to describe the clinical and epidemiological profile of acute appendicitis (AA) of the patients treated at a referral center in the Juiz de Fora macro-region, Minas Gerais State, Brazil. Methods: we conducted a retrospective, observational study in the Dr. Mozart Geraldo TeixeiraEmergency Hospital. We selected 638 patients diagnosed with AA, and analyzed the variables gender, age, evolutionary phase, length of hospital stay, pathological diagnosis, use of antibiotics, use of drains, complications and mortality. Results: AA was more prevalent in young adults (19-44 years) and males (65.20%). The mean hospital stay was seven days and phase II was the most prevalent. We found the histopathological diagnosis of primary tumor of the appendix in six patients (0.94%), adenocarcinoma being the most common histologic type (66.7%). Regarding the use of antibiotics, 196 patients underwent antibiotic prophylaxis and 306 received antibiotic therapy. Eighty-one patients used some kind of drain, for an average of 4.8 days. Seventeen patients died (2.67%), predominantly males (70.59%), with mean age of 38.47 years. Conclusion: AA has a higher prevalence in males and young adults. The length of stay is directly associated with the evolutionary phase. The most common complication is infection of the surgical site. Mortality in our service is still high when compared with developed centers.

RESUMO Objetivo: avaliar a epidemiologia e os resultados do tratamento cirúrgico de doentes portadores de graus III e IV, mais avançados, da Síndrome de Mirizzi (SM) de acordo com a classificação de Csendes. Métodos: estudo retrospectivo, de corte transversal através da revisão de prontuários de 13 pacientes portadores de graus III e IV da SM operados de dezembro de 2001 a setembro de 2013, entre 3691 colecistectomias realizadas neste período. Resultados: a incidência da SM foi 0,6% (23 casos) e os graus III e IV perfizeram 0,35% deste número. Houve um predomínio de tipo IV (12 casos). O diagnóstico pré-operatório foi possível em 53,8% dos casos. A conduta preferencial foi derivação biliodigestiva (10 casos) e foi optado por drenagem com tubo "T" e sutura da via biliar em três ocasiões especiais. Três pacientes apresentaram fístula biliar resolvida com conduta expectante e um caso de coleperitônio necessitou reoperação. No seguimento ambulatorial dos pacientes que realizaram a anastomose biliodigestiva (oito), 50% estão assintomáticos, 25% apresentaram estenose da anastomose e 25% perderam seguimento. O tempo médio de acompanhamento foi 41,8 meses. Conclusão: de incidência baixa e de diagnóstico pré-operatório em apenas metade dos casos, a SM em graus avançados tem na anastomose biliodigestiva sua melhor conduta, porém não isenta de morbimortalidade.

Acute apendicitis in liver transplant recipients / Apendicite aguda em receptores de transplante de fígado

Background: Appendicitis is a common cause of emergency surgery that in the population undergoing organ transplantation presents a rare incidence due to late diagnosis and treatment. Aim: To report the occurrence of acute appendicitis in a cohort of liver transplant recipients. Methods: Retrospective analysis in a period of 12 years among 925 liver transplants, in witch five cases of acute appendicitis were encountered. Results: Appendicitis occurred between three and 46 months after liver transplantation. The age ranged between 15 and 58 years. There were three men and two women. The clinical presentations varied, but not discordant from those found in non-transplanted patients. Pain was a symptom found in all patients, in two cases well located in the right iliac fossa (40%). Two patients had symptoms characteristic of peritoneal irritation (40%) and one patient had abdominal distention (20%). All patients were submitted to laparotomies. In 20% there were no complications. In 80% was performed appendectomy complicated by suppuration (40%) or perforation (40%). Superficial infection of the surgical site occurred in two patients, requiring clinical management. The hospital stay ranged from 48 h to 45 days. Conclusion: Acute appendicitis after liver transplantation is a rare event being associated with a high rate of drilling, due to delays in diagnosis and therapy, and an increase in hospital stay.

Racional: Apendicite é causa comum de emergência cirúrgica, que na população de indivíduos submetidos ao transplante de órgãos possui incidência rara e atrasos no diagnóstico são frequentes. Objetivo: Relatar a ocorrência de apendicite aguda em uma coorte de pacientes receptores de transplante hepático. Método: Foram analisados retrospectivamente, no período de 12 anos casuística de 925 transplantes de fígado, onde cinco casos de apendicite aguda foram encontrados. Resultados: O aparecimento da apendicite ocorreu entre 3 e 46 meses após o transplante, a idade variou entre 15 e 58 anos; três eram homens (60%) e duas mulheres (40%). As apresentações clínicas foram variadas, mas não discordantes daquelas encontradas em pacientes não transplantados. Dor foi achado presente em todos os pacientes, sendo em dois bem localizada em fossa ilíaca direita (40%). Dois deles apresentaram sintomatologia característica de irritação peritoneal (40%) e um distensão abdominal (20%). Todos foram abordados por laparotomia. Em 20% não houve complicações e em 80% foram realizadas apendicectomias complicadas por supuração (40%) ou perfuração (40%). Infecção do sítio cirúrgico superficial ocorreu em dois pacientes tratados clinicamente. O tempo de alta hospitalar variou de 48 h a 45 dias. Conclusão: A apendicite aguda após transplante hepático é evento raro. Associa-se com alta taxa de perfuração decorrente aos atrasos no diagnóstico e tratamento. Cursa com mais longo internamento hospitalar.

Single-incision laparoscopic appendectomy versus conventional laparoscopy in adults. A systematic review

PURPOSE: To determine the best treatment option for not complicated acute appendicitis (AA) in adult patients, between single incision laparoscopy (SIL) and conventional laparoscopy (CL), measured by morbidity associated with disease. METHODS: Systematic review. Articles of adults diagnosed with AA treated by SIL or CL were analyzed. Databases included: MEDLINE, LILACS, IBECS, Web of Science, Scopus and Cochrane, using MeSH terms and free words. The studies were analyzed using the MINCIR methodology. Variables included: conversion rate, morbidity, hospital stay, surgery duration, and methodological quality (MQ) of primary studies. Averages, medians and weighted averages were calculated. RESULTS: Thirteen articles were analyzed. For SIL and CL the conversion rate were 3.4% and 0.7 %, the morbidity were 8% and 6.5%, the hospital stay were 2.5 and 2.8 days, the surgery duration were 53.4 and 53.8 minutes, and the MQ were 14.3±6.6 and 16.0±6.9 points, respectively. CONCLUSION: With the exception of the conversion rate, there are no differences between single incision laparoscopy and conventional laparoscopy for the treatment of acute appendicitis in adults. .

RIPASA score: a new diagnostic score for diagnosis of acute appendicitis

To determine the usefulness of RIPASA score for the diagnosis of acute appendicitis using histopathology as a gold standard. Cross-sectional study. Department of General Surgery, Combined Military Hospital, Kohat, from September 2011 to March 2012. A total of 267 patients were included in this study. RIPASA score was assessed. The diagnosis of appendicitis was made clinically aided by routine sonography of abdomen. After appendicectomies, resected appendices were sent for histopathological examination. The 15 parameters and the scores generated were age [less than 40 years = 1 point; greater than 40 years = 0.5 point], gender [male = 1 point; female = 0.5 point], Right Iliac Fossa [RIF] pain [0.5 point], migration of pain to RIF [0.5 point], nausea and vomiting [1 point], anorexia [1 point], duration of symptoms [less than 48 hours = 1 point; more than 48 hours = 0.5 point], RIF tenderness [1 point], guarding [2 points], rebound tenderness [1 point], Rovsing's sign [2 points], fever [1 point], raised white cell count [1 point], negative urinalysis [1 point] and foreign national registration identity card [1 point]. The optimal cut-off threshold score from the ROC was 7.5. Sensitivity analysis was done. Out of 267 patients, 156 [58.4%] were male while remaining 111 patients [41.6%] were female with mean age of 23.5 +/- 9.1 years. Sensitivity of RIPASA score was 96.7%, specificity 93.0%, diagnostic accuracy was 95.1%, positive predictive value was 94.8% and negative predictive value was 95.54%. RIPASA score at a cut-off total score of 7.5 was a useful tool to diagnose appendicitis, in equivocal cases of pain

Diagnostic value of C-reactive protein in suspected acute appendicitis - A prospective case control study.

Aim: To find out the Sensitivity, Specificity and Predictive value of C-reactive protein in the diagnosis of acute appendicitis. Materials and Methods: Hundred patients undergoing emergency appendicectomy were cases and thirty patients undergoing interval appendicectomy during the same period were controls. Creactive protein was measured pre-operatively. Results: CRP was reactive in 89% of cases and 3 of 30 controls (P = 0). Among the thirteen complicated cases, two had a CRP reactivity of 1.2 mg/dl, eight had 2.4 mg/dl and three had 3.6 mg/dl. In the uncomplicated cases, forty nine were reactive at 1.2 mg/dl, twenty six at 2.4 mg/dl and one at 3.6 mg/dl ( P = 0.0009). In histopathologically inflamed appendix, reactivity was 94.4% and in normal appendix reactivity was 40% ( P = 0.00007). CRP positivity had a sensitivity of 94.4% (CI 89.9-98.9) and a positive predictive value of 95.5% (CI 91.4-99.6). CRP reactivity and leucocytosis if combined, the sensitivity, specificity, PPV and NPV were 85%, 100%, 100% and 81% respectively. Threshold for CRP reactivity if raised to 2.4 mg/dl, the sensitivity, specificity, PPV and NPV are 42%, 100%, 100% and 16% respectively. Conclusion: CRP estimation is a good 'rule-in' test and not-so-good 'rule-out' test to diagnose acute appendicitis.

Apendicitis aguda en el adulto mayor, resultados del tratamiento quirúrgico en un hospital regional / Acute appendicitis in the elderly and the results of surgical treatment in a regional hospital

El 55 por ciento de las personas que llegan a 60 años requerirán al menos una operación, y el 50 por ciento son urgentes, y dentro de las principales causas se encuentra la apendicitis aguda. Objetivo: conocer las características epidemiológicas y clínicas de la apendicitis aguda en el adulto mayor, con el propósito de intentar mejorar el diagnóstico y los resultados del tratamiento quirúrgico en ellos. Métodos: estudio observacional descriptivo, del tipo de serie de casos, de carácter retrospectivo, desde el 1º de enero de 2005 hasta el 31 de diciembre de 2008, en el Hospital Clinicoquirúrgico Docente Miguel Enríquez. Se incluyeron a todos los enfermos mayores de 60 años operados de apendicitis aguda. La incidencia de apendicitis aguda en el adulto mayor fue de 4,7 por ciento El grupo más afectado fue de 60 a 69 años. De los síntomas predominó el dolor abdominal y las náuseas y vómitos. El dolor típico predominó en el grupo de 60-69 años, y a medida que aumentó la edad predominó el denominado dolor atípico. Son significativas las cifras de inflamación apendicular avanzada: perforaciones (13,5 por ciento ), gangrena (13,5 por ciento ) y la supuración (21,1 por ciento ). La morbilidad global fue de 28,8 por ciento No existió mortalidad en esta serie. Conclusiones: la apendicitis en el adulto mayor muestra logros en términos de tratamiento y resultados en nuestra institución. Continúa con presentaciones atípicas y morbilidad significativa. Quedan acciones por realizar, en el área de diagnóstico y tratamiento quirúrgico, para lograr perfeccionar y mejorar todavía más los resultados(AU)

the 55 percent of the persons arriving to 60 years old will require at the least one operation and the 50 percent are urgent and within the leading causes is the acute appendicitis. Objective: to know the epidemiological and clinical features of the acute appendicitis in the elderly, to trying of improve the diagnosis and the results of surgical treatment in them. Methods: a retrospective, case series, descriptive and observational study was conducted from January,1, 2005 to December 31, 2008 in the Miguel Enriquez Clinical Surgical Hospital. All patients aged over 60 and operated on of acute appendicitis were included. From all the symptoms there was predominance of abdominal pain, nauseas and vomiting. The typical pain predominated in the age group of 60-69 and according aging there was predominance of atypical pain. The figures of appendicular advanced inflammation: perforations (13.5 percent ), gangrene (13.5 percent ) and suppuration (21.1 percent). Global morbidity was of 28,8 percent . In present series there was not mortality. Conclusions: the appendicitis in elderly shows achievements in relation to treatment and results in our institution. The atypical presentations remain with a significant morbidity. It is necessary to take actions in the area of diagnosis and surgical treatment to achieve to improve still more the results(AU)

Cirugía laparoscópica en la apendicitis aguda / Laparoscopic surgery in acute appendicitis

La apendicitis aguda como entidad dentro del abdomen agudo, continúa siendo una de las principales causas de intervención quirúrgica de urgencia en los servicios de cirugía. La misma puede ser tratada a través de la cirugía video laparoscópica, mostrando este proceder importantes avances en los últimos años. Objetivo: analizar los resultados de la cirugía video-laparoscópica en el tratamiento de la apendicitis aguda. Métodos: estudio descriptivo, de corte transversal. Contexto: Servicio de urgencias del Hospital Militar Docente Dr. Mario Muñoz Monroy. Universo: conformado por 38 pacientes operados de apendicitis aguda por video laparoscópica en el periodo comprendido de febrero de 2000 a junio de 2009. Variables: Sexo, edad, tiempo quirúrgico, enfermedades que condicionan riesgo quirúrgico, antecedentes de operaciones anteriores, complicaciones más frecuentes, tipo de operación, causas de conversión, estadía hospitalaria y estado de los pacientes al egreso. Principales resultados: el sexo más afectado fue el masculino (65,7 por ciento); la edad promedio fue de 34 años; el tiempo quirúrgico promedio fue 35 minutos; la principal enfermedad que ocasiona riesgo fue la hipertensión arterial; el 84 por ciento de los pacientes no tenía antecedentes de operaciones sobre el abdomen; se presentaron complicaciones postoperatorias en el 5,6 por ciento; el índice de conversión fue de un 2,8 por ciento; el 94,7 por ciento de los pacientes tuvo una estadía hospitalaria menor de 24 horas; no hubo fallecidos; y en el 98 por ciento de los pacientes operados hubo correlación clínico patológica

Acute appendicitis as an entity inside the acute abdomen is still one of the main causes of emergency surgical intervention in the surgical services. It can be done with video-laparoscopic surgery, showing this procedure important advances during the last years. Objective: analyzing the results of the video-laparoscopic surgery in treating acute appendicitis. Methods: cross-sectional descriptive study. Context: Emergency Service of the Teaching Military Hospital Dr Mario Muñoz Monroy. Universe: 38 patients operated by video-laparoscopic surgery in the period from January 2000 to June 2009. Variables: Genre, age, surgical time, diseases conditioning surgical risk, records of previous operations, more frequent complications, kind of operation, conversion causes, hospital staying, and patient's status when discharging. Main results: the most affected genre was the male one (65,7 percent); the average age was 34 years; the average surgical time was 35 minutes; the main disease causing risk was the arterial hypertension; 84 per cent of the patients did not have records of previous operations on the abdomen; there were post-surgery complications in 5,6 percent; conversion index was 2,8 percent; 94,7 percent of the patients had a hospital staying of less than 24 hours; there were no deceases; and in 98 percent of the operated patients there was pathological clinical correlation

The Prevalence of Yersinia Infection in Adult Patients with Acute Right Lower Quadrant Pain / 대한소화기학회지

BACKGROUND/AIMS: Clinical manifestations of intestinal yersiniosis include enterocolitis, mesenteric adenitis, and terminal ileitis presenting with fever, right lower quadrant pain, and leukocytosis. According to a previous Korean study in 1997, Yersinia was revealed in two among 15 adult patients with mesenteric adenitis (13%). However, recent reports on the prevalence of Yersinia infection in adult patients are few. The aim of this study was to investigate the prevalence of Yersinia infection in adult patients with acute right lower quadrant pain. METHODS: Adult patients (>18 years) who visited Eulji medical center, due to acute right lower quadrant pain were enrolled prospectively from December 2007 to July 2009. Abdominal CT, stool culture, serologic test for Yersinia, and Widal test were performed. RESULTS: Among 115 patients, 5 patients were excluded due to positive Widal test or salmonella culture. In 110 patients, abdominal CT showed right colitis in 20 (18.2%), terminal ileitis in 16 (14.5%), mesenteric adenitis in 13 (11.8%), acute appendicitis in 10 (9.1%), acute diverticulitis in 7 (6.4%), non specific mucosal edema in 36 (32.7%) and no specific lesion in 8 (7.3%). Two (1.8%) of the 110 patients had antibodies to Yersinia. One patient showed acute enteritis and the other patient was diagnosed with acute appendicitis and underwent appendectomy. No Yersinia species were grown on stool or tissue culture. CONCLUSIONS: Nowadays, among adult Korean patients presenting with acute right lower quadrant pain, there have been few incidences of Yersinia infection.

Acute perforated appendicitis: An analysis of risk factors to guide surgical decision making.

Introduction: Acute perforated appendicitis is associated with increased post-operative morbidity and mortality. Avoiding delays in surgery in these patients may play a role in reducing observed morbidity. Objective: To analyze the clinico-pathological profile and outcomes in a cohort of patients undergoing emergency appendicectomies for suspected acute appendicitis and to determine factors influencing the risk of perforated appendicitis in order to aid better identification of such patients and develop protocols for improved management of this subset of patients. Materials and Methods: A retrospective analysis of patients undergoing emergency appendicectomies following presentation with acute appendicitis to the Modbury hospital, South Australia from March 2007 to April 2011 was conducted. Statistical analyses were performed in SAS 9.2. Results and Discussion: 506 patients underwent emergency appendectomy for acute appendicitis which included equal number of male and female patients with a median age of 25 years. Perforated appendicitis was found in 102 (20%) patients. Post-operative morbidity was significantly higher in patients with perforated appendicitis (28.4% vs 4.7%; P<0.0001). Male sex, patients older than 60 years, along with raised neutrophil counts and C-reactive protein levels were found to be significantly associated with the risk of perforation (P<0.05). Conclusions: Acute perforated appendicitis is associated with high morbidity. The increased risk of perforation in males and elderly patients appears unrelated to delays in presentation, diagnosis, or surgery. Patients with clinically diagnosed acute appendicitis and an elevation in neutrophil count and CRP level must be considered candidates for early surgery as they are likely to have an appendicular perforation.

Modified Alvarado Score; accuracy in diagnosis of acute appendicitis in adults

To compare the frequency of inflamed appendix in suspected patients of acute appendicitis having Modified Alvarado Score [MAS] of 7 or more with patients having MAS of 6 or below. Comparative cross sectional study. The study was carried out at Surgical Departments of Combined Military Hospital [CMH] and Military Hospital [MH] Rawalpindi from April 2006 to April 2007. This study involved 100 patients who were operated with provisional diagnosis of acute appendicitis. Preoperatively MAS of each patient was calculated and the patients were divided in two groups. Group-l had MAS of 7 or more while Group-ll had MAS of 6 or below. Postoperatively appendices of all the patients were sent for histopathological examination and its result regarding presence or absence of acute appendicitis was then compared with MAS of respective group. [a] Group-l :- A total of 72 patients with 64 [88.9%] positive inflamed appendices on histology. Negative appendicectomy rate 8 [11.1%], [b] Group-ll:-A total of 28 patients with 8 [28.6] positive inflamed appendices. Negative appendicectomy rate 20 [71.4%]. There is statistical significant difference of positive appendicectomy rate between two groups with [p-value<0.001]. Frequency of inflamed appendix is more in patients having MAS of seven or above. The number of negative appendicectomies can be reduced by using MAS in clinical practice

Comportamiento de la apendicitis aguda en el embarazo / Behavior of acute appendicitis in pregnancy

OBJETIVO: evaluar el comportamiento de la apendicitis aguda en pacientes embarazadas. MÉTODOS: se realizó un estudio observacional descriptivo retrospectivo tipo serie, de casos en los hospitales universitarios Ramón González Coro y Manuel Fajardo durante un período de 11 años. Nuestro universo estuvo constituido por 16 pacientes embarazadas intervenidas por apendicitis aguda entre enero del 1996 y diciembre del 2007 en los dos centros hospitalarios. RESULTADOS: la edades más frecuentes fueron entre 20-29 y de 30-39 años de edad con un 43,75 por ciento cada una, la incisión más utilizada fue la de McBurney (68,7 por ciento). El dolor espontáneo en hemiabdomen inferior estuvo presente en el 100 por ciento de las pacientes y más de la mitad presentaron un parto a término. El 50 por ciento tenía un leucograma normal y estaban en la fase catarral, el resto estaban flemonosas o supuradas. Diez culminaron su embarazo en el tiempo previsto, 2 abortaron espontáneamente, 2 fueron abortos programados y a dos se les realizó la cesárea el mismo día de la apendicectomía. CONCLUSIONES: la apendicitis aguda en la mujer embarazada es un grave problema de salud a considerar en mujeres entre 20 y 39 años de edad con dolor espontáneo en cuadrante inferior derecho del abdomen y náuseas, no tiene repercusiones fatales si realizamos un diagnóstico temprano y una intervención oportuna que aumenta las posibilidades de llegar al término del embarazo. Las incisiones de McBurney y Rockey-Davis son ideales en el diagnóstico temprano y la media cuando se decide realizar la cesßrea y culminar con la apendicetomía.

OBJECTIVE: To evaluate the behaviour of acute appendicitis in pregnant patients. METHODS: A case series-type retrospective observational and descriptive study was conducted at Ramón Gonzßlez Coro and Manuel Fajardo university hospitals for 11 years. Our universe of study was made up of 16 pregnant patients who were operated on from acute appendicitis from January 1996 to December 2007 in these two hospitals. RESULTS: The most common age groups were 20-29 years and 30-39 years, with 43,75 percent of affected patients each; the most common incision type was McBurnev (68,7 percent). All the patients suffered spontaneous pain in their lower hemiabdomen and over 50 percent of them had preterm childbirth. Fifty percent showed normal leukogram values and had cold whereas the rest were either on phlegmonous or suppurative condition. Ten women had term pregnancy, 2 suffered miscarriages, 2 abortions and 2 underwent appendicectomy plus cesarean section at the same time. CONCLUSIONS: Acute appendicitis in pregnant women is a serious health problem to be taken into account in females aged 20-39 years, who suffered spontaneous pain in the right lower quadrant of their abdomen and also nauseas. It does not bring about fatal outcome if early diagnosis and timely intervention are present to increase the possibilities of term pregnancy. McBurney y Rockey-Davis are the ideal types of incision in early diagnosis when performing cesarean section to end up with appendicectomy.

Acute abdomen; causes

The term [acute abdomen] denotes any sudden spontaneous non-traumatic disorder whose chief manifestation is in the abdominal area. There is frequently a progressive underlying intra-abdominal disorder, the correct early diagnosis and treatment of which is essential for a favorable outcome. [I] To find out the most common causes of acute abdomen. [II] To compare the preoperative assessment with postoperative diagnosis. A Non-interventional Analytical [Comparative] study. Emergency department of Combined Military Hospital Kharian. Oct 2001 to Mar 2002. Total of 220 patients who presented with acute abdomen. The most frequent cause was found to be Acute Appendicitis, followed by Nonspecific abdominal pain, acute cholecystitis, acute intestinal obstruction and perforated duodenal ulcer. Preoperative diagnosis was wrong in 9.5% [n=21] of cases. Acute appendicitis was found to be the most common cause of acute abdomen and the single most important cause of acute abdominal pain causing great diagnostic difficulties, the preoperative diagnostic accuracy can be increased especially in female of child bearing age by using modern diagnostic tools especially laparoscopy