Alternative therapy for acute appendicitis with appendicolith using traditional Chinese medicine: A case report.

INTRODUCTION: Treating older patients with acute appendicitis with multiple underlying diseases is a challenging situation in the clinical setting. Throughout the history of East Asian medicine, many texts have noted the use of herbal decoctions to successfully treat symptoms associated with appendicitis, thereby providing an alternative management strategy for treating frail patients with acute appendicitis. CASE PRESENTATION: This report presents the case of a 93-year-old male diagnosed with acute appendicitis with appendicolith who was unsuitable for surgical intervention due to poor lung condition and prolonged prothrombin time caused by Apixaban. By receiving complementary therapy consisting of traditional Chinese medicine (TCM) and antibiotics, he recovered successfully. DISCUSSION: In the early stage of acute appendicitis, infection control and gastrointestinal mobility are the most important factors to consider. Scientific research has demonstrated that many herbs used in TCM formulas possess anti-inflammatory, anti-oxidative and immune attenuation effects. For many patients who are unsuitable for surgical intervention due to unfavorable conditions, such as the prolonged prothrombin time presented in this case, complementary treatment with TCM offers adjuvant therapeutical effects associated with infection control, and improvement of the gastrointestinal environment and function of elderly patients.

Efficacy of daikenchuto after laparoscopic surgery for perforated appendicitis.

BACKGROUND: Although many recent studies have scientifically verified the efficacy of the traditional herbal medicine daikenchuto (DKT) for postoperative gastrointestinal function, its efficacy has not been established in children. We retrospectively evaluated the effect of DKT in pediatric patients with panperitonitis associated with perforated appendicitis (PaPA) who underwent laparoscopic appendectomy. METHODS: Among 34 children with PaPA who underwent laparoscopic appendectomy from May 2012 to May 2021, 19 received DKT (group D) and 12 did not (group C). We compared postoperative gastrointestinal function, complications, and improvement in the inflammatory response between the two groups. RESULTS: Of the evaluation parameters for postoperative gastrointestinal function, the mean ± standard deviation time to first flatus was significantly shorter in group D than in group C (1.21 ± 0.42 and 2.17 ± 0.94 days respectively; p = 0.0005). The time to ingestion of half a meal was also significantly shorter in group D than in group C (8.42 ± 3.69 and 12.50 ± 4.96 meal occasions respectively; p = 0.01). There was no significant difference in complication rates between the two groups. CONCLUSION: Daikenchuto rapidly and safely improved postoperative gastrointestinal symptoms in children with PaPA. To the best of our knowledge, this is the first study to evaluate the effect of DKT on postoperative symptoms in laparoscopic appendectomy and in children.

A shortened course of Amoxicillin/Clavulanate is the preferred antibiotic treatment after surgery for perforated appendicitis in children.

BACKGROUND/PURPOSE: Despite evidence supporting short course outpatient antibiotic treatment following appendectomy for perforated appendicitis, evidence of real-world implementation and consensus for antibiotic choice is lacking. We therefore aimed to compare outpatient antibiotic treatment regimens in a national cohort. METHODS: We identified children who underwent surgery for perforated appendicitis between 2010 and 2018 using the PearlDiver database and compared 45-day disease-specific readmission between children who received shortened (5-8 days) versus prolonged (10-14 day) total antibiotic courses (inpatient intravenous and/or oral) completed with outpatient Amoxicillin/Clavulanate versus Ciprofloxacin/Metronidazole, and compared antibiotic type (5-14 days) to each other. RESULTS: 4916 children were identified, 2001 (90.0%) treated with Amoxicillin/Clavulanate (5-14 days), 381 (19.0%) with shortened (5-8 days), 1464 (73.2%) with prolonged (10-14 days) courses. 222 (10.0%) were treated with Ciprofloxacin/Metronidazole, 44 (19.8%) with shortened, 174 (78.4%) with prolonged courses. Freedom from readmission was not different between prolonged and shortened course whether they received Amoxicillin/Clavulanate (adjusted hazard ratio [AHR] 1.54, 95%CI 0.95-2.5) or Ciprofloxacin/Metronidazole (AHR 3.49, 95%CI 0.45-27.3). Antibiotic type did not affect readmission rate (Amoxicillin/Clavulanate versus Ciprofloxacin/Metronidazole, AHR 1.21, 95%CI 0.71-2.05). CONCLUSION: Prolonged antibiotic regimens are routinely prescribed despite evidence suggesting shorter courses and antibiotic choice are not associated with greater treatment failure. As it is better tolerated, we recommend a shortened course of Amoxicillin/Clavulanate for oral management of perforated appendicitis. STUDY DESIGN: Retrospective. LEVEL OF EVIDENCE: Level III.

A randomized, placebo-controlled study of magnetic acupuncture for supplementary analgesia after laparoscopic appendectomy in children.

PURPOSE: Magnetic acupuncture (MA) is a noninvasive technique potentially useful for postoperative pain reduction. While anecdotal case series have reported analgesic effects, this has not been systematically studied. We evaluated the analgesic properties of supplemental MA versus placebo and standard treatment in children who underwent laparoscopic appendectomy (LA). METHODS: Children age 2-18 years who underwent LA for acute appendicitis were recruited from 2018 through 2020. Standardized postoperative pain medication including Ibuprofen, Acetaminophen, and narcotics were given as needed. Patients were randomized to 3 groups: Group 1 had adhesive acupuncture magnets placed on 5 predetermined meridian points for 48 h. Group 2 had corresponding non-magnetic adhesive metal disks placed in the same locations. Group 3 received no supplemental treatment. Pain was measured every 4 h using a 1-10 Visual-Analog-Scale (VAS). Cumulative demand of as-needed pain medication was calculated. Patients and families were handed open questionnaires upon discharge assessing satisfaction with treatment. RESULTS: A total of 126 patients were randomized. Groups were similar in age and gender distribution. Differences of means of cumulative VAS scores were significantly lower for group 1 (8.0,SD5.2) compared to group 2 (12.8,SD4.4; -4.8[95%CI -7.1 to -2.5], p < 0.01), and group 3 (19.8,SD7.7; -11.8[95%CI -15.0 to -8.6], p < 0.01). Cumulative acetaminophen and ibuprofen use per patient during the entire hospital stay was lower for group 1 (1510 mg, 20 mg) than for group 2 (2950 mg, 1800 mg), and group 3 (6100 mg; 2300 mg), respectively. In contrast to groups 2 and 3, none of the patients in group 1 asked for narcotics. Patients were highly satisfied with MA. CONCLUSIONS: Supplemental MA after LA in children had a beneficial effect on the postoperative pain perception and on-demand use of analgesics that could not be explained by placebo mechanism. MA is a safe, simple, and effective adjunct to standard postoperative care. Further studies are warranted. TYPE OF STUDY: Prospective randomized, placebo-controlled trial LEVEL OF EVIDENCE: Level I.

Common Conditions II: Acute Appendicitis, Intussusception, and Gastrointestinal Bleeding.

Perforated appendicitis continues to be a significant cause of morbidity for children. In most centers, ultrasound has replaced computed tomography as the initial imaging modality for this condition. Controversies surrounding optimal medical and surgical management of appendicitis are discussed. Management of intussusception begins with clinical assessment and ultrasound, followed by image-guided air or saline reduction enema. When surgery is required, laparoscopy is typically utilized unless bowel resection is required. The differential diagnosis for pediatric gastrointestinal bleeding is broad but often made with age, history, and physical examination. Endoscopy or laparoscopy is sometimes needed to confirm a diagnosis or for treatment.

Peritonitis Due to Appendicitis Related to Mercury Sequestration: An Unusual Peruvian Case Report.

Elemental mercury ingestion caused by folk practices is rare and usually harmless. Nevertheless, some complications related to mercury ingestion have been reported such as appendicitis related to mercury sequestration and poisoning leading to systemic toxicity. Patients usually present with nausea, vomiting, and abdominal tenderness. Mercury sequestration in the appendix depends on its anatomy and mercury physical properties, both of which may lead to appendicitis, resulting in subsequent peritonitis leading to multiple and severe surgical complications. A 26-year-old Peruvian man complaining of vomiting and abdominal pain after ingestion of elemental mercury as part of a folk practice presented to the emergency department. Physical exam was remarkable for rigid abdomen and diffuse rebound sign. A clinical diagnosis of peritonitis was made. The patient was taken to the operating room where an open appendectomy and peritoneal lavage were performed. On gross inspection, a silver foreign body within the perforated appendix was seen by the surgical team. The patient developed multiple surgical complications leading to multiple organ failure and death. Clinicians should be aware that mercury ingestion is usually benign. However, severe complications may develop. Early surgical and medical intervention should be initiated promptly to achieve better outcomes. We present the first case of peritonitis due to appendicitis related to mercury sequestration in the appendix.

Incidental Appendiceal Tumors During Appendectomy: A Nineteen-Year Retrospective Review at a Municipal Hospital.

Non-operative management of appendicitis (NOMA) has recently gained popularity, but a concern is that NOMA might miss appendiceal neoplasms. We conducted a retrospective review of 1694 appendectomies done for acute appendicitis at our institution between January 2001 and December 2019 to study the incidence and distribution of appendiceal tumors. We identified 24 appendiceal neoplasms (1.43%), including 9 Low Grade Appendiceal Mucinous Neoplasms (LAMNs), 6 neuroendocrine tumors (NETs), 6 mucoceles, and one each of adenocarcinoma, endometrioma, and neurofibroma. Tumor occurrence had two age peaks, with LAMNs prominent in the 5th and 6th decades of life and NETs in the 2nd and 3rd decades. All patients under age 40 had benign disease. Presence of appendicoliths was independent of the presence of neoplasms. All cases were managed per National Comprehensive Cancer Network (NCCN) guidelines, with twenty cases cured by appendectomy alone. Given these, we conclude that NOMA is safe for patients under 40.

Hyperbilirubinemia and Hyponatremia as Predictors of Complicated Appendicitis.

Several studies have reported elevated serum bilirubin or reduced serum sodium levels in patients with complicated appendicitis (CA). This study examined the efficacy of hyperbilirubinemia, hyponatremia, and both combined in the preoperative diagnosis of CA. Patients who underwent surgery for acute appendicitis were included in this retrospective review. In total, 247 patients were included in the final analysis. Of these, 36 (14.2%) had early appendicitis, 177 (72.0%) had acute suppurative appendicitis, 32 (13.0%) had necrotizing/gangrenous acute appendicitis, and 2 (0.8%) had other types of appendicitis. The mean total bilirubin (TBIL) level was significantly higher in patients with CA than in those with uncomplicated appendicitis. Conversely, the mean serum sodium level was significantly lower in patients with CA than in those with uncomplicated appendicitis. The levels of TBIL (odds ratio: 1.098, 95% CI: 1.052-1.147) and serum sodium (odds ratio: 0.743, 95% CI: 0.646-0.855) were associated with CA. Hyponatremia combined with hyperbilirubinemia yielded significant discriminatory value for the diagnosis of CA. TBIL and serum sodium levels can be considered as adjuvant parameters in the diagnosis of perforated/necrotizing appendicitis. Although hyperbilirubinemia and hyponatremia together were better able to determine the risk of CA than either marker alone, other markers are required to definitively predict CA. Furthermore, large-scale studies are needed to confirm these findings.

Development and Validation of a Clinical Prediction Model for Complicated Appendicitis in the Elderly.

Background: For elderly patients with mild clinical symptoms of uncomplicated appendicitis(UA), non-surgical treatment has been shown to be feasible, whereas emergency surgical treatment is recommended in elderly patients with complicated appendicitis(CA), but it is still challenging to accurately distinguish CA and UA before treatment. This study aimed to develop a predictive model to assist clinicians to quickly determine the type of acute appendicitis. Methods: We retrospectively studied the clinical data of elderly patients with acute appendicitis who visited the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine from January 2012 to January 2022. The patients were divided into UA group and CA group, and the general conditions, medical history, physical examination, laboratory examination and imaging examination were compared between the two groups, and SPSS 26.0 and R 4.0.2 software were used to establish CA clinic. Predict the model, and validate it internally. Results: The clinical data of 441 elderly patients with acute appendicitis were collected, 119 patients were excluded due to incomplete clinical data or other diseases. Finally, 332 patients were included in the study and divided into UA group (n = 229) and CA group (n = 103). By analyzing the clinical data of the two groups of patients, the duration of abdominal pain [OR = 1.094, 95% CI (1.056-1.134)], peritonitis [OR = 8.486, 95% CI (2.017-35.703))] and total bilirubin [OR = 1.987, 95% CI (1.627-2.426)] were independent predictors of CA (all p < 0.01). The model's Area Under Curve(AUC) = 0.985 (95% CI, 0.975-0.994). After internal verification by Bootstrap method, the model still has high discriminative ability (AUC = 0.983), and its predicted CA curve is still in good agreement with the actual clinical CA curve. Conclusion: We found that a clinical prediction model based on abdominal pain duration, peritonitis, and total bilirubin can help clinicians quickly and effectively identify UA or CA before treatment of acute appendicitis in the elderly, so as to make more scientific clinical decisions.

Recurrent ileocolic intussusception with appendiceal lead point in a 2-year-old child: an etiology to be aware of on ultrasound.

Ileocolic intussusception is a differential consideration in young pediatric patients presenting with acute abdominal pain. Appendiceal intussusception is an uncommon variant of ileocolic intussusception where the appendix is contained within the intussusception, which can be challenging to diagnose preoperatively. In this case report, we present a 25-month-old female presenting with intermittent, diffuse abdominal pain. Initial ultrasound evaluation demonstrated ileocolic intussusception, which was successfully reduced by air enema. The patient experienced recurrent symptoms and had several recurrent episodes of ileocolic intussusception with the appendix contained within the intussusceptum. After the fifth recurrence, the patient underwent surgical intervention. The inflamed appendix was discovered to be inverted within the cecum, resulting in a lead point for intussusception of the terminal ileum. The patient underwent laparoscopic reduction of the ileocolic intussusception and appendectomy. Few cases of appendiceal and concurrent ileocolic intussusception are described in the literature. It is important that radiologists and surgeons be aware of this entity when evaluating pediatric ileocolic intussusception, particularly at the time of ultrasound and air enema, in order to ensure appropriate management and prevent complications.

Same day discharge after pediatric laparoscopic appendectomy in community hospitals.

INTRODUCTION: Same-day discharge (SDD) protocols after pediatric laparoscopic appendectomy have not been well studied in a community hospital setting, especially when hospitals with low inpatient pediatric censuses are increasingly closing their pediatric units. This study evaluates the outcomes of a SDD protocol after pediatric appendectomy that was implemented across an integrated healthcare system in which hospitals experienced closure of pediatric units. METHODS: Patients between ages 6 to 13 years-old who underwent laparoscopic appendectomy for uncomplicated appendicitis from January 1st 2015 to December 31st 2020 were reviewed. During the study period, an inter-hospital SDD protocol was introduced at nine hospitals, four of which closed their pediatric units. RESULTS: There were 1293 patients in the pre-protocol cohort and 953 patients in the post-protocol cohort. There were 588 (45.5%) patients who underwent SDD in the pre-protocol cohort, compared with 804 (84.4%) patients in the post-protocol cohort (p<0.00001). Postoperative narcotics were prescribed to 358 (27.7%) patients in the pre-protocol cohort, compared to 482 (50.6%) patients in the post-protocol cohort (P<0.00001). There was no difference in the 30-day emergency department visit rate or 30-day readmission rate between the two cohorts. A subgroup analysis comparing the surgical outcomes at community hospitals with and without pediatric units after implementation of the SDD protocol showed no difference. CONCLUSION: Same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis in community hospitals, even after pediatric unit closure, is safe and feasible. The decrease in postoperative LOS and the increase in SDD are not associated with higher complication rates.

Epiploic Appendagitis Mimicking Acute Appendicitis: An Osteopathic Case Report.

Acute epiploic appendagitis is a rare cause of abdominal pain, often misdiagnosed as acute appendicitis or diverticulitis given similar clinical presentation and findings. The treatment is supportive care and is typically self-limited. The osteopathic structural exam can give insight into pathology and in this case, was suggestive of a non-appendiceal origin of her pain, in which emergent surgery could be avoided. Requiring computerized tomography to identify, acute epiploic appendagitis is a rare cause of abdominal pain and should be considered in the differential diagnosis.

The use of a pediatric appendicitis pathway in a large integrated health system reduced computed tomography imaging in the ED.

BACKGROUND: Appendicitis is the most common cause of an acute surgical abdomen in children. Diagnosis is often challenging as few pediatric patients present with classic symptoms. Clinicians are thus dependent on imaging to reach an accurate diagnosis. Although computerized tomography (CT) has high sensitivity and specificity, it has the disadvantage of imparting ionizing radiation. Ultrasound (US) is readily available and has comparable accuracy to CT when performed by experienced sonographers. We sought to examine the impact of a system-wide process improvement plan on CT use and other metrics in pediatric patients who presented to the Emergency Department (ED) with suspected appendicitis. METHODS: This is a retrospective study of the impact of a Pediatric Appendicitis Pathway (PAP) within a large integrated hospital system with 12 EDs including 3 designated hub EDs. Patients were placed in an initial risk category utilizing the Pediatric Appendicitis Score (PAS), and received US of the appendix at a hub ED if indicated by the PAS. Patients presenting to community EDs who required US appendix were transferred to hub EDs for imaging. Patients presenting in the 6-month pre-implementation period were compared to patients presenting in a 14-month post-implementation period on CT and US utilization, negative and missed appendectomy rates, and ED length of stay (LOS). RESULTS: 1874 patients (401 pre-PAP and 1473 post-PAP) were included in the study. At the hub EDs the rate of CT imaging for suspected appendicitis was reduced from 31% to 17% with a resultant increase in US utilization from 83% (333/401) to 90% (1331/1473) (p < 0.001). At community general EDs (404 pre-PAP and 449 post-PAP), the rate of CT was decreased from 45% (181/404) to 32%(144/449) (p < 0.001)) There was no significant change in the negative appendectomy rate pre-PAP (1/59 = 1.7%) and post-PAP (4/168 = 2.4%) (p = 0.99) at the hub EDs. There were no missed appendicitis cases after PAP implementation compared to 1 case in the pre-PAP period. Overall LOS was similar pre and post-PAP, however LOS was longer in patients that required transfer from community general EDs to hub EDs (median 264 vs 342 min, p < 0.001). CONCLUSIONS: A PAP that stratified patients into risk groups using the PAS and encouraged the use of US as a first line imaging modality, reduced the number of CT performed in a large integrated health system without significant changes to clinical outcomes. Furthermore, transferring select patients for an US as opposed to obtaining an initial CT in community general EDs was feasible and reduced CT use in the pediatric population.

Barium appendicitis.

We have presented a case of barium appendicitis, which is a rare complication of barium enema studies. Barium sulfate is used widely for gastrointestinal radiographic studies and is associated with few complications. Clinicians need to be fully aware of this complication.

Double Appendix: Implications for the Emergency Department.

BACKGROUND: A double appendix, also known as vermiform appendix duplex, is a rare anomaly in humans, with a reported incidence of 1 in 25,000. The rarity of vermiform appendix duplication makes it a noteworthy medical occurrence. Approximately 100 reported cases have been documented since the first observed case in 1892. There are multiple types of appendiceal duplications, some of which include duplications of other organs. CASE REPORT: A 10-year-old boy was diagnosed with acute appendicitis by clinical examination and ultrasound. He underwent a laparoscopic appendectomy and had an unremarkable recovery. His pathology revealed acute suppurative appendicitis. Two months later, he presented to the emergency department due to bilateral lower abdominal pain with guarding and distension on examination. He underwent a computed tomography of the abdomen and pelvis secondary to concern for a postoperative abscess, which instead showed a normal-appearing retrocecal appendix containing oral contrast. The patient was diagnosed with constipation, and his symptoms resolved with an enema. Our patient had two completely separate appendices, one arising from the cecal tinea coli, and one retrocecal. Why Should an Emergency Physician Be Aware of This? Clinicians should be aware of this rare anomaly as a potential diagnosis in a patient with a history of prior appendectomy and clinical signs consistent with recurrent appendicitis. This also underscores the need for communication between doctors and patients, along with their families, to avoid delays in diagnosis in the future.

The antegrade continence enema procedure in the setting of acute appendicitis.

The antegrade continence enema (ACE), known as the ACE procedure, has gained popularity over the past two decades in the treatment of refractory fecal incontinence. This case report describes an acutely inflamed appendix being used for an ACE procedure. To my knowledge, this has not previously been documented in the literature.

Carbapenems versus ciprofloxacin/metronidazole for decreasing complications and hospital stay following complicated acute appendicitis surgery: A prospective cohort in an Ecuadorian population.

BACKGROUND: After appendectomy due to complicated acute appendicitis (CAA), there are some alternatives as antibiotic scheme: ciprofloxacin/metronidazole; as well as monoscheme based on carbapenems: ertapenem, meropenem, and imipenem. AIM: This study aims to prove the efficacy of carbapenems versus ciprofloxacin/metronidazole in CAA post-operative management in terms of preventing complications during post-operative period and decreasing hospital stay. MATERIALS AND METHODS: This was an observational, analytical, longitudinal, and prospective cohort study (March 2014-November 2016). Patients were classified into two groups, according to the prescribed antibiotic scheme: some carbapenems or ciprofloxacin/metronidazole. RESULTS: Ninety-eight patients were enrolled. There was an requirement for antibiotic therapy rotation only in the ciprofloxacin/metronidazole (7/49, 14.3%; p = 0.004). Carbapenems reached a mean hospital stay of 4.45 days, in contrast with ciprofloxacin/metronidazole, 8.29 days (p = 0.020). In post-surgical follow-up, there were more cases of curative resolution in the group in the carbapenems group (35/49 vs. 15/49 p < 0.001) as well as a greater number of cases with some late infection in the ciprofloxacin/metronidazole group (1/49 vs. 10/49, p = 0.010). CONCLUSION: In the post-operative management of CAA, carbapenems represent an important indication to be considered as first-line antibiotic therapy.

ANTECEDENTES: Tras la cirugía por apendicitis aguda complicada existen varias alternativas de esquema antibiótico, entre las que destacan ciprofloxacino/metronidazol, o bien monoterapia con algún carbapenémico, como ertapenem, meropenem e imipenem. OBJETIVO: Determinar la eficacia de los carbapenémicos en comparación con ciprofloxacino/metronidazol en el manejo posquirúrgico de la apendicitis aguda complicada, en términos de prevención de complicaciones durante el ­posoperatorio y de reducción de la estancia hospitalaria. MÉTODO: Estudio observacional, analítico, longitudinal, prospectivo y de cohorte, de marzo de 2014 a noviembre de 2016. Los pacientes fueron clasificados en dos grupos según el esquema antibiótico prescrito: un carbapenémico o ciprofloxacino/metronidazol. RESULTADOS: Se seleccionaron 98 pacientes. Solo hubo necesidad de rotación de antibiótico en el grupo de ciprofloxacino/metronidazol (7 de 49, 14.3%; p = 0.004). En el grupo de carbapenémico, la media de estancia hospitalaria fue de 4.45 días, y en el grupo de ciprofloxacino/metronidazol fue de 8.29 días (p = 0.020). En el seguimiento posquirúrgico hubo más casos de resolución curativa en el grupo de carbapenémico (35 de 49 vs. 15 de 49; p < 0.001), así como un mayor número de casos con alguna infección tardía en el grupo de ciprofloxacino/metronidazol (1 de 49 vs. 10 de 49; p < 0.001). CONCLUSIÓN: En el manejo posquirúrgico de la apendicitis aguda complicada, los carbapenémicos representan una importante indicación que debe considerarse como antibioticoterapia de primera línea.

Impact of hospital size on the outcomes of appendectomy in children: an analysis of a comprehensive nationwide pediatric dataset.

PURPOSES: The purpose of this study was to investigate the outcomes after appendectomy in children according to hospital size. METHODS: The records of 11,565 patients with the diagnosis-related group code for appendectomy were extracted from HIRA-Pediatric Patient Sample from 2012 to 2016. The number of hospital visits and the length of stay in hospital within 30 days after appendectomy were analyzed. RESULTS: Patients who were treated at large-sized hospitals were more likely to be younger, more likely to reside in metropolitan areas, and tended to receive laparoscopic surgery. The number of hospital visits within 30 days in patients managed by medium- and large-sized hospitals decreased in comparison to small-sized hospitals. The length of hospital stay in large-sized hospitals was decreased in comparison to small- and medium-sized hospitals. A subgroup analysis revealed that complicated appendectomy did not have a significant impact on the difference in the length of hospital stay between hospital sizes. CONCLUSION: The number of hospital visits and the length of hospital stay was higher in small-sized hospitals in comparison to large-sized hospitals. Appendectomy performed in the larger hospital showed better outcomes in pediatric patients. We recommend that pediatric surgical procedures be performed in large hospitals, and that proper incentives be given for procedures to be performed by pediatric specialists.

Uselessness of microbiological samples in acute appendicitis with frank pus: to collect or not to collect?

INTRODUCTION: Current use of antimicrobial therapy is prophylactic, empirical and broad spectrum. But, the age-old practice of obtaining cultures still remain. The aim of this study was to evaluate bacterial etiology and adequacy of antibiotic prophylaxis in patients diagnosed with acute appendicitis to help determine the utility of intraoperative cultures in guiding clinical decision-making. MATERIALS AND METHODS: A retrospective analysis of a prospectively constructed database of all patients who underwent appendectomy from September 2013 to November 2016 was performed. RESULTS: 456 patients underwent surgery for acute appendicitis in our academic hospital. 101 patients (22.1%) had intraoperative swabs taken, and the cultures were positive in 57.4% of patients. These 101 patients comprise our study group. The most commonly recovered species were E. coli, Streptococcus spp., Bacteroides fragilis, Enterococcus faecium, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Proteus. In the comparison between positive and negative swab, there were no differences in terms of surgical site infection, deep infection, and in terms of Clavien-Dindo classification. An appropriate empiric therapy was set in 88.5% and inappropriate in 11.5%. No differences in terms of surgical site infection or in length of stay (p = 0.657) were found, with a median of 7 days in both groups. CONCLUSION: The etiological agents causing peritonitis due to acute appendicitis are predictable and empiric-targeted antibiotic therapy is effective in a high percentage of patients. The postoperative patient outcome may be dependent on the severity of the appendicitis more than on the results of the swab at the time of surgery. In this study, intraoperative culture was not associated with the choice of antibiotics, incidence of SSI, DPI or the length of stay.

Correlación diagnóstica de la escala RIPASA en pacientes intervenidos quirúrgicamente por apendicitis aguda / Diagnostic correlation of the RIPASA score in patients operated on for acute appendicitis

Antecedentes: La apendicitis aguda (AA) es la urgencia quirúrgica más frecuente alrededor del mundo. Su diagnóstico precoz y certero es fundamental para evitar cirugías innecesarias y complicaciones asociadas a su evolución natural. Objetivo: Determinar la sensibilidad y especificidad diagnóstica de la escala RIPASA en pacientes con sospecha clínica de apendicitis aguda. Material y métodos: Estudio analítico, transversal, observacional y retrospectivo; se incluyeron todas las piezas de apendicectomías de pacientes de ambos sexos mayores de 18 años operados con diagnóstico clínico de apendicitis aguda que consultaron entre el 1º de enero y el 31 de diciembre de 2017. Como procedimiento de referencia (gold standard) diagnóstico se analizaron los hallazgos histopatológicos del apéndice extirpado. Se aplicó la escala RIPASA a cada uno de los pacientes (punto de corte de 7,5). Se realizó estadística descriptiva y pruebas diagnósticas (sensibilidad, especificidad, valor predictivo positivo [VPP], valor predictivo negativo [VPN]). Resultados: Se incluyeron 68 apendicectomías. Cincuenta y siete muestras (83,82%) fueron positivas para apendicitis aguda. El promedio de edad fue 43,32 años. De los 38 hombres, 32 (84,21%) tuvieron diagnóstico histopatológico de AA. De las 30 mujeres, 25 (83,33%) tuvieron AA. Para la escala RIPASA, 54 pacientes tuvieron un resultado verdadero positivo (punto de corte ≥7,5 e histología positiva para AA) resultando con una sensibilidad del 93%, especificidad del 40%, VPP del 90%, VPN del 50%, razón de verosimilitud positiva de 1,55 y razón de verosimilitud negativa de 0,175. Conclusión: El puntaje (score) RIPASA ha demostrado una excelente sensibilidad y especificidad para el diagnóstico clínico de AA de manera rápida, simple y no invasiva.

Background: Acute appendicitis (AA) is the most common surgical emergency worldwide. Its correct and early diagnosis is essential to avoid unnecessary surgeries and complications associated with its natural history. Objective: The aim of this study was to determine the diagnostic sensitivity and specificity of the RIPASA score in patients with suspected AA. Material and methods: This analytical, cross-sectional, observational and retrospective study included appendectomy specimens of patients of both sexes > 18 years operated on with clinical diagnosis of AA between January 1 and December 31, 2017. The histopathological examination of the appendectomy specimens was considered the gold standard diagnostic test. A score of 7.5 for the RIPASA score was chosen as cut-off value. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. Results: A total of 68 appendectomies were included; 57 (83.82%) specimens were positive for acute appendicitis. Mean age was 43.32 years. The histological diagnosis of AA was present in 32 (84.21%) men and in 25 (83.33%) women. For the RIPASA score, 54 patients had a true positive result (cut-off point ≥ 7.5 and positive histology for AA) with a sensitivity of 93%, specificity of 40%, PPV of 90%, NPV of 50%, positive likelihood ratio of 1.55 and negative likelihood ratio of 0.175. Conclusion: The RIPASA score has demonstrated excellent sensitivity and specificity for the clinical diagnosis of AA in a fast, simple and non-invasive fashion.