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.

Multi-institutional trial of non-operative management and surgery for uncomplicated appendicitis in children: Design and rationale.

Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children's hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a "successful" treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.

Adenocarcinoma mimicking appendicular lump: a diagnostic dilemma-a case report.

BACKGROUND: Primary appendiceal adenocarcinoma is a rare tumor, mucinous variety being common. This case is reported to highlight the unusual presentation and diagnostic difficulty of appendiceal adenocarcinoma. CASE PRESENTATION: Patient presented with acute appendicitis with ill-defined tender lump which responded to conservative management. CONCLUSIONS: High index of suspicion should be kept in mind for elderly patients presenting with appendicular lump. Every effort should be made during elective appendectomy to remove stump in case of sloughed out appendix.

Apendicitis aguda. Estudio comparativo entre puerto único, laparoscopia convencional versus laparotomía / Acute appendicitis. Comparative study of single port, conventional laparoscopic versus laparotomy

Objetivo:Comparar las tres técnicas de abordaje para la apendicectomía: puerto único (APU), laparoscopia convencional (ALC) y laparotomía (AL) en pacientes con diagnóstico de apendicitis aguda. Métodos: se realizó AL por incisión de McBurney, ALC por tres puertos y APU. Para las cirugías por APU y ALC se utilizó pinza de LigaSure AtlasTM 37cms Hand de 10mm (Covidien®) para ligar el mesoapéndice, sutura crómico catgut® 0 o endoloop®para ligar la base de la apéndice, en abierta o laparoscopica, respectivamente. Para la APU se utilizó el SILS Port™ (Covidien®). Se realizó un estudio comparativo, prospectivo, monocéntrico, entre abril 2014 y octubre 2014, en pacientes con diagnóstico de apendicitis aguda en el Hospital General del Este "Dr. Domingo Luciani"y que cumplieron los criterios de inclusión. Resultados: Se realizaron 58 apendicectomías, 20 AL, 20 ALC y 18 APU. El tiempo quirúrgico y la estancia hospitalaria fueron menores en las ALC con promedio de 47 minutos y 33,6 horas, respectivamente. La incidencia de complicaciones intraoperatorias y postoperatorias fueron mayores el las AL estableciéndose una relación estadística-mente significativa entre la técnica quirúrgica y la infección del sitio operatorio (p < 0,05). La técnica quirúrgica influye en la manifestación de dolor en las primeras 08 horas de postoperatorio (p < 0,05). Conclusión: La decisión del abordaje quirúrgico será determinado por la experiencia del cirujano y la disponibilidad del instrumental quirúrgico, sin embargo, la evidencia actual sugiere que la ALC debe ser considerada como primera elección(AU)

Objective: To compare the three techniques approach appendectomy: single port (SPA), conventional laparoscopy (CLA) and laparotomy (LA) in patients with acute appendicitis. Methods: LA was performed by McBurney incision, CLA was performed with three ports and SPA. LigaSure clamp 10mm Hand AtlasTM 37cms (Covidien®) was used to cut the mesoappendix, chromic suture catgut® 0 or endoloop® to ensure the base of the appendix, in open or laparoscopic, respectively. The SILS™ Port (Covidien®) was used for the SPA. A comparative, prospective, single-center study was conducted between April 2014 and October 2014, in patients with a diagnosis of acute appendicitis in East General Hospital "Dr.Domingo Luciani" and who met the inclusion criteria. Results: 58 appendectomies, 20 LA, 20 CLA and 18 SPA were performed. The operative time and hospital stay were lower in the CLA average of 47 minutes and 33.6 hours, respectively. The incidence of intraoperative and postoperative complications were higher on the LA establishing a statistically significant relationship between surgical technique and surgical site infection (p <0.05). The surgical technique influences the manifestation of pain in the first 08 hours postoperatively (p <0.05). Conclusion: The decision of surgical approach will be determined by the surgeon's experience and availability of surgical instruments, however, current evidence suggests that CLA should be considered as first choice(AU)

Access to emergency operative care: a comparative study between the Canadian and American health care systems.

BACKGROUND: Canada provides universal health insurance to all citizens, whereas 47 million Americans are uninsured. There has not been a study comparing access to emergency operative care between the 2 countries. As both countries contemplate changes in health care delivery, such comparisons are needed to guide health policy decisions. The purpose of this study is to determine whether or not there is a difference in access to emergency operative care between Canada and the United States. METHODS: All patients diagnosed with acute appendicitis from 2001 to 2005 were identified in the Canadian Institute for Health Information database and the US Nationwide Inpatient Sample. Severity of appendicitis was determined by ICD-9 codes. Patients were further characterized by age, gender, insurance status, race, and socioeconomic status (SES; income). Univariate and multivariate analyses were performed to determine the odds of appendiceal perforation at different levels of SES in each country. RESULTS: There were 102,692 Canadian patients and 276,890 American patients with acute appendicitis. In Canada, there was no difference in the odds of perforation between income levels. In the United States, there was a significant, inverse relationship between income level and the odds of perforation. The odds of perforation in the lowest income quartile were significantly higher than the odds of perforation in the highest income bracket (odds ratio, 1.20; 95% confidence interval, 1.16-1.24). CONCLUSION: The results suggest that access to emergency operative care is related to SES in the United States, but not in Canada. This difference could result from the concern over the ability to pay medical bills or the lack of a stable relationship with a primary care provider that can occur outside of a universal health care system.

[Left-sided appendicitis: description of a rare case in an adult patient diagnosed in Antananarivo]. / Appendicite a gauche: a propos d'un cas exceptionnel chez l'adulte diagnostiqué a Antananarivo.

The purpose of this report is to describe a case of appendicitis in the left iliac fossa. Clinical presentation involved pain in the right iliac fossa with all classical signs of appendicitis. Anomalous location of the appendix was suspected on the basis of a special clinical feature and the patient's family history. Confirmation was achieved by colic contrast enema before surgical treatment.

¿Es suficiente la observación clínica en los casos dudosos de apendicitis aguda? / Is clinical observation enough in doubtful cases of acute appendicitis?

Introducción: El diagnóstico de apendicitis aguda sigue siendo uno de los problemas más habituales en los servicios de urgencias. El objetivo del presente estudio es evaluar los resultados de la observación clínica en pacientes con clínica dudosa de apendicitis aguda, comparándolos con los de una serie contemporánea de pacientes diagnosticados e intervenidos de inicio. Métodos: Se estudia una serie de 547 pacientes intervenidos por apendicitis aguda en un período de 4 años divididos en 2 grupos: Grupo A, 310 pacientes diagnosticados de entrada de apendicitis aguda e intervenidos y Grupo B, 237 pacientes con diagnóstico dudoso sometidos a observación clínica y posteriormente intervenidos. Se analizan los datos demográficos, los datos cronológicos desde el inicio del cuadro al ingreso y a la intervención, y el número de apendicectomías innecesarias y de apendicitis gangrenosas-perforadas. Resultados: No se evidenciaron diferencias significativas en las características generales de los 2 grupos, salvo un mayor número de mujeres en el grupo B, y un mayor porcentaje de pacientes sometidos a exploraciones complementarias. Con respecto a los datos cronológicos, existen diferencias significativas entre ambos grupos que evidencian un retraso diagnóstico, siendo el dato más importante que esta conducta de observación clínica no reduce el número de apendicectomías innecesarias (7,7% por 8,4%) ni de apendicitis gangrenosas-perforadas (25,2% por 37,1%). Conclusiones: Aunque los resultados son en líneas generales aceptables, la actitud de observación clínica en pacientes de diagnóstico dudoso, con o sin exploraciones complementarias, no ha sido satisfactoria en nuestra experiencia. En los casos de duda debería seguirse una actitud diagnóstica más agresiva, posiblemente mediante la realización de tomografía axial computadorizada (AU)

Introduction: Diagnosis of acute appendicitis is still one of the most usual problems in emergency departments. The aim of our study is to evaluate the results of clinical observation in patients with doubtful clinical features of acute appendicitis, comparing with a series of patients initially diagnosed and operated on. Methods: A series of 547 patients operated with diagnosis of acute appendicitis in a period of 4 years are studied. Patients are divided in 2 groups: Group A, 310 patients initially diagnosed and operated and Group B, 237 patients with doubtful diagnosis and left under clinical observation and operated lately. Demographic data and chronological data (time elapsed since the begin of suymptomatology to operation) are analysed, and the number of unnecessary appendectomies and gangrenous-perforated appendicitis. Results: There were not differences in general characteristics between both groups, except a higher incidence of women and radiological explorations in group B. There was a significative diagnostic delay in group B, the clinical observation do not decrease unnecessary appendectomies (7.7% in group A vs. 8.4% in group B) neither gangrenousperforated appendicitis (25.2% in group A vs. 37.1% in group B). Conclusions: Although our results could be considered as acceptable, clinical observation in doubtful cases, with or without radiological explorations have not been useful in our experience. In doubtful cases it had better a more aggressive diagnostic approach, probably performing an abdominal CT scan (AU)

It is not always appendicitis.

BACKGROUND: Patients who are suspected of having acute appendicitis usually undergo surgery in order to avoid life-threatening complications such as perforation and peritonitis. However, acute appendicitis is difficult to distinguish from other sources of right-sided abdominal pain. The clinical picture is almost indistinguishable from appendiceal diverticulitis, which is a rare entity and remains a difficult diagnostic problem. PATIENTS AND METHODS: We describe the case of a 39-year-old male with perforated appendiceal diverticulitis. The patient was admitted to our surgical unit with acute appendicitis-like symptoms and underwent surgery with a diagnosis of suspected acute appendicitis. RESULTS: The patient was found to have perforated appendiceal diverticulitis and standard appendectomy with abdominal lavage was carried out. DISCUSSION: Most patients presenting with acute right-sided peritonitic pain are diagnosed and managed as cases of acute appendicitis. Acute pain in the lower right side of the abdomen caused by appendiceal diverticulitis is very rare and clinically indistinguishable from acute appendicitis. Inflammatory complications of appendiceal diverticula mimic acute appendicitis. CONCLUSION: Every surgeon should be aware of the possibility of diverticulitis of the appendix in the operating room, even if this does not change the operative management. As diverticula of the cecum can be found as solitary lesions, as multiple lesions confined to the right colon, or as part of a generalized disease of the entire colon, postoperative barium enema examination may be useful.

[Diagnosis of appendicitis with particular consideration of the acupuncture point Lanwei--a prospective study]. / Die Diagnostik der Appendizitis unter besonderer Berücksichtigung des Akupunkturpunktes Lanwei -- eine prospektive Studie.

BACKGROUND: In almost all Western industrial nations, appendicitis is the most frequent cause for acute abdomen. Nevertheless, the diagnosis of appendicitis is often difficult, which manifests in highly negative laparotomy rates. In a prospective study we aimed to investigate if palpation of the acupuncture point Lanwei (extra point 22, extra point 33) which is located on the right leg may increase the accuracy in the diagnosis of appendicitis. PATIENTS AND METHODS: Presurgically, the Lanwei point was examined for reproducible tenderness on 116 cooperative nonanesthetized patients admitted to hospital for suspected appendicitis. The results were compared with those of histological diagnosis. The examination of tenderness of the Lanwei sign was performed without knowing the results of other examinations. Additionally, other signs and laboratory parameters for appendicitis were examined using a standardized documentation form. Altogether, 17 presurgical variables, 18 clinical signs, and 3 tests were evaluated. RESULTS: A positive Lanwei sign was documented in 65 cases (56%), whereas 51 patients (44%) had a negative Lanwei sign. 65 of the 116 patients were operated. 59 of those had a histologically proven appendicitis. The sensitivity of the Lanwei sign was 64.4%, specificity ranged at 50%. Rates for positive and negative predictive values were 92.7% and 12.5%, respectively. Odds ratio was estimated as 1.8. When comparing these parameters, the Lanwei sign ranged between the 7th and 10th place of the 22 most important clinical signs for appendicitis. The negative laparotomy rate was 9%, of which 4 of 6 patients had other indications for an operation. The rate of perforation was 15%. CONCLUSION: Compared with many conventional signs for appendicitis as for example Mc Burney, tender Sherren triangle, reduced peristalsis, the diagnostic value of the Lanwei sign is not sufficient. Although a reproducible positive Lanwei sign is a good hint for a true appendicitis, in case of a negative Lanwei sign the probability for an appendicitis may be relatively high. Because of the low negative predictive value, the Lanwei sign is not suitable for reducing negative laparatomy rates. As in many other studies, the one and only indicator for appendicitis which yields high results in all statistical parameters was not detected in this study. In comparison to the statistical parameters of traditional signs for appendicitis, the Lanwei sign cannot be regarded as a good diagnostic parameter for appendicitis.

Apendicitis aguda en el Hospital San Juan de Dios / Acute appendicitis at Hospital San Juan de Dios

La serie esta constituida por 305 pacientes operados por cuadro de apendicitis aguda entre diciembre de 1990 y diciembre 1995. Se tabularon en una hoja de registro especialmente diseñada datos de la historia clínica, examen físico, laboratorio, hallazgos operatorios, evolución postoperatoria y estudio histopatológico de la pieza quirúrgica. El dolor fue el síntoma más frecuentemente relatado (84 por ciento) con una evolución típica del cuadro clínico en el 60 por ciento de los casos, el 72,4 por ciento de los pacientes presentaban signología de irritación peritoneal. La mayoría de los pacientes fueron intervenidos mediante laparotomía de Mc Burney (55 por ciento), se realizó jareta invaginante del muñón apendicular en el 58 por ciento de los casos, y se instalaron drenajes en el 11,9 por ciento de los casos. El estudio histopatológico de los apéndices resecados demostró un 3 por ciento de apéndices normales; de los apéndices con compromiso inflamatorio el 74,7 por ciento de ellos fueron informados como apendicitis aguda simple. con respecto a la impresión macroscópica del cirujano, existe una baja correlación macroscópico-histológica. Un 8,7 por ciento de los pacientes presentó complicación postoperatoria

[Invagination of the vermiform appendix in mucinous cystadenoma]. / Invagination der Appendix vermiformis bei mucinösem Cystadenom.

Intussusception of the appendix vermiformis in adults is an uncommon event. The combination of a mucinous cystadenoma with an intussuscepted appendix is extremely rare. Clinical symptoms are nonspecific; in most cases the correct diagnosis is not made before surgical exploration. With the radiologic and endoscopic presentation of a polypoid lesion of the caecum, a neoplasm is often considered. Endoscopic appendectomy or disinvagination by enema have been described. Thus the definitive therapy is surgery and depends on the histological diagnosis.

The appearance of a normal appendix on barium enema examination does not rule out a diagnosis of chronic appendicitis: report of a case and review of the literature.

We report herein the rare case of a 15-year-old girl with chronic appendicitis in whom the appendix was clearly depicted by a barium enema (BE) examination. The patient presented with a 4-month history of diffuse abdominal pain and tenderness in the lower abdomen. Neither computed tomography nor ultrasonography showed any abnormal findings in the lower abdomen or pelvic cavity. Furthermore, BE examination depicted an appendix filled with the contrast medium. However, at elective surgery, she was found to have chronic appendicitis which was later confirmed histologically. Following this case report, a discussion on the value and limitations of BE examination for the diagnosis of acute and chronic appendicitis is presented.

Susceptibility of intra-abdominal isolates at operation: a predictor of postoperative infection.

Antimicrobial resistance of operative site flora was correlated with postoperative infection in 175 patients undergoing operation for intra-abdominal sepsis: Diagnoses for study patients were acute or gangrenous appendicitis in 48 (27%), complicated appendicitis in 98 (56%), perforated viscus other than appendix in 21 (12%), and eight (5%) had other intra-abdominal infections. One hundred thirty-six (78%) patients were males. The average age was 33 +/- 14 years, average number of hospital days was 11.6 +/- 13.5, and average number of days on antibiotics was 6.9 +/- 2.5. Overall recovery without infection was 75 per cent (131/175). Analysis of susceptibility of 939 intraoperative isolates indicated a significant relationship (P = 0.0002) between resistance to the empiric antimicrobials received and postoperative infection. Of 131 patients with resolution of the intra-abdominal infection, 57 (44%) had resistant isolates while 36 (82%) of 44 patients with postoperative infectious complications had resistant isolates. Streptococcus Group D, Escherichia coli, and Bacteroides fragilis were the most prevalent resistant organisms isolated from both intra- and postoperative cultures. Other variables that were significantly different between those without complications and those who had complications were, respectively: average age 31 versus 38; admission WBC 14.5 versus 16.7; and diagnosis, acute appendicitis 28 per cent versus 2 per cent. A stepwise logistic regression analysis confirmed the predictive value of intraoperative isolate resistance, age, and admission WBC, in that order, on outcome.

Is the appendix where you think it is--and if not does it matter?

For over 100 years the recognized surface marking for the appendix has been McBurney's point (the junction of the lateral and middle thirds of a line joining the umbilicus with the right anterior superior iliac spine (ASIS)). In order to test its validity, the relationship between McBurney's point and the appendix was determined on 275 double contrast barium enemas (DCBE). A wide spread of distribution of the site of the appendix base was seen. Only 35% of appendix bases were found to lie within 5 cm of McBurney's point, and 15% were more than 10 cm distant. Seventy-five per cent of appendix bases were below and medial to a line joining the umbilicus with the right ASIS. These findings are in agreement with world-wide studies conducted by the World Organisation of Gastroenterology which showed that less than half of all patients with appendicitis have tenderness maximal over McBurney's point. A record was also made in 93 cases of the position of the appendix in relation to the caecum. The importance of these results in the diagnosis and management of patients with suspected appendicitis is discussed.

Colonic malignancy mimicking an appendiceal mass.

The records of 99 patients admitted for inflammatory appendiceal mass were evaluated. Eight of these patients (8%) had a malignancy of the right colon with, in four cases, secondary inflammation of the appendix. Remnants of inflammation limited to the appendix were present in 64 patients. These two groups were compared to a group of 21 patients treated in the same period for a palpable malignancy of the right colon. In patients older than 50 years absence of pain, symptoms which last more than one week, a painless palpable mass in the right lower abdomen and the presence of anemia indicate (underlying) colonic malignancy. Barium enema of the colon remains the most reliable method for a correct preoperative diagnosis of colonic malignancy and should be done in every patient older than 50 years who presents with an appendiceal mass, as well as in younger patients with a protracted course of the disease.

Acute appendicitis and barium enema.

Retained barium may lead to acute appendicitis. This should be kept in mind when a patient has an abnormality of the gastrointestinal tract, as retained barium seems to increase the risk.

Barium appendicitis: fact or fancy? Report of a case and review of the literature.

Whether barium retained in the appendix can be a cause of acute appendicitis is debatable. We describe a 40-year-old man who developed nonspecific right abdominal pain 7 weeks after a barium enema, which proved to be normal. On abdominal film a distended appendix containing barium was seen, and at laparotomy acute appendicitis was present. Thus far, 26 cases of "barium appendicitis" have been reported. On the basis of the relevant literature and the cases collected, it is appropriate to draw the following conclusions: 1) With present knowledge it is not possible to state whether retained barium plays any etiologic role in the development of subsequent uncomplicated acute appendicitis. 2) If a later appendicitis does supervene, it carries a high risk of being complicated; barium seems to be responsible for the complication. 3) The longer the interval between the barium study and the subsequent appearance of acute appendicitis, the higher will be the risk of complications.