Retrospective analysis of the incidence of appendiceal neoplasm and malignancy in patients treated for suspected acute appendicitis.

BACKGROUND: Nonoperative management of uncomplicated appendicitis is currently being promoted as treatment option, albeit 0.7-2.5% of appendectomies performed due to suspected acute appendicitis show histologically malignant findings. The purpose of this study was to investigate the incidence of neoplasm and malignancy of the appendix in patients presenting with suspected acute appendicitis in real world setting. METHODS: This is a retrospective single-centre investigation of 457 patients undergoing appendectomy between the years 2017-2020. The patients' demographics, symptoms and diagnosis, intraoperative findings, and histopathological results were analysed. RESULTS: In 3.7% (n = 17) histological analysis revealed neoplasms or malignancies. Median age was 48 years (20-90 years), without sex predominance. Leukocytes (11.3 ± 3.7 G/l) and C-reactive protein (54.2 ± 69.0 mg/l) were elevated. Histological analysis revealed low-grade mucinous appendiceal neoplasia (n = 3), sessile serrated adenoma of the appendix (n = 3), neuroendocrine tumours (n = 7), appendiceal adenocarcinoma of intestinal type (n = 3), and goblet cell carcinoma (n = 1). Additional treatment varied between no treatment or follow-up due to early tumour stage (n = 4), follow-up care (n = 3), additional surgical treatment (n = 8), or best supportive care (n = 2). CONCLUSIONS: Preoperative diagnosis of appendiceal tumours is difficult. Nonoperative management of patients with acute, uncomplicated appendicitis potentially prevents the correct diagnosis of malignant appendiceal pathologies. Therefore, close follow-up or surgical removal of the appendix is mandatory.

Trial Participation and Outcomes Among English-Speaking and Spanish-Speaking Patients With Appendicitis Randomized to Antibiotics: A Secondary Analysis of the CODA Randomized Clinical Trial.

Importance: Spanish-speaking participants are underrepresented in clinical trials, limiting study generalizability and contributing to ongoing health inequity. The Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial intentionally included Spanish-speaking participants. Objective: To describe trial participation and compare clinical and patient-reported outcomes among Spanish-speaking and English-speaking participants with acute appendicitis randomized to antibiotics. Design, Setting, and Participants: This study is a secondary analysis of the CODA trial, a pragmatic randomized trial comparing antibiotic therapy with appendectomy in adult patients with imaging-confirmed appendicitis enrolled at 25 centers across the US from May 1, 2016, to February 28, 2020. The trial was conducted in English and Spanish. All 776 participants randomized to antibiotics are included in this analysis. The data were analyzed from November 15, 2021, through August 24, 2022. Intervention: Randomization to a 10-day course of antibiotics or appendectomy. Main Outcomes and Measures: Trial participation, European Quality of Life-5 Dimensions (EQ-5D) questionnaire scores (higher scores indicating a better health status), rate of appendectomy, treatment satisfaction, decisional regret, and days of work missed. Outcomes are also reported for a subset of participants that were recruited from the 5 sites with a large proportion of Spanish-speaking participants. Results: Among eligible patients 476 of 1050 Spanish speakers (45%) and 1076 of 3982 of English speakers (27%) consented, comprising the 1552 participants who underwent 1:1 randomization (mean age, 38.0 years; 976 male [63%]). Of the 776 participants randomized to antibiotics, 238 were Spanish speaking (31%). Among Spanish speakers randomized to antibiotics, the rate of appendectomy was 22% (95% CI, 17%-28%) at 30 days and 45% (95% CI, 38%-52%) at 1 year, while in English speakers, these rates were 20% (95% CI, 16%-23%) at 30 days and 42% (95% CI 38%-47%) at 1 year. Mean EQ-5D scores were 0.93 (95% CI, 0.92-0.95) among Spanish speakers and 0.92 (95% CI, 0.91-0.93) among English speakers. Symptom resolution at 30 days was reported by 68% (95% CI, 61%-74%) of Spanish speakers and 69% (95% CI, 64%-73%) of English speakers. Spanish speakers missed 6.69 (95% CI, 5.51-7.87) days of work on average, while English speakers missed 3.76 (95% CI, 3.20-4.32) days. Presentation to the emergency department or urgent care, hospitalization, treatment dissatisfaction, and decisional regret were low for both groups. Conclusions and Relevance: A high proportion of Spanish speakers participated in the CODA trial. Clinical and most patient-reported outcomes were similar for English- and Spanish-speaking participants treated with antibiotics. Spanish speakers reported more days of missed work. Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Relationship Between Appendectomy Incidence and Computed Tomography Scans Based on Korean Nationwide Data, 2003-2017.

BACKGROUND: Advances in medicine and changes in the medical environment can affect the diagnosis and treatment of diseases. The main purpose of the present study was to investigate whether the difference in accessibility to diagnosis and treatment facilities influenced the occurrence of appendectomy in Korea. METHODS: We collected data on 183,531 appendectomy patients between 2003 and 2017 using the National Health Insurance Services claims. Retrospective analysis of relationship between the age-standardized rate (ASR) of appendectomy and clinical variables affecting medical accessibility was performed. Pearson's correlation analyses were used. RESULTS: The incidence of appendectomy decreased from 30,164 cases in 2003 to 7,355 cases in 2017. The rate of computerized tomography (CT) scans for diagnosis of appendicitis increased from 4.73% in 2003 to 86.96% in 2017. The ASR of appendectomy in uncomplicated and complicated appendicitis decreased from 48.71 in 2005 to 13.40 in 2010 and 8.37 in 2005 to 2.96 in 2009, respectively. The ASR of appendectomy was higher in the high-income group. The proportion and ASR of appendectomy in older age group increased steadily with years. The total admission days continued to decrease from 6.02 days in 2003 to 4.96 days in 2017. CONCLUSION: The incidence of appendectomy was seemingly associated with the rate of CT scan. In particular, the incidence of appendectomy in uncomplicated appendicitis was markedly reduced. Through enhanced accessibility to CT scans, accurate diagnosis and treatment of appendicitis can be facilitated.

Emergency General Surgery Procedures and Cost of Care for Older Adults in the State of Maryland.

BACKGROUND: Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland. METHODS: A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant. RESULTS: Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age. CONCLUSION: These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.

Does Wound Management Technique Impact Surgical Site Infection in Open Emergency Colon Procedures?

BACKGROUND: Emergency open large bowel procedures have higher rates of intraoperative contamination and increased risk of surgical site infection (SSI) than elective colon surgeries. Several wound management strategies have been proposed, such as vacuum-assisted closure (VAC) therapy and delayed primary closure to improve results. The purpose of this study is to evaluate the relationship between wound management technique and SSI and other quality measures. METHODS: We performed a retrospective review of patients undergoing open emergency colon surgery from January 2017 to December 2018 by our acute care surgery service. The primary outcome measure was incidence of SSI. Secondary outcome measures included length of stay, reoperation, and 30-day readmission. RESULTS: A total of 118 patients were included in the study, with a mean age of 62.8 years and mean BMI of 28.8. Overall incidence of SSI was 19.5%. There was no significant difference in incidence of SSI, reoperation, or 30-day readmission when stratifying by wound management technique or procedure type after controlling for confounding variables. Notably, patients managed with VAC therapy had a statistically significant longer average length of stay and higher total postoperative antibiotic days (both P = .001) than other techniques. DISCUSSION: We conclude from our data that wound management technique does not seem to influence rate of SSI, but wound management may influence length of stay or antibiotic duration. These findings suggest that there may not be an advantage to alternative methods of wound management in this high-risk population. Further prospective evaluation should be performed to confirm these findings.

Lessons learned from value-based pediatric appendectomy care: A shared savings pilot model.

PURPOSE: We aim to assess the healthcare value achieved from a shared savings program for pediatric appendectomy. METHODS: All appendectomy patients covered by our health plan were included. Quality targets were 15% reduction in time to surgery, length of stay, readmission rate, and patient satisfaction. Quality targets and costs for an appendectomy episode in two 6-month performance periods (PP1, PP2) were compared to baseline. RESULTS: 640 patients were included (baseline:317, PP1:167, PP2:156). No quality targets were met in PP1. Two quality targets were met during PP2: readmission rate (-57%) and patient satisfaction. No savings were realized because the cost reduction threshold (-9%) was not met during PP1 (+1.7%) or PP2 (-0.4%). CONCLUSIONS: Payer-provider partnerships can be a platform for testing value-based reimbursement models. Setting achievable targets, identifying affectable quality metrics, considering case mix index, and allowing sufficient time for interventions to generate cost savings should be considered in future programs.

Impact of the SARS-CoV-2 pandemic on the course and treatment of appendicitis in the pediatric population.

SARS-CoV-2 is a highly contagious virus causing mainly respiratory track disease called COVID-19, which dissemination in the whole world in the 2020 has resulted in World Health Organisation (WHO) announcing the pandemic. As a consequence Polish Government made a decision to go into a lockdown in order to secure the population against SARS-CoV-2 outbreak what had its major influence on the Polish Health Care System. All of the social and medical factors caused by the pandemic might influence children's health care, including urgent cases. The aim of this survey was the analysis of medical charts with focus on the course and results of surgical treatment of children who underwent appendectomy before and during the COVID-19 pandemic. Material and methods: We performed analysis of charts of 365 subjects hospitalized in the Pediatric Surgery Department from 1st January 2019 to 31st December 2020 because of acute appendicitis. Patients were divided into two groups-those treated in 2019-before pandemic outbreak, and those treated in 2020 in the course of pandemic. Results: the most common type of appendicitis was phlegmonous (61% of cases in 2019 and 51% of cases in 2020). Followed by diffuse purulent peritonitis (18% of cases in 2019 vs 31% of cases in 2020), gangrenous (19% of cases in 2019 vs 15% of cases in 2020) and simple superficial appendicitis (1% of cases in 2019 vs 3% of cases in 2020). There was statistically significant difference in the length of hospitalization: in 2019 the mean length of hospi-talization was 4.761 vs 5.634 in 2020. Laparoscopic appendectomy was performed more frequently before the COVID period (63% of cases treated in 2019 vs 61% of cases treated in 2020). In the pandemic year 2020, there was double increase in the number of conversion from the laparoscopic approach to the classic open surgery. In the year 2019 drainage of abdominal cavity was necessary in 22% of patients treated with appendectomy, in 2020 the amount of cases threated with appendectomy and drainage increased to 32%. Conclusions: fear of being infected, the limited availability of appointments at General Practitioners and the new organisation of the medical health care system during pandemic, delay proper diagnosis of appendicitis. Forementioned delay leads to higher number of complicated cases treated with open appendectomy and drainage of abdominal cavity, higher number of conversions from the laparoscopic to classic open technique, and longer hospitalization of children treated with appendectomy in the year of pandemic.

Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study.

BACKGROUND: Uncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up. METHODS: A prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment. RESULTS: A total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P < 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery. CONCLUSION: This study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions.

A surge in appendicitis: Management of paediatric appendicitis during the COVID-19 surge in the Royal Belfast Hospital for Sick Children.

BACKGROUND: Traditional surgical dogma is that paediatric appendicitis necessitates an appendicectomy; however there is an increasing cohort of evidence suggesting that non-operative management (NOM) using antibiotic therapy is safe and effective. During the COVID-19 surge (April - June 2020) with centralization of paediatric surgical care and risks from anaesthetics to both patients and staff a NOM pathway was used to manage clinically diagnosed appendicitis in the Royal Belfast Hospital for Sick Children (RBHSC). METHODS: Prospective data collection was undertaken of all children (<16 years) diagnosed with appendicitis who entered the NOM pathway in RBHSC from 01/04/2020 to 30/06/2020. This was compared to a cohort from the same timeframe in 2019. Primary end-points were inpatient success rate of NOM and 30-day success rate of NOM (success defined as no appendectomy performed). RESULTS: 47 patients completed the NOM pathway, with 43% (20/47) suspected to have complicated appendicitis. The cohort was similar to that of 2019 in terms of age (p=0.1) and sex (p=0.8), but was 155% larger (42 v. 20).For those with simple appendicitis, there was a 96% (26/27) success rate of NOM on discharge, with a 93% (25/27) 30-day success rate. For complicated appendicitis, there was a 40% (8/20) success rate on discharge, with a 30% (6/20) 30-day success rate. CONCLUSION: The use of a NOM pathway for paediatric appendicitis during the COVID-19 surge in Northern Ireland was safe and effective for staff and patients. With a small sample size and restricted follow up more evidence is required to prove if this is an effective treatment modality with a return to normal theatre availability. In the interests of antibiotic stewardship we would not advocate NOM pathways utilisation by non-surgical clinicians.

Appendicitis in the COVID-19 era: a modern challenge for experienced hands.

INTRODUCTION: The first wave of COVID-19 was accompanied by global uncertainty. Delayed presentation of patients to hospitals ensued, with surgical pathologies no exception. This study aimed to assess whether delayed presentations resulted in more complex appendicectomies during the first wave of COVID-19. METHODS: Operation notes for all presentations of appendicitis (n=216) within a single health board (three hospitals) during two three-month periods (control period (pre-COVID) vs COVID pandemic) were analysed, and the severity of appendicitis was recorded as per the American Association for the Surgery of Trauma (AAST) grading system. RESULTS: Presentations of appendicitis were delayed during the COVID period with a median duration of symptoms prior to hospital attendance of two days versus one day (p=0.003) with individuals presenting with higher median white cell count than during the control period (14.9 vs 13.3, p=0.031). Use of preoperative CT scanning (OR 3.013, 95% CI 1.694-5.358, p<0.001) increased significantly. More complex appendicectomies (AAST grade >1) were performed (OR 2.102, 95% CI 1.155-3.826, p=0.015) with a greater consultant presence during operations (OR 4.740, 95% CI 2.523-8.903, p<0.001). Despite the greater AAST scores recorded during the COVID period, no increase in postoperative complications was observed (OR 1.145, 95% CI 0.404-3.244, p=0.798). CONCLUSIONS: Delayed presentations during the COVID-19 pandemic were associated with more complex cases of appendicitis. Important lessons can be learnt from the changes in practice employed as a result of this global pandemic.

Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study.

BACKGROUND: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. METHODS: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. RESULTS: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P < 0·001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. CONCLUSION: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2.

ANTECEDENTES: Las estrategias quirúrgicas están siendo adaptadas en presencia de la pandemia de la COVID-19. Las recomendaciones del tratamiento de la apendicitis aguda se han basado en la opinión de expertos, pero hay muy poca evidencia disponible. Este estudio abordó este aspecto a través de una visión de los enfoques mundiales de la cirugía de la apendicitis. MÉTODOS: La Asociación de Cirujanos Italianos en Europa (ACIE) diseñó una encuesta electrónica en línea para evaluar la actitud actual de los cirujanos a nivel mundial con respecto al manejo de pacientes con apendicitis aguda durante la pandemia. Las preguntas se dividieron en información basal, organización del hospital y cribaje, equipo de protección personal, manejo y abordaje quirúrgico, así como las características de presentación del paciente antes y durante de la pandemia. Se utilizó una prueba de ji al cuadrado para las comparaciones. RESULTADOS: De 744 respuestas, se habían completado 709 (66 países) cuestionarios, los datos de los cuales se incluyeron en el estudio. La mayoría de los hospitales estaban tratando a pacientes con y sin COVID. Hubo variabilidad en las indicaciones de cribaje de la COVID-19 y en la modalidad utilizada, siendo la tomografía computarizada (CT) torácica y el análisis molecular (PCR) (18,1%) las pruebas utilizadas con más frecuencia. El tratamiento conservador de la apendicitis complicada y no complicada se utilizó en un 6,6% y un 2,4% antes de la pandemia frente a un 23,7% y un 5,3% durante la pandemia (P < 0.0001). Un tercio de los encuestados cambió la cirugía laparoscópica a cirugía abierta debido a las recomendaciones de los grupos de expertos (pero carente de evidencia científica) durante la fase inicial de la pandemia. No hubo acuerdo en cómo filtrar el humo generado por la laparoscopia. Hubo una reducción general del número de pacientes ingresados con apendicitis y un tercio consideró que los pacientes atendidos presentaban una apendicitis más grave que las comúnmente observadas. CONCLUSIÓN: La pandemia ha demostrado que ha sido posible el tratamiento conservador de la apendicitis leve. El hecho de que algunos cirujanos cambiaran a una apendicectomía abierta podría ser el reflejo de las pautas deficientes que se propusieron en la fase inicial del SARS-CoV2.

Parasitic Appendicitis in 14.797 Cases: A Retrospective Cohort Study

Objective: This study aimed to determine the frequency of Enterobius vermicularis in appendectomy specimens and evaluate the histopathological characteristics of adult and pediatric cases with E. vermicularis infection. Methods: Appendectomies examined from 1 January 2010, to 1 December 2020, were analysed retrospectively. Cases were divided into two groups: under 18 years (children) and 18 and over (adults). Demographic and histopathological characteristics of patients were also examined. Results: Out of 14.797 patients that underwent appendectomy, 6.130 were children and 8.667 were adults. E. vermicularis was detected in 268 patients, wherein 64.2% were children and 35.8% were adults. In the detection of E. vermicularis in appendectomy specimens, the frequency was higher in children compared to that in adults (2.85%, 1.1%, respectively) (p<0.001). Histopathologically, acute appendicitis was defined in 31.7% (n=85) of 268 cases, and E. vermicularis was found to cause a higher rate of acute appendicitis in adults (p<0.001). Conclusion: The frequency of E. vermicularis in appendectomy specimens is higher in children. However, E. vermicularis causes acute appendicitis more frequently in adults.

Making it Complicated: Does Disparity in Access to Care Lead to More Perforated Appendicitis?

INTRODUCTION: Delays in obtaining care may lead to perforated appendicitis, increasing risk of morbidity and mortality. We previously explored the role of social determinants in patients undergoing cholecystectomy, finding that emergent presentation is associated with neighborhood Social Vulnerability Index (SVI). We hypothesize that social vulnerability is associated with increased incidence of perforated appendicitis. METHODS: We retrospectively identified patients presenting to our urban, academic hospital with acute appendicitis during a 9-month timeframe (11/2019 - 7/2020). Patients were classified as perforated or non-perforated. Patient SVI was determined using geocoding at the census tract level. Because rates of perforation were higher in older patients, we performed a subset analysis of patients ≥ 40 years. RESULTS: 190 patients were included. Patients with perforated appendicitis (n = 48, 25%) were older and were more likely to present to a clinic versus the emergency department (P = 0.009). Perforated patients had longer delay before seeking care (56% versus 6% with > 72 hours of symptoms, P < 0.001). However, there were no differences between groups in terms of sex, race/ethnicity, insurance type, language barrier, having a primary care physician, or any of the SVI subscales. Of patients ≥ 40 years, a higher proportion were perforated (28/80, 35%) despite similar rates of delayed care. In this cohort, higher overall SVI as well as the socioeconomic status and household composition/disability subscales were associated with perforation. CONCLUSIONS: Contrary to our hypothesis, while perforation was associated with delayed care in this population, we did not find overall that social vulnerability or individual social determinants accounted for this delay.

Emergency appendicectomy during COVID-19 pandemic - A single UK centre experience.

Background - In December 2019 following an outbreak of Novel coronavirus infection (COVID-19) in Wuhan, China, it spread rapidly overwhelming the healthcare systems globally. With little knowledge of COVID-19 virus, very few published reports on surgical outcomes; hospitals stopped elective surgery, whilst emergency surgery was offered only after exhausting all conservative treatment modalities. This study presents our experience of outcomes of emergency appendectomies performed during the pandemic. Methods - Prospectively we collected data on 132 patients in peak pandemic period from 1st March to 5th June 2020 and data compared with 206 patients operated in similar period in 2019. Patient demographics, presenting symptoms, pre-operative events, investigations, surgical management, postoperative outcomes and complications were analysed. Results - Demographics and ASA grades of both cohorts were comparable. In study cohort 84.4% and 96.7% in control cohort had laparoscopic appendicectomy. Whilst the study cohort had 13.6% primary open operations, control cohort had 5.3%. Mean length of stay and early post-operative complications (<30 days) were similar in both cohorts apart from surgical site infections (p = 0.02) and one mortality in study cohort. Conclusion - In these overwhelming pandemic times, although conservative treatment of acute appendicitis is an option, a proportion of patients will need surgery. Our study shows that with careful planning and strict theatre protocols, emergency appendicectomy can be safely offered with minimal risk of spreading COVID-19 infection. These observations warrant further prospective randomised studies. Keywords - appendicectomy, COVID-19, Coronavirus, emergency surgery, laparoscopy.

Management of Acute Appendicitis during the COVID-19 Pandemic: A Single Tertiary Center Experience.

BACKGROUND: The coronavirus disease-2019 (COVID-19) outbreak had an effect on healthcare. OBJECTIVES: To evaluate the presentation and management of patients with acute appendicitis. METHODS: A retrospective study was conducted of all patients presenting with acute appendicitis to the emergency department of a large tertiary center during March and April 2020. Clinical features, diagnostic workup, and management were compared. RESULTS: Seventy-four patients presented with acute appendicitis during the pandemic compared to 60 patients during the same time the year before. There were no significant differences in patient demographics: age (P = 0.65), gender (P = 0.73), smoking status (P = 0.48). During COVID-19 patients were more likely to complain of right lower quadrant pain (100% vs. 78.3%, P < 0.01). Rates of surgical treatment was similar (83.8% vs. 81.7%, P = 1); mean operative time was longer during COVID-19 (63 ± 23 vs. 52 ± 26 minutes, P = 0.03). There were no significant differences in intra-operative findings including the presence of appendiceal perforation (16.3% vs. 14.5%, P = 0.8), abscess (6.1% vs. 9.7%, P = 0.73), or involvement of cecum or terminal ileum (14.28% vs. 19.63%, P = 1). Postoperative treatment with antibiotics was more prevalent during COVID-19 (37.1% vs. 18%, P = 0.04). Length of stay (1.82 ± 2.04 vs. 2.74 ± 4.68, P = 0.2) and readmission rates (6% vs. 11.3%, P =0.51) were similar. CONCLUSIONS: The COVID-19 pandemic did not significantly affect the presentation, clinical course, management, and outcomes of patients presenting with acute appendicitis.

Delta neutrophil index and symptomatic time are effective factors for predicting perforated appendicitis.

ABSTRACT: Appendicitis is a common intra-abdominal inflammatory disease, and morbidity increases with age when perforation occurs. Because, not all patients require emergency surgery, there have been numerous studies on factors for predicting perforated appendicitis. In this study, we aimed to confirm whether the delta neutrophil index (DNI) and the time from symptom onset to surgery are effective predictors for perforated appendicitis in different age groups.This was a retrospective study conducted on 542 appendicitis patients who underwent surgery at Kangdong Sacred Heart Hospital. The simple group consisted of 431 subjects, and the perforation group consisted of 111 subjects.Multiple logistic regression analyses demonstrated that age, neutrophil percentage, DNI, C-reactive protein (CRP), and symptomatic time were significant predictors of perforation. Analysis of the receiver-operating characteristic curve showed that the DNI was the most reliable predictive value. In the analyses according to age, the perforation rate was higher in the >65-year-age group; these patients also had a higher DNI, CRP, and symptomatic time. In the DNI analysis using receiver operating characteristic (ROC) analysis, the area under the curve was higher in the >65-year-age group than in other age groups. In addition, the cutoff values have been determined and perforation occurred significantly in the group with a DNI value of 2.1 or higher and a symptomatic time of 33 hours or longer.DNI is effective in predicting perforation in patients with appendicitis compared with other inflammatory factors. Furthermore, the simultaneous measurement of symptomatic time and DNI is helpful in predicting perforation and determining whether emergency surgery is necessary.

Routine group and save screening prior to emergency laparoscopic surgery.

INTRODUCTION: Two group and save (G&S) samples are routinely collected from patients undergoing diagnostic laparoscopy and/or emergency appendicectomy. We aimed to identify the necessity of this practice by looking at the perioperative transfusion rates. METHODS: Data were obtained from our electronic theatre system for all patients who underwent emergency laparoscopic surgery (specifically diagnostic laparoscopy and/or laparoscopic appendicectomy) between January 2017 and December 2018. Records were reviewed for the number of G&S samples sent and perioperative transfusion rates. RESULTS: A total of 451 patients were included in the study. The numbers of procedures performed in 2017 and 2018 were 202 (44.8%) and 249 (55.2%), respectively. The total number of samples sent was 930. Only 786 (84.5%) samples were processed and the rest were rejected for various reasons. Of the 451 patients included in the study, 308 (68.3%) had two G&S samples sent, whereas 41 patients (9.1%) had only one G&S sample sent. Fifty-six (12.4%) and 20 (4.4%) patients had three and four G&S samples sent, respectively. Only two patients required transfusion perioperatively (0.4%), and the indication in both was irrelevant to the primary operation. CONCLUSIONS: These results demonstrate a near-zero transfusion rate in this patient cohort. Omitting G&S is safe and potentially saves time and resources.

How COVID-19 pandemic influences paediatric acute appendicitis cases? / Milyen hatása van a COVID-19-járványnak a gyermekkori akut appendicitisekre?

Összefoglaló. Bevezetés: A COVID-19-pandémia miatt a gyermekkori appendicitisek kezelésében számos változás történt (laparoszkópia helyett nyílt mutét, antibiotikumkezelés). Világszerte emelkedett a szövodményes appendicitisek aránya. Célkituzés: Munkánk során a COVID-19-járványnak a gyermekkori akut appendicitisekre kifejtett hatását szerettük volna vizsgálni: lett-e több perforált eset? Módszerek: A 2012 és 2020 között akut vakbélgyulladás miatt operált gyermekeket vizsgáltuk, külön, havi bontásban a 2020-as eseteket. A szövettani diagnózis alapján perforált és nem perforált appendicitis csoportokat alkottunk. A 2020-ban operált betegek COVID-19-statusát is rögzítettük. Statisztikai analízisre a khi2-próbát ('chi2 test for trend') és a Fisher-féle egzakt tesztet alkalmaztuk. Eredmények: A vizsgált idoszakban 1343 appendectomia történt, többségében nem perforált akut appendicitis miatt (1166/1343). 2015-tol kezdodoen a perforált esetek aránya szignifikáns emelkedést mutat (p = 0,0002). Az igazoltan COVID-19-pozitív betegek között magasabb volt a perforáltak aránya (5/8), mint az igazoltan negatív betegek között (15/92) (p = 0,0075). Megbeszélés: A nemzetközi trendeknek megfeleloen 2020-ban osztályunkon is magasabb volt a perforált appendicitisek aránya, mint a korábbi években. Ez az emelkedés 2015-tol tart, a pandémiával nem mutat szoros összefüggést. A perforált appendicitisek COVID-19-pozitív betegek között észlelt magas arányának okát nem ismerjük. Következtetés: További vizsgálat indokolt annak feltárására, hogy mi okozza a perforált appendicitisek COVID-19-pozitív betegek között észlelt magas, illetve 2015 óta emelkedo rátáját. Orv Hetil. 2021; 162(16): 608-610. INTRODUCTION: As a result of the COVID-19 pandemic, the management of paediatric appendicitis has changed (open instead of laparoscopic appendectomy, antibiotic treatment). The number of complicated appendicitis cases increased worldwide. OBJECTIVE: Our aim was to study the effect of the COVID-19 pandemic on paediatric acute appendicitis: has there been more perforated cases? METHODS: Children operated because of acute appendicitis between 2012 and 2020 were studied. Cases from the year 2020 were analysed monthly. Patients were divided into perforated and non-perforated appendicitis groups according to their histological findings. COVID-19 status of patients in 2020 was studied. Chi2 test for trend and Fisher's exact test were used for statistical analysis. RESULTS: In the study period, 1343 appendectomies were performed. The majority of our cases were non-perforated (1166/1343). The rate of perforated appendicitis cases has been increasing from 2015 (p = 0.0002). The number of perforated cases was higher in COVID-19 positive patients (5/8) then in negative ones (15/92) (p = 0.0075). DISCUSSION: In line with the international trend, more perforated appendicitis cases were treated in our departement in 2020. However, this increase started in 2015, and there is no correlation with the COVID-19 pandemic. The cause of the increased number of perforated cases in COVID-19 positive appendicitis patients is unknown. CONCLUSION: The causes of the high proportion of perforated cases in COVID-19 positive patients and the rising rate of perforated appendicitis cases since 2015 need further studies. Orv Hetil. 2021; 162(16): 608-610.