Effect of high volume enema in children with abdominal pain: Pediatric emergency department experience.

BACKGROUND: Abdominal pain is one of the most common reasons for admission to the pediatric emergency clinic. The appropriate evaluation of clinical and laboratory clues to make the correct diagnosis is of great importance in terms of directing the treatment medically or surgically and preventing unnecessary investigations. The aim of our study was to evaluate the contribution of high-volume enema application among pediatric patients with abdominal pain in terms of clinical and radiological findings. METHODS: Among the pediatric patients who applied to the pediatric emergency clinic of our hospital between January 2020 and July 2021 with abdominal pain, those who had intense gas stool image on abdominal X-ray and abdominal distension on physical examination and who underwent high-volume enema treatment were included in the study. The physical examination and radiological findings of these patients were evaluated. RESULTS: During the study period, 7819 patients were admitted to the pediatric emergency outpatient clinic with abdominal pain. Classic enema was performed in 3817 of these patients who had a dense gaseous stool image and abdominal distention on abdominal X-ray graphy. Defecation occurred in 3498 (91.6%) of 3817 patients who underwent classical enema, and the complaints regressed after enema. High-volume enema was applied to 319 (8.4%) patients who did not find relief with classical enema. Complaints of 278 (87.1%) patients regressed after the high-volume enema. Control ultrasonography (US) was performed in the remaining 41 (12.9%) patients, 14 (34.1%) patients were diagnosed with appendicitis. US results of 27 (65.9%) patients who had repeated US were evaluated as normal. CONCLUSION: High volume enema treatment is an effective and safe method in children with abdominal pain who are unresponsive to classical enema application in the pediatric emergency department.

Evaluation of factors predicting appendiceal tumoral lesions in patients undergoing appendectomy for acute appendicitis.

BACKGROUND: Tumoral lesions are a relatively rare cause of acute appendicitis. Accurate pre-operative diagnosis is essential to provide appropriate treatment. The aim of this study was to evaluate factors that may increase diagnostic rate of appendiceal tumoral lesions in patients undergoing appendectomy. METHODS: A retrospective review of a large cohort of patients who underwent appendectomy for acute appendicitis from 2011 to 2020 was undertaken. Demographics, clinicopathologic findings, and pre-operative laboratory values were recorded. Univariate and multivariate logistic regression and receiver-operating characteristic curve analysis were performed to identify the factors that predict appendiceal tumoral lesions. RESULTS: A total of 1400 patients were included in the study, with median age of 32 (range, 18-88) years, and of whom 54.4% were male. Overall, 2.9% (n=40) of patients had appendiceal tumoral lesions. Multivariate analysis revealed that age (Odds Radio [OR] 1.06, 95% confidence interval [CI] 1.03-1.08) and WBC count (OR 0.84, 95% CI 0.76-0.93) were independent predictors of appendiceal tumoral lesions. The optimal cutoff age was 37 years old (AUC: 0.79; sensitivity: 82.0%; specificity: 62.0%). WBC count <10×109/L was another independent predictive factor (AUC: 0.69, sensitivity: 74%; specificity: 60%). CONCLUSION: Predicting an appendiceal tumoral lesion preoperatively is critical to ensure a favorable post-operative outcome. Higher age and low WBC counts appear to be independent risk factors for an appendiceal tumoral lesion. In case of doubt and in the presence of these factors, wider resection should be favored over appendectomy only to provide a clear surgical margin.

Nonoperative Management Versus Laparoscopic Appendectomy in Children: A Cost-Effectiveness Analysis.

INTRODUCTION: Nonoperative management (NOM) of acute appendicitis in the pediatric population is highly debated with uncertain cost-effectiveness. We performed a decision tree cost-effectiveness analysis of NOM versus early laparoscopic appendectomy (LA) for acute appendicitis in children. METHODS: We created a decision tree model for a simulated cohort of 49,000 patients, the number of uncomplicated appendectomies performed annually, comparing NOM and LA. We included postoperative complications, recurrent appendicitis, and antibiotic-related complications. We used the payer perspective with a 1-year time horizon. Model uncertainty was analyzed using a probabilistic sensitivity analysis. Event probabilities, health-state utilities, and costs were obtained from literature review, Healthcare Cost and Utilization Project, and Medicare fee schedules. RESULTS: In the base-case analysis, NOM costs $6530/patient and LA costs $9278/patient on average at 1 y. Quality-adjusted life year (QALY) differences minimally favored NOM compared to LA with 0.997 versus 0.996 QALYs/patient. The incremental cost-effectiveness ratio for NOM over LA was $4,791,149.52/QALY. NOM was dominant in 97.4% of simulations, outperforming in cost and QALYs. A probabilistic sensitivity analysis showed NOM was 99.6% likely to be cost-effective at a willingness-to-pay threshold of $100,000/QALY. CONCLUSIONS: Our model demonstrates that NOM is a dominant strategy to LA over a 1-year horizon. We use recent trial data demonstrating higher rates of early and late NOM failures. However, we also incorporate a shorter length of index hospitalizations with NOM, reflecting a contemporary approach to NOM and ultimately driving cost-effectiveness. Long-term follow-up data are needed in this population to assess the cost-effectiveness of NOM over longer time horizons, where healthcare utilization and recurrence rates may be higher.

Retrospective cohort study of the impact of faecoliths on the natural history of acute appendicitis.

BACKGROUND: Despite acute appendicitis is one of the most common surgical emergencies, its aetiology remains incompletely understood. AIM: This study aimed to assess the rate at which faecoliths were present in acute appendicitis treated with appendicectomy and whether their presence was associated with complicated appendicitis. METHODS: All adult patients who underwent appendicectomy for acute appendicitis in a 2 years period (January 2018 and December 2019) at a single institution were retrospectively reviewed. The presence of a faecolith was identified by at least one of three methods: pre-operative CT scan, intraoperative identification, or histopathology report. Patients were grouped according to the presence or absence of a faecolith and demographics, type of appendicitis and surgical outcomes analysed. Complicated appendicitis was defined as appendicitis with perforation, gangrene and/or periappendicular abscess formation. RESULTS: A total of 1035 appendicectomies were performed with acute appendicitis confirmed in 860 (83%), of which 314 (37%) were classified as complicated appendicitis. Three hundred thirty-nine (35%) of the appendicitis cases had faecoliths (complicated 165/314 cases; 53%; uncomplicated 128/546; 23%, p < 0.001). The presence of a faecolith was associated with higher complications and a subsequent longer post-operative stay. CONCLUSION: The rigorous methodology of this study has demonstrated a higher rate of faecolith presence in acute appendicitis than previously documented. It reinforces the association of faecoliths with a complicated disease course and the importance in prioritising emergency surgery and postoperative monitoring for complications.

Variations in clinical course and surgical outcomes of acute appendicitis during COVID-19 Pandemic: a multicenter cohort study.

BACKGROUND: COVID-19 pandemic has led to changes in the presentation and treatment of surgical pathologies. Therefore, we aim to describe the influence of the COVID-19 pandemic on the clinical presentation and management of acute appendicitis (AAp) and its surgical outcomes. STUDY DESIGN: A multicenter cohort study with prospectively collected databases. Three high-volume centers were included and all patients over 18 years of age who underwent appendectomy for AAp were included. Multiple logistic regression and multinomial logistic regression were performed, and odds ratio, relative risk, and B-coefficient were reported when appropriate, statistical significance was reached with p-values < 0.05. RESULTS: 1.468 patients were included (709 in the pre-pandemic group and 759 in the COVID-19 group). Female patients constituted 51.84%. Mean age was 38.13 ± 16.96 years. Mean Alvarado's score was 7.01 ± 1.59 points. Open surgical approach was preferred in 90.12%. Conversion rate of 1.29%. Mortality rate was 0.75%. There was an increase of perforated and localized peritonitis (p 0.01) in the COVID-19 group. Presence of any postoperative complication (p 0.00), requirement of right colectomy and ileostomy (p 0.00), and mortality (p 0.04) were higher in the COVID-19 group. Patients in the pre-pandemic group have a lesser risk of mortality (OR 0.14, p 0.02, 95% CI 0.02-0.81) and a lesser relative risk of having complicated appendicitis (RR 0.68, p 0.00, 95% CI 0.54-0.86). CONCLUSION: Complicated appendicitis was an unexpected consequence of the COVID-19 pandemic, due to surgical consultation delay, increased rates of morbidity, associated procedures, and mortality, influencing the clinical course and surgical outcomes of patients with AAp.

Clinical Applicability of Automated Hematology Analyzer Research Parameters for Disease Diagnosis: a Reference Interval Study.

BACKGROUND: We established reference intervals for research parameters of complete blood cell count and examined their usefulness for diagnosing certain diseases. METHODS: Reference intervals for 26 basic and 38 research parameters were established for 3,457 and 1,325 men and 2,742 and 830 women aged 20 - 59 and ≥ 60 years, respectively. Research parameter values for patients with iron deficiency anemia (IDA), appendicitis, sepsis, and myelodysplastic syndromes (MDS) were compared against gender- and age-matched reference values. RESULTS: Seven basic and 10 research parameters among men and one research parameter among women required partitioning by age. No partitioning by gender was required. Further, 67% patients with IDA showed micro red blood cell ratio values above the upper reference limits of their corresponding age and gender subgroups; 3% and 5% patients with appendicitis showed immature granulocyte percentages and counts above the upper reference limits, respectively; 12% - 42% of patients with sepsis showed numerous values exceeded their reference limits, and 67% and 100% patients with MDS showed neutrophil cell complexity and structural dispersion values outside their reference ranges, respectively. CONCLUSIONS: Overall, < 60% of research parameter values were outside their reference ranges among most patients, indicating their limited diagnostic usefulness.

Differentiating abdominal pain due to COVID-19 associated multisystem inflammatory syndrome from children with acute appendicitis: a score system.

PURPOSE: Differentiating abdominal pain due to coronavirus disease (COVID-19)-associated multisystem inflammatory syndrome (MIS-C) in children with acute appendicitis (AA) can cause diagnostic dilemmas. This study aimed to evaluate the efficacy of a previously described scoring system and improve its diagnostic ability in differentiating between these diseases. METHODS: This study was conducted between March 2020 and January 2022. Patients who had MIS-C with gastrointestinal system (GIS) involvement and patients who underwent surgery for appendicitis were included. First, all patients were evaluated using the new scoring system (NSS). The groups were compared by adding new MISC-specific parameters to NSS. The scoring system was evaluated using propensity score matching (PSM). RESULTS: A total of 35 patients with abdominal pain due to GIS involvement in MIS-C (group A) and 37 patients with AA who had ALT, PRC, and D-dimer results at their first admission (group B) were included in the study. The mean age of patients in group A was lower than that of patients in group B (p < 0.001). False NSS positivity was found in 45.7% of the patients with MIS-C. Lymphocyte (p = 0.021) and platelet counts (p = 0.036) were significantly lower in the blood count and serum D-dimer (p = 0.034), C-reactive protein (CRP) (p < 0.001), and procalcitonin (p < 0.001) were significantly higher in the MIS-C group. We created a scoring system called the Appendicitis-MISC Score (AMS) using the NSS and new parameters. The sensitivity and specificity of AMS diagnostic scores were 91.9% and 80%, respectively. CONCLUSION: MIS-C with GIS involvement may present as acute abdomen. It is difficult to differentiate this condition from acute appendicitis. AMS has been shown to be useful for this differentiation.

Diagnostic value of systemic immune inflammation index in acute appendicitis.

OBJECTIVE: Clinical diagnosis of acute appendicitis is often difficult and involves a synthesis of clinical, laboratory, and radiological findings. The aim of this study was to investigate whether the systemic immune inflammation index can be used as an effective parameter in the diagnosis of acute appendicitis and its reliability in the differentiation of complicated vs. non-complicated appendicitis. METHODS: The study was conducted retrospectively with patients admitted to the emergency department with abdominal pain and diagnosed with acute appendicitis. In total, 150 patients and 150 control cases were included in the study. Demographic data, medical history, white blood cell count, platelet count, neutrophil count, systemic immune inflammation index values, Alvarado score, adult appendicitis score, and pathology result of appendectomy material were retrieved from the hospital automation system and recorded in the data form. RESULTS: Neutrophil-lymphocyte ratio and systemic immune inflammation index were significantly higher, and platelet-neutrophil ratio and lymphocyte-neutrophil ratio were significantly lower in the patient group compared to the control group (p<0.001). Receiver operating characteristic analysis revealed that the sensitivity and specificity of systemic immune inflammation index with a cutoff value of 840.13 was 82 and 66.7%, respectively, for the diagnosis of acute appendicitis. Correlation analysis revealed that systemic immune inflammation index, Alvarado score, and adult appendicitis score were positively correlated, and this correlation was statistically significant. CONCLUSION: Systemic immune inflammation index may be used to promote the diagnosis of acute appendicitis and may reduce the need for radiation exposure and diagnostic imaging tests such as contrast-enhanced abdominal computed tomography. It can also be used to differentiate between complicated and non-complicated acute appendicitis cases.

Are only a few hours adequate for hospitalisation following mini-incision open appendectomy in paediatric patients?

Background: A very short hospital length of stay following an open appendectomy in children with acute simple appendicitis has never been mentioned yet in the literature. The authors reviewed the outcome of these paediatric patients who were treated with the open technique. Materials and Methods: In this analytical cohort observational study, we retrospectively reviewed the medical records of the 115 consecutive patients who underwent open appendectomy from June 2017 to July 2021. Results: There were 84 patients whose appendices were inflammatory or suppurative and appendectomies were done only through McBurney's point. Of these, the average age was 9.11 ± 2.67 years. The mean length of the incision was 1.95 ± 0.48 cm. Nearly one-third (25/85) were discharged within 3 h following surgery. Of the remaining cases, nine patients were discharged within the same day. There were increased percentages of patients who were eligible for early discharge in each consecutive year. Conclusion: The idea of immediate discharge within 3 h seems to be feasible for children with acute simple appendicitis who were treated with open appendectomy. We believe that the practice will be widely acknowledged and proceed to reduce the resources and the expenses in the hospital.

Patient-centred outcomes following non-operative treatment or appendicectomy for uncomplicated acute appendicitis in children.

While non-operative treatment has emerged as an alternative to surgery for the treatment of uncomplicated acute appendicitis in children, comparative patient-centred outcomes are not well documented. We investigated these in a feasibility randomised trial. Of 57 randomised participants, data were available for 26. Compared with appendicectomy, children allocated to non-operative treatment reported higher short-term quality of life scores, shorter duration of requiring analgesia, more rapid return to normal activities and shorter parental absence from work. These preliminary data suggest differences exist in recovery profile and quality of life between these treatments that are important to measure in a larger RCT. Trial registration number is ISRCTN15830435.

Detection of Enterobius vermicularis in archived formalin-fixed paraffin-embedded (FFPE) appendectomy blocks: It's potential to compare genetic variations based on mitochondrial DNA (cox1) gene.

Acute appendicitis represents one of the most common causes of emergency abdominal surgery worldwide. Meanwhile, Enterobius vermicularis has been suggested as one of the probable causes of appendicitis. In this study, the morphological characteristics of the remnant pinworms and pathologic changes were explored in old-archived FFPE tissues of appendectomies. Moreover, we provide the first molecular identification, genetic, and haplotype variation of this nematode from the old-archived FFPE tissue section of appendectomy using the mitochondrial cytochrome c oxidase subunit 1 (cox1) gene. Seventeen FFPE appendectomies with E. vermicularis infection, stored over 12-22 years, were collected from two different geographical areas of Iran. In the histopathological examination, tissue changes were observed in thirteen cases (76.4%) and inflammation in four blocks (23.5%). After DNA extraction, the cox1 gene was amplified in twelve (70.6%) cases using the nested polymerase chain reaction (PCR). Phylogenetic analysis and a median-joining network of 78 available cox1 sequences of E. vermicularis revealed 59 haplotypes. We identified five haplotypes that fell into type B. All Haplotypes are novel except for two haplotypes, Hap32 and Hap37, identical to E. vermicularis sequences from Iran, Greece, and Germany. The ranges of diversity distance and haplotype diversity within the isolates were 0-1.9% and HD:0.643-0.667, subsequently. Overall, the absence of inflammation or even tissue changes in some sections can suggest the possible non-inflammatory role of E. vermicularis in appendicitis. Although FFPE material suffers from PCR inhibition, we could successfully use nested PCR to characterize E. vermicularis in old-archived appendectomy blocks and suggest this method as a complementary diagnosis technique in pathology. While the predominant type was B in the Middle East and Europe, further studies on a larger sample size from different geographical regions could probably confirm the results obtained in the present study.

Is it necessary to use specimen retrieval bag for reducing surgical site infection in laparoscopic appendectomy?A randomized controlled trial.

BACKGROUND: The aim of the study was to investigate the comparison the effects of the extraction of specimen by using a specimen retrieval bag (SRB) or direct extraction through trochar in terms of surgical site infection (SSI) in patients who underwent laparoscopic appendectomy. METHODS: A total of 165 patients were randomly allocated into two groups. A SRB was used in 77 patients (Group 1, 46.7%) and not used in 88 patients (Group 2, 53.3%). Demographics, comorbid diseases, laboratory results, preoperative diameter of appendix, intraoperative observations, intraoperative procedures, hospitalization times, SSIs, pathology results, culture results, and findings of the patients who developed complications and the treatments given to the patients due to complications during the post-operative period were recorded. RESULTS: The mean age of the patients was 33.95 SD 13.25 (min-max: 18-78) years. No significant difference was observed in the demographics, hospitalization times, distribution of the incidence rates of diabetes mellitus, perioperative perforation, perioperative fluid/abscess, drain insertion, aspiration-irrigation, superficial incisional SSI, drainage requirement, leakage, positive culture results, and post-operative intra-abdominal infection (p>0.05) between the groups. Neutrophil and leukocyte values were statistically significantly different between the groups (p=0.044 and p=0.012, respectively). There was a significant difference between the two groups in terms of the complicated appendicitis (p=0.040). There was no significant difference in terms of the positive culture results and incidence of post-operative intra-abdominal infection between the patients in Group 1 and Group 2 in both the complicated and uncomplicated appendicitis groups (p>0.05). The difference between the patients in Group 1 and Group 2 regarding the incidence of superficial incisional SSI was significant in the uncomplicated appendicitis group (p=0.037), whereas not significant in the complicated appendicitis group (p=1.000). In the multivariate model, only perioperative perforation was observed to be the effective parameter on post-operative intra-abdominal infection at the p<0.05 level (p=0.045). CONCLUSION: The results of the present study revealed that the use of SRB does not prevent microbial seeding in patients who underwent laparoscopic appendectomy; therefore, it was concluded that using SRB is not associated with SSI at laparoscopic appendectomy.

Maternal Smoking During Pregnancy and Risk of Appendicitis in the Offspring.

BACKGROUND: Existing evidence on the link between smoking and appendicitis is scarce and ambiguous. We therefore conducted a population-based cohort study in Denmark to investigate whether smoking during pregnancy is associated with an increased risk of appendicitis in offspring. METHODS: We used the Danish Birth Registry to include all singletons born during 1991-2017 and to identify maternal smoking status during pregnancy. We followed the children from birth until date of appendicitis, emigration, death, or administrative end of study (31 December 2018), whichever came first. We calculated crude and adjusted hazard ratios (HRs) of appendicitis with 95% confidence intervals (CIs) comparing children of mothers who smoked during pregnancy to children of nonsmokers. Further, we conducted a bias analysis and sibling analysis. RESULTS: We included 1,659,526 singletons of whom 19% were born to mothers who smoked during pregnancy. After maximum 28 years of follow-up, hazard rates for children of smokers were slightly higher than for children of nonsmokers [adjusted HR: 1.07 (95% CI = 1.04, 1.10)]. Stratification by sex revealed no association for males [adjusted HR: 1.02 (95% CI = 0.99, 1.06)], but a higher HR for females [adjusted HR: 1.13 (95% CI = 1.09, 1.18)]. This association increased with increasing length of follow-up, indicating that the association may be mediated by later-life exposures. The bias analysis indicated that misclassification of maternal smoking could attenuate a true association, while the sibling analysis showed no association. CONCLUSIONS: Maternal smoking during pregnancy and appendicitis in the offspring may be associated.

Prospective study of laparoscopic management of appendicitis during the COVID pandemic in a single paediatric centre.

Background: The coronavirus (COVID-19) pandemic affected the presentation of many conditions. This study analyses and describes the impact of the COVID-19 pandemic on the management of appendicitis in children and the role of laparoscopy. Materials and Methods: We performed a prospective (during the pandemic) and retrospective (historic control) review of the management of appendicitis in a tertiary paediatric surgical unit. Preoperative data, operative findings and patient outcomes were compared between groups to identify differences between the study periods and to identify any factors predictive of outcomes. Results: Sixty-two patients were identified in the pre-pandemic cohort, 72 in the pandemic cohort. There was no significant difference in patient demographics, length of admission or time between admission and surgery between groups. There was however a significantly longer time to presentation to hospital in the pandemic group. Clinical outcomes were comparable between the two groups, with no difference in the presence of surgical complications or histologically advanced appendicitis between the two groups. Laparoscopic surgery was safely used to manage appendicitis in the pandemic cohort through utilisation of a COVID-19 pathway that included guidance on testing, and use of personal protective equipment (PPE). Conservative management in the pandemic cohort was reserved for patients with appendicitis with the presence of mass formation. Conclusion: Despite a delayed presentation to hospital, there was no rise in the incidence of complicated appendicitis, complications of surgery or length of stay during the COVID-19 pandemic. Laparoscopic appendicectomy was also shown to be a safe and effective standard for the management of appendicitis during the pandemic. Level of Evidence: III, treatment.

Comparison of Contrast-enhanced versus Non-enhanced Helical Computed Tomography in the Diagnosis of Acute Appendicitis: A Meta-analysis.

The aim of this review was to compare the performance of contrast-enhanced versus non-contrast-enhanced helical computed tomography (CT) for acute appendicitis as reported. A systematic search of PubMed and Embase was conducted. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the summary receiver operating characteristic curves (AUC) were evaluated using Meta-DiSc. Quality was assessed using QUADAS 2. Eight articles with 1602 patients were included. For contrast-enhanced CT, the pooled sensitivity was 0.95 (95% CI: 0.93-0.96) with a specificity of 0.94 (95%CI: 0.93-0.96). The PLR, NLR, and DOR were 14.74 (95%CI: 9.06-23.97), 0.06 (95%CI: 0.03-0.11), and 305.31 (95%CI: 107.14-870.08), respectively. For non-contrast-enhanced CT, the pooled sensitivity was 0.85 (95% CI: 0.82-0.87) with a specificity of 0.93 (95%CI: 0.92-0.95). The PLR, NLR, and DOR were 12.22 (95% CI: 9.52-15.69), 0.15 (95%CI: 0.09-0.25), 80.98 (95%CI: 41.65-157.45), respectively. The AUC was not statistically different (Z=0.737, p=0.461). This data suggest that the contrast-enhanced CT has better diagnostic performance for acute appendicitis than non-contrast CT. Key Words: Acute appendicitis, Contrast-enhanced computed tomography' scan, Non-contrast-enhanced computed tomography' scan, Meta-analysis.

Acute Appendicitis Non-Operative Management Rate Trends Over Two Decades (2000 to 2019): The Israel experience.

BACKGROUND: Acute appendicitis (AA) is a medical emergency. The standard of care for AA had been surgical appendectomy. Recently, non-operative management (NOM) has been considered, mainly for uncomplicated AA. OBJECTIVES: To evaluate AA NOM trends over two decades. METHODS: We conducted a retrospective cohort study based on Israel's National Hospital Discharges Database (NHDD). Inclusion criteria were AA admissions from 1 January 2000 to 31 December 2019, with either primary discharged diagnosis of AA, or principal procedure of appendectomy. Predefined groups were children (5 ≤ 18 years) and adults (≥ 18 years). We compared the last decade (2010-2019) with the previous one (2000-2009). RESULTS: The overall AA incidence rate over two decades was 126/100,000/year; higher in children 164/100,000/year than 113/100,000/year in adults. Surgery was the predominant AA treatment in 91.9%; 93.7% in children and 91.1% in adults. There was an increase in AA NOM rates when comparing the previous decade (5.6%) to the past decade (10.2%); 3.2% vs. 9.1% in children and 6.8% vs. 10.7% in adults, respectively. Annual trends revealed a mild increase in AA NOM rates. Delayed appendectomy (within 90 days of AA NOM) was 19.7% overall; 17.3% in adults and 26.3% in children. CONCLUSIONS: There was an increase in AA NOM rates during the last decade in the overall population. Since 2015, there has been a noticeable increase in AA NOM rates, probably associated with World Society of Emergency Surgery Jerusalem guidelines. Surgery is still the predominant treatment for AA despite the increasing trend in NOM.

Using Microbiology Culture in Pediatric Appendicitis to Risk Stratify Patients: A Cohort Study.

Background: We sought to investigate the value of intra-operative microbiology samples in pediatric appendicitis. Proposed benefits include tailoring post-operative antimicrobial management, risk-stratifying patients, and reducing post-operative intra-abdominal abscess formation. Patients and Methods: All cases of appendicitis managed with appendicectomy in a single center were collected from January 2015 to August 2020. Intra-operative microbiology samples were taken routinely. Post-operative outcomes were analyzed with reference to culture and sensitivity results. Histologic findings were further categorized as normal, simple, or complex. Results: Six hundred seventy-eight children had appendicectomies, and 608 had both microbiology and histology samples taken. Intra-abdominal fluid collection and subsequent intervention rates were 22% and 9%, respectively. There were more collections in those with a culture positive result (p < 0.001), and those growing each of three recognized organisms, Escherichia coli (p < 0.001), Pseudomonas aeruginosa (p = 0.01), and Streptococcus anginosus group (p < 0.001). Intervention rate was higher in the culture-positive result group (p = 0.002) and the Streptococcus anginosus group (p < 0.001). Conclusions: This study shows an increased risk of developing a collection with the isolation of one of three key organisms (Escherichia coli, Pseudomonas aeruginosa, Streptococcus anginosus group). Sersoal swabs are an effective and practical method of gathering information on organisms. Microbiologic yield was correlated to the severity of appendicitis. Isolation of Streptococcus anginosus increases the incidence of collections to 50%. This is useful to empower surgeons to prognosticate patients' potential outcomes based on both intra-operative, and microbiologic findings, and is useful in counseling patients and managing expectations. A prolonged course of antibiotic agents or higher dose may mitigate this risk.

Lacticaseibacillus rhamnosus dfa1 Attenuate Cecal Ligation-Induced Systemic Inflammation through the Interference in Gut Dysbiosis, Leaky Gut, and Enterocytic Cell Energy.

Despite an uncommon condition, the clinical management of phlegmon appendicitis (retention of the intra-abdominal appendiceal abscess) is still controversial, and probiotics might be partly helpful. Then, the retained ligated cecal appendage (without gut obstruction) with or without oral Lacticaseibacillus rhamnosus dfa1 (started at 4 days prior to the surgery) was used as a representative model. At 5 days post-surgery, the cecal-ligated mice demonstrated weight loss, soft stool, gut barrier defect (leaky gut using FITC-dextran assay), fecal dysbiosis (increased Proteobacteria with reduced bacterial diversity), bacteremia, elevated serum cytokines, and spleen apoptosis without kidney and liver damage. Interestingly, the probiotics attenuated disease severity as indicated by stool consistency index, FITC-dextran assay, serum cytokines, spleen apoptosis, fecal microbiota analysis (reduced Proteobacteria), and mortality. Additionally, impacts of anti-inflammatory substances from culture media of the probiotics were demonstrated by attenuation of starvation injury in the Caco-2 enterocyte cell line as indicated by transepithelial electrical resistance (TEER), inflammatory markers (supernatant IL-8 with gene expression of TLR4 and NF-κB), cell energy status (extracellular flux analysis), and the reactive oxygen species (malondialdehyde). In conclusion, gut dysbiosis and leaky-gut-induced systemic inflammation might be helpful clinical parameters for patients with phlegmon appendicitis. Additionally, the leaky gut might be attenuated by some beneficial molecules from probiotics.