Complicated Appendicitis: A Surgical Controversy Concerning Risk Factors, Diagnostic Algorithm and Therapeutic Management

By surgeon’s perspective, complicated appendicitis is defined as perforated appendicitis, periappendicular abscess, gangrenous appendicitis or peritonitis, noted on radiological studies upon hospital admission, operative reports or pathology results of the surgical specimen. Despite that this clinical condition is truly common in everyday surgical routine, its causes and risk factors are still unclear. Some parameters have been associated with complicated appendicitis, like older age, type 2 diabetes, symptoms for longer duration, appendicoliths/fecaliths, delays in surgery after onset of symptoms and after admission. Furthermore, currently, there is no standard diagnostic algorithm for complicated appendicitis. To be specific, radiological findings lack sensitivity, intraoperative assessment may overestimate it while, histopathological examination is regarded as more specific diagnostic method. In addition, the optimal treatment for complicated appendicitis remains controversial between an immediate surgical operation (laparotomy/laparoscopy) or a trial of nonoperative management. Hereby, by reviewing the current literature, we would aim to clarify the risk factors and the diagnostic procedure of complicated appendicitis as well as to compare the operative management with the conservative one according to the type of complicated appendicitis, the success rate and the postoperative complications.

Larger Physique as a Risk Factor for Infantile Appendicitis: A Retrospective Study

The clinical features and risk factors of acute appendicitis in infants are unclear. Our aim was to evaluate the association between anthropometrics and the occurrence of infantile appendicitis. This was a retrospective study of infants (<6 years of age) and school-age children (6–10 years of age) of Asian ethnicity who required hospitalization for appendicitis at our two participating institutions between 2004 and 2018. The Z-score for height, body weight, and body mass index (BMI) was compared between the two groups, as well as between patients presenting with perforated and non-perforated appendicitis. The analysis included data from 73 infants and 362 school-age children. Z-scores were greater in infants than in school-age children for height (0.37 versus −0.03, p = 0.003) and body weight (0.12 versus −0.36, p = 0.023), with no between-group difference for the Z-score of BMI. There was no difference in Z-scores for height, weight, and BMI between the perforated and non-perforated appendicitis infant groups. Infants presenting with acute appendicitis were characterized by a larger physique but with normal proportion. This trend was not observed in school-age children. Therefore, larger infants presenting with abdominal pain should be screened for appendicitis.

Frequency of wound infection in children undergoing appendectomy for acute versus perforated appendicitis.

Objective: To find out the frequency of wound infection in children undergoing appendectomy for acute vs perforated appendicitis. Study Design: Observational and Cross-sectional study. Setting: Department of Surgery at Children’s Hospital and the Institute of Child Health Lahore. Period: January 2018 to July 2018. Material & Methods: Data was collected by using Random sampling technique. Patients of both genders were included. Diabetic children were excluded. Questionnaire was developed with the help of experts, literature review and data collection. Results: A sum of 120 patients were included with mean age of 9 + 1.94 SD minimum was 7 and maximum was 13. Some patients have acute appendicitis 20(16.67%) and 100 (80.33) perforated appendix undergone appendectomy. Conclusion: The findings of the study indicated that there is less wound infection in acute appendix but more wound infection observed in perforated appendix after appendectomy.

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies

Introduction Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery. Materials and Methods Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien–Dindo classification. Results A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien–Dindo grade I to III complications (mild–moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades. Conclusion Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.

Study of serum bilirubin as a diagnostic method to predict acute perforated appendicitis

Background: Acute appendicitis is the commonest cause of ‘acute surgical abdomen’. Appendicectomy is the most frequently performed urgent abdominal operation and is often the first major procedure performed by a surgeon in training. The aim of the study was to whether hyperbilirubinemia might be used as a diagnostic tool to predict perforated appendicitis.Methods: This study comprised patients who presented with the condition of appendicitis and abnormal liver function tests on admission and had a laparoscopic or open appendectomy. The age information, duration of symptoms, temperature, white blood cell counts, bilirubin levels, and histology data were gathered. Peritoneal fluid was cultured and examined for sensitivity.Results: The average bilirubin level of all participating patients was 0.92 mg/dl (range, 0.1-4.3 mg/dl). The mean bilirubin levels were higher for patients with simple appendicitis compared to those with a non-inflamed appendix (0.7 mg/dl and 0.4 mg/dl, p<0.001). Hyperbilirubinaemia was reported to have a specificity of 89% and a positive predictive value of 90.02% for acute appendicitis. Patients with appendiceal perforation, however, had a mean bilirubin level of 1.7 mg/dl and were more likely to have hyperbilirubinaemia (p<0.001). The specificity of hyperbilirubinaemia for perforation or gangrene was 73%.Conclusions: Patients with hyperbilirubinemia with appendicitis condition should be screened for a greater risk of appendiceal perforation than those with normal bilirubin levels.

Incidence of Appendicitis in Adults

Background: Appendicitis is a common infection which can lead to serious illness in children as well as adults. Objective: To assess the incidence of appendicitis in adults. Study Design: Retrospective study. Place and Duration of Study: Department of General Surgery, Shalamar Medical & Dental College, Lahore from 1st January 2020 to 30th June 2021. Methodology: One hundred and eighty cases registered for abdominal pain in right iliac fossa. The appendectomy cases of adults (>45 years) were scrutinized from these cases. Demographic and clinical information was gathered from each appendicitis patient with diagnostic symptoms as well as histopathology and radiology imaging. Result: Eighty seven were confirmed acute appendicitis with 48 males and 39 females within the age group of 45-75 years. Gangrenous appendicitis was presented in 11.5% and perforated appendicitis was noticed in 31.03% of the total patients. Conclusion: The incidence of appendicitis was 48.33% in adults. Keywords: Appendectomy, Perforated, Misdiagnosis