ABSTRACT Analogous to organ injury scales developed for trauma, a scoring system is needed for acute care surgery. The purpose of this study was to develop a disease severity score (DSS) for acute appendicitis, the most common surgical emergency.
A panel of acute care surgery experts reviewed the literature and developed a DSS for acute appendicitis as follows: grade 1, inflamed; Grade 2, gangrenous; Grade 3, perforated with localized free fluid; Grade 4, perforated with a regional abscess; and Grade 5, perforated with diffuse peritonitis. We applied the DSS to 1,000 consecutive patients undergoing appendectomy from 1999 to 2009 and examined its association with outcomes (mortality, length of hospital stay, incidence of in-hospital, and postdischarge complications). Of the 1,000 patients, 82 were excluded owing to negative or interval appendectomy or advanced end-stage renal disease.
Among 918 eligible patients, the DSS distribution was Grade 1 at 62.4%, Grade 2 at 13.0%, Grade 3 at 18.7%, Grade 4 at 4.4%, and Grade 5 at 1.5%. Statistical analyses indicated a stepwise risk increase in adverse outcomes with higher DSS grades (c statistics ≥ 0.75 for all outcomes). Covariates (age, sex, and type of surgical access) did not add to the predictive power of DSS.
Based on this single-institution study, the proposed appendicitis DSS seems to be a useful tool. This DSS can inform future, national efforts, which can build on the knowledge provided by the present investigation. This DSS may be useful for comparing therapeutic modalities, planning resource use, improving programs, and adjusting reimbursement
Epidemiologic study, level III.
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ABSTRACT: Introduction: A transumbilical laparoscopic-assisted single-channel, single-port procedure was introduced during laparoscopic interval appendectomy for mass-forming appendicitis in children. The aim of this study was to evaluate the results of the original laparoscopic interval appendectomy. Methods: This study analyzed 31 children who underwent laparoscopic interval appendectomy using a single-channel, single-port procedure. The appendectomy was usually planned 8-12 weeks following initial conservative treatment. The procedure was a single-channel surgery using a 12-mm single port. Both a 5-mm telescope and grasper were inserted simultaneously into the single channel. The grasper held the appendix, and an extracorporeal appendectomy was performed. Results: Appendectomy was planned for 29 patients, as 2 patients deviated from the protocol. The procedure was successful in 21 patients (72.4%). An accessory port was necessary in eight patients, two of whom successfully underwent laparoscopic surgery; the remaining six were converted to open appendectomy. The average length of surgery was 43 min in the single-channel, single-port procedure. No postoperative complications occurred in any patient. Conclusion: The single-channel, single-port procedure was successfully performed in over 70% of the patients. This preliminary retrospective analysis indicates that the procedure is safe and potentially beneficial in children with mass-forming appendicitis who require laparoscopic interval appendectomy.Asian Journal of Endoscopic Surgery 05/2014; 7(3). DOI:10.1111/ases.12111
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ABSTRACT: Background: Appendicectomy (AE), the most frequent emergency surgical procedure, can be performed as a transvaginal hybrid natural orifice translumenal endoscopic surgery (NOTES) technique (TVAE). The question of feasibility also arises in cases of advanced inflammation with perforation. Material and methods: Since May 2012 all female patients with suspected acute appendicitis were offered a TVAE as an alternative to the standard procedure. Preoperative, intraoperative and postoperative parameters were registered prospectively. Results: Until October 2013 a total of 13 TVAEs had been performed. The median age of the patients was 41 years (range 20-76 years), median BMI was 23.1 (range 18.1-28.3 kg/m(2)) and the American Society of Anesthesiologists score (ASA) distribution (I/II/≥ III) was 8/5/0. Histology revealed three cases of perforated, one hemorrhagic necrotizing and seven phlegmonous appendicitis. Furthermore, there were two findings without inflammation, namely one neurogenic appendicopathy and one neuroendocrine tumor. For the three patients with perforated appendicitis, there was a trend for higher age (67.0 years versus 33.5 years, p=0.063) and a higher C-reactive protein (CRP) level on admission (134.4 mg/l versus 26.4 mg/l, p=0.043). Also, procedural time and hospital stay were longer (64 min versus 47 min, p=0.033 and 14 days versus 3 days, p=0.004, respectively). The former was mostly due to more extensive intraoperative flushing (volume 3000 ml versus 500 ml, p=0.013 and duration 13 min versus 2 min, p=0.011). None of the cases required conversion but two of the three postoperative complications occurred in patients with perforation, which also resulted in the longer hospital stay. Conclusion: Technically, TVAE seems feasible also in cases of perforated appendicitis. However, in these cases procedural time is prolonged due to more extensive flushing. Whether or not the longer hospital stay can be attributed to the perforation or if TVAE results in a higher rate of complications in cases of perforated appendicitis needs further evaluation.Der Chirurg 06/2014; 86(4). DOI:10.1007/s00104-014-2774-2 · 0.57 Impact Factor
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ABSTRACT: Background: Studies evaluating mortality in patients with acute appendicitis focus on the outcomes of appendicectomy alone. We hypothesize this may not be representative of what happens in clinical practice as a small proportion of patients with acute appendicitis undergo procedures other than appendicectomy, for example, caecectomy or right hemicolectomy. To clarify the issue, the authors evaluated Australian adult patients who died with a primary diagnosis of acute appendicitis regardless of whether they underwent an operation or the type of operation performed. Methods: A cross-sectional analysis of systematically collected mortality data from the Australian and New Zealand Audit of Surgical Mortality was conducted on adults who died in hospital with a primary diagnosis of acute appendicitis between January 2009 and December 2012. Results: Twenty-six patients died with a primary diagnosis of acute appendicitis. The median age was 83 years and the median number of co-morbidities was three. Four patients died without surgery due to their family's wishes. Twenty-two patients were treated surgically: five for right hemicolectomy, four for laparoscopic/McBurney appendicectomy, 10 for laparotomy with appendicectomy, two for unknown method of appendicectomy and one for open abscess drainage. Conclusion: Most adult patients who died following surgery for acute appendicitis did not undergo simple appendicectomy but underwent more complicated procedures for complex appendicitis.ANZ Journal of Surgery 08/2014; DOI:10.1111/ans.12829 · 1.12 Impact Factor