Search

BackgroundThe comprehensive coverage offered by the Taiwan National Health Insurance program enabled us to effectively evaluate the effect of age on postoperative morbidity.PurposesTo investigate whether age affected the outcomes and management of appendicitis in children in Taiwan.MethodsWe use the Collaboration Center for Health Information Application database to identify 21,827 patients ≤18 years of age with a diagnosis of acute appendicitis between 2007 and 2012 in Taiwan. Study outcomes included postoperative morbidity, undergoing laparoscopic appendectomy (LA) or open appendectomy (OA), and the length of hospitalization. Postoperative morbidity included the incidence of intra-abdominal abscesses (IAAs) and postoperative bowel obstructions (PBOs). Patients were divided into: ≤6, 7–12, and 13–18 years. Data were calculated using Chi-squared test and multivariate logistic regression models.ResultsThe perforation rate was highest for patients ≤6 years old and also an LA was least often performed in younger children compared with those aged 7–12 years 13–18 years; (p < 0.0001). In the multivariable analysis, the ORs for IAAs and PBOs for patients aged 7–12 and 13–18 years who had a perforated appendicitis and underwent an LA were (0.66; p = 0.0182), (0.51; p = 0.0001); and (0.49; p = 0.0125), (0.41; p = 0.0014), respectively, compared with those aged ≤6 years. Our study demonstrates that children in the (≤6 years) age group had a high rate of appendix perforation and required fewer LAs; when LAs were performed on children in this age group to treat perforated appendicitis, IAA and PBO risks were higher than other older age groups.

Background In this study, we studied the therapeutic effectiveness of percutaneous drainage with antibiotics and the need for an interval appendectomy for treating appendiceal abscess in children with a research-oriented dataset released by the Bureau of National Health Insurance in Taiwan through the Collaboration Center for Health Information Application (CCHIA). Methods We identified 1225 patients under 18 years of age who had non-surgical treatment for an appendiceal abscess between 2007 and 2012 in a Taiwan CCHIA dataset. The treatment included percutaneous drainage with antibiotics or antibiotics alone. We also analyzed data of patient’s baseline characteristics, outcomes of percutaneous drainage, and indicating factors for performing an interval appendectomy. Results Totally, 6190 children had an appendiceal abscess, an 1225 patients received non-operative treatment. Of 1225 patients, 150 patients received treatment with percutaneous drainage and antibiotics, 78 had recurrent appendicitis, 185 went on to receive an interval appendectomy, and 10 had postoperative complications after the interval appendectomy. We found that patients treated with percutaneous drainage and antibiotics had a significantly lower rate of recurrent appendicitis (p

Objective The goal of this study was to assess the optimum diagnostic cutoff value of maximum outer appendiceal diameter on computed tomography (CT) images in patients with suspected acute appendicitis in the emergency department. Methods A total of 328 patients with clinical suspicion of appendicitis were retrospectively reviewed. Evaluation of CT images, and chart review for clinical, laboratory, surgical, and pathologic findings were performed. Logistic regression was used to identify possible predictive factors influencing diagnosis of acute appendicitis. The receiver operating characteristic (ROC) curve was applied to determine the most suitable diagnostic cutoff value of appendiceal diameter for acute appendicitis. Results In a total of 136 patients (41.5%) the diagnosis of acute appendicitis was made; 192 patients (58.5%) had nonacute appendicitis. Mean appendiceal diameter was 12.68 ± 3.31 mm in patients with acute appendicitis and 6.01 ± 1.50 mm in patients without. The appendiceal diameter had a significantly statistical difference to differentiate the presence from the absence of acute appendicitis with an area under the ROC curve of 0.985 (95% confidence interval, 0.973–0.996). An appendiceal diameter cutoff value of 8.15 mm had a sensitivity of 97%, a specificity of 93.2%, and an accuracy of 94.8%. Appendiceal wall enhancement with intravenous contrast medium also had a significantly statistical difference for discriminating patients with acute appendicitis from those without by logistic regression. Conclusion Detection of maximum outer appendiceal diameter and appendiceal wall enhancement with intravenous contrast medium on CT could help differentiate patients with acute appendicitis from those without. An appendiceal diameter greater than 8.15 mm is particularly useful for diagnosis of acute appendicitis.

Laparoscopic surgery is frequently applied in the operative management of appendicitis and symptomatic cholelithiasis because it is a minimally invasive procedure. There are, however, some complications of laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA) that result in the need for reoperation. In the current study, we examine the effects of repeat laparoscopic surgery on the treatment of complications arising from LC/LA. From April 2005 to March 2011, we examined a cohort of patients who had received LC or LA and experienced complications that required reoperations. We focused on patients with postoperative hemorrhages, postoperative peritonitis, early postoperative small bowel obstructions (EPSBO), and biliary complications (after LC) who were treated through a repeat laparoscopic approach. The general demographics of the patients, their postoperative complications, procedures for selecting the appropriate reoperation method, and repeat laparoscopic findings are described in detail. During the 6-year period examined, 1608 patients received LC and 1486 patients received LA at the hospitals participating in this study. In patients with complications requiring reoperation, the repeat laparoscopic approach was performed successfully (without the need for further laparotomy) in 50 per cent of the patients with postoperative hemorrhage (2 of 4), 50 per cent of the patients with postoperative peritonitis (2 of 4), 75 per cent of the EPSBO patients (3 of 5), and 50 per cent the of patients with biliary complications (1 of 2). The repeat laparoscopic approach is an appropriate method for the management of complications arising from laparoscopic surgery. In patients with postoperative hemorrhage, laparoscopic hemostasis and hematoma evacuations can be performed while maintaining stable hemodynamics. In addition, laparoscopic approaches are also feasible for selective post-LC ductal injuries, EPSBO, and unconfirmed diagnoses of peritonitis after laparoscopic surgery.

The incidence of acute appendicitis in elderly patients is increasing due to prolonged life span. The associated morbidity and mortality related to perforation of acute appendicitis continue to present challenges to physicians. The role of laparoscopic appendectomy is still controversial. This study aimed to compare the postoperative outcomes of elderly patients who received either a laparoscopic or an open appendectomy. We retrospectively reviewed charts of patients with acute appendicitis between January 2005 and February 2009. Elderly patients who received laparoscopic or open appendectomies were enrolled. The demographics, preoperative condition, operating time, intraoperative blood loss, and postoperative course were analyzed. A total of 150 patients were enrolled in this study. On average, patients who received a laparoscopic appendectomy had fewer hospital days and lower rates of postoperative ventilator dependence than patients who received an open appendectomy. In the management of elderly patients with acute appendicitis, laparoscopic appendectomy provides better outcomes than open appendectomy.

Acute appendicitis may become life threatening if it is complicated by retroperitoneal abscess. To the best of our knowledge, only case reports have been documented; thus, we analyzed the published experiences and reviewed this issue.In addition to two patients treated at our institution, a PubMed search identified 22 cases of acute appendicitis, complicated by retroperitoneal abscess, reported by 18 authors between 1955 and 2005. The patients' characteristics, onset of symptoms, timing and methods of diagnosis and management, and outcome are reviewed and analyzed.Most of the patients were adults (21/24, 87.5%), of whom seven were older than 65 years. None of the patients presented with the classical symptoms of acute appendicitis at the onset of the disease, and less than half (9/24) reported abdominal pain. The average interval between the onset of symptoms and diagnosis was 16 days, and the most effective diagnostic tool was computed tomography. Pathogens were usually polymicrobial, and appendectomy followed by adequate drainage of the abscess was the best treatment. The mortality rate was 16.7% (4/24), and all deaths were caused by profound sepsis. According to the available data, the average hospital stay was 27.3 days for the survivors.The formation of complicated retroperitoneal abscesses involving thigh, psoas muscle, perinephric space, or even the lateral abdominal wall is a serious complication of perforated acute appendicitis. An intra-abdominal pathological abnormality cannot be excluded in a patient presenting without abdominal symptoms. The mortality rate can only be reduced by a high index of suspicion, accurate diagnosis, and appropriate treatment.

To define the pattern of therapeutic approaches for pediatric appendicitis and compare their benefits in Taiwan, we analyzed a research-oriented dataset released by the Bureau of National Health Insurance in Taiwan through the Collaboration Center for Health Information Application (CCHIA) to document the impact of the rise of laparoscopic treatment on outcomes.We identified 22,161 patients under 18 years who had been hospitalized with a diagnosis of acute appendicitis between 2007 and 2012 in the CCHIA. Statistical comparisons between the Laparoscopic appendectomy (LA) and open appendectomy (OA, control) groups were computed using a Chi squared test. The odds ratios (ORs) and 95% confidence intervals (CIs) of risk factors for intra-abdominal abscess (IAA) and postoperative bowel obstruction (PBO) were derived from multivariate logistic regression models.In each respective year, the incidence of LA increased from 29.17% in 2007 to 57.4% in 2012, while that of OA decreased from 70.83% in 2007 to 42.60% in 2012; incidences of non-perforated appendicitis and perforated appendicitis with LA or OA seemed similar. The length of hospitalization between an LA and OA for non-perforated appendicitis was the same, but that with an LA was shorter for perforated appendicitis. The adjusted ORs for IAA and PBO for those patients with perforated and non-perforated appendicitis were 6.30 (95% CI = 5.09-7.78; p0.001) and 6.49 (95% CI = 4.45-9.48; p0.001); while for those cases undergoing an LA and OA, they were 0.50 (95 % CI = 0.40-0.62; p0.001) and 2.07 (95% CI = 1.45-2.95; p0.001), respectively. The ORs of IAA and PBO for those patients ≤6 and 7-12 years of age were 1.67 (95% CI = 1.23-2.25; p = 0.001) and 1.20 (95% CI = 0.97-1.49; p = 0.095), and 1.88 (95% CI = 1.08-3.24; p = 0.025) and 1.47 (95% CI = 1.01-2.14; p = 0.043), respectively, compared to those aged 13-18 years.Our study demonstrated that young age and perforated appendicitis can affect postoperative IAA and PBO. LA appeared beneficial in reducing the length of hospitalization and postoperative IAA, but had an increasing risk of PBO. Although laparoscopic approach for pediatric appendectomy is increasing in our country, the different hospital levels and pediatric surgeon's laparoscopic experience must be evaluated in further study.

Controversies abound as regards the optimal treatment for patients with diverticulitis of the right colon.This is a retrospective review of 113 patients with a diagnosis of right colonic diverticulitis who received treatment at the China Medical University Hospital from July 1994 to June 2004.Medical therapy was undertaken in 56 patients diagnosed preoperatively with uncomplicated diverticulitis. All but one patient was successfully treated with bowel rest and antibiotics. Of the 51 patients with a preoperative diagnosis of acute appendicitis, 32 received appendectomy along with postoperative antibiotic therapy, 8 received diverticulectomy in addition to appendectomy, and 11 received colectomy. In all, 17 patients required right hemicolectomy or ileocecal resection due to diverticulitis-related complications or suspected malignancy. Of the 87 (56-1+32) patients who responded to conservative treatment, 11 developed recurrent diverticulitis. All 11 patients were successfully treated with medical therapy, and 2 subsequently received elective right hemicolectomy. Of the 9 patients who received medical treatment alone at the second attack, 2 suffered a third attack. Both were successfully managed with medical therapy.For uncomplicated diverticulitis of the right colon diagnosed preoperatively, antibiotic therapy with bowel rest is an effective treatment. Once it is encountered during surgery for presumed acute appendicitis, a conservative approach involving prophylactic appendectomy and postoperative antibiotics is recommended. For patients with recurrent diseases, medical treatment is still safe and efficient. Colectomy is indicated when complications occur or when malignancy is strongly suspected.

Background: Laboratory measurements such as leucocyte count, neutrophil percentage and C-reactive protein (CRP) concentration are commonly used as diagnostic aids in patients with suspected acute appendicitis. The present study aimed to clarify the role of these laboratory tests in diagnosing acute appendicitis. Methods: The medical records of 897 patients who underwent appendicectomy for suspected acute appendicitis during a 30-month period were retrospectively reviewed. The laboratory findings were correlated with the histopathology of the excised appendices. Data were analysed to calculate the sensitivity and specificity of the individual tests, as well as the test combinations. Results: Histologically verified appendicitis was found in 740 of the 897 patients (82.5%). The rise in leucocyte count and neutrophil percentage correlated with the degree of appendiceal inflammation. The median CRP level was much higher in the patients with ruptured appendicitis compared with that in patients with a normal appendix (96.8 vs 39.6 mg/L, P

Background: Laparoscopic appendectomy is increasingly being employed to treat acute appendicitis. The aim of the present study was to evaluate the efficacy and safety of the LigaSure™ Vessel Sealing System (Valleylab, Boulder, CO) in laparoscopic appendectomy. Patients and Methods: Laparoscopic appendectomy was performed using the LigaSure system in 15 patients who had a preoperative diagnosis of acute appendicitis. Results: In two patients, the operation was converted to open appendectomy. The mean operative time was 47 minutes (range, 22–120 minutes). There was no evidence of any complications related to the use of the LigaSure system. Neither surgical endoclips nor an endostapler were used in any patient. Conclusion: Laparoscopic appendectomy using the LigaSure system is a safe and efficient procedure for acute appendicitis. Use of the LigaSure system in laparoscopic appendectomy may simplify the operative procedure and reduce the operative time.

This study aimed to compare the outcomes of laparoscopic and open appendectomy among the elderly.Data on 53 elderly patients with a diagnosis of suspected appendicitis were prospectively collected and retrospectively reviewed. Among these patients, 24 had undergone laparoscopic appendectomy (LA) and 29 had undergone open appendectomy (OA). The indications for either method were based on the patient's choice.No statistically significant difference in operative time was found between the LA (70 +/- 28 min) and OA (60 +/- 22 min) groups. There was no statistically significant difference in lengths of hospital stay between the LA (4.8 +/- 3.0 days) and OA (5.0 +/- 3.1 days) groups, and there was a statistically significant difference in the postoperative analgesic doses between the LA (0.5 +/- 0.3 doses) and OA (1.7 +/- 1.5 doses) groups. No conversion of laparoscopic to open surgery was necessary, and no intraabdominal abscesses developed.According to this study, LA is as safe and effective as OA for the elderly. Furthermore, it significantly reduces postoperative wound pain.

Several reports have indicated the benefits of the acute care surgery (ACS) model in surgical outcomes. We tried to delineate the impact of the ACS model on surgical efficiency and quality.Before the ACS model was implemented, abdominal surgical emergencies were evaluated by an on-call nontrauma general surgeon (pre-ACS model). An in-house trauma surgeon treated all patients with trauma or nontrauma abdominal surgical emergencies after the ACS model. Patients with acute appendicitis who underwent appendectomies were included. We conducted a pre- and poststudy to compare the time patients were in the emergency department and surgical qualities.There were 146 and 159 patients enrolled in the pre-ACS model and ACS model, respectively. The overall ED length of stay in the ACS model was significantly shorter than that in the pre-ACS model (300.3 ± 61.7 vs 719.1 ± 339.0 minutes, P.001). Hospital LOS was also significantly shorter in the ACS model than in the pre-ACS model (2.44 ± 1.39 vs 3.83 ± 2.21 days, P = .022).The ACS model may improve abdominal surgical efficiency and quality. Our study results echoed the benefits of the implementation of the ACS model shown in North America.

Rationale and Objectives To assess the necessity of intravenous contrast medium for abdominopelvic computed tomography (CT) diagnosis of acute appendicitis (APP) among adult patients with right lower quadrant (RLQ) abdominal pain at emergency department (ED). Materials and Methods ED patients with clinical suspicion of APP from RLQ pain for a period of 8 months were enrolled retrospectively. Both pre- and postintravenous contrast-enhanced CT scans were performed for these patients. The visibility of vermiform appendix and specific CT findings of APP were recorded separately for noncontrast CT (NCT) and contrast-enhanced CT (CCT) images without knowledge of the patient's identity and final diagnosis. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of CT diagnosis for APP were compared between the two groups. The ease of identifying appendix was also compared. Results Forty-two (42.0%) of the 100 patients (55 males, 45 females; age range, 16–90 years; mean age, 49.3 years) were APP. There was no significant difference for the visibility of appendix (94% vs. 91%; P = .589) and radiological characters between the CCT and NCT groups. There were significant differences between the two groups for sensitivity (100% vs. 90.5%; P = .036), specificity (94.8% vs. 100%; P = .038), PPV (93.3% vs. 100%; P = .021), NPV (100% vs. 93.5%; P = .021), but no significant difference for accuracy (97% vs. 96%; P = 1). The appendix was easier to detect on CCT than NCT images ( P = .013). Conclusion The diagnostic sensitivity of CCT was significantly better than that of NCT. Intravenous contrast administration could also make doctors easier in indentifying appendixes.

Leukocyte count, neutrophil percentage, and C-reactive protein (CRP) have been shown to give valuable information in the diagnosis of acute appendicitis. However, whether these laboratory tests have the same clinical applicability in the elderly as in young patients remains unclear. This retrospective study aimed to clarify the role of these tests in the diagnosis of acute appendicitis in patients aged 60 years or over. Eighty-five consecutive elderly patients underwent appendectomy for suspected acute appendicitis during a 30-month period. Histologically verified appendicitis was found in 77 of the 85 patients (90.6%). There was no significant difference in leukocyte counts or CRP values between patients with acute appendicitis and those with a normal appendix. The sensitivities of leukocyte count, neutrophil percentage, and CRP in the diagnosis of acute appendicitis were 71.4 per cent, 88.3 per cent, and 90 per cent, respectively, while the specificities were 37.5 per cent, 25 per cent, and 37.5 per cent, respectively. Of 77 patients with acute appendicitis, only two had all three tests simultaneously normal. In conclusion, patients with normal results in all three tests are highly unlikely to have acute appendicitis and should be evaluated with extra caution before surgery.

Background Because of the difficulties in preoperative diagnosis and controversies in the management, cecal diverticulitis has received much discussion in the literature. There, however, are still many questions that remain unanswered. Methods During a 5-year period, 112 patients with a clinical diagnosis of cecal diverticulitis were treated. Twenty-seven patients were excluded because of uncertainty in diagnosis or incomplete data collection, leaving 85 patients as the study group. The diagnosis of cecal diverticulitis was made by pathology, surgical findings, or image study. Results Nonoperative management was applied to 18 patients initially. Three patients had recurrent diverticulitis during follow up. These patients responded satisfactorily to another course of medical treatment. Laparotomy was performed in 67 patients. Acute appendicitis was the preoperative diagnosis in 47 patients (70%). Of the other 20 patients, 6 received operation because of repeated attack of diverticulitis, 7 had preoperative computed tomography (CT) diagnosis of cecal diverticulitis with perforation, 5 had preoperative diagnosis of cecal tumor, and 2 had medical treatment failure. All these 20 patients received right hemicolectomy. In the 47 patients with a preoperative diagnosis of acute appendicitis, 24 received appendectomy, 9 received diverticulectomy, and 14 received right hemicolectomy. Overall, 34 patients received right hemicolectomy, 9 received diverticulectomy, and 24 received appendectomy only. In the right hemicolectomy group, there were 2 deaths with underlying diseases and 5 complications. In the appendectomy group, there was no postoperative mortality, but in 7 patients recurrent diverticulitis developed. Three of them required right hemicolectomy. Conclusions The natural history of cecal diverticulitis varies from benign and self-limiting to fulminant in the oriental population. Less than 40% (32 of 85) of patients were successfully treated with conservative methods initially and had no recurrence during the follow-up period. We recommend aggressive surgical resection for patients with a definite diagnosis. Adjuvant appendectomy without resection of the lesion should be considered only in uncomplicated patients whose diagnosis is in doubt.

As a disease commonly encountered in daily practice, acute appendicitis is usually diagnosed and managed easily with a low mortality and morbidity rate. However, acute appendicitis may occasionally become extraordinarily complicated and life threatening. A 56-year-old man, healthy prior to this admission, was brought to the hospital due to spiking high fever, poor appetite, dysuria, progressive right flank and painful swelling of the thigh for 3 d. Significant inflammatory change of soft tissue was noted, involving the entire right trunk from the subcostal margin to the knee joint. Painful disability of the right lower extremity and apparent signs of peritonitis at the right lower abdomen were disclosed. Laboratory results revealed leukocytosis and an elevated C-reactive protein level. Abdominal CT revealed several communicated gas-containing abscesses at the right retroperitoneal region with mass effect, pushing the duodenum and the pancreatic head upward, compressing and encasing inferior vena cava, destroying psoas muscle and dissecting downward into the right thigh. Laparotomy and right thigh exploration were performed immediately and about 500 mL of frank pus was drained. A ruptured retrocecal appendix was the cause of the abscess. The patient fully recovered at the end of the third post-operation week. This case reminds us that acute appendicitis should be treated carefully on an emergency basis to avoid serious complications. CT scan is the diagnostic tool of choice, with rapid evaluation followed by adequate drainage as the key to the survival of the patient.