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Background: Emergencies and emergency surgeries are a central part of everyday surgical care in Germany. However, it is unclear how emergency surgery is practically trained in clinics on a daily basis and what training concept is underlying. Therefore, the aim of this survey study was to capture the status quo of emergency surgical training of German general and visceral surgeons. Methods: The members of the German Society for General and Visceral Surgery were surveyed online (n = 5281). The questionnaire included demographic data and expertise in surgery and assistance in emergency surgery regarding common emergency surgical operations. In addition, further training measures in emergency surgery and their support by employers were queried. Results: Only complete questionnaires (n = 184, response rate 3.5%) were included in the analysis. Most participants were in training (n = 69; 38%), followed by senior physicians (n = 52; 29%), specialists (n = 31; 17%) and chief physicians (n = 30; 17%). 64% of the participants were employed at university hospitals or maximum care hospitals. Regarding further training opportunities, in-clinic shock room training was most frequently used. Outside of their own clinic, the ATLS course was most frequently mentioned. Operations for cholecystitis and appendicitis as well as emergency stoma procedures are the most common emergency procedures. There was a strong difference in the frequency of operated cases depending on the level of training. For operations to treat acute abdominal traumas (hemostasis of liver and spleen, packing) as well as outside of visceral surgery, only low competence was reported. Over 90% of survey participants consider emergency surgery to be an indispensable core competence. Neither in the old (76%) nor in the new training regulations (47%) is emergency surgery adequately represented according to the participants' assessment. There was a significantly lower prevalence of the "sub-steps concept" in emergency surgery at 38% compared to elective surgery (44%). Important elements of imparting skills in emergency surgery are simulation and courses as well as operative sub-steps, according to the majority of survey participants. Conclusion: The results show that general and visceral surgeons in Germany are introduced to emergency surgery too little structured during further training and at specialist level. The survey participants had, as expected, hardly any experience in emergency surgery outside of visceral surgery but surprisingly also little experience in visceral surgical trauma care. There is a need to discuss the future organization of emergency surgical training. Adequate simulation structures and extracurricular courses could contribute to an improvement in this respect. [ABSTRACT FROM AUTHOR]

Introduction: Appendicectomy remains the standard treatment for appendicitis. There is a lack of clarity on the timeframe in which surgery should be performed to avoid unfavourable outcomes. Aim: To perform a systematic review and network meta-analysis to evaluate the impact the (1)time-of-day surgery is performed (2), time elapsed from symptom onset to hospital presentation (patient time) (3), time elapsed from hospital presentation to surgery (hospital time), and (4)time elapsed from symptom onset to surgery (total time) have on appendicectomy outcomes. Methods: A systematic review was performed as per PRISMA-NMA guidelines. The time-of-day which surgery was done was divided into day, evening and night. The other groups were divided into < 24 h, 24–48 h and > 48 h. The rate of complicated appendicitis, operative time, perforation, post-operative complications, surgical site infection (SSI), length of stay (LOS), readmission and mortality rates were analysed. Results: Sixteen studies were included with a total of 232,678 patients. The time of day at which surgery was performed had no impact on outcomes. The incidence of complicated appendicitis, post-operative complications and LOS were significantly better when the hospital time and total time were < 24 h. Readmission and mortality rates were significantly better when the hospital time was < 48 h. SSI, operative time, and the rate of perforation were comparable in all groups. Conclusion: Appendicectomy within 24 h of hospital admission is associated with improved outcomes compared to patients having surgery 24–48 and > 48 h after admission. The time-of-day which surgery is performed does not impact outcomes. [ABSTRACT FROM AUTHOR]

Purpose: Surgery wait times after diagnosis of appendicitis are an important factor influencing the success of a patient's treatment. The proposed study will be a quantitative multicenter retrospective cohort design with the primary aim of assessing the difference between appendicectomy wait times between rural and urban hospitals in Western Australia and the effect of this on operative outcomes. Selected outcome measures will be examined by time from initial presentation at an emergency department to the patient being diagnosed and then time of diagnosis to surgery being performed. The secondary aim is to compare rates of negative appendicectomies between hospitals. Methods: Appendicectomy patients will be identified from operating room register by medical student data collectors; then, each respective hospital's emergency room data collection will subsequently be accessed to complete case report forms based on demographics and clinical findings, pre-operative investigations, and management and follow-up. Case report forms with > 95% completeness will be accepted for pooled analysis. The expected duration of retrospective data collection will be 8 months. This study RGS6483 has received HREC approval by the Royal Perth Hospital HREC Ethics Committee, with a waiver of consent obtained and the HREC was notified of amendments to the protocol made on April 21, 2024. Dissemination of results. Data will be collected and stored online through a secure server running the Research Electronic Data Capture (REDCap) web application. No patient-identifiable data will be entered into the system. Results will subsequently be shared via scientific journal publication and presentation at relevant meetings. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of this analysis was to investigate the most appropriate duration of postoperative antibiotic treatment to minimize the incidence of intraabdominal abscesses and wound infections in patients with complicated appendicitis. Materials and methods: In this retrospective study, which included 396 adult patients who underwent appendectomy for complicated appendicitis between January 2010 and December 2020 at the University Hospital Erlangen, patients were classified into two groups based on the duration of their postoperative antibiotic intake: ≤ 3 postoperative days (group 1) vs. ≥ 4 postoperative days (group 2). The incidence of postoperative intraabdominal abscesses and wound infections were compared between the groups. Additionally, multivariate risk factor analysis for the occurrence of intraabdominal abscesses and wound infections was performed. Results: The two groups contained 226 and 170 patients, respectively. The incidence of postoperative intraabdominal abscesses (2% vs. 3%, p = 0.507) and wound infections (3% vs. 6%, p = 0.080) did not differ significantly between the groups. Multivariate analysis revealed that an additional cecum resection (OR 5.5 (95% CI 1.4–21.5), p = 0.014) was an independent risk factor for intraabdominal abscesses. A higher BMI (OR 5.9 (95% CI 1.2–29.2), p = 0.030) and conversion to an open procedure (OR 5.2 (95% CI 1.4–20.0), p = 0.016) were identified as independent risk factors for wound infections. Conclusion: The duration of postoperative antibiotic therapy does not appear to influence the incidence of postoperative intraabdominal abscesses and wound infections. Therefore, short-term postoperative antibiotic treatment should be preferred. [ABSTRACT FROM AUTHOR]

The diagnosis of acute appendicitis and concurrent surgery referral is primarily based on clinical presentation, laboratory and radiological imaging. However, utilizing such an approach results in as much as 10–15% of negative appendectomies. Hence, in the present study, we aimed to develop a machine learning (ML) model designed to reduce the number of negative appendectomies in pediatric patients with a high clinical probability of acute appendicitis. The model was developed and validated on a registry of 551 pediatric patients with suspected acute appendicitis that underwent surgical treatment. Clinical, anthropometric, and laboratory features were included for model training and analysis. Three machine learning algorithms were tested (random forest, eXtreme Gradient Boosting, logistic regression) and model explainability was obtained. Random forest model provided the best predictions achieving mean specificity and sensitivity of 0.17 ± 0.01 and 0.997 ± 0.001 for detection of acute appendicitis, respectively. Furthermore, the model outperformed the appendicitis inflammatory response (AIR) score across most sensitivity–specificity combinations. Finally, the random forest model again provided the best predictions for discrimination between complicated appendicitis, and either uncomplicated acute appendicitis or no appendicitis at all, with a joint mean sensitivity of 0.994 ± 0.002 and specificity of 0.129 ± 0.009. In conclusion, the developed ML model might save as much as 17% of patients with a high clinical probability of acute appendicitis from unnecessary surgery, while missing the needed surgery in only 0.3% of cases. Additionally, it showed better diagnostic accuracy than the AIR score, as well as good accuracy in predicting complicated acute appendicitis over uncomplicated and negative cases bundled together. This may be useful in centers that advocate for the conservative treatment of uncomplicated appendicitis. Nevertheless, external validation is needed to support these findings. [ABSTRACT FROM AUTHOR]

Introduction: Surgery for acute appendicitis has been associated with significant morbidity. This study aimed to determine the factors associated with early inhospital adverse outcomes following surgery for acute appendicitis in Uganda. Methods: This was a multicentre, prospective cohort in which early inhospital outcome following surgery for acute appendicitis was assessed at 4 regional referral hospitals in Uganda. The occurrence of complications during the admission period was documented as well as the length of hospital stay. Factors associated with adverse outcomes were determined using Poisson regression. Results: Of the 102 patients who underwent surgery for acute appendicitis, the majority were males 79(77.5%) with a mean age of 23.8(SD = 12.5) years. The perforated appendix was seen in 26 (25.5%) patients. Post-operative complications occurred in 21(20.6%) with the commonest being surgical site infection in 19(18.6%) patients. The median length of hospital stay was 3(IQR = 3–4) days with 43(42.2%) staying in hospital for more than 3 days. The presence of anemia (Hb < 8) (aRR = 1.376, CI = 1.159–1.634, P = < 0.001) and having a perforated appendix (aRR = 1.263, CI = 1.026–1.555, P = 0.027) were independently associated with occurrence of complications while being HIV positive (aRR = 1.379, CI = 1.105–1.721, P = 0.005) and having a perforated appendix (aRR = 1.258, CI = 1.019–1.554, P = 0.033) were independently associated with prolonged hospital stay. Conclusion: Community education about early presentation is still required in order to reduce the number of patients that present late which should, in turn, reduce the risk of complications and length of hospital stay. [ABSTRACT FROM AUTHOR]

Background: The role of Enterobius vermicularis infestation in the context of appendicitis is largely overlooked, but Enterobius vermicularis is considered an unexpected and significant appendicectomy finding. The aim of this study was to investigate the frequency of Enterobius vermicularis findings in appendectomies and to evaluate the clinical and histopathologic features of patients with Enterobius vermicularis-associated acute appendicitis and those with appendiceal Enterobius vermicularis infestation. Methods: The medical records of all children who underwent an appendectomy in two large pediatric centers in Croatia between 1 January 2009 and 1 January 2024 were retrospectively reviewed. Of 6359 appendectomies, 61 (0.96%) children were diagnosed with Enterobius vermicularis on histopathology and included in further analysis. The groups were compared with regard to demographic characteristics, laboratory values, clinical features and histopathological findings. Results: The incidence of enterobiasis fluctuated slightly in the individual study years, but was constant overall. The median age of all patients was 11 years (IQR 8.5, 13), with females predominating (60.7%). Acute appendicitis was observed in 34% of the appendiceal species. The patients with Enterobius vermicularis infestation, without appendicitis, were younger (9 years (IQR 8, 13) vs. 12 years (IQR 10, 15); p = 0.020), had longer duration of symptoms (36 h (IQR, 12, 48) vs. 24 h (IQR, 12, 36); p = 0.034), lower body temperature (37 °C (IQR 36.8, 37.4) vs. 37.6 °C (IQR, 37, 38.6) p = 0.012), lower Appendicitis Inflammation Response (AIR) score (3 (IQR 2, 5) vs. 7 (IQR 5, 9.5) p < 0.001), lower incidence of rebound tenderness (57.1% vs. 20%; p = 0.003) and less frequent vomiting (12.5% vs. 47.6%; p = 0.004) compared to the patients with Enterobius vermicularis-associated acute appendicitis. Acute inflammatory markers in the laboratory showed significantly higher values in the group of patients with acute appendicitis: C-reactive protein (p = 0.009), White blood cells (p = 0.001) and neutrophils (p < 0.001). Eosinophilia was not found in any of the groups, although eosinophil counts were significantly higher in children who had Enterobius vermicularis infestation than in those with Enterobius vermicularis-related appendicitis (2.5% (IQR 0.9, 4.3) vs. 1.8% (IQR 0.7, 2.1); p = 0.040). Conclusions: Pediatric surgeons should consider Enterobius vermicularis infestation as a differential diagnosis when removing a vermiform appendix. Younger age, longer duration of symptoms, lower body temperature, lower AIR score, lower diameter of the appendix and normal laboratory inflammatory markers could predict Enterobius vermicularis infection in children presenting with right iliac fossa pain and avoid unnecessary appendectomy. [ABSTRACT FROM AUTHOR]

Globally, acute appendicitis has an estimated lifetime risk of 7–8%. However, there are numerous controversies surrounding the management of acute appendicitis, and the best treatment approach depends on patient characteristics. Non-operative management (NOM), which involves the utilization of antibiotics and aggressive intravenous hydration, and surgical appendectomy are valid treatment options for healthy adults. NOM is also ideal for poor surgical candidates. Another important consideration is the timing of surgery, i.e., the role of interval appendectomy (IA) and the possibility of delaying surgery for a few hours on index admission. IA refers to surgical removal of the appendix 8–12 weeks after the initial diagnosis of appendicitis. It is ideal in patients with a contained appendiceal perforation on initial presentation, wherein an initial nonoperative approach is preferred. Furthermore, IA can help distinguish malignant and non-malignant causes of acute appendicitis, while reducing the risk of recurrence. On the contrary, a decision to delay appendectomy for a few hours on index admission should be made based on the patients' baseline health status and severity of appendicitis. Post-operatively, surgical drain placement may help reduce postoperative complications; however, it carries an increased risk of drain occlusion, fistula formation, and paralytic ileus. Furthermore, one of the most critical aspects of appendectomy is the closure of the appendiceal stump, which can be achieved with the help of endoclips, sutures, staples, and endoloops. In this review, we discuss different aspects of management of acute appendicitis, current controversies in management, and the potential role of endoscopic appendectomy as a future treatment option. [ABSTRACT FROM AUTHOR]

Background: Controversies remain on the diagnostic strategy in suspected AA, considering the different settings worldwide. Material and Methods: A prospective observational international multicentric study including patients operated for suspected AA with a definitive histopathological analysis was conducted. Three groups were analyzed: (1) No radiology; (2) Ultrasound, and (3) Computed tomography. The aim was to analyze the performance of three diagnostic schemes. Results: Three thousand and one hundred twenty three patients were enrolled; 899 in the no radiology group, 1490 in the US group, and 734 in the CT group. The sex ratio was in favor of males (p < 0.001). The mean age was lower in the no radiology group (24 years) compared to 28 and 38 years in US and CT‐scan groups, respectively (p < 0.001). Overall, the negative appendectomy rate 3.8%: no radiology group (5.1%) versus US (2.9%) and CT‐scan (4.1%) (p < 0.001). The sensitivity and specificity analysis showed the best balance in clinical evaluation + score + US. These data reach the best results in those patients with an equivocal Alvarado score (4–6). Inverse probability weighting (IPW), showed as the use of ultrasound, is significantly associated with an increased probability of formulating the correct diagnosis (p 0.004). In the case of a CT scan, this association appears weaker (p 0.08). Conclusion: The association of clinical scores and ultrasound seems the best strategy to reach a correct preoperative diagnosis in patients with clinical suspicion of AA, even in those population subgroups where the clinical score may have an equivocal result. This strategy can be especially useful in low‐resource settings worldwide. CT‐scan association may improve the detection of patients who may potentially be submitted to conservative treatment. [ABSTRACT FROM AUTHOR]

Background: The vermiform appendix is considered a potential reservoir for the abnormal α‐synuclein aggregate in Parkinson's disease (PD). Previous epidemiologic evidence on the association between appendectomy and PD risk remains inconclusive, especially outside the Western world. Objectives: To investigate the association between appendectomy and PD risk in Korea. Methods: Among 703,831 eligible adult subjects in the National Health Insurance Service sample cohort, we identified 16,122 patients who underwent appendectomy. The rest formed the control group. PD risk was assessed using time‐dependent Cox regression analyses. Results: The appendectomy group did not have altered risk of PD compared with the control group in either unadjusted [hazard ratio (HR) 1.32, 95% confidence interval (CI) 0.97–1.80, P = 0.08] or adjusted model (HR 1.42, CI 0.88–2.30, P = 0.15). No further statistical difference appeared when stratified by sex. Conclusions: Appendectomy is not associated with altered risk of PD in the Korean population. [ABSTRACT FROM AUTHOR]

Nonoperative management (NOM) of uncomplicated appendicitis (UA) has been increasingly utilized in recent years. The aim of this study was to describe nationwide trends of sociodemographic characteristics, outcomes, and costs of patients undergoing medical versus surgical management for UA. The 2018-2019 National (Nationwide) Inpatient Sample was queried for adults (age ≥18 y) with UA; diagnosis, as well as laparoscopic and open appendectomy, were defined by the International Classification of Diseases, 10th Revision, Clinical Modification codes. We examined several characteristics, including cost of care and length of hospital stay. Among the 167,125 patients with UA, 137,644 (82.4%) underwent operative management and 29,481 (17.6%) underwent NOM. In bivariate analysis, we found that patients who had NOM were older (53 versus 43 y, P < 0.001) and more likely to have Medicare (33.6% versus 16.1%, P < 0.001), with higher prevalence of comorbidities such as diabetes (7.8% versus 5.5%, P < 0.001). The majority of NOM patients were treated at urban teaching hospitals (74.5% versus 66.3%, P < 0.001). They had longer LOS's (5.4 versus 2.3 d, P < 0.001) with higher inpatient costs ($15,584 versus $11,559, P < 0.001) than those who had an appendectomy. Through logistic regression we found that older patients had up to 4.03-times greater odds of undergoing NOM (95% CI: 3.22-5.05, P < 0.001). NOM of UA is more commonly utilized in patients with comorbidities, older age, and those treated in teaching hospitals. This may, however, come at the price of longer length of stay and higher costs. Further guidelines need to be developed to clearly delineate which patients could benefit from NOM. • NOM of UA continues to be increasingly utilized. • Between 2018 and 19, 17.6% of UA were found to undergo NOM. • Older patients have up to 4.03 times greater odds of undergoing NOM for UA. • Patients with higher comorbidities have 1.36 times greater odds of undergoing NOM for UA. [ABSTRACT FROM AUTHOR]

Background: Application of artificial intelligence (AI) in general surgery is evolving. Real-world implementation of an AI-based computer-vision model in laparoscopic appendectomy (LA) is presented. We aimed to evaluate (1) its accuracy in complexity grading and safety adherence, (2) clinical correlation to outcomes. Methods: A retrospective single-center study of 499 consecutive LA videos, captured and analyzed by 'Surgical Intelligence Platform,' Theator Inc. (9/2020–5/2022). Two expert surgeons viewed all videos and manually graded complexity and safety adherence. Automated annotations were compared to surgeons' assessments. Inter-surgeons' agreements were measured. Since 7/2021 videos were linked to patients' admission numbers. Data retrieval from medical records was performed (n = 365). Outcomes were compared between high and low complexity grades. Results: Low and high complexity grades comprised 74.8 and 25.2% of 499 videos. Surgeons' agreements were high (76.9–94.4%, kappa 0.77/0.91; p < 0.001) for all annotated complexity grades. Surgeons' agreements were also high (96.0–99.8%, kappa 0.78/0.87; p < 0.001) for full safety adherence, whereas agreement was moderate in partial safety adherence and none (32.8–58.8%). Inter-surgeons' agreements were high for complexity grading (kappa 0.86, p < 0.001) and safety adherence (kappa 0.88, p < 0.001). Comparing high to low grade complexity, preoperative clinical features were similar, except larger appendix diameter on imaging (13.4 ± 4.4 vs. 10.5 ± 3.0 mm, p < 0.001). Intraoperative outcomes were significantly higher (p < 0.001), including time to achieve critical view of safety (29.6, IQR 19.1–41.6 vs. 13.7, IQR 8.5–21.1 min), operative duration (45.3, IQR 37.7–65.2 vs. 25.0, IQR 18.3–32.7 min), and intraoperative events (39.4% vs. 5.9%). Postoperative outcomes (7.4% vs. 9.2%) including surgical complications, mortality, and readmissions were comparable (p = 0.6), except length of stay (4, IQR 2–5.5 vs. 1, IQR 1-2 days; p < 0.001). Conclusion: The model accurately assesses complexity grading and full safety achievement. It can serve to predict operative time and intraoperative course, whereas no clinical correlation was found regarding postoperative outcomes. Further studies are needed. [ABSTRACT FROM AUTHOR]

Background: Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis. Methods: A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Results: Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty. Conclusions: These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened. [ABSTRACT FROM AUTHOR]

Background: When pregnant patients present with nonobstetric pathology, the physicians caring for them may be uncertain about the optimal management strategy. The aim of this guideline is to develop evidence-based recommendations for pregnant patients presenting with common surgical pathologies including appendicitis, biliary disease, and inflammatory bowel disease (IBD). Methods: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee convened a working group to address these issues. The group generated five key questions and completed a systematic review and meta-analysis of the literature. An expert panel then met to form evidence-based recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Expert opinion was utilized when the available evidence was deemed insufficient. Results: The expert panel agreed on ten recommendations addressing the management of appendicitis, biliary disease, and IBD during pregnancy. Conclusions: Conditional recommendations were made in favor of appendectomy over nonoperative treatment of appendicitis, laparoscopic appendectomy over open appendectomy, and laparoscopic cholecystectomy over nonoperative treatment of biliary disease and acute cholecystitis specifically. Based on expert opinion, the panel also suggested either operative or nonoperative treatment of biliary diseases other than acute cholecystitis in the third trimester, endoscopic retrograde cholangiopancreatography rather than common bile duct exploration for symptomatic choledocholithiasis, applying the same criteria for emergent surgical intervention in pregnant and non-pregnant IBD patients, utilizing an open rather than minimally invasive approach for pregnant patients requiring emergent surgical treatment of IBD, and managing pregnant patients with active IBD flares in a multidisciplinary fashion at centers with IBD expertise. [ABSTRACT FROM AUTHOR]

Background: Many scoring systems, algorithms, and guidelines have been developed to aid in the evaluation and diagnosis of acute appendicitis (AA). Many of these algorithms advocate against the routine use of radiological investigations when there is a high clinical suspicion of AA. However, there has been a significant rise in the use of imaging techniques for diagnosing AA in the past two decades. This is a national study aimed at assessing the adherence of residents assigned to the emergency department to the clinical guidelines for diagnosing AA. Methods: We introduced a case study of a male patient with highly suspicious clinical findings of AA to all surgical and emergency medicine residents assigned to the emergency department with the autonomy to make critical decisions to determine the preferred way of diagnosing AA. Results: A total of 62.4% of all relevant residents participated in this survey; 69.6% reported that the Alvarado score was eight or higher, and 82.1% estimated that the next step recommended by most clinical guidelines was appendectomy without further abdominal imaging tests. However, 83.4% chose to perform an imaging test to establish the diagnosis of AA. Conclusions: Our study revealed a notable non-adherence to clinical guidelines in diagnosing AA. Given the significance of these guidelines, we assert that adopting medical recommendations should not solely depend on individual education but should also be incorporated as a departmental policy. [ABSTRACT FROM AUTHOR]

Introduction: Appendicitis is one of the most frequent surgical diseases. In uncomplicated appendicitis, outpatient protocols have been shown to significantly reduce costs and can be replicated by residents. In Colombia, this type of protocol has never been evaluated. The aim of this study was to evaluate the outcomes of a low-cost, outpatient laparoscopic appendectomy protocol performed by first- and second-year general surgery residents in uncomplicated appendicitis. A prospective longitudinal study of outpatient management after laparoscopic appendectomy was conducted in Bogotá, Colombia. It included patients with uncomplicated acute appendicitis and excluded those with evidence of perforation, abscess, or gangrenous appendicitis. The frequency of complications, readmissions, and postoperative pain were evaluated as outcomes. Results: 285 patients were included, with a median age of 28 years and 52.3% (n = 149) were female. All patients had modulated pain and tolerance of the oral route during the postoperative period. There were only 10 (3.5%) readmissions and 12 (4.2%) complications, of which 80% (n = 8) and 58.3% (n = 7) corresponded to the laparoscopic group. On bivariate analysis, no association was found between the frequency of complications and the surgical approach (open vs laparoscopic surgery, p = 0.10), the stage of appendicitis (edematous vs fibrinopurulent, p = 0.14), or the American Society of Anesthesiologists classification (I vs II, p = 0.44). Conclusions: This study demonstrated that the low-cost outpatient management protocol for uncomplicated appendicitis by laparoscopic appendectomy performed by first- and second-year residents had a low frequency of complications and readmission, with no significant differences compared with open surgery or appendicular phase. Clinical significance: The findings of this study have important implications for clinical practice. Outpatient postoperative management can reduce healthcare costs and improve patient satisfaction by reducing hospital stays and facilitating earlier recovery. This alternative should be considered for selected patients who meet the criteria for safe and effective care. [ABSTRACT FROM AUTHOR]

Introduction: Ulcerative colitis (UC) is an inflammatory bowel disease that affects the colon and rectum of unknown etiology. Elective appendectomy has been proposed as a possible treatment for patients with refractory ulcerative colitis. Objective: To report the clinical case of a patient with refractory UC who showed improvement in symptomatology and quality of life after undergoing elective appendectomy. Results: We present the case of a 46-year-old patient with a 2-year history of hypothyroidism and ulcerative colitis, with rectal bleeding, abdominal pain, and significant diarrhea despite biological therapy. Elective laparoscopic appendectomy was performed, resulting in symptomatic improvement of the patient as measured by the Inflammatory Bowel Disease Questionnaire. The patient’s preoperative score was 60 points, and the postoperative score was 176. Discussion: It seems evident that ulcerative colitis and the cecal appendix are intimately related. Future challenges should aim to identify clinical characteristics that determine which patients benefit from this intervention. [ABSTRACT FROM AUTHOR]

Background: Although ultrasound is considered the gold standard for the evaluation of children with suspected appendicitis, there is still much debate about the most accurate ultrasound findings. The purpose of this study was to define the best ultrasound signs that could ultimately improve the diagnostic accuracy of ultrasound for diagnosing pediatric acute appendicitis, and to differentiate between simple appendicitis and complicated appendicitis. Patients and Methods: After approval by our Institutional Review Board, a prospective study was carried out from January 1, 2022, to July 31, 2023, in a pediatric emergency department. We included all patients aged under 14 years with suspected appendicitis and ultrasound-visualized appendix. Results: A total of 550 patients presented with suspected appendicitis during the study period. Of these children, 411 had an ultrasound-visualized appendix. Our patients' mean age was 9.4 years. The best positive predictive value of ultrasound was found for appendiceal diameter ≥7.5 mm. The combination of an appendiceal diameter <6 mm and the lack of peri-appendiceal free fluid on ultrasound rules out the diagnosis of appendicitis. The best diagnostic accuracy of ultrasound, which was 92%, was achieved for appendix diameters ≥6.5 mm. The sonographic sign giving the best ultrasound accuracy for diagnosing complicated appendicitis was an appendix diameter ≥9 mm. Conclusions: In conclusion, our present study demonstrated that appendiceal diameter ≥6.5 mm is the gold standard for diagnosing appendicitis in pediatric patients. The combination of an appendiceal diameter <6 mm and the lack of peri-appendiceal free fluid on ultrasound would rule out appendicitis. [ABSTRACT FROM AUTHOR]

The role of appendectomy in the pathogenesis of colorectal cancer (CRC) is a recent topic of contention. Given that appendectomy remains one of the most commonly performed operations and a first‐line management strategy of acute appendicitis, it is inherently crucial to elucidate the association between prior appendectomy and subsequent development of CRC, as there may be long‐term health repercussions. In this review, we summarize the data behind the relationship of CRC in post‐appendectomy patients, discuss the role of the microbiome in relation to appendectomy and CRC pathogenesis, and provide an appraisal of our current understanding of the function of the appendix. We seek to piece together the current landscape surrounding the microbiome and immunological changes in the colon post‐appendectomy and suggest a direction for future research involving molecular, transcriptomic, and immunologic analysis to complement our current understanding of the alterations in gut microbiome. [ABSTRACT FROM AUTHOR]

Background: Acute appendicitis is known as the most common diagnosis of acute abdomen leading to surgery. Therefore, timely diagnosis is of special importance. This study was conducted with the aim of pathological assessment of the appendix in appendectomies performed in children to determine the rate of negative appendectomies and the predictors of negative appendectomy and to evaluate the paraclinical tools used in the diagnosis of acute appendicitis. Methods: This is a cross-sectional descriptive study. All children who underwent appendectomy at Shahid Motahari Hospital in Urmia from March 2021 to March 2022 were examined. The required data including demographic, paraclinical, and final pathology characteristics were collected and recorded. The investigated cases were classified into positive and negative appendectomy categories for comparison. Results: Among 234 pathology samples of the appendix, 22 cases were related to accidental appendectomy. In addition, 11.3% of cases were negative appendectomy and 88.7% were positive appendectomy. The age range of 8 to 14 years and male gender were associated with a lower negative appendectomy rate (both P < 0.001). Inflammatory (49.5%) and gangrenous appendicitis (30.2%) were the most commonly reported histopathologies. Sonography had a sensitivity of 84%, a specificity of 79%, and an overall diagnostic accuracy of 83%. Conclusion: A relatively significant number of accidental and negative appendectomies are performed. More careful investigation and the use of expectant and medical treatment instead of surgery, especially in females and young children, can be effective in improving diagnostic accuracy and preventing negative appendectomies. [ABSTRACT FROM AUTHOR]

Objectives The appendix, although considered a vestigial organ, is of considerable clinical importance because acute appendicitis is a common medical problem. There are also other disease processes involving the appendix. The appendix is among the first specimens that the pathologist (and surgeon) cuts one's teeth on. Thus, there may be a tendency to underestimate the clinically and prognostically significant appendiceal pathologies. Methods We provide a vade mecum of the pathologic features of a wide range of nonneoplastic appendiceal pathologies, with an emphasis on developing a practical approach to grossing, microscopy, and reporting—all with clinical and therapeutic implications. Much of this is based on literature on MEDLINE with reference to years 2008 to 2023, as well as on personal experiences and interpretations. Results The appendix can harbor a myriad of nonneoplastic pathologies, including infections, inflammations of varying etiologies (including interval appendectomy), endometriosis, diverticulosis, and so on. Chronic appendicitis, Crohn disease, and clinical audit are recurring themes while COVID-19 is a new entity. Conclusions Most importantly, all pathologists should appreciate that the appendix is not as "routine" a specimen as one would want to believe. [ABSTRACT FROM AUTHOR]

The association between prenatal exposure to general anaesthesia for maternal surgery during pregnancy and subsequent risk of disruptive or internalising behavioural disorder diagnosis in the child has not been well-defined. A nationwide sample of pregnant women linked to their liveborn infants was evaluated using the Medicaid Analytic eXtract (MAX, 1999–2013). Multivariate matching was used to match each child prenatally exposed to general anaesthesia owing to maternal appendectomy or cholecystectomy during pregnancy with five unexposed children. The primary outcome was diagnosis of a disruptive or internalising behavioural disorder in children. Secondary outcomes included diagnoses for a range of other neuropsychiatric disorders. We matched 34,271 prenatally exposed children with 171,355 unexposed children in the database. Prenatally exposed children were more likely than unexposed children to receive a diagnosis of a disruptive or internalising behavioural disorder (hazard ratio [HR], 1.31; 95% confidence interval [CI], 1.23–1.40). For secondary outcomes, increased hazards of disruptive (HR, 1.32; 95% CI, 1.24–1.41) and internalising (HR, 1.36; 95% CI, 1.20–1.53) behavioural disorders were identified, and also increased hazards of attention-deficit/hyperactivity disorder (HR, 1.32; 95% CI, 1.22–1.43), behavioural disorders (HR, 1.28; 95% CI, 1.14–1.42), developmental speech or language disorders (HR, 1.16; 95% CI, 1.05–1.28), and autism (HR, 1.31; 95% CI, 1.05–1.64). Prenatal exposure to general anaesthesia is associated with a 31% increased risk for a subsequent diagnosis of a disruptive or internalising behavioural disorder in children. Caution is advised when making any clinical decisions regarding care of pregnant women, as avoidance of necessary surgery during pregnancy can have detrimental effects on mothers and their children. [ABSTRACT FROM AUTHOR]

Immediate complications of appendicitis are common, but the prevalence of long-term complications is uncertain. We studied all publicly-insured children in the US with uncomplicated or complicated appendicitis in 2018-2019 using administrative claims. The main outcome was late hospital care defined as hospitalization or abdominal procedure within 180 d of an appendicitis discharge, excluding interval appendectomies. Time to late hospital care was evaluated using Cox regression. We evaluated health-care expenditures arising from appendicitis episodes. Among 95,942 children with appendicitis, 5727 (6.0%) had late hospital care, with 5062 requiring rehospitalization and 2012 (2.1%) surgery. The median time to late hospital care was 10 d (interquartile range 4-33). Age under 5 y (compared with >14 y, hazard ratio [HR] 1.88, 95% confidence interval [CI] 1.70-2.08), complex chronic conditions (HR 2.35, 95% CI 2.13-2.59), and complicated appendicitis (HR 2.81, 95% CI 2.67, 2.96) were each associated with time to late hospital care. Expenditures over 180 d were a median $6553 and $19,589 respectively in those requiring no late hospital care versus those requiring it (P < 0.001). Late hospital care is uncommon in pediatric appendicitis but is costly. Prevention efforts should be targeted to the youngest, most complex children, and those with complicated appendicitis at presentation. • Late hospital care in pediatric appendicitis is uncommon. • 30 Days is a reasonable window to ascertain the large majority of disease complications. • Prevention of late hospital care is associated with reduced costs. [ABSTRACT FROM AUTHOR]

Taking into account the pathogenesis peculiarities of appendicular pylephlebitis, the risk group includes patients with a retrocecal location of the appendix, gangrenous and perforating appendicitis, the course of which was complicated by peritonitis or abscess. The purpose of our clinical-experimental study was to justify the method of pathogenetic treatment of acute appendicular pylephlebitis based on an experimental model of portal hypertension. Acute experiments were performed on male Wistar rats and outbred dogs. Clinical studies were prospectively-retrospective. In addition to traditional methods of treatment, we used the developed technique of draining the retroperitoneal space and introducing antibacterial compositions in a complex with a 10% dimethylsulfoxide (DMSO) solution was used. On the basis of experimental data, it was established that a 10% solution of DMSO complexed with a dye, when injected transperitoneally in the ileocecal angle area, preferentially penetrates the lymphatic and portal systems, even in conditions of portal hypertension. This is explained by the peculiarities of the anatomical structure. The use of the method of intraperitoneal administration of antibiotics in combination with DMSO is pathogenetically justified in patients with appendicular pylephlebitis, as it achieves local sanitation of the immediate source and primary ways of spreading the infection. Implementation of the developed method of prevention and treatment of acute pylephlebitis of appendicular genesis as part of improved treatment tactics allows to improve treatment results by likely reducing the frequency of postoperative complications from 18.7% to 2.7% (χ² = 20.02, 95% CI 9.25-23.8) and the duration of hospitalization from 22.8 days to 8.5 days. [ABSTRACT FROM AUTHOR]

Summary: Appendicectomy is a common procedure in children with a low risk of mortality, however, complication rates and risk factors are largely unknown. This study aimed to characterise the incidence and epidemiology of postoperative complications in children undergoing appendicectomy in the UK. This multicentre prospective observational cohort study, which included children aged 1–16 y who underwent surgery for suspected appendicitis, was conducted between November 2019 and January 2022. The primary outcome was 30‐day postoperative morbidity. Data collected included: patient characteristics; comorbidities; and physiological status. Multivariable regression analysis was used to identify independent risk factors for poor outcomes. Data from 2799 children recruited from 80 hospitals were analysed, of which 185 (7%) developed postoperative complications. Children from black and 'other' minority ethnic groups were at significantly higher risk of poor outcomes: OR (95%CI) 4.13 (1.87–9.08), p < 0.001 and 2.08 (1.12–3.87), p = 0.021, respectively. This finding was independent of socio‐economic status and type of appendicitis found on histology. Other risk factors for complications included: ASA physical status ≥ 3 (OR (95%CI) 4.05 (1.70–9.67), p = 0.002); raised C‐reactive protein (OR 95%CI 1.01 (1.00–1.01), p < 0.001); pyrexia (OR (95%CI) 1.77(1.20–2.63), p = 0.004); and peri‐operative oxygen supplementation (OR (95%CI) 4.20 (1.44–12.24), p = 0.009). In the UK NHS, which is a universally accessible healthcare system, ethnicity, but not socio‐economic status, was associated with an increased risk of postoperative complications in children having surgery for acute appendicitis. Further evaluations and interventions are required to address this health inequality in keeping with NHS and international priorities. [ABSTRACT FROM AUTHOR]

Resection of the left atrial appendage reportedly improves blood pressure in patients with hypertension. This study aimed to validate the transcriptional profiles of atrial genes responsible for blood pressure regulation in patients with hypertension as well as to identify the molecular mechanisms in rat biological systems. RNA sequencing data of left atrial appendages from patients with (n = 6) and without (n = 6) hypertension were subjected to unsupervised principal component analysis (PCA). Reduction of blood pressure was reflected by third and ninth principal components PC3 and PC9, and that eighteen transcripts, including endothelin-1, were revealed by PCA-based pathway analysis. Resection of the left atrial appendage in hypertensive rats improved their blood pressure accompanied by a decrease in serum endothelin-1 concentration. Expression of the endothelin-1 gene in the atrium and atrial appendectomy could play roles in blood pressure regulation in humans and rats. [ABSTRACT FROM AUTHOR]

A low‐grade appendiceal mucinous neoplasm (LAMN) is a cystic dilatation of the appendix resulting from the accumulation of mucinous secretions caused by a luminal obstruction. Although usually benign, pseudomyxoma peritonei may occur in the event of rupture, and 10% of cases may be secondary to appendiceal cystadenocarcinoma. A LAMN is both more common and more likely to have a malignant association in women, making it an entity with which practitioners of gynaecological ultrasound should be familiar. Although not the primary aim, early pregnancy ultrasound assessments can offer the diagnostic opportunity to identify pelvic pathology. A LAMN can be identified on ultrasonography by visualisation of an adnexal mass separate to the ovary, which due to the layers of secretions has a distinctive appearance previously likened to 'onion‐skin' or 'whipped‐cream'. Here, we describe an incidental finding of a LAMN during an early pregnancy assessment. Practitioners of early pregnancy ultrasound should be familiar with the characteristic morphology of this rare but important finding. [ABSTRACT FROM AUTHOR]

Background: Acute abdomen is a frequent occurrence in emergency department settings and often necessitates prompt diagnosis and urgent surgical intervention. Owing to the overlapping symptoms of many serious and benign intra-abdominal conditions, identifying life-threatening situations early in their progression can be challenging. The current study aimed to assess the diagnostic effectiveness of abdominal ultrasound in identifying common conditions presenting as an acute abdomen. Methods: This prospective comparative study included patients presenting with an acute abdomen at the Emergency Department of CDSIMER. Clinical diagnoses were established, followed by abdominal ultrasound. Ultrasound findings were compared with intraoperative observations and histopathological results, or in cases in which surgery was not performed, based on CT scan findings. Various diagnostic performance parameters, including sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), and accuracy, were used for the statistical analysis. Results: A total of 77 patients with acute abdominal pain were included in the study. Appendicitis was the most common diagnosis (33.77%), followed by cholecystitis (20.77%), pancreatitis (16.88%), intestinal obstruction (12.98%), and enteric perforation (15.58%). USG may have moderate accuracy for some conditions, such as appendicitis, acute intestinal obstruction, and acute cholecystitis, where it has shown acceptable sensitivity. CT scans are likely to have higher overall accuracy; across different conditions, CT scans are generally expected to be more accurate than USG for diagnosing acute abdominal conditions because of their ability to provide more detailed anatomical images. Conclusion: Ultrasound is a highly effective imaging modality for accurate diagnosis of acute appendicitis, acute intestinal obstruction, and acute cholecystitis. Even in hospitals lacking highly advanced imaging facilities, clinical assessment combined with ultrasound results can provide reliable diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Introduction: Endometriosis is a common condition affecting 5 to 10% of women of childbearing age. The true incidence of endometriosis of the appendix is currently unknown. Since symptoms often overlap with those of acute appendicitis, endometriosis of the appendix presents a diagnostic challenge in the emergency department. This large retrospective study investigates the incidence and perioperative clinical, radiologic, and laboratory findings, as well as possible differences between patients with and without endometriosis. Methods: Data from consecutive patients who underwent appendectomy for suspected appendicitis without a history of endometriosis were analyzed. Perioperative clinical, laboratory, perioperative, and histopathologic findings were compared between women with and without endometriosis. Results: Between January 2008 and June 2023, 2484 consecutive patients without a history of endometriosis underwent urgent appendectomy for suspected appendicitis. Endometriosis was detected on histopathologic examination in 17 (0.7%) patients. Signs of appendicitis were found less frequently on ultrasound in the endometriosis group compared to the non-endometriosis group (23.4% vs. 61.5%; p = 0.002; OR = 0.193; 95% CI 0.063–0.593). There were no differences in physical examination findings, duration of symptoms, degree of inflammation, surgical outcomes, or complication rates. Conclusion: The incidence of endometriosis of the appendix in patients undergoing appendectomy for suspected appendicitis was higher than suggested by data from autopsy series and populations with biopsy-proven endometriosis. Patients with endometriosis of the appendix were less likely to have a positive ultrasound finding, but perioperative and histopathologic findings and severity of inflammation did not differ from patients without endometriosis, presenting diagnostic challenges for clinicians. [ABSTRACT FROM AUTHOR]

Appendiceal diverticulitis is an uncommon condition that clinically resembles acute appendicitis. However, it is an incidental finding in histopathological studies and is rarely diagnosed preoperatively by imaging studies. In this article, we present the clinical and imaging findings of a male patient presenting with right upper quadrant pain with a preoperative imaging diagnosis of appendiceal diverticulitis. He underwent laparoscopic appendectomy and confirmed the diagnosis of appendiceal diverticulitis. This is a rare preoperative diagnosis. The management is often like typical appendicitis which is appendectomy. It is important to differentiate it from diverticulitis of the small intestine or colon because these diseases usually require only conservative treatment. [ABSTRACT FROM AUTHOR]

Background/Objective: The association between appendicitis and colon cancer is not yet fully understood. Previous studies have shown contradictory results. Currently, no population-based data from Germany are available with regard to the incidence of colon cancer following appendicitis. This study investigated the association between appendicitis and the incidence of colon cancer in Germany. Methods: In this retrospective cohort study, the incidence of colon cancer was compared for patients with appendicitis and patients without appendicitis, matched for age, sex, index year, average annual consultation frequency, and comorbidity. The aim of the study was to explore the relationship between appendicitis and the incidence of colon cancer. The evaluation was carried out using logistic regression analyses. Results: The study included 49,790 people with and without appendicitis, with a median age of 41 years. During a follow-up period of up to 15 years, 1.04% of cases with appendicitis and 0.60% of cases without appendicitis were newly diagnosed with colon cancer, with some 36.4% of colon cancer cases diagnosed within the first six months after appendicitis. Regression analyses revealed a significant association between appendicitis and colon cancer, particularly in men and in the age groups 41–50 (HR: 10.30; 95% CI: 1.03–43.82) and 18–30 years (HR: 8.17; 95% CI: 1.03–64.58). Conclusions: The present retrospective cohort study suggests an association between appendicitis and the incidence of colon cancer in Germany. Based on our results, we recommend offering a colonoscopy or at least a stool test within 12 months after appendicitis, especially for 18–50-year-olds and >60-year-olds in good general health. [ABSTRACT FROM AUTHOR]

Purpose: Appendicitis, characterized by inflammation of the vermiform appendix, is a common abdominal emergency necessitating appendectomy. Recent evidence suggests a potential link between appendicitis and subsequent diverticular disease, yet population-based studies investigating this association are limited. Methods: Utilizing the Disease Analyzer database encompassing data from over 1000 primary care practices in Germany, we conducted a retrospective cohort study. We included 25,379 adults diagnosed with appendicitis and an equal number of matched controls without appendicitis. The incidence of diverticular disease over a 10-year follow-up period was compared between the two cohorts. Cox regression analysis was performed to assess the association between appendicitis and diverticular disease, adjusting for potential confounders. Results: Our findings revealed a significant association between appendicitis and subsequent diverticular disease (HR: 1.76; 95% CI: 1.57–1.97), with an increased risk observed across all age groups. Notably, this association was stronger in men (HR: 2.00; 95% CI: 1.68–2.37) than in women (HR: 1.58; 95% CI: 1.36–1.84). The cumulative 10-year incidence of diverticular disease was higher in patients with appendicitis (6.5%) compared to those without (3.6%). Additionally, we observed a clear age-dependent increase in the incidence of diverticular disease. Conclusion: This large-scale population-based study provides valuable insights into the interaction between appendicitis and diverticular disease. The study underscores the need for further research elucidating the underlying mechanisms linking appendicitis to diverticular disease. Probiotics emerge as a potential therapeutic avenue warranting exploration in the management of both conditions. These findings have important implications for clinical practice, highlighting the importance of considering appendicitis as a potential risk factor for diverticular disease, particularly in men. Further investigation is warranted to validate these findings and explore potential therapeutic interventions targeting the shared pathophysiological pathways underlying both conditions. [ABSTRACT FROM AUTHOR]

Background & Objective: Regarding the urgent needs of students for an efficient teaching methodology, it is necessary to use self-directed and self-centered teaching methods that encourage the power of reasoning and judgment. This study aimed to investigate the effect of using the game-based Appendectomy Surgical Simulation software on the academic achievement of undergraduate operating room students in Khomein, Iran. Materials & Methods: This quasi-experimental study was conducted during the COVID-19 pandemic. Forty undergraduate operating room students who were in the second semester of the first year of the operating room undergraduate program participated in this quasiexperimental single-blind study. The participants were assigned randomly to the control and intervention groups after their consent was obtained. Following the use of the game-based Appendectomy Surgical Simulation software for the intervention group and lecture-based classes on a specific academic learning software for the control group, the data were collected using a researcher-made questionnaire concerning academic achievement, whose validity and reliability were approved. The data were then analyzed using descriptive and analytical tests in IBM SPSS (version 22) at a significance level of P<0.05. Results: The average score of academic achievement was significantly higher in the intervention group (58.35±2.38) than in the control group (35.65±4.14) (P<0.05). Conclusion: Using the game-based Appendectomy Surgical Simulation software has been effective in improving the academic achievement of students during the COVID-19 pandemic and afterward. Therefore, it can be used in academic and educational programs. [ABSTRACT FROM AUTHOR]

Disparate access to laparoscopic surgery may contribute to poorer health outcomes among racial and ethnic minorities, especially among children. We investigated whether racial and ethnic disparities in laparoscopic procedures existed among four common surgical operations in the pediatric population in the United States. Using the American College of Surgeons National Surgical Quality Improvement Program–Pediatrics, we conducted a retrospective review of pediatric patients, aged less than 18 y old, undergoing appendectomy, fundoplication, cholecystectomy, and colectomy from 2012 to 2021. To compare the surgical approach (laparoscopy or open), a propensity score matching algorithm was used to compare laparoscopic and open procedures between non-Hispanic Black with non-Hispanic White children and Hispanic with non-Hispanic White children. 143,205, 9,907, 4,581, and 26,064 children underwent appendectomy, fundoplication, colectomy, and cholecystectomy, respectively. After propensity score matching, non-Hispanic Black children undergoing appendectomy were found to be treated laparoscopically less than non-Hispanic White children (93.5% versus 94.4%, P = 0.007). With fundoplication, Hispanic children were more likely to be treated laparoscopically than White ones (86.7% versus 80.9%, P < 0.0001). There were no statistically significant differences between Black or Hispanic children and White children in rates of laparoscopy for other procedures. Though some racial and ethnic disparities exist with appendectomies and fundoplications, there is limited evidence to indicate that widespread inequities among common laparoscopic procedures exist in the pediatric population. [ABSTRACT FROM AUTHOR]

Background: Appendectomy is the gold standard for simple appendicitis. During the coronavirus-19 pandemic, it was estimated that appendectomies in the United States decreased by 24%. We aimed to describe trends in acute appendicitis management at a center located in one of the largest epicenters of the pandemic. Methods: This is a retrospective cohort study in a single institution located in Queens, New York, of patients who presented with acute appendicitis. A pre-COVID time period, March-June 2019, was compared to peak-COVID, March-June 2020, and late-COVID, March-June 2021. Results: Of the 382 patients admitted with appendicitis during the time periods, 164 were admitted pre-COVID. Appendicitis presentations decreased by 44% during peak-COVID and 23% in late-COVID. Patients were younger during peak-COVID compared to pre-COVID (39 vs 34 years old, P =.036). Incidence of complicated appendicitis in pre-, peak-, and late-COVID was equivalent (41% vs 46% vs 45%) and operative management was similar (85% vs 76% vs 79%). Non-operative patients had shorter lengths of stay (pre- vs peak-COVID: 4.6 vs 2.9 days, P =.006). Readmission rates were similar between the cohorts across time periods. Conclusions: During peak-COVID, there was a significant decrease in presentation of acute appendicitis but clinical presentation and outcomes remained similar between the cohorts. Patients who were managed non-operatively may be discharged earlier without increased rates of readmissions. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to evaluate the added value of duplex Doppler examination to the routinely graded compression grayscale ultrasound (US) for patients with suspected acute appendicitis (AA) in correlation with surgical management outcomes. Methods: The study lasted from January 2020 to March 2021. Throughout that period, patients who had suspected appendicitis were included with a visible appendix in the grayscale US. These patients were categorized clinically based on Alvarado's score. They underwent graded compression grayscale US of the appendix and duplex Doppler study. Subsequently, they were assigned for non-contrast multislice computed tomography (MSCT) according to Alvarado's score and underwent either emergency appendicectomy or conservative clinical management afterward. A Student's t-test was used to determine if there were significant differences in the mean values between the groups. The diagnostic performance of spectral Doppler US for the diagnosis of AA was depicted. Results: Eighty-four patients with visualized color flow in the appendicular Doppler US were enrolled, with 60 (71.4%) having AA, and 24 (28.6%) not having appendicitis. Spectral Doppler criterion of PSV greater than 8.6 cm/s demonstrated a high sensitivity of 91.67% and specificity of 77.78% for patients with Alvarado score ranging from 4 to 7, and appendiceal MOD ranging from 6 to 8 mm, while a discriminatory criterion of RI greater than 0.51 had a high sensitivity of 100% and a relatively lower specificity of 66.67%. Conclusion: The patients with AA have significantly higher point PSV and point RI values than those without AA and are especially useful in equivocal patients whose MODs and Alvarado scores are in the diagnostically equivocal ranges of 6–8 mm and 4–7, respectively, with the point PSV and RI demonstrating negative predictive value 87.5% and 100%. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the relationship between postoperative pain and circadian rhythm after pediatric acute appendicitis surgery. Methods: Two hundred patients, aged 6–18 years, undergoing acute appendicitis surgery were included in this prospective observational study. The patients were divided into four groups according to the time they underwent surgery: the night group, 01:01–07:00; morning group, 07:01–13:00; afternoon group, 13:01–19:00; and evening group, 19:01–01:00. Intraoperative and postoperative vital signs, postoperative 24-h Wong–Baker Faces Pain Rating Scale (FACEs) scores, and the amount of analgesic required were recorded. Results: A total of 186 patients were analyzed in the study. There was no statistically significant difference in the demographic characteristics of the patient groups. Additionally, no differences were observed in intraoperative and postoperative vital signs among the four groups. However, patients in the night group had significantly higher FACEs values than those in the other groups at each time point (1st, 3rd, 6th, and 12th h) up to 12 h (P = 0.007, P = 0.023, P = 0.048, and P = 0.003, respectively). The amount of analgesic required in the night group was statistically higher than in the other groups until 12 h (P = 0.002, P < 0.001, P = 0.002, and P = 0.004, respectively). Conclusions: A relationship was found between acute appendicitis operations performed at night (01:01 to 07:00) under general anesthesia and circadian rhythm in children. We believe that considering circadian time in the relief of postoperative pain would be beneficial. [ABSTRACT FROM AUTHOR]

Background: Conventional three-access laparoscopic appendectomy (CLA) is currently the gold standard treatment, however, Single-Port Laparoscopic Appendectomy (SILA) has been proposed as an alternative. The aim of this systematic review/meta-analysis was to evaluate safety and efficacy of SILA compared with conventional approach. Methods: Per PRISMA guidelines, we systematically reviewed randomised controlled trials (RCTs) comparing CLA vs SILA for acute appendicitis. The randomised Mantel–Haenszel method was used for the meta-analysis. Statistical data analysis was performed with the Review Manager software and the risk of bias was assessed with the Cochrane "Risk of Bias" assessment tool. Results: Twenty-one studies (RCTs) were selected (2646 patients). The operative time was significantly longer in the SILA group (MD = 7,32), confirmed in both paediatric (MD = 9,80), (Q = 1,47) and adult subgroups (MD = 5,92), (Q = 55,85). Overall postoperative morbidity was higher in patients who underwent SILA, but the result was not statistically significant. In SILA group were assessed shorter hospital stays, fewer wound infections and higher conversion rate, but the results were not statistically significant. Meta-analysis was not performed about cosmetics of skin scars and postoperative pain because different scales were used in each study. Conclusions: This analysis show that SILA, although associated with fewer postoperative wound infection, has a significantly longer operative time. Furthermore, the risk of postoperative general complications is still present. Further studies will be required to analyse outcomes related to postoperative pain and the cosmetics of the surgical scar. [ABSTRACT FROM AUTHOR]

Background Usually umbilical hernia contains bowel loops and omentum. The diagnosis becomes even more challenging when they imitate strangulated umbilical hernia. An acutely inflamed appendix has been seen in the femoral and inguinal hernia but is rarely found in the paraumbilical hernia. Objectives To observe the symptoms, findings, and treatment process of cases of umbilical/paraumbilical hernia in past literature and document a case report in the appendix within the paraumbilical hernia. Methods Literature has been searched with keywords and statements of umbilical hernia, appendix within the umbilical hernia, and paraumbilical hernia. Studies on appendix within paraumbilical hernia are scarce in the literature. Six studies from the past 12 years were included. Results There were six studies included. Pain, fever, vomiting, and swelling on the umbilicus were the common symptoms. No postoperative complication was seen. Conclusion Several factors can be responsible for umbilical hernia. A case report of a 50-years old male presented to Jinnah Hospital, Lahore with pain and umbilical swelling. Appendiceal inflammation was found in the hernia sac. Umbilical herniorrhaphy and appendectomy were done. [ABSTRACT FROM AUTHOR]

Background: Atrial tachycardia (AT) originating from the left atrial appendage (LAA) is uncommon and the most difficult arrhythmia to eliminate. Therefore, we present the case of a 5-year-old girl with tachycardia-induced cardiomyopathy (TIC) caused by AT originating from the LAA and successfully treated with RFCA associated to left atrial appendectomy. With resolution of AT, we observed a progressive improvement of LV function. The effectiveness and safety of this combination therapy were evaluated over a one-month follow-up period. Case presentation: A 5 -year-old female was evaluated for three days of incessant cough and a syncopal episode. Surface echocardiography and 24-hour monitoring showed that the infant had persistent atrial tachycardia. Echocardiography revealed an enlarged tele diastolic diameter (46.1 mm) and malfunctioning (EF 28.53%) left ventricle. The location of the lesion at the apex of the LAA was further confirmed by electrophysiological study and RFCA. After RFCA, the infant's ECG monitor showed that sinus rhythm was maintained for up to 22 h. Subsequently, atrial tachycardia recurred and sinus rhythm disappeared. Finally, atrial appendectomy was performed and sinus rhythm returned to normal. Conclusions: The heart function of the infant improved and sinus rhythm was maintained, further demonstrating the safety and effectiveness of combined treatment with RFCA and atrial appendectomy after electrophysiological localization of AT from LAA to TIC. [ABSTRACT FROM AUTHOR]

Purpose: The volume of surgical services has significantly reduced globally due to the coronavirus disease 2019 (COVID-19) pandemic. This study evaluated the level of recovery in terms of the number of operations performed in Japan in 2021, based on nationwide periodic surveillance. Methods: Information on the weekly and annual volumes of 20 representative procedures in 6 surgical subspecialties in 2021 was extracted from the National Clinical Database. Statistical data for 2018 and 2019 (pre-pandemic era) were compared with those for 2020. Data on waves of infection, peak period, and high-prevalence areas (13 of 47 prefectures) were analyzed individually. Results: The volumes of the 10 procedures, including gastrectomy, hepatectomy, valve replacement and valve plasty, coronary artery bypass grafting, infrarenal abdominal aorta replacement, ventricular septal defect closure, lung lobectomy, inguinal hernia repair (age < 16 years old), and appendectomy (age < 16 years old), did not reach 95% of that in the pre-pandemic era. The most striking decline in the surgical volume of these 10 procedures was observed during the peak period of wave 5 in high-prevalence areas. Conclusion: This near-complete enumeration survey identified the polarization of 20 representative procedures in terms of resumption of surgical service after the pandemic. [ABSTRACT FROM AUTHOR]

Background: Amyand's hernia (AH) is an appendix (with or without acute inflammation) trapped within an inguinal hernia. Most AH with acute appendicitis had a preexisting appendix within the hernia sac. We herein report a variant of AH that has never been described before. An inflamed appendix that was managed conservatively was found to have migrated and trapped in the sac of a previously unrecognized right inguinal hernia 6 weeks after the index admission, resulting in a secondary Amyand's hernia. Case presentation: A 25-year-old healthy Taiwanese woman had persistent right lower abdominal pain for 1 week and was diagnosed with perforated appendicitis with a localized abscess by abdominal computed tomography (CT). No inguinal hernia was noted at that time. Although the inflamed appendix along with the abscess was deeply surrounded by bowel loops so that percutaneous drainage was not feasible, it was treated successfully with antibiotics. However, she was rehospitalized 6 weeks later for having a painful right inguinal bulging mass for a week. Abdominal CT revealed an inflamed appendix with abscess formation in an indirect inguinal hernia raising the question of a Amyand's hernia with a perforated appendicitis. Via a typical inguinal herniorrhaphy incision, surgical exploration confirmed the diagnosis, and it was managed by opening the hernial sac to drain the abscess and reducing the appendix into the peritoneal cavity, followed by conventional tissue-based herniorrhaphy and a laparoscopic appendectomy. She was then discharged uneventfully and remained well for 11 months. Conclusions: Unlike the traditional definition of Amyand's hernia, where the appendix is initially in the hernia sac, the current case demonstrated that Amyand's hernia could be a type of delayed presentation following initial medical treatment of acute appendicitis. However, it can still be managed successfully by a conventional tissue-based herniorrhaphy followed by laparoscopic appendectomy. [ABSTRACT FROM AUTHOR]

Background: Glucocorticoids are conventionally associated with increased postoperative infection risk. It is necessary to clarify if preoperative glucocorticoid exposure is associated with postoperative infection in appendectomy patients and if the association is different for open and laparoscopic appendectomies. Methods: A Danish nationwide study of appendectomy patients between 1996 and 2018. Exposures were defined as high (≥ 5 mg) versus no/low (< 5 mg) glucocorticoid exposure in milligram prednisone-equivalents/day preoperatively. The main outcome was any postoperative infection. Then, 90-day cumulative incidences (absolute risk) and adjusted hazard ratios (relative risk) of the outcome were calculated for high versus no/low glucocorticoid exposure within all appendectomies and within open and laparoscopic subgroups. Propensity-score matching was used for sensitivity analysis. Results: Of 143,782 patients, median age was 29 years, 74,543 were female, and 7654 experienced at least one infection during the 90-day follow-up. The 90-day cumulative incidence for postoperative infection was 5.3% within the no/low glucocorticoid exposure group and 10.0% within the high glucocorticoid exposure group. Compared to no/low glucocorticoid exposure, adjusted hazard ratios for 90-day postoperative infection with high glucocorticoid exposure were 1.25 [95% CI 1.02–1.52; p = 0.03] for all appendectomies, 1.59 [1.16–2.18; p = 0.004] for laparoscopic appendectomies, and 1.09 [0.85–1.40; p = 0.52] for open appendectomies (pinteraction < 0.001). The results were robust to sensitivity analyses. Conclusion: Preoperative high (≥ 5 mg/day) glucocorticoid exposure was associated with increased absolute risk of postoperative infections in open and laparoscopic appendectomies. The relative risk increase was significant for laparoscopic but not open appendectomies, possibly due to lower absolute risk with no/low glucocorticoid exposure in the laparoscopic subgroup. [ABSTRACT FROM AUTHOR]

Background: Duplex or vermiform appendix refers to the presence of an appendix beside the naturally occurring one. Although, duplex appendix emerges from the caecum most of the time, yet it is encountered in other parts of the colon. Inflammation of duplex appendix may represent not only a clinical, but also a surgical dilemma, and this would be confusing further among patients who already had prior appendectomy. Case presentation: We present a case of 29-years old Egyptian male patient with history of appendectomy one and half year before presenting to the emergency department with recurrent acute abdominal pain that was linked to duplex appendicitis abnormally emerged from the mid-ascending colon. The first episode was treated conservatively considering atypical right colon diverticulitis as a potential differential diagnosis. Seven months later the patient was treated by laparoscopic appendectomy and experienced an uneventful pot-operative course. Conclusion: Duplex appendicitis, though rare, should be considered in the differential diagnosis of recurrent acute abdomen even after appendectomy. [ABSTRACT FROM AUTHOR]

Background: The primary treatment of ulcerative colitis (UC) is medical therapy using a standard step-up approach. An appendectomy might modulate the clinical course of UC, decreasing the incidence of relapses and reducing need for medication. The objective of the ACCURE trial is to assess the efficacy of laparoscopic appendectomy in addition to standard medical treatment in maintaining remission in UC patients. This article presents the statistical analysis plan to evaluate the outcomes of the ACCURE trial. Design and methods: The ACCURE trial was designed as a multicentre, randomised controlled trial. UC patients with a new diagnosis or a disease relapse within the past 12 months, treated with 5-ASA, corticosteroids, or immunomodulators until complete clinical and endoscopic remission (defined as total Mayo score < 3 with endoscopic subscore of 0 or 1), were counselled for inclusion. Also, patients previously treated with biologicals who had a washout period of at least 3 months were considered for inclusion. Patients were randomised (1:1) to laparoscopic appendectomy plus maintenance treatment or a control group (maintenance therapy only). The primary outcome is the 1-year UC relapse rate (defined as a total Mayo-score ≥ 5 with endoscopic subscore of 2 or 3, or clinically as an exacerbation of symptoms and rectal bleeding or FCP > 150 or intensified medical therapy other than 5-ASA therapy). Secondary outcomes include number of relapses per patient, time to first relapse, disease activity, number of colectomies, medication usage, and health-related quality of life. Discussion: The ACCURE trial will provide comprehensive evidence whether adding an appendectomy to maintenance treatment is superior to maintenance treatment only in maintaining remission in UC patients. Trial registration: Dutch Trial Register (NTR) NTR2883. Registered May 3, 2011. ISRCTN, ISRCTN60945764. Registered August 12, 2019. [ABSTRACT FROM AUTHOR]

Objective: Loop ligation of the appendix is a challenging surgical skill and well suited to be trained in a simulator. We aimed to develop an affordable and easy-to-build simulator and test its training effect. Design and participants: Different materials were tested, and the best training modality was identified by researching the literature. The developed simulator training was tested on 20 surgical novices. Results: A video was produced including an instruction on how to build the simulator and a step-by-step tuition on how to ligate the appendix. The Peyton approach was utilized to guide learners. Training with the simulator leads to reliable skill acquisition. All participants improved significantly in completing the task successfully during the structured learning. Conclusion: We succeeded in developing a simulator for loop ligation of the appendix during laparoscopic appendectomy. Participants significantly improve in handling the loops. The transferability of the skill learned during simulation to the operating room will be subject of a follow-up study. [ABSTRACT FROM AUTHOR]

Purpose: Polymeric clips (Hem-o-lok ligation system) are now widely used to securing the base of the appendix during laparoscopic appendectomy. Studies comparing the use of single or double hem-o-lok clips are limited. The aim of this study was to compare the reliability of a single hem-o-lok clips with a double hem-o-lok clips for closure of an appendiceal stump. Methods: This prospective randomized study includes patients from two centers who underwent laparoscopic appendectomy with the diagnosis of appendicitis between September 2020 and March 2023. Demographic, operative and clinical outcomes of the use of single or double hem-o-lok clips for closure of the appendiceal stump were compared. Factors affecting long postoperative hospital stay were investigated using univariate and multivariate analyzes. Results: One hundred forty two (48.3%) patients in the single hem-o-lok arm and 152 (51.7%) patients in the double hem-o-lok arm were included in the analysis.The shortest operative time was noted in the single hem-o-lok group (52.1 ± 19.9 versus 61.6 ± 24.9 min, p < 0.001). The median hospital stay was 1 day (range 1–10) in the single hem-o-lok group and 1 day (range 1–12) in the double hem-o-lok group, and was shorter in the single hem-o-lok arm (1.61 ± 1.56 vs 1.84 ± 1.69, p = 0.019). Based on multivariate analysis, drain placement was identified as an independent predictive factor for long hospital stay. Conclusions: The use of single hem-o-lok clips for appendiceal stump closure during laparoscopic appendectomy is safe and effective. Trial registration NCT04387370 (http://www.clinicaltrials.gov). [ABSTRACT FROM AUTHOR]

Introduction: Appendiceal neoplasms (ANs) are rare, with an estimated incidence of around 1%: neuroendocrine tumours (NETs) and low-grade appendiceal mucinous neoplasms (LAMNs) comprise most cases. Most tumours are cured by appendectomy alone, although some require right hemicolectomy and intra-operative chemotherapy. The aim of the present study is to evaluate our institution's experience in terms of the prevalence of AN, their histological types, treatment and outcomes in adult patients undergoing emergency appendectomy. Material and methods: Single-centre retrospective cohort analysis of patients treated for acute appendicitis at a large academic medical centre. Patients with a diagnosis of acute appendicitis (AA) where further compared with patients with acute appendicitis and a histologically confirmed diagnosis of appendiceal neoplasm (AN). Results: A diagnosis of acute appendicitis was made in 1200 patients. Of these, 989 patients underwent emergency appendectomy. The overall incidence of appendiceal neoplasm was 9.3% (92 patients). AN rate increased with increasing age. Patients under the age of 30 had a 3.8% (14/367 patients) rate of occult neoplasm, whereas patients between 40 and 89 years and older had a 13.0% rate of neoplasm. No difference was found in clinical presentations and type of approach while we found a lower complicated appendicitis rate in the AN group. Conclusion: ANs are less rare with respect to the literature; however, clinically, there are no specific signs of suspicious and simple appendicectomy appears to be curative in most cases. However, age plays an important role; older patients are at higher risk for AN. ANs still challenge the non-operative management concept introduced into the surgical literature. [ABSTRACT FROM AUTHOR]

Introduction Appendectomy is the treatment of choice for acute appendicitis. The procedure can be performed open or laparoscopically. However, laparoscopy is not available on military missions abroad. It is unclear whether treatment outcomes differ between the two surgical approaches. Materials and Methods Treatment data of all patients undergoing open and laparoscopic appendectomies in the German Armed Forces Hospital of Ulm from 2013 to 2017 were collected retrospectively. A propensity score matching analysis was performed to minimize the influence of potential confounders and to assess the influence of surgical approach on outcome (reoperations, superficial and deep surgical infections, length of postoperative ileus, need for intravenous analgesics, and operative time). Results A total of 542 patients with complete datasets were included in the propensity score matching analysis, among these 64 with open and 478 laparoscopic procedures. There were no statistically significant differences between open and laparoscopic surgeries with respect to all outcome variables, with the exception of a 25-minute prolonged operative time for the open approach. Conclusions Open appendectomy can be considered equivalent in outcome to the laparoscopic procedure and thus can be performed on military missions abroad without compromising outcome. Military surgeons must continue to be trained and confident in open appendectomy. [ABSTRACT FROM AUTHOR]

Our objective was to perform a feasibility study using real-world data from a learning health system (LHS) to describe current practice patterns of wound closure and explore differences in outcomes associated with the use of tissue adhesives and other methods of wound closure in the pediatric surgical population to inform a potentially large study. A multi-institutional cross-sectional study was performed of a random sample of patients <18 y-old who underwent laparoscopic appendectomy, open or laparoscopic inguinal hernia repair, umbilical hernia repair, or repair of traumatic laceration from January 1, 2019, to December 31, 2019. Sociodemographic and operative characteristics were obtained from 6 PEDSnet (a national pediatric LHS) children's hospitals and OneFlorida Clinical Research Consortium (a PCORnet collaboration across 14 academic health systems). Additional clinical data elements were collected via chart review. Of the 692 patients included, 182 (26.3%) had appendectomies, 155 (22.4%) inguinal hernia repairs, 163 (23.6%) umbilical hernia repairs, and 192 (27.8%) traumatic lacerations. Of the 500 surgical incisions, sutures with tissue adhesives were the most frequently used (n = 211, 42.2%), followed by sutures with adhesive strips (n = 176, 35.2%), and sutures only (n = 72, 14.4%). Most traumatic lacerations were repaired with sutures only (n = 127, 64.5%). The overall wound-related complication rate was 3.0% and resumption of normal activities was recommended at a median of 14 d (interquartile ranges 14-14). The LHS represents an efficient tool to identify cohorts of pediatric surgical patients to perform comparative effectiveness research using real-world data to support medical and surgical products/devices in children. [ABSTRACT FROM AUTHOR]