#acute appendicitis

#shorts #mcqs #appendicitis “Acute Appendicitis: Questions and Answers” #acuteappendicitis #appendicitis #symptoms #causes #treatment “Everything You Need to Know About Acute Appendicitis” #acuteappendicitis #appendicitis #symptoms #causes #treatment #prevention “Acute Appendicitis: Frequently Asked Questions” #acuteappendicitis #appendicitis #faqs #symptoms #causes #treatment “Can You Really Die…

Abstract

Introduction: It is important to note the risk COVID-19 poses to the demographic of recovering postoperative patients and ascertain identifiable factors which may reflect on their prognosis.

Aim: To explore the 30-day postoperative outcomes among COVID-19 positive patients operated for acute appendicitis (AA) in Dubai Hospital while surveying their relation to age, gender, modality of management, type of operative technique, presence of pre-existing conditions, smoking habits, preoperative vital signs and laboratory results, and other variables. In addition, we aim to assess the relation of length of hospital stay with the aforementioned variables.

Methods: Our study is a retrospective electronic medical record (EMR) review of 68 patients admitted to the general surgery department of Dubai Hospital and who underwent conservative or surgical management of acute appendicitis between March 1 and December 31, 2020. Analysis was performed with a 30-day follow up. The data was retrieved from electronic medical records (EMR) via the SALAMA (EPIC) system and then recorded using a Microsoft Excel spreadsheet.

Results: Our results showed that, out of the 68 patients included in the study, 6 (9%) patients were found to be COVID-19 positive. 7 patients (10%) were managed conservatively, 1 of which was COVID-19 positive, while the remaining 61 (90%) patients underwent operative management. Only 1 (1.5%) patient (COVID-19 negative) developed complications requiring ventilation and ICU (intensive care unit) admission. Length of hospital stay (LOS) for COVID-19 positive patients was 6.5 days ±4.57 while LOS for COVID-19 negative patients was shorter at 3.8 days ±2.14.

Discussion/Conclusion: Our data revealed no significant complications in COVID-19 positive patients who were diagnosed with AA regardless of the method of treatment adopted. However, LOS was prolonged for these patients in comparison to the COVID-19 negative group. Therefore, we recommend that the choice of treatment be made on a case-by-case basis.

Keywords: perioperative COVID-19, COVID-19, acute appendicitis, appendectomy

Introduction

COVID-19, or Coronavirus disease 2019, caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), was declared a global pandemic by the WHO on March 11, 2020 [1]. Since then, the virus has spread across the globe, causing significant financial and economic burden. This has been in part due to the creation of qualified and specialized medical teams, COVID-19 units, increase in ICU beds, enhancement of medical supply chains, increased requirements for personal protective equipment, creation of field hospitals, production and use of PCR swab tests, and rising health insurance costs. With nearly 90 per cent of the global economy being affected during lockdown [2], any means of alleviating the financial burden of healthcare during the pandemic are of paramount importance.

In order to cope with the increased medical demand in the initial phase of the COVID-19 pandemic, many hospitals and medical centers elected to suspend non-emergent and elective surgeries to reduce the transmission of COVID-19 between infected individuals, patients, and staff  [3]. During this time, only emergent surgeries were performed. The most common surgical emergency, acute appendicitis, serves as an excellent target for assessing differences in surgical outcomes between SARS-CoV-2 negative and positive patients. Additionally, numerous factors may affect perioperative morbidity and mortality rates among this group of patients, such as changes in clinical presentation and severity [4], conversion of laparoscopic to an open surgical approach due to poor early guidelines [5] and fear of aerosolization of blood borne viruses [6], and delay in initiation of surgical management in favor of non-operative management (NOM) [7].

Surgical patients are especially vulnerable to SARS-CoV-2 infection as the derangements of metabolic and physiological processes linked to surgically-induced stress response can lead to deviations in acute phase inflammatory responses. Hypermetabolism and hypercatabolism associated with this stress response can lead to impaired immune function through elevations of catecholamines, cortisol, and inflammatory cytokines. In addition, this group of patients is at a higher risk of pulmonary complications due to immunosuppressive responses to mechanical ventilation [8]. It is imperative that measures are taken to identify predictors of perioperative morbidity and mortality in COVID-19 positive patients, in order to reduce patient suffering, mortality rates, and the national financial and medical burden.

Materials and Methods

This study is a retrospective chart review of the electronic medical records of 68 patients diagnosed with acute appendicitis (AA) and admitted to the general surgery department of Dubai Hospital, UAE, for conservative or surgical management of acute appendicitis between March 1 and December 31, 2020. Conservative treatment was defined as treatment with antibiotics and supportive management alone. Ethical approval was obtained from the Dubai Scientific Research Ethics Committee (DSREC). Patients admitted within this time period without a nasopharyngeal RT-PCR swab for COVID-19 on admission were excluded from the study. All demographic, clinical, radiological, and laboratory data was retrieved from the SALAMA electronic file system.

Variables evaluated for each patient include: age, sex, COVID-19 status, modality of management (conservative or operative), incidence of complications, type of surgical technique if managed operatively (open or laparoscopic appendicectomy), past medical and drug history, presence of pre-existing comorbidities, smoking status, preoperative vital signs (temperature, heart rate, respiratory rate, and blood pressure), radiological findings on chest x-ray if COVID-19 positive, preoperative laboratory markers, and length of hospital stay. The data was entered into the data collection tool (Microsoft Excel spreadsheet), exported, and analyzed in SPSS Version 22 software using Fisher’s exact test. The analysis was carried out in accordance with the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines for observational studies.

Statistical Data and Analysis

This study is a retrospective chart review of the electronic medical records of 68 patients diagnosed with acute appendicitis (AA) and admitted to the general surgery department of Dubai Hospital, UAE, for conservative or surgical management of acute appendicitis between March 1 and December 31, 2020. Conservative treatment was defined as treatment with antibiotics and supportive management alone. Ethical approval was obtained from the Dubai Scientific Research Ethics Committee (DSREC). Patients admitted within this time period without a nasopharyngeal RT-PCR swab for COVID-19 on admission were excluded from the study. All demographic, clinical, radiological, and laboratory data was retrieved from the SALAMA electronic file system.

Variables evaluated for each patient include: age, sex, COVID-19 status, modality of management (conservative or operative), incidence of complications, type of surgical technique if managed operatively (open or laparoscopic appendicectomy), past medical and drug history, presence of pre-existing comorbidities, smoking status, preoperative vital signs (temperature, heart rate, respiratory rate, and blood pressure), radiological findings on chest x-ray if COVID-19 positive, preoperative laboratory markers, and length of hospital stay. The data was entered into the data collection tool (Microsoft Excel spreadsheet), exported, and analyzed in SPSS Version 22 software using Fisher’s exact test. The analysis was carried out in accordance with the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines for observational studies.

Results

84 patients were diagnosed with acute appendicitis between March 1 and December 31, 2020. Most patients were diagnosed clinically. Out of this group, 16 patients were excluded due to lack of nasopharyngeal RT-PCR COVID-19 swab on admission. The remaining 68 patients were entered in the study. 20 (30%) patients were female and 48 (70%) patients were male. 6 (9%) patients were found to be COVID-19 positive. Analysis of the demographic characteristics revealed no significant difference in the age or sex between both groups (conservative or operative). 7 (10%) patients were managed conservatively with antibiotics alone, 1 of them was COVID-19 positive. 61 (90%) patients underwent operative management, of which 8 (13%) patients had an open appendicectomy - 3 (4.4%) of them were COVID-19 positive - and 53 (87%) patients had a laparoscopic appendicectomy.

Figure 1: Flow chart for recruitment of patients in retrospective chart review.

Figure 2: Percentage of patients treated conservatively (blue), or operatively with open appendicectomy (orange), and with laparoscopic appendicectomy (grey) on a monthly basis during the study period.

Table 1: Comparison of patient characteristics by treatment group. Continuous data is presented as a mean with standard deviation. Categorical data are presented as numbers/denominators.

7 (10%) patients were found to have pre-existing comorbidities, none of which were respiratory in nature. 10 (15%) patients were found to be current smokers. Only 1 (1.5%) patient, COVID-19 negative, developed complications requiring ventilation and ICU (intensive care unit) admission. There were no mortalities among this patient group.

Preoperative vital signs were analyzed for all patients. 17 (25%) patients were febrile on pre-operative assessment, of which 2 were COVID-19 positive. 9 (13%) patients were tachycardic, of which 1 was COVID-19 positive. 6 (9%) patients had an elevated blood pressure. 1 (1.5%) patient was tachypneic. C-Reactive Protein (CRP) was elevated in 48 (71%) patients, of which 5 were COVID-19 positive. White blood cell count was elevated in 51 (75%) patients, of which 5 were COVID-19 positive. Neutrophil value was elevated in 54 (79%) patients, of which 5 were COVID-19 positive. Laboratory reference ranges are shown in Table 2. Among those testing COVID-19 positive, 6 (100%) patients had positive radiological findings on chest x-ray, 3 (50%) had elevated ferritin levels, 2 (33.3%) had elevated d-dimer levels, and 1 (16.67%) had elevated lactate dehydrogenase (LDH). Laboratory reference ranges are shown in Table 2.

Table 2: Laboratory markers reference ranges and units.

There was no significant difference in the length of hospital stay (LOS) between the conservatively and operatively managed groups; the LOS in conservatively managed patients was 4.43 days ±5.29. The LOS in operatively managed patients was 4.00 days ±2.16. However, LOS for COVID-19 positive patients was 6.5 days ±4.57 while LOS for COVID-19 negative patients was shorter at 3.8 days ±2.14. Furthermore, the mean hospital stay for those who swabbed positive and underwent open laparotomy was 5.3±2.05 in comparison to a mean of 4±2.68 in those who were negative. As for laparoscopic appendicectomy, there was less difference in the LOS, with the LOS for COVID-19 positive patients at 3.5±0.5 in contrast to 3.94±2.09 for negative patients.

Discussion

Appendicitis is defined as an inflammation of the vermiform appendix which results from an obstruction of the appendix lumen either mechanically or through fecalith impaction resulting in bacterial overgrowth. It is one of the most common surgical emergencies with a global incidence rate of 1%. [9] The classical presentation of the disease manifests as periumbilical abdominal pain that migrates to the right lower quadrant, in association with anorexia, nausea, vomiting, and fever. Appendicitis is most often diagnosed clinically, however, a diagnostic computed tomography (CT) scan of the abdomen carries a sensitivity of 98.5% [10]. Management is typically surgical, either through laparoscopy, or through open laparotomy reserved for complicated cases. Furthermore, conservative management through antibiotics and supportive measures can also be adopted. Complications may include appendicular abscess, perforation, and peritonitis. Following the emergence of SARS-CoV-2, the declaration of the COVID-19 pandemic had an immense impact on healthcare systems worldwide. Surgical procedures were affected through major delays or cancellations as hospitals sought to decrease surgical caseload and capacity pressures as a result of the pandemic. Non-emergent or elective surgeries were similarly cancelled in our facilities due to the emergence of COVID-19 cases. However, appendicitis was managed in a very compelling way. Diagnosis was reliant on CT scans rather than clinical diagnosis and scans were performed for every patient regardless of their age group, in an effort to treat the case appropriately.

A conservative approach using antibiotics was instilled in our facility whenever possible in treating uncomplicated cases of acute appendicitis in accordance with national guidelines [11]. On the other hand, complicated cases, along with those patients who did not respond to conservative management, were treated operatively with appendicectomy. Patients managed conservatively were given empiric broad-spectrum antibiotics (metronidazole and ceftriaxone) for a duration of 10 days.  86% of patients in this group were COVID-19 negative; with 50% of them being hemodynamically unstable, according to the normal ranges of vital signs established by the American College of Emergency Physicians (ACEP) guidelines. The mean LOS was 2.5± 1.38. The remaining 14% of patients were COVID-19 positive, hemodynamically stable, with normal laboratory parameters and a mean LOS of 16 days due to the isolation period of 14 days being included in the calculation. Furthermore, both groups had abnormal inflammatory marker values and neither group had long lasting complications. These findings are consistent with existing published articles stating that conservative management is an effective means of treating appendicitis in patients that are COVID-19 positive [12-14].

50% of the population who tested positive underwent open laparotomy in comparison to only 9% of those who did not. This notable difference could be attributed to early guidelines set in place during the start of the pandemic, as many sources encouraged surgeons to minimize laparoscopic procedures for COVID-19 positive patients in fear of viral transmission through aerosolization. However, as ongoing research is being conducted regarding the matter, many recent publications have since revealed that there is no strong evidence of increased risk [15-17]. Our data revealed only one COVID-19 negative patient who developed postoperative complications out of all the patients included in this study who were surgically managed for AA, regardless of COVID status. The patient, a 71 years old male known to have diabetes mellitus and hypertension treated with regular medication, developed pulmonary complications requiring ventilation and ICU admission which increased his length of hospital stay to 12 days. This comes in contrast to the expected outcomes of increased postoperative complications in COVID-19 positive patients who underwent emergency surgery according to a report [18]. However, it is worth noting that most of our patients are young and had no previous comorbidities, therefore, decreasing their chance of developing postoperative morbidity or mortality.

Keeping in mind that open appendicectomy can increase the length of hospital stay, thus placing COVID-19 negative patients at an increased risk of developing the infection during hospitalization, we recommend that the length of hospital stay be reduced to the minimum to decrease this risk. In addition, as our results show no difference in outcome between conservative and surgical management, we also recommend that the choice of treatment be made on a case-by-case basis and evaluation of the risk-to-benefit ratio for each individual, as well as taking into consideration the performing surgeon's expertise and comfort. As is now standard in many hospitals, incorporating pre-operative swabbing as part of routine procedures allows the physician to plan accordingly. Furthermore, we highly recommend for surgeons to adamantly follow protective measures to reduce the risk of contracting the virus as much as possible; this includes proper handwashing and hygiene as well as the proper use of personal protective equipment (PPE). Limitations in our research included lack of postoperative follow up and inadequate information about the patients’ past medical and social history.

Conclusion

Our retrospective chart review of patients diagnosed with and treated for acute appendicitis between March 1 and December 31, 2020 in Dubai Hospital included a total of 68 patients. Cases of acute uncomplicated appendicitis were managed conservatively, while complicated cases or those who failed to respond to medical management were operated. In summary, our data revealed no significant postoperative complications in COVID-19 positive patients undergoing appendectomy regardless of the method of treatment adopted (open vs. laparoscopic). However, the LOS was prolonged for these patients in comparison to the COVID-19 negative group. Therefore, COVID-19 infection should not be used as a singular variable when deciding the modality of treatment, but rather each case should be considered independently to assess existing risk factors, deliver the best management plan, and avoid complications.

Appendicitis should never be ignored: requires emergency surgery

Appendicitis happens if your appendix becomes irritated or infected; it is commonly called acute appendicitis. The appendix is a small tube-shaped organ affixed to cecum, a part of the large intestinal tract on the right lower abdomen. Nobody understands what the appendix’s function is– but we do recognize that appendicitis is a serious condition. A surgeon is required to diagnose and treat…

Introduction: Acute appendicitis is the inflammation of the vermiform appendix and it is the most common intra-abdominal surgical emergency. Therefore, perforated appendicitis is rarely accompanied by pneumoperitoneum and that apparent rarity of association of pneumoperitoneum and acute appendicitis prompted us to discuss this condition.

Materials and Methods: This retrospective study reviewed all cases of acute abdomen with pneumoperitoneum admitted in King Abdulaziz University Hospital from January 2011 to December 2015. Only cases with acute appendicitis were selected to be in the study, Leucocytic count and C-reactive protein, as well as plain X-ray abdomen in erect position and C.T.scan were reviewed preoperatively.

All demographic data (age, gender), as well as the clinical details which included relevant  investigations results, in addition to the perioperative data (the type of the performed operative procedure, operative time and the hospital stay with reference to the postoperative complications for each patient), all were collected and analyzed by IBM-SPSS version 22.

Results: Pneumoperitoneum due to perforated appendix was found in 7 out of 131 cases in this study (5.3%), with male predominance 6/7, with a mean age of 29.7 years. The documented postoperative complications were pulmonary complications; intra-abdominal pus collection (pelvic and subphrenic) as well as wound dehiscence, all were found post conventional exploratory laparotomy cases.

Conclusion: The study documented the rarity of pneumoperitoneum due to perforated appendix. Therefore, it should be considered as a cause of acute abdomen with pneumoperitoneum, imaging studies were very essential to visualize these cases, Laparoscopic approach provided better outcome than the conventional laparotomy approach.

Author(s) Details

Dr. Ahmed Makki Department of Surgery, King Abdulaziz University, Saudi Arabia.

Read full article: http://bp.bookpi.org/index.php/bpi/catalog/view/71/848/662-1

Management of Complicated Appendicitis: Open or Laparoscopic Surgery?

Patients with acute appendicitis can present at different stages of the disease process, ranging from mild mucosal inflammation to frank perforation with abscess formation. The reported overall incidence of acute appendicitis varies with age, gender, and geographical differences. Interestingly, while the incidence of…