Appendicitis is the most common condition necessitating emergency abdominal surgery. While most cases are localized, 20% become complicated, resulting in perforation. The management of non-complicated appendicitis varies across medical centers, encompassing both surgical and non-surgical options, whereas complicated appendicitis is predominantly managed surgically. Differentiating them is clinically challenging, especially in pediatric patients, crucial for guiding appropriate treatment strategies. Therefore, there is an unmet need for biomarkers to distinguish the two entities. Here we examined the utility of epigenetic liquid biopsies in appendicitis. We used DNA methylation markers specific to immune and gastrointestinal epithelial cells to assess the tissue origins of plasma cell-free DNA (cfDNA) in appendicitis patients. Appendix epithelium cfDNA was undetected in plasma samples from children with appendicitis relative to control groups. In contrast, neutrophil and regulatory T-cell cfDNA were elevated in appendicitis enhancing the specificity and sensitivity of appendicitis diagnosis beyond the information provided by neutrophil counts. Notably, eosinophil cfDNA was most significantly elevated in children with perforated compared with non-perforated appendicitis. This finding was cross-validated using a machine-learning approach. In conclusion, eosinophil cfDNA levels are elevated in children with a perforated appendix and may have potential as a non-invasive aid in diagnosing perforated appendicitis in the future.

Acute appendicitis is a common surgical emergency in children. Prior radiology studies have described Puylaert staging on ultrasound to determine the severity of appendicitis. We investigated the feasibility and utility of assessing Puylaert staging on emergency department (ED) point-of-care ultrasound (POCUS) to differentiate uncomplicated from complicated appendicitis in children.

This was a pilot feasibility study of children ages 5-17 diagnosed with acute appendicitis in nine pediatric EDs. POCUS was performed by trained ED physicians. Puylaert staging of the submucosal layer was used to categorize the severity of appendicitis (stages 1-4) and was compared with surgical pathology reports. Test characteristics were computed to evaluate the accuracy of POCUS in differentiating appendicitis severity. Physicians recorded time to complete POCUS, ease of use, and their perception of acceptability by patients and families.

Of 72 patients with complete data, all patients with uncomplicated appendicitis were accurately identified using POCUS (Puylaert stage 1 or 2). The sensitivity for identifying complicated appendicitis (Puylaert Stage 3 or 4) was 100% (95% CI: 77%-100%), and specificity was 65% (95% CI: 52%-78%). Ninety four percent of physicians agreed that the POCUS was easy to perform. One hundred percent agreed that it was well accepted by families. The average time to complete POCUS was 8 min.

This study supports the feasibility and utility of assessing Puylaert staging by POCUS for children with appendicitis in the ED. High sensitivity to rule out complicated cases coupled with ease of use and perceived patient acceptance make this a potential adjunct to aid in the management of pediatric appendicitis.

Randomised controlled trials (RCTs) have found antibiotics to be a feasible and safe alternative to appendicectomy in adults with imaging-confirmed acute appendicitis. However, patient inclusion criteria and outcome definitions vary greatly between RCTs. We aimed to compare antibiotics with appendicectomy for the treatment of acute appendicitis using individual patient data and uniform outcome definitions.

In this individual patient data meta-analysis, we searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials without language restrictions between database inception and June 6, 2023, for RCTs comparing appendicectomy with antibiotics for the treatment of adults (≥18 years) with imaging-confirmed acute appendicitis. Studies without 1-year follow-up data on complications were excluded, as were patients. Corresponding authors of eligible studies were contacted and invited to share data; individual patient data were merged after validation. One-stage meta-analyses were conducted using a generalised, mixed-effects linear regression model, accounting for clustering of patients within studies. The primary outcome was the complication rate at 1-year follow-up, uniformly harmonised across trials using the Clavien-Dindo classification. Complications were further divided into minor (grade 1-2 or equivalent) and major (grade 3-5 or equivalent) complications. Appendicectomy rate during 1 year was a key secondary outcome but not considered a complication for the antibiotics group. Outcomes were described separately for patients with and without an appendicolith. This study is registered with PROSPERO, CRD42023391676.

Of 887 potentially relevant articles, eight were eligible for inclusion, of which six RCTs could provide data for 2101 eligible patients (1050 assigned to antibiotics and 1051 assigned to appendicectomy; 830 [39·5%] women and 1271 [60·5%] men). All studies raised some bias concerns due to absence of blinding. One study was judged to have a high risk of bias due to the exclusion of eligible patients after randomisation, but these patients were eligible for inclusion in our meta-analysis. At 1 year, 57 (5·4%) of 1050 patients randomly assigned to antibiotics had a complication compared with 87 (8·3%) of 1051 patients randomly assigned to appendicectomy (odds ratio [OR] 0·49 [95% CI 0·20 to 1·20]; risk difference -4·5 percentage points [95% CI -11·6 to 2·6]). At 1 year, 1025 (97·5%) patients in the appendicectomy group had undergone appendicectomy compared with 356 (33·9%) patients in the antibiotics group. In patients with an appendicolith at pre-interventional imaging, there were more complications at 1 year among patients who received antibiotic treatment than among those who underwent appendicectomy (29 [15·0%] of 193 patients vs 12 [6·3%] of 190 patients; OR 2·82 [95% CI 1·11 to 7·18]; risk difference 13·2 percentage points [95% CI 2·3 to 24·2]). In the antibiotics group, 94 (48·7%) of 193 patients with an appendicolith underwent appendicectomy within 1 year versus 262 (30·6%) of 857 patients without an appendicolith.

This meta-analysis showed that antibiotic treatment in adults with imaging-confirmed acute appendicitis was a safe alternative to surgery and resulted in around two-thirds of patients avoiding appendicectomy during the first year. In patients with an appendicolith, initial antibiotic treatment increased the risk of complications compared with appendicectomy, and around half of these patients assigned to antibiotics underwent step-up appendicectomy within 1 year. These data should be key components in shared decision making.

None.

To determine whether superb microvascular imaging (SMI) provides a more precise delineation between reversible and irreversible stages of uncomplicated acute appendicitis managed non-operatively.

This prospective clinical study examined pediatric patients with acute appendicitis initially treated non-operatively and evaluated using power Doppler (PD) and SMI. We determined case severity, monitor appendiceal blood flow (BF), and appendicitis reversibility. Complicated cases were excluded. Severity was classified using B-mode as well as PD, or SMI: Grade I, smooth wall/normal BF; Grade IIa, irregular wall/increased BF; Grade IIb, irregular wall/decreased BF; and Grade III, absence of wall/loss of BF.

This study examined a total of 100 patients with acute appendicitis, after excluding 29 patients. All 10 patients with normal BF on PD (Grade I) showed similar BF on SMI (Grade I). Among 29 patients with increased BF on PD (Grade IIa), corresponding increased BF was noted on SMI (Grade IIa), and all these patients showed full recovery. Of the 55 patients showing decreased BF on PD (Grade IIb), 52 showed increased BF on SMI (Grade IIa). The remaining three patients, identified with an impacted appendicolith, showed decreased BF on SMI (Grade IIb) and experienced treatment failure, subsequently developing abscesses. In all six patients with undetectable BF on PD (Grade III), SMI similarly could not detect appendiceal BF (Grade III), and non-operative management failed for these patients.

SMI offers an objective and effective means of delineating the threshold between reversible and irreversible stages in uncomplicated acute appendicitis following non-operative management.

Background/Objectives: Acute appendicitis (AA) is one of the most common causes of emergency department visits due to acute abdominal pain, with a lifetime risk of 7-8%. Managing AA presents significant challenges, particularly among vulnerable patient groups, due to its association with substantial morbidity and mortality. Methods: The EUPEMEN (European PErioperative MEdical Networking) project aims to optimize perioperative care for AA by developing multidisciplinary guidelines that integrate theoretical knowledge and clinical expertise from five European countries. This study presents the key elements of the EUPEMEN protocol, which focuses on reducing surgical stress, optimizing perioperative care, and enhancing postoperative recovery. Results: Through this standardized approach, the protocol aims to lower postoperative morbidity and mortality, shorten hospital stays, and improve overall patient outcomes. The recommendations are tailored to address the variability in clinical practice across Europe and are designed to be widely implementable in diverse healthcare settings. Conclusions: The conclusions drawn from this study highlight the potential for the EUPEMEN protocol to significantly improve perioperative care standards for AA, demonstrating its value as a practical, adaptable tool for clinicians.

Appendectomy and cholecystectomy are the surgical procedures to treat appendicitis and cholecystitis, respectively. However, there is a lack of investigation regarding these two similar types of abdominal complication-based disease which may primarily create confusion within patients.

To understand the variation and similarities within the preoperative symptoms of these two diseases, we included 224 participants including both appendicitis (n = 175) and cholecystitis (n = 49) patients. We obtained the preoperative symptoms through physical check-ups, thorough observation, and questionnaires.

We found several symptoms in both patients where abdominal pain was present in all patients in both groups. However, followed by abdominal pain, vomiting (118 (67.42%)), pain RIF (right iliac fossa) (101 (57.71%)), nausea (71 (40.57%)), and sharp pain (22 (12.57%)) were prevalent in the appendicitis group whereas tenderness (49 (100%)), epigastric pain (13 (26.53%)), and hypertension (10 (20.41%)) were prevalent in the cholecystitis group. However, fever was commonly present in several patients in both groups.  Conclusion: Abdominal pain can be a major indicator of surgery in both appendicitis and cholecystitis patients. However, observation of other symptoms is crucial for initial symptomatic diagnosis and differentiating between these diseases.

Acute appendicitis (AA) stands as the most prevalent cause of acute abdominal pain among children. The potential for morbidity escalates significantly when uncomplicated appendicitis (UA) progresses to complicated appendicitis (CA), which can encompass gangrenous, necrotic, or perforated appendicitis. Consequently, establishing an early and accurate diagnosis of AA, and effectively differentiating CA from UA, becomes paramount. This study explores the diagnostic utility of various blood biomarkers for distinguishing CA from UA in pediatric patients.

We conducted a retrospective review of medical records pertaining to pediatric patients who underwent surgery for AA. Patients were categorized as either having UA or CA based on histopathological examination of the appendix. The data collected and analyzed included demographic information, white blood cell (WBC) count, neutrophil proportion, lymphocyte proportion, neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP) levels upon admission.

Among the 192 pediatric patients who underwent surgery for AA, 150 were diagnosed with UA, while 42 were diagnosed with CA. The CA group exhibited significantly higher neutrophil proportions, NLRs, PLRs, and CRP levels, alongside lower lymphocyte proportions (all p < 0.01) compared to the UA group. Receiver operating characteristic (ROC) curve analysis disclosed that CRP exhibited the highest specificity, sensitivity, and positive and negative predictive values for predicting CA.

CRP emerges as a valuable biomarker for differentiating complicated appendicitis from uncomplicated appendicitis.

Appendicitis is the commonest paediatric surgical emergency. Adult studies suggest non-operative management (NOM) may have a place in care. There have been no adequately powered randomized controlled trials in children.

to determine the safety and efficacy of NOM for paediatric simple appendicitis.

A non-inferiority randomized controlled trial was conducted comparing operative (OM) to NOM of SA in children aged five-15 years. Primary outcome was treatment success (no unplanned or unnecessary operation, or complication) at 30 days and 12 months, with a non-inferiority margin of 15%. (anzctr.org.au: ACTRN12616000788471).

From 11 June 2016 to 30 November 2020, 222 children were randomized: 94 (42.34%) to OM and 128 (57.66%) to NOM. Non-inferiority of NOM was not demonstrated at either time point, with 45.67% of NOM patients subsequently undergoing operation. There was no significant difference in complications.

While noninferiority was not shown, NOM was safe, with no difference in adverse outcomes between the two groups. Further research to refine the place of NOM of simple appendicitis in children is required, including nuanced patient selection, longer term evaluation, the place of choice, and the acceptability of the treatment for children and their carers.

Conservative treatment of acute appendicitis is gaining popularity, and identifying patients with a higher risk of recurrence is becoming increasingly important. Previous studies have suggested that older age, male sex, diabetes, appendicolith and abscess formation may be contributing factors, however, results from the adult population are inconsistent.

This study aims to identify predictive factors for recurrent appendicitis after conservative treatment.

This retrospective study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and follow-up data were retrieved from medical charts and radiologic images. Uni -and multivariable logistic regression analysis were performed using Stata Statistical Software.

In total, 379 patients with conservatively treated acute appendicitis were identified, of which 78 (20.6%) had recurrence. All patients were followed-up for a minimum of 41 months after the first diagnosis of acute appendicitis unless appendectomy after successful conservative treatment or death occurred during follow-up. The median time to recurrence was 6.5 (1-17.8) months. After multivariable logistic regression analysis, external appendix diameter >10 mm [OR 2.4 (CI 1.37-4.21), p = .002] and intra-abdominal abscess [OR 2.05 (CI 1.18-3.56), p = .011] on computed tomography were significant independent risk factors for recurrent appendicitis. Appendicolith was not associated with an increased risk of recurrence.

This study suggests abscess formation and appendix distension of >10 mm to be potential risk factors for recurrent acute appendicitis after initial successful conservative treatment.

Background/Objectives: In patients diagnosed with uncomplicated acute appendicitis (UAA), the absence of calcified deposits or stones, called appendicoliths, often leads to consideration of non-operative treatment (NOT), despite the notable treatment failure rate associated with this approach. Previous research has indirectly estimated the prevalence of appendicoliths to range between 15% and 38% retrospectively by CT scan, intraoperative palpation, and pathology report, thereby potentially missing certain concrements. Our hypothesis proposes that this reported prevalence significantly underestimates the occurrence of appendicoliths, which could explain the high failure rate of 29% of patients with appendicitis observed with NOT. Methods: In our prospective study, conducted with a cohort of 56 adult patients diagnosed with acute appendicitis (AA), we employed intraoperative extracorporeal incisions of the vermiform appendix, in addition to standard diagnostic methods. Results: Our findings revealed 50% more appendicoliths by intraoperative incision (n = 36, p < 0.001) compared to preoperative imaging (n = 24). Appendicoliths were present in 71.4% (n = 40, p < 0.001) of AA patients. Conclusions: These results suggest that conventional diagnostic procedures plausibly underestimate the actual prevalence of appendicoliths, potentially elucidating the frequent treatment failures observed in NOT approaches applied to patients with UAA.

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.

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.

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.

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.

Appendicitis is a common surgical condition that requires urgent medical attention. Recent advancements in artificial intelligence and large language processing, such as ChatGPT, have demonstrated potential in supporting healthcare management and scientific research. This study aims to evaluate the accuracy and comprehensiveness of ChatGPT's knowledge on appendicitis management.

Six questions related to appendicitis management were created by experienced RACS qualified general surgeons to assess ChatGPT's ability to provide accurate information. The criteria of ChatGPT answers' accuracy were compared with current healthcare guidelines for appendicitis and subjective evaluation by two RACS qualified General Surgeons. Additionally, ChatGPT was then asked to provide five high level evidence references to support its responses.

ChatGPT provided clinically relevant information on appendicitis management, however, was inconsistent in doing so and often provided superficial information. Further to this, ChatGPT encountered difficulties in generating relevant references, with some being either non-existent or incorrect.

ChatGPT has the potential to provide timely and comprehensible medical information on appendicitis management to laypersons. However, its issue of inaccuracy in information and production of non-existent or erroneous references presents a challenge for researchers and clinicians who may inadvertently employ such information in their research or healthcare. Therefore, clinicians should exercise caution when using ChatGPT for these purposes.

Recent studies have discussed the role of antibiotic treatment in the conservative management of acute appendicitis and whether antibiotics are a safe option to replace appendicectomy, which has been the gold standard treatment of acute appendicitis for many years. The bibliographic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, Medline, and PubMed comparing conservative versus surgical treatment of acute appendicitis were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty-one studies consisting of systematic reviews and meta-analyses involving 44,699 participants were identified. At least 17,865 participants were treated with antibiotics. Our studies compare antibiotic versus appendicectomy among acute appendicitis patients ranging from 7 to 94 years of age. In most studies, patients received parenteral antibiotics for a total of one to three days, and oral antibiotics such as oral cephalosporin plus metronidazole, oral amoxicillin/clavulanate, oral fluoroquinolones plus Tinidazole upon hospital discharge for a total of 7 to 10 days. The total course of antibiotics for both parenteral and oral regimes ranged from 2 to 16 days, with 10 days being the commonest duration. The recurrence rate following initial antibiotic treatment at one-year follow-up ranged from 13% to 38%, while the mean duration of recurrence ranged from three to eight months. The majority of the patients with recurrence underwent appendicectomy, while some patients were either given a repeat or different course of antibiotics due to the possible presence of antibiotic resistance; however, only 2.4% of the patients were successfully treated upon completion of the second course of antibiotics. Most of the studies concluded that appendicectomy remains the gold standard treatment for uncomplicated acute appendicitis, given its higher efficacy and lower complication rates. Although antibiotic treatment cannot be routinely recommended, it can be considered an appropriate alternative in selected patients with uncomplicated appendicitis who wish to avoid surgery and also acknowledge the risk of recurrence and the potential need for subsequent surgery at the same time.

To assess the efficacy and safety of endoscopic retrograde appendicitis treatment (ERAT) for acute appendicitis (AA) by conducting a meta-analysis of clinical randomized trials (RCTs).

Eight electronic databases were searched. Study quality was assessed using the Cochrane risk of bias tool. RevMan5.3 and STATA14 software were used to for statistical analysis.

Twenty-six RCTs with 2236 subjects were analyzed. First, operative time, length of hospital stay and duration of bed rest were shorter in the ERAT groups than in the control groups, with the pooled MD and 95 % CI being -13.22(-20.09, -6.35)(p = 0.0002), -2.13 (-2.47, -1.80)(p < 0.00001) and -3.15 (-3.76, -2.53)(p < 0.00001), respectively. Second, patients in the ERAT groups had a lower incidence of complications than the control groups, with a pooled RR and 95 % CI of 0.25(0.18, 0.35)(p < 0.00001). Third, patients who received ERAT returned to normal temperature faster than the control groups, the pooled MD and 95 % CI was -3.39(-4.36, -2.42)(p<0.00001). Finally, the result showed that the recurrence rate in the ERAT groups was approximately twice that of control groups, with the pooled RR and 95 % CI being 2.10(1.02, 4.32)(p < 0.00001).

ERAT results in fewer complications and shorter recovery time. And compared to appendectomy, ERAT reduces operative time and intraoperative bleeding. However, the recurrence of acute appendicitis after ERAT remains a concern. And more multicenter and large-scale RCTs are needed to confirm the benefits of ERAT.

We have registered on the PROSPERO [https://www.crd.york.ac.uk/PROSPERO/], and the registration number is CRD42023420171.

The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children.

Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively.

2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04).

This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.

Appendicitis typically develops secondary to obstruction of appendiceal lumen and one of the causes of obstruction is appendicolith. Appendicolith has become a relevant issue due to heightened interest in the treatment of uncomplicated appendicitis with antibiotics. This study aimed to determine the prevalence of appendicolith in pediatric patients with appendicitis and to investigate the association between the presence of appendicoliths and radiological disease severity.

Patients under the age of 18 diagnosed with appendicitis between March 2021 and April 2022 and had available preoperative computed tomography (CT) images were identified retrospectively. The presence of an appendicolith and if present, its longest diameter in the axial plane, its visibility on direct radiographs, appendiceal diameter, degree of inflammation, and the presence of perforation were evaluated. Radiological severity of inflammation was rated on a 3-point scale.

CT scans were available in 77 (32.1%) of 240 patients with histopathologically confirmed diagnosis of acute appendicitis. 39% (n=30) of the patients were girls and the median age was 13 years. The prevalence of appendicoliths detected on CT scans was 32.5% (n=25) and the median size of appendicoliths was 6 mm. In only 1 patient, appendicolith was detected by direct radiography. The median appendiceal diameter was significantly greater in the group with appendicoliths (10 mm vs. 8 mm; p=0.001). A moderate correlation was found between appendicolith size and appendiceal diameter (r=0.407, p=0.043). Perforation was present in 10.4% (n=8) of the patients with appendicitis and 25% (n=2) of them had appendicoliths. The presence of appendicoliths was not significantly associated with the occurrence of perforation (p=0.485). Periappendiceal inflammation scores were 1.52±0.74 in the group with appendicoliths and 1.42±0.63 in the group without appendicoliths (p=0.591).

The prevalence of CT-detected appendicoliths was 32.5% in pediatric patients with appendicitis. Patients with appendicoliths showed higher inflammation scores and greater appendiceal diameter than those without appendicoliths. These factors may be associated with poor outcomes in patients with appendicoliths treated with antibiotics. Therefore, knowledge of the prevalence of appendicoliths and questioning their presence may guide clinicians when deciding on the suitability of nonoperative treatment in a patient diagnosed with uncomplicated acute appendicitis.

Prior to the development of laparoscopic procedures, open appendectomy was the standard of care for the majority of appendicitis cases. Recently, studies have debated using antibiotics as a first-line treatment in uncomplicated appendicitis cases. The definition of uncomplicated appendicitis is not always clear-cut; however, with the large-scale accessibility of radiologic techniques, it is becoming increasingly easier to classify patient groups. As suggested by clinical and radiological patient data, this has raised the speculation of considering antibiotic therapy as the sole treatment modality in uncomplicated appendicitis cases. We aim to compare the options of surgery and antibiotics only in terms of efficacy, complications, and financial cost. A range of databases and search strategies were adopted, and various databases were used, including PubMed, ScienceDirect, Google Scholar, and JAMA. Collectively, 30 studies were reviewed, but only 18 were included. Efficacy rates were higher in the appendectomy group. Nevertheless, the antibiotics-only group maintained an efficacy rate greater than 70% at one-year follow-up. Risk factors that decreased the efficacy in medical management included the presence of appendicolith, neoplasm, appendiceal dilatation, peri-appendiceal fluid collection, higher mean temperature, CRP, and bilirubin. Complications were more frequent and significant in the surgery group. These included complications related to anaesthesia, surgical site infections, damage to nearby structures, and pulmonary embolism. Despite several years of follow-up and disease recurrences, higher financial costs were observed in surgically treated patients compared to the antibiotics-only group. Given the high success rates post-appendectomy for acute appendicitis over the decades, the efficacy of conservatively treated acute appendicitis raises a strong argument when choosing one of the two options. The efficacy remained consistently higher across the literature in the surgery group than in the antibiotics-only group. However, it is still arguable that antibiotics may be a preferable option given an efficacy rate of more than 70% at one year and overall higher complications associated with surgery. The argument of missing a neoplasm by avoiding surgery is valid. However, most are carcinoid neuroendocrine neoplasms with a low probability of metastasis (<5%) and are usually considered benign. Given the current practice focused on conservative and minimally invasive treatments and recently the COVID-19 pandemic, with its restrictions and lessons learnt, antibiotics may be the future standard for treating uncomplicated acute appendicitis. Lastly, we noticed higher efficacy rates in articles published recently than those published at least five to ten years earlier. Antibiotics-only therapy for uncomplicated appendicitis is cost-effective with fewer complications than surgery. However, appendectomies have higher efficacy. Thus, surgical treatment prevails as the standard of care. Future literature should yield larger sample sizes and explore the numbers of emergency appendectomies mandated following antibiotics-only therapy.

The aim of this study was to investigate the ability of a new marker that could be easily obtained to differentiate between complicated and uncomplicated appendicitis in a patients with a white blood cell (WBC) count within the normal range.

The patients who underwent surgery with histopathologically proven acute appendicitis (AA) between January 2021 and October 2022 were evaluated retrospectively. Patients were classified into two groups as uncomplicated and complicated appendicitis, based on the surgical and histopathological findings. Groups were compared in terms of laboratory parameters at the time of hospital admission.

During the study period, 2589 patients underwent an appendectomy, among these 612 patients who had a WBC count within the normal range at the time of admission were analyzed. Uncomplicated appendicitis was detected in 79.6% of the patients and complicated appendicitis in 20.4%. Neutrophil%, neutrophil-to-lymphocyte ratio, C-reactive protein, and total bilirubin levels were significantly higher, whereas lymphocyte%, lymphocyte count, lymphocyte-to-monocyte ratio, sodium levels, and large unstained cells (LUC)% were significantly lower in patients with complicated appendicitis. Multiple logistic regression analysis revealed that lower LUC% (Odds Ratio [OR]: 0.45; 95% Confidence Intervals [CI]: 1.08-2.09; P=0.01) and higher total bilirubin levels (OR: 1.50; 95% CI: 1.08-2.09; P=0.01) were independent risk factors for complicated appendicitis.

In patients with a diagnosis of AA with a normal WBC value, LUC% obtained from the complete blood count can be used as a new parameter predicting the diagnosis of complicated appendicitis.

The objective of this study was to identify the predominant bacteria cultured from the surface of removed appendices in pediatric patients with acute appendicitis and determine the appropriate choice of antibiotics for preoperative and postoperative management.

A 2-year retrospective cohort study was conducted at Mediclinic Parkview Hospital, Dubai, UAE. Patients under 14 years of age with diagnosed acute appendicitis who underwent laparoscopic appendectomy were included. Swab cultures, along with demographic, laboratory, and pathology data, were analyzed.

Out of the 56 enrolled patients, 27 (48 %) exhibited bacterial growth on swab cultures, while 29 (52 %) showed no bacterial growth. Escherichia coli (E. coli) was the predominant isolated bacteria, present in 23/27 patients (85 %). Seven patients had co-infections involving E. coli and other bacteria, with Pseudomonas being the second most common bacteria identified in 7/27 patients (25 %). Antibiotic sensitivity testing indicated that 85 % of the isolated bacteria were sensitive to Gentamicin, 63 % to Amoxicillin/Clavulanic acid, 59 % to Trimethoprim + Sulfamethoxazole, and 27 % to Cefazolin.

E. coli was the most prevalent bacteria identified on swabs taken from inflamed appendices in pediatric patients. Amoxicillin/Clavulanic acid was determined to be an appropriate choice for preoperative prophylaxis. This study provides valuable insights for guiding the management of pediatric appendicitis and facilitating the appropriate and judicious use of antibiotics.

To develop a logistic regression model that combines clinical and radiological parameters for prediction of complicated appendicitis.

248 patients with histologically proven uncomplicated (n = 214) and complicated (n = 34) acute appendicitis were analyzed retrospectively. All patients had undergone a presurgical abdominal and/or pelvic computed tomography (CT) scan, assessed by two radiologists. A model using univariate and multivariate logistic regression analyses was developed, and the strength of association between independent predictors and complicated acute appendicitis was evaluated by adjusted odds radio. Clinical parameters were gender, age, anorexia, vomiting, duration of symptoms, right lower abdominal quadrant (RLQ) tenderness, rebound tenderness, body temperature, white blood cell (WBC) count, and neutrophil ratio. Radiological parameters were appendix diameter, appendicolith, caecal wall thickening, mesenteric lymphadenopathy, extraluminal air, abscess, fat stranding, and periappendicular fluid.

Four features (body temperature＞37.2 °C, vomiting, appendicolith, and periappendiceal fluid) were included in the logistic regression model, and yielded an area under the curve (AUC) of 0.87 (95% confidence interval (CI), 0.80-0.93), sensitive of 88%, and specificity of 74%.

The logistic regression model makes an accurate and simple prediction of complicated appendicitis possible.

This meta-analysis aimed to compare the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis.

We searched the randomized controlled studies (RCTs) comparing appendectomy with antibiotic treatment for uncomplicated acute appendicitis in the electronic database including Pubmed, Embase, Cochrane, Web of Science, CNKI, VIP, and WanFang. The primary outcomes included complication-free treatment success at 1 year, complications, surgical complications, and the complicated appendicitis rates. Secondary outcomes included negative appendicitis, length of hospital stay, the quality of life at 1 month, and the impact of an appendicolith on antibiotic therapy.

Twelve randomized controlled studies were included. Compared with surgery group, the antibiotic group decreased the complication-free treatment success at 1 year (RR 0.81; 95% CI 0.73-0.91; z = 3.65; p = 0.000). Statistically significance was existed between antibiotic group and surgical group with both surgical types(open and laparoscopic) (RR 0.43; 95% CI 0.31-0.58; z = 5.36; p = 0.000), while no between the antibiotic treatment and laparoscopic surgery (RR 0.72; 95% CI 0.41-1.24; z = 1.19; p = 0.236). There was no statistically significant differences between two groups of surgical complications (RR 1.38; 95% CI 0.70-2.73; z = 0.93; p = 0.353), the complicated appendicitis rate (RR 0.71; 95% CI 0.36-1.42; z = 0.96; p = 0.338), negative appendectomy rate (RR 1.11; 95% CI 0.69-1.79; z = 0.43; p = 0.670), duration of hospital stay (SMD 0.08; 95%CI -0.11-0.27; z = 0.80; p = 0.422), and quality of life at 1 month (SMD 0.09; 95%CI -0.03-0.20; z = 1.53; p = 0.127). However, in the antibiotic treatment group, appendicolith rates were statistically higher in those whose symptoms did not improve (RR 2.94; 95% CI 1.28-6.74; z = 2.55; p = 0.011).

Although the cure rate of antibiotics is lower than surgery, antibiotic treatment is still a reasonable option for patients with uncomplicated acute appendicitis who do not want surgery without having to worry about complications or complicating the original illness.

This study aims to determine the most accurate appendicitis scoring system and optimal cut-off points for each scoring system.

This single-centred prospective cohort study was conducted from January-to-June 2021, involving all patients admitted on suspicion of appendicitis. All patients were scored according to the Alvarado score, Appendicitis Inflammatory Response (AIR) score, Raja Isteri Pengiran Anak Saleha (RIPASA) score and Adult Appendicitis score (AAS). The final diagnosis for each patient was recorded. Sensitivity and specificity were calculated for each system. Receiver operating characteristic (ROC) curve was constructed for each scoring system, and the area under the curve (AUC) was calculated. Optimal cut-off scores were calculated using Youden's Index.

A total of 245 patients were recruited with 198 (80.8%) patients underwent surgery. RIPASA score had higher sensitivity and specificity than other scoring systems without being statistically significant (sensitivity 72.7%, specificity 62.3%, optimal score 8.5, AUC 0.724), followed by the AAS (sensitivity 60.2%, specificity 75.4%, optimal score 14, AUC 0.719), AIR score (sensitivity 76.7%, specificity 52.2%, optimal score 5, AUC 0.688) and Alvarado score (sensitivity 69.9%, specificity 62.3%, optimal score 5, AUC 0.681). Multiple logistic regression revealed anorexia (p-value 0.018), right iliac fossa tenderness (p-value 0.005) and guarding (p-value 0.047) as significant clinical factors independently associated with appendicitis.

Appendicitis scoring systems have shown moderate sensitivity and specificity in our population. The RIPASA scoring system has shown to be the most sensitive, specific and easy-to-use scoring system in the Malaysian population whereas the AAS is most accurate in excluding low-risk patients.

The treatment strategies for acute appendicitis differ depending on the facility, and various studies have investigated the usefulness of conservative treatment with antibiotics, laparoscopic surgery, and interval appendectomy (IA). However, although laparoscopic surgery is widely used, the clinical strategy for acute appendicitis, especially complicated cases, remains controversial. We assessed a laparoscopic surgery-based treatment strategy for all patients diagnosed with appendicitis, including those with complicated appendicitis (CA).

We retrospectively analysed patients with acute appendicitis treated in our institution between January 2013 and December 2021. Patients were classified into uncomplicated appendicitis (UA) and CA groups based on computed tomography (CT) findings on the first visit, and the treatment course was subsequently compared.

Of 305 participants, 218 were diagnosed with UA and 87 with CA, with surgery performed in 159 cases. Laparoscopic surgery was attempted in 153 cases and had a completion rate of 94.8% (145/153). All open laparotomy transition cases (n = 8) were emergency CA surgery cases. No significant differences were found in the incidence of postoperative complications in successful emergency laparoscopic surgeries. In univariate and multivariate analyses for the conversion to open laparotomy in CA, only the number of days from onset to surgery ≥ 6 days was an independent risk factor (odds ratio: 11.80; P < 0.01).

Laparoscopic surgery is preferred in all appendicitis cases, including CA. Since laparoscopic surgery is difficult for CA when several days from the onset have passed, it is necessary that surgeons make an early decision on whether to operate.

Complicated appendicitis (CA) is often indicated for emergency surgery; however, preoperative predictors of pathological CA (pCA) remain unclear. Furthermore, characteristics of CA that can be treated conservatively have not yet been established.

305 consecutive patients diagnosed with acute appendicitis were reviewed. The patients were divided into two groups: an emergency surgery and a conservative treatment group. The emergency surgery group was pathologically classified as having uncomplicated appendicitis (pUA) and pCA, and the preoperative predictors of pCA were retrospectively assessed. Based on the preoperative pCA predictors, a predictive nomogram whether conservative treatment would be successful or not was created. The predictors were applied to the conservative treatment group, and the outcomes were investigated.

In the multiple logistic regression analysis of the factors contributing to pCA, C-reactive protein ≥3.5 mg/dL, ascites, appendiceal wall defect, and periappendiceal fluid collection were independent risk factors. Over 90% of cases without any of the above four preoperative pCA predictors were pUA. The accuracy of the nomogram was 0.938.

Our preoperative predictors and nomogram are useful to aid in distinguishing pCA and pUA and to predict whether or not conservative treatment will be successful. Some CA can be treated with conservative treatment.

Appendicitis is a frequent condition, with peak incidences in the second decade of life. Its pathogenesis is under debate, but bacterial infections are crucial, and antibiotic treatment remains essential. Rare bacteria are accused of causing complications, and various calculated antibiotics are propagated, yet there is no comprehensive microbiological analysis of pediatric appendicitis. Here we review different pre-analytic pathways, identify rare and common bacterial pathogens and their antibiotic resistances, correlate clinical courses, and evaluate standard calculated antibiotics in a large pediatric cohort.

We reviewed 579 patient records and microbiological results of intraoperative swabs in standard Amies agar media or fluid samples after appendectomies for appendicitis between May 2011 and April 2019. Bacteria were cultured and identified via VITEK 2 or MALDI-TOF MS. Minimal inhibitory concentrations were reevaluated according to EUCAST 2022. Results were correlated to clinical courses.

Of 579 analyzed patients, in 372 patients we got 1330 bacterial growths with resistograms. 1259 times, bacteria could be identified to species level. 102 different bacteria could be cultivated. 49% of catarrhal and 52% of phlegmonous appendices resulted in bacterial growth. In gangrenous appendicitis, only 38% remained sterile, while this number reduced to 4% after perforation. Many fluid samples remained sterile even when unsterile swabs had been taken simultaneously. 40 common enteral genera were responsible for 76.5% of bacterial identifications in 96.8% of patients. However, 69 rare bacteria were found in 187 patients without specifically elevated risk for complications.

Amies agar gel swabs performed superior to fluid samples and should be a standard in appendectomies. Even catarrhal appendices were only sterile in 51%, which is interesting in view of a possible viral cause. According to our resistograms, the best in vitro antibiotic was imipenem with 88.4% susceptible strains, followed by piperacillin-tazobactam, cefuroxime with metronidazole, and ampicillin-sulbactam to which only 21.6% of bacteria were susceptible. Bacterial growths and higher resistances correlate to an elevated risk of complications. Rare bacteria are found in many patients, but there is no specific consequence regarding antibiotic susceptibility, clinical course, or complications. Prospective, comprehensive studies are needed to further elicit pediatric appendicitis microbiology and antibiotic treatment.

Nonoperative management (NOM) of uncomplicated appendicitis is a safe and effective treatment alternative to surgery that may be preferred by some families. Surgery and NOM differ significantly in their associated risks and benefits. Choosing a treatment for acute appendicitis requires patients and their caregivers to make timely, informed decisions that allow for incorporation of personal perspectives, values, and preferences. This article will address the concept of shared decision-making and establish its role in patient-centered care. It will demonstrate the effectiveness of shared decision-making in a high acuity surgical setting for children and highlight how the choice for management of acute appendicitis may be impacted by patients' and families' individualized circumstances and values.

Changes in clinical care for appendicitis have impacted healthcare use associated with treatment. We evaluated national trends and assessed factors associated with healthcare costs for appendicitis in the United States.

The Disease Expenditure Project, the Global Burden of Disease study, and the National Inpatient Sample were used to estimate total national expenditures, per-capita costs for incident cases, and factors associated with inpatient costs for appendicitis management, respectively. The national estimates of appendicitis costs were obtained from 1996 to 2016. Appendicitis incidence was estimated to calculate per-capita costs. After application of survey weights for the stratified sample design, 191,180 weighted discharges for appendicitis from the 2016 National Inpatient Sample study were evaluated. The Disease Expenditure Project and the Global Burden of Disease study were used to estimate total and per-capita spending. Temporal trends were evaluated using joinpoint regression, expressed as annual percent change. Multivariable linear regression was used to evaluate patient factors associated with total hospital charges.

In 2016, total spending on appendicitis was $9.3 billion (95% confidence interval: $8.0-$10.8], a 2-fold increase from $4.7 billion ($4.0-$5.3) in 1996. Per-capita spending decreased significantly after 2011 (annual percent change -3.7% [-4.4% to -2.9%]). Patients ≥65 years accounted for 64.1% (61.1%-67.3%) of total spending for appendicitis. The hospital charges for older patients were significantly higher among those undergoing appendectomy.

Overall healthcare spending for appendicitis has doubled from 1996 to 2016, but per capita spending has decreased since 2011, driven by improved efficiency of inpatient care. Nearly two-thirds of spending is on patients ≥65 years, with significantly higher costs associated with surgical management in this population.

The aim of the present study was to identify risk factors associated with postoperative morbidity and major morbidity, with a prolonged length of hospital stay and with the need of readmission in patients undergoing appendectomy due to acute appendicitis.

We performed a retrospective analysis of 1638 adult patients who underwent emergency appendectomy for preoperatively suspected acute appendicitis from 2010 to 2020 at the University Hospital Erlangen. Data including patient demographics, pre-, intra-, and postoperative findings were collected and compared between different outcome groups (morbidity, major morbidity, prolonged length of postoperative hospital stay (LOS) and readmission) from those patients with verified acute appendicitis (n = 1570).

Rate of negative appendectomies was 4%. In patients with verified acute appendicitis, morbidity, major morbidity and readmission occurred in 6%, 3% and 2%, respectively. Mean LOS was 3.9 days. Independent risk factors for morbidity were higher age, higher preoperative WBC-count and CRP, lower preoperative hemoglobin, longer time to surgery and longer duration of surgery. As independent risk factors for major morbidity could be identified higher age, higher preoperative CRP, lower preoperative hemoglobin and longer time to surgery. Eight parameters were independent risk factors for a prolonged LOS: higher age, higher preoperative WBC-count and CRP, lower preoperative hemoglobin, need for conversion, longer surgery duration, presence of intraoperative complicated appendicitis and of postoperative morbidity. Presence of malignancy and higher preoperative WBC-count were independent risk factors for readmission.

Among patients undergoing appendectomy for acute appendicitis, there are relevant risk factors predicting postoperative complications, prolonged hospital stays and readmission. Patients with the presence of the identified risk factors should receive special attention in the postoperative course and may benefit from a more individualized therapy.

PURPOSE Acute appendicitis is the most common cause of the acute abdomen requiring surgery. Although standard treatment has been surgery, it has been seen in recent years that treatment is possible with antibiotics and non-operative observation. In this study, our aim is to determine whether the CT findings in patients diagnosed with acute appendicitis can be used for directing treatment. METHODS A retrospective analysis was conducted on 138 patients with acute appendicitis who underwent CT between 2015 - 2019. In this study, medical treatment group (n = 60) versus surgical treatment group (n = 78) and successful antibiotic treatment group (n = 23) versus unsuccessful antibiotic treatment group (n = 14) were compared. Appendiceal wall thickness, appendiceal diameter, the severity of mural enhancement, intra-abdominal free fluid, the severity of periappendiceal fat stranding, size of pericecal lymph node, appendicolith, adjacent organ findings and the CT appendicitis score of groups were compared with Pearson Chi-square and Mann Whitney U tests. Multivariable logistic regression was used to identify predictors of surgical treatment, expressed as odds ratios (ORs) with 95% confidence intervals. Diagnostic efficacies of appendiceal diameter, the CT appendicitis score and developed model were quantified by ROC curves. RESULTS Appendiceal diameter (P < .001), adjacent organ findings (P = .041), the CT appendicitis score (P < .001), the severity of periappendiceal fat stranding (P = .002), appendicolith (P = .001) and intra-abdominal free fluid (P <0.001) showed statistically significant differences between the medical and surgical treatment groups. According to the logistic regression test, if the patients with appendiceal diameter ≥13mm (OR = 5.1, 95%CI 1.58 - 16.50), appendicolith (OR = 4, 95%CI 1.17 - 13.63) and intra-abdominal free fluid (OR = 3.04, 95%CI 1.28 - 7.20), surgeons should prefer surgical treatment. The AUCs for the CT appendicitis score, the appendiceal diameter and the model were 0.742 (95% CI 0,659 - 0,824), 0.699 (95% CI 0.613 - 0.786) and 0.745 (95% CI 0.671 - 0.819), respectively. As the successful and unsuccessful medical treatment groups were compared, the only significant parameter was the severity of mural enhancement (P = .005). CONCLUSION CT findings may be helpful in patients with uncomplicated acute appendicitis whose treatment surgeons are indecisive about. We can recommend surgical treatment in cases with appendix diameter ≥13mm, intraabdominal free fluid, appendicolith, high CT appendicitis score and severe mural enhancement.

Both the CODA trial and the 2020 WSES Jerusalem guidelines concluded that nonoperative management of appendicitis (NOMA) was non-inferior for uncomplicated appendicitis but appendicoliths increase risk for complications. Thus "Appendicoliths on CT" are a relative contraindication to NOMA but accuracy of CT in identifying appendicoliths is just assumed.

We conducted an EMR review of 1552 appendectomy patients, who had pre-operative CT scans for suspected acute appendicitis from 2001-2019. Two radiologists reinterpreted images from 2011 and 2019 for presence of appendicoliths. Appendicoliths identified on CT were compared to appendicoliths in corresponding pathology specimens. Cohorts A (2001-10) & B (2011-19) were created on account of changes in CT scanners. PPV, NPV, sensitivity and specificity rates were calculated for contemporaneous readings and for 2011 and 2019 reinterpretations.

397 CT scans were read as positive for appendicoliths; 167 for A, 230 for B. 246 corresponding specimens had appendicoliths. PPV was 62% overall; 69% for A, 57% for B. 1155 scans were negative for appendicoliths. 191 corresponding specimens had appendicoliths; NPV was 83% overall; 80% for A, 87% for B. 447 specimens had appendicoliths; only 246 were identified by CT. Sensitivity was 55% overall; 48% for A, 66% for B. Specificity was 86% overall (964/1115); 91% for A, 82% for B. Radiologist accuracies varied.

Complicated appendicitis is often associated with appendicoliths. The assumption that CT identification of appendicoliths is reliable is unsupported by this study. CT finding of an appendicolith should not be used to exclude patients from antibiotics treatment but rather used in the shared decision-making conversation about management with patients.

Appendicolith causes acute appendicitis. However, surgical indications for appendicolith-related acute appendicitis have not been established. We aimed to clarify the clinical features of appendicolith-associated appendicitis and determine an appropriate treatment strategy based on the initial presentation.

We retrospectively reviewed the records of 479 consecutive patients with acute appendicitis and verified the therapeutic strategy as per the appendicolith and clinical status.

Appendicoliths were identified in 214 of 479 patients (44.6%) using computed tomography. Surgery was more frequently required in patients with appendicolith than in patients without appendicolith (82.7 versus 64.9%; P < 0.001). The stones were smaller and serum C-reactive protein (CRP) concentration was lower among patients with appendicoliths treated with medication alone than among those surgically treated (both P < 0.001). An appendicolith measuring ≤5 mm in diameter and CRP concentration ≤5.36 mg/dL were predictive of completion of nonsurgical therapy. CRP concentration >10 mg/dL and stone diameter of 10 mm were significantly associated with appendiceal perforation.

Nonsurgical therapy could be considered for patients with appendicoliths measuring ≤5 mm in diameter and in cases where the serum CRP concentration is ≤5 mg/dL. An appendicolith measuring >10 mm in diameter or CRP concentration >10 mg/dL is an indication for surgery.

This aim of this study was to provide an updated meta-analysis comparing antibiotic therapy with appendicectomy in adults (16 years or older) with uncomplicated acute appendicitis.

A search for randomized clinical trials comparing antibiotic therapy with appendicectomy in adults with uncomplicated acute appendicitis from inception to 3 October 2021 in MEDLINE, Embase and CENTRAL with no language constraints was performed. Studies were excluded if they included paediatric participants or those with complicated appendicitis. Data on complications of treatment, treatment efficacy (defined in the antibiotic group as not undergoing appendicectomy within 1 year of enrolment, versus surgery without complications or no negative histology in the appendicectomy group), readmissions, and length of stay (LOS) were presented.

Eight RCTs involving 3203 participants (1613 antibiotics/1590 appendicectomy; 2041 males/1162 females) were included. There was no significant benefit of antibiotic treatment on complication rates (risk ratio (RR) 0.66, 95 per cent c.i. 0.41 to 1.04). Antibiotics had a reduced treatment efficacy compared with appendicectomy (RR 0.75, 95 per cent c.i. 0.63 to 0.89). Antibiotic treatment at 1 year was successful in 1016 of 1613 (62.9 per cent) participants. There was a six-fold increase in hospital readmissions within 1 year of enrolment in participants receiving antibiotic treatment (RR 6.28, 95 per cent c.i. 2.87 to 13.74). There was no difference in index admission LOS (mean difference 0.15 days (95 per cent c.i. -0.05 to 0.35)).

Earlier optimism regarding the benefits of antibiotic therapy for uncomplicated acute appendicitis does not persist at the same level now that further, large trials have been included. If antibiotic treatment is to be offered routinely as first-line therapy, patients should be counselled appropriately.

In this study, we aimed to evaluate the laboratory markers used in the diagnosis of acute appendicitis (AA) and present the parameters that can be used to predict acute perforated appendicitis.

The cases who underwent an appendectomy in our clinic between September 2018 and March 2020 were evaluated retrospectively. A total of 530 patients who met the study criteria were included in the study. Patients were divided into two groups according to the presence of an intraoperative perforation. Non-complicated appendicitis patients formed Group-1, and perforated appendicitis patients formed Group-2. The demographic, clinical, and laboratory characteristics of the patients were compared.

The number of non-complicated patients in Group 1 was 443, while there were 87 (16.4%) patients in Group 2 who had perforated appendicitis. The mean age of the patients in the normal appendicitis group was 29.90±10.51 years, and the mean age of the patients in the perforated appendicitis group was 36.32±14.58 years. In the normal appendicitis group, 257 (58%) of the patients were male, 186 (42%) were female, while in the perforated appendicitis group, 38 (43.7%) were male, 49 (56.3%) were female. In the perfo-rated appendicitis group, white blood cell (WBC) value was 16.19±4.71 (p<0.001), C-reactive protein (CRP) value was 146.28±113.59 (p<0.001), total bilirubin value was 0.71±0.36 (p<0.001), and neutrophil-lymphocyte ratio (NLR) was 10.85±6.25 (p<0.001).

We believe that the WBC, total bilirubin, CRP, and NLR values obtained within this study, which is tested in the rapid and easily accessible blood tests in routine examinations that can contribute to the prediction of perforation.

This study aims to compare medical treatment and appendectomy in patients diagnosed with uncomplicated acute appendicitis during the COVID-19 pandemic.

Retrospectively analyzed were the data of 80 patients who received medical or surgical treatment for uncomplicated acute appendicitis between March 15, 2020, and August 31, 2020. The demographic characteristics of the patients, length of hospital stay, physical examination and radiology findings, laboratory results, and any complications were recorded. Patients were divided into two groups depending on the mode of treatment, as surgical and non-surgical.

Forty patients were given medical treatment and 40 patients were directly operated on for appendicitis. Of the 40 patients who received medical treatment, 8 (20%) ended up requiring an operation due to recurrence. The mean duration of hospitalization was 2 days (range: 1-3), and the mean follow-up duration was 285.35±65.66 days (range: 101-379). The white blood cell count was significantly higher in the surgical group (p=0.004), and the length of hospital stay was longer in the non-surgical group (p<0.001). The prevalence of post-operative complications was similar for patients who underwent appendectomy directly on admission or after recurrence (p=1.000). Among the patients who received medical treatment, the most important predictors of requiring surgery were the red cell distribution width and increased appendix diameter in computed tomography (p<0.05).

Medical treatment is an effective alternative in patients with uncomplicated appendicitis. Even in the case of a recurrence in follow-up, surgery due to a potential recurrence is not associated with an increased rate of complication compared to direct surgery.

The factors associated with the failure of nonoperative management of appendicitis and the differences in patient-reported outcomes between successful and unsuccessful nonoperative management remain unknown.

To investigate factors associated with the failure of nonoperative management of appendicitis and compare patient-reported outcomes between patients whose treatment succeeded and those whose treatment failed.

This study was a planned subgroup secondary analysis conducted in 10 children's hospitals that included 370 children aged 7 to 17 years with uncomplicated appendicitis enrolled in a prospective, nonrandomized clinical trial between May 1, 2015, and October 31, 2018, with 1-year follow-up comparing nonoperative management with antibiotics vs surgery for uncomplicated appendicitis. Statistical analysis was performed from November 1, 2019, to February 12, 2022.

Nonoperative management with antibiotics vs surgery.

Failure of nonoperative management and patient-reported outcomes. The relative risk (RR) of failure based on sociodemographic and clinical characteristics was calculated. Patient-reported outcomes were compared based on the success or failure of nonoperative management.

Of 370 patients (34.6% of 1068 total patients; 229 boys [61.9%]; median age, 12.3 years [IQR, 10.0-14.6 years]) enrolled in the nonoperative group, treatment failure occurred for 125 patients (33.8%) at 1 year, with 53 patients (14.3%) undergoing appendectomy during initial hospitalization and 72 patients (19.5%) experiencing delayed treatment failure after hospital discharge. Higher patient-reported pain at presentation was associated with increased risk of in-hospital treatment failure (RR, 2.1 [95% CI, 1.0-4.4]) but not delayed treatment failure (RR, 1.3 [95% CI, 0.7-2.3]) or overall treatment failure at 1 year (RR, 1.5 [95% CI, 1.0-2.2]). Pain duration greater than 24 hours was associated with decreased risk of delayed treatment failure (RR, 0.3 [95% CI, 0.1-1.0]) but not in-hospital treatment failure (RR, 1.2 [95% CI, 0.5-2.7]) or treatment failure at 1 year (RR, 0.7 [95% CI, 0.4-1.2]). There was no increased risk of treatment failure associated with age, white blood cell count, sex, race, ethnicity, primary language, insurance status, transfer status, symptoms at presentation, or imaging results. Health care satisfaction at 30 days and patient-reported, health-related quality of life at 30 days and 1 year were not different. Satisfaction with the decision was higher with successful nonoperative management at 30 days (28.0 vs 27.0; difference, 1.0 [95% CI, 0.01-2.0]) and 1 year (28.1 vs 27.0; difference, 1.1 [95% CI, 0.2-2.0]).

This analysis suggests that a higher pain level at presentation was associated with a higher risk of initial failure of nonoperative management and that a longer duration of pain was associated with lower risk of delayed treatment failure. Although satisfaction was high in both groups, satisfaction with the treatment decision was higher among patients with successful nonoperative management at 1 year.

ClinicalTrials.gov Identifier: NCT02271932.

Since its initial discovery in the 1500s, the cecal appendix has been an anatomical structure of great intrigue, notorious for its inconvenient tendency to become inflamed and often require surgical intervention. Appendicitis is one of the most common indications for emergency abdominal surgery, costing healthcare systems billions of dollars globally and causing tens of thousands of deaths annually. Yet, recent studies have indicated that the appendix may serve important protective functions in fortifying the body's immune response against invading pathogens and re-inoculating the gut with commensal bacteria after periods of gastrointestinal illness. While the cecal appendix was once believed to be a synapomorphy of hominoids (humans and other great apes), recent studies suggested that it is a recurrent trait found in several other species of primates, rodents, lagomorphs, marsupials, and monotremes. Mapping appendiceal and other gastrointestinal traits across a mammalian consensus phylogeny revealed that the cecal appendix has evolved independently numerous times throughout mammalian evolution, significantly more than would be expected due to chance alone, suggesting that the appendix is adaptively advantageous. However, attempts to identify an overarching ecological, behavioral, dietary, or environmental factor driving some species to evolve an appendix have been largely unsuccessful, indicating that the cecal appendix has a complex and diverse evolutionary history. This review discusses the current understanding of the pathophysiology, evolution, and possible functions of the appendix, both within humans and broadly across the class Mammalia.

Acute appendicitis (AA) is a common disease that includes all age groups and both genders in societies and is one of the most common causes of acute abdomen. It is important to distinguish between complicated and non-complicated appendicitis before surgery. This study aims to determine laboratory parameters that can be used to determine whether the disease is complicated or non-complicated in patients admitted to the emergency department with AA.

Female and male patients admitted to the Emergency General Surgery Department between May 2019 and November 2020 and diagnosed with appendicitis were included in the study. Demographic data (age, gender, and protocol numbers), complete blood counts (Delta neutrophil index [DNI], hemoglobin, monocyte, neutrophil, eosinophil, basophil, platelet, platelet distribution width, mean platelet volume, reticulocyte distribution width), biochemical parameters (amylase, direct bilirubin, indirect bilirubin, albumin, calcium, and lactate dehydrogenase), and examination information were obtained from the hospital automation system and recorded via SPSS software. Parameters of patients were divided into two groups as complicated and non-complicated appendicitis groups were compared.

White blood cell (WBC), monocyte, neutrophil, DNI, total bilirubin, and direct bilirubin values were found to be statisti-cally significantly higher in the complicated appendicitis group compared to the non-complicated appendicitis group (p-values; <0.001, 0.003, <0.001, <0.001 and 0.008, respectively).

DNI, bilirubin values, WBC, monocyte, neutrophil, and eosinophil can be used as laboratory parameters to distin-guish between complicated and non-complicated AA.

In children with appendicitis, rupture of the appendix is associated with a significant increase in morbidity. We sought to characterize the spectrum of illness in children with complicated appendicitis and to define those factors associated with a longer hospital stay.

We conducted a retrospective review of 132 children, 18 years of age or younger at a large urban teaching hospital in the Bronx, NY between October 2015 and April 2018 with an intraoperative diagnosis of perforated appendix. Clinical, laboratory and radiologic findings were reviewed, and the primary study outcome was length of stay (LOS) dichotomized at the median, which was 7 days. Statistical analyses were done to characterize morbidity and define variables predictive of longer stay.

Children in the longer LOS group experienced significantly more morbidity, including ICU stay, ileus, and need for multiple drainage procedures. A longer duration of symptoms prior to presentation was associated with a longer stay. Multivariable logistic regression analysis indicated that the presence of abscess and presence of free fluid in the right upper quadrant (RUQ FF) on initial imaging and C-reactive protein (CRP) level >12 at admission, were independently associated with a longer stay.

There is considerable variation in the morbidity of complicated appendicitis. The association between longer stay and the findings of abscess and RUQ FF on initial imaging along with an elevated CRP may provide a useful tool in identifying those children at risk for worse outcomes.