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Update on the Diagnosis and Treatment of Appendicitis
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Update on the Diagnosis and Treatment of Appendicitis

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Gastroenterology & Hepatopancreatobiliary Medicine".

Deadline for manuscript submissions: closed (30 June 2024) | Viewed by 8401

Special Issue Editors

Prof. Dr. George Vaos

E-Mail Website
Guest Editor
Department of Pediatric Surgery, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
Interests: neonatal surgery; pediatric gastrointestinal surgery; pediatric thoracic surgery; pediatric urology
Prof. Dr. Nikolaos Zavras

E-Mail Website
Guest Editor
Department of Pediatric Surgery, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
Interests: pediatric laparoscopic surgery; bariatric surgery; oncology

Special Issue Information

Dear Colleagues,

Appendicitis is one of the most common abdominal surgical emergencies in adults and children in the world, with a lifetime risk of 8.6% in males and 6.7% in females. The diagnosis of appendicitis is always a challenge. Delays in presenting to the physician and further delays in proper treatment due to misdiagnosis can increase the possibility of complications, especially in children. Although diagnosis is primarily clinical, the utilization of imaging and different scores can stratify patients in low, moderate, or high-risk groups and help in making a timely diagnosis. In patients at moderate to high-risk, surgical consultation should be conducted promptly to reduce morbidity and mortality resulting from the perforation of the appendix. Some controversies over strategies for treating appendicitis have been generated without a complete consensus. Laparoscopic or open appendicectomy is the standard treatment of appendicitis. However, some patients with perforated appendicitis may benefit from immediate surgery or initial antibiotic treatment, followed by interval appendicectomy, and several studies have even suggested a non-operative treatment with antibiotics alone in selected cases. The purpose of this Special Issue is to provide an update on the critical debates regarding the above aspects of appendicitis, and to discuss recent controversies in the field. Original articles, systematic reviews, meta-analyses and short communications on the topics described above are welcome. We also invite relevant basic, translational and clinical research.

Prof. Dr. George Vaos
Prof. Dr. Nikolaos Zavras
Guest Editors

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Keywords

  • appendicitis
  • complicated appendicitis
  • imaging in appendicitis
  • scoring in appendicitis
  • laparoscopic appendicectomy
  • open appendicectomy
  • conservative treatment of appendicitis
  • controversies in diagnosis
  • controversies in treatment

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Published Papers (7 papers)

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Research

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15 pages, 1593 KiB  
Article
A Novel Deep Learning Approach for the Automatic Diagnosis of Acute Appendicitis
by Kamil Dogan and Turab Selcuk
J. Clin. Med. 2024, 13(16), 4949; https://doi.org/10.3390/jcm13164949 - 22 Aug 2024
Viewed by 387
Abstract
Background: Acute appendicitis (AA) is a major cause of acute abdominal pain requiring surgical intervention. Approximately 20% of AA cases are diagnosed neither early nor accurately, leading to an increased risk of appendiceal perforation and postoperative sequelae. AA can be identified with good [...] Read more.
Background: Acute appendicitis (AA) is a major cause of acute abdominal pain requiring surgical intervention. Approximately 20% of AA cases are diagnosed neither early nor accurately, leading to an increased risk of appendiceal perforation and postoperative sequelae. AA can be identified with good accuracy using computed tomography (CT). However, some studies have found that a false-negative AA diagnosis made using CT can cause surgical therapy to be delayed. Deep learning experiments are aimed at minimizing false-negative diagnoses. However, the success rates reported in these studies are far from 100%. In addition, the methods used to divide patients into groups do not adequately reflect situations in which accurate radiological diagnosis is difficult. Therefore, in this study, we propose a novel deep-learning approach for the automatic diagnosis of AA using CT based on establishing a new strategy for classification according to the difficulties encountered in radiological diagnosis. Methods: A total of 266 patients with a pathological diagnosis of AA who underwent appendectomy were divided into two groups based on CT images and radiology reports. A deep learning analysis was performed on the CT images and clinical and laboratory parameters that contributed to the diagnosis of both the patient and age- and sex-adjusted control groups. Results: The deep learning diagnosis success rate was 96% for the group with advanced radiological findings and 83.3% for the group with radiologically suspicious findings that could be considered normal. Conclusions: Using deep learning, successful results can be achieved in cases in which the appendix diameter has not increased significantly and there is no significant edema effect. Full article
(This article belongs to the Special Issue Update on the Diagnosis and Treatment of Appendicitis)
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13 pages, 1513 KiB  
Article
Hidden Appendicoliths and Their Impact on the Severity and Treatment of Acute Appendicitis
by Maximilian Dölling, Mirhasan Rahimli, Jonas Pachmann, Malik Szep, Sara Al-Madhi, Mihailo Andric, Ulf D. Kahlert, Tobias Hofmann, Michael Boettcher, Luis E. Muñoz, Martin Herrmann, Aristotelis Perrakis and Roland S. Croner
J. Clin. Med. 2024, 13(14), 4166; https://doi.org/10.3390/jcm13144166 - 16 Jul 2024
Viewed by 702
Abstract
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 [...] Read more.
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. Full article
(This article belongs to the Special Issue Update on the Diagnosis and Treatment of Appendicitis)
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11 pages, 1177 KiB  
Article
Observation Safely Reduces the Use of the Computerized Tomography in Medium-to-Low-Risk Patients with Suspected Acute Appendicitis: Results of a Randomized Controlled Trial
by Raminta Luksaite-Lukste, Igne Gecaite, Kristina Marcinkeviciute, Eimantas Dumskis, Arturas Samuilis, Tadas Zvirblis, Eugenijus Jasiunas, Augustinas Bausys, Mantas Drungilas, Martynas Luksta, Marius Kryzauskas, Marius Petrulionis, Augustas Beisa, Simonas Uselis, Gintare Valeikaite-Taugininene, Rokas Rackauskas, Kestutis Strupas and Tomas Poskus
J. Clin. Med. 2024, 13(12), 3363; https://doi.org/10.3390/jcm13123363 - 7 Jun 2024
Viewed by 596
Abstract
Objectives—The objective was to compare the effectiveness of observation in standard-of-care computed tomography (CT) in adult patients with suspected acute appendicitis (AA). Methods—Patients with clinically suspected AA and inconclusive diagnosis after primary clinical examination, laboratory examination, and transabdominal ultrasound (TUS) were [...] Read more.
Objectives—The objective was to compare the effectiveness of observation in standard-of-care computed tomography (CT) in adult patients with suspected acute appendicitis (AA). Methods—Patients with clinically suspected AA and inconclusive diagnosis after primary clinical examination, laboratory examination, and transabdominal ultrasound (TUS) were eligible for the study, and they were randomized (1:1) to parallel groups: observation-group patients were observed for 8–12 h and then, repeated clinical and laboratory examinations and TUS were performed; CT group (control group) patients underwent abdominopelvic CT scan. The study utilized Statistical Analysis System 9.2 for data analysis, including tests, logistic regression, ROC analysis, and significance evaluation. Patients were enrolled in the study at Vilnius University Hospital Santaros Klinikos in Lithuania between December 2018 and June 2021. Results—A total of 160 patients (59 men, 101 women), with a mean age of 33.7 ± 14.71, were included, with 80 patients in each group. Observation resulted in a reduced likelihood of a CT scan compared with the CT group (36.3% vs. 100% p < 0.05). One diagnostic laparoscopy was performed in the observation group; there were no cases of negative appendectomy (NA) in the CT group. Both conditional CT and observation pathways resulted in high sensitivity and specificity (97.7% and 94.6% vs. 96.7% and 95.8%). Conclusions—Observation including the repeated evaluation of laboratory results and TUS significantly reduces the number of CT scans without increasing NA numbers or the number of complicated cases. Full article
(This article belongs to the Special Issue Update on the Diagnosis and Treatment of Appendicitis)
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11 pages, 925 KiB  
Article
Management and Incidence of Enterobius vermicularis Infestation in Appendectomy Specimens: A Cross-Sectional Study of 6359 Appendectomies
by Zenon Pogorelić, Vlade Babić, Marko Bašković, Vladimir Ercegović and Ivana Mrklić
J. Clin. Med. 2024, 13(11), 3198; https://doi.org/10.3390/jcm13113198 - 29 May 2024
Viewed by 1135
Abstract
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 [...] Read more.
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. Full article
(This article belongs to the Special Issue Update on the Diagnosis and Treatment of Appendicitis)
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Review

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13 pages, 280 KiB  
Review
Controversies and Future Directions in Management of Acute Appendicitis: An Updated Comprehensive Review
by Dushyant Singh Dahiya, Hamzah Akram, Aman Goyal, Abdul Moiz Khan, Syeda Shahnoor, Khawaja M. Hassan, Manesh Kumar Gangwani, Hassam Ali, Bhanu Siva Mohan Pinnam, Saqr Alsakarneh, Andrew Canakis, Abu Baker Sheikh, Saurabh Chandan and Amir Humza Sohail
J. Clin. Med. 2024, 13(11), 3034; https://doi.org/10.3390/jcm13113034 - 22 May 2024
Cited by 1 | Viewed by 1473
Abstract
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, [...] Read more.
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. Full article
(This article belongs to the Special Issue Update on the Diagnosis and Treatment of Appendicitis)

Other

Jump to: Research, Review

12 pages, 1536 KiB  
Systematic Review
Utility of Ischemia-Modified Albumin as a Biomarker for Acute Appendicitis: A Systematic Review and Meta-Analysis
by Apoorv Singh, Zenon Pogorelić, Aniket Agrawal, Carlos Martin Llorente Muñoz, Deepika Kainth, Ajay Verma, Bibekanand Jindal, Sandeep Agarwala and Sachit Anand
J. Clin. Med. 2023, 12(17), 5486; https://doi.org/10.3390/jcm12175486 - 24 Aug 2023
Cited by 7 | Viewed by 1973
Abstract
Background: Acute appendicitis is a frequently encountered surgical emergency. Despite several scoring systems, the possibility of delayed diagnosis persists. In addition, a delayed diagnosis leads to an increased risk of complicated appendicitis. Hence, there is a need to identify biological markers to help [...] Read more.
Background: Acute appendicitis is a frequently encountered surgical emergency. Despite several scoring systems, the possibility of delayed diagnosis persists. In addition, a delayed diagnosis leads to an increased risk of complicated appendicitis. Hence, there is a need to identify biological markers to help clinicians rapidly and accurately diagnose and prognosticate acute appendicitis with a high sensitivity and specificity. Although several markers have been evaluated, the pressing concern is still the low specificity of these markers. One such marker is serum ischemia-modified albumin (IMA), which can be a novel biomarker for accurately diagnosing and prognosticating acute appendicitis. Methods: The authors conducted a systematic search of the PubMed, EMBASE, Web of Science, and Scopus databases through February 2023 as per the PRISMA guidelines. The difference in the levels of IMA between patients with acute appendicitis vs. healthy controls, and the difference in the levels of IMA between patients with complicated vs. non-complicated acute appendicitis were taken as the outcome measures. Statistical analysis was performed using a random effects model and mean difference (MD) was calculated. The methodological quality of the studies was assessed by utilizing the Newcastle–Ottawa scale. Results: A total of six prospective comparative studies were included in the meta-analysis. The analysis revealed that the mean level of serum IMA was significantly raised in the acute appendicitis group (MD 0.21, 95% CI 0.05 to 0.37, p = 0.01). Similarly, the mean serum IMA levels were also raised in the complicated appendicitis group compared to the non-complicated appendicitis group (MD 0.05, 95% CI 0.01 to 0.10, p = 0.02). Three of the studies included were, however, of poor methodological quality. Conclusions: Serum IMA is a viable potential marker for diagnosing and prognosticating acute appendicitis. However, due to the limited methodological quality of available studies, further prospectively designed and adequately powered studies are needed. Full article
(This article belongs to the Special Issue Update on the Diagnosis and Treatment of Appendicitis)
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14 pages, 568 KiB  
Systematic Review
The Impact of Obesity on Perioperative Outcomes for Children Undergoing Appendectomy for Acute Appendicitis: A Systematic Review
by Nikolaos Zavras, Natalia Vaou, Sofia Zouganeli, Arezina Kasti, Papakonstantinou Dimitrios and George Vaos
J. Clin. Med. 2023, 12(14), 4811; https://doi.org/10.3390/jcm12144811 - 21 Jul 2023
Cited by 1 | Viewed by 1341
Abstract
Today, the prevalence of obesity in the pediatric population has increased dramatically. Acute appendicitis (AA) is the most common surgical condition among pediatric patients. We aimed to investigate the impact of obesity on postoperative outcomes in terms of operative time (OT), length of [...] Read more.
Today, the prevalence of obesity in the pediatric population has increased dramatically. Acute appendicitis (AA) is the most common surgical condition among pediatric patients. We aimed to investigate the impact of obesity on postoperative outcomes in terms of operative time (OT), length of stay (LOS), surgical site infection (SSI), overall complications, adverse events, and mortality in children undergoing appendectomy for acute appendicitis. An extensive search of the literature in PubMed and Google Scholar was conducted to evaluate the outcomes of normal weight (NW), overweight (OW), and obese (OB) children who underwent appendectomy. Although no statistically significant differences were noted in perioperative outcomes and overall postoperative complications between OW/OB and NW children in the majority of the included studies, prolonged OT and LOS and SSI were found in some studies. Moreover, no differences in terms of readmissions and ED visits were recorded. We conclude that the impact of obesity on postoperative outcomes for children undergoing appendectomy for AA is unclear, and, therefore, no safe conclusions can be drawn with the currently available data. Due to the lack of high-quality studies, further research is required to optimize the surgical approach and prevent unwarranted complications. Full article
(This article belongs to the Special Issue Update on the Diagnosis and Treatment of Appendicitis)
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