Appendicitis why so complicated

Try out PMC Labs and tell us what you think. Learn More. Definition of the type of appendicitis is based on examination of the peritoneum and appendix. Gomes et al. The aim of this study was to evaluate the reproducibility of this score.

All patients managed for acute appendicitis between January and June were included in this single-center prospective study. Laparoscopic appendectomy procedures were filmed by analogy to Sugerbaker's peritoneal carcinomatosis score 9 quadrants, all of the abdomen was filmed. The videos were then analyzed by seven staff surgeons blinded to each other and the operative report. The primary endpoint was to determine the concordance between staff surgeons for grading of appendicitis using the laparoscopic grading system of acute appendicitis described by Gomes et al.

A total of 40 patients were included in this study. For diffuse peritonitis, the mean SD number of quadrants in which the staff surgeons reported signs of peritonitis was 2. The classification used to determine the type of appendicitis is reproducible.

Mariage M, Sabbagh C, et al. Euroasian J Hepatogastroenterol ;9 1 Definition of the type of appendicitis based on the appearance of the appendix and peritoneum is important, as it determines the type of preoperative management ambulatory surgery or immediate surgery , 3 - 5 intraoperative management aspiration, lavage and subsequent management hospitalization, postoperative antibiotic therapy. The type of appendicitis also has a direct impact on postoperative morbidity.

The nature of appendicitis complicated or not can be determinate preoperatively with high specificity, 6 but this definition must be confirmed preoperatively. Localized or generalized appendicitis must also be confirmed peroperatively. Definition of the type of appendicitis is an operative diagnosis. Complicated appendicitis is defined as perforated appendicitis, periappendicular abscess or peritonitis, defined as acute inflammation of the peritoneum secondary to infection of the appendix.

Purulent peritonitis is defined by the presence of purulent fluid and fecal peritonitis corresponds to the presence of fecal matter in the peritoneal cavity. However, operative description of peritonitis has not been standardized in particular, the distinction between regional and diffuse peritonitis remains unclear , and can vary from one surgeon to another, but this description has a direct impact on the preoperative, operative and postoperative management of patients and can have a direct impact on the reproducibility of the outcomes of studies on the management of appendicular peritonitis.

A clear definition of complicated appendicitis is essential to design studies, interpret data, and, more generally, ensure appropriate management of patients. In , Gomes et al. Grades 1 and 2 correspond to uncomplicated appendicitis and grades correspond to complicated appendicitis Table 1.

The authors compared the laparoscopic grading system to the histopathological assessment of the removed appendix and biochemical analysis of the peritoneal fluid. No external validation of this score has been performed. The aim of this study was to perform an external validation of this score by evaluating the concordance of this score between surgeons to propose a clear definition for each type of appendicitis. All patients managed for acute appendicitis between January and June were included in this prospective single-center study.

The appearance of the appendix and peritoneum was clearly described in all operative reports. Laparoscopic appendectomy is always the first choice. Laparoscopic appendectomy procedures were filmed using an HD camera from the insertion of the camera into the abdomen until the end of laparoscopy.

The entire abdomen 9 quadrants was systematically filmed. A video montage was then performed by one of the authors MM to produce one-minute sequences showing the nine quadrants of the abdomen by analogy with Sugerbaker's score of peritoneal carcinomatosis and the appendix, as described below.

All videos were then saved in a dedicated file. A blinded number was randomly assigned to all the videos. The videos were then analyzed by seven staff surgeons three first year consultant surgeons, three second year consultant surgeons and one surgeon with 5 years of experience blinded to each other and to the operative report. The surgeons reported their findings using the Gomes classification on an Excel file using the blinded number of each video.

Grades 1 and 2 corresponded to uncomplicated appendicitis and grades 3, 4 and 5 corresponded to complicated appendicitis Table 1.

All patients with acute appendicitis, operated as an emergency by laparoscopy during the study period and in whom all quadrants of the abdomen could be explored by laparoscopy were included in the study. Patients operated by laparotomy or operated by laparoscopy with poor quality video or in whom certain quadrants could not be explored were not included in the study.

For grades 4B and 5 of the laparoscopic grading system of acute appendicitis, to determine the mean number of quadrants in which the surgeon reported signs of peritonitis and to provide a clear definition of regional grade 4B and diffuse peritonitis grade 5. To determine the concordance between the staff surgeons and the initial operative report after unblinding.

To compare the difference between postoperative antibiotic therapy guidelines according to the type of peritonitis regional, diffuse, purulent, fecal and actual prescription of postoperative antibiotic therapy. The laparoscopic grading system of acute appendicitis was developed by Gomes et al. In their prospective study, the authors described 5 laparoscopic grades of acute appendicitis Table 1 and correlated this score with histopathological examination of the removed appendix and biochemical analysis of the peritoneal fluid.

Two main groups of patients can be distinguished: grades 1 and 2 correspond to noncomplicated appendicitis and grades 3, 4 and 5 correspond to complicated appendicitis. All procedures were performed by one of the seven staff surgeons. At present the benefits and harms of early versus delayed appendicectomy are not well understood because the current information is based upon very low quality evidence. Both trials were at a high risk of bias.

Overall, we judged the quality of the evidence to be very low. Thus, further well-designed trials are urgently needed. It is unclear whether early appendicectomy prevents complications compared to delayed appendicectomy for people with appendiceal phlegmon or abscess. The evidence indicating increased length of hospital stay and time away from normal activities in people with early open appendicectomy is of very low quality.

The evidence for better health-related quality of life following early laparoscopic appendicectomy compared with delayed appendicectomy is based on very low quality evidence. For both comparisons addressed in this review, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy.

Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities, quality of life and the length of hospital stay. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms and avoid complications.

The timing of appendicectomy for appendiceal phlegmon or abscess is controversial. To assess the effects of early versus delayed appendicectomy for appendiceal phlegmon or abscess, in terms of overall morbidity and mortality. We included all individual and cluster-randomised controlled trials, irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess.

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed meta-analyses using Review Manager 5. The trial was at high risk of bias. There was no mortality in either group. There is insufficient evidence to determine the effect of using either early or delayed open appendicectomy onoverall morbidity RR The quality of evidence for increased length of hospital stay and time away from normal activities in the early appendicectomy group MD 6.

Twenty-six patients had no predictive factors and thus, whose appendicitis were suspected to have be uncomplicated appendicitis. Out of the 26 patients, 14 patients who presented to our hospital during office hours underwent the immediate surgery. The other 12 patients who presented to our hospital at night or on a holiday underwent delayed surgery during office hours Fig.

Algorithm indicating the timing of surgery according to the predictive factors of uncomplicated appendicitis. Histopathologically, catarrhal appendicitis was defined as the apparent enlargement of lymphoid follicles in the appendix mucosa, and cellulitis appendicitis was defined as neutrophil infiltration into all layers.

Gangrenous appendicitis was defined as neutrophil infiltration and muscle layer necrosis, and perforated appendicitis was defined as necrosis and perforation in all layers. Complicated appendicitis was defined as a pathologically proven gangrenous or perforated appendix. Our strategies for patients with acute appendicitis indicated for surgery included immediate operation for patients with suspicion of complicated appendicitis and short, in-hospital delay for patients with suspicion of uncomplicated appendicitis.

The general patient characteristics are shown in Table 1. The mean patient age was However, there were no significant differences in the postoperative complication rate and hospitalization period between the prospective and retrospective studies Tables 3 and 4. The Alvarado and AIR scores are standardized diagnostic approaches in evaluating patients with suspected acute appendicitis, using only clinical signs and symptoms and laboratory values. Di Saverio et al.

Moreover, they emphasized that both scores were the only independent predictive factors of non-operative management failure with antibiotics for uncomplicated appendicitis [ 8 ]. The treatment of patients with complicated intra-abdominal infection involves both timely source control and antimicrobial therapy [ 9 ]. Clinical trials have demonstrated the successful treatment of acute appendicitis with antibiotics [ 4 , 10 — 12 ]. Notably, not all cases of appendicitis can be treated surgically, especially cases involving catarrhal appendicitis [ 13 ], and unnecessary surgeries should be avoided in light of the risk complications such as ileus 1.

However, cases of complicated appendicitis, such as perforated appendicitis and gangrenous appendicitis, can potentially progress to acute peritonitis, which necessitates emergency surgery. Cases of complicated appendicitis with localized abscesses, however, present a lower risk of progression to acute peritonitis, allowing surgery to be delayed until normal office hours, and recent studies of this protocol, or interval appendectomy, have confirmed the safety of this approach [ 3 , 15 ].

The surgical indication criteria for acute appendicitis in our department are shown in Fig. Some of the patients with uncomplicated appendicitis and all of the patients with complicated appendicitis had surgical indication according to our criteria. Although cases of complicated appendicitis should be treated immediately, it remains a question whether cases of uncomplicated appendicitis indicated for surgical treatment should be treated immediately even at night or on a holiday.

Although several previous reports have discussed factors associated with the diagnosis of acute appendicitis, the ability of preoperative factors in predicting the presence of complicated appendicitis is not easy to verify [ 6 , 16 — 18 ]. However, Atema et al.

Of the patients, had a score of 6 points or less, of whom eight 5. Herein, we report another simple scoring system predicting the complicated appendicitis.

We performed a receiver operating characteristic ROC analysis to identify the most sensitive cut-off level and used multivariate logistic regression analysis to investigate these three predictive values for clinical events in the retrospective study [ 5 ]. In the prospective study, we were able to exclude all cases of uncomplicated appendicitis using these predictive factors.

In these latter cases, indicated procedures could be postponed to avoid surgeries at night or over holidays. Moreover, a short, in-hospital delay for uncomplicated appendicitis indicated for surgery has proved to be a safe procedure. However, the discrimination of cases with only one or two predictive factors remains controversial, and further prospective study is needed to support decisions regarding emergency surgery in such cases.

After adopting our scoring system, we observed an increase in the frequency of complicated appendicitis, and we expected that the number of patients treated successfully with antibiotics also increased. Non-operative management would be an alternative for uncomplicated appendicitis if cases of complicated appendicitis can be excluded prior to surgery.

However, we also recognized some bias in this study, as we excluded patients who were treated successfully with antibiotics from the trial, because we have no way to know their actual pathology. Recently, the strategy of short, in-hospital delay for uncomplicated appendicitis indicated for surgery has been recommended in the World Society of Emergency Surgery Jerusalem guidelines for diagnosis and treatment of acute appendicitis [ 1 ]. The scoring system can avoid emergency surgery at night or on a holiday and lead to non-operative management.

WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials. Anderson PA. Nonsurgical treatment of patients with thoracolumbar fractures. Instr Course Lect. Appendectomy versus antibiotic treatment in acute appendicitis. World J Surg.

Article PubMed Google Scholar. A study of preoperative predictive factors of appendicitis requiring rapid emergency operation in Japanese with English abstract.