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6IXISLANDS Group

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Ian Ramirez
Ian Ramirez

Late Gui Da Hood Fixed



Geographical differences are reported, with a lifetime risk for AA of 9% in the USA, 8% in Europe, and 2% in Africa [4]. Moreover, there is great variation in the presentation, severity of the disease, radiological workup, and surgical management of patients having AA that is related to country income [5].




Late Gui Da Hood


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Based upon the list of topics, research questions (Patients/Population, Intervention/Exposure, Comparison, Outcome (PICO)) were formulated, reviewed, and adopted as guidance to conduct an exploratory literature search (Table 1).


Tan et al. recently performed a prospective data collection on 350 consecutive patients with suspected AA for whom the Alvarado score for each patient was scored at admission and correlated with eventual histology and CT findings. The positive likelihood ratio of disease was significantly greater than 1 only in patients with an Alvarado score of 4 and above. An Alvarado score of 7 and above in males and 9 and above in females had a positive likelihood ratio comparable to that of CT scan [36].


Statement 1.1 Establishing the diagnosis of acute appendicitis based on clinical presentation and physical examination may be challenging. As the value of individual clinical variables to determine the likelihood of acute appendicitis in a patient is low, a tailored individualized approach is recommended, depending on disease probability, sex, and age of the patient. Recommendation 1.1 We recommend to adopt a tailored individualized diagnostic approach for stratifying the risk and disease probability and planning an appropriate stepwise diagnostic pathway in patients with suspected acute appendicitis, depending on age, sex, and clinical signs and symptoms of the patient [QoE: Moderate; Strength of recommendation: Strong; 1B].


One recent study identified a panel of biomarkers, the APPY1 test, consisting of WBC, CRP, and myeloid-related protein 8/14 levels that have the potential to identify, with great accuracy, children and adolescents with abdominal pain who are at low risk for AA. The biomarker panel exhibited a sensitivity of 97.1%, a negative predictive value of 97.4%, and a negative likelihood ratio of 0.08, with a specificity of 37.9% for AA [51].


Benito et al. prospectively evaluated the usefulness of WBC and ANC and other inflammatory markers such as CRP, procalcitonin, calprotectin, and the APPY1 test panel of biomarkers, to identify children with abdominal pain at low risk for AA. The APPY1 test panel showed the highest discriminatory power, with a sensitivity of 97.8, negative predictive value of 95.1, negative likelihood ratio of 0.06, and specificity of 40.6. In the multivariate analysis, only the APPY1 test and ANC > 7500/mL were significant risk factors for AA [55].


Estimating pre-image likelihood of AA is important in tailoring the diagnostic workup and using scoring systems to guide imaging can be helpful: low-risk adult patients according to the AIR/Alvarado scores could be discharged with appropriate safety netting, whereas high-risk patients are likely to require surgery rather than diagnostic imaging. Intermediate-risk patients are likely to benefit from systematic diagnostic imaging [64]. A positive US would lead to a discussion of appendectomy and a negative test to either CT or further clinical observation with repeated US. A conditional CT strategy, where CT is performed after the negative US, is preferable, as it reduces the number of CT scans by 50% and will correctly identify as many patients with AA as an immediate CT strategy.


The meta-analysis by Matthew Fields et al. found that the sensitivity and specificity for POCUS in diagnosing AA were 91% and 97%, respectively. The positive and negative predictive values were 91% and 94%, respectively [66]. US reliability for the diagnosis of AA can be improved through standardized results reporting. In the study by Sola et al., following the adoption of a diagnostic algorithm that prioritized US over CT and encompassed standardized templates, the frequency of indeterminate results decreased from 44.3% to 13.1% and positive results increased from 46.4% to 66.1% in patients with AA [67].


A systematic literature review was performed to evaluate the effectiveness of abdominal US and abdominal CT in diagnosing AA in adult and pediatric patients. Data reported that for US, the calculated pooled values of sensitivity, specificity, positive predictive value, and negative predictive value were 86%, 94%, 100%, and 92%, respectively. For CT, the calculated pooled values of sensitivity, specificity, positive predictive value, and negative predictive value were 95%, 94%, 95%, and 99%, respectively. These results suggest that US is an effective first-line diagnostic tool for AA and that CT should be performed for patients with inconclusive ultrasonographic finding [92]. Recently, a meta-analysis was carried out to compare the accuracy of US, CT, and MRI for clinically suspected AA in children. The area under the receiver operator characteristics curve of MRI (0.995) was a little higher than that of US (0.987) and CT (0.982) but with no significant difference [93].


The 5-year follow-up results of the APPAC trial reported that, among patients who were initially treated with antibiotics, the likelihood of late recurrence was 39.1%. Only 2.3% of patients who had surgery for recurrent AA were diagnosed with complicated forms of the disease. The overall complication rate was significantly reduced in the antibiotic group compared to the appendectomy group (6.5% vs 24.4%). This long-term follow-up supports the feasibility of NOM with antibiotics as an alternative to surgery for uncomplicated AA [104]. Furthermore, patients receiving antibiotic therapy incur lower costs than those who had surgery [105].


Regarding complicated AA, some authors support initial antibiotics with delayed operation whereas others support immediate operation. Regarding complicated appendicitis, some authors support initial antibiotics with delayed operation whereas others support immediate operation. A population-level study with a 1-year follow-up period found that children undergoing late appendectomy were more likely to have a complication than those undergoing early appendectomy. These data support that early appendectomy is the best management in complicated AA [136].


Results from the American College of Surgeons NSQIP (pediatric database) demonstrated that obesity was not found to be an independent risk factor for postoperative complications following LA. Although operative time was increased in obese children, obesity did not increase the likelihood of 30-day postoperative complications [155].


Monopolar electrocoagulation, being safe, quick, and related to very low rates of complications and conversion to OA, can be considered the most cost-effective method for mesoappendix dissection in LA [164]. A recent retrospective cohort study by Wright et al. has proposed that the use of a single stapler line for transection of the mesoappendix and appendix as a safe and efficient technique that results in reduced operative duration with excellent surgical outcomes [165].


The most recent Cochrane review comparing mechanical appendix stump closure (stapler, clips, or electrothermal devices) versus ligation (endoloop, Roeder loop, or intracorporeal knot techniques) for uncomplicated AA included eight RCTs encompassing 850 participants. Five studies compared titanium clips versus ligature, two studies compared an endoscopic stapler device versus ligature, and one study compared an endoscopic stapler device, titanium clips, and ligature. No differences in total complications, intra-operative complications, or postoperative complications between ligature and all types of mechanical devices were found. However, the analyses of secondary outcomes revealed that the use of mechanical devices saved approximately 9 min of the total operating time when compared with the use of a ligature, even though this result did not translate into a clinically or statistically significant reduction in inpatient hospital stay [170].


In 2014, the AAST also proposed a system for grading the severity of emergency general surgery diseases based on several criteria encompassing clinical, imaging, endoscopic, operative, and pathologic findings, for eight commonly encountered gastrointestinal conditions, including AA, ranging from grade I (mild) to grade V (severe) [188]. In 2017, Hernandez et al. validated this system in a large cohort of patients with AA, showing that increased AAST grade was associated with open procedures, complications, and length of stay. AAST grade in emergency for AA determined by preoperative imaging strongly correlated with operative findings [189]. In 2018, the same researchers assessed whether the AAST grading system corresponded with AA outcomes in a US pediatric population. Results showed that increased AAST grade was associated with increased Clavien-Dindo severity of complications and length of hospital stay [190].


Statement 5.2 Operative findings and intra-operative grading seem to correlate better than histopathology with morbidity, overall outcomes and costs, both in adults and children. Intra-operative grading systems can help the identification of homogeneous groups of patients, determining optimal postoperative management according to the grade of the disease and ultimately improve utilization of resources. Recommendation 5.2 We suggest the routine adoption of an intra-operative grading system for acute appendicitis (e.g., WSES 2015 grading score or AAST EGS grading score) based on clinical, imaging and operative findings [QoE: Moderate; Strength of recommendation: Weak; 2B].


Intra-operative macroscopic distinction between a normal appendix and AA during surgery can be challenging. Several studies have shown a 19% to 40% rate of pathologically abnormal appendix in the setting of no visual abnormalities [182, 196]. Therefore, the risk of leaving a potentially abnormal appendix must be weighed against the risk of appendectomy in each individual scenario. Cases of postoperative symptoms requiring reoperation for appendectomy have been described in patients whose normal appendix was left in place at the time of the original procedure. The risks of leaving in situ an apparently normal appendix are related to later AA, subclinical or endo-appendicitis with persisting symptoms, and missed appendiceal malignancy. 041b061a72


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