Institutional variations in the management of patients with acute appendicitis

The purpose of this study was to evaluate institutional differences in preoperative workup, operative approach, complications, and cost in patients with acute appendicitis. A retrospective chart review was performed of all adults operated on for acute appendicitis from June 1999 to November 2000 at the University of New Mexico Hospital (UNMH) and Stanford University Medical Center (SUMC). Variables compared included age, race, sex, duration of symptoms, type of symptoms, results of radiographic evaluation, time from emergency room to operating room, operative approach (open vs. laparoscopic), operative time, length of hospital stay, pathologic findings, and complications. Statistical analysis was performed by means of Fisher’s exact test. A total of 154 appendectomies were performed for acute appendicitis at UNMH and 165 at SUMC. Statistically significant differences were found at UNMH vs. SUMC in time from emergency room to operating room (9.1 hours vs. 13.7 hours; P < 0.001), operative approach (48% laparoscopic vs. 29% open; P < 0.001), and negative appendectomy rate (13% vs. 4.8%; P < 0.001). There were no differences in the perforation rate or other complications. Cost analysis showed that $56,744 more was spent at UNMH for the additional negative appendectomy operations, whereas $99,842 more was spent at SUMC for the additional CT scans. Institutional differences in the management of patients with acute appendicitis can result in significant differences in cost without clinically significant differences in outcome. The use of clinical examination and laparoscopy as diagnostic modalities instead of CT scanning resulted in a more cost-effective approach. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

Suspected acute appendicitis: trends in management over 30 years

BACKGROUND: Tradition taught that patients with signs suspicious of acute appendicitis should be explored surgically, but studies in the 1960s found that if this group was closely observed about one-third recovered without treatment. To differentiate these patients a strict regimen of active observation was introduced and this has now been studied over 30 years. Ultrasonography, laparoscopy and computed tomography (CT) have also been used to clarify the diagnosis in these patients. METHODS: Papers on the management of patients with suspected appendicitis published since 1970 were traced through Index Medicus, English-language journals and Medline. All those that mention the use of observation are reviewed, with selective reports on the other methods used. The advantages and disadvantages of various methods of management are compared. RESULTS AND CONCLUSION: Active observation has yielded a consistently low negative appendicectomy rate without a rise in the perforation rate; there was one death in over 1600 patients. It has proved to be a practical method of discriminating between patients who do and do not need an operation. In this situation, both ultrasonography and CT yield some false-negative reports, so results must be checked at the bedside. Furthermore, CT involves exposure to significant doses of radiation.     

The seasonal incidence of acute appendicitis

The seasonal incidence of acute appendicitis in a black community is described. This phenomenon is explained and its implications for the aetiology and pathogenesis of this common disease are illustrated.     

Sex differences in presentation, management, and prognosis of patients with non-small cell lung carcinoma

Objective And Methods: To characterize gender differences in lung cancer, we conducted a retrospective analysis including all patients undergoing surgery for non-small cell lung carcinoma in a single institution over a 20-year period. RESULTS: Compared with men (n = 839), women (n = 198) were more likely to be asymptomatic (32% vs 20%, P =.006), nonsmokers (27% vs 2%, P <.001), or light smokers (31 pack-years vs 52 pack-years; P <.001). Squamous cell carcinoma predominated in men (65%), and adenocarcinoma predominated in women (54%). Preoperative bronchoscopy contributed more frequently to a histologic diagnosis in men (69% vs 49% in women, P <.001), and fewer pneumonectomies were performed in women (22% vs 32% in men, P =.01). After multivariate Cox regression analysis, women survived longer than men (hazard ratio, 0.72; 95% confidence interval, 0.56-0. 92; P =.009) independently of age, presence of symptoms, smoking habits, type of operation, histologic characteristics, and stage of disease. The protective effect linked to female sex was present in early-stage carcinoma (stage I and II) and absent in more advanced-stage carcinoma (stage III and IV). CONCLUSIONS: This study emphasizes strong sex differences in presentation, management, and prognosis of patients with non-small cell lung cancer.     

Explaining insurance-related and racial disparities in the surgical management of patients with acute appendicitis

BACKGROUND: Race and insurance status influence the likelihood of undergoing laparoscopic appendectomy (LA) versus open appendectomy for the treatment of acute appendicitis. We hypothesized that these disparities are caused by presenting hospitals' use of LA. METHODS: The analysis included 26,104 appendectomies for acute appendicitis in New York State during 2003 and 2004. Multiple logistic regression was used to determine independent predictors for undergoing LA versus open appendectomy. RESULTS: Before adjustment for individual hospital use of LA, both white patients (odds ratio [OR] = 1.28, 95% confidence interval [CI] 1.21-1.36; P < .0001] and privately insured patients (OR = 1.52, 95% CI 1.44-1.61; P < .0001) were more likely to undergo LA. Controlling for differential hospitals' use of LA decreased the OR for laparoscopic surgery to 1.08 (95% CI 1.01-1.15; P = .04) for white patients and to 1.22 (95% CI 1.15-1.31; P < .0001) for privately insured patients. CONCLUSIONS: Differences in presenting hospitals' use of LA maintain racial and, to a lesser extent, insurance-related disparities in the surgical management of patients with acute appendicitis.     

Changing trends in surgery for acute appendicitis

Background:

Laparoscopic appendicectomy (LA) offers faster recovery times and a reduced rate of wound infection compared with open appendicectomy (OA) but may be associated with more intra‐abdominal abscesses. This study examines the changing trends in management of appendicitis in a regional setting during service reorganization and compares infective complication rates for each procedure.

Methods:

Data were retrieved from the Lothian Surgical Audit database on 1824 patients treated for appendicitis by OA or LA during equal 31‐month periods before and after service reorganization in August 2002. Outcome measures were duration of admission, recovery time from operation to discharge and reintervention for infective complications. Analysis was by intention to treat.

Results:

The rate of LA in Lothian increased from 29·9 to 39·4 per cent (P < 0·001) after subspecialist service reorganization. Recovery time from operation to discharge was significantly shorter after LA than OA when results were stratified with respect to sex (mean 2·5 versus 4·4 days respectively in women, P < 0·001; 2·7 and 3·1 days in men, P = 0·023), timing of surgery (2·7 versus 3·3 days before subspecialization, P = 0·007; 2·5 versus 3·6 days after subspecialization, P < 0·001) and whether appendicitis was associated with peritoneal contamination (2·2 versus 3·0 days for uncontaminated surgery, P < 0·001; 4·3 versus 5·1 days for contaminated surgery, P = 0·060). Peritoneal contamination at primary operation was the only independent risk factor that predicted reintervention for infective complications.

Conclusion:

LA is associated with a shorter hospital stay from operation to discharge than OA, with no evidence of an increased rate of intra‐abdominal infective complications. Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Ultrasonography in the management of acute appendicitis

Background: Ultrasonography (US) shows promise in the diagnosis of acute appendicitis. Methods: The authors present their own experience in ultrasonography (US) employed in the diagnosis of appendicitis, based on 40 patients admitted to the Department of Surgery of the University of Perugia. Results: US was found to be easily obtainable and reliable; it had good specificity and sensitivity, was not very time consuming, and had a good cost/benefit ratio. Conclusions: The authors believe US is an important diagnostic tool that can reduce useless laparotomies for false acute appendicitis, particularly in cases presenting with unclear clinical findings.     

Laboratory tests in patients with acute appendicitis

BACKGROUND: Laboratory measurements such as leucocyte count, neutrophil percentage and C-reactive protein (CRP) concentration are commonly used as diagnostic aids in patients with suspected acute appendicitis. The present study aimed to clarify the role of these laboratory tests in diagnosing acute appendicitis. METHODS: The medical records of 897 patients who underwent appendicectomy for suspected acute appendicitis during a 30-month period were retrospectively reviewed. The laboratory findings were correlated with the histopathology of the excised appendices. Data were analysed to calculate the sensitivity and specificity of the individual tests, as well as the test combinations. RESULTS: Histologically verified appendicitis was found in 740 of the 897 patients (82.5%). The rise in leucocyte count and neutrophil percentage correlated with the degree of appendiceal inflammation. The median CRP level was much higher in the patients with ruptured appendicitis compared with that in patients with a normal appendix (96.8 vs 39.6 mg/L, P < 0.001). However, patients with uncomplicated appendicitis had a lower median CRP concentration than those with a normal appendix, although the difference was not statistically significant (24.1 vs 39.6 mg/L, P = 0.079). The sensitivity of leucocyte count, neutrophil percentage and CRP in diagnosing acute appendicitis was 85.8, 87.2 and 76.5%, respectively, whereas the specificity was 31.9, 33.1 and 26.1%, respectively. Of the 740 patients with acute appendicitis, only six had all three tests simultaneously within the reference interval. CONCLUSIONS: Abnormal laboratory findings cannot reliably deliver a diagnosis of acute appendicitis. However, acute appendicitis is very unlikely when leucocyte count, neutrophil percentage and CRP level are simultaneously normal.     

CT scan in the management of acute appendicitis

BACKGROUND: Recent studies demonstrate a 98% accuracy of a CT scan in the diagnosis of acute appendicitis. We aimed to determine the accuracy and clinical value of CT scans in patients suspected of having acute appendicitis. PATIENTS AND MATERIALS: We reviewed outcomes of 125 patients over a 5-month period who had CT scans for the initial diagnosis of acute appendicitis. CT scan interpretations were correlated with surgical and pathologic findings. Follow-up was attempted in all patients who did not undergo appendectomy. RESULTS: CT scans and clinical courses were complete in 110 patients (88%); 14 patients were lost to follow-up and 1 was excluded. One patient had two CT scans. Thus, there were 111 CT scans available for review. Radiologic interpretation of these CT scans yielded 36 positive (33%), 67 negative (60%), and 8 indeterminate (7%), resulting in a sensitivity of 90%, a specificity of 89%, a PPV of 78%, and a NPV of 96%. CONCLUSIONS: CT scan may be useful in the diagnosis of acute appendicitis, but the reported high accuracy rate was not reproduced at our institution. CT scan was not clinically useful in 21% of patients. We conclude that a CT scan may be beneficial in the diagnosis of appendicitis with selected patients who have equivocal findings. Thus, at our institution, the accuracy of a CT scan does not justify its routine use in patients with clinical findings of appendicitis.     

Laparoscopy in the contemporary management of acute appendicitis

BACKGROUND: We sought to compare laparoscopic appendectomy (LA) with open appendectomy (OA) focusing on the negative appendectomy rate (NAR), emergency department (ED) to operating room (OR) time, procedure length, and histopathological correlation. METHODS: All appendectomies for appendicitis over a 6-year period at a single hospital were reviewed. Open and laparoscopic procedures were compared. RESULTS: There were 1,312 appendectomies (54.6% OA and 45.4% LA) Mean ED to OR time was as follows: LA 10.8 hours (standard deviation [SD] +/- 9.0) versus 9.8 hours (SD +/- 8.5) OA (P = .0333). Mean OR time was 61.2 minutes (SD +/- 29.1) LA versus 57.7 minutes (SD +/- 28) OA (P = .0293). NAR was 18.3%, LA 23.3% versus 14.0% OA (P < .0001). Postoperative correlation with histopathology was 86% for LA versus 92% OA (P = .0003). In the LA group, 9.9% with a "normal" appendix had appendicitis by histopathology. CONCLUSIONS: LA is associated with increased presentation to procedure time, operative time, and negative appendectomy rate. Removing a "normal" appendix during LA in the absence of alternate pathology is recommended.     

白血病并发急性阑尾炎的外科处理

目的：提高对白血病并发急性阑尾炎时的诊断和治疗水平。方法：对我院1980-2002年间收治的17例该病例进行回顾性分析。结果：均于全麻下行阑尾切除术,治愈16例,死亡1例。结论：白血病患者化疗期间较正常人更易罹患急性阑尾炎,应首选手术治疗。患者免疫及凝血功能低下是增加手术危险性的主要原因。故围手术期应采用相应的措施。因术后切口并发症多见,需加强术后切口观察。     

腹腔镜治疗阑尾炎497例

目的:总结腹腔镜阑尾切除术在治疗阑尾炎中的效果。方法:回顾分析经腹腔镜行阑尾切除术497例的临床资料,并与同期剖腹治疗阑尾炎进行比较。结果:497例中63例无法满意处理残端或盲肠壁内阑尾、腹膜外位阑尾而中转开腹。11例腹腔脓肿,9例皮下气肿,6例术后肩背部疼痛,余者无粪瘘、肠粘连、切口感染、阑尾残株炎等术后并发症。结论:经腹腔镜治疗阑尾炎为首选治疗方式。经腹腔镜切除阑尾可取代传统的开腹阑尾切除术。     

Laboratory tests in patients with suspected acute appendicitis

The clinical usefulness of preoperative determination of total and differential white blood cell count and C-reactive protein was studied in 113 patients undergoing emergency appendectomy for suspected acute appendicitis. The diagnosis was confirmed in 86 (76%) of the patients. In all 86 cases at least one of the three laboratory tests gave an abnormal result. The highest incidence of abnormal results was found in the most advanced stages of inflammatory reaction in the appendix. In nine of the 27 patients with histologically normal appendix all three laboratory parameters were normal. The "negative appendectomy rate" would have fallen from 24% to 16% in this study if the patients with negative results in all three tests had not been operated on.     

急性阑尾炎患者早期止痛的临床探讨

目的 探讨早期使用止痛剂(盐酸哌替啶)对急性阑尾炎患者腹痛症状缓解、体格检查、诊断准确性和治疗效果的影响.方法 对120例急性阑尾炎进行疼痛VAS评分和早期止痛意愿调查,94例实施手术,73例VAS 5级以上者分为实验组与对照组进行统计学分析.结果 94例急性阑尾炎VAS 4级腹痛为21例(22.34%)均无止痛意愿;5～7级中度疼痛者为47例(50.00%),其中有16例(34.04%)要求紧急止痛处理;8级剧烈疼痛患者26例(27.66%)中有23例(88.46%)要求紧急止痛;73例腹痛VAS 5级以上紧急止痛意愿率为53.42%,39例有紧急止痛意愿患者予盐酸哌替啶1.5 mg/kg肌肉注射,30～45 min后再次评估,疼痛评分下降2～5级,平均3.10级,止痛效果良好.实验组和对照组二次腹痛评估差异有统计学意义(P＜0.05);而二次体格检查的腹部压痛部位均无改变,部分病例腹部压痛程度有所改变但未影响诊断,平均住院时间、术后并发症、误诊率的比较差异均无统计学意义(P＞0.05).结论 早期止痛可有效缓解急性阑尾炎患者的腹痛症状,对体格检查、诊断准确性和治疗效果无影响.     

Role of laparoscopy in the management of acute appendicitis

Minimal invasive surgery had a considerable impact on common surgical techniques and has almost replaced established operative procedures such as cholecystectomy. However, the laparoscopic approach for the treatment of acute appendicitis is still not very popular. We discuss the role of laparoscopy for appendectomy and include three studies from our institution (University Hospital Zürich, Switzerland) and prospective studies reported in the literature. We conclude that laparoscopic appendectomy, when compared with the open approach, has the following advantages for the diagnosis and treatment of acute appendicitis. (1) Diagnostic laparoscopy is an effective and relatively atraumatic tool to investigate the abdominal cavity, which results in a sensitivity of almost 100%. This allows for accurate decision making, which is especially advantageous in young women and obese patients. (2) Prospective studies demonstrate that laparoscopic appendectomy is at least as good as open appendectomy and that the laparoscopic approach results in a reduced postoperative infection rate. (3) The similar complication rate after laparoscopic appendectomy, when performed by residents rather than staff surgeons, underlines the feasibility and teaching potential of this minimal invasive procedure.     

Gender-related differences in the management of non-ST-elevation acute coronary syndrome patients

OBJECTIVES: To compare management and outcome of female and male non-ST-elevation acute coronary syndrome (ACS) patients. DESIGN: FINACS Studies are prospective registries of non-ST-elevation ACS patients conducted in 2001, 2003, and 2005 in nine hospitals. RESULTS: The studies enrolled 1,399 patients from which 39% were women. During hospitalisation women were treated less often than men with aspirin (odds ratio [OR]) for women 0.60, 95% confidence interval [CI] 0.41 to 0.88, p=0.03). Women underwent less often in-hospital coronary angiography than men (adjusted OR 0.71, 95% CI 0.55 to 0.93, p=0.01). Also in the subgroup of younger (<75 years) high-risk patients, female sex was independent predictor for not performing in-hospital angiography (OR 0.64, 95% CI 0.42 to 0.97, p=0.04). Age-adjusted mortality at 6 months was similar between men and women. CONCLUSIONS: Compared to men women received less often aspirin. Women were referred less often to in-hospital coronary angiography. Under-use of in-hospital angiography was evident also in patients with high-risk features when guidelines recommend early invasive treatment.