Appendicitis in the elderly: a change in the laparoscopic era

BACKGROUND: Appendicitis in elderly patients is associated with significant morbidity and mortality. Early and correct diagnosis together with minimally invasive surgery can lead to more favorable outcomes than occurred in the prelaparoscopic era. METHODS: A retrospective review of 116 elderly patients (age > 60) from 1999 to 2004 is compared with the authors' previously published studies from 1978 to 1988 (n = 96) and from 1988 to 1998 (n = 113), respectively. RESULTS: In our current series (1999-2004), more cases were managed laparoscopically (n = 68) than with open surgery (n = 48). Perforated appendicitis cases resulted in significantly longer hospital stays, more complications, and longer operating time than nonperforated cases. The laparoscopic cases had significantly shorter lengths of hospital stay and fewer complications than open cases, and comparable operating times. As compared with our previous studies from 1978 to 1988) and from 1988 to 1998, the current series (1999-2004) consists of patients presenting with fewer classical symptoms. Computed tomography (CT) scanning was more accurate in the current study and more routinely used. The patients in the current series had more correct preoperative diagnoses. Perforated appendicitis was encountered less frequently and associated with fewer complications. The 4% mortality rate in the previous two series decreased to less than 1% in this series. CONCLUSION: Minimally invasive surgery combined with increased use and accuracy of preoperative CT scans has changed the clinical management of acute appendicitis in elderly patients, leading to decreased lengths of stay, decreased mortality, and more favorable outcomes.     

Appendicitis in the Elderly

The charts of 68 patients from 65 to 99 years of age who underwent appendectomy for appendicitis were reviewed between 1964 and 1976. Thirty-three were men and 35 women. All patients underwent appendectomy. Four patients had normal appendices. The remainder had appendicitis; 74% were ruptured. The duration of symptoms varied greatly, and was related to outcome. The mean duration was 58 hours, but both those who died and those who suffered complications had significantly longer mean duration while those who had an uncomplicated course had a shorter mean duration of symptoms. The incidence of rupture rose from 60% in those seen with symptoms less than 48 hours to 90% in those with symptoms longer than 49 hours. Delay was invariably related to delay in seeking medical treatment. In no case was the patient under the care of another physician for an extended period of time. Pain was the chief complaint in 63 patients, and was present in all. Seventy-four per cent had fever and 78% had leukocytosis. Those with normal appendices had normal white blood cell counts. Right lower quadrant tenderness was present in 80%. Thirty-nine per cent had significant additional medical problems. Most (73%) had operation within six hours of their original evaluation, and yet the overall complication rate was 34% including six deaths. Delay during evaluation did not correlate with unsatisfactory outcome as did delay in seeking medical attention. The most common complications were due to infection. In at least three of the deaths wound infection was associated with sepsis and death. Delay in seeking medical care, advanced age, and underlying problems were the most significant factors in those who died.     

Appendicitis in the aged

Peculiarities relating to appendicitis in advanced age are described in this paper, with reference being made to a prospective study conducted in 1982 into acute abdominal processes. Covered by that study were 545 patients with acute abdominal symptoms. Reference was also made to an evacuation of 890 cases of appendectomy performed between 1983 and 1985. Appendicitis was found to be relatively rare in advanced age and accounted for merely seven per cent of all appendectomies. Frequent reports on increased perforation rates in advanced age were confirmed by the authors' own findings. Presurgical diagnostic accuracy was between 70 and 75 per cent, relative to the surgeon's visual intra-operative findings. The assumption has to be made that in 25 to 30 per cent of all appendectomies the vermiform appendix processus is removed without detection of any acute inflammation. In patients in advanced age, particular attention should be given to renal and urinary tract findings with complaints that might encourage falsely positive indications for laparotomy.     

Appendicitis in the aged

From 1984 to 1989 78 patients over the age of 60 years were operated on acute appendicitis. Compared to appendicitis in younger people these older patients showed 3 times longer an interval between the first appearance of symptoms and their contact to the doctor, or surgical treatment. As result of this longer period appeared the high perforation rate 53.8%. In this group of patients with perforation the complication rate was 4 times higher than the intraoperative and histologically confirmed acute appendicitis. From these facts results a mortality rate of 4%. In the retrospective evaluation was also seen that there was no conclusion between the laboratory parameters, the physical symptoms and the degree of the inflammation of the evidence of perforation with local or diffused peritonitis. The inclusion of appendicitis in the differential diagnosis of acute abdominal pain in older people offers the chance of an earlier surgical treatment, so reducing the risk of postoperative complication and mortality.     

Appendicitis in the obese child

Background/Purpose

Little data exist that examine the surgical challenges of obese children. We hypothesize that obesity affects the presentation, diagnosis, surgery, and postoperative course in children with appendicitis.

Methods

Cases of all children treated for appendicitis over 6 years were reviewed retrospectively. Demographics, presentation, pathology, and hospital course were examined.

Results

A total of 282 cases were reviewed; 25 were moderately obese and 31 very obese (VO), which were defined, respectively, as greater than 1.5 and greater than 2 standard deviations above the standardized mean weight for age. Groups were similar in age, sex, presentation, use of ultrasound, and surgical management. Compared with the nonobese group, median operative time was higher in the VO group (63.5 vs 55.5 minutes; P = .028), with the association between obesity and longer operative time maintained when stratifying for perforated/nonperforated and open/laparoscopic cases. Almost twice as many VO children were in the hospital for more than 5 days (nonobese 23.6%, VO 40.0% [odds ratio, 2.2; 95% confidence interval, 0.99-4.8]). This association between obesity and longer length of stay was seen when stratifying for both perforated and nonperforated cases. In the perforated group, higher rates of postoperative wound infections and significantly longer times to full diet and ambulation likely contributed to these longer stays.

Conclusions

Childhood obesity is associated with longer surgery and hospital stays and increased risk of postoperative infections. Obesity should be considered an important variable when looking at surgical outcomes in the pediatric population.     

Appendicitis in children

Among children presenting to hospital with abdominal pain, acute appendicitis is common. The history is short in the majority. Where the diagnosis is in doubt, active observation and judicious investigation are appropriate. For confirmed cases and children in whom appendicitis is strongly suspected, surgery is the standard treatment though the child with an appendix mass can initially be managed conservatively. Adequate resuscitation and broad-spectrum antibiotics are important pre-operatively to ensure successful outcomes. Appendicectomy can be carried out open or laparoscopically. Laparoscopic appendicectomy is becoming the intervention of choice where facilities and expertise are available. Operating late at night and in the early hours of the morning is not recommended. Complications of the disease include rupture with localized or generalized peritonitis. Surgical and post-operative complications include injury to the bowel or the ureter which are both uncommon, but abscess formation is frequently seen. While acute appendicitis remains a cause of morbidity and occasionally mortality, with timely presentation the majority of children have a good outcome.     

Appendicitis in pregnancy

Appendicitis continues to be the most common nonobstetric surgical diagnosis in pregnancy. Historically, this diagnosis has been associated with an increased risk of fetal loss as well as maternal morbidity. The physiologic and anatomic changes in pregnancy have been thought to obscure and thus delay the diagnosis of acute appendicitis, contributing to its increased risk in pregnancy. Such increased risks have been well reported in literature. To further evaluate the overall incidence, to determine the factors contributing to delay in diagnosis, and to assess overall outcomes in appendicitis in pregnancy, we performed a retrospective contemporary evaluation of pregnant patients with the diagnosis of acute appendicitis during the period 1991-1998. Twenty-two patients had the combined admitting diagnoses of pregnancy and acute appendicitis among 44,845 deliveries for the same time period (incidence, 0.05%). Gestational stage at diagnosis was the first trimester in 5 patients (22%), second trimester in 6 patients (27%), and third trimester in 11 patients (50%). Nineteen patients (86%) had pathologically proven acute appendicitis. Sixteen patients (73%) presented with less than 24 hours of abdominal symptoms. Seventeen patients (77%) presented with findings of rebound and guarding on initial physical examination. Fifteen patients (68%) were taken to the operating room within 24 hours of presentation. Of these, 10 patients (68%) had acute perforated appendicitis. Overall, there were 12 cases of perforated appendicitis (55%), which is an incidence higher than what has been reported in literature. There were no instances of fetal mortality. Preterm labor occurred in 5 patients, all in their third trimester with perforated appendicitis. Our study found that our population paralleled the incidence of gestational appendicitis of 0.05-0.07 per cent; physical examination on presentation was the most reliable diagnostic tool for appendicitis; and there is a higher incidence of perforation with increased gestational age, which does not result in increased fetal mortality.     

Appendicitis in infancy

One percent (40 infants) of all the children treated for acute appendicitis at Our Lady's Hospital for Sick Children presented during the first 2 yr of life. Nineteen of the 40 children had an appendix mass at the time of the diagnosis. Conservative management of the appendix mass followed by delayed elective appendectomy is a safe and effective method of treatment.     

Appendicitis

Appendicitis is a common condition, occurring in 250,000 patients every year in the United States and accounting for an estimated 1 million hospital days per year. Acute appendicitis is the most common cause of an acute abdomen that requires surgical treatment. A diagnosis can be made on clinical grounds in most patients, but imaging studies are useful in patients with equivocal findings. Prompt diagnosis and surgical treatment are the cornerstones of therapy to preempt progression of the disease to perforation that is associated with increased morbidity. Both laparoscopic and open appendectomy are viable surgical options, with most recent studies suggesting more favorable outcomes with a laparoscopic approach. In practice, the choice for either is usually based on the expertise of the surgeon along with the availability of hospital resources.The precise etiology of appendicitis is unclear. Accordingly, surgeons will continue to evaluate and treat patients with appendicitis for the foreseeable future. The liberal use of imaging modalities to improve the accuracy of preoperative diagnosis and minimize the negative appendectomy rate is a trend that is likely to continue. Operating on a patient without an imaging examination may often be appropriate, but will be the exception, not the rule. Finally, the trend toward laparoscopy is relatively slow compared with its adoption for the surgical treatment of other diseases, but inexorable. It would not be surprising if laparoscopic appendectomy becomes the most popular treatment for appendicitis in the future.     

Appendicitis in childhood

Appendicitis in infancy has proved to be accompanied by particular problems in general and differential diagnosis. Recommendations are made for proper establishment of case histories as well as for clinical examination and surgical approach, with reference being made to the authors' own experience. The authors' perforation rate was 7.3 per cent in more than 1,000 appendectomies on children (up to 20 per cent in literature). Reported in this paper is experience obtained from treatment of severe cases.