Appendiceal mass:Is interval appendicectomy “something of the past” ?

The need for interval appendicectomy (I.A) after successful conservative management of appendiceal mass has recently been questioned.Furthermore,emergency appendicectomy for appendiceal mass is increasingly performed with equal success and safety to that performed in non-mass forming acute appendicitis.There is an increasing volume of evidence-although mostly retrospective-that if traditional conservative management is adopted,there is no need for routine I.A except for a small number of patients who continue to develop recurrent symptoms.On the other hand,the routine adoption of emergency laparoscopic appendicectomy (LA) in patients presenting with appendiceal mass obviates the need for a second admission and an operation for I.A with a considerable complication rate.It also abolishes misdiagnoses and deals promptly with any unexpected ileo-cecal pathology.Moreover,it may prove to be more cost-effective than conservative treatment even without I.A due to a much shorter hospital stay and a shorter period of intravenous antibiotic administration.If emergency LA is to become the standard of care for appendiceal mass,I.A will certainly become 'something' of the past.

Efficacy of Laparoscopic Approach for Appendicectomy and Orchiopexy across the Pediatric Age and Size Spectrum

Context: It remains, as yet, an issue unsettled?by evidence that whether the younger age and smaller size of the pediatricpatient affect the efficacy of laparoscopy for appendicectomy and intraabdominal testes. Aims: To prospectively assess the level of difficulty, surgical stress and outcomes of two commonly done laparoscopic procedures?i.e., appendicectomy and orchiopexy for intraabdominal testes, across the pediatric age and size spectrum. Settings and Design: Prospective interventional study conducted in Pediatric Surgery department of a tertiary hospital.?Subjects and Methods: From April 2013 to August 2014, 60 children underwent either laparoscopic interval appendicectomy or orchiopexy (unilateral or bilateral) by same surgeon. Difficulty level, metabolic stress and other clinical outcomes of the laparoscopic procedures were compared across various age groups. Statistical Analysis: Kruskal-Wallis test was used to compare various age groups with respect to the study variables. Results: The patients were divided into three groups?with age ranges of 1 - 6 years, 6 - 9 years and 9 - 13 years. The three groups were very different (P?= 0.000) with respect to the body surface area of included children. Each of the three age groups had a similar set of 20 laparoscopic procedures?viz., 10 appendicectomies, 8 unilateral orchiopexies and 2 bilateral orchiopexies. The three groups had no difference in the total level of difficulty score, duration of capnoperitoneum, postop increase in serum CRP and blood glucose levels (surrogates for metabolic stress sustained due to surgery), time to full orals and postop hospital stay. Conclusion: The younger age and smaller size of patient do not affect the efficacy of laparoscopic appendicectomy and orchiopexy.

Back to basics:A meta-analysis of stump management during open appendicectomy for uncomplicated acute appendicitis

AIM: To compare simple ligation vs stump invagination during open appendicectomy for uncomplicated acute appendicitis on the risk of postoperative complications. METHODS: A meta-analysis was conducted on randomised controlled trials comparing the two stump closure methods in open appendicectomy. Databases searched were Pub Med, EMBASE and Cochrane Library databases. Included were those studies focusing on inflamed and suppurative appendicitis while perforated and gangrenous appendix was excluded. We also excluded retrospective case-control studies, commentaries, historical technical articles, or trials involving laparoscopic appendicectomies. The outcome of the meta-analysis was to find eventual differences in theincidence of postoperative ileus and wound infections between the two techniques of stump invagination. RESULTS: Seven studies were included corresponding to 1468 patients. Postoperative complications consisted in wound infections(7%), ileus(4%), pyrexia(2%), vomiting(1%), obstructions from adhesions(0.1%). No cases of peritonitis, fecal fistulas(stump leaks), abdominal abscesses or wound dehiscences were reported. Postoperative ileus within the first 72 h was four times more frequent with stump invagination compared to simple ligation(OR: 4.06; 95%CI: 2.14-7.70; P < 0.0001). No significant differences were noted for wound infections(OR: 1.24; 95%CI: 0.83-1.87; P = 0.30) while for the remaining complications the incidence was extremely low in both groups. There was a high homogeneity on results(Q value for heterogeneity of postoperative ileus P = 0.17; Q value for heterogeneity of wound infections P = 0.98). CONCLUSION: Stump invagination does not seem to prevent infective complications but is associated with an increased risk of postoperative ileus in uncomplicated cases. Appropriate studies on complicated appendicitis should now evaluate the influence of the two techniques in this higher-risk subgroup.

Intraperitoneal drains during open appendicectomy for gangrenous and perforated appendicitis

Intra-abdominal drains are still routinely used in the surgical management of gangrenous and perforated appendicitis. A systematic review was performed with the aim of establishing their influence on postoperative complications in such cases. A literature search was conducted using the search engines Pub Med and Cochrance Central Register of Controlled Trials. Included were retrospective case-controlled and prospective randomized controlled trials on the use of drain for open appendicectomy in gangrenous and perforated appendicitis. Twelve articles were found that met the inclusion criteria. Intrabdominal abscesses, postoperative ileus, surgical site infections, fecal fistulas and burst abdomen had significant higher incidences in the drain vs non drain group(10.3%, 20.3%, 32.5%, 3.4% and 5.7% vs 4.7%, 8.5%, 16.2%, 0% and 0%, respectively). In most cases the risk was more than doubled in the drain group compared to the non-drain one. There were no significant differences among groups in termsof mortality while the results were underpowered to effectively evaluate wound dehiscence and adhesions. The use of intra-abdominal drains in the management of gangrenous and perforated appendicitis by open appendicectomy is associated with an increased rate of common postoperative complications.

A Case of Anesthetic Treatment of Appendicectomy to a Patient under Potato Poisoning

We reported a case of anesthetic treatment of appendicectomy to a patient under potato poisoning. The overview of potato poisoning has been reviewed in the report and the symptom of the patient under potato poisoning comparing with other appendicitis patients has been described. We highlighted the deference of methodology of anesthetic treatment comparing the patient under potato poisoning with other appendicitis patients.

Clinical study of enhanced recovery after surgery in laparoscopic appendectomy for acute appendici

BACKGROUND Enhanced recovery after surgery(ERAS)protocol is a comprehensive manage-ment modality that promotes patient recovery,especially in the patients undergo-ing digestive tumor surgeries.However,it is less commonly used in the appen-dectomy.AIM To study the application value of ERAS in laparoscopic surgery for acute appen-dicitis.METHODS A total of 120 patients who underwent laparoscopic appendectomy due to acute appendicitis were divided into experimental group and control group by random number table method,including 63 patients in the experimental group and 57 patients in the control group.Patients in the experimental group were managed with the ERAS protocol,and those in the control group were received the tra-ditional treatment.The exhaust time,the hospitalization duration,the hospita-lization expense and the pain score between the two groups were compared.RESULTS There was no significant difference in age,gender,body mass index and Sunshine Appendicitis Grading System score between the experimental group and the con-trol group(P>0.05).Compared to the control group,the patients in the expe-rimental group had earlier exhaust time,shorter hospitalization time,less hospi-talization cost and lower degree of pain sensation.The differences were statis-tically significant(P<0.01).CONCLUSION ERAS could significantly accelerate the recovery of patients who underwent la-paroscopic appendectomy for acute appendicitis,shorten the hospitalization time and reduce hospitalization costs.It is a safe and effective approach.

Interval routine appendectomy following conservative treatment of acute appendicitis: Is it really needed?

Conservative management of acute appendicitis (AA) is gradually being adopted as a valuable therapeutic choice in the treatment of selected patients with AA. This approach is based on the results of many recent studies indicating that it is a valuable and effective alternative to routine emergency appendectomy. Existing data do not support routine interval appendectomy following successful conservative management of AA; indeed, the risk of recurrence is low. Moreover, recurrences usually exhibit a milder clinical course compared to the first episode of AA. The role of routine interval appendectomy is also questioned recently, even in patients with AA complicated by plastron or localized abscess formation. Surgical judgment is required to avoid misdiagnosis when selecting a conservative approach in patients with a presumed &#x0201c;appendiceal&#x0201d; mass.

Effects of appendectomy and oral tolerance on dextran sulfate sodium colitis

AIM： To evaluate the concomitant effects of appendec- tomy and oral tolerance on colitis.METHODS： Delayed-type hypersensitivity （DTH） was investigated at a 7-d interval after ovalbumin （OVA） ad- ministration and immunization under normal and colitis conditions in appendectomized or sham-operated mice. Pathological scores for the colon were graded after in- gestion of colon-extracted protein （CEP） and induction of dextran sulfate sodium （DSS） colitis in appendecto- mized or sham-operated mice. Thereafter, Thl and Th2 in Peyer＇s patches and spleen lymphocytes were de- tected in CEP-treated and bovine serum albumin （BSA）-treated control mice.RESULTS： In appendectomized mice, DTH was not inhibited at day 7 after OVA administration and at the initial phase of DSS colitis, whereas it was inhibited at day 14 and day 21. However, in sham-operated mice, it was inhibited during the whole procedure and the onset of DSS colitis. The protective role of CEP against DSScolitis was present in sham-operated mice, with pre- dominant improvement of colonic pathological changes, while vanished in the appendectomized mice. A shift from Thl to Th2 in Peyer＇s patches resulted from a de- crease of Thl cells with the ingestion of CEP. Compared with BSA in the sham-operated group, no predominant changes were observed in the appendectomized mice.CONCLUSION： Appendectomy interferes with the pro- tective role of CEP in DSS colitis via a shift from Th2 to Thl during oral tolerance induction.

Low Grade Appendiceal Mucinous Neoplasm Presenting as a Mucocoele of the Appendix

Low grade appendiceal mucinous neoplasm (LAMN) is a rare malignancy with incidence of 0.7% to 1.7% of all appendicectomies [1]. LAMN has the worst complication of mucin seeding into adjacent peritoneum leading to pseudomyxoma peritonei. LAMN lacks standardised treatment approach where only appendicectomy is preferred for resection of non metastatic disease. Case Presentation A 38 yr old female presented with right lower quadrant where CT Abdomen revealed Mucocele of Appendix. Patient underwent Laparoscopic Appendicectomy and Histopathological examination revealed Low grade appendiceal mucinous neoplasm. Patient is on regular follow up and is disease free. Conclusion low grade appendiceal mucinous neoplasm is usually an incidental finding where treatment depends on staging and histology of the tumour.