The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

/pdf/the-sifipac-wses-sicg-simeu-guidelines-for-diagnosis-and-28c1mjyv18.pdf

The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition)

Background: Acute appendicitis (AA) is the most common surgical emergency in childhood. The risk of rupture is negligible within the first 24 h, climbing to 6% after 36 h from the onset of symptoms. Because of difficulty in accurate diagnosis of AA a significant number of children still are being managed when it is already perforated. There is always a need to make an early diagnosis of AA and to find out the risk factors associated with development of complication in this condition. Patients and Methods: A total of 102 patients with a clinical diagnosis of AA were admitted during the study period. On admission, a good clinical history and proper physical examination was performed. All the eligible patients who finally diagnosed clinically as having AA were planned for emergency open appendectomy. The removed appendix was sent for histopathological examination in all the study subjects. Results: Out of 102 cases, 93 cases were histopathologically appendicitis, rest nine cases showed no evidence of inflammation so the rate of negative appendectomy was around 9%. On histopathology normal appendix was found in nine patients (8.9%), AA in 71 patients (69.6%), complicated appendicitis (CA) which includes perforated and gangrenous appendicitis was present in 22 patients (21.5%). Perforations were more common in patients who were younger than 5 years. >60% patients presented with CA when the duration of pain was >72 h. Presence of appendicolith increased the probability of CA.

Complicated appendicitis: Analysis of risk factors in children

Objective. This study aimed to explore the laboratory markers associated with perforation in children with acute appendicitis. Methods. This retrospective study reviewed 1895 children (3–18 years old) with confirmed acute appendicitis from 2007 to 2017. Clinical (demographic characteristics, symptoms, and signs) and laboratory data (white blood cell count, C-reactive protein (CRP), procalcitonin, D-lactate, platelet count, bilirubin, aspartate aminotransferase, and alanine aminotransferase) were collected and compared between perforated and nonperforated groups. The logistic regression analysis was performed to identify independent risk factors. Results. Of all patients, 613 children were perforated. Children with perforation had significantly longer duration of symptoms, higher white blood cell count, CRP level, and neutrophils percentage, and lower serum sodium level. Elevated white blood cell count with CRP level and elevated neutrophils percentage with CRP level were found to be associated with risk of perforation. Conclusions. White blood cell count with C-reactive protein and neutrophils percentage with CRP are important markers in distinguishing perforated appendicitis from nonperforated appendicitis in pediatric subjects.

/pdf/laboratory-markers-in-the-prediction-of-acute-perforated-3euhnrm5ju.pdf

Laboratory Markers in the Prediction of Acute Perforated Appendicitis in Children.

Primary appendectomy is the current standard of care for treating uncomplicated acute appendicitis, but interest in conservative treatment with antibiotics alone has been increasing in recent years. Clinical trials so far have shown controversial results. A series of meta-analyses were reviewed. Studies comparing surgery versus antibiotics alone for treating uncomplicated acute appendicitis in adults were included. Descriptive statistics and data on treatment effects were retrieved and summarized. The conservative approach has a success rate of around 60 % and is associated with shorter pain duration, reduced analgesic medication, faster resolution of the inflammation process, lower expenses and quicker return to work. On the other hand, medical treatment leads to high (up to 20 %) readmission rates and more often requires surgery. An operative approach is associated with higher treatment success rates (>90 %) and very a low mortality rate. Based on the current body of evidence, the use of antibiotics for primary treatment of uncomplicated acute appendicitis cannot be routinely recommended. Appendectomy remains the gold-standard treatment.

/pdf/antibiotics-alone-versus-appendectomy-to-treat-uncomplicated-4k29cru6br.pdf

Antibiotics alone versus appendectomy to treat uncomplicated acute appendicitis in adults: what do meta-analyses say?

Background The aim of this study was to establish the diagnostic value of leucocyte count and neutrophil percentage in both diagnosing simple appendicitis and predicting complicated appendicitis. Methods The patients who underwent appendectomy with a clinical diagnosis of acute appendicitis (AA) between January 2011 and December 2012 were studied retrospectively. The data of total WBC count, neutrophil ratio, and physical findings were analyzed. Sensitivities and specificities of leucocyte count and neutrophil ratio were calculated. Results One hundred and fifty-nine patients, diagnosed with acute appendicitis, were operated. Simple appendicitis was detected in 82.4% of the patients and complicated appendicitis in 17.6%. Leucocyte count had low sensitivity and specificity for diagnosing acute appendicitis (67.5% and 36.3%, respectively). Neutrophil ratio had a sensitivity rate of 60.1% and specificity rate of 90.9%. Complicated appendicitis was more common in male patients. Leucocyte count was statistically higher in patients with complicated appendicitis. Conclusion Two inflammatory markers, leucocyte count and neutrophil ratio, were evaluated for diagnosing acute appendicitis. Neutrophil ratio had higher sensitivity and specificity for acute appendicitis. On the other hand, increased leucocyte count and male gender was found to be a risk factor for complicated appendicitis.

The clinical value of leucocyte count and neutrophil percentage in diagnosing uncomplicated (simple) appendicitis and predicting complicated appendicitis.

Introduction: Acute perforated appendicitis is associated with increased post-operative morbidity and mortality. Avoiding delays in surgery in these patients may play a role in reducing observed morbidity. Objective: To analyze the clinico-pathological profile and outcomes in a cohort of patients undergoing emergency appendicectomies for suspected acute appendicitis and to determine factors influencing the risk of perforated appendicitis in order to aid better identification of such patients and develop protocols for improved management of this subset of patients. Materials and Methods: A retrospective analysis of patients undergoing emergency appendicectomies following presentation with acute appendicitis to the Modbury hospital, South Australia from March 2007 to April 2011 was conducted. Statistical analyses were performed in SAS 9.2. Results and Discussion: 506 patients underwent emergency appendectomy for acute appendicitis which included equal number of male and female patients with a median age of 25 years. Perforated appendicitis was found in 102 (20%) patients. Post-operative morbidity was significantly higher in patients with perforated appendicitis (28.4% vs 4.7%; P P Conclusions: Acute perforated appendicitis is associated with high morbidity. The increased risk of perforation in males and elderly patients appears unrelated to delays in presentation, diagnosis, or surgery. Patients with clinically diagnosed acute appendicitis and an elevation in neutrophil count and CRP level must be considered candidates for early surgery as they are likely to have an appendicular perforation.

Acute perforated appendicitis: an analysis of risk factors to guide surgical decision making.

Background: There is lack of consensus on the incidence of appendiceal carcinoids in recent times. The influence of number of appendicectomies performed has been postulated to play a role in this. To determine the incidence and clinico-pathological profile of appendiceal carcinoids in a cohort of patients undergoing emergency appendicectomies for clinically suspected acute appendicitis, and examine the influence of the trend (if any) of the number of appendicectomies performed on the overall incidence of appendiceal carcinoids. Methods: A retrospective analysis of patients diagnosed with appendiceal carcinoids following presentation with acute appendicitis to the Modbury hospital, South Australia from March 2007 to April 2011. The patient cohort was divided into Group 1 (March 2007 - March 2009) and group 2 (April 2009 - April 2011) to study the influence of time trends on incidence of appendiceal carcinoids. Statistical analyses were performed using the Statistical Product and Service Solutions, SPSS 14.0 for Windows. Results: Of 506 patients who underwent emergency appendicectomy for acute appendicitis, 8 patients (1.6%) were found to have appendiceal carcinoids. The median age was 23 years with 7 patients being female. There was no difference in the incidence of appendiceal carcinoids over the two time periods (P < 0.12) . Conclusions: Appendiceal carcinoids were found in 1.6% of patients undergoing emergency appendicectomy for acute appendicitis. These tumors are found more commonly in young females with a predilection for the tip of the appendix. The perceived increased incidence appendiceal carcinoids appear to be unrelated to the increase in the number of appendicectomies being performed. doi: http://dx.doi.org/10.4021/wjon400w

/pdf/incidental-appendiceal-carcinoids-is-surgery-affecting-their-47xpcsmz3d.pdf

Incidental Appendiceal Carcinoids: Is Surgery Affecting Their Incidence?

Background: Background: Traditional salvage chemotherapy followed by autologous

https://doi.org/10.1097/01.hs9.0000847184.45889.7a

P1079: comparison of novel salvage regimens and traditional salvage chemotherapy in relapsed and refractory classic hodgkin lymphoma

Screening for colorectal neoplastic lesions following acute diverticulitis: Would a sigmoidoscopy suffice?

Background: Intramuscular myxomas (IM) are uncommon tumours composed of stellate cells set in a loose myxoid stroma through which course very delicate reticulin fibres. Since the first characterisation of IM as a distinct entity, their presence in different locations in the body has been increasingly reported. While the thigh muscles appear to be the most common site for these benign tumours, only 1 case of an IMM in the soleus muscle has been previously reported. Case report: We report a case of a right soleal IMM in a young lady whilst presenting the characteristic radiological features noted. Conclusion: To the best of our knowledge, this is only the second case of an IMM of the soleus muscle reported in literature.

Intramuscular myxoma involving the soleus muscle:: An uncommon tumour in an uncommon site!

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