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Objectives: To perform a systematic review on the use of magnetic resonance imaging (MRI) of the abdomen to evaluate clinically suspected appendicitis in the general adult population. We examined the diagnostic accuracy, the reported trends of MRI use, and the factors that affect the utility of MRI abdomen, including study duration and cost-benefits. Methods: We conducted a systematic literature search on PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library databases. We enrolled primary studies investigating the use of MRI in diagnosing appendicitis in the general adult population, excluding studies that predominantly reported on populations not representative of typical adult appendicitis presentations, such as those focusing on paediatric or pregnant populations. Results: Twenty-seven eligible primary studies and 6 secondary studies were included, totaling 2,044 patients from eight countries. The sensitivity and specificity of MRI for diagnosing appendicitis were 96% (95% CI: 93–97%) and 93% (95% CI: 80–98%), respectively. MRI can identify complicated appendicitis and accurately propose alternative diagnoses. The duration of MRI protocols in each primary study ranged between 2.26 and 30 minutes, and only one study used intravenous contrast agents in addition to the non-contrast sequences. Decision analysis suggests significant benefits for replacing computed tomography (CT) with MRI and a potential for cost reduction. Reported trends in MRI usage showed minimal utilisation in diagnostic settings even when MRI was available. Conclusions: MRI accurately diagnoses appendicitis in the general adult population and improves the identification of complicated appendicitis or alternative diagnoses compared to other modalities using a single, rapid investigation. [ABSTRACT FROM AUTHOR]

Acute appendicitis is inflammation of the vermiform appendix. It is the commonest general surgical emergency in children and young adults, yet its diagnosis can still confound even the most skilled surgeon due to its highly variable presentation of appendicitis, with fewer than 50% of patients exhibiting classical features. Taking a detailed history and performing a careful examination remains the cornerstone of diagnosis. Urinalysis and blood tests, particularly C-reactive protein, are useful adjuncts and are performed routinely. Radiological imaging, commonly ultrasound and computed tomography scans, also have a role when the diagnosis is unclear and/or other common conditions need to be excluded, such as gynaecological pathology in young females. Nevertheless 20% of appendices removed in UK are histologically normal. Appendicitis scoring systems may further assist in stratifying risk and increasing the accuracy of diagnosis. Recently, there has been growing interest in non-surgical management of appendicitis, particularly during the COVID-19 pandemic. Antibiotics alone have been used to successfully treat uncomplicated appendicitis (without perforation, abscess or gangrene) in the short-term, however nearly 40% of these cases eventually require appendicectomy. Surgery, usually laparoscopic appendicectomy, remains the treatment of choice for acute appendicitis and non-operative management is reserved for specific cases. [ABSTRACT FROM AUTHOR]

Stump appendicitis, an inflammation of the residual appendix after appendicectomy, presents with all the clinical features of acute appendicitis. This variant poses diagnostic challenges, particularly in patients with right iliac fossa pain. We present a case of a 58-year-old man who developed an appendiceal stump abscess eight months after laparoscopic appendectomy. In addition to stable vital signs, abdominal examination revealed pain in the right lower quadrant. The CT scan showed a collection with a tubular structure corresponding to a remaining appendiceal stump. He underwent emergency laparoscopic surgery. Intraoperatively, a perforated stump and cecal involvement were noted, necessitating stump resection and abscess drainage. Literature review underscores stump appendicitis as rare but serious. Surgeons face challenges in accurately identifying the appendix base, crucial for preventing stump appendicitis. Imaging, especially computed tomography, aids diagnosis. Stump appendicitis complications, including necrosis and perforation, emphasize the need for prompt intervention. Differential diagnoses include cecal diverticulitis and duplicated appendix. Imaging techniques, particularly CT, play pivotal roles in diagnosis. Preventive measures include stump length control and heightened suspicion in patients with prior appendectomy. Surgical excision remains the preferred treatment, though optimal approach remains unclear. Stump appendicitis may manifest months to years post-appendectomy, necessitating vigilant follow-up. Awareness of this complication and prompt management are crucial for favorable outcomes. • Despite being a rare occurrence, stump appendicitis poses a significant clinical challenge. • The delay of this diagnosis can increase morbidity and can lead to serious complications. • The length of the appendiceal stump post-appendectomy is crucial in preventing stump appendicitis. • Ultrasonography and computed tomography play vital roles in diagnosing stump appendicitis. • Surgical excision remains the preferred treatment for stump appendicitis. [ABSTRACT FROM AUTHOR]

• Response of post-appendicectomy collections to medical management appears related to the size of the collection. • Weight adjusted volume (in ml/kg) appears to predict response to medical management more closely than maximum diameter or volume of collection alone. • A volumetric cut off (e.g. 2 ml/kg) may provide a practical guide to when to consider intervention e.g. percutaneous drainage. Intra-abdominal collections (IAC) are a common complication following appendicectomy, one of the most commonly performed emergency abdominal procedures in childhood. The option to drain a collection is frequently available but not always required. The aim of this study was to compare the outcomes of medically and procedurally-managed post appendicectomy IACs and suggest a method of standardising the need for intervention. A single centre, retrospective review of children aged ≤ 16 years presenting between 2014 and 2019 was performed. Patient demographics, management, and outcome data were collected. IAC volume and surface area were calculated assuming a prolate spheroid or true ellipsoid depending on the number of dimensions reported. 60 patients (18%) of 334 patients developed an IAC post appendicectomy. Medical management was undertaken in 44 (73%), drainage in 12 (20%), and surgical washout in 4 (7%). Collection size was associated with failure of medical management: maximum diameter (p = 0.028), volume (p = 0.002), and surface area (p = 0.001). Collections with a volume of 2 ml/kg were significantly less likely to fail medical management than larger collections (0/33 vs 6/11; p < 0.0001). Not all post appendicectomy IACs require drainage. The relationship between collection volume and need for drainage is more closely assessed using a volume calculation rather than a single dimension measurement, particularly when adjusted for weight of the child. A cut off of 2 ml/kg appears to be a good objective measure for intervention and provides a communication tool for discussion amongst the multidisciplinary team. Prospectively collected multicentre data on this subject would be timely. III. [ABSTRACT FROM AUTHOR]

Aims: The aim of this systematic review and meta-analysis is to compare outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis.Methods: A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis and trial sequential analysis of outcomes were conducted. Post-operative pain at 12-h, cosmesis, need for an additional port(s), operative time, port-site hernia, ileus, surgical site infection (SSI), intra-abdominal collection, length of hospital stay (LOS), readmission, and reoperation were the evaluated outcome parameters.Results: Sixteen RCTs with total number of 2017 patients who underwent SPLA (n = 1009) or CLA (n = 1008) were included. SPLA was associated with a significantly higher cosmetic score (MD 1.11, P= 0.03) but significantly longer operative time (MD 7.08, P = 0.00001) compared to CLA. However, the difference was not significant between SPLA and CLA in the post-operative pain score at 12-h (MD -0.13, P = 0.69), need for additional port(s) (RR0.03, P = 0.07), port-site hernia (RD: 0.00, P = 0.68), ileus (RR 0.74, P = 0.51), SSI (RR 1.38, P = 0.28), post-operative intra-abdominal collection (RR 0.00, P = 0.62), LOS (MD -2.41, P = 0.16), readmission to the hospital (RR 0.45, P = 0.22), and return to theatre (RR 0.00, P = 0.49). Trial sequential analysis demonstrated that the meta-analysis is conclusive for most of the outcomes, except LOS and intra-abdominal collection.Conclusion: Although SPLA is associated with a slightly longer operative time, its efficacy and safety are comparable to CLA in management of uncomplicated appendicitis. Moreover, it offers improved post-operative cosmesis. The available evidence is conclusive, and further trials may not be required. [ABSTRACT FROM AUTHOR]

Human appendix is critical for the maintenance of intestinal homeostasis. Appendicectomy has been the optimal treatment of acute appendicitis, yet the cancer incidence after appendix removal remains unclear. In this territory-wide retrospective cohort study, adult participants who underwent appendicectomy from 2000 to 2018 were retrieved from a population database (n = 43,983), while matched reference participants were retrieved as controls (n = 85,853). After appendicectomy, the overall cancer risk was significantly increased (subdistribution hazard ratio (SHR) = 1.124) compared to the non-appendicectomy group. Appendicectomy-treated males had higher cancer risk than males without appendicectomy (SHR = 1.197), while such difference was not observed in female participants. Significant increase in cancer risk was also observed in elder participants (age >60) with appendicectomy (SHR = 1.390). Appendicectomy was positively correlated with the risk of digestive tract and respiratory cancers including colon (SHR = 1.440), pancreas (SHR = 1.930), and trachea, bronchus, and lung (SHR = 1.394). In contrast, the risk of liver cancer was markedly decreased after appendicectomy (SHR = 0.713). In conclusion, we reported the association of appendicectomy with subsequent cancer incidence. These findings highlight the potential complication after appendix removal and the necessity of post-operative management to monitor and prevent long-term adverse events. • Populational-based retrospective cohort analysis identified the increased risk of cancer in participants with appendicectomy. • The increased risk of cancer was more significant in males or elder participants after surgical removal of appendix. • Appendicectomy was associated with increased risk of digestive and respiratory cancers, as well as decreased risk of liver cancer. [ABSTRACT FROM AUTHOR]

Introduction: Acute Appendicitis and appendicectomy are common surgical emergencies worldwide. However, there is a lack of published data on the impact of hospital grade, surgeon- and hospital-volumes on patient outcomes following appendicectomy.Aim: To establish if hospital grade, hospital-volume, or surgeon-volume impacted patient outcomes following appendicectomy.Methods: Using the National Quality Assurance and Improvement System (NQAIS) data for all appendicectomies performed in Ireland between January 2014 and November 2017 were examined. Data relating to patient demographics, type of surgery (open/laparoscopic/laparoscopic converted to open), length of stay (LOS), mortality, admission to critical care and re-admission rates were collected and analysed.Results: During the study period, 15,896 adult appendicectomies were performed, 14,521 were laparoscopic procedures. Patients treated in district general hospitals (DGHs) had lower LOS (2.96 v 3.37 days, p < 0.0001) than patients treated in tertiary referral hospitals (TRHs), had lower rates of laparoscopic procedures (87.38% v 95.56% p < 0.0001) and higher admission rates to critical care (1.91% v 0.75% p < 0.0001). No significant outcome difference was seen between those treated by high-volume (>62 cases/year) or low volume surgeons (<20 cases/year). Patients treated in high-volume hospitals (>260 cases/year) had higher rates of laparoscopic procedures (94.9% v 83.5%, p < 0.0001), lower rates of admission to critical care (0.85% v 2.25%, p < 0.0001) and lower 7-day re-admission rates (2.54% v 3.55%, p = 0.02) than those operated in low-volume hospitals (<161 cases/year).Conclusion: Patients operated on in high-volume hospitals benefit from higher rates of laparoscopic surgery and fewer critical care admissions. No significant difference in outcome was noted in those patients operated upon by high- or low-volume surgeons or based on hospital grade. [ABSTRACT FROM AUTHOR]

Acute appendicitis is inflammation of the vermiform appendix. It is the most common general surgical emergency in children and young adults, yet its diagnosis can still confound the most skilled surgeon. This difficulty arises because the presentation of appendicitis is highly variable, with less than 50% of patients exhibiting classical features. Taking a detailed history and performing a careful examination remains the cornerstone of diagnosis. Urinalysis and blood test, particularly CRP are useful adjuncts and are performed routinely. Radiological imaging, commonly US and CT scans, also have a role when the diagnosis is unclear and/or other common conditions need to be excluded such as gynaecological pathology in young females. Nevertheless, 20% of appendices removed in UK are histologically normal. Appendicitis scoring systems may further assist in stratifying risk and increasing the accuracy of diagnosis. Recently, there has been growing interest in non-surgical management of appendicitis. Antibiotics alone have been used to successfully treat uncomplicated appendicitis, i.e. without perforation, abscess or gangrene, thereby potentially avoiding the risks of surgery. However, nearly 40% of these cases eventually require appendicectomy. Therefore surgery, usually laparoscopic appendicectomy, remains the treatment of choice for acute appendicitis and non-operative management is reserved for specific cases. [ABSTRACT FROM AUTHOR]

• Foreign body appendicitis in children may be caused by a variety of ingested foreign bodies. • Pins are the most common cause of foreign body appendicitis. • The reported incidence of bowel perforation is less than 1%, especially with sharp, thin, pointed or long objects. Ingestion of foreign bodies and their impaction at the lumen of the appendix is a very rare finding and only few cases have been reported all over the world. A variety of metallic foreign bodies when ingested may be lodged in the lumen of the appendix such as screws, bird shots, and needles. This is called in most literatures as foreign body appendicitis. A 4-year-old boy with history of an accidental ingestion of a metallic nail presented to the emergency department one week later with right iliac fossa pain and one attack of vomiting. During abdominal examination there was tenderness and rebound tenderness at the right iliac fossa. Plain abdominal X-ray showed the metallic nail in the region of the right iliac fossa. Ultrasound examination was normal apart from tenderness of putting the probe on the right lilac fossa. The white blood cell counts were 14,000 cell per microliter. During surgery the nail was found to be impacted inside the lumen of the vermiform appendix causing inflammation of the appendix. Appendicectomy done and the patient discharged on the third day in a good general condition. Acute appendicitis may be caused by a variety of causes including ingested foreign bodies if impacted in its lumen. When the patient has signs of generalized peritonitis it is important to exclude bowel perforation. The surgery can be done by the open surgery or laparoscopically. [ABSTRACT FROM AUTHOR]

Introduction Foreign body ingestion is a common clinical presentation with less than 1% of the cases requiring surgical intervention. In this report, we present a rare case of razor blades lodged in the appendix as a result of intentional ingestion. Presentation of case A 25 year old male prisoner presented to our hospital with persistent right iliac fossa pain after razor blade ingestion. After 5 days of conservative management, there was no sign of transition on serial X-Rays. Laparoscopy with intraoperative image intensification confirmed the presence of the razor blades in the appendix and appendicectomy was subsequently performed without complications. Discussion Most ingested objected with diameter less than 2.5 cm and length less than 6 cm can pass through the gastrointestinal tract spontaneously in less than one week. The entry of foreign objects into the appendix is thought to be due to relative low motility of the caecum, the dependent position of the appendix and the size of the appendiceal orifice. Radiographic localisation to the appendiceal lumen was complicated by metallic artefact, but was consistent with failure to transit. Appendicectomy was felt to be the safest mode of retrieval. Conclusion Ingested foreign body lodged in the appendix is a rare event. Once the exact location is confirmed, a simple laparoscopic appendicectomy can be performed to facilitate the removal. [ABSTRACT FROM AUTHOR]

Appendicitis is defined as inflammation of the vermiform appendix, the most common surgical emergency in children and young adults with abdominal pain. The current standard of care for patients with appendicitis is the surgical appendicectomy, either laparoscopic or open. A non-operative strategy with antibiotics is favourable in some cases and emerging evidence suggests there could be wider applicability. Diagnosis is based on history, clinical examination and laboratory tests, although 30–45% of patients exhibit atypical signs and symptoms on presentation. Where the diagnosis remains ambiguous, ultrasound and CT scans are the most widely used imaging modalities. Diagnostic laparoscopy can be a useful approach in low-risk patients, particularly young women. Appendicitis is classified into simple or complex disease, complex in the presence of a peri-appendicular abscess, gangrene or perforation. Complex appendicitis has significantly higher rates of morbidity and mortality. Limiting the progression from simple to complex disease, although not inevitable, is the rationale for early definitive treatment. An appendicectomy performed for suspected appendicitis resulting in a normal appendix on histopathological examination is referred to as a negative appendicectomy. A negative appendicectomy has a postoperative complication rate of around 10%, demonstrating the need for both accurate and timely diagnosis. [ABSTRACT FROM AUTHOR]

• Acute appendicitis is the commonest surgical emergency worldwide. • Surgery is usually needed which could be done by open or laparoscopic techniques. • Tumors of the appendix may cause intussusception of the appendix. Intussusception of the appendix occurs when part of the appendix passes the part next to it or the whole appendix to the cecum. It is classified as primary or secondary, or can be classified to partial or complete. Most cases are secondary and partial. Patients usually presents with right lower abdominal pain and most cases are diagnosed during surgery. A 27-year-old female presented with right iliac fossa pain and nausea for 2 days. Abdominal examination showed tenderness, guarding, and rebound tenderness at the right iliac fossa. The WBC count was 11,000 c/mm and the urinalysis was normal. At surgery, there was intussusception of the vermiform appendix in its middle part with palpable mass attached to its wall. Appendicectomy was performed successfully. The result of the histopathology was consistent with mucinous cystadenoma of the appendix with no evidence of malignancy. Surgery is the main form of treatment as most of the cases are diagnosed during surgery, the operation type may include appendicectomy or more extensive surgery is required such as right hemicolectomy depending on the cause. Surgery can be performed laparoscopically. Trials of colonoscopic reduction are not recommended. [ABSTRACT FROM AUTHOR]

A male child 9 years of age presented with fever, tender swelling in the right flank, with a right paramedian scar. Child had undergone exploratory laparotomy for peritonitis with appendicectomy one year back. Radiological investigations (Ultrasonography and Computed Tomography) revealed retrocecal abscess extending to the psoas muscle, which was drained via flank incision. Intermittent discharge continued through an opening in the flank just above the posterior superior iliac spine. Ultrasonography and CT fistulogram revealed a fistulous communication from skin to the cecum/appendix. Upon second exploration a fistulous communication from the tip of residual appendix (which was left in situ at the initial exploration) was found with multiple adhesions in the terminal ileum, cecum, and ascending colon. Local resection of the cecum and ascending colon was performed with ileocolic anastomosis. Fistulous tract was curetted out. Exploration confirmed the incomplete appendicectomy as a cause of this hazardous condition. [ABSTRACT FROM AUTHOR]

Background De Garengeot hernia is defined as femoral hernia containing appendix. An acute appendicitis in a femoral hernia is a extremely unusual surgical finding and occurs in 0.08%–0.013% of all cases. Case report We report the case of an elderly woman, who presented with a typical clinical image of incarcerated femoral hernia and underwent open surgery. An infrainguinal incision was performed and after the dissection of hernia sac, an acute appendicitis within femoral hernia was revealed. Subsequently, appendectomy and hernioplasty were performed. Conclusion Acute appendicitis within femoral hernia should be included in differential diagnosis of patients presenting with clinical signs of an incarcerated femoral hernia and prompt surgical treatment is essential in order to avoid severe complications. [ABSTRACT FROM AUTHOR]

Acute appendicitis is very uncommon in the first year of life and often its presentation is atypical with high risk of complications. Hereby, we present 4 clinical cases of infants, who were diagnosed with acute appendicitis in our hospital over the last year. The reported clinical cases highlight the several drawbacks clinicians face when managing infants with symptoms suggestive for acute appendicitis. After specific diagnostic work-up, even if not conclusive, patients were intraoperatively diagnosed with acute appendicitis and underwent appendicectomy. Maintaining a high index of suspicion for acute appendicitis in infants presenting with intra-abdominal sepsis of unclear etiology is, in our opinion, the most crucial factor to avoid complications and longer hospitalization. [ABSTRACT FROM AUTHOR]

Summary Objectives Recent literature has concluded antibiotic therapy results in fewer complications than appendicectomy for patients with uncomplicated appendicitis. This studies aim was to undertake a meta-analysis of major post-intervention outcomes in patients with suspected uncomplicated appendicitis treated with antibiotics or appendicectomy, and determine which treatment is associated with the lowest rate of major complications. Methods We analysed randomised trials of antibiotics vs. appendicectomy in adults with suspected uncomplicated appendicitis. The primary outcome measure was a composite of major complications, peritonitis and intra-abdominal abscess, occurring after appendicectomy or initiation of therapeutic antibiotics. Results The rate of major post-intervention complications was 0.8% (2/263) in the appendicectomy group and 10.1% (27/268) in the antibiotic group. This difference was statistically significant by the random effects model: Risk Ratio 7.71, 95% C.I. 2.33 to 25.53, Risk Difference 0.09: 95% C.I. 0.05 to 0.13. The Number Needed to Harm (NNH) from antibiotic therapy is 10.7. Conclusions Suspected uncomplicated appendicitis has a lower rate of major post-intervention complications when managed with primary appendicectomy compared to antibiotic therapy. [ABSTRACT FROM AUTHOR]

Background Neuroendocrine tumours (NET) of the appendix are rare histopathological neoplasms detected following operation for appendicitis in childhood. The role (if any) for radical surgery notably right hemicolectomy (RHC) has often reflected the ‘expert opinion’ of adult general surgeons with wider experience of managing NET lesions of the gastrointestinal tract. Critical decisions have focused on (a) tumour size, (b) histology, (c) tumour location/invasion and (d) positive lymph nodes. Against this background we report the clinical outcome of children with ‘incidental’ appendix carcinoid tumours managed at two regional UK paediatric surgery centres. A critical review of the literature is additionally provided in an effort to define contemporary patterns of care in paediatric surgical practice. Methods Hospital records and pathology database(s) identified 27 patients at two UK centres with a confirmed histological diagnosis of appendix NET lesions during January 1997–January 2013. A PUBMED and EMBASE search strategy—(English language publications only), 1975–present, was performed to gather information on all patients younger than 20 years at primary diagnosis with NET appendix tumours to review their management and outcomes. Results All 27 patients treated at the two institutions had acute appendicitis including 3 cases presenting with an appendix mass. Twenty-five underwent appendicectomy with two having interval operations. Tumours had a maximum diameter of 2–18 mm (median 9 mm) with 73% of lesions located at the appendix tip. Fourteen (52%) had tumour invading the mesoappendix. All patients underwent appendicectomy only with no single case having RHC or additional surgery. Surveillance studies (5HIAA, chromogranin-A) and imaging including ultrasound or CT were deployed in a minority of patients revealing no abnormality. All 27 cases are alive and well—(mean follow up 5 years; range: 9 months–16 years). The literature highlights varied management strategies and no recorded fatalities with radical surgery in children largely evolving from adult surgical practice. Conclusions This study confirms that paediatric patients with ‘incidental’ NET tumours of the appendix have an excellent prognosis. Consensus guidelines should ideally be developed by paediatric oncology surgeons to avoid unnecessary radical surgery in many otherwise healthy children. [ABSTRACT FROM AUTHOR]

Abstract: Abdominal pain in children is common and sometimes results from serious pathology amenable to surgical intervention. Though the true cause of many symptoms is not always determinable a diagnostic label is often assigned. The final diagnosis for many children is ‘non-specific abdominal pain’ – an ill-understood group of conditions. Acute appendicitis is common in children and can be life threatening; the history is short in the majority and the diagnosis can be obvious, but when the diagnosis is in doubt, active observation and judicious investigation are appropriate. For children in whom appendicitis is strongly suspected, surgery is the standard treatment though the child with an appendix mass may be managed conservatively. Adequate resuscitation and preoperative broad-spectrum antibiotics are important for successful outcomes. Appendicectomy can be carried out open or laparoscopically. Laparoscopic appendicectomy is the intervention of choice where facilities and expertise are available. Operating late at night is not recommended. Complications of the disease include rupture with localized or generalized peritonitis leading to intra-abdominal and pelvic abscesses, and wound infections. Rarely there may be an iatrogenic injury to the bowel or an appendix stump rupture resulting in a faecal fistula. While acute appendicitis remains a cause of morbidity and occasionally mortality, with timely presentation the majority of children have a good outcome. [Copyright &y& Elsevier]

Objective: To study whether subsequent pregnancy rate is reduced after appendicectomy. Design: A cohort study was carried out in the General Practice Research Database, a United Kingdom primary care database. Setting: University hospital. Patient(s): Female patients who underwent appendicectomy between 1986 and 2009 and appropriate comparators were followed until first pregnancy. Intervention(s): None. Main Outcome Measure(s): The association between appendicectomy and subsequent pregnancy was determined by Cox regression models. Result(s): The analyses included 76,426 appendicectomy patients, with 152,852 comparators from the database. There were 30,030 pregnancies (39.3%) in the appendicectomy cohort and 43,321 (28.3%) in the comparator cohort during a mean (SD) follow-up of 10.5 (6.6) years. Adjusted hazard ratios for subsequent birth rates were 1.54 (95% confidence interval, 1.52–1.56). Conclusion(s): Appendicectomy was associated with increased subsequent pregnancy rate in this study. This suggests that a history of appendicectomy is not associated with impaired fertility. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Although laparoscopic appendicectomy (LA) is an accepted alternative to the open appendicectomy (OA) approach, it has been suggested that there is a higher incidence of intraabdominal abscesses (IAAs). Our aim was to determine the incidence of IAA in 3 pediatric surgical centers routinely practicing both techniques. Methods: Data were collected retrospectively for pediatric patients undergoing LA or OA over an 8-year period. Analysis included IAA formation, appendicitis complexity, radiologic/histologic investigations, grade of surgeon, and wound infection. Main Results: A total of 1267 appendicectomies were performed (514 LAs and 753 OAs). There was no difference between the incidences of IAA (LA, 3.9% [19/491] vs OA, 3.9% [28/714]; P = 1.0). The incidence of IAA was increased in those with complicated appendicitis (34/375 [9.1%] vs 13/830 [1.6%]; P ≤ .0001). There was an increased proportion of those with complicated appendicitis in the LA group (182/491 [37.1%] vs 193/714 [27.0%]; P = .0002). Surgical trainees were more likely to be the primary surgeon in the OA group (79% vs 63%; P = .0001), although the incidence of IAA did not correlate with grade of surgeon. There was no significant difference in incidence of wound infection between groups (LA, 4.6% [8/173] vs OA, 2.5% [18/377]; P = .93). Conclusion: This large retrospective study shows that the technique of appendicectomy does not appear to affect the incidence of IAAs. Patients with complicated appendicitis are more likely to develop an IAA regardless of technique. [Copyright &y& Elsevier]

Abstract: Background/Purpose: A systematic review aimed to compare patient outcomes after (1) appendicectomy and (2) pyloromyotomy performed by different surgical specialties, surgeons with different annual volumes, and in different hospital types, to inform the debate surrounding children''s surgery provision. Methods: Embase, Medline, Cochrane Library, and Health Management Information Consortium were searched from January 1990 to February 2010 to identify relevant articles. Further literature was sought by contacting experts, citation searching, and hand-searching appropriate journals. Results: Seventeen relevant articles were identified. These showed that (1) rates of wrongly diagnosed appendicitis were higher among general surgeons, but there were little differences in other outcomes and (2) outcomes after pyloromyotomy were superior in patients treated by specialist surgeons. Surgical specialty was a better predictor of morbidity than hospital type, and surgeons with higher operative volumes had better results. Conclusions: Existing evidence is largely observational and potentially subject to selection bias, but general pediatric surgery outcomes were clearly dependent on operative volumes. Published evidence suggests that (1) pediatric appendicectomy should not be centralized because children can be managed effectively by general surgeons; (2) pyloromyotomy need not be centralized but should be carried out in children''s units by appropriately trained surgeons who expect to see more than 4 cases per year. [Copyright &y& Elsevier]

Abstract: Acute appendicitis is one the most common causes of acute abdominal pain and the peak incidence is amongst teenagers and young adults. The diagnosis is made from salient features in the history and examination with additional guidance from appropriate imaging. Treatment is usually in the form of open or laparoscopic appendicectomy; the latter approach may be associated with an increased risk of miscarriage in pregnant patients. Antibiotic treatment alone may be successful, albeit with a risk of recurrence. Complications of appendicectomy occur frequently and the most common is wound infection. [Copyright &y& Elsevier]

Background The effect of adding transversus abdominis plane (TAP) blocks to local anaesthetic infiltration on morphine consumption and postoperative pain in children undergoing laparoscopic appendicectomy is unknown. Methods After random allocation, 93 children aged 7–16 were randomized to receive ultrasound-guided TAP blocks placed before surgery or not (control). All subjects had port sites infiltrated with ropivacaine and were prescribed i.v. patient-controlled analgesia (PCA) with morphine and oral paracetamol for postoperative pain. The primary outcome was the proportion of subjects using >200 µg kg−1 morphine. Secondary outcomes included PCA morphine use, pain scores, time intervals to the first use of PCA and other analgesics, sedation scores, postoperative nausea or vomiting, and time to hospital discharge. Results The procedure duration was longer in the TAP group (111 compared with 97 min for controls, P=0.03). The duration in the recovery ward and that of the hospital stay were similar. There was no difference in the proportion of subjects requiring >200 µg kg−1 of PCA morphine [control 31/45 (69%), TAP 29/42 (69%), P=0.99]. There was no significant difference in PCA morphine use, time intervals to the first use of PCA or other analgesics, or amounts of other analgesics. More patients in the TAP group had complicated appendicitis [TAP 13/42 (31%), control 5/45 (11%), P=0.02]. Pain scores were reduced for the TAP group in the recovery ward only (median score 0 vs 2, 95% confidence interval 0–3, P=0.03). Conclusions TAP blocks increased anaesthesia time by 14 min on average but offered no clinically important benefit over local anaesthetic port-site infiltration to paediatric patients undergoing laparoscopic appendicectomy. [ABSTRACT FROM AUTHOR]

Abstract: Acute appendicitis is the commonest abdominal surgical emergency with a lifetime incidence of just under 7.6%. It is most common in patients under the age of 30 years. Appendicitis is thought to occur after occlusion of the appendix orifice. The diagnosis is usually made clinically but the clinical findings vary widely with only half the patients presenting with classical clinical findings. The diagnosis is more difficult at extremes of age and where there is uncertainty, laboratory investigations, radiological investigations or diagnostic laparoscopy are of use. If the presentation is delayed, patients may present with a perforated appendix, an appendix mass or abscess. Appendicectomy may be performed via the open or laparoscopic techniques. Laparoscopic appendicectomy is increasing in popularity with increasing use of diagnostic laparoscopy and increasing surgeon skills. The most common complication following appendicectomy is wound infection with an overall incidence of about 15%. [ABSTRACT FROM AUTHOR]

Abstract: 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. [Copyright &y& Elsevier]

Abstract: Purpose: The study aimed to compare paediatric appendicectomy practice in a specialist paediatric centre (SPC) with a district general hospital (DGH). Methods: This was a retrospective study of children younger than 16 years treated between January 1, 2005, and September 30, 2007. Results: Two hundred seven patients (SPC) and 264 (DGH) had an operation for suspected appendicitis. Thirty-one percent of SPC patients were female vs 41% in the DGH (P = .03). Median age (range) was 10.3 years (1.2-15.9 years) in the SPC and 11.8 (3.3-16.0 years) in the DGH (P ≤ .0001). The negative appendicectomy rate was 4% at the SPC and 20% at the DGH (P ≤ .0001). Perforated appendicitis was found in 37% of children at the SPC compared with only 18% at the DGH (P ≤ .0001). Median (range) length of stay was 5 days at the SPC (1-21 days) compared with 2 days at the DGH (1-21 days) (P ≤ .0001). Conclusion: Our findings have important implications for local practice in our 2 centres but may also have wider implications for the national organisation of the surgical care of children and for the training of general surgeons. [Copyright &y& Elsevier]

Abstract: Acute appendicitis is the most common abdominal emergency and the overall lifetime risk in the UK is between 6% and 20%. The exact cause remains unclear, but luminal obstruction, diet and familial factors have been suggested, and the aetiology may be multifactorial in some cases. Inflammation of the appendix ranges from minor, simple acute inflammation to suppurative necrosis and perforation. The findings of history and examination can vary widely, and only about one-half of patients with acute appendicitis have a ‘classical’ presentation. Age can influence presentation and, because the appendix is a relatively mobile structure, the clinical picture is also dictated by the anatomical position of the inflamed organ. Due to the variability in presentation, there is a wide range of differential diagnoses when suspecting acute appendicitis and, although blood and radiological investigations may be requested, the diagnosis is often clinical. The first-line treatment for acute appendicitis in the UK is appendicectomy, which can be performed as an open procedure or laparoscopically. Wound infection is the most common complication of appendicectomy and rates vary according to the stage of disease and the degree of surgical contamination. [Copyright &y& Elsevier]

Abstract: Background/Purpose: Appendicitis is the most common surgical emergency in children. However, management varies widely. The aim of this study was to assess the impact of introducing a care pathway on the management of childhood appendicitis. Methods: Data were collected prospectively for 3 successive cohorts: Group A, before introduction of pathway; Group B, after introduction of pathway; Group C, after modification of pathway. All patients operated for suspected appendicitis were included. The pathway was modified after interim analysis of group B data. P < .05 was significant. Results: Six hundred patients were included. When compared with group A, group C patients were more likely to receive preoperative antibiotics (P < .0001), undergo formal pain assessment (P < .0001), and be operated before midnight (P = .025). There was a significant decrease in readmission rates from 10.0% to 4.2% (P = .023) despite an increase in cases of gangrenous and perforated appendicitis (P = .010). Conclusions: The introduction of a care pathway resulted in improved compliance with antibiotic regimens, more frequent pain assessment, and fewer post-midnight operations. Postappendicectomy readmission rates were reduced despite an increase in disease severity. This was achieved by critical reevaluation of outcomes and pathway redesign where appropriate. [Copyright &y& Elsevier]

Abstract: Acute appendicitis is the most common abdominal emergency and the overall lifetime risk in the UK is between 6% and 20%. The exact cause remains unclear, but luminal obstruction, diet and familial factors have been suggested, and the aetiology may be multifactorial in some cases. Inflammation of the appendix ranges from minor, simple acute inflammation to suppurative necrosis and perforation. The findings of history and examination can vary widely, and only about one-half of patients with acute appendicitis have a ‘classical’ presentation. Age can influence presentation and, because the appendix is a relatively mobile structure, the clinical picture is also dictated by the anatomical position of the inflamed organ. Due to the variability in presentation, there is a wide range of differential diagnoses when suspecting acute appendicitis and, although blood and radiological investigations may be requested, the diagnosis is often clinical. The first-line treatment for acute appendicitis in the UK is appendicectomy, which can be performed as an open procedure or laparoscopically. Wound infection is the most common complication of appendicectomy and rates vary according to the stage of disease and the degree of surgical contamination. [Copyright &y& Elsevier]

Objective. – To determine on a national level the factors associated with the use of laparoscopy for digestive surgery.Study design. – Nation wide study using a large representative sample (3 days of anaesthesia in France).Methods. – Univariate followed by multivariate analyses of data gathered in 1996 during the survey led by the French Society of Anaesthesia and Intensive care (« SFAR ») including 2847 surgical procedures for cholecystectomy, appendicectomy or inguinal herniorraphy.Results. – Independent factors associated with the use of laparoscopy were: for cholecystectomy: age (less frequent when ≥71 years: adjusted Odds ratio [AOR] 0.4), sex (more frequent in female: AOR 1.7), ASA physical status (less frequent when ≥3: AOR 0.5), private hospital (AOR 2.0), procedure scheduled at least the night before (AOR 2.1), and use of closed circuit general anaesthesia (AOR 1.6); for appendicetomy: age >15 years (AOR 1.9–2.2), female (AOR 2.1), private hospital (AOR 2.7), scheduled procedure (AOR 2.1), prolonged procedure (AOR 8.4), endotracheal intubation (AOR 16.7), and closed circuit (AOR 2.7); for inguinal herniorraphy: ASA physical status (less frequent when ≥3: AOR 0.4), private hospital (AOR 3.4), prolonged procedure (AOR 5.6), and endotracheal intubation (AOR 21.6). Association with a closed circuit was confirmed for general anaesthesia using a volatile agent (AOR 1.5). Overall, ambulatory surgery was rarely performed and used only for open procedures. Regional anaesthesia was used only for inguinal open herniorraphy.Conclusion. – These data obtained from a large national survey confirmed the higher frequency of laparoscopy in middle aged patients, female (except for inguinal herniorraphy), without important comorbidity, in private hospitals. Laparoscopy was associated with prolonged procedures and with a change in the anaesthetic technique for appendicectomy and inguinal herniorraphy: tracheal intubation was almost constantly used. Whatever the procedure, closed circuit anaesthesia was more frequently used when surgery was performed under laparoscopy, reflecting newer equipment of the hospital, private or public. [Copyright &y& Elsevier]

Introduction Stump appendicitis is one of the rare delayed complications post appendectomy with a reported incidence of 1 in 50,000 cases. Stump appendicitis can present as a diagnostic dilemma if the treating clinician is unfamiliar with this rare clinical entity. A PubMed search was conducted to identify cases of stump appendicitis following appendectomy. Sixty one cases of SA that were reported in English medical literature were analyzed. Presentation of case We report a case of stump appendicitis (SA) with a systematic review and challenges encountered during the management. Discussion The interval from original appendectomy to stump appendicitis ranged from 4 days to 50 years. SA followed appendectomy in 58% of open and 31.6% of laparoscopic procedures. SA was frequently misdiagnosed as constipation, gastroenteritis or right sided diverticulitis, therefore leading to a significant delay to surgery. Computerized Tomography diagnosed SA in 56.3% of cases. Perforation with gangrene of the stump occurred in 60%. Conclusion Stump appendicitis can represent a diagnostic dilemma if the treating physician is unfamiliar with this uncommon clinical entity. Radiological imaging is required to aid diagnosis and a completion appendectomy is the modality of treatment. [ABSTRACT FROM AUTHOR]

Amyand's hernia (AH) is a form of inguinal hernia which is consider as very rare and this type of hernia occurred up to 1% of all inguinal hernia cases. In this type of inguinal hernia, the content of hernia sac is appendix. Most patient with AH often remains asymptomatic and diagnosed intraoperatively. The diagnosis is challenging, since needs a high index of suspicion and imaging is key. Surgery is the mainstay management. We report a case of Amyand's hernia that was managed operatively in our medium complex public institution. A 28 year's old man with normal body mass index (BMI) who had a history of right-side reducible linguino-scrotal swelling for 8 years, was admitted for elective right inguinal hernia repair. Two weeks back before admission, he noticed that swelling was slightly painful. Ultrasound of the abdomen reported normal findings. There was no history of abdominal pain and vomiting. Laboratory parameters were within normal limit. So, with a diagnosis of right sided partially reducible, incomplete, and indirect inguinal hernia, patient was operated for open hernia repair surgery, intra operatively we found dense adhesions within the sac, adhesions were released which revealed herniation of appendix into the inguinal canal. Appendix was mildly congested without gross evidence of inflammation. Hence, in view of noninflamed appendix, preperitoneal mesh (polypropylene) hernioplasty from Lichtenstein tension-free mesh repair was performed with appendicectomy. Postoperative period was uneventful, patient discharged at second day. Amyand's hernia is very uncommon and characterized by the presence of the appendix in the hernia sac and it is 0.4–1% of all inguinal hernia cases, literature review also showed that incidence of Amyand's hernia is very rare, whereas only 0.1% of cases complicate into acute appendicitis due to late presentation and missed diagnosis. Amyand's hernia (AH) makes up only a small proportion of most inguinal hernia cases, and its diagnosis is usually based on incidental finding intra-operatively. This condition may remain asymptomatic and behave like a normal inguinal hernia. Management of this type of hernia should be individualized according to appendix's inflammation stage, presence of abdominal sepsis and co-morbidity. With this approach it enables surgeons to manage more variations of Amyand's hernia. Laparoscopy for dealing Amyand's hernia is frequently diagnostic as well as therapeutic. [ABSTRACT FROM AUTHOR]

INTRODUCTION Small bowel volvulus, as a complication of laparoscopic surgery, is a rarely reported clinical entity. We present a case of a young female who developed small intestinal volvulus after laparoscopic appendicectomy. She had this complication in the absence of malrotation or other previous abdominal operations. PRESENTATION OF CASE A 17-year-old woman presented with acute appendicitis. After an uneventful laparoscopic appendicectomy, she developed acute small intestinal obstruction on the second post-operative day. A prompt laparotomy showed small bowel volvulus, which was reduced, with no evidence of malrotation. She had an uneventful recovery and was discharged within 3 days of the second operation, in a stable condition. DISCUSSION This article presents a review of the literature of this rare cause of small intestinal obstruction after laparoscopic surgery, stressing on the importance of early diagnosis and treatment. A discussion of the potential factors predisposing to this entity is presented, emphasising the need of a higher-evidence study as to its aetiology and prevalence. CONCLUSION Small bowel volvulus is a rare complication of laparoscopic surgery, but its early diagnosis and prompt treatment is essential to avoid morbid outcomes. Surgery is the therapeutic mainstay. [ABSTRACT FROM AUTHOR]

Abstract: Pediatric laparoscopic appendicectomy in the presence of an appendicular mass following recurrent appendicitis can represent an operative challenge. To address this problem, we describe a laparoscopic technique, which involves a retrograde appendicectomy combined with trans-mesoappendicular and selective subserosal dissection thus preventing the possible damage to the surrounding anatomical structures. This technique has been reported in open appendectomy. However, to the best of our knowledge, it has never been described using the laparoscopic approach. [Copyright &y& Elsevier]

Abstract: The adrenocortical insufficiency may mimic an acute surgical abdomen. We report the case of 20-year-old patient, who presented abdominal pain syndrome, associated with isolated moderate hyponatremia (135 mmol/l). The first diagnostic given is an appendicular syndrome, and she underwent surgery. Given the persistence of abdominal pain syndrome and hyponatremia (133 mmol/l), adrenocortical insufficiency was sought. The follow-ups were simple after the introduction of replacement therapy. [ABSTRACT FROM AUTHOR]

Abstract: Background/Purpose: Ongoing debate surrounds the future provision of general paediatric surgery. The aim of this study was to compare outcomes for childhood appendicitis managed in a district general hospital (DGH) and a regional paediatric surgical unit (RU). Methods: Data collected retrospectively for a 2-year period in a DGH were compared with data collected prospectively for 1 year in an RU, where appendicitis management is guided by a care pathway. Children aged 6 to 15 years were included. Results: Four hundred and two patients were included (DGH ,196; RU, 206). There were more cases of gangrenous/perforated appendicitis in the RU (P < .0001). In the DGH, fewer patients received preoperative antibiotics (P < .0001) or underwent preoperative pain scoring (P < .0001). When adjusted for case mix, the relative risk of complications for a child managed at the DGH was 1.76 (95% confidence interval, 1.44-2.16; P < .0001) and that of readmission was 1.76 (95% confidence interval, 1.43-2.16; P < .0001) when compared with the RU. Conclusions: Patients with appendicitis managed in the DGH had a higher risk of complications and readmission. However, this appears to be related to the use of a care pathway at the RU. Introduction of a care pathway in the DGH may improve outcomes and thus support the ongoing provision of general paediatric surgery. [Copyright &y& Elsevier]

Introduction Ectopic or heterotopic pancreas is a congenital disorder defined as abnormally located pancreatic tissue found outside the pancreatic frame. It is a rare entity that occasionally causes symptoms depending on its location. Presentation of case We present the case of an incidental finding of proximal jejunal ectopic pancreas in a middle-aged woman presenting with appendicitis. Discussion and conclusion Although rare it is necessary to be aware that jejunal ectopic pancreas can lead to jejunojejunal intussusception. Although diagnostic tools are emerging, pre operative diagnosis is difficult and resection is the management of choice of the incidentally found lesion. [ABSTRACT FROM AUTHOR]

The presence of a vermiform appendix in an inguinal hernia sac is known as Amyand's hernia. It is an uncommon and rare condition estimated to be found in approximately 1 % of hernia. However, in just 0.08 %, the condition is complicated by an acute appendicitis. The clinical presentation varies, depending on the extent of inflammation of the appendix, and is most often misdiagnosed as an incarcerated inguinal hernia. As such, it is rarely recognized prior to surgical exploration. We report a case of Amyand’s hernia in a 2-month-old male, who presented as a right-sided congenital hernia with pain in the right groin. He underwent herniotomy, which revealed that the hernia sac containing elongated inflamed appendix appeared with some adhesions to sac, lying in the inguinal canal. [ABSTRACT FROM AUTHOR]

Abstract: A case of right ureteric damage in a 7-year-old boy who underwent appendicectomy is described. Ultrasound, magnetic resonance urography, nephrostogram, and retrograde ureterogram were helpful in defining the nature and extent of the lesion. He underwent staged procedures of percutaneous nephrostomy, elective resection and reconstruction of midureteral segment, and subsequent removal of double J stent and made a smooth recovery. Ureteric injuries, although rare, have serious consequences. A high index of suspicion is essential for diagnosis. Management is influenced by site, type, extent, and mechanism of injury, as well as the timing of detection. [Copyright &y& Elsevier]

Abstract: A 12-year-old girl presented with a “threadlike fiber” in her underwear associated with lower abdominal pain. She denied insertion of any foreign body, and at examination under anesthetic, a threadlike substance was seen exiting her external cervical os. Her only medical history was of an open appendicectomy for perforated appendicitis. Subsequent pathologic examination showed a collapsed mesothelial cyst, and laparoscopy showed a cyst and inflammatory changes consistent with previous appendicectomy surrounding her right ovary. We review the possible causes for this most unusual presentation. [Copyright &y& Elsevier]