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Acute Care Emergency Surgery
Published in Mansoor Khan, David Nott, Fundamentals of Frontline Surgery, 2021
Marcelo A. F. Ribeiro, Mansoor Khan
Nowadays, the gold standard in treatment continues to be the appendicectomy, preferably by lap-aroscopic approach. In certain circumstances, the treatment will be performed by an open surgical procedure and, in selected cases, treated by antibiotic therapy with or without interval appendicectomy. The treatment of non-perforated acute appendicitis remains surgical, preferably within the first 12 hours after diagnosis. However, this approach can change in a resource-limited environment. The patients can have delayed presentation and surgery in this environment should only be undertaken if absolutely necessary.
AI and the Bioscience and Clinical Considerations for Immunology
Published in Louis J. Catania, AI for Immunology, 2021
Diagnosis of acute appendicitis is challenging, especially due to the frequently unspecific clinical picture. Inflammatory blood markers and imaging methods like ultrasound are limited as they have to be interpreted by experts and still do not offer sufficient diagnostic certainty. A recent study presents a method for automatic diagnosis of appendicitis as well as the differentiation between complicated and uncomplicated inflammation using values/parameters which are routinely and unbiasedly obtained for each patient with suspected appendicitis. A total of 590 patients (473 patients with appendicitis in histopathology and 117 with negative histopathological findings) were analyzed retrospectively with modern algorithms from machine learning (ML) and artificial intelligence (AI). Results revealed the capability to prevent two out of three patients without appendicitis from useless surgery as well as one out of three patients with uncomplicated appendicitis. The presented method has the potential to change the current therapeutic approach for appendicitis and demonstrates the capability of algorithms from AI and ML to significantly improve diagnostics even based on routine diagnostic parameters.15
Appendectomy
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
Acute appendicitis is usually diagnosed on the basis of the classical clinical symptoms of migratory right iliac fossa pain, nausea, right lower quadrant tenderness, and fever. Children aged over 5 years more often experience a longer delay in diagnosis and higher incidence of perforation. Every effort should be made to confirm the diagnosis of appendicitis before surgery. Formerly reported rates of negative explorations (20–40%) are no longer acceptable. Repeated clinical examinations and appropriate imaging should reduce the negative rates below 10%. Abdominal US is an excellent and accurate screening tool for acute appendicitis. Computed tomography (CT) has slightly higher sensitivity and specificity than US, but the radiation dose remains a significant concern. Therefore, CT with minimized radiation dose is preserved for special situations and complicated patients with an unclear diagnosis and increased operation risk. Significant medical conditions causing appendicitis-like symptoms should be ruled out by clinical examination, laboratory tests, and imaging. These include right basal pneumonia, cholecystitis, meningitis, urinary tract infections, Henoch–Schönlein purpura, and acutely presenting ketoacidosis of type 1 diabetes.
Low intra-operative diagnostic accuracy does not affect postoperative treatment of acute appendicitis
Published in Acta Chirurgica Belgica, 2020
Eric E. Vinck, Ricardo A. Villarreal, Carlos Luna-Jaspe, Luis F. Cabrera, Tim F. Peterson, Felipe Bernal, Carmen L. Roa
Acute appendicitis continues to be the most common cause of emergency abdominal surgery performed by general surgeons. The lifetime risk of appendicitis is 8.6% in men and 6.7% in women [1,2]. Surgery is the gold-standard treatment for acute appendicitis despite trials using antibiotics alone. Despite being such a common surgical pathology, preoperative and intra-operative diagnosis continue to be a challenge. Clinical signs and symptoms, lab work, and imaging studies help guide surgeons in making the decision to take a patient to surgery. Although various imaging modalities exist along with preoperative scores, many patients are taken to surgery only to find that the presurgical suspicion was different than the intra-operative findings. During surgical explorations, a subjective-macroscopic classification is given by the surgeon [3,4]. Postoperative treatment is directly influenced by this designation. Once the pathologist examines these specimens, an objective-microscopic classification is given. This being the ‘true’ classification since appendicitis is a histopathological diagnosis. A total of 11–27% of negative appendicitis have been reported and 70% of patients with right-sided diverticulitis are taken to surgery only to find a normal appendix [3–5]. True histopathological appendicitis reaches 88.8% of specimens. Strong et al. reported that 27.8% of intra-operative ‘normal-looking’ appendices had histopathological findings of appendicitis and 9.6% of specimens considered to have appendicitis by the surgeon where histologically normal [4–7].
Beneficence, Interests, and Wellbeing in Medicine: What It Means to Provide Benefit to Patients
Published in The American Journal of Bioethics, 2020
A patient has acute appendicitis. This condition causes severe pain, suffering, and functional impairment, and has the potential to cause long-term loss of life or functioning. Appendicitis is treatable through surgery, where the chances of success are very high and the chances for adverse effects that may affect functioning very low. The patient wants to be well; she enjoys a wide range of activities as part of her life, which would all be affected should she develop complications from appendicitis. She has no objections to the surgery, and there are no other forms of successful treatment available. Criterion (1) provides grounding for prima facie beneficence obligations to provide surgery. Criterion (2) provides no reasons to overrule surgery, and the surgery promotes the ability of the patient to return to the activities that comprise her own view of the good. Both criteria, therefore, give grounds to count provision of surgery here to be beneficial.
Beyond the commonest: right lower quadrant abdominal pain is not always appendicitis
Published in Alexandria Journal of Medicine, 2020
Mahmoud Agha, Maha Sallam, Mohamed Eid
Another one 67 y male patient (0.1%) was presented with severe acute appendicitis like symptoms and signs. CT scan revealed showed a linear dense foreign body in the mesentery, in close relation to the tip of a pre-ileal inflamed appendix. There was an ileocecal mucosal hyperenhancement and submucosal edema and regional stranding of the right iliac fossa fat planes. This mesenteric foreign body was surrounded with a considerable ring-enhancing collection, which was reported as sealed appendicular perforation with periappendicular abscess Figure 11(a-b). The patient was first managed conservatively with intense broad-spectrum short antibiotic course, with repeated CT scan after 1 week. The second study revealed a significant resolution of the collection and clearly demonstrated the residual inflamed appendix. Figure 11 (C-D) Operative feedback history documented a sealed appendicular perforation with extra-appendicular fish bone foreign body.