Complicated Appendicitis: A Surgical Controversy Concerning Risk Factors, Diagnostic Algorithm and Therapeutic Management

By surgeon’s perspective, complicated appendicitis is defined as perforated appendicitis, periappendicular abscess, gangrenous appendicitis or peritonitis, noted on radiological studies upon hospital admission, operative reports or pathology results of the surgical specimen. Despite that this clinical condition is truly common in everyday surgical routine, its causes and risk factors are still unclear. Some parameters have been associated with complicated appendicitis, like older age, type 2 diabetes, symptoms for longer duration, appendicoliths/fecaliths, delays in surgery after onset of symptoms and after admission. Furthermore, currently, there is no standard diagnostic algorithm for complicated appendicitis. To be specific, radiological findings lack sensitivity, intraoperative assessment may overestimate it while, histopathological examination is regarded as more specific diagnostic method. In addition, the optimal treatment for complicated appendicitis remains controversial between an immediate surgical operation (laparotomy/laparoscopy) or a trial of nonoperative management. Hereby, by reviewing the current literature, we would aim to clarify the risk factors and the diagnostic procedure of complicated appendicitis as well as to compare the operative management with the conservative one according to the type of complicated appendicitis, the success rate and the postoperative complications

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Somatostatin Infusions Reduce Post-Operative Bile Leak after Hepatopancreatobiliary Surgery: An Observational Preliminary Study

Background: Bile leak is a complication of hepatopancreatobiliary surgery and results from injury to the bile ducts. Treatment usually consists of percutaneous drainage combined with the placement of a biliary stent or a nasobiliary draining tube in the biliary tree via endoscopic retrograde cholangiopancreatography. Animal experiments and studies in humans have shown that somatostatin reduces bile secretion. Objective: To evaluate the efficacy of somatostatin as a conservative monotherapy for the successful management of mild to moderate post-operative bile leak. Place and Duration of Study: 2nd Department of at the University General Hospital of Alexandroupolis, during the period of 2010 and 2012. Patients and Methods: Fifteen patients (11male/4 female) with a mean age of 70.1±4.2 years who developed uncomplicated post-operative bile leak with a daily output ranging from 100ml to 800ml were included in the study. Eleven patients were operated for benign diseases of the liver and biliary tract, while the rest 4 patients for pancreatic or biliary tract malignancies. Somatostatin was administered intravenously to all patients in continuous infusions of 3000μg/12hours until complete recession of bile leak along with total parenteral nutrition. Results: Somatostatin treatment was successful in 14 patients (93.3%), with success being defined as the complete cessation of bile leak. Overall, mean duration of bile leak was 13.8±3.9 days. No major adverse reactions or complications were observed and no patients died. Conclusions: Somatostatin appears to be effective in the treatment of post-operative bile leak. The efficacy of somatostatin is observed both in patients with benign or malignant disease

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND: The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not. METHODS: Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not. RESULTS: A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001]. CONCLUSIONS: The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands