Introduction : Acute appendicitis (AA) is one of the most common surgical disease with a lifetime risk of 7–8%. Improving the diagnostic & Management pathway is the cornerstone for decreasing the negative appendectomy rate and the risk of wrong diagnosis. The primary aim of the this study is to describe the clinical, diagnostic, treatment, and pathological profile of patients with AA in surgical departments of randomly selected hospitals
Methods: This Retrospective study involved Prior Consent from Hospital Authorities Subjects included both the genders , all age groups including pediatric and geriatric age group and all classes of socio economic strata. A total of 100 patients case sheet were selected which were proven cases of acute appendicitis during a period of 6 months. This retrospective Analytical Study was planned to see the current trends of Management of Acute Appendicitis in Randomly selected Tertiary Care Hospitals of Raipur district.
Results: Case sheets of total 100 diagnosed patients were chosen . They included 35% women and 65% men, with a median age of 31 years . 18% patients had previous episodes of AA. 23% patients underwent abdominal CT scan, 66% patients had an USG, Rest 11% patients had both CT scan and USG. 90 % patients had their Alvarado Score recorded, with a median value of 7 (IQR, 6–8). The Alvarado score was ??4 in 9% patients, between 5 and 6 in 1067 29% patients, between 7 and 8 in 41% patients, and between 9 and 10 in rest of the patients. 94 % patients had their Andersson’s Score recorded, with a median value of 6 (IQR, 5–8). In 21% patients, the Andersson’s score was ??4, between 5 and 8 in 68% patients, and between 9 and 12 in rest of the patients.
Conclusion: The results of the present study gives a snapshot of current worldwide trend in the diagnostic work-up and therapeutic management of AA. Ultrasound and CT are used in Sufficient cases . Alvarado, Andersson’s, and WSES grading scores are useful methods to classify the patients, and they predict and correlate with the surgical or pathological diagnosis. 97 % of patients are treated with surgery, which, in more than 50% cases, is performed using a laparoscopic approach, with a low conversion rate. The hospital stay is usually short, with few complications at 7 and 30 days postoperatively. Further analysis based on the present data are needed to study in detail the role of preoperative diagnostic work-up, the usefulness of prognostic scores, the potential value of appropriate antibiotic therapy, and the real advantages of a laparoscopic approach.
Acute appendicitis (AA) is one of the most common surgical disease with a lifetime risk of 7–8% 1 . Appendectomy has been the treatment of choice for acute appendicitis. Mortality rate after appendectomy is very low and may range from 0.07 to 0.7% rising to 0.5 to 2.4% in patients without and with perforation 3, 2. Furthermore, overall postoperative complication rates ranged between 10 and 19% for uncomplicated AA and reaching 30% in cases of complicated AA.
Improving the diagnostic & Management pathway is the cornerstone for decreasing the negative appendectomy rate and the risk of wrong diagnosis. Before the wide spread use of CT scans, the diagnosis of acute appendicitis was mainly based on symptoms, signs, and laboratory data.
Several diagnostic scoring systems for acute appendicitis have been described. The most commonly used are the Alvarado score and AIR—Appendicitis Inflammatory Response (Andersson) score 5, 4 . Both of these scoring systems can increase the diagnostic accuracy, thus guiding the decision-making and decreasing the need of potentially harmful and expensive imaging. In view of the potentially higher morbidity associated with open appendectomy, several authors have proposed less invasive management. Although many controversies exist regarding non-operative management of AA, antibiotics play an important role in the treatment of patients with AA as demonstrated by several prospective trials and meta-analyses 14, 13, 12, 11, 10, 9, 8, 7, 6 . AA successfully treated with antibiotics remains a potential cause of recurrent appendicitis. Postoperative wound infections and post-appendectomy adhesional bowel obstruction occurring many decades after the index surgery are commonly described sequalae of appendectomies. Therefore, the comparison of surgery and antibiotic therapy still represent a challenging and debated issue.
The effort to distinguish non-complicated from complicated appendicitis is paramount in ensuring appropriate patient management. Utilizing a CT scan to diagnose cases of suspected AA has been demonstrated, it has high sensitivity and specificity 17, 16, 15 . However, even a CT scan struggles to differentiate between uncomplicated and complicated appendicitis 19, 18 .
In the last few Years the laparoscopic approach has overtaken open surgery for most surgeons worldwide in the treatment of both simple and complicated AA. However, it is not yet unanimously considered the “gold standard” in the management of AA because of its higher operative time, increased intra-abdominal abscess risk, and higher costs compared to open appendectomy. Several meta-analyses of prospective randomized trials were performed in an attempt to define the role of laparoscopic appendectomy 25, 24, 23, 22, 21, 20 . Literature reports that 2 to 7% of appendicitis tend to present with complex features such as a phlegmon or peri-appendicular abscess 27, 26 . Various published papers suggest treating such patients conservatively, by such methods as ultrasound-guided percutaneous drainage and antibiotic therapy, followed by delayed interval appendectomy31, 30, 29, 28 . The role of appendectomy after successful drainage and resolution of clinical symptoms is even more controversial than percutaneous drainage. The recommendation for interval appendectomy is based on the risk of recurrence and risk of missing an underlying malignancy32 . The recurrence rate has been reported by several studies to be around 7%, reassuringly low; thus, according to some authors, after successful conservative treatment, an interval appendectomy may not be always necessary 37, 36, 35, 34, 33, 32 .
Recently, a new AA grading system has been proposed by the World Society of Emergency Surgery (WSES). This new grading system is based on clinical presentation, imaging, and surgical findings and aims to provide a standardized classification system based on a uniform patient stratification. The new scoring system intends to aid in determining the optimal post-appendectomy management according to the grade of severity and ultimately contribute to clinical research in appendicitis 38 .
Hence a retrospective Analytical Study was planned to see the current trends of Management of Acute Appendicitis in Randomly selected Tertiary Care Hospitals of Raipur district. The primary aim of the this study is to describe the clinical, diagnostic, treatment, and pathological profile of patients with AA in surgical departments of randomly selected hospitals in Raipur CG India.
This Retrospective study involved Prior Consent from Hospital Authorities / Medical Superintendent of the tertiary care hospitals to see the records of the patients & were found within ethical standards. Patients admitted in the various Randomly selected Trauma centres and other surgical units / Emergency / ICU Units of tertiary care hospitals in Raipur district including Raipur Institute of Medical Sciences , Raipur as diagnosed cases of Acute Appendicitis were included in this study.
This retrospective Analytical Study was planned to see the current trends of Management of Acute Appendicitis in Randomly selected Tertiary Care Hospitals of Raipur district. The primary aim of the this study is to describe the clinical, diagnostic, treatment, and pathological profile of patients with AA in surgical departments of randomly selected hospitals in Raipur CG India.
Case sheets of 100 patients were selected which were proven cases of Acute Appendicitis during a period of 6 months from year Mar 2019 to Aug 2019. Subjects included both the genders , all age groups including pediatric and geriatric age group and all classes of socio economic strata.
Patient demographics included the following: age, sex, previous episodes of suspected appendicitis, comorbidities (immunosuppression, severe cardiovascular disease, Charlson Comorbidity Index (CCI)) , previous antimicrobial therapy, clinical data (axillary temperature, diffuse tenderness, right lower quadrant pain, right lower quadrant tenderness, vomiting) and laboratory findings at admission (white blood count (WBC) and C-reactive protein (CRP)), radiological diagnosis (ultrasound (US) and computer tomography (CT) findings), Alvarado Score, Andersson’s Score 5, 4 , type of surgical treatment and adequate source control, WSES Grading System38 , type and duration of antimicrobial therapy, collection of peritoneal swab, microorganisms isolated, admission to intensive care unit (ICU), duration of hospitalization, re-operation, management of postoperative complications at days 7 and after if any.
Data were analyzed in absolute frequency and percentage, in the case of qualitative variables. Quantitative variables were analyzed as medians and interquartile range (IQR). Univariate analyses were performed to study the association between risk factors and in-hospital mortality using a chi-square test, or a Fisher’s exact test, if the expected value of a cell was < 5. All tests were two-sided, and p values of 0.05 were considered statistically significant. To investigate factors associated with death, we constructed a logistic regression model, including variables with p < 0.05 in the univariate analysis. All statistical analyses were performed using Stata 11 software package (StataCorp, College Station, TX, USA).
Case sheets of total 100 diagnosed patients were chosen . They included 35% women and 65% men, with a median age of 31 years . 18% patients had previous episodes of AA. One (1 %) patient were immunosuppressed, and 3 % patients suffered from severe cardiovascular disease. 8% having Hypertension & 13 % had Diabetes Mellitus type 2 . Rest Patients had no comorbidities, 13% patients had a CCI between 1 and 5, and in 1%, the CCI was greater than 5. 327 where patients received an antimicrobial therapy in the previous 30 days.
The total numbers of patients of AA analysed who were admitted in the various Randomly selected Trauma centres and other surgical units / Emergency / ICU Units of tertiary care hospitals in Raipur district including Raipur Institute of Medical Sciences , Raipur as diagnosed cases of AA . 23% patients underwent abdominal CT scan, 66% patients had an USG, Rest 11% patients had both CT scan and USG.
90 % patients had their Alvarado Score recorded, with a median value of 7 (IQR, 6–8). The Alvarado score was ≤ 4 in 9% patients, between 5 and 6 in 1067 29% patients, between 7 and 8 in 41% patients, and between 9 and 10 in rest of the patients.
94 % patients had their Andersson’s Score recorded, with a median value of 6 (IQR, 5–8). In 21% patients, the Andersson’s score was ≤ 4, between 5 and 8 in 68% patients, and between 9 and 12 in rest of the patients.
The Alvarado Score was ≥ 5 in 89% cases of AA confirmed by pathologic exam (RR = 1.11, 1.07–1.15 CI 95%, p < 0.001), while Andersson’s Score was ≥ 5 in 83%) cases of AA confirmed by histopathology (RR = 1.11, 1.07–1.14 CI 95%, p < 0.001).
97% patients underwent surgery, of which 44% underwent open appendectomy and 53% laparoscopic appendectomy,
5% had open lavage and drainage, 4 % had laparoscopic lavage and drainage, 1% had an open ileocaecal resection, 2% underwent percutaneous drainage, and 4% had other surgical procedures.
100% patients received antibiotics during the hospitalization, which was monotherapy in the case of 43% patients . The median duration of the antimicrobial therapy was 4.5 days . Among the patients who received antibiotics, 64% patients received them as antibiotic prophylaxis.
Intraperitoneal microbiological swab was collected from 23% who underwent surgical intervention, resulting in 9 positive cultures. The aerobic and anaerobic bacteria identified in samples of peritoneal fluid were reported
The median length of hospital stay was 3 days .
In the early postoperative phase, 5% patients were admitted to the ICU. 2% patients underwent re-laparotomy. A total of 93% appendixes were analyzed by histopathology, with the reports as shown in Table 1 .
|S.No.||Appendix Types found during Histopathology||Percentage found|
A total of 86 % patients were monitored for complications at 7 days after the intervention. Major complications occurred in 5%. A total of 13% developed complications at 7 days. Among these patients with complication, there were with intra-abdominal abscesses , surgical site infections & other medical complications.
AA is one of the most commonly occurring clinical challenges for emergency surgeons, because of its diagnostic work-up.41, 40, 39 The clinical presentation of AA may vary widely from mild symptoms, like moderate abdominal pain or fever, to most severe scenarios, such as diffuse peritonitis and sepsis 42 . The most frequent clinical symptom is right lower quadrant abdominal pain. If fever with chills is present, systemic involvement should be suspected. However, these symptoms are not specific for AA, since they can be present in other septic conditions, like infectious gastrointestinal disorders or genitourinary tract disorders in young female patients 41 . The median age demonstrates the prevalence of this disease in young population. Our data showed that right lower quadrant pain and tenderness were the most frequently reported symptoms (91% and 57%), followed by vomiting, fever, and diffuse tenderness .
Laboratory findings showed a high prevalence of white blood count (WBC) > 10,000 cells/ml (79 %) and C-reactive protein (CRP) > 10 mg/L in 43% of cases. As reported in various studies, WBC and CRP are the most significant laboratory markers to be considered in case of AA. WBC cut-off > 10,000/ml has a range of sensitivity between 65 and 85% and specificity between 32 and 82%, and CRP values > 10 mg/L have a range of sensitivity between 65 and 85% and specificity between 59 and 73% 43 .
Imaging plays a cardinal role in the diagnosis of AA. Reliable imaging in patients with clinical suspicion of appendicitis results in reducing the rate of negative appendectomy by almost 15%. The most commonly used imaging techniques are ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) . In our study, maximum patients used these investigations . The data demonstrates that often an accurate clinical examination supported by laboratory findings can help the surgeon to manage AA. However, in some cases, a radiological confirmation of the clinical suspicion is paramount, and when USG is not sufficient for definitive diagnosis or there is no availability of USG-specialized radiologists (i.e., during night-time in some hospitals), a CT scan would be the ideal option, with a sensitivity of 98.5% and a specificity of 98% 45, 44 .
Different prognostic scores have been proposed for the clinical evaluation of AA. Alvarado and Appendicitis Inflammatory Responses (AIR; also called Andersson’s score) scores are the most commonly used and validated, being the result of a combination of clinical and biochemical variables with a significant predicting value4 . Alvarado score has a sensitivity and specificity of 99 and 43% to rule out the diagnosis of AA when < 5 and a sensitivity of 82% and specificity of 81% if < 7. Andersson’s score has a sensitivity of 96% to rule out AA when < 4 and a specificity of 99% to diagnose appendicitis when > 846 . In our study, Alvarado and Andersson’s scores were recorded . The Alvarado Score was ≥5 in cases of AA confirmed by pathologic exam (RR = 1.11, 1.07–1.15 CI 95%, p < 0.001), while Andersson’s Score was ≥ 5 in cases of AA confirmed by pathologic exam (RR = 1.11, 1.07–1.14 CI 95%, p < 0.001).
97 % patients in our study underwent surgery . both with Laparoscopy as well as Open Laparotomy Despite there being several reports in the literature regarding non-operative management of uncomplicated AA ], this global snapshot from our study demonstrates how operative management still forms the backbone of treatment by surgeons.49, 48, 47, 46, 13
Both laparoscopic and open approach are safe and effective techniques for the treatment of suspected AA. Both techniques are associated with good clinical outcomes and few complications 50 . The benefits of laparoscopic approach include reduced incidence of surgical site infections, shorter postoperative stay, less pain, reduced incidence of incisional hernias, and faster postoperative recovery and return to everyday activities, along with better cosmesis 52, 51, 24 . However, the traditional open approach is still widely used, probably due to reduced cost, shorter operative and anesthetic times, the increased risk of intra-abdominal abscess associated with laparoscopic appendectomies and a reduced requirement of higher surgical skill levels55, 54, 53, 26, 24, 23
Recently, WSES recommended the use of broad spectrum antibiotics in case of complicated AA for a minimum duration of 3–5 days of antibiotic treatment 54 , and no postoperative antibiotics for uncomplicated appendicitis. In our study, 100% of patients received at least one antibiotic during hospitalization . The most commonly used antiobiotic was and third-generation cephalosporines along with metronidazole . Escherichia coli (aerobic gram-negative) was found in most of the cultures (52%), followed by anaerobic bacteria (Bacteroides spp. 38 %) and Enterococcus faecalis (aerobic gram-positive) in 10%. These multiple isolations correlated with the use of multiple antibiotics in about 70% of cases.
The results of the present study gives a snapshot of current worldwide trend in the diagnostic work-up and therapeutic management of AA. Ultrasound and CT are used in Sufficient cases . Alvarado, Andersson’s, and WSES grading scores are useful methods to classify the patients, and they predict and correlate with the surgical or pathological diagnosis. 97 % of patients are treated with surgery, which, in more than 50% cases, is performed using a laparoscopic approach, with a low conversion rate. The hospital stay is usually short, with few complications at 7 and 30 days postoperatively. Further analysis based on the present data are needed to study in detail the role of preoperative diagnostic work-up, the usefulness of prognostic scores, the potential value of appropriate antibiotic therapy, and the real advantages of a laparoscopic approach.
- The epidemiology of appendicitis and appendectomy in the United States Addiss D G, Shaffer N, Fowler B S, Tauxe R V. Am J Epidemiol.1990;132:910-935.
- Appendectomy in Sweden 1989-1993 assessed by the Inpatient Registry Blomqvist P, Ljung H, Nyren O, Ekbom A. J ClinEpidemiol.1998;51:859-65.
- Risk factors for adverse outcomes after the surgical treatment of appendicitis in adults Margenthaler J A, Longo W E, Virgo K S, Johnson F E, Oprian C A, Henderson W G. Ann Surg.2003;238:59-66.
- A practical score for the early diagnosis of acute appendicitis Alvarado A. Ann Emerg Med.1986;15:557-64.
- The appendicitis inflammatory response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score Andersson M, Andersson R E. World J Surg.2008;32:1843-1852.
- Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients Hansson J, Korner U, Khorram-Manesh A, Solberg A, Lundholm K. Br J Surg.2009;96:473-81.
- Appendectomy versus antibiotic treatment in acute appendicitis. A prospective multicenter randomized controlled trial Styrud J, Eriksson S, Nilsson I, Ahlberg G, Haapaniemi S, Neovius G. World J Surg.2006;30:1033-1040.
- Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial Vonns C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B. Lancet.2011;377:1573-1582.
- Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC Randomized Clinical Trial Salminen P, Paajanen H, Rautio T, Nordstrom P, Aarnio M, Rantanen T. JAMA.2015;313:2340-2348.
- Surgery versus conservative antibiotic treatment in acute appendicitis: a systematic review and meta-analysis of randomized controlled trials Ansaloni L, Catena F, Coccolini F, Ercolani G, Gazzotti F, Pasqualini E. Dig Surg.2011;28:210-231.
- Use of antibiotics alone for treatment of uncomplicated acute appendicitis: a systematic review and meta-analysis Liu K, Fogg L. Surgery.2011;150:673-83.
- Appendectomy versus antibiotic treatment for acute appendicitis Wilms I M, De Hoog D E, Visser De, Janzing D C, . H M. Cochrane Database Syst Rev.2011;11:8359-8359.
- Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials Varadhan K K, Neal K R, Lobo D N. BMJ.2012;344:2156-2156.
- The NOTA Study (Non Operative Treatment for Acute Appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis Saverio S, Sibilio A, Giorgini E, Biscardi A, Villani S, Coccolini F. Ann Surg.2014;260:109-126.
- Alvarado score: can it reduce unnecessary CT scans for evaluation of acute appendicitis? Apisarnthanarak P, Suvannarerg V, Pattaranutaporn P, Charoensak A, Raman S S, Apisarnthanarak A. Am J Emerg Med.2015;33:266-70.
- Examining the relevance of the physician's clinical assessment and the reliance on computed tomography in diagnosing acute appendicitis Nelson D W, Causey M W, Porta C R, Mcvay D P, Carnes A M, Johnson E K. Am J Surg.2013;205:452-458.
- Computed tomography mimics of acute appendicitis: predictors of appendiceal disease confirmed at pathology Duda J B, Lynch M L, Bhatt S, Dogra V S. J Clin Imaging Sci.2012;2:73-73.
- A prospective trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient Horton M D, Counter S F, Florence M G, Hart M J. Am J Surg.2000;179:379-81.
- CT evaluation of appendicitis and its complications: imaging techniques and key diagnostic findings Pinto Leite N, Pereira J M, Cunha R, Pinto P, Sirlin C. AJR Am J Roentgenol.2005;185:406-423.
- Choice of approach for appendicectomy: a meta-analysis of open versus laparoscopic appendicectomy Bennet J, Boddy A, Rhodes M. Surg Laparosc Endosc Percutan Tech.2007;17:245-55.
- Laparoscopy or not: a meta-analysis of the surgical effects of laparoscopic versus open appendicectomy Liu Z, Zhang P, Ma Y, Chen H, Zhou Y, Zhang M. Surg Laparosc Endosc Percutan Tech.2010;20:362-70.
- Laparoscopic versus open surgery for suspected appendicitis Sauerland S, Jaschinski T, Neugebauer E A. Cochrane Database Syst Rev.2010;10:1546-1546.
- Laparoscopic versus open appendectomy for acute appendicitis: a metaanalysis Wei B, Qi C L, Chen T F, Zheng Z H, Huang J L, Hu B G, Wei H B. Surg Endosc.2011;25:1199-208.
- Meta-analysis of the results of randomized controlled trials that compared laparoscopic and open surgery for acute appendicitis Ohtani H, Tamamori Y, Arimoto Y, Nishiguchi Y, Maeda K, Hirakawa K. J Gastrointest Surg.2012;16:1929-1968.
- Evidence to support the use of laparoscopic over open appendicectomy for obese individuals: a meta-analysis Woodham B L, Cox M R, Eslick G D. Surg Endosc.2012;26:2566-70.
- Appendiceal abscess revisited Bradley El 3rd Isaacs J. Arch Surg.1978;113:130-132.
- Nonoperative management of the ultrasonically evaluated appendiceal mass Bagi P, Dueholm S. Surgery.1987;101:602-607.
- Initial nonoperative management for periappendiceal abscess Oliak D, Yamini D, Udani V M, Lewis R J, Arnell T, Vargas H. Dis Colon Rectum.2001;44:936-977.
- Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America Solomkin J S, Mazuski J E, Bradley J S, Rodvold K A, Goldstein E J, Baron E J. Clin Infect Dis.2010;50:133-64.
- Appendiceal abscess: immediate operation or percutaneous drainage? Brown C V, Abrishami M, Muller M, Velmahos G C. Am Surg.2003;69:829-861.
- WSES consensus conference: guidelines for first-line management of intra-abdominal infections Sartelli M, Viale P, Koike K, Pea F, Tumietto F, Van Goor H. World J Emerg Surg.2011;6(2).
- Interval appendicectomy after appendiceal mass or abscess in adults: what is “best practice”? Surg Today Corfield L. 2007.
- Complicated appendicitis in children: a clear role for drainage and delayed appendectomy Roach J P, Partrick D A, Bruny J L, Allshouse M J, Karrer F M, Ziegler M M. Am J Surg.2007;194:772-775.
- The value of a laparoscopic interval appendectomy for treatment of a periappendiceal abscess: experience of a single medical center You K S, Kim D H, Yun H Y, Jang L C, Choi J W, Song Y J. Surg Laparosc Endosc Percutan Tech.2012;22:127-157.
- Resource utilization and outcomes from percutaneous drainage and interval appendectomy for perforated appendicitis with abscess Keckler S J, Tsao K, Sharp S W, Ostlie D J, Holcomb G W, Iii St, Peter S D. J Pediatr Surg.2008;43:977-80.
- Appendiceal abscesses: primary percutaneous drainage and selective interval appendicectomy Lasson A, Lundagårds J, Lorén I, Nilsson P E. Eur J Surg.2002;168:264-273.
- Routine interval appendectomy is not justified after initial nonoperative treatment of acute appendicitis Kaminski A, Liu I L, Applebaum H, Lee S L, Haigh P I. Arch Surg.2005;140:897-901.
- Acute appendicitis: proposal of a new comprehensive grading system based on clinical, imaging and laparoscopic findings Gomes C A, Sartelli M, Saverio Di, Ansaloni S, Catena L, Coccolini F, . F. World J Emerg Surg.2015;10:60-60.
- A new method of classifying prognostic comorbidity in longitudinal studies: development and validation Charlson M E, Pompei P, Ales K L, Mackenzie C R. J Chronic Dis.1987;40:373-83.
- Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey Dindo D, Demartines N, Clavien P A. Ann Surg.2004;240:205-218.
- Improving the preoperative diagnostic accuracy of acute appendicitis. Can fecal calprotectin be helpful Ambe P C, Orth V, Gödde D, Zirngibl H. PLoS One.2016;11:168769-168769.
- Diagnosis and management of acute appendicitis. EAES consensus development conference Gorter R R, Eker H H, Gorter-Stam M A, Abis G S, Acharya A, Ankersmit M. Surg Endosc.2015;30:4668-90.
- Diagnosing appendicitis: evidence-based review of the diagnostic approach in 2014 Shogilev D J, Duus N, Odom S R, Shapiro N I. West J Emerg Med.2014;15:859-71.
- Diagnostic performance of multidetector computed tomography for suspected acute appendicitis Pickhardt P J, Lawrence E M, Pooler B D, Bruce R J. Ann Intern Med.2011;154:789-96.
- Impact of computed tomography of the abdomen on clinical outcomes in patients with acute right lower quadrant pain: a meta-analysis Krajewski S, Brown J, Phang P T, Raval M, Brown C J. Can J Surg.2011;54:43-53.
- WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis Saverio S, Birindelli A, Kelly M D, Catena F, Weber D G, Sartelli M. World J Emerg Surg.2016;11:34-34.
- Laparoscopy grading system of acute appendicitis: new insight for future trials Gomes C A, Nunes T A, Chebli Fonseca, Junior J M, Gomes C S, . C C. Surg Laparosc Endosc Percutan Tech.2012;22:463-469.
- Antibiotics versus appendicectomy for the treatment of uncomplicated acute appendicitis: an updated meta-analysis of randomised controlled trials Rollins K E, Varadhan K K, Neal K R, Lobo D N. World J Surg.2016;40:2305-2323.
- Antibiotics-first strategy for uncomplicated acute appendicitis in adults is associated with increased rates of peritonitis at surgery. A systematic review with meta-analysis of randomized controlled trials comparing appendectomy and non-operative management with antibiotics Podda M, Cillara N, Saverio Di, Lai S, Feroci A, Luridiana F, . G. Surgeon.2017;15:303-317.
- Laparoscopic versus open appendectomy in patients with suspected appendicitis: a systematic review of meta-analyses of randomised controlled trials Jaschinski T, Mosch C, Eikermann M, Neugebauer E A. BMC Gastroenterol.2015;15:48-48.
- Comparison of outcomes of laparoscopic versus open appendectomy in adults: data from the nationwide inpatient sample (NIS) Massoomi H, Mills S, Dolich M O, Ketana N, Carmichael J C, Nguyen N T. J Gastrointest Surg.2006;15:2226-2257.
- Surgical site infection after laparoscopic and open appendectomy: a multicenter large consecutive cohort study Xiao Y, Shi G, Zhang J, Cao J G, Liu L J, Chen T H. Surg Endosc.2014;29:1384-93.
- Intra-abdominal collections following laparoscopic versus open appendicectomy: an experience of 516 consecutive cases at a district general hospital Wilson D G, Bond A K, Ladwa N, Sajid M S, Baig M K, Sains P. Surg Endosc.2013;27:2351-2357.
- Short- and long-term results of open versus laparoscopic appendectomy Swank H A, Eshuis E J, Van Berge Henegouwen M I, Bemelman W A. World J Surg.2011;35:1221-1227.
- Laparoscopic versus conventional appendectomy-a meta-analysis of randomized controlled trials Zhang X, Sang J, Zhang L, Chu W, Li Z, . X. BMC Gastroenterol.2010;10:129-129.