Acute Appendicitis: Clinical Clues and Conundrums Related to the Greatest Misses.

Introduction In the United States (US), appendicitis is the most common acute abdominal emergency requiring surgery. Patients with appendicitis continue to display a complex and atypical range of clinical manifestations, providing a subsequent high risk for emergency physicians to miss acute abdominal pathology on a patient's initial visits. Due to the risk of potential perforation, the proper and timely clinical identification of acute appendicitis is vital. The current study aims to identify clinical characteristics that could be useful in identifying patients at risk for having acute appendicitis that was misdiagnosed on their initial visits. Methods Medical charts consisting of patients between the ages of 19 and 55 years on their second visit were flagged and reviewed by the emergency department quality assurance (EDQA) committee. The retrospective chart review included patients who presented to the emergency department (ED) with the chief complaint of an abdominal-related complaint, were discharged, returned within 72 hours, and were diagnosed with a pathologically confirmed appendicitis. All patients were managed operatively, with pathology results reviewed for evidence of acute appendicitis. Those with confirmed pathologic appendicitis upon return were considered to have a "misdiagnosis." Any patients managed nonoperatively and those with negative pathology were excluded from the study and considered not to have appendicitis. Results Fifty-five patients were identified through the EDQA committee from May 2011 to January 2014. After exclusion criteria were applied, 18 patients met the inclusion criteria for this study (7 males, 11 females). The mean age was 36.2 (range: 19-55). The most common presenting complaint on the initial visit was pain in the epigastric region of the abdomen (50%, n = 9). Twenty-two percent (n = 4) of patients had pain in the right lower quadrant documented in the physician's note on the initial visit and 83% (n = 15) had right lower quadrant pain documented on the second visit. Two patients (11%) did not have right lower quadrant tenderness on either visit. The most common discharge diagnosis on the initial visit was undifferentiated abdominal pain (50%), followed by gastritis (28%). Opioid pain medication was administered or prescribed to 39% (n = 7) of the patients. The average return time was 23.9 hours. Conclusion The administration of opioid pain medication is associated with many of the return visits to the emergency department for missed appendicitis. Finally, discharge diagnosis and planning are imperative, as detailed early appendicitis instructions or extended ED observation can include more cases and decrease litigation risk.

Hernia incisional en laparotomía de McBurney: complicaciones de una hernia inusual / Incisional hernia after McBurney incision: complications of an unusual hernia

Resumen Introducción Actualmente, la mayoría de las series que hablan sobre hernia incisional, no mencionan hernias incisionales en laparotomías de McBurney. La incidencia reportada de hernia incisional en esta laparotomía varía entre 0,7% y 2%. Aún más escasas son las publicaciones sobre sus complicaciones. El objetivo del presente reporte de casos es el de discutir el diagnóstico, tratamiento y resultados de dos pacientes operados en nuestra institución por hernia de McBurney complicada. Reporte de Casos: Se describen 2 pacientes femeninos de 68 y 65 años de edad que fueron operadas de urgencia por hernia incisional en laparotomía de McBurney complicada. La evolución postoperatoria fue diferente en ambas y una de ellas falleció. Discusión Se discuten los factores de riesgo para el desarrollo de estas hernias, el diagnóstico y tratamiento. Además, se discute la importancia de la apendicectomía laparoscópica para la prevención de estas hernias. Conclusiones Las complicaciones de la hernia en laparotomía de McBurney, las cuales son severas y potencialmente letales, se diagnostican tardíamente debido al retraso en la presentación y en el diagnóstico. La amplia utilización de la cirugía laparoscópica para la apendicectomía seguramente reducirá aún más la incidencia de este tipo de hernia durante los próximos años.

Introduction Currently, most series over incisional hernia do not mention this hernia occurring in McBurney's laparotomy. The reported incidence for this type of hernia is 0.7% to 2%. Even more scarce are publications regarding its complications. The purpose of this report is to discuss the diagnostic, treatment and outcomes of two patients operated on our institution for complicated McBurney´s hernia. Report of Cases: Two female patients 68 and 65 years-old operated on emergency grounds for complicated incisional hernia over a McBurney´s incision are described. Postoperative evolution was different in both cases and one of them died. Discussion We discuss risk factor for this specific incisional hernia development, its diagnosis and treatment. Besides, the importance of laparoscopic appendectomy was stressed. Conclusions Complicated incisional hernia over McBurney's incision is an infrequent severe clinical condition habitually diagnosed late. The widespread utilization of laparoscopic appendectomy will reduce even more the incidence of this kind of hernia within the next few years.

Current Trends in Training in the Surgical Management of Acute Appendicitis at a Veteran Affairs Hospital.

INTRODUCTION: An open appendectomy used to be one of the most common cases performed by interns and physical exam dictated operative intervention. We hypothesized that the management of acute appendicitis has drastically changed from these previous practices. METHODS: A retrospective, single institution study was performed at the VA North Texas Health Care System between July 2005 to June 2017 for all patients who underwent an appendectomy. Using postgraduate year (PGY)-level (PGY 1-3 and PGY 4-5) as a dependent variable, univariate analyses, and multiple logistic regression analyses were performed. All statistical tests were 2-sided, and the statistical significance level was set at a p ≤ 0.05. RESULTS: Only patients with acute appendicitis were included (n = 257; male = 90.7%; age = 45.4 ± 15.6 year old; body mass index = 30.3 ± 6.3 Kg/m2). Of these, only 8 were performed by interns, 25 by PGY-2, 147 by PGY-3, 22 by PGY-4, and 55 by PGY-5. On presentation, 92.2% of patients had a computed tomography scan and 90.7% underwent a laparoscopic appendectomy. Conversion rate was 4.7%. There were 20 complications (7.8%) and length of hospital stay was 2.2±3.7 days. Comparing patients operated by senior (PGY-4 and 5) to junior (PGY-1 to -3) residents: patients were of similar age, gender, body mass index, American Society of Anesthesiologists (ASA), and had similar WBC and blood pressure on initial presentation (all p's > 0.05); but were more likely to have diabetes mellitus, hypertension or pulmonary disease. Complication rate was the same (7.8%) for both senior and junior residents. CONCLUSIONS: At the VA North Texas Health Care System, most patients presenting with suspected appendicitis undergo a computed tomography scan. Most cases are performed laparoscopically mainly by PGY ≥ 3 residents. The rate of post-operative complications was similar between junior and senior residents.

A new right groin incision versus McBurney's incision for open appendectomy: a randomized controlled trial.

PURPOSE: We aimed to introduce a new surgical method for open appendectomy including a right groin incision with adipocutaneous flap and to compare its feasibility, safety, and cosmetic outcomes with classic McBurney's incision. METHODS: Patients with the diagnosis of acute appendicitis who were candidates for appendectomy surgery at General Surgery Department, Besat Hospital, Hamadan University of Medical Sciences, Iran, in 2016 and 2017, were enrolled in a randomized controlled clinical study. Patients were randomly assigned to two groups each containing 50 patients. In the case and control groups, patients underwent appendectomy using right groin incision with adipocutaneous flap and traditional McBurney's methods, respectively. RESULTS: One hundred patients with the mean age of 23.6 years (range = 4-44) old including 65 males were enrolled in the study. Patients' demographics, histopathology, and anatomical location of the appendix were not significantly different in the case and control groups. There was no significant difference in postoperative wound infection, cellulitis, hematoma, and seroma between the two groups. Patients in the case group were significantly more satisfied in terms of cosmesis than in the control group (P < .001); however, the operative time and pain were higher in the case group compared to the control group (P values = 0.016 and 0.033, respectively). CONCLUSIONS: The right groin incision for open appendectomy may be safe and feasible and the most cosmetically appealing method especially in children and patients with cosmetic concerns.

Acute Appendicitis, Somatosensory Disturbances ("Head Zones"), and the Differential Diagnosis of Anterior Cutaneous Nerve Entrapment Syndrome (ACNES).

BACKGROUND: Anterior cutaneous nerve entrapment syndrome (ACNES) is a neuropathic abdominal wall pain syndrome typically characterized by locally altered skin sensations. On the other hand, visceral disease may also be associated with similar painful and altered skin sensations ("Head zones"). Aim of the study was to determine if patients with acute appendicitis demonstrated somatosensory disturbances in the corresponding right lower quadrant Head zone. METHODS: The presence of somatosensory disturbances such as hyperalgesia, hypoesthesia, altered cool perception, or positive pinch test was determined in 100 patients before and after an appendectomy. Potential associations between altered skin sensations and various items including age, sex, history, body temperature, C-reactive protein (CRP), leukocyte count, and type of appendicopathy (normal, inflamed, necrotic, or perforated) were assessed. RESULTS: A total of 39 patients demonstrated at least one right lower abdominal quadrant skin somatosensory disturbance before the laparoscopic appendectomy. However, locoregional skin sensation normalized in all but 2 patients 2 weeks postoperatively. No differences were found concerning patient characteristics or type of appendicopathy between populations with or without altered lower abdominal skin sensations. CONCLUSION: A substantial portion of patients with acute appendicitis demonstrate right lower abdominal somatosensory disturbances that are similar as observed in acute ACNES. Both may be different sides of the same coin and are possibly expressions of segmental phenomena as described by Head. McBurney's point, a landmark area of maximum pain in acute appendicitis, is possibly a trigger point within a Head zone. Differentiating acute appendicitis from acute ACNES is extremely difficult, but imaging and observation may aid in the diagnostic process.

Umbilical-spinous line: a morphological term that should be included in the anatomical terminology / Linea umbilico-espinosa: un término morfológico que debe incluirse en la terminologia anatómica

Abstract We argue the need to include in the International Anatomical Terminology the term "Umbilical-spinous line" for its importance as a morphological referent in bioscopic and surface anatomy. Also, in order to avoid using eponyms, it is suggested that the traditional term "McBurney point" be replaced by "supra spinous point" as being more descriptive of location.

Resumen Se argumenta la necesidad de incluir en la Terminología Anatómica Internacional el término "línea umbilico-espinosa" por su importancia como referente morfológico en la anatomía bioscópica y de superficie. Además, con el propósito de evitar la utilización de epónimos, se sugiere que el tradicional término "punto de McBurney" sea remplazado por el de "punto supraespinoso", por ser más descriptiva su ubicación.

Umbilical-spinous line: a morphological term that should be included in the anatomical terminology.

We argue the need to include in the International Anatomical Terminology the term "Umbilical-spinous line" for its importance as a morphological referent in bioscopic and surface anatomy. Also, in order to avoid using eponyms, it is suggested that the traditional term "McBurney point" be replaced by "supra spinous point" as being more descriptive of location.

Se argumenta la necesidad de incluir en la Terminología Anatómica Internacional el término "línea umbilico-espinosa" por su importancia como referente morfológico en la anatomía bioscópica y de superficie. Además, con el propósito de evitar la utilización de epónimos, se sugiere que el tradicional término "punto de McBurney" sea remplazado por el de "punto supraespinoso", por ser más descriptiva su ubicación.

Predictors of early outcome after acute appendicitis: is delaying surgery for acute appendicitis an option? A retrospective study.

PURPOSE: This study analysed the clinical and para-clinical criteria that may allow surgeons and emergency physicians to take a decision regarding the surgery of acute appendicitis. METHODS: A retrospective analysis was conducted on 284 acute appendicitis patients who underwent surgery between January 2007 and December 2009 in our institution. The registered data were extracted from patient files and statistically analysed. These data included past medical history, clinical, laboratory and imaging data, duration of hospital stay and post-operative complications. Patient delay (time between the appearance of symptoms and patient arrival at the emergency department) and hospital delay (time between hospital arrival and operation) were correctly investigated. Statistical analysis was done by using SPSS software. RESULTS: The patient delay is significantly increased in relation to the severity of appendicitis: 24 h (10.8-30.8 h) versus 37.4 h (36.8-38 h) (P < 0.05), unlike hospital delay, which remains constant (between simple and severe appendicitis): 7.5 h (5-14.8 h) versus 8 h (5-13 h). In severe appendicitis, the proportion of guarding, rebound tenderness, tachycardia (P < 0.05) and fever (P < 0.005) were significantly high, and leucocytosis (P < 0.05), C-reactive protein (CRP) (P < 0.001) and eosinopaenia [37.0 vs. 72.8 (P < 0.001)] were significantly different. Concerning computed tomography (CT) and echography, perforation, abscess formation (P < 0.05), phlegmon (P < 0.005) and peritonitis (P < 0.05) were significant signs of complicated cases. The length of hospital stay (P < 0.001) and duration of antibiotic therapy (P < 0.001) were statistically significant in cases of complicated appendicitis. CONCLUSION: Patient delay is a determining factor for the grade of appendicitis. It has an influence on the complications, length of hospital stay and duration of antibiotic treatment, unlike hospital delay.