Management of Acute Appendicitis in Ambulatory Surgery: Is It Possible? How to Select Patients?

OBJECTIVE: Establish a protocol of management of acute appendicitis (AA) in ambulatory surgery (AmbSurg) on the basis of preoperative criteria. BACKGROUND: Ambulatory laparoscopic appendectomy (LA) for AA has not been yet reported. METHODS: All patients who underwent LA between 2010 and 2012 were reviewed. A multivariate analysis was performed to create a predictive score of discharge within the first 24 hours. The score was prospectively used on every AA from January 1, 2013, to December 15, 2013. All patients with 5 or 4 points were proposed for AmbSurg. RESULTS: A total of 468 patients were included retrospectively, 181(38.7%) were discharged within the first 24 hours. In multivariate analysis, predictive factors of early discharge were body mass index less than 28 kg/m, white cell count less than 15,000/mL, C-reactive protein less than 30 mg/L, no radiological signs of perforation, and appendix diameter of 10 mm or smaller. Rate of discharge at day 1 was 72%, 45%, 39%, 21%, 0%, and 0% according to the score 5 to 0 (P < 0.0001). Prospectively, 184 patients had AA and 103 (56%) had a score of 4 or 5. Thirty-eight underwent ambulatory LA [16 (42%) patients were postponed to the next day and went back home]. All patients were directly discharged from recovery room, except 1 (2.6%) patient, after a mean hospital stay of 8.4 hours ± 6.9 hours. A total of 146 patients underwent LA in conventional surgery and 58% were discharged at day 1. Rate of early discharge was significantly associated with the score ranging from 0% to 92% for a score 0 or 5, validating prospectively the score (P < 0.0001). CONCLUSIONS: We establish a simple validated predictive score of early discharge. When applied to AmbSurg, it allowed us to select patients eligible with a success rate of 97%.

Ruptured inferior mesenteric artery aneurysm in a patient with a type 1 neurofibromatosis.

We describe the case of a 61-year-old woman having a type 1 neurofibromatosis (von Recklinghausen disease), whose acute abdominal pain revealed a voluminous retroperitoneal hemorrhage caused by a 25-mm ruptured inferior mesenteric artery aneurysm. She underwent emergent aneurysm and left colonic resection. This report of a rare digestive artery aneurysm rupture, which added to increasing reports of vascular abnormalities in type 1 neurofibromatosis patients, underlines the need to maintain a high suspicion index of a vascular etiology in case of any abdominal complaint in these patients.