Ray-Zack, Mohamed D.

Objective: We sought to describe contemporary presentation, treatment, and outcomes of patients presenting with acute (A), perforated (P), and gangrenous (G) appendicitis in the United States. Summary Background Data: Recent European trials have reported that medical (antibiotics only) treatment of acute appendicitis is an acceptable alternative to surgical appendectomy. However, the type of operation (open appendectomy) and average duration of stay are not consistent with current American practice and therefore their conclusions do not apply to modern American surgeons. Methods: This multicenter prospective observational study enrolled adults with appendicitis from January 2017 to June 2018. Descriptive statistics were performed. P and G were combined into a “complicated” outcome variable and risk factors were assessed using multivariable logistic regression. Results: A total 3597 subjects were enrolled across 28 sites: median age was 37 (27–52) years, 1918 (53%) were male, 90% underwent computed tomography (CT) imaging, 91% were initially treated by appendectomy (98% laparoscopic), and median hospital stay was 1 (1–2) day. The 30-day rates of Emergency Department (ED) visit and readmission were 10% and 6%. Of 219 initially treated with antibiotics, 35 (16%) required appendectomy during index hospitalization and 12 (5%) underwent appendectomy within 30 days, for a cumulative failure rate of 21%. Overall, 2403 (77%) patients had A, whereas 487 (16%) and 218 (7%) patients had P and G, respectively. On regression analysis, age, symptoms >48 hours, temperature, WBC, Alvarado score, and appendicolith were predictive of “complicated” appendicitis, whereas co-morbidities, smoking, and ED triage to appendectomy >6 hours or >12 hours were not. Conclusion: In the United States, the majority of patients presenting with appendicitis receive CT imaging, undergo laparoscopic appendectomy, and stay in the hospital for 1 day. One in five patients selected for initial non-operative management required appendectomy within 30 days. In-hospital delay to appendectomy is not a risk factor for “complicated” appendicitis.

AbstractBackgroundCoagulopathy can delay or complicate surgical diseases that require emergent surgical treatment. Prothrombin complex concentrates (PCC) provide concentrated coagulation factors which may reverse coagulopathy more quickly than plasma (FFP) alone. We aimed to determine the time to operative intervention in coagulopathic emergency general surgery patients receiving either PCC or FFP. We hypothesize that PCC administration more rapidly normalizes coagulopathy and that the time to operation is diminished compared to FFP alone.MethodsSingle institution retrospective review was performed for coagulopathic EGS patients during 2/1/2008 to 8/1/2016. Patients were divided into three groups (1) PCC alone (2) FFP alone and (3) PCC and FFP. The primary outcome was the duration from clinical decision to operate to the time of incision. Summary and univariate analyses were performed.ResultsCoagulopathic EGS patients (n = 183) received the following blood products: PCC (n = 20, 11%), FFP alone (n = 119, 65%) and PCC/FFP (n = 44, 24%). The mean (± SD) patient age was 71 ± 13 years; 60% were male. The median (IQR) Charlson comorbidity index was similar in all three groups (PCC = 5(4–6), FFP = 5(4–7), PCC/FFP = 5(4–6), p = 0.33). The mean (± SD) dose of PCC administered was similar in the PCC/FFP group and the PCC alone group (2539 ± 1454 units vs. 3232 ± 1684, p =. 09). The mean (±SD) time to incision in the PCC alone group was significantly lower than the FFP alone group (6.0 ± 3.6 vs. 8.8 ± 5.0 h, p = 0.01). The mean time to incision in the PCC + FFP group was also significantly lower than the FFP alone group (7.1 ± 3.6 vs. 8.8 ± 5.0, p = 0.03). The incidence of thromboembolic complications was similar in all three groups.ConclusionsPCC, alone or in combination with FFP, reduced INR and time to surgery effectively and safely in coagulopathic EGS patients without an apparent increased risk of thromboembolic events, when compared to FFP use alone.Level of evidenceIV single institutional retrospective review.