Manne Andersson

WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis

Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.

Causes of Short-Term Mortality After Appendectomy: A Population-Based Case-Controlled Study

Objective:This case control study is a detailed analysis of the causes of death and the risk factors of short-term mortality after appendectomy. Summary Background Data:Although death is a rare event after appendectomy, we found a 7-fold excess mortality after appendectomy overall and a 9-fold excess mortality after negative appendectomy, compared to the background population in a previous study from Sweden, in accordance with others. Materials and Methods:All patients who died within 30 days after appendectomy, and controls matched to age, sex and period, were identified of 119,060 patients who were operated with appendectomy in 1987 to 1996 from the Swedish National Inpatient Registry. Causes of death and differences between the cases and controls in comorbidity and appendectomy diagnoses were analyzed on the basis of a review of hospital records. Only patients and controls with appendectomy as the only surgical intervention and without prevalent malignant diagnosis were included in the analysis to avoid bias. Results:A total of 179 patients who died within 30 days and 400 matched controls remained for the analyses. Nonproductive and negative exploration was strongly associated with mortality [odds ratio (OR), 5.11; confidence interval (CI), 2.09–12.48; P < 0.001 and OR, 2.38; CI, 1.24–4.57; P = 0.009, respectively] in contrast to perforated appendicitis (OR, 1.60; CI, 0.95–2.70; P = 0.078) after adjustment for age, sex, and comorbidity. Chronic obstructive pulmonary disease (OR, 3.31; CI, 1.05–10.45, P = 0.041), renal insufficiency (OR, 2.32; CI, 1.26–4.27; P = 0.007), and diabetes mellitus were also independent risk factors (OR, 2.39; CI, 1.12–5.12; P = 0.025). Cardiovascular or thromboembolic disease was responsible for the death in more than 50% of the cases, whereas appendicitis was responsible in only 17.9%. Conclusions:Appendicitis is only responsible for a small portion of the deaths after appendectomy. Comorbidity and negative appendectomy are strongly associated with mortality, suggesting that comorbidity, diagnostic failure, and the anesthesiosurgical trauma may play an important role.

Systemic Th17-like cytokine pattern in gangrenous appendicitis but not in phlegmonous appendicitis

BACKGROUND Increasing circumstantial evidence suggests that not all patients with appendicitis will progress to perforation and that appendicitis that resolves may be a common event. Based on this theory and on indications of aberrant regulation of inflammation in gangrenous appendicitis, we hypothesized that phlegmonous and gangrenous appendicitis are different entities with divergent immunoregulation. METHODS Blood samples were collected from patients with gangrenous appendicitis (n = 16), phlegmonous appendicitis (n = 21), and nonspecific abdominal pain (n = 42). Using multiplex bead arrays, we analyzed a range of inflammatory markers, such as interleukin (IL)-1ra, IL-1rbeta, IL-2, IL-6, IL-10, IL-12p70, IL-15, and IL-17; interferon-gamma; tumor necrosis factor; CXCL8; CCL2; CCL3; and matrix metalloproteinase (MMP)-1 MMP-2, MMP-3, MMP-7, MMP-8, MMP-9, MMP-12, and MMP-13 in blood. RESULTS Compared with patients with phlegmonous appendicitis and nonspecific abdominal pain, the patients with gangrenous appendicitis had increased levels of the proinflammatory markers IL-6, CCL2, IL-17, MMP-8, and MMP-9 (P < or = .04 each) accompanied by increased levels of the anti-inflammatory cytokines IL-1ra and IL-10 (P < or = .02). Patients with phlegmonous appendicitis had increased levels of IL-10 only. CONCLUSION The finding of a pattern of inflammatory markers compatible with the highly inflammatory Th17 subset in sera from patients with gangrenous appendicitis, but not in phlegmonous appendicitis, supports the hypothesis that gangrenous and phlegmonous appendicitis are different entities with divergent immune regulation. Additional studies of the differential immunopathogenesis of phlegmonous and gangrenous appendicitis are warranted, as this may have important implications in the diagnosis and management of patients with suspicion of appendicitis.

Mercury exposure as a model for deviation of cytokine responses in experimental Lyme arthritis: HgCl2 treatment decreases T helper cell type 1‐like responses and arthritis severity but delays eradication of Borrelia burgdorferi in C3H/HeN mice

Lyme borreliosis is a complex infection, where some individuals develop so‐called ‘chronic borreliosis’. The pathogenetic mechanisms are unknown, but the type of immune response is probably important for healing. A strong T helper cell type 1 (Th1)‐like response has been suggested as crucial for eradication of Borrelia and for avoiding development of chronic disease. Many studies aimed at altering the Th1/Th2 balance in Lyme arthritis employed mice deficient in cytokine genes, but the outcome has not been clear‐cut, due possibly to the high redundancy of cytokines. This study aimed at studying the importance of the Th1/Th2 balance in murine Borrelia arthritis by using the Th2‐deviating effect of subtoxic doses of inorganic mercury. Ninety‐eight C3H/HeN mice were divided into four groups: Borrelia‐infected (Bb), Borrelia‐infected exposed to HgCl2 (BbHg), controls exposed to HgCl2 alone and normal controls. Mice were killed on days 3, 16, 44 and 65 post‐Borrelia inoculation. Arthritis severity was evaluated by histology, spirochaetal load determined by Borrelia culture, IgG2a‐ and IgE‐levels analysed by enzyme‐linked immunosorbemt assay (ELISA) and cytokine‐secreting cells detected by enzyme‐linked immunospot (ELISPOT). BbHg mice showed less severe histological arthritis, but delayed eradication of spirochaetes compared to Bb mice, associated with increased levels of IgE (Th2‐induced) and decreased levels of IgG2a (Th1‐induced), consistent with a Th2‐deviation. Both the numbers of Th1 and Th2 cytokine‐secreting cells were reduced in BbHg mice, possibly explained by the fact that numbers of cytokine‐secreting cells do not correlate with cytokine concentration. In conclusion, this study supports the hypothesis that a Th1‐like response is required for optimal eradication of Borrelia.

Randomized clinical trial of Appendicitis Inflammatory Response score‐based management of patients with suspected appendicitis

The role of imaging in the diagnosis of appendicitis is controversial. This prospective interventional study and nested randomized trial analysed the impact of implementing a risk stratification algorithm based on the Appendicitis Inflammatory Response (AIR) score, and compared routine imaging with selective imaging after clinical reassessment.

Correction: The Appendicitis Inflammatory Response Score: A Tool for the Diagnosis of Acute Appendicitis that Outperforms the Alvarado Score (vol 32, pg 1843–1849, 2008, DOI 10.1007/s00268-008-9649-y

Relocation of pain ns – ?1 Vomiting 0.45 ?1 ?1 Pain in RIF 1.12 ?1 ?2 Anorexia ns – ?1 Male gender ns – – Rebound tenderness or muscular defense None 0 0 0 Light 1.54 ?1 ?1 Medium 1.90 ?2 ?1 Strong 2.32 ?3 ?1 Body temperature 37.5–37.9 C 0 0 ?1 38.0–38.4 C 0 0 ?1 C38.5 C 0.85 ?1 ?1 Proportion polymorphonuclear leukocytes 70–74% 0.92 ?1 0 75–84% 0.92 ?1 ?1 C85% 1.41 ?2 ?1 WBC count 10.0–14.9 9 10/L 0.96 ?1 ?2 C15.0 9 10/L 1.46 ?2 ?2 CRP concentration 10–49 mg/L 1.04 ?1 – C50 mg/L 2.35 ?2 –

Impact of Comorbidity, Medication, and Gender on Amputation Rate Following Revascularisation for Chronic Limb Threatening Ischaemia

OBJECTIVE/BACKGROUND Chronic limb threatening ischaemia (CLTI) has a high risk of amputation and mortality. Increased knowledge on how sex, comorbidities, and medication influence these outcomes after revascularisation may help optimise results and patient selection. METHODS This population based observational cohort study included all individuals revascularised for CLTI in Sweden during a five year period (10,617 patients in total). Data were retrieved and merged from mandatory national healthcare registries, and specifics on amputations were validated with individual medical records. RESULTS Mean age at revascularisation was 76.8 years. Median follow up was 2.7 years (range 0-6.6 years). Male sex (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.09-1.33), renal insufficiency (HR 1.57, 95% CI 1.32-1.87), diabetes (HR 1.45, 95% CI 1.32-1.60), and heart failure (HR 1.17, 95% CI 1.05-1.31) were independently associated with an increased amputation rate, whereas the use of statins (HR 0.71, 95% CI 0.64-0.78) and low dose acetylsalicylic acid (HR 0.77, 95% CI 0.70-0.86) were associated with a reduced amputation rate. For the combined end point of amputation or death, an association with increased rates was found for male sex (HR 1.25, 95% CI 1.18-1.32), renal insufficiency (HR 1.94, 95% CI 1.75-2.14), heart failure (HR 1.50, 95% CI 1.40-1.60), and diabetes (HR 1.31, 95% CI 1.23-1.38). The use of statins (HR 0.74, 95% CI 0.67-0.82) and low dose acetylsalicylic acid (HR 0.82, 95% CI 0.77-0.88]) were related to a reduced risk of amputation or death. CONCLUSIONS Renal insufficiency is the strongest independent risk factor for both amputation and amputation/death in revascularised CLTI patients, followed by diabetes and heart failure. Men with CLTI have worse outcomes than women. These results may help govern patient selection for revascularisation procedures. Statin and low dose acetylsalicylic acid are associated with an improved limb outcome. This underlines the importance of preventive medication to reduce general cardiovascular risk and increase limb salvage.