A COMPARISON OF OUTCOMES BETWEEN UNCOMPLICATED AND COMPLICATED APPENDICITIS. CAN A RATIONAL APPROACH OF INJECTABLE ANTIBIOTICS BE APPLIED FOR UNCOMPLICATED APPENDICITIS? - A SINGLE CENTRE EXPERIENCE.

Conclusion: Complicated Appendicitis must be managed surgically with a prolonged course of Antibiotics, where as a single day regime of rationally justified course of antibiotics can be successfully instilled in patients with uncomplicated appendicitis to decrease the burden due to morbidity. this descriptive study to identify pre- and intra-operative factors predicting prolonged antibiotic administration in appendicitis. We have summarized the presentation of our patients from the data that we have collected over the last year in a single unit from a teaching Medical Institution in West Bengal, India. We aim to compare the outcomes of Acute appendicitis from our institute and have also tried to evaluate whether our patients would benefit from a Rational single day course of Antibiotics for uncomplicated Appendicitis of patients in complicated appendicitis, was 3.1852 ±.8531 days with a range OF 2.00-6.00 days and statistically (p<0.0001). Presentation with fever alleviates the necessary use of antibiotics and thus the post-operative morbidity increases.


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Conclusion: Co mplicated Appendicitis must be managed surgically with a prolonged course of Antibiotics, where as a single day regime of rationally justified course of antibiotics can be successfully instilled in patients with uncomplicated appendicitis to decrease th e burden due to morb idity.

…………………………………………………………………………………………………….... Introduction:-
Acute Appendicitis is the frequent cause of an Acute Abdomen that requires surgical management, lead ing to hospital admissions. Although once considered vestigial the immunological role of the appendix cannot be completely denied. Earlier Appendicectomy was considered as a standard of care, due to the fear of a perforated appendix. [1] An Uncomplicated appendicitis would be an inflamed appendix that is grossly intact, non -gangrenous without any suppuration or signs of peritonitis. The defin ition of Co mplica ted Appendicitis has not been described well in literature but it would refer to an appendicular phlegmon, gangrene, abscess localized or generalized peritonitis. [2][3][4][5]. Now there has been a paradigm shift towards a conservative (Non -operative) approach for Acute appendicitis. [6] In many centres traditional open surgery has been abandoned and Laparoscopic Surgery [7] is becoming the standard of care. However, the role of a Classical Open Mc.Burney's approach [8] to the appendix cannot be denied.
The Infectious Diseases Society of America reco mmends against postoperative antibiotic therapy beyond 24 hours for uncomplicated intra-abdominal infection. [9] However, prolonged antibiotic admin istration is common despite intra-operative diagnosis of uncomplicated appendicitis. There are no definite guidelines in India regarding the duration of antibiotics for acute appendicitis. Experiences vary in between institutions. Most of our patients present late and the number of Emergency surgeries for co mplicated append icitis are on the rise in our institution.
We undertook this descriptive study to identify pre-and intra-operative factors predicting prolonged antibiotic administration in appendicitis. We have summarized the presentation of our patients from the data t hat we have collected over the last year in a single unit from a teaching Medical Institution in West Bengal, India. We aim to compare the outcomes of Acute appendicitis fro m our institute and have also tried to evaluate whether our patients would benefit fro m a Rat ional single day course of Antibiotics for uncomp licated Appendicitis

Materials And Methods:-
Our institution is a high volume tertiary referral teaching hospital. Ethical Clearance to conduct the study was obtained from the Intuitional Ethics co mmittee. The work has been carried out according to the Code of Ethics in the Declaration of Helsin ki for experiments involving human subjects. We and have prospectively analysed patients that have presented in our Emergency department and have been diagnosed with Acute Appendicitis fro m June 2017 to May 2018.
Inclusion criteria: Patients diagnosed with acute appendicitis belonging to ASA Grade I to III who can be taken up for surgery were included in the study, after a proper informed consent and their signature.
Exclusion criteria: Patients with severe systemic disease, those unwilling to participate in the study, and those belonging to ASA Grade IV and later and well defined appendicular lu mps were excluded fro m the study.
Demographics, presenting symptoms like fever, duration of surgery and intra operative findings were evaluated and documented. The correlation of intra operative findings of complicated appendicitis such as phlegmon, gangrene, perforation abscess, Localized and Generalized peritonit is have been recorded and compared. Patients with complicated appendicitis have been administered Injectable Antib iotics like Ceftriaxone 1g m Intravenous Infusion along with Metronidazole Infusion as per their dosage recommendations. The duration of admin istration depended upon the requirement and clinical response of patients. Post-operative parameters such as Ileus, Fever, Beginning of oral intake and wound infection have been evaluated. The morbidity of the patient on Injectable Antibiotics was analysed using thClavien-Dindo [10] scoring system where a value of > 1 would be considered significant. The relation of the use of antibiotics to the duration of hospital stay has been analysed. Finally, our aim to evaluate the outcomes for a rat ional use of Antibiotics use for Unco mplicated Appendicitis has been tabulated using Microsoft Excel and statistically analysed using SPSS 24.0.
198 Statistical Anal ysis:-For statistical analysis data were entered into a Microsoft excel spreadsheet and then analyzed by SPSS 24.0. and GraphPad Prism version 5. Data had been summarized as mean and standard deviation for numerical variables and count and percentages for categorical variables. Two-sample t-tests for a difference in mean involved independent samples or unpaired samples. Paired t-tests were a form of blocking and had greater power than unpaired tests. A chi-squared test (χ2 test) was any statistical hypothesis test wherein the sampling distribution of the test statistic is a chi-squared distribution when the null hypothesis is true. Without other qualificat ion, 'chi -squared test' often is used as short for Pearson' s chi-squared test. Unpaired proportions were compared by Chi-square test or Fischer's exact test, as appropriate. p-value ≤ 0.05 was considered for statistically significant. Mean days of symptoms such as anorexia, nausea or vomiting pain in the Right lower quadrant of the abdomen (mean± s.d.) of patients in comp licated appendicitis, was 3.1852 ±.8531 days with a range OF 2.00-6.00 days and the median was 3.00 days. In uncomplicated appendicitis, the mean days of symptoms (mean± s.d.) of patients were 1.5698 ±.4980 days with range 1.0000 -2.0000 days and the median was 2.0000 days. Difference of mean age in t wo groups was statistically significant (p<0.0001). A lmost all our co mplicated appendicitis patients 81(100.0%) had fever during presentation, compared to the 26(30.2%) patients belonging to the uncomplicated group. This association was statistically significant (p<0.0001). Presentation with fever alleviates the necessary use of antibiotics and thus the post-operative morbid ity increases.

Result And Analysis:-
In complicated appendicitis, mean operative time (mean± s.d.) of patients was 40.6914 ±10.3388 mins with a range 20.0000 -70.0000 mins and the median was 40.0000 mins. In uncomp licated group, The mean operative time of symptoms (mean± s.d.) of patients was 24.8140 ±4.6615 mins with range 18.0000-47.0000 mins and the median was 25.0000 mins. Difference of mean age in two groups was statistically significant (p<0.0001).
In comp licated appendicitis patients required an increase in, duration of antib iotics (mean± s.d.) of patients was 9.1975 ±3.4728 days with range 5.0000 -28.0000 days and the median was 7.0000 days. In uncomplicated appendicitis, duration of antibiotics of symptoms (mean± s.d.) of patients was 3.5116 ±2.9773 days with range 1.0000 -7.0000 days and the median was 1.0000 days. Difference of mean age in two groups was statistically significant (p<0.0001).
Co mplicated appendicitis patients could tolerate the beginning of oral intake (mean± s.d.) by 32.8889 ±14.9131 hours with range 24.0000 -96.0000 hours and the median was 24.0000 hours. Co mpared to the patients with uncomplicated appendicitis, wh ich was 24.5581 ±3.6384 hours with range 24.0000 -48.0000 hours and the median was 24.0000 hours. Difference of mean age in two groups was statistically significant (p<0.0001).
In complicated appendicits, length of stay (mean± s.d.) of patients was 5.7160 ±2.7894 days with range 3.0000 -28.0000 days and the median was 5.0000 days. In uncomplicated appendicits, length of stay of symptoms (mean± s.d.) of patients was 3.0465 ±.3032 days with range 3.0000 -5.0000 days and the median was 3.0000 days. Difference of mean age in two groups was statistically significant (p<0.00 01).

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In uncomplicated appendicitis receiving antibiotics post-surgery had their morbid ity evaluated by the Clavien Dindo Scoring system. Here, 51(59.3%) patients had score 1, 34(39.5%) patients had score 2 and 1(1.2%) patient had score 3. Co mp licated Appendicitis patients however, had 63(77.8%) patients with score 2 and 18(22.2%) patients had score 3. This association was statistically significant (p<0.0001). 50 patients out of 85 patients (58%) with uncomplicated appendicitis were given a rationally justified, dosage of antibiotics. Hence the prognosis of such patients were better leading to less morbidity. The rest 36 had postoperative complications that augmented the duration of antibiotics (average 7 days).

Discussion:-
Acute appendicitis, the most common pathology requiring Emergency surgery is perhaps the first case a surgical resident is taught to perform independently. Appendicitis, is the most common cause of acute abdomen in a young adult. presents classically with Murphy's triad, namely periu mb ilical pain, with associated nausea, vomiting and anorexia. There may be associated fever. The pain gradually shifts to the Right Iliac Fossa as the uncomplicated appenditis tends to become comp licated with more inflammation. It progresses to an appendicular phlegmon with localized peritonitis. If the Greater o mentum is unable to seal the infection, as in children, old age, immunocomp ro mised adults to form an appendicular lu mp the appendix perforated and may cause generalized or localized peritonitis or a pelvic abscess. Various scoring system have been developed in the past that correlate severity of the disease. The ALVARDO score is perhaps the most commonly used parameter before surgery. Radio logical tests such as an Ultrasound and Contrast Enhanced CT scan are ancillary investigations when the score is equivocal (5-6) a score of >7 is considered as Appendicitis and surgery may be planned. [11]. In our study the patients have been categorised as Co mplicated and Uncomplicated based upon their initial presentat ion [12] and duration of symptoms. Many centres prefer a conservative approach to Acute appendicitis but our institution considers Open Emergency Surgery as the standard of care.
Most of our patients present late and the mean duration of symptoms of prog ression from an uncomp licated to an appendicular lu mp is appro ximately 4 days. Co mplicated appendicitis patients deteriorate clinically and present with more symptoms that need to be detected on clinical examination. A decision fo r surgery must be prompt. Appendicular lu mps if not certain are to be evaluated under anaesthesia. Co mplicated Appendicetomies require more time, there is no difference in surgical outcomes between Senior consultants and Residents when it comes to time. Meticulous hemostasis is ess ential an a drain may be left in the pelvis if a possible collection or an appendicular abscess is detected. Wound infection is common after surgery specially due to the contact of the infected phlegmatogenous contents with the wound site. Faecal fistulas are rare but they occur. [8,11] Ileusisfairly co mmon after surgery (30% as in our case) and are g iven oral feeds once the bowel sounds resume. Our study shows an increase in ileus amongst complicated cases because of the tendency of the inflamed appendix to form a lu mp with the adjoining loops of bowel. Post-operative fever is a sign of infection and requires rigorous use of antibiotics. Most patients are discharged by 5-6 days and are requested to return after 7-10 days for stich removal.
There is no doubt that complicated antibiotics require a better antibiotic support. However, uncomplicated appendicitis can be controlled with a min imu m rational dose of Antibiotics to prevent patient morbid ity. Out of all 86 patients suffering fro m uncomplicated appendicitis, 50 patients (58%) were given a rationally justified, dosage of antibiotics. Hence the prognosis of such patients was better leading to less morbidity.

Conclusion:-
Delayed presentation with complicated appendicitis requires a more rigorous surgical approach and a course of antibiotics, leading to a longer post-operative recovery. When patients present early with uncomp licated appendicitis a rational approach of minimu m duration of antibiotics may be tried after surgery since a prolonged course of antibiotics may aug ment the mo rbidity of the patient.