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ORIGINAL RESEARCH Risk Factors in the Development of Acute V. Moraru et al. Moldovan Medical Journal. December 2018;61(4):3-9 ORIGINAL RESEARCH DOI: 10.5281/zenodo.1456892 UDC: 616.346.2-002.1 Risk factors in the development of acute appendicitis complications *1Viorel Moraru, MD, PhD, Associate Professor; 1Petru Bujor, MD, PhD, Professor; 1Galina Pavliuc, MD, PhD, Associate Professor; 2Sergiu Bujor, MD, PhD, Researcher Fellow 1Department of Surgery No 2, 2Laboratory of Liver Surgery Nicolae Testemitsanu State University of Medicine and Pharmacy, Chisinau, the Republic of Moldova *Corresponding author: [email protected] Manuscript received September 02, 2018; revised manuscript December 03, 2018 Abstract Background: To study the risk factors of the development of acute appendicitis (AA) complications in adults in order to improve the results of surgical treatment. Material and methods: The research included 449 patients with AA treated surgically during the years 2015-2017 divided into 2 groups: 117 patients who were admitted with complicated appendicitis (intra- and extraabdominal complications) and 332 patients with non-complicated AA were randomly selected from the same period. The rate and characteristic of the complications evolved during the pre- and postoperative period in these two groups were specified and analyzed. Results: In the acute complicated appendicitis group (CAA), there was a predominance of women with a ratio of 1.60 versus 1.26 in the uncomplicated acute appendicitis group (NAA). The proportion of people aged> 60 years was significantly higher in the case of CAA-23.1% (n=27), while in uncomplicated AA it was only 3.9% (n=13). In the case of AA complications, there was an emphasis on late addressing, the debut-addressing term being higher compared to uncomplicated AA. The low socio-economic status has a significant negative impact on the evolution of AA and its complications, as well as on the results of appendectomy. Thus, uninsured patients (n=59, 49.6%) formed almost half of CAA group. Associated comorbidities were established in 76 or 16.9% of cases, respectively in CAA-21.4% vs 15.4% in NAA group. In summary we note that the presence of associated uncorrected comorbidities has an obvious negative impact on the development of AA. Conclusions: Our findings suggest that clinical assessment is most important for identifying individuals at risk of developing complications of AA and the above-mentioned risk factors are useful for emergency surgical decisions. Key words: Complications of acute appendicitis, risk factors. Introduction AA complications may evolve either as a natural stage in Acute appendicitis (AA) is the most common surgical the pathophysiological process of vermicular appendicitis abdominal emergency and its lifetime risk is 8.6% for men with plastron formation or depending on wall integrity with and 6.7% for women, yet the risk of undergoing appendec- its perforation and triggering of generalized or localized ap- tomy is higher for women (12 vs. 23%) [1-3]. In developed pendicular peritonitis [11,12]. This type of complications countries the incidence of AA is 400-520 cases per 100000 can be called intraabdominal complications, according to population, while in poorly developed countries it is 100- the literature; they have an incidence of about 5-7% cases in 320 cases per 100000 population [4, 5]. In the Republic of the developed countries and up to 30% in the case of coun- Moldova the AA frequency denotes 220 cases per 100000 tries with poor socio-economic status [13]. Notwithstand- inhabitants [6]. ing the general decrease in the morbidity rate through AA, Apparently simple as a pathology, AA does not always an impressive number of studies demonstrate the stability of find an easy solution, and by its complications it can some- these rates over the past decades [14-16]. times generate situations requiring complex therapeutic fea- Another group of complications are caused by the pu- tures. Although surgical treatment is well tolerated by most rulent processes in the postoperative wound (suppuration, patients, it is associated with a risk of postoperative com- abscess, ligature fistula) at a rate of 18-20%, they do not have plications in 2%- 23% of cases [7, 8]. In addition, notwith- a certain tendency to diminish [17,18]. Even despite the fre- standing the implementation of miniinvasive techniques, it quent and prolonged use of antibacterial drugs for prophy- is noted that about 3% of patients who underwent an appen- laxis of postoperative wound complications, the frequency dectomy with or without laparoscopy [9] were repeatedly of appearance remains at a constant level [19]. In general, admitted to hospital with a diagnosis of intestinal occlusion, post-appendectomy complications rates are usually with- cataloged as a tardive post-operative complication, often a in 10%-19% range for acute AA without perforation and long time after primary surgery [10]. reaches to 12%-30% for perforated AA [20-24]. Perforation 3 V. Moraru et al. Moldovan Medical Journal. December 2018;61(4):3-9 ORIGINAL RESEARCH increases the AA mortality rate from 0.0002% to 3% and bidity) 2-3 points, √CCI-IV (decompensated co-morbidity) causes an increase in morbidity from 3% to 47% [25-27]. >4 points, √CCI-V (decompensated co-morbidity refrac- Thus, we can see that, despite all the surgical progress tory to any treatment). achieved, the AA complications remain a problem that still Table 1 requires increased attention. This determines the need to The value and conditions considered in the Charlson specify risk and prognostic factors in the development of co-morbidity index AA complications for their prophylaxis and improvement of surgical treatment results. Value Conditions The purpose of the paper: to study the risk factors of the 1 Myocardial infarction, congestive heart failure, peripheral development of acute appendicitis complications in adults vascular pathology, cerebrovascular disease, dementia, in order to improve the results of surgical treatment. chronic pulmonary pathology, connective tissue patholo- gies, ulcerative disease, non-severe compensated hepat- Material and methods opathy. 2 Diabetes, hemiplegia, moderate or severe kidney patholo- Study Design. The study includes a retrospective analy- gies, complicated diabetes with internal organ damage, sis of clinical material focused on the estimation of the inci- leukemia, lymphoma. dence, character and risk factors of the development of AA 3 Moderate or severe hepatopathy. complications. We designed a case-control study to compare different perceived risk factors among patients with com- 6 Non-metastatic solid tumors, Metastatic tumors, AIDS. plicated or uncomplicated AA. The point of reference was the analysis and evaluation of the anamnestic disease, the Definitions. In order to standardize the results we di- clinical picture, the laboratory and instrumental data estab- vided all patients into 2 groups: Non-complicated acute ap- lished preoperatively in connection with the morphological pendicitis (NAA) group, consisting of patients without the changes of the vermicular appendix performed by morpho- progression of complications of cataract and phlegmonous pathological examination of the operative piece. The rate AA without perforation; and complicated acute appendicitis and characteristic of the complications evolved during the (CAA) group, consisting of patients with complications of pre- and postoperative period in the analyzed patients were acute appendicitis. It included phlegmonous with perfora- specified. For the purpose of assessing the microbial etio- tion AA, gangrenous AA, appendicular infiltration or peri- logical factor, the patients of the study group were subjected appendicular abscess, local, diffuse or generalized peritoni- to the bacteriological examination which included seeding tis; septic complications of postoperative wound. The same on aerobic culture media as a source of collected material group included 4 patients who were previously operated for for samples collected during diagnostic laparoscopy, surgi- AA, who at distant point had acute adherent intestinal oc- cal intervention, pathological leakage from the safety drains clusion, treated surgically, 1 patient with external intestinal or postoperative wound. fistula, 6 patients with ligature fistula, and 5 with post-apen- Participants and data collection. The research inclu- dectomy hernias. ded 449 AA patients treated surgically by classical approach Statistical analysis. For the purpose of processing quan- during the years 2015-2017 at Surgical Clinic Nr. 2 and titative summaries, statistical software was used. Pearson’s Nr. 3 of Surgery Department Nr. 2 of Nicolae Testemitsanu chi-square and independent sample t tests were used to State University of Medicine and Pharmacy. The analyzed compare categorical and continuous variables as indicated. data were extracted from: clinical observation sheets, op- A p -value ≤ 0.05 was considered statistically significant. erative protocols, histopathological examination bulletins and electronic database Sfinta Treime Municipial Hospital Results and discussion (code K35.0-3, K35.9). An individual clinical research file AA complications have evolved in 117 out of 449 cases was complemented for each patient. The terms of evolution or 26.1%, index compatible with literature data [28-30]. So of the disease were analyzed, the studied cases being classi- the control group included 332 patients without complica- fied in 3 time intervals: addressing up to 6 hours after the tions (NAA), and
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