Clinical significance of peri-appendiceal abscess and phlegmon in acute complicated appendicitis patients undergoing emergency appendectomy: A single-center retrospective study

Clinical significance of peri-appendiceal abscess and phlegmon in acute complicated appendicitis patients undergoing emergency appendectomy: A single-center retrospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical significance of peri-appendiceal abscess and phlegmon in acute complicated appendicitis patients undergoing emergency appendectomy: A single-center retrospective study Lingqiang Min, Jing Lu, Hongyong He This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4682091/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study aimed to analyze the clinical data of patients who underwent emergency appendectomy for acute complicated appendicitis with peri-appendiceal abscess or phlegmon, identify factors influencing the postoperative length of hospital stay (LOS), and improve treatment strategies. Methods The clinical data of acute complicated appendicitis patients with peri-appendiceal abscess or phlegmon who underwent emergency appendectomy at the Department of Emergency Surgery, Zhongshan Hospital, Fudan University, from January 2016 to March 2023, were retrospectively analyzed. Results A total of 234 patients were included in our study. The duration of symptoms and the presence of an appendicolith were significantly correlated with the occurrence of peri-appendiceal abscess in patients with acute complicated appendicitis (P < 0.001 and P = 0.015, respectively). Patients with symptoms lasting longer than 72 hours had a significantly longer postoperative LOS compared to those with symptoms lasting 72 hours or less (HR, 1.208; 95% CI, 1.107 to 1.319; P < 0.001). Additionally, patients with peri-appendiceal abscesses had a significantly longer postoperative LOS compared to those with phlegmon (HR, 1.217; 95% CI, 1.095 to 1.352; P < 0.001). The patients with peri-appendiceal abscesses were divided into two groups based on the median size of the abscess: those with abscesses smaller than 5.0 cm (n = 69) and those with abscesses 5.0 cm or larger (n = 82). Patients with peri-appendiceal abscesses measuring 5.0 cm or larger had a significantly longer postoperative LOS than those with abscesses smaller than 5.0 cm (P = 0.038). Conclusion The duration of symptoms and the presence of an appendicolith are significant risk factors for the formation of peri-appendiceal abscesses in patients with acute complicated appendicitis. Patients with peri-appendiceal abscesses experience a significantly longer postoperative LOS compared to those with peri-appendiceal phlegmon. Acute appendicitis Abscess Phlegmon Appendectomy Figures Figure 1 Figure 2 Introduction Appendicitis, characterized by inflammation of the vermiform appendix, is the most common cause of emergency abdominal surgery worldwide.[ 1 ] The global annual incidence ranges from 96.5 to 100 cases per 100,000 adults.[ 2 ] Although antibiotic therapy has become the primary treatment for acute uncomplicated appendicitis, often enabling patients to avoid surgery, the management of acute complicated appendicitis necessitates careful consideration of various treatment options.[ 3 , 4 ] Complicated appendicitis, marked by the presence of peri-appendiceal phlegmon or abscess formation, poses additional challenges and often necessitates a more comprehensive treatment approach.[ 5 , 6 ] Management strategies have evolved to incorporate both conservative and surgical treatments tailored to the patient's condition.[ 6 ] Typically, for early-stage appendicitis (duration of symptoms ≤ 72 hours) with peri-appendiceal phlegmon, surgical treatment is recommended. In contrast, late-stage appendicitis (duration of symptoms > 72 hours) or cases with peri-appendiceal abscess formation are initially managed conservatively with percutaneous drainage and antibiotics.[ 1 ] Despite these guidelines, some surgeons and patients still prefer surgical intervention for various reasons.[ 7 ] Currently, there is a lack of studies on the outcomes of patients with acute complicated appendicitis who choose surgery over conservative treatment, underscoring the need for further research. In practical terms, the benefits and risks of all treatment options should be thoroughly discussed with patients.[ 8 ] Recommendations for surgery versus a conservative treatment-first approach should be based on individual clinical and radiographic findings, as well as patient treatment expectations and preferences.[ 9 ] This study investigated the clinical significance of peri-appendiceal abscess and phlegmon in the surgical management of acute complicated appendicitis. Our single-center retrospective analysis revealed that the presence of a peri-appendiceal abscess is a significant predictor of prolonged postoperative length of hospital stay (LOS) for patients with acute complicated appendicitis. These findings underscore the importance of conservative treatment in patients with peri-appendiceal abscess. These insights are valuable for clinicians managing complicated appendicitis and suggest directions for future research to optimize treatment protocols and improve patient outcomes. Materials and Methods Study design and patients We prospectively recruited consecutive patients with acute appendicitis, collected their clinicopathological data, and retrospectively analyzed the clinicopathological features correlated with prognosis to improve treatment strategies. Between January 2016 and March 2023, 3896 patients with acute appendicitis were diagnosed at the Department of Emergency Surgery, Zhongshan Hospital, Fudan University (Shanghai, China). The analytical data included general patient information, clinical manifestations, preoperative blood test results, imaging examination results, treatment method, surgical approach, length of hospital stay, and prognosis. All patients with acute appendicitis underwent a CT scan of the abdomen and pelvis upon arrival at the emergency department. Patients with peri-appendiceal abscesses or phlegmon on CT scans were selected as candidates for this study. This retrospective study included patients who met the following criteria: aged 18 years or older, clinically diagnosed with acute appendicitis, had a peri-appendiceal abscess or phlegmon on a CT scan, opted for immediate emergency surgery as their primary choice, and refused conservative treatment (antibiotic therapy and ultrasound/CT-guided drainage). The exclusion criteria were patients younger than 18 years, those with a history of prior malignancies, those with diffuse peritonitis, and those with incomplete clinical or pathological records. Based on these criteria, 3896 patients were screened, and 234 patients were included in our study. The cohort consisted of 134 males and 100 females, with ages ranging from 18 to 87 years (median age 60 years) (Fig. 1 ). Based on the findings from the CT scan, patients were divided into two groups: the peri-appendiceal abscess group (n = 151) and the peri-appendiceal phlegmon group (n = 83) (Fig. 1 ). All patients underwent surgical intervention and received postoperative antibiotic treatment (second-generation cephalosporins plus metronidazole) until recovery and discharge from the hospital. The primary endpoint of this study was the postoperative LOS. The discharge criteria included the resolution of symptoms such as pain and fever, stable vital signs, the ability to tolerate oral intake, normalization of laboratory parameters (e.g., white blood cell count), and the absence of postoperative complications. The secondary endpoints included postoperative complications, such as surgical site infections (SSI), incisional hernias, and the surgical approach used. Ethical approval for this study was granted by the Clinical Research Ethics Committee of Zhongshan Hospital, Fudan University (Shanghai, China). Informed consent was obtained from all patients for the collection and use of anonymized clinical data. Statistical analysis Statistical analysis was conducted using SPSS Software (version 27.0; SPSS Inc., Chicago, IL, USA). Normally distributed data are presented as the mean ± SD, while skewed data are presented as the median (interquartile range). Categorical variables are expressed as counts and percentages. Differences in distribution were assessed using Pearson’s χ² test or Fisher’s exact test for categorical variables, and Student’s t-test for continuous variables. Univariate analyses were performed using the Cox proportional hazards regression model. Kaplan-Meier survival analysis utilized postoperative LOS as the "survival time," and survival curves were compared using the log-rank test. A P value < 0.05 was considered to indicate statistical significance. Results Clinical characteristics of the patients at baseline A total of 234 patients with acute complicated appendicitis accompanied by peri-appendiceal abscess or phlegmon were included in our study. The median age was 60 years, ranging from 18 to 87 years. The gender distribution was 57.3% male and 42.7% female. The mean white blood cell (WBC) count was 13.4×10^9/L, and the mean granulocyte percentage (GR%) was 88.9%. Appendicoliths were present in 56.4% of patients (n = 132). Peri-appendiceal abscesses were found in 64.5% of patients (n = 151), while peri-appendiceal phlegmon was observed in 35.5% (n = 83). The vast majority of patients were diagnosed with acute appendicitis (n = 228, 97.4%). Additionally, there were cases of appendiceal adenocarcinoma (n = 4, 1.7%), appendiceal neuroendocrine neoplasm (n = 1, 0.4%), and appendiceal mucinous neoplasm (n = 1, 0.4%) (Table 1 ). Table 1 Baseline clinical characteristics of the patients Characteristic All patients-N-% 234 (100) Age, median (range), year 60 (18–87) Sex-N-% Female 100 (42.7) Male 134 (57.3) WBC count, mean (SD), ×10 9 /L 13.4 (5.2) GR% granulocyte, mean (SD), % 88.9 (4.8) Appendicolith-N-% 132 (56.4) Peri-appendiceal abscess-N-% 151 (64.5) Peri-appendiceal phlegmon-N-% 83 (35.5) Pathology-N-% Acute appendicitis 228 (97.4) Appendiceal adenocarcinoma 4 (1.7) Appendiceal neuroendocrine neoplasm 1 (0.4) Appendiceal mucinous neoplasm 1 (0.4) Correlations between clinical factors and peri-appendiceal abscess or phlegmon The correlations between clinical factors and the presence of peri-appendiceal abscess or phlegmon among the 234 patients are summarized in Table 2 . The duration of symptoms was significantly different between the two groups (P 72 hours, 82 had abscesses, while only 12 had phlegmons. The presence of an appendicolith was also significantly correlated (P = 0.015); 94 patients with appendicoliths had abscesses compared to 38 with phlegmons, while among those without appendicoliths, 57 had abscesses and 45 had phlegmons. There was no significant difference in age (P = 0.947) or sex (P = 0.897) between patients with abscesses and those with phlegmons. Additionally, temperature (P = 0.923), WBC count (P = 0.668), and granulocyte percentage (P = 0.557) did not significantly differ between the two groups. Table 2 Correlation between clinical factors and peri-appendiceal abscess or phlegmon Peri-appendiceal Characteristic Abscess Phlegmon P All patients 151 83 Age (year) † 0.947 ≤ 60 83 46 > 60 68 37 Sex 0.897 Female 65 35 Male 86 48 Temperature 0.923 ≤ 37℃ 50 28 > 37℃ 101 55 WBC count, ×10 9 /L 0.668 ≤ 9.5 44 22 > 9.5 107 61 GR% granulocyte 0.557 ≤ 80% 36 17 > 80% 115 66 Duration of symptoms 72 hours 82 12 Appendicolith 0.015 Yes 94 38 No 57 45 †Split at median. Cox regression analyses for postoperative length of hospital stay Cox regression analysis of postoperative LOS among patients revealed that the duration of symptoms and the presence of a peri-appendiceal abscess significantly influenced the LOS. Patients with symptoms lasting ≤ 72 hours had a median postoperative LOS of 5 days, whereas those with symptoms lasting > 72 hours had a median postoperative LOS of 7 days (hazard ratio [HR], 1.208; 95% CI, 1.107 to 1.319; P < 0.001). Additionally, patients with a peri-appendiceal abscess had a median postoperative LOS of 6 days, compared to 5 days for those with peri-appendiceal phlegmon (HR, 1.217; 95% CI, 1.095 to 1.352; P < 0.001). Other factors, such as age, sex, temperature, WBC count, granulocyte percentage, and the presence of an appendicolith, did not show significant correlations with postoperative LOS. Specifically, patients with a granulocyte percentage ≤ 80% had a median postoperative LOS of 5 days, whereas patients with a granulocyte percentage > 80% had a median postoperative LOS of 6 days (HR: 1.081, P = 0.097). Although this difference was not statistically significant, there appeared to be an observable trend (Table 3 ). Table 3 Cox regression analyses for postoperative length of hospital stay Characteristic LOS (days) Hazard Radio (95%CI) P Age (years) † 0.913 ≤ 60 6.0 (4.0–8.0) 1.000 (reference) > 60 6.0 (4.0–8.0) 0.997 (0.946 to 1.050) Sex 0.327 Male 6.0 (4.0–8.0) 1.000 (reference) Female 6.0 (4.0–8.0) 1.027 (0.974 to 1.083) Temperature 0.745 ≤ 37℃ 6.0 (4.0–7.0) 1.000 (reference) > 37℃ 6.0 (4.0–8.0) 1.009 (0.954 to 1.068) WBC count, ×10 9 /L 0.981 ≤ 9.5 6.0 (4.0–7.0) 1.000 (reference) > 9.5 6.0 (4.0–8.0) 1.001 (0.945 to 1.060) GR% granulocyte 0.097 ≤ 80% 5.0 (3.0-7.5) 1.000 (reference) > 80% 6.0 (4.0–8.0) 1.081 (0.986 to 1.185) Duration of symptoms 72 hours 7.0 (5.0–10.0) 1.208 (1.107 to 1.319) Appendicolith 0.699 No 6.0 (4.0–8.0) 1.000 (reference) Yes 6.0 (4.0–8.0) 1.010 (0.959 to 1.064) Peri-appendiceal < 0.001 Phlegmon 5.0 (4.0–7.0) 1.000 (reference) Abscess 6.0 (5.0–8.0) 1.217 (1.095 to 1.352) Abbreviation: LOS, length of hospital stay; 95% CI, 95% confidence interval. †Split at median. To evaluate the clinical prognostic significance of peri-appendiceal abscess or phlegmon on postoperative LOS for patients in this study, Kaplan-Meier survival analyses were performed. As shown in Fig. 2 , Kaplan-Meier survival curves were generated to compare the postoperative LOS between patients with peri-appendiceal abscess and those with peri-appendiceal phlegmon. The findings revealed that patients with peri-appendiceal abscess had a significantly longer postoperative LOS than those with phlegmon (Fig. 2 A, P < 0.001). Additionally, based on the median size of the abscess, patients with peri-appendiceal abscesses were categorized into two groups: those with abscesses smaller than 5.0 cm (n = 69) and those with abscesses 5.0 cm or larger (n = 82). Both abscess groups exhibited significantly longer postoperative LOS than the phlegmon group (P < 0.001 for both comparisons), and the difference between the two abscess size groups was also statistically significant (Fig. 2 B, P = 0.038). These results suggest that the presence of a peri-appendiceal abscess, especially a larger abscess, is associated with prolonged hospital stays compared to the presence of peri-appendiceal phlegmon. Correlations between surgical factors and peri-appendiceal abscess or phlegmon The analysis of surgical factors related to peri-appendiceal abscess or phlegmon revealed several significant findings. There was a notable correlation between the type of surgical site infection (SSI) and the presence of peri-appendiceal abscess or phlegmon (P < 0.001). Among the patients with peri-appendiceal abscess, there were 14 cases of superficial infections, 6 cases of deep incisional infections, and 2 cases of organ/space infections. In contrast, patients with peri-appendiceal phlegmon had only 1 case of superficial infection and no cases of deep incisional or organ/space infections. There was no significant difference in the occurrence of incisional hernias between the two groups, with only 1 patient with a peri-appendiceal abscess developing an incisional hernia and none with phlegmon. The type of surgery performed was also significantly correlated with the presence of abscess or phlegmon (P < 0.001). Among the patients with peri-appendiceal abscesses, 56 underwent laparoscopic appendectomy, 44 underwent open appendectomy, and 51 required conversion to open appendectomy. Among the patients with phlegmon, 49 underwent laparoscopic appendectomy, 5 underwent open appendectomy, and 29 required conversion to open appendectomy (Table 4 ). Table 4 Correlation between surgical factors and peri-appendiceal abscess or phlegmon Peri-appendiceal P Characteristic Abscess Phlegmon Surgical site infections by type < 0.001 Superficial 14 1 Deep incisional 6 0 Organ/space 2 0 Incisional hernias 1 0 1.000 Surgery < 0.001 Laparoscopic appendectomy 56 49 Open appendectomy 44 5 Conversion to open appendectomy 51 29 Discussion Appendicitis remains one of the most common and urgent surgical conditions worldwide, with a lifetime risk of 8.6% in men and 6.9% in women.[ 10 ] Prompting intervention is crucial for preventing complications and improving prognosis.[ 11 ] Traditionally, the standard treatment for acute appendicitis has been an appendectomy, performed either through open surgery or laparoscopically.[ 12 ] However, there is growing interest in nonsurgical management for patients with uncomplicated appendicitis. Several studies have demonstrated the efficacy of antibiotic therapy as a nonsurgical alternative for patients with acute uncomplicated appendicitis, reducing the immediate need for surgery.[ 3 , 4 ] Despite its effectiveness, there remains a risk of recurrence, necessitating careful patient selection and diligent follow-up.[ 13 , 14 ] Complicated appendicitis presents additional challenges and often necessitates a more comprehensive treatment approach than uncomplicated appendicitis.[ 15 ] There have been significant advancements in the management of complicated appendicitis via both conservative and surgical methods.[ 16 , 17 ] In conservative treatment, optimized antibiotic regimens and the use of broad-spectrum antibiotics have reduced the need for immediate surgery.[ 18 ] Additionally, imaging-guided percutaneous drainage techniques have improved the safety and effectiveness of managing abscesses.[ 19 , 20 ] Enhanced patient monitoring protocols, along with the advent of telemedicine and home-based care, have improved follow-up and reduced hospital stays.[ 21 ] In surgical treatment, laparoscopic appendectomy and robotic-assisted surgery are revolutionary surgical procedures, that offer shorter recovery times and fewer complications compared to open surgery.[ 22 , 23 ] The concepts of interval appendectomy, risk stratification methods, and enhanced recovery protocols, including multimodal analgesia and early mobilization, have further refined surgical approaches.[ 24 , 25 ] Ongoing comparative studies, research on long-term outcomes, and evaluations of patient preferences and quality of life are essential for developing comprehensive and patient-centered care strategies for complicated appendicitis patients. Despite advances in conservative management, some surgeons and patients still prefer surgical intervention for various reasons, such as resolving the patient's issue in a single procedure and avoiding the prolonged duration of conservative treatment.[ 7 ] Typically, surgical treatment is recommended for early-stage appendicitis (duration of symptoms ≤ 72 hours) with peri-appendiceal phlegmon due to the effectiveness of immediate intervention in preventing further complications. Conversely, for late-stage appendicitis (duration of symptoms > 72 hours) or cases with peri-appendiceal abscess formation, an initial conservative approach involving antibiotics and percutaneous drainage is often favored to manage the condition effectively.[ 6 ] For patients who refuse conservative treatment initially, surgery becomes the only viable option. However, is surgery the right option? In our study, patients with peri-appendiceal abscesses had a significantly longer LOS compared to those with phlegmon. Additionally, we divided the patients with peri-appendiceal abscesses into two groups based on the median size of the abscess: those with abscesses less than 5.0 cm and those with abscesses 5.0 cm or larger. Both groups with abscesses had a significantly longer LOS than patients with phlegmon, and patients with peri-appendiceal abscess measuring 5.0 cm or larger had a significantly longer LOS than those with abscess smaller than 5.0 cm. These data suggest that the presence of a peri-appendiceal abscess, especially a larger abscess, is associated with longer hospital stays compared to the presence of peri-appendiceal phlegmon. When reviewing the treatment approach for patients with acute complicated appendicitis with peri-appendiceal abscess or phlegmon, different strategies are recommended based on the patient’s condition.[ 11 ] For patients with peri-appendiceal phlegmon, immediate surgical intervention is typically advised.[ 26 ] In contrast, for patients with peri-appendiceal abscesses, especially larger abscesses, an initial conservative treatment approach is recommended.[ 16 , 17 ] This involves the use of antibiotics and percutaneous drainage to manage infection and inflammation.[ 27 ] The efficacy of conservative treatment for peri-appendiceal abscesses was highlighted in another clinical study (NCT06469086), which concluded that conservative treatment can effectively reduce the need for immediate surgery and minimize complications for selected patients. The presence of an appendicolith, a calcified deposit within the appendix, significantly affects the progression and severity of acute appendicitis and the formation of peri-appendiceal abscesses.[ 28 ] An appendicolith can obstruct the appendix lumen, leading to increased pressure, bacterial overgrowth, and inflammation, often delaying symptom relief. This obstruction is also a major risk factor for localized perforation and abscess formation, necessitating more complex treatment approaches.[ 29 ] In this study, we found that the presence of an appendicolith is a risk factor for peri-appendiceal abscess formation in patients with acute complicated appendicitis. Our previous research demonstrated that identifying an appendicolith through imaging helps stratify patients by risk, guiding treatment decisions such as early surgical intervention to prevent severe complications or conservative management with antibiotics and drainage for abscess formation. Understanding the relationship between appendicoliths and these complications is crucial for improving patient outcomes, emphasizing the need for careful diagnosis, appropriate management strategies, and further research into effective treatment protocols. This study has several limitations that should be considered. First, as a retrospective analysis, it is inherently prone to selection biases, despite utilizing data from a prospectively recruited database. The retrospective nature of the study limits the ability to control for all potential confounding variables, which might impact the generalizability of the findings. Second, the lack of long-term follow-up data restricts our ability to assess the long-term outcomes of the treatment strategies evaluated. This absence makes it challenging to determine the durability of the results and the potential for late complications, which are crucial for a comprehensive understanding of treatment efficacy. Third, the analysis did not incorporate various subjective factors, such as sociocultural influences, which can significantly affect treatment outcomes, particularly in the context of China.[ 30 , 31 ] Moreover, the study's focus on clinical and demographic factors without considering the broader socioeconomic context may overlook important variables that influence health outcomes. Factors such as access to healthcare, economic constraints, and educational levels can also play a significant role in the success of treatment and patient adherence to medical advice. Conclusions The duration of symptoms and the presence of an appendicolith are significant risk factors for the formation of peri-appendiceal abscesses in patients with acute complicated appendicitis. Clinical data indicate that patients with peri-appendiceal abscesses experience a significantly longer postoperative LOS compared to those with peri-appendiceal phlegmon. Early identification through imaging and appropriate risk stratification can guide decisions toward either early surgical intervention or initial conservative management with antibiotics and percutaneous drainage. Understanding the complex interplay between appendicoliths, abscess formation, and patient outcomes is crucial for optimizing management approaches and improving overall clinical outcomes for patients with acute complicated appendicitis. Declarations Competing interests The authors have no conflicts of interest. Ethical Approval The Clinical Research Ethics Committee of Zhongshan Hospital, Fudan University (Shanghai, China) granted ethical approval for this study. Informed consent was obtained from all patients for the collection and use of anonymized clinical data. Funding This work was sponsored by the National Natural Science Fund of China (82373417), Natural Science Foundation of Shanghai (23ZR1409900), and the Clinical Research Fund of Zhongshan Hospital, Fudan University (ZSLCYJ202343). Author Contribution HH conceived, designed, and refined the study protocol, as well as edited the manuscript. LM and JL were responsible for data collection and analysis. LM and JL drafted the manuscript. LM and JL contributed equally to this work as co-first authors. References Moris D, Paulson EK, Pappas TN. Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA 2021; 326: 2299-2311. Ferris M, Quan S, Kaplan BS et al. The Global Incidence of Appendicitis: A Systematic Review of Population-based Studies. Ann Surg 2017; 266: 237-241. Salminen P, Paajanen H, Rautio T et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA 2015; 313: 2340-2348. 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Laparoscopic versus open surgery for complicated appendicitis in adults: a randomized controlled trial. Surg Endosc 2016; 30: 1705-1712. Liao YT, Huang J, Wu CT et al. The necessity of abdominal drainage for patients with complicated appendicitis undergoing laparoscopic appendectomy: a retrospective cohort study. World J Emerg Surg 2022; 17: 16. Mallinen J, Vaarala S, Makinen M et al. Appendicolith appendicitis is clinically complicated acute appendicitis-is it histopathologically different from uncomplicated acute appendicitis. Int J Colorectal Dis 2019; 34: 1393-1400. Wang N, Lin X, Zhang S et al. Appendicolith: an explicit factor leading to complicated appendicitis in childhood. Arch Argent Pediatr 2020; 118: 102-108. Zhang L, Yang J, Cao Y, Kang W. Sociocultural-psychological predictors influencing parents' decision-making regarding HPV vaccination for their adolescent daughters in mainland China: An extended TPB model. Front Public Health 2022; 10: 1035658. Kenessey DE, Vlemincq-Mendieta T, Scott GR, Pilloud MA. An Anthropological Investigation of the Sociocultural and Economic Forces Shaping Dental Crowding Prevalence. Arch Oral Biol 2023; 147: 105614. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4682091","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":326639711,"identity":"169ef969-3471-4f6e-946a-13e3191e7a4c","order_by":0,"name":"Lingqiang Min","email":"","orcid":"","institution":"Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Lingqiang","middleName":"","lastName":"Min","suffix":""},{"id":326639713,"identity":"77ab38b9-6d66-42b2-9c1c-f039d4f023d2","order_by":1,"name":"Jing Lu","email":"","orcid":"","institution":"Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Lu","suffix":""},{"id":326639714,"identity":"08fa4517-001e-4afa-a3bb-8bb186ae099d","order_by":2,"name":"Hongyong He","email":"data:image/png;base64,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","orcid":"","institution":"Fudan University","correspondingAuthor":true,"prefix":"","firstName":"Hongyong","middleName":"","lastName":"He","suffix":""}],"badges":[],"createdAt":"2024-07-03 17:46:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4682091/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4682091/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62126294,"identity":"1a857f10-a113-42d7-add3-fcb5bfed3c62","added_by":"auto","created_at":"2024-08-09 14:46:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":126118,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the inclusion process of patients.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4682091/v1/b7c76bf6be2a69e758bf6a79.png"},{"id":62126295,"identity":"b5a9109b-9c00-42ef-b729-4ad0fdfbfe41","added_by":"auto","created_at":"2024-08-09 14:46:26","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":167077,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Kaplan-Meier analysis of postoperative length of hospital stay (LOS) comparing patients with peri-appendiceal abscess versus those with phlegmon; (B) Kaplan-Meier analysis of postoperative LOS comparing patients with peri-appendiceal phlegmon, abscesses less than 5.0 cm, and abscesses 5.0 cm or larger. P values were calculated using the log-rank test.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4682091/v1/59630a5b1c19994567d7adc6.png"},{"id":62332804,"identity":"6e19bf9f-e962-433b-8bf1-9e4b155fe08a","added_by":"auto","created_at":"2024-08-13 04:29:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":925320,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4682091/v1/dc13019d-3510-4987-8cff-3f4cffa63b89.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical significance of peri-appendiceal abscess and phlegmon in acute complicated appendicitis patients undergoing emergency appendectomy: A single-center retrospective study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAppendicitis, characterized by inflammation of the vermiform appendix, is the most common cause of emergency abdominal surgery worldwide.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] The global annual incidence ranges from 96.5 to 100 cases per 100,000 adults.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Although antibiotic therapy has become the primary treatment for acute uncomplicated appendicitis, often enabling patients to avoid surgery, the management of acute complicated appendicitis necessitates careful consideration of various treatment options.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eComplicated appendicitis, marked by the presence of peri-appendiceal phlegmon or abscess formation, poses additional challenges and often necessitates a more comprehensive treatment approach.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Management strategies have evolved to incorporate both conservative and surgical treatments tailored to the patient's condition.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Typically, for early-stage appendicitis (duration of symptoms\u0026thinsp;\u0026le;\u0026thinsp;72 hours) with peri-appendiceal phlegmon, surgical treatment is recommended. In contrast, late-stage appendicitis (duration of symptoms\u0026thinsp;\u0026gt;\u0026thinsp;72 hours) or cases with peri-appendiceal abscess formation are initially managed conservatively with percutaneous drainage and antibiotics.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Despite these guidelines, some surgeons and patients still prefer surgical intervention for various reasons.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Currently, there is a lack of studies on the outcomes of patients with acute complicated appendicitis who choose surgery over conservative treatment, underscoring the need for further research.\u003c/p\u003e \u003cp\u003eIn practical terms, the benefits and risks of all treatment options should be thoroughly discussed with patients.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Recommendations for surgery versus a conservative treatment-first approach should be based on individual clinical and radiographic findings, as well as patient treatment expectations and preferences.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] This study investigated the clinical significance of peri-appendiceal abscess and phlegmon in the surgical management of acute complicated appendicitis. Our single-center retrospective analysis revealed that the presence of a peri-appendiceal abscess is a significant predictor of prolonged postoperative length of hospital stay (LOS) for patients with acute complicated appendicitis. These findings underscore the importance of conservative treatment in patients with peri-appendiceal abscess. These insights are valuable for clinicians managing complicated appendicitis and suggest directions for future research to optimize treatment protocols and improve patient outcomes.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patients\u003c/h2\u003e \u003cp\u003eWe prospectively recruited consecutive patients with acute appendicitis, collected their clinicopathological data, and retrospectively analyzed the clinicopathological features correlated with prognosis to improve treatment strategies. Between January 2016 and March 2023, 3896 patients with acute appendicitis were diagnosed at the Department of Emergency Surgery, Zhongshan Hospital, Fudan University (Shanghai, China). The analytical data included general patient information, clinical manifestations, preoperative blood test results, imaging examination results, treatment method, surgical approach, length of hospital stay, and prognosis. All patients with acute appendicitis underwent a CT scan of the abdomen and pelvis upon arrival at the emergency department. Patients with peri-appendiceal abscesses or phlegmon on CT scans were selected as candidates for this study.\u003c/p\u003e \u003cp\u003eThis retrospective study included patients who met the following criteria: aged 18 years or older, clinically diagnosed with acute appendicitis, had a peri-appendiceal abscess or phlegmon on a CT scan, opted for immediate emergency surgery as their primary choice, and refused conservative treatment (antibiotic therapy and ultrasound/CT-guided drainage). The exclusion criteria were patients younger than 18 years, those with a history of prior malignancies, those with diffuse peritonitis, and those with incomplete clinical or pathological records. Based on these criteria, 3896 patients were screened, and 234 patients were included in our study. The cohort consisted of 134 males and 100 females, with ages ranging from 18 to 87 years (median age 60 years) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBased on the findings from the CT scan, patients were divided into two groups: the peri-appendiceal abscess group (n\u0026thinsp;=\u0026thinsp;151) and the peri-appendiceal phlegmon group (n\u0026thinsp;=\u0026thinsp;83) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All patients underwent surgical intervention and received postoperative antibiotic treatment (second-generation cephalosporins plus metronidazole) until recovery and discharge from the hospital.\u003c/p\u003e \u003cp\u003eThe primary endpoint of this study was the postoperative LOS. The discharge criteria included the resolution of symptoms such as pain and fever, stable vital signs, the ability to tolerate oral intake, normalization of laboratory parameters (e.g., white blood cell count), and the absence of postoperative complications. The secondary endpoints included postoperative complications, such as surgical site infections (SSI), incisional hernias, and the surgical approach used. Ethical approval for this study was granted by the Clinical Research Ethics Committee of Zhongshan Hospital, Fudan University (Shanghai, China). Informed consent was obtained from all patients for the collection and use of anonymized clinical data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted using SPSS Software (version 27.0; SPSS Inc., Chicago, IL, USA). Normally distributed data are presented as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, while skewed data are presented as the median (interquartile range). Categorical variables are expressed as counts and percentages. Differences in distribution were assessed using Pearson\u0026rsquo;s χ\u0026sup2; test or Fisher\u0026rsquo;s exact test for categorical variables, and Student\u0026rsquo;s t-test for continuous variables. Univariate analyses were performed using the Cox proportional hazards regression model. Kaplan-Meier survival analysis utilized postoperative LOS as the \"survival time,\" and survival curves were compared using the log-rank test. A P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eClinical characteristics of the patients at baseline\u003c/h2\u003e \u003cp\u003eA total of 234 patients with acute complicated appendicitis accompanied by peri-appendiceal abscess or phlegmon were included in our study. The median age was 60 years, ranging from 18 to 87 years. The gender distribution was 57.3% male and 42.7% female. The mean white blood cell (WBC) count was 13.4\u0026times;10^9/L, and the mean granulocyte percentage (GR%) was 88.9%. Appendicoliths were present in 56.4% of patients (n\u0026thinsp;=\u0026thinsp;132). Peri-appendiceal abscesses were found in 64.5% of patients (n\u0026thinsp;=\u0026thinsp;151), while peri-appendiceal phlegmon was observed in 35.5% (n\u0026thinsp;=\u0026thinsp;83). The vast majority of patients were diagnosed with acute appendicitis (n\u0026thinsp;=\u0026thinsp;228, 97.4%). Additionally, there were cases of appendiceal adenocarcinoma (n\u0026thinsp;=\u0026thinsp;4, 1.7%), appendiceal neuroendocrine neoplasm (n\u0026thinsp;=\u0026thinsp;1, 0.4%), and appendiceal mucinous neoplasm (n\u0026thinsp;=\u0026thinsp;1, 0.4%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline clinical characteristics of the patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll patients-N-%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e234 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median (range), year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (18\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex-N-%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (42.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e134 (57.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC count, mean (SD), \u0026times;10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.4 (5.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGR% granulocyte, mean (SD), %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.9 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppendicolith-N-%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e132 (56.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeri-appendiceal abscess-N-%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151 (64.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeri-appendiceal phlegmon-N-%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (35.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathology-N-%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute appendicitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e228 (97.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppendiceal adenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppendiceal neuroendocrine neoplasm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppendiceal mucinous neoplasm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCorrelations between clinical factors and peri-appendiceal abscess or phlegmon\u003c/h2\u003e \u003cp\u003eThe correlations between clinical factors and the presence of peri-appendiceal abscess or phlegmon among the 234 patients are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The duration of symptoms was significantly different between the two groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Specifically, among patients with symptoms lasting\u0026thinsp;\u0026le;\u0026thinsp;72 hours, 69 had abscesses, and 71 had phlegmons. In contrast, among those with symptoms lasting\u0026thinsp;\u0026gt;\u0026thinsp;72 hours, 82 had abscesses, while only 12 had phlegmons. The presence of an appendicolith was also significantly correlated (P\u0026thinsp;=\u0026thinsp;0.015); 94 patients with appendicoliths had abscesses compared to 38 with phlegmons, while among those without appendicoliths, 57 had abscesses and 45 had phlegmons. There was no significant difference in age (P\u0026thinsp;=\u0026thinsp;0.947) or sex (P\u0026thinsp;=\u0026thinsp;0.897) between patients with abscesses and those with phlegmons. Additionally, temperature (P\u0026thinsp;=\u0026thinsp;0.923), WBC count (P\u0026thinsp;=\u0026thinsp;0.668), and granulocyte percentage (P\u0026thinsp;=\u0026thinsp;0.557) did not significantly differ between the two groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation between clinical factors and peri-appendiceal abscess or phlegmon\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003ePeri-appendiceal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbscess\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePhlegmon\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.947\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.897\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTemperature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.923\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;37℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;37℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eWBC count, \u0026times;10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.668\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGR% granulocyte\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.557\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;72 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;72 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppendicolith\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026dagger;Split at median.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCox regression analyses for postoperative length of hospital stay\u003c/h2\u003e \u003cp\u003eCox regression analysis of postoperative LOS among patients revealed that the duration of symptoms and the presence of a peri-appendiceal abscess significantly influenced the LOS. Patients with symptoms lasting\u0026thinsp;\u0026le;\u0026thinsp;72 hours had a median postoperative LOS of 5 days, whereas those with symptoms lasting\u0026thinsp;\u0026gt;\u0026thinsp;72 hours had a median postoperative LOS of 7 days (hazard ratio [HR], 1.208; 95% CI, 1.107 to 1.319; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, patients with a peri-appendiceal abscess had a median postoperative LOS of 6 days, compared to 5 days for those with peri-appendiceal phlegmon (HR, 1.217; 95% CI, 1.095 to 1.352; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Other factors, such as age, sex, temperature, WBC count, granulocyte percentage, and the presence of an appendicolith, did not show significant correlations with postoperative LOS. Specifically, patients with a granulocyte percentage\u0026thinsp;\u0026le;\u0026thinsp;80% had a median postoperative LOS of 5 days, whereas patients with a granulocyte percentage\u0026thinsp;\u0026gt;\u0026thinsp;80% had a median postoperative LOS of 6 days (HR: 1.081, P\u0026thinsp;=\u0026thinsp;0.097). Although this difference was not statistically significant, there appeared to be an observable trend (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCox regression analyses for postoperative length of hospital stay\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLOS (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHazard Radio (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.913\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (4.0\u0026ndash;8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.000 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (4.0\u0026ndash;8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.997 (0.946 to 1.050)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.327\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (4.0\u0026ndash;8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.000 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (4.0\u0026ndash;8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.027 (0.974 to 1.083)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTemperature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.745\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;37℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (4.0\u0026ndash;7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.000 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;37℃\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (4.0\u0026ndash;8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.009 (0.954 to 1.068)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC count, \u0026times;10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.981\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (4.0\u0026ndash;7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.000 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (4.0\u0026ndash;8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.001 (0.945 to 1.060)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGR% granulocyte\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.097\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.0 (3.0-7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.000 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (4.0\u0026ndash;8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.081 (0.986 to 1.185)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;72 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.0 (4.0\u0026ndash;7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.000 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;72 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.0 (5.0\u0026ndash;10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.208 (1.107 to 1.319)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppendicolith\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.699\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (4.0\u0026ndash;8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.000 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (4.0\u0026ndash;8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.010 (0.959 to 1.064)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeri-appendiceal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhlegmon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.0 (4.0\u0026ndash;7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.000 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (5.0\u0026ndash;8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.217 (1.095 to 1.352)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAbbreviation: LOS, length of hospital stay; 95% CI, 95% confidence interval.\u003c/p\u003e \u003cp\u003e\u0026dagger;Split at median.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo evaluate the clinical prognostic significance of peri-appendiceal abscess or phlegmon on postoperative LOS for patients in this study, Kaplan-Meier survival analyses were performed. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Kaplan-Meier survival curves were generated to compare the postoperative LOS between patients with peri-appendiceal abscess and those with peri-appendiceal phlegmon. The findings revealed that patients with peri-appendiceal abscess had a significantly longer postoperative LOS than those with phlegmon (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, based on the median size of the abscess, patients with peri-appendiceal abscesses were categorized into two groups: those with abscesses smaller than 5.0 cm (n\u0026thinsp;=\u0026thinsp;69) and those with abscesses 5.0 cm or larger (n\u0026thinsp;=\u0026thinsp;82). Both abscess groups exhibited significantly longer postoperative LOS than the phlegmon group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for both comparisons), and the difference between the two abscess size groups was also statistically significant (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB, P\u0026thinsp;=\u0026thinsp;0.038). These results suggest that the presence of a peri-appendiceal abscess, especially a larger abscess, is associated with prolonged hospital stays compared to the presence of peri-appendiceal phlegmon.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCorrelations between surgical factors and peri-appendiceal abscess or phlegmon\u003c/h2\u003e \u003cp\u003eThe analysis of surgical factors related to peri-appendiceal abscess or phlegmon revealed several significant findings. There was a notable correlation between the type of surgical site infection (SSI) and the presence of peri-appendiceal abscess or phlegmon (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among the patients with peri-appendiceal abscess, there were 14 cases of superficial infections, 6 cases of deep incisional infections, and 2 cases of organ/space infections. In contrast, patients with peri-appendiceal phlegmon had only 1 case of superficial infection and no cases of deep incisional or organ/space infections. There was no significant difference in the occurrence of incisional hernias between the two groups, with only 1 patient with a peri-appendiceal abscess developing an incisional hernia and none with phlegmon. The type of surgery performed was also significantly correlated with the presence of abscess or phlegmon (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among the patients with peri-appendiceal abscesses, 56 underwent laparoscopic appendectomy, 44 underwent open appendectomy, and 51 required conversion to open appendectomy. Among the patients with phlegmon, 49 underwent laparoscopic appendectomy, 5 underwent open appendectomy, and 29 required conversion to open appendectomy (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Correlation between surgical factors and peri-appendiceal abscess or phlegmon\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003ePeri-appendiceal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbscess\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhlegmon\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical site infections by type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuperficial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeep incisional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrgan/space\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisional hernias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic appendectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen appendectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion to open appendectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAppendicitis remains one of the most common and urgent surgical conditions worldwide, with a lifetime risk of 8.6% in men and 6.9% in women.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Prompting intervention is crucial for preventing complications and improving prognosis.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Traditionally, the standard treatment for acute appendicitis has been an appendectomy, performed either through open surgery or laparoscopically.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] However, there is growing interest in nonsurgical management for patients with uncomplicated appendicitis. Several studies have demonstrated the efficacy of antibiotic therapy as a nonsurgical alternative for patients with acute uncomplicated appendicitis, reducing the immediate need for surgery.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Despite its effectiveness, there remains a risk of recurrence, necessitating careful patient selection and diligent follow-up.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eComplicated appendicitis presents additional challenges and often necessitates a more comprehensive treatment approach than uncomplicated appendicitis.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] There have been significant advancements in the management of complicated appendicitis via both conservative and surgical methods.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] In conservative treatment, optimized antibiotic regimens and the use of broad-spectrum antibiotics have reduced the need for immediate surgery.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Additionally, imaging-guided percutaneous drainage techniques have improved the safety and effectiveness of managing abscesses.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Enhanced patient monitoring protocols, along with the advent of telemedicine and home-based care, have improved follow-up and reduced hospital stays.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] In surgical treatment, laparoscopic appendectomy and robotic-assisted surgery are revolutionary surgical procedures, that offer shorter recovery times and fewer complications compared to open surgery.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] The concepts of interval appendectomy, risk stratification methods, and enhanced recovery protocols, including multimodal analgesia and early mobilization, have further refined surgical approaches.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Ongoing comparative studies, research on long-term outcomes, and evaluations of patient preferences and quality of life are essential for developing comprehensive and patient-centered care strategies for complicated appendicitis patients.\u003c/p\u003e \u003cp\u003eDespite advances in conservative management, some surgeons and patients still prefer surgical intervention for various reasons, such as resolving the patient's issue in a single procedure and avoiding the prolonged duration of conservative treatment.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Typically, surgical treatment is recommended for early-stage appendicitis (duration of symptoms\u0026thinsp;\u0026le;\u0026thinsp;72 hours) with peri-appendiceal phlegmon due to the effectiveness of immediate intervention in preventing further complications. Conversely, for late-stage appendicitis (duration of symptoms\u0026thinsp;\u0026gt;\u0026thinsp;72 hours) or cases with peri-appendiceal abscess formation, an initial conservative approach involving antibiotics and percutaneous drainage is often favored to manage the condition effectively.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] For patients who refuse conservative treatment initially, surgery becomes the only viable option. However, is surgery the right option? In our study, patients with peri-appendiceal abscesses had a significantly longer LOS compared to those with phlegmon. Additionally, we divided the patients with peri-appendiceal abscesses into two groups based on the median size of the abscess: those with abscesses less than 5.0 cm and those with abscesses 5.0 cm or larger. Both groups with abscesses had a significantly longer LOS than patients with phlegmon, and patients with peri-appendiceal abscess measuring 5.0 cm or larger had a significantly longer LOS than those with abscess smaller than 5.0 cm. These data suggest that the presence of a peri-appendiceal abscess, especially a larger abscess, is associated with longer hospital stays compared to the presence of peri-appendiceal phlegmon.\u003c/p\u003e \u003cp\u003eWhen reviewing the treatment approach for patients with acute complicated appendicitis with peri-appendiceal abscess or phlegmon, different strategies are recommended based on the patient\u0026rsquo;s condition.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] For patients with peri-appendiceal phlegmon, immediate surgical intervention is typically advised.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] In contrast, for patients with peri-appendiceal abscesses, especially larger abscesses, an initial conservative treatment approach is recommended.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] This involves the use of antibiotics and percutaneous drainage to manage infection and inflammation.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] The efficacy of conservative treatment for peri-appendiceal abscesses was highlighted in another clinical study (NCT06469086), which concluded that conservative treatment can effectively reduce the need for immediate surgery and minimize complications for selected patients.\u003c/p\u003e \u003cp\u003eThe presence of an appendicolith, a calcified deposit within the appendix, significantly affects the progression and severity of acute appendicitis and the formation of peri-appendiceal abscesses.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] An appendicolith can obstruct the appendix lumen, leading to increased pressure, bacterial overgrowth, and inflammation, often delaying symptom relief. This obstruction is also a major risk factor for localized perforation and abscess formation, necessitating more complex treatment approaches.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] In this study, we found that the presence of an appendicolith is a risk factor for peri-appendiceal abscess formation in patients with acute complicated appendicitis. Our previous research demonstrated that identifying an appendicolith through imaging helps stratify patients by risk, guiding treatment decisions such as early surgical intervention to prevent severe complications or conservative management with antibiotics and drainage for abscess formation. Understanding the relationship between appendicoliths and these complications is crucial for improving patient outcomes, emphasizing the need for careful diagnosis, appropriate management strategies, and further research into effective treatment protocols.\u003c/p\u003e \u003cp\u003eThis study has several limitations that should be considered. First, as a retrospective analysis, it is inherently prone to selection biases, despite utilizing data from a prospectively recruited database. The retrospective nature of the study limits the ability to control for all potential confounding variables, which might impact the generalizability of the findings. Second, the lack of long-term follow-up data restricts our ability to assess the long-term outcomes of the treatment strategies evaluated. This absence makes it challenging to determine the durability of the results and the potential for late complications, which are crucial for a comprehensive understanding of treatment efficacy. Third, the analysis did not incorporate various subjective factors, such as sociocultural influences, which can significantly affect treatment outcomes, particularly in the context of China.[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] Moreover, the study's focus on clinical and demographic factors without considering the broader socioeconomic context may overlook important variables that influence health outcomes. Factors such as access to healthcare, economic constraints, and educational levels can also play a significant role in the success of treatment and patient adherence to medical advice.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe duration of symptoms and the presence of an appendicolith are significant risk factors for the formation of peri-appendiceal abscesses in patients with acute complicated appendicitis. Clinical data indicate that patients with peri-appendiceal abscesses experience a significantly longer postoperative LOS compared to those with peri-appendiceal phlegmon. Early identification through imaging and appropriate risk stratification can guide decisions toward either early surgical intervention or initial conservative management with antibiotics and percutaneous drainage. Understanding the complex interplay between appendicoliths, abscess formation, and patient outcomes is crucial for optimizing management approaches and improving overall clinical outcomes for patients with acute complicated appendicitis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors have no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthical Approval\u003c/h2\u003e \u003cp\u003e The Clinical Research Ethics Committee of Zhongshan Hospital, Fudan University (Shanghai, China) granted ethical approval for this study. Informed consent was obtained from all patients for the collection and use of anonymized clinical data.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was sponsored by the National Natural Science Fund of China (82373417), Natural Science Foundation of Shanghai (23ZR1409900), and the Clinical Research Fund of Zhongshan Hospital, Fudan University (ZSLCYJ202343).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHH conceived, designed, and refined the study protocol, as well as edited the manuscript. LM and JL were responsible for data collection and analysis. LM and JL drafted the manuscript. LM and JL contributed equally to this work as co-first authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMoris D, Paulson EK, Pappas TN. Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA 2021; 326: 2299-2311.\u003c/li\u003e\n\u003cli\u003eFerris M, Quan S, Kaplan BS et al. 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Laparoscopic versus open surgery for complicated appendicitis in adults: a randomized controlled trial. Surg Endosc 2016; 30: 1705-1712.\u003c/li\u003e\n\u003cli\u003eLiao YT, Huang J, Wu CT et al. The necessity of abdominal drainage for patients with complicated appendicitis undergoing laparoscopic appendectomy: a retrospective cohort study. World J Emerg Surg 2022; 17: 16.\u003c/li\u003e\n\u003cli\u003eMallinen J, Vaarala S, Makinen M et al. Appendicolith appendicitis is clinically complicated acute appendicitis-is it histopathologically different from uncomplicated acute appendicitis. Int J Colorectal Dis 2019; 34: 1393-1400.\u003c/li\u003e\n\u003cli\u003eWang N, Lin X, Zhang S et al. Appendicolith: an explicit factor leading to complicated appendicitis in childhood. Arch Argent Pediatr 2020; 118: 102-108.\u003c/li\u003e\n\u003cli\u003eZhang L, Yang J, Cao Y, Kang W. Sociocultural-psychological predictors influencing parents\u0026apos; decision-making regarding HPV vaccination for their adolescent daughters in mainland China: An extended TPB model. Front Public Health 2022; 10: 1035658.\u003c/li\u003e\n\u003cli\u003eKenessey DE, Vlemincq-Mendieta T, Scott GR, Pilloud MA. An Anthropological Investigation of the Sociocultural and Economic Forces Shaping Dental Crowding Prevalence. Arch Oral Biol 2023; 147: 105614.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Acute appendicitis, Abscess, Phlegmon, Appendectomy","lastPublishedDoi":"10.21203/rs.3.rs-4682091/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4682091/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aimed to analyze the clinical data of patients who underwent emergency appendectomy for acute complicated appendicitis with peri-appendiceal abscess or phlegmon, identify factors influencing the postoperative length of hospital stay (LOS), and improve treatment strategies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe clinical data of acute complicated appendicitis patients with peri-appendiceal abscess or phlegmon who underwent emergency appendectomy at the Department of Emergency Surgery, Zhongshan Hospital, Fudan University, from January 2016 to March 2023, were retrospectively analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 234 patients were included in our study. The duration of symptoms and the presence of an appendicolith were significantly correlated with the occurrence of peri-appendiceal abscess in patients with acute complicated appendicitis (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and P\u0026thinsp;=\u0026thinsp;0.015, respectively). Patients with symptoms lasting longer than 72 hours had a significantly longer postoperative LOS compared to those with symptoms lasting 72 hours or less (HR, 1.208; 95% CI, 1.107 to 1.319; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, patients with peri-appendiceal abscesses had a significantly longer postoperative LOS compared to those with phlegmon (HR, 1.217; 95% CI, 1.095 to 1.352; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The patients with peri-appendiceal abscesses were divided into two groups based on the median size of the abscess: those with abscesses smaller than 5.0 cm (n\u0026thinsp;=\u0026thinsp;69) and those with abscesses 5.0 cm or larger (n\u0026thinsp;=\u0026thinsp;82). Patients with peri-appendiceal abscesses measuring 5.0 cm or larger had a significantly longer postoperative LOS than those with abscesses smaller than 5.0 cm (P\u0026thinsp;=\u0026thinsp;0.038).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe duration of symptoms and the presence of an appendicolith are significant risk factors for the formation of peri-appendiceal abscesses in patients with acute complicated appendicitis. Patients with peri-appendiceal abscesses experience a significantly longer postoperative LOS compared to those with peri-appendiceal phlegmon.\u003c/p\u003e","manuscriptTitle":"Clinical significance of peri-appendiceal abscess and phlegmon in acute complicated appendicitis patients undergoing emergency appendectomy: A single-center retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-09 14:46:22","doi":"10.21203/rs.3.rs-4682091/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"65aebf72-6169-4b80-9088-9da16055ee83","owner":[],"postedDate":"August 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-13T04:21:14+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-09 14:46:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4682091","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4682091","identity":"rs-4682091","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}