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ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 32-38

Complicated appendicitis is predicted by the presence of systemic inflammatory response syndrome


Department of Surgery, Umm Al-Qura University, Makkah, Saudi Arabia

Date of Submission26-Feb-2020
Date of Acceptance17-Sep-2020
Date of Web Publication19-Jan-2021

Correspondence Address:
Dr. Hassan Adnan Bukhari
Department of Surgery, Umm Al-Qura University, Makkah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_6_20

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  Abstract 

Context: Systemic inflammatory response syndrome (SIRS) can be a result of ischemia, inflammation, trauma, infection, or a combination of several “insults.”
Aims: The present study aims to estimate the relationship between SIRS and different predictive factors including sex, renal disease, diabetes (DM), comorbidities ultrasound, computed tomography (CT) abdomen, operative intervention, and other operational findings of inflamed appendicitis, gangrenous and perforated appendicitis, and postoperative complications.
Settings and Design: Retrospective cohort study was conducted at Al-Noor Hospital Emergency Department in Makkah.
Materials and Methods: Data were collected from 259 patients with acute appendicitis presented to the Al-Noor Hospital Emergency Department in Makkah during 1435H. Variables such as comorbidities, vital sign on presentation, the result of certain investigation (white blood cell count, arterial blood gas, ultrasound, and CT abdomen), interventions provided, postoperative complication, intensive care unit length stay, and outcome along with SIRS criteria were followed to collect the data.
Statistical Analysis Used: A secondary logistic analysis was also performed (SPSS version 19.0) on key risk factors, in order to exclude confounding covariates.
Results: The findings of the study indicate a significant relation between SIRS criteria and the operation findings of perforation with collection with a significant P = 0.001. The presence of gangrenous appendicitis intraoperatively provided almost significant relationship with SIRS criteria (0.065).
Conclusion: The present study concluded that SIRS has a significant predictive value with the presence of complicated appendicitis in the form of perforation and gangrene.

Keywords: Appendicitis, C-reactive protein, multiple organ failure, sepsis, systemic inflammatory response syndrome


How to cite this article:
Bukhari HA, Mirza M. Complicated appendicitis is predicted by the presence of systemic inflammatory response syndrome. Saudi Surg J 2020;8:32-8

How to cite this URL:
Bukhari HA, Mirza M. Complicated appendicitis is predicted by the presence of systemic inflammatory response syndrome. Saudi Surg J [serial online] 2020 [cited 2021 Feb 24];8:32-8. Available from: https://www.saudisurgj.org/text.asp?2020/8/1/32/307426


  Introduction Top


The present study estimates the relationship between systemic inflammatory response syndrome (SIRS) and different predictive factors, including sex, renal disease, diabetes, comorbidities, ultrasound, computed tomography [CT] abdomen, operative intervention, and other operational findings of inflamed appendicitis, gangrenous and perforated appendicitis, and postoperative complications. Contributions of this study are important as it provides an in-depth analysis of prevalence of SIRS in acute appendicitis. The study is of greater use for clinical experts as it provides advanced knowledge regarding the given disease. The study is of significant value for the clinical experts belonging specifically from the region of Saudi Arabia, as it is centered toward Saudi population.


  Subjects and Methods Top


A retrospective cohort study design is followed, and the study is conducted in the Al-Noor Hospital Emergency Department in Makkah. All patients with acute appendicitis presented to Al-Noor Hospital Emergency Department in Makkah during 1435H served as the target population of this study. Sample of 259 patients with acute appendicitis presented at the Al-Noor Hospital Emergency were included in this study. The selection of the participants was based on the inclusion and the exclusion criteria, as indicated in [Table 1].
Table 1: Inclusion and exclusion criteria

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Data were collected through certain variables by following the SIRS criteria.[1] The included variables of this study are: comorbidities, vital signs on presentation, the result of certain investigation (white blood cell count, arterial blood gases, plain X-ray, ultrasound, and CT abdomen), intervention which was done to each patient, presence of postoperative complication, intensive care unit length of stay, and outcome. Approvals for conducting the study were obtained from the Al-Noor Hospital authorities before data collection.

All the patients with acute appendicitis were identified within the medical charting system. Patients that were unstable preoperatively or were being operated on for frank bowel perforation or intestinal necrosis were excluded. A retrospective review was conducted identifying patients that exhibited a severe SIRS or shock (septic or septic shock-like syndrome). The definition of severe sepsis and septic shock were taken from the landmark paper “International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction.[2] However, as not all patients in a state of significant SIRS had identifiable sources of infection, the terms of “severe SIRS” and “SIRS related shock” were used instead. These terms indicate the states of inflammation identical to severe sepsis and septic shock, but in the absence of defined infection as stated above.[2]

Patients who met these criteria made up the study group (SIRS + ve group). The remaining patients were placed in the control group (SIRS-ve group). The two groups were then compared using the Chi-square test to identify the potential risk factors of a significant SIRS. Statistical significance was defined as a P = 0.05. A secondary logistic analysis was also performed (SPSS version 19.0, IBM, NY, USA) on key risk factors, in order to exclude confounding covariates. These latter results are reported as the beta coefficient and P value.


  Results Top


[Table 2] shows the relationship between SIRS criteria and Sex. 61.8% of male participants showed positive SIRS criteria, whereas 58.2% of them indicated negative SIRS criteria. Among female participants, positive SIRS was 38.2% and 41.8% of them showed negative SIRS criteria. This determines that the predictive value of SIRS is common in both males and females. The findings with respect to the relation between SIRS criteria and sex indicate an insignificant relation providing a P = 0.579.
Table 2: Relationship between systemic inflammatory response syndrome criteria and sex

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[Table 3] provides the findings regarding the relationship between SIRS criteria and diagnosis of patients in ER group. The findings indicated that there was no significant relation between SIRS criteria and time of diagnosis in ER with a P = 0.872. In the ER group, ranged from 1 to 96 by median (interquartile range [IQR]) 7.125 (129.459) in negative SIRS and ranged from 1 to 96 by median (IQR) 7.5 (131.034) in positive SIRS. The findings showed that there was no significant relation between SIRS criteria and onset of symptoms in ER presentation providing a P = 0.102. Moreover, the onset of symptoms to ER presentation ranged from 2 to 360 by median (IQR) of 24 in negative SIRS while ranged from 3 to 168 by median (IQR) of 48 in positive SIRS.
Table 3: Relation between systemic inflammatory response syndrome criteria, diagnosis of patients, and onset of symptoms in ER Group

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[Table 4] provides the relationship between SIRS criteria and PaO2 on patients' presentation. Findings indicated that there is no significant relation between positive and negative SIRS regarding PaO2 providing a P = 0.964. The PaO2 ranged from 23 to 100 by mean ± SD (93.313 ± 18.867) in negative SIRS and ranged from 39 to 100 by mean ± SD (93 ± 17.072) in positive SIRS.
Table 4: Relation between systemic inflammatory response syndrome criteria and PaO2 on presentation in patients' group

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[Table 5] shows the relationship between the SIRS criteria and renal disease in patients' group. 98.9% of positive SIRS were observed for negative renal disease and 1.1% of positive SIRS were observed for positive renal disease. Whereas, 98.2% of negative SIRS were observed for negative renal disease, and 1.8% of negative SIRS were observed for positive renal disease. The findings indicated that there is no significant relation between SIRS criteria and renal disease (P value = 0.683), which indicates that SIRS criteria are not predictive in patients with renal disease. 98.9% of positive SIRS was found in patients with negative DM, and 1.1% of positive SIRS was found in patients with positive DM. 97.1% of negative SIRS were found in patients with negative diabetes and 2.9% of negative SIRS was found in patients with positive DM. The findings, therefore, reflect that there is no significant relation between SIRS criteria and DM in patients' group, providing a P = 0.32. These results indicate that diabetes patients do not predict the SIRS criteria [Table 5]. 97.8% of positive SIRS was found in patients with negative hypertension [HTN], and 2.2% of positive SIRS was found in patients with positive HTN. 96.5% of negative SIRS was found in patients with negative HTN and 3.5% of negative SIRS was found in patients with positive HTN. The findings show that there is no significant relation between SIRS criteria and HTN in patients' group with a P = 0.561. These results further indicate that SIRS criteria were insignificantly predictive in hypertensive patients [Table 5]. 4.5% of positive SIRS criteria was observed for patients with negative comorbidity and 95.5% of positive SIRS criteria was attained for patients with positive comorbidity. 7.1% of negative SIRS criteria was obtained for patients with negative comorbidity and 92.9% of negative SIRS criteria was obtained for patients with positive comorbidity [Table 5]. This further indicates that SIRS criteria are not predictive in comorbidity of patients in patient's group.
Table 5: Relation between systemic inflammatory response syndrome criteria and renal disease in patients' group

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[Table 6] provides the findings related to the relationship between SIRS criteria and ultrasound in patients' group. 80.9% of positive SIRS criteria were found among patients that did not have ultrasound, 10.1% of positive SIRS criteria was found among patients that were detected with phlegmon/abscess on ultrasound, 2.2% of positive SIRS criteria was obtained for patients with normal ultrasound findings, and 6.7% of positive SIRS criteria was for patients with inconclusive ultrasound findings.
Table 6: Relationship between systemic inflammatory response syndrome criteria and ultrasound, computed tomography abdomen, intervention in patients' Group

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In contrast to this, 77.6% of negative SIRS criteria were found among patients that did not have ultrasound, 9.4% of negative SIRS criteria was for patients with inconclusive ultrasound findings, 7.6% of negative SIRS criteria was for normal ultrasound, and 5.3% of negative SIRS criteria was obtained for patients that were detected with phlegmon/abscess on ultrasound.

Eighty-two percent of positive SIRS criteria was obtained for patients that did not have CT abdomen. 12.4% of positive SIRS criteria was obtained for patients that were detected with phlegmon/abscess on CT abdomen and 5.6% of positive SIRS criteria was obtained for patients with the findings of appendicitis during CT abdomen. In contrast to this, 84.7% of negative SIRS criteria was obtained for patients that did not have CT abdomen, 7.6% of negative SIRS criteria was obtained for patients that were detected with phlegmon/abscess on CT abdomen, 4.7% of negative SIRS criteria was obtained for patients with the findings of appendicitis during CT abdomen and 2.9% of negative SIRS criteria was obtained for patients with normal CT abdomen findings.

[Table 6] shows the relationship between SIRS criteria and intervention in patients' group. Sixty-four percent of positive SIRS criteria was found among patients that had the intervention of open appendectomy, 33.7% of positive SIRS criteria was found among patients with the intervention of laparoscopic appendectomy while 2.2% of positive SIRS criteria were found among patients that had conservative intervention.

In contrast to this, 62.1% of negative SIRS criteria was obtained for patients with open appendectomy intervention, 33.7% of negative SIRS criteria was obtained for patients with laparoscopic appendectomy, 3.6% of negative SIRS criteria was obtained for patients with conservative intervention, while 0.6% of negative SIRS criteria was obtained for patients with percutaneous drainage intervention. The findings indicate that there is no significant relation between SIRS criteria and intervention procedure in patients' group with a P = 0.749.

[Table 7] shows the relationship between SIRS criteria and operational findings of inflamed appendix in patients' group. 81.6% of positive SIRS criteria was obtained for patients with positive operational findings of inflamed appendix, whereas 18.4% of positive SIRS criteria was obtained for patients with negative operational findings of inflamed appendix.
Table 7: Relationship between systemic inflammatory response syndrome criteria and operation finding of inflamed appendix, gangrenous, and perforation in patients' group

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In contrast to this, 88.3% of negative SIRS criteria was obtained for patients with positive operational findings of inflamed appendix, whereas 11.7% of negative SIRS criteria was obtained for patients with negative operational findings of inflamed appendix. The findings indicate that there is no significant relation between SIRS criteria and operation finding of inflamed appendix in patients' group with a P = 0.150.

88.6% of positive SIRS criteria was found among patients with no gangrenous appendicitis, whereas 11.4% of positive SIRS criteria was found among patients with operation findings of gangrenous appendicitis. In contrast to this, 95.1% of negative SIRS criteria was found among patients with no gangrenous appendicitis operation findings, whereas 4.9% of negative SIRS criteria was found among patients with gangrenous appendicitis findings. The results show that there might be a significant relation between SIRS criteria and operation finding of gangrenous appendicitis in patients' group with a P = 0.065.

54.5% of negative SIRS criteria was obtained for patients with no perforation in operation findings, while 45.5% of negative SIRS criteria was obtained for patients with perforation with collection on operational findings. In contrast to this, 75.5% of positive SIRS criteria was obtained for patients with no perforation in operation findings, whereas 24.5% of positive SIRS criteria was obtained for patients with no perforation in operation findings. The findings show that there is a significant relation between SIRS criteria and operation finding of perforation with collection in patients' group providing a P = 0.001.

[Table 8] provides the findings in relation to the SIRS criteria and postoperative complications. 94.4% of positive SIRS criteria was obtained for patients with no postoperative complication, whereas 4.5% of positive SIRS criteria was found in patients with postoperative complication of wound infection or dehiscence, 0.6% of positive SIRS criteria was found among patients with positive postoperative complication of colo-cutaneous fistula while remaining 0.6% of positive SIRS criteria was found among patients with the postoperative complication of intra-operative abscess.
Table 8: Relation between systemic inflammatory response syndrome criteria and postoperative complication in patients' group

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In contrast to this, 97.6% of negative SIRS criteria was obtained for patients with no postoperative complication, 1.2% of negative SIRS criteria was obtained for patients with postoperative complication of wound infection or dehiscence, while 1.1% of negative SIRS criteria was obtained for patients with postoperative complications of intra-operative abscess, 0.0% of negative SIRS criteria was obtained for postoperative complication of colocutaneous fistula. Insignificant P values were obtained for no complication (0.186), postoperative complication of wound infection or dehiscence (0.103), with postoperative complications of intra-operative abscess (0.649), and postoperative complication of colocutaneous fistula (0.357).


  Discussion Top


The findings of the study indicated that SIRS criteria share an insignificant relation with the diagnosis of patients in ER group. Similarly, an insignificant relation was found between SIRS criteria and other variables, including PaO2, onset of symptoms in ER presentation in patients' group, sex, renal disease, diabetes (DM), HTN, comorbidity, ultrasound findings, CT abdomen outcomes, treatment interventions, operational findings of inflamed appendix, and post-operative complications. However, significant relationship was only obtained for SIRS criteria and operational findings of perforation and possible relationship to the presence of gangrenous appendicitis among patients.

The measurement of the SIRS criteria, as stated by Beltran et al.[3] takes place through the process where a single point is assigned for each positive parameter, which provided a score between 0 and 4 points. SIRS criteria are identified among patients, if any two or more points are present together.[4]

For Shrestha and Kumar,[5] SIRS refers to an inflammatory state that affects the whole body, mostly a response of the immune system to infection. However, in certain cases, it may also occur in the absence of infection. The problem is regarded as sepsis when an individual meets criterion for SIRS with a known source of infection. The syndrome serves as a clinical response to an infected, inflammatory, or traumatic stimulus of tissue. The American College of Chest Physicians/Society of Critical Care Medicine Committee developed the concept of SIRS in 1992. For the diagnosis of SIRS occurs if at least two of the following criteria are present: (1) hyperthermia >38°C or hypothermia <36°C, (2) heart rate >90/min, (3) respiratory rate >20/min or PaCO2 <32 mmHg, (4) white cell count >12,000/μL or <4000/μL, or >10% immature white cells. With these clear criteria, clinicians can easily assess whether SIRS is present in these patients.[6] SIRS can be a result of ischemia, inflammation, trauma, infection or a combination of several “insults”. Some have proposed the terms “severe SIRS” and “SIRS shock” to describe serious clinical syndromes that are not infectious in nature and thus cannot be labeled according to the various sepsis definitions. These terms are still not universally accepted and suggest that organ dysfunction is not related to an infectious etiology, but rather it is an ischemic, traumatic, or inflammatory process.[7]

Beltrán[4] indicated that SIRS reflects the inflammatory response of humans toward certain body infections or injury. The key to prevent the multiple hits is adequate identification of the cause of SIRS and appropriate resuscitation and intervention. Depending on the inciting factors, many SIRS states resolve without specific intervention.[8] Trauma, inflammation, or infections lead to the activation of the inflammatory cascade. When SIRS is mediated by an infectious insult, the inflammatory cascade is often initiated by endotoxin or exotoxin. Once the inhibitor is removed, nuclear factor-kappa B (NF-κB) is able to initiate the production of messenger RNA that will induce the production of other pro-inflammatory cytokines. Interleukins 6 (IL-6) and 8 (IL-8) and Interferon-gamma are the primary pro-inflammatory mediators induced by NF-κB. Tumor necrosis factor and IL-1 have been shown to be released in large quantities providing both local and systemic effects.[9]

The overall assessment of SIRS is important to predict the occurrence of complicated health issues such as acute appendicitis. Besides, routine metabolic tests along with the overall laboratory findings must be provided depending upon the findings of the physical examination and patient's history.[10] The criteria of assessment are different for both outpatient that are treated in physician's office and those that are hospitalized for a longer duration.[11] The management of the SIRS criteria and other acute diseases are, however, related, since one predicts the presence of another disease. Ceresoli et al.[11] provided the idea in relation to acute appendicitis which is one of the most common emergent surgical diseases. Delayed management of an inflamed appendix will lead to perforation, intra-abdominal abscess, and peritonitis. Continuity of the inflammation may predict SIRS which can lead to organ failure and (MODS).[12]

Stephenson et al.[13] conducted similar study to determine the SIRS response to appendicitis. The fundamental aim of the study is to identify the association between the presence and absence of SIRS and patient's length of stay, mortality, and in-hospital interventions in emergency surgical admissions. However, the most influential factor was WBCs count, respiratory rate, and heart rate/temperature. Davies and Hagen,[9] on the other hand, conducted a study and identified that the use of SIRS criteria among patients with traumatic conditions is ineffective in predicting the occurrence of multiple organ dysfunction syndromes (MODS) and infection. These findings are in contrast with the present findings.

Ye-Ting and Dao-Ming et al.[14] conducted a study to investigate the risks of SIRS-negative and SIRS-positive sepsis with gastrointestinal (GI) perforation. The findings indicated that the increased sequential organ failure assessment served as an independent predictor for the GI perforation with sepsis. Besides, patients with negative sepsis provided insignificant favorable outcomes for GI perforation, with 31.3% risk of mortality. These results are not similar to those provided in the present study.

Saar et al.[15] provided contradicting results, according to which the rate of postoperative complications was high among the involved patients with a significant P = 0.23. These results are in line with those proposed in the present study. However, the length of hospital stay was significantly reduced among patients treated through short therapies. The present study involved certain limitations in terms of small sample size, which ultimately reduces the probability for the generalizability of the results. The study is further limited, since it did not provide information regarding the provided treatments, medications, and interventions. Future researchers are recommended to conduct the study further by involving a large sample along with fulfilment of gaps identified in this study.


  Conclusion Top


The assessment of the SIRS criteria acts as a useful tool in providing the predictive value of complicated appendicitis. Findings of the study indicated a significant relation between SIRS criteria and operative findings of perforation with collection. A timely diagnosis and intervention of patients with appendicitis and positive SIRS is necessary to reduce the growing risks of morbidity and possible mortality. Findings of this study are significant as they may assist clinical experts in their everyday clinical practices. Since the predictive value of SIRS criteria is associated to the rate of prevalence of several surgical diseases, therefore identification of SIRS criteria during different conditions is important to reduce the rate of mortality.

Acknowledgments

The author is thankful to all the associated personnel, who contributed for this study. Further, this research is not funded through any source.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Chao A, Chou WH, Chang CJ, Lin YJ, Fan SZ, Chao AS. The admission systemic inflammatory response syndrome predicts outcome in patients undergoing emergency surgery. Asian J Surg 2013;36:99-103.  Back to cited text no. 1
    
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van der Poll T, Opal SM. Host–pathogen interactions in sepsis. Lancet Infect Dis 2008;8:32-43.  Back to cited text no. 2
    
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Beltran MA, Mendez PE, Barrera RE, Contreras MA, Wilson CS, Cortes VJ, et al. Is hyperbilirubinaemia in appendicitis a better predictor of perforation than C-reactive protein? – A prospective study. Indian J Surg 2009;71:265-72.  Back to cited text no. 3
    
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Beltrán MA. The systemic inflammatory response in patients with appendicitis: A progressive phenomenon. Indian J Surg 2015;77:1050-6.  Back to cited text no. 4
    
5.
Shrestha M, Kumar A. Systemic inflammatory response syndrome: The current status. J Univers Coll Med Sci 2018;6:56-61.  Back to cited text no. 5
    
6.
American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. Definitions of sepsis and organ failure and guidelines for the use of the innovative therapies in sepsis. Crit Care Med 1992;20:864-74.  Back to cited text no. 6
    
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Becher RD, Hoth JJ, Miller PR, Meredith JW, Chang MC. Systemic inflammation worsens outcomes in emergency surgical patients. J Trauma Acute Care Surg 2012;72:1140-9.  Back to cited text no. 7
    
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Bone R. Systemic inflammatory response syndrome: a unifyng concept of systemic sepsis and MOF. Ch 1:1. Alan Fein- Williams & Wilkins. 1997. p. 3-11.  Back to cited text no. 8
    
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Davies MG, Hagen PO. Systemic inflammatory response syndrome. BJS 1997;84:920-35.  Back to cited text no. 9
    
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Bukhari HA, Mirza MA. The predictive value of systemic inflammatory response syndrome on the outcome of perforated viscus in adult. Saudi Surg J 2016;4:7.  Back to cited text no. 10
  [Full text]  
11.
Ceresoli M, Zucchi A, Allievi N, Harbi A, Pisano M, Montori G, et al. Acute appendicitis: Epidemiology, treatment and outcomes-analysis of 16544 consecutive cases. World J Gastrointest Surg 2016;8:693.  Back to cited text no. 11
    
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Vollmar B, Menger MD. Intestinal ischemia/reperfusion: Microcirculatory pathology and functional consequences. Langenbecks Arch Surg 2011;396:13-29.  Back to cited text no. 12
    
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Stephenson JA, Gravante G, Butler NA, Sorge R, Sayers RD, Bown MJ. The systemic inflammatory response syndrome (SIRS)--number and type of positive criteria predict interventions and outcomes in acute surgical admissions. World J Surg 2010;34:2757-64.  Back to cited text no. 13
    
14.
Ye-Ting Z, Dao-Ming T. Systemic inflammatory response syndrome (SIRS) and the pattern and risk of sepsis following gastrointestinal perforation. Med Sci Monit 2018;24:3888-94.  Back to cited text no. 14
    
15.
Saar S, Mihnovitš V, Lustenberger T, Rauk M, Noor EH, Lipping E, et al. Twenty-four hour versus extended antibiotic administration after surgery in complicated appendicitis: A randomized controlled trial. J Trauma Acute Care Surg 2019;86:36-42.  Back to cited text no. 15
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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