Geographic Association Between Incidence of Acute Appendicitis and Socioeconomic Status

Income-Based Disparities in Outcomes Following Pediatric Appendectomy: A National Analysis

BACKGROUND

Appendectomy remains a common pediatric surgical procedure with an estimated 80,000 operations performed each year. While prior work has reported the existence of racial disparities in postoperative outcomes, we sought to characterize potential income-based inequalities using a national cohort.

METHODS

All non-elective pediatric (<18 years) hospitalizations for appendectomy were tabulated in the 2016-2020 National Inpatient Sample. Only those in the highest (HI) and lowest income (LI) quartiles were considered for analysis. Multivariable regression models were developed to assess the independent association of income and postoperative major adverse events (MAE).

RESULTS

Of an estimated 87,830 patients, 36,845 (42.0%) were HI and 50,985 (58.0%) were LI. On average, LI patients were younger (11 [7-14] vs 12 [8-15] years, P < .001), more frequently insured by Medicaid (70.7 vs 27.3%, P < .05), and more commonly of Hispanic ethnicity (50.8 vs 23.4%, P < .001). Following risk adjustment, the LI cohort was associated with greater odds of MAE (adjusted odds ratio [AOR] 1.30 95% confidence interval [CI] 1.06-1.64). Specifically, low-income status was linked with increased odds of infectious (AOR 1.65, 95% CI 1.12-2.42) and respiratory (AOR 1.67, 95% CI 1.06-2.62) complications. Further, LI was associated with a $1670 decrement in costs ([2220-$1120]) and a +.32-day increase in duration of stay (95% CI [.21-.44]).

CONCLUSION

Pediatric patients of the lowest income quartile faced increased risk of major adverse events following appendectomy compared to those of highest income. Novel risk stratification methods and standardized care pathways are needed to ameliorate socioeconomic disparities in postoperative outcomes.

Pre-hospital management and patient-related factors affecting access to the surgical care of appendicitis - a survey study

BACKGROUND AND AIMS

Long pre-hospital delay substantially increases the likelihood of perforated appendicitis. This study aimed to find patient-related factors affecting this delay.

METHODS

A survey was conducted for patients with acute appendicitis after appendectomy. The participants were asked about their path to the surgical center and socioeconomic status. Variables affecting delays and the rate of complicated appendicitis were analyzed.

RESULTS

The study included 510 patients; 157 (31%) had complicated appendicitis with a median prehospital delay of 42 h. In patients with uncomplicated appendicitis, the delay was 21 h, p < .001. Forty-six (29%) patients with complicated appendicitis were not referred to the hospital after the first doctor's visit. The multivariate analysis discovered factors associated with long pre-hospital delay: age 40-64 years (OR 1.63 (95% CI 1.06-2.52); compared to age 18-39), age more than 64 years (OR 2.84 (95% CI 1.18-6.80); compared to age 18-39), loss of appetite (OR 2.86 (95% CI 1.64-4.98)), fever (OR 1.66 (95% CI 1.08-2.57)), non-referral by helpline nurse (OR 2.02 (95% CI 1.15-3.53)) and non-referral at first doctors visit (OR 2.16 (95% CI 1.32-3.53)). Age 40-64 years (OR 2.41 (95% CI 1.50-3.88)), age more than 64 years (OR 8.79 (95% CI 2.19-35.36)), fever (OR 1.83 (95% CI 1.15-2.89)) and non-referral at first doctors visit (OR 1.90 (95% CI 1.14-3.14)) were also risk factors for complicated appendicitis.

CONCLUSIONS

Advanced age, fever and failure to suspect acute appendicitis in primary care are associated with prolonged pre-hospital delay and complicated appendicitis.

Characterizing Inequities in Pediatric Appendicitis Delayed Diagnosis and Perforation

Objective

We sought to characterize the impact of a child's sociodemographic characteristics on their odds of delayed diagnosis and perforation in pediatric appendicitis.

Study design

We performed a single-center, retrospective cohort study of all pediatric appendicitis admissions between 2016 and 2021. Using a multivariable model, we evaluated for associations between delayed diagnosis and perforation and a child's sociodemographic characteristics, including their age, sex, race and ethnicity, insurance status, and their home census-tract Material Community Deprivation Index value.

Results

The study included 3248 patients. The median age was 12.1 years (IQR 9.5-14.9 years). Most patients were male (60.3%), identified as non-Hispanic White (78.0%), and had private insurance (55.4%). The delayed diagnosis and perforation rates were 6.4% and 25.1%, respectively. Delayed diagnosis cases had a greater perforation rate (56% compared with 21.5%, P < .001). On adjusted analysis, older age decreased the odds (OR 0.91, CI 0.87-0.94) of delayed diagnosis, whereas female sex (OR 1.50, CI 1.13-2.00) and socioeconomic disadvantage (OR 1.56 for quartile 4 vs quartile 1, CI 1.00-2.43) increased the odds. Furthermore, older age (OR 0.91, CI 0.89-0.93) decreased the odds of perforation, whereas non-Hispanic Black (OR 1.72, CI 1.3-2.29) or Hispanic (OR 1.60, CI 1.24-2.08) compared with non-Hispanic White identification and socioeconomic disadvantage (OR 1.43 Q4 vs Q1, CI 1.12-1.83) increased the odds.

Conclusions

Our reported delayed diagnosis rate is greater than recent literature, highlighting the need to consider visits that occur across different health care settings. We further identify sociodemographic factors, including socioeconomic status, that impact a child's risk of delayed diagnosis and perforation.

Association of social determinants of health International Classification of Disease, Tenth Edition clinical modification codes with outcomes for emergency general surgery and trauma admissions

BACKGROUND

Patients with Acute Care Surgery needs (ie, emergency general surgery diagnosis or trauma admission) are at particularly high risk for nonmedical patient-related factors that can be important drivers of healthcare outcomes. These social determinants of health are typically ascertained at the geographic area level (ie, county or neighborhood) rather than at the individual patient level. Recently, the International Classification of Diseases Tenth Revision, Tenth Edition created codes to capture health hazards related to patient socioeconomic and psychosocial circumstances. We sought to characterize the impact of these social determinants of health-related codes on perioperative outcomes among patients with acute care surgery needs.

METHODS

Patients diagnosed between 2017 and 2020 with acute care surgery needs (ie, emergency general surgery diagnosis or a trauma admission) were identified in the California Department of Healthcare Access and information Patient Discharge database. Data on concomitant social determinants of health-related codes (International Classification of Diseases Tenth Revision, Tenth Edition Z55-Z65), which designated health hazards related to socioeconomic and psychosocial (socioeconomic and psychosocial, respectively) circumstances, were obtained. After controlling for patient factors, including age, sex, race, payer type, and admitting hospital, the association of socioeconomic and psychosocial codes with perioperative outcomes and hospital disposition was analyzed.

RESULTS

Among 483,280 with an acute care surgery admission (emergency general surgery: n = 289,530, 59.9%; trauma: n = 193,705, 40.1%) mean age was 56.5 years (standard deviation: 21.5) and 271,911 (56.3%) individuals were male. Overall, 16,263 (3.4%) patients had a concomitant socioeconomic and psychosocial diagnosis code. The percentage of patients with a concurrent social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis increased throughout the study period from 2.6% in 2017 to 4.4% in 2020. Patients that were male (odds ratio 1.89; 95% confidence interval 1.82, 1.96), insured by Medicaid (odds ratio 5.43; 95% confidence interval 5.15, 5.72) or self-pay (odds ratio 3.04; 95% confidence interval 2.75, 3.36) all had higher odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. Black race did not have a significant association with an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis (odds ratio 0.99; 95% confidence interval 0.94, 1.04); however, Hispanic (odds ratio 0.44; 95% confidence interval 0.43, 0.46) and Asian (odds ratio 0.40; 95% confidence interval 0.36, 0.44) race/ethnicity was associated with a lower odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. After controlling for competing risk factors on multivariable analyses, the risk-adjusted probability of hospital postoperative death was 3.1% (95% confidence interval 2.8, 3.4) among patients with a social determinants of health diagnosis versus 5.9% (95% confidence interval 5.9, 6.0) (odds ratio 0.48; 95% confidence interval 0.44, 0.54) among patients without a social determinants of health diagnosis. Risk-adjusted complications were 26.7% (95% confidence interval 26.1, 37.3) among patients with a social determinants of health diagnosis compared with 31.9% (95% confidence interval 31.7, 32.0) (odds ratio 0.74; 95% confidence interval 0.71, 0.77) among patients without a social determinants of health diagnosis.

CONCLUSION

International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code use was low, with only 3.4% of patients having documentation of a socioeconomic and psychosocial circumstance. The presence of an International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code was not associated with greater odds of complications or death; however, it was associated with longer length of stay and higher odds of being discharged to a skilled nursing facility.

Gender specific data in patients with acute appendicitis: a single center perspective

BACKGROUND

The influence of sex, socioeconomic status, and other factors on outcomes from acute illness has been found recently with an increasing interest; acute appendicitis is the most frequent urgency in pediatric age. The aim of this study was to show any gender differences.

METHODS

We retrospectively analyzed the medical records of consecutive patients who underwent surgical exploration for acute appendicitis. Inclusion and exclusion criteria were created. Patient data, demographics, characteristics, and outcomes were studied and evaluated on a gender perspective.

RESULTS

After reviewing medical charts following the inclusion and exclusion criteria, 364 patients were studied; focusing on final outcomes, it was possible to add news from a gender perspective of appendicitis: gangrenous appendicitis was associated with younger female and older female were more likely to have false positive appendicitis; female had less postoperative pain respect to age-match male for all appendicitis and males had more symptoms respect to females especially for phlegmonous and gangrenous appendicitis.

CONCLUSIONS

There is a gender difference in appendicitis; as for adult girls appear to be affected less, have fewer symptoms, and have better postoperative results.

Association of ICD-10 Clinical Modification Codes for Social Determinants of Health with Surgical Outcomes and Hospital Charges Among Cancer Patients

INTRODUCTION

We sought to characterize the impact of social determinants of health (SDOH)-related codes on outcomes among patients with a cancer diagnosis.

METHODS

Patients diagnosed with lung, pancreas, colon, or rectal cancer between 2017 and 2020 were identified in the California Department of Healthcare Access and Information Patient Discharge Database. Data on concomitant SDOH-related codes (International Classification of Diseases, Tenth Revision [ICD-10] Z55-Z65) designating health hazards related to socioeconomic and psychosocial circumstances were obtained. The association of these SDOH codes with postoperative outcomes was evaluated.

RESULTS

Among 10,421 patients who underwent an operation from 2017 to 2020, median age was 66 years (interquartile range [IQR] 56-75) and nearly half of the cohort was male (n = 551,252.9%). In total, 102 (1%) patients had a concurrent ICD-10 SDOH diagnosis. After controlling for competing risk factors, the risk-adjusted probability of in-hospital death was 4.1% (95% confidence interval [CI] 1.0-7.2) among patients with an SDOH diagnosis compared with 2.9% (95% CI 2.5-3.2) among patients without an SDOH diagnosis (odds ratio [OR] 1.52, 95% CI 0.63-3.66; p = 0.258); postoperative complications were 27.0% (95% CI 20.0-34.1) compared with 24.9% (95% CI 24.1-25.6) among patients without an SDOH diagnosis (OR 1.15, 95% CI 0.73-1.82; p = 0.141), and length of stay was 10.6 days (95% CI 10.0-11.2) compared with 9.4 days (95% CI 9.3-9.5) among patients without an SDOH diagnosis. Patients with an SDOH diagnosis had a 5.19 (95% CI 3.23-8.34; p < 0.005) higher odds of being discharged to a skilled nursing facility versus patients without an SDOH diagnosis.

CONCLUSION

Uptake and utilization of ICD-10 SDOH was 1% among California patients with lung, pancreas, colon, or rectal cancer. Patients with a concomitant ICD-10 SDOH code had longer length of stay and had higher odds of being discharged to a skilled nursing facility.

Addressing health equity in pediatric surgical care in the United States- Progress and challenges

There are notable inequities in health outcomes for children based on their social determinants of health (SDOH), including where they are born and live, their primary language, their race and ethnicity, socioeconomic status, and more. These health inequities are not restricted to resource limited settings; here we highlight three broad topics that are relevant to pediatric surgeons in the United States (US): access to care and disparities, and examples of inequities in firearm-related injuries and appendicitis. Most of our patients will at some point require operative interventions, yet there can be significant challenges in accessing this care and navigating our health systems, particularly around complex perioperative care. There are significant opportunities to improve equitable care by helping patients navigate our health systems and connecting them with additional resources, including screening for primary care services. Firearm-related injuries are now the leading cause of death in children in the US, with significant associated morbidity for non-fatal injuries. There are notable inequities in the risk of injury and types of injuries experienced by children based on their SDOH. Appendicitis is one of the most common pathologies managed by pediatric surgeons, with similar inequities in the rates of perforated appendicitis based on a child's SDOH. For both issues, addressing the inequities our patients experience requires moving upstream and working towards prevention. Key opportunities include better research and data to understand the drivers for observed inequities, multidisciplinary collaboration, community engagement, and public health advocacy among others. As a profession, we have a responsibility to work to address the health inequities our patients experience.

Analysis of risk factors for complicated appendicitis during pregnancy and evaluation of clinical prediction model: A prospective cohort study

OBJECTIVE

To investigate the risk factors and the value of clinical prediction model for complicated appendicitis (CA) during pregnancy.

METHODS

Prospective analysis of pregnant patients who underwent appendectomy at a single tertiary care center between February 2020 and February 2023 and who ultimately had pathologically confirmed acute appendicitis (AA). According to intraoperative conditions and postoperative pathology, they were divided into the CA group and the uncomplicated appendicitis (UA) group. The two groups of patients were then compared in terms of demographic characteristics, disease features, ancillary tests and predictive models of acute appendicitis.

RESULTS

A total of 90 patients with AA in pregnancy were included, 21 of whom had CA in pregnancy and 69 had UA in pregnancy. Multivariate regression analysis showed that gestational week, neutrophil ratio and C-reactive protein (CRP) were independent risk factors for CA during pregnancy. Relative to the first trimester, the third trimesters had an increased risk of complicated appendicitis (OR = 12.48, 95% CI: 1.56-99.57, P = 0.017). Neutrophil ratio ≥85.30% (OR = 24.54, 95% CI: 2.59-232.72, P = 0.005) and CRP ≥34.26 mg/L (OR = 7.86, 95% CI: 2.18-28.38, P = 0.002) had a significantly increased risk of CA. The AIR and AAS score models were statistically different between the two groups, but with a lower sensitivity of 52.38% and 42.86%, respectively.

CONCLUSION

The third trimesters, neutrophil ratio ≥85.30% and CRP ≥34.26 mg/L may be key predictors of CA in pregnancy. The current scoring model is inadequate to identify complex appendicitis in pregnancy and further research is needed.

Acute Appendicitis with Appendicolith and its Complication and Management: A Case Report

Acute appendicitis is a common cause of acute abdominal pain requiring urgent surgery. Despite characteristic clinical signs, diagnosis can be challenging, leading to unnecessary appendectomies. This case report focuses on a 34-year-old male with escalating right lower quadrant abdominal pain. Imaging revealed acute appendicitis with a substantial appendicolith. Surgical intervention involved a open appendectomy with possible ileocecal resection due to cecal inflamation. Surgical findings indicated successful resection, and the patient recovered without complications. While urgent appendectomy is the norm, conservative approaches are gaining traction for peri-appendiceal abscesses. Interval appendectomy post-conservative treatment is a debated strategy. Management decisions are influenced by patient factors and disease severity. Future research is needed to establish standardized treatment protocols for complicated appendicitis. The case illustrates the evolving landscape of acute appendicitis management.

Development of a nomogram for the prediction of complicated appendicitis during pregnancy

BACKGROUND

Complicated appendicitis during pregnancy directly affects the clinical prognosis of both mother and fetus. However, accurate identification of complicated appendicitis in pregnancy is fraught with various challenges. The purpose of this study was to identify the risk factors and to develop a useful nomogram to predict complicated appendicitis during pregnancy.

METHODS

This retrospective study involved pregnant women who underwent appendectomy at the Maternal and Child Health Hospital of Hubei Provincial from May 2016 to May 2022 and who ultimately had histopathological confirmed acute appendicitis. Univariate and multivariate logistic regression were applied to analyze clinical parameters and imaging features as a way to identify risk factors. Then, nomogram and scoring systems predicting complicated appendicitis in pregnancy were constructed and evaluated. Finally, the potential non-linear association between risk factors and complicated appendicitis was analyzed using restricted cubic splines.

RESULTS

Three indicators were finally identified for the construction of the nomogram: gestational weeks, C-reactive protein (CRP), and neutrophil percentage (NEUT%). To improve the clinical utility, the gestational weeks were divided into three periods (first trimesters, second trimesters, and third trimesters), while the optimal cut-offs for CRP level and NEUT% were found to be 34.82 mg/L and 85.35%, respectively. Multivariate regression analysis showed that third trimesters (P = 0.013, OR = 16.81), CRP level ≥ 34.82 mg/L (P = 0.007, OR = 6.24) and NEUT% ≥85.35% (P = 0.011, OR = 18.05) were independent risk factors for complicated appendicitis. The area under the ROC curve (AUC) of the nomogram predicting complicated appendicitis in pregnancy was 0.872 (95% CI: 0.803-0.942). In addition, the model was shown to have excellent predictive performance by plotting calibration plots, Decision Curve Analysis (DCA), and clinical impact curves. When the optimal cut-off point of the scoring system was set at 12, the corresponding AUC, sensitivity, specificity, Positive Likelihood Ratio (PLR), Negative Likelihood Ratio (NLR), Positive Predictive Value (PPV), and Negative Predictive Value (NPV) values were AUC: 0.869(95% CI: 0.799-0.939),100%, 58.60%, 2.41, 0, 42%, and 100%, respectively. The restricted cubic splines revealed a linear relationship between these predictors and complicated appendicitis during pregnancy.

CONCLUSIONS

The nomogram utilizes a minimum number of variables to develop an optimal predictive model. Using this model, the risk of developing complicated appendicitis in individual patients can be determined so that reasonable treatment choices can be made.

The intracorrelation of family health insurance and job lock

This paper tests for the presence of job lock and "health insurance plan lock" stemming from the health shock of a child family member. Using the onset of an acute, unanticipated health shock, I estimate a 7-14 percent decreased likelihood of all family members leaving their current health insurance network and health plan within one year of the emergency. This corresponds to a reduced one-year job mobility rate of approximately 13 percent for the health plan's primary policyholder. Furthermore, the non-portability of health insurance products may contribute to the observed job and health plan lock.

Impact of socioeconomic status and road distance to hospital on perforated appendicitis rates at a large rural referral centre

BACKGROUND

Socioeconomic status and distance from hospital have been shown to be associated with poor surgical outcomes related to acute appendicitis. Indigenous populations experience greater socioeconomic disadvantages and poorer healthcare access than their non-Indigenous counterparts. This study aims to determine whether socioeconomic status and road distance from hospital are predictors of perforated appendicitis. It will also compare surgical outcomes of appendicitis between Indigenous and non-Indigenous populations.

METHODS

We performed a 5-year retrospective study of all patients who underwent appendicectomy for acute appendicitis at a large rural referral centre. Patients were identified using the hospital database for theatre events coded as appendicectomy. Regression modelling was used to determine if socioeconomic status and road distance from hospital were associated with perforated appendicitis. The outcomes of appendicitis between Indigenous and non-Indigenous populations were compared.

RESULTS

Seven hundred and twenty-two patients were included in this study. The rate of perforated appendicitis was not significantly impacted by socioeconomic status (OR 0.993, 95% CI 0.98-1.006, P = 0.316) or road distance from hospital (OR = 0.911, 95% CI 0.999-1.001, P = 0.911). Indigenous patients did not have a significantly higher rate of perforation compared to non-Indigenous patients (P = 0.849) despite having overall lower socioeconomic status (P = 0.005) and longer road distance from hospital (P = 0.025).

CONCLUSION

Lower socioeconomic status and longer road distance from hospital were not associated with an increased risk of perforated appendicitis. Indigenous populations have poorer socioeconomic status and longer road distance to hospital but did not have higher rates of perforated appendicitis.

An Update on Acute Appendicitis in Lebanon: Insights From a Single-Center Retrospective Study

Background Acute appendicitis is the most common surgical emergency worldwide with scarce reports about its prevalence in the Middle East. To date, no epidemiological article has described the incidence of appendicitis in Lebanon. Our primary objective was to estimate the rate of appendicitis in a single center in Lebanon. Our secondary objectives included identifying differences between simple and complicated appendicitis regarding demographics, pre and postoperative characteristics, and symptoms and signs of appendicitis. Methodology A retrospective study was conducted at a single central university hospital in Lebanon. Patients with a clear diagnosis of acute appendicitis were included. Pregnant women, lactating women, patients with organ dysfunction, and patients younger than 18 years old or older than 80 years old were excluded. We reviewed and collected the data of patients who presented to the hospital between November 2018 and November 2019 and November 2020 and November 2021. Results A total of 95 patients were included in our study, with 35 women and 60 men. The mean body mass index of patients with simple appendicitis was 19.14 ± 9.66 kg/m² compared to 18.97 ± 10.37 kg/m² in patients with complicated appendicitis (p = 0.94). A total of 42.3% of patients who used antibiotics 24 hours after the operation had simple appendicitis, whereas 20.8% had complicated appendicitis (p = 0.004). Conclusions Antibiotic usage and the length of hospital stay were correlated with the severity of appendicitis, as reported in the literature. Further randomized studies with a larger number of patients and covering several hospitals in Lebanon are warranted.

An observational study on lifestyle and environmental risk factors in patients with acute appendicitis

Purpose

Acute appendicitis is a common abdominal emergency worldwide. This study aimed at characterizing environmental risk factors influencing the development and severity of acute appendicitis.

Methods

Patients from a Belgian acute appendicitis cohort (n = 374) and healthy controls from the 500 functional genomics (500FG) cohort (n = 513) were compared. Individuals with a history of appendectomy (n = 1067) and without a history of appendectomy (n = 8656) were available from the Nijmegen Biomedical Study (NBS). Questionnaires on demographics, lifestyle and environment were available. Binary logistic regression was used for prediction models.

Results

Fifteen risk factors for developing acute appendicitis were identified. Binary logistic regression showed that 7 were independent risk factors: family history of acute appendicitis, having grown up in a rural environment, having a lower education, probiotic use as well as antibiotic use increased the risk of developing appendicitis. Fruit and fiber-rich vegetable consumption decreased the risk. Findings on vegetable consumption, smoking and level of education were replicated in the NBS population. Independent risk factors for complicated appendicitis were being male, higher age, and a delay to diagnosis of more than 48 h.

Conclusions

Environmental exposures influence the risk of developing appendicitis. Further research into these factors is needed.

Impacts of short-term air pollution exposure on appendicitis admissions: Evidence from one of the most polluted cities in mainland China

Background

Emerging evidence indicates that air pollutants contribute to the development and progression of gastrointestinal diseases. However, there is scarce evidence of an association with appendicitis in mainland China.

Methods

In this study, Linfen city, one of the most polluted cities in mainland China, was selected as the study site to explore whether air pollutants could affect appendicitis admissions and to identify susceptible populations. Daily data on appendicitis admissions and three principal air pollutants, including inhalable particulate matter (PM10), nitrogen dioxide (NO2), and sulfur dioxide (SO2) were collected in Linfen, China. The impacts of air pollutants on appendicitis were studied by using a generalized additive model (GAM) combined with the quasi-Poisson function. Stratified analyses were also performed by sex, age, and season.

Results

We observed a positive association between air pollution and appendicitis admissions. For a 10 μg/m3 increase in pollutants at lag01, the corresponding relative risks (RRs) and 95% confidence intervals (95% CIs) were 1.0179 (1.0129–1.0230) for PM10, 1.0236 (1.0184–1.0288) for SO2, and 1.0979 (1.0704–1.1262) for NO2. Males and people aged 21–39 years were more susceptible to air pollutants. Regarding seasons, the effects seemed to be stronger during the cold season, but there was no statistically significant difference between the seasonal groups.

Conclusions

Our findings indicated that short-term air pollution exposure was significantly correlated with appendicitis admissions, and active air pollution interventions should be implemented to reduce appendicitis hospitalizations, especially for males and people aged 21–39 years.

The global, regional, and national burden of appendicitis in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Appendicitis is the most common abdominal surgical emergency worldwide, and its burden has been changing. We report the level and trends of appendicitis prevalence, and incidence; and years lived with disability (YLD) in 204 countries and territories from 1990 to 2019, based on data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

The numbers and age-standardized prevalence, incidence, and YLD rates per 100,000 population of appendicitis were estimated across regions and countries by age, sex, and sociodemographic index (SDI). All the estimates were reported with 95% uncertainty intervals (UIs).

RESULTS

Globally, the age-standardized prevalence and incidence rates of appendicitis in 2019 were 8.7 (95% UI 6.9 to 11.0) and 229.9 (95% UI 180.9 to 291.0) per 100,000 population, with increases of 20.8% (95% UI 18.9 to 23.0%) and 20.5% (95% UI 18.7 to 22.8%) from 1990 to 2019, respectively. Additionally, the age-standardized YLDs rate was 2.7 (95% UI 1.8 to 3.9) in 2019, with an increase of 20.4% (95% UI 16.2 to 25.1%) from 1990 to 2019. In 2019, the age-standardized prevalence, incidence, and YLD rates peaked in the 15-to-19-year age groups in both male and female individuals. However, no statistically significant differences were observed between the male and female individuals in all groups. Ethiopia, India, and Nigeria showed the largest increases in the age-standardized prevalence rate between 1990 and 2019. Generally, positive associations were found between the age-standardized YLD rates and SDI at the regional and national levels.

CONCLUSIONS

Appendicitis remains a major public health challenge globally. Increasing awareness of appendicitis and its risk factors and the importance of early diagnosis and treatment is warranted to reduce its the burden.

Acute appendicitis manifests as two microbiome state types with oral pathogens influencing severity

Mounting evidence suggests that acute appendicitis (AA) is not one but two diseases: complicated appendicitis, which is associated with necrosis leading to perforation or periappendicular abscess, and uncomplicated appendicitis, which does not necessarily result in perforation. Even though AA is the most frequent cause of surgery from abdominal pain, little is known about the origins and etiopathogenesis of this disease, much less regarding the different disease types. In this study, we investigated the microbiome (inter-domain amplicon and metagenome sequencing) of samples from the appendix, rectum and peritoneum of 60 children and adolescents with AA to assess the composition and potential function of bacteria, archaea and fungi. The analysis of the appendix microbial community revealed a shift depending on the severity of the AA. This shift was reflected by two major community state types that represented the complicated and uncomplicated cases. We could demonstrate that complicated, but not uncomplicated, appendicitis is associated with a significant local expansion of oral, bacterial pathogens in the appendix, most strongly influenced by necrotizing Fusobacterium spp., Porphyromonas and Parvimonas. Uncomplicated appendicitis, however, was characterized by gut-associated microbiomes. Our findings support the hypothesis that two disease types exist in AA, which cannot be distinguished beyond doubt using standard clinical characterization methods or by analysis of the patient's rectal microbiome. An advanced microbiome diagnosis, however, could improve non-surgical treatment of uncomplicated AA.

The Global Burden of Appendicitis in 204 Countries and Territories from 1990 to 2019

OBJECTIVE

Appendicitis is a common surgical emergency. This study aimed to estimate the worldwide burden and trends of appendicitis from 1990 to 2019.

METHODS

Data on appendicitis were derived from the Global Burden of Disease 2019. Incidence and disability-adjusted life-years (DALYs) data were analyzed at global, regional, and national levels and stratified by sex, age, and socio-demographic index. The estimated annual percentage change and relative change were used to assess changing trends. Pearson's correlation test was used to assess the correlation between different measures.

RESULTS

Global incidence grew by 63.55% between 1990 and 2019, age-standardized incidence rate climbed by an estimated percentage change of 0.58 per year, whereas the number of DALY declined by 31.93% during the same period, with an estimated annual percentage change of -2.77. In 2019, the areas of Andean Latin America and the Caribbean had the highest age-standardized rates of incidence and DALYs. While South Asia saw the largest increase in age-standardized incidence rates, Andean Latin America saw the biggest decline in age-standardized rates of incidence and DALYs. At the national level, Bangladesh, Bhutan, and Peru were the top three countries in terms of age-standardized incidence rates in 2019, and Honduras, Haiti, and the Central African Republic held the highest age-standardized DALY rates. Ethiopia experienced the most age-standardized incidence rate increase, and Peru saw the largest decline in age-standardized rate of incidence and DALYs. Significant negative correlations between age-standardized DALY rates and socio-demographic index, between estimated annual percentage change and age-standardized incidence rates, were observed at the national level.

CONCLUSION

Appendicitis remains a major global health concern. Although the trends in DALYs decreased, the burden of incidence increased from 1990 to 2019. Policymakers should create health policies adapted to local conditions to manage the burden of appendicitis globally.

A novel Appendicitis TriMOdal prediction Score (ATMOS) for acute appendicitis in pregnancy: a retrospective observational study

Several scoring systems exist for the management of acute appendicitis (AA) during pregnancy. However, the systems are based on the nonpregnant adult population. The aim of this study was to create a highly accurate scoring system that can be applied to pregnant women and to compare it to the most commonly used scores in general population and pregnant women. The creation and subsequent implementation of a highly accurate score system could shorten the diagnostic period and minimize the use of (ionizing) diagnostic imaging allowing the selection of the best treatment approach in pregnant patients with acute appendicitis. A single-center, retrospective cohort observational study was conducted at the University Hospital Centre Zagreb, Zagreb, Croatia. Data were extracted from medical records of pregnant patients with suspected AA from January 2010 to December 2020. A total of 59 pregnant patients diagnosed with AA during pregnancy were identified, 41 were treated surgically, and 18 had non-surgical management. The main objective of our study was the detection of predictive factors of AA during pregnancy. Anorexia, pain migration to the right lower quadrant, rebound pain, axillary temperature over 37.3 °C, CRP/platelet ratio > 0.0422, neutrophil/lymphocyte ratio > 7.182, and ultrasonic signs of AA were scored. Scoring in Appendicitis TriMOdal Score (ATMOS) consists of positive clinical parameter, each bringing 1 point and other parameters mentioned above that bring 2 points each. The score ranges from 0 to 10. Our model of ATMOS yields a high area under the receiver-operating characteristic curve of 0.963. The positive likelihood ratio is 9.97 (95% CI 2.64-38.00), and the negative likelihood ratio is 0.1 (95% CI 0.03-0.31), meaning that 94% of cases with ATMOS > 4 have AA, while less than 13% with an ATMOS ≤ 4 have the diagnosis of AA. The potential of ATMOS differentiating AA during pregnancy was demonstrated. Future prospective, randomized trials are needed to evaluate its accuracy and whether it should be used instead of Alvarado or Tzanakis scores in clinical decision-making.Trial registration number ClinicalTrials.gov-NCT05202483. Date of registration: January 21, 2022.

＜Editors' Choice＞ Advantages of gasless single-port transumbilical extracorporeal laparoscopic-assisted appendectomy in the treatment of uncomplicated acute appendicitis in children in China: a multi-institutional retrospective study

Gasless transumbilical extracorporeal laparoscopic-assisted appendectomy is an approach used increasingly to treat uncomplicated acute appendicitis (UAA). However, there is limited information on its clinical effects and value in the Chinese pediatric population. This study retrospectively reviewed patients with UAA treated in two pediatric institutions from January 2018 through October 2021. Enrolled patients were divided into two groups by operative technique: gasless transumbilical laparoscopic-assisted appendectomy (gasless-TULAA, n=142) and conventional laparoscopic appendectomy (CLA, three-port, n=126). The perioperative clinical data, including age, sex, body mass index (BMI), operation time, time to postoperative ambulation, time to first postoperative exhaust, hospitalization expenses, and postoperative complications (incision infection, intestinal obstruction, and residual abdominal abscess), were compared between the two groups. Operations in both groups were successfully conducted without converting to open surgery. There were no significant differences (p > 0.05) in age and BMI in the two groups. Compared with CLA, gasless-TULAA showed significantly shorter operation time, earlier postoperative ambulation, shorter postoperative exhaust time, and lower hospital cost (p < 0.001). All patients were followed for 3 months, and postoperative complications were observed in three patients: two patients in the gasless-TULAA group (one with surgical wound effusion, one with intra-abdominal abscess), and one patient in the CLA group (surgical wound infection); there was no significant difference between the groups. Notably, 38 patients initially treated by gasless-TULAA were converted because of intraoperative factors. The gasless-TULAA technique had potential benefits: shortened operation time, better outcome, and greater cost-efficiency. These superiorities are worthy of future large-scale prospective study.

Clinical, Radiological and Pathological Appraisal of Acute Appendicitis in Al Qassim, Saudi Arabia: A Single-Center Retrospective Analysis

Background

Acute appendicitis can occur at any age but is rare among people of extreme age; it is more common in teenagers and young adults. Traditionally diagnosis is made on clinical grounds. In recent times imaging techniques have been deployed to improve diagnosis and reduce negative appendicectomy rates. The aim of the study was to describe the common clinical features of acute appendicitis among our patients, highlight the role of medical imaging, and compare all these with the histological report of the excised appendix.

Methods

A 24-months retrospective review of all patients who underwent appendicectomy (July 1, 2019-June 30, 2021) for suspected acute appendicitis was performed. Medical records numbers of patients who had appendicectomies were retrieved from the operating room register. These numbers were used to access the hospital's electronic medical records database for the patients' records. These records were reviewed for biodata, clinical features, laboratory, medical imaging findings, and histological reports.

Result

In this hospital, 354 appendicectomies were performed. Only 336 had complete data set suitable for further review. There were more males (N=257; 76.5%) than females (N=79, 23.5%), yielding a male to female ratio of 4:1. There were also more Saudi citizens (n=266, 79.2%), with the predominant age group being 11-30 years. Abdominal pain was the predominant symptom (100%) and was localized to the right iliac region in 331 (98.7%) of patients. Other symptoms recorded were anorexia (n=247, 73.5%), vomiting (n=190, 56.5%), and nausea (n=93, 27.7%). Atypical symptoms included diarrhoea (n=27, 8%) and constipation (n=12, 3.6%). Acute appendicitis, complicated appendicitis, and no appendicitis were the reported histological disposition in 174 (51.8%), 124 (36.9%), and 38 (11.3%) cases respectively. Abdominal CT scan had a higher sensitivity (98.6% vs 70.5%), higher diagnostic odd ratio (2.5 vs 1.4) and a lower miss (false negative) rate (1.4% vs 29.5%) compared to ultrasonography. However, the CT scan, from this study, has a rather low specificity (3.4%) and high false positive rates (96.5%). Open (n=205; 61%) and laparoscopic (n=131;39%) approaches were used for the appendicectomies. In our study, 44 patients were diagnosed with the decision to operate based on clinical grounds; and of this, 42 (95.4%; n=44) had confirmatory histology reports of appendicitis. Also, 38 patients had negative appendicectomy; giving a negative appendicectomy rate of 11.3%. This high rate may be due to the lower specificity and high false positive rate observed in this study. The post-operative complication rate was 21.4%, and this was solely due to surgical site infection, and this was more common with the open approach (p=0.001).

Conclusion

Suspected acute appendicitis was the sole indication for our appendicectomies. A computerized tomography scan was a more reliable diagnostic tool than ultrasonography. Despite the fact that acute appendicitis is majorly a clinical diagnosis, and good clinical acumen is an excellent skill in the management of patients, we observed an overreliance on medical imaging for diagnosis. Open appendicectomies were more common, and surgical site infection was the sole complication of surgery. There was a relatively high negative appendicectomy rate for an image-assisted diagnosis.

Spatial Heterogeneity and Its Influencing Factors of Syphilis in Ningxia, Northwest China, from 2004 to 2017: A Spatial Analysis

Syphilis remains a growing and resurging infectious disease in China. However, exploring the influence of environmental factors on the spatiotemporal distribution of syphilis remains under explore. This study aims to analyze the spatiotemporal distribution characteristics of syphilis in Ningxia, Northwest China, and its potential environmental influencing factors. Based on the standardized incidence ratio of syphilis for 22 administrative areas in Ningxia from 2004 to 2017, spatiotemporal autocorrelation and scan analyses were employed to analyze the spatial and temporal distribution characteristics of syphilis incidence, while a fixed-effect spatial panel regression model identified the potential factors affecting syphilis incidence. Syphilis incidence increased from 3.78/100,000 in 2004 to 54.69/100,000 in 2017 with significant spatial clustering in 2007 and 2009-2013. The "high-high" and "low-low" clusters were mainly distributed in northern and southern Ningxia, respectively. The spatial error panel model demonstrated that the syphilis incidence may be positively correlated with the per capita GDP and tertiary industry GDP and negatively correlated with the number of health facilities and healthcare personnel. Sex ratio and meteorological factors were not significantly associated with syphilis incidence. These results show that the syphilis incidence in Ningxia is still increasing and has significant spatial distribution differences and clustering. Socio-economic and health-resource factors could affect the incidence; therefore, strengthening syphilis surveillance of migrants in the economically developed region and allocating health resources to economically underdeveloped areas may effectively help prevent and control syphilis outbreaks in high-risk cluster areas of Ningxia.

Caveat emptor: The accuracy of claims data in appendicitis research

BACKGROUND

International Classification of Disease, ninth/tenth revision codes are used to identify patients with appendicitis and classify severity of disease for research and hospital reimbursement. We sought to determine accuracy of International Classification of Disease, ninth/tenth revision codes in classifying appendicitis as uncomplicated versus complicated (defined as perforated, necrotic, or abscess) compared with the clinical gold standard: surgeon characterization of the appendix in the operative report.

METHODS

Retrospective review of operative reports and discharge International Classification of Disease, ninth/tenth revision codes for patients ≥18 years old who underwent noninterval, nonincidental appendectomy between January 2012 and December 2019 at a tertiary referral center. Sensitivity, specificity, and positive predictive value were calculated for International Classification of Disease, ninth/tenth revision codes to classify appendicitis accurately as complicated compared with surgeon description. ICD-9/10 codes and surgeon description were categorized into complicated/uncomplicated based on the American Association for the Surgery of Trauma grading system.

RESULTS

In the study, 1,495 patients with acute appendicitis underwent appendectomy. Per surgeon description, 200 (13%) were complicated and 1,295 (87%) uncomplicated. Compared with surgeon description, discharge International Classification of Disease, ninth/tenth revision codes did not accurately identify complicated appendicitis: sensitivity = 0.68, positive predictive value = 0.77. As a sensitivity analysis, the cohort was stratified by public versus private payers, and the results did not change.

CONCLUSION

International Classification of Disease, ninth/tenth revision codes do not accurately identify surgeon-described complicated appendicitis. Nearly one-third of the cases of complicated appendicitis were coded as uncomplicated. Such misclassification negatively impacts reimbursement for complicated appendicitis care and could lead to misleading results in research and quality improvement activities that rely on these codes.

The Role of Alvarado Score in Predicting Acute Appendicitis and Its Severity in Correlation to Histopathology: A Retrospective Study in a Qatar Population

Background/objective

Acute appendicitis (AA) is one of the most common surgical emergencies that require a proper diagnosis to avoid a negative outcome in the case of missed or delayed diagnosis. Our study aims to assess the diagnostic power of the Alvarado score and the prediction of the severity of acute appendicitis in correlation to intraoperative findings and the final histopathology (HP) result.

Methods

This retrospective study was applied to 1,303 patients with clinically proven acute appendicitis (AA) and available HP results. We correlated Alvarado score to the gold standard HP and intraoperative findings. We selected the cutoff point of Alvarado at 5 and 7 as they were the most frequent cutoff value mentioned in the literature and based on the ROC curve in this study to assess sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

Results

The mean age of the study cohort is 33.3 ± 9.5 years, with a male predominance (75.8%). The negative appendectomy (NA) rate was 4%. The operative complication rate was 1.2%, and we recorded one mortality case (0.1%). The diagnostic evidence of AA was in 95.9% of cases. Alvarado score ≥ 7 presented sensitivity and specificity of 66.4% and 69.8%, respectively, with PPV of 98.1% and NPV of 8.1%, with an accuracy of 66.5%. For Alvarado score ≥ 5, the sensitivity was 91.2%, specificity was 22.6%, PPV was 96.5%, NPV was 9.8%, and accuracy was 88.4%. In addition, we demonstrated statistical significance between Alvarado risk stratification with HP and intraoperative grades (p = 0.001 each).

Conclusion

The Alvarado scoring system alone is not enough to diagnose AA with unsatisfactory sensitivity and specificity. However, it is a good indicator of the severity of AA that we can depend on to prioritize those patients waiting for surgery.

Social Vulnerability and Appendicitis: Single-Institution Study in a High Insurance State

INTRODUCTION

Multiple factors signifying higher social vulnerability, including lower socioeconomic status and minority race, have been associated with presentation with complicated appendicitis (CA). In this study, we compared the Social Vulnerability Index (SVI) of our population by appendicitis severity (uncomplicated appendicitis [UA] versus CA). We hypothesized that SVI would be similar between patients with UA and CA presenting to our institution, a safety-net hospital in a state with high healthcare insurance coverage.

METHODS

We included all patients at our hospital aged 18 y and older who underwent appendectomy for acute appendicitis between 2012 and 2016. SVI values were determined based on the 2010 census data using ArcMap software. We used nonparametric univariate statistics to compare the SVI of patients with CA versus UA and multivariable regression to model the likelihood of operative CA.

RESULTS

A total of 997 patients met inclusion criteria, of which 177 had CA. The median composite SVI score for patients with CA was lower than for patients with UA (80% versus 83%, P = 0.004). UA was associated with higher socioeconomic (83% versus 80%, P = 0.007), household/disability (68% versus 55%, P = 0.037), and minority/language SVI scores (91% versus 89%, P = 0.037). On multivariable analysis controlling for age, sex, ethnicity, insurance status, relevant comorbidities, and chronicity of symptoms, there was an inverse association between SVI and the likelihood of CA (odds ratio 0.59, 95% confidence interval 0.4-0.87, P = 0.008).

CONCLUSIONS

In the setting of high healthcare insurance and a medical center experienced in caring for vulnerable populations, patients presenting with UA have a higher composite SVI, and thus greater social vulnerability, than patients presenting with CA.

The appendix‐mucosal immunity and tolerance in the gut: consequences for the syndromes of appendicitis and its epidemiology

The cause of appendicitis is unknown. A review is presented across diverse sources relating to the biology of the appendix and its perturbations. A mechanistic model of the function of the appendix is presented, and its application to the syndromes and consequences of appendicitis is described.

Appendicitis in Far North Queensland: a new take on an old story

BACKGROUND

Appendicitis is a leading cause of surgical hospital admission. To date, there have been no published epidemiological studies describing appendicitis in tropical and remote Australia and none specifically documenting appendicitis in Indigenous Australians. This descriptive study used available state data to investigate appendicitis across Far North Queensland (FNQ).

METHODS

Queensland Health hospital admission data for FNQ was analysed to explore appendicitis epidemiology and outcomes in FNQ, 2012-2018. Population data for the same time period provided rates.

RESULTS

Over the study period, 3458 hospital presentations for appendicitis were available for analysis. Mean incidence was 178 per 100 000/yr. Median age was 27 years with 50.1% female patients. The annual rate of appendicitis was higher in the Indigenous population. Most patients had a laparoscopic procedure with a low rate of conversion to open surgery (2.6%). More than 80% of patients were discharged from hospital in less than 3 days. Intensive care (ICU) admission rate was low overall (1.1%) although higher for Indigenous people (2.4%). Following discharge, the hospital re-admission rate was 3.8% and all-cause mortality was 0.03%.

CONCLUSION

The incidence of appendicitis in FNQ is higher than that reported in the rest of Australia in both Indigenous and non-Indigenous populations. Despite logistical challenges of health care, clinical outcomes are in line with best practice across the country. Clinicians in FNQ should maintain a high index of suspicion for diagnosing appendicitis in rural and remote settings.

Diagnosis and Management of Acute Appendicitis in Adults: A Review

IMPORTANCE

Acute appendicitis is the most common abdominal surgical emergency in the world, with an annual incidence of 96.5 to 100 cases per 100 000 adults.

OBSERVATIONS

The clinical diagnosis of acute appendicitis is based on history and physical, laboratory evaluation, and imaging. Classic symptoms of appendicitis include vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever. The diagnosis of acute appendicitis is made in approximately 90% of patients presenting with these symptoms. Laparoscopic appendectomy remains the most common treatment. However, increasing evidence suggests that broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, successfully treats uncomplicated acute appendicitis in approximately 70% of patients. Specific imaging findings on computed tomography (CT), such as appendiceal dilatation (appendiceal diameter ≥7 mm), or presence of appendicoliths, defined as the conglomeration of feces in the appendiceal lumen, identify patients for whom an antibiotics-first management strategy is more likely to fail. CT findings of appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with higher risk of treatment failure (≈40%) of an antibiotics-first approach. Therefore, surgical management should be recommended in patients with CT findings of appendicolith, mass effect, or a dilated appendix who are fit for surgery, defined as having relatively low risk of adverse outcomes or postoperative mortality and morbidity. In patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy. In unfit patients without these high-risk CT findings, the antibiotics-first approach is recommended, and surgery may be considered if antibiotic treatment fails. In unfit patients with high-risk CT findings, perioperative risk assessment as well as patient preferences should be considered.

CONCLUSIONS AND RELEVANCE

Acute appendicitis affects 96.5 to 100 people per 100 000 adults per year worldwide. Appendectomy remains first-line therapy for acute appendicitis, but treatment with antibiotics rather than surgery is appropriate in selected patients with uncomplicated appendicitis.

Abdominal drainage to prevent intra-peritoneal abscess after appendectomy for complicated appendicitis

BACKGROUND

This is the second update of a Cochrane Review first published in 2015 and last updated in 2018. Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. Patients who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer postoperative complications. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial.

OBJECTIVES

To assess the safety and efficacy of abdominal drainage to prevent intraperitoneal abscess after appendectomy (irrespective of open or laparoscopic) for complicated appendicitis; to compare the effects of different types of surgical drains; and to evaluate the optimal time for drain removal.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, Web of Science, the World Health Organization International Trials Registry Platform, ClinicalTrials.gov, Chinese Biomedical Literature Database, and three trials registers on 24 February 2020, together with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared abdominal drainage versus no drainage in people undergoing emergency open or laparoscopic appendectomy for complicated appendicitis. We also included RCTs that compared different types of drains and different schedules for drain removal in people undergoing appendectomy for complicated appendicitis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We used the GRADE approach to assess evidence certainty. We included intraperitoneal abscess as the primary outcome. Secondary outcomes were wound infection, morbidity, mortality, hospital stay, hospital costs, pain, and quality of life.

MAIN RESULTS

Use of drain versus no drain We included six RCTs (521 participants) comparing abdominal drainage and no drainage in participants undergoing emergency open appendectomy for complicated appendicitis. The studies were conducted in North America, Asia, and Africa. The majority of participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open appendectomy. None of the trials was assessed as at low risk of bias. The evidence is very uncertain regarding the effects of abdominal drainage versus no drainage on intraperitoneal abscess at 30 days (risk ratio (RR) 1.23, 95% confidence interval (CI) 0.47 to 3.21; 5 RCTs; 453 participants; very low-certainty evidence) or wound infection at 30 days (RR 2.01, 95% CI 0.88 to 4.56; 5 RCTs; 478 participants; very low-certainty evidence). There were seven deaths in the drainage group (N = 183) compared to one in the no-drainage group (N = 180), equating to an increase in the risk of 30-day mortality from 0.6% to 2.7% (Peto odds ratio 4.88, 95% CI 1.18 to 20.09; 4 RCTs; 363 participants; low-certainty evidence). Abdominal drainage may increase 30-day overall complication rate (morbidity; RR 6.67, 95% CI 2.13 to 20.87; 1 RCT; 90 participants; low-certainty evidence) and hospital stay by 2.17 days (95% CI 1.76 to 2.58; 3 RCTs; 298 participants; low-certainty evidence) compared to no drainage. The outcomes hospital costs, pain, and quality of life were not reported in any of the included studies. There were no RCTs comparing the use of drain versus no drain in participants undergoing emergency laparoscopic appendectomy for complicated appendicitis. Open drain versus closed drain There were no RCTs comparing open drain versus closed drain for complicated appendicitis. Early versus late drain removal There were no RCTs comparing early versus late drain removal for complicated appendicitis.

AUTHORS' CONCLUSIONS

The certainty of the currently available evidence is low to very low. The effect of abdominal drainage on the prevention of intraperitoneal abscess or wound infection after open appendectomy is uncertain for patients with complicated appendicitis. The increased rates for overall complication rate and hospital stay for the drainage group compared to the no-drainage group are based on low-certainty evidence. Consequently, there is no evidence for any clinical improvement with the use of abdominal drainage in patients undergoing open appendectomy for complicated appendicitis. The increased risk of mortality with drainage comes from eight deaths observed in just under 400 recruited participants. Larger studies are needed to more reliably determine the effects of drainage on morbidity and mortality outcomes.

Pattern and Outcome of Acute Appendicitis: Observational Prospective Study from a Teaching Hospital, Addis Ababa, Ethiopia

Background

Acute appendicitis is the most common cause of acute abdomen surgery. Despite its commonness and the abundance of literature on the subject, its diagnosis remains challenging. Delay in intervention results in complications of the process leading to increased morbidity and mortality.

Methodology

An observational prospective cohort study was conducted, and all patients who had undergone appendectomy for a clinical diagnosis of appendicitis were included in the study. Data were analysed using Statistical Package for Social Sciences (SPSS) version 23.

Results

Half of the study participants were in the age range of 18–25 years with male preponderance (63.9%). The mean duration of symptoms was 51.3 hours. The most common presenting symptom was abdominal pain (98.2%), while right lower quadrant tenderness was the most common sign (93.4%). Abdominal ultrasound was done in 81% of the study population with a sensitivity and specificity of 95.7% and 33.3%, respectively. Three-quarters (74.4%) of the patients had uncomplicated appendicitis, while 1.8% had a grossly normal appendix. None of the appendectomy specimens were sent for pathology. The mean hospital stay was 3.2 days. The morbidity and mortality rate were 3.8% and 0.4%, respectively.

Conclusion

Acute appendicitis was the most common emergency surgical procedure in the study period. Abdominal ultrasound was used in the majority of the patients as supplementary imaging for the diagnosis of acute appendicitis. Uncomplicated appendicitis took the major share of the intraoperative finding leading to acceptable morbidity and mortality rates.

The prevalence of right-sided colonic diverticulosis in a New Zealand population

BACKGROUND

Once considered to be a congenital condition, the epidemiology of right-sided colonic diverticulosis (RCD) is evolving. Acute diverticulitis (AD) is a complication of RCD which is frequently misdiagnosed as appendicitis, resulting in unnecessary surgery, as there is strong evidence supporting medical management for right-sided AD. In general, the incidence of AD correlates with the prevalence of RCD, which shows marked geographic variation. Few data reporting RCD prevalence come from Western countries, so the aim of this study is to define the prevalence of RCD in a New Zealand population.

METHODS

Independent review of the imaging from 1000 consecutive patients undergoing a computed tomography Kidney/Ureter/Bladder scan for suspected urolithiasis at Christchurch Hospital between January and November 2017 was undertaken, to determine the presence or absence, and distribution of colonic diverticulosis. Patients were excluded if they had a history of colonic resection, known IBD, or were less than 18-years old.

RESULTS

Thirty-one patients were excluded, leaving 969 eligible patients. Overall, 95 patients (9.8%) had RCD identified. The prevalence of RCD increased significantly with advancing age, being present in 2.3% of those aged 18-29, increasing to 20.3% in those greater than 70-years old (p < 0.001).

CONCLUSION

The prevalence of RCD in a New Zealand population is relatively high and increases significantly with age. This adds support to the role of cross-sectional imaging in the evaluation of suspected appendicitis, to exclude right-sided AD. The association with advancing age supports RCD being an acquired condition rather than a congenital condition as was previously thought.

Cost-effectiveness analysis of nonoperative management versus open and laparoscopic surgery for uncomplicated acute appendicitis in Colombia

Background

Traditionally, uncomplicated acute appendicitis (AA) has been treated with appendectomy. However, the surgical alternatives might carry out significant complications, impaired quality of life, and higher costs than nonoperative treatment. Consequently, it is necessary to evaluate the different therapeutic alternatives' cost-effectiveness in patients diagnosed with uncomplicated appendicitis.

Methods

We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18–60 years with a diagnosis of uncomplicated AA from the payer´s perspective at the secondary and tertiary health care level. The time horizon was 5 years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed.

Methods

We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18–60 years with a diagnosis of uncomplicated AA from the payer’s perspective at the secondary and tertiary health care level. The time horizon was five years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed.

Results

LA presents a lower cost ($363 ± 35) than OA ($384 ± 41) and NOM ($392 ± 44). NOM exhibited higher QALYs (3.3332 ± 0.0276) in contrast with LA (3.3310 ± 0.057) and OA (3.3261 ± 0.0707). LA dominated the OA. The ICER between LA and NOM was $24,000/QALY. LA has a 52% probability of generating the highest NMB versus its counterparts, followed by NOM (30%) and OA (18%). There is a probability of 0.69 that laparoscopy generates more significant benefit than medical management. The mean value of that incremental NMB would be $93.7 per patient.

Conclusions

LA is a cost-effectiveness alternative in the management of patients with uncomplicated AA. Besides, LA has a high probability of producing more significant monetary benefits than NOM and OA from the payer’s perspective in the Colombian health system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-021-00288-2.

Making it Complicated: Does Disparity in Access to Care Lead to More Perforated Appendicitis?

INTRODUCTION

Delays in obtaining care may lead to perforated appendicitis, increasing risk of morbidity and mortality. We previously explored the role of social determinants in patients undergoing cholecystectomy, finding that emergent presentation is associated with neighborhood Social Vulnerability Index (SVI). We hypothesize that social vulnerability is associated with increased incidence of perforated appendicitis.

METHODS

We retrospectively identified patients presenting to our urban, academic hospital with acute appendicitis during a 9-month timeframe (11/2019 - 7/2020). Patients were classified as perforated or non-perforated. Patient SVI was determined using geocoding at the census tract level. Because rates of perforation were higher in older patients, we performed a subset analysis of patients ≥ 40 years.

RESULTS

190 patients were included. Patients with perforated appendicitis (n = 48, 25%) were older and were more likely to present to a clinic versus the emergency department (P = 0.009). Perforated patients had longer delay before seeking care (56% versus 6% with > 72 hours of symptoms, P < 0.001). However, there were no differences between groups in terms of sex, race/ethnicity, insurance type, language barrier, having a primary care physician, or any of the SVI subscales. Of patients ≥ 40 years, a higher proportion were perforated (28/80, 35%) despite similar rates of delayed care. In this cohort, higher overall SVI as well as the socioeconomic status and household composition/disability subscales were associated with perforation.

CONCLUSIONS

Contrary to our hypothesis, while perforation was associated with delayed care in this population, we did not find overall that social vulnerability or individual social determinants accounted for this delay.

Spatial-temporal clusters of pediatric perforated appendicitis in California

BACKGROUND

Perforated appendicitis is a well-documented child health disparity. Geographic patterns in perforated appendicitis exist in several United States regions, but such patterns have not been described in California. We aimed to analyze spatial-temporal patterns of pediatric perforated appendicitis and identify population characteristics contributing to these cluster patterns.

METHODS

We geocoded risk-adjusted perforated appendicitis rates per 1000 appendicitis cases in patients 1-17 years from 2005-2015 in California. We performed a space-time cube analysis to identify hot spot trends. We performed logistic regression to estimate rural classification associated with spatial-temporal hot spots and multivariate analysis to assess effects of socioeconomic factors.

RESULTS

In 2005-2015, 43,888 cases of pediatric perforated appendicitis occurred in California. Median risk-adjusted perforated appendicitis rate was 312 per 1000 appendicitis cases. We identified 11 spatial-temporal hot spots of perforated appendicitis. Rural micropolitan counties had 14 times higher odds of being classified as a hot spot (p<0.05, 95% CI 1-185). Poverty was a significant predictor of high perforated appendicitis median risk-adjusted rate (p<0.004).

CONCLUSIONS

We identified 11 California hot spots of perforated appendicitis that persisted across a ten-year time span. Incorporating geography alongside our understanding of socioeconomic factors is a critical step in addressing this important child health disparity.

Association of Neighborhood Socioeconomic Disadvantage With Complicated Appendicitis in Children

BACKGROUND

Lower socioeconomic status (SES) is linked to poorer outcomes for a variety of health conditions in children, potentially through delay in accessing care. The objective of this study was to measure the association between SES and delay in surgical care as marked by presentation with complicated appendicitis (CA).

METHODS

Children treated for acute appendicitis between 2015-2019 at a large academic children's hospital were reviewed. Patient home addresses were used to calculate travel time to the children's hospital and to determine Area Deprivation Index (ADI), a neighborhood-level SES marker. Multivariable logistic regression models were used to compare the likelihood of CA across ADI while adjusting for confounders.

RESULTS

Of 1,697 children with acute appendicitis, 38.8% had CA. Compared to those with uncomplicated disease, children with CA were younger, lived farther from the children's hospital, and were more likely to have Medicaid insurance and have ED visits in the 30 days preceding diagnosis. Children with CA disproportionately came from disadvantaged neighborhoods (P < 0.007), with 32% from the two most disadvantaged ADI deciles. The odds of CA rose 5% per ADI decile-increase (adjusted odds ratio [aOR] 1.05, 95%CI 1.01-1.09, P = 0.02). Younger age and >60-min travel time were also associated with CA. Association between ADI and CA remained among younger (<10 y) children (aOR 1.07, 95%CI 1.00-1.15, P = 0.048) and those living closer (<30 min) to the hospital (aOR 1.06, 95%CI 1.01-1.11, p=0.02).

CONCLUSIONS

ADI is associated with CA among children, suggesting ADI may be a valuable marker of difficulty accessing surgical care among disadvantaged children.

Increase in Pediatric Perforated Appendicitis in the New York City Metropolitan Region at the Epicenter of the COVID-19 Outbreak

OBJECTIVE

The aim of the study was to determine whether perforated appendicitis rates in children were influenced by the Coronavirus disease 2019 (COVID-19) surge.

BACKGROUND

Disruption of care pathways during a public health crisis may prevent children from obtaining prompt assessment for surgical conditions. Progression of appendicitis to perforation is influenced by timeliness of presentation. In the context of state-mandated controls and public wariness of hospitals, we investigated the impact of the COVID-19 outbreak on perforated appendicitis in children.

STUDY DESIGN

We conducted an analysis of all children presenting to 3 hospital sites with acute appendicitis between March 1 and May 7, 2020, corresponding with the peak COVID-19 outbreak in the New York City region. Control variables were collected from the same institutions for the preceding 5 years. The primary outcome measure was appendiceal perforation.

RESULTS

Fifty-five children presented with acute appendicitis over 10 weeks. Compared to a 5-year control cohort of 1291 patients, we observed a higher perforation rate (45% vs 27%, odds ratio 2.23, 95% confidence interval 1.29-3.85, P = 0.005) and longer mean duration of symptoms in children with perforations (71 ± 39 vs 47 ± 27 h, P = 0.001) during the COVID-19 period. There were no differences in perforation rates (55% vs 59%, P = 0.99) or median length of stay (1.0 vs 3.0 days, P = 0.58) among children screening positive or negative for SARS-CoV-2.

CONCLUSIONS

Children in the epicenter of the COVID-19 outbreak demonstrated higher rates of perforated appendicitis compared to historical controls. Preoperative detection of SARS-CoV-2 was not associated with inferior outcomes. Although children likely avoid much of the morbidity directly linked to COVID-19, disruption to local healthcare delivery systems may negatively impact other aspects of pediatric surgical disease.

Quarantine and Appendicitis: A Macro-Area Experience

PURPOSE

Appendicitis is the most frequent urgency in pediatric age; the aim of this study was to investigate the association of quarantine for severe acute respiratory syndrome coronavirus 2 pandemic and the incidence of pediatric appendicitis in a specific macro area.

METHODS

We retrospectively analyzed the medical records of consecutive patients who underwent surgical exploration for acute appendicitis in the period March-April since 2014. This specific quarantine period was divided into two phases as indicated by National government. Patient data, demographics, characteristics and outcomes were studied and evaluated comparing patients treated during quarantine especially phase 1 vs. phase 2 (March-April 2020).

RESULTS

After reviewing medical charts following the inclusion and exclusion criteria, 155 patients were studied; focusing on the final outcome, it is possible to show a decreased amount of appendicitis during phase 1 and a progressive increase during phase 2; respect to previous years, there was a statistical increase in severity of appendicitis during quarantine (gangrenous vs. phlegmonous appendicitis).

CONCLUSION

During this specific quarantine there was a reduction in appendicitis and a progressive increase during phase 2. These results offer new perspective among disease incidences during lockdown.

County-Level Social Vulnerability is Associated with Worse Surgical Outcomes Especially Among Minority Patients

OBJECTIVE

We sought to characterize the association between patient county-level vulnerability with postoperative outcomes.

SUMMARY BACKGROUND DATA

While the impact of demographic-, clinical- and hospital-level factors on outcomes following surgery have been examined, little is known about the effect of a patient's community of residence on surgical outcomes.

METHODS

Individuals who underwent colon resection, coronary artery bypass graft (CABG), lung resection, or lower extremity joint replacement (LEJR) were identified in the 2016-2017 Medicare database, which was merged with CDC vulnerability index (SVI) dataset at the beneficiary level of residence. Logistic regression models were utilized to estimate the probability of postoperative complications, mortality, readmission, and expenditures.

RESULTS

Among 299,583 Medicare beneficiary beneficiaries who underwent a colectomy (n = 88,778, 29.6%), CABG (n = 109,564, 36.6%), lung resection (n = 30,401, 10.1%), or LEJR (n = 70,840, 23.6%).Mean SVI score was 50.2 (SD: (25.2); minority patients were more likely to reside in highly vulnerable communities (low SVI: n = 3,531, 5.8% vs. high SVI: n = 7,895, 13.3%; p < 0.001). After controlling for competing risk factors, the risk-adjusted probability of a serious complication among patients from a high versus low SVI county was 10-20% higher following colectomy (OR 1.1 95%CI 1.1-1.2) or CABG (OR 1.2 95%CI 1.1-1.3), yet there no association of SVI with risk of serious complications following lung resection (OR 1.2 95%CI 1.0-1.3) or LEJR (OR 1.0 95%CI 0.93-1.2). The risk-adjusted probability of 30-day mortality was incrementally higher among patients from high SVI counties following colectomy (OR 1.1 95%CI 1.1-1.3), CABG (OR 1.4, 95%CI 1.2-1.5), and lung resection (OR 1.4 (95%CI 1.1-1.8), yet not LEJR (OR 0.95 95%CI 0.72-1.2). Black/minority patients undergoing a colectomy, CABG, or lung resection who lived in highly socially vulnerable counties had an estimate 28-68% increased odds of a serious complication and a 58-60% increased odds of 30-day mortality compared with a black/minority patient from a low socially vulnerable county, as well as a markedly higher risk than white patients (all p > 0.05).

CONCLUSION

Patients residing in vulnerable communities characterized by a high SVI generally had worse postoperative outcomes. The impact of social vulnerability was most pronounced among black/minority patients, rather than white individuals. Efforts to ensure equitable surgical outcomes need to focus on both patient-level, as well as community-specific factors.

Where did the patients go? Changes in acute appendicitis presentation and severity of illness during the coronavirus disease 2019 pandemic: A retrospective cohort study

BACKGROUND

The coronavirus disease 2019 pandemic restricted movement of individuals and altered provision of health care, abruptly transforming health care-use behaviors. It serves as a natural experiment to explore changes in presentations for surgical diseases including acute appendicitis. The objective was to determine if the pandemic was associated with changes in incidence of acute appendicitis compared to a historical control and to determine if there were associated changes in disease severity.

METHODS

The study is a retrospective, multicenter cohort study of adults (N = 956) presenting with appendicitis in nonpandemic versus pandemic time periods (December 1, 2019-March 10, 2020 versus March 11, 2020-May 16, 2020). Corresponding time periods in 2018 and 2019 composed the historical control. Primary outcome was mean biweekly counts of all appendicitis presentations, then stratified by complicated (n = 209) and uncomplicated (n = 747) disease. Trends in presentations were compared using difference-in-differences methodology. Changes in odds of presenting with complicated disease were assessed via clustered multivariable logistic regression.

RESULTS

There was a 29% decrease in mean biweekly appendicitis presentations from 5.4 to 3.8 (rate ratio = 0.71 [0.51, 0.98]) after the pandemic declaration, with a significant difference in differences compared with historical control (P = .003). Stratified by severity, the decrease was significant for uncomplicated appendicitis (rate ratio = 0.65 [95% confidence interval 0.47-0.91]) when compared with historical control (P = .03) but not for complicated appendicitis (rate ratio = 0.89 [95% confidence interval 0.52-1.52]); (P = .49). The odds of presenting with complicated disease did not change (adjusted odds ratio 1.36 [95% confidence interval 0.83-2.25]).

CONCLUSION

The pandemic was associated with decreased incidence of uncomplicated appendicitis without an accompanying increase in complicated disease. Changes in individual health care-use behaviors may underlie these differences, suggesting that some cases of uncomplicated appendicitis may resolve without progression to complicated disease.