Appendicectomy in Scotland: a 20-year epidemiological comparison

Appendectomy and women’s reproductive outcomes: a review of the literature

Background

The most frequent abdominal surgery performed for benign disease in females of fertile age is appendectomy, which remains among the most common surgeries and is a possible cause of peritoneal adhesions. The fact that appendectomy can cause adhesions may lead one to think that this may be a relevant risk factor for infertility; however, there is no universal agreement regarding the association between appendectomy and fertility. The aim of this review is to evaluate weather appendectomy may have a relevant impact on female fertility.

Methods

The search was conducted in PubMed and there was no limitation set on the date of publication. All studies regarding populations of female patients who had undergone appendectomy for inflamed appendix, perforated appendix, or negative appendix between childhood and the end of the reproductive period were included.

Results

Some authors believe that pelvic surgery can cause adhesions which can potentially lead to tubal infertility by causing tubal obstruction or by altering motility of fimbriae, tubal fluid secretion, and embryo transport. On the other hand, the most recent evidence reported that removal of the appendix seems to be associated with an increased pregnancy rate in large population studies.

Conclusion

Despite the existence of contrasting opinions concerning fertility after appendectomy, the most recent evidence suggests that appendectomy may actually lead to improved fertility and decreased time to pregnancy. Appendectomy seems to be correlated with improved fertility and higher pregnancy rates.

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Background

NHS expenditure has stagnated since the economic crisis of 2007, resulting in financial pressures. One response is for policy-makers to regulate use of existing health-care technologies and disinvest from inefficiently used health technologies. A key challenge to disinvestment is to identify existing health technologies with uncertain cost-effectiveness.

Objectives

We aimed to explore if geographical variation in procedure rates is a marker of clinical uncertainty and might be used by local commissioners to identify procedures that are potential candidates for disinvestment. We also explore obstacles and solutions to local commissioners achieving disinvestment, and patient and clinician perspectives on regulating access to procedures.

Methods

We used Hospital Episode Statistics to measure geographical variation in procedure rates from 2007/8 to 2011/12. Expected procedure numbers for each primary care trust (PCT) were calculated adjusting for proxies of need. Random effects Poisson regression quantified the residual inter-PCT procedure rate variability. We benchmarked local procedure rates in two PCTs against national rates. We conducted rapid systematic reviews of two high-use procedures selected by the PCTs [carpal tunnel release (CTR) and laser capsulotomy], searching bibliographical databases to identify systematic reviews and randomised controlled trials (RCTs). We conducted non-participant overt observations of commissioning meetings and semistructured interviews with stakeholders about disinvestment in general and with clinicians and patients about one disinvestment case study. Transcripts were analysed thematically using constant comparison methods derived from grounded theory.

Results

There was large inter-PCT variability in procedure rates for many common NHS procedures. Variation in procedure rates was highest where the diffusion or discontinuance was rapidly evolving and where substitute procedures were available, suggesting that variation is a proxy for clinical uncertainty about appropriate use. In both PCTs we identified procedures where high local use might represent an opportunity for disinvestment. However, there were barriers to achieving disinvestment in both procedure case studies. RCTs comparing CTR with conservative care indicated that surgery was clinically effective and cost-effective on average but provided limited evidence on patient subgroups to inform commissioning criteria and achieve savings. We found no RCTs of laser capsulotomy. The apparently high rate of capsulotomy was probably due to the coding inaccuracy; some savings might be achieved by greater use of outpatient procedures. Commissioning meetings were dominated by new funding requests. Benchmarking did not appear to be routinely carried out because of capacity issues and concerns about data reliability. Perceived barriers to disinvestment included lack of collaboration, central support and tools for disinvestment. Clinicians felt threshold criteria had little impact on their practice and that prior approval systems would not be cost-effective. Most patients were unaware of rationing.

Conclusions

Policy-makers could use geographical variation as a starting point to identify procedures where health technology reassessment or RCTs might be needed to inform policy. Commissioners can use benchmarking to identify procedures with high local use, possibly indicating overtreatment. However, coding inconsistency and limited evidence are major barriers to achieving disinvestment through benchmarking. Increased central support for commissioners to tackle disinvestment is needed, including tools, accurate data and relevant evidence. Early engagement with patients and clinicians is essential for successful local disinvestment.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Appendicectomy is associated with increased pregnancy rate: a cohort study

OBJECTIVE

This study was carried out to determine whether pregnancy rate is reduced after appendicitis or appendicectomy.

BACKGROUND

The association between appendicectomy, appendicitis, and subsequent fertility is controversial.

METHODS

A cohort study was carried out in the Medicines Monitoring database. The cohort of women who underwent appendicectomy and appropriate comparators were followed up until first pregnancy after appendicectomy date. Pathology of the appendix was verified manually. The association between appendicectomy, appendicitis, and pregnancy was determined by Cox regression models.

RESULTS

The age and social deprivation score-matched analyses included 2935 patients who had appendicectomy with 5870 comparators. There were 1277 (43.5%) pregnancies in the appendicectomy cohort and 2319 (39.5%) in the comparator cohort during a mean follow-up of 12.4 (standard deviation: 7.3) years. The adjusted hazard ratios (HRs) for pregnancy rates were 1.20 (95% confidence interval [CI]: 1.10-1.31). In an unmatched cohort analysis (3009 in the appendicectomy cohort and 122,912 in the comparator cohort), the adjusted HRs for pregnancy rates were 1.65 (95% CI: 1.55-1.75). Within the histologically proven appendicitis subset, the adjusted HR was 1.21 (95% CI: 1.08-1.37) in comparison with the matched comparator cohort. In comparison with the group of participants who had appendicectomy for a normal appendix, the HRs were 0.98 (95% CI: 0.83-1.15) for mucosal and catarrhal appendicitis, 0.72 (95% CI: 0.64-0.82) for suppurative appendicitis, and 0.64 (95% CI: 0.50-0.80) for gangrenous appendicitis.

CONCLUSIONS

Appendicectomy and early appendicitis were associated with increased pregnancy rates. Young women with early appendicitis had better pregnancy rates than those with advanced appendicitis. Early referral for laparoscopy and appendicectomy is advocated.

Trend, variability, and outcome of open vs. laparoscopic appendectomy based on a large administrative database

The aim of this study was to ascertain the variability and 9-year trends in the use of laparoscopic surgery for appendicitis using data from a large administrative database, to compare the effectiveness and efficiency of laparoscopic (LA) and open appendectomy, and to ascertain whether different choices of surgical approach stem from evidence-based recommendations. This was a retrospective cohort study based on administrative data collected from 2000 to 2008 in the Veneto Region (northeastern Italy). Funnel plots were used to display variability between local health units (LHUs). A total of 38,314 appendectomies were performed from 2000 to 2008 in the Veneto Region, 53% of them in males. The laparoscopic procedure was used more often for females than for males of fertile age. There was a significant rising linear trend in the use of LA, with a higher increment among females. The overall regional standardized appendectomy rate was 82.9/10,000. The mean proportion of LAs (27.3%) ranged from 2.8 to 59.4% at different LHUs, and there was no relationship between the volume of procedures undertaken and the proportion of LAs. The proportion of LAs performed in females of reproductive age also varied considerably, on no apparent evidence-based grounds. The analysis of aggregate clinical data is a powerful tool for supporting regional health management units in efforts to improve the quality of medical care and assess the appropriateness of therapeutic or diagnostic approaches in the light of practical guidelines. Variability in the treatment of a given disease that lacks any evidence-based justification remains an important issue in national health systems.

Comparison of outcomes after laparoscopic versus open appendectomy for acute appendicitis at 222 ACS NSQIP hospitals

BACKGROUND

The benefit of laparoscopic (LA) versus open (OA) appendectomy, particularly for complicated appendicitis, remains unclear. Our objectives were to assess 30-day outcomes after LA versus OA for acute appendicitis and complicated appendicitis, determine the incidence of specific outcomes after appendectomy, and examine factors influencing the utilization and duration of the operative approach with multi-institutional clinical data.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2005-2008), patients were identified who underwent emergency appendectomy for acute appendicitis at 222 participating hospitals. Regression models, which included propensity score adjustment to minimize the influence of treatment selection bias, were constructed. Models assessed the association between surgical approach (LA vs OA) and risk-adjusted overall morbidity, surgical site infection (SSI), serious morbidity, and serious morbidity/mortality, as well as individual complications in patients with acute appendicitis and complicated appendicitis. The relationships between operative approach, operative duration, and extended duration of stay with hospital academic affiliation were also examined.

RESULTS

Of 32,683 patients, 24,969 (76.4%) underwent LA and 7,714 (23.6%) underwent OA. Patients who underwent OA were significantly older with more comorbidities compared with those who underwent LA. Patients treated with LA were less likely to experience an overall morbidity (4.5% vs 8.8%; odds ratio [OR], 0.60; 95% confidence interval [CI], 0.54-0.68) or a SSI (3.3% vs 6.7%; OR, 0.57; 95% CI, 0.50-0.65) but not a serious morbidity (2.6% vs 4.2%; OR, 0.86; 95% CI, 0.74-1.01) or a serious morbidity/mortality (2.6% vs 4.3%; OR, 0.87; 95% CI, 0.74-1.01) compared with those who underwent OA. All patients treated with LA were significantly less likely to develop individual infectious complications except for organ space SSI. Among patients with complicated appendicitis, organ space SSI was significantly more common after laparoscopic appendectomy (6.3% vs 4.8%; OR, 1.35; 95% CI, 1.05-1.73). For all patients with acute appendicitis, those treated at academic-affiliated versus community hospitals were equally likely to undergo LA versus OA (77.0% vs 77.3%; P = .58). Operative duration at academic centers was significantly longer for both LA and OA (LA, 47 vs 38 minutes [P < .0001]; OA, 49 vs 44 minutes [P < .0001]). Median duration of stay after LA was 1 day at both academic-affiliated and community hospitals.

CONCLUSION

Within ACS NSQIP hospitals, LA is associated with lower overall morbidity in selected patients. However, patients with complicated appendicitis may have a greater risk of organ space SSI after LA. Academic affiliation does not seem to influence the operative approach. However, LA is associated with similar durations of stay but slightly greater operative times than OA at academic versus community hospitals.

Traditional and laparoscopic appendectomy in adults: outcomes in English NHS hospitals between 1996 and 2006

OBJECTIVE

This study investigated length of stay, readmission rates, and postoperative mortality in adult patients undergoing traditional and laparoscopic appendectomy in England between April 1, 1996, and March 31, 2006.

METHODS

All procedures coded to the "H01-Emergency Excision of Appendix" procedure code in the Hospital Episode Statistics database were included. Multivariate analyses were used to identify independent predictors of length of hospital stay, 30-day and 365-day mortality.

RESULTS

A total of 259,735 procedures were assigned to the H01-Emergency excision of appendix OPCS-4 3-digit code procedure between 1996 and 2006. A laparoscopic technique was employed in 16,315 (6.3%). A greater proportion of deaths occurred in hospital within 30 days of "open" appendectomy surgery (0.25%) compared with procedures utilizing a laparoscopic technique (0.09%, P < 0.001). One-year mortality rates, measured over a 5-year period, were also higher after open surgery (0.64% vs. 0.29%, P < 0.001). Multiple logistic regressions demonstrated that an open operative technique, older age, male gender, and increasing comorbidity were strong independent determinants of early and 1-year postoperative mortality after emergency appendectomy. The duration of stay for patients undergoing open emergency appendectomy exceeded that for patients undergoing the laparoscopic technique (P < 0.001). Patients undergoing a laparoscopic technique were, however, more likely to be readmitted within 28 days of surgery (7.10% vs. 4.95%, P < 0.001).

CONCLUSIONS

Laparoscopic appendectomy is safe and associated with lower postoperative mortality rates than open procedures. The cost implications are uncertain as this technique is associated with shorter hospital stay but higher subsequent readmission rates.

Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management

OBJECTIVE

Appendicitis has been declining in frequency for several decades. During the past 10 years, its preoperative diagnosis has been made more reliable by improved computed tomography (CT) imaging. Thresholds for surgical exploration have been lowered by the increased availability of laparoscopic exploration. These innovations should influence the number of appendectomies performed in the United States. We analyzed nationwide hospital discharge data to study the secular trends in appendicitis and appendectomy rates.

METHODS

All appendicitis and appendiceal operations reported to the National Hospital Discharge Survey (NHDS) 1970-2004 were classified as perforated, nonperforated, negative, and incidental appendectomies and analyzed over time and by various demographic measures. Secular trends in the population-based incidence rates of nonperforated and perforated appendicitis and negative and incidental appendectomy were examined.

RESULTS

Nonperforated appendicitis rates decreased between 1970 and 1995 but increased thereafter. The 25-year decreasing trend was accounted for almost entirely by a decreasing incidence in the 10-19 year age group. The rise after 1995 occurred in all age groups above 5 years and paralleled increasing rates of CT imaging and laparoscopic surgery on the appendix. Since 1995 the negative appendectomy rate has been falling, especially in women, and incidental appendectomies, frequent in prior decades, have been rarely performed. Despite these large changes, the rate of perforated appendicitis has increased steadily over the same period. Although perforated and nonperforated appendicitis rates were correlated in men, they were not significantly correlated in women nor were there significant negative correlations between perforated and negative appendectomy rates.

CONCLUSION

The 25-year decline in nonperforated appendicitis and the recent increase in appendectomies coincident with more frequent use of CT imaging and laparoscopic appendectomies did not result in expected decreases in perforation rates. Similarly, time series analysis did not find a significant negative relationship between negative appendectomy and perforation rates. This disconnection of trends suggests that perforated and nonperforated appendicitis may have different pathophysiologies and that nonoperative management with antibiotic therapy may be appropriate for some initially nonperforated cases. Further efforts should be directed at identifying preoperative characteristics associated with nonperforating appendicitis that may eventually allow surgeons to defer operation for those cases of nonperforating appendicitis that have a low perforation risk.

Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database

OBJECTIVE

To compare length of hospital stay, in-hospital complications, in-hospital mortality, and rate of routine discharge between laparoscopic and open appendectomy based on a representative, nationwide database.

SUMMARY BACKGROUND DATA

Numerous single-institutional randomized clinical trials have assessed the efficacy of laparoscopic and open appendectomy. The results, however, are conflicting, and a consensus concerning the relative advantages of each procedure has not yet been reached.

METHODS

Patients with primary ICD-9 procedure codes for laparoscopic and open appendectomy were selected from the 1997 Nationwide Inpatient Sample, a database that approximates 20% of all US community hospital discharges. Multiple linear and logistic regression analyses were used to assess the risk-adjusted endpoints.

RESULTS

Discharge abstracts of 43757 patients were used for our analyses. 7618 patients (17.4%) underwent laparoscopic and 36139 patients (82.6%) open appendectomy. Patients had an average age of 30.7 years and were predominantly white (58.1%) and male (58.6%). After adjusting for other covariates, laparoscopic appendectomy was associated with shorter median hospital stay (laparoscopic appendectomy: 2.06 days, open appendectomy: 2.88 days, P < 0.0001), lower rate of infections (odds ratio [OR] = 0.5 [0.38, 0.66], P < 0.0001), decreased gastrointestinal complications (OR = 0.8 [0.68, 0.96], P = 0.02), lower overall complications (OR = 0.84 [0.75, 0.94], P = 0.002), and higher rate of routine discharge (OR = 3.22 [2.47, 4.46], P < 0.0001).

CONCLUSIONS

Laparoscopic appendectomy has significant advantages over open appendectomy with respect to length of hospital stay, rate of routine discharge, and postoperative in-hospital morbidity.

Appendicectomy in Western Australia: profile and trends, 1981-1997

OBJECTIVE

To measure and describe changes in the incidence of appendicectomy in the population of Western Australia (WA) for 1981-1997.

DESIGN

Population-based incidence study using hospital discharge data.

SETTING

All hospitals in WA (1981-1997).

PATIENTS

All patients who underwent an appendicectomy in WA hospitals.

MAIN OUTCOME MEASURES

Changes in the incidence of appendicectomy procedures over time; age-standardised rates and age-sex profiles of four appendicectomy subgroups: (1) acute emergency admission, (2) other emergency admission, (3) incidental appendicectomy and (4) other appendicectomy.

RESULTS

From 1981 to 1997, there were 59,749 appendicectomies in WA hospitals. The age-standardised rate of appendicectomy declined by 63% in metropolitan females, by 44% in non-metropolitan females, by 41% in metropolitan males and by 21% in non-metropolitan males. The rate of decline was significantly greater in females and in metropolitan patients. From 1988 to 1997, acute emergency admission for appendicectomy was the most common admission status and was more common in males than females (122 v 103 per 100,000 person-years) and in non-metropolitan areas. The rate of incidental appendicectomy was higher among females than males (20 v 7 per 100,000 person-years). From 1988 to 1997, recorded diagnosis coding for appendicitis became more specific, with a marked reduction in the use of the "unspecified" appendicitis code.

CONCLUSIONS

The overall incidence of appendicectomy has declined markedly in WA and includes a decline in the practice of incidental appendicectomy. The trend was greatest in the metropolitan hospitals.

Appendicectomies in Albanians in Greece: outcomes in a highly mobile immigrant patient population

BACKGROUND

Albanian immigrants in Greece comprise a highly mobile population with unknown health care profile. We aimed to assess whether these immigrants were more or less likely to undergo laparotomy for suspected appendicitis with negative findings (negative appendicectomy), by performing a controlled study with individual (1:4) matching. We used data from 6 hospitals in the Greek prefecture of Epirus that is bordering Albania.

RESULTS

Among a total of 2027 non-incidental appendicectomies for suspected appendicitis performed in 1994-1999, 30 patients with Albanian names were matched (for age, sex, time of operation and hospital) to 120 patients with Greek names. The odds for a negative appendicectomy were 3.4-fold higher (95% confidence interval [CI], 1.24-9.31, p = 0.02) in Albanian immigrants than in matched Greek-name subjects. The difference was most prominent in men (odds ratio 20.0, 95% CI, 1.41-285, p = 0.02) while it was not formally significant in women (odds ratio 1.56, 95% CI, 0.44-5.48). The odds for perforation were 1.25-fold higher in Albanian-name immigrants than in Greek-name patients (95% CI 0.44- 3.57).

CONCLUSIONS

Albanian immigrants in Greece are at high risk for negative appendicectomies. Socioeconomic, cultural and language parameters underlying health care inequalities in highly mobile immigrant populations need better study.

Mortality after appendectomy in Sweden, 1987-1996

OBJECTIVE

To study mortality after appendectomy.

SUMMARY BACKGROUND DATA

The management of patients with suspected appendicitis remains controversial, with advocates of early surgery as well as of expectant management. Mortality is not known.

METHODS

The authors conducted a complete follow-up of deaths within 30 days after all appendectomies in Sweden (population 8.9 million) during the years 1987 to 1996 (n = 117,424) by register linkage. The case fatality rate (CFR) and the standardized mortality ratio (SMR) were analyzed by discharge diagnosis.

RESULTS

The CFR was 2.44 per 1,000 appendectomies. It was strongly related to age (0.31 per 1,000 appendectomies at 0-9 years of age, decreasing to 0.07 at 20-29 years, and reaching 164 among nonagenarians) and diagnosis at surgery (0.8 per 1,000 appendectomies after nonperforated appendicitis, 5.1 after perforated appendicitis, 1.9 after appendectomies for nonsurgical abdominal pain, and 10.0 for those with other diagnoses). The SMR showed a sevenfold excess rate of deaths after appendectomy compared with the general population. The relation to age was less marked (SMR of 44.4 at 0-9 years, decreasing to 2.4 in patients aged 20-29 years. and reaching 8.1 in nonagenarians). The SMR was doubled after perforation compared with nonperforated appendicitis (6.5 and 3.5, respectively). Nonsurgical abdominal pain and other diagnoses were associated with a high excess rate of deaths (9.1 and 14.9, respectively). The most common causes of deaths were appendicitis, ischemic heart diseases and tumors, followed by gastrointestinal diseases.

CONCLUSIONS

The CFR after appendectomy is high in elderly patients. The excess rate of death for patients with nonperforated appendicitis and nonsurgical abdominal pain suggests that the deaths may partly be caused by the surgical trauma. Increased diagnostic efforts rather than urgent appendectomy are therefore warranted among frail patients with an equivocal diagnosis of appendicitis.