National survey on the treatment of acute appendicitis in Spain during the initial period of the COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic has had a significant impact on Spanish hospitals, which have had to allocate all available resources to treat these patients, reducing the ability to attend other common pathologies. The aim of this study is to analyze how the treatment of acute appendicitis has been affected.

METHOD

A national descriptive study was carried out by an online voluntary specific questionnaire with Google Drive™ distributed by email by the Spanish Association of Surgeons (AEC) to all affiliated surgeons currently working in Spain (5203), opened from April 14th to April 24th.

RESULTS

We received 337 responses from 170 centers. During the first month of the pandemic, the incidence of acute appendicitis decreased. Although conservative management increased, the surgical option has been the most used in both simple and complicated appendicitis. Despite the fact that the laparoscopic approach continues to be the most widely used in our services, the open approach has increased during this pandemic period.

CONCLUSION

Highlight the contribution of this study in terms of knowledge of the status of the treatment of acute appendicitis during this first month of the pandemic, being able to serve for a better possible organization in future waves of the pandemic and a reorganization of current protocols and management of acute appendicitis in a pandemic situation.

Comparison of acute appendicitis before and within lockdown period in COVID-19 era: A retrospective study from rural Nepal

Introduction

The world has been engulfed with the pandemic of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which have created significant impact in the emergency surgical health delivery including acute appendicitis. The main aim of this study was to compare the demographic and clinical parameters between two cohorts before the onset of lockdown and within the pandemic.

Methods

A retrospective analysis was performed between two groups A and B, who presented with acute appendicitis three months prior to and after initiation of lockdown on March 24 2020 respectively in one of the tertiary centers of Nepal. These two cohorts were compared in demographics, clinicopathological characteristics and surgical aspects of acute appendicitis.

Results

There were 42 patients in group A and 50 patients in group B. Mean age of the patients was 31.32±17.18 years with male preponderance in group B (N = 29). Mean duration of pain increased significantly in group B [57.8±25.9(B) vs 42.3±25.0(A) hours, P = 0.004] along with mean duration of surgery [51.06±9.4(B) vs 45.27±11.8(A) minutes, P = 0.015]. There was significant decrease in post-operative hospital stay among group B patients [3.04±1.1(B) vs 3.86±0.67(A) days, P = 0.0001]. Complicated cases increased in group B including appendicular perforation in 10 cases. Similarly, mean duration of presentation to hospital significantly increased in group B patients with perforation [69.6±21.01 vs 51.57±17.63 hours, P = 0.008].

Conclusion

During the adversity of the current pandemic, increased number of cases of acute appendicitis can be dealt with surgery as the chances of late presentation and complexity of the lesion exists.

Factors affecting the length of hospital stay after laparoscopic appendectomy: A single center study

AIM

This study aimed to explore factors may affect the length of hospital stay after laparoscopic appendectomy.

METHODS

The data of 636 patients undergoing laparoscopic appendectomy between July 2016 and July 2019 in Beijing Tsinghua Changgung Hospital were retrospectively analyzed. The patients were divided into group A (hospital stay ≤3 days, 348 patients) and group B (hospital stay >3 days, 288 patients) according to their hospital stay.Sex, age, disease onset time(time from onset to admission), nausea, vomiting, diarrhea, peritonitis, comorbidities, and history of appendicitis; preoperative body temperature (T), white blood cell (WBC) count, percentage of neutrophilic granulocytes, and preoperative C-reactive protein (CRP) level; time from diagnosis to surgery. appendix diameter, appendicolith, and ascites in ultrasound or CT; surgical time(the surgery start time was the time of skin incision, and the end time was the time the anesthesia intubation was removed), intraoperative blood loss (the volume of blood infiltrating into a gauze was calculated by weighing the gauze infiltrated with water and calculating the volume of water), intraoperative adhesions or effusions, and stump closure methods, convert to open appendectomy, appendix pathology(perforated or gangrenous appendicitis were defined as complicated appendicitis and simple or suppurative appendicitis were defined as uncomplicated appendicitis) and antibiotic treatment schemes were analyzed.

RESULTS

Significant differences were detected between group A and group B in age (37.10 ± 13.52y vs 42.94 ± 15.57y, P<0.01), disease onset time (21.36 ± 16.56 h vs 32.52 ± 27.99 h, P <0.01), time from diagnosis to surgery (8.63 ± 7.29 h vs 10.70 ± 8.47 h, P<0.01); surgical time(64.09 ± 17.24 min vs 86.19 ± 39.96 min, P < 0.01); peritonitis(52.9% vs 74%, P < 0.01), comorbidities (12.4% vs 20.5%, P < 0.01), appendicolith (27.6% vs 41.7%, P < 0.01), ascites before the surgery(13.8% vs 22.9%, P < 0.01), intraoperative adhesions or effusions(56% vs 80.2%, P < 0.01); preoperative temperature (37.11 ± 0.64°C vs 37.54 ± 0.90°C, P < 0.01); preoperative WBC count (13.06 ± 3.39 × 109/L vs 14.21 ± 4.54 × 109/L, P = 0.04);preoperative CRP level(18.99 ± 31.72 mg/L vs 32.46 ± 46.68 mg/L, P < 0.01); appendix diameter(10.22 ± 2.59 mm vs 11.26 ± 3.23 mm, P < 0.01); intraoperative blood loss (9.36 ± 7.29 mL vs 13.74 ± 13.49 mL, P < 0.01); using Hem-o-lok for stump closure(30.7% vs 38.5%, P = 0.04); complicated appendicitis (9.5% vs 45.8%, P < 0.01); and using ertapenem for antibiotic treatment after the surgery(4.3% vs 21.5%, P < 0.01). Multivariate analysis demonstrated that age (OR = 1.021; 95%CI = 1.007-1.036), peritonitis (OR = 1.603; 95% CI = 1.062-2.419), preoperative WBC count (OR = 1.084; 95% CI = 1.025-1.046), preoperative CRP level (OR = 1.010; 95% CI = 1.005-1.015), time from diagnosis to surgery (OR = 1.043; 95% CI = 1.015-1.072), appendicolith (OR = 1.852; 95% CI = 1.222-2.807), complicated appendicitis (OR = 3.536; 95% CI = 2.132-5.863), surgical time (OR = 1.025; 95% CI = 1.016-1.034), use of Hem-o-lok for stump closure (OR = 1.894; 95% CI = 1.257-2.852), and use of ertapenem for antibiotic treatment (OR = 3.076; 95% CI = 1.483-6.378) were the risk factors for a prolonged hospital stay.

CONCLUSIONS

The patient with appendicitis was older and had peritonitis, higher preoperative WBC count or CRP level, longer time from diagnosis to surgery, appendicolith, and complicated appendicitis, predicting a prolonged hospital stay. Shorter surgical time and the use of silk ligation for stump closure and cephalosporins + metronidazole for antibiotic treatment might be better choices to obtain a shorter hospital stay.

Trends in the Use of Laparoscopic Versus Open Paediatric Appendicectomy: A Regional 12-Year Study and a National Survey

BACKGROUND

In adult patients, it is generally accepted that laparoscopic appendicectomy (LA) is the predominant operative pathway in treating acute appendicitis. The case for a similar pathway utilising LA in children is less clear. We investigate usage, trends and complications after LA in children in a single co-located adult/paediatric centre with contemporaneous adults as controls.

METHODS

A retrospective case-control study was conducted over 12 years including patients who underwent appendicectomy, and the paediatric series (<16 years) was divided into age-groups-based quartiles. An anonymous questionnaire-based national survey was circulated among general and paediatric surgeons.

RESULTS

Of the 5784 appendicectomy patients, 2960 were children. LA rate in paediatric appendicitis was 65%. Yearly trends in LA reached a steady state in both groups after 2010 (Δ 0-1%/year). Rates of LA and LA IAA (respectively) differed significantly between age groups: 60, 3% (0-9 years); 65, 1% (10-13 years); 71, 2% (14-16 years) and 93, 3% (>16 years) (p = 0.001, 0.02). The national survey showed respondents believed LA was not superior to OA in paediatric patients except in terms of cosmesis. There was strong support in the use of LA in older children and children >40 kg.

CONCLUSION

The use of LA in paediatric appendicectomies in the study region is similar to international rates, but not increasing over time. Irish surgeons still favour OA in younger children and prefer a case-by-case approach rather LA being the preferred pathway. This is despite the regional and international evidence showing favourable outcomes with LA in children.

[Novelties in surgery in 2016]

The year 2016 allowed further implementation of previous years innovations with the PIPAC treatment for peritoneal carcinomatosis, the development of new surgical technologies and procedures and challenging general principles in general and digestive surgery, including cholecystectomy and appendectomy. Prevention, improved general and perioperative care (ERAS program) become an integral part of our standard surgical activity.

Emerging Techniques in Minimally Invasive Surgery. Pros and Cons

New trends have emerged regarding the best minimally invasive access approaches to perform gastrointestinal surgery. However, these newer approaches are seen critically by those who demand a more strict assessment of outcomes and safety. An international panel of expert gathered at the 2014 American College of Surgeons Meeting with the goal of providing an evidence-based understanding of the real value of these approaches in gastrointestinal surgery. The panel has compared the efficacy and safety of most established approaches to gastrointestinal diseases to those of new treatment modalities: peroral esophageal myotomy vs. laparoscopic myotomy for achalasia, transgastric vs. transvaginal approach, and single-incision vs. multi-port access minimally invasive surgery. The panel found that (1) the outcome of these new approaches was not superior to that of established surgical procedures; (2) the new approaches are generally performed in few highly specialized centers; and (3) transgastric and transvaginal approaches might be safe and feasible in very experienced hands, but cost, training, operative time, and tools seem to limit their application for the treatment of common procedures such as cholecystectomy and appendectomy. Because the expected advantages of new approaches have yet to be proven in controlled trials, new approaches should be considered for adoption into practice only after thorough analyses of their efficacy and effectiveness and appropriate training.

Laparoscopic appendectomy trends and outcomes in the United States: data from the Nationwide Inpatient Sample (NIS), 2004-2011

Laparoscopic appendectomy (LA) is becoming the standard procedure of choice for appendicitis. We aimed to evaluate the frequency and trends of LA for acute appendicitis in the United States and to compare outcomes of LA with open appendectomy (OA). Using the Nationwide Inpatient Sample database, we examined patients who underwent appendectomy for acute appendicitis from 2004 to 2011. A total of 2,593,786 patients underwent appendectomy during this period. Overall, the rate of LA was 60.5 per cent (children: 58.1%; adults: 63%; elderly: 48.7%). LA rate significantly increased from 43.3 per cent in 2004 to 75 per cent in 2011. LA use increased 66 per cent in nonperforated appendicitis versus 100 per cent increase in LA use for perforated appendicitis. The LA rate increased in all age groups. The increased LA use was more significant in male patients (84%) compared with female patients (62%). The overall conversion rate of LA to OA was 6.3 per cent. Compared with OA, LA had a significantly lower complication rate, a lower mortality rate, a shorter mean hospital stay, and lower mean total hospital charges in both nonperforated and perforated appendices. LA has become an established procedure for appendectomy in nonperforated and perforated appendicitis in all rates exceeding OA. Conversion rate is relatively low (6.3%).

Acceptable outcome after laparoscopic appendectomy in children

INTRODUCTION

An increasing proportion of childhood -appendicitis is being treated with laparoscopic appendectomy (LA). We wanted to elucidate the outcome of childhood appendicitis treated primarily by residents in a university hospital.

MATERIAL AND METHODS

All children (age<16 years) with appendectomy treated surgically in our department between January 2006 and January 2011 were identified retrospectively. Readmission, reoperation or post-operative length of hospital stay (LOS) exceeding five days were considered non-satisfactory outcomes.

RESULTS

A total of 390 children had an appendectomy performed. The mean age was 9.8 years, and mortality was 0.0%. The surgeon was a resident in 92% of the cases. A total of 246 (63.1%) had an LA. The rate of LA increased over the five-year period from 45% to 88% (p=0.01). The conversion rate decreased from 28% to 15% (p=0.02). The median post-operative LOS was one and three days for simple and complicated appendicitis, respectively. A total of 45 patients (11.5%) had a complication, 40 patients (10.3%) were readmitted, and 56 patients (14.4%) had a non-satisfactory outcome. Logistic regression found open surgery and complicated appendicitis to be associated with an increased risk of complications (p<0.01).

CONCLUSION

Increased use of LA did not increase the number of patients with a non-satisfactory outcome. Residents manage this treatment at a highly professional level. Readmission due to pain and discomfort was frequent and more targeted and systematic post-operative analgesic care of our children is called for.

FUNDING

Not relevant.

TRIAL REGISTRATION

The study was submitted to ClinicalTrials.gov (NCT01657565).

Appendicitis and appendectomies among non-service member beneficiaries of the Military Health System, 2002-2011

Among non-service member beneficiaries of the Military Health System, there were 79,820 cases of appendicitis and 98,385 appendectomies during 2002 to 2011; from the fi rst to last year of the period, the annual number of appendicitis cases increased by 61.1 percent. Perforated acute appendicitis occurred in one quarter of all cases; the proportion of perforated cases was higher among males (30.2%) than females (23.3%). The annual number of total appendectomies decreased during the period; however, outpatient appendectomies increased 5-fold. Th e proportion of inpatient appendectomies that were incidental was greater in females (15.6%) than males (8.8%). During the period, the number of nonincidental appendectomies that were not associated with diagnoses of appendicitis ("negative appendectomies") decreased by 65 percent, and the mean number of inpatient bed days per appendicitis case decreased by one day (21.1%). The findings likely reflect more frequent uses of and advances in diagnostic imaging to detect and characterize appendicitis and a shift in surgical treatment to the outpatient setting with increasing use of laparoscopy for appendectomies.

Appendicitis and appendectomies, active and reserve components, U.S. Armed Forces, 2002-2011

Appendicitis is common among young, healthy populations; appendectomy is one of the most common surgical procedures performed in the United States. Among active and reserve component members, there were 31,610 cases of appendicitis and 30,183 appendectomies during 2002 to 2011. The overall incidence rate of appendicitis in the active component was 18.4 per 10,000 person-years (p-yrs). During the period the incidence rates of appendicitis in the active component and counts in the reserve component increased. Active component males reported greater rates of perforated appendicitis (2.6 per 10,000 p-yrs). Active component females had higher rates of incidental appendectomies (2.6 per 10,000 p-yrs). During the period there was a four-fold increase in outpatient appendectomies, a decrease in nonincidental appendectomies without a diagnosis of appendicitis ("negative appendectomies"), and a decrease in inpatient bed days. The findings likely reflect more frequent uses of and advances in diagnostic imaging to detect and characterize appendicitis and a shift in surgical treatment to the outpatient setting with increasing use of laparoscopy for appendectomies.

Increased use of pre-operative imaging and laparoscopy has no impact on clinical outcomes in patients undergoing appendicectomy

INTRODUCTION

The aim of this study was to review changes in the management of acute appendicitis in a ten-year period at a large university teaching hospital in London.

METHODS

This was a retrospective cohort study reviewing the medical records of patients who underwent an appendicectomy over a period of 12 months either in 1999 or 2009. Data collected included use of radiological investigations (ultrasonography, computed tomography [CT]), technique of appendicectomy (open [OA] or laparoscopic [LA]), operative time, histopathology and post-operative complications. Univariate and multivariate analysis was performed to assess the influence of variables on the incidence of negative appendicectomy, appendiceal perforation and post-operative complications.

RESULTS

All of the patients operated on in 1999 (n=109) had OA. Of the patients operated on in 2009 (n=164), 67 had OA, 91 had LA and 6 had LA converted to OA. None of the patients in 1999 had CT whereas in 2009 26% of patients had CT (sensitivity 94.7%, specificity 75.0%). This increased use of pre-operative imaging had no effect on negative appendicectomy (25.7% vs 12.8%, p=0.445), perforation (30.0% vs 21.3%, p=0.308) or complication rates (9.2% vs 10.4%). The complication rate was also similar regardless of whether patients had OA or LA (11.9% vs 9.9%). Multivariate analysis revealed that age was the only predictor of negative appendicectomy (p=0.029) or perforation (p=0.014).

CONCLUSIONS

This study shows that significant increase in the use of pre-operative imaging and laparoscopy in the management of patients with acute appendicitis failed to reduce negative appendicectomy, perforation and complications rates. The patient's age was the only predictor of negative appendicectomy and perforation.

Laparoscopic appendectomy in children with complicated appendicitis: ethnic disparity amid changing trend

BACKGROUND

Laparoscopic appendectomy (LA) has gained acceptance in the treatment of uncomplicated appendicitis in the pediatric population. The role of LA versus open appendectomy (OA) in complicated (perforated) appendicitis has remained controversial.

METHODS

A 10-y review of the Nationwide Inpatient Sample (HCUP-NIS) and 3 y of non-overlapping data from the Kids' Inpatient Database (KID) (2000, 2003, and 2006) was performed on pediatric patients (age <18 y) with complicated appendicitis. Patients were classified based on gender, race, insurance status, and type of appendectomy performed. Multivariate regression was conducted adjusting for age, race, gender, and type of appendectomy, with mortality and length of hospital stay (LOS) as outcomes.

RESULTS

An estimated 72,787 patients met the inclusion criteria with a median age of 11 y. The majorities of the patients were male (59.9%), Caucasian (38.1%), and insured (89.7%). Twenty-nine percent underwent LA while 71% had OA. Proportion of LA increased from 9.9% in 1999 to 46.6% in 2007. On multivariate analysis, African-Americans were less likely to undergo LA compared with Caucasians (OR: 0.80, CI = 0.69-0.92, P = 0.002) despite an increased odds of undergoing LA over the last decade from 1998 to 2007 in the entire study population (OR 6.27, 95% CI 4.73-8.30, P = 0.000). Increasing age and gender were also associated with likelihood of receiving LA (OR: 1.08, CI = 1.06-1.10 and OR 1.25, 95% CI 1.18-1.31, P < 0.001).

CONCLUSIONS

LA is gradually gaining acceptance over the years as an alternative to OA for complicated appendicitis, However, minority difference still exists in choice of procedure. There is a need to further investigate this disparity as it may be related to access to skilled laparoscopic pediatric surgeons.

Acute appendicitis: a descending trend?

AIM

The diagnosis-related group (DRG) system is a prospective hospital payment system used to categorize hospital patients expected to require similar hospital services. In Italy, hospital productivity is calculated from DRG-based data coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), which is a classification system for coding of diagnoses and operations for indexing medical records by diagnosis and operations. The aim of our survey was to determine the national incidence of appendectomies based on the coded summary of selected data in hospital discharge reports (HDR).

METHODS

The Italian Ministry of Health online database was searched for data collected between 2001 and 2003. The search engine allows analysis by different regions but not by individual hospital. The national incidence of appendectomy was calculated using data collected from the ICD-9-CM and from the HDR. In a deeper analysis, regional data and data from individual hospitals were compared.

RESULTS

The analysis revealed the incidence of appendectomy, rates of simple acute appendicitis vs complicated appendicitis, common laparotomic appendectomy vs laparoscopic appendectomy, as well as mean duration of hospitalization.

CONCLUSION

The incidence of acute appendicitis has considerably decreased, whereas the rates of complicated appendicitis have increased because of longer diagnostic and therapeutic delay, inappropriate antibiotic therapy and upclassifying of diagnosis and procedures in the HDR (ICD-9-CM) in order to obtain a ''wider impact'' on DRG.

Appendicectomy: who performs it, when and how?

A comparative review of changing patterns between 1997 and 2002 of who performs appendicectomy and a snapshot of the surgical approaches in use. It also indicates the stage at which competency in appendicectomy may be achieved by contemporary trainees in surgery and anaesthesia.

Trends in utilization and outcomes of laparoscopic versus open appendectomy

BACKGROUND

Although a number of trials have analyzed the outcomes of laparoscopic versus open appendectomy, the clinical advantages, and cost-effectiveness of laparoscopic appendectomy in the management of acute and perforated appendicitis are still not clearly defined. The aim of this study was to examine utilization and outcomes of laparoscopic versus open appendectomy using a national administrative database of academic medical centers and teaching hospitals.

METHODS

Using ICD-9 diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent appendectomy for acute and perforated appendicitis between 1999 and 2003 (n = 60,236). Trends in utilization of laparoscopic appendectomy were examined over the 5-year period. The outcomes of laparoscopic and open appendectomy were compared including length of hospital stay, 30-day readmission, complications, observed and expected (risk-adjusted) in-hospital mortality, and costs.

RESULTS

Overall, 41,085 patients underwent open appendectomy and 19,151 patients underwent laparoscopic appendectomy. The percentage of appendectomy performed by laparoscopy increased from 20% in 1999 to 43% in 2003 (P <0.01). Compared with patients who underwent open appendectomy, patients who underwent laparoscopic appendectomy were more likely female, more likely white, had a lower severity of illness, and were less likely to have perforated appendicitis. Laparoscopic appendectomy was associated with a shorter length of hospital stay (2.5 days vs 3.4 days), lower rate of 30-day readmission (1.0% vs 1.3%), and lower rate of overall complications (6.1% vs 9.6%). There was no significant difference in the observed to expected mortality ratio between laparoscopic and open appendectomy (0.5 vs 0.6, respectively). The mean cost per case was similar between the two groups (US$ 6,242 vs US$ 6,260).

CONCLUSIONS

Utilization of laparoscopic appendectomy at academic centers has increased more than two-fold between 1999 and 2003. Patients selected for laparoscopic appendectomy have less advanced appendicitis and have a shorter length of stay and fewer complications without increasing the inpatient care cost.

Moving from open to laparoscopic appendicectomy

The argument in favour of laparoscopic appendicectomy

Suspected acute appendicitis: trends in management over 30 years

BACKGROUND

Tradition taught that patients with signs suspicious of acute appendicitis should be explored surgically, but studies in the 1960s found that if this group was closely observed about one-third recovered without treatment. To differentiate these patients a strict regimen of active observation was introduced and this has now been studied over 30 years. Ultrasonography, laparoscopy and computed tomography (CT) have also been used to clarify the diagnosis in these patients.

METHODS

Papers on the management of patients with suspected appendicitis published since 1970 were traced through Index Medicus, English-language journals and Medline. All those that mention the use of observation are reviewed, with selective reports on the other methods used. The advantages and disadvantages of various methods of management are compared.

RESULTS AND CONCLUSION

Active observation has yielded a consistently low negative appendicectomy rate without a rise in the perforation rate; there was one death in over 1600 patients. It has proved to be a practical method of discriminating between patients who do and do not need an operation. In this situation, both ultrasonography and CT yield some false-negative reports, so results must be checked at the bedside. Furthermore, CT involves exposure to significant doses of radiation.

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.

[Acute appendicitis at the National University Hospital in Bangui, Central African Republic: epidemiologic, clinical, paraclinical and therapeutic aspects]

We carried out a retrospective study to analyse clinical, paraclinical and therapeutic aspects of acute appendicitis cases as the National University Hospital (CNHU) at Bangui in the Central African Republic. We compared our findings with those for other African countries and for industrialized countries. From September 15 1990 to February 15 1992, 285 patients underwent laparotomy to treat acute appendicitis. We carried out a study of clinical, paraclinical and therapeutic aspects on 57 patients with complete case histories (20% of the patients undergoing surgery). The appendices of these patients were sent to the Laboratory of Pathological Anatomy of the Faculty of Medicine at Marseille, France, for analysis. The frequency of appendectomy among patients undergoing visceral surgery by laparotomy with no acute traumatic abdominal syndrome was 42.3%. The incidence of appendectomy for the city of Bangui in 1991 was 36.5 per 100,000 inhabitants. These cases of appendicitis were diagnosed essentially on clinical grounds. Leukocyte counts exceeded 10,000 per mm3 in 30% of the patients. Histological examination revealed the presence of parasites in 10 cases : Schistosoma mansoni eggs (seven cases) and Ascaris lumbricoides eggs (one case) in patients with acute appendicitis and one case each of Schistosoma mansoni eggs and Ascaris lumbricoides eggs at the time of diagnosis but normal histological results for the removed appendix. Most of the patients consulted late, a mean of four days after the onset of symptoms. The frequency of appendectomy on principle was 12.7% and parenteral antibiotic treatment was prescribed systematically follow- ing surgery. The mean duration of hospital stay after surgery was 7.6 days. No early postoperative complications were noted. However, two late postoperative complications resulting in the death of the patient were observed, giving a mortality rate of 3.5%. These complications were one case of peritonitis after appendectomy involving intestinal resection and one case of occlusive syndrome with septic shock. The frequency of acute appendicitis at the CNHU at Bangui was similar to that reported in another tropical African country (~ 1%). However, the incidence of appendectomies at Bangui is lower than generally reported for western countries (15 to 40%). Positive diagnosis was made on classic data obtained on clinical examination and on associated biological data, if available. Parasites were identified on histological examination in some cases of acute appendicitis, but it is unclear whether these parasites were actually responsible for the appendicitis. Efficient examinations for the exploration of acute nonspecific abdominal pain, such as the measurement of inflammation indicators, particularly serum activated protein C levels, graded-compression ultrasound scans and celioscopy, should be made available in the hospitals of African countries to increase the precision of diagnosis and to decrease the still too high frequency of appendectomies performed on principle. The postoperative mortality rate at the CNHU of Bangui is higher than the low rates (0.1 to 0.25%) reported for industrialized countries but is close to those reported for African countries. This high rate of mortality results partly from the lateness of consultations, because patients in tropical Africa often consult a traditional healer before resorting to modern medicine, and partly from misdiagnoses.

[Current status of treatment of appendicitis. Results of 2 prospective multicenter studies in East Germany. East German Working Group "Outcome Assessment and Quality Assurance in Surgery" of the CAQ of the German Society of Surgery]

In a period of 10 years we carried out two prospective multicentric trials to evaluate the state of the art in treatment of appendicitis. One study was performed before introduction of laparoscopy. Important criteria like new diagnostic methods (sonography, laparoscopy), frequency of operation, perforation rate, frequency of appendectomies in case of non acute inflammation and postoperative complications were compared.

Is the incidence of acute appendicitis really falling?

To determine if there has been a genuine fall in the incidence of acute appendicitis, an epidemiological study using HAA and Korner datasets for the years 1975-1994 was carried out to identify those children and young adults undergoing appendicectomy for acute appendicitis. The overall incidence of acute appendicitis fell from 1.84/1000 to 1.17/1000. This fall was statistically significant (R2 = 0.74, P < 0.01). The decrease was significant in both males (overall reduction, 34%) and females (overall reduction, 40%). No significant reduction was observed in either males or females between 15 and 19 years of age. The overall reduction remains essentially unexplained, but may have implications for health planning and provision of services.

Appendicectomy in Scotland: a 20-year epidemiological comparison

BACKGROUND

The objective of the research was to study the pattern of appendicectomies in Scotland over the last 20 years.

METHOD

Routine National Health Service data on patients discharged after appendicectomy in Scotland during 1973-1993 were analysed.

RESULTS

For all ages, the appendicectomy rate has fallen steadily from 1.97 per 1000 (10,325 operations) in 1973 to 0.96 per 1000 (4906 operations) in 1993. The proportion of emergency operations increased from 76 to 80 per cent. The median age at operation rose from 18 to 22 years. The proportion of male patients remained higher for emergency operations, whereas the proportion of females, and age at operation, were both higher for non-emergency appendicectomies. In the period 1992-1995, appendicectomy rates were higher for patients with postcodes in areas of greater deprivation, particularly for children aged 0-14 years. Variation in childhood appendicectomy rates across Scotland has declined: apart from Ayrshire and Arran, which had a lower than expected rate, no Health Board had a rate significantly different from the rate in the rest of Scotland in 1993. The case fatality rate fell from 7.0 per 1000 to 1.6 per 1000 (with all the latter deaths in elderly patients).

CONCLUSION

Over the last 20 years, appendicectomy rates have declined in Scotland and there is now greater uniformity of childhood appendicectomy rates across Scotland.

[Effect of minimally invasive technique on the educational curriculum of future surgeons]

The retrospective evaluation of 1219 operations for appendicitis (n = 602) or cholecystolithiasis and/or cholecystitis (n = 617) in the advent of minimal invasive techniques reveals a shift from educational interventions to mere care-taking interventions. In our investigation, we observed a decrease in appendectomies and an increase in cholecystectomies which nevertheless hazards surgical education because of the marked decrease in "teaching operations" in the advent of minimal invasive techniques. This development has to be taken into consideration in order to guarantee a qualified education for future generations of surgeons, and specific measures have to be taken to face this problem effectively.

Pediatric endoscopic surgery: pride and prejudice

82 endoscopic surgical procedures (abdominal: 77; thoracic: 5) were performed by the same surgeon on 75 children aged from 1 month to 17 years (median 8.1 years) during the two-year period from January 1991 to December 1992. Due to the multispecialization of the Children's Hospital, a variety of pathologies were explored or treated with appendectomy accounting for 33% (27/82). There were no perioperative deaths. Three major complications occurred (1 post-appendectomy peritonitis, 1 hemorrhage during splenectomy and 1 post-operative occlusion). 14 patients required conversion to open surgery. Indications for endoscopic exploration of advanced lesions, prospective indications, and policy when confronted with a healthy appendix are discussed.

Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway

We examined the incidence of seven common surgical procedures in seven hospital service areas in southern Norway, in 21 districts in the West Midlands of the United Kingdom, and in the 18 most heavily populated hospital service areas in Vermont, Maine, and Rhode Island. Although surgical rates were higher in the New England states than in the United Kingdom or Norway, there was no greater degree of variability in the rates of surgery among the service areas within the three New England states. Hernia repair was more variable in England (P less than 0.05) and hysterectomy in Norway (P less than 0.05) than in the other countries. There was consistency among countries in the rank order of variability for most procedures: tonsillectomy, hemorrhoidectomy, hysterectomy, and prostatectomy varied more from area to area than did appendectomy, hernia repair, or cholecystectomy. The degree of variation generally appeared to be more characteristic of the procedure than of the country in which it was performed. Thus, differences among countries in the methods of organizing and financing care appear to have little relation to the intrinsic variability in the incidence of common surgical procedures among hospital service areas in these countries. Despite the differences in average rates of use, the degrees of controversy and uncertainty concerning the indications for these procedures seem to be similar among clinicians in all three countries.

Ten-year trends in Canada for selected operations

Of 16 operations common in Canada the national rates over a 10-year period for the 9 discretionary procedures varied much more than those for the nondiscretionary operations. The rates of tonsillectomy and adenoidectomy, hemorrhoidectomy, varicose vein stripping and appendectomy decreased substantially, whereas those of extraction of lens, cesarean section and colectomy increased. The rates of hysterectomy and cholecystectomy first increased and then decreased. With the exception of Newfoundland the provinces generally followed these trends. Neither the Canadian nor the provincial rates were significantly associated with the availability of hospital beds or surgeons. Factors other than resources probably accounted for much of the variation among the provinces.