Risk of colorectal cancer and adenoma after an appendectomy: results from three large prospective cohort studies and meta-analysis.

PURPOSE: The relationship between appendectomy and subsequent colorectal cancer risk remains unclear, and no study has examined its association with colorectal adenoma. METHODS: We used data from three prospective cohorts: Health Professionals Follow-up Study, Nurses' Health Study (NHS), and NHSII. Appendectomy history was self-reported at baseline. Colorectal cancer risk was analyzed with Cox proportional hazard models among 224,109 participants followed up to 32 years. Colorectal adenoma risk was evaluated among 157,490 participants with at least one lower gastrointestinal endoscopy during follow-up with logistic regression models accounting for repeated observations. We also performed a meta-analysis of cohort studies that examined association between appendectomy and colorectal cancer risk. RESULTS: We documented 3,384 colorectal cancers, 13,006 conventional adenomas, and 11,519 serrated polyps during the follow-up period. Compared to participants without appendectomy, those who reported appendectomy history were not at higher risk of colorectal (HR [95% CI], 0.92 [0.84-1.00]), colon (0.92 [0.83-1.01]), or rectal (0.85 [0.70-1.03]) cancer. Similarly, appendectomy history was not associated with higher risk of conventional adenoma (OR [95% CI], 1.00 [0.97-1.02]), serrated polyp (0.97 [0.94-1.00]), or high-risk adenoma (0.96 [0.92-1.01]). The meta-analysis showed appendectomy was associated with a higher risk of colorectal cancer within a short time after the procedure (1.68 [1.01-2.81]), while the long-term risk was slightly inverse (0.94 [0.90-0.97]). CONCLUSION: We found no evidence of an association between appendectomy history and long-term risk of colorectal cancer or its precursors. The observed higher risk of colorectal cancer right after appendectomy in the first few years is likely due to reverse causation.

Extent of Resection and Long-Term Outcomes for Appendiceal Adenocarcinoma: a SEER Database Analysis of Mucinous and non-Mucinous Histologies.

BACKGROUND: Mucinous appendiceal adenocarcinomas (MAA) and non-mucinous appendiceal adenocarcinomas (NMAA) demonstrate differences in rates and patterns of recurrence, which may inform the appropriate extent of surgical resection (i.e., appendectomy versus colectomy). The impact of extent of resection on disease-specific survival (DSS) for each histologic subtype was assessed. PATIENTS AND METHODS: Patients with resected, non-metastatic MAA and NMAA were identified in the Surveillance, Epidemiology, and End Results database (2000-2020). Multivariable models were created to examine predictors of colectomy for each histologic subtype. DSS was calculated using Kaplan-Meier estimates and examined using Cox proportional hazards modeling. RESULTS: Among 4674 patients (MAA: n = 1990, 42.6%; NMAA: n = 2684, 57.4%), the majority (67.8%) underwent colectomy. Among colectomy patients, the rate of nodal positivity increased with higher T-stage (MAA: T1: 4.6%, T2: 4.0%, T3: 17.1%, T4: 21.6%, p < 0.001; NMAA: T1: 6.8%, T2: 11.4%, T3: 25.6%, T4: 43.8%, p < 0.001) and higher tumor grade (MAA: well differentiated: 7.7%, moderately differentiated: 19.2%, and poorly differentiated: 31.3%; NMAA: well differentiated: 9.0%, moderately differentiated: 20.5%, and 44.4%; p < 0.001). Nodal positivity was more frequently observed in NMAA (27.6% versus 16.4%, p < 0.001). Utilization of colectomy was associated with improved DSS for NMAA patients with T2 (log rank p = 0.095) and T3 (log rank p = 0.018) tumors as well as moderately differentiated histology (log rank p = 0.006). Utilization of colectomy was not associated with improved DSS for MAA patients, which was confirmed in a multivariable model for T-stage, grade, and use of adjuvant chemotherapy [hazard ratio (HR) 1.00, 95% confidence interval (CI) 0.81-1.22]. CONCLUSIONS: Colectomy was associated with improved DSS for patients with NMAA but not MAA. Colectomy for MAA may not be required.

Power Has Pitfalls: (In)accuracy of Administrative Data for Nonoperative Management of Appendicitis.

INTRODUCTION: Nonoperative management (NOM) of uncomplicated appendicitis is increasingly common. Effectiveness of NOM has been studied by identifying patients via International Classification of Diseases (ICD) 9/ICD-10 codes for uncomplicated appendicitis and no code for appendectomy. We sought to assess the accuracy of such administrative definitions. METHODS: We retrospectively identified patients with ICD-9/ICD-10 codes for appendicitis at five sites across the United States. Initial management plan and clinical severity were recorded by trained abstractors. We identified a gold standard cohort of patients with surgeon-diagnosed uncomplicated appendicitis and planned NOM. We defined two administrative cohorts with ICD-9/ICD-10 codes for uncomplicated appendicitis and either no surgery during initial admission (definition #1) or no surgery on day 0-1 of admission (definition #2). We compared each definition to the gold standard. RESULTS: Among 1224 patients with uncomplicated appendicitis, 72 (5.9%) underwent planned NOM. NOM patients were older (median [Q1-Q3] of 37 [27-56] versus 32 [25-44] y) and less frequently male (51.4% versus 54.9%), White (54.1% versus 67.6%), and privately insured (38.9% versus 50.2%) than patients managed operatively. Definition #1 had sensitivity of 0.81 and positive predictive value of 0.87 for NOM of uncomplicated appendicitis. Definition #2 had sensitivity of 0.83 and positive predictive value of 0.72. The gold standard cohort had a true failure/recurrence rate of 23.6%, compared with apparent rates of 25.4% and 39.8%, respectively. CONCLUSIONS: Administrative definitions are prone to misclassification in identifying planned NOM of uncomplicated appendicitis. This likely impacts outcomes in studies using administrative databases. Investigators should disclose how misclassification may affect results and select an administrative definition that optimally balances sensitivity and specificity for their research question.

Using Consumer Wearable Devices to Profile Postoperative Complications After Pediatric Appendectomy.

INTRODUCTION: Markers of postoperative recovery in pediatric patients are difficult for parents to evaluate after hospital discharge, who use subjective proxies to assess recovery and the onset of complications. Consumer-grade wearable devices (e.g., Fitbit) generate objective recovery data in near real time and thus may provide an opportunity to remotely monitor postoperative patients and identify complications beyond the initial hospitalization. The aim of this study was to use daily step counts from a Fitbit to compare recovery in patients with complications to those without complications after undergoing appendectomy for complicated appendicitis. METHODS: Children ages 3-17 years old undergoing laparoscopic appendectomy for complicated appendicitis were recruited. Patients wore a Fitbit device for 21 d after operation. After collection, patient data were included in the analysis if minimum wear-time criteria were achieved. Postoperative complications were identified through chart review, and step count trajectories for patients recovering with and without complications were compared. Additionally, to account for the patients experiencing a complication on different postoperative days, median daily step count for pre- and post-complication were analyzed. RESULTS: Eighty-six patients with complicated appendicitis were enrolled in the study, and fourteen children developed a postoperative complication. Three patients were excluded because they did not meet the minimum wear time requirements. Complications were divided into abscesses (n = 7, 64%), surgical site infections (n = 2, 18%), and other, which included small bowel obstruction and Clostridioides difficile infection (n = 2, 18%). Patients presented with a complication on mean postoperative day 8, while deviation from the normative recovery trajectory was evident 4 d prior. When compared to children with normative recovery, the patients with surgical complications experienced a slower increase in step count postoperatively, but the recovery trajectory was specific to each complication type. When corrected for day of presentation with complication, step count remained low prior to the discovery of the complication and increased after treatment resembling the normative recovery trajectory. CONCLUSIONS: This study profiled variations from the normative recovery trajectory in patients with complication after appendectomy for complicated appendicitis, with distinct trajectory patterns by complication type. Our findings have potentially profound clinical implications for monitoring pediatric patients postoperatively, particularly in the outpatient setting, thus providing objective data for potentially earlier identification of complications after hospital discharge.

Using Wearable Devices to Profile Demographic-Specific Recovery After Pediatric Appendectomy.

INTRODUCTION: Counseling patients and parents about the postoperative recovery expectations for physical activity after pediatric appendectomy varies significantly and is not specific to patients' demographic characteristics. Consumer wearable devices (CWD) can be used to objectively assess patients' normative postoperative recovery of physical activity. This study aimed to develop demographic-specific normative physical activity recovery trajectories using CWD in pediatric patients undergoing appendectomy. METHODS: Children ages 3-18 y old undergoing laparoscopic appendectomy for acute appendicitis were recruited. Patients wore a Fitbit device for 21 d postoperatively and daily step counts were measured. Patients with postoperative complications were excluded. Segmented regression models were fitted and time-to-plateau was estimated for patients with simple and complicated appendicitis separately for each age group, sex, race/ethnicity, and body mass index category. RESULTS: Among 147 eligible patients; 76 (51.7%) were female, 86 (58.5%) were in the younger group, and 79 (53.7%) had complicated appendicitis. Patients 3-11 y old demonstrated a faster trajectory to a physical activity plateau compared to those 12-18 in both simple (postoperative day [POD] 9 versus POD 17) and complicated appendicitis (POD 17 versus POD 21). Males and females had a similar postoperative recovery trajectory in simple and complicated appendicitis. There was no clear pattern differentiating trajectories based on race/ethnicity. Overweight/obese patients demonstrated a slower recovery trajectory in simple appendicitis. CONCLUSIONS: This study demonstrates that factors other than the disease itself, such as age, may affect recovery, suggesting the need for more tailored discharge instructions. CWDs can improve our understanding of recovery and allow for better data-driven counseling perioperatively.

National Health Insurance Claim of Pediatric Appendectomy With Mandatory Diagnosis-Related Group Payment System in Korea.

INTRODUCTION: Enforcement of diagnosis-related group system for appendectomy under the National Health Insurance Service has gradually widened and since July 2013 it has been enforced in all medical institutions in Korea. We have analyzed Health Insurance Review & Assessment Service data to observe changes in claim patterns of pediatric appendectomy during this period. METHODS: All claims data for appendectomy of patients younger than 18 y from 2011 to 2015 were collected. We analyzed the following factors of all cases: age, gender, length of hospital stay, medical cost, method of insurance claim and region. RESULTS: A total of 112,143 claims were made for appendectomy during the study period. In that, 66,510 (59.3%) were boys and 45,633 (40.7%) were girls. Median length of stay was 5 d and median sum of reimbursement of each claim was 2,198,630 won. Annual number of claims for appendectomy showed a steady decline from 24,888 in 2011 to 19,070 in 2015. Median sum of reimbursement of each claim was 1,862,615, 1,975,500, 2,233,360, 2,376,700, and 2,468,000 won, respectively from 2011 to 2015. Reimbursement for complicated appendectomy increased from 4400 out of 24,888 cases (17.7%) in 2011 to 3865 out of 19,070 cases (20.3%) in 2015. Overall medical cost of all reimbursement for pediatric appendectomy increased from 46,113,202,580 to 47,572,253,300 won. CONCLUSIONS: Following the universal enforcement of the diagnosis-related group claim system for appendectomy by the National Health Insurance Service, we observed an increase in the median sum of reimbursement per claim and a rise in the rate of claims for complicated appendectomies. These changes were associated with an overall increase in national medical costs.

Evaluation of Limited English Proficiency in the Management and Outcomes of Appendicitis in Children.

INTRODUCTION: Appendectomies are one of the most common pediatric surgical procedures. Limited English proficiency (LEP) may lead to disparities in health outcomes between English-proficient and LEP patients. This study assesses the association between LEP and postoperative outcomes in pediatric appendectomy. METHODS: We analyzed records from the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2010 to 2023 under 18 y of age undergoing appendectomy at our institution. LEP was defined as the need for an interpreter. Primary outcomes were postoperative complications, length of stay (LOS), and postoperative emergency department (ED) visits within 30 d of discharge. Multivariable analyses were performed. RESULTS: One thousand one hundred forty three children with appendicitis were identified, with 208 (18.2%) LEP and 935 (81.8%) English-proficient patients. LEP children were more likely to present with complicated appendicitis (42.8% versus 25.5%, P < 0.0001) and sepsis (34.1% versus 21.6%, P = 0.0003). LEP patients experience more serious (8.6% versus 3.9%, P = 0.02), overall complications (10.1% versus 5.5%, P = 0.006), and organ/surgical space site infections (8.2% versus 3.3%, P = 0.003). On multivariable analysis controlling for ethnicity and factors associated with complicated presentation, LEP was associated with increased postoperative ED visits (adjusted odds ratio [aOR] 2.64, 95% confidence interval [CI] = 1.40-4.39), but not LOS (aOR 1.86, 95% CI = 0.87-3.97) or complications (aOR 1.76, 95% CI = 0.79-4.00). CONCLUSIONS: LEP is independently associated with increased postoperative ED visits. Higher rates of complications and longer LOS may be related to increased complicated appendicitis at presentation. The role of cultural preferences and other social determinants of health that contribute to these disparities needs more investigation.

Daytime versus nighttime appendectomy in term of complications and clinical outcomes: a meta-analysis.

BACKGROUND: Appendicitis is one of the most common acute surgical conditions globally. However, the association between nighttime appendectomy and patients' morbidity and mortality is unclear. This study aims to compare outcomes following nighttime versus daytime appendectomy. METHODS: The PubMed, Embase, Cochrane Library, and Web of Science databases up to March 26, 2024 (updated on July 1, 2024) were searched. The primary outcomes were postoperative complications and mortality. Secondary outcomes included intraoperative complications, reoperation, readmission, conversion to laparotomy, hospital stay and operation time. Mean difference (MD) or odds ratios (OR) and 95% confidence intervals were calculated. RESULTS: Fifteen studies totaling 33,596 patients were included. There were no differences between nighttime and daytime appendectomy for rates of overall postoperative complications (OR 0.93, 95% CI 0.87, 1.00, 14 studies), mortality (OR 1.70, 95% CI 0.37, 7.88, 7 studies), intraoperative complications (OR 0.88, 95% CI 0.08, 9.86; 2 studies), reoperation (OR 0.39, 95% CI 0.06, 2.55; 3 studies) and readmission (OR 0.86, 95% CI 0.65, 1.13; I2 = 0%, 5 studies). However, the conversion to laparotomy risks (OR 1.92, 95% CI 1.12, 3.29; 6 studies) among patients who underwent appendectomy during nighttime was significantly elevated compared to daytime. CONCLUSIONS: There was no increased risk or difference in postoperative mortality and complication rates associated with nighttime compared with daytime appendectomy. However, future studies should assess the reasons for higher conversion rates during the night.

Evaluation of geographic variations in appendicectomy outcomes within Western Australia assessing the impact of surgical wait times and rate of negative appendicectomies in both urban and rural locations statewide.

PURPOSE: Surgery wait times after diagnosis of appendicitis are an important factor influencing the success of a patient's treatment. The proposed study will be a quantitative multicenter retrospective cohort design with the primary aim of assessing the difference between appendicectomy wait times between rural and urban hospitals in Western Australia and the effect of this on operative outcomes. Selected outcome measures will be examined by time from initial presentation at an emergency department to the patient being diagnosed and then time of diagnosis to surgery being performed. The secondary aim is to compare rates of negative appendicectomies between hospitals. METHODS: Appendicectomy patients will be identified from operating room register by medical student data collectors; then, each respective hospital's emergency room data collection will subsequently be accessed to complete case report forms based on demographics and clinical findings, pre-operative investigations, and management and follow-up. Case report forms with > 95% completeness will be accepted for pooled analysis. The expected duration of retrospective data collection will be 8 months. This study RGS6483 has received HREC approval by the Royal Perth Hospital HREC Ethics Committee, with a waiver of consent obtained and the HREC was notified of amendments to the protocol made on April 21, 2024. Dissemination of results. Data will be collected and stored online through a secure server running the Research Electronic Data Capture (REDCap) web application. No patient-identifiable data will be entered into the system. Results will subsequently be shared via scientific journal publication and presentation at relevant meetings.

Ethnic disparities in pediatric appendicitis: the impact of hispanic ethnicity on presentation, complications, and postoperative outcomes.

PURPOSE: Our study investigates ethnic disparities in pediatric appendicitis, focusing on the impact of Hispanic ethnicity on presentation, complications, and postoperative outcomes. METHODS: We conducted a retrospective analysis of pediatric patients undergoing appendectomy for acute appendicitis from 2015 to 2020 using the National Surgical Quality Improvement Program-Pediatric database. We compared 30-day postoperative complications, postoperative length of stay, and postoperative interventions between Hispanic and non-Hispanic White patients. RESULTS: 65,976 patients were included, of which 23,462 (35.56%) were Hispanic and 42,514 (64.44%) non-Hispanic White. Hispanic children were more likely to present to the hospital with complicated appendicitis (31.75% vs. 25.15%, P < 0.0001) and sepsis (25.22% vs. 19.02%, P < 0.0001) compared to non-Hispanic White. Hispanics had higher rates of serious complications (4.06% vs. 3.55%, P = 0.001) but not overall complications (5.37% vs. 5.09%, P = 0.12). However, after multivariate analysis, Hispanic ethnicity was not associated with an increased rate of serious postoperative complications (OR 0.93, CI 0.85-1.01, P = 0.088); it was associated with less overall complications (OR 0.88, CI 0.81-0.96, P = 0.003) but a longer postoperative length of stay (OR 1.09, CI 1.04-1.14, P < 0.0001). CONCLUSION: Hispanic children are more likely to present with complicated appendicitis, contributing to increased postoperative complications. Notably, upon adjustment for the impact of complicated appendicitis, our findings suggest potentially favorable outcomes for Hispanic ethnicity. This emphasizes the need to understand delays in presentation to improve outcomes in the Hispanic population.

Is there a link between appendicitis and the risk of diverticular disease?: a large German cohort study.

PURPOSE: Appendicitis, characterized by inflammation of the vermiform appendix, is a common abdominal emergency necessitating appendectomy. Recent evidence suggests a potential link between appendicitis and subsequent diverticular disease, yet population-based studies investigating this association are limited. METHODS: Utilizing the Disease Analyzer database encompassing data from over 1000 primary care practices in Germany, we conducted a retrospective cohort study. We included 25,379 adults diagnosed with appendicitis and an equal number of matched controls without appendicitis. The incidence of diverticular disease over a 10-year follow-up period was compared between the two cohorts. Cox regression analysis was performed to assess the association between appendicitis and diverticular disease, adjusting for potential confounders. RESULTS: Our findings revealed a significant association between appendicitis and subsequent diverticular disease (HR: 1.76; 95% CI: 1.57-1.97), with an increased risk observed across all age groups. Notably, this association was stronger in men (HR: 2.00; 95% CI: 1.68-2.37) than in women (HR: 1.58; 95% CI: 1.36-1.84). The cumulative 10-year incidence of diverticular disease was higher in patients with appendicitis (6.5%) compared to those without (3.6%). Additionally, we observed a clear age-dependent increase in the incidence of diverticular disease. CONCLUSION: This large-scale population-based study provides valuable insights into the interaction between appendicitis and diverticular disease. The study underscores the need for further research elucidating the underlying mechanisms linking appendicitis to diverticular disease. Probiotics emerge as a potential therapeutic avenue warranting exploration in the management of both conditions. These findings have important implications for clinical practice, highlighting the importance of considering appendicitis as a potential risk factor for diverticular disease, particularly in men. Further investigation is warranted to validate these findings and explore potential therapeutic interventions targeting the shared pathophysiological pathways underlying both conditions.

Beyond a vestigial organ: effects of the appendix on gut microbiome and colorectal cancer.

The role of appendectomy in the pathogenesis of colorectal cancer (CRC) is a recent topic of contention. Given that appendectomy remains one of the most commonly performed operations and a first-line management strategy of acute appendicitis, it is inherently crucial to elucidate the association between prior appendectomy and subsequent development of CRC, as there may be long-term health repercussions. In this review, we summarize the data behind the relationship of CRC in post-appendectomy patients, discuss the role of the microbiome in relation to appendectomy and CRC pathogenesis, and provide an appraisal of our current understanding of the function of the appendix. We seek to piece together the current landscape surrounding the microbiome and immunological changes in the colon post-appendectomy and suggest a direction for future research involving molecular, transcriptomic, and immunologic analysis to complement our current understanding of the alterations in gut microbiome.

The utility of intraperitoneal drain placement after laparoscopic appendectomy for perforated appendicitis in postoperative intraperitoneal abscess prevention.

BACKGROUND: Perforated appendicitis is associated with postoperative development of intraperitoneal abscess. Intraperitoneal drain placement during appendectomy is thought to reduce the risk of developing postoperative intraperitoneal abscess. The aim of this study was to determine whether intraperitoneal drainage could reduce the incidence of intraperitoneal abscess formation after laparoscopic appendectomy for perforated appendicitis. METHODS: This is a retrospective study of all patients (aged 7 and above) who were diagnosed with perforated appendicitis and subsequently underwent laparoscopic appendectomy between January 2018 and December 2022 at two government hospitals in the state of Kuwait. Demographic, clinical, and perioperative characteristics were compared between patients who underwent intraoperative intraperitoneal drain placement and those who did not. The primary outcome was the development of postoperative intraperitoneal abscess. Secondary outcomes included overall postoperative complications, superficial surgical site infection (SSI), length of stay (LOS), readmission and postoperative percutaneous drainage. RESULTS: A total of 511 patients met the inclusion criteria between 2018 and 2022. Of these, 307 (60.1%) underwent intraoperative intraperitoneal drain placement. Patients with and without drains were similar regarding age, sex, and Charlson Comorbidity Index (CCI) (Table 1). The overall rate of postoperative intraperitoneal abscess was 6.1%. Postoperatively, there was no difference in postoperative intraperitoneal abscess formation between patients who underwent intraperitoneal drain placement and those who did not (6.5% vs. 5.4%, p = 0.707). Patients with intraperitoneal drains had a longer LOS (4 [4, 6] vs. 3 [2, 5] days, p < 0.001). There was no difference in the overall complication (18.6% vs. 12.3%, p = 0.065), superficial SSI (2.9% vs. 2.5%, p = 0.791) or readmission rate (4.9% vs. 4.4%, p = 0.835). CONCLUSIONS: Following laparoscopic appendectomy for perforated appendicitis, intraperitoneal drain placement appears to confer no additional benefit and may prolong hospital stay.

Feasibility of a novel unassisted single-channel transcolonic endoscopic appendectomy for the treatment of appendiceal lesions (with video).

BACKGROUND: Transcolonic endoscopic appendectomy (TEA) is rapidly evolving and has been reported as a minimally invasive alternative to appendectomy. We aimed to characterize the feasibility and safety of a novel unassisted single-channel TEA. METHOD: We retrospectively investigated 23 patients with appendicitis or appendiceal lesions who underwent TEA from February 2016 to December 2022. We collected clinicopathological characteristics, procedure­related parameters, and follow­up data and analyzed the impact of previous abdominal surgery and traction technique. RESULTS: The mean age was 56.0 years. Of the 23 patients with appendiceal lesions, fourteen patients underwent TEA and nine underwent traction-assisted TEA (T-TEA). Eight patients (34.8%) had previous abdominal surgery. The En bloc resection rate was 95.7%. The mean procedure duration was 91.1 ± 45.5 min, and the mean wound closure time was 29.4 ± 18.6 min. The wounds after endoscopic appendectomy were closed with clips (21.7%) or a combination of clip closure and endoloop reinforcement (78.3%), and the median number of clips was 7 (range, 3-15). Three patients (13.0%) experienced major adverse events, including two delayed perforations (laparoscopic surgery) and one infection (salvage endoscopic suture). During a median follow-up of 23 months, no residual or recurrent lesions were observed, and no recurrence of abdominal pain occurred. There were no significant differences between TEA and T-TEA groups and between patients with and without abdominal surgery groups in each factor. CONCLUSION: Unassisted single-channel TEA for patients with appendiceal lesions has favorable short- and long-term outcomes. TEA can safely and effectively treat appendiceal disease in appropriately selected cases.

Internal and external factors affecting the performance score of surgical trainees doing laparoscopic appendectomy: a prospective, observational cohort study in a structured training programme.

BACKGROUND: Laparoscopic appendectomy is a common procedure and introduced early in general surgical training. How internal (i.e. surgeon's experience) or external (i.e. disease severity) may affect procedure performance is not well-studied. The aim of this study was to evaluate factors that may have an influence on the performance scores for surgical trainees. METHODS: A prospective, observational cohort study of laparoscopic appendectomies performed by surgical trainees (experience < 4 years) operating under supervision. Trainers evaluated trainees' overall performance on a 6-point scale for proficiency. Perioperative data were recorded, including appendicitis severity, operating time and the overall difficulty of the procedure as assessed by the trainer. A "Challenging" procedure was defined as a combination of either/or "perforation" and "difficult". Trainees who had performed > 30 appendectomies were defined as "experienced". The trainees were asked if they had used simulation or web-based tools the week prior to surgery. RESULTS: 142 procedure evaluation forms were included of which 19 (13%) were "perforated", 14 (10%) "difficult" and 24 (17%) "Challenging". Perforated appendicitis was strongly associated with procedure difficulty (OR 21.2, 95% CI 6.0-75.6). Experienced trainees performed "proficient" more often than non-experienced (OR 34.5, 95% CI 6.8-176.5). "Difficult" procedures were inversely associated with proficiency (OR 0.1, 95% CI 0.0-0.9). In "Challenging" procedures, identifying the appendix had lowest proficiency (OR 0.4, 95% CI 0.1-0.9). The procedures assessed as "difficult" had significantly longer operating time with a median (IQR) of 90 (75-100) min compared to 59 (25-120) min for the non-difficult (p < 0.001). CONCLUSION: Both internal and external factors contribute to the performance score. Perforated appendicitis, technical difficult procedures and trainee experience all play a role, but a "difficult" procedure had most overall impact on proficiency evaluation.

Patients' attitudes toward negative appendectomies and surgery for suspected appendicitis: a qualitative interview study.

INTRODUCTION: From a surgeon's perspective, appendicitis is treated with appendectomy and sometimes a normal appendix is removed. This study aimed to investigate the patients' perspectives on having surgery but not appendicitis and their involvement in treatment decisions. METHODS: This study is reported according to the COnsolidated criteria for REporting Qualitative research (COREQ) guideline. Eligible participants either had a normal diagnostic laparoscopy with no resection of the appendix or a negative appendectomy confirmed by histopathology. Interviews were conducted using a semi-structured interview guide and transcribed verbatim. Data were analyzed using content analysis. RESULTS: This study consisted of 15 interviews. Analysis of the interviews resulted in the formulation of four categories: (1) discovering the results of the histopathology report, (2) thoughts on having a normal appendix removed or left in situ, (3) the scarce use of shared decision-making, and (4) general anesthesia and the risk of a burst appendix made the participants nervous. CONCLUSION: The amount of information communicated to the patients before and after surgery was sparse. The participants were not aware of the histopathology results and the participants were not involved in decision-making and were generally anxious about anesthesia and a burst appendix.

Implementation of artificial intelligence-based computer vision model in laparoscopic appendectomy: validation, reliability, and clinical correlation.

BACKGROUND: Application of artificial intelligence (AI) in general surgery is evolving. Real-world implementation of an AI-based computer-vision model in laparoscopic appendectomy (LA) is presented. We aimed to evaluate (1) its accuracy in complexity grading and safety adherence, (2) clinical correlation to outcomes. METHODS: A retrospective single-center study of 499 consecutive LA videos, captured and analyzed by 'Surgical Intelligence Platform,' Theator Inc. (9/2020-5/2022). Two expert surgeons viewed all videos and manually graded complexity and safety adherence. Automated annotations were compared to surgeons' assessments. Inter-surgeons' agreements were measured. Since 7/2021 videos were linked to patients' admission numbers. Data retrieval from medical records was performed (n = 365). Outcomes were compared between high and low complexity grades. RESULTS: Low and high complexity grades comprised 74.8 and 25.2% of 499 videos. Surgeons' agreements were high (76.9-94.4%, kappa 0.77/0.91; p < 0.001) for all annotated complexity grades. Surgeons' agreements were also high (96.0-99.8%, kappa 0.78/0.87; p < 0.001) for full safety adherence, whereas agreement was moderate in partial safety adherence and none (32.8-58.8%). Inter-surgeons' agreements were high for complexity grading (kappa 0.86, p < 0.001) and safety adherence (kappa 0.88, p < 0.001). Comparing high to low grade complexity, preoperative clinical features were similar, except larger appendix diameter on imaging (13.4 ± 4.4 vs. 10.5 ± 3.0 mm, p < 0.001). Intraoperative outcomes were significantly higher (p < 0.001), including time to achieve critical view of safety (29.6, IQR 19.1-41.6 vs. 13.7, IQR 8.5-21.1 min), operative duration (45.3, IQR 37.7-65.2 vs. 25.0, IQR 18.3-32.7 min), and intraoperative events (39.4% vs. 5.9%). Postoperative outcomes (7.4% vs. 9.2%) including surgical complications, mortality, and readmissions were comparable (p = 0.6), except length of stay (4, IQR 2-5.5 vs. 1, IQR 1-2 days; p < 0.001). CONCLUSION: The model accurately assesses complexity grading and full safety achievement. It can serve to predict operative time and intraoperative course, whereas no clinical correlation was found regarding postoperative outcomes. Further studies are needed.

Video consent significantly improves patient knowledge of general surgery procedures.

INTRODUCTION: Informed consent is essential in ensuring patients' understanding of their medical condition, treatment, and potential risks. The objective of this study was to investigate the impact of utilizing a video consent compared to standard consent for patient knowledge and satisfaction in selected general surgical procedures. METHODS AND PROCEDURES: We included 118 patients undergoing appendectomy, cholecystectomy, inguinal hernia repair, and fundoplication at two hospitals in Omaha, NE. Patients were randomized to either a standard consent or a video consent. Outcomes included a pretest and posttest objective knowledge assessment of their procedure, as well as a satisfaction survey which was completed immediately after consent and following discharge. Given the pre-post design, a linear mixed-effect model was estimated for both outcomes. A two-way interaction effect was of primary interest to assess whether pre-to-post change in the outcome differed between patients randomized to standard or video consent. RESULTS: Baseline characteristics were mostly similar between groups except for patient sex, p = 0.041. Both groups showed a statistically significant increase in knowledge from pretest to posttest (standard group: 0.25, 95% CI 0.01 to 0.51, p = 0.048; video group: 0.68, 95% CI 0.36 to 1.00, p < 0.001), with the video group showing significantly greater change (interaction p = 0.043) indicating that incorporating a video into the consent process resulted in a better improvement in patient's knowledge of the proposed procedure. Further, both groups showed a decrease in satisfaction post-discharge, but no statistically significant difference in the magnitude of decrease between the groups (interaction p = 0.309). CONCLUSION: Video consent lead to a significant improvement in a patient's knowledge of the proposed treatment. Although the patient satisfaction survey didn't show a significant difference, it did show a trend. We propose incorporating videos into the consent process for routine general surgical procedures.

SAGES guideline for the diagnosis and treatment of appendicitis.

BACKGROUND: Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis. METHODS: A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. RESULTS: Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty. CONCLUSIONS: These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.

Learning curve of laparoscopic appendectomy in a low-resource setting: a cumulative sum analysis of operative length.

BACKGROUND: Cumulative sum (CUSUM) analysis is a valuable tool for quantifying the learning curve of surgical teams by detecting significant changes in operative length. However, there is limited research evaluating the learning curve of laparoscopic techniques in low-resource settings. The objective of this study is to evaluate the learning curve for laparoscopic appendectomy within a single surgical team in Senegal. METHODS: This was a single-center prospective study conducted from May 1, 2018, to August 31, 2023 of patients who underwent laparoscopic appendectomy at a tertiary care institution in West Africa. The AAST classification was used to describe the severity of appendicitis. Parameters studied included age, sex, operative length, conversion rate, and postoperative outcomes. To quantify the learning curve, CUSUM analysis of operative length was performed. RESULTS: A total of 81 patients were included. The mean age was 26.7 years (range 11-70 years) with a sex ratio of 1.9. Pre-operative severity according to AAST was Grade I in 75.4% (n = 61), Grade III in 7.4% (n = 6), Grade IV in 6.1% (n = 5), and Grade V in 11.1% (n = 9). Conversion occurred in 5 cases (6.1%). The average operative length was 76.8 min (range 30-180 min) and the average length of hospitalization was 2.7 days (range 1-13 days). Morbidity was observed in 3.7% (n = 3) and there were no deaths. The CUSUM analysis showed that a steady operative length was achieved after 28 procedures, with decreasing operative lengths thereafter. CONCLUSION: Surgeons in our setting overcame the learning curve for laparoscopic appendectomy after performing 28 procedures. Moreover, laparoscopic appendectomy is safe and feasible throughout the learning curve. CUSUM analysis should be applied to other laparoscopic procedures and individualized by surgical teams to improve surgical performance and patient outcomes in low-resource settings.