Comparative analysis of Cochrane and non-Cochrane reviews over three decades.

BACKGROUND: Systematic reviews are viewed as the best study design to guide clinical decision-making as they are the least biased publications assuming they are well-conducted and include well-designed studies. Cochrane was initiated in 1993 with an aim of conducting high-quality systematic reviews. We aimed to examine the publication rates of non-Cochrane systematic reviews (henceforth referred to simply as "systematic reviews") and Cochrane reviews produced throughout Cochrane's existence and characterize changes throughout the period. METHODS: This observational study collected data on systematic reviews published between 1993 and 2022 in PubMed. Identified Cochrane reviews were linked to data from the Cochrane Database of Systematic Reviews via their Digital Object Identifier. Systematic reviews and Cochrane reviews were analyzed separately. Two authors screened a random sample of records to validate the overall sample, providing a precision of 98%. RESULTS: We identified 231,602 (94%) systematic reviews and 15,038 (6%) Cochrane reviews. Publication of systematic reviews has continuously increased with a median yearly increase rate of 26%, while publication of Cochrane reviews has decreased since 2015. From 1993 to 2002, Cochrane reviews constituted 35% of all systematic reviews in PubMed compared with 3.5% in 2013-2022. Systematic reviews consistently had fewer authors than Cochrane reviews, but the number of authors increased over time for both. Chinese first authors conducted 15% and 4% of systematic reviews published from 2013-2022 and 2003-2012, respectively. Most Cochrane reviews had first authors from the UK (36%). The native English-speaking countries the USA, the UK, Canada, and Australia produced a large share of systematic reviews (42%) and Cochrane reviews (62%). The largest publishers of systematic reviews in the last 10 years were gold open access journals. CONCLUSIONS: Publication of systematic reviews is increasing rapidly, while fewer Cochrane reviews have been published through the last decade. Native English-speaking countries produced a large proportion of both types of systematic reviews. Gold open access journals and Chinese first authors dominated the publication of systematic reviews for the past 10 years. More research is warranted examining why fewer Cochrane reviews are being published. Additionally, examining these systematic reviews for research waste metrics may provide a clearer picture of their utility.

Appendectomy versus antibiotic treatment for acute appendicitis.

BACKGROUND: Acute appendicitis is one of the most common emergency general surgical conditions worldwide. Uncomplicated/simple appendicitis can be treated with appendectomy or antibiotics. Some studies have suggested possible benefits with antibiotics with reduced complications, length of hospital stay, and the number of days off work. However, surgery may improve success of treatment as antibiotic treatment is associated with recurrence and future need for surgery. OBJECTIVES: To assess the effects of antibiotic treatment for uncomplicated/simple acute appendicitis compared with appendectomy for resolution of symptoms and complications. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and two trial registers (World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov) on 19 July 2022. We also searched for unpublished studies in conference proceedings together with reference checking and citation search. There were no restrictions on date, publication status, or language of publication. SELECTION CRITERIA: We included parallel-group randomised controlled trials (RCTs) only. We included studies where most participants were adults with uncomplicated/simple appendicitis. Interventions included antibiotics (by any route) compared with appendectomy (open or laparoscopic). DATA COLLECTION AND ANALYSIS: We used standard methodology expected by Cochrane. We used GRADE to assess the certainty of evidence for each outcome. Primary outcomes included mortality and success of treatment, and secondary outcomes included number of participants requiring appendectomy in the antibiotic group, complications, pain, length of hospital stay, sick leave, malignancy in the antibiotic group, negative appendectomy rate, and quality of life. Success of treatment definitions were heterogeneous although mainly based on resolution of symptoms rather than incorporation of long-term recurrence or need for surgery in the antibiotic group. MAIN RESULTS: We included 13 studies in the review covering 1675 participants randomised to antibiotics and 1683 participants randomised to appendectomy. One study was unpublished. All were conducted in secondary care and two studies received pharmaceutical funding. All studies used broad-spectrum antibiotic regimens expected to cover gastrointestinal bacteria. Most studies used predominantly laparoscopic surgery, but some included mainly open procedures. Six studies included adults and children. Almost all studies aimed to exclude participants with complicated appendicitis prior to randomisation, although one study included 12% with perforation. The diagnostic technique was clinical assessment and imaging in most studies. Only one study limited inclusion by sex (male only). Follow-up ranged from hospital admission only to seven years. Certainty of evidence was mainly affected by risk of bias (due to lack of blinding and loss to follow-up) and imprecision. Primary outcomes It is uncertain whether there was any difference in mortality due to the very low-certainty evidence (Peto odds ratio (OR) 0.51, 95% confidence interval (CI) 0.05 to 4.95; 1 study, 492 participants). There may be 76 more people per 1000 having unsuccessful treatment in the antibiotic group compared with surgery, which did not reach our predefined level for clinical significance (risk ratio (RR) 0.91, 95% CI 0.87 to 0.96; I2 = 69%; 7 studies, 2471 participants; low-certainty evidence). Secondary outcomes At one year, 30.7% (95% CI 24.0 to 37.8; I2 = 80%; 9 studies, 1396 participants) of participants in the antibiotic group required appendectomy or, alternatively, more than two-thirds of antibiotic-treated participants avoided surgery in the first year, but the evidence is very uncertain. Regarding complications, it is uncertain whether there is any difference in episodes of Clostridium difficile diarrhoea due to very low-certainty evidence (Peto OR 0.97, 95% CI 0.24 to 3.89; 1 study, 1332 participants). There may be a clinically significant reduction in wound infections with antibiotics (RR 0.25, 95% CI 0.09 to 0.68; I2 = 16%; 9 studies, 2606 participants; low-certainty evidence). It is uncertain whether antibiotics affect the incidence of intra-abdominal abscess or collection (RR 1.58, 95% CI 0.61 to 4.07; I2 = 19%; 6 studies, 1831 participants), or reoperation (Peto OR 0.13, 95% CI 0.01 to 2.16; 1 study, 492 participants) due to very low-certainty evidence, mainly due to rare events causing imprecision and risk of bias. It is uncertain if antibiotics prolonged length of hospital stay by half a day due to the very low-certainty evidence (MD 0.54, 95% CI 0.06 to 1.01; I2 = 97%; 11 studies, 3192 participants). The incidence of malignancy was 0.3% (95% CI 0 to 1.5; 5 studies, 403 participants) in the antibiotic group although follow-up was variable. Antibiotics probably increased the number of negative appendectomies at surgery (RR 3.16, 95% CI 1.54 to 6.49; I2 = 17%; 5 studies, 707 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS: Antibiotics may be associated with higher rates of unsuccessful treatment for 76 per 1000 people, although differences may not be clinically significant. It is uncertain if antibiotics increase length of hospital stay by half a day. Antibiotics may reduce wound infections. A third of the participants initially treated with antibiotics required subsequent appendectomy or two-thirds avoided surgery within one year, but the evidence is very uncertain. There were too few data from the included studies to comment on major complications.

The microbiome of the appendix differs in patients with and without appendicitis: A prospective cohort study.

BACKGROUND: Appendicitis seems to be a disease of infectious origin, but the detailed pathogenesis is unknown. We aimed to investigate the microbiome of the appendix lumen in patients with and without appendicitis, including a comparison of the subgroups of complicated versus uncomplicated appendicitis. METHODS: This prospective observational cohort study included adult patients undergoing laparoscopic appendectomy for suspected appendicitis. According to histopathologic findings, the investigated groups consisted of patients with and without appendicitis, including subgroups of complicated versus uncomplicated appendicitis based on the surgical report. A swab of the appendix lumen was analyzed for genetic material from bacteria with shotgun metagenomics, and outcomes included analyses of microbiome diversity and differential abundance of bacteria. RESULTS: A total of 53 swabs from patients with suspected appendicitis were analyzed: 42 with appendicitis (16 complicated) and 11 without appendicitis. When comparing patients with and without appendicitis, they were equally rich in bacteria (alpha diversity), but the microbiome composition was dissimilar between these groups (beta diversity) (P < .01). No consistent bacterial species were detected in all patients with appendicitis, but a least 3 genera (Blautia, Faecalibacterium, and Fusicatenibacter) and 2 species, Blautia faecis and Blautia wexlerae, were more abundant in patients without appendicitis. For the subgroups complicated versus uncomplicated appendicitis, both measures for microbiome diversity were similar. CONCLUSION: The appendix microbiome composition of genetic material from bacteria in adult patients with and without appendicitis differed, but the microbiome was similar for patients with complicated versus uncomplicated appendicitis. Trial registration NCT03349814.

Clinical decision rules for appendicitis are not used by surgeons in training: A survey.

BACKGROUNDS: We aimed to investigate surgeons in training knowledge of clinical decision rules (CDR) for diagnosing appendicitis and their attitudes toward implementing them. METHODS: We included surgeons in training practicing in East Denmark who independently could decide to perform a diagnostic laparoscopy for suspected appendicitis. The survey was developed in Research Electronic Data Capture and face-validated before use. It consisted of three parts: (1) the characteristics of the surgeons, (2) their diagnostic approach, and (3) their knowledge and attitude toward introducing CDR in the clinic. Data were collected in January 2023. RESULTS: We achieved 83 (90%) responses, and 52% of surgeons in training believed that appendicitis was difficult to diagnose. Their diagnostic approach mostly included symptoms and physical examinations for abdominal pain, and C-reactive protein. A total of 48% knew of at least one clinical decision rule, and 72% had never used a clinical decision rule. Regarding the necessity of CDR in clinical practice, surgeons in training options were divided into thirds: not needed, neither needed nor not needed, and needed. Surgeons in training indicated that CDR needed to be validated and easily applied before they would implement them. CONCLUSION: Approximately 3/4 of surgeons in training had never utilized a clinical decision rule to diagnose appendicitis, and only half knew of their existence. The symptoms and findings incorporated in most CDR aligned with their diagnostic approach. They were conflicted if CDR needed to be implemented in clinical practice.

Parenteral Fosfomycin in Gastrointestinal Surgery: A Systematic Review.

BACKGROUND: To investigate if perioperative parenteral administration of fosfomycin given before or during gastrointestinal surgery could protect against postoperative infectious complications and characterise the administration of fosfomycin and its harms. METHODS: This systematic review included original studies on gastrointestinal surgery where parental administration of fosfomycin was given before or during surgery to≥5 patients. We searched three databases on March 24 2023 and registered the protocol before data extraction (CRD42020201268). Risk of bias was assessed with Cochrane Handbook risk of bias assessment tool or the Newcastle-Ottawa Scale. A narrative description was undertaken. For infectious complications, results from emergency and elective surgery were presented separately. RESULTS: We included 15 unique studies, reporting on 1,029 patients that received fosfomycin before or during gastrointestinal surgery. Almost half of the studies were conducted in the 1980s to early 1990s, and typically a dose of 4 g fosfomycin was given before surgery co-administered with metronidazole and often repeated postoperatively. The risk of bias across studies was moderate to high. The rates of infectious complications were low after fosfomycin; the surgical site infection rate was 0-1% in emergency surgery and 0-10% in elective surgery. If reported, harms were few and mild and typically related to the gastrointestinal system. CONCLUSION: There were few postoperative infectious complications after perioperative parenteral administration of one or more doses of 4 g fosfomycin supplemented with metronidazole in various gastrointestinal procedures. Fosfomycin was associated with few and mild harms.

Christmas article: Well-being in hot weather ­ a randomised crossover trial.

Introduction While some studies have investigated the cooling properties of warm beverages, no studies have examined thermal well-being in warm environments in relation to beverage temperature. Methods Thirty researchers were randomised in a 1:1 ratio in a double-blinded cross-over study. Participants were randomised to drink 10cl of 10°C and 50°C decaffeinated tea, 15 minutes apart while staying outside in the Turkish summer heat at noon. Well-being was assessed using the American Society of Heating, Refrigeration and Air-conditioning Engineers (ASHRAE) thermal sensation scale, Bedford thermal comfort scale, Brief Mood Introspection Scale (BMIS), and the last two domains of EuroQol 5-domain, 5-point scale: EQ-5D-5L. Results Neither clinically nor statistically significant differences were found in well-being between warm and cold tea. Moods soured significantly as the trial course passed (using BMIS, µ 1.9; P=0.03), but comfort in the heat bettered (using Bedford, µ -0.37; P less-than 0.001). These changes were not considered to be clinically significant. Conclusion We were unable to show any correlation between beverage temperature and comfort in a hot environment. The mood of participants did, however, deteriorate as time passed-a lesson to any future researchers conducting drawn-out experiments just before lunch. Funding none. Trial registration NCT05900960.

A survey of preoperative diagnosis and management of complicated appendicitis.

INTRODUCTION: Complicated appendicitis is a severe condition, requiring early diagnosis and intervention to prevent complications. We aimed to investigate how resident surgeons distinguish and manage complicated appendicitis and their perspectives on preoperative diagnostic markers. METHODS: The electronic survey was face validated. It contained questions about demographics, resident surgeons' considerations on the preoperative diagnosis of complicated appendicitis, and views on the need for and relevance of preoperative diagnostic markers. It was sent to all resident surgeons in the Eastern part of Denmark. RESULTS: Seven hospitals and their 92 resident surgeons received the survey, and 90% responded. Most resident surgeons used symptoms and signs of pain to diagnose suspected complicated appendicitis. Half of the surgeons used computed tomographies, and 95% used routine blood tests. Most surgeons (83%) would change the management of patients with preoperatively diagnosed complicated appendicitis in comparison to uncomplicated appendicitis. However, only 17% felt the need for a preoperative diagnostic marker. CONCLUSIONS: Resident surgeons in Eastern Denmark use non-specific diagnostic techniques to distinguish complicated from uncomplicated appendicitis and would change treatment if appendicitis was diagnosed preoperatively. However, despite limited interest, our results suggest a need for new diagnostic markers to differentiate between the severity of appendicitis, thus enhancing education and training in managing such cases. FUNDING: None. TRIAL REGISTRATION: None.

Mesh versus non-mesh for emergency groin hernia repair.

BACKGROUND: A groin hernia is a collective name for inguinal and femoral hernias, which can present acutely with incarceration or strangulation of the hernia sac content, requiring emergency treatment. Timely repair of emergency groin hernias is crucial due to the risk of reduced blood supply and thus damage to the bowel, but the optimal surgical approach is unclear. While mesh repair is the standard treatment for elective hernia surgery, using mesh for emergency groin hernia repair remains controversial due to the risk of surgical site infection. OBJECTIVES: To assess the benefits and harms of mesh compared with non-mesh in emergency groin hernia repair in adult patients with an inguinal or femoral hernia. SEARCH METHODS: On 5 August 2022, we searched the following databases: CENTRAL, MEDLINE Ovid, and Embase Ovid, as well as two trial registers for ongoing and completed trials. Additionally, we performed forward and backward citation searches for the included trials and relevant review articles. We searched without any language or publication restrictions. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing mesh with non-mesh repair in emergency groin hernia surgery in adults. We included any mesh and any non-mesh repairs. All studies fulfilling the study, participant, and intervention criteria were included irrespective of reported outcomes. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodology. We presented dichotomous data as risk ratios (RR) with 95% confidence intervals (CI). We based missing data analysis on best- and worst-case scenarios. For outcomes with sufficiently low heterogeneity, we performed meta-analyses using the random-effects model. We analysed subgroups when feasible, including the degree of contamination. We used RoB 2 for risk of bias assessment, and summarised the certainty of evidence using GRADE. MAIN RESULTS: We included 15 trials randomising 1241 participants undergoing emergency groin hernia surgery with either mesh (626 participants) or non-mesh hernia repair (615 participants). The studies were conducted in China, the Middle East, and South Asia. Most patients were men, and most participants had an inguinal hernia (41 participants had femoral hernias). The mean/median age in the mesh group ranged from 35 to 70 years, and from 41 to 69 years in the non-mesh group. All studies were performed in a hospital emergency setting (tertiary care) and lasted for 11 to 139 months, with a median study duration of 31 months. The majority of the studies only included participants with clean to clean-contaminated surgical fields. For all outcomes, we considered the certainty of the evidence to be very low, mainly downgraded due to high risk of bias (due to deviations from intended intervention and missing outcome data), indirectness, and imprecision. Mesh hernia repair may have no effect on or slightly increase the risk of 30-day surgical site infections (RR 1.66, 95% CI 0.96 to 2.88; I² = 21%; 2 studies, 454 participants) when compared with non-mesh hernia repair, but the evidence is very uncertain. The evidence is also very uncertain about the effect of mesh hernia repair compared with non-mesh hernia repair on 30-day mortality (RR 1.38, 95% CI 0.58 to 3.28; 1 study, 208 participants). In summary, the results showed 70 more (from 5 fewer to 200 more) surgical site infections and 29 more (from 32 fewer to 175 more) deaths within 30 days of mesh hernia repair per 1000 participants compared with non-mesh hernia repair. The evidence is very uncertain about 90-day surgical site infections after mesh versus non-mesh hernia repair (RR 1.00, 95% CI 0.15 to 6.64; 1 study, 60 participants; very low-certainty evidence). No 30-day recurrences were recorded, and mesh hernia repair may not reduce recurrence within one year (RR 0.19, 95% CI 0.04 to 1.03; I² = 0%; 2 studies, 104 participants; very low-certainty evidence). Within 30 days of hernia repair, no meshes were removed from clean to clean-contaminated fields, but 6.7% of meshes (1 study, 208 participants) were removed from contaminated to dirty surgical fields. Among the four studies reporting 90-day mesh removal, no events occurred. We were not able to identify any studies reporting complications classified according to the Clavien-Dindo Classification or reoperation for complications within 30 days of repair. AUTHORS' CONCLUSIONS: Our results show that in terms of 30-day surgical site infections, 30-day mortality, and hernia recurrence within one year, the evidence for the use of mesh hernia repair compared with non-mesh hernia repair in emergency groin hernia surgery is very uncertain. Unfortunately, firm conclusions cannot be drawn due to very low-certainty evidence and meta-analyses based on small-sized and low-quality studies. There is a need for future high-quality RCTs or high-quality registry-based studies if RCTs are unfeasible.

Erectile Dysfunction Is Common after Rectal Cancer Surgery: A Cohort Study.

Erectile dysfunction is a known late complication following surgery for rectal cancer. We aimed to determine the prevalence of erectile dysfunction after rectal cancer surgery and characterize it. This was a prospective observational cohort study. Data from men after surgery for rectal cancer were collected between October 2019 and April 2023. The primary outcome was the prevalence of erectile dysfunction following surgery based on the International Index of Erectile Function questionnaires, IIEF-5 and 15. Secondary outcomes were prevalence in subgroups and self-perceived erectile function. In total, 101 patients agreed to participate, while 67 patients (67%) responded after a median six-month follow-up after surgery. Based on IIEF-15, 84% of the patients had erectile dysfunction. For subgroups, 74% of patients who underwent robot-assisted surgery had erectile dysfunction, whereas all patients who underwent either laparoscopic or open surgery had erectile dysfunction (p = 0.031). Furthermore, half of the patients rated their self-perceived ability to obtain and keep an erection as very low. In conclusion, in our cohort, erectile dysfunction was common after rectal cancer surgery, and half of the patients were unconfident that they could obtain and keep an erection. Information regarding this finding should be given so that patients feel comfortable discussing therapeutic solutions if needed.

A qualitative study of groin hernia management in adolescents.

INTRODUCTION: Groin hernias in adolescents are rare and their management is associated with challenges for surgeons as some adolescents are fully grown, whereas others are not. Current groin hernia guidelines only differentiate between young children and adults; hence, no guidelines exist that may aid surgeons in handling adolescents. The aim of this study was to explore surgeons' considerations on the management of groin hernias in adolescents. METHODS: We conducted a qualitative study using pilot-tested individual semi-structured interviews. The participants were surgical specialists with experience in groin hernia repair in adolescents aged 10-17 years. Data were analysed using content analysis where essential quotes were extracted from transcripts and coded, categorised and interpreted into themes. RESULTS: Sixteen surgeons were included. Their considerations were reflected in four themes: 1) mesh-related concerns, 2) watchful waiting, 3) growth and 4) lack of evidence and guidelines. Surgeons performed sutured repairs on adolescents who are still growing due to concerns about mesh-related complications. A watchful waiting strategy was used by some to postpone surgery until adolescents were fully grown, thereby enabling mesh repair. Methods for evaluating growth varied and were not standardised. Finally, surgeons highlighted the need for evidence and guidelines to support their decision-making. CONCLUSIONS: This study found a lack of consensus and uniformity on the management of groin hernias in adolescents. Increased research efforts producing clinical guidelines are needed. FUNDING: This study was funded by the Michaelsen Foundation, the Aage and Johanne Louis-Hansens Foundation, Direktør Emil C. Hertz and Hustru Inger Hertz' Foundation, and the Torben and Alice Frimodts Foundation. The funders had no role in the design, conduct or reporting of the study. TRIAL REGISTRATION: not relevant.

The Alvarado Score Is the Most Impactful Diagnostic Tool for Appendicitis: A Bibliometric Analysis.

INTRODUCTION: The objective of this bibliometric analysis was to investigate the citation pattern of studies that have developed a diagnostic tool to diagnose appendicitis. METHODS: We investigated characteristics of citations, publication frequency, evolution of citations, and fluctuation of previously highly cited studies. We analyzed which studies had been cited in the method section and identified impactful studies in this research field by a network visualization. We analyzed the differences in citations between diagnostic tools requiring a doctor to be present against the diagnostic tools not requiring doctors to be present, English language studies against non-English studies, and identified diagnostic tools targeting children. RESULTS: There was an upward trend in publications in this research field, and between 1999-2021 the Alvarado score has been cited the most. In general, there was a high fluctuation, and 40 studies had been cited in the methods sections. There were significant differences in studies regarding diagnostic tools written in English compared to non-English studies, with more citations in the English-language studies. Furthermore, 22 studies had children as the target population. CONCLUSIONS: The Alvarado score was the highest cited study since 1999, with 1086 citations, making it the most impactful study in this research field of diagnostic tools to diagnose appendicitis. Due to the diversity of target populations and settings for which diagnostic tools are developed, there is a need to expand research on diagnostic tools for appendicitis.

Other Pathologies Were Rarely Reported after Laparoscopic Surgery for Suspected Appendicitis: A Systematic Review and Meta-Analysis.

BACKGROUND: Diagnostic laparoscopy is often used when a patient is suspected of having acute appendicitis. The aim of this study was to assess the rate of other pathologies found during diagnostic laparoscopy for suspected acute appendicitis. METHODS: This systematic search included studies with ≥100 patients who received laparoscopy for suspected acute appendicitis and reported on the histopathologic and other intra-abdominal findings. We performed a meta-analysis estimating the rate of other pathologies, and a sensitivity analysis excluding smaller cohorts (≤500 patients). Age groups, sex, specific findings, and geographic regions were investigated. Certainty of evidence was assessed with GRADE. RESULTS: A total of 27 studies were included covering 25,547 patients and of these 793 had an unexpected pathology. The findings were benign pathology in the appendix (34%), malignancy (30%), gynecologic pathology (5%), gastrointestinal pathology (4%), or unspecified (27%). Meta-analysis showed an overall rate of unexpected findings of 3.5% (95% CI 2.7-4.3; moderate certainty), and the sensitivity analysis showed similar results. Malignancy found in the appendix when treating suspected acute appendicitis was 1.0% (95% CI 0.8-1.3%; high certainty). CONCLUSION: The rate of other histopathological findings in patients with suspected acute appendicitis was low and a malignancy in appendix was found in 1% of patients.

Varying negative appendectomy rates after laparoscopic appendectomy: a systematic review and meta-analysis.

PURPOSE: Appendicitis is a common cause of acute abdominal pain, and treatment with laparoscopy has become increasingly common during the past two decades. Guidelines recommend that normal appendices are removed if operated for suspected acute appendicitis. It is unclear how many patients are affected by this recommendation. The aim of this study was to estimate the rate of negative appendectomies in patients undergoing laparoscopic surgery for suspected acute appendicitis. METHODS: This study was reported following the PRISMA 2020 statement. A systematic search was conducted in PubMed and Embase for retrospective or prospective cohort studies (with n ≥ 100) including patients with suspected acute appendicitis. The primary outcome was the histopathologically confirmed negative appendectomy rate after a laparoscopic approach with a 95% confidence interval (CI). We performed subgroup analyses on geographical region, age, sex, and use of preoperative imaging or scoring systems. The risk of bias was assessed using the Newcastle-Ottawa Scale. Certainty of the evidence was assessed using GRADE. RESULTS: In total, 74 studies were identified, summing up to 76,688 patients. The negative appendectomy rate varied from 0% to 46% in the included studies (interquartile range 4-20%). The meta-analysis estimated the negative appendectomy rate to be 13% (95% CI 12-14%) with large variations between the individual studies. Sensitivity analyses did not change the estimate. The certainty of evidence by GRADE was moderate due to inconsistency in point estimates. CONCLUSION: The overall estimated negative appendectomy rate after laparoscopic surgery was 13% with moderate certainty of evidence. The negative appendectomy rate varied greatly between studies.

Diarrhoea-causing microorganisms are rare in adult patients undergoing diagnostic laparoscopy for suspected appendicitis: a prospective observational cohort study.

We investigated if diarrhoea-causing bacteria, including Yersinia species, could mimic the symptoms of appendicitis and lead to surgery. This prospective observational cohort study (NCT03349814) included adult patients undergoing surgery for suspected appendicitis. Rectal swabs were analysed with polymerase chain reaction (PCR) for Yersinia, Campylobacter, Salmonella, Shigella and Aeromonas spp. Blood samples were analysed routinely and with an in-house ELISA serological test for Yersinia enterocolitica antibodies. We compared patients without appendicitis and patients with appendicitis confirmed by histopathology. The outcomes included PCR-confirmed infection with Yersinia spp., serologic-confirmed infection with Y. enterocolitica, PCR-confirmed infection with other diarrhoea-causing bacteria and Enterobius vermicularis confirmed by histopathology. A total of 224 patients were included, 51 without and 173 with appendicitis, and followed for 10 days. PCR-confirmed infection with Yersinia spp. was found in one patient (2%) without appendicitis and no patients (0%) with appendicitis (p = 0.23). Serology was positive for Y. enterocolitica for the same patient without appendicitis and two patients with appendicitis (p = 0.54). Campylobacter spp. were detected in 4% vs 1% (p = 0.13) of patients without and with appendicitis, respectively. Infection with Yersinia spp. and other diarrhoea-causing microorganisms in adult patients undergoing surgery for suspected appendicitis was rare.

Many diagnostic tools for appendicitis: a scoping review.

BACKGROUND: We aimed to provide an overview of all diagnostic tools developed to diagnose appendicitis with their reported accuracy and to further characterize these including their need for diagnostic equipment. METHODS: This scoping review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews and a protocol was registered at Open Science Framework. We performed a systematic literature search in PubMed, Embase, China National Knowledge Infrastructure, Índice Bibliográfico Espanhol de Ciências da Saúde, and Latin American and Caribbean Health Sciences Literature. We included original articles of all languages with the purpose to derive an accessible diagnostic tool. We extracted data regarding study- and diagnostic tool characteristics, and the accuracy of each diagnostic tool. RESULTS: The search led to 6419 records, where 74 studies were included, yielding 82 diagnostic tools reported in seven different languages. Among these tools, 35% included patient characteristics, 85% symptoms, 93% physical examinations, 37% vital signs, 78% laboratory values, and 16% imaging. Among the diagnostic tools, 35% relied on a medical doctor/surgeon with access to a laboratory, and six diagnostic tools did not require a bedside medical doctor/surgeon. The median positive predictive value, negative predictive value, sensitivity, and specificity across diagnostic tools were 91%, 94%, 89%, and 86%, respectively. CONCLUSIONS: We identified 82 diagnostic tools that most frequently were based on symptoms and physical examinations. Most diagnostic tools relied on a medical doctor/surgeon with access to laboratory values. The accuracy was high across the diagnostic tools.

Celestial risk factors in groin hernia repair and random statistical association: a nationwide register-based study.

AIM: We aimed to investigate how celestial phenomena like zodiac signs, lunar phases, and Friday the 13th impacted the risk of reoperation after groin hernia repair. METHODS: We conducted a nationwide register-based study based on the Danish Hernia Database and Danish Patient Safety Authority's Online Register between 2000-2019. We included patients ≥18 years undergoing open Lichtenstein or laparoscopic groin hernia repair. The main outcomes were risk of reoperation after groin hernia repair in relation to patient and surgeon zodiac sign, lunar phase at the time of the repair, and Friday the 13th vs other Fridays. RESULTS: 151,901 groin hernias were included in the analysis of patient zodiac sign, and 25,075 groin hernias were included in the analysis of surgeon zodiac sign. Compared with the Sagittarius, there was a significantly higher risk of reoperation (HR [95% CI]) if the performing surgeon was born under the Capricorn (1.93 [1.16-3.12]); Pisces (1.68 [1.09-2.57]); Aries (1.61 [1.07-2.38]); Taurus (1.62 [1.04-2.54]); Cancer (2.21 [1.48-3.28]); or Virgo (1.71 [1.13-2.59]). Repairs performed under the waxing (1.23 [1.03-1.46]) and the new moon (1.54 [1.11-2.13]) had significantly higher risk of reoperation (HR [95% CI]) compared with the waning moon. Neither patient zodiac sign nor Friday the 13th affected risk of reoperation after groin hernia repair. CONCLUSIONS: Surgeons' zodiac sign and lunar phase significantly affected the risk of reoperation after groin hernia repair. Neither patients' zodiac sign nor Friday the 13th influenced on the risk of reoperation after groin hernia repair. This indicates why significant findings should be considered carefully to distinguish between random statistical association and cause-and-effect relations.

Risk of Reoperation for Recurrence After Elective Primary Groin and Ventral Hernia Repair by Supervised Residents.

Importance: Surgical training involves letting residents operate under supervision. Since hernia repair is a common procedure worldwide, it is a frequent part of the surgical curriculum. Objective: To assess the risk of reoperation for recurrence after elective primary groin and ventral hernia repair performed by supervised residents compared with that by specialists. Design, Setting, and Participants: This nationwide register-based cohort study included data from January 2016 to September 2021. Patients were followed up until reoperation, emigration, death, or the end of the study period. The study used data from the Danish Inguinal and Ventral Hernia Databases linked with data from the Danish Patient Safety Authority's Online Register via surgeons' unique authorization ID. The cohort included patients aged 18 years or older who underwent primary elective hernia repairs performed by supervised residents or specialists for inguinal, femoral, epigastric, or umbilical hernias. Hernia repairs were divided into the following 4 groups: Lichtenstein groin, laparoscopic transabdominal preperitoneal (TAPP) groin, open ventral, and laparoscopic ventral. Exposures: Hernia repairs performed by supervised residents vs specialists. Main Outcomes and Measures: Reoperation for recurrence, analyzed separately for all 4 groups. Results: A total of 868 specialists and residents who performed 31 683 primary groin and 7777 primary ventral hernia repairs were included in this study. The median age of patients who underwent hernia repair was 60 years (IQR, 48-70 years), and 33 424 patients (84.7%) were male. There was no significant difference in the adjusted risk of reoperation after Lichtenstein groin hernia repair (hazard ratio [HR], 1.26; 95% CI, 0.99-1.59), laparoscopic groin hernia repair (HR, 1.01; 95% CI, 0.73-1.40), open ventral hernia repair (HR, 0.89; 95% CI, 0.61-1.29), and laparoscopic ventral hernia repair (HR, 2.96; 95% CI, 0.99-8.84) performed by supervised residents compared with those by specialists. There was, however, a slightly increased unadjusted, cumulative reoperation rate after Lichtenstein repairs performed by supervised residents compared with those by specialists (4.8% vs 4.2%; P = .048). Conclusions and Relevance: The findings of this study suggest that neither open nor laparoscopic repair of groin and ventral hernias performed by supervised residents appeared to be associated with a higher risk of reoperation for recurrence compared with the operations performed by specialists. This indicates that residents may safely perform elective hernia repair when supervised as part of their training curriculum.

Individual biomarkers in the blood are not yet applicable in diagnosing complicated appendicitis: A scoping review.

BACKGROUND: Appendicitis is one of the most common surgical emergencies globally and it can both be difficult to diagnose but also to differentiate complicated from uncomplicated appendicitis preoperatively. The objective of this scoping review was to develop an overview of biomarkers in blood discriminating complicated from uncomplicated appendicitis and characterize their applicability in an acute setting including time, cost, and analysis technique required as well as their individual precision. METHOD: This scoping review was reported in accordance with PRISMA-ScR. The included studies had to report on biomarkers measured in the blood for at least ten patients with suspected appendicitis. A systematic literature search was conducted on August 28, 2022, in PubMed and Embase but restricted to articles published in January 2000 and onwards. A protocol was uploaded to Open Science Framework prior to data extraction. RESULTS: A total of 65 biomarkers were included from 52 studies, covering 14,312 patients. There was 60% routine- and 40% novel biomarkers based on the reported analysis technique. The most frequently investigated biomarkers within each group were white blood cell count and procalcitonin. The routine biomarkers were of low financial cost but poor diagnostic accuracy with sensitivity ranging between 15 and 100% and specificity between 27 and 100%. Novel markers were costly ranging from 275 to 800$, and their diagnostic accuracy was based on limited population sizes (median 34 patients) and reported for only 5% of the novel markers. CONCLUSION: Routine biomarkers were applicable in an acute setting but had poor diagnostic accuracy. Novel biomarkers are being investigated for potential, but the concept is still premature due to lack of diagnostic accuracy studies reporting cost-benefit for individual markers and whether they can be applied in an acute setting.

Validity of the coding for appendicitis, appendectomy, and diagnostic laparoscopy in the Danish National Patient Registry.

BACKGROUND AND OBJECTIVE: We aimed to validate the diagnostic accuracy of appendicitis, its severity, its description, and the surgical approach, including open or laparoscopic appendectomy and diagnostic laparoscopy, in the Danish National Patient Registry (DNPR) against information from the electronic medical records. METHODS: A random sample of 1046 patients of all ages and sexes recorded in the DNPR from the Capital Region of Denmark during 2010-2015 was investigated. Patients' admission had to include a discharge code for appendicitis (K35-K379) according to the International Classification of Disease version 10 (ICD-10) alone or in combination with a surgical code for appendectomy or the surgical code for a diagnostic laparoscopy. We calculated the positive predictive values (PPVs) with 95% confidence intervals. RESULTS: Data from a total of 1018 patients were available for data analysis. The ICD-10 codes for appendicitis resulted in a good PPV of >95% when combined with a surgical code. ICD-10 codes combined with the surgical codes could discriminate between uncomplicated and complicated appendicitis with some caution as the PPVs ranged from 68% to 93%. Only the surgical code for laparoscopic appendectomy yielded a good PPV (99%) for the actual surgical approach. The surgical code for a diagnostic laparoscopy alone did not cover a normal diagnostic laparoscopy. CONCLUSIONS: The diagnostic accuracy of appendicitis and appendectomy in routinely collected administrative health data is good for ICD-10 codes for appendicitis in combination with a surgical code and especially for laparoscopic appendectomy. Uncomplicated and complicated appendicitis can be distinguished with some caution.