Clinical outcomes of children with COVID-19 and appendicitis: a propensity score matched analysis.

OBJECTIVE: Early in the COVID-19 pandemic, many children with appendicitis and COVID-19 were initially treated non-operatively and later underwent interval appendectomy. Currently, children with both appendicitis and COVID-19 frequently undergo upfront appendectomy. The impact of this return to upfront surgical management on patient outcomes is unknown. This study compared outcomes of pediatric patients with and without COVID-19 infection undergoing appendectomy. STUDY DESIGN: A retrospective cohort study of children < 21y who underwent appendectomy from 3/19/2020 to 7/31/2022 at 50 Pediatric Health Information System children's hospitals was conducted. Children with documented COVID-19 were identified. Exclusions included preoperative ventilator or supplemental oxygen dependence, and missing data. To evaluate COVID-19 positive versus COVID-19 negative patients, we used a propensity score matched on sociodemographics, comorbidities, laparoscopy, perforation, and hospital. Chi-square and Mann-Whitney U tests identified differences between groups in length of stay, postoperative drain placement, 30-day re-admission, and mechanical ventilation requirements. RESULTS: Overall, 51,861 children of median age 11y (IQR: 8-14) underwent appendectomy, of whom 1,440 (2.3%) had COVID-19. Most were male (60.3%), White (72.1%) and non-Hispanic (61.4%). Public insurance was the most common (47.5%). We created a matched cohort of 1,360 COVID-19 positive and 1,360 COVID-19 negative children. Children with COVID-19 had shorter hospitalizations (1d, IQR: 1-4 vs. 2d, IQR: 1-5, p = 0.03), less postoperative peritoneal drain placement (2.4% vs. 4.1%, p = 0.01), and fewer 30-day readmissions (9.0% vs. 11.4%, p = 0.04). However, no difference in incidence or duration of mechanical ventilation (p > 0.05) was detected. CONCLUSIONS: Our findings suggest that upfront appendectomy for children with appendicitis and COVID-19 has similar outcomes compared to children without COVID-19. LEVEL OF EVIDENCE: Level III.

Nationwide prospective audit for the evaluation of appendicitis risk prediction models in adults: right iliac fossa treatment (RIFT)-Turkey.

BACKGROUND: Appendicitis is the most prevalent surgical emergency. The negative appendicectomy rate and diagnostic uncertainty are important concerns. This study aimed to assess the effectiveness of current appendicitis risk prediction models in patients with acute right iliac fossa pain. METHODS: A nationwide prospective observational study was conducted, including all consecutive adult patients who presented with right iliac fossa pain. Diagnostic, clinical and negative appendicectomy rate data were recorded. The Alvarado score, Appendicitis Inflammatory Response (AIR), Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Adult Appendicitis Score systems were calculated with collected data to classify patients into risk categories. Diagnostic value and categorization performance were evaluated, with use of risk category-based metrics including 'true positive rate' (percentage of appendicitis patients in the highest risk category), 'failure rate' (percentage of patients with appendicitis in the lowest risk category) and 'categorization resolution' (true positive rate/failure rate). RESULTS: A total of 3358 patients from 84 centres were included. Female patients were less likely to undergo surgery than men (71.5% versus 82.5% respectively; relative risk 0.866, 95% c.i. 0.834 to 0.901, P < 0.001); with a three-fold higher negative appendicectomy rate (11.3% versus 4.1% respectively; relative risk 2.744, 95% c.i. 2.047 to 3.677, P < 0.001). Ultrasonography was utilized in 56.8% and computed tomography in 75.2% of all patients. The Adult Appendicitis Score had the best diagnostic performance for the whole population; however, only RIPASA was significant in men. All scoring systems were successful in females patients, but Adult Appendicitis Score had the highest area under the receiver operating characteristic curve value. The RIPASA and the Adult Appendicitis Score had the best categorization resolution values, complemented by their exceedingly low failure rates in both male and female patients. Alvarado and AIR had extremely high failure rates in men. CONCLUSION: The negative appendicectomy rate was low overall, but women had an almost three-fold higher negative appendicectomy rate despite lower likelihood to undergo surgery. The overuse of imaging tests, best exemplified by the 75.2% frequency of patients undergoing computed tomography, may lead to increased costs. Risk-scoring systems such as RIPASA and Adult Appendicitis Score appear to be superior to Alvarado and AIR.

Association of complicated appendicitis with geographic and socioeconomic measures in children.

BACKGROUND: Complicated appendicitis, considered a marker of delay in accessing surgical care among children, has been inconsistently associated with race, socioeconomic status, insurance type, rurality, and distance to care. This statewide assessment measured factors associated with complicated appendicitis while overcoming limitations of prior work, namely, selection bias and use of inexact socioeconomic status measures. METHODS: Children (<18 years) undergoing appendectomy for appendicitis in Wisconsin from 2018 to 2021 were identified in the Wisconsin Hospital Association database. Patient residence and hospital locations were used to determine rurality, travel distances, and socioeconomic status as measured by Area Deprivation Index, Child Opportunity Index, Community Need Index, and county-level poverty rates. Multivariable logistic regression was used to assess factors associated with complicated appendicitis. RESULTS: Among 5,881 children undergoing appendectomy, 1,375 (23.4%) had complicated appendicitis. Adjusting for other variables, complicated appendicitis was associated with younger age (adjusted odds ratio 0.90 per year increase); Hispanic White race/ethnicity (adjusted odds ratio 1.40-1.63); distance to the hospital where surgery was performed (adjusted odds ratio 1.16-1.17 per 10-mile increase); and very low Child Opportunity Index (adjusted odds ratio 1.29), Community Need Index (adjusted odds ratio 1.20 per 1-score increase), and county-level poverty (adjusted odds ratio 1.02 per 1% increase). Insurance type, rurality, and Area Deprivation Index were not associated with complicated appendicitis. Residential county-level complicated appendicitis rates (0.0%-50.0%) had moderate correlation to pediatric county-level poverty rates (rs=0.43). CONCLUSION: Complicated appendicitis was associated with Child Opportunity Index, Community Need Index, and county-level poverty but not insurance type, rurality, or Area Deprivation Index. There was geographic variability in complicated appendicitis rates, with modest correlation to county-level poverty. Targeted interventions among Hispanic populations and those with travel- and socioeconomic status-related barriers to care may be beneficial in preventing complicated appendicitis among children.

Appendiceal neoplasms in Saudi Arabia: prevalence and clinicopathological profile.

BACKGROUND: The appendix is a small organ with no particular known function. Primary appendiceal neoplasms (ANs) are rare. While the prevalence is increasing worldwide over the past two decades, no apparent increase in the prevalence of ANs has been reported in the Arabian Gulf States. Recently, a significant decline in the age at diagnosis of some types of ANs has been reported worldwide, with a female predominance. OBJECTIVES: Evaluate the prevalence and clinicopathological characteristics of ANs within our institution in Saudi Arabia and compare them to limited existing studies from different regions as well as the Arabian Gulf States. DESIGN: Retrospective cohort. SETTING: Tertiary care center in Riyadh. PATIENTS AND METHODS: All patients who underwent appendectomy and had the appendix submitted for histopathological evaluation between May 2015 and June 2020 were included to allow for a follow-up of 5 years or more at the time of data collection. MAIN OUTCOME MEASURES: Demographics, clinical presentations, surgical interventions, histopathological findings, complications, and recurrence rates. SAMPLE SIZE: 25 AN patients. RESULTS: Of 1110 patients, 25 had ANs (13 female and 12 male participants) with a mean (standard deviation) age of 54.6 (14.1) years. Only 40% presented with acute appendicitis, 64% had comorbidities, and less than 50% underwent laparoscopic appendectomy. Histopathologically, 72% were low-grade appendiceal mucinous neoplasms (LAMNs). Complications were minimal grades (Clavien-Dindo classification), with 80% experiencing none. The mean hospital stay was 9.96 days. Local recurrence occurred in 8% of cases, and distant metastasis was documented in one adenocarcinoma case. However, the 5-year overall and disease-free survival rates were 88% and 80%, respectively. CONCLUSIONS: The incidence of ANs is increasing in Saudi Arabia with the higher prevalence of LAMNs. The pathological examination of the resected appendix played a pivotal role in the diagnosis of ANs. LIMITATIONS: Data collected retrospectively, a single institution, and a small population.

Appendicectomy pathway: Insights from electronic medical records of a local health district in Australia.

BACKGROUND: This study aims to identify the common pathways of appendicectomy, the most common emergency surgery in Australia's public hospitals and any variations within a regional public health district in New South Wales, Australia. METHODS: We analyzed the electronic medical records of 3,943 patients who underwent appendicectomy between January 2014 and July 2020 at 2 hospitals in the Illawarra Shoalhaven Local Health District, New South Wales, Australia, using the PM2 approach for surgical pathway identification and subsequent statistical analyses. RESULTS: Among 3,943 patients, 3,606 (91.5%) followed an 11-step main pathway: (1) emergency department admission, (2) surgery booking, (3) anesthesia start, (4) operating room entry, (5) surgery start, (6) surgery end, (7) anesthesia end, (8) operating room discharge, (9) postanesthesia care unit admission, (10) postanesthesia care unit discharge, and (11) hospital discharge. The median length of stay was 48.13 hours (interquartile range 32.74). The main pathway differed from either variation 1 (n = 246, 6.2%) or variation 2 (n = 30, 0.8%) only in the timing and location of anesthesia administration or conclusion. Variation 3 (n = 26, 0.7%) included patients who underwent appendicectomy twice, whereas variation 4 (n = 25, 0.6%) included patients booked for surgery before emergency department admission through community doctor referrals. Thirteen exceptional cases experienced combinations of the aforementioned pathways. The length of stay and phase durations varied between the main pathway and these variations. CONCLUSION: The appendicectomy pathway was largely standardized across the studied hospitals, with the location of anesthesia administration or conclusion affecting specific stages but not the overall length of stay. Only a complex 2-surgery pathway increased length of stay.

Laparoscopy experience in East, Central, and Southern Africa: insights from operative case volume analysis.

BACKGROUND: With the primary objective of addressing the disparity in global surgical care access, the College of Surgeons of East, Central, and Southern Africa (COSECSA) trains surgeons. While sufficient operative experience is crucial for surgical training, the extent of utilization of minimally invasive techniques during COSECSA training remains understudied. METHODS: We conducted an extensive review of COSECSA general surgery trainees' operative case logs from January 1, 2015, to December 31, 2020, focusing on the utilization of minimally invasive surgical procedures. Our primary objective was to determine the prevalence of laparoscopic procedures and compare this to open procedures. We analyzed the distribution of laparoscopic cases across common indications such as cholecystectomy, appendicitis, and hernia operations. Additionally, we examined the impact of trainee autonomy, country development index, and hospital type on laparoscopy utilization. RESULTS: Among 68,659 total cases, only 616 (0.9%) were laparoscopic procedures. Notably, 34 cases were conducted during trainee external rotations in countries like the United Kingdom, Germany, and India. Gallbladder and appendix pathologies were most frequent among the 582 recorded laparoscopic cases performed in Africa. Laparoscopic cholecystectomy accounted for 29% (276 of 975 cases), laparoscopic appendectomy for 3% (76 of 2548 cases), and laparoscopic hernia repairs for 0.5% (26 of 5620 cases). Trainees self-reported lower autonomy for laparoscopic (22.5%) than open cases (61.5%). Laparoscopy usage was more prevalent in upper-middle-income (2.7%) and lower-middle-income countries (0.8%) compared with lower-income countries (0.5%) (p < 0.001). Private (1.6%) and faith-based hospitals (1.5%) showed greater laparoscopy utilization than public hospitals (0.5%) (p < 0.001). CONCLUSIONS: The study highlights the relatively low utilization of minimally invasive techniques in surgical training within the ECSA region. Laparoscopic cases remain a minority, with variations observed based on specific diagnoses. The findings suggest a need to enhance exposure to minimally invasive procedures to ensure well-rounded training and proficiency in these techniques.

Characteristics of and cost of care for children with impaired development and acute appendicitis: A study of two national databases.

BACKGROUND: Characteristics of children with impaired development who have acute appendicitis are not well described in the literature. METHODS: We reviewed the National Surgical Quality Improvement Program-Pediatric and the multicenter Pediatric Health Information System for patients with acute appendicitis. Comparisons for demographics, clinical outcomes, and hospital charges between children with impaired development versus neurotypical children were made using independent t test or Wilcoxon rank sum tests. The multivariable logistic regression model estimated the odds of complicated acute appendicitis in impaired development patients. Based on correlation analyses, hierarchical linear modeling was used to examine the extent to which impaired development influenced resource use. RESULTS: Patients with impaired development were younger, had higher comorbidities, and were more commonly male sex. In the National Surgical Quality Improvement Program-Pediatric database, impaired development was associated with higher rates of complicated acute appendicitis (33.6% vs 27.5, P < .001), particularly in older children, and higher usage of computed tomography at National Surgical Quality Improvement Program-Pediatric hospitals (23.1% vs 15.1%, P < .001). In the Pediatric Health Information System database, the adjusted odds of complicated acute appendicitis were significantly higher in patients with impaired development (1.20 [1.09-1.31]), low childhood opportunity level (1.39 [95% confidence interval: 1.31-1.47]), and Black race (1.25 [1.17-1.33]). Hierarchical adjusted linear modeling showed that impaired development was associated with significantly higher hospital charges (9% increase). CONCLUSION: Management of acute appendicitis in children with impaired development remains a challenge to clinicians, as evidenced by the higher rate of perforated appendicitis in older children, diagnostic computed tomography use at National Surgical Quality Improvement Program-Pediatric hospitals, postoperative computed tomography use, and increased costs.

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.

Pathological Assessment of the Appendix in Appendectomies Performed in Children.

BACKGROUND: Acute appendicitis is known as the most common diagnosis of acute abdomen leading to surgery. Therefore, timely diagnosis is of special importance. This study was conducted with the aim of pathological assessment of the appendix in appendectomies performed in children to determine the rate of negative appendectomies and the predictors of negative appendectomy and to evaluate the paraclinical tools used in the diagnosis of acute appendicitis. METHODS: This is a cross-sectional descriptive study. All children who underwent appendectomy at Shahid Motahari Hospital in Urmia from March 2021 to March 2022 were examined. The required data including demographic, paraclinical, and final pathology characteristics were collected and recorded. The investigated cases were classified into positive and negative appendectomy categories for comparison. RESULTS: Among 234 pathology samples of the appendix, 22 cases were related to accidental appendectomy. In addition, 11.3% of cases were negative appendectomy and 88.7% were positive appendectomy. The age range of 8 to 14 years and male gender were associated with a lower negative appendectomy rate (both P<0.001). Inflammatory (49.5%) and gangrenous appendicitis (30.2%) were the most commonly reported histopathologies. Sonography had a sensitivity of 84%, a specificity of 79%, and an overall diagnostic accuracy of 83%. CONCLUSION: A relatively significant number of accidental and negative appendectomies are performed. More careful investigation and the use of expectant and medical treatment instead of surgery, especially in females and young children, can be effective in improving diagnostic accuracy and preventing negative appendectomies.

Determination of Risk Factors for Nausea and Vomiting in Children After Appendectomy.

PURPOSE: This study aimed at investigating the risk factors for postoperative nausea and vomiting (PONV) in pediatric patients undergoing appendectomy. DESIGN: This is a prospective, descriptive, cross-sectional study. METHODS: The study involved 163 children aged 5 to 18 years who underwent appendectomy in the pediatric surgery clinic of a tertiary hospital between December 2022 and June 2023. The study data were collected through the patient information form, Baxter Retching Faces scale, and Wong-Baker Faces Pain Rating Scale, which included questions about the descriptive and clinical characteristics of the participants and was prepared by the researcher consistent with the literature. FINDINGS: A significant relationship was observed between the severity of postoperative pain and the occurrence of PONV in patients with both nonperforated and perforated appendicitis (P < .001). In addition, operative time and the time to the first oral feeding were shorter in patients with nonperforated appendicitis in the non-PONV group (P = .005 and P = .042, respectively) Logistic regression analysis revealed that postoperative pain, family history of PONV and appendix perforation were risk factors for PONV in children with both nonperforated and perforated appendicitis (P < .001, P = .040, and P < .001, respectively). CONCLUSIONS: In children undergoing appendectomy, family history of PONV, severity of postoperative pain, increased operative time, and increased transition time to oral feeding are risk factors for PONV. Pediatric nurses, who have an important role in the management of PONV, should evaluate patients in terms of PONV risk in the preoperative period within the scope of evidence-based practices and perform pharmacological or nonpharmacological interventions according to the degree of risk.

Management of Uncomplicated Appendicitis in Adults: A Nationwide Analysis From 2018 to 2019.

INTRODUCTION: Nonoperative management (NOM) of uncomplicated appendicitis (UA) has been increasingly utilized in recent years. The aim of this study was to describe nationwide trends of sociodemographic characteristics, outcomes, and costs of patients undergoing medical versus surgical management for UA. METHODS: The 2018-2019 National (Nationwide) Inpatient Sample was queried for adults (age ≥18 y) with UA; diagnosis, as well as laparoscopic and open appendectomy, were defined by the International Classification of Diseases, 10th Revision, Clinical Modification codes. We examined several characteristics, including cost of care and length of hospital stay. RESULTS: Among the 167,125 patients with UA, 137,644 (82.4%) underwent operative management and 29,481 (17.6%) underwent NOM. In bivariate analysis, we found that patients who had NOM were older (53 versus 43 y, P < 0.001) and more likely to have Medicare (33.6% versus 16.1%, P < 0.001), with higher prevalence of comorbidities such as diabetes (7.8% versus 5.5%, P < 0.001). The majority of NOM patients were treated at urban teaching hospitals (74.5% versus 66.3%, P < 0.001). They had longer LOS's (5.4 versus 2.3 d, P < 0.001) with higher inpatient costs ($15,584 versus $11,559, P < 0.001) than those who had an appendectomy. Through logistic regression we found that older patients had up to 4.03-times greater odds of undergoing NOM (95% CI: 3.22-5.05, P < 0.001). CONCLUSIONS: NOM of UA is more commonly utilized in patients with comorbidities, older age, and those treated in teaching hospitals. This may, however, come at the price of longer length of stay and higher costs. Further guidelines need to be developed to clearly delineate which patients could benefit from NOM.

Appendectomy and Risk of Prostate Cancer in the Health Professionals Follow-up Study.

BACKGROUND: Appendectomy is a common surgical procedure to treat appendicitis. Limited studies have examined its association with prostate cancer, with one large cohort study suggesting a significantly increased risk of overall and advanced prostate cancer, especially among younger men. METHODS: A total of 49,104 men in the Health Professionals Follow-up Study were followed from 1986 to 2016. Cox proportional hazards models were applied to evaluate the association between self-reported history of appendectomy and risk of overall and subtype-specific prostate cancer, adjusted for multiple risk factors. RESULTS: During 30 years of follow-up, we documented 7,253 overall prostate cancer cases, including 579 advanced and 1,092 lethal events. Compared to men without appendectomy, those who reported at baseline having had appendectomy were not at higher risk of overall [HR, 1.01; 95% confidence interval (CI), 0.95-1.07], advanced (HR, 0.99; 95% CI, 0.81-1.23), or lethal (HR, 1.04; 95% CI, 0.89-1.20) prostate cancer. The association remained null when stratified by age. CONCLUSIONS: We found no evidence of an association between appendectomy and the risk of overall and clinically important prostate cancer. IMPACT: We showed that appendectomy was not associated with overall or advanced prostate cancer after adjusting for multiple risk factors in a large population of men with 30 years of follow-up.

Retrospective analysis of the incidence of appendiceal neoplasm and malignancy in patients treated for suspected acute appendicitis.

BACKGROUND: Nonoperative management of uncomplicated appendicitis is currently being promoted as treatment option, albeit 0.7-2.5% of appendectomies performed due to suspected acute appendicitis show histologically malignant findings. The purpose of this study was to investigate the incidence of neoplasm and malignancy of the appendix in patients presenting with suspected acute appendicitis in real world setting. METHODS: This is a retrospective single-centre investigation of 457 patients undergoing appendectomy between the years 2017-2020. The patients' demographics, symptoms and diagnosis, intraoperative findings, and histopathological results were analysed. RESULTS: In 3.7% (n = 17) histological analysis revealed neoplasms or malignancies. Median age was 48 years (20-90 years), without sex predominance. Leukocytes (11.3 ± 3.7 G/l) and C-reactive protein (54.2 ± 69.0 mg/l) were elevated. Histological analysis revealed low-grade mucinous appendiceal neoplasia (n = 3), sessile serrated adenoma of the appendix (n = 3), neuroendocrine tumours (n = 7), appendiceal adenocarcinoma of intestinal type (n = 3), and goblet cell carcinoma (n = 1). Additional treatment varied between no treatment or follow-up due to early tumour stage (n = 4), follow-up care (n = 3), additional surgical treatment (n = 8), or best supportive care (n = 2). CONCLUSIONS: Preoperative diagnosis of appendiceal tumours is difficult. Nonoperative management of patients with acute, uncomplicated appendicitis potentially prevents the correct diagnosis of malignant appendiceal pathologies. Therefore, close follow-up or surgical removal of the appendix is mandatory.

Validation and comparison of two new scoring systems for the prediction of complicated versus uncomplicated appendicitis.

OBJECTIVES: To validate the Atema and APSI scoring systems in the diagnosis of complicated vs uncomplicated appendicitis. To compare these scoring systems with computed tomography (CT) imaging alone to establish which method provides most accurate prediction of complicated vs uncomplicated appendicitis. METHODS: This was a retrospective review of a sample of 160 patients that underwent appendicectomy and CT imaging for suspected appendicitis between 2018 and 2021 in a tertiary university teaching hospital. Each scoring system was applied to all patients and results analysed and compared with the effectiveness of CT imaging, RESULTS: 32.5% (n = 52) were found to have complicated appendicitis and 67.5% (n = 108) uncomplicated appendicitis. Application of the Atema score to our cohort of patients resulted in a sensitivity 76.9% [CI (64.2, 87.5), specificity 58.7% [CI (48.9, 68.1)], PPV 47.1% [CI (40.5, 53.8) and NPV 84.2% [CI (76.0, 89.9)]. By comparison, the APSI yielded a sensitivity 50.9% [CI (36.6, 65.4)], specificity 76.1% [CI (67.0, 87.8)], PPV 50% [CI (39.2, 60.6)] and NPV 76% [CI (71.1, 81.7)]. Radiology prediction of complicated vs uncomplicated appendicitis with CT imaging showed sensitivity 46% [CI (32.2, 60.5)], specificity 79%; [CI (69.8, 86)], PPV 51% [CI (39.6, 62.5)] and NPV 75% [CI (69.8, 79.9)]. CONCLUSION: By comparing the APSI and Atema et al. scoring systems with CT reporting in our hospital, it appears that the Atema may confer some benefit in stratifying patient risk of complicated versus uncomplicated appendicitis. Further larger scale prospective studies are required.

Retrospective study of patients submitted to appendectomy in a tertiary hospital: is there a difference between the public and supplementary health system?

Introduction: Appendicitis is the surgical disease with the highest prevalence in emergency rooms. Its clinical and/or surgical complications are associated with the time course of symptoms, age, comorbidities, and stages of the disease. Objectives: To analyze the demographic and clinical data of patients who underwent appendectomy for acute appendicitis in a tertiary referral hospital in the city of São Paulo and compare these data between services provided by the Public and Supplementary Health System. Methodology: Retrospective analysis of data from electronic medical records of patients over 14 years old who underwent appendectomy for acute appendicitis at Hospital Santa Marcelina, both in the Public and Supplementary Health Systems from January 2015 to December 2017. Results: A total of 536 patients were analyzed, 354 (66%) of whom were male with a general mean age of 29.85 years (14-81 years). The mean time from symptoms to seeking medical care was 53.84 hours. Regarding the phases of acute appendicitis, a greater number of cases of complicated disease was observed in patients operated on in the Public Health System (p < 0.0001), as well as the time course of symptoms (p = 0.0005) and Conclusion: There was a predominance of male patients undergoing appendectomy for acute appendicitis, with longer time course of symptoms in those operated on in the Public Health System and a predominance of appendicitis in advanced stages (3 and 4) in this group. However, in this group there was no significant increase in the rate of postoperative infection, and the length of stay was shorter than that of patients operated on in the Supplementary Health System. (AU)

Trial Participation and Outcomes Among English-Speaking and Spanish-Speaking Patients With Appendicitis Randomized to Antibiotics: A Secondary Analysis of the CODA Randomized Clinical Trial.

Importance: Spanish-speaking participants are underrepresented in clinical trials, limiting study generalizability and contributing to ongoing health inequity. The Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial intentionally included Spanish-speaking participants. Objective: To describe trial participation and compare clinical and patient-reported outcomes among Spanish-speaking and English-speaking participants with acute appendicitis randomized to antibiotics. Design, Setting, and Participants: This study is a secondary analysis of the CODA trial, a pragmatic randomized trial comparing antibiotic therapy with appendectomy in adult patients with imaging-confirmed appendicitis enrolled at 25 centers across the US from May 1, 2016, to February 28, 2020. The trial was conducted in English and Spanish. All 776 participants randomized to antibiotics are included in this analysis. The data were analyzed from November 15, 2021, through August 24, 2022. Intervention: Randomization to a 10-day course of antibiotics or appendectomy. Main Outcomes and Measures: Trial participation, European Quality of Life-5 Dimensions (EQ-5D) questionnaire scores (higher scores indicating a better health status), rate of appendectomy, treatment satisfaction, decisional regret, and days of work missed. Outcomes are also reported for a subset of participants that were recruited from the 5 sites with a large proportion of Spanish-speaking participants. Results: Among eligible patients 476 of 1050 Spanish speakers (45%) and 1076 of 3982 of English speakers (27%) consented, comprising the 1552 participants who underwent 1:1 randomization (mean age, 38.0 years; 976 male [63%]). Of the 776 participants randomized to antibiotics, 238 were Spanish speaking (31%). Among Spanish speakers randomized to antibiotics, the rate of appendectomy was 22% (95% CI, 17%-28%) at 30 days and 45% (95% CI, 38%-52%) at 1 year, while in English speakers, these rates were 20% (95% CI, 16%-23%) at 30 days and 42% (95% CI 38%-47%) at 1 year. Mean EQ-5D scores were 0.93 (95% CI, 0.92-0.95) among Spanish speakers and 0.92 (95% CI, 0.91-0.93) among English speakers. Symptom resolution at 30 days was reported by 68% (95% CI, 61%-74%) of Spanish speakers and 69% (95% CI, 64%-73%) of English speakers. Spanish speakers missed 6.69 (95% CI, 5.51-7.87) days of work on average, while English speakers missed 3.76 (95% CI, 3.20-4.32) days. Presentation to the emergency department or urgent care, hospitalization, treatment dissatisfaction, and decisional regret were low for both groups. Conclusions and Relevance: A high proportion of Spanish speakers participated in the CODA trial. Clinical and most patient-reported outcomes were similar for English- and Spanish-speaking participants treated with antibiotics. Spanish speakers reported more days of missed work. Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Emergency General Surgery Procedures and Cost of Care for Older Adults in the State of Maryland.

BACKGROUND: Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland. METHODS: A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant. RESULTS: Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age. CONCLUSION: These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.

Lessons learned from value-based pediatric appendectomy care: A shared savings pilot model.

PURPOSE: We aim to assess the healthcare value achieved from a shared savings program for pediatric appendectomy. METHODS: All appendectomy patients covered by our health plan were included. Quality targets were 15% reduction in time to surgery, length of stay, readmission rate, and patient satisfaction. Quality targets and costs for an appendectomy episode in two 6-month performance periods (PP1, PP2) were compared to baseline. RESULTS: 640 patients were included (baseline:317, PP1:167, PP2:156). No quality targets were met in PP1. Two quality targets were met during PP2: readmission rate (-57%) and patient satisfaction. No savings were realized because the cost reduction threshold (-9%) was not met during PP1 (+1.7%) or PP2 (-0.4%). CONCLUSIONS: Payer-provider partnerships can be a platform for testing value-based reimbursement models. Setting achievable targets, identifying affectable quality metrics, considering case mix index, and allowing sufficient time for interventions to generate cost savings should be considered in future programs.

Does Wound Management Technique Impact Surgical Site Infection in Open Emergency Colon Procedures?

BACKGROUND: Emergency open large bowel procedures have higher rates of intraoperative contamination and increased risk of surgical site infection (SSI) than elective colon surgeries. Several wound management strategies have been proposed, such as vacuum-assisted closure (VAC) therapy and delayed primary closure to improve results. The purpose of this study is to evaluate the relationship between wound management technique and SSI and other quality measures. METHODS: We performed a retrospective review of patients undergoing open emergency colon surgery from January 2017 to December 2018 by our acute care surgery service. The primary outcome measure was incidence of SSI. Secondary outcome measures included length of stay, reoperation, and 30-day readmission. RESULTS: A total of 118 patients were included in the study, with a mean age of 62.8 years and mean BMI of 28.8. Overall incidence of SSI was 19.5%. There was no significant difference in incidence of SSI, reoperation, or 30-day readmission when stratifying by wound management technique or procedure type after controlling for confounding variables. Notably, patients managed with VAC therapy had a statistically significant longer average length of stay and higher total postoperative antibiotic days (both P = .001) than other techniques. DISCUSSION: We conclude from our data that wound management technique does not seem to influence rate of SSI, but wound management may influence length of stay or antibiotic duration. These findings suggest that there may not be an advantage to alternative methods of wound management in this high-risk population. Further prospective evaluation should be performed to confirm these findings.

Impact of the SARS-CoV-2 pandemic on the course and treatment of appendicitis in the pediatric population.

SARS-CoV-2 is a highly contagious virus causing mainly respiratory track disease called COVID-19, which dissemination in the whole world in the 2020 has resulted in World Health Organisation (WHO) announcing the pandemic. As a consequence Polish Government made a decision to go into a lockdown in order to secure the population against SARS-CoV-2 outbreak what had its major influence on the Polish Health Care System. All of the social and medical factors caused by the pandemic might influence children's health care, including urgent cases. The aim of this survey was the analysis of medical charts with focus on the course and results of surgical treatment of children who underwent appendectomy before and during the COVID-19 pandemic. Material and methods: We performed analysis of charts of 365 subjects hospitalized in the Pediatric Surgery Department from 1st January 2019 to 31st December 2020 because of acute appendicitis. Patients were divided into two groups-those treated in 2019-before pandemic outbreak, and those treated in 2020 in the course of pandemic. Results: the most common type of appendicitis was phlegmonous (61% of cases in 2019 and 51% of cases in 2020). Followed by diffuse purulent peritonitis (18% of cases in 2019 vs 31% of cases in 2020), gangrenous (19% of cases in 2019 vs 15% of cases in 2020) and simple superficial appendicitis (1% of cases in 2019 vs 3% of cases in 2020). There was statistically significant difference in the length of hospitalization: in 2019 the mean length of hospi-talization was 4.761 vs 5.634 in 2020. Laparoscopic appendectomy was performed more frequently before the COVID period (63% of cases treated in 2019 vs 61% of cases treated in 2020). In the pandemic year 2020, there was double increase in the number of conversion from the laparoscopic approach to the classic open surgery. In the year 2019 drainage of abdominal cavity was necessary in 22% of patients treated with appendectomy, in 2020 the amount of cases threated with appendectomy and drainage increased to 32%. Conclusions: fear of being infected, the limited availability of appointments at General Practitioners and the new organisation of the medical health care system during pandemic, delay proper diagnosis of appendicitis. Forementioned delay leads to higher number of complicated cases treated with open appendectomy and drainage of abdominal cavity, higher number of conversions from the laparoscopic to classic open technique, and longer hospitalization of children treated with appendectomy in the year of pandemic.