Appendicitis Mortality in a Resource-Limited Setting: Issues of Access and Failure to Rescue.

BACKGROUND: Appendicitis is one of the most common emergency surgery conditions worldwide, and the incidence is increasing in low- and middle-income countries. Disparities in access to care can lead to disproportionate morbidity and mortality in resource-limited settings; however, outcomes following an appendectomy in low- and middle-income countries remain poorly described. Therefore, we aimed to describe the characteristics and outcomes of patients with appendicitis presenting to a tertiary care center in Malawi. METHODS: We conducted a retrospective analysis of the Kamuzu Central Hospital (KCH) Acute Care Surgery database from 2013 to 2020. We included all patients ≥13 years with a postoperative diagnosis of acute appendicitis. We performed bivariate analysis by mortality, followed by a modified Poisson regression analysis to determine predictors of mortality. RESULTS: We treated 214 adults at KCH for acute appendicitis. The majority experienced prehospital delays to care, presenting at least 1 week from symptom onset (n = 99, 46.3%). Twenty (9.4%) patients had appendiceal perforation. Mortality was 5.6%. The presence of a postoperative complication the only statistically significant predictor of mortality (RR 5.1 [CI 1.13-23.03], P = 0.04) when adjusting for age, shock, transferring, and time to presentation. CONCLUSIONS: Delay to intervention due to inadequate access to care predisposes our population for worse postoperative outcomes. The increased risk of mortality associated with resultant surgical complications suggests that failure to rescue is a significant contributor to appendicitis-related deaths at KCH. Improvement in barriers to diagnosis and management of complications is necessary to reduce further preventable deaths from this disease.

Trends in Appendicitis Among Pregnant Women, the Risk for Cardiac Arrest, and Maternal-Fetal Mortality.

BACKGROUND: Appendicitis is the most common extra-uterine surgical emergency requiring immediate intervention during pregnancy. However, risks for mortality and morbidity among pregnant women with appendicitis remain poorly understood. This study was conducted to determine the temporal trends of appendicitis in pregnant women, and to calculate the risk of maternal-fetal mortality and near-miss marker (i.e., cardiac arrest) among pregnant women in general, and by race/ethnicity. METHODS: We conducted this retrospective study using data from the Nationwide Inpatient Sample (NIS) from January 1, 2002, through December 31, 2015. Joinpoint regression was used to estimate and describe temporal changes in the rates of all and acute appendicitis during the 14-year study period. We also estimated the risk of cardiac arrest, maternal, and fetal mortality among mothers of various racial/ethnic groups with a diagnosis of acute appendicitis. Within each group, patients without acute appendicitis were the referent category. RESULTS AND CONCLUSIONS: Out of the 58 million pregnancy hospitalizations during the study period, 63,145 cases (10.74 per 10,000 hospitalizations) were for acute appendicitis. There was a 5% decline (95% CI: - 5.1, - 5.0) in the rate of appendicitis hospitalizations over the period of the study. After adjusting for covariates, pregnant mothers with acute appendicitis had increased likelihood when compared to those without acute appendicitis to suffer fetal loss (OR: 2.05, 95% CI: 1.85-2.28) and nearly fivefold increase for inpatient maternal death. In conclusion, appendicitis during pregnancy remains an important cause of in-hospital maternal-fetal mortality overall and regardless of race/ethnicity.

The Unintended Consequences of Nonoperative Management of Acute Appendicitis.

BACKGROUND: Appendicitis has traditionally been treated surgically. Recently, nonoperative management is emerging as a viable alternative to the traditional operative approach. This raises the question of what are the unintended consequences of nonoperative management of appendicitis with respect to cost and patient burden. METHODS: National Readmissions Database was queried between 2010 and 2014. Patients who were admitted with acute appendicitis between January and June of each year were identified. Patients who underwent appendectomy were compared with those treated nonoperatively. Six-month all-cause readmission rates and aggregate costs between index hospitalization and readmissions were calculated. RESULTS: We identified 438,995 adult admissions for acute appendicitis. Most cases were managed with appendectomy (93.2%). There was a significant increase in the rate of nonoperative management, from 3.6% in 2010 to 6.8% in 2014 (P value for trend <0.01). Discharges receiving nonoperative management tended to be older and have more comorbidities. There was a 59% decreased adjusted odds of readmission within 6 mo among patients receiving appendectomy in comparison to those managed nonoperatively. Despite this, in multivariable linear regression, there was an adjusted $2900 cost increase associated with surgical management (P < 0.01). CONCLUSIONS: This study shows that nonoperative management is increasing. Patients treated nonoperatively may have an increased risk of readmission within 6 mo but incur a decreased average adjusted total cost. Given this, it is important that surgeons critically assess patients who are being considered for nonoperative management of appendicitis.

Management and Outcomes of Acute Appendicitis in the Presence of Cirrhosis: A Nationwide Analysis.

Best management for acute appendicitis (AA) in adults with liver cirrhosis is controversial and needs more investigation. We aimed to examine the impact of different treatment modalities on outcomes in this complex patient population. The Nationwide Inpatient Sample database from 2012 to 2014 was queried to identify AA patients with no cirrhosis, compensated cirrhosis (CC), and decompensated cirrhosis (DC). Each cohort was further stratified according to the treatment type: nonoperative management, open appendectomy, and laparoscopic appendectomy (LA). Chi-square, ANOVA, and binary regression analyses were used to determine differences between groups and risk factors for mortality and complications, with P < 0.05 considered statistically significant. A total of 108,289 AA patients were analyzed; of those, 304 with CC and 134 with DC were identified. Compared with CC and no cirrhosis, DC patients had significantly higher mortality, higher cost, and longer hospital length of stay. LA is accompanied by higher survival, lower cost, shorter duration of hospitalization, and lower incidence of complications across all groups. We conclude that LA is the best management strategy for AA in cirrhotic patients. Even in decompensated cirrhotics, which are associated with worse clinical outcomes, LA is still a favorable option over open appendectomy and nonoperative management.

Comparison of conservative versus surgical therapy for acute appendicitis with abscess in five German hospitals.

INTRODUCTION: The aim of this study was to evaluate the effectiveness of initially conservative therapy compared to immediate appendectomy for acute appendicitis with abscess in terms of medical and economic outcomes. METHODS: Of all the patients treated for appendicitis from January 2009 to December 2017 in five German hospitals, 240 were included in the study. Fifty-three patients received conservative (CON) and 195 patients received surgical (SUR) therapy as initial treatment. RESULTS: Length of stay was similar (12.5 days in CON vs. 13.3 days in SUR, p = 0.530). Readmission rate was higher in the conservative group (54.7% vs. 6.2%, p < 0.001). The majority (53.7%) of the 41 operations in CON group were appendectomies (22 procedures), 1 (4.5%) of them was in the first hospital stay because of persisting symptoms, 21 (95.5%) after a recovery interval. Seven (33.3%) of the recovery appendectomies were performed due to persisting or recurrent symptoms and 14 (66.7%) due to the request of patient. Twenty-one patients (39.6%) in the CON group did not need surgery. The rates of complication-related operations per patient (0.04 versus 0.58, p < 0.001), conversions of surgical technique (1.9% vs. 34.9%, p = 0.0287), and extended resections (1.9% vs. 31.3%, p < 0.001) were higher in SUR group. Furthermore, morbidity, hospital costs, and loss in quality of life were significantly higher in the surgical group (17.0% vs. 66.2%, p < 0.001; € 5044 vs. € 8457, p < 0.001, and 4.3 days vs. 7.5 days, p < 0.001, CON vs. SUR). CONCLUSION: Initially, conservative treatment for acute appendicitis with abscess is preferable to immediate surgical treatment in reduction of morbidity, hospital costs, and loss in quality of life.

Two versus five days of antibiotics after appendectomy for complex acute appendicitis (APPIC): study protocol for a randomized controlled trial.

BACKGROUND: Acute appendicitis is one of the most common indications for emergency surgery. In patients with a complex appendicitis, prolonged antibiotic prophylaxis is recommended after appendectomy. There is no consensus regarding the optimum duration of antibiotics. Guidelines propose 3 to 7 days of treatment, but shorter courses may be as effective in the prevention of infectious complications. At the same time, the global issue of increasing antimicrobial resistance urges for optimization of antibiotic strategies. The aim of this study is to determine whether a short course (48 h) of postoperative antibiotics is non-inferior to current standard practice of 5 days. METHODS: Patients of 8 years and older undergoing appendectomy for acute complex appendicitis - defined as a gangrenous and/or perforated appendicitis or appendicitis in presence of an abscess - are eligible for inclusion. Immunocompromised or pregnant patients are excluded, as well as patients with a contraindication to the study antibiotics. In total, 1066 patients will be randomly allocated in a 1:1 ratio to the experimental treatment arm (48 h of postoperative intravenously administered (IV) antibiotics) or the control arm (5 days of postoperative IV antibiotics). After discharge from the hospital, patients participate in a productivity-cost-questionnaire at 4 weeks and a standardized telephone follow-up at 90 days after appendectomy. The primary outcome is a composite endpoint of infectious complications, including intra-abdominal abscess (IAA) and surgical site infection (SSI), and mortality within 90 days after appendectomy. Secondary outcomes include IAA, SSI, restart of antibiotics, length of hospital stay (LOS), reoperation, percutaneous drainage, readmission rate, and cost-effectiveness. The non-inferiority margin for the difference in the primary endpoint rate is set at 7.5% (one-sided test at ɑ 0.025). Both per-protocol and intention-to-treat analyses will be performed. DISCUSSION: This trial will provide evidence on whether 48 h of postoperative antibiotics is non-inferior to a standard course of 5 days of antibiotics. If non-inferiority is established, longer intravenous administration following appendectomy for complex appendicitis can be abandoned, and guidelines need to be adjusted accordingly. TRIAL REGISTRATION: Dutch Trial Register, NTR6128 . Registered on 20 December 2016.

Incidence, demographics, and outcomes of nonoperative management of appendicitis in the United States.

BACKGROUND: Appendicitis is the most common intraabdominal surgical emergency in the United States, with over 250,000 cases each year. Several recent studies have evaluated the efficacy of nonoperative management of appendicitis. We measured changes in the treatment of appendicitis in the United States from 1998 to 2014 and evaluated outcomes in the contemporary cohort of appendicitis cases from 2010 to 2014. METHODS: The National Inpatient Sample was queried for cases with a principal diagnosis of appendicitis. Cases with peritoneal abscesses were excluded. We determined trends in management and then compared cases managed nonoperatively versus those managed with early operation for demographics and outcomes including mortality, total charges, and length of stay using univariate analysis, binary logistic regression analysis, and case-control matching. RESULTS: Although early operation remains the dominant treatment for acute appendicitis in the United States, there is an accelerating trend in nonoperative management. Nonoperative management is associated with increased age, number of comorbidities, and inpatient diagnoses. In univariate, multiple regression, and case-control analysis, nonoperative management is associated with decreased total charges but significantly increased risk of mortality. CONCLUSIONS: Elderly patients and patients with medical comorbidities are more likely to be treated nonoperatively for appendicitis than younger patients. Although previously published data support nonoperative management of appendicitis in low-risk surgical patients, we suggest that elderly or medically complex patients may benefit from early operative treatment of appendicitis and are potentially at risk of poor outcomes from nonoperative management.

Statewide assessment of surgical outcomes and the acute care surgery model.

BACKGROUND: The acute care surgery (ACS) model has been widely implemented with single institution studies demonstrating improved outcomes. Recent multicenter studies have raised questions about the economics and efficacy of ACS. This study compares traditional and ACS outcomes across an entire state. METHODS: A retrospective review of Virginia's Health Information administrative database was completed. Adults admitted with appendicitis or cholecystitis between 2008 and 2014 were included. Hospital administration was contacted to determine surgical model. To compare patient characteristics, t-test and chi-square analyses were used. Total charges and length of stay (LOS) differences between ACS and traditional were examined using generalized linear models, whereas logistic regression was used for the presence of complications and 30-day mortality. RESULTS: Overall, the ACS model showed an increased proportion of uninsured patients with a higher rate of comorbidities. In the appendicitis subgroup, (n = 22,011; ACS n = 1993), ACS patients had higher total charges ($30,060 versus $28,460, P = 0.013), longer LOS (3.31 versus 2.92 d, P < 0.001), and higher chance of complications (odds ratio [OR] = 1.2, P = 0.016) and mortality (OR = 2.4, P = 0.029). After adjustment for comorbidities and insurance, mortality was no longer significantly different. In the cholecystitis group (n = 6936; ACS n = 777), ACS patients had a longer LOS (4.55 versus 4.13 d; P = 0.009) without significant differences in mortality, complications, or cost. There were no significant differences after adjustment for patient characteristics. CONCLUSIONS: ACS patients in Virginia have a higher rate of medical comorbidities and uninsured status, with slightly worse outcomes than the traditional model for appendicitis. Further studies to determine which patients benefit the most from ACS are warranted.

Operative versus non-operative management in the care of patients with complicated appendicitis.

BACKGROUND: The approach to complicated appendicitis is unclear. We have sought to determine factors which may persuade surgeons to non-operative management and whether such treatment affects outcome. METHODS: All adult patients admitted over a five-year period 2009-2014 with a diagnosis of appendicitis were reviewed. Patients were grouped into uncomplicated and complicated presentations and stratified by age, gender, ethnicity, socio-economic status, and time to presentation. Mortality, morbidity, length of hospital stay (LOS), readmission, and hospital charges were used as outcome measures. RESULTS: 611 adult patients were admitted with the diagnosis of appendicitis. Of those 306 patients presented in an uncomplicated manner, and 305 patients were complicated presentations. Selection for non-operative management was significantly correlated with older age and a longer time to presentation. For outcome patients who underwent early surgery experienced a longer LOS (5.8 ± 4.4 days versus 3.4 ± 4.5 days, p < 0.0001), and more readmissions. CONCLUSION: Surgical treatment of patients presenting with complicated appendicitis is preferable to non-operative, antibiotic oriented treatment in reduction of LOS and need for readmissions.

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

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

[Matched-pair analysis comparing laparoscopic (LA) vs. single-port appendectomy (SP) for initial assessment of a new surgical approach during its inauguration]. / "Matched-Pair"-Analyse der laparoskopischen (LA) vs. Single-Port-Appendektomie (SP) zur initialen Evaluation im Rahmen der Etablierung einer neuen Operationsmethode.

INTRODUCTION: By minimising the invasiveness of a surgical intervention, a reduction of operative trauma can be achieved. AIM AND METHODS: The aim of this study was based on a theoretical approach to investigate (i) the feasibility of the SP approach and its overall costs, and, furthermore, (ii) the patients' outcome based on simple perioperative parameters available in daily clinical practice. Therefore, single-port (SP) and laparoscopic appendectomies (LA) were compared using a matched-pair analysis. As a prediction, an absolute match between the criteria histology, sex and ASA stage was required. RESULTS: From 01/01/2009 to 12/31/2010, 196 (60 % were females) consecutive patients underwent appendectomy. Out of them, in 23 patients with either SP or LA appendectomy the predictions for matched-pair analysis (congruence in histopathological finding, sex and ASA criteria) were fulfilled. The operating time was the target criterion for the feasibility of the new surgical method (SP), which could be shortened as seen by comparing SP No. 1-10 with 11-23 (54.6 ± 19.8 min vs. 28.5 ± 18.9 min) expressing the typical effect of a learning curve. The times were similar to those for LA. The postoperative hospital stay and complication rate used to appropriately assess patient outcome did not show a significant difference if comparing SP and LA. Based on the use of single ports, which can be re-used (which has been also a further target) in SP (34.8 %) at the end of the investigation period, SP and LA can be considered comparable surgical techniques with regard to operating times, middle-term outcome and general costs. CONCLUSION: SP is (in case of well-developed laparoscopic expertise) a surgical method that can be easily inaugurated and considered as a feasible approach in daily surgical practice; it is comparable to LA with regard to outcome and general costs. Based on this, SP can be gradually added to the spectrum of surgical procedures in clinical practice and can be performed in suitable cases. A further systematic institutional or even country-wide case register appears to be recommendable to recruit a larger case number and, thus, to achieve a better knowledge on the perioperative management as well as the especially interesting long-term outcome for an appropriate assessment of treatment quality.

Do you need a computed tomographic scan to evaluate suspected appendicitis in young men: an administrative database review.

BACKGROUND: The purpose of this study was to evaluate the impact of computed tomographic (CT) scans of the abdomen on clinical outcomes and costs in young male patients presenting with suspected appendicitis. METHODS: Discharge data from the University HealthSystem Consortium was accessed for all male patients between 18 and 55 years of age from October 2007 to June 2011. RESULTS: Of a total of 13,228 patients who met the inclusion criteria, 11,340 (85%) were assessed using a CT scan of the abdomen, whereas 1,888 (15%) did not undergo CT evaluation. Patients undergoing CT imaging compared with those without a CT scan had less morbidity (.86% vs 2.2%, P < .0001) and fewer 30-day readmissions (1.8% vs 5.13%, P < .0001). However, CT imaging resulted in a higher overall length of hospital stay and a higher total cost. CONCLUSIONS: This study suggests that in young men with suspected appendicitis, the use of an abdominal CT scan is associated with improved immediate postoperative complications, lower readmission rates with observed higher length of stay, and increased cost of care.

Dramatic decline of acute appendicitis in Greece over 30 years: index of improvement of socioeconomic conditions or diagnostic aids?

BACKGROUND AND AIMS: There are several reports showing a continuing fall in the incidence of acute appendicitis in the western countries. Our aim was to study the trend of the incidence of acute appendicitis in the Greek population over 30 years. METHODS: We analyzed the data referring to the years 1970-1999 on the incidence and mortality of acute appendicitis for the entire Greek population. Data were retrieved from the Annual Bulletin for the Social Welfare and Health Statistics of the National Statistics Service of Greece. In this database, acute appendicitis was a hospital discharge diagnosis. RESULTS: Over the study period, there was a 75% decrease of the age-standardized incidence of acute appendicitis from 652/100,000 to 164/100,000. The median female-to-male ratio of hospitalized patients for appendicitis of the study period (1970-1999) fell progressively from 1.27 in the year 1970 to 0.93 in the year 1999. The case fatality rates remained constant, ranging below 0.09 deaths per 100 appendicitis cases. CONCLUSION: There is a significant decline of the incidence of acute appendicitis in the Greek population over the years 1970-1999. This time trend is probably related to the improvement of the socioeconomic conditions over the same period and not to the introduction of new diagnostic aids.

Racial disparities in the management of pediatric appenciditis.

BACKGROUND: Our objective was to compare the racial differences in incidence and management of pediatric appendicitis. MATERIALS AND METHODS: Data for this study come from two large national hospital discharge databases from the Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project: The Nationwide Inpatient Sample (NIS) and the Kids' Inpatient Database (KID). Analysis was restricted to age less than 18 years with an ICD-9 diagnosis of either simple (540.9) or complex (540.0 and 540.1) appendicitis. Data were weighted to represent national estimates. Incidence was defined as the number of new disease cases divided by the number of at risk hospitalized children. RESULTS: The data for this study contained an estimated 428,463 [95% confidence interval (CI) = 414, 672-442, 253] cases of appendicitis, representing approximately 65,000 to 75,000 cases annually. Multi-variant analysis suggests that African-Americans, as compared to Caucasians, were less prone to develop appendicitis [odds ratio (OR) = 0.39, 95% CI (0.38, 0.41)], but less frequently underwent laparoscopic treatment [OR = 0.78, 95% CI (0.74, 0.87)], and were more likely to have complex appendicitis [OR = 1.39, 95% CI (1.30, 1.49)]. In contrast, Hispanics were more likely than Caucasians to both develop appendicitis [OR = 1.48, 95% CI (1.41, 1.56)] and to have complex disease [OR = 1.10, 95% CI (1.05, 1.16)]. The incidence of appendicitis was less frequent in females versus males [OR = 0.69, 95% CI (0.68, 0.70)] but the likelihood of laparoscopic exploration was higher [OR = 1.39, 95% CI (1.34, 1.43)]. Finally, children with public insurance [OR = 1.25, 95% CI (1.21, 1.29)] and uninsured children [OR = 1.10, 95% CI (1.04, 1.16)] were more likely to have complex appendicitis when compared to children with private insurance. CONCLUSIONS: African-American children with appendicitis have lower overall hospitalization rates, higher rates of perforation, a greater delay to surgical management, and lower laparoscopic rates. In contrast, Hispanic children more frequently had appendicitis and complex disease. The treatment of African-American and Hispanic children overall was associated with a longer hospital stay and higher charges. The lower incidence of appendicitis in African-American children is incompletely understood and the disparity in surgical management among minority children remains troubling.

The burden of appendicitis-related hospitalizations in the United States in 1997.

BACKGROUND: Acute appendicitis is among the most frequent causes of surgical abdominal disease worldwide. METHODS: Data from the Nationwide Inpatient Sample of the Healthcare Utilization Project were used to estimate the prevalence and disease burden of appendicitis-related hospitalizations in the United States in 1997. The data are a representative sample of discharge records from community hospitals drawn from 22 states in the United States. RESULTS: In the United States in 1997, there were an estimated 252,682 (95% CI: 242,957-262,407) appendicitis-related hospitalizations. The mean length of stay and total charges for appendicitis-related hospitalizations were four days (95% CI: 3.4-4.6) and $11,645 (95% CI: $11,299-$11,992) per hospitalization, respectively. Appendicitis-related hospitalizations associated with post-operative infection, peritoneal abscess, or peritonitis had longer average lengths of stay and higher average costs when compared to hospitalizations associated with local appendicitis without post-operative infection. Appendicitis cases among very young and older patients were more likely to be associated with peritoneal abscess, peritonitis, or post-operative infection. CONCLUSIONS: In 1997, appendicitis-related hospitalizations accounted for 0.6% of all hospitalizations in the United States, resulting in approximately one million hospital days and $3 billion in hospital charges. Between 1984 and 1997, the rate of appendicitis hospitalizations in the U. S. population declined slightly, whereas the total number of hospital days remained unchanged.

Implications of removing a normal appendix.

BACKGROUND: The diagnosis of acute appendicitis remains difficult, and therefore 15-30% of the removed appendices appear to be normal. The aim of this study is to investigate the morbidity, mortality and costs of removing a normal appendix in patients with suspected appendicitis. PATIENTS AND METHODS: A retrospective study was performed on patients who underwent a negative appendectomy for suspected appendicitis in the period 1991-1999 with a median follow-up of 4.4 years. Patients who underwent an elective appendectomy or appendectomy for other reasons were excluded. RESULTS: In 285 patients (70% women, 30% men) a normal appendix was removed. In 192 (67%) patients a muscle-splitting incision was performed, in 6 (2%) a median laparotomy, and in 51 (18%) the normal appendix was removed by laparoscopy. In 36 patients (13%) a diagnostic laparoscopy was converted to a muscle-splitting incision. Complications occurred in 16 (6%) patients, in 5 (2%) a reoperation was needed. The mean hospital stay was 4.4 (SE 2.8) days, in case of complication 7.4 (SE 4.2) days. The mean extra hospital costs of a negative appendectomy were EUR 2,712. CONCLUSION: The removal of a normal appendix has considerable complications and costs. In an attempt to prevent these costs, extra diagnostic tools should be considered. Expensive diagnostic tools as diagnostic laparoscopy should be used selectively in order to not further exceed costs.

Effectiveness of imaging studies in acute appendicitis: a simplified decision model.

Computed tomography (CT) and ultrasonography (US) have been proposed as non-invasive diagnostic aids in patients with suspected acute appendicitis. Currently, clear guidelines about the indications to use these techniques are lacking. Using the concepts of decision analysis, a model was created to calculate the effectiveness of US and CT in patients with clinically suspected appendicitis. The perspective chosen was the health of individual patients. The model makes use of published data and provides a critical threshold probability (ctp). Decisions in individual cases can be made by comparing ctp with the clinical probability of disease. The calculated ctp-values for US and CT were 0.58 and 0.74, respectively. In other words, on average, US (CT) is indicated only if the expert clinician considers the probability of disease to be smaller than 58% (74%). It is concluded that in patients with suspected acute appendicitis, selective rather than routine use of imaging studies is recommended. The exact value of the decision threshold should be determined in function of the local situation.

Appendectomy incidental to cholecystectomy among elderly Medicare beneficiaries.

To assess the risks of adverse outcomes after appendectomy incidental to cholecystectomy among elderly Medicare beneficiaries, 8,936 persons undergoing cholecystectomy with incidental appendectomy and 44,461 persons undergoing cholecystectomy without incidental appendectomy were studied. Controlling for age, race, gender and co-morbidity status, the risk for wound infection in persons with incidental appendectomy was 83 percent higher than in persons without incidental appendectomy (95 percent confidence interval, 1.53 to 2.18). The risks for having other adverse outcomes, including other infections, extensive intrahospital complications and mortality rate at 30 days, were also higher for the former group, although these differences were not statistically significant. In addition, the demographic characteristics and health status of persons undergoing cholecystectomy with incidental appendectomy with persons undergoing cholecystectomy only were compared. Males, persons of younger ages, of white race or with no co-morbid conditions, were significantly more likely to undergo cholecystectomy with incidental appendectomy. Variables to control for differences in the demographic characteristics and health status between persons receiving and not receiving incidental appendectomy were included in the regression models for adverse outcomes. However, these models may not completely control for differences between the two groups. As a result, the actual relationship between incidental appendectomy and adverse outcomes may be underestimated. The preventive effect of incidental appendectomy on morbidity and mortality rates from future instances of appendicitis was assessed by determining the remaining lifetime risk for acute appendicitis. For persons 65 to 69 years of age, 115 incidental appendectomies would be required to prevent one future instance of appendicitis and 4,472 incidental appendectomies would be needed to prevent a single future death from acute appendicitis. Because incidental appendectomy increases the risk for wound infection among persons undergoing cholecystectomy and because the lifetime risk for acute appendicitis is relatively low for persons of this age group, surgeons should carefully consider the risks and benefits of incidental appendectomy in the elderly.

[Current treatment status in juvenile appendicitis. A quality assessment]. / Uber die aktuelle Behandlungssituation der kindlichen Appendizitis. Eine Qualitätsstudie.

The diagnosis of appendicitis in 1989 admitted patients with an age of 1 to 14 years was prospectively investigated. In 82.6% acute inflammatory changes were found. Rate of perforation was 9.9%. Between 2 and 5 years old patients 28.5% had a perforated appendix. In two cases a colon disease and in one case a malignant carcinoid was found. No death was registered after appendectomy.