Management Of Appendicitis Research Articles

Ultrasound and computed tomography in differentiating between simple and complicated appendicitis in pediatric patients.

This study aims to measure the diagnostic accuracy and reliability of US and CT in diagnosing complicated appendicitis among pediatric patients and to find the performance of the imaging modalities in detecting complication signs. a systematic review and meta-analysis were done on 15 eligible studies from the Medline Database concerning pediatric appendicitis and its complications. Studies either provided an overall estimate of sensitivity and specificity of the imaging modality or addressed signs of complicated appendicitis The reference standard employed was either surgical findings or histopathology reports. The review included assessments of 4,497 pediatric patients, with 285 undergoing CT and 4,212 undergoing US imaging. CT demonstrated sensitivities of 62% and 68.4%, and specificities of 81% and 92.4%. US showed sensitivities of 33.9% to 51.5% and specificities ranging from 68.8% to 95%. The ultrasound's ability to detect appendiceal wall diameter > 5mm showed the highest sensitivity (99.4%), while the conglomerate sign indicated the highest specificity (99.9%). The findings suggest that both US and CT exhibit higher specificity than sensitivity in diagnosing complicated appendicitis in pediatric patients. Given its favorable specificity, non-invasiveness, and lack of radiation exposure, US should be the first-line imaging modality in suspected cases of pediatric appendicitis. CT, offering robust specificity, should be reserved for ambiguous cases where US results are inconclusive. These insights underscore the critical role of precise imaging modalities in enhancing diagnostic accuracy, reducing unnecessary surgeries, and improving clinical outcomes in pediatric appendicitis management.

What you need to know: Current management of acute appendicitis in adults

ABSTRACT Acute appendicitis is one of the most common acute surgical diseases in the world today. Acute appendicitis can present with a well-recognized clinical presentation with abdominal pain which localize in the right lower quadrant. This presentation is more typical in men than in women of child baring age. Several clinical and laboratory calculations can be used to increase the likelihood of making a correct diagnosis. Various imaging modalities can be used to make the diagnosis which include ultrasound, computer tomography, and magnetic resonance imaging. Each study has well known sensitivity/specificity of positive predictive value of making the diagnosis of appendicitis. The management of acute appendicitis is based on the presentation of the patient and dividing it into uncomplicated and complicated disease. Each requires management with antibiotics and followed with timely appendectomy. Recent studies have demonstrated nonoperative management of uncomplicated appendicitis without no fecalith that can be managed with antibiotics alone. Complicated acute appendicitis should undergo timely surgical intervention. Patients presenting with a large appendiceal abscess or phlegmon should undergo percutaneous drainage and antibiotic management. There are certain patient populations that should be considered for surgical intervention. Pregnant patients as well as immunosuppressed patients should undergo timely surgical intervention to decrease the risk of complications. This review outlines the current principles of the diagnosis, imaging, and treatment of acute appendicitis based on the best available evidence of acute appendicitis in adults. LEVEL OF EVIDENCE Original Review Article, Level III.

Laparoscopic Appendectomy in Children: Tunisian Experience.

The purpose of this study is to compare the surgical outcomes of open appendectomy (OA) and laparoscopic appendectomy (LA) for pediatric acute appendicitis in order to guide its future management. We conducted a retrospective study including all children under the age of 14 years, who underwent appendectomy for acute appendicitis, during a period of 6 years (2013-2018). We divided our patients in two groups based on the surgical modality: the laparoscopic and open group. P values of less than .05 were considered statistically significant. A total of 690 appendectomies were identified: 151 (22%) were performed laparoscopically and 539 (78%) via laparotomy. The demographic data were comparable between the 2 groups. There was no statistical difference regarding the age, sex. However the frequency of obese patients was higher in laparoscopic approach (P < .001).The mean operative time was significantly longer in the Laparoscopic group (77 ± 39, 6 minutes) compared with Open group (57 ± 27 minutes) (P < .001). Prophylactic drain placement was significantly more common in the open appendectomy group (P = .034). Patients undergoing laparoscopic appendectomy experienced a quicker recovery to apyrexia, reduced use of postoperative analgesics, and postoperative antibiotic compared to those undergoing open appendectomy (P < .05). The mean length of hospital stay was respectively 4 ± 1 day in LA group and 4 ± 2 days in the OA group. No significant difference was observed. The results showed no significant difference between the 2 groups regarding the incidence of wound infection, intra abdominal abscess, intestinal obstruction and umbilical hernia (P > .05).There was no death in this study. Laparoscopic appendectomy is safe and feasible for the management of appendicitis without significant influence on the complications rate.

Classic yet challenging case of stump appendicitis: a case report

Introduction: Stump appendicitis is a rare complication of appendectomy in which residual appendiceal tissue becomes inflamed, mimicking acute appendicitis. This case report highlights the classic clinical presentation, diagnosis, and management of stump appendicitis. Case Presentation: A 61-year-old male presented with abdominal pain and a past history of open appendectomy performed four years prior. Clinical examination, laboratory, and radiological findings were highly suggestive of stump appendicitis. Surgical exploration confirmed an inflamed appendiceal stump, which was resected, and the patient had an uneventful recovery post-operatively. Discussion: Stump appendicitis is a rare but important differential diagnosis in patients with a history of appendectomy who present with acute abdominal pain. Delayed diagnosis can result in complications such as perforation and peritonitis. Imaging plays a crucial role in diagnosis, and surgical resection, typically performed through open completion appendectomy, remains the treatment of choice. Conclusion: Although stump appendicitis is rare, it should always be considered in patients with a prior appendectomy who present with acute abdomen. Early recognition and prompt surgical intervention are essential to prevent morbidity and mortality.

Stump Appendicitis: An Update on Current Management: A Narrative Review Article

Stump appendicitis is a rare complication that occurs after an appendectomy and the diagnosis of this condition is usually delayed. The diagnosis is confirmed by either an ultrasound or computerized tomography. The management of stump appendicitis is by performing a completion appendectomy, which can be done as an open or laparoscopic procedure. The delay in diagnosis can often lead to complications like perforation and abscess formation. We have conducted this review article to look at the diagnosis and management of stump appendicitis. The method of stump closure is also discussed by looking at the various methods that are employed.

Predictors of appendicectomy one year after antibiotic treatment for acute appendicitis: Insights from a prospective, multicentre, observational study.

Surgeons are sometimes reluctant to manage uncomplicated appendicitis non-operatively. Reasons cited include the risk of recurrent appendicitis and the risk of missed appendiceal malignancy. The aim of this study was to address these uncertainties and determine the long-term efficacy of antibiotic versus operative management of appendicitis. One-year follow-up of patients enrolled in the multicentre, COVID:HAREM cohort study during March-June 2020 was performed. Initial operative or non-operative management was determined on a case-by-case basis by the responsible surgeon. Outcomes were appendicectomy rate at 1-year, histology of removed appendix and predictors of unsuccessful antibiotic treatment. A total of 625 patients who had non-operative management were included. Emergency appendicectomy had been performed by 1-year in 24% (149/625), with a median time to appendicectomy of 12days [IQR 1-77] from presentation. Thirty-one patients had elective appendicectomy. Normal histology was reported in 6% of emergency procedures and 58% of elective ones. There were 7 malignancies and 3 neuroendocrine tumors identified at histology. All patients with malignant histology had ≥1 risk factors for malignancy at initial presentation. Faecolithiasis (hazard ratios (HR) 2.3, 95% confidence intervals (CI) 1.51-3.49) and a high Adult Appendicitis Score (AAS >16; HR 2.44, 95% CI 1.52-3.92) were independent risk factors for unsuccessful non-operative management. At 1year, 71% of patients managed non-operatively did not undergo an appendicectomy. Recurrence of appendicitis was associated with faecolithiasis and a high AAS. Patients at higher risk for appendiceal malignancy should have targeted follow-up. These factors should be considered when counseling patients on non-operative management.

An FUO patient diagnosed as appendicitis: a case report

BackgroundThe diagnosis and management of fever of unknown origin pose significant challenges in the field of infectious diseases, as it is influenced by various factors. Infectious diseases have long been recognized as the primary etiology of fever of unknown origin. However, not all infectious diseases can definitively identify the causative pathogen and infection sites.Case presentationwe present a case report of an individual with fever, nausea, and anorexia but did not report any abdominal pain. Physical examination revealed no signs of abdominal tenderness. Repeated imaging studies including enhanced CT and color US of the appendix, only one color US suggested the possibility of appendicitis. Despite effective anti-infective treatment, the patient continued to experience low-grade fever, leading to the decision for laparoscopic exploration and subsequent appendectomy. Pathological findings confirmed the presence of appendicitis. After the surgical procedure, the patient’s temperature and infectious markers returned to within normal range, ultimately leading to a diagnosis of appendicitis.ConclusionsThe atypical symptoms and signs, along with the negative imaging results, contribute to the under diagnosis of appendicitis and the progression of fever of unknown origin, thereby exacerbating the physical, mental, and economic burden on patients. Consequently, there are valuable insights to be gained regarding the management of both appendicitis and fever of unknown origin.

WP4.1 - Costs of acute appendicitis in COVID-19 pandemic period: a cohort study

Abstract Aims During COVID 19 pandemic, aerosol generating procedures were deemed high risk for patients &amp; staff. NHS England set guidelines on appendicitis management, thus acute appendictomy rates were reduced. Aim of study is to assess cost implications of appendicitis management at a single centre. Methods Cohort study carried out from Mar'2020 to Jan'2024. Descriptive demography &amp; post-operative outcomes were evaluated in appendicitis in COVID19, post-COVID19 appendicitis were controls. Costing calculated using the standardised NHS cost ledger for resources, procurement and services Results COVID (n = 306) Post COVID (n = 446) Interval (n = 45) Kruskal Wallis (p value) Age(yrs) 35.2 38.0 47.9 &amp;lt; 0.0005 Sex(M : F) 155 : 151 216 : 230 19 : 26 NS BMI(kg/m2) 25.4 25.8 26.5 NS GP 49 162 A &amp; E 257 284 WCC(x109/L) 12.5 13.1 6.5 &amp;lt; 0.0001 CRP(mg/L) 67.2 70.9 3.4 &amp;lt; 0.0001 Conservative(n) 148 87 0 &amp;lt; 0.0001 Surgery(n) 158 359 45 &amp;lt; 0.0001 Open(n) 6 2 0 NS Lap(n) 300 444 45 &amp;lt; 0.0001 ASA(median) 2 1 2 NS Uncomplicated 178 170 42 &amp;lt; 0.0001 Complicated 128 276 3 &amp;lt; 0.0001 Clinical 0 21 USS scan 89 113 CT scan 334 312 Op time(mins) 72.8 75.9 74.4 NS LOS(days)(med) 2 2 0 &amp;lt; 0.0001 IP AB(days) 2 2 0 &amp;lt; 0.0001 Post-op AB(days) 5 3 0 &amp;lt; 0.0001 Appendix HPA(mm) Length 66.8 66.5 55.7 &amp;lt; 0.005 Diameter 11.5 11.1 9.9 NS Cost(£) 2160 4422 1046 &amp;lt; 0.0001 Conclusion Clinically &amp; radiologically grading of appendicitis (uncomplicated or complicated) has allowed safe conservative management (antibiotic therapy). Non surgical management is cheaper for index admission, but there are additional costs &amp; workload.

Potential risks of nonoperative management of appendicitis in high-risk patients

IntroductionThe popularity of nonoperative management for acute appendicitis is based on the untested assumption that it offers a lower risk alternative to surgery in patients who are at high risk for morbidity and mortality with appendectomy. We hypothesized that patients who were at a high risk with appendectomy would also be at a high risk for complications following nonoperative management. MethodsThis is a retrospective cohort study of patients with acute, uncomplicated appendicitis in the 2004–2017 National Inpatient Sample. We used a logistic regression model to predict the risk of morbidity or mortality following appendectomy and applied this model to predict the risk of patients managed nonoperatively. High risk was defined as ≥2 standard deviations above the mean predicted risk of morbidity or mortality. We used inverse probability weighting of the propensity score to compare outcomes of nonoperative versus operative management for high-risk patients. ResultsThe sample included 21,242 high-risk patients with a median age of 68 years (interquartile range 57–78), and 31% were managed nonoperatively. Compared to surgery, nonoperative management was associated with a 9% decrease in complications (95% confidence interval [CI] 7%–10%), 2% increase in mortality (95% CI 2%–3%), $10,202 increase in hospital costs (95% CI $9,065–$11,339), 3-day increase in length of stay (95% CI 2–3), and 9% greater likelihood of discharge to skilled nursing facilities (95% CI 8%–10%). ConclusionNonoperative management of acute appendicitis in high-risk patients may reduce morbidity but increase mortality, duration of hospitalization, discharge to skilled facility, and costs. Surgeons should exercise caution when considering nonoperative management in these vulnerable patients.

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

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

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

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

Non-Operative Management of Uncomplicated Appendicitis in Children: Can Patients Be Discharged From the Emergency Department?

IntroductionNon-operative management of uncomplicated appendicitis in children is a safe alternative to laparoscopic appendectomy. The purpose of this study is to determine the feasibility of nonoperative outpatient management of uncomplicated appendicitis in pediatric patients. MethodsA standardized pathway for non-operative outpatient management of uncomplicated appendicitis in children (NOMA-C) was implemented in a university pediatric surgery practice starting October 2021. Those who met criteria would be considered for discharge from the emergency department (ED) with oral antibiotics and close followup over the following year. A quality improvement project started concurrently to monitor patients for recurrent symptoms of appendicitis. ResultsA total of 121 patients were diagnosed with acute appendicitis during the study period (October 2021 to April 2023). Forty-five children (38%) met criteria for the NOMA-C protocol, and 11 patients/families chose appendectomy. Of the 34 patients who pursued nonoperative management, 14 patients were admitted to the hospital and 20 patients were discharged from the ED. Total time in the ED/hospital was significantly shorter for patients discharged from the ED (7 hours versus 23 hours; p<0.001). At one year follow up only 4 (12%) had undergone appendectomy. There were no adverse events for patients who underwent nonoperative management. ConclusionA protocol offering non-operative management of appendicitis with an option for outpatient management was feasible and safe. Outpatient management was associated with shorter ED/hospital stays than those admitted. Future studies should evaluate whether this protocol can be adopted by EDs without pediatric surgery services to avoid the need for transfer.

Surgical Management of Appendicitis During Pregnancy.

Surgical Management of Appendicitis During Pregnancy.

The contemporary management of perforated appendicitis in adults: To operate or wait?

ObjectivesThe optimal management of perforated appendicitis remains controversial. Many studies advocate for antibiotics and an interval appendectomy whereas others suggest that performing an appendectomy at the time of presentation decreases post-operative morbidity. Confounding this argument further are the patients who fail non-operative management and end up requiring surgery during their initial hospitalization. This study aims to determine if early operative intervention should be considered for perforated appendicitis. MethodsThis was a retrospective review of all patients who underwent an appendectomy (both laparoscopic or open) for perforated appendicitis between 2015 and 2020 at our institution. ResultsA total of 271 patients met inclusion criteria for this study. Of this group, 250 patients underwent an immediate appendectomy whereas the remaining 21 patients underwent a trial of non-operative management and eventually required an appendectomy during their initial admission. When comparing the immediate versus delayed operative groups, there were no differences in demographic data including age and gender, and no differences in various imaging findings including AAST Grade IV or V appendicitis. Operatively, patients in the delayed group had a longer operative time (83.1 ± 32.9 vs. 64.1 ± 26.2, p = 0.01), were more likely to require an open operation (23.8 % vs. 2.8 %, p < 0.0001), and were more likely to have a drain placed intra-operatively (42.9 % vs 14.4 %, p = 0.004). While there were no differences in 30-day readmission rates, patients in the delayed group had a significantly longer hospital length of stay than patients in the immediate group (9.4 ± 7.4 vs. 3.1 ± 3.3, p = 0.008). ConclusionsPatients undergoing an immediate appendectomy for perforated appendicitis can discharge from the hospital sooner and demonstrate no increase in post-operative morbidity suggesting that surgeons can initially manage this disease process in an operative fashion.

Balancing Costs and Care: Nonoperative Appendicitis Treatment Outcomes in Pakistan.

Dear Respected Editor, In Pakistan, approximately 110,000 cases of appendicitis are reported annually [1], highlighting the condition's prevalence and significance. Traditional management predominantly revolves around widely practiced surgical intervention, such as appendectomy. [2]. Immediate appendectomy has become the standard treatment due to the significant morbidity and mortality difference between perforated and non-perforated acute appendicitis. However, the country's healthcare landscape presents a complex challenge due to varying regional access to medical resources. This variation in healthcare infrastructure exacerbates the difficulty of effectively managing appendicitis and underscores the need for solutions that strike a balance between clinical outcomes and economic considerations. While appendectomy remains a standard surgical procedure, it comes with inherent disadvantages, chief among them being the cost burden it places on patients and healthcare systems [3]. For patients in a low- to middle-income nation like Pakistan, the financial strain associated with surgery—which includes preoperative evaluations, surgical costs, hospital stays, and postoperative care—can be challenging [4]. Furthermore, the ripple effects affect the whole healthcare system, diverting resources that may otherwise be used for other urgent medical needs. A study by Siddiqui et al. emphasizes the need for a comprehensive analysis of economic factors in appendicitis management, particularly in low- and middle-income countries like Pakistan. The challenges in countries such as Pakistan require the exploration of alternative approaches that can optimize clinical outcomes while effectively managing healthcare costs without compromising patient care. [2] The recent study by Lee et al. introduces a promising alternative to conventional appendicitis management [5]. The research focuses on nonoperative treatment approaches, such as antibiotic therapy and observation, which have gained traction for their potential benefits Further, the study shows that the majority of the patients who had nonoperative treatment did not encounter a recurrence of appendicitis and were able to avoid surgical intervention for a period of around 20 years. Furthermore, there is a lack of data indicating any long-term dangers associated with nonoperative care. One of the prominent advantages lies in the reduction of immediate healthcare expenses, which can alleviate the financial burden on both patients and healthcare systems. By presenting evidence on the effectiveness and safety of nonoperative approaches, this study opens avenues for a paradigm shift in appendicitis management in Pakistan. The potential to achieve comparable clinical outcomes while minimizing the economic burden is a compelling proposition that warrants further exploration and consideration within Pakistan's healthcare challenges.

Complicated Appendicitis: An Update on Management: Mini Review

Complicated appendicitis is a complication of acute appendicitis, which is defined as perforation of the appendix, with abscess or mass formation. The management of complicated appendicitis was initially with conservative treatment with intra-venous antibiotics, with percutaneous drainage of abscess reserved for patients with abscess formation. The recent trend has seen a movement towards immediate appendectomy with laparoscopic appendectomy being the preferred surgical option. As there is no definitive consensus on the management of complicated appendicitis, we have conducted this mini review to look at the treatment option for complicated appendicitis in adults and children.

Exploring the seasonal impact on appendectomy: incidence, patterns, predictors, and healthcare implication of appendectomy at Prince Ali military hospital

Background: This study at Prince Ali military hospital in Al Karak, Jordan, investigates seasonal variations in appendicitis incidence and outcomes, assessing diagnostic and treatment strategies across different seasons. The aim is to understand how seasonal changes influence appendicitis rates and to evaluate the effectiveness of diagnostic methods and treatment approaches. Methods: A retrospective observational study was conducted on 321 confirmed cases of inflamed or perforated appendicitis from March 2021 to February 2024. Patient demographics, dates of surgery, surgical interventions, and postoperative complications were analyzed, with a focus on seasonal trends. Results: Out of 394 reviewed cases, 321 (81.47%) met the inclusion criteria, showing significant seasonal variations in appendicitis incidence. Autumn saw the highest rate of appendicitis cases at 32.09% while the lowest was in Winter (22.12%). Regarding normal appendix, the highest rate was in winter (21.98%), and the lowest was in summer (13.09%). The mean patient age was 25.20 years, with a majority being male (66.36%). Open surgeries were the most common, comprising 91.9% of cases, compared to 8.1% for laparoscopic procedures. Diagnostic analysis revealed a very strong correlation between CT findings and histopathological outcomes (p=3.23×10^-11) and a significant but less strong correlation for ultrasound findings (p=0.000446). These results suggest that both diagnostic methods are effective, with CT scans showing a stronger correlation. The distribution of cases across seasons was 32.087% in autumn, 23.05% in spring, 22.741% in summer, and 22.118% in winter. Conclusions: Significant seasonal peaks in appendicitis are evident, particularly in autumn, driven by changes in diet and viral infections. The superior effectiveness of CT scans during winter highlights the need for adaptive diagnostic strategies across seasons. These findings advocate for healthcare systems to seasonally adjust resources and diagnostics to optimize appendicitis management, with further research needed to expand these insights globally.

Laparoscopic versus Open Appendectomy in the Management of Complicated Appendicitis

Laparoscopic versus Open Appendectomy in the Management of Complicated Appendicitis

Interhospital variation in the non-operative management of uncomplicated appendicitis in adults

BackgroundRecent randomized trials have suggested non-operative management to be a safe alternative to appendectomy for acute uncomplicated appendicitis. Yet, there remains significant variability in treatment approach. This study sought to characterize center-level variation in non-operative management within a national cohort of adults presenting with appendicitis. MethodsThe 2016–2020 Nationwide Readmissions Database was queried to identify all adult (≥18 years) hospitalizations for acute uncomplicated appendicitis. Hierarchical, mixed-effects models were developed to ascertain factors linked with non-operative management. Bayesian methodology was applied to predict random effects, which were then used to rank centers by increasing hospital-attributed rate of non-operative management. Institutions with high center-specific rates of non-operative management (>90th percentile) were considered low-operating hospitals (LOH). ResultsOf an estimated 447,500 patients, 52,523 (11.7 %) were managed non-operatively. Compared to those undergoing appendectomy, the non-operative cohort was older, more commonly male, and of a higher comorbidity burden. Approximately 30 % in the variability of non-operative management was attributable to hospital effects, with absolute, risk-adjusted rates ranging from 0.5 to 22.5 %. Centers with non-operative management rates ≥90th percentile were considered LOH.Following risk adjustment, among patients undergoing appendectomy, care at LOH was linked with greater odds of postoperative infection, resource utilization, and non-elective readmission. ConclusionsWe identified significant interhospital variation in the utilization of non-operative management for acute uncomplicated appendicitis. Further, we found LOH to be associated with inferior outcomes following surgical management. Future work is needed to assess the care pathways that contribute to increased utilization of non-operative strategies, and disseminate best practices across institutions.

Navigating appendicitis care during the Covid-19 pandemic: a retrospective cohort study in China

BackgroundThe emergence of the COVID-19 pandemic in December 2019 initiated a global transformation in healthcare practices, particularly with respect to hospital management. PCR testing mandates for medical treatment seekers were introduced to mitigate virus transmission.AimsThis study examines the impact of these changes on the management of patients with appendicitis.MethodsWe conducted a retrospective analysis of medical records for 748 patients diagnosed with appendicitis who underwent surgery at a tertiary care hospital during two distinct periods, the pre-pandemic year 2019 and the post-pandemic year 2021. Patient demographics, clinical characteristics, laboratory data, surgical outcomes, and hospital stay duration were assessed.ResultsWhile no significant differences were observed in the general characteristics of patients between the two groups, the time from hospital visit to operation increased significantly during the pandemic. Unexpectedly, delayed surgical intervention was associated with shorter hospital stays but did not directly impact complication rates. There was no discernible variation in the type of surgery or surgical timing based on symptom onset. The pandemic also prompted an increase in appendicitis cases, potentially related to coronavirus protein expression within the appendix.ConclusionsThe COVID-19 pandemic has reshaped the landscape of appendicitis management. This study underscores the complex interplay of factors, including changes in hospital protocols, patient concerns, and surgical timing. Further research is needed to explore the potential link between COVID-19 and appendicitis. These insights are valuable for informing healthcare practices during and beyond the pandemic.