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The efficacy and safety of antibiotic treatment for uncomplicated acute appendicitis has been established at long-term follow-up with the majority of recurrences shown to occur within the first year. Overall costs of antibiotics are significantly lower compared with appendectomy at short-term follow-up, but long-term durability of these cost savings is unclear. The study objective was to compare the long-term overall costs of antibiotic therapy versus appendectomy in the treatment of uncomplicated acute appendicitis in the APPAC (APPendicitis ACuta) trial at 5 years. This multicentre, non-inferiority randomized clinical trial randomly assigned 530 adult patients with CT-confirmed uncomplicated acute appendicitis to appendectomy or antibiotic treatment at six Finnish hospitals. All major costs during the 5-year follow-up were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis. Between November 2009 and June 2012, 273 patients were randomized to appendectomy and 257 to antibiotics. The overall costs of appendectomy were 1.4 times higher (p<0.001) (€5716; 95% CI: €5510 to €5925) compared with antibiotic therapy (€4171; 95% CI: €3879 to €4463) resulting in cost savings of €1545 per patient (95% CI: €1193 to €1899; p<0.001) in the antibiotic group. At 5 years, the majority (61%, n = 156) of antibiotic group patients did not undergo appendectomy. At 5-year follow-up antibiotic treatment resulted in significantly lower overall costs compared with appendectomy. As the majority of appendicitis recurrences occur within the first year after the initial antibiotic treatment, these results suggest that treating uncomplicated acute appendicitis with antibiotics instead of appendectomy results in lower overall costs even at longer-term follow-up.

Background Superficial surgical site infection (SSI) is common after appendectomy. This study aims to determine a clinical prediction score for SSI after appendectomy in complicated appendicitis. Methods Data from randomized controlled trial of delayed versus primary wound closures in complicated appendicitis was used. Nineteen patient- and operative-related predictors were selected in the logit model. Clinical prediction score was then constructed using coefficients of significant predictors. Risk stratification was done by receiver operating characteristic (ROC) curve analysis. Bootstrap technique was used to internal validate the score. Results Among 607 patients, the SSI incidence was 8.7% (95% CI 6.4, 11.2). Four predictors were significantly associated with SSI, i.e., presence of diabetes, incisional length > 7 cm, fecal contamination, and operative time > 75 min with the odds ratio of 2.6 (95% CI 1.2, 5.9), 2.8 (1.5, 5.4), 3.6 (1.9, 6.8), and 3.4 (1.8, 6.5), respectively. Clinical prediction score ranged from 0 to 4.5 with its discrimination concordance (C) statistic of 0.74 (95% CI 0.66, 0.81). Risk stratification classified patients into very low, low, moderate, and high risk groups for SSI when none, one, two, and more than two risk factors were presented with positive likelihood ratio of 1.00, 1.45, 3.32, and 9.28, respectively. A bootstrap demonstrated well calibration and thus good internal validation. Conclusions Diabetes, incisional length, fecal contamination, and operative time could be used to predict SSI with acceptable discrimination. This clinical risk prediction should be useful in prediction of SSI. However, external validation should be performed. Trial registration ClinicalTrials.gov (ID NCT01659983 ), registered August 8, 2012

This study aims to determine whether refugee patients are more likely to present with complicated appendicitis. Patients who were hospitalized and treated with the diagnosis of acute appendicitis in a single center between 2018 and 2020 were evaluated within the scope of this study, and the included patients were divided into two groups as refugees (n=140) and local patients (n=386). The primary outcome was complicated appendicitis rate, and the duration of symptoms, time to appendectomy, operation time, diagnostic modality, and length of hospital stay were also analyzed. According to operational diagnosis and pathology reports, cases were categorized as either non-complicated or complicated. The complicated appendicitis rate, and the number of patients with symptoms lasting longer than 72 h were statistically more significant in refugee patients (p=0.009 and n: 186, p=0.000, respectively). The refugee patients had a younger mean age and a higher male patient rate which was statistically significant (p=0.000 for both). There was no significant difference between the groups concerning time to appendectomy, operation time, type of surgery, hospital length of stay, and diagnostic modality (p>0.05). The findings of this study demonstrated that refugee patients have a higher complicated appendicitis rate and late admission rate, even though refugee patients have equal access to healthcare in our country. Future research is needed to identify factors affecting outcomes of refugee patients.

Appendicitis is the most commonly performed emergency abdominal surgery. The appendix can also be the site of a variety of neoplasms and unusual inflammatory conditions. A retrospective review was performed to determine the pathological diagnoses in appendicectomy specimens. This study is a retrospective analysis of 2660 appendicectomies performed from 1997 to 2003. The reports were analyzed for the following parameters: age-related incidence of acute appendicitis, seasonal variation in presentation, perforation rate, rate of negative and incidental appendicectomy, and the incidence of other pathologies encountered. Of the 2660 appendicectomy specimens, acute appendicitis was seen in 1718 patients (64.58%), with a peak in patients in their second decade (35.09% of cases of acute appendicitis). The perforation rate was 13.9% and was significantly higher in patients aged 70 years or more (P < 0.001). The negative appendicectomy rate was 28.8%, and was significantly higher in female patients (P < 0.001) and in the 11-30 year age group (P < 0.001). Other pathologies include carcinoid (0.52%), adenocarcinoma (0.39%), and mucinous cystadenoma (0.60%). The high rate of negative appendicectomy among female patients and the increased incidence of perforation in elderly patients reinforce the validity of the judicious use of laparoscopy in these populations. There are still a number of unusual histologies found in appendicectomy specimens supporting the continued use of routine histology.

Background As the novel coronavirus disease 19 (COVID-19) spreads, a decrease in the number of patients with acute appendicitis (AA) has been noted in our institutions. The aim of this study was to compare the incidence and severity of AA before and during the COVID-19 pandemic. Methods A retrospective cohort analysis was performed between December 2019 and April 2020 in the four high-volume centres that provide health care to the municipality of Jerusalem, Israel. Two groups were created. Group A consisted of patients who presented in the 7 weeks prior to COVID-19 first being diagnosed, whilst those in the 7 weeks after were allocated to Group B. A comparison was performed between the clinicopathological features of the patients in each group as was the changing incidence of AA. Results A total of 378 patients were identified, 237 in Group A and 141 in Group B (62.7% vs. 37.3%). Following the onset of COVID-19, the weekly incidence of AA decreased by 40.7% ( p  = 0.02). There was no significant difference between the groups in terms of the length of preoperative symptoms or surgery, need for postoperative peritoneal drainage or the distribution of complicated versus uncomplicated appendicitis. Conclusions The significant decrease in the number of patients admitted with AA during the onset of COVID-19 possibly represents successful resolution of mild appendicitis treated symptomatically by patients at home. Further research is needed to corroborate this assumption and identify those patients who may benefit from this treatment pathway.

BackgroundPatient attendance at emergency departments (EDs) during the COVID-19 pandemic outbreak has decreased dramatically under the “stay at home” and “lockdown” restrictions. By contrast, a notable rise in severity of various surgical conditions was observed, suggesting that the restrictions coupled with fear from medical facilities might negatively impact non-COVID-19 diseases. This study aims to assess the incidence and outcome of complicated appendicitis (CA) cases during that period.MethodsA retrospective study comparing the rate and severity of acute appendicitis (AA) cases during the COVID-19 initial outbreak in Israel during March and April of 2020 (P20) to the corresponding period in 2019 (P19) was conducted. Patient data included demographics, pre-ED status, surgical data, and postoperative outcomes.ResultsOverall, 123 patients were diagnosed with acute appendicitis, 60 patients during P20 were compared to 63 patients in P19. The rate of complicated appendicitis cases was significantly higher during the COVID-19 Lockdown with 43.3% (26 patients) vs. 20.6% (13 patients), respectively (p < 0.01). The average delay in ED presentation between P20 and P19 was 3.4 vs. 2 days (p = 0.03). The length of stay was 2.6 days in P20 vs. 2.3 days in P19 (p = 0.4), and the readmission rate was 12% (7 patients) vs. 4.8% (3 patients), p = 0.17, respectively. Logistic regression demonstrated that a delay in ED presentation was a significant risk factor for complicated appendicitis (OR 1.139, CI 1.011–1.284).ConclusionThe effect of the COVID-19 initial outbreak and Lockdown coupled with hesitation to come to medical facilities appears to have discouraged patients with acute appendicitis from presenting to the ED as complaints began, causing a delay in diagnosis and treatment, which might have led to a higher rate of complicated appendicitis cases and a heavier burden on health care systems.

Reduced use of the emergency department during the COVID-19 pandemic may result in increased disease acuity when patients do seek health care services. We sought to evaluate emergency department visits for common abdominal and gynecologic conditions before and at the beginning of the pandemic to determine whether changes in emergency department attendance had serious consequences for patients. We conducted a population-based analysis using administrative data to evaluate the weekly rate of emergency department visits pre-COVID-19 (Jan. 1–Mar. 10, 2020) and during the beginning of the COVID-19 pandemic (Mar. 11–June 30, 2020), compared with a historical control period (Jan. 1–July 1, 2019). All residents of Ontario, Canada, presenting to the emergency department with appendicitis, cholecystitis, ectopic pregnancy or miscarriage were included. We evaluated weekly incidence rate ratios (IRRs) of emergency department visits, management strategies and clinical outcomes. Across all study periods, 39 691 emergency department visits met inclusion criteria (40.2 % appendicitis, 32.1% miscarriage, 21.3% cholecystitis, 6.4% ectopic pregnancy). Baseline characteristics of patients presenting to the emergency department did not vary across study periods. After an initial reduction in emergency department visits, presentations for cholecystitis and ectopic pregnancy quickly returned to expected levels. However, presentations for appendicitis and miscarriage showed sustained reductions (IRR 0.61–0.80), with 1087 and 984 fewer visits, respectively, after the start of the pandemic, relative to 2019. Management strategies, complications and mortality rates were similar across study periods for all conditions. Although our study showed evidence of emergency department avoidance in Ontario during the first wave of the COVID-19 pandemic, no adverse consequences were evident. Emergency care and outcomes for patients were similar before and during the pandemic.

Background The study was designed to examine the epidemiology of appendicitis and risk factors of perforation and appendectomy. Methods Retrospective analysis of the California Office of Statewide Health Planning and Development Patient Discharge Data was performed from 1995 to 2009. Patients with appendicitis were identified by ICD-9 diagnosis code. Population statistics from the RAND Corporation were used to calculate incidence rates. Risk factors of perforation and appendectomy were also calculated. Results A total of 608,116 patients with appendicitis (70 % non-perforated) were included. The incidence increased at an average rate of 0.5 cases/100,000 population/year ( p  < 0.001), with annual incidence peaking during the third quarter. Children age 10–14 had the highest rates of appendicitis (169.6 cases/100,000). The lifetime cumulative incidence rate is 9.0 %. Appendicitis is most common in whites and Hispanics and less common in African Americans and Asians. Risks of perforation include Hispanic or Asian race, young or old age, and non-private insurance. The adjusted odds of appendectomy increased since 1995 in patients with non-perforated appendicitis (OR 1.5, 95 % CI (1.3–1.7); p  < 0.001), but it decreased in patients with perforated appendicitis (OR 0.4, 95 % CI (0.4–0.5); p  < 0.001). Conclusions This is the largest epidemiological study of appendicitis to our knowledge in recent years. Incidence has increased over time and is higher in the summer months. Whites and Hispanics have higher rates of appendicitis, but Hispanics and Asians and patients with non-private insurance, have higher odds of perforation. Surgical management of perforated appendicitis has decreased over time. It is unknown why the incidence has increased, displays seasonality, and varies by race.

Objective To evaluate the perioperative severity of acute appendicitis during the COVID-19 pandemic compared to the same periods in 2018 and 2019 in the Nancy-Metz region, France. Summary background data Acute appendicitis is a common surgical emergency that can lead to severe complications if not treated promptly. The COVID-19 pandemic and subsequent lockdowns resulted in reduced hospital visits, potentially delaying treatment for appendicitis and increasing perioperative severity. Methods This retrospective, bicentric cohort study included 634 adult patients who underwent emergency appendectomy at the Nancy University Hospital and Metz Regional Hospital. The study compared patients from the pandemic period (March 17, 2020, to December 14, 2020) with those from the same periods in 2018 and 2019. The primary outcome was perioperative severity, defined by a Gomes score ≥ 3 and/or a Clavien-Dindo classification ≥ 3. Secondary outcomes included time to treatment, severity of biological inflammatory syndrome, postoperative complications, and hospitalization metrics. Logistic regression analyses were performed with adjustments for ASA scores. Results The study included 194 patients from the COVID-19 cohort and 440 from the non-COVID cohort. The perioperative severity was higher during the COVID period (33.5% vs. 25.9%), though this difference was not statistically significant ( p  = 0.0845). Secondary outcomes such as time to treatment, severity of the inflammatory syndrome, and postoperative complications did not show significant differences between cohorts. However, the duration of postoperative antibiotic therapy was longer during the COVID period (6 days vs. 5 days, p  = 0.0410). Conclusion The COVID-19 pandemic led to a non-significant increase in perioperative severity of acute appendicitis. Despite the challenges posed by the pandemic, the French healthcare system maintained effective management of surgical emergencies, with no significant increase in postoperative complications. Further research is required to explore the broader impact of the pandemic on the management of appendicitis.

Healthcare disparities that impact patients with disabilities are relatively understudied in surgery. We investigated whether patients with neurodevelopmental disabilities present more often with complicated appendicitis than do patients without disabilities by conducting a retrospective review of patients under the age of 50 presenting with acute appendicitis between 2016 and 2021 within the largest public hospital system in the United States. Patients with neurodevelopmental disabilities (NDD) were identified using ICD-10 codes for the most common diagnoses in this category and matched to controls in a 1:2 ratio based on age, gender, and race/ethnicity. Our results indicate that patients with NDD presented significantly more often with complicated appendicitis with an odds ratio of 2.15 (p ​= ​0.003), had greater LOS, and more post-operative complications. These results point to a potential disparity that patients with disabilities may experience within emergency general surgery. •Patients with disabilities face numerous healthcare disparities.•These disparities have been less well documented in Surgery than in Medicine.•Results suggest disabled patients present more often with complicated appendicitis.