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Background: A recent meta-analysis concluded that outpatient appendectomy appears feasible and safe, but there is a lack of high-quality evidence and a randomized trial is needed. The aim of this trial is to demonstrate that outpatient appendectomy is non-inferior to conventional inpatient appendectomy in terms of overall morbi-mortality on the 30th postoperative day (D30)., Methods: SAMBA is a prospective, randomized, controlled, multicenter non-inferiority trial. We will include 1400 patients admitted to 15 French hospitals between January 2023 and June 2025. Inclusion criteria are patients aged between 15 and 74 years presenting acute uncomplicated appendicitis suitable to be operated by laparoscopy. Patients will be randomized to receive outpatient care (day-surgery) or conventional inpatient care with overnight hospitalization in the surgery department. The primary outcome is postoperative morbi-mortality at D30. Secondary outcomes include time from diagnosis to appendectomy, length of total hospital stay, re-hospitalization, interventional radiology, re-interventions until D30, conversion from outpatient to inpatient, and quality of life and patient satisfaction using validated questionnaires., Discussion: The SAMBA trial tests the hypothesis that outpatient surgery (i.e., without an overnight hospital stay) of uncomplicated acute appendicitis is a feasible and reliable procedure in establishments with a technical platform able to support this management strategy., Trial Registration: ClinicalTrials.gov NCT05691348. Registered on 20 January 2023., (© 2024. The Author(s).)

Introduction: The 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., Methods: This 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., Results: The 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%)., Conclusion: Nonoperative 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., Competing Interests: Conflict of Interest/Disclosure We have no conflicts of interest to report., (Published by Elsevier Inc.)

Importance: The optimal treatment of acute uncomplicated appendicitis in older adults with frailty is not defined., Objective: To examine outcomes associated with treatment strategies for acute uncomplicated appendicitis in older adults with or without frailty., Design, Setting, and Participants: This retrospective cohort study used National Inpatient Sample data from adults 65 years or older with a diagnosis of uncomplicated appendicitis from January 1, 2016, to December 31, 2018. Data were analyzed from July to November 2023. The National Inpatient Sample database approximates a 20% stratified sample of all inpatient hospital discharges in the US., Exposures: Study patients were categorized into 3 groups: nonoperative management, immediate operation, and delayed operation., Main Outcomes and Measures: Clinical outcomes, including hospital complications and in-hospital mortality, were assessed among older adults with and without frailty, identified using an adapted claims-based frailty index., Results: A total of 24 320 patients were identified (median [IQR] age, 72 [68-79] years; 50.9% female). Of those, 7290 (30.0%) were categorized as having frailty. Overall, in-hospital mortality was 1.4%, and the incidence of complications was 37.3%. In patients with frailty, multivariable analysis showed both nonoperative management (odds ratio [OR], 2.89; 95% CI, 1.40-5.98; P < .001) and delayed appendectomy (OR, 3.80; 95% CI, 1.72-8.43; P < .001) were associated with increased in-hospital mortality compared with immediate appendectomy. In patients without frailty, immediate appendectomy was associated with increased hospital complications compared with nonoperative management (OR, 0.77; 95% CI, 0.64-0.94; P = .009) and lower hospital complications compared with delayed appendectomy (OR, 2.05; 95% CI, 1.41-3.00; P < .001)., Conclusions and Relevance: In this cohort study of older adults with uncomplicated appendicitis, outcomes differed among management strategies based on frailty status. Routine frailty assessments incorporated in the care of older adult patients may help guide discussions for shared decision-making.

Background: Acute appendicitis is a global disease with high incidence. The main objective was to assess the association between time from admission to surgery (TAS) and surgery during emergency hours with operative outcome in light of conflicting evidence., Methods: This is a retrospective population-wide analysis of hospital billing data (2010-2021) of all adult patient records of surgically treated cases of acute appendicitis in Germany by TAS. The primary outcome was a composite clinical endpoint (CCE; prolonged length of stay, surgical site infection, interventional draining after surgery, revision surgery, ICU admission and/or in-hospital mortality). Cases of complicated appendicitis were identified using diagnosis (ICD-10) and procedural codes (resection beyond appendectomy)., Results: 855 694 patient records were included, of which 27·6% (236,481) were complicated cases of acute appendicitis. 49·0% (418,821) were females and median age was 37 (interquartile range 22·5-51·5). Age, male sex, and comorbidity were associated with an increased proportion of CCE and in-hospital mortality. TAS was associated with a clinically relevant increase of CCE after 12 h in complicated appendicitis [Odd's ratio (OR), 1·19, 95% CI: 1·14-1·21] and after 24 h in uncomplicated appendicitis (OR 1·10, 95% CI: 1·02-1·19). Beyond the primary endpoint, the proportion of complicated appendicitis increased after TAS of 72 h. Surgery during emergency hours (6 pm-6.59 am) was associated with an increase of CCE and mortality (OR between 1·14 and 1·49). Age, female sex, night-time admission, weekend admission, a known previous surgery, obesity, and therapeutic anticoagulation were associated with delayed performance of surgery., Conclusion: This work found an increase of a CCE after TAS of 12 h for complicated appendicitis and an increase of the CCE after TAS of 24 h for uncomplicated appendicitis with a stable proportion of complicated appendicitis in these time windows. Both CCE and mortality were increased if appendectomy was performed during emergency hours., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Appendicitis is one of the most common acute surgical conditions globally, and hence appendectomy is a common procedure performed around the clock in many hospitals. The aim of the current study was to determine whether acute appendectomy due to acute appendicitis performed during day, evening, and night was equally safe, in terms of postoperative complications, readmission, death, and length of hospital stay., Methods: A retrospective single-center cohort study, using a local quality register of all consecutive acute appendectomies performed at the Department of Surgery, Södersjukhuset, Stockholm, Sweden. During the study period from December 2015 to August 2022, 4950 patients were included. Risk of complications, readmission, and death were determined using multivariable logistic regression models. Association with length of hospital stay was determined using multiple linear regression., Results: There was no significant difference in the associated risk of postoperative complications, readmission within 30 days, or death, regardless of when appendectomy was performed. Using daytime surgery as reference, hospital stay was shortened by 4.21 h (P = 0.008) for evening surgery and by 6.71 h (P < 0.001) for nightly surgery., Conclusion: Risks of postoperative complications, readmission, and death were similar regardless of when acute appendectomy was performed. However, surgery during evening and night was associated with shortened hospital stay, as compared to daytime surgery., (© 2023. The Author(s).)

Results: A total of 336,880 patients were included in the cohort. Mean age was 37.7 and 73.8 years in adult and elderly patients, respectively. 97.3% of adults and 94.2% of elderly patients underwent an operation. The mortality rate in the elderly patients (1.04%, n=402/38,509) was 22 times higher (p<0.0001) than that in adult patients (0.047%, n=144/301,408). Mean (SD) hospital length of stay (HLOS) was 2.6 (2.9) days in adults and 4.9 (5.2) days in elderly patients (p<0.0001). Ninety-nine percent of adult and elderly patients were discharged within 11 and 20 days after emergent hospitalization, respectively. In the final regression model, every one year older in age increased the odds of mortality by 5% (OR=1.05, 95%CI: 1.04-1.06, p<0.001), and for every one day longer, HLOS increased the odds of mortality by 1% (OR=1.01, 95%CI: 1.001-1.02, p<0.001). The multivariable logistic regression model was built on 82,006 patients whose HLOS was ≥4 days, the odds ratio for HLOS was 1.05 (95%CI: 1.04-1.06). This means that for every additional day in hospital after day 4, the odds of mortality increase by 5%.

Background: During the coronavirus disease 2019 pandemic, New York instituted a statewide stay-at-home mandate to lower viral transmission. While public health guidelines advised continued provision of timely care for patients, disruption of safety-net health care and public fear have been proposed to be related to indirect deaths because of delays in presentation. We hypothesized that admissions for emergency general surgery (EGS) diagnoses would decrease during the pandemic and that mortality for these patients would increase., Methods: A multicenter observational study comparing EGS admissions from January to May 2020 to 2018 and 2019 across 11 NYC hospitals in the largest public health care system in the United States was performed. Emergency general surgery diagnoses were defined using International Classification Diseases, Tenth Revision, codes and grouped into seven common diagnosis categories: appendicitis, cholecystitis, small/large bowel, peptic ulcer disease, groin hernia, ventral hernia, and necrotizing soft tissue infection. Baseline demographics were compared including age, race/ethnicity, and payor status. Outcomes included coronavirus disease (COVID) status and mortality., Results: A total of 1,376 patients were admitted for EGS diagnoses from January to May 2020, a decrease compared with both 2018 (1,789) and 2019 (1,668) (p < 0.0001). This drop was most notable after the stay-at-home mandate (March 22, 2020; week 12). From March to May 2020, 3.3%, 19.2%, and 6.0% of EGS admissions were incidentally COVID positive, respectively. Mortality increased in March to May 2020 compared with 2019 (2.2% vs. 0.7%); this difference was statistically significant between April 2020 and April 2019 (4.1% vs. 0.9%, p = 0.045)., Conclusion: Supporting our hypothesis, the coronavirus disease 2019 pandemic and subsequent stay-at-home mandate resulted in decreased EGS admissions between March and May 2020 compared with prior years. During this time, there was also a statistically significant increase in mortality, which peaked at the height of COVID infection rates in our population., Level of Evidence: Epidemiological, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction:  Children with appendicitis often present with complicated disease. The aim of this study was to describe the clinical management of pediatric appendicitis, and to report how disease severity and operative modality are associated with short- and long-term risks of adverse outcome., Materials and Methods:  A nationwide retrospective cohort study of all Swedish children (<18 years) diagnosed with appendicitis, 2001 to 2014 ( n  = 38,939). Primary and secondary outcomes were length of stay, surgical site infections, readmissions, 30-day mortality, and long-term risk of surgery for small bowel obstruction (SBO). Implications of complicated disease and operative modality were assessed with adjustment for age, gender, and trends over time., Results:  Complicated appendicitis was associated with longer hospital stay (4 vs. 2 days, p  < 0.001), increased risk of surgical site infection (5.9 vs. 2.3%, adjusted odds ratio [aOR]: 2.64 [95% confidence interval, CI: 2.18-3.18], p  < 0.001), readmission (5.5 vs. 1.2, aOR: 4.74 [95% CI: 4.08-5.53], p  < 0.001), as well as long-term risk of surgery for SBO (0.7 vs. 0.2%, adjusted hazard ratio [aHR]: 3.89 [95% CI: 2.61-5.78], p  < 0.001). Intended laparoscopic approach was associated with reduced risk of surgical site infections (2.3 vs. 3.1%, aOR: 0.74 [95% CI: 0.62-0.89], p  = 0.001), but no overall reduction in risk for SBO; however, successful laparoscopic appendectomy was associated with less SBO during follow-up compared with open appendectomy (aHR: 0.27 [95% CI: 0.11-0.63], p  = 0.002)., Conclusion:  Children treated for complicated appendicitis are at risk of substantial short- and long-term morbidities. Fewer surgical site infections were seen after intended laparoscopic appendectomy, compared with open appendectomy, also when converted procedures were accounted for., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction: Studies have proposed the use of antibiotics only in cases of acute uncomplicated appendicitis (AUA). However, there remains a paucity of data evaluating this nonoperative approach in the vulnerable frail geriatric population. The aim of this study was to examine long-term outcomes of frail geriatric patients with AUA treated with appendectomy compared with initial nonoperative management (NOP)., Methods: We conducted a 1-year (2017) analysis of the Nationwide Readmissions Database and included all frail geriatric patients(age, ≥65 years) with a diagnosis of AUA. Frailty was assessed using the five-factor modified frailty index. Patients were stratified into those undergoing appendectomy at index admission (operative management) versus those receiving antibiotics only without operative intervention (NOP). Propensity score matching in a 1:1 ratio was performed adjusting for patient- and hospital-related factors., Results: A total of 5,562 frail geriatric patients with AUA were identified from which a matched cohort of 1,320 patients in each group was obtained. Patients in the NOP and operative management were comparable in terms of age (75.5 ± 7.7 vs. 75.5 ± 7.4 years; p = 0.882) and modified frailty index (0.4 [0.4-0.6] vs. 0.4 [0.4-0.6]; p = 0.526). Failure of NOP management was reported in 18% of patients, 95% of which eventually underwent appendectomy. Over the 6-month follow-up period, patients in the NOP group had significantly higher rates of Clostridium difficile enterocolitis (3% vs. 1%; p < 0.001), greater number of overall hospitalized days (5 [3-9] vs. 4 [2-7] days; p < 0.001), and higher overall costs (US $16,000 [12,000-25,000] vs. US $11,000 [8,000-19,000]; p < 0.001). Patients undergoing appendectomy after failed NOP had significantly higher rates of complications (20% vs. 11%; p < 0.001), mortality (4% vs. 2%; p = 0.019), and appendiceal neoplasm (3% vs. 1%; p = 0.027)., Conclusion: One in six patients failed NOP within 6 months and required appendectomy with subsequent more complications and higher mortality. Appendectomy may offer better outcomes in managing AUA in the frail geriatric population., Level of Evidence: Therapeutic, level IV., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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.

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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The number of geriatric patients is expected to grow 3-fold over the next 30 years, and as many as 50% of the surgeries done in the United States may occur in geriatric patients. Geriatric patients often have increased comorbidities and more often present in a delayed manner for acute appendicitis. The aim of this study was to evaluate outcomes between geriatric patients and younger patients undergoing appendectomy, hypothesizing that geriatric patients will have a higher risk of abscess and/or perforation, conversion to open surgery, postoperative intra-abdominal abscess, and 30-day readmission., Methods: The 2016 to 2017 American College of Surgeons National Surgical Quality Improvement Program Procedure Targeted Appendectomy database was queried for patients with preoperative image findings consistent with acute appendicitis. Geriatric patients (age ≥65 years old) were compared with younger patients (age <65 years old). A multivariable logistic regression model was used for analysis., Results: From 21,586 patients undergoing appendectomy, 2,060 (9.5%) were geriatric patients. Compared with the younger cohort, geriatric patients were less likely to have leukocytosis (59.0% vs 65.8%, P < .001) and more likely to have a tumor and/or malignancy involving the appendix on final pathology (2.0% vs 0.8%, P < .001), an unplanned laparoscopic conversion to open surgery (4.2% vs 1.5%, P < .001), and 30-day readmission (7.0% vs 3.3%, P < .001). Geriatric patients had a longer median length of stay (2 vs 1 days, P < .001) and higher mortality rate (0.5% vs <0.1%, P < .001). After adjusting for covariates, there was an increased associated risk of intraoperative abscess and/or perforation (odds ratio 2.23, 2.01-2.48, P < .001) and postoperative intra-abdominal abscess (odds ratio 1.43, 1.12-1.83, P = .005) but no difference in associated risk for mortality (odds ratio 2.56, 0.79-8.25, P = .116), compared with the younger cohort., Conclusion: Nearly 10% of laparoscopic appendectomies are done on geriatric patients with geriatric patients having a higher rate of conversion to open surgery and tumor and/or malignancy on final pathology. Geriatric patients have an associated increased risk of intraoperative perforation and/or abscess and postoperative intra-abdominal abscess but have similar risk for mortality compared with nongeriatric patients undergoing laparoscopic appendectomy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Objectives: Life expectancy has increased substantially. Elderly patients currently represent a large part of patients requiring emergency abdominal surgery. The aim of this study was to evaluate the postoperative outcomes of elderly patients who underwent appendectomy in a single French tertiary center., Methods: We retrospectively reviewed the medical records of all patients who underwent appendectomy for acute appendicitis between January 1, 1994 and December 31, 2014. We used the French threshold of ≥ 75 y-old to define elderly patients. Hence, elderly patients who underwent appendectomy were compared to the younger group., Results: During the study period, 2,060 consecutive patients underwent appendectomy for acute appendicitis. Laparoscopic appendectomy was performed in 52% of cases. Similar rates of laparoscopic approach were recorded in both groups, but conversion to open surgery was six times more frequent in elderly patients (17% vs. 3%; P < .0001). A higher incidence of complicated appendicitis was observed in the elderly group (63% vs. 13.6%; P < .0001). Complications occurred more frequently in the elderly group (46% vs. 8%; P < .0001). 30-d mortality was 0.15% for patients < 75 y and 6.15% for elderly patients ( P < .0001). Unsuspected presence of an appendiceal neoplasm was higher (7.7%) in the elderly population., Conclusion: This study highlights the fact that appendicitis in the elderly is associated with a higher rate of complicated appendicitis, morbidity, and mortality., Competing Interests: Conflicts of Interest: none., (© 2020 by JSLS, Journal of the Society of Laparoscopic & Robotic Surgeons.)

Background: Appendicitis is one of the most preventable causes of death worldwide. We aimed to determine the trend of mortality due to appendicitis by sex and age at national and provincial levels in Iran during 26 years., Methods: Data were collected from Iran Death Registration System (DRS), cemetery databanks in Tehran and Esfahan, and the national population and housing censuses of Iran. The estimated population was determined for each group from 1990 to 2015 using a growth model. Incompleteness, misalignment, and misclassification in the DRS were addressed and multiple imputation methods were used for dealing with missing data. ICD-10 codes were converted to Global Burden of Disease (GBD) codes to allow comparison of the results with the GBD study. A Spatio-Temporal model and Gaussian Process Regression were used to predict the levels and trends in child and adult mortality rates, as well as cause fractions., Results: From 1990 to 2015, 6,982 deaths due to appendicitis were estimated in Iran. The age-standardized mortality rate per 100000 decreased from 0.72 (95% UI: 0.46-1.12) in 1990 to 0.11 (0.07-0.16) in 2015, a reduction of 84.72% over the course of 26 years. The male: female ratio was 1.13 during the 26 years of the study with an average annual percent change of -2.31% for women and -2.63% for men. Among men and women, appendicitis mortality rate had the highest magnitude of decline in the province of Zanjan and the lowest in the province of Hormozgan. In 1990, the lowest age-standardized appendicitis-related mortality was observed in both women and men in the province of Alborz and the highest mortality rate among men were observed in the province of Lorestan. In 2015, the lowest mortality rates in women and men were in the province of Tehran. The highest mortality rates in women were in Hormozgan, and in men were in Golestan province., Conclusion: The mortality rate due to appendicitis has declined at national and provincial levels in Iran. Understanding the causes of differences across provinces and the trend over years can be useful in priority setting for policy makers to inform preventive actions to further decrease mortality from appendicitis., (© 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Diffuse peritonitis represents a life-threatening complication of acute appendicitis (AA). Whether laparoscopy is a safe procedure and presents similar results compared with laparotomy in case of complicated AA is still a matter of debate. The objective of this study is to compare laparoscopic (LA) and open appendectomy (OA) for the management of diffuse peritonitis caused by AA. This is a prospective multicenter cohort study, including 223 patients with diffuse peritonitis from perforated AA, enrolled in the Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) study from February to May 2018. Two groups were created: LA = 78 patients, mean age 42.51 ± 22.14 years and OA = 145 patients, mean age 38.44 ± 20.95 years. LA was employed in 34.98% of cases. There was no statically significant difference between LA and OA groups in terms of intra-abdominal abscess, postoperative peritonitis, rate of reoperation, and mortality. The wound infection rate was higher in the OA group (OR 21.63; 95% CI 3.46-895.47; P = 0.00). The mean postoperative hospital stay in the LA group was shorter than in the OA group (6.40 ± 4.29 days versus 7.8 ± 5.30 days; P = 0.032). Although LA was only used in one-third of cases, it is a safe procedure and should be considered in the management of patients with diffuse peritonitis caused by AA, respecting its indications.

Objective: To examine differences between England and the USA in the rate of surgical intervention and in-hospital mortality for 7 index surgical emergencies., Background: Considerable international variation exists in the configuration, provision, and outcomes of emergency healthcare., Methods: Patients aged <80 years hospitalized with 1 of 7 surgical emergencies (ruptured abdominal aortic aneurysm, aortic dissection, appendicitis, perforated esophagus, peptic ulcer, small bowel or large bowel, and incarcerated or strangulated hernias) were identified from English Hospital Episode Statistics and the USA Nationwide Inpatient Sample (2006-2012) and classified by whether they received a corrective surgical intervention. The rates of surgical intervention and population mortality were compared between England and the USA after adjustment for patient demographic factors., Results: From 2006 to 2012, there were 136,047 admissions in English hospitals and 1,863,626 admissions in US hospitals due to the index surgical emergencies.Proportion of patients receiving no surgical intervention, for all 7 conditions was greater in the England (OR 4.25, 1.55, 8.53, 1.92, 2.06, 2.42, 1.75) and population in-hospital mortality was greater in England (OR 1.34, 1.67, 2.22, 1.65, 2.7, 4.46, 3.22) for ruptured abdominal aortic aneurysm, aortic dissection, appendicitis, perforated esophagus, peptic ulcer, small bowel or large bowel, and incarcerated or strangulated hernias respectively.In England (where follow-up was available), lack of utilization of surgery was also associated with increased in-hospital and long-term mortality for all conditions., Conclusion: England and US hospitals differ in the threshold for surgical intervention, which may be associated with increases in mortality in England for these 7 general surgical emergencies.

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.

Background: To compare the presentation, management, and outcome of HIV-positive patients with appendicitis to those of HIV-negative patients with appendicitis., Summary Background Data: The literature is limited regarding the impact of HIV infection on patients with appendicitis., Methods: A retrospective review of patients with appendicitis and known HIV status admitted to Princess Marina Hospital, Gaborone, Botswana, aged 13 years and greater was performed from January 2013 to December 2015. Data on patient demographics, presentation, laboratory findings, management, and outcomes were analyzed., Results: A total of 295 patients with appendicitis and known HIV status were identified, of which 119 (40.3%) were HIV positive. The median [IQR] ages for HIV-positive and HIV-negative patients were 34 [29-42] and 26 [20-33] years, respectively. The male-to-female ratio for the same two groups was 0.8:1 and 1.4:1, respectively. Presenting symptoms, signs, and white blood cell count were similar in both groups. HIV-positive patients had significantly higher overall (4.2 vs. 0.0%, p = 0.010) and postoperative (4.4 vs. 0.0%, p = 0.024) mortality rates. There was no significant difference in the total complication rate between HIV-positive and HIV-negative patients (13.2 vs. 7.9%, p = 0.192). Compared to HIV-positive patients with a CD4 count ≥200, patients with a CD4 count <200 have a significantly higher postoperative mortality rate (17.6 vs. 1.4%, p = 0.023) and a trend toward a higher total postoperative complication rate (31.3 vs. 10.8%, p = 0.054)., Conclusion: Within our setting, HIV infection, particularly with a CD4 <200, was correlated with significantly higher mortality in patients with acute appendicitis.

Background: Delta neutrophil index (DNI) is the fraction of circulating immature granulocytes provided by a routine, complete blood cell analyzer. It is known to be a useful prognostic marker of sepsis. The aim of this study was to evaluate the role of DNI in the diagnosis and prognosis of patients who had undergone emergent surgery for an acute abdomen., Methods: A total of 694 patients who had visited the emergency room for acute abdominal pain and undergone emergent abdominal surgery from May 2015 to September 2016 were retrospectively reviewed. Clinical characteristics, laboratory findings on the day of hospital visit, hospital stay, postoperative complications, and 30-day mortality were investigated., Results: In the analysis of patients who had undergone an operation for acute peritonitis, the DNI was a good predictor for predicting 30-day mortality rate (area under the curve [AUC]: 0.826). It was not inferior to other laboratory values, including activated partial thromboplastin time (AUC: 0.729), C-reactive protein (AUC: 0.727), albumin (AUC: 0.834), prothrombin time (AUC: 0.816), and creatinine (AUC: 0.837) known to be associated with sepsis. Patients with high DNI displayed higher incidence of bacteremia and sepsis, longer hospital stay, higher postoperative complication rate, and higher 30-day mortality rate than patients with low DNI. Among patients diagnosed with acute appendicitis, the DNI was a useful marker for differentiating appendiceal perforation., Conclusion: The DNI was a practical and useful marker for predicting the prognosis of patients who needed emergent abdominal surgery., (© 2019 The Authors. Journal of Clinical Laboratory Analysis Published by Wiley Periodicals, Inc.)

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.

Background: Our aim is to compare the management approaches and clinical outcomes of acute appendicitis according to annual Gross National Income per Capita (GNI/Capita) of countries., Methods: Consecutive patients who were diagnosed to have acute appendicitis from 116 centers of 44 countries were prospectively studied over a 6-month period (April-September 2016). Studied variables included demography, Alvarado score, comorbidities, radiological and surgical management, histopathology, and clinical outcome. Data were divided into three groups depending on the GNI/Capita., Results: A total of 4271 patients having a mean (SD) age of 33.4 (17.3) years were studied. Fifty-five percent were males. Two hundred and eighty patients were from lower-middle-income (LMI) countries, 1756 were from upper-middle-income (UMI) countries, and 2235 were from high-income (HI) countries. Patients in LMI countries were significantly younger (p < 0.0001) and included more males (p < 0.0001). CT scan was done in less than 8% of cases in LMI countries, 23% in UMI countries, and 38% in HI countries. Laparoscopy was performed in 73% of the cases in the HI countries, while open appendectomy was done in more than 60% of cases in both LMI and UMI countries (p < 0.0001). The longest mean hospital stay was in the UMI group (4.84 days). There was no significant difference in the complication or death rates between the three groups. The overall death rate was 3 per 1000 patients., Conclusions: There is great variation in the presentation, severity of disease, radiological workup, and surgical management of patients having acute appendicitis that is related to country income. A global effort is needed to address this variation. Individual socioeconomic status could be more important than global country socioeconomic status in predicting clinical outcome.

Objective: To assess the factors affecting the morbidity and mortality in patients over 65 years of age who underwent appendectomy., Study Design: An observational study., Place and Duration of Study: Department of General Surgery, Faculty of Medicine, Ahi Evran University, Kirsehir, Turkey, from November 2014 to March 2017., Methodology: Medical records of the patients over 65 years of age with the diagnosis of acute appendicitis who underwent appendectomy during the study period were retrospectively analyzed. Age and complications were noted. The reviewed outcome measures were perforation rates, morbidity and mortality., Results: Three hundred and seventy-eight patients over 65 years of age presenting with abdominal pain were hospitalized for diagnosis and treatment. Appendectomy was performed in 112 patients. Laparoscopic appendectomy was performed in 70 of these patients. Perforation rate and morbidity were 40% and 28%, respectively. There was no mortality., Conclusion: Elderly patients show a high perforation rate and morbidity after appendectomy.

Background: The optimal timing of appendectomy for acute appendicitis has been analyzed with mixed results. We hypothesized that delayed appendectomy would be associated with increased 30-d morbidity and mortality., Materials and Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients undergoing nonelective appendectomy from 2012 to 2015 with a postoperative diagnosis of appendicitis. Patients were grouped based on hospital day (HD) of operation. Primary outcomes included 30-d mortality and major complications. Logistic regression was performed to determine predictors of major morbidity and mortality., Results: From 2012 to 2015, 112,122 patients underwent appendectomy for acute appendicitis. Appendectomies performed on HD 3 had significantly worse outcomes as demonstrated by increased 30-d mortality (0.6%) and all major postoperative complications (8%) in comparison with operations taking place on HD 1 (0.1%; 3.4%) or HD 2 (0.1%, P < 0.001; 3.6%, P < 0.001). In subgroup analysis, open operations had significantly higher mortality and major postoperative complications, including organ/space surgical site infections (4.6% open versus 2.1% laparoscopic; P < 0.001). Patients with decreased baseline physical status by the American Society of Anesthesiologists Physical Status class had the worst outcomes (1.5% mortality; 14% major complications) when operation was delayed to HD 3. Logistic regression revealed higher American Society of Anesthesiologists Physical Status class and open operations as predictors of major complications; however, HD was not (P = 0.2)., Conclusions: Data from the American College of Surgeons National Surgical Quality Improvement Program demonstrate similar outcomes of appendectomy for acute appendicitis when the operation is performed on HD 1 or 2; however, outcomes are significantly worse for appendectomies delayed until HD 3. Increased complications in this group are likely not attributable to HD of operation, but rather decreased baseline health status and procedure type., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Delays in surgery for patients with acute appendicitis may increase the risk of perforation and complications. These risks must be balanced with the theoretical risk of nighttime operations., Objective: To determine the effect of (i) time of day of surgery and (ii) time between triage presentation and surgery, on surgical complications in patient undergoing appendectomy for appendicitis., Methods: Population level data from Ontario from 2009 to 2015 was used to conduct this retrospective cohort study. The primary exposure was (i) time of day of surgery and (ii) time between triage and surgery. The primary outcome was a composite outcome of perioperative complications. Conditional logistic regression adjusted for patient factors was used to estimate adjusted odds ratios (OR) between the exposure and complications., Results: Twelve thousand nine hundred thirty-seven matched pairs (N = 25,874) of adult patients were included. Compared to day operations, the odds of complications were lower during the evening (OR, 0.90; 95% confidence interval [CI], 0.84-0.96) and no different at night (OR, 0.90; 95% CI, 0.77-1.04). The odds of complications were higher in patients who waited longer than 24 hours for surgery compared with those who waited less than 6 hours (OR, 1.27; 95% CI, 1.14-1.43) with no increased risk in those who waited 6 hours to 12 hours or 12 hours to 24 hours., Conclusion: This large population study is the first to assess surgical risks using a case-crossover design to account for the surgeon as a potential confounder. Nighttime surgery and delaying surgery up to 24 hours were not associated increased risks of complications., Level of Evidence: Therapeutic, level III.

Emergency general surgery (EGS) is defined as the urgent assessment and treatment of nontrauma, general surgical emergencies involving adults. Acute surgical emergencies often represent the most common reason for hospital admission with diagnoses, including bowel obstruction and appendicitis. EGS is a growing surgical subspecialty that includes both operative and nonoperative management of acutely ill patients. We sought to assess the burden of nonoperative care in EGS patients at our academic medical center. This study was conducted by retrospective analysis of prospectively collected data from patients entered into the Duke EGS Registry between July 1, 2016 and September 10, 2017. Fifty-six per cent (n = 771) of patients in the Duke EGS Registry (n = 1377) were managed nonoperatively as compared with 44 per cent (n = 606) who were managed operatively. Nonoperative management of disease represents a large subset of EGS and, therefore, needs further investigation to improve processes, outcomes, and standardization of care.

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.

Background: The aim of this study was to evaluate and compare the diagnostic value of a Modified Alvarado Score (MAS) ≥7 for acute appendicitis in both Human Immunodeficiency Virus (HIV)-negative (HIVneg) and positive (HIVpos) patientcohorts., Methods: This retrospective study included all HIV-tested patients undergoing appendectomy at a regional hospital from March 2010 to March 2011. The MAS was calculated for all patients, as well as for the HIVneg and HIVpos groups separately. Two subgroups were considered for each of these: MAS ≥7 (high likelihood of appendicitis) and MAS <7 (low likelihood of appendicitis). These subgroups were then analysed against histopathological findings of the resected appendix. MAS specificities and sensitivities were determined by comparing Receiver Operator Characteristic (ROC) curves for the various scores., Results: The study comprised 133 patients. Eighty-six (65%) were men and the median age was 20 years (range 4-64); 18 patients (14%) were HIVpos. Appendicitis was confirmed histologically in 113 patients, 100 in the HIVneg group and 13 in the HIVpos group. Specificity and sensitivity of a MAS ≥7 for HIVneg patients was 73 and 85% respectively. Based on the ROC curves, HIVpos patients only showed similar sensitivities (69%) and specificities (80%) at a MAS ≥8., Conclusion: A MAS ≥7 is a reliable predictor of acute appendicitis in HIVneg patients. In HIVpos patients, the MAS threshold required to accurately predict appendicitis is 8. The use of a MAS ≥7 in this group of patients will result in unnecessary surgical intervention.

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., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: The literature regarding outcomes in patients on irreversible antithrombotic therapy (IAT) undergoing urgent laparoscopic appendectomy is limited. The aim of this multicenter retrospective study was to examine the impact of prehospital IAT on outcomes in this population., Methods: From 2010 to 2014, seven institutions from the Southwest Surgical Multicenter Trials (SWSC MCT) group conducted a retrospective study to evaluate the clinical course of all patients on IAT who underwent urgent/emergent laparoscopic appendectomy. The IAT+ group was subdivided into IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix). These groups were matched 1:1 to controls. The primary outcomes were estimated blood loss (EBL) and transfusion requirement. Secondary outcomes included infections (SSI - Surgical Site Infection, DSI - Deep Space Infection, and OSI - Organ Space Infection), hospital length of stay (HLOS), complications, 30-day readmissions, and mortality., Results: Out of the 2903 patients included in the study, 287 IAT+ patients were identified and matched in a 1:1 ratio to 287 IAT-patients. In the IAT+ vs IAT-analysis, no significant differences in EBL (p = 1.0), transfusion requirement during the preoperative (p = 0.5), intraoperative (p = 0.3) or postoperative periods (p = 0.5), infectious complications (SSI; p = 1.0, DSI; p = 1.0, and OSI; p = 0.1), overall complications (p = 0.3), HLOS (p = 0.7), 30-day readmission (p = 0.3), or mortality (p = 0.1) were noted. Similarly, outcomes in the IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix) subgroups failed to demonstrate any significant differences when compared to controls., Conclusions: Our analysis suggests that IAT is not associated with worse outcomes in urgent/emergent laparoscopic appendectomy. Prehospital use of IAT should not be used to delay laparoscopic appendectomy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

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., (Copyright © 2017 Elsevier Inc. All rights reserved.)

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., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Only 5-10% of cases of acute appendicitis (AA) are diagnosed above the age of 60 years. Complicated AA is more common in the elderly, who also have more comorbidities. The goals of this study were to describe our experience with elderly patients and identify predictors of increased morbidity., Material and Methods: Patients ≥65 years who were treated for AA between 2006 and 2013 were selected. The control consisted of patients aged 20-45 years, who were randomly selected from a pool of 900 patients., Results: Seventy-four patients ≥65 years, mean age of 74.6 ± 7.4, were included. Time from onset of symptoms to surgery was similar between the groups. CT scan was performed for all patients in the elderly group compared to 55.6% in the younger group (p < 0.001). 77% of the younger patients underwent laparoscopic appendectomy compared to 43.2% of the elderly patients (p < 0.001). Pathological findings of severe appendicitis were significantly more common in the elderly group (39.2 vs. 10.5%, p < 0.001). Sixteen elderly patients (21.6%) developed complications, compared with 4 patients (3.2%) in the younger group (p < 0.001). The length of stay was longer in the elderly group and even longer for patients with complications (p < 0.001). There was no mortality. Cardiac disease was the only independent predictor of peri-operative complications (OR = 4.2)., Conclusions: Severe forms of acute appendicitis and post-operative morbidity are higher in the elderly population. Cardiac disease is the only predictor for increased morbidity. Although CT scan was performed universally in the elderly group, it did not appear to increase time from presentation to surgery.

Background: Severity of emergency general surgery (EGS) diseases has not been standardized until recently. The American Association for the Surgery of Trauma (AAST) proposed an anatomic severity grading system for EGS diseases to facilitate communication and quality comparisons between providers and hospitals. Previous work has demonstrated validity of the system for appendicitis in the United States. To demonstrate generalizability, we aim to externally validate this grading system in South African patients with appendicitis., Methods: Patients with acute appendicitis during 2010 to 2016 were identified at multi-institutional sites within South Africa. Baseline demographics and procedure types were recorded, and AAST grades were assigned based on intraoperative findings. Outcomes included duration of stay, mortality, and Clavien-Dindo complications. Summary statistical univariate and nominal logistic regression analyses were performed to compare AAST grade and outcomes., Results: A total of 1,415 patients with a median (interquartile range) age of 19 years (14-28 years) were included (55% men). One hundred percent underwent appendectomy: 63.5% completed via midline laparotomy, 36.5% via limited incision (31.8% via McBurney incision and 4.7% via laparoscopy). Overall, 30-day mortality rate was 1.4% with an overall complication rate of 44%. Most common complications included surgical site infection (n = 147, 10.4%), pneumonia (n = 105, 7.4%), and renal failure (n = 64, 4.5%). Distribution of AAST grade is as follows: Grade 0 (10, 0.7%), Grade 1 (247, 17.4%), Grade 2 (280, 19.8%), Grade 3 (158, 11.3%), Grade 4 (179, 12.6%), and Grade 5 (541, 38.2%). Increased median (interquartile range) AAST grades were recorded in patients with complications, 5 (3-5) compared with those without (2 [1-3], p = 0.001). Duration of stay was increased for patients with higher AAST grades: 4 and 5 (10.6 ± 5.9 days) versus I and II (3.6 ± 4.3 days; p = 0.001). Area under the receiver operating characteristic analysis to predict presence of any complication based on AAST grade was 0.90., Conclusion: The AAST EGS grading system is valid to predict important clinical outcomes in a South African population with an increased degree of severity on presentation. These results support generalizability of the AAST EGS grading system for appendicitis in a developing nation., Level of Evidence: Prognostic, level II.

Background: Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms and avoid complications. The timing of appendicectomy for appendiceal phlegmon or abscess is controversial., Objectives: To assess the effects of early versus delayed appendicectomy for appendiceal phlegmon or abscess, in terms of overall morbidity and mortality., Search Methods: We searched the Cochrane Library (CENTRAL; 2016, Issue 7), MEDLINE Ovid (1950 to 23 August 2016), Embase Ovid (1974 to 23 August 2016), Science Citation Index Expanded (1900 to 23 August 2016), and the Chinese Biomedical Literature Database (CBM) (1978 to 23 August 2016). We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform search portal (23 August 2016) and ClinicalTrials.gov (23 August 2016) for ongoing trials., Selection Criteria: We included all individual and cluster-randomised controlled trials, irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess., Data Collection and Analysis: Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI)., Main Results: We included two randomised controlled trials with a total of 80 participants in this review. 1. Early versus delayed open appendicectomy for appendiceal phlegmonForty participants (paediatric and adults) with appendiceal phlegmon were randomised either to early appendicectomy (appendicectomy as soon as appendiceal mass resolved within the same admission) (n = 20), or to delayed appendicectomy (initial conservative treatment followed by interval appendicectomy six weeks later) (n = 20). The trial was at high risk of bias. There was no mortality in either group. There is insufficient evidence to determine the effect of using either early or delayed open appendicectomy onoverall morbidity (RR 13.00; 95% CI 0.78 to 216.39; very low-quality evidence), the proportion of participants who developed wound infection (RR 9.00; 95% CI 0.52 to 156.91; very low quality evidence) or faecal fistula (RR 3.00; 95% CI 0.13 to 69.52; very low quality evidence). The quality of evidence for increased length of hospital stay and time away from normal activities in the early appendicectomy group (MD 6.70 days; 95% CI 2.76 to 10.64, and MD 5.00 days; 95% CI 1.52 to 8.48, respectively) is very low quality evidence. The trial reported neither quality of life nor pain outcomes. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscessForty paediatric participants with appendiceal abscess were randomised either to early appendicectomy (emergent laparoscopic appendicectomy) (n = 20) or to delayed appendicectomy (initial conservative treatment followed by interval laparoscopic appendicectomy 10 weeks later) (n = 20). The trial was at high risk of bias. The trial did not report on overall morbidity or complications. There was no mortality in either group. We do not have sufficient evidence to determine the effects of using either early or delayed laparoscopic appendicectomy for outcomes relating to hospital stay between the groups (MD -0.20 days; 95% CI -3.54 to 3.14; very low quality of evidence). Health-related quality of life was measured with the Pediatric Quality of Life Scale-Version 4.0 questionnaire (a scale of 0 to 100 with higher values indicating a better quality of life). Health-related quality of life score measured at 12 weeks after appendicectomy was higher in the early appendicectomy group than in the delayed appendicectomy group (MD 12.40 points; 95% CI 9.78 to 15.02) but the quality of evidence was very low. This trial reported neither the pain nor the time away from normal activities., Authors' Conclusions: It is unclear whether early appendicectomy prevents complications compared to delayed appendicectomy for people with appendiceal phlegmon or abscess. The evidence indicating increased length of hospital stay and time away from normal activities in people with early open appendicectomy is of very low quality. The evidence for better health-related quality of life following early laparoscopic appendicectomy compared with delayed appendicectomy is based on very low quality evidence. For both comparisons addressed in this review, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy.Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities, quality of life and the length of hospital stay.

Background: Determination and reporting of disease severity in emergency general surgery lacks standardization. Recently, the American Association for the Surgery of Trauma (AAST) proposed an anatomic severity grading system. We aimed to validate this system in patients with appendicitis and determine if cross-sectional imaging correlates with disease severity at operation., Methods: Patients 18 years or older undergoing treatment for acute appendicitis between 2013 and 2015 were identified. Baseline demographics, procedure types were recorded, and AAST grades were assigned based on intraoperative and radiologic findings. Outcomes including length of stay, 30-day mortality, and complications based on Clavien-Dindo categories and National Surgical Quality Improvement Program variables. Summary statistical univariate, nominal logistic, and standard least squares analyses were performed comparing AAST grade with key outcomes. Bland-Altman analysis compared operative findings with preoperative cross-sectional imaging to compare assigning grades., Results: Three hundred thirty-four patients with mean (±SD) age of 39.3 years (±16.5) were included (53% men), and all patients had cross-sectional imaging. Two hundred ninety-nine underwent appendectomy, and 85% completed laparoscopic. Thirty-day mortality rate was 0.9%, complication rate was 21%. Increased (median [interquartile range, IQR]) AAST grade was recorded in patients with complications (2 [1-4]) compared with those without (1 [1-1], p = 0.001). For operative management, (median [IQR]) AAST grades were significantly associated with procedure type: laparoscopic (1 [1-1]), open (4 [2-5]), conversion to open (3 [1-4], p = 0.001). Increased (median [IQR]) AAST grades were significantly associated in nonoperative management: patients having a complication had a higher median AAST grade (4 [3-5]) compared with those without (3 [2-3], p = 0.001). Bland-Altman analysis comparing AAST grade and cross-sectional imaging demonstrated no difference (-0.02 ± 0.02; p = 0.2; coefficient of repeatability 0.9)., Conclusions: The AAST grading system is valid in our population. Increased AAST grade is associated with open procedures, complications, and length of stay. The AAST emergency general surgery grade determined by preoperative imaging strongly correlated to operative findings., Level of Evidence: Epidemiologic/prognostic study, level III.

Object: To define the mortality rate of appendectomy patients and appendectomy-related risk factors., Background: Appendectomy has been considered as a safe operation and negative appendectomies acceptable in order to avoid perforations. There are few publications on appendectomy-related mortality. Removal of a normal appendix has been suggested to be related to a higher mortality rate versus removal of an inflamed appendix., Methods: Data on all appendectomy patients between 1990 and 2010 in Finland were retrieved from the Discharge Register of the National Institute for Health and Welfare and combined with data from the Death Certificate Register of Statistics Finland. Thirty-day mortality was identified and compared with overall mortality. Detailed information from death certificates of patients dying within 30-day post-surgery was collected and analyzed., Results: Over the study period, the thirty-day post-appendectomy mortality rate was 2.1/1000. Increased mortality was found in patients over 60 years of age. Negative appendectomy and complicated appendicitis were related to mortality. The negative appendectomy rate was higher in patients older than 40 years of age. During the study period, both mortality and the rate of negative appendectomies decreased, while the rate of laparoscopic appendectomies increased., Conclusions: Post-appendectomy mortality is related to both negative appendectomies and complicated appendicitis. Diagnostic accuracy is fundamental in the care of patients with acute appendicitis, especially in the elderly. Improved diagnostic accuracy may have reduced mortality over the last two decades in Finland.

During the latter half of the 19th century, surgeons increasingly reported performing appendicectomies. Fitz from Harvard, Groves from Canada and Tait from Britain all recorded successful removal of the appendix. McBurney described the point of maximal tenderness in classic appendicitis and also the muscle-splitting incision centred on this point. Priority is given to McArthur in describing the lateral muscle-splitting incision. The direction of the cutaneous incision was later modified by Elliott and Lanz. Incisions that healed well were essential to recovery. Appendicectomy became a 'fashionable' operation after the London surgeon, Treves, removed the appendix of King Edward VII. Through the 20th century, the mortality from appendicitis fell notably with the advent of sulphonamide and penicillin, improvements in fluid therapy and safer anaesthesia. By 1990, diagnostic delay was the main cause of death. Semm performed the first laparoscopic appendicectomy in 1990, roundly criticized at the time for what is now a routine procedure. We view contemporary debates on the indications for appendicectomy, the best approach and how to optimize recovery in the light of the history of this intriguing disease., (© 2016 Royal Australasian College of Surgeons.)

Background: Preoperative imaging for suspected acute appendicitis (AA), such as ultrasonography (US), was shown to improve diagnostic accuracy and patient outcomes. Criteria for diagnosis of AA by US are well established and reliable. In previous studies, US assessments were always performed by skilled radiologist physicians. However, a radiologist and computed tomography scanning equipment are not always available in the community hospitals or remote sites of developing countries., Objective: Our aim was to assess a diagnostic pathway using clinical evaluation, routine US performed by an emergency physician, and clinical re-evaluation for patients suspected of having AA., Methods: Patients suspected of having AA admitted to the emergency department in a developing country were prospectively enrolled between November 2010 and January 2011. Clinical and US data were studied. A noncompressible appendix with a diameter ≥6 mm was the main US diagnosis criterion., Results: Among the 104 included patients, surgery was performed on 28. Of the 25 patients with positive US, 22 actually had AA, matching the surgical report. The remaining 76 patients without US appendicitis criteria underwent clinical follow-up and had medical conditions. Sensitivity of US was 88%, specificity was 96%, positive predictive value was 88%, and negative predictive value was 96%. The likelihood ratios for our US assessment highlight the need for a test with enhanced diagnostic accuracy., Conclusions: A diagnostic strategy using clinical evaluations, routine US performed by emergency physicians, and clinical re-evaluation of patients with acute abdominal pain is appropriate to provide positive results for the diagnosis and treatment of appendicitis in remote locations., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Designated trauma centers improve outcomes for severely injured patients. However, major trauma workload can disrupt other care pathways and some patient groups may compete ineffectively for resources with higher priority trauma cases. This study tested the hypothesis that treatment at a higher-level trauma center is an independent predictor for worse outcome after appendectomy., Methods: An observational study was undertaken using an all-payer longitudinal data set (California State Inpatient Database 2007-2011). All patients with an ICD-90-CM diagnosis of "acute appendicitis" (International Classification of Diseases, Ninth Revision, Clinical Modification code 540) that subsequently underwent appendectomy were included. Patients transferred between hospitals were excluded to minimize selection bias. The outcome measures were days to the operating room, length of stay, unplanned 30-d readmission (to any hospital in California), and in-hospital mortality. Logistic and generalized linear regression models were used to adjust for patient- (age, sex, payer status, race, Charlson comorbidity index, weekend admission, and generalized peritonitis) and hospital-level (teaching status and bed size) factors., Results: There were 119,601 patients treated in 278 individual hospitals. Patients in level I trauma centers (L1TCs) reached the operating room later (predicted mean difference 0.25 d [95% confidence interval 0.14-0.36]), stayed in hospital longer (0.83 d [0.36-1.31]), and had higher adjusted odds of generalized peritonitis (odds ratio 1.63 [95% confidence interval 1.13-2.36]) than those in nontrauma centers. There were no differences in mortality or unplanned 30-d readmissions to hospital; or between level II trauma centers and nontrauma centers across any of the measured outcomes., Conclusions: Odds of generalized peritonitis are higher and hospital length of stay is longer in L1TCs, although we found no evidence that patients come to serious harm in such institutions. Further work is necessary to determine whether pressure for resources in L1TCs can explain these findings., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures--caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair--to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety., Methods: We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates., Findings: From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs., Interpretation: All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care., Funding: None., (Copyright © 2016 Uribe-Leitz et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.)

The results of treatment of 33 patients, suffering diffuse peritonitis, with postoperatively applied tactics of the programmed surgical sanation of abdominal cavity were analyzed. Indications for relaparotomy were established, based on the estimation scale for the enteral insufficiency severity. The patients death and the complications causes were analyzed, depending on terms and rates of relaparotomy conduction.

Introduction: With each passing year, the number of patients with end-stage renal disease (ESRD) is increasing steadily, but there are limited data on the postoperative outcomes of these patients after appendectomy., Methods: Using the Nationwide Inpatient Sample, we identified all patients who underwent appendectomy in the United States between 1998 and 2010. We used International Classification of Diseases, 9th Revision, Clinical Modification codes to identify patients with ESRD and to track postoperative complications during hospital admission. Statistical models were controlled for age, sex, race, insurance type, number of Elixhauser comorbidities, year of admission, perforation of the appendix, and operative approach., Results: The study population included 5,712 patients with ESRD, with the remaining 3,615,391 patients serving as reference controls. Patients with ESRD had risk of death that was nearly 5 times greater than controls (odds ratio [OR] 5.68; 95% confidence interval [95% CI] 3.96-8.15; P < .001); this risk was similar for nonperforated (OR 4.97; P < .001) and perforated (5.96; P = .004) appendicitis. The risk of death, however, was greater for open appendectomy (OR 6.65; P < .001) compared with laparoscopic appendectomy (OR 2.50; P = .060). Patients with ESRD also were at an increased risk of mechanical wound complication (OR 1.58; P = .040) and had a mean duration of stay that was 34% greater compared with controls (P < .001)., Conclusion: Patients with ESRD undergoing appendectomy were at an increased risk of death. These patients also had an increased risk of mechanical wound complications and had a greater duration of hospital stay. Future studies should investigate the specific causes of death among patients with ESRD after appendectomy and optimal management strategies in this subset of patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: The purpose of the study was to determine the proportion of pediatric deaths investigated by HM Coronial autopsy which were potentially preventable deaths due to treatable natural disease, and what implications such findings may have for health policies to reduce their occurrence., Methods: A retrospective study of 1779 autopsies of individuals between 7 days and 14 years of age requested by HM Coroner, taking place in one specialist pediatric autopsy center, was undertaken. Cases were included if they involved a definite natural disease process in which appropriate recognition and treatment was likely to have affected their outcome. Strict criteria were used and cases were excluded where the individual had any longstanding condition which might have predisposed them to, or altered the recognition of, acute illness, or its response to therapy., Results: Almost 8% (134/1779) of the study group were potentially preventable deaths as a result of natural disease, the majority occurring in children younger than 2 years of age. Most individuals reported between 1 and 7 days of symptoms before their death, and the majority had sought medical advice during this period, including from general practitioners within working hours, and hospital emergency departments. Of those who had sought medical attention, around one-third had done so more than once (28%, 15/53). Sepsis and pneumonia accounted for the majority of deaths (46 and 34% respectively), with all infections (sepsis, pneumonia and meningitis) accounting for 110/134 (82%)., Conclusion: Around 10% of pediatric deaths referred to HM Coroner are potentially preventable, being the result of treatable natural acute illnesses. In many cases medical advice had been sought during the final illness. The results highlight how a review of autopsy data can identify significant findings with the potential to reduce mortality, and the importance of centralized investigation and reporting of pediatric deaths.

Background: Studies evaluating mortality in patients with acute appendicitis focus on the outcomes of appendicectomy alone. We hypothesize this may not be representative of what happens in clinical practice as a small proportion of patients with acute appendicitis undergo procedures other than appendicectomy, for example, caecectomy or right hemicolectomy. To clarify the issue, the authors evaluated Australian adult patients who died with a primary diagnosis of acute appendicitis regardless of whether they underwent an operation or the type of operation performed., Methods: A cross-sectional analysis of systematically collected mortality data from the Australian and New Zealand Audit of Surgical Mortality was conducted on adults who died in hospital with a primary diagnosis of acute appendicitis between January 2009 and December 2012., Results: Twenty-six patients died with a primary diagnosis of acute appendicitis. The median age was 83 years and the median number of co-morbidities was three. Four patients died without surgery due to their family's wishes. Twenty-two patients were treated surgically: five for right hemicolectomy, four for laparoscopic/McBurney appendicectomy, 10 for laparotomy with appendicectomy, two for unknown method of appendicectomy and one for open abscess drainage., Conclusion: Most adult patients who died following surgery for acute appendicitis did not undergo simple appendicectomy but underwent more complicated procedures for complex appendicitis., (© 2014 Royal Australasian College of Surgeons.)

Background: Surgery is indicated for acute uncomplicated appendicitis but the optimal timing is controversial. Recent literature is conflicting on the effect of time to intervention., Methods: We queried the American College of Surgeons National Surgical Quality Improvement Project dataset for patients undergoing laparoscopic and open appendectomy between 2007 and 2012. Logistic regression was used to evaluate 30-day morbidity and mortality of intervention at different time periods, adjusting for preoperative risk factors., Results: A total of 69,926 patients undergoing appendectomy were identified. Groups were divided by time to intervention: group 1, less than 24 hours (n = 55,839; 79.9%); group 2, 24 to 48 hours (n = 13,409; 18.6%); and group 3, greater than 48 hours (n = 1,038; 1.5%). After adjustment, the risk of complication remained increased for group 3 versus group 1 or 2 (odds ratio 1.66, 95% confidence interval 1.34 to 2.07)., Conclusions: These data demonstrate equivalent outcomes between time to appendectomy of less than 24 and 24 to 48 hours. There was a 2-fold increase in complication rate for patients delayed longer than 48 hours., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The appendix, considered an intestinal microbiota reservoir, may be protective against the risk of fulminant Clostridium difficile infection., Methods: Retrospective analysis was performed in patients with C. difficile infection at St. Francis Medical Center from 2007 to 2011. Outcome of infection and history of appendectomy were compared. Statistical analysis was by chi-square and multivariate logistic regression., Results: In total, 507 patients were hospitalized for C. difficile. Of 388 patients with intact appendix, 20 (5.2%) developed fulminant infection and required colectomy, whereas of 119 patients with previous appendectomy, 13 (10.9%) required colectomy. An increased severity of disease, indicated by increased rate of colectomy, occurred for the group with a history of appendectomy (P = .03). Age and sex were adjusted by multivariant regression (P = .05)., Conclusions: Appendectomy may be a risk factor for increased severity of C. difficile infection. Although the mechanism is unknown, further studies are warranted., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The effect of diabetes and the role of laparoscopic surgery on outcomes following appendectomy for acute appendicitis are not known., Methods: National Surgical Quality Improvement Program study, including patients with acute appendicitis and no significant comorbidities (American Society of Anesthesiologists grade I or II) who underwent appendectomy. Diabetic patients were matched (1:3) with nondiabetic patients. The primary outcomes were 30-day mortality, surgical site infections (SSIs), and systemic infectious complications., Results: SSI was encountered more frequently in the diabetic group as compared with the nondiabetic group (6.1% vs 4.3%, P = .010). Also, the hospital length of stay was significantly longer in the diabetic group. In the diabetic group, laparoscopic appendectomy did not affect mortality, reoperation, SSI, and systemic infectious complication rates in patients with or without peritonitis (P > .05), but the hospital length of stay was significantly shorter when compared with the open procedure., Conclusions: Patients with diabetes and no significant comorbidities have a higher risk of developing SSIs and longer hospital stay than patients without diabetes. Laparoscopic appendectomy had no effect on SSIs in patients with diabetes., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: Our objective was to augment the limited evidence mainly from local, clinical studies of ethnic differences in gastrointestinal disorders. Our question was: are there ethnic variations in hospitalisation/death for lower gastrointestinal disorders in Scotland?, Setting: Scotland., Population: This retrospective-cohort linked 4.65 (of 4.9) million people in the 2001 census of Scotland (providing data on ethnicity, country of birth and indicators of socioeconomic deprivation) to 9 years of National Health Service hospitalisation and death records., Primary and Secondary Outcome Measures and Analysis: For appendicitis, we studied all ages; for irritable bowel syndrome, ulcerative colitis, Crohn's disease and diverticular disease, we included those ≥20 years. Using Poisson regression (robust variance) we calculated, by ethnic group and sex, first-hospitalisation/death age-adjusted rates per 100,000 person-years, and relative risks (RRs) with 95% CIs multiplied by 100, so the White Scottish reference population had an RR=100., Results: There were ethnic variations; for example, for irritable bowel syndrome, RRs (95% CIs) were comparatively high in Other White British women (128.4 (111.0 to 148.6)), and low in Pakistani women (75.1 (60.6 to 93.1)). For appendicitis, RRs were high in men in Other White British (145.2 (127.8 to 164.9)), and low in most non-White groups, for example, Pakistanis (73.8 (56.9 to 95.6)). For ulcerative colitis, RRs were high in Indian (169.8 (109.7 to 262.7)) and Pakistani (160.8 (104.2 to 248.2)) men. For Crohn's disease, the RR was high in Pakistani men (209.2 (149.6 to 292.6)). For diverticular disease, RRs were high in Irish men (176.0 (156.9 to 197.5)), and any Mixed background women (144.6 (107.4 to 194.8)), and low in most non-White groups, for example, Chinese men (47.1 (31.0 to 71.6) and women (46.0 (30.4 to 69.8))., Conclusions: Appendicitis and diverticular disease were comparatively low in most non-White groups, while ulcerative colitis and Crohn's disease were mostly higher in South Asians. Describing and understanding such patterns may help clinical practice and research internationally., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

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%).