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Smith CB, Marapese KD, Charles AG. Management of acute appendicitis in low- and middle-income countries. Curr Probl Surg 2024; 61:101444. [PMID: 38548428 DOI: 10.1016/j.cpsurg.2024.101444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 04/02/2024]
Affiliation(s)
| | | | - Anthony G Charles
- School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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Basher MOS, Ahmed AA, Hamza AA. Mean platelet volume and total white blood cells as diagnostic biomarkers for acute appendicitis at Omdurman military hospital: a cross-sectional study - 2021. BMC Gastroenterol 2023; 23:444. [PMID: 38104067 PMCID: PMC10725578 DOI: 10.1186/s12876-023-03091-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 12/12/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Acute appendicitis (AA) is among the most common nontraumatic indications for emergent abdominal surgical procedures. However, accurately diagnosing all cases can be challenging, physical examination, biochemical markers, and imaging techniques can sometimes be insufficient. This study aimed to (a) compare the mean platelet volume (MPV) and total white blood cell count (TWBCs) in patients with or without histological evidence of an inflamed appendix and (b) determine the positive predictive value, negative predictive value, sensitivity, and specificity of both MPV and TWBCs as diagnostic biomarkers in the diagnosis of AA. We conducted this research at Omdurman Military Hospital, focusing on patients who presented with symptoms suggestive of AA. MATERIALS AND METHODS An analytical cross-sectional study conducted at Omdurman Military Hospital from December 2020 - December 2021. The study population was patients who presented to our emergency department with symptoms and signs suggestive of AA. Participants were patients operated on as cases of AA. Data variables included sociodemographic characteristics, clinical presentations, intraoperative appendix macroscopic findings, preoperative MPV and total white blood cell count (TWBCs), and postoperative histopathological findings. RESULTS A total of 106 patients were included in this study, with 75 (68.2%) males; half were 10-19 years old. Sixty-three patients (57.3%) had low (< 7.5 fL) MPV, whereas 47 (42.7%) had normal values. Comparing MPV to total white blood cells (TWBCs) revealed that MPV was more sensitive (84.6%) and specific (90%) than TWBCs during the first 24 h of inflammation. However, the TWBCs were more sensitive (97.2%) but less specific (94.7% vs. 100%) after 24 h of onset. CONCLUSION In this study, MPV was lower in patients with AA, while there was an increase in TWBCs. The high sensitivity and specificity of TWBCs and MPV indicated that they form a promising diagnostic marker for AA.
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Affiliation(s)
| | - Ahmed Abdelfattah Ahmed
- Department of General Surgery, Omdurman Military Hospital, Alneelain University, Khartoum, Sudan
| | - Aamir Abdullahi Hamza
- Department of General Surgery, Omdurman Teaching Hospital, College of Medicine, University of Bahri, Khartoum, Sudan
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Louw J, McCaul M, English R, Nyasulu PS, Davies J, Fourie C, Jassat J, Chu KM. Factors Contributing to Delays to Accessing Appendectomy in Low- and Middle-Income Countries: A Scoping Review. World J Surg 2023; 47:3060-3069. [PMID: 37747549 PMCID: PMC10694117 DOI: 10.1007/s00268-023-07183-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Appendicitis is one of the most common emergency surgical conditions worldwide. Delays in accessing appendectomy can lead to complications. Evidence on these delays in low- and middle-income countries (LMICs) is lacking. The aim of this review was to identify and synthesise the available evidence on delays to accessing appendectomy in LMICs. METHODS This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews framework. The delays and their interconnectivity in LMICs were synthesised and interpreted using the Three Delays framework. We reviewed Africa Wide EBSCOhost, PubMed-Medline, Scopus, Web of Science, African Journals Online (AJOL), and Bioline databases. RESULTS Our search identified 21 893 studies, of which 78 were included in the final analysis. All of the studies were quantitative. Fifty per cent of the studies included all three types of delays. Delays in seeking care were influenced by a lack of awareness of appendicitis symptoms, and the use of self and alternative medication, which could be linked to delays in receiving care, and the barrier refusal of medical treatment due to fear. Financial concerns were a barrier observed throughout the care pathway. CONCLUSION This review highlighted the need for additional studies on delays to accessing appendectomy in additional LMICs. Our review demonstrates that in LMICs, persons seeking appendectomy present late to health-care facilities due to several patient-related factors. After reaching a health-care facility, accessing appendectomy can further be delayed owing to a lack of adequate hospital resources.
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Affiliation(s)
- Johnelize Louw
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - M McCaul
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - R English
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - P S Nyasulu
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - J Davies
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - C Fourie
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - J Jassat
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - K M Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Surgery, University of Botswana, Plot 4775 Notwane Rd, Gaborone, Botswana
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Laäs R, Clarke DL, Dufourq N, Smith MTD, Bruce JL, Naidoo M. The Influence of HIV Status on Acute Appendicitis: A Retrospective Study from South Africa. World J Surg 2023; 47:2608-2616. [PMID: 37580602 PMCID: PMC10545630 DOI: 10.1007/s00268-023-07103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Despite the human immunodeficiency virus (HIV) being the most common comorbidity in South African surgical patients, its impact on appendicitis has not been well-described. We aimed to determine HIV status' influence on patients' presentation, assessment, management and outcomes with acute appendicitis. METHODS The retrospective chart review included all patients aged 12 years and older who were HIV-positive or HIV-negative and presented with acute appendicitis between 1 January 2013 and 31 December 2019. The primary outcome measure was survival to discharge. Secondary outcomes included analysis of the presentation (vital signs), assessment (biochemical, inflammatory markers) and management (intraoperative anatomical severity grading, length of hospital stay). RESULTS Of the 1096 patients with appendicitis, 196 (17.9%) were HIV-positive, and CD4 counts were available for 159. The median age was 23 years, with the HIV-positive patients being older and HIV-negative group having more males (58.7%). While the HIV-positive patients had a longer median length of hospital stay, there was no statistically significant difference in the two groups' incidence of high-grade appendicitis (p = 0.670). The HIV-positive patients had a higher median shock index (OR 7.65; 95% [CI 2.042-28.64]) than their HIV-negative counterparts. HIV-positivity had a significant association with mortality (OR 9.56; 95% CI [1.68-179.39]), and of the seven HIV-positive patients who died, 66.7% (n = 4) had a CD4 < 200 cells/mm3 (OR 8.6; 95% CI [1.6-63.9]). CONCLUSION HIV-positive patients, those with CD4 < 200 cells/mm3 or not on ART, have increased mortality risk and may benefit from increased perioperative surveillance. Patients with an unknown HIV status in a high-prevalence population should be offered HIV testing to risk stratify more accurately.
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Affiliation(s)
- Reza Laäs
- Department of Emergency Medicine, Nelson R Mandela, School of Medicine, University of KwaZulu-Natal, 719 Umbilo Rd, Umbilo, Berea, 4001, South Africa.
| | - Damian L Clarke
- Department of General Surgery and Trauma, Grey's Hospital, 201 Townbush Road, Pietermaritzburg, 3201, South Africa
| | - Nicholas Dufourq
- Department of Emergency Medicine, Nelson R Mandela, School of Medicine, University of KwaZulu-Natal, 719 Umbilo Rd, Umbilo, Berea, 4001, South Africa
- Department of Emergency Medicine, Harry Gwala Regional Hospital, 89 Selby Msimang Road, Pietermaritzburg, 3201, South Africa
| | - Michelle T D Smith
- Department of Anaesthetics and Critical Care, Grey's Hospital, 201 Townbush Road, Pietermaritzburg, 3201, South Africa
| | - John L Bruce
- Department of General Surgery and Trauma, Grey's Hospital, 201 Townbush Road, Pietermaritzburg, 3201, South Africa
| | - Mergan Naidoo
- Discipline of Family Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Room 225F, George Campbell Building, King George V Avenue, Durban, South Africa
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Gillespie BM, Harbeck EL, Sandy-Hodgetts K, Rattray M, Thalib L, Patel B, Andersson AE, Walker RM, Latimer S, Chaboyer WP. Incidence of wound dehiscence in patients undergoing laparoscopy or laparotomy: a systematic review and meta-analysis. J Wound Care 2023; 32:S31-S43. [PMID: 37591664 DOI: 10.12968/jowc.2023.32.sup8a.s31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
Surgical wound dehiscence (SWD) is a serious complication-with a 40% estimated mortality rate-that occurs after surgical intervention. Since the implementation of advanced recovery protocols, the current global incidence of SWD is unknown. This systematic review and meta-analysis estimated the worldwide incidence of SWD and explored its associated factors in general surgical patients. Eligible full-text cross-sectional, cohort and observational studies in English, between 1 January 2010 to 23 April 2021, were retrieved from MEDLINE, CINAHL, EMBASE and the Cochrane Library. Data extraction and quality appraisal were undertaken independently by three reviewers. Random effects meta-analytic models were used in the presence of substantial inconsistency. Subgroup, meta-regression and sensitivity analyses were used to explore inconsistency. Publication bias was assessed using Hunter's plots and Egger's regression test. Of 2862 publications retrieved, 27 studies were included in the final analyses. Pooled data from 741,118 patients across 24 studies were meta-analysed. The 30-day cumulative incidence of SWD was 1% (95% Confidence Interval (CI): 1-1%). SWD incidence was highest in hepatobiliary surgery, at 3% (95% CI: 0-8%). Multivariable meta-regression showed SWD was significantly associated with duration of operation and reoperation (F=7.93 (2-10); p=0.009), explaining 58.2% of the variance. Most studies were retrospective, predated the agreed global definition for SWD and measured as a secondary outcome; thus, our results likely underestimate the scope of the problem. Wider uptake of the global definition will inform the SWD surveillance and improve the accuracy of reporting.
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Affiliation(s)
- Brigid M Gillespie
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Griffith University, Australia
- Gold Coast University Hospital, Gold Coast Health Nursing and Midwifery Education and Research Unit, Queensland, Australia
| | - Emma L Harbeck
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Griffith University, Australia
| | - Kylie Sandy-Hodgetts
- School of Biomedical Sciences, University of Western Australia Centre for Molecular Medicine and Innovative Therapeutics, Murdoch University, Australia
| | - Megan Rattray
- Menzies Health Institute Queensland, Griffith University, Australia
| | - Lukman Thalib
- Department of Biostatistics, Faculty of Medicine, Istanbul Aydın University, Istanbul, Turkey
| | - Bhavik Patel
- Acute Care and Trauma Surgery, Gold Coast University Hospital, Queensland, Australia
| | - Annette Erichsen Andersson
- Institute of Health Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Rachel M Walker
- School of Nursing and Midwifery, Griffith University, Queensland, Australia
- Division of Surgery, Princess Alexandra Hospital, Queensland, Australia
| | - Sharon Latimer
- School of Nursing and Midwifery, Griffith University, Queensland, Australia
| | - Wendy P Chaboyer
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Griffith University, Australia
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Pattiiha AM, Selomo PAM, Faruk M. Comparison of the RIPASA and Labeda Scoring Systems to Assess the Morphological Severity of Acute Appendicitis. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.10274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Acute appendicitis is the most common emergency surgical case, leading to further complications if not treated immediately. Limited diagnostics infrastructure is an obstacle in developing countries, especially in the regions. Therefore, alternatives such as clinical scoring systems are required to assist in diagnosis.
AIM: This study aimed to compare the use of the RIPASA and Labeda scores to assess the severity of acute appendicitis morphology by determining the accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and negative appendectomy rate.
METHODS: This was a cross-sectional study designed to assess the severity of morphology of intra-operative acute appendicitis in Dr. Chasan Boesoirie Hospital and network hospitals in Ternate, North Maluku, Indonesia. Data regarding patient characteristics, leukocytes, and acute appendicitis severity were collected and analyzed alongside RIPASA and Labeda scores using the Chi-square test. p < 0.05 were considered statistically significant.
RESULTS: Of 59 cases, 39 (66.1%) were complicated acute appendicitis and 20 (33.9%) were noncomplicated acute appendicitis. Chi-square test results showed that there was a significant relationship (p ≤ 0.001) between RIPASA/Labeda scores and the severity of acute appendicitis morphology.
CONCLUSION: RIPASA and Labeda scores had the same accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for acute appendicitis severity. Thus, RIPASA and Labeda scores can be used by physicians to help establish a diagnosis of acute appendicitis and determine the need for emergency surgery, as well as predict the possibility of morbidity/complications in patients.
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Naidoo M, Thirayan V, Kong V, Govindasamy V, Dasrath A, Mills B, Bruce J, Laing G, Clarke D. Trends in Adoption of Laparoscopic Appendicectomy in a Developing Country: Closing the Gap. World J Surg 2022; 46:1015-1021. [PMID: 35142874 DOI: 10.1007/s00268-022-06454-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND This study reviews our use of laparoscopic versus open appendicectomy over the last decade to track the trends in their usage in a middle-income country. METHODS A retrospective study was conducted on patients with intraoperative confirmed acute appendicitis from January 2013 to December 2019 at Grey's Hospital, Pietermaritzburg, South Africa. RESULTS Eight hundred fifty-one cases of AA were included. 724 (85%) patients underwent open surgery; 435 (60%) via a midline incision and 194 (27%) via a local incision. 127 (15%) patients underwent laparoscopic appendicectomy. A significant rend was noted for an increasing proportion of surgery performed by laparoscopy compared to open surgery (p = 0.02). Patients who underwent open surgery compared to laparoscopy presented with greater peritonism (48.5% vs. 28%, p < 0.001), delay from symptom onset (3 vs. 2 days, p < 0.001), more frequently from rural areas (94% vs. 86%, p = 0.002) and with higher AAST scores (46.7% AAST ≥ 4, vs. 14.9%, p < 0.001). This former group had significantly greater morbidity (42% vs. 35%, p < 0.001) with higher Clavien-Dindo scores, were more likely to require ICU admission (8.3% vs. 2.3%, p < 0.001) and have longer hospital stay (4 days vs. 2 days, p < 0.001); no statistically significant difference in mortality was observed (1.1% vs. 0.8%, p = 0.75). CONCLUSIONS There has been a steady increase in the uptake of laparoscopic appendicectomy and decrease in open approaches in our centre. There is still a high rate of patients with advanced disease, and it is unlikely that this cohort will be suitable for laparoscopic surgery. If we hope to increase the uptake of laparoscopic surgery for acute appendicitis even further, we must focus on identifying patients with early and low-grade disease.
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Affiliation(s)
- Maheshwar Naidoo
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Varun Thirayan
- Mental Health and Addictions, Waikato Hospital, Hamilton, New Zealand.
| | - Victor Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Ash Dasrath
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Bob Mills
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - John Bruce
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Grant Laing
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Damian Clarke
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
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Factors Affecting Patient Outcomes in Acute Appendicitis in Rural Areas: An Observational Cohort Study. World J Surg 2021; 45:2337-2346. [PMID: 33813629 DOI: 10.1007/s00268-021-06093-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The most common surgical emergency both in developed and non-developed countries is acute appendicitis and it has a time-dependent clinical course. In this observational cohort study, we aim to investigate the factors affecting patient outcomes in acute appendicitis at a rural hospital. METHODS This observational cohort study was held between November 2012 and May 2014 at a rural hospital. Patients' pre-operative, perioperative, and post-operative data were collected prospectively. Patients were followed-up for 12-months. RESULTS A total of 151 patients were recorded. Factors significantly associated with complicated cases (abscess/perforation) were referral region as remote towns (OR:7.94, 95%CI [3.46-18.23]; p < 0.001), referral season as winter (OR:2.47, %95CI [1.14-5.36]; p = 0.022), pre-operative hospital delay (OR:6.52, 95%CI [3.49-12.20]; p < 0.001), and duration of referral (OR:1.01, 95%CI [1.00-1.01]; p < 0.001). In the multivariate analysis, only pre-operative hospital delay remained as a significant factor (OR:5.87, 95%CI [2.85 - 12.07]; p < 0.001). Factors affecting length of hospital stay (LoHS) were referral region as remote towns (95%CI, β = 3.10 [2.28-3.93], t = 1.91; p < 0.001), abscess/perforation (95%CI, β = 4.70 [4.04-5.36], t = 14.05; p < 0.001), pre-operative hospital delay (95%CI, β = 1.25 [0.87-1.62], t = 6.58; p < 0.001), and duration of referral (95%CI, β = 0.011 [0.01-0.14], t = 7.34; p < 0.001). In the multivariate analysis, all four factors stayed significant. The rate of complicated appendicitis was significantly high in winter than other seasons for patients referring from remote towns (75% vs 33%, p < 0.001). CONCLUSIONS This observational cohort study is the only study specifically focused on the effect of season and region on abscess/perforation rates, LoHS, and accessibility to hospital in patients with acute appendicitis.
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Wheeler N, Steel HC, Setlai BDP, Meintjes F, Mokoena T. Human immunodeficiency virus infection is associated with a differential increase in cytokine response and increased risk of perforation in acute appendicitis. Br J Surg 2021; 108:463-468. [PMID: 33787850 DOI: 10.1093/bjs/znaa170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 12/12/2020] [Indexed: 11/12/2022]
Abstract
HIV infection causes increased perforation rate in acute appendicitis and alters cytokine profile resulting in increased pro-inflammatory cytokines in serum but decreased in peritoneal fluid. It is also accompanied by increased anti-inflammatory cytokines.
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Affiliation(s)
- N Wheeler
- Department of Surgery, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - H C Steel
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - B D P Setlai
- Department of Surgery, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - F Meintjes
- Department of Surgery, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - T Mokoena
- Department of Surgery, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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Williams BM, Purcell LN, Varela C, Gallaher J, Charles A. Appendicitis Mortality in a Resource-Limited Setting: Issues of Access and Failure to Rescue. J Surg Res 2021; 259:320-325. [PMID: 33129505 PMCID: PMC7897218 DOI: 10.1016/j.jss.2020.09.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Brittney M Williams
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Laura N Purcell
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Carlos Varela
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Jared Gallaher
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Anthony Charles
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina; Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi.
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Adu A, Birhanu Y. Acute appendicitis in Ethiopia: A systematic review and meta-analysis. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2021. [DOI: 10.1016/j.ijans.2021.100343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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12
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Bessoff KE, Forrester JD. Appendicitis in Low-Resource Settings. Surg Infect (Larchmt) 2020; 21:523-532. [DOI: 10.1089/sur.2019.365] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Kovi E. Bessoff
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Joseph D. Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
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Afenigus AD, Bayieh AM, Kassahun B. Treatment outcomes of acute appendicitis and associated factors among admitted patients with a diagnosis of acute abdomen in Debre Markos Referral Hospital, Amhara Region, North West Ethiopia. J Perioper Pract 2020; 32:123-130. [PMID: 32638653 DOI: 10.1177/1750458920928473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Appendicitis is an inflammation of the vermiform appendix and is one of the most common causes of an acute abdomen in young adults. If left untreated, it can lead to appendiceal abscess, perforation and peritonitis. OBJECTIVE To assess treatment outcomes of acute appendicitis and associated factors among admitted patients with a diagnosis of acute abdomen. Methods and materials: A cross sectional study was employed among 169 patients using a census. Data were collected from patient medical records by using a checklist. Data were entered using Epi-data and analysed by statistical product and service solution. Logistic regression analysis was employed. RESULTS Among 303 patients with a diagnosis of acute abdomen, 169 (55.7%) developed acute appendicitis; of whom, 45 (26.6%) developed unfavourable treatment outcomes. Patients who had elevated white blood cell count at the time of presentation (adjusted odds ratio = 4.7; 95% confidence interval (1.95, 11.35)) and intraoperative appendiceal abscess (adjusted odds ratio = 3.8; 95% confidence interval (1.61, 9.07)) were significantly associated with an unfavourable appendicitis treatment outcome. Conclusion and recommendation: Nearly a quarter of the patients developed unfavourable treatment outcomes. Elevated white blood cell count and intraoperative appendiceal abscess were significantly associated with unfavourable appendicitis treatment outcome. Therefore, early detection and treatment of appendiceal abscess is crucial for a better outcome.
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Affiliation(s)
- Abebe Dilie Afenigus
- Department of Nursing, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | | | - Berhanu Kassahun
- Department of Surgery, School of Medicine, Debre Markos University, Debre Markos, Ethiopia
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Rickard J, Beilman G, Forrester J, Sawyer R, Stephen A, Weiser TG, Valenzuela J. Surgical Infections in Low- and Middle-Income Countries: A Global Assessment of the Burden and Management Needs. Surg Infect (Larchmt) 2019; 21:478-494. [PMID: 31816263 DOI: 10.1089/sur.2019.142] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: The burden of surgical infections in low- and middle-income countries (LMICs) remains poorly defined compared with high-income countries. Although there are common infections necessitating surgery prevalent across the world, such as appendicitis and peptic ulcer disease, other conditions are more localized geographically. To date, comprehensive assessment of the burden of surgically treatable infections or sequelae of surgical infections in LMICs is lacking. Methods: We reviewed the literature to define the burden of surgical infections in LMICs and characterize the needs and challenges of addressing this issue. Results: Surgical infections comprise a broad range of diseases including intra-abdominal, skin and soft tissue, and healthcare-associated infections and other infectious processes. Treatment of surgical infections requires a functional surgical ecosystem, microbiology services, and appropriate and effective antimicrobial therapy. Systems must be developed and maintained to evaluate screening, prevention, and treatment strategies. Solutions and interventions are proposed focusing on reducing the burden of disease, improving surveillance, strengthening antibiotic stewardship, and enhancing the management of surgical infections. Conclusions: Surgical infections constitute a large burden of disease globally. Challenges to management in LMICs include a shortage of trained personnel and material resources. The increasing rate of antimicrobial drug resistance, likely related to antibiotic misuse, adds to the challenges. Development of surveillance, infection prevention, and antimicrobial stewardship programs are initial steps forward. Education is critical and should begin early in training, be an active process, and be sustained through regular programs.
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Affiliation(s)
- Jennifer Rickard
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gregory Beilman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joseph Forrester
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Robert Sawyer
- Department of Surgery, Homer Stryker MD School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Andrew Stephen
- Department of Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Julie Valenzuela
- Department of Surgery, Northwell Health, New Hyde Park, New York, USA
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Hernandez MC, Kong VY, Bruce JL, Aho JM, Laing GL, Zielinski MD, Clarke DL. Pediatric Appendicitis Severity in KwaZulu-Natal, South Africa: A Retrospective Cohort Analysis. World J Surg 2018; 42:3785-3791. [PMID: 29777269 DOI: 10.1007/s00268-018-4677-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute appendicitis is a common pediatric surgical emergency; however, there are few grading systems to assign disease severity. The American Association for the Surgery of Trauma (AAST) recently developed a grading system for a variety of emergency surgical conditions, including appendicitis. The severity of acute appendicitis in younger patients in KwaZulu-Natal (South Africa) is unknown. We aimed to describe the disease severity in this patient population using the AAST grading system hypothesizing that the AAST grade would correlate with morbidity, management type, and duration of stay. MATERIALS Single institutional review of patients <18 years old with a final diagnosis of acute appendicitis during 2010-2016 in KwaZulu-Natal, South Africa, was performed. Demographics, physiologic and symptom data, procedural details, postoperative complications, and Clavien-Dindo classification were abstracted. AAST grades were generated based on intraoperative findings. Summary, univariate, and nominal logistic regression analyses were performed to compare AAST grade and outcomes. RESULTS A total of 401 patients were identified with median [IQR] age of 11 [5-13], 65% male. Appendectomy was performed in all patients; 2.4% laparoscopic, 37.6% limited incision, and 60% midline laparotomy. Complications occurred in 41.6%, most commonly unplanned relaparotomy (22.4%), surgical site infection (8.9%), pneumonia (7.2%), and acute renal failure (2.9%). Complication rate and median length of stay increased with greater AAST grade (all p < 0.001). AAST grade was independently associated with increased risk of complications. CONCLUSION Pediatric appendicitis is a morbid disease in a developing middle-income country. The AAST grading system is generalizable and accurately corresponds with management strategies as well as key clinical outcomes. LEVEL OF EVIDENCE Retrospective study, Level IV. STUDY TYPE Retrospective single institutional study.
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Affiliation(s)
- Matthew C Hernandez
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Victor Y Kong
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - John L Bruce
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Johnathon M Aho
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Grant L Laing
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Martin D Zielinski
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Damian L Clarke
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa
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Dresser C, Periyanayagam U, Dreifuss B, Wangoda R, Luyimbaazi J, Bisanzo M. Management and Outcomes of Acute Surgical Patients at a District Hospital in Uganda with Non-physician Emergency Clinicians. World J Surg 2018; 41:2193-2199. [PMID: 28405807 DOI: 10.1007/s00268-017-4014-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Acute surgical care services in rural Sub-Saharan Africa suffer from human resource and systemic constraints. Developing emergency care systems and task sharing aspects of acute surgical care addresses many of these issues. This paper investigates the degree to which specialized non-physicians practicing in a dedicated Emergency Department contribute to the effective and efficient management of acute surgical patients. METHODS This is a retrospective review of an electronic quality assurance database of patients presenting to an Emergency Department in rural Uganda staffed by non-physician clinicians trained in emergency care. Relevant de-identified clinical data on patients admitted directly to the operating theater from 2011 to 2014 were analyzed in Microsoft Excel. RESULTS Overall, 112 Emergency Department patients were included in the analysis and 96% received some form of laboratory testing, imaging, medication, or procedure in the ED, prior to surgery. 72% of surgical patients referred by ED received preoperative antibiotics, and preoperative fluid resuscitation was initiated in 65%. Disposition to operating theater was accomplished within 3 h of presentation for 73% of patients. 79% were successfully followed up to assess outcomes at 72 h. 92% of those with successful follow-up reported improvement in their clinical condition. The confirmed mortality rate was 5%. CONCLUSION Specialized non-physician clinicians practicing in a dedicated Emergency Department can perform resuscitation, bedside imaging and laboratory studies to aid in diagnosis of acute surgical patients and arrange transfer to an operating theater in an efficient fashion. This model has the potential to sustainably address structural and human resources problems inherent to Sub-Saharan Africa's current acute surgical care model and will benefit from further study and expansion.
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Affiliation(s)
- Caleb Dresser
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 120 Peterborough St Apt #4, Boston, MA, 02215, USA.
| | | | - Brad Dreifuss
- Department of Emergency Medicine, University of Arizona College of Medicine, Kampala, Uganda
| | - Robert Wangoda
- Department of Surgery, Makerere University, Kampala, Uganda
| | - Julius Luyimbaazi
- Department of Surgery, Karoli Lwanga Hospital Nyakibale, Kampala, Uganda
| | - Mark Bisanzo
- Global Emergency Care Collaborative, Kampala, Uganda.,Division of Emergency Medicine, Department of Surgery, University of Vermont Medical Center, Burlington, VT, USA
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Choksuwattanasakul M. Incidental appendectomy during mini incision post-partum sterilization (Chokchai technique): A prospective cross-sectional study. J Obstet Gynaecol Res 2017; 43:1863-1869. [PMID: 28892212 DOI: 10.1111/jog.13458] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 05/30/2017] [Accepted: 06/30/2017] [Indexed: 12/12/2022]
Abstract
AIM We aimed to determine the success rate of incidental appendectomy during post-partum sterilization (PPS) using the Chokchai technique and to compare the postoperative morbidity between patients who underwent this procedure with those who underwent simple PPS. METHODS Appendectomy during PPS was performed in 141 patients from 1 May 2012 to 30 April 2014. The control group consisted of 182 simple PPS patients. Primary outcomes were the success rate of the procedure and secondary outcomes were postoperative morbidity and complications. RESULTS The success rate of this procedure was 98.6%. There was no statistically significant difference in intraoperative blood loss, hospital length of stay, or postoperative morbidity. Appendectomy added 7.5 min to the total procedure. Intravenous sedation requirements were 13.7% and 33.3% in the control and study groups, respectively. Pathologic evaluation of resected appendices revealed 15 abnormalities (10.8%), including two cases of periappendicitis (1.4%). CONCLUSION When carried out by experienced surgeons and with appropriate anesthesia, incidental appendectomy during PPS is safe. The Chokchai technique (approach through a small periumbilical incision) achieved a high success rate and resulted in minimal scar. Incidental appendectomy not only prevents any future appendicitis but also helps to detect periappendicitis and treat its primary cause. However, this is an option for only selected patients who are clearly informed about the possible risks and benefits of the procedure.
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Increased anatomic severity in appendicitis is associated with outcomes in a South African population. J Trauma Acute Care Surg 2017; 83:175-181. [PMID: 28301395 DOI: 10.1097/ta.0000000000001422] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Scriba MF, Laing GL, Bruce JL, Sartorius B, Clarke DL. The Role of Planned and On-Demand Relaparotomy in the Developing World. World J Surg 2017; 40:1558-64. [PMID: 27160454 DOI: 10.1007/s00268-015-3379-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION/BACKGROUND This study compares planned repeat laparotomy (PR) with on-demand repeat laparotomy (OD) in a developing world setting. MATERIALS AND METHODS This study was conducted over a 30-month study period (December 2012-May 2015) at Greys Hospital, Pietermaritzburg, South Africa. All trauma and general surgery adult patients requiring a single relaparotomy were included in this study. Prospectively gathered data entered into an established electronic registry were retrospectively analysed. Full ethical approval for the registry and this study was granted by the University of KwaZulu-Natal Biomedical Ethics Committee. RESULTS A total of 162 patients were included, with an average age of 36 years (standard deviation 17) and 69 % male predominance. Appendicitis and stab abdomen were the most common underlying diagnoses. PR strategy was used in 46 % and an OD approach in 54 %. Patients selected for the PR strategy had higher admission pulse rates, higher Modified Early Warning System (MEWS) scores and significantly higher rates of diffuse intra-abdominal sepsis at initial laparotomy. However, findings at relaparotomy were similar in both groups. The PR group had a much shorter time between operations, but much higher need for intensive care unit (ICU) admission. There was no difference between the groups in terms of open abdomen at discharge, length of hospital stay, morbidity or mortality. CONCLUSION In our environment, a planned approach to relaparotomy shows no major outcome advantages over an on-demand approach. There is however increased need for ICU admission with the PR approach. This is in keeping with international literature. Of concern is the much longer time delay between index procedure and repeat operation in the OD group. Improved post-operative decision making may help address this.
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Affiliation(s)
- M F Scriba
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - G L Laing
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - J L Bruce
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - B Sartorius
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - D L Clarke
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa.
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Appendicitis in the HIV Era: a South African perspective. Indian J Surg 2016; 80:207-210. [PMID: 29973748 DOI: 10.1007/s12262-016-1564-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 10/17/2016] [Indexed: 01/17/2023] Open
Abstract
The relationship between HIV infection and the clinical spectrum of appendicitis has not been fully elucidated in the South African context. The aim of this study is to compare the surgical management, histopathology, and outcomes between HIV-positive and HIV-negative patients undergoing surgery for appendicitis. A retrospective chart analysis was performed of 50 patients who underwent surgery for appendicitis at King Edward VIII Hospital, Durban, South Africa between January 2012 and December 2012. Patients were stratified by HIV serostatus into HIV-positive and HIV-negative groups. Fifty patients underwent surgery for appendicitis during the study period. Of the 50 patients, 14 were HIV-positive (28 %) and 36 were HIV-negative (72 %). Perforated appendicitis was more frequent in the HIV-positive group (50 vs. 25 %, p > 0.05). There was a significantly higher laparotomy rate in HIV-positive patients (71 vs. 33 %, p < 0.05). Granulomatous inflammation of the appendix was only noted in HIV-positive patients (n = 3). There was no significant difference in the complication rate between the two groups (p > 0.05) and no difference in the mean length of hospital stay (7.8 ± 4.89 vs. 5.8 ± 3.94 days, p > 0.05). In this retrospective study, perforated appendicitis was seen to be more common in HIV-positive patients resulting in a higher laparotomy rate in this group. Granulomatous inflammation was only found in HIV-positive patients. There was no difference seen in the complication rate, length of hospital stay, and mortality between HIV-positive and HIV-negative patients.
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Healy JM, Olgun LF, Hittelman AB, Ozgediz D, Caty MG. Pediatric incidental appendectomy: a systematic review. Pediatr Surg Int 2016; 32:321-35. [PMID: 26590816 DOI: 10.1007/s00383-015-3839-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2015] [Indexed: 12/17/2022]
Abstract
Incidental appendectomy is the removal of the vermiform appendix accompanying another operation, without evidence of acute appendicitis. It is generally performed to eliminate the risk of future appendicitis. The risks and benefits of incidental appendectomy during various operations in children have been debated for over a century, but need to be revisited in light of innovations in medical practice, including minimally invasive surgery, improved imaging techniques, and use of the appendix as a tubular conduit for reconstruction. A detailed review was undertaken of the techniques, pathology, risks of appendectomy, utility of the appendix, and incidental appendectomy in the treatment of specific pediatric medical conditions. A comprehensive literature search was performed, and retrieved results were reviewed for relevance to the topic. The decision to perform a pediatric incidental appendectomy relies on informed consideration of the individual patient's co-morbid conditions, the indication for the initial operation, the future utility of the appendix, and the risk of future appendiceal pathology. The discussion includes a variety of situations and comorbid conditions that may influence a surgeon's decision to perform incidental appendectomy.
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Affiliation(s)
- James M Healy
- Department of Surgery, Yale University School of Medicine, 333 Cedar Street, TMP202, Box 208062, New Haven, CT, 06520, USA
| | - Lena F Olgun
- Department of Surgery, Yale University School of Medicine, 333 Cedar Street, TMP202, Box 208062, New Haven, CT, 06520, USA
| | - Adam B Hittelman
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Doruk Ozgediz
- Department of Surgery, Yale University School of Medicine, 333 Cedar Street, TMP202, Box 208062, New Haven, CT, 06520, USA
| | - Michael G Caty
- Department of Surgery, Yale University School of Medicine, 333 Cedar Street, TMP202, Box 208062, New Haven, CT, 06520, USA.
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Terlinder J, Andersson RE. Incidence of appendicitis according to region of origin in first- and second-generation immigrants and adoptees in Sweden. A cohort follow-up study. Scand J Gastroenterol 2016; 51:111-20. [PMID: 25876851 DOI: 10.3109/00365521.2015.1030688] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Geographic variations in incidence of appendicitis and proportion of perforations suggest environmental or genetic etiological factors. We study incidence of appendicitis and proportion of perforations according to geographical origin in immigrants and international adoptees in Sweden. METHODS A cohort of 11,557,566 Swedish residents - 277,104 first- and 377,773 second-generation immigrants and 57,304 adoptees - was followed from 1988 till 2010. Differences in proportion of operation for perforated appendicitis and negative appendectomy and standardized incidence ratios (SIR) of perforated and non-perforated appendicitis associated with geographic origin was analyzed. RESULTS High incidence rates are seen in first- and second-generation immigrants from South America for perforated (SIR 1.58 and 1.81, respectively) and non-perforated appendicitis (SIR 1.18 and 1.22, respectively), and in adoptees from South America for non-perforated appendicitis (SIR 1.07). Low incidence rates are seen for perforated appendicitis in first-generation immigrants and adoptees from Asia (SIR 0.74 and 0.56, respectively), and for non-perforated appendicitis in immigrants from Africa and Asia (SIR 0.69 and 0.76 in first-generation, 0.51 and 0.74 in second-generation, respectively) and in adoptees from Asia (SIR 0.71). A high proportion of perforated appendicitis is associated with a low incidence rate of non-perforated appendicitis but no increase in the incidence rate of perforated appendicitis. CONCLUSIONS The association of different incidence of appendicitis with geographic origin which remains over generations and is seen in adoptees suggest genetic etiologic factors. The proportion of perforation can be high without an increased incidence rate of perforation and is therefore an imperfect indicator of quality of care.
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Affiliation(s)
- John Terlinder
- a 1 Departments of Pediatrics, County Hospital Ryhov , Jönköping, Sweden
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Kong VY, Sartorius B, Clarke DL. Acute appendicitis in the developing world is a morbid disease. Ann R Coll Surg Engl 2015; 97:390-5. [PMID: 26264094 PMCID: PMC5096553 DOI: 10.1308/003588415x14181254790608] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2015] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Acute appendicitis in the developing world has a markedly different disease profile to that in the developed world. METHODS A retrospective study was undertaken over a four-year period at a university hospital in South Africa to review the disease spectrum and the clinical outcome of acute appendicitis. RESULTS A total of 1,004 patients (54% male, median age: 18 years) with intraoperatively confirmed appendicitis were reviewed. Over half (56%) were from the urban district within the city of Pietermaritzburg and the remaining 44% were from the rural health district. The median duration of illness from onset to definitive care was 4 days. Sixty per cent of appendices were perforated and associated with intra-abdominal contamination. Forty per cent of patients required reoperation to control intra-abdominal sepsis. Ten per cent required admission to the intensive care unit. The median overall length of hospital stay was 5 days. The mortality rate was 1%. Rural patients had a longer median duration of illness (3 vs 5 days, p<0.001) as well as a more advanced disease profile associated with perforation and severe intra-abdominal sepsis (19% vs 71%, p<0.001). Female patients had a longer median duration of illness (3 vs 4 days, p<0.001), were more likely to present with severe intra-abdominal sepsis (31% vs 54%, p<0.001) and were more likely to require a laparotomy (50% vs 73%, p<0.001). The total cost of managing the entire cohort of 1,004 patients over the 4-year period was £2,060,972. CONCLUSIONS Acute appendicitis in South Africa is a serious disease associated with significant morbidity. Late presentation is common. Female and rural patients have the worst clinical outcomes, with significant cost to the health system.
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Affiliation(s)
- VY Kong
- Pietermaritzburg Metropolitan Hospital Complex, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
| | - B Sartorius
- Pietermaritzburg Metropolitan Hospital Complex, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
| | - DL Clarke
- Pietermaritzburg Metropolitan Hospital Complex, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
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Laing GL, Skinner DL, Bruce JL, Aldous C, Oosthuizen GV, Clarke DL. Understanding the burden and outcome of trauma care drives a new trauma systems model. World J Surg 2015; 38:1699-706. [PMID: 24449412 DOI: 10.1007/s00268-014-2448-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Pietermaritzburg Metropolitan Trauma Service (PMTS) attempts to provide care for a whole city and hence is referred to as a service rather than a center. As part of a multifaceted quality improvement program, the PMTS has developed and implemented a robust electronic surgical registry (ESR). This review of the first year's data from the ESR forms part of a situational analysis to assess the burden of trauma managed by the service and the quality of care delivered within the constraints of the available resources. METHODS Formal ethical approval was obtained prior to design and development of this study, and appropriate commercial software was sourced. The exercise of data capture was integrated into the process of service delivery and was accomplished at the endpoint of patient care. 12 months after implementation of the registry, the data were extracted and audited. RESULTS A total of 2,733 patients were admitted over the 12 month study period. The average patient age was 28.3 years. There were 2,255 (82.5 %) male patients and 478 (17.5 %) female patients. The average monthly admission rate was 228 patients, with a peak of 354 admissions over the December period. The mean injury severity score (ISS) was 12 [interquartile range (IQR) 6.7-23.2]. A quarter (24.8 %) of all new emergency admissions had an ISS > 15. The average duration of stay for patients was 5.12 days (IQR 2.3-13.2 days). Some 2,432 (92.1 %) patients survived, and 208 (7.9 %) died. A total of 333 (13 %) patients required admission to either the intensive care unit (ICU) or the high dependency unit. From the city mortuary data a further 362 deaths were identified. These included 290 deaths that occurred on scene and 72 that occurred within Pietermaritzburg hospitals other than Greys and Edendale. The total trauma-related mortality for the entire city in 2012 was 570 (51 % on-scene deaths and 49 % in-hospital deaths). Blunt trauma accounted for 62 % of deaths. CONCLUSIONS The PMTS treats a significant volume and spectrum of trauma. Despite significant resource limitations, we have managed to implement a functional and sustainable trauma service across multiple hospitals. We believe the major resource deficits limiting our service could be ameliorated by the development of an additional trauma facility, adequately equipped with dedicated trauma operating slates and trauma ICU beds. The adoption of our current model of trauma care came out of a need to work within our resource constraints, and it differs from the traditional model. Within the aforementioned limits, our data suggest that this model of delivering care is feasible, practical, and successful. Considering the universal burden of trauma and the all-too-common imbalance between resource demand and supply among many health-care institutions, it is our hope that this report will contribute to the ongoing academic debate around the topic of optimal systems of providing global trauma care.
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Affiliation(s)
- G L Laing
- Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg Metropolitan Hospital Complex, Department of General Surgery, University of Kwa-Zulu Natal Nelson R Mandela School of Medicine, Post-Net Suite 156, Private Bag X9118, Pietermaritzburg, 3200, South Africa,
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Scriba MF, Laing GL, Bruce JL, Clarke DL. Repeat laparotomy in a developing world tertiary level surgical service. Am J Surg 2015; 210:755-8. [PMID: 26116321 DOI: 10.1016/j.amjsurg.2015.03.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 03/02/2015] [Accepted: 03/16/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Repeat laparotomy is associated with significant morbidity and mortality; however, developing world data are scarce. This study reviews the spectrum and outcomes of relaparotomy in a developing world setting. METHODS Prospectively collected data from adult patients needing repeat laparotomy over an 18-month period were analyzed. RESULTS Relaparotomy rate was 24% and average age was 38 years with a male predominance (70%). Appendicitis and trauma were the most common diagnoses. Planned relaparotomy rate was high (41%); however, negative relaparotomy rate was only 9%. Need for intensive care unit admission (51%) and morbidity rate (64%) were both high, but overall mortality rate was 14%. Patients requiring multiple relaparotomies had further worsened outcomes. CONCLUSIONS The need for repeat laparotomy in the developing world is high and it is associated with significant morbidity and need for intensive care unit admission. However, mortality rates and negative repeat laparotomy rates were low.
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Affiliation(s)
- Matthias F Scriba
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu Natal, Townbush Road, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - Grant L Laing
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu Natal, Townbush Road, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - John L Bruce
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu Natal, Townbush Road, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - Damian L Clarke
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu Natal, Townbush Road, Pietermaritzburg, KwaZulu-Natal, South Africa.
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Murata A, Mayumi T, Muramatsu K, Ohtani M, Matsuda S. Effect of hospital volume on outcomes of laparoscopic appendectomy for acute appendicitis: an observational study. J Gastrointest Surg 2015; 19:897-904. [PMID: 25595310 DOI: 10.1007/s11605-015-2746-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 01/05/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND This study investigated the effect of hospital volume on outcomes of laparoscopic appendectomy for acute appendicitis. METHODS In total, 30,525 patients who underwent laparoscopic appendectomy for acute appendicitis were referred to 825 hospitals in Japan from 2010 to 2012. We compared appendectomy-related complications, length of stay (LOS), and medical costs in relation to hospital volume. For this study period, hospitals were categorized as low-volume hospitals (LVHs, <50 cases), medium-volume hospitals (MVHs, 50-100 cases), or high-volume hospitals (HVHs, >100 cases). RESULTS Significant differences in appendectomy-related complications were observed among the LVHs, MVHs, and HVHs (6.9, 7.2, and 6.0 %, respectively; p = 0.001). Multiple logistic regression revealed that HVHs were associated with a lower relative risk of appendectomy-related complications than were LVHs and MVHs (odds ratio [OR], 0.84; 95 % confidence interval [CI], 0.74-0.95; p = 0.006). Multiple linear regression showed that HVHs were associated with shorter LOS and lower medical costs than were LVHs and MVHs. The unstandardized coefficient for LOS was -0.92 days (95 % CI, -1.07 to -0.78; p < 0.001), whereas that for medical costs was - $167.4 (95 % CI, -256.2 to -78.6; p < 0.001). CONCLUSIONS Hospital volume was significantly associated with laparoscopic appendectomy outcomes.
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Affiliation(s)
- Atsuhiko Murata
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan,
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Abstract
Peritonitis is a progressive disease leading inexorably from local peritoneal irritation to overwhelming sepsis and death unless this trajectory is interrupted by timely and effective therapy. In children peritonitis is usually secondary to intraperitoneal disease, the nature of which varies around the world. In rich countries, appendicitis is the principal cause whilst in poor countries diseases such as typhoid must be considered in the differential diagnosis. Where resources are limited, the clinical diagnosis of peritonitis mandates laparotomy for diagnosis and source control. In regions with unlimited resources, radiological investigation, ultrasound, CT scan or MRI may be used to select patients for non-operative management. For patients with appendicitis, laparoscopic surgery has achieved results comparable to open operation; however, in many centres open operation remains the standard. In complicated peritonitis "damage control surgery" may be appropriate wherein source control is undertaken as an emergency with definitive repair or reconstruction awaiting improvement in the patient's general condition. Awareness of abdominal compartment syndrome is essential. Primary peritonitis in rich countries is seen in high-risk groups, such as steroid-dependent nephrotic syndrome patients, whilst in poor countries the at-risk population is less well defined and the diagnosis is often made at surgery.
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Affiliation(s)
- G P Hadley
- Department of Paediatric Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag, Congella 4013, Durban 17039, South Africa.
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Kong VY, van der Linde S, Aldous C, Handley JJ, Clarke DL. The accuracy of the Alvarado score in predicting acute appendicitis in the black South African population needs to be validated. Can J Surg 2014; 57:E121-5. [PMID: 25078937 DOI: 10.1503/cjs.023013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The Alvarado score is the most widely used clinical prediction tool to facilitate decision-making in patients with acute appendicitis, but it has not been validated in the black South African population, which has much wider differential diagnosis than developed world populations. We investigated the applicability of this score to our local population and sought to introduce a checklist for rural doctors to facilitate early referral. METHODS We analyzed patients with proven appendicitis for the period January 2008 to December 2012. Alvarado scores were retrospectively assigned based on patients' admission charts. We generated a clinical probability score (1-4 = low, 5-6 = intermediate, 7-10 = high). RESULTS We studied 1000 patients (54% male, median age 21 yr). Forty percent had inflamed, nonperforated appendices and 60% had perforated appendices. Alvarado scores were 1-4 in 20.9%, 5-6 in 35.7% and 7-10 in 43.4%, indicating low, intermediate and high clincial probability, respectively. In our subgroup analysis of 510 patients without generalized peritonitis, Alvarado scores were 1-4 in 5.5%, 5-6 in 18.1% and 7-10 in 76.4%, indicating low, intermediate and high clinical probability, respectively. CONCLUSION The widespread use of the Alvarado score has its merits, but its applicability in the black South African population is unclear, with a significant proportion of patients with the disease being potentially missed. Further prospective validation of the Alvarado score and possible modification is needed to increase its relevance in our setting.
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Affiliation(s)
- Victor Y Kong
- The Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Stefan van der Linde
- The Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Colleen Aldous
- The Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Jonathan J Handley
- The Department of Anaesthetics and Critical Care, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Damian L Clarke
- The Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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Nshuti R, Kruger D, Luvhengo TE. Clinical presentation of acute appendicitis in adults at the Chris Hani Baragwanath academic hospital. Int J Emerg Med 2014; 7:12. [PMID: 24533851 PMCID: PMC3938026 DOI: 10.1186/1865-1380-7-12] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 02/03/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Acute appendicitis is the most common surgical abdominal emergency. Delayed treatment increases the incidence of complications. The aim of this study was to investigate the presentation, incidence, and predictors of complications, and histological findings in adult patients with clinical diagnosis of acute appendicitis. METHODS The study was a prospective observational study and included patients aged 12 years and older diagnosed with acute appendicitis. Data collected included demographic data, clinical presentation, duration of symptoms and reasons for presentation delay, diagnostic investigations, operative and histology findings, length of hospital stay, and mortality. RESULTS A total of 146 patients were admitted with a mean age of 26 years (SD = 12 years). The male to female ratio was 1.6:1. Predominant presenting symptoms were right iliac fossa pain (95%), nausea (80%), and vomiting (73%), with 63% of patients presenting 2 days after onset of symptoms. Fever was present in 15% and only 31% of patients gave a typical history of acute appendicitis of vague peri-umbilical pain. The negative predictive values of white cell count and C-reactive protein for acute appendicitis were 28% and 50%, respectively. Sensitivity of the ultrasound to detect acute appendicitis was 60% with a negative predictive value of 31%; 30% of patients had complicated appendicitis. Histology results showed a normal appendix in 11% of patients. The 30-day mortality rate was 1.4%. CONCLUSIONS Patients with acute appendicitis rarely present with a typical history of vague peri-umbilical pain. The negative predictive values of both white cell count and ultrasound proved that neither of these measurements was accurate in the diagnosis of acute appendicitis. Most of our patients with complicated disease present late, with the most common reasons for this delay being lack of access to a medical clinics and prior treatment by general practitioners. Complications were higher in males and in those aged 45 years and above.
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Affiliation(s)
- Richard Nshuti
- Department of Surgery, Chris Hani Baragwanath Academic Hospital and University of Witwatersrand, Witwatersrand, South Africa
| | - Deirdré Kruger
- Department of Surgery, Chris Hani Baragwanath Academic Hospital and University of Witwatersrand, Witwatersrand, South Africa
| | - Thifheli E Luvhengo
- Department of Surgery, Chris Hani Baragwanath Academic Hospital and University of Witwatersrand, Witwatersrand, South Africa
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de Souza AC, Lange RR, Guerios SD, Froes TR. Ultrasonographic examination in non-human primates with acute abdomen signs. J Med Primatol 2013; 42:336-42. [DOI: 10.1111/jmp.12065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2013] [Indexed: 11/29/2022]
Affiliation(s)
| | - Rogério Ribas Lange
- Department of Veterinary Medicine; Federal University of Paraná; Curitiba Paraná Brazil
| | - Simone Domit Guerios
- Department of Veterinary Medicine; Federal University of Paraná; Curitiba Paraná Brazil
| | - Tilde Rodrigues Froes
- Department of Veterinary Medicine; Federal University of Paraná; Curitiba Paraná Brazil
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Kong V, Aldous C, Handley J, Clarke D. The cost effectiveness of early management of acute appendicitis underlies the importance of curative surgical services to a primary healthcare programme. Ann R Coll Surg Engl 2013; 95:280-4. [PMID: 23676814 PMCID: PMC4132504 DOI: 10.1308/003588413x13511609958415] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2012] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Appendicitis in the developing world is a cause of significant preventable morbidity. This prospective study from a regional hospital in South Africa constructs a robust cost model that demonstrates the cost effectiveness of an efficient curative surgical service in a primary healthcare-orientated system. METHODS A prospective audit of all patients with acute appendicitis admitted to Edendale Hospital was undertaken from September 2010 to September 2011. A microcosting approach was used to construct a cost model based on the estimated cost of operative and perioperative interventions together with the associated hospital stay. For cost analysis, patients were divided into the following cohorts: uncomplicated appendicitis, complicated appendicitis with localised intra-abdominal sepsis, complicated appendicitis with generalised intra-abdominal sepsis, with and without intensive care unit admission. RESULTS Two hundred patients were operated on for acute appendicitis. Of these, 36% (71/200) had uncomplicated appendicitis and 57% (114/200) had perforation. Pathologies other than appendicitis were present in 8% (15/200) and these patients were excluded. Of the perforated appendices, 45% (51/114) had intra-abdominal contamination that was localised while 55% (63/114) generalised sepsis. The mean cost for each patient was: 6,578 ZAR (£566) for uncomplicated appendicitis; 14,791 ZAR (£1,272) for perforation with localised intra-abdominal sepsis and 34,773 ZAR (£2,990) for perforation with generalised intra-abdominal sepsis without intensive care admission. With intensive care admission it was 77,816 ZAR (£6,692). The total cost of managing acute appendicitis was 4,272,871 ZAR (£367,467). Almost 90% of this total cost was owing to advanced disease with abdominal sepsis and therefore potentially preventable. CONCLUSIONS Early uncomplicated appendicitis treated appropriately carries little morbidity and is relatively inexpensive to treat. As the pathology progresses, the cost rises exponentially. An efficient curative surgical service must be regarded as a cost effective component of a primary healthcare orientated system.
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Affiliation(s)
- V Kong
- University of KwaZulu-Natal, South Africa.
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