Imaging in pediatric appendicitis is key to a low normal appendix percentage: a national audit on the outcome of appendectomy for appendicitis in children

Negative appendectomy rate in the pediatric population: can we reach near-zero rates? An observational study

INTRODUCTION

Correct diagnosis of acute appendicitis may sometimes be challenging. The Negative appendectomy rate (NAR) has declined in the recent years in Europe and USA, in part due to better diagnostic imaging tools. The aim of this study was to examine the rates of negative appendectomy in our institution, investigate trends in its incidence, and identify possible predicting factors.

METHODS

A retrospective cohort study, including all patients younger than 18 years of age who underwent an appendectomy between 2007 and 2021 in a single tertiary medical center. Data regarding patient's demographics, laboratory and imaging results, pathological results and clinical outcome were collected.

RESULTS

Between 2007 and 2021, a total of 3937 pediatric patients underwent appendectomy due to a working diagnosis of acute appendicitis. Overall, 143 patients (3.6%) had normal appendix on pathological examination. However, in the last 5 years, the rate of normal appendix was 1.9%, together with an increased rate of pre-operative imaging (from 40% to nearly 100%).

CONCLUSION

Low NAR under 2% is an achievable benchmark in the era of accessible pre-operative imaging. In unequivocal cases, a secondary survey that includes repeated physical examination, blood work and imaging is recommended and may result in near-zero rates of NAR.

Acute Appendicitis in Children: Evaluation of the Diagnostic Efficacy of Ultrasonography and Computed Tomography

OBJECTIVE

Acute appendicitis (AA), the most common cause of acute abdomen in childhood, can result in significant morbidity and mortality if not diagnosed and treated in a timely manner. Diagnosis of AA is more difficult in children due to the limited communication skills, in comparison to adults. The aim of this study is to evaluate the diagnostic accuracy of abdominal ultrasonography (US) and computed tomography (CT) in the diagnosis of AA in children.

MATERIALS AND METHODS

Pediatric patients who were operated on with the diagnosis of AA between January 2016 and December 2021 were retrospectively reviewed. Preoperative abdominal US and CT findings of the patients and postoperative pathology results were recorded.

RESULTS

A total of 263 patients with a mean age of 11.3 years were included in the study. There were 164 (62.3%) males and 99 (37.7%) females. Histopathology revealed AA in 215 (81.7%) patients. Preoperatively, US and CT were performed in 139 (52.8%) and 137 (54.5%), respectively. Both imaging methods were applied to 13 (5.1%) patients. US had a sensitivity and specificity rate of 77.2% and 52.6%, respectively. Positive predictive value (PPV) was found to be 81.2%, whereas negative predictive value (NPV) was 46.5% for US. The diagnostic accuracy rate of US was found as 70.5%. CT had a sensitivity and specificity rate of 88.1% and 57.1%, respectively. PPV was found to be 88.8%, whereas NPV was 55.1% for CT. The diagnostic accuracy rate of CT was found as 81.8%.

CONCLUSION

In case of suspicion of AA, US may be the first choice because it is inexpensive and easily accessible. However, considering patient incompatibility and subjective factors in children, US may sometimes be insufficient. We think that CT should be performed as an advanced examination method in cases where US is not compatible with the patient's condition, not clinic.

Other Pathologies Were Rarely Reported after Laparoscopic Surgery for Suspected Appendicitis: A Systematic Review and Meta-Analysis

BACKGROUND

Diagnostic laparoscopy is often used when a patient is suspected of having acute appendicitis. The aim of this study was to assess the rate of other pathologies found during diagnostic laparoscopy for suspected acute appendicitis.

METHODS

This systematic search included studies with ≥100 patients who received laparoscopy for suspected acute appendicitis and reported on the histopathologic and other intra-abdominal findings. We performed a meta-analysis estimating the rate of other pathologies, and a sensitivity analysis excluding smaller cohorts (≤500 patients). Age groups, sex, specific findings, and geographic regions were investigated. Certainty of evidence was assessed with GRADE.

RESULTS

A total of 27 studies were included covering 25,547 patients and of these 793 had an unexpected pathology. The findings were benign pathology in the appendix (34%), malignancy (30%), gynecologic pathology (5%), gastrointestinal pathology (4%), or unspecified (27%). Meta-analysis showed an overall rate of unexpected findings of 3.5% (95% CI 2.7-4.3; moderate certainty), and the sensitivity analysis showed similar results. Malignancy found in the appendix when treating suspected acute appendicitis was 1.0% (95% CI 0.8-1.3%; high certainty).

CONCLUSION

The rate of other histopathological findings in patients with suspected acute appendicitis was low and a malignancy in appendix was found in 1% of patients.

The impact of delay and prehospital factors on acute appendicitis severity in New Zealand children: a national prospective cohort study

BACKGROUND

Appendicitis is the most common reason children undergo acute general surgery but international, population-level disparities exist. This is hypothesised to be caused by preoperative delay and differential access to surgical care. The impact of prehospital factors on paediatric appendicitis severity in New Zealand is unknown.

METHODS

A prospective, multicentre cohort study with nested parental questionnaire was conducted by a national trainee-led collaborative group. Across 14 participating hospitals, 264 patients aged ≤16 years admitted between January and June 2020 with suspected appendicitis were screened. The primary outcome was the effect of prehospital factors on the American Association for the Surgery of Trauma (AAST) anatomical severity grade.

RESULTS

Overall, 182 children had confirmed appendicitis with a median age of 11.6. The rate of complicated appendicitis rate was 38.5% but was significantly higher in rural (44.1%) and Māori children (54.8%). Complicated appendicitis was associated with increased prehospital delay (47.8 h versus 20.1 h; P < 0.001), but not in-hospital delay (11.3 h versus 13.3 h; P = 0.96). Multivariate analysis revealed increased anatomical severity in rural (OR 4.33, 95% CI 1.78-7.25; P < 0.001), and Māori children (OR 2.39, 95% CI 1.24-5.75; P = 0.019), as well as in families relying on external travel sources or reporting unfamiliarity with appendicitis symptomology.

CONCLUSION

Prehospital delay and differential access to prehospital determinants of health are associated with increased severity of paediatric appendicitis. This manifested as increased severity of appendicitis in rural and Māori children. Understanding the pre-hospital factors that influence the timing of presentation can better inform health-system improvements.

Varying negative appendectomy rates after laparoscopic appendectomy: a systematic review and meta-analysis

PURPOSE

Appendicitis is a common cause of acute abdominal pain, and treatment with laparoscopy has become increasingly common during the past two decades. Guidelines recommend that normal appendices are removed if operated for suspected acute appendicitis. It is unclear how many patients are affected by this recommendation. The aim of this study was to estimate the rate of negative appendectomies in patients undergoing laparoscopic surgery for suspected acute appendicitis.

METHODS

This study was reported following the PRISMA 2020 statement. A systematic search was conducted in PubMed and Embase for retrospective or prospective cohort studies (with n ≥ 100) including patients with suspected acute appendicitis. The primary outcome was the histopathologically confirmed negative appendectomy rate after a laparoscopic approach with a 95% confidence interval (CI). We performed subgroup analyses on geographical region, age, sex, and use of preoperative imaging or scoring systems. The risk of bias was assessed using the Newcastle-Ottawa Scale. Certainty of the evidence was assessed using GRADE.

RESULTS

In total, 74 studies were identified, summing up to 76,688 patients. The negative appendectomy rate varied from 0% to 46% in the included studies (interquartile range 4-20%). The meta-analysis estimated the negative appendectomy rate to be 13% (95% CI 12-14%) with large variations between the individual studies. Sensitivity analyses did not change the estimate. The certainty of evidence by GRADE was moderate due to inconsistency in point estimates.

CONCLUSION

The overall estimated negative appendectomy rate after laparoscopic surgery was 13% with moderate certainty of evidence. The negative appendectomy rate varied greatly between studies.

Systematic Review of Definitions and Outcome Measures for Postoperative Ileus and Return of Bowel Function after Abdominal Surgery in Children

This review aims to objectify which definitions and outcome measures are used for the return of bowel function and postoperative ileus in children. PubMed and Embase were systematically searched from inception to December 17, 2020. Prospective studies conducted in children (aged 0-18 years) undergoing gastrointestinal surgery which reported on definitions and/or outcome measures for post-operative ileus or return of bowel function were evaluated. Definitions and outcome measures were extracted. From 4,027 references, 71 articles were included. From the 17 articles mentioning postoperative ileus, 8 (47%) provided a definition. In total, 34 outcome measures were used and 12 were unique. "Abdominal distension" was the most reported (41%) measure. In 41%, the outcome measures only described the return of gastric motility, while 18% described the return of intestinal motility. The return of bowel function was mentioned in 67 articles, none provided a definition. In total, 133 outcome measures were used and 37 were unique. Time to oral intake was the most reported (14%) measure. In 49%, the outcome measures only described the return of gastric motility, while 10% described the return of intestinal motility. High variation in definitions and outcome measures has limited the generalizability of research into postoperative bowel function in children. Without standardization, it will be impossible to compare research results and evaluate treatments. In children, the return of gastric motility seemingly should get more focus compared to adults. Therefore, we believe that a definition of postoperative ileus with an accompanying core outcome set, developed by a multidisciplinary team, specifically for children is required.

Comparison of Appendicitis Inflammatory Response (AIR) and Lintula scoring systems in diagnosing acute appendicitis among children

Appendectomy is still the best treatment for acute appendicitis in pediatric patients. Given the problems of early and immediate diagnosis of acute appendicitis, defining the best diagnostic protocol for this condition is of utmost importance. Different diagnostic methods, such as Lintula and appendicitis inflammatory response (AIR) scoring systems, are used for this purpose. This study aims to compare Lintula and AIR scoring systems among children with suspicion of acute appendicitis regarding their postoperative outcomes. During two years, a prospective multicentric study was carried out in the selected hospitals of Iran. Pediatric patients admitted with the diagnosis of acute appendicitis were enrolled in the study. Before decision making, each patient's score was calculated according to two appendicitis scoring systems of Lintula and AIR. The clinical outcomes and diagnosis of patients were then compared to the results of each scoring system. For those patients who were a candidate to undergo surgery, the final diagnosis of acute appendicitis was made by histopathology. Patients were divided into high and low-risk groups according to scoring systems outcomes. Among the patients with lower scoring for appendicitis, the AIR scoring system had a sensitivity and specificity of 95%, which was more promising than that of the Lintula system (19%); however, the specificity was comparable between the two models (74% vs. 83%). For patients at higher risk of acute appendicitis, although the AIR scoring systems did not provide reliable results (sen: 45% and spe: 25%), the Lintula scoring showed remarkable sensitivity (87%), accompanied by a high diagnostic accuracy (87%). AIR and Lintula scoring systems are not accurate models to predict the risk of acute appendicitis among children; therefore, they can serve as an adjacent modality for other diagnostic methods.

Identification of the optimal treatment strategy for complex appendicitis in the paediatric population: a protocol for a multicentre prospective cohort study (CAPP study)

INTRODUCTION

In daily practice large heterogeneity in the treatment of children with complex appendicitis exists. Complex appendicitis can be divided into two subtypes; complex appendicitis with and without appendiceal mass and/or abscess. As complex appendicitis is associated with high morbidity and costs, identification of the optimal treatment strategy is essential. In this article, we present the study protocol for the CAPP (Complex Appendicitis in the Pediatric Population) study.

METHODS AND ANALYSIS

This nation-wide, multi-centre, comparative, non-randomised prospective cohort study includes all children <18 years old with a preoperative suspicion of complex appendicitis, which is based on imaging confirmed acute appendicitis and predefined criteria regarding the severity of appendicitis. Eligible patients are recruited in more than 30 hospitals. Open appendectomy will be compared with laparoscopic appendectomy for children without appendiceal mass and/or abscess and initial non-operative treatment (ie, intravenous antibiotics with or without percutaneous drainage) to direct appendectomy for children with appendiceal mass and/or abscess. Based on historical data supplied by the participating hospitals and an inclusion period of 2 years and 9 months, a sample size of 1308 patients is aimed. Primary outcome is the proportion of patients experiencing any complication at 3 months follow-up. Reported complications will be assessed by an independent adjudication committee. Secondary outcomes include, but are not limited to, quality of life, and (in)direct costs. To adjust for baseline differences and selection bias, outcomes will be compared after propensity score analysis (inverse probability weighting and stratification).

ETHICS AND DISSEMINATION

The Medical Ethics Review Committee of the Amsterdam UMC, location AMC, declared that the Medical Research involving Human Subjects Act (WMO) did not apply to this study. Therefore, no official approval was required by national law. Study results will be presented in peer-reviewed scientific journals and at (inter)national conferences.

TRIAL REGISTRATION NUMBERS

NCT04755179; NL9371.

Predictive scoring systems to differentiate between simple and complex appendicitis in children (PRE-APP study)

BACKGROUND

Several clinical prediction rules have been developed for preoperative differentiation between simple and complex appendicitis in children, as potential treatment strategies differ. This study aimed to externally validate applicable clinical prediction rules that could be used to differentiate between simple and complex appendicitis in children.

METHODS

Potential clinical prediction rules were identified by a scoping review of the literature. Clinical prediction rules applicable in our daily practice were subsequently externally validated in a multicenter historical cohort consisting of 1 tertiary center and 1 large teaching hospital. All children (<18 years old) with histopathologically confirmed acute appendicitis between 2013 and 2020 were included. Test results of clinical prediction rules were compared to the gold standard of either simple or complex appendicitis consisting of predefined perioperative and histopathological criteria. Areas under the receiver operating characteristic curves were determined for the selected clinical prediction rules. Areas under the receiver operating characteristic curve >0.7 were considered acceptable and potentially useful.

RESULTS

In total, 31 clinical prediction rules were identified, of which 12 could be evaluated in our cohort consisting of 550 children. The main reason to exclude clinical prediction rules was the use of variables that were not routinely measured in our cohort. In our cohort, 208/550 (38%) were diagnosed with complex appendicitis according to the gold standard. Clinical prediction rules with areas under the receiver operating characteristic curve >0.7 were: Gorter (0.81), Bogaard (0.79), Bröker (0.79), Graham (0.77), Hansson (0.76), BADCF (0.76), and Eddama (0.75).

CONCLUSION

In this study, clinical prediction rules consisting of a combination of clinical and objective variables had the highest discriminative ability. External validation showed that 7 clinical prediction rules were potentially useful. Integration of these clinical prediction rules in daily practice is proposed to guide decision making regarding treatment strategies.

The Management of Post-appendectomy Abscess in Children; A Historical Cohort Study and Update of the Literature

INTRODUCTION

Recent studies have shown that specific cases of post-appendectomy abscess (PAA) in children could be treated conservatively. However, due to the lack of high-quality evidence, choice of treatment still depends on preferences of the treating surgeon, leading to heterogeneity in clinical practice. Therefore, we aimed to provide an update of recent literature on the management of PAA in children and subsequently evaluate the outcomes of a large multicenter cohort of children treated for PAA.

METHODS

A literature search was performed in Pubmed and Embase, selecting all randomized controlled trials, prospective and retrospective cohort studies, and case series published from 2014 and onward and reporting on children (<18 years) treated for a PAA. Subsequently, a historical cohort study was performed, including all children (<18 years) treated for a radiologically confirmed PAA between 2014 and 2021 in a tertiary referral center and two large peripheral centers. Medical charts were reviewed to compare non-invasive (i.e., antibiotics) and invasive (i.e., drainage procedures) treatment strategies. Primary outcome was the success rate of treatment, defined as no need for further interventions related to PAA or its complications.

RESULTS

The search yielded 1,991 articles, of which three were included. Treatment success ranged between 69-88% and 56-100% for non-invasive and invasive strategies, respectively. Our multicenter cohort study included 70 children with a PAA, of which 29 (41%) were treated non-invasively and 41 (59%) invasively. In the non-invasive group, treatment was effective in 21 patients (72%) compared to 25 patients (61%) in the invasive group. Non-invasive treatment was effective in 100% of unifocal small (<3 cm) and 80% of unifocal medium size PAA (3-6 cm), but not effective for multiple abscesses.

CONCLUSION

Non-invasive treatment of especially unifocal small and medium size (<6 cm) PAA in children seems to be safe and effective. Based on these results, a standardized treatment protocol was developed. Prospective validation of this step-up approach-based treatment protocol is recommended.

A New Score for the Diagnosis of Complicated Appendicitis in Children - Complicated Appendicitis Pediatric Score

Aim

This study aims to construct and validate a new score for diagnosis of complicated appendicitis in children, complicated appendicitis pediatric score (CoAPS), to guide residents' clinical decision-making on choosing the correct patients for immediate surgery, reducing the emergency negative surgeries.

Methods

This prospective observational study enrolled two cohorts of patients 5-15 years old. Four hundred and seven consecutive patients were enrolled for the derivation cohort. Demographic data, clinical features, and histopathology data were collected. The outcome measure was the histological diagnosis of gangrenous appendicitis with or without perforation. The score was next validated in a separate cohort of 312 consecutive patients who were classified according to their risk of complicated appendicitis. The diagnostic performance of the score and the potential for the risk stratification to select patients for diagnostic imaging, emergency operative management, and reduce emergency negative operation rates were quantified.

Results

A positive "jumping up" test, vomiting, white blood cell >13.5 × 10^3/ml, lymphocytes <18%, and C-reactive protein >50 mg/dl were independent predictors for complicated appendicitis. The final prediction model exhibited an area under the curve of 0.890 (95% confidence interval: 0.859-0.922). The low-risk group demonstrated high sensitivity (90.4%) for complicated appendicitis, while scores 6 or more were very specific (95%) for the disorder. Describing the potential utility of the score, emergency ultrasound imaging would have been postponed in 14.5% of patients (P = 0.0016), and emergency negative explorations would have been cut by 87%.

Conclusion

The CoAPS score could guide residents in emergency management of children with complicated appendicitis reducing hospitalizations and urgent surgeries.

Comparison of the appendicitis inflammatory response and Alvarado scoring systems in the diagnosis of acute appendicitis in children

Our objective was to compare the diagnostic accuracy of Alvarado and appendicitis inflammatory response (AIR) scoring systems among children suspected of acute appendicitis concerning their postoperative outcomes. During a two-year period, a prospective multicentric study was carried in the selected hospitals of Iran. All children who were admitted with the diagnosis of acute appendicitis were enrolled in the study. However, patients suffering from generalized peritonitis or those who had a history of abdominal surgery were excluded. Before decision-making, each patient’s score according to two appendicitis scoring systems was calculated. The clinical outcomes and diagnosis of patients were then compared to the results of each scoring system. For those patients who were a candidate for surgery, the final diagnosis of acute appendicitis was made by histopathology. Patients were divided into a high- and low-risk group according to scoring systems outcomes. Among the patients with a low score for appendicitis, the AIR scoring system had a sensitivity and specificity of 95% and 74%, respectively, which was more promising in comparison to that of the Alvarado system (90% and 70%, respectively). Regarding the patients at higher risk of acute appendicitis, none of the scoring systems provided reliable results since both systems showed sensitivity and specificity of less than 50%, which was not sufficient to distinguish patients who are a candidate for surgery. AIR and Alvarado scoring systems are not accurate models to predict the risk of acute appendicitis among children; however, the AIR system could be used as a reliable material to rule out the acute appendicitis diagnosis.

Outcomes after appendectomy in children with acute appendicitis treated at a tertiary paediatric centre: results from a retrospective cohort study

PURPOSE

In general, an appendectomy is presumed to have a limited burden of disease. However, in current literature, reported complication rates vary. This study aims to provide additional insights in the incidence of post-appendectomy complications in children with acute appendicitis.

METHODS

This retrospective cohort study included children (0-17 years old) that underwent appendectomy at our tertiary referral centre for suspected acute appendicitis (January 2011-December 2018). Children referred to our centre, and those that underwent non-operative treatment were excluded. Post-appendectomy complications were recorded from electronic medical charts using predefined definitions and classified as severe (Clavien-Dindo III-IV) or less severe (Clavien-Dindo I-II).

RESULTS

A total of 131 children were included. Simple and complex appendicitis was diagnosed in 66 (50%) and 60 (46%) children, respectively. A non-inflamed appendix was seen in five (4%) children. One or more complications were identified in 33 (25%) patients. Eight (12%) children with simple appendicitis developed a complication, three of these were severe. In children with complex appendicitis, 23 (38%) children developed a complication, 14 of these were severe.

CONCLUSION

This study shows a high rate of complications compared with current literature, both in children with simple and complex appendicitis. This is probably the result of our definition of complications and being a tertiary referral centre receiving more severe appendicitis cases. However, these results still show that appendectomy is not always a routine procedure with only few complications. Substantiating the need to keep optimizing treatment for children with appendicitis.

Management of appendiceal mass and abscess in children; early appendectomy or initial non-operative treatment? A systematic review and meta-analysis

Background

Appendiceal mass and abscess and its treatment are associated with significant morbidity and high costs. Still, the optimal treatment strategy is the point of debate. Therefore, this systematic review and meta-analysis aimed to compare overall complications between initial non-operative treatment (NOT) and early appendectomy (EA) in children with appendiceal mass and/or abscess.

Methods

Pubmed and Embase were searched. Only randomized controlled trials and prospective or historical cohort studies that compared NOT with EA in children with appendiceal mass or abscess in terms of complications were eligible for inclusion. Risk of bias was assessed. Primary outcome was the overall complication rate. Secondary, length of stay and readmission rate were investigated. A meta-analysis of overall complications associated with both treatment strategies was performed.

Results

14 of 7083 screened studies were selected, including 1022 children in the NOT group and 333 in the EA group. Duration of follow-up ranged between four weeks and 12 years. Risk of bias was moderate in four and serious in 10 studies. NOT was associated with a lower overall complication rate (risk ratio (RR) 0.37 [95% confidence interval (CI) 0.21–0.65]). However, NOT led to increased length of stay (mean difference varied between 0.2 and 8.4 days) and higher readmission rate (RR 1.75 [95%CI 0.79–3.89]), although not significantly. Interval appendectomy after NOT was performed as a routine procedure in all but one study. This study found a recurrence rate of 34% in a group of 38 patients during a follow-up period of 3.4 ± 1.7 years.

Conclusion

NOT may reduce the overall complication rate compared to EA, but the evidence is very uncertain. As evidence is scarce, and of low level, and heterogeneity between studies is substantial, the results should be interpreted with caution. Large prospective studies are needed to determine the optimal treatment strategy for children with appendiceal mass and/or abscess.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07822-y) contains supplementary material, which is available to authorized users.

Neuroimmunoendocrine peptides on inflammed and morphologically normal appendices removed due to clinical acute appendicitis

INTRODUCTION

Despite clinical characteristics and complementary exams indicate acute appendicitis, 15% to 40% of all appendectomies result in removal of appendices with normal macro- and micromorphological aspects. Even so, manifestations of acute abdomen disappear immediately after the appendectomy, and never show back again.

OBJECTIVE

To assess changes of neuroimmunoendocrine peptides on removed appendices due to clinical presentation of acute appendicitis.

METHOD

This article presents an updated revision of acute appendicitis, based on references found on PUBMED, LILACS, MEDLINE, WHOLIS and SciELO, using key words "acute appendicitis", "neuroimmune appendicitis", "neurogenic appendicopathy", and "incidental appendectomy".

RESULTS

Fourteen neuropeptides were analyzed by different authors who suggested the presence of neurogenic appendicopathy in morphologically normal appendices removed from patients with clinical presentation suggesting acute appendicitis.

CONCLUSION

The etiopathogeny of acute appendicitis continues to be unknown, and there is a great possibility that patients with morphologically normal appendices with clinical presentation of acute appendicitis that heal after appendectomy present a neuroimmunoendocrine disease.

Disease burden of appendectomy for appendicitis: a population-based cohort study

Background

Few large-scale epidemiologic studies evaluate the clinical and economic burden of appendicitis. These data may impact future research and treatment strategies. In this study, the objective was to determine the burden of appendectomy for appendicitis in terms of incidence rates, length of hospital stay (LOS) and hospital costs on a national level. In addition, outcomes were compared for subgroups based on surgical treatment, age and hospital setting.

Methods

Observational retrospective population-based cohort study using the national Dutch healthcare reimbursement registry, which covers hospital registration and reimbursement for 17 million inhabitants. Patients with a diagnosis of appendicitis who underwent appendectomy between 2006 and 2016 were included. Primary outcomes were incidence rates, LOS and hospital costs.

Results

A total of 135,025 patients were included. Some 53% of patients was male, and 64% was treated in a general hospital. The overall incidence rate of appendectomy was 81 per 100,000 inhabitants and showed a significant decreasing trend across time and age. Mean ± SD LOS per patient was 3.66 ± 3.5 days. LOS showed a significant increase with age and was significantly longer for open versus minimally invasive appendectomy. Mean ± SD hospital costs per patient were €3700 ± 1284. Costs were initially lower for open compared to minimally invasive appendectomy, but were similar from 2012 onward. Compared to non-university hospitals, patients treated in university hospitals had a significantly longer LOS and higher costs.

Conclusions

Appendectomy for appendicitis represents a substantial clinical and economic burden in the Netherlands. A preference for minimally invasive technique seems justified.