The global, regional, and national burden of appendicitis in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

Trends and levels of the global, regional, and national burden of appendicitis between 1990 and 2021: findings from the Global Burden of Disease Study 2021

BACKGROUND

Appendicitis is a common surgical emergency that poses a large clinical and economic burden. Understanding the global burden of appendicitis is crucial for evaluating unmet needs and implementing and scaling up intervention services to reduce adverse health outcomes. This study aims to provide a comprehensive assessment of the global, regional, and national burden of appendicitis, by age and sex, from 1990 to 2021.

METHODS

Vital registration and verbal autopsy data, the Cause of Death Ensemble model (CODEm), and demographic estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) were used to estimate cause-specific mortality rates (CSMRs) for appendicitis. Incidence data were extracted from insurance claims and inpatient discharge sources and analysed with disease modelling meta-regression, version 2.1 (DisMod-MR 2.1). Years of life lost (YLLs) were estimated by combining death counts with standard life expectancy at the age of death. Years lived with disability (YLDs) were estimated by multiplying incidence estimates by an average disease duration of 2 weeks and a disability weight for abdominal pain. YLLs and YLDs were summed to estimate disability-adjusted life-years (DALYs).

FINDINGS

In 2021, the global age-standardised mortality rate of appendicitis was 0·358 (95% uncertainty interval [UI] 0·311-0·414) per 100 000. Mortality rates ranged from 1·01 (0·895-1·13) per 100 000 in central Latin America to 0·054 (0·0464-0·0617) per 100 000 in high-income Asia Pacific. The global age-standardised incidence rate of appendicitis in 2021 was 214 (174-274) per 100 000, corresponding to 17 million (13·8-21·6) new cases. The incidence rate was the highest in high-income Asia Pacific, at 364 (286-475) per 100 000 and the lowest in western sub-Saharan Africa, at 81·4 (63·9-109) per 100 000. The global age-standardised rates of mortality, incidence, YLLs, YLDs, and DALYs due to appendicitis decreased steadily between 1990 and 2021, with the largest reduction in mortality and YLL rates. The global annualised rate of decline in the DALY rate was greatest in children younger than the age of 10 years. Although mortality rates due to appendicitis decreased in all regions, there were large regional variations in the temporal trend in incidence. Although the global age-standardised incidence rate of appendicitis has steadily decreased between 1990 and 2021, almost half of GBD regions saw an increase of greater than 10% in their age-standardised incidence rates.

INTERPRETATION

Slow but promising progress has been observed in reducing the overall burden of appendicitis in all regions. However, there are important geographical variations in appendicitis incidence and mortality, and the relationship between these measures suggests that many people still do not have access to quality health care. As the incidence of appendicitis is rising in many parts of the world, countries should prepare their health-care infrastructure for timely, high-quality diagnosis and treatment. Given the risk that improved diagnosis may counterintuitively drive apparent rising trends in incidence, these efforts should be coupled with improved data collection, which will also be crucial for understanding trends and developing targeted interventions.

FUNDING

Bill and Melinda Gates Foundation.

Accurate diagnosis of acute appendicitis in the emergency department: an artificial intelligence-based approach

The diagnosis of abdominal pain in emergency departments is challenging, and appendicitis is a common concern. Atypical symptoms often delay diagnosis. Although the Alvarado score aids in decision-making, its low specificity can lead to unnecessary surgeries. By leveraging machine learning, we aim to enhance diagnostic accuracy by predicting appendicitis and distinguishing it from other causes of abdominal pain in the emergency department. Data were collected from 534 patients who presented with acute abdominal pain. Patient characteristics, laboratory results, and causes of pain were recorded. Machine learning algorithms (support vector classifier, random forest classifier, gradient boosting classifier, and Gaussian naive Bayes) were used to predict the cause of pain. Model calibration was assessed using the Brier score. The mean age was 46.89 (20.3) years, with an almost equal sex distribution (49% male, 51% female). Cholecystitis was the most prevalent outcome (37.07%), followed by appendicitis (25.84%). The Gaussian naive Bayes model exhibited superior performance in terms of accuracy (95.03% 95% CI 90.44-97.83%), sensitivity (87.18% 95% CI 72.57-95.70%), and specificity (97.54% 95% CI 92.98-99.49%), while the random forest model showed a sensitivity of 79.49%, specificity of 96.72%, and accuracy of 92.55%. The gradient boosting algorithm achieved a sensitivity, specificity, and accuracy of 89.74%, 95.90%, and 94.41%, respectively. The support vector classifier demonstrated a sensitivity of 89.74%, specificity of 92.62%, and accuracy of 91.93%. The use of modern machine learning methods aids in the accurate diagnosis of appendicitis.

The impact of surgical timing on outcome in acute appendicitis in adults: a retrospective observational population-based cohort study

BACKGROUND

Acute appendicitis is a global disease with high incidence. The main objective was to assess the association between time from admission to surgery (TAS) and surgery during emergency hours with operative outcome in light of conflicting evidence.

METHODS

This is a retrospective population-wide analysis of hospital billing data (2010-2021) of all adult patient records of surgically treated cases of acute appendicitis in Germany by TAS. The primary outcome was a composite clinical endpoint (CCE; prolonged length of stay, surgical site infection, interventional draining after surgery, revision surgery, ICU admission and/or in-hospital mortality). Cases of complicated appendicitis were identified using diagnosis (ICD-10) and procedural codes (resection beyond appendectomy).

RESULTS

855 694 patient records were included, of which 27·6% (236,481) were complicated cases of acute appendicitis. 49·0% (418,821) were females and median age was 37 (interquartile range 22·5-51·5). Age, male sex, and comorbidity were associated with an increased proportion of CCE and in-hospital mortality. TAS was associated with a clinically relevant increase of CCE after 12 h in complicated appendicitis [Odd's ratio (OR), 1·19, 95% CI: 1·14-1·21] and after 24 h in uncomplicated appendicitis (OR 1·10, 95% CI: 1·02-1·19). Beyond the primary endpoint, the proportion of complicated appendicitis increased after TAS of 72 h. Surgery during emergency hours (6 pm-6.59 am) was associated with an increase of CCE and mortality (OR between 1·14 and 1·49). Age, female sex, night-time admission, weekend admission, a known previous surgery, obesity, and therapeutic anticoagulation were associated with delayed performance of surgery.

CONCLUSION

This work found an increase of a CCE after TAS of 12 h for complicated appendicitis and an increase of the CCE after TAS of 24 h for uncomplicated appendicitis with a stable proportion of complicated appendicitis in these time windows. Both CCE and mortality were increased if appendectomy was performed during emergency hours.

Appendectomy and Risk of Prostate Cancer in the Health Professionals Follow-up Study

BACKGROUND

Appendectomy is a common surgical procedure to treat appendicitis. Limited studies have examined its association with prostate cancer, with one large cohort study suggesting a significantly increased risk of overall and advanced prostate cancer, especially among younger men.

METHODS

A total of 49,104 men in the Health Professionals Follow-up Study were followed from 1986 to 2016. Cox proportional hazards models were applied to evaluate the association between self-reported history of appendectomy and risk of overall and subtype-specific prostate cancer, adjusted for multiple risk factors.

RESULTS

During 30 years of follow-up, we documented 7,253 overall prostate cancer cases, including 579 advanced and 1,092 lethal events. Compared to men without appendectomy, those who reported at baseline having had appendectomy were not at higher risk of overall [HR, 1.01; 95% confidence interval (CI), 0.95-1.07], advanced (HR, 0.99; 95% CI, 0.81-1.23), or lethal (HR, 1.04; 95% CI, 0.89-1.20) prostate cancer. The association remained null when stratified by age.

CONCLUSIONS

We found no evidence of an association between appendectomy and the risk of overall and clinically important prostate cancer.

IMPACT

We showed that appendectomy was not associated with overall or advanced prostate cancer after adjusting for multiple risk factors in a large population of men with 30 years of follow-up.

Partial visualization of appendix on ultrasound: What does it mean in the child with suspected appendicitis?

BACKGROUND

Visualization of the entire appendix, including the tip, is thought, but has not been demonstrated, to be important for exclusion of appendicitis by ultrasound.

OBJECTIVE

To determine if incomplete visualization of the appendix has negative clinical ramifications including missed appendicitis.

METHODS

Under IRB approval we retrospectively reviewed right lower quadrant ultrasound reports from January 2017 to December 2020 to identify examinations with impressions of full visualization of the normal appendix, non-visualization of the appendix with and without secondary findings of appendicitis, and partial visualization of the appendix. Electronic health records were reviewed for follow-up imaging within 48 h, and surgery with pathology reports (if available).

RESULTS

12,193 examinations were included. 4171 (34.2 %) had full visualization of a normal appendix, 5369 (44.0 %) had non-visualization with no secondary findings, and 234 (1.9 %) had non-visualization with secondary findings, The frequencies of appendicitis in these three groups were 34 (0.8 %), 283 (5.3 %), and 127 (54.3 %) respectively. The appendix was partially visualized in 338 (2.8 %) patients with secondary findings present in 53 (15.6 %). Partial visualization without secondary findings had a similar frequency (4.9 %, 14/285) of appendicitis to non-visualized appendix without secondary findings (p = 0.797) and a higher frequency than full visualization of a normal appendix (p < 0.0001). Partial visualization with secondary findings had similar rates (54.7 %, 29/53) to non-visualized appendix with secondary findings (p = 0.953).

CONCLUSION

Partial visualization of the appendix with ultrasound (with and without secondary findings) is associated with similar frequencies of appendicitis as non-visualization of appendix (with and without secondary findings).

A Tale of Two "Citis": Appendicitis Versus Crohn's Appendicitis

Appendicitis is one of the most common emergencies worldwide. One of the rare causes of acute appendicitis is Crohn's disease (CD). Management of appendicitis should not be decided in haste without a complete workup of the patient, including coexisting symptoms and past history. The appendix is essential for intestinal homeostasis, preventing the development of certain pathologies. It is important to correlate clinical and radiographic findings in diagnosing and managing Crohn's appendicitis. The mainstay of management of CD with appendicitis involves the use of systemic steroids.

Diagnostic performance of serum CA-125 for overall and complicated acute appendicitis: a systematic review and meta-analysis

This study aimed to analyze the diagnostic performance of serum CA-125 in acute appendicitis (AA). This review was registered in PROSPERO (CRD42023450988). We included prospective and retrospective original clinical studies evaluating the diagnostic performance of serum CA-125 in AA. A search was conducted in PubMed, Web of Science, Scopus, and OVID. Search terms and keywords were: (appendicitis OR appendectomy) AND (CA-125 OR CA125). Two independent reviewers selected the articles and extracted relevant data. Methodological quality was assessed using the QUADAS-2 index. A synthesis of the results, standardization of the metrics, and three random-effect meta-analyses were performed. Five studies with data from 533 participants (including 219 patients with a confirmed diagnosis of AA and 107 controls) were included in this review. The random-effect meta-analysis of serum CA-125 (AA vs controls) included 3 articles (125 AA and 70 controls) and resulted in a non-significant mean difference [95% CI] of - 6.80 [- 20.51, 6.92] U/mL (p = 0.33). The meta-analysis by subgroups that included only male patients resulted in a significant mean difference [95% CI] of 3.48 [0.46, 6.49] U/mL (p = 0.02). Although serum CA-125 does not appear to be a good overall marker for the diagnosis of AA, our subgroup analyses show that this marker could be useful for diagnosing AA in males. It also appears to be a potentially useful tool for discriminating complicated and uncomplicated AA. However, the limited number of included studies precludes drawing generalizable conclusions. Future prospective studies focused on males and in its potential ability to discriminate between complicated and uncomplicated AA are required.Registration. PROSPERO (CRD42023450988).

Compilation of Evidence Supporting the Role of a T Helper 2 Reaction in the Pathogenesis of Acute Appendicitis

Despite being the most common abdominal surgical emergency, the cause of acute appendicitis (AA) remains unclear, since in recent decades little progress has been made regarding its etiology. Obstruction of the appendicular lumen has been traditionally presented as the initial event of AA; however, this is often the exception rather than the rule, as experimental data suggest that obstruction is not an important causal factor in AA, despite possibly occurring as a consequence of the inflammatory process. Type I hypersensitivity reaction has been extensively studied, involving Th2 lymphocytes, and cytokines such as IL-4, IL-5, IL-9 and IL-13, which have well-defined functions, such as a positive-feedback effect on Th0 for differentiating into Th2 cells, recruitment of eosinophils and the release of eosinophilic proteins and the production of IgE with the activation of mast cells, with the release of proteins from their granules. Cytotoxic activity and tissue damage will be responsible for the clinical manifestation of the allergy. AA histological features are similar to those found in allergic reactions like asthma. The intestine has all the components for an allergic immune response. It has contact with hundreds of antigens daily, most of them harmless, but some can potentially induce an allergic response. In recent years, researchers have been trying to assess if allergy is a component of AA, with their latest advances in the understanding of AA as a Th2 reaction shown by the authors of this article.

Impact of Education and Experience on Radiographers' Ability to Diagnose Acute Appendicitis: A Survey in Private Malaysian Hospitals

Background

Acute appendicitis is a global surgical emergency. Radiographic modalities usually identify acute appendicitis, although radiographers' competence is questionable. This study examines how clinical radiographers' education and experience affect their ability to identify acute appendicitis using computed tomography (CT), magnetic resonance imaging (MRI) and ultrasonography (USG) characteristics. The study also aimed to determine which variable strongly influences their knowledge level.

Methods

The study surveyed radiographers with a four-part self-administered questionnaire containing demographic information and eight knowledge-based questions about the appearance of acute appendicitis in MRI, CT and USG, separately. Before distribution, the questionnaire was validated and checked the reliability.

Results

Clinical radiographers' knowledge about using MRI to diagnose acute appendicitis was strongly affected by education and experience (η2 = 0.13 and 0.14; P < 0.05), with bachelor's degree holders scoring higher regardless of experience. Radiographers with more than 5 years of experience knew more about CT and USG features to identify acute appendicitis (η2 = 0.40 and 0.27; P < 0.05). Radiographers with a bachelor's degree and greater experience had higher overall knowledge of MRI, CT and USG to diagnose acute appendicitis (η2 = 0.51 and 0.11; P < 0.05). With adjusted R2 = 54% (F [2, 44] = 27.94; P < 0.001), education and experience highly predicted the overall knowledge level.

Conclusion

The study found gaps in radiographers' knowledge of the radiographic appearance of acute appendicitis. Clinical radiographers' education level and years of experience substantially affect their knowledge level. In addition, experience is a good predictor than education level for overall knowledge level. Therefore, the study emphasises the importance of continuing education and training for radiographers to diagnose acute appendicitis quickly and accurately.

Left-sided acute appendicitis in a patient with situs inversus totalis: A case report and a comprehensive review

AA is a frequent surgical condition that demands urgent intervention. It accounts for approximately 6% of all emergency department visits. Situs inversus is a rare condition in which the orientation of asymmetric organs is a mirror image of normal anatomy. It can be partial (involving either the abdominal or thoracic cavities) or complete (situs inversus totalis: transposition of both abdominal and thoracic organs). SIT is very rare, with an incidence of 1 per 5000 to 10,000 live births. It is inherited in an autosomal recessive pattern with incomplete penetrance. LSAA is very rare and can happen in association with other congenital abnormalities such as situs inversus, midgut malrotation (MM), or a usually long right-sided appendix projecting into the left lower quadrant. SIT is responsible for greater than 67% of left-sided appendicitis cases. Due to atypical clinical presentation, the diagnosis of AA can be difficult and often delayed. Hence, a complete medical history, physical examination, laboratory tests, and imaging tools are necessary to reach a correct diagnosis in a timely manner and prevent complications like abscesses, perforations, and peritonitis. We report a case of a 50-year-old male with symptoms of left lower abdominal pain along with fever, nausea, vomiting, and loose stools that were later diagnosed as LSAA in the setting of SIT.

A Case of Left-Sided Acute Appendicitis in a 45-Year-Old Man with Situs Inversus Totalis Managed by Emergent Laparoscopic Appendectomy

BACKGROUND Situs inversus totalis (SIT) is a rare congenital abnormality that includes mirror-image transposition of both the abdominal and the thoracic organs. It may remain undetected into adulthood until an acute medical emergency results in diagnostic imaging. This report presents a challenging case of left-sided acute appendicitis in a 45-year-old man with SIT. CASE REPORT A 45-year-old man with a medical history of gastroesophageal reflux disease, class 2 obesity, prediabetes, and elevated low-density lipoprotein cholesterol presented with severe acute abdominal pain localized in the left lower quadrant with localized tenderness, nausea, and 2 episodes of non-bloody and non-bilious emesis that started a day before the clinical encounter. Computed tomography of the abdomen and pelvis revealed previously undiagnosed congenital SIT. In addition, physical, laboratory, and radiological findings suggested early acute appendicitis with no evidence of complications. Hence, the patient was managed with an emergent laparoscopic appendectomy. Acute appendicitis was confirmed in the post-surgery histopathological examination. The post-surgery recovery was uneventful, and the patient was discharged home on the second postoperative day. CONCLUSIONS This report highlights that SIT may remain undiagnosed into adulthood and poses a challenge in the diagnosis of left-side appendicitis due to atypical symptom presentation, supporting the findings of previous case reports. Therefore, the inclusion of left-sided acute appendicitis in the differential diagnosis of abdominal pain in the left lower quadrant is warranted.

Tryptase in Acute Appendicitis: Unveiling Allergic Connections through Compelling Evidence

The aetiology of acute appendicitis (AA), the most frequent abdominal surgical emergency, is still unclarified. Recent epidemiologic, clinical and laboratorial data point to an allergic component in the pathophysiology of AA. Mastocytes participate in the Th2 immune response, releasing inflammatory mediators from their granules upon stimulation by IgE-specific antigens. Among the well-known mediators are histamine, serotonin and tryptase, which are responsible for the clinical manifestations of allergies. We conducted a prospective single-centre study to measure histamine and serotonin (commercial ELISA kit) and tryptase (ImmunoCAP System) concentrations in appendicular lavage fluid (ALF) and serum. Consecutive patients presenting to the emergency department with a clinical diagnosis of AA were enrolled: 22 patients with phlegmonous AA and 24 with gangrenous AA The control group was composed of 14 patients referred for colectomy for colon malignancy. Appendectomy was performed during colectomy. Tryptase levels were strikingly different between histological groups, both in ALF and serum (p < 0.001); ALF levels were higher than serum levels. Tryptase concentrations in ALF were 109 times higher in phlegmonous AA (APA) (796.8 (194.1-980.5) pg/mL) and 114 times higher in gangrenous AA (AGA) (837.4 (272.6-1075.1) pg/mL) than in the control group (7.3 (4.5-10.3) pg/mL. For the diagnosis of AA, the discriminative power of serum tryptase concentration was good (AUC = 0.825), but discriminative power was weak (AUC = 0.559) for the differential diagnosis between APA and AGA. Mastocytes are involved in AA during clinical presentations of both phlegmonous and gangrenous appendicitis, and no significant differences in concentration were found. No differences were found in serum and ALF concentrations of histamine and serotonin between histological groups. Due to their short half-lives, these might have elapsed by the time the samples were collected. In future research, these determinations should be made immediately after appendectomy. Our findings confirm the hypersensitivity type I reaction as an event occurring in the pathogenesis of AA: tryptase levels in ALF and serum were higher among patients with AA when compared to the control group, which is in line with a Th2 immune response and supports the concept of the presence of an allergic reaction in the pathogenesis of acute appendicitis. Our results, if confirmed, may have clinical implications for the treatment of AA.

Study on the burden of digestive diseases among Chinese residents in the 21st century

Background

The global burden of digestive diseases has increased in recent years. The study aims to comprehend the trend of incidence and death rates related to digestive diseases in China from 2000 to 2020.

Methods

The study collected data on digestive diseases and their causes, such as incidence rates, death rates, Years of Life Lost, Years Lived with Disability, Disability-Adjusted Life Years and estimated annual percentage change from the 2019 Global Burden of Disease website and the Chinese Health and Wellness Statistical Yearbook spanning. And we employed the age-period-cohort model to analyze the influence of age, period, and birth cohort on the trend of death rates associated with digestive diseases.

Results

In contrast to the global burden of digestive disease, China experienced increases in the age-standardized incidence for inflammatory bowel disease, gallbladder and biliary diseases, as well as appendicitis from 2000 to 2019. The corresponding estimated annual percentage change for these diseases were 2.06, 1.74, and 0.99. Females showed a significantly higher incidence of digestive diseases, while males experienced a higher death rate. Moreover, individuals in the age groups under 5 years and over 60 years exhibited higher death rates than those in other age groups.

Conclusion

The findings underscore the ongoing importance of digestive diseases as a substantial public health issue in China. Reducing the disease burden of IBD in China necessitates healthcare systems to enhance their infrastructure and personnel readiness, ensuring an equitable, affordable, and accessible distribution of care for IBD patients. To reduce the occurrence and mortality rates of digestive diseases in China, the government should promote the adoption of early screening policies for individuals under the 5 year and those above the 60 year. These policies should be accompanied by customized preventive measures.

Bacteremia caused by Comamonas kerstersii in a patient with acute perforated appendicitis and localized peritonitis: case report and literature review

Comamonas kerstersii (C. kerstersii) is a Gram-negative bacterium that was initially thought to be non-pathogenic to humans and is abundant in the environment. In recent years, with the availability of matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) that enable fast and accurate bacterial identification, there have been increasing number of reports of human infections caused by C. kerstersii, indicating that this organism has emerged as human pathogen. In fact, most clinical isolates of C. kerstersii are recovered from peritoneal liquid, and bacteremia has been infrequently reported. Here, we report a case of bacteremia caused by C. kerstersii in a 28-year-old male patient with acute perforated appendicitis and localized peritonitis and present a comprehensive review of C. kerstersii infections in pathogenic diagnosis and clinical treatment as well as prognosis, thus providing a better understanding of C. kerstersii-related infections.

Diagnostic performance of urinary 5-Hydroxyindoleacetic Acid in acute appendicitis: a systematic review and diagnostic test accuracy meta-analysis

OBJECTIVES

This study aimed to analyze the diagnostic performance of urinary 5-Hydroxyindoleacetic Acid (5-HIAA) in acute appendicitis (AA).

METHODS

This review was registered in PROSPERO (CRD42023399541). We included prospective or retrospective original clinical studies evaluating the diagnostic performance of 5-HIAA in AA. A search was conducted in PubMed, Web of Science, Scopus and OVID. Search terms and keywords were: (appendicitis OR acute appendicitis) AND (5-HIAA OR 5-Hydroxyindoleacetic acid OR serotonin metabolite). Two independent reviewers selected the articles and extracted relevant data. Methodological quality was assessed using the QUADAS2 index. A synthesis of the results, standardization of the metrics, and a random-effect meta-analysis were performed. Additionally, a coupled forest plot and a diagnostic test accuracy meta-analysis (DTA) were performed.

RESULTS

Twelve studies with data from 1467 participants (724 patients with a confirmed diagnosis of AA and 743 controls) were included in this review. The random-effect meta-analysis of urinary 5-HIAA (AA vs controls) included 7 articles (352 AA and 258 controls) and resulted in a significant mean difference [95% CI] of 23.30 [15.82-30.77] μmol/L (p < 0.001). The DTA meta-analysis of urinary 5-HIAA included 8 articles and resulted in a pooled sensitivity [95% CI] of 68.6 [44.1-85.9]% and a pooled specificity [95% CI] of 82 [54.7-94.5]%.

CONCLUSIONS

Although the evidence is heterogeneous and limited, urinary 5-HIAA emerges as a potential non-invasive diagnostic tool for AA. Urinary 5-HIAA does not seem to be a useful biomarker to distinguish between NCAA and CAA. Future prospective studies with a large sample size and a rigorous design are necessary to validate these findings.

TRIAL REGISTRATION

PROSPERO (CRD42023399541).

The Vermiform Appendix and Its Pathologies

The vermiform appendix is a muscular cylindrical structure originating near the junction of the cecum and ileum, averaging 9 cm (5-35 cm) in size. As the most mobile viscera, it can adopt several positions, the most common being the retrocecal position. Perceived as an atavistic organ lacking physiological relevance, the vermiform appendix appears to be involved in immune function, serving in the maturation of B lymphocytes and the production of immunoglobulin A, in endocrine function, excreting amines and hormones in the 2-3 mL of mucus secreted daily, and in digestive function, by storing beneficial bacteria from where they can recolonize the colon. With a lumen of about 6 mm, the vermiform appendix has a reduced storage capacity, so any blockage of the appendix with fecoliths (fecaliths), seeds derailed from the colon, or enlarged lymph nodes prevents drainage and intraluminal accumulation of secreted mucus. Unable to relax, the appendix wall severely limits its intraluminal volume, so mucus accumulation leads to inflammation of the appendix, known generically as appendicitis. In addition, the vermiform appendix may be the site of the development of neoplastic processes, which may or may not involve mucus production, some of which can significantly affect the standard of living and ultimately lead to death. In general, mucinous tumors may have a better prognosis than non-mucinous tumors. This review takes a comprehensive path, starting by describing the anatomy and embryology of the vermiform appendix and further detailing its inflammatory pathologies, pathologies related to congenital anomalies, and appendix tumors, thus creating an up-to-date framework for better understanding, diagnosis, and treatment of these health problems.

Propensity score matching analysis of laparoscopic surgery vs. open approach in 4 297 adult patients with acute appendicitis, acute cholecystitis or gastrointestinal tract perforation: a prospective multicentre study of nationwide outcomes

BACKGROUND AND AIMS

Previous studies indicated that laparoscopic surgery could improve postoperative outcomes in acute appendicitis, acute cholecystitis, perforated gastroduodenal ulcer, or acute diverticulitis, but some reported opposite results or differences in the magnitude of improvement. A contemporary analysis using propensity score matching that compares outcomes is lacking.

METHODS

Over a 6-month period, 38 centres (5% of all public hospitals) attending emergency general surgery patients on a 24 h, 7 days a week basis, enroled all consecutive adult patients who underwent laparoscopic surgery or open approach.

RESULTS

The study included 2 645 patients with acute appendicitis [32 years (22-51), 44.3% women], 1 182 with acute cholecystitis [65 years (48-76); 46.7% women], and 470 with gastrointestinal tract perforation [65 years (50-76); 34% women]. After propensity score matching, hospital stays decreased in acute appendicitis [open, 2 days (2-4); lap, 2 days (1-4); P <0.001], acute cholecystitis [open, 7 days (4-12); lap, 4 days (3-6); P <0.001], and gastrointestinal tract perforation [open, 11 days (7-17); lap, 6 days (5-8.5); P <0.001]. A decrease in 30-day morbidity was observed in acute appendicitis (open, 15.7%; lap, 9.7%; P <0.001), acute cholecystitis (open, 41%; lap, 21.7%; P <0.001), and gastrointestinal tract perforation (open, 45.2%; lap, 23.5%; P <0.001). A decrease in 30-day mortality was found in acute cholecystitis (open, 8.8%; lap, 2.8%; P =0.013) and gastrointestinal tract perforation (open, 10.4%; lap, 1.7%; P =0.013).

CONCLUSIONS

This clinically based, multicentre study suggests that an initial laparoscopic approach could be considered not only in patients with acute appendicitis or acute cholecystitis but also in patients with a perforation of the gastrointestinal tract.