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Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study
NIHR Unit on Global Surgery (Universities of Birmingham, Edinburgh and Warwick), University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK.
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.ORCID iD: 0000-0002-7516-9543
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
2018 (English)In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 32, no 8, p. 3450-3466Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide.

METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days.

RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45).

CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments.

TRIAL REGISTRATION: NCT02179112.

Place, publisher, year, edition, pages
Springer, 2018. Vol. 32, no 8, p. 3450-3466
Keywords [en]
Appendectomy, Appendicitis, Global surgery, Laparoscopic, Operative standards, Postoperative care, Postoperative complications, Surgical site infection
National Category
Surgery
Identifiers
URN: urn:nbn:se:umu:diva-154582DOI: 10.1007/s00464-018-6064-9ISI: 000438285100004PubMedID: 29623470OAI: oai:DiVA.org:umu-154582DiVA, id: diva2:1272812
Available from: 2018-12-19 Created: 2018-12-19 Last updated: 2019-01-07Bibliographically approved

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Sund, MalinAndersson, LindaGunnarsson, Ulf

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