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Observational Study
. 2018 Aug;32(8):3450-3466.
doi: 10.1007/s00464-018-6064-9. Epub 2018 Apr 5.

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study

GlobalSurg Collaborative
Collaborators
Observational Study

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study

GlobalSurg Collaborative. Surg Endosc. 2018 Aug.

Abstract

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.

Keywords: Appendectomy; Appendicitis; Global surgery; Laparoscopic; Operative standards; Postoperative care; Postoperative complications; Surgical site infection.

PubMed Disclaimer

Conflict of interest statement

GlobalSurg Collaborative have no conflicts of interest or financial ties to disclose.

Figures

Fig. 1
Fig. 1
Odds ratio plot for all outcome measures after propensity score matching by HDI group. OR odds ratio, CD Clavien–Dindo grade, CI confidence interval. Note there was an insufficient number of events to specify models for 30-day mortality
See this image and copyright information in PMC

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