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Surgical site infection (SSI) is one of the most common postoperative complications after appendectomy leading to recurrent surgery, prolonged hospital stay, and the use of antibiotics. The burden of surgical site infection varies from 1.2 to 20% across the previously conducted studies. However, there are limited studies available on this problem in Ethiopia. Therefore, this study aimed to assess prevalence of post-appendectomy surgical site infection among children in Amhara region, Ethiopia. A cross-sectional study was employed. The data extraction tool was used to collect data from 423 sampled participants. Simple random sampling technique was used. Data cleaned, coded and entered into Epi Data version 4.6 and exported to STATA version 14.0. The data was presented using table and text forms. The logistic regression model was fitted after checking the required assumptions through Hosmer and lemeshow test to identify predictors of post-operative complications. The bivariable analysis was done to identify associations between dependent and each independent variable. Moreover, variables with P ≤ 0.25 levels in the bivariable analysis were entered into the multivariable analysis. Adjusted odd ratio with 95% CI was used to assess the direction, strength of association and statistical significance. Any statistical test was considered significant at P-value < 0.05. A total of 406 study participants were considered for analysis. The prevalence of surgical site infection was 9.11% (95%CI; 6.67%, 12.34%). Having fever (AOR = 2.788, 95%CI (1.10, 7.05)), being taking preoperative antibiotics (AOR = 7.3, 95%CI (2.5, 21)) and having drainage following appendectomy (AOR = 6.3, 95%CI (2.7, 14.7)) were statistically significant predictors of surgical site infection following appendectomy in children. The prevalence of surgical site infection was high as compared the national target. Taking preoperative antibiotics, having fever, and having drainage after operation were significantly associated with surgical site infection. Therefore, a prospective follow up study is important. Those children with appendicitis who presented with a clinical symptom of fever, leaving drainage after procedure and timing of preoperative antibiotics requires special attention of the surgical safety team., Competing Interests: Declarations. Competing interests: The authors declare no competing interests. Ethics approval and consent to participate: Ethical clearance was obtained from Woldia University Institutional Review Board (Woldia University IRB) on November, 2023. The research directorate office wrote a supportive letter for each selected respective comprehensive specialized hospital. In turn, an internal permission letter obtained from chief executive officers of each hospital to the health service departments within the hospital. The name and the medical record number of the participants were not included in the tool. The retrieved information was used only for the study purpose. This study did not expose the study participants to unnecessary risk due to reviewing their medical records. Due to the retrospective nature of the study, Woldia University Institutional Review Board waived the need of obtaining informed consent. Confidentiality was kept at all levels of the study. The data was also used only for this study purpose. The study was carried out according to the Declaration of Helsinki’s relevant guidelines and regulations., (© 2025. The Author(s).)

Background: Reported outcomes after appendectomy during pregnancy remain inconclusive, and the risk for preterm delivery is not necessarily procedure-related., Methods: This retrospective cohort study included 185 pregnant women who underwent appendectomy during pregnancy and gave birth between 2005 and 2022, compared using a 3:1 ratio to 555 parturients who did not undergo surgery. clinical, obstetrical and neonatal outcomes were analyzed., Results: Laparoscopic appendectomy was the most common procedure (117/185; 63.2 ​%) whereas 68/185 (36.8 ​%) had open appendectomy. Pathological findings revealed that 141/185 cases (76.2 ​%) had an inflamed appendix, while 44/185 (23.8 ​%) were classified as having a "white appendix" (negative appendectomy). Preterm delivery occurred more frequently in the appendectomy group [22/185 (11.9 ​%) vs 30/555 (5.4 ​%), p ​= ​0.003] with even higher incidence in negative appendectomies compared to inflamed appendix cases [9/44 (20.5 ​%) vs 13/141 (9.2 ​%), p ​= ​0.044]. Multivariate analysis identified appendectomy (but not an inflamed appendix) as the sole significant risk factor for preterm birth (odds ratio 2.3, CI 1.26-4.15, p ​= ​0.006)., Conclusion: Preterm delivery correlates with negative appendectomies. Careful assessment is essential to avoid unnecessary surgical interventions during pregnancy., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Postoperative recovery of children is difficult to gauge by parents after hospital discharge. Consumer wearable devices (CWD) generate valid and near real-time pulse rate data, integer pulse rate variability (PRVi), that can serve as digital biomarkers for the onset of complications during post-discharge recovery. This study sought to explore whether pediatric patients with surgical complications after appendectomy exhibited a CWD-derived PRVi trajectory that differs from the normative PRVi recovery trajectory., Methods: In this retrospective analysis, children aged 3-17 undergoing appendectomy for complicated appendicitis was invited to participate. Participants wore a Fitbit device for 21 days postoperatively. PRVi was calculated as the variance, defined as the sum of the squared differences of each value from the mean, of the heart rate in beats per minute measured over 5 consecutive minutes. The mean daily PRVi was calculated for patients recovering with and without complications., Results: Ninety-eight patients were enrolled in the study; 60 (61 %) were ages 3-11, 54 (55 %) were female, and 57 (58 %) were Caucasian. Eleven (11 %) developed surgical complications. Those with complications experienced a slower increase in the mean PRVi over the 21-day period., Conclusions: In this prospective observational study, it was demonstrated that PRVi derived from CWD data can be used as an objective digital biomarker to profile surgical complications. This finding provides clinicians with an additional tool for monitoring children during the postoperative period, enhancing their ability to proactively detect and address complications., Level of Evidence: IV., Competing Interests: Conflicts of interest The authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: General Medical Council (GMC) guidelines dictate that reasonable alternatives to treatment should be disclosed during the consent process. We aimed to determine whether GMC guidelines on disclosure of alternatives during consent are being followed in a real-world example which is disclosure of non-operative management as an alternative to appendicectomy in uncomplicated paediatric appendicitis., Methods: We undertook a retrospective single-centre observational study and national consultant specialist paediatric surgeon survey. Two groups of 50 consecutively treated children (<16 years) with acute uncomplicated appendicitis were included in the observational study during two periods. UK-based consultant surgeons who treat appendicitis were included in the national survey. The main outcomes were disclosure and use of non-operative management (NOM) as an alternative to appendicectomy., Results: Overall, in the observational study, NOM was disclosed in 30 (30%) children and 77% (23/30) opted for this treatment method when it was disclosed. There were 83 survey respondents representing all 25 eligible specialist paediatric surgery centres. Ten (12%) consultants reported routinely offering NOM, 39 (47%) offer it in select circumstances, and 34 (41%) never offer NOM. Only 25 (30%) respondents always disclose NOM as an alternative to appendicectomy, whereas 22 (27%) never do. Consultants who never disclose NOM are more likely to prefer appendicectomy over NOM compared with those who always disclose it ( p <0.001)., Conclusion: In this illustrative clinical scenario, observed and reported practice regarding disclosure of alternative treatments during the consent process do not meet GMC guidance. This risks depriving children and caregivers of a choice that they are entitled to.

Background: The surgical environment can influence the clinical outcomes of procedures and patient conditions. This retrospective study aimed to evaluate how surgical timing affects short-term outcomes in emergency laparoscopic appendectomy for acute appendicitis. Methods: A total of 647 patients with acute appendicitis who underwent emergency laparoscopic appendectomy at Chuncheon Sacred Heart Hospital between January 2018 and June 2021 were included in this study. The study cohort was divided into the following two groups based on the timing of surgery: work hours and out-of-hours (weekends, holidays, or weekday nights). Clinical outcomes were then compared between the groups. Results: Work-hour and out-of-hours appendectomies were performed in 282 and 365 patients, respectively. Baseline characteristics and types of appendicitis were similar between the groups (complicated appendicitis: 26.6% in the work-hours group versus 30.4% in the out-of-hours group, P = .288). Operation times were comparable (35.10 minutes versus 34.33 minutes, P = .620), with no cases requiring conversion to open appendectomy in either group. The overall rate of 30-day postoperative complications did not differ significantly between the groups (7.8% versus 10.4%, P = .849). The severity of postoperative complications, categorized by the modified Clavien-Dindo classification, did not show significant differences between the groups ( P = .849). In addition, the time to functional recovery was similar in both groups. Conclusions: The clinical outcomes of out-of-hours laparoscopic appendectomy were similar to those of procedures performed during working hours. Therefore, scheduling emergency surgery can be determined based on the patient's condition and the hospital's capacity to manage acute appendicitis.

Purpose: Guidelines for management and treatment of appendicitis recommends the removal of a normal-looking appendix, but the recommendations are deemed as weak because they are based on low quality evidence. We aimed to provide an overview of the recommendations from the European societies or associations of surgeons regarding the treatment of acute appendicitis and especially recommendations for the macroscopically normal-looking appendix., Methods: European surgical societies were contacted and sent an electronic questionnaire. Questions concerned if the association had a national guideline or recommended an existing one, and if they recommended a specific approach for the management of the normal-looking appendix, including who decided to remove the appendix., Results: We contacted surgical societies from 28 European countries, and 17 surgical societies (61%) responded. Two societies had a national guideline for the treatment of appendicitis and one of these addressed how to treat the normal-looking appendix. Most societies (59%) answered that the operating surgeon decided whether to remove the normal-looking appendix. Eleven societies recommended using an existing guideline (65%), four societies (24%) did not recommend a guideline, and two societies did not know., Conclusion: Only two surgical societies had a published national recommendation or guideline on the treatment of suspected appendicitis, only one had a guideline for the management of the normal-looking appendix, and most societies answered that the operating surgeon decided., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2025. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Introduction: Appendicolith can be incidentally detected on abdominal computer tomography (CT) without any signs of appendicitis. However, it has also been found to be a risk factor for failure of nonoperative management in acute appendicitis. The present retrospective study aimed to evaluate whether appendicolith predicts complicated appendicitis in patients with any appendicitis., Methods: A retrospective chart review was conducted for patients undergoing appendectomy from January 2016 to December 2018. Appendicolith was considered to be present when it was described in a CT scan., Results: Of the 267 patients, appendicolith was found in 120 cases, while there were no in 147 cases in preoperative CT scans. In the case of complicated appendicitis (gangrenous or gangrenous perforated appendicitis), appendicolith was visible in CT scans in 57.7% of the patients. Of the patients with uncomplicated appendicitis, 38.3% had appendicolith in CT scan (p = 0.002). In univariate logistic regression analysis, based on the finding of the histological specimen, appendicolith was associated with complicated appendicitis (OR: 2.12; 95% CI: 1.28-3.51; p = 0.004). When adjusting for sex, age group (age ≤50 vs. >50 years), and duration of symptoms (≤24 vs. >24 h), the odds ratio was 3.52 (95% CI: 1.88-6.58; p < 0.001)., Conclusion: Our study found that appendicolith can be considered an independent risk factor for complicated appendicitis. Therefore, in the presence of appendicolith, surgical treatment should probably be preferred over nonsurgical treatment in acute appendicitis., (© 2025 The Author(s). Published by S. Karger AG, Basel.)

Background: The usage of specific ICD-10 diagnosis codes significantly influences hospital reimbursement compared to non-specific codes. This study hypothesized that a formal orientation program for pediatric surgery residents would enhance the selection of accurate and specific diagnosis codes for acute appendicitis such as K35.30 for "Acute appendicitis with localized peritonitis" rather than K35.80 for "Unspecified acute appendicitis," thereby improving hospital reimbursement., Methods: We implemented a comprehensive orientation for pediatric surgery residents at our institution in late 2020, a component of which emphasized the importance of having specific ICD-10 diagnosis codes. We conducted a retrospective analysis of laparoscopic appendectomy billing data for pediatric patients, comparing the use of specific versus unspecified diagnosis codes and associated hospital reimbursement rates before (2020) and after (2022) the program's initiation. Patients without payment were excluded. Statistical significance was determined by a two-tailed p-value of ≤0.05., Results: Analysis of 267 patient records showed a significant increase in the use of the specific diagnosis code (K35.30) from 3.6% in 2020 to 87.5% in 2022 (p < 0.0001). Adjusted for inflation and billing changes, mean hospital reimbursement per case increased by $661 (from $4414 to $5,075, p = 0.027), totaling an additional $84,616 in 2022, just for a single subset of appendicitis patients., Conclusions: A targeted resident orientation program significantly improves the use of specific ICD-10 codes for acute appendicitis, leading to increased hospital reimbursement. Such programs represent a valuable approach for enhancing the financial outcomes of pediatric surgical care while reinforcing the importance of accurate medical documentation., Study Design: Retrospective., Level of Evidence: III., Competing Interests: Conflicts of interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The optimal method for appendix stump closure in laparoscopic appendectomy (LA) remains debated. This study aims to evaluate the impact of suture-based closure and Hem-O-lok techniques on postoperative complications following LA for uncomplicated appendicitis., Methods: A retrospective analysis was conducted on patients with uncomplicated appendicitis treated by LA from January 2019 to December 2021. These patients were categorized into two groups: the suture-based closure group (223 cases) and the Hem-O-lok group (272 cases). Propensity score matching addressed potential discrepancies between the groups. Intraoperative and postoperative parameters of both groups were then compared., Results: Post-matching, the operative duration in the suture-based group was longer than in the Hem-O-lok group (45.9 ± 9.7 min versus 42.8 ± 8.9 min, P = 0.001). The incidence of postoperative intra-abdominal abscesses and fluid collections was significantly lower in the suture-based closure group (P = 0.032). Multivariate logistic regression analysis revealed that the Hem-O-lok clamp technique [odds ratio (OR) = 5.69, 95% confidence interval (CI): 1.01-64.25, P = 0.047] was a notable risk factor for intra-abdominal abscesses and fluid collections., Conclusions: The suture-based closure technique significantly reduced the incidence of postoperative intra-abdominal abscesses and fluid collections compared with the Hem-O-lok technique in patients undergoing LA for uncomplicated appendicitis., Competing Interests: Declarations. Conflict of interest: We certify that the authors of this article have no commercial associations that might pose a confLict of interest with regard to the submitted manuscript. The authors have no relevant financial or non-fInancial interests to disclose. Ethical approval: This study was conducted with the approval of the institutional review board of Central South University Xiangya School of Medicine Affiliated Haikou Hospital. Each patient in this study was adequately informed about their potentially therapeutic regimens by clinicians. The study followed the STROBE guidelines for observational studies. Human ethics and consent to participate: Not applicable. Informed consent: Informed consent was waived owing to the retrospective nature of the study., (© 2024. Springer Nature Switzerland AG.)

Neutropenia increases the complexity of surgical decision-making in cases of acute appendicitis. In this systematic review, we discuss medical vs surgical management and timing of appendectomy in the neutropenic adult patient. We queried databases utilizing the key words "neutropenia" and "appendicitis." The search identified 999 articles of which 481 articles were reviewed after duplicates were removed. Studies with pediatric patients, single case studies, and abdominal pain in neutropenic patients not caused by appendicitis were excluded. Seven studies remained in this review accounting for 130 patients, of which 28 were diagnosed with neutropenic appendicitis, and were included for final analysis. Four of the 7 articles were case reports, demonstrating the relative paucity of literature on this subject. Studies referred to the high risk of morbidity and mortality after surgical intervention in the neutropenic population, and attempting medical management first was common but not universal, reserving appendectomy for failure of medical management. Three studies suggested medical therapy as first-line management while 2 studies suggested surgical management and 2 studies did not distinguish a precedence. Both medical and surgical management have been successfully used in treating appendicitis in neutropenic patients. In most patients, medical management was attempted first (n = 16/28) vs immediate appendectomy (n = 7/28). Appendectomy was performed when medical management failed (n = 2/28) or after correction of neutropenia (n = 1/28). Timing or performance of appendectomy was unclear in 2 patients. With the increasing use of immunosuppressive medications, broad-spectrum antibiotics, and recent data from the CODA (Comparison of Outcomes of Antibiotic Drugs and Appendectomy) trial, medical management as a first-line treatment for most patients with neutropenia and appendicitis is warranted, and identifying a protocol for such patients would be of value., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Ultrasound (US) or magnetic resonance imaging (MRI) is recommended over computed tomography (CT) as the initial imaging modality when considering a diagnosis of appendicitis in children. This reduces unnecessary radiation exposure and has excellent accuracy. We hypothesized a significant increase in US utilization and a reduction in CT utilization in hospitals across the United States., Methods: We retrospectively reviewed NSQIP-P data from 2015 to 2021 for patients <18 years undergoing appendectomy for acute appendicitis. Rates of US, CT, and MRI usage were compared between NSQIP-P hospitals and referring non-NSQIP-P hospitals., Results: Of the 115,186 children included, 66,303 (57.6%) were imaged in NSQIP-P hospitals, 37,962 (33.0%) in non-NSQIP-P hospitals, and 7947 (6.9%) in both. US alone was used in 53.3%, followed by CT alone in 25.1%, both US + CT in 16.4%, and MRI ± CT/US in 2.6%. Non-NSIQP-P hospitals used less US than NSQIP-P centers (38.6% vs 90.8%, P < 0.0001) and more CT (74.0% vs 25.4%, P < 0.0001). From 2015 to 2021, overall US utilization increased from 68.5% to 72.3% (p < 0.0001) while CT utilization remained unchanged (43.1%-43.2%, P = 0.07). US use increased in non-NSQIP-P centers (18.8%-25.7%, P < 0.0001) but not in NSQIP-P (71.7% vs 70.9%, p = 0.28), while CT alone decreased in both (NSQIP-P: 10.1%-7.7%, P < 0.0001; non-NSQIP-P: 71.0%-59.8%, P < 0.0001)., Conclusion: US and MRI remain underutilized in diagnosing pediatric appendicitis, especially in non-NSQIP-P hospitals. Trends show modest increase in US utilization; however, CT alone remains a highly used modality in non-NSQIP-P hospitals. Adopting diagnostic strategies from NSQIP-P centers could optimize diagnostic imaging in children., Level of Evidence: III., Competing Interests: Conflicts of interest The authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Pembrolizumab is a humanized monoclonal antibody IgG4 programmed cell death protein 1 antagonist, and its use in oncology has been increasing in recent years, providing durable and favorable responses and tolerable toxicity profiles in various types of cancer. We describe a case of pembrolizumab related perforated appendicitis in a patient with stage 3C malignant melanoma (MM)., Case Report: A 70-year-old male patient who had no known disease was diagnosed with MM as a result of the excision of the mass on his right shoulder. The disease stage was stage 3C (pT4aN1bM0). Subsequently, adjuvant pembrolizumab treatment was started. A few days after the fourth maintenance course, he presented to the emergency department complaining of abdominal pain, nausea and vomiting. Emergency abdominal tomography showed a significant increase in the diameter of the appendix vermiformis, peritoneal thickening and appendiceal wall defects that could be significant in terms of perforation., Management and Outcome: The mentioned finding and given the clinical presentation, was attributed to a perporating of the appendix, so the patient was hospitalized in the Department of Surgery and the patient underwent emergency appendectomy. Histological findings were consistent with appendicitis. After a day in the hospital, the abdominal pain subsided, C-reactive protein tended to decrease and the patient was discharged., Discussion: In patients who develop acute abdominal pain with or without diarrhea during immunotherapy, urgent imaging, endoscopic and clinical evaluation should be performed, and bowel perforation, although rare, should be considered as a potential complication of any immunotherapy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aim: Acute appendicitis (AA) is treated primarily surgically with histopathology being the gold standard for confirmation of appendicitis and reported rates of negative appendicectomies (NA) ranging between 3.2% and 19% worldwide and 15.9-20.6% in the UK. NA rates are frequently used to identify poor performing centers as part of a Model Health System and form an integral part of appendicitis scoring systems. This study aims to evaluate the prevalence of negative appendicectomies within our institution and critically analyze the appropriateness of its use as a quality metric and its impact on clinical practice and research., Patients and Methods: Data analysis from a prospective dataset of pediatric appendicitis patients between 2015 and 2021 in a tertiary center in the UK was performed. Detailed analysis of negative appendicectomies was performed and further stratified by two distinct age and gender groups looking at the incidence of NA and the classification of non-histologically normal appendix specimens., Results: In our series, 819 patients met inclusion criteria, 736 (89.9%) had acute appendicitis. Our overall institutional negative appendicectomy rate was 10.1% (83 patients) with the breakdown as follows: 65 histologically normal appendix (7.9%), 10 Enterobius vermicularis, 3 eosinophilic appendicitis, 2 neoplasms, 1 isolated faecolith, 1 fibrous obliteration of the lumen, and 1 peri-appendiceal inflammation., Conclusion: Our negative appendicectomy rate is below established UK pediatric NA rates. This rate ranges from 7.9% to 10.1% depending on the definition of NA utilized. A single standard pathological definition for histological acute appendicitis is required when being used as a comparative quality metric. Centers engaged in clinical research should be aware of variations in NA definitions both in scoring systems and individual centers to avoid skewing derived results., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Emergency surgery (ES) for complicated appendicitis (CA) is associated with high morbidity. Interval appendectomy (IA) decreases this rate; however, nonoperative management (NOM) is not always successful. Some patients require unplanned ES due to NOM failure (IA failure: IA-F). This study aimed to verify the benefits of IA and to evaluate the risk factors for NOM failure., Methods: Patients diagnosed with CA who underwent surgery between January 2012 and December 2021 were included in this study. We compared the surgical outcomes of the ES group with those of the IA success (IA-S) and IA-F groups. We also analyzed 14 factors that predicted NOM failure., Results: Among 302 patients, the rate of severe complications (Clavien-Dindo grade ≥ III) was significantly higher in the ES group (N = 165) than in the IA-S group (N = 102). The rates were equal between the ES (N = 165) and IA-F (N = 35) groups. NOM was successful in 110 patients and failed in 27. Lack of abscesses, comorbidities, high WBC count, and free air were independent risk factors for NOM failure., Conclusions: Considering the benefits of IA and the non-inferior surgical outcomes of IA-F compared to ES, IA is a good therapeutic strategy for CA. However, in patients exhibiting four independent risk factors for NOM failure, careful monitoring of unplanned ES is necessary., (© 2024. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Background: Surgeons are sometimes reluctant to manage uncomplicated appendicitis non-operatively. Reasons cited include the risk of recurrent appendicitis and the risk of missed appendiceal malignancy. The aim of this study was to address these uncertainties and determine the long-term efficacy of antibiotic versus operative management of appendicitis., Method: One-year follow-up of patients enrolled in the multicentre, COVID:HAREM cohort study during March-June 2020 was performed. Initial operative or non-operative management was determined on a case-by-case basis by the responsible surgeon. Outcomes were appendicectomy rate at 1-year, histology of removed appendix and predictors of unsuccessful antibiotic treatment., Results: A total of 625 patients who had non-operative management were included. Emergency appendicectomy had been performed by 1-year in 24% (149/625), with a median time to appendicectomy of 12 days [IQR 1-77] from presentation. Thirty-one patients had elective appendicectomy. Normal histology was reported in 6% of emergency procedures and 58% of elective ones. There were 7 malignancies and 3 neuroendocrine tumors identified at histology. All patients with malignant histology had ≥1 risk factors for malignancy at initial presentation. Faecolithiasis (hazard ratios (HR) 2.3, 95% confidence intervals (CI) 1.51-3.49) and a high Adult Appendicitis Score (AAS >16; HR 2.44, 95% CI 1.52-3.92) were independent risk factors for unsuccessful non-operative management., Conclusion: At 1 year, 71% of patients managed non-operatively did not undergo an appendicectomy. Recurrence of appendicitis was associated with faecolithiasis and a high AAS. Patients at higher risk for appendiceal malignancy should have targeted follow-up. These factors should be considered when counseling patients on non-operative management., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Introduction: Suspected appendicitis is the most common indication for non-obstetric surgery during pregnancy. Diagnosis and management of these patients can be challenging. Atypical clinical presentation has been described before, but the current literature consists mostly of small case series. Therefore, we conducted a large retrospective study to analyze the frequency and diagnostic accuracy of clinical signs, laboratory findings and imaging modalities in pregnant woman undergoing surgery for suspected appendicitis compared to a control group of non-pregnant women of childbearing age. We further describe intra- and postoperative findings in both groups., Methods: Data from consecutive patients who underwent appendectomy for suspected appendicitis during pregnancy were retrieved from the electronic patient database and analyzed. Preoperative clinical, laboratory and imaging findings as well as intra- and postoperative characteristics were compared between pregnant and non-pregnant women., Results: Between January 2008 and June 2023, 99 pregnant woman and 1796 non-pregnant woman between the ages of 16 and 49 underwent emergency surgery for suspected appendicitis. Pregnant women were less likely to have right lower quadrant tenderness (p = 0.002), guarding (p = 0.011) and rebound tenderness (p = 0.097). A greater percentage of pregnant women had a symptom duration of more than 24 h before presentation (p = 0.003) Abdominal ultrasound showed a reduced diagnostic accuracy in pregnant women (p = 0.004). MRI was used in eight pregnant women and showed a diagnostic accuracy of 100%. Pregnant women had a longer operating time (p = 0.006), a higher rate of open appendectomies or conversion (p < 0.001) and a longer postoperative hospital stay (3.2 days vs. 2.2 days, p < 0.001). The perforation rate was also higher in pregnant women at 16% vs. 10% (p = 0.048)., Conclusion: The diagnosis of acute appendicitis during pregnancy presents a challenge for the clinician. Our data confirm the paradigm of "atypical presentation" which should lead to an extended diagnostic workup. Ultrasound showed less diagnostic accuracy in pregnant women in our study. MRI is a useful tool to reduce uncertainty and the rate of negative appendectomies., (© 2024. The Author(s).)

Background: Congenital heart disease (CHD) care has evolved during the past decades. Advances in care have contributed to improved survival among CHD patients. Children with CHD are requiring interventions for non-CHD related medical issues that occur in the general pediatric population., Methods: A retrospective review of the Pediatric Health Information System (PHIS) database from January 1, 2004, to July 31, 2023. Discharges of patients with an admitting/principal diagnosis of appendicitis were evaluated and categorized as CHD or non-CHD., Results: A total of 319,228 patients were identified with 1,25,858(39.4%) female, 1,38,966(43.5%) white, and median age of 11[IQR:8-14] years. 708(0.2%) had CHD with 85(12%) of them having a diagnosis consistent with single-ventricle CHD (SV-CHD). In univariate analysis, CHD patients were more likely to undergo conservative treatment (n = 172(24.2%)vs n = 59,358(18.6%)) and less likely to undergo laparoscopic appendectomy (n = 483(68.2%) vs n = 2,35,324(73.8%))(p < 0.001) compared to non-CHD. After adjustment, CHD patients had increased odds of undergoing open appendectomy compared to non-CHD. CHD patients were more likely to have an ICU admission (OR:8.36(95%CI 6.35-10.00),p < 0.001) and had a 77.6%(95%CI 40.89-123.93) increase in length of stay (LOS) (p < 0.001)., Conclusion: CHD patients are more likely to have an open appendectomy than non-CHD patients. These findings suggest a distinctive pattern in the care of CHD patients compared to non-CHD. Overall, CHD patients had a more intense level of care with longer LOS and increased ICU admissions. Further work is needed to evaluate drivers of management decisions, the role of conservative treatment with antibiotics alone in the CHD population, and the potential impacts and safety of a laparoscopic approach., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Surgical site infection (SSI) is common after laparoscopic appendectomy, resulting in prolonged hospital stay and increased costs. This study examined the relationship between body composition parameters and risk of incisional SSI in patients with complicated appendicitis., Methods: We included 411 patients who underwent laparoscopic surgery for complicated appendicitis at a single institution between March 2015 and October 2023. Body composition parameters were derived from preoperative computed tomography (CT). A nomogram was constructed based on the independent predictors of incisional SSI., Results: Overall, 45 (10.9%) patients developed incisional SSI. Visceral fat area (VFA) was independently associated with risk of incisional SSI (hazard ratio 1.015, 95% confidence interval 1.010-1.020, P < 0.001). A nomogram integrating VFA and two other independent predictors (diabetes and conversion) demonstrated high discriminative (area under the curve = 0.793) and calibration abilities., Conclusions: CT-derived VFA could be a valuable predictor of incisional SSI in patients with complicated appendicitis undergoing laparoscopic surgery. A VFA-based nomogram may help in identifying patients at high risk of SSI., (© 2024. The Author(s).)

Objective: Early in the COVID-19 pandemic, many children with appendicitis and COVID-19 were initially treated non-operatively and later underwent interval appendectomy. Currently, children with both appendicitis and COVID-19 frequently undergo upfront appendectomy. The impact of this return to upfront surgical management on patient outcomes is unknown. This study compared outcomes of pediatric patients with and without COVID-19 infection undergoing appendectomy., Study Design: A retrospective cohort study of children < 21y who underwent appendectomy from 3/19/2020 to 7/31/2022 at 50 Pediatric Health Information System children's hospitals was conducted. Children with documented COVID-19 were identified. Exclusions included preoperative ventilator or supplemental oxygen dependence, and missing data. To evaluate COVID-19 positive versus COVID-19 negative patients, we used a propensity score matched on sociodemographics, comorbidities, laparoscopy, perforation, and hospital. Chi-square and Mann-Whitney U tests identified differences between groups in length of stay, postoperative drain placement, 30-day re-admission, and mechanical ventilation requirements., Results: Overall, 51,861 children of median age 11y (IQR: 8-14) underwent appendectomy, of whom 1,440 (2.3%) had COVID-19. Most were male (60.3%), White (72.1%) and non-Hispanic (61.4%). Public insurance was the most common (47.5%). We created a matched cohort of 1,360 COVID-19 positive and 1,360 COVID-19 negative children. Children with COVID-19 had shorter hospitalizations (1d, IQR: 1-4 vs. 2d, IQR: 1-5, p = 0.03), less postoperative peritoneal drain placement (2.4% vs. 4.1%, p = 0.01), and fewer 30-day readmissions (9.0% vs. 11.4%, p = 0.04). However, no difference in incidence or duration of mechanical ventilation (p > 0.05) was detected., Conclusions: Our findings suggest that upfront appendectomy for children with appendicitis and COVID-19 has similar outcomes compared to children without COVID-19., Level of Evidence: Level III., (© 2024. The Author(s).)

Purpose: Study was designed in order to evaluate the discrepancies between surgical and histological diagnosis in pediatric acute appendicitis (AA) and to compare the outcomes of laparoscopic (LA) and open appendectomies (OA)., Methods: In a retrospective observational cohort, AA patients were included under 18 years of age, operated between 2011 and 2020. Surgical diagnosis was defined by the operating surgeon. The histological findings were classified as uncomplicated and complicated AA. The LOS and complications were also statistically analyzed., Results: Altogether, 1444 patients were included. Significant strong correlation and a moderate to substantial agreement were found between the surgeon's and the histopathological findings in all appendectomy cases (weighted kappa value in OA: 0.633, LA: 0.639, total sample: 0.637). If the surgeon's diagnosis was less severe than the pathologist's, the LOS was 4 (3;7) days, whereas if the surgical diagnosis was correct, the LOS was 3 (3;5) days (p < 0.0001)., Conclusions: In contrary to the literature, our study revealed a strong correlation and moderate agreement between the intraoperative and histopathological findings regarding the severity of AA. Complicated cases are distinctly recognizable during the surgery. In case the surgeon underestimates the severity of AA, the chance of complications is higher., Level of Evidence: II., (© 2024. The Author(s).)

Background: Language preference is a contributing factor for prolonged time from symptom onset to appendectomy within pediatrics, but is poorly characterized in adults. We aimed to investigate associations between language barriers and delays in assessment and treatment for adults with acute appendicitis., Methods: In a multiethnic community, patients aged ≥18 years old who underwent appendectomy were identified between January 2017 and August 2022 at a single institution. Negative binomial regression was used to compare interval wait times to imaging, medication administration, and surgical evaluation between patients with limited English proficiency and those who are English proficient., Results: Of the 1469 patients included, 48% (n = 699) were with limited English proficiency. Average age was higher for patients with limited English proficiency (45 vs 36, P < .001). Most of them were Asian (54%) and without private insurance (65%, P < .001). Symptom duration, incidence of septic shock, and date/time of presentation to the emergency department were similar. Patients with limited English proficiency presented more frequently with gangrenous appendicitis (20% vs 15%, P = .013) but not perforated (23% vs 20%, P = .065). They experienced longer wait times for surgical evaluation (376 vs 348 min, incidence rate ratio [IRR], 1.08; P = .002) but similar times for imaging, and medications administered. After controlling for demographics, triage acuity, and hospital factors, significantly longer wait times for surgical evaluation persisted (IRR adjusted, 1.07; P = .038). There was no significant difference in hospital length-of-stay, postoperative infection, or 30-day readmission rate., Conclusion: Adult patients with limited English proficiency may experience longer wait times for surgical evaluation for acute appendicitis, but this may not result in clinically significant delays in the initiation of treatment., (Published by Elsevier Inc.)

Background: Transcolonic endoscopic appendectomy (TEA) is rapidly evolving and has been reported as a minimally invasive alternative to appendectomy. We aimed to characterize the feasibility and safety of a novel unassisted single-channel TEA., Method: We retrospectively investigated 23 patients with appendicitis or appendiceal lesions who underwent TEA from February 2016 to December 2022. We collected clinicopathological characteristics, procedure‑related parameters, and follow‑up data and analyzed the impact of previous abdominal surgery and traction technique., Results: The mean age was 56.0 years. Of the 23 patients with appendiceal lesions, fourteen patients underwent TEA and nine underwent traction-assisted TEA (T-TEA). Eight patients (34.8%) had previous abdominal surgery. The En bloc resection rate was 95.7%. The mean procedure duration was 91.1 ± 45.5 min, and the mean wound closure time was 29.4 ± 18.6 min. The wounds after endoscopic appendectomy were closed with clips (21.7%) or a combination of clip closure and endoloop reinforcement (78.3%), and the median number of clips was 7 (range, 3-15). Three patients (13.0%) experienced major adverse events, including two delayed perforations (laparoscopic surgery) and one infection (salvage endoscopic suture). During a median follow-up of 23 months, no residual or recurrent lesions were observed, and no recurrence of abdominal pain occurred. There were no significant differences between TEA and T-TEA groups and between patients with and without abdominal surgery groups in each factor., Conclusion: Unassisted single-channel TEA for patients with appendiceal lesions has favorable short- and long-term outcomes. TEA can safely and effectively treat appendiceal disease in appropriately selected cases., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Appendectomies are one of the most common pediatric surgical procedures. Limited English proficiency (LEP) may lead to disparities in health outcomes between English-proficient and LEP patients. This study assesses the association between LEP and postoperative outcomes in pediatric appendectomy., Methods: We analyzed records from the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2010 to 2023 under 18 y of age undergoing appendectomy at our institution. LEP was defined as the need for an interpreter. Primary outcomes were postoperative complications, length of stay (LOS), and postoperative emergency department (ED) visits within 30 d of discharge. Multivariable analyses were performed., Results: One thousand one hundred forty three children with appendicitis were identified, with 208 (18.2%) LEP and 935 (81.8%) English-proficient patients. LEP children were more likely to present with complicated appendicitis (42.8% versus 25.5%, P < 0.0001) and sepsis (34.1% versus 21.6%, P = 0.0003). LEP patients experience more serious (8.6% versus 3.9%, P = 0.02), overall complications (10.1% versus 5.5%, P = 0.006), and organ/surgical space site infections (8.2% versus 3.3%, P = 0.003). On multivariable analysis controlling for ethnicity and factors associated with complicated presentation, LEP was associated with increased postoperative ED visits (adjusted odds ratio [aOR] 2.64, 95% confidence interval [CI] = 1.40-4.39), but not LOS (aOR 1.86, 95% CI = 0.87-3.97) or complications (aOR 1.76, 95% CI = 0.79-4.00)., Conclusions: LEP is independently associated with increased postoperative ED visits. Higher rates of complications and longer LOS may be related to increased complicated appendicitis at presentation. The role of cultural preferences and other social determinants of health that contribute to these disparities needs more investigation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Pinworm, Enterobius vermicularis, is a common parasitic illness, particularly among children in Palestine. On rare occasions, it can cause serious consequences such as acute appendicitis, which can still present a challenging diagnosis especially in children., Case Presentation: This report describes two cases (a 9 year old male and a 11 year old female, both Palestinian children from Hebron district) of acute appendicitis referred to Queen Alia Hebron Governmental Hospital in Palestine. The clinical examination revealed a lower abdominal pain, and they were diagnosed with appendicitis. The pathological examination after appendectomy showed the presence of eggs and pinworms. Anthelminthic medication was provided, and they were followed up for 6 weeks after the operation without any incidents., Conclusion: These cases highlight the importance of considering Enterobius vermicularis infestation in children with abdominal pain, as the parasites can mimic appendicitis. Prompt recognition and cautious laparoscopic appendectomy are crucial to prevent unnecessary surgery and peritoneal contamination, with the infestation being easily treatable with anthelmintic medication., (© 2024. The Author(s).)

Purpose: Choosing the best stump closure method for laparoscopic appendectomy has been a debated issue, especially for patients with acute appendicitis. The lack of consensus in the literature and the diverse techniques available have prompted the need for a comprehensive evaluation to guide surgeons in selecting the most optimal appendiceal stump closure method., Methods: A comprehensive search was conducted on multiple databases from inception until December 2023 to find relevant studies according to eligibility criteria. The primary outcome was the incidence of total complications., Results: 25 studies with a total of 3308 patients were included in this study, overall complications did not reveal a significant advantage for any intervention (RR = 0.72, 95% CI: 0.53; 1.01), Superficial and deep infection risks were similar across all methods, Operative time was significantly longer with endoloop and Intracorporeal sutures (MD = 7.07, 95% CI: 3.28; 10.85) (MD = 26.1, 95% CI: 20.9; 31.29)., Conclusions: There are no significant differences in overall complications among closure methods. However, Intracorporeal sutures and endoloop techniques were associated with extended operative durations., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Aims: Long pre-hospital delay substantially increases the likelihood of perforated appendicitis. This study aimed to find patient-related factors affecting this delay., Methods: A survey was conducted for patients with acute appendicitis after appendectomy. The participants were asked about their path to the surgical center and socioeconomic status. Variables affecting delays and the rate of complicated appendicitis were analyzed., Results: The study included 510 patients; 157 (31%) had complicated appendicitis with a median prehospital delay of 42 h. In patients with uncomplicated appendicitis, the delay was 21 h, p  < .001. Forty-six (29%) patients with complicated appendicitis were not referred to the hospital after the first doctor's visit. The multivariate analysis discovered factors associated with long pre-hospital delay: age 40-64 years (OR 1.63 (95% CI 1.06-2.52); compared to age 18-39), age more than 64 years (OR 2.84 (95% CI 1.18-6.80); compared to age 18-39), loss of appetite (OR 2.86 (95% CI 1.64-4.98)), fever (OR 1.66 (95% CI 1.08-2.57)), non-referral by helpline nurse (OR 2.02 (95% CI 1.15-3.53)) and non-referral at first doctors visit (OR 2.16 (95% CI 1.32-3.53)). Age 40-64 years (OR 2.41 (95% CI 1.50-3.88)), age more than 64 years (OR 8.79 (95% CI 2.19-35.36)), fever (OR 1.83 (95% CI 1.15-2.89)) and non-referral at first doctors visit (OR 1.90 (95% CI 1.14-3.14)) were also risk factors for complicated appendicitis., Conclusions: Advanced age, fever and failure to suspect acute appendicitis in primary care are associated with prolonged pre-hospital delay and complicated appendicitis.

Objective: To investigate the psoriatic disease risk among patients with previous appendicitis., Methods: This study was a nationwide population-based case-control study about the association between the psoriatic disease risk among patients with a history of appendicitis in Taiwan. The study population consisted of newly diagnosed psoriatic disease with at least two outpatient visits, and the control group included those patients without psoriatic disease at the same index date. Patients with a previous diagnosis of appendicitis or who underwent appendectomy surgery prior to their psoriatic disease diagnosis were recorded. The odds ratio of psoriatic disease diagnosis in the two groups with and without a history of appendicitis were analyzed and compared., Results: A total of 48 894 individuals diagnosed with psoriatic disease were matched with 292 656 controls by age and gender. Notably, the proportion of patients with a history of appendicitis or primary appendectomy was significantly elevated among those with psoriatic disease compared with the control cohort (both p < .05). On average, the occurrence of appendicitis preceded the index date by 3.3 ± 2.3 years. Multivariate analysis revealed a heightened incidence rate of psoriatic disease in patients previously diagnosed with appendicitis, periodontal disease, Charlson comorbidity index score (CCIS) ≧1, and ill-defined intestinal infections. This association persisted after adjusting for confounding factors, such as periodontal disease, CCIS, Salmonella, and ill-defined intestinal infections. The odds ratios for psoriatic disease in individuals with a history of appendicitis, periodontal disease, CCIS ≧1, and ill-defined intestinal infections were 1.16, 1.008, 1.69, and 1.23, respectively, with corresponding 95% confidence intervals of 1.03-1.31, 1.05-1.11, 1.65-1.74, and 1.20-1.26. These findings underscore the independent association between appendicitis and subsequent development of psoriatic disease, even after adjusting for relevant comorbidities and potential confounders., Conclusion: Our research illustrates that appendicitis is associated with an increased likelihood of developing a psoriatic disease, despite several limitations. These limitations encompass variables such as dietary and smoking habits, alongside other potential confounding factors that were not fully considered. Moreover, inherent biases in utilizing national health insurance data, such as the absence of laboratory information, as well as the constraints inherent in a retrospective study design, should be acknowledged., (© 2024 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.)

Introduction: From a surgeon's perspective, appendicitis is treated with appendectomy and sometimes a normal appendix is removed. This study aimed to investigate the patients' perspectives on having surgery but not appendicitis and their involvement in treatment decisions., Methods: This study is reported according to the COnsolidated criteria for REporting Qualitative research (COREQ) guideline. Eligible participants either had a normal diagnostic laparoscopy with no resection of the appendix or a negative appendectomy confirmed by histopathology. Interviews were conducted using a semi-structured interview guide and transcribed verbatim. Data were analyzed using content analysis., Results: This study consisted of 15 interviews. Analysis of the interviews resulted in the formulation of four categories: (1) discovering the results of the histopathology report, (2) thoughts on having a normal appendix removed or left in situ, (3) the scarce use of shared decision-making, and (4) general anesthesia and the risk of a burst appendix made the participants nervous., Conclusion: The amount of information communicated to the patients before and after surgery was sparse. The participants were not aware of the histopathology results and the participants were not involved in decision-making and were generally anxious about anesthesia and a burst appendix., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Appendicitis is the commonest paediatric surgical emergency. Adult studies suggest non-operative management (NOM) may have a place in care. There have been no adequately powered randomized controlled trials in children., Objective: to determine the safety and efficacy of NOM for paediatric simple appendicitis., Methods: A non-inferiority randomized controlled trial was conducted comparing operative (OM) to NOM of SA in children aged five-15 years. Primary outcome was treatment success (no unplanned or unnecessary operation, or complication) at 30 days and 12 months, with a non-inferiority margin of 15%. (anzctr.org.au: ACTRN12616000788471)., Results: From 11 June 2016 to 30 November 2020, 222 children were randomized: 94 (42.34%) to OM and 128 (57.66%) to NOM. Non-inferiority of NOM was not demonstrated at either time point, with 45.67% of NOM patients subsequently undergoing operation. There was no significant difference in complications., Conclusions: While noninferiority was not shown, NOM was safe, with no difference in adverse outcomes between the two groups. Further research to refine the place of NOM of simple appendicitis in children is required, including nuanced patient selection, longer term evaluation, the place of choice, and the acceptability of the treatment for children and their carers., (© 2024 The Author(s). ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Purpose: TULAA combines the laparoscopic and open technique and is considered to be a safe, fast and cost-effective procedure. On the other hand, preparation is limited due to the single instrument, especially in complicated appendicitis. In this study we analyze the outcome of our TULAA patients, focusing on conversion and complication rates., Methods: We performed a retrospective study including all patients treated with TULAA in our department between 2006 and 2016. We analyzed patient data, operative data, costs, complications, and conversion rate to standard laparoscopic or open appendectomy., Results: 1275 children and adolescents were enrolled. Mean age was 10.2 years. TULAA was completed in 88% of cases. The overall mean operative time was 33 min. The overall complication rate was 5.7%. The most common complications were wound infection (2.7%), seroma (1.7%) and wound abscess (1.4%). Both the conversion rate and the complication rate were significantly higher in complicated appendicitis. Furthermore, the conversion rate is higher in overweight or obese patients., Conclusion: TULAA is a safe, quick and cost-effective treatment option for acute appendicitis in children and adolescents. The complication rate and conversion rate are significantly correlated with the degree of appendiceal inflammation and comparable other surgical procedures., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: This study aimed to assess the impact of peritoneal drainage and its type on prognosis, encompassing postoperative recovery and complications, in pediatric patients (≤ 16 years old) following appendectomy based on the grade of appendicitis., Methods: In this retrospective study, we analyzed pediatric patients (≤ 16 years old) with appendicitis who met the inclusion and exclusion criteria in our center from January 2017 to January 2024 and classified them into grade I-V based on the grade of appendicitis, with V representing the most serious cases. The patients were grouped according to drainage status and type. The main clinical outcomes included postoperative rehabilitation indexes such as time to resume a soft diet, time to remove the drain, duration of postoperative antibiotic use and length of hospitalization (LOH), as well as postoperative complications including intra-abdominal abscess (IAA), ileus and wound infection (WI), and readmission within 30 days after surgery., Results: A total of 385 pediatric patients with appendicitis were included in the study and divided into No-drainage (ND) group (n = 74), Passive drainage (PD) group (n = 246) and Active drainage (AD) group (n = 65) according to drainage status and type. Compared to the other two groups, the ND group had a significantly shorter time to resume a soft diet, duration of postoperative antibiotic use and LOH, and these differences were statistically significant. Similar findings were observed in grade I patients too (P < 0.05). In all cases examined here, the AD group had a significantly shorter time for drain removal compared to the PD group (3.04 [1-12] vs 2.74 [1-15], P = 0.049); this difference was also evident among grade I patients (2.80 [1-6] vs 2.47 [1-9], P = 0.019). Furthermore, within the same grade, only in grade IV did the AD group exhibit a shorter duration of postoperative antibiotic use compared to the PD group (4.75 [4-5] vs 8.33 [5-15], P = 0.009). Additionally, the LOH in the AD group was longer than that in the PD group (8.00 [4-13] vs 4.75 [4-5], P = 0.025). Among all cases, the ND group exhibited significantly lower incidences of overall complications and WI compared to the other two groups (P < 0.05). Additionally, the incidence of IAA in the ND group was significantly lower than that in the PD group (0% vs 5.3%, P = 0.008 < 0.0167). Furthermore, although there were no statistically significant differences in the incidence of overall complications, IAA, ileus, and WI between the PD and AD groups during grade ≥ II analysis (P > 0.05), a higher readmission rate within 30 days was observed in the PD group compared to the AD group; however, these differences were not statistically significant (P > 0.05). Moreover, multivariate analysis revealed that a higher grade of appendicitis was associated with an increased risk of overall complications and IAA as well as a longer duration of postoperative antibiotic use and LOH., Conclusion: The appendicitis grade is a crucial indicator for predicting postoperative IAA and LOH. In patients with grade I appendicitis, peritoneal drainage, even if active drainage, is not recommended; For patients with grade ≥ II appendicitis, active drainage may be more effective than passive drainage in reducing the duration of postoperative antibiotic use and LOH., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Complicated appendicitis is associated with a higher risk of postoperative complications, including adhesive bowel obstruction. The aim of this meta-analysis is to investigate the difference in rates of postoperative bowel obstruction in paediatric patients with complicated versus simple appendicitis and whether this is influenced by the surgical approach., Methods: A systematic literature search following PRISMA guidelines was conducted using MEDLINE, Embase and Cochrane Library for studies that analysed incidence of adhesive bowel obstruction in paediatric patients after appendicectomy. Studies from 1998 to 2022 were included in analysis. The study protocol was registered on PROSPERO (ID CRD42022309769)., Results: Pooled analysis of 6 studies with low risk of bias and adequate follow up periods, considering 58,962 cases of appendicectomy, revealed complex appendicitis was associated with a near two-fold increase in incidence of SBO (pooled odds ratio 2.02 (95% CI 1.35-2.69)). Interestingly, a similar pooled analysis of 10 studies, considering 62,433 cases of appendicectomy, revealed no significant difference between open and laparoscopic management of complex appendicitis (pooled odds ratio 0.93 (95% CI 0.24 to 1.62))., Conclusion: Complex appendicitis is associated with a two-fold increase in the rates of adhesive bowel obstruction. Whilst there are cosmetic advantages of a laparoscopic approach, surgical expertise should be favoured in decision making relating to surgical approach (laparoscopic versus open) as the evidence for a laparoscopic approach reducing risks of adhesive bowel obstruction is not convincing., Level of Evidence: Level II., Competing Interests: Conflicts of interest The authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Pediatric surgical care is becoming increasingly regionalized, often resulting in limited access. Interfacility transfers pose a significant financial and emotional burden to when they are potentially avoidable. Of transferred patients, we sought to identify clinical factors associated with avoidable transfers in pediatric patients with suspected appendicitis., Methods: We performed a single-center retrospective study at an academic tertiary referral children's hospital in an urban setting. We included children who underwent interfacility transfer to our center with a transfer diagnosis of appendicitis from July 1, 2021 to June 30, 2023. Encounters were designated as either an appropriate transfer (underwent appendectomy) or an avoidable transfer (did not undergo appendectomy). Encounters treated nonoperatively for complicated appendicitis were excluded. Bivariate analysis was performed using Mann-Whitney test and chi-square tests., Results: A total of 444 patients were included: 71.2% were classified as appropriate transfers and 28.8% as avoidable transfers. Patients with avoidable transfer were younger compared to those in the appropriate transfer cohort (median age 9 y, interquartile range: 7-13 versus 11 y, interquartile range: 8-14; P < 0.001). Avoidable transfers less frequently presented with the typical symptoms of fever, migratory abdominal pain, anorexia, and nausea/emesis (P = 0.005). Avoidable transfers also reported shorter symptom duration (P = 0.040) with lower median white blood cell count (P < 0.001), neutrophil percentage (P < 0.001), and C-reactive protein levels (P < 0.003). Avoidable transfers more frequently underwent repeat imaging upon arrival (42.9% versus 12.7%, P < 0.001)., Conclusions: These findings highlight the importance of clinical history in children with suspected appendicitis. Younger patients without typical symptoms of appendicitis, those with a shorter duration of symptoms, and lower serum inflammatory markers may benefit from close observation without transfer., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Surgeons may encounter a grossly normal appearing appendix in a patient with clinically suspected appendicitis. The purpose of this study is to determine the practice of pediatric surgeons in Saudi Arabia when this is encountered, and determine the reasons behind their decision making., Methods: An electronic survey was sent to all pediatric surgeons in Saudi Arabia. Data points collected included demographics, peri-operative imaging preference, and personal practice when managing an intra-operative grossly normal appendix in symptomatic children., Results: A total of 105 responses were obtained yielding a response rate of 33.8% The majority of respondents, 88 (87.1%) would remove the appendix while 13 (12.9%) would leave it in situ. The most common reason for removing the appendix was the possibility of microscopic/Endo appendicitis 71 (34.8%) while the most common reason for leaving the appendix in situ was the possible usage of the appendix for reconstructive benefits in the future 11 (50%). The overwhelming majority 87 (86.1%) felt that there were no sufficient guidelines on removal of the normal appearing appendix at the time of surgery for suspected acute appendicitis., Conclusion: The majority of pediatric surgeons in Saudi Arabia would proceed with an appendectomy when an intra-operative grossly normal appendix is seen in patients suspected to have acute appendicitis. There is a clear lack of published pediatric guidelines and large studies to guide the correct course of action., (Copyright: © Saudi Medical Journal.)

Introduction: Appendicectomy remains the standard treatment for appendicitis. There is a lack of clarity on the timeframe in which surgery should be performed to avoid unfavourable outcomes., Aim: To perform a systematic review and network meta-analysis to evaluate the impact the (1)time-of-day surgery is performed (2), time elapsed from symptom onset to hospital presentation (patient time) (3), time elapsed from hospital presentation to surgery (hospital time), and (4)time elapsed from symptom onset to surgery (total time) have on appendicectomy outcomes., Methods: A systematic review was performed as per PRISMA-NMA guidelines. The time-of-day which surgery was done was divided into day, evening and night. The other groups were divided into < 24 h, 24-48 h and > 48 h. The rate of complicated appendicitis, operative time, perforation, post-operative complications, surgical site infection (SSI), length of stay (LOS), readmission and mortality rates were analysed., Results: Sixteen studies were included with a total of 232,678 patients. The time of day at which surgery was performed had no impact on outcomes. The incidence of complicated appendicitis, post-operative complications and LOS were significantly better when the hospital time and total time were < 24 h. Readmission and mortality rates were significantly better when the hospital time was < 48 h. SSI, operative time, and the rate of perforation were comparable in all groups., Conclusion: Appendicectomy within 24 h of hospital admission is associated with improved outcomes compared to patients having surgery 24-48 and > 48 h after admission. The time-of-day which surgery is performed does not impact outcomes., (© 2024. The Author(s).)

Purpose: Surgery wait times after diagnosis of appendicitis are an important factor influencing the success of a patient's treatment. The proposed study will be a quantitative multicenter retrospective cohort design with the primary aim of assessing the difference between appendicectomy wait times between rural and urban hospitals in Western Australia and the effect of this on operative outcomes. Selected outcome measures will be examined by time from initial presentation at an emergency department to the patient being diagnosed and then time of diagnosis to surgery being performed. The secondary aim is to compare rates of negative appendicectomies between hospitals., Methods: Appendicectomy patients will be identified from operating room register by medical student data collectors; then, each respective hospital's emergency room data collection will subsequently be accessed to complete case report forms based on demographics and clinical findings, pre-operative investigations, and management and follow-up. Case report forms with > 95% completeness will be accepted for pooled analysis. The expected duration of retrospective data collection will be 8 months. This study RGS6483 has received HREC approval by the Royal Perth Hospital HREC Ethics Committee, with a waiver of consent obtained and the HREC was notified of amendments to the protocol made on April 21, 2024. Dissemination of results. Data will be collected and stored online through a secure server running the Research Electronic Data Capture (REDCap) web application. No patient-identifiable data will be entered into the system. Results will subsequently be shared via scientific journal publication and presentation at relevant meetings., (© 2024. The Author(s).)

Background: The aim of this study was to examine the association between appendectomy and advanced colorectal neoplasia (aCRN) in patients with inflammatory bowel disease (IBD)., Methods: Inflammatory bowel disease patients diagnosed in Denmark in the period 1977 to 2017 were identified from the Danish National Patient Registry. Inflammatory bowel disease patients who underwent appendectomy were matched with up to 10 IBD patients without appendectomy and followed until aCRN, death, or emigration. Absolute risks of aCRN were calculated, treating death and bowel resections as competing risks. Stratified Cox regression was used to calculate adjusted hazard ratios (aHRs) of aCRN, comparing IBD patients with appendectomy to IBD patients without appendectomy., Results: We identified 3789 IBD patients with appendectomy and 37 676 IBD patients without appendectomy. A total of 573 patients (1.4%) developed aCRN, with an absolute risk of aCRN at 20 years of 4.9% (95% confidence interval [CI], 2.9%-7.7%) for ulcerative colitis (UC) patients with appendectomy after UC diagnosis compared with 2.8% (95% CI, 2.3%-3.3%) for UC patients without appendectomy. Appendectomy after UC was associated with an increased rate of aCRN 5 to 10 years (aHR, 2.5; 95% CI, 1.1-5.5) and 10 to 20 years after appendectomy (aHR, 2.3; 95% CI, 1.0-5.5). Appendectomy prior to UC diagnosis was not associated with an increased rate of aCRN, and Crohn's disease was not associated with the rate of aCRN, regardless of timing or histological diagnosis of the appendix specimen., Conclusions: Although appendectomy may have a positive effect on the clinical course of UC, our study suggests that this may come at the expense of a higher risk of aCRN., (© The Author(s) 2023. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Non-operative management (NOM) of simple appendicitis is becoming an increasingly researched treatment option. This systematic review aims to describe the short and long-term failure rates of NOM and the complication rate of appendicectomy in children with simple appendicitis., Methods: The systematic review was registered a priori (CRD42022322149). Study inclusion criteria are: participants aged ≤ 18 years of age; groups undergoing both NOM and appendicectomy for simple appendicitis; outcomes including one or more of: NOM failure rate at 30 days or 1 year and beyond; study design: RCT or case control study. Four databases were searched and 3 reviewers determined study eligibility and data extraction. Risk of bias was assessed and meta-analysis was performed using Stata., Results: The database search identified 2731 articles, 14 studies met the inclusion criteria; 4 RCTs and 10 case controlled studies. All studies had moderate-serious risk of bias. There were no deaths in either group in any study. Meta-analysis demonstrated a 30 day failure rate of 20 % (95 % CI 11-29 %) and 11 studies reported failure rate at 1 year or beyond at 32 % (95 % CI 25-38 %). Rates of significant complications of appendicectomy was 1 % (95 % CI 0-1 %)., Conclusions: Non-operative management of simple appendicitis in children is safe, with moderate early success. The failure rate increases over time, resulting in eventual appendicectomy in a third of the children diagnosed with appendicitis. These data will enable clinicians to have an informed discussion with children and their parents about their treatment options for simple appendicitis., Level of Evidence: II., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis., Methods: A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts., Results: Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty., Conclusions: These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: When pregnant patients present with nonobstetric pathology, the physicians caring for them may be uncertain about the optimal management strategy. The aim of this guideline is to develop evidence-based recommendations for pregnant patients presenting with common surgical pathologies including appendicitis, biliary disease, and inflammatory bowel disease (IBD)., Methods: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee convened a working group to address these issues. The group generated five key questions and completed a systematic review and meta-analysis of the literature. An expert panel then met to form evidence-based recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Expert opinion was utilized when the available evidence was deemed insufficient., Results: The expert panel agreed on ten recommendations addressing the management of appendicitis, biliary disease, and IBD during pregnancy., Conclusions: Conditional recommendations were made in favor of appendectomy over nonoperative treatment of appendicitis, laparoscopic appendectomy over open appendectomy, and laparoscopic cholecystectomy over nonoperative treatment of biliary disease and acute cholecystitis specifically. Based on expert opinion, the panel also suggested either operative or nonoperative treatment of biliary diseases other than acute cholecystitis in the third trimester, endoscopic retrograde cholangiopancreatography rather than common bile duct exploration for symptomatic choledocholithiasis, applying the same criteria for emergent surgical intervention in pregnant and non-pregnant IBD patients, utilizing an open rather than minimally invasive approach for pregnant patients requiring emergent surgical treatment of IBD, and managing pregnant patients with active IBD flares in a multidisciplinary fashion at centers with IBD expertise., (© 2024. The Author(s).)

Background: Controversies remain on the diagnostic strategy in suspected AA, considering the different settings worldwide., Material and Methods: A prospective observational international multicentric study including patients operated for suspected AA with a definitive histopathological analysis was conducted. Three groups were analyzed: (1) No radiology; (2) Ultrasound, and (3) Computed tomography. The aim was to analyze the performance of three diagnostic schemes., Results: Three thousand and one hundred twenty three patients were enrolled; 899 in the no radiology group, 1490 in the US group, and 734 in the CT group. The sex ratio was in favor of males (p < 0.001). The mean age was lower in the no radiology group (24 years) compared to 28 and 38 years in US and CT-scan groups, respectively (p < 0.001). Overall, the negative appendectomy rate 3.8%: no radiology group (5.1%) versus US (2.9%) and CT-scan (4.1%) (p < 0.001). The sensitivity and specificity analysis showed the best balance in clinical evaluation + score + US. These data reach the best results in those patients with an equivocal Alvarado score (4-6). Inverse probability weighting (IPW), showed as the use of ultrasound, is significantly associated with an increased probability of formulating the correct diagnosis (p 0.004). In the case of a CT scan, this association appears weaker (p 0.08)., Conclusion: The association of clinical scores and ultrasound seems the best strategy to reach a correct preoperative diagnosis in patients with clinical suspicion of AA, even in those population subgroups where the clinical score may have an equivocal result. This strategy can be especially useful in low-resource settings worldwide. CT-scan association may improve the detection of patients who may potentially be submitted to conservative treatment., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Purpose: Appendicitis is one of the most common acute surgical conditions globally, and hence appendectomy is a common procedure performed around the clock in many hospitals. The aim of the current study was to determine whether acute appendectomy due to acute appendicitis performed during day, evening, and night was equally safe, in terms of postoperative complications, readmission, death, and length of hospital stay., Methods: A retrospective single-center cohort study, using a local quality register of all consecutive acute appendectomies performed at the Department of Surgery, Södersjukhuset, Stockholm, Sweden. During the study period from December 2015 to August 2022, 4950 patients were included. Risk of complications, readmission, and death were determined using multivariable logistic regression models. Association with length of hospital stay was determined using multiple linear regression., Results: There was no significant difference in the associated risk of postoperative complications, readmission within 30 days, or death, regardless of when appendectomy was performed. Using daytime surgery as reference, hospital stay was shortened by 4.21 h (P = 0.008) for evening surgery and by 6.71 h (P < 0.001) for nightly surgery., Conclusion: Risks of postoperative complications, readmission, and death were similar regardless of when acute appendectomy was performed. However, surgery during evening and night was associated with shortened hospital stay, as compared to daytime surgery., (© 2023. The Author(s).)

Background: The emergence of the COVID-19 pandemic in December 2019 initiated a global transformation in healthcare practices, particularly with respect to hospital management. PCR testing mandates for medical treatment seekers were introduced to mitigate virus transmission., Aims: This study examines the impact of these changes on the management of patients with appendicitis., Methods: We conducted a retrospective analysis of medical records for 748 patients diagnosed with appendicitis who underwent surgery at a tertiary care hospital during two distinct periods, the pre-pandemic year 2019 and the post-pandemic year 2021. Patient demographics, clinical characteristics, laboratory data, surgical outcomes, and hospital stay duration were assessed., Results: While no significant differences were observed in the general characteristics of patients between the two groups, the time from hospital visit to operation increased significantly during the pandemic. Unexpectedly, delayed surgical intervention was associated with shorter hospital stays but did not directly impact complication rates. There was no discernible variation in the type of surgery or surgical timing based on symptom onset. The pandemic also prompted an increase in appendicitis cases, potentially related to coronavirus protein expression within the appendix., Conclusions: The COVID-19 pandemic has reshaped the landscape of appendicitis management. This study underscores the complex interplay of factors, including changes in hospital protocols, patient concerns, and surgical timing. Further research is needed to explore the potential link between COVID-19 and appendicitis. These insights are valuable for informing healthcare practices during and beyond the pandemic., (© 2024. The Author(s).)

Introduction: Immediate complications of appendicitis are common, but the prevalence of long-term complications is uncertain., Methods: We studied all publicly-insured children in the US with uncomplicated or complicated appendicitis in 2018-2019 using administrative claims. The main outcome was late hospital care defined as hospitalization or abdominal procedure within 180 d of an appendicitis discharge, excluding interval appendectomies. Time to late hospital care was evaluated using Cox regression. We evaluated health-care expenditures arising from appendicitis episodes., Results: Among 95,942 children with appendicitis, 5727 (6.0%) had late hospital care, with 5062 requiring rehospitalization and 2012 (2.1%) surgery. The median time to late hospital care was 10 d (interquartile range 4-33). Age under 5 y (compared with >14 y, hazard ratio [HR] 1.88, 95% confidence interval [CI] 1.70-2.08), complex chronic conditions (HR 2.35, 95% CI 2.13-2.59), and complicated appendicitis (HR 2.81, 95% CI 2.67, 2.96) were each associated with time to late hospital care. Expenditures over 180 d were a median $6553 and $19,589 respectively in those requiring no late hospital care versus those requiring it (P < 0.001)., Conclusions: Late hospital care is uncommon in pediatric appendicitis but is costly. Prevention efforts should be targeted to the youngest, most complex children, and those with complicated appendicitis at presentation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Endometriosis is a common condition affecting 5 to 10% of women of childbearing age. The true incidence of endometriosis of the appendix is currently unknown. Since symptoms often overlap with those of acute appendicitis, endometriosis of the appendix presents a diagnostic challenge in the emergency department. This large retrospective study investigates the incidence and perioperative clinical, radiologic, and laboratory findings, as well as possible differences between patients with and without endometriosis., Methods: Data from consecutive patients who underwent appendectomy for suspected appendicitis without a history of endometriosis were analyzed. Perioperative clinical, laboratory, perioperative, and histopathologic findings were compared between women with and without endometriosis., Results: Between January 2008 and June 2023, 2484 consecutive patients without a history of endometriosis underwent urgent appendectomy for suspected appendicitis. Endometriosis was detected on histopathologic examination in 17 (0.7%) patients. Signs of appendicitis were found less frequently on ultrasound in the endometriosis group compared to the non-endometriosis group (23.4% vs. 61.5%; p = 0.002; OR = 0.193; 95% CI 0.063-0.593). There were no differences in physical examination findings, duration of symptoms, degree of inflammation, surgical outcomes, or complication rates., Conclusion: The incidence of endometriosis of the appendix in patients undergoing appendectomy for suspected appendicitis was higher than suggested by data from autopsy series and populations with biopsy-proven endometriosis. Patients with endometriosis of the appendix were less likely to have a positive ultrasound finding, but perioperative and histopathologic findings and severity of inflammation did not differ from patients without endometriosis, presenting diagnostic challenges for clinicians., (© 2024. The Author(s).)

While consensus on single-incision laparoscopic appendectomy (SILA) for acute appendicitis is lacking, our meta-analysis evaluated the safety and efficacy of SILA compared to conventional three-port laparoscopic appendectomy (CTLA). A computer-based search was conducted in the China National Knowledge Infrastructure (CNKI), VIP, Wanfang, China Biological Medicine (CBM), PubMed, Embase, and Cochrane Library databases to identify randomized controlled trials (RCTs) comparing SILA with CTLA groups. Meta-analysis was performed using RevMan 5.3 software. A total of 26 RCTs were included. The meta-analysis results indicated that, compared to the CTLA group, the SILA group had a longer operation time [MD = 7.97, 95 % CI (5.84, 10.10), P < 0.00001], and a higher rate of conversion to open surgery [RR = 2.60, 95 % CI (1.27, 5.31), P = 0.009], but had a shorter time to return to normal activities [MD = -0.76, 95 % CI (-1.15, -0.37), P = 0.0001]. Additionally, the SILA group had higher satisfaction scores [SMD = 1.21, 95 % CI (0.75, 1.68), P < 0.00001] and cosmetic scores [SMD = 0.68, 95 % CI (0.45, 0.90), P < 0.00001]. There was no significant difference between the two groups in terms of pain scores at 24 h postoperatively [MD = -0.21, 95 % CI (-0.56, 0.14), P = 0.25], the incidence of wound infection [RR = 1.13, 95 % CI (0.74, 1.73), P = 0.58], or the overall complication rate [RR = 0.86, 95 % CI (0.66, 1.12), P = 0.27]. SILA is a safe and effective surgical approach that allows patients to recover to normal activities earlier, particularly for patients with a strong demand for better cosmetic outcomes. However, the quality of some RCTs in this meta-analysis is low, and further verification is needed through future high-quality RCTs., Competing Interests: Declaration of competing interest The authors have no conflicts of interest that are relevant to the content of this article to declare., (Copyright © 2024 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

The aim of the study was to evaluate the impact of the COVID-19 pandemic on the number of patients presenting to the emergency room with acute appendicitis and subsequent results of surgical treatment. Our single center retrospective study was conducted in Sestre milosrdnice University Hospital Center, Zagreb, Croatia. We analyzed data on the patients diagnosed with acute appendicitis, their duration of symptoms, length of hospital stay, histopathologic diagnosis, and operative techniques, recorded from September 1, 2019 to October 17, 2020. The results showed a statistically significant increase in the ratio of open laparotomies (p=0.006) and ratio of perforated appendicitis (p=0.047) during the COVID-19 pandemic in relation to the pre-pandemic period. The time between symptom onset and hospitalization, measured in days, did not demonstrate a statistically significant increase (p=0.379), and minor increase in the postoperative length of stay was not statistically significant either (p=0.879)., (Sestre Milosrdnice University Hospital.)

Background: Polymeric clips are easy to apply, but whether they present more advantages than endoloops is unclear. This single-center, open-label, randomized controlled trial study was conducted to compare the advantages of using a polymeric clip versus an endoloop in terms of the surgical time., Methods: Adult patients who were diagnosed with acute appendicitis without perforation on preoperative abdominal computed tomography and underwent laparoscopic appendectomy between August 6, 2019, and December 26, 2022, were included. Single-blinded randomization was performed in a 1:1 ratio between the endoloop and polymeric clip groups. The primary endpoint was the difference in surgery time between the polymeric clip and endoloop groups. The secondary endpoints were the difference in the application time of each instrument, difference in operation and anesthesia fees, as well as the frequency of complications., Results: The completed trial included 104 and 103 patients in the polymeric clip and endoloop groups, respectively. The median surgery time with a polymeric clip was shorter than that with an endoloop; however, the difference was not significant (18 min 56 s vs 19 min 49 s, p = 0.426). Interestingly, the median time from applying the instrument to appendiceal cutting in the polymeric clip group was significantly shorter than that in the endoloop group (49.0 s vs 84.5 s, p < 0.001). No significant difference was observed between the two groups in terms of surgical (p = 0.120) and anesthetic (p = 0.719) costs, as well as the total number of postoperative complications (p > 0.999)., Conclusion: A polymeric clip is a safe instrument that can reduce the time from applying the instrument to appendiceal cutting, although it does not affect the overall surgical time and operation fee when performing laparoscopic appendectomy for uncomplicated appendicitis., Trial Registration: KCT0004154., (© 2023. The Author(s).)