Original Paper
Dig Surg
DOI: 10.1159/000477269
Trends in the Management of Acute
Appendicitis in a Single-Center Quality
Register Cohort of 5,614 Patients
Martin J.A. Dahlberg Emil H.A. Pieniowski Lennart Å.S. Boström
Department of Surgery, Clinical Science and Education, Stockholm South General Hospital (Södersjukhuset),
Karolinska Institute, Stockholm, Sweden
Keywords
Acute appendicitis · Incidence · Imaging · Appendectomy ·
Laparoscopy
Abstract
Acute appendicitis is one of the most common reasons for
emergency surgery. At Stockholm South General Hospital,
information on all patients – 15 years or older – undergoing
surgery for acute appendicitis is included in a quality regis-
ter. Data on surgical method, preoperative imaging, hospi-
tal stay, intraoperative findings, and 30-day complications
were recorded for each patient. From January 2004 to
December 2014, 5,614 consecutive patients were regis-
tered. The percentage of patients examined with preopera-
tive imaging increased from 30% in 2004 to 93% in 2014.
The use of laparoscopic appendectomy increased from 6 to
79%. Negative appendectomies decreased from 7.5–10 to
1.7%. The mean perforation rate was 28.6%. Some form of
postoperative complication occurred in 6.6% of those on
whom laparoscopy was performed and 10.5% of those who
underwent an open surgery, with a significant difference (p
< 0.001) in the rate of surgical site infections (surgical site
infections, higher in open cases) but with no difference in
the number of deep postoperative abscesses. The overall
hospital stay decreased from 2004 to 2014 for perforated
and non-perforated appendicitis. The overall 30-day mor-
tality rate was 0.12%. Changes in preoperative imaging and
© 2017 S. Karger AG, Basel
E-Mail karger@karger.com
www.karger.com/dsu
Received: December 12, 2016
Accepted: May 2, 2017
Published online: June 24, 2017
treatment strategy for appendicitis during this period re-
sulted in a lower rate of negative appendectomies with ac-
ceptable complication rates and shortened hospital stay.
© 2017 S. Karger AG, Basel
Introduction
Acute appendicitis is one of the most common acute
abdominal conditions with a lifetime incidence of 7–9%
[1]. Because appendicitis is such a common occurrence,
even minor improvements made in practice, which affect
hospital stay and complication rates, have the potential to
significantly decrease costs to the patient and hospital.
The standard treatment for acute appendicitis in the past
century has been surgical removal of the appendix, but
there is still some debate whether open appendectomy
(OA) or laparoscopic appendectomy (LA) is the prefera-
ble surgical approach. More recently, some data suggest
that medical treatment can suffice in uncomplicated cas-
es [2].
When comparing surgical techniques, systematic re-
views and meta-analyses show some benefits with each of
the 2 techniques [3, 4]. The laparoscopic approach was
most commonly found to decrease the number of super-
ficial surgical site infections (SSIs), and therefore consid-
ered to be a preferable approach with respect to postop-
erative pain, length of hospital stay, and time to return to
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Martin Dahlberg
Department of Surgery, Clinical Science, and Education
University Library Utrecht
Stockholm South General Hospital (Södersjukhuset)
Södersjukhuset, SE–11883 Stockholm (Sweden)
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E-Mail martin.dahlberg @ sodersjukhuset.se
work. The open approach has been found to have a short-
er duration of surgery and lower risk of intra-abdominal
abscess formation [3–7]. Reported perforation rates vary
in the range 12–29% and several prior studies have not
been able to show that a more proactive management de-
creases the perforation rate [8–10]. If the timing of sur-
gery is less important than previously perceived, the time
spent with imaging studies could improve care by possi-
bly avoiding negative exploratory surgery, which is asso-
ciated with the occurrence of significant complications
and even increased mortality [11, 12]. However, the opti-
mal use of imaging in acute appendicitis is still not clear,
and using only negative appendectomies as a measure of
quality is not satisfactory [13]. Some authors promote im-
aging only in selected cases, using scoring systems to
stratify patients where imaging is not necessary due to
low yield [14], whereas others have shown a decrease in
negative appendectomies with the use of extensive preop-
erative imaging [15–18].
Stockholm South General Hospital (Södersjukhuset)
in Sweden provides emergency medical care to a catch-
ment area of approximately 500,000 inhabitants. Since
2004, patients who underwent acute appendectomy are
registered into a local database. Between 2004 and 2014,
some changes in the management of acute appendicitis
have occurred at this institution. An increased use of
laparoscopy, preoperative ultrasound and/or CT, and
changes in antibiotic regimens and postoperative mo-
bilization could contribute to changing outcomes.
Quality indicators for appendicitis care have been pub-
lished as regional care programs [19], and include the
number of negative appendectomies, a short preopera-
tive duration, rates of postoperative complications such
as SSI and small bowel obstruction (SBO), and readmis-
sion rates. Our register provides an opportunity to ob-
serve the implications of changes in treatment strate-
gies. The aim of this study was to analyze data from the
register and to describe trends or significant changes in
preoperative imaging, surgical approach, and postop-
erative complications that existed during the period
2004–2014. An additional goal was to describe current
practices and results relevant to a general hospital pop-
ulation.
Methods
Data Collection
Included in this retrospective cohort study with prospective
data collection were all patients 15 years or older, who under-
went acute appendectomy at the Stockholm South General Hos-
2 Dig Surg
DOI: 10.1159/000477269
pital from January 1, 2004, through December 31, 2014. Data
concerning the operation were transferred automatically from
the department surgical planning software (Orbit 4, Evry) to a
database. A retrospective review of each patient’s electronic
medical record (Melior, January 1, 2004–October 31, 2011,
Siemens Health Services; Take Care November 1, 2011–December
31, 2014, CompuGroup Medical) was then performed according
to a standardized protocol. This review was carried out no soon-
er than 30 days postoperatively. Gender, age, length of hospi-
tal stay (in days), surgical approach, appendicitis or normal ap-
pendix (and if the latter, other diagnoses), perforation or not,
30-day complication rates and reoperation rates, and 30-day
mortality rates were recorded. Where hospital stay exceeded
10 days it was collected in a 10+ days’ category. The retrospec-
tive review was performed by 1 of 4 different surgeons or surgi-
cal residents.
Incomplete data were found in 0.6% of cases. In cases with in-
complete data, the available data were used if possible. Inhabitant
data from the Swedish population register between 2006 and 2013
were available for catchment area and received from Statistiska
Centralbyrån (SCB, Statistics Sweden) for the calculation of age-
specific incidences.
Definition of the Diagnosis and Surgical Methods
Appendicitis (appendicitis vs. normal appendix) was diag-
nosed with the help of macroscopic examination performed by the
individual surgeon during surgery. During the period of the study,
only when the diagnosis was unclear, the appendix was sent to the
pathologist for microscopic examination and pathological-ana-
tomical diagnosis (PAD); on average, 43% cases with PAD were
detected. The number of negative appendectomies was estimated
here as the (i) number of negative pathologic specimens, (ii) and
cases without microscopic diagnosis where the operating surgeon
determined the appendix as noninflamed by macroscopic exami-
nation. Perforated appendicitis was determined macroscopically
by the operating surgeon. OA was performed with a muscle-split-
ting (McBurney) incision. Conversion from laparoscopic to open
surgery was not recorded in the register.
Definitions of Complications
Complications were assessed by the reviewing surgeon accord-
ing to the following guidelines:
• Hematoma: requiring action (additional hemoglobin testing,
reoperation, or radiology). Obvious superficial hematomas re-
quiring no further action were not included.
• SBO: verified by radiology and requiring Gastrografin® chal-
lenge (or similar) and/or surgery.
• Postoperative paralytic ileus: postoperative course longer than
expected with radiologic or clinical signs of paralytic ileus.
• Wound infection: requiring prolonged or additional antibiot-
ics, or wound debridement.
• Intra-abdominal abscess: verified by radiology, but not neces-
sarily amenable to drainage.
• Other complications: judged on a case-to-case basis (e.g., uri-
nary tract infection, wound dehiscence).
Statistical Analyses
Differences in the number of complications between groups
were tested with the 2-sided Fisher’s exact test and ORs were re-
ported with 95% CIs. Hospital stay distributions were compared
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 800
Male
Female

600

Number of cases
400

200
1 female
0 males

15–19 20–29 30–39 40–49 50–59 60–69 70–79 80–89 90–99 100–109
a Age, years

100 Fraction of female patients

Fraction of cases, %

Perforations
75

50 50%

Fig. 1. a Age distribution of appendectomy 25

cases. Dashed lines represent males and
solid lines, females. b Fraction of female
15–19 20–29 30–39 40–49 50–59 60–69 70–79 80–89 90–99 100–109
(dotted) cases and cases with perforated
appendicitis (solid) averaged over 2004– b Age, years
2014.

with the 2-sided Mann-Whitney U test. Time trends (assumed
monotonic) were tested with the 2-sided Mann-Kendall test and
linear regression. A linear model was fitted to the perforation fre-
quency data and incidence data and the adjusted R2 and F-statistic
p values were reported. Standard error of the mean was calculated
for age-specific incidences and differences between men and wom-
en were tested with the 2-sided Student t test. Statistical analyses
were done with R (version 3.2.4).
Results
Age, Gender, and Perforations
Between January 2004 and December 2014, a total of
5,614 patients were included in the register. The age dis-
tribution of the patients is presented in Figure 1a. In all,
males were slightly overrepresented (52.7%). From the
fifth decade of life and on, women were overrepresented,
but on the basis of age category this difference did not
reach significance.
Age-specific appendicitis incidence averaged over the
years 2006–2013 (where detailed population registry data
were available) is shown in Figure 2. A slight but signifi-
cant increase in the appendicitis incidence over time,
+4.1  ± 0.4 cases per 100,000 inhabitants per year (p <
0.001, R2 = 0.93), was found. The mean incidence was
100 ± 4 (SEM) per 100,000 inhabitants per year, which
was similar to the data available from the Swedish na-
tional registries for 2006–2009 [20].
The mean perforation rate was 28.6% and the inci-
dence rate was 28 cases per 100,000 inhabitants per year
respectively. The fraction of appendicitis with perfora-
tion decreased slightly during the study (p < 0.02). Tak-
en as the fraction of total cases operated (including neg-
ative appendectomies, tumors, and other diagnoses),
perforated appendicitis was found in 26.3% of patients,
with no significant change during the study. Risk of per-
foration increased significantly with age (p < 0.001;
Fig.  1b) from about 20% in the youngest to >50% for
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Stockholm Appendectomy Cohort Dig Surg 3

DOI: 10.1159/000477269
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200
Incidence/100,000/year
150
100
50
Fig. 2. Age-specific incidence of appendici-
tis (cases per 100,000 inhabitants per year)
for males (dashed line) and females (solid
line). Error bars are SEM with respect to
year.
patients in their 80s. These data are similar to that in
previous reports (see e.g., [21]), but perforation rates
were slightly higher during the first years of the study
than others have reported, and within the reported rates
later in the study.
Preoperative Imaging
The use of preoperative imaging (abdominal ultra-
sound or CT) increased from 30% in 2004 to 93% in 2014
(Fig. 3b). Ultrasound and CT were both used in 6–7% of
patients in 2013–2014. CT investigations decreased in the
2 last years of the time period with a rise in ultrasound
utilization, with ultrasound being the most common
technique used before appendectomy (51% in 2014 as
compared with CT at 48%). No policy changes were is-
sued regarding the use of imaging, but ultrasound per-
formed by 24-h radiologists increased.
Operation
As the laparoscopic approach was broadly introduced
in 2011, we saw a reversal of the most commonly used
technique for appendectomy (Fig. 3a). LA was used only
in 6% of cases in 2004, rising to 79% in 2014. OA started
at 90% in 2004 and decreased to 20% in 2014. Midline in-
cisions were the final incision used in 3.3% of cases. Be-
cause the subgroup with midline incisions was relatively
small and generally had a more complicated postopera-
tive course, we have excluded this group in the compari-
sons between the main techniques OA and LA. Parame-
dian incisions were used more sparingly (13 cases) and
were similarly excluded from further analysis and discus-
sion. Comparing OA and LA, we observed longer opera-
4 Dig Surg
DOI: 10.1159/000477269
Male
Female
0
15–19 20–29 30–39 40–49 50–59 60–69 70–79 80–89 90+
Age, years
tive times with the laparoscopic technique (Fig.  4).
Mean (median) operative times were 59.6 (56) and 49.4
(42) min for LA and OA, respectively. However, the mean
time used for LA decreased from 74 to 55 min from 2004
to 2014 (inset in Fig. 4).
The proportion of negative appendectomies was 7.5%
in 2004, was maximum at 10.9% in 2007, and reduced to
1.7% in 2014 (Fig. 3c). In the cases of clinically suspected
appendicitis where specimens were sent to the patholo-
gist, a mean (per year) of 94% (range 85–97%) was classi-
fied as appendicitis. Where appendicitis was not suspect-
ed perioperatively, but appendectomy was still performed,
the pathologist described appendicitis in 16% of speci-
mens (range 0–46%). During 2012–2014, these figures
were >94% (true positives) and 0% (false negatives) re-
spectively. These data suggest that the macroscopic ex-
amination by the surgeon gives a reasonable agreement
with PAD. Improved characteristics at the end of the
study are probably influenced by knowledge of the imag-
ing results.
Postoperative Complications
Some form of complication occurred in 6.6% and
10.5% (p < 0.001) in LA and OA, respectively, and pa-
tients were separated into cases with and without perfora-
tion (Table 1), the latter including patients with other di-
agnoses. Patients with perforated appendicitis were more
likely to experience paralytic ileus or SBO, or an abscess
at the cecum or pouch of Douglas, regardless of the surgi-
cal technique (OA or LA) used. SSIs were more likely to
occur in OA cases than in LA cases. Importantly, SSI in
laparoscopic cases was not significantly different between
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patients with or without perforated appendicitis. There
was no difference in the occurrence of deep abscesses
comparing OA to LA in either the perforated or non-per- LA Midline
100
forated appendicitis groups. Urinary retention represent- OA Paramedian
ed 36% of complications designated “other” and was
much more common than any other complication in that 75
category. Urinary retention rates were similar in all
groups except slightly more common in OA for non-per-

Cases, %
forated cases, OR 0.5 (0.2–1.0, p = 0.044). Patients with a 50
macroscopically normal appendix had complications in
12% of cases (3.1% SSI, 1.4% hematoma/bleeding, 1%
25
pneumonia), similar (p = 0.49) to what we found for OA
of all appendectomies.
In 1.8% of cases, reoperation within 30 days was re- 0
a
quired (ranging between 1.3% and 2.8% in the years of this
study). The risk of reoperation was approximately 3 times
higher in the event of perforated appendicitis (1.3 vs. 3.2%). CT and/or US US CT

100 No imaging CT and US

Hospital Stay
Hospital stay for 3-year increments (beginning, mid-
dle, and end of the study) is shown in Figure 5. Cases with 75
perforation and without perforation are presented sepa-
rately because they a priori represent different hospitaliza-
Cases, %

tion patterns. Overall, hospital stay was shortened from 50

2004 to 2014, both for those with perforated appendicitis
and for those with non-perforated appendicitis. In non-
perforated cases, there was a shift from a most common 25
hospital stay of 2 days to 1 day, with median (mean) de-
creasing from 2 to 1.5 days (3.3–2.0). In perforated cases,
0
the median (mean) was decreased from 4 to 3 days (5.6– b
3.6), and the most common number of days at the hospital
decreased from 5 days or more in 2004 to 3 days in 2014. Perforations Negative appendectomies
The distributions of hospital stay were statistically signifi- 40
cantly changed (p < 0.001) between 2004 and 2014. Mean
hospital stays decreased significantly in the perforated
Cases, %

group but not in the non-perforated group, reflecting sen- 20

sitivity to a small number of patients where complications

led to prolonged stay.
0

Mortality and Malignancy

04

05

06

07

08

09

10

11

12

13

14

c
20

20

20

20

20

20

20

20

20

20

20

Tumors of the appendix were found in 54 cases (1%).

Seven patients (0.12%) died within 30 days of app-
endectomy. Their mean and median age was 81 years
(range 62–93). In 2 of these cases signs of advanced ma-
lignancy were found at the time of operation. The
causes of death in the other cases were aspiration pneu-
monia (2), congestive heart failure (1), pulmonary em-
bolism (1), and unknown (1). Perforations were over-
represented in this group, with perforated appendicitis
in 4 out of the 7.
Fig. 3. Development from 2004 to 2014 of the surgical technique
(a). OA, open appendectomy; LA, laparoscopic appendectomy,
midline, or paramedian incisions. b Preoperative investigations.
CT, US, ultrasound. c Fraction of cases with perforation (with lin-
ear approximation and 95% CI) and negative appendectomies.
Negative appendectomies are defined as cases with negative PAD +
cases without microscopic diagnosis where appendix was deemed
noninflamed by macroscopic examination.
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Stockholm Appendectomy Cohort Dig Surg 5

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0.20
0.15
Fraction of cases
0.10
0.05
Fig. 4. Distributions of the duration of sur-
gery for OA (open appendectomy, dashed
line) and LA (laparoscopic appendectomy,
solid line). Inset shows the mean durations
of surgery by year for OA (dashed) and LA
(solid), respectively.
Discussion
This cohort study shows outcomes and practice chang-
es over an 11-year period with surgical results similar to
those observed in previous cohorts [8, 10, 16, 18, 22–24],
with some exceptions outlined and discussed below. Ear-
lier concerns about increased risk of deep abscesses with
LA as compared to OA [4] could not be supported with
our data, where no difference in this regard was found in
either perforated or non-perforated appendicitis. This
finding is not unique to our study [25] but is disputed by
the highest quality randomized controlled study data [3].
Complication rates in our study were overall similar to
those of the previous work. The risk of SSI in the group
who underwent LA compared to OA was similar with OR
0.3 (0.1–0.4) to data in a recent systematic review with OR
0.43 (0.34–0.54) [4]. Higher perforation rates among the
elderly, similar to our results, were also found previously
[8, 26]. These data, which are in agreement with prior
studies [27], suggest that mortality from surgically treated
appendicitis is primarily a problem among the elderly,
where the incidence of appendicitis is lower, while that of
comorbid conditions is higher.
During our study period, there was a significant shift
in the preferred surgical approach toward LA. Simultane-
ous changes toward laparoscopic techniques in other ar-
eas of surgery at our institution (e.g., hernia repair,
colorectal surgery, and urology) likely influenced institu-
tional support for laparoscopy, as did increased technical
skill in teaching laparoscopy with more senior surgeons
comfortable with the techniques. LA had a longer mean
6 Dig Surg
DOI: 10.1159/000477269
Open Laparoscopic
Mean time , min
70
65
Laparoscopic 60
55
50 Open
45
2004 2006 2008 2010 2012 2014
Year
0
0 50 100 150 200 250
Time, min
duration of surgery by about 10 min compared to the
open procedure, matching the finding of the previous
work [4]. We also observed, as expected when introduc-
ing surgical techniques, a decreasing duration of LA with
time. This probably reflects both the individual learning
curve for surgeons and nursing staff, and routine use of
laparoscopic stapling devices (which was the dominant
technique by the end of our study). Conversely, mean
times for OA increased in the latter part of the study pe-
riod. This probably reflects that more complicated cases,
where conversion from LA to OA was deemed necessary,
were then a larger proportion of the OA cases, but data
on conversion rates were not available to confirm this hy-
pothesis.
Simultaneously with laparoscopy becoming the pre-
ferred technique, the number of negative appendectomies
decreased significantly. Because our registry only deals
with patients undergoing appendectomy, patients under-
going open or laparoscopic exploration without periop-
erative findings of appendicitis will lead to bias in the neg-
ative appendectomy rate. In OA, the recommendation
was to remove the appendix (negative appendectomy),
which would include the patient in the registry. With the
laparoscopic approach, other conditions are easier to di-
agnose, and appendectomy is not always performed (ap-
pendectomy was not recommended when a normal ap-
pendix was found during laparoscopic exploration in local
protocols), thus excluding the case from the registry.
We believe that the main reason for decreased negative
appendectomy is the increased use of preoperative imag-
ing (CT and/or ultrasound), but cannot show this caus-
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Table 1. Complications of appendectomy averaged over an entire cohort. OR with 95% CI from Fisher’s exact test for pairwise com-
parisons

Complication Open appendectomy Laparoscopic appendectomy

perforated, n (%) non-perforated, perforated, n (%) non-perforated,
n (%) n (%)

Hematoma 8 (0.8) 16 (0.6) 1 (0.3) 5 (0.4)

Ileus 27 (2.6) 9 (0.3) 8 (2.6) 2 (0.2)
SBO 15 (1.4) 9 (0.3) 6 (1.9) 3 (0.2)
SSI 85 (8.1) 65 (2.4) 4 (1.3) 13 (1.0)
Cecal abscess 40 (3.8) 12 (0.4) 17 (5.4) 10 (0.8)
Douglas pouch abscess 18 (1.7) 9 (0.3) 7 (2.2) 3 (0.2)
Urinary retention 13 (1.2) 39 (1.4) 2 (0.6) 9 (0.7)
Other 40 (3.8) 47 (1.7) 6 (1.9) 22 (1.7)
No complication 841 (80.2) 2,539 (93.1) 269 (85.9) 1,241 (95.2)
Some complication 208 (19.8) 187 (6.9) 44 (14.1) 62 (4.8)

Complication Perforated vs. non-perforated

OR (95% CI) p value OR (95% CI) p value
open laparoscopy

Hematoma 1.3 (0.5–3.2) 0.50 0.8 (0.0–7.5) 1.00

Ileus 8.0 (3.6–19) <0.001 17.0 (3.4–165) <0.001
SBO 4.4 (1.8–11) <0.001 8.5 (1.8–53) 0.003
SSI 3.6 (2.6–5.1) <0.001 1.3 (0.3–4.2) 0.76
Cecal abscess 9.0 (4.6–19) <0.001 7.4 (3.2–18) <0.001
Douglas pouch abscess 5.3 (2.2–13) <0.001 9.9 (2.2–60) 0.001
Urinary retention 0.9 (0.4–1.7) 0.76 0.9 (0.1–4.5) 1.00
Other 2.3 (1.4–3.5) <0.001 1.1 (0.4–2.9) 0.81
No complication 0.3 (0.2–0.4) <0.001 0.3 (0.2–0.5) <0.001
Some complication 3.4 (2.7–4.2) <0.001 3.3 (2.1–5.0) <0.001

Complication Open vs. laparoscopic

OR (95% CI) p value OR (95% CI) p value OR (95% CI) p value
perforated non-perforated total

Hematoma 0.4 (0.0–3.1) 0.69 0.7 (0.2–1.9) 0.49 0.6 (0.2–1.5) 0.32
Ileus 1.0 (0.4–2.3) 1.00 0.5 (0.0–2.2) 0.52 0.6 (0.3–1.3) 0.26
SBO 1.3 (0.4–3.7) 0.60 0.7 (0.1–2.8) 0.76 0.9 (0.4–2.0) 0.85
SSI 0.1 (0.0–0.4) <0.001 0.4 (0.2–0.8) 0.002 0.3 (0.1–0.4) <0.001
Cecal abscess 1.4 (0.8–2.7) 0.20 1.7 (0.7–4.4) 0.25 1.2 (0.7–2.0) 0.46
Douglas pouch abscess 1.3 (0.5–3.3) 0.63 0.7 (0.1–2.8) 0.76 0.9 (0.4–1.8) 0.86
Urinary retention 0.5 (0.1–2.3) 0.54 0.5 (0.2–1.0) 0.044 0.5 (0.2–1.0) 0.027
Other 0.5 (0.2–1.2) 0.11 1.0 (0.6–1.7) 1.00 0.7 (0.5–1.2) 0.22
No complication 1.5 (1.1–2.2) 0.02 1.5 (1.1–2.0) 0.01 1.7 (1.3–2.1) <0.001
Some complication 0.7 (0.5–0.9) 0.02 0.7 (0.5–0.9) 0.01 0.6 (0.5–0.8) <0.001

SSI, surgical site infection; SBO, small bowel obstruction.

ally with the present study design. A risk with overuse of
radiology could be that some patients with appendicitis
may have undergone surgery unnecessarily due to posi-
tive imaging but a potential for spontaneous resolution.
These patients would possibly have healed spontaneously
if a strategy with observation and repeated examination
had been used. An increased proportion of uncomplicat-
ed cases could have indicated the overuse of surgery when
additional radiology was used but this outcome was not
found in our study. Other studies have also demonstrated
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 Non-perforated
0.5
0.4
Proportion of patients
0.3
0.2
0.1
0 0
0 2 4 6
Hospital stay, days
Fig. 5. Distributions of hospital stay (0 through 9, or 10+ days) during the period 2004–2006 (dashed), 2008–2010
(dotted), and 2011–2014 (solid) in the case of non-perforated appendicitis or negative appendectomy (left), and
perforated appendicitis (right).
a decrease in the number of negative appendectomies
with increased use of preoperative imaging [18, 28, 29].
An important benefit of reducing the number of negative
appendectomies is avoiding complications from unnec-
essary surgery, which according to our data are compa-
rable in number to that of OA. Weighing the risks of
missed appendicitis, negative appendectomy, and the sto-
chastic risk of cancer due to radiation exposure when CT
is used is difficult due to large uncertainties in these risks
and their composite. The benefit of using ultrasound to
minimize CT use is probably small [30] and local test
characteristics (sensitivity and specificity) of the different
procedures determine what is to be gained from an “ul-
trasound first” approach. The decrease in the fraction of
patients undergoing CT seen in the last years of our study
is probably due to a perceived increase in ultrasound op-
erator skill and 24-h availability of ultrasound.
The fraction of patients with perforated appendicitis
decreased slightly during the study, which is contrary to
previous results [13]. It should be noted, however, that
rates were closer to previously reported rates of perfora-
tion at the end of our study. Related to the question of
perforation rate is the increase in the incidence of appen-
dicitis that we observed in the order of 20–30 cases per
100,000 per year. Is the increase in appendicitis incidence
caused by unnecessary surgery in patients where symp-
toms were mild and the clinical course would be unevent-
ful even with expectant care, but who were found with
preoperative imaging? This would tend to decrease the
relative frequency of perforations by introducing extra
non-perforated cases. First of all, changes in the appendi-
8 Dig Surg
DOI: 10.1159/000477269
Perforated
0.5
2004–2006
2008–2010
0.4
2012–2014
Proportion of patients
0.3
0.2
0.1
8 10+ 0 2 4 6 8 10+
Hospital stay, days
citis rate for the catchment area could potentially arise
from changes in the true disease incidence, the tendency
to opt for surgery, changes in the composition of the
catchment area, bias between the true and reported catch-
ment areas, or combinations of these. The increased use
of imaging probably does not change the appendectomy
rate in the group with perforations as most require sur-
gery. Patients with abscess formation or other diagnoses
on presentation would be detected more readily, poten-
tially preventing surgery in some or all of those cases. We
did not record how the surgeon made the decision to op-
erate, but it is possible that knowledge of positive imaging
results would increase the likelihood of opting for sur-
gery, as was found in previous work on what influences
the decision to operate in a similar appendicitis cohort
[31]. If this was the only mechanism for increasing the
incidence, however, the perforation rate would be even
lower (about 21%, assuming the same true perforation
rate over the time interval, the observed number of ap-
pendicitis cases, and using a linear approximation of the
observed incidence). It should be noted that our rates of
perforation are high when compared to the rates in other
cohorts [8–10], leading us to believe that our tendency to
opt for surgery is not excessive. In some cases, it could be
argued that positive imaging resulted in shorter observa-
tion before surgery, possibly decreasing the risk of perfo-
ration. As described in the introduction, this mechanism
is not supported by cohort data suggesting delays are safe.
Due to all these factors, using perforation rate as a quality
indicator is dubious and could lead to unnecessary sur-
gery. Changes in regional health care policy have allowed
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catchment areas to become more diffuse, potentially in-
creasing the number of patients from other areas, but we
do not have access to detailed data to quantify this further.
Because changes of this magnitude have health and cost
consequences, further work will be needed to follow this
trend, and it could also be examined at the national or
regional level where patient movement is minimal.
One of the main outcomes was a decrease in hospital
stay. A number of factors influencing hospital stay were
observed during the study but are not quantitatively de-
scribed here. The use of laparoscopy is known to decrease
postoperative pain and enable quick mobilization [3].
Shorter duration of in-hospital antibiotic treatment regi-
mens was instituted during the study period, leading to
earlier discharge with per oral antibiotics in suitable pa-
tients with perforated appendicitis. An increased number
of surgical staff during weekends and increased focus on
early mobilization and discharge also contributed. As in
other groups of patients, focus on early postoperative
feeding, with minimal bowel rest, probably also contrib-
uted in early mobilization and discharge. As hospital stay
shortens, more detailed data (hours and minutes) on the
timing of admittance and imaging, time to start of sur-
gery, and postoperative stay will probably be required in
the future to resolve and follow changes in care and pro-
tocol at our institution.
Some potential biases must be considered with our ret-
rospective study design beyond the limits in finding caus-
al relationships; these biases are presented below.
First, cases with conversion from LA to OA tend to be
more complex and have additional incision length. These
cases were registered as OA, which will mix SSI from LA
and OA approaches. The conversion rate in randomized
controlled studies comparing OA and LA is reported to
be in the 0–20% range [3], and we have no reason to sus-
pect different conditions here. We hypothesize that the
additional risk of SSI due to LA and OA incisions is prob-
ably due to the complexity of the surgery rather than the
incisions. Another hypothesis for the mechanism of low-
er SSI with LA is that the incisions are further removed
from the site of maximal contamination, which usually is
close to the cecum.
Second, because our case review at 30 days only in-
cludes patients who were seen at Stockholm South General
Hospital (most often in the emergency department, sur-
gical ward, or outpatient clinic), patients who went to
other health care providers are lost to follow-up. This will
make our apparent complication rates lower than the ac-
tual rate. Our register and study design unfortunately do
not allow us to approximate the extent of this bias.
Stockholm Appendectomy Cohort
Third, because deep abscesses can develop after dis-
charge, there is reason to suspect that loss to follow-up is
greater for deep abscesses. However, deep abscesses prob-
ably increase the likelihood of further contact with the
surgical unit as follow-up with general practice or other
surgical units tends to be referred to the initial hospital
(unlike some SSI, which are cared for in general practice).
Fourth, there is some uncertainty about the correct di-
agnosis with the low rate of microscopic examinations/
PAD. That the same routine (for diagnosis) has been used
at the department during the time period makes us be-
lieve that any changes or trends could be properly as-
sessed. The cases with PAD overall had a reasonable
agreement with the clinical diagnosis, with very low false
positive and false negative rates at the end of the study.
Because the policy was not to send all specimens to pa-
thology, detailed data on the degree of microscopic in-
flammation were not collected. Macroscopic appearances
were only coded as perforated or not perforated, omitting
other gross descriptors of serosal and mucosal surfaces.
This is a shortcoming of the register.
Fifth, missing data could bias the results but was found
only in 0.6% of patients. This would be most problematic
if missing data were preferentially in the cases with com-
plications (as this group was small but within one order
or magnitude of the complication rates). However, such
cases are carefully examined in the 30-day surgeon review
and tend to cause multiple registry entries (e.g., complica-
tion yes/no and ICD-code of complication). We have
manually gone through available data in a retrospective
review where such partly missing entries were found to
minimize this potential issue.
Over the course of this study, several changes have
been introduced and are described above. In closing, we
describe our current practice. The decision of whether to
perform preoperative imaging is left to the discretion of
the surgeon, with 24-h access to radiologist-performed
ultrasound and radiologist-interpreted CT. The surgical
approach is also decided by the surgeon, with 24-h access
to open or laparoscopic equipment. Laparoscopic sta-
pling devices and endobags are available. Lavage/irriga-
tion of the abdomen is decided by the surgeon. In gen-
eral, no drains are placed during the initial operation.
Fascia closure with uninterrupted PDS sutures is recom-
mended for port sites >5 mm. Skin suturing is chosen by
the surgeon. A single preoperative dose of Metronidazole
is given to all patients before surgery, with additional 24 h
of parenteral Cefotaxime and Metronidazole in gangre-
nous appendicitis, and 72 h of the same antibiotic combi-
nation in perforated appendicitis, with per oral Cipro-
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DOI: 10.1159/000477269
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floxacin/Metronidazole or Trimethoprim/Sulfamethox-
azole/Metronidazole combinations for a total of 5 days.
Full enteral feeding is allowed directly after surgery.
In conclusion, we describe significant positive changes
in outcomes of patients with appendicitis. Laparoscopy
was safely introduced with benefits in reduced SSI and
without increases in abscess formation. Negative appen-
dectomies – unnecessary operations with the same risk of
complications as OA – were increasingly rare, which is
probably attributable to a marked increase in preopera-
tive imaging. This change was not mandated by hospital
policy but by changes in surgeon behavior. Encouraging-
ly, CT use has decreased to less than 50% in the latter part
of our study, in part reflecting increasing availability and
efficacy of ultrasonography and individual efforts to lim-
it radiation exposure.
Acknowledgment
We acknowledge all operating surgeons and secretarial staff in-
volved in data gathering. We are grateful to Fredrik Ros at SLL who
supplied data on catchment area from Statistiska Centralbyrån
(Statistics Sweden). We thank Camilla Gustafsson for useful com-
ments on the manuscript.
Statement of Ethics
The work with the register was approved by a local Stockholm
South General Hospital ethics council.
Disclosure Statement
The authors declare no conflicts of interest.

References
1 Addiss DG, Shaffer N, Fowler BS, Tauxe RV:
The epidemiology of appendicitis and appen-
dectomy in the United States. Am J Epidemi-
ol 1990;132:910–925.
2 Sallinen V, Akl EA, You JJ, Agarwal A, Shou-
cair S, Vandvik PO, et al: Meta-analysis of an-
tibiotics versus appendicectomy for non-per-
forated acute appendicitis. Br J Surg 2016;103:
656–667.
3 Jaschinski T, Mosch C, Eikermann M, Neuge-
bauer EA: Laparoscopic versus open appen-
dectomy in patients with suspected appendi-
citis: a systematic review of meta-analyses of
randomised controlled trials. BMC Gastroen-
terol 2015;15:48.
4 Sauerland S, Jaschinski T, Neugebauer EA:
Laparoscopic versus open surgery for sus-
pected appendicitis. Cochrane Database Syst
Rev 2010;10:CD001546.
5 Andersson RE: Short-term complications and
long-term morbidity of laparoscopic and
open appendicectomy in a national cohort. Br
J Surg 2014;101:1135–1142.
6 Li X, Zhang J, Sang L, Zhang W, Chu Z, Li X, et
al: Laparoscopic versus conventional appen-
dectomy – a meta-analysis of randomized con-
trolled trials. BMC Gastroenterol 2010;10:129.
7 Xiao Y, Shi G, Zhang J, Cao JG, Liu LJ, Chen
TH, et al: Surgical site infection after laparo-
scopic and open appendectomy: a multi-
center large consecutive cohort study. Surg
Endosc 2014;29:1384–1393.
8 Drake FT, Mottey NE, Farrokhi ET, et al:
Time to appendectomy and risk of perfora-
tion in acute appendicitis. JAMA Surg 2014;
149:837–844.
9 Andersson R, Hugander A, Thulin A, Nys-
trom PO, Olaison G: Indications for opera-
tion in suspected appendicitis and inci-
dence  of perforation. BMJ 1994; 308: 107–
110.
10 Andersson RE: The natural history and tra-
ditional management of appendicitis revis-
ited: spontaneous resolution and predomi-
nance of prehospital perforations imply that
a correct diagnosis is more important than
an early diagnosis. World J Surg 2007;31:86–
92.
11 Andersson MN, Andersson RE: Causes of
short-term mortality after appendectomy: a
population-based case-controlled study. Ann
Surg 2011;254:103–107.
12 Jeon BG: Predictive factors and outcomes of
negative appendectomy. Am J Surg 2017;213:
731–738.
13 Bhangu A, Søreide K, Di Saverio S, Assarsson
JH, Drake FT: Acute appendicitis: modern
understanding of pathogenesis, diagnosis,
and management. Lancet 2015; 386: 1278–
1287.
14 Andersson M, Andersson RE: The appendici-
tis inflammatory response score: a tool for the
diagnosis of acute appendicitis that outper-
forms the Alvarado score. World J Surg 2008;
32:1843–1849.
15 Hong JJ, Cohn SM, Ekeh AP, Newman M,
Salama M, Leblang SD: A prospective ran-
domized study of clinical assessment versus
computed tomography for the diagnosis of
acute appendicitis. Surg Infect 2003; 4: 231–
239.
16 Lahaye MJ, Lambregts DM, Mutsaers E, Ess-
ers BA, Breukink S, Cappendijk VC, et al:
Mandatory imaging cuts costs and reduces
the rate of unnecessary surgeries in the diag-
nostic work-up of patients suspected of hav-
ing appendicitis. Eur Radiol 2015; 25: 1464–
1470.
17 Raja AS, Wright C, Sodickson AD, Zane RD,
Schiff GD, Hanson R, et al: Negative appen-
dectomy rate in the Era of CT: an 18-year per-
spective. Radiology 2010;256:460–465.
18 Rao PM, Rhea JT, Rattner DW, Venus LG,
Novelline RA: Introduction of appendiceal
CT: impact on negative appendectomy and
appendiceal perforation rates. Ann Surg 1999;
229:344–349.
19 Boström L, Styrud J, Jorulf H, Westman B,
Nilsson I, Apelman J, et al: Akut Appendicit
(Regional Care Program. Acute Appendicitis)
[Internet]. Stockholm Region (SLL), 2007.
http://www.vardgivarguiden.se/behan-
dlingsstod/vardriktlinjer/regionala-vardpro-
gram/vardprogram/akut-appendicit/.
20 Song H, Abnet CC, Andrén-Sandberg Å,
Chaturvedi AK, Ye W: Risk of gastrointestinal
cancers among patients with appendectomy:
a large-scale Swedish register-based cohort
study during 1970–2009. PLoS One 2016;
11:e0151262.
21 Andersson R, Hugander A, Thulin A, Nys-
tröm PO, Olaison G: Indications for ope-
ration in suspected appendicitis and inci-
dence of perforation. BMJ 1994; 308: 107–
110.
22 Boonstra PA, van Veen RN, Stockmann HB:
Less negative appendectomies due to imaging
in patients with suspected appendicitis. Surg
Endosc 2014;29:2365–2370.
23 Ruffolo C: Acute appendicitis: what is the
gold standard of treatment? World J Gastro-
enterol 2013;19:8799–8807.
24 Teixeira PG, Sivrikoz E, Inaba K, Talving P,
Lam L, Demetriades D: Appendectomy tim-
ing: waiting until the next morning increases
the risk of surgical site infections. Ann Surg
2012;256:538–543.
131.211.208.19 - 7/7/2017 2:21:34 PM

10 Dig Surg Dahlberg/Pieniowski/Boström

DOI: 10.1159/000477269
University Library Utrecht
Downloaded by:
25 Sohn M, Hoffmann M, Hochrein A, Buhr HJ,
Lehmann KS: Laparoscopic appendectomy is
safe: influence of appendectomy technique on
surgical-site infections and intra-abdominal
abscesses. Surg Laparosc Endosc Percutan
Tech 2015;25:e90–e94.
26 Körner H, Söndenaa K, Söreide JA, An-
dersen E, Nysted A, Lende TH, et al: Inci-
dence  of acute nonperforated and perfo-
rated appendicitis: age-specific and sex-
specific  analysis. World J Surg 1997; 21:
313–317.
Stockholm Appendectomy Cohort
27 Blomqvist PG, Andersson RE, Granath F,
Lambe MP, Ekbom AR: Mortality after
appendectomy in Sweden, 1987–1996. Ann
Surg 2001;233:455–460.
28 Kim K, Lee CC, Song KJ, Kim W, Suh G, Sing-
er AJ: The impact of helical computed tomog-
raphy on the negative appendectomy rate: a
multi-center comparison. J Emerg Med 2008;
34:3–6.
29 Schok T, Simons PC, Janssen-Heijnen ML,
Peters NA, Konsten JL: Prospective evalua-
tion of the added value of imaging within the
Dig Surg
DOI: 10.1159/000477269
Dutch National Diagnostic Appendicitis
Guideline – do we forget our clinical eye? Dig
Surg 2015;31:436–443.
30 Kiatpongsan S, Meng L, Eisenberg JD, Her-
ring M, Avery LL, Kong CY, et al: Imaging for
appendicitis: should radiation-induced can-
cer risks affect modality selection? Radiology
2014;273:472–482.
31 Sandell E, Berg M, Sandblom G, Sundman J,
Fränneby U, Boström L, et al: Surgical deci-
sion-making in acute appendicitis. BMC Surg
2015;15:69.
131.211.208.19 - 7/7/2017 2:21:34 PM
11
University Library Utrecht
Downloaded by: