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:: Volume 7, Issue 3 (Autumn 2019) ::
Journal of Surgery and Trauma 2019, 7(3): 91-97 Back to browse issues page
Epidemiological aspects of patients underwent appendectomy in Birjand, Iran, from May 2017 to 2019
Mohammad Reza Ghasemian Moghaddam , Mohammadmehdi Hassanzadeh-Taheri , Mehran Hosseini , Mojtaba Salimi , Mahsa Hassanzadeh-Taheri *
Medical Student, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran
Keywords: Age, Appendicitis, Epidemiology, Incidence, Seasons
Full-Text [PDF 881 kb]   (262 Downloads)     |   Abstract (HTML)  (1354 Views)
Type of Study: Research | Subject: General Surgery
Received: 2019/07/18 | Accepted: 2019/09/16 | Published: 2019/11/2 | ePublished: 2019/11/2
Full-Text:   (239 Views)

 

Epidemiological aspects of patients underwent appendectomy in Birjand, Iran, from May 2017 to 2019

Mohammad Reza Ghasemian Moghaddam1images, Mohammadmehdi Hassanzadeh-Taheri2images, Mehran Hosseini3images, Mojtaba Salimi4images, Mahsa Hassanzadeh-Taheri5*images

1Assistant Professor, Department of Surgery, Imam Reza Hospital, Birjand University of Medical Sciences, Birjand, Iran

2Associate Professor, Department of Anatomy, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran

3Cellular and Molecular Research Center, Department of Anatomy, Birjand University of Medical Sciences, Birjand, Iran

4Department of Anatomy, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran

5Medical Student, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran

Received: July 18, 2019       Revised: September 16, 2019         Accepted: September 16, 2019

Abstract

Introduction: Appendectomy is one of the most performed surgeries worldwide. There are lots of factors involved in the incidence of appendicitis, and most of them vary among populations. Therefore, the present study aimed to evaluate the epidemiological aspects of appendicitis in Birjand, Iran, for the first time.

Methods: This prospective study included 666 cases out of 673 acute appendicitis patients treated surgically in Imam Reza Hospital in Birjand, Iran, from May 2017 to 2019. The data were analyzed regarding gender, age groups, and season in SPSS software (version. 22) using a t-test and the Chi-square test. A p-value less than 0.05 was considered statistically significant.

Results: The annual incidence of acute appendicitis in Birjand was 12.74 per 10.000 population with the mean age of 25.43±14.97 years. The highest frequency of appendectomy was observed in 11-20-year-old groups (32.1%) and then in 21-30-year-old groups (27.3%). The frequency of the appendectomy was higher in male than female (P=0.005), and the peak of the surgeries was in the summer. Moreover, the majority of the admitted patients in the summer were male (n=123), whereas the frequency of female patients in the autumn was higher than that of male (n=81). The most frequent pathological diagnosis in both genders was acute gangrenous appendicitis (i.e., 44% in female and 40% in male). Furthermore, the incidence rates of advanced stages of appendicitis, such as "acute supportive appendicitis and periappendicitis" and "acute supportive appendicitis and priappendicitis with perforation" were significantly higher in male than female (P<0.05).

Conclusions: The findings of this study provide basic epidemiological information for the first time regarding appendicitis status in Birjand, Iran. Since the appendicitis was more frequent among youth and was more complicated in male, it is essential to inform these target groups about the signs and symptoms of this medical emergency. 

Key words: Age, Appendicitis, Epidemiology, Incidence, Seasons


 

 

Introduction

Appendicitis is one of the most common clinical conditions accounts for referral of patients to the hospital (1). Despite advances in therapeutic and diagnostic techniques, acute appendicitis remains a clinical emergency and is one of the most common causes of acute abdominal pain (2). The early diagnosis of this disease is very important and challenging. In case of latency in diagnosis, serious complications, such as perforation, peritonitis, and sepsis may occur, which even might lead to death (3-5).

Since the first description of appendectomy by Fitz in 1886 as a lifesaving treatment for acute appendicitis, this surgical technique has remained the gold standard for the treatment of this disease (6). Nowadays, the surgical treatment of this condition is well developed and widely performed worldwide; however, the etiology of this
medical emergency is yet little developed (7). Appendectomy is one of the most common surgical procedures in the world. More than 300000 appendectomy procedures are performed in the United States (US) each year (8).

 In England, approximately, one in seven people may expect to undergo appendectomy at some time in his/her life (1). Some studies have shown that the lifetime risk of appendectomy procedure is 11 per 10,000 population in the US and the most affected group is between the ages of 10 and 19 years (9). Therefore, appendicitis as a costly problem imposes huge budgeting directly or indirectly on the health care systems (7). The incidence rate of acute appendicitis has been reported to vary based on several factors, such as country, racial/ethnic differences, geographic regions, age, gender, season, diet, occupation, and socioeconomic levels; however, the reasons for this variation are still unknown (10).

Appendicitis has shown different incidence rates over the past decades in different countries. In the late 19th century, the incidence rate of this condition was high in Western countries which decreased in the mid part of the 20th century. On the other hand, the incidence rate of appendicitis was very low in developing countries in the 20th century; however, it increased dramatically at the beginning of the 21st century (11). Information from epidemiological studies is used to plan new health services and evaluate the overall health status of the population.

With this background in mind, it is necessary
to understand the epidemiological feature of appendicitis in each part of the world to develop plans for healthcare resource utilization.
In spite of numerous studies that have been carried out regarding different aspects of appendicitis in the world, to the best of our knowledge, few studies have been conducted on the status of appendicitis in different parts of Iran. Moreover, there is a dearth of research regarding appendicitis and appendectomy in Birjand, Iran. One of the most striking epidemiologic features of appendicitis is the marked variation in incidence rates by geographic area. Currently, our knowledge about acute appendicitis is largely based on studies which carried out in other countries. Therefore, this study aimed to investigate the epidemiological aspects of acute appendicitis in patients who underwent appendectomy in Imam Reza hospital in Birjand, Iran, from May 2017 to 2019.

Methods

This cross-sectional, prospective study was carried out in the surgical ward of Imam Reza Hospital affiliated to Birjand University of Medical Sciences, Birjand, Iran, from May 2017 to 2019. The study protocol was approved by the Ethical Committee of Birjand University of Medical Sciences, Birjand, Iran (IR.BUMS.REC.1398.090).

The inclusion criteria were 1) pathologically approved cases, 2) residency in Birjand, and 3) participants' or parents' (for the cases lower than the legal age of 18 years) willingness to participate in the study. On the other hand, the participants from other cities, those who were unwilling to participate in the study, and the patients with pathologically unapproved appendicitis were excluded from the study.

During the research procedure, a total of 673 appendectomy surgery were performed out of which 666 cases met the inclusion criteria.

 

The routine process for hospitalization and surgery is as follows

Firstly, each patient receives a hospital code and his/her demographic characteristics, including age, gender, occupation, educational status, and living area are asked and recorded in special forms.  Subsequently, the cases are examined by an emergency medicine specialist or an on-call surgeon. The cases whose acute appendicitis is confirmed based on the clinical symptoms using Alvarado Scoring System are selected for an emergency appendectomy. Alvarado constructed a scoring system in which the scores 1-4, 5-6, 7-8, and 9-10 represent unlikely appendicitis, possible appendicitis, acute appendicitis, and definitive appendicitis, respectively (Table 1). Eventually, the participants are surgically treated. After surgery, the removed tissue is histologically examined to confirm acute appendicitis and determine an exact pathological diagnosis.

The data obtained from the participants who met the inclusion criteria were noted and used in the present study. All patients were grouped according to age, gender, and season of operation. The frequency of acute appendicitis was tested in each category. Moreover, continuous variables were expressed as mean±SD, and their association was tested using a t-test and the Chi-square test. The data were analyzed in SPSS software (version 22). A P-value less than 0.05 was considered statistically significant.

Results

During the research procedure, (i.e., from 2017 to 2019) 673 patients underwent appendectomy operation; however, seven patients were excluded from the study due to not meeting the inclusion criteria. The incidence rate of appendicitis in urban and rural areas of Birjand, Iran, was 12.74, per 10000 population per year. The mean age of the patients was 25.43±14.97 year (age range: 4-87 years). In total, 79% of the patients lived in the urban area, whereas 21% of them lived in rural and suburban areas. Regarding the occupational status, the majority of the patients were students (54.8%) and self-employed (22%). Moreover, most patients had educational degrees less than high-school diploma (38.9%) and 26.8% of them had a high-school diploma or its equivalent.

With respect to the mean age, there was no statistically significant difference between males (25.52±14.87 years) and females (25.30±15.09 years) (P=0.29, Table 2). In addition, the mean age of urban living patients (24.43±14.22 years) was significantly lower than those living in rural and suburban areas (29.45±17.98 years; P<0.001). The results obtained from the present study showed that out of 666 patients who underwent appendectomy, 350 cases (52.66%) were male (Table 3). Moreover, the age group of 11-20-year-olds obtained the highest frequency of appendectomy (i.e., 32.1%-32.3% in female and 32% in male) followed by the age group of 21-30

 

 

Table 1: Alvarado scoring system as an aid for diagnosing acute appendicitis

Symptoms

Variables

Score

Migratory right iliac fossa pain

1

Nausea / Vomiting

1

Anorexia

1

Signs

Tenderness in right iliac fossa

2

Rebound tenderness in right iliac fossa

1

Elevated temperature

1

Laboratory findings

Leucocytosis

Shift to left of Neutrophils

2

1

Total

-

10

 

Table 2: Comparison of the mean age of patients regarding gender and living area

 

Categories

Age

mean±SD

P-value

Gender

Male

25.52±14.87

0.29

Female

25.30±15.09

Living area

Urban

24.43±14.22

<0.001*

Rural and suburban

29.45± 17.98

* Independent t-test showing differences at significant level of 0.05

 

Table 3: Frequency of appendicitis regarding age and gender

P-value

Total

N (%)

Male

N (%)

Female

N (%)

Age groups

0.77

82 (12.3)

40 (11.4)

42 (13.3 )

0-10

214 (32.1)

112 (32.0)

102 (32.3)

11-20

182 (27.3)

104 (29.7)

78 (24.7)

21-30

94 (14.1)

47 (13.4)

47 (14.19)

31-40

47 (7.1)

23 (6.6)

24 (7.6)

41-50

47 (7.1)

24 (6.9)

23 (7.3)

≥51

666 (100)

350 (52.55)

316 (47.44)

Total

Figure 1

          Figure 1: Seasonal variation of appendicitis regarding gender (A) and age groups (B)

 

Table 4: The frequency (%) of pathological diagnosis regarding gender and age groups

Diagnosis

P-value

1

N (%)

2

N (%)

3

N (%)

4

N (%)

5

N (%)

6

N (%)

Gender

Male

39 (12%)

96 (29.5%)

35 (10.7%)

123 (37.7%)

27 (8.3%)

6 (1.8%)

0.019*

Female

26 (8.7%)

73 (24.3%)

14 (4.7%)

131 (43.7%)

46 (15.3%)

10 (3.3%)

Age

0-10

12 (15%)

19 (23.8%)

4 (5%)

32 (40%)

10 (12.5%)

3 (3.7%)

0.014*

11-20

21 (10.5%)

51 (25.5%)

4 (2%)

84 (42%)

34 (17%)

6 (3%)

21-30

15 (8.7%)

54 (31.2%)

12 (6.9%)

75 (43.3%)

15 (8.7%)

2 (1.2%)

31-40

5 (5.7%)

24 (27.6%)

10 (11.5%)

37 (42.5%)

10 (11.5%)

1 (1.2%)

41-50

9 (20.9%)

7 (16.3%)

12 (27.9%)

11 (25.6%)

1 (2.3%)

3 (7%)

≥51

3 (7%)

14 (32.5%)

7 (16.3%)

15 (34.9%)

3 (7%)

1 (2.3%)

Total

65 (10.4%)

169 (27%)

49 (7.8%)

254 (40.6%)

73 (11.7%)

16 (2.5%)

626 (100)                                                             6666

* Chi-square is significant at 0.05 significant level.

Diagnosis; 1:Reactive follicular hyperplasia, 2:Acute supportive appendicitis and priappendicitis, 3:Acute supportive appendicitis and priappendicitis with perforation, 4: Acute gangrenous appendicitis and priappendicitis, 5: Early acute appendicitis, and 6: Other (including fibrotic appendix with serosal congestion, fecal impaction and serosal congestion, necrotic tissue with chronic inflammation,