Introduction

Acute appendicitis is the most prevalent abdominal surgical disease worldwide, with between 96.5 and 100 cases reported per 100,000 adults per year [1]. The lifetime risk is estimated to be approximately 8.6%, with 6.7% for men and women, respectively [2]. Although no age is exempt, acute appendicitis usually affects people between 10 and 20 years of age more frequently [3]. Acute appendicitis in people over 50 years of age shows some differences with respect to younger patients and its clinical presentation may be more atypical and the symptoms may be more subtle [4].

Acute appendicitis is an inflammatory condition that commonly affects the vermiform appendix, a small sac-shaped organ attached to the cecum. It occurs when the lumen of the vermiform appendix becomes inflamed, usually due to an obstruction [5]. Obstruction may be caused by a fecalith (“fecal stone” or stool mass), lymphoid hyperplasia (more common in young people), a rare parasitic infection, or a tumor (carcinoids, adenocarcinomas, mucoceles, or metastatic carcinomas) [6—8].

As mentioned above, acute appendicitis tends to be less common in pediatric, pregnant, and older adult populations [9]. However, in this last group, the presentation of the disease may be atypical, which leads to a delay in diagnosis and an increase in associated complications [10]. Additionally, in people over 50 years of age, acute appendicitis may be related to other underlying diseases or conditions, such as inflammatory bowel diseases, tumors, or diverticulosis [11]. Therefore, it is crucial to consider acute appendicitis as a possible diagnosis in those over 50 years of age with abdominal pain, even if the symptoms are not typical.

If left untreated, acute appendicitis can cause complications, leading to inflammatory masses, appendiceal abscesses or ruptures, with generalized peritonitis [12]. In this regard, some studies have reported higher rates of mortality and perforation, a marked increase in the delay from symptom onset to hospital admission, significant complication rates, as well as excessive findings of malignancy on histopathological examinations in patients. over 50 years of age with acute appendicitis [13].

Although there are several studies that have focused on the diagnosis and treatment of acute appendicitis in elderly populations, that is, in people over 65 years of age, there is a significant lack of information on the specific situation of patients over 50 years of age [14]. Although this age group is generally considered part of the “older adults” category, it is important to recognize that there are clinical and physiological differences between patients aged 50 years and older and that their clinical, laboratory and intraoperative characteristics could help identify who are at higher risk of postoperative complications.

In a study conducted by Y. Li et al., in China, the variation of procalcitonin (PCT) was examined in adult patients with acute appendicitis, both complicated and uncomplicated. For this, 336 patients who underwent appendectomy were analyzed, dividing them into two groups: uncomplicated acute appendicitis (AAG) with 246 cases and complicated acute appendicitis (CAA) with 90 cases. Age and PCT and C-reactive protein (CRP) levels were found to be significantly higher in the AAC group (p< 0.05). Spearman correlation analysis revealed a positive correlation between PCT and age (r=0.452; p< 0.01) and between PCT and CRP (r=0.715; p< 0.01). The area under the curve (AUC) for PCT, CRP, and age was 0.987, 0.902, and 0.748, respectively. Using logistic regression analysis, it was determined that PCT remained an independent risk factor for the diagnosis of CAA, even after adjusting for age and CRP (p< 0.05) [15].

The study carried out by O. Balogun et al., in Nigeria, evaluated in adult patients the pattern of presentation, risk factors, morbidity and mortality of patients treated for perforated appendicitis, for this they carried out a seven-year retrospective review of patients operated on for appendicitis. acute; They found that the perforation rate in the study was 28.5%. 5.1% of the cohorts had a history of recurrent abdominal pain and in relation to the ASA score, 44.1% belonged to categories II and 42.4% to category III. The most common complications were surgical site infections (SSI) (18.6%), wound dehiscence (15.2%), and pelvic abscess (13.5%). The incidence of SSI was correlated with male sex (p=0.041), comorbidity (p=0.037), and ASA score (0.03) with a 95% confidence interval [16].

O. Hançerlioğulları et al., in Turkey, investigated clinical, laboratory and imaging factors that could influence surgical and postoperative outcomes in patients over 50 years of age with acute appendicitis. The study included 152 patients who underwent emergency appendectomy, with a median age of 59 years. The results revealed that the development of surgical complications was significantly associated with intensive care unit (ICU) hospitalization and the presence of two or more comorbidities before surgery (p=0.006 and p=0.002, respectively). Additionally, patients with surgical complications were observed to have a longer total hospital stay (p<0.001), lower preoperative albumin levels (p=0.017), and a higher rate of ICU hospitalization during the follow-up period (p =0.006). Preoperative leukocyte counts were found to be significantly increased in patients undergoing open appendectomy (p=0.047). Furthermore, both the duration of preoperative abdominal pain and preoperative C-reactive protein levels showed a significant correlation with the duration of hospitalization (p<0.001 and p<0.001, respectively) [17].

J. Ashcroft et al., in the United Kingdom, set out to validate risk prediction models and investigate the diagnostic accuracy of ultrasonography and computed tomography (CT) in adults undergoing appendectomy, conducted a retrospective review of adult patients undergoing appendectomy. 206 patients (52% women) were included in the study. A high-risk appendicitis score correctly identified 84.0% (79/94) of cases in men and 85.9% (67/78) of cases in women. Ultrasound was equivocal in 85.7% (18/21) of low-risk women and 59.0% (23/39) of high-risk women. CT correctly detected or excluded appendicitis in 75.0% (6/8) of low-risk women and 88.5% (23/26) of high-risk women [18].

In a study carried out by L. Moreira et al., in Brazil, the main risk factors associated with postoperative complications in patients undergoing appendectomy for acute appendicitis were analyzed. The retrospective analysis included 1241 patients, divided into four groups: Group 1, without postoperative complications, and Groups 2, 3 and 4, with postoperative complications classified according to the Clavien—Dindo scale (grades I, II and ≥III, respectively). The results indicated that patients older than 38.5 years had more serious postoperative complications (p<0.0001). It was observed that the majority of patients in Group 1, without complications, underwent laparoscopic appendectomy, while Groups 2, 3 and 4 were mainly subjected to open surgery (p<0.0001). In the case of acute appendicitis, it was found that the odds ratio (OR) of complications was 3.09, 3.04 and 12.41 for groups 2, 3 and 4, respectively (p<0.0001). A relationship was also observed between the anesthetic risk, the duration of the surgical intervention and the hospital stay with a greater risk and severity of complications [19].

The objective is to understand postoperative complications in patients over 50 years of age with acute appendicitis, a condition that presents specific challenges in this population group. The lack of consensus in the medical literature on the variables associated with these complications motivates the identification of these factors, which could improve clinical management and prevent complications. The use of the Clavien—Dindo classification system provides a standardized assessment of complications, facilitating comparison between studies. This knowledge can lead to early identification of high-risk patients and more effective prevention strategies, as well as guide the development of specific care protocols to improve the quality of life of patients over 50 years of age with acute appendicitis.

Material and methods

Study design

An observational, analytical and cross-sectional design was carried out to examine the relationship between serious postoperative complications and various clinical, laboratory and intraoperative variables in patients with acute appendicitis.

Study population

Patients over 50 years of age who underwent surgery for acute appendicitis during the period from January 2019 to July 2023 were included.To calculate the sample size, the sample size statistical formula for proportions with infinite population was used; the proportion of serious postoperative complications (Clavien—Dindo III—IV) reported by T. Wu et al. [20] was taken. which was 9.5% in adult patients operated on for acute appendicitis.206 patients were selected as study participants.Patients operated on for reasons other than appendectomy, patients with incomplete medical records, absence of postoperative controls, pregnant women, and patients operated on in other hospitals were excluded from this study.

Procedure

Sociodemographic, clinical, laboratory and surgical data were collected from the medical records. This was performed by reviewing hospital records, progress notes, laboratory reports, and surgical reports. These data were used to complete the data collection sheet. The operational definitions of postoperative complications were governed by the Clavien—Dindo classification system, based on the reason for hospital consultation (HC). In classification group I, the absence of postoperative complications was considered, where any deviation from the ideal postoperative course did not require pharmacological treatment or surgical, endoscopic or radiological interventions, only allowing the use of certain drugs. Groups II and III involved pharmacological treatments with drugs other than those allowed for grade I complications, as well as the need for surgical, endoscopic or radiological interventions. Groups IV and V indicated life-threatening complications, with the need for treatment in the ICU and, unfortunately, the death of the patient. It should be noted that category I included surgical wounds drained at the bedside, and category II included blood transfusions and total parenteral nutrition. Finally, a database was created in Microsoft Office where the information was recorded.

Statistical analysis

The statistical analysis played a central role in the research stage, being executed with the SPSS program in version 28 to carry out a thorough exploration of the collected data. During this process, various analytical techniques were used, including chi-square tests, Student’s t tests and logistic regression, with the aim of unraveling patterns, relationships and associations present in the data set. The chi-square test evaluated the dependence or independence of categorical variables, while the Student t test compared means between two groups, offering insights into possible significant differences in continuous variables.

In a more advanced approach, a logistic regression analysis was implemented to explore the relationships between a binary dependent variable and multiple predictor variables, identifying significant factors that could influence the variable of interest. To enrich the evaluation, the adjusted odds ratio was calculated, providing an accurate measure of the strength of association between variables adjusted for possible confounding factors. This refined approach contributed to a more complete interpretation of the results, allowing the statistical implications of the emerging findings to be clearly discerned in the research context.

Ethical aspects

The study was carried out with the corresponding permissions and complied with ethical standards, including the confidentiality of participant information, in accordance with the Helsinki principles and national and Medical College regulations.Approval was obtained from the ethics committee of the University, as well as the Hospital.

Results

206 patients over 50 years of age who underwent surgery for acute appendicitis were included. In this sample, a prevalence of postoperative complications of 30.09% was observed according to the Clavien—Dindo classification, and no mortality was recorded in the study.

The distribution of patients according to clinical and laboratory variables, and their association with postoperative complications is analyzed. Variables such as age, male sex, duration of illness, presence of type 2 diabetes (DM2) and high blood pressure (HTN), as well as leukocyte count, RNL, blood glucose, creatinine and CRP values, showed significant associations with postoperative complications (p-value<0.05) (table 1).

Table 1.Distribution of patients over 50 years of age with acute appendicitis according to clinical and laboratory variables associated with postoperative complications

The relationship between intraoperative variables and postoperative complications. It was observed that operative time, ASA III Score, the presence of perforated appendicitis and peritonitis, the type of laparoscopic appendectomy and the length of hospital stay were significantly associated with postoperative complications (p-value<0.05) (table 2).

Table 2. Distribution of patients over 50 years of age with acute appendicitis according to intraoperative variables and postoperative complications

Finally, multivariate analysis identifies independent factors associated with postoperative complications in patients over 50 years of age with acute appendicitis. It was found that the ASA III Score, CRP, perforated appendicitis and operative time were factors significantly independently associated with postoperative complications, with the ASA III Score being the most strongly associated, with an ORa of 8.98; 95% CI [2.54 — 31.78] (table 3).

Table 3.Multivariate analysis for the prediction of postoperative complications in patients over 50 years of age with acute appendicitis

Discussion

Acute appendicitis represents the most common abdominal surgical emergency worldwide, with an annual incidence ranging between 96.5 and 100 cases per 100,000 adults [10]. The epidemiology and outcomes of acute appendicitis in older adult patients differ significantly from those observed in the younger population. These patients suffering from acute appendicitis have a greater susceptibility to a higher mortality rate, a higher probability of perforation, a lower accuracy in diagnosis, a longer delay from the onset of symptoms to hospitalization, a higher rate of postoperative complications, and an increased risk of developing colon and appendix cancer (eleven).

However, it must be considered that each population has its own clinical characteristics associated with its health systems that make it necessary to evaluate how these clinical, laboratory and surgical variables are associated with postoperative complications in this population of older adults who present with acute appendicitis.

The prevalence of postoperative complications in this sample was 30.09%, measured according to the Clavien—Dindo classification. Compared with other series, our prevalence was higher; for example, C. Seow et al. [12], in Singapore, evaluated 1185 patients operated on for acute appendicitis, whose average age was 36.4 years, postoperative morbidity was 5.5% and a 30-day readmission rate was 2.4%; another study conducted in India by A. Surabhi et al. [13], reported a postoperative complication rate of 10% in a sample of 87 patients with complicated acute appendicitis; another study by O. Cohen-Arazi et al. [14], in Israel, evaluated 74 patients ≥65 years of age and, comparing them with patients under 45 years of age, reported a 21.6% prevalence of postoperative complications. It is important to highlight that our study used a classification that includes not only complications associated with the wound or surgery itself, but other complications such as medical ones; This has probably generated a higher prevalence, unlike the findings reported by the other authors.

In relation to the clinical variables associated with postoperative complications, this study found that, at older age, male sex, a prolonged duration of illness, the presence of type 2 diabetes and high blood pressure constituted significant associated factors; In this sense, a study carried out in Turkey by O. Hançerlioğulları et al. [8], in a sample of 152 middle-aged and elderly patients undergoing emergency appendectomy, postoperative complications were significantly associated with the presence of 2 or more preoperative comorbidities; something similar was found by O. Cohen-Arazi et al. [14], in the sense that advanced age and heart disease were predictive of complications.

Regarding laboratory findings, the results suggest that laboratory markers such as leukocyte count, Neutrophil Lymphocyte Ratio (NLR), blood glucose, creatinine and CRP also turned out to be useful indicators. to predict postoperative complications in this population of patients with acute appendicitis; the same study conducted by O. Hançerlioğulları et al. [8], found that preoperative leukocyte count, CRP levels were significantly correlated with longer hospital stay due to postoperative complications. Inflammatory markers on the one hand and the effects of intra-abdominal infection have an impact on the laboratory tests studied and this is corroborated not only by our study but also by the Turkish study.

Regarding the intraoperative variables that influence postoperative complications, we found that operative time, ASA III score, the presence of perforated appendicitis, peritonitis and the type of appendectomy were identified as factors significantly associated with complications; a study conducted in adults by O. Balogun et al. [7], in Nigeria, found that appendiceal perforation and ASA score II and III were associated with complications, the most frequent being SSI (18.6%), wound dehiscence (15.2%) and pelvic abscess (13.5%); F. Rondelli et al. [15], in Italy, reported a mean surgical time of 58±18.7 minutes and a mean length of hospital stay of 6.5±1.8 days in complicated patients. Our results are similar to these investigations, reinforcing the idea that postoperative complications are associated with a greater preoperative risk and a longer hospital stay.

The clinical, laboratory and intraoperative variables evaluated may be associated with postoperative complications in patients with acute appendicitis due to several reasons, on the one hand, clinical variables such as age, sex, the presence of comorbidities such as DM2 and high blood pressure (HBP) can influence the patient’s ability to cope with the stress of surgery and subsequent recovery. Older patients, for example, may have decreased organ function and a reduced immune response, increasing the risk of complications. [16]. Additionally, comorbidities can make it difficult to manage the inflammatory response and wound healing. Also, laboratory variables such as leukocyte count, Neutrophil Lymphocyte Ratio (NLR), CRP and other similar markers provide information about the patient’s inflammatory response and organ function. An increase in these markers may indicate an exaggerated inflammatory response, infection or organ dysfunction, which could predispose to postoperative complications such as wound infections, sepsis or organ dysfunction and intraoperative variables such as operative time, type of appendicitis (suppurative, gangrenous, perforated), the presence of peritonitis and the type of appendectomy (open or laparoscopic) directly influence the patient’s exposure to risk factors during surgery [17]. More complex surgery or the presence of intraoperative complications may increase the risk of subsequent complications, as they may increase the surgical stress burden and the possibility of complications such as infections, bleeding, or organ dysfunction.

Based on our findings, we suggest that future research could focus on the evaluation of specific preventive interventions aimed at reducing postoperative complications in this group of patients. These studies could investigate the effectiveness of improved perioperative management protocols, patient selection strategies for laparoscopic versus open surgery, or the implementation of comorbidity management programs such as diabetes and hypertension to reduce the risk of complications.

Conclusion

In patients over 50 years of age with acute appendicitis, a prevalence of 30.09% of postoperative complications was observed, evaluated according to the Clavien—Dindo classification. Clinical factors, such as advanced age, male sex, DM2 and HTN, were significantly associated with these complications. Likewise, laboratory variables, such as leukocyte count, Neutrophil Lymphocyte Ratio (NLR), blood glucose, creatinine and CRP, showed relevant associations. Intraoperative variables, including duration of surgery, ASA III score, type of perforated appendicitis, presence of peritonitis, type of laparoscopic appendectomy, and length of hospital stay, also significantly impacted postoperative complications.

Ethical aspects:All authors certify that they meet the current authorship criteria of the International Committee of Medical Journal Editors (ICMJE).

Declaration of conflict of interest:The authors have no conflict of interest to declare.

Funding Sources: The authors declare that this work has not received any funding from funding agencies in the public, commercial, or non-profit sectors.

Author Contributions:

Flores Quiñonez M, Caballero-Alvarado J, Lozano Peralta K: Conceptualization, Formal research analysis, Methodology, Resources, Software, Validation, Visualization, Approval of the final manuscript.

Zavaleta-Corvera C: Writing, Review and editing, Approval of the final manuscript.