Demographic characteristics
A total of 93 patients from the Surgical Hospital who underwent appendectomy surgery have participated in the research. We found that the mean age in years was 31.14 (± 13.728), with 63.4% less than age 31. The predominance of patients (65.6%) was males. 58% were employed. Approximately half of the patients (54.8%) were vaccinated against COVID-19, while 81.7% had no history of infection. 41.9% were smokers, and of those, 37.6% were light smokers defined as individuals who smoke fewer than 10 cigarettes per day [19]. 49.5% were considered normal weight with a mean BMI of 24.99 (± 3.7336). 76.4% are in grade 12 or less. Table 1 in Appendix is an overview of our sociodemographic characteristics and risk factors in this study.
Preoperative and intraoperative clinical findings
Regarding pre-operative characteristics, 50.5% of patients took medications before presentation, with 42.9% using painkillers and 7.7% taking antibiotics. Of all 93 patients, (71.8%), (77%), (66.3%) ultrasound (U/S) showed non-compressible appendix, with diameter > 6 mm, and periappendicular signs (fat stranding and free fluid), respectively. However, only 16.1% of patients had a computed tomography (CT) scan that showed positive findings, defined as the presence of an enlarged appendix (> 6 mm diameter), periappendiceal fat stranding, fluid collection, or appendicolith. We found that the mean diameter of the appendix was 8.05 ± 7.47. Approximately three-quarters of patients (78.5%) showed an elevation in white blood cells (WBCs) of more than 10.5*103/μL with a mean of 13.5*103/μL ± 3.9, and a neutrophil percentage mean of 80.43 ± 9.73. Of patients who had their C-reactive protein (C-RP) tested, 81.7% were above 10 mg/dL, with a mean of 52.83 ± 2.26. The mean temperature was 37.11 ± 0.637. Moreover, (75.3%) of patients had an Alvarado score equal to or more than 7. Table 2 in Appendix shows the detailed frequencies of pre-operative characteristics among the participants.
83.9% of the participants’surgeries were open. Approximately half of them (55.9%) were done in a period between 08:00–20:00. Intraoperative surgical findings showed that 21.5% were phlegmonous, 18.3% were perforated, 10.8% were gangrenous, and 8.6% were severely inflamed. While on histopathology, 92.5%, 36.6%, and 8.6% showed inflammation, suppurative, and periappendicitis, respectively. Table 3 in Appendix shows the detailed frequencies of Intraoperative characteristics among the participants.
Table 4 in Appendix presents the percentages of each sociodemographic variable regarding the Alvarado score and the P-value. Alvarado’s score ≥ 7 was interpreted as having the diagnosis of acute appendicitis. There was a significant association (P-value < 0.05) with the age group, but no significant association with gender. WBC and PMN counts, which are part of the components of the Alvarado score, were strongly associated with it. CRP classification was also shown to be associated with the Alvarado score (P-value < 0.05).
Postoperative outcomes
In the study, 62.4% of the participants reported their pain during the first 8 h’ post-surgery as severe. During the next 8 h, 47.3% reported their pain score as severe. During the last one-third of the day, only 37.1% of the participants had a severe pain score. The median length of hospital stay was two days. Most patients (86%) experienced no early complications, (7.5%) had surgical site infections, and the remaining suffered from fluid collection (3.2%), fever (2.2%), and intestinal obstruction (1.1%). The mean sick leave days in the study were 10.22 ± 11.81. Table 5 in Appendix shows the detailed frequencies of Postoperative characteristics among the participants.
Postoperative pain assessment
The median pain score was 8 with the interquartile range (5–9), 6 with the interquartile range (5–8), and 5 with the interquartile range (3.5–7) at intervals of 0–8, 9–16, and 17–24 h post appendectomy, respectively. In comparison, the mean was 7.08 ± 2.58, 6.11 ± 2.4, and 5.48 ± 2.53. Furthermore, the Cronbach alpha of the pain severity score was 0.72, indicating good internal validity.
49.2% of males who underwent appendectomy consider their VAS score as severe during the first 8 h, while 87.5% of females consider their pain as severe (P-value 0.001), which is statistically significant. During 9–16 h, 41.7% of male patients reported their pain as severe compared to 58.1% of female patients (P-value of 0.043). 50% of patients less than or equal to 31 years considered their VAS score as severe compared to 42.4% of those aged more than 31, but these results were not significant.
63.3% of female patients in the last one-third of the day reported their pain as severe compared to 23.7% of males at a P-value of 0.001, which is statistically significant.
Pain Scores and Quality of Life (QoL)
We found that the median of the EQ-5D index score was 0.569 with the interquartile range (0.38–0.74) at discharge, 0.778 with the interquartile range (0.58–0.83) at one week, and 0.827 with the interquartile range (0.8–1) two weeks after surgery. In comparison, the mean was 0.549 ± 0.211, 0.718 ± 0.196, and 0.848 ± 0.147 at discharge, one and two weeks later, respectively. Cronbach’s alpha was used to measure internal consistency and was 0.79, which was considered acceptable. Regarding the EQ-VAS score, the median was 65 with the interquartile range (55–76.5) at discharge, 80 with the interquartile range (70–90) at one week, and 90 with the interquartile range (80–95) two weeks after discharge. At the same time, the mean was 63.72 ± 17.526, 78.26 ± 14.877, and 87.2 ± 11.678 at discharge, one and two weeks after surgery, respectively.
Figure 1a, b, c show the distribution of quality of life indices in the three levels of the five dimensions of the European Quality of Life scale (EQ-5D) at discharge, one and two weeks later, respectively. The worst health status in all dimensions of the EQ-5D at discharge was: usual activities (52.2%), self-care (17.4%), pain/discomfort (10.9%), mobility (6.5%), and anxiety/depression (4.3%). At seven days following discharge, the worst dimensions were: usual activities (21.7%), pain/discomfort (7.6%), self-care and mobility (2.2%), and anxiety/depression (1.1%). Two weeks after discharge, patients showed improvement in all dimensions except the Pain/discomfort, which was unchanged from the first week following discharge (1.1%).
a Distribution of quality of live indices in the three levels of five dimension of European Quality of Life scale (EQ-5D) at discharge. b Distribution of quality of live indices in the three levels of five dimension of European Quality of Life scale (EQ-5D) one week after surgery. c Distribution of quality of live indices in the three levels of five dimension of European Quality of Life scale (EQ-5D) two weeks after surgery
The associations between sociodemographic characteristics and quality of life (QoL) across the five EQ-5D dimensions at discharge, one week, and two weeks after surgery are summarized. Detailed breakdowns of the percentage distribution of each level (L1/L2/L3) for the five dimensions across different variables are presented Tables 4, 5 and 6 in Appendix.
Statistically significant associations were observed between QoL dimensions and various sociodemographic factors, including gender, age, marital status, COVID infection, vaccination status, education, BMI, smoking status, and occupation.
Gender showed a statistically significant association (p < 0.05) with anxiety/depression, with females reporting higher rates of problems (28.1%, 31.2%, and 25%) at discharge, one week, and two weeks postoperatively, respectively, compared to males (20%, 8.3%, and 5%). Age was significantly associated with usual activities (p < 0.05), where patients older than 31 reported a higher percentage of problems (88.2% and 52.9%) at one and two weeks after discharge compared to younger patients (53.4% and 27.6%). Additionally, education was associated with mobility (p = 0.037), self-care (p = 0.005), and usual activities (p = 0.015) two weeks postoperatively.
Figure 2a and b compare the quality of life in multiple dimensions affected by gender.
a Males and hrqol. b Females and HRqol
Pre-hospital delay (patient delay)
We defined the time from the onset of pain to presentation to the emergency department as a”patient delay”, measured in hours. There were strong associations with age (P-value = 0.042), as patients older than 31 had more delay in their presentation to ER (27.3%) compared to young patients (10.2%). However, there was no association with gender. Also, there was a strong association with complicated appendicitis, as more complications (26.7%) occurred when the presentation was delayed more than 48 h, while there were no associations with histopathology. Table 6 in Appendix presents patient characteristics and delay to presentation associations.
Regarding the EQ-5D, the patient presented after 48 h had an association with anxiety/depression (P-value = 0.017) at discharge, but no association two weeks after discharge. We found that at two weeks, patients’self-care and usual activities were affected due to the delay; as the delayed patient had problems in self-care (26.7%) and usual activities (73.3%), compared to patients who presented before 48 h (6.6%) and (30.3%), respectively. Table 7 in Appendix presents EQ-5D and patient delay associations.
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