World Journal of Surgery

, Volume 43, Issue 1, pp 67–74 | Cite as

Clinical Outcomes and Healthcare Costs Associated with Laparoscopic Appendectomy in a Middle-Income Country with Universal Health Coverage

  • Giancarlo BuitragoEmail author
  • Edgar Junca
  • Javier Eslava-Schmalbach
  • Ruben Caycedo
  • Pilar Pinillos
  • Luis Carlos Leal
Original Scientific Report



Although many studies have compared outcomes of laparoscopic appendectomy (LA) and open appendectomy (OA), some clinical and economic outcomes continue to be controversial, particularly in low–medium-income countries. We aimed at determining clinical and economic outcomes associated with LA versus OA in adult patients in Colombia.


Retrospective, cohort study based on administrative healthcare records included all patients who underwent LA or OA in Colombia’s contributory regime between July 1, 2013, and September 30, 2015. Outcomes were 30-day mortality rates, ICU admissions rates, length of stay (LOS), and hospital costs provided until discharge. Propensity score matching techniques were used to balance the baseline characteristics of patients (age, sex, comorbidities based on the Charlson index, insurer, and geographic location) and to estimate the average treatment effect (ATE) of LA as compared to OA over outcomes.


A total of 65,625 subjects were included, 92.9% underwent OA and 7.1% LA. For the entire population, 30-day mortality was 0.74 per 100 appendectomies (95% CI 0.67–0.81), the mean and median LOS were 3.83 days and 1 day, respectively, and the ICU admissions rate during the first 30 days was 7.92% (95% CI 7.71–8.12). The ATE shows an absolute difference in the mortality rate after 30 days of −0.35 per 100 appendectomies (p = 0.023), in favor of LA. No effects on ICU admissions or LOS were identified. LA was found to increase costs by 514.13 USD on average, with total costs of 772.78 USD for OA and 1286.91 USD for LA (p < 0.001).


In Colombia’s contributory regime, LA is associated with lower 30-day mortality rate and higher hospital costs as compared to OA. No differences are found in ICU admissions or LOS.



The authors thank Office of Information and Communication Technology of Ministry of Health and Social Protection from Colombia (Dolly Ovalle and Luz Emilse Rincon), for providing anonymized data for this study.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Bhangu A, Søreide K, Di Saverio S et al (2015) Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet Lond Engl 386:1278–1287. CrossRefGoogle Scholar
  2. 2.
    Tan WJ, Acharyya S, Goh YC et al (2015) Prospective comparison of the Alvarado score and CT scan in the evaluation of suspected appendicitis: a proposed algorithm to guide CT use. J Am Coll Surg 220:218–224. CrossRefGoogle Scholar
  3. 3.
    Addiss DG, Shaffer N, Fowler BS, Tauxe RV (1990) The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 132:910–925CrossRefGoogle Scholar
  4. 4.
    Kong VY, Sartorius B, Clarke DL (2015) Acute appendicitis in the developing world is a morbid disease. Ann R Coll Surg Engl 97:390–395. CrossRefGoogle Scholar
  5. 5.
    Won RP, Friedlander S, Lee SL (2017) Regional variations in outcomes and cost of appendectomy in the United States. J Surg Res 219:319–324. CrossRefGoogle Scholar
  6. 6.
    Jaschinski T, Mosch C, Eikermann M, Neugebauer EAM (2015) Laparoscopic versus open appendectomy in patients with suspected appendicitis: a systematic review of meta-analyses of randomised controlled trials. BMC Gastroenterol 15:48. CrossRefGoogle Scholar
  7. 7.
    Sauerland S, Jaschinski T, Neugebauer EA (2010) Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. Google Scholar
  8. 8.
    Ohtani H, Tamamori Y, Arimoto Y et al (2012) Meta-analysis of the results of randomized controlled trials that compared laparoscopic and open surgery for acute appendicitis. J Gastrointest Surg Off J Soc Surg Aliment Tract 16:1929–1939. CrossRefGoogle Scholar
  9. 9.
    Wei B, Qi C-L, Chen T-F et al (2011) Laparoscopic versus open appendectomy for acute appendicitis: a metaanalysis. Surg Endosc 25:1199–1208. CrossRefGoogle Scholar
  10. 10.
    Temple LK, Litwin DE, McLeod RS (1999) A meta-analysis of laparoscopic versus open appendectomy in patients suspected of having acute appendicitis. Can J Surg J Can Chir 42:377–383Google Scholar
  11. 11.
    Liu Z, Zhang P, Ma Y et al (2010) Laparoscopy or not: a meta-analysis of the surgical effects of laparoscopic versus open appendicectomy. Surg Laparosc Endosc Percutan Tech 20:362–370. CrossRefGoogle Scholar
  12. 12.
    Meara JG, Leather AJM, Hagander L et al (2015) Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet Lond Engl 386:569–624. CrossRefGoogle Scholar
  13. 13.
    Bardey D, Buitrago G (2017) Supplemental health insurance in the Colombian managed care system: adverse or advantageous selection? J Health Econ 56:317–329. CrossRefGoogle Scholar
  14. 14.
    Sundararajan V, Henderson T, Perry C et al (2004) New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality. J Clin Epidemiol 57:1288–1294. CrossRefGoogle Scholar
  15. 15.
    Austin PC (2011) An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivar Behav Res 46:399–424. CrossRefGoogle Scholar
  16. 16.
    Austin PC (2009) Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat Med 28:3083–3107. CrossRefGoogle Scholar
  17. 17.
    Abadie A, Imbens GW (2016) Matching on the Estimated Propensity Score. Econometrica 84:781–807. CrossRefGoogle Scholar
  18. 18.
    Abadie A, Imbens GW (2006) Large sample properties of matching estimators for average treatment effects. Econometrica 74:235–267. CrossRefGoogle Scholar
  19. 19.
    Abadie A, Imbens GW (2011) Bias-corrected matching estimators for average treatment effects. J Bus Econ Stat 29:1–11. CrossRefGoogle Scholar
  20. 20.
    Cattaneo MD (2010) Efficient semiparametric estimation of multi-valued treatment effects under ignorability. J Econom 155:138–154. CrossRefGoogle Scholar
  21. 21.
    Austin PC, Stuart EA (2015) Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies. Stat Med 34:3661–3679. CrossRefGoogle Scholar
  22. 22.
    Yu M-C, Feng Y-J, Wang W et al (2017) Is laparoscopic appendectomy feasible for complicated appendicitis? A systematic review and meta-analysis. Int J Surg Lond Engl 40:187–197. CrossRefGoogle Scholar
  23. 23.
    Hernán M, Robins JM Causal inferenceGoogle Scholar
  24. 24.
    Ariyaratnam R, Palmqvist CL, Hider P et al (2015) Toward a standard approach to measurement and reporting of perioperative mortality rate as a global indicator for surgery. Surgery 158:17–26. CrossRefGoogle Scholar
  25. 25.
    Ng-Kamstra JS, Arya S, Greenberg SLM et al (2018) Perioperative mortality rates in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Glob Health 3:e000810. CrossRefGoogle Scholar
  26. 26.
    Palmqvist CL, Ariyaratnam R, Watters DA et al (2015) Monitoring and evaluating surgical care: defining perioperative mortality rate and standardising data collection. Lancet Lond Engl 385(Suppl 2):S27. CrossRefGoogle Scholar
  27. 27.
    Kotaluoto S, Ukkonen M, Pauniaho S-L et al (2017) Mortality related to appendectomy; a population based analysis over two decades in Finland. World J Surg 41:64–69. CrossRefGoogle Scholar
  28. 28.
    Sartelli M, Baiocchi GL, Di Saverio S et al (2018) Prospective observational study on acute appendicitis worldwide (POSAW). World J Emerg Surg WJES 13:19. CrossRefGoogle Scholar
  29. 29.
    Biondi A, Di Stefano C, Ferrara F et al (2016) Laparoscopic versus open appendectomy: a retrospective cohort study assessing outcomes and cost-effectiveness. World J Emerg Surg WJES 11:44. CrossRefGoogle Scholar
  30. 30.
    Long KH, Bannon MP, Zietlow SP et al (2001) A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: clinical and economic analyses. Surgery 129:390–400. CrossRefGoogle Scholar
  31. 31.
    Minutolo V, Licciardello A, Di Stefano B et al (2014) Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4-year experience in a district hospital. BMC Surg 14:14. CrossRefGoogle Scholar
  32. 32.
    Garbutt JM, Soper NJ, Shannon WD et al (1999) Meta-analysis of randomized controlled trials comparing laparoscopic and open appendectomy. Surg Laparosc Endosc 9:17–26CrossRefGoogle Scholar
  33. 33.
    Haas L, Stargardt T, Schreyoegg J (2012) Cost-effectiveness of open versus laparoscopic appendectomy: a multilevel approach with propensity score matching. Eur J Health Econ HEPAC Health Econ Prev Care 13:549–560. CrossRefGoogle Scholar
  34. 34.
    Costa-Navarro D, Jiménez-Fuertes M, Illán-Riquelme A (2013) Laparoscopic appendectomy: quality care and cost-effectiveness for today’s economy. World J Emerg Surg WJES 8:45. CrossRefGoogle Scholar
  35. 35.
    Ruiz-Patiño A, Rey S, Molina G et al (2018) Cost-effectiveness of laparoscopic versus open appendectomy in developing nations: a Colombian analysis. J Surg Res 224:33–37. CrossRefGoogle Scholar
  36. 36.
    Meara JG, Hagander L, Leather AJM (2014) Surgery and global health: a Lancet Commission. Lancet Lond Engl 383:12–13. CrossRefGoogle Scholar
  37. 37.
    Higashi H, Barendregt JJ, Kassebaum NJ et al (2015) Surgically avertable burden of digestive diseases at first-level hospitals in low and middle-income regions. Surgery 157:411–419. discussion 420–422 CrossRefGoogle Scholar
  38. 38.
    Lin K-B, Chan C-L, Yang N-P et al (2015) Epidemiology of appendicitis and appendectomy for the low-income population in Taiwan, 2003–2011. BMC Gastroenterol 15:18. CrossRefGoogle Scholar
  39. 39.
    Yang E, Cook C, Kahn D (2015) Acute appendicitis in the public and private sectors in Cape Town, South Africa. World J Surg 39:1700–1707. CrossRefGoogle Scholar
  40. 40.
    Hernandez MC, Finnesgaard E, Aho JM et al (2018) Appendicitis: rural patient status is associated with increased duration of prehospital symptoms and worse outcomes in high- and low-middle-income countries. World J Surg 42:1573–1580. CrossRefGoogle Scholar
  41. 41.
    Livingston EH, Woodward WA, Sarosi GA, Haley RW (2007) Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management. Ann Surg 245:886–892. CrossRefGoogle Scholar
  42. 42.
    Andersson RE (2013) Short and long-term mortality after appendectomy in Sweden 1987–2006. Influence of appendectomy diagnosis, sex, age, co-morbidity, surgical method, hospital volume, and time period. A national population-based cohort study. World J Surg 37:974–981. CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  1. 1.Departamento de Cirugía, Facultad de MedicinaUniversidad Nacional de ColombiaBogotáColombia
  2. 2.Hospital Universitario Nacional de ColombiaBogotáColombia

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