Appendicitis Global Outcomes (AlliGatOr) Study Protocol: Identifying areas for whole systems strengthening in emergency care pathways

Abstract

Background: Acute appendicitis is one of the most common surgical emergencies worldwide. The presentation of appendicitis and its management can serve as a benchmark for evaluating the efficiency and effectiveness of emergency health systems. This prospective cohort study aims to identify areas for whole systems strengthening in emergency care using pre-defined key performance measures.

Methods: This international prospective, multicentre cohort study will include all consecutive patients undergoing appendicectomy for suspected appendicitis. A measurement set comprising eight key outcome measures has been pre-defined to comprehensively evaluate emergency system performance across the world: time from symptom onset to surgical assessment, imaging rate, time from surgical assessment to theatre, laparoscopy rate, perforation rate, negative appendicectomy rate, post-operative length of stay and complication rate. Patients will be followed up at 30 days to collect outcome data. No changes will be made to routine patient care pathways/management or follow-up in this observational study. A mandatory hospital-level survey will explore available resources, infrastructure, surgical expertise, and relevant care protocols of sites participating in the study. It will allow us to account for variations in hospital capabilities and adjust analyses, improving the accuracy of cross-country comparisons and identifying system-level factors that may affect surgical success. Consultant Leads in each participating hospital will ensure appropriate study registration approval as per local regulations and this is mandatory for participation. There will be two optional sub-studies on waste management and sustainability and financing at select sites.

Discussion: This study will generate granular data on the global variability in appendicectomy management and outcomes, offering insights into access to emergency care, imaging, and minimally invasive surgery for whole system strengthening. The findings will guide recommendations for both high-income and low- and middle-income countries, informing government policy and improving patient outcomes.