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CASAP (Children’s Acute Surgical Abdomen Programme) and Acute Appendicitis

CASAP, for those of you with short memories, was a national collaboration between surgeons from BAPS and anaesthetists from the Royal College of Anaesthetists looking at factors in the management of the “acute abdomen” in children (Children’s Acute Surgical Abdomen Programme).

It has now produced its 2nd paper (1) concentrating on appendicitis and its sequelae and is the largest such prospective study in the UK (2).  So, all children from  1 – 16 years who underwent surgery in 80 hospitals between November 2019 and January 2022 were included . There were over 3100 children in the survey of which 2799 (90%) were operated on for suspected appendicitis. The primary measure of outcome was postoperative complications (CD ≥ 2) within 30 days of surgery and this occurred in 185 (7%).  As expected, these were largely surgical site infections (3%), small bowel obstruction and respiratory infections being relatively uncommon (1-2%). Only 2% required a second anaesthetic for intervention.

Ethnicity played a major role in risk of complication, with those of black ethnicity having a four-fold and other minority ethnic groups a two-fold increased risk of poorer outcomes. Other associations, perhaps  less surprisingly, included higher ASA physical status grades (OR 4.0) and need for peri-operative oxygen supplementation (OR 4.2). Deprivation did not seem to affect outcome.

Length of stay was a secondary outcome and was significantly associated with younger age groups (<5 years), deprivation, and, of course, complicated appendicitis. Ethnicity was not a factor here.

Given that it was a national outcome study involving not only specialist institutions but also district general hospitals the final pathology breakdown was interesting. So, 13% (n = 283) had a normal appendix, which some might regard as still too high, set alongside rarer pathologies including 11 malignancies and 9 cases of Meckel’s diverticulum.

What is the context of this study?

Stefano Giuliani’s study (2001-12 – HES-based) suggested that the negative appendicectomy rate varied from 11-13% and was increasing (3). The complication rate (14-18%) was much higher, but with a similar reintervention rate (2%). Simon Kenny’s GIRFT report (2017-18 – HES-based) suggested a negative appendicectomy rate of ~10% but provided no data on complications (4).


Read the original paper: 

Risk factors for complications after emergency surgery for paediatric appendicitis: a national prospective observational cohort study



  1. Selman AMR, Sogbodjor LA, Williams K, Davenport M, Moonesinghe SR. Structural indicators of quality care for children undergoing emergency abdominal surgery. Brit J Surg 2023; 110: 1100–1103,
  2. Sogbodjor LA, Razavi C, Williams K, Selman A, Pinto Pereira M, Davenport M, CASAP investigators* and Moonesinghe SR. Risk factors for complications after emergency surgery for paediatric appendicitis: a national prospective observational cohort study.

Anaesthesia 2023 doi:10.1111/anae.16184 [E published]

  1. Giuliani S, Cecil EV, Apelt N, Sharland M, Saxena S. Pediatric emergency appendectomy and 30-day postoperative outcomes in district general hospitals and specialist pediatric surgical centers in England, April 2001 to march 2012:retrospective cohort study. Ann Surg 2016; 263: 184–90.
  2. Kenny SE. NHS England and NHS Improvement; Getting It RightFirst Time: Paediatric Surgery GIRFT Programme National Specialty Report. 2021.

Mark Davenport

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