Manejo prehospitalario y evolución postoperatoria en los pacientes con apendicitis aguda atendidos en el Hospital Básico Jipijapa en Ecuador J. Adv. Educ. Sci. Humanit. (July - December 2025) 3(2): 1-8 https://doi.org/10.5281/zenodo.16664353 ISSN 3091-1583 ORIGINAL ARTICLE Prehospital management and postoperative course of patients with acute appendicitis treated at the Jipijapa Basic Hospital in Ecuador  Alfredo L. Marín alfredo.marin@utm.edu.ec Received: 09 March 2025 / Accepted: 11 June 2025 / Published online: 31 July 2025 © The Author(s) 2025 Edwin Escobar · Alfredo L. Marín · Nancy Toledo · Cristhian S. Macías Abstract Acute appendicitis is a common medical emer- gency, the prehospital management of which can vary sig- nificantly, impacting postoperative patient outcomes. The general objective of this study is to analyze the prehospital management and postoperative evolution in patients with acute appendicitis treated at this hospital. This analysis is based on an observational, retrospective, and descriptive methodology applied from May 2021 to May 2022. The study population includes all patients operated on for acute appendicitis at the hospital, selecting a sample of 219 pa- tients who meet the established inclusion criteria. The specif- ic results of the study include a detailed characterization of the sociodemographic characteristics of patients with acute appendicitis, the establishment of the prehospital manage- ment practices currently applied, the determination of the evolution patterns and postoperative complications, and the identification of the relationship between sociodemographic characteristics and postoperative complications, delving into how distances, time and other sociodemographic conditions impact outcomes. Keywords appendicitis, prehospital services, postoperative complications, descriptive epidemiology. Resumen La apendicitis aguda es una emergencia mé- dica común, cuyo manejo prehospitalario puede variar sig- nificativamente, impactando los resultados postoperatorios de los pacientes. El presente estudio tiene como objetivo general analizar el manejo prehospitalario y la evolución postoperatoria en pacientes con apendicitis aguda tratados en dicho hospital. Este análisis se basa en una metodología observacional, retrospectiva y descriptiva, aplicada durante el periodo de mayo de 2021 a mayo de 2022. La población de estudio incluye a todos los pacientes operados por apen- dicitis aguda en el hospital, seleccionando una muestra de 219 pacientes que cumplen con los criterios de inclusión es- tablecidos. Los resultados específicos del estudio incluyen una caracterización sociodemográfica de los pacientes con apendicitis aguda; el establecimiento de las prácticas de ma- nejo prehospitalario actualmente aplicadas; la determinación de los patrones de evolución y las complicaciones postopera- torias; y la identificación de la relación entre las característi- cas sociodemográficas y las complicaciones postoperatorias, profundizando en cómo las distancias, el tiempo y otras con- diciones sociodemográficas impactan en los resultados. Palabras clave apendicitis, servicios prehospitalarios, com- plicaciones posoperatorias, epidemiología descriptiva. How to cite Escobar, E., Marín, A. L., Toledo, N., & Macías, C. S. (2025). Prehospital management and postoperative course of patients with acute appendicitis treated at the Jipijapa Basic Hospital in Ecuador. Journal of Advances in Education, Sciences and Humanities, 3(2), 1-8. https://doi.org/10.5281/zenodo.16664353 Facultad de Ciencias de la Salud, Universidad Técnica de Manabí, Portoviejo, Ecuador.

J. Adv. Educ. Sci. Humanit. (July - December 2025) 3(2): 1-8 2 Introduction Acute appendicitis is one of the most common surgi- cal emergencies worldwide, with an annual incidence of approximately 100 cases per 100,000 inhabitants (Addiss et al., 1990). Despite progress in diagnostic and therapeu- tic techniques, this condition continues to be associated with significant levels of morbidity and mortality, particularly in regions with limited access to medical services or in patients with atypical clinical manifestations (Bhangu et al., 2015). Acute appendicitis is recognized as a true medical and sur- gical emergency. It is the leading cause of urgent abdominal surgery worldwide. Inflammation of the appendix can pro- gress to rupture within 48 to 72 hours of the onset of symp- toms, which can lead to serious complications such as perito- nitis, sepsis, and even death if not treated promptly. In recent decades, surgical techniques have undergone significant advances, with the most notable being the use of laparoscopy, including minimally invasive approaches such as single-port surgery through the umbilical cord or natural orifices, utilizing retrograde endoscopic access with inter- nal prostheses. These innovations have even facilitated ou- tpatient appendectomy. In parallel, there has been a debate about the possibility of avoiding surgery in all cases, explo- ring conservative therapeutic alternatives similar to those used in conditions such as diverticulitis (Andersson, 2007). Given this situation, it is important to identify the factors that influence the postoperative recovery of patients diagno- sed with acute appendicitis. Several studies have analyzed variables such as age, sex, the presence of peritonitis at the time of diagnosis, and the time elapsed from the onset of symptoms to definitive treatment (Andersson, 2007). Recent work has highlighted the vulnerability of patients from rural areas, who face greater barriers to accessing ti- mely medical care. Rodríguez and Carasa (2021), for exam- ple, found that rural patients had a 25% postoperative com- plication rate, compared to 15% in urban areas, highlighting the importance of ensuring rapid access to health services. Similarly, Ghosh et al. (2023) identified a strong correlation (r = 0.62) between delayed prehospital care and increased postoperative morbidity, underscoring the need to imple- ment targeted strategies to enhance care in rural settings. However, surgical treatment remains the preferred option for many specialists, as it is considered the safest and most effective approach. Appendectomy, whether laparoscopic or conventional, immediate or delayed, not only allows for de- finitive resolution of the clinical picture but also confirms the diagnosis and rules out other pathologies, including neopla- sia. In contrast, conservative approaches can have high recu- rrence rates, which continues to generate controversy in the medical community. To clarify the best therapeutic strategy, prospective, randomized clinical studies with larger sample sizes will be necessary to compare outcomes between di- fferent surgical and conservative approaches in the coming years. In general, the postoperative course after an appendec- tomy is favorable, with rapid recovery. Most patients can be discharged the day after the procedure and return to their daily activities within one to two weeks. However, compli- cations such as surgical wound infections, intra-abdominal abscesses, adhesion formation, or, in more complex cases, cecal fistulas, may occur. In the particular case of the Jipijapa Basic Hospital, it has been observed that the postoperative course of patients with acute appendicitis can vary significantly, influenced mainly by the quality of prehospital management and limitations in access to specialized medical care. In this context, the present study is justified. Its purpose is to analyze both the prehospital management and postope- rative outcomes of patients with acute appendicitis treated at the Jipijapa Basic Hospital. This analysis aims to provide valuable insights for enhancing the quality of care in vulne- rable populations with limited access to healthcare services. It should be noted that acute appendicitis is more common in people between 20 and 30 years of age, with no marked di- fference between genders. Its clinical presentation can vary, making the use of imaging studies necessary for an accurate diagnosis. Treatment generally involves surgery, which can be performed laparoscopically or with open surgery (Her- nández-Cortez et al., 2019). It is estimated that approximately 10% of the general po- pulation will develop acute appendicitis at some point in their lives, with the condition being more common during the second and third decades (Pastrana & García de Casaso- la, 2023). Although it is one of the most common causes of emergency surgery, its diagnosis and treatment continue to pose a clinical challenge for healthcare professionals (Di Saverio et al., 2020). Postoperative complications may de- pend on the stage of the disease, the surgical technique em- ployed, and the patient’s characteristics. Patients from rural settings or with limited access to health services may experience longer delays in care, with a higher risk of complications. Factors such as self-medication and type of health insurance also influence this problem (Tom et al., 2019; Wong et al., 2022). Within this framework, the objective of this study was to analyze the prehospital mana-

J. Adv. Educ. Sci. Humanit. (July - December 2025) 3(2): 1-8 3 gement and postoperative outcomes of patients with acute appendicitis treated between May 2021 and May 2022 at the Jipijapa Basic Hospital. Methodology This study employed an observational, retrospective, analytical, and cross-sectional design. The research was ba- sed on a review of the medical records of patients diagnosed with acute appendicitis who underwent surgery at the Jipija- pa Basic Hospital between May 2021 and May 2022. The total population consisted of 265 cases recorded du- ring that period. Of these, 219 met the established criteria for inclusion in the study. From this group, a sample of 140 patients was selected using simple random probability sam- pling. The sample size was calculated using a statistical for- mula for proportions, considering a 95% confidence level and a 5% margin of error to ensure data representativeness. Inclusion criteria were established for patients with a confirmed diagnosis of acute appendicitis who underwent surgery at the Jipijapa Basic Hospital and had a complete medical record, including information on their postoperative progress. Patients whose medical records were incomplete, those whose postoperative follow-up was not performed at the same hospital, and cases referred to other health institu- tions for recovery were excluded from the study. Data collection was carried out using a structured form specifically designed to record sociodemographic data, characteristics of prehospital management (such as type of transfer and waiting time for medical care), and the presen- ce of postoperative complications, including infections and disorders of the respiratory, gastrointestinal, or urinary sys- tems. This instrument was developed based on models vali- dated in previous studies (Ortiz & Ortiz, 2021; Castro et al., 2022), ensuring data reliability. SPSS version 23.0 was used for statistical analysis. Des- criptive statistical techniques were used to present absolute and relative frequencies, as well as inferential tests to ex- plore associations between variables. Specifically, Pearson’s chi-square test was used to examine the relationship between patient origin and postoperative outcome, Spearman’s co- rrelation test was used to analyze the relationship between nonparametric variables such as waiting time and type of transfer, and a binary logistic regression model was used to identify factors that could predict the occurrence of posto- perative complications. A statistical significance level of p ≤ 0.05 was adopted. Regarding ethical aspects, the study was approved by the Human Research Ethics Committee of the Technical Univer- sity of Manabí (CEISH-UTM) and had the appropriate insti- tutional authorization from the Jipijapa Basic Hospital. The confidentiality of information and the anonymity of partici- pants were guaranteed at all times. Furthermore, efforts were made to comply with the ethical principles established for scientific health research, and approaches promoting gender equity and equality were respected throughout all phases of the study. Results and discussion Table 1 presents the sociodemographic characteristics of patients diagnosed with acute appendicitis. The results show that the predominant age group was 26 to 40 years (70%), indicating that acute appendicitis most frequently affects young adults, related to biological factors and lifestyles typi- cal of these ages. In terms of gender, a balanced distribution was observed between men (47.9%) and women (52.1%), suggesting that the condition does not have a significant sex predisposition. Table 1. Sociodemographic characteristics of patients with acute appendicitis Feature Category Frequency Percentage (%) Age (Years old) 18-25 40 28.6 26-40 98 70.0 >40 2 1.4 Sex Male 67 47.9 Female 73 52.1 Home Rural 85 60.7 Urban 55 39.3 Education level Not in school 10 7.1 Primary 35 25.0 Secondary 65 46.4 University 30 21.4 The household analysis revealed that 60.7% of patients were from rural areas, which made it difficult for them to ac- cess timely health services. 46.4% of patients had a medium level of education, which may have contributed to the late identification of symptoms and, consequently, increased wait times for medical care. Baranov et al. (2023) found that 65% of patients with acu- te appendicitis in their study were from rural areas, a result similar to the 60.7% observed in the present investigation. Alyhari et al. (2022) reported that 55% of their patients were female, a figure similar to the 52.1% reported in this study, suggesting a comparable gender distribution across geogra- phical settings. These results suggest that geographic location and educa-

J. Adv. Educ. Sci. Humanit. (July - December 2025) 3(2): 1-8 4 tional level may be determining factors in the progression of the disease, impacting medical response time and postopera- tive complications. Table 2 shows the prehospital management of patients with acute appendicitis, including the type of transfer and waiting time before receiving medical care. Regarding the type of transfer, most patients (50.0%) arrived at the hospital by private vehicle, while only 28.6% used an ambulance and 21.4% used other means of transportation. This highlights li- mited access to ambulances, especially in rural areas, where 60.7% of patients live. Table 2. Prehospital management of patients with acute appendicitis Variable Category Frequency Percentage (%) Type of transfer Ambulance 40 28.6 Private vehicle 70 50.0 Other 30 21.4 Waiting time (h) < 6 45 32.1 6-12 60 42.9 12-24 25 17.9 > 24 10 7.1 Waiting times for medical care show that 42.9% of patients waited between 6 and 12 hours before receiving care, which is a long period for a condition requiring im- mediate surgical intervention. Furthermore, 25% of pa- tients had to wait more than 12 hours, which is associated with a higher risk of postoperative complications. The relationship between the type of transfer and the location of the patient’s residence indicates that rural patients have less access to ambulances and tend to rely more on private vehicles or informal transportation. This contributes to delays in medical care and, therefore, a worse postoperative prognosis. These data highlight the need to improve the timing of medical care available to reduce associated complications. Alyhari et al. (2022) reported that 48% of patients arrived at the hospital by private vehicle, similar to the 50.0% reported in this study. Similarly, Gutiérrez et al. (2009) reported that 40% of patients waited more than 6 hours for care, a figure close to the 42.9% observed in this study, suggesting that long wait times remain a common problem. Table 3 presents the main postoperative complications in the evaluated patients. Surgical site infections are the most frequent complications, accounting for 35.7% of cases. This result is consistent with the literature, as bac- terial contamination during surgery and the patient’s in- flammatory response can increase the risk of infection, especially in emergency procedures or those with pro- longed surgical time. Table 3. Postoperative evolution and complications Postoperative complication Frequency Percentage (%) Surgical site infection 50 35.7 Wound dehiscence 15 10.7 Evisceration 5 3.6 Paralytic ileus 20 14.3 Gastric dilation/vomiting 5 3.6 Intestinal occlusion by bands 8 5.7 Urinary infection 10 7.1 Urinary fistula 5 3.6 Bronchopneumonia 10 7.1 Pleural effusion 5 3.6 Subphrenic abscess 3 2.1 Douglas pouch abscess 2 1.4 Interloop abscess 2 1.4 Diffuse peritonitis 5 3.6 Generalized sepsis 20 14.3 Thrombophlebitis / PTE 3 2.1 Thrombophlebitis of the upper limbs 2 1.4 Among wound integrity-related complications, wound dehiscence (10.7%) and evisceration (3.6%) represent ad- verse events that can prolong hospital stay and increase morbidity. These problems may be associated with fac- tors such as inadequate suturing, excessive tissue tension, malnutrition, or underlying diseases, including diabetes mellitus. Digestive complications are also significant, with para- lytic ileus (14.3%) and intestinal obstruction due to intes- tinal bands (5.7%) being the most common. Paralytic ile- us is a common consequence of intestinal manipulation during surgery and can be exacerbated by opioid use and prolonged rest. On the other hand, intestinal obstruction due to intestinal bands is a late complication that may re- quire reoperation in some cases. Secondary infections, such as urinary tract infections (7.1%) and urinary fistulas (3.6%), may be due to the pro- longed use of urinary catheters or unnoticed injuries to the urinary tract during surgery. In the respiratory setting, bronchopneumonia (7.1%) and pleural effusion (3.6%) may be associated with postoperative immobilization, prolonged mechanical ventilation, or aspiration second- ary to vomiting. Intra-abdominal infections, such as subphrenic abscess

J. Adv. Educ. Sci. Humanit. (July - December 2025) 3(2): 1-8 5 (2.1%), pouch of Douglas abscess (1.4%), interloop ab- scess (1.4%), and diffuse peritonitis (3.6%), are serious complications that can lead to generalized sepsis, which occurred in 14.3% of cases. Sepsis remains a leading cause of postoperative mortality, highlighting the impor- tance of close monitoring and timely antibiotic treatment in patients with signs of systemic infection. Finally, thromboembolic complications, such as throm- bophlebitis/pulmonary thromboembolism (PTE) (2.1%) and upper limb thrombophlebitis (1.4%), although less frequent, represent a significant risk for postoperative pa- tients, especially those with prolonged immobilization or a history of hypercoagulability. Overall, the data indicate that infections and digestive complications are the primary postoperative issues in the analyzed sample. These results underscore the need to implement effective strategies for antibiotic prophylaxis, metabolic control, and early mobilization to reduce the in- cidence of complications and improve patient outcomes. A rate of 30% (29) was reported for infection of the sur- gical site, which is comparable to the 35.7% observed in this study. While the incidence of sepsis was 12%, similar to the 14.3% reported in this study, indicating that gen- eralized sepsis is a significant complication that requires urgent attention (Lee & Yoon, 2022). Table 4 presents the relationship between the socio- demographic characteristics of the patients and the ap- pearance of the three most frequent postoperative com- plications: surgical site infection, paralytic ileus, and generalized sepsis (Table 3). Table 4. Relationship between sociodemographic characteristics and postoperative complications (Pearson coeffi- cients) Sociodemographic variable Surgical site infection (r) Paralytic ileus (r) Generalized sepsis (r) Age 0.20 0.15 0.25 Sex 0.30 0.25 0.40 Home 0.60 0.50 0.70 Education level 0.25 0.20 0.30 Pearson’s coefficients indicate the strength and direction of the correlation between each sociodemographic variable and the occurrence of these complications. The results show that residence has the highest correlation with all the postoperati- ve complications analyzed, particularly in generalized sepsis (r = 0.70) and surgical site infection (r = 0.60). This suggests that patients from rural areas may be more exposed to factors that increase the risk of complications, such as less access to early medical care or inadequate hygiene conditions. Sex also shows relatively high correlations, with values of r = 0.40 for generalized sepsis and r = 0.30 for surgical site infection. This could indicate differences in immunological response or exposure to risk factors based on patient sex. On the other hand, age and educational level show lower correlations compared to the other variables, although they still show some association with the onset of complications. The strongest correlation among these factors is observed between educational level and generalized sepsis (r = 0.30), which suggests that a lower educational level may influence access to information on postoperative care and adherence to recommended medical treatments. Overall, the results consider sociodemographic factors in the postoperative prognosis of patients, especially in the de- velopment of strategies to reduce complications in vulnera- ble populations. A higher incidence of postoperative complications (65%) was recorded in patients from rural areas, with a correlation coefficient of 0.70, suggesting a significant association be- tween rural residence and increased postoperative compli- cations (Hançerlioğulları et al., 2022). For their part, Seow et al. (2022) reported a correlation of 0.45 between sex and the incidence of sepsis, a value comparable to the 0.40 ob- served in this study, indicating that gender may play a role in the occurrence of sepsis; therefore, sociodemographic fac- tors should be considered in the care of patients with acute appendicitis. Alyhari et al. (2022) identified a correlation of 0.65 be- tween rural residence and ambulance use, a result similar to the correlation of 0.70 reported in this study, suggesting that geographic location significantly influences the type of transport used by patients. The correlation between sex and waiting time was 0.50, slightly higher than the 0.40 observed in this study, indicating that gender may influence patterns of access to and use of health services (Roemer et al., 2021). Analysis in Table 5 reveals a significant association be- tween patient residence and the presence of postoperative complications (p = 0.001). Patients from rural areas had a considerably higher complication rate (65.0%) compared to those residing in urban areas (40.0%). This result suggests that living conditions and access to health services may in- fluence postoperative outcomes. Rural patients may face barriers to medical care or difficulties in following postope-

J. Adv. Educ. Sci. Humanit. (July - December 2025) 3(2): 1-8 6 rative instructions, which would increase their risk of com- plications. Furthermore, factors such as access to hospitals, health education, and hygiene conditions could influence these results. Table 5. Association between home and postoperative evolution (Chi-Square test) Home With complications (%) No complications (%) p-value Rural 65.0 35.0 0.001 Urban 40.0 60.0 The higher percentage of urban patients without compli- cations (60.0%) may be attributed to proximity to health services and better socioeconomic conditions, which could facilitate a more optimal recovery. These results justify con- sidering the patient’s home address when planning follow-up and postoperative care strategies, especially in populations with limited access to medical services. Table 6 shows a significant relationship between waiting time and the incidence of postoperative complications in pa- tients with acute appendicitis. Waiting time before surgical care is strongly correlated with the development of gene- ralized sepsis (ρ = 0.65, p = 0.002), suggesting that longer delays in surgery increase the risk of a severe systemic in- flammatory response. This is consistent with previous stu- dies indicating that delays in surgical intervention in cases of complicated appendicitis can lead to the spread of intra-ab- dominal infections, increasing the risk of sepsis and posto- perative mortality. Table 6. Relationship between prehospital management and postoperative complications Prehospital management Surgical site infection (ρ) Paralytic ileus (ρ) Generalized sepsis (ρ) Waiting time 0.50 0.45 0.65 Type of transfer 0.40 0.35 0.58 Furthermore, the correlation between waiting time and surgical site infection (ρ = 0.50) indicates that patients who experience longer delays in surgery are more likely to de- velop postoperative infections. This may be related to the progression of the inflammatory process and the possible perforation of the appendix, which can facilitate bacterial contamination during surgery and the postoperative period. Similarly, waiting time also shows a moderate correlation with the occurrence of paralytic ileus (ρ = 0.45), suggesting that longer delays in surgery may contribute to postoperati- ve intestinal motility dysfunctions. This finding is consistent with the literature, which indicates that prolonged inflam- mation and surgical stress increase the risk of postoperative ileus by disrupting the gut-autonomic nervous system axis. On the other hand, the type of transfer also influences the occurrence of postoperative complications, although with moderate correlation coefficients. A correlation of ρ = 0.58 was found between the type of transfer and generalized sep- sis, indicating that patients who arrive at the hospital by pri- vate vehicle or other informal means have a higher incidence of this complication compared to those who are transferred by ambulance. This may be attributed to the lack of adequa- te life support measures during transfer, delayed arrival at the hospital, and inadequate monitoring during the referral process. Furthermore, the correlation between transfer type and surgical site infection (ρ = 0.40) indicates that patients trans- ported in non-specialized transport may be at a higher risk of developing postoperative infections. This may be due to factors such as longer delays in administering preoperative antibiotics, inadequate patient stabilization, and suboptimal transport conditions. The relationship between transfer type and the occurrence of paralytic ileus (ρ = 0.35) suggests that how a patient is transported to the hospital may also affect postoperative gastrointestinal function, possibly due to he- modynamic instability or prolonged pain during transport. These results show that both waiting time and type of transfer significantly influence the postoperative outcome of patients with acute appendicitis. The strong correlation between waiting time and generalized sepsis highlights the need to reduce care times to minimize serious complications. Furthermore, the influence of transfer type on postoperative outcome reinforces the importance of emergency medical systems and ensuring timely access to appropriate transpor- tation. These results suggest that improving hospital infras- tructure and prehospital transfer logistics could have a sig- nificant impact on reducing postoperative complications and improving patient outcomes. Table 7 illustrates the relationship between waiting time, type of transfer, and postoperative outcomes in patients with acute appendicitis. A strong positive correlation (ρ = 0.65) was found between waiting time and postoperative outcome, with a p-value of 0.002. This means that the longer the wai- ting time, the greater the likelihood of patients developing

J. Adv. Educ. Sci. Humanit. (July - December 2025) 3(2): 1-8 7 postoperative complications. This confirms the importance of prompt medical attention in cases of acute appendicitis to prevent adverse outcomes. Table 7. Relationship between waiting time and type of transfer with postoperative evolution (Spearman coefficient) Independent variable Dependent variable Correlation coefficient (ρ) p-value Waiting time Postoperative evolution 0.65 0.002 Type of transfer 0.58 0.004 The correlation (ρ = 0.58, p = 0.004) between the type of transport and postoperative outcome can be considered moderate. This indicates that patients who were transported by private vehicle or other means had a higher incidence of complications compared to those who arrived at the hospi- tal by ambulance. A p-value ≤ 0.05 indicates that this rela- tionship is statistically significant. This result is related to the need to ensure adequate access to ambulance services, especially in rural areas, to improve the postoperative outco- me of patients with acute appendicitis. Identifying predictors of postoperative complications is essential for improving patient care and clinical outcomes. Table 8 presents the analysis of three key variables related to postoperative complications: waiting time exceeding 12 hours, type of transport by private vehicle, and rural resi- dence. Table 8. Binary logistic regression for predictive factors of postoperative complications Independent variable OR (95% CI) p-value Waiting time (>12 h) 2.8 (1.5-5.2) 0.003 Type of transfer (private vehicle) 1.9 (1.1-3.4) 0.025 Home (rural) 3.5 (2.0-6.1) 0.001 The results show that patients with a waiting time of more than 12 hours are almost three times more likely to expe- rience postoperative complications (OR = 2.8; 95% CI: 1.5- 5.2; p = 0.003). Transport by private vehicle also increases the risk of complications compared with ambulance use (OR = 1.9; 95% CI: 1.1-3.4; p = 0.025). Patients in rural areas have a significantly higher risk of postoperative complica- tions (OR = 3.5; 95% CI: 2.0-6.1; p = 0.001), supporting the hypothesis that limited access to prehospital medical servi- ces contributes to worse clinical outcomes. Conclusions Acute appendicitis primarily affected young adults, with no differences between sexes, and mostly patients from rural areas, where limited access to health services and inadequate transportation hampered timely care. The predominant ave- rage educational level may have contributed to late identifi- cation of symptoms. Delays in care and prolonged waiting times before surgery were associated with a higher risk of postoperative complications, especially in rural patients. The results highlighted the need to strengthen healthcare infras- tructure and expedite access to surgical treatment for vulne- rable populations. References Addiss, D. G., Shaffer, N., Fowler, B. S., & Tauxe, R. V. (1990). The epidemiology of appendicitis and appen- dectomy in the United States. American Journal of Epi- demiology, 132(5), 910–925. https://doi.org/10.1093/ oxfordjournals.aje.a115734 Alyhari, Q., Ahmed, F., Nasreldin, M., Nikbakht, H. A., Alamin, A., Al-wageeh, S., Ghabisha, S., Al-Shami, E., & Mohammed, F. (2022). Prehospital delay and its associated factors in Sudanese patients presenting with acute appendicitis at a teaching hospital. Cureus, 14, e23036. https://doi.org/10.7759/cureus.23036 Andersson, R. E. (2007). The natural history and traditional management of appendicitis revisited: Spontaneous re- solution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World Journal of Surgery, 31(1), 86–92. https://doi.org/10.1007/s00268-006-0056-y Baranov, A. V., Cheremisina, V. N., Simonov, S., & Bara- nova, S. A. (2023). Medical and social characteristics of patients with acute appendicitis at prehospital de- lay. Tambov Medical Journal, 5(4), 58–64. https://doi. org/10.20310/2782-5019-2023-5-4-58-64 Bhangu, A., Søreide, K., Di Saverio, S., Assarsson, J. H., & Drake, F. T. (2015). Acute appendicitis: Modern un- derstanding of pathogenesis, diagnosis, and manage- ment. The Lancet, 386(10000), 1278–1287. https://doi. org/10.1016/S0140-6736(17)31502-7 Castro, P., Rincón, J., Sánchez, C., Molina, I., & Buitrago, G. (2022). Presurgical time and associated factors as pre- dictors of acute perforated appendicitis: A prospective cohort study in a teaching pediatric hospital in Colom- bia. BMC Pediatrics, 22(1), 49. https://doi.org/10.1186/ s12887-022-03121-8 Di Saverio, S., Podda, M., De Simone, B., Ceresoli, M., Augustin, G., Gori, A., Boermeester, M., Sartelli, M., Coccolini, F., Tarasconi, A., De’ Angelis, N., Weber,

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American Volume, 85(8), 1454–1460. https://pubmed.ncbi.nlm. nih.gov/12925624/ Conflicts of interest The authors declare that they have no conflicts of interest. Author contributions Conceptualization: Edwin Escobar, Cristhian S. Macías. Data curation: Alfredo L. Marín, Nancy Toledo. Formal analysis: Edwin Escobar, Alfredo L. Marín. Research: Ed- win Escobar, Alfredo L. Marín, Nancy Toledo, Cristhian S. Macías. Methodology: Alfredo L. Marín, Nancy Toledo. Supervision: Alfredo L. Marín, Nancy Toledo. Validation: Alfredo L. Marín, Nancy Toledo. Visualization: Edwin Escobar, Cristhian S. Macías. Writing the original draft: Edwin Escobar, Cristhian S. Macías. Writing, review and editing: Edwin Escobar, Alfredo L. Marín, Nancy Toledo, Cristhian S. Macías. Data availability statement The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Statement on the use of AI The authors acknowledge the use of generative AI and AI-assisted technologies to improve the readability and cla- rity of the article. Disclaimer/Editor’s note The statements, opinions, and data contained in all publi- cations are solely those of the individual authors and contri- butors and not of Journal of Advances in Education, Scien- ces and Humanities. Journal of Advances in Education, Sciences and Humani- ties and/or the editors disclaim any responsibility for any in- jury to people or property resulting from any ideas, methods, instructions, or products mentioned in the content.