Acute appendicitis serves as a critical indicator of emergency healthcare performance, and the AlliGatOr study is set to examine global variations in appendectomy care. Project lead Theophilus Teddy Kojo Anyomih discusses the study’s aims, its potential to inform policy recommendations and how its findings around best practice could help strengthen emergency care systems and improve patient outcomes worldwide.
Acute appendicitis is one of the most frequent surgical emergencies worldwide. Yet, the choice between conservative (non-operative) management and appendicectomy is influenced by a complex interplay of clinical, systemic and sociocultural factors. Patient presentation, access to imaging, surgical workforce availability, and even the patient’s ability to afford care all contribute to this decision.
In high-resource settings, early diagnosis supported by imaging enables tailored care pathways, often including laparoscopic surgery. In contrast, many low- and middle-income countries (LMICs) face limited diagnostic and surgical resources, leading to delayed or even missed operative intervention. In some contexts, conservative management with antibiotics may be adopted – not because it is optimal, but because surgery is unavailable.
The Appendicitis Global Outcomes study
This global heterogeneity in resources and decision-making is a key motivator behind the Appendicitis Global Outcomes (AlliGatOr) study. By comparing systems worldwide, we aim to distinguish decisions driven by clinical best practices from those shaped by logistical constraints.
AlliGatOr leverages a common emergency condition to illuminate how surgical systems function across diverse contexts. By using appendicitis as a tracer condition, the study provides real-time insight into the performance, equity and resilience of emergency surgical care worldwide.
Coordinated by the National Institute for Health and Care Research (NIHR) Global Surgery Unit at the University of Birmingham, the study is supported by a vast network of collaborators spanning multiple countries and hospitals. Its delivery is powered by national leads, consultant hospital leads, co-leads and mini-teams comprising residents and trainees, medical students and allied professionals.
This inclusive and decentralised model builds local capacity, empowers teams on the ground and fosters peer-to-peer learning across borders.
AlliGatOr study aims
The AlliGatOr study has two key aims:
1. To identify areas for system strengthening in emergency surgical care
2. To evaluate global variation in the presentation, diagnosis, management and outcomes of acute appendicitis.
To achieve these goals, the study collects standardised data across eight predefined 14-day windows between February and May 2025. During each period, participating teams record all consecutive appendicectomy cases, collecting detailed patient-level data on presentation, imaging, surgical approach and 30-day outcomes – including complications, length of hospital stay and readmissions.
In parallel, hospitals complete a mandatory site survey that provides contextual data on imaging availability, surgical expertise and resource access.
Additionally, two sub-studies are nested within AlliGatOr: one focusing on waste management and sustainability in operating theatres, and another exploring the financial burden of surgery in LMICs.
A global vision for emergency surgical care
AlliGatOr is not just a data collection exercise: it is a mechanism for shaping policy and practice at both local and global levels. It contributes to progress in several key areas, including improving emergency surgical care, identifying disparities in access to healthcare and refining clinical guidelines.
By benchmarking metrics such as time to surgery, imaging use, access to laparoscopy and complication rates, AlliGatOr identifies modifiable bottlenecks in care delivery. Hospitals can compare their own data against global standards to drive targeted, locally led quality improvements.
Previous studies, such as Hippo, GlobalSurg 1 and 2 run by the GlobalSurg Collaborative, have revealed stark disparities in regional access to safe surgery.
AlliGatOr continues this work, mapping disparities and generating evidence for targeted investment and policy reform.
Most existing appendicitis guidelines are based on data from high-income countries. AlliGatOr provides a richer, more inclusive dataset, allowing for greater nuance in clinical recommendations. Whether adjusting imaging expectations or tailoring antibiotic use, the study redefines what ‘best practice’ means across different contexts.
Creating efficiencies and driving best practice via AlliGatOr
As of April 2025, we are in period six of eight in our data collection timeline. The response has been phenomenal. Of over 2,000 hospitals registered globally, more than 1,100 across 108 countries have already contributed data. We have captured high-quality information from over 22,000 patients, making this the largest international cohort on appendicitis ever assembled.
This remarkable momentum reflects the strength of our collaborative network and the global commitment to improving emergency surgical care. Each data point brings us closer to uncovering the trends and insights that could reshape clinical practice.
One of the greatest values of global collaborative studies like AlliGatOr is the ability to surface low-cost, high-impact strategies that are adaptable across systems.
The study may also validate innovations such as outpatient appendicectomy protocols or task-shifting models, offering alternative pathways to effective care. By capturing and sharing these success stories, AlliGatOr builds a global repository of practical solutions.
Turning global data into national and local policy is challenging. Barriers include political inertia, limited funding and systemic resistance to change. While data is essential, it is rarely sufficient on its own.
The strength of AlliGatOr lies in its embedded model in that research is conducted within the hospitals themselves, fostering ownership and accountability. National leads can use their own country’s data to advocate for change, whether it is improved access to imaging, surgical workforce expansion or updated training curricula.
At the international level, partnerships with the World Health Organization, Ministries of Health and academic societies will be key to translating evidence into policy. Previous NIHR Global Surgery initiatives, such as COVIDSurg and Hippo, have already influenced real-world guidelines. AlliGatOr is expected to do the same.
A strong foundation of multidisciplinary care
The multidisciplinary team (MDT) extends beyond surgeons to include emergency physicians, radiologists, anaesthetists, operating theatre staff, nurses and, increasingly, allied health professionals. Their coordinated input influences diagnostic clarity, time to theatre, surgical approach and postoperative recovery.
Well-functioning MDTs are pivotal to improving patient outcomes, ensuring timely diagnosis, safer surgery and smoother recovery. Streamlined radiology support can reduce negative appendicectomy rates, while timely anaesthesia facilitates early intervention in complicated cases. In many systems, effective MDT collaboration is underpinned by clear protocols, rapid communication and a culture of shared decision-making.
However, in resource-constrained settings, MDTs often operate under strain, affecting both the reliability and timeliness of care. AlliGatOr captures this variability, offering an opportunity to benchmark how team structures influence outcomes and where improved MDT integration could offer the greatest benefit.
Hopes for the future of AlliGatOr
Our vision is for AlliGatOr to transform how appendicitis, and by extension, emergency surgery, is delivered worldwide. Specifically, we hope to see:
- Reduced variability in time to diagnosis and surgical intervention
- Increased access to minimally invasive techniques, where safe and feasible
- Strengthened surgical ecosystems in LMICs, with better coordination of diagnostics, operating theatres and postoperative care
- A stronger data-driven culture in surgery, where hospitals use outcome data to inform real-time improvements.
Ultimately, the quality of appendicitis care should not depend on where a patient lives. AlliGatOr brings us one step closer to achieving true global equity in emergency surgical care.
Conclusion
In a world where disparities in healthcare access persist, and emergency systems are under immense pressure, global collaborative research is not a luxury – it is a necessity. The AlliGatOr study is a powerful example of what can be achieved when clinicians worldwide unite around shared challenges.
Its legacy will extend beyond publications or conference presentations. It will live on in better-informed policies, stronger systems and, ultimately, in lives saved through safer, more equitable and more efficient surgical care.
Author
Theophilus Teddy Kojo Anyomih MBChB
National Institute for Health and Care Research Global Surgery Unit, University of Birmingham, UK
