Luis R Taveras, MD, Omar Harirah, BS, Dang-Huy Do, BA, Folarin M Adeyemi, BS, Maryanne L Pickett, MD, Holly B Cunningham, MD, Jonathan B Imran, MD, Tarik D Madni, MD, MBA, Meaghan M Colletti, John Kubasiak, MD, Michael W Cripps, MD, MSCS. University of Texas Southwestern
INTRODUCTION: The objective of this study is to evaluate the relationship between intraoperative (IO) findings and the diagnosis of complicated appendicitis (CA). Postoperative management of these patients is highly dependent on the operative findings. Furthermore, IO assessment is a strong prognostic predictor of clinical outcomes.
METHODS: A multicenter cross-sectional study surveyed all surgeons performing emergent laparoscopic appendectomies from September 2017 to September 2018. The survey collected information regarding disease severity, case complexity, and IO findings. General demographics, preoperative parameters, operative details, and histopathological (HP) descriptions were collected for all cases. Descriptive statistics were compared using chi-square and t-test where appropriate. Significance was set at p <0.05 with a two-tailed distribution. Predictors of a diagnosis of CA were evaluated using a multivariable regression model.
RESULTS: Twelve surgeons completed surveys for 263 patients, of which 57.9% were male and median age was 33 years old (IQR 24.5-43). Respondents rated case difficulty, on a Likert-type scale, with a median score of 2 out of 5 (IQR 1-3). Conversion to open rate was 0.004%. The most common IO finding was hyperemia (45.63%). Median OR time was 49 (IQR 39-64.5) minutes. An IO diagnosis of CA was made in 12.55% of cases, while 4.56% were reported as complicated by HP. IO diagnosis has a sensitivity of 75% (CI 95% 50.9%, 91.34%), specificity of 81.59% (CI 95% 76.08%, 86.29%) and accuracy of 81.08% (CI 95% 75.77,85.66).
Cohorts were divided by HP diagnosis. Those with CA had higher creatinine (0.86 vs 0.77, p = 0.031), higher heart rates (96.76 vs 85.32, p = 0.007), increased rate of appendicolith on imaging (55.56 % vs 31.14%, p = 0.034) and larger appendix diameter (millimeters) on imaging (14.11 vs 11.38, p < 0.001).
Operative findings predictive of IO diagnosis were abscess (33.312, 2.270-488.879, p = 0.011), necrotic appendiceal wall (OR 13.71, 95% CI 2.148-87.497, p = 0.006) and purulent fluid (OR 7.703, 1.902-31.204, p = 0.004). While the findings that correlated with a HP diagnosis were gross perforation (OR 14.381, 95% CI 3.232-63.992, p < 0.001) and areas of necrosis (OR 5.36, 95% CI 1.249-23.039, p = 0.02), neither presence of purulent fluid or abscess was predictive for HP diagnosis.
CONCLUSION: Intraoperative findings of abscess and purulent fluid have a significant weight in the IO diagnosis of CA but do not correlate with a HP diagnosis. These findings start to explain the dichotomy between IO and HP diagnosis.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95594
Program Number: P015
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster