The usefulness of subjective vs objective factors in predicting postoperative complications after appendectomy

Author(s):
Andrew Vallejo; Patrick McGillen; Tejal Brahmbhatt; Minh-Thuy Nguyen; F. Thurston Drake; Sabrina Sanchez, MD

Background:

There is little data exploring the role of a surgeon’s intraoperative assessment of disease severity when assessing patients for risk of postoperative complications. We aimed to compare intraoperative findings, imaging, and histopathology results to determine reliable predictors of postoperative complications.

Hypothesis:

We hypothesized that a surgeon’s assessment of disease severity during appendectomy would be more closely associated with the development of postoperative complications than objective measures of disease severity.

Methods:

We conducted a single-institution retrospective review of patients receiving an appendectomy for acute appendicitis, 2012-2016. Variables measured included admission vital signs and laboratory results, imaging findings, the surgeon’s intraoperative description of the appendix, and histopathology results. Complications of interest included readmission, postoperative ileus, surgical site infection, extra-abdominal infection, clostridium difficile infection, and death. Descriptive and inferential statistics were used to [1] compare complicated and uncomplicated appendicitis as determined by imaging characteristics, final histopathology, and surgeon’s intraoperative diagnosis and [2] evaluate the risk of postoperative complications based on these variables.

Results:

1,058 patients underwent appendectomy for acute appendicitis during the study period. Based on the surgeon’s intraoperative findings, 188 had complicated appendicitis. Of these, 136 (72.3%) were classified as uncomplicated on histopathology and 128 (68.1%) were classified as uncomplicated on imaging. A total of 73 patients (6.9%) developed a postoperative complication of which 48 (65.8%) were patients with complicated appendicitis based on intraoperative assessment. On nominal logistic regression, surgeon’s intraoperative diagnosis of complicated appendicitis was the only factor found to be significantly associated with postoperative complications (OR=5.54, p=0.0004).

Conclusions:

In this cohort, intraoperatively identified complicated appendicitis, but not complicated appendicitis classified as such by imaging or histopathology, was associated with higher rates of postoperative complications. This highlights the importance of a surgeon’s intraoperative evaluation of the appendix compared to preoperative imaging and final histopathology both in perioperative management and in clinical outcomes research comparing uncomplicated versus complicated appendicitis.