Masakazu Fujii1, Yusuke Watanabe, MD2, Chisato Ichimaru, MD1, Shintaro Takeuchi, MD1, Kiyotaka Imamura, MD1, Kentaro Katou, MD1, Yoshihiro Kinoshita, MD1, Minoru Takada, MD1, Yoshiyasu Anbo, MD1, Fumitaka Nakamura, MD1. 1Department of Surgery, Teine Keijinkai Medical Center, 2Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine
Introduction: Validity evidence of the American Association for the Surgery of Trauma (AAST) grading system for appendicitis has been reported in the US and South America. We evaluated whether the preoperative AAST severity scores correlate with outcomes of appendicitis in the Japanese healthcare system and correspond with intraoperative findings in order to forecast case difficulties.
Methods and Procedures: Patients (≥18 years) with a preoperative diagnosis of appendicitis during 2013-2017 in a major teaching hospital were reviewed. The image-based AAST (iAAST) grades were assigned based on CT findings (range 1-5, grade≥3 were defined as perforated appendicitis). Demographics, operative findings, and procedure types were collected. Outcomes including 30-day mortality, complications based on Clavien-Dindo categories, length of stay, and institutional costs were reviewed. Descriptive and univariate analyses were performed to compare iAAST grades with operative findings and clinical outcomes. The correlation of iAAST with intraoperative AAST grades was calculated using a kappa statistic. Malignant cases were excluded from data analysis.
Results: A total of 406consecutivepatients with a median[IQR] age of 45[32-63] (range 18-92) were analyzed (46% female). The iAAST grade is as follows: Grade I(115, 28%), Grade ?(46, 11%),Grade ?(144, 36%),Grade ?(58, 14%),and Grade ?(43, 11%). Management included appendectomy(n=295, 76%), interval appendectomy(n=36, 9.0%), and conservative management with antibiotics(n=63, 15%). Operative management consisted of laparoscopic appendectomy(LA; n=319, 93%), LA with partial cecectomy(n=13, 3.8%), laparoscopic ileocecal resection(n=3, 0.9%), and open surgery(n=8, 2.3%).Among all patients, increased iAAST grade correlated with length of stay(rs=0.44, p<0.01) and institutional cost(rs=0.30, p<0.01) regardless of management pathways. Of 295 patients with initial operative management performed by surgeons at varying levels of experience [24 surgical trainees(72%), 8 attending surgeons(28%)], the iAAST grade associated with operative time(rs=0.33, p<0.01) but didn’t correlate with procedure types. No 30-day mortality was observed, and overall complication rate was 10% (Clavien-Dindo≥2). From operative findings, 29% of the patients with iAAST grade ≤2(n=121) were diagnosed with perforated appendicitis, and 48% with iAAST grade 3-5(n=174) were diagnosed with non-perforated appendicitis(kappa coefficient= 0.22, p<0.01). Perforated appendicitis significantly increased operation time(65[50-85] vs. 102[72-127], p<0.01) and complication rate(p<0.01), regardless of level experience.
Conclusions: Although the iAAST grade predicts clinical outcomes in a Japanese population, the preoperative grading has some limitations to forecast intraoperative findings. Better estimations of intraoperative findings may help predict case difficulty to optimize the efficacy of surgical care in teaching hospitals.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93872
Program Number: P031
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster