Ann Surg Treat Res.  2017 Aug;93(2):88-97. 10.4174/astr.2017.93.2.88.

Meaningful standard of reference for appendiceal perforation: pathology, surgery, or both?

• Kim HJ
• Kim MS
• Park JH
• Ahn S
• Ko Y
• Song SY
• Woo JY
• Lee KH
• Low-dOse Computed Tomography for Appendicitis Trial (LOCAT) Group

• KMID: 2387339
• DOI: http://doi.org/10.4174/astr.2017.93.2.88

Abstract

PURPOSE
This retrospective study was aimed to determine if appendiceal perforation identified pathologically but not surgically is clinically meaningful.
METHODS
The study consists of 2 parts. First, we reviewed 74 studies addressing appendiceal perforation published in 2012 and 2013. Second, in a cross-sectional study, we classified 1,438 adolescents and adults (mean age, 29.3 ± 8.4 years; 785 men) with confirmed appendicitis as "nonperforation" (n = 1,083, group 1), "pathologically-identified perforation" (n = 55, group 2), "surgically-identified perforation" (n = 202, group 3), or "pathologically- and surgically-identified perforation" (n = 98, group 4). The 4 groups were compared for the frequency of laparoscopic appendectomy and the length of hospital stay using multivariable logistic regression analyses.
RESULTS
The reference standard for appendiceal perforation was frequently missing or inconsistent in the previous studies. Laparoscopic appendectomies were less frequent in groups 3 (52.5%, P = 0.001) and 4 (65%, P = 0.040) than in group 1 (70.7%), while group 2 (73%, P = 0.125) did not significantly differ from group 1. Median hospital stays were 2.9, 3.0, 5.1, and 6.0 days for groups 1-4, respectively. Prolonged hospital stay (≥3.7 days) was more frequent in groups 3 (77.7%, P < 0.001) and 4 (89%, P < 0.001) than in group 1 (23.4%), while group 2 (35%, P = 0.070) did not significantly differ from group 1.
CONCLUSION
We recommend using surgical rather than pathologic findings as the reference standard for the presence of appendiceal perforation in future investigations.

Keyword

Appendicitis; Perforation

MeSH Terms

Adolescent
Adult
Appendectomy
Appendicitis
Cross-Sectional Studies
Humans
Length of Stay
Logistic Models
Pathology*
Retrospective Studies

Figure

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  Fig. 1 Flowchart of the literature search results.

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  Fig. 2 Patient flow diagram. Group 1, nonperforation; group 2, perforation identified pathologically but not surgically; group 3, perforation identified surgically but not pathologically; group 4, perforation identified both pathologically and surgically.

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  Fig. 3 Length of hospital stay. Group 1, nonperforation; group 2, perforation identified pathologically but not surgically; group 3, perforation identified surgically but not pathologically; group 4, perforation identified both pathologically and surgically. The middle lines in the boxes denote medians, and the upper and lower margins in the boxes represent the upper and lower quartiles, respectively. The ends of the vertical lines indicate 1.5 times the interquartile range. The crosses indicate outliers.

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