Z. Farzal1,2, Z. Farzal1,2, N. Khan2, A. Fischer3 1University Of Texas Southwestern Medical Center,Pediatric Surgery,Dallas, TX, USA 2Children’s Medical Center,Pediatric Surgery,Dallas, TX, USA 3Beaumont Children’s Hospital,Pediatric Surgery,Royal Oak, MI, USA
Introduction: Despite decades of research, a best clinical pathway for classifying perforated versus nonperforated appendicitis remains undefined. The lack of accuracy in the classification of appendicitis can affect the therapeutic course and associated costs with the average cost per case of complicated appendicitis often being twice as much as that of a case of uncomplicated appendicitis. We hypothesized that there is variability in identification of perforated and nonperforated appendicitis across specialties due to lack of standardized criteria.
Methods:
An IRB-approved retrospective review of appendectomies (N=1311) allowed a comparison of classification as perforated appendicitis (PA) or nonperforated appendicitis (NPA) based on radiology (R), operative (O), and pathology (P) reports. For the radiology arm (R), only cases in which CTs were performed were included to use the most definitive radiologic diagnosis. Three groups: P+O (N=1241), P+R (N=516), O+R (N=512), were compared to identify the inter-group discordance in classification of appendicitis. The length of stay (LOS) served as a metric of clinical behavior and was compared to the designated classification of the case of appendicitis to test if the diagnosis was consistent with being clinically nonperforated (NPA) with a LOS less than or equal to 48 (LOS≤48) hours or perforated (PA) with a length of stay greater than 48 (LOS>48) hours.
Results:
The subsets P+O, P+R, O+R revealed a discordance of 11%, 15.7% and 16.6%, respectively. Operative and radiology (O+R) reports were the most discordant. In the O+R group, 35% of the cases that were operatively designated as perforated appendicitis (PA) were discordant with their radiologic diagnosis of nonperforated appendicitis (NPA). Cases designated as perforated appendicitis (PA) in all subsets (P+O, P+R, O+R) clinically behaved as perforated with an average LOS>48 hours (97, 95, 95, respectively), whereas the cases designated as nonperforated appendicitis (NPA) displayed greater variation from the expected LOS≤48 hours, with means of 35, 83, and 52 hours, respectively.
Conclusion:
There is significant variability in classifying perforated versus nonperforated appendicitis. With up to 16.6% discordance between operative and imaging findings, the absence of standardized classification criteria results in a continued lack of diagnostic accuracy, as confirmed by variation in clinical behavior. Standardizing the criteria for the classification of the type of appendicitis across specialties may improve diagnostic accuracy needed for meaningful clinical trials and to identify best practices for optimal use of hospital resources and health care costs.