THE IMPRESSION OF RADIOLOGISTS AND PATHOLOGISTS CAN PREDICT COMPLICATIONS AFTER APPENDECTOMY BETTER THAN SURGEONS
Mohamad A. Minhem*1, Jose Cataneo Serrato2, Rami E. Lutfi2
1Internal Medicine, Mercy Hospital and Medical Center, Chicago, IL; 2Surgery, Mercy Hospital and Medical Center, Chicago, IL
Introduction: Appendicitis is a common surgical disease in which multiple specialists contribute to diagnosis and treatment. Radiologists, surgeons and pathologists’ interpretation may sometimes differ in describing the extent and the complexity of the disease. Our study aims to correlate the radiology, surgery and pathology’s impression with complications post-appendectomy.
Methods: This is an IRB approved retrospective review of prospectively collected data from an inner-city hospital (2008-2017). The primary outcome was 30-day composite postoperative complications. Univariate and two models of multivariate analyses were performed. Variables included in the first multivariate analysis were age, gender, race, hypertension, diabetes, radiologist’s CT report, surgeon’s operative report, and pathologist’s specimen report. A Scoring system for advanced disease was developed based on radiology, surgery, or pathology impressions. A second multivariate analysis assessed the effect of the advanced disease scores by radiology, surgery, and pathology on the postoperative complications.
Results: Out of 558 appendectomies studied, 85 patients (15.2%) had complications post appendectomy. On CT scan findings, patients with complications had more appendicolith (49.4% VS 32.9%, P=0.005), appendix diameter≥14mm (44.8% VS 27.3%, P=0.004) and presence of free fluid (38.0% VS 24.2%, P = 0.01). Based on surgeon’s intraoperative findings, patients with complications had more purulence (31.8% VS 20.9%, P=0.03), phlegmon (17.6% VS 8.7%, P=0.01) and perforation (36.5% VS 13.7%, P <0.001). Microscopically on the pathology specimen, patients with complications had more perforation (29.3% VS 11.3%, P<0.001) and cancer (7.3% VS 2.4%, P=0.03). Based on the first model of multivariate analysis (Fig1), factors that were associated with increased adjusted risk for complications were the presence of an appendicolith on CT scan [OR=1.99(1.12, 3.54), P=0.02], surgeon's intraoperative impression of perforation [OR=3.29(1.75, 6.16), P<0.001], and cancer diagnosis based on pathology results [OR=3.98(1.23, 12.88), P=0.02]. A second multivariate analysis model was performed based on scoring of advanced disease by radiology, surgery and pathology. The impression of advanced disease by radiology [OR=1.35(1.11,1.65), P=0.003] and pathology [OR=1.52(1.02,2.28), P=0.04] but not surgery [OR=1.17(0.95,1.43), P=0.15] were significantly associated with increased complications.
Conclusion: From a comprehensive point of view, the impression by radiology or pathology on appendicitis severity appears to be more predictive of complications than the impression by surgeons. Therefore, surgeons should always consider admission CT findings and pathology report, when discussing prognosis and planning postop treatment after appendectomy.
Figure 1. Forest plot representing the predictors of composite morbidity endpoint categorized by radiology surgery, and pathology different factors.
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