PREDICTORS OF IN-HOSPITAL APPENDICEAL PERFORATION IN PATIENTS WITH NON-PERFORATED ACUTE APPENDICITIS WITH APPENDICOLITHIASIS AT PRESENTATION
Amir H. Sohail*1, Hazim Hakmi1, Joshua C. Hurwitz1, Koral Cohen1, Jasmine Brite1, Sawyer Cimaroli1, Harry Tsou1, Matthew Symer1, James Maurer2, Michael Khalife1
1Department of Surgery, New York University, New York, NY; 2Mount Sinai Health System, New York, NY
Introduction:
An estimated 280,000 appendectomies are performed in the United States annually. Appendicolithiasis is an important factor associated with perforated acute appendicitis. However, within this subgroup, there is a paucity of data regarding factors associated with the development of appendiceal preformation.
Methods:
We retrospectively reviewed Electronic Medical Records to identify patients (≥18 years) who presented with non-perforated acute appendicitis with appendicolithiasis on computed tomography, and underwent appendectomy on index admission. Information on key variables was retrieved. Univariate and multivariate logistic regression was used to investigate factors associated with in-hospital appendiceal perforation (as determined on histopathology).
Results:
During the study period, 296 patients with non-perforated acute appendicitis with appendicolithiasis were identified; 48 patients (16.2%) were found to have perforated appendicitis on histopathology. The mean (standard deviation [SD]) age for study participants was 39(14.9) years. The majority of patients were male (n=172; 58.1%), and white (n=198; 66.9%). Mean (SD) body mass index (BMI) for study participants was 24.7 (4.4) kg/m2. Two percent (n=6) participants were on steroids at the time of presentation. The mean (SD) time to the operating room was 12.1 (6.2) hours.
The mean (SD) length of hospital stay (LOS) was 1.5 (1.8) days. LOS was significantly longer in the perforated acute appendicitis (mean [SD]: 3.0 [3.1] days) group as compared to non-performed (mean [SD]: 1.2 [1.2] days) group (p<0.001). Overall, 4.1 % (n=12) of participants required intensive care unit (ICU) admission, and there was no significant difference in incidence of ICU admission in perforated (8.3%; n=4) vs non-perforated (3.2%; n=8) appendicitis groups (p-value: 0.214).
On multivariate analysis, in-hospital perforation was significantly associated with age >65 years old (OR 5.7, 95% CI: 1.6-21.0); p=0.008), BMI >30 kg/m2 (OR 3.7, 95% CI: 1.4-9.4; p=0.007), hyponatremia (OR 3.9, 95% CI: 1.4-10.9; p=0.009), and polymorphonuclear neutrophils (PMN) >85% (10.3, 95% CI: 1.4-217.7; p=0.047). There was no significant association between perforation and age 25-65 years old, gender, race, steroid use, time to operating room, PMN 65-85%, or leukocyte count (p>0.05 for all covariates).
Conclusion
A sizable proportion of patients presenting with non-perforated acute appendicitis with appendicolithiasis on initial imaging experience in-hospital appendiceal perforation (16.2% in our data). Factors associated with in-hospital perforation include geriatric age, obesity, hyponatremia, and PMN >85%.
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