Siladri Sen Gupta

Retrospective observational study of performance in outcome of emergency appendicectomy

Gupta S.S¹, Pal B², Jha H.N³

¹Dr. Siladri Sen Gupta, Associate Professor Head, unit II, ²Dr Banyeswar Pal , Assistant Professor, ³Dr Hem Narayan Jha, Junior Resident; all authors are affiliated with Department of General Surgery, ESIC-PGIMSR, ESIC Medical College And ESIC Hospital DOC (EZ) Zoka Diamond Harbour Road, Kolkata, West Bengal, India

Address for correspondence: Dr. Siladri Sen Gupta, Email: siladrisen2@gmail.com

Abstract

Objective: The present study is aimed to investigate variations in outcome of Emergency Appendectomy being conducted in Surgery Unit- II at ESIC Medical College, Joka, Diamond Harbour Road, Kolkata, West Bengal. The main outcome interest was the normal Histopathology rate, secondary outcomes and thirty (30) days adverse events rate with varied parameters like different timings of operation, presence or absence of consultant etc. Method: The study was performed in Surgery UNIT II in ESIC Medical College, Joka, Kolkata, and West Bengal. The trainee level Investigator was responsible for identifying patients, entering DATA in the prespecified database and ensuing completeness of data. Patients undergoing appendectomy for suspected Acute Appendicitis between Aug 2015 to Aug 2016 inclusive of all age & sex are included in this study. The study was approved by the Institutional ethical committee. The post operative complications were followed for 30 days after surgical appendectomy during day time, evening hours and night time and compared in terms of percentage of evidence. Results: A total number of fifty (50) Emergency appedidectomy cases were studied by open surgery. Histologically Normal appendix was removed in 10 numbers of cases i.e. 20%.It was observed that the outcome percentage of daytime operation with requisite duration and by specialist consultant is far better than that of night time or evening time operation by senior trainee . It was also observed that adverse effects after 30days post operative period were significantly reduced in case of day time operation. Conclusions: This study reveals the wide variations in practice patterns and outcome which should be addressed to improve performance.. The surgical procedure done in day time by expertise consultant can effectively reduce the adverse post operative complications.

Key words: Emergency appendectomy, post appendectomy complications, Adverse affects of appendectomy

Manuscript Received: 04th September 2016, Reviewed: 12th September 2016
Author Corrected: 20th September 2016, Accepted for Publication: 30th September 2016

Introduction

Emergency appendectomy is the most common performed Acute General Surgical Operations [1]. Differing Hospital policies, financial constraints, clinical burdens and a conflicting evidence base may result in variation in the provision and outcome of appendectomy [2].

Mortality following appendectomy is low and is unsuitable as a quality marker. Several controversies remain surrounding the management and outcome of appendicitis including the best investigation for diagnosis, optimal surgical approach and strategies to limit adverse post-operative events [3-5]. The aim of the present study is to identify retrospectively and investigate the variations in the provision and outcome of Emergency Appendectomy. While taking into account the various measures and working mode of performing acute emergency appendectomy the study aims at measures which can be modified to achieve more favourable result.

Method

The study was performed according to a prespecified protocol which were tested and modified in Surgery Unit II in Esic Medical College, Joka, Kolkata, West Bengal. The trainee level Investigator was responsible for identifying patients, entering DATA in the prespecified database and ensuing completeness of data. Patients undergoing appendectomy for suspected Acute Appendicitis between Aug 2015 to Aug 2016 inclusive of all age & sex are included in this study. Patients in which surgical appendectomy was planned electively or was a part of another procedure (such as a part of elective Right Hemi colonectomy) were excluded from this study design. The study was approved by the Institutional ethical committee.

Outcome Measures: The main outcome of interest was the histopathologic normal appendectomy rate. Other adverse events were wound infection, intra-abdominal abscess, readmission, unscheduled postoperative ultrasound scan, or computerised tomography and further radiological or surgical intervention within 30 days. Wound infection was defined according to the definition provided by the Centre for disease control [6]. The detail outcome measure for the operation is tabulated along with the result in table 1.

Data Collection: Data domains were collected relating to the patient, surgeon, operation, hospital, operative method and post-operative period. The details of the operative protocol is given in table 1 along with the results

Results

Normal Appendix was removed in 10 patients which was significantly higher in females than in males and lower in those aged between 16 – 50 yrs. or less than 16 yrs.

The Table-1 shows that the outcome percentage of daytime operation with requisite duration and by specialist consultant is far better than that of night time or evening time operation by senior trainee. As evident from the fact that the wound infection is observed only in 16% cases in case of daytime operation with presence of senior consultant and abscess formation is reduced to only 4% cases.

Table-1: Experimental protocol along with the outcome in terms of percentage

Parameters

Number

Timing

Percentage

1 No of cases

50 ( Fifty )

2 Alvardo scoring

I – II - 20

III – IV – 30

40%

60%

3 Age in yrs

8 – 65 yrs

4 Sex

Male – 25

Female – 25

50%

5Pre-operative imaging

X-Ray – 50

USG – 50

CT – Nil

100%

6 Timing of Operations

Day timing – 8.00 -1800

Evening Timing - 1800-2200

Night Timing - 2200 – 8.00

50%

30%

20%

7 Earlier Antibiotics

Pre-operative/ Induction

Intraoperative / Postoperative

100%

8 Operative Method

Open appendectomy

100%

9. Operating Surgeon

Nil

Consultant

Senior Trainee

Junior Trainee

60%

40%

10 Consultant Surgeon in theatre

Yes

60%

40%

11. Duration of Surgery

< 60 mins

> 60 mins

80%

20%

12. Abdominal washout -

Yes

80%

20%

13. Drain

Yes

80%

20%

14. Skin Closure

Subcutaneous Suture

Interrupted suture

80%

20%

15. Histopathology

Normal appendix

Simple appendicitis

Complicated appendicitis

20 %

30%

50%

16. 30-Day adverse events

Wound Infection

Pelvic abscess

16%

17. Post – operative Imaging

20%

18. Surgical / Radiological Intervention

It was also observed that adverse effects after 30 days post operative period were experienced by only 10 patients ( 10 of 50). Hospital Characteristics is also significantly associated with a reduced rate of adverse events.

Discussion

Daytime surgery, higher volume, consultant presence in theatre was organizational factors associated with improved provision and outcome from emergency appendectomy in the present study. These factors could be addressed to ensure high quality delivery of acute surgical care with appendectomy potentially acting as a quality marker of this care. The present study shows a clear association between higher volume, consultant presence and day time surgery thereby showing a reduction in 30 day morbidity rates. Daytime surgery further reduced normal appendectomy rate and there is increasing evidence that short delays to allow operation within normal hours does not increase the rate of perforation [7,8] but the impact of surgical site infection (SSI) requires further research. As it is found that a short delay will improve the outcome by performing during day time in presence of consultants without causing any morbidity on patients.

Improvements to standardize variation could be drawn from the markers of provision identified including imaging, Laparoscopy, and Consultant supervision rates. Increased use of laparoscopy may reliably reduce normal appendectomyrate [6], although this analysis was beyond the scope of this study. Although a high rate of CT use was not associated with a reduction in normal appendectomy rate, the overall use of CT was low [9] and non-randomized. The low rate suggests that there may be underutilization especially in comparison with the higher Imaging rates used elsewhere. In the USA pre-operative imaging rate of 91% (predominantly CT) with associated normal appendectomy rate 5.6% have been reported [9]. Both randomized and population based studies (cite reference) also support the effectiveness of CT in reducing the Normal appendectomy rates.

The strength of the present study is the generalized ability and the detail DATA collection. This study used the original pathology report as the marker of final histopathology, although differing criteria between pathologists regarding the definition of appendicitis is controversial [4,10].

Although the SSI rate in this study (3-4 %) was in keeping with that from randomized trials and meta-analysis these rates still may significantly underestimate the true incidence. When properly defined and assessed the rate following abdominal operations may be as high as 20%. The limitation of using this composite end point includes its inability to identify specific benefits or risks for a particular intervention. The association of abdominal washout, drains and various skin closure techniques was variable and often high with little robust evidence to guide their practice. Their association within this non-randomized study is more likely as marker of severity than as causative factors. The above observation concludes that if Emergency operations are performed in Daytime and in presence of Consultants than the rate of associated complications are low.

Funding: Nil, Conflict of interest: None initiated.
Permission from IRB: Yes

References

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How to cite this article?

Gupta S.S, Pal B, Jha H.N. Retrospective observational study of performance in outcome of emergency appendicectomy. Int J surg Orthopedics 2016;2(3):35-38.doi: 10.17511/ijoso.2016.i3.03.