Measuring Anatomic Severity in Pediatric Appendicitis: Validation of the American Association for the Surgery of Trauma Appendicitis Severity Grade

Utility of the American Association for the Surgery of Trauma Appendicitis Severity Grade in Predicting Prognosis in Children

INTRODUCTION

The American Association for the Surgery of Trauma (AAST) proposed a grade classification (I (mild) to V (severe)) to predict the risks and outcomes of acute appendicitis. However, its utility in children remains unknown. We investigated the relationship between the AAST grade and disease severity in children.

METHODS

We retrospectively evaluated 93 patients aged ≤16 years who underwent surgery for acute appendicitis between 2012 and 2020. The AAST computed tomography (CT), operative, and pathologic grades were analyzed. We collected data for demographics, length of stay (LOS), and complications. Trend tests were performed to compare the AAST grade and outcomes. Bland-Altman plots were used to evaluate the correlation between grades. Multiple regression analysis was performed to identify the factors related to LOS.

RESULTS

AAST grades included CT (n=55), operative (n=93), and pathologic (n=93) grades. The number of complications and LOS increased significantly with the increase of every three-grade. Bland-Altman plots revealed that each of the three-grade correlated with each other. Multiple regression analysis identified AAST operative grades III-V as risk factors for prolonged LOS.

CONCLUSION

Higher CT, operative, and pathologic grades were found to be significantly associated with an increased number of complications and prolonged LOS in pediatric patients. We further concluded that the AAST grading system could be useful in predicting the prognosis of acute appendicitis in children.

Clinicopathological Profile of Appendicular Disease in Children: A Tertiary Health Care Center Study

Background Acute appendicitis (AA) is the most common surgical emergency worldwide. Delay in diagnosis of disease often leads to serious complications such as perforation appendicitis (PA) and gangrenous appendicitis (GA). Aims and objectives The purpose of the study is to document clinicopathological outcomes in pediatric age group patients in a tertiary health care center. Material and method This study was a prospective observation study of 50 patients with pediatric appendicitis who had undergone emergency appendectomy from January 2022 to December 2022. All pediatric patients below 15 years of age with a diagnosis of AA were included. Institute ethical permission was granted before the study, and parent consent was taken for the surgery and also for inclusion in the study. After proper resuscitation, all patients underwent appendectomy, and necessary specimens were sent for histological examination. Based on histopathology reports, all patients were classified into four groups: AA, PA, GA, and normal appendix (NA). Results Out of 50 patients, 33 (66%) patients were males and 17 (34%) patients were females. The mean age of the patients was 10.22 ± 2.73 years. The mean age of AA, PA, GA, and NA patients were 10.25 ± 2.6 years, 9.78 ± 2.99 years, 10.00 ± 4.6 years, and 12.00 ± 2.8 years, respectively. The mean duration of symptoms at the time of hospital admission was 2.42 ± 0.97 days for histopathologically proven AA patients, 4.67 ± 2.1 days for GA patients, 2.8 ± 0.83 for PA patients, and one day for NA patients. Overall clinical presentation was right iliac fossa (RIF) pain in 36 (72%) patients, migration of pain in 31 (62%) patients, anorexia in 37 (74%) patients, nausea and vomiting in 43 (86%) patients fever in 26 (52%) patients, RIF tenderness in 50 (100%) patients, rebound tenderness in 39 (78%) patients, guarding in 19 (38%) patients, Psoas's sign in nine (18% patients), and Rovsing's sign in 19 (38%) patients. On histopathological examination of the sent specimen, AA was found in 36 (72%) patients, PA was found in nine (18%) patients, GA was found in three (6%) patients, and NA was found in two (4%) patients. Wound infection was the most common complication and was found in five (10%) patients. The average duration of hospital stay for AA, PA, GA, and NA was 4.33 ± 1.04 days, 9.56 ± 4.2 days, 12.33 ± 8.5 days, and 3.50 ± 0.71 days, respectively. Conclusion The appendicular disease is common in teenage male children. Fever, dehydration, and rebound tenderness at the RIF are clinically significant findings. Duration of symptoms at the time of diagnosis, post-appendectomy complication, and duration of hospital stay significantly correlated with histopathological findings.

The impact of delay and prehospital factors on acute appendicitis severity in New Zealand children: a national prospective cohort study

BACKGROUND

Appendicitis is the most common reason children undergo acute general surgery but international, population-level disparities exist. This is hypothesised to be caused by preoperative delay and differential access to surgical care. The impact of prehospital factors on paediatric appendicitis severity in New Zealand is unknown.

METHODS

A prospective, multicentre cohort study with nested parental questionnaire was conducted by a national trainee-led collaborative group. Across 14 participating hospitals, 264 patients aged ≤16 years admitted between January and June 2020 with suspected appendicitis were screened. The primary outcome was the effect of prehospital factors on the American Association for the Surgery of Trauma (AAST) anatomical severity grade.

RESULTS

Overall, 182 children had confirmed appendicitis with a median age of 11.6. The rate of complicated appendicitis rate was 38.5% but was significantly higher in rural (44.1%) and Māori children (54.8%). Complicated appendicitis was associated with increased prehospital delay (47.8 h versus 20.1 h; P < 0.001), but not in-hospital delay (11.3 h versus 13.3 h; P = 0.96). Multivariate analysis revealed increased anatomical severity in rural (OR 4.33, 95% CI 1.78-7.25; P < 0.001), and Māori children (OR 2.39, 95% CI 1.24-5.75; P = 0.019), as well as in families relying on external travel sources or reporting unfamiliarity with appendicitis symptomology.

CONCLUSION

Prehospital delay and differential access to prehospital determinants of health are associated with increased severity of paediatric appendicitis. This manifested as increased severity of appendicitis in rural and Māori children. Understanding the pre-hospital factors that influence the timing of presentation can better inform health-system improvements.

Accuracy of computed tomography in staging acute appendicitis and its impact on surgical outcome and strategy: a multi-center retrospective case-control study

INTRODUCTION

The aims of this study were to evaluate the concordance between AAST-CT appendicitis grading criteria, first published in 2014, and surgical findings and to assess the impact of CT staging on the choice of surgical approach.

METHODS

This was a multi-center retrospective case-control study including 232 consecutive patients undergoing surgery for acute appendicitis and who had undergone preoperative CT evaluation between 1 January 2017 and 1 January 2022. Appendicitis severity was classified in 5 grades. For each degree of severity, the surgical outcome between patients undergoing open and surgical approach was compared.

RESULTS

An almost perfect agreement (k = 0.96) was found between CT and surgery in staging acute appendicitis. The vast majority of patients with grade 1 and 2 appendicitis underwent laparoscopic surgical approach and showed low morbidity rate. In patients with grade 3 and 4 appendicitis, laparoscopic approach was adopted in 70% of cases and was associated, if compared to open, with a higher prevalence of postoperative abdominal collections (p = 0.05; fisher's exact test) and a significantly lower prevalence of surgical site infections (p = 0.0007; fisher's exact test). All the patients with grade 5 appendicitis were treated by laparotomy.

CONCLUSIONS

AAST-CT appendicitis grading system seems to show a relevant prognostic value and a potential impact on the choice of surgical strategy, directing toward a laparoscopic approach in patients with grade 1 and 2, an initial laparoscopic approach, replaceable by the open one, for grade 3 and 4 and an open approach in patients with grade 5.

The Prognostic Value of Ultrasound Findings in Preoperatively Distinguishing between Uncomplicated and Complicated Types of Pediatric Acute Appendicitis Based on Correlation with Intraoperative and Histopathological Findings

OBJECTIVE

This study compares the preoperative ultrasound findings of all children with a clinical picture of acute appendicitis on the basis of intraoperative and histopathological findings to assess the feasibility of this approach in preoperatively distinguishing between uncomplicated and complicated cases.

METHODS

This retrospective study includes 224 pediatric patients who underwent ultrasound prior to appendectomy at our institution between January 2016 and February 2022. Logistic regression analysis was used to investigate the association between sonographic and intraoperative histopathological findings.

RESULTS

Of the 224 participants, 61.1% were intraoperatively diagnosed with uncomplicated appendicitis (59.8% male). Multivariate logistic regression analysis revealed that patients with a higher appendiceal diameter, presence of appendicolith, and peritonitis were more likely to suffer from complicated appendicitis. Finally, the common anatomical position of the appendix and an appendiceal diameter greater than 6 mm had the highest sensitivity (94.6% and 94.5%, respectively) for predicting complicated appendicitis, with the most specific (99.3%) sonographic finding being the existence of an abscess.

CONCLUSIONS

Preoperative abdominal ultrasound in children with a clinical diagnosis of acute appendicitis can distinguish between uncomplicated and complicated appendicitis in most cases of pediatric appendicitis. A higher appendiceal diameter, the presence of appendicolith, and peritonitis are parameters noted by ultrasound that strongly predict complicated appendicitis.

Trends in Adoption of Laparoscopic Appendicectomy in a Developing Country: Closing the Gap

BACKGROUND

This study reviews our use of laparoscopic versus open appendicectomy over the last decade to track the trends in their usage in a middle-income country.

METHODS

A retrospective study was conducted on patients with intraoperative confirmed acute appendicitis from January 2013 to December 2019 at Grey's Hospital, Pietermaritzburg, South Africa.

RESULTS

Eight hundred fifty-one cases of AA were included. 724 (85%) patients underwent open surgery; 435 (60%) via a midline incision and 194 (27%) via a local incision. 127 (15%) patients underwent laparoscopic appendicectomy. A significant rend was noted for an increasing proportion of surgery performed by laparoscopy compared to open surgery (p = 0.02). Patients who underwent open surgery compared to laparoscopy presented with greater peritonism (48.5% vs. 28%, p < 0.001), delay from symptom onset (3 vs. 2 days, p < 0.001), more frequently from rural areas (94% vs. 86%, p = 0.002) and with higher AAST scores (46.7% AAST ≥ 4, vs. 14.9%, p < 0.001). This former group had significantly greater morbidity (42% vs. 35%, p < 0.001) with higher Clavien-Dindo scores, were more likely to require ICU admission (8.3% vs. 2.3%, p < 0.001) and have longer hospital stay (4 days vs. 2 days, p < 0.001); no statistically significant difference in mortality was observed (1.1% vs. 0.8%, p = 0.75).

CONCLUSIONS

There has been a steady increase in the uptake of laparoscopic appendicectomy and decrease in open approaches in our centre. There is still a high rate of patients with advanced disease, and it is unlikely that this cohort will be suitable for laparoscopic surgery. If we hope to increase the uptake of laparoscopic surgery for acute appendicitis even further, we must focus on identifying patients with early and low-grade disease.

Appendicitis in the COVID-19 era: a modern challenge for experienced hands

INTRODUCTION

The first wave of COVID-19 was accompanied by global uncertainty. Delayed presentation of patients to hospitals ensued, with surgical pathologies no exception. This study aimed to assess whether delayed presentations resulted in more complex appendicectomies during the first wave of COVID-19.

METHODS

Operation notes for all presentations of appendicitis (n=216) within a single health board (three hospitals) during two three-month periods (control period (pre-COVID) vs COVID pandemic) were analysed, and the severity of appendicitis was recorded as per the American Association for the Surgery of Trauma (AAST) grading system.

RESULTS

Presentations of appendicitis were delayed during the COVID period with a median duration of symptoms prior to hospital attendance of two days versus one day (p=0.003) with individuals presenting with higher median white cell count than during the control period (14.9 vs 13.3, p=0.031). Use of preoperative CT scanning (OR 3.013, 95% CI 1.694-5.358, p<0.001) increased significantly. More complex appendicectomies (AAST grade >1) were performed (OR 2.102, 95% CI 1.155-3.826, p=0.015) with a greater consultant presence during operations (OR 4.740, 95% CI 2.523-8.903, p<0.001). Despite the greater AAST scores recorded during the COVID period, no increase in postoperative complications was observed (OR 1.145, 95% CI 0.404-3.244, p=0.798).

CONCLUSIONS

Delayed presentations during the COVID-19 pandemic were associated with more complex cases of appendicitis. Important lessons can be learnt from the changes in practice employed as a result of this global pandemic.

Validation of the American Association for the Surgery of Trauma grading system for acute appendicitis severity

OBJECTIVE

The American Association for the Surgery of Trauma (AAST) developed an anatomic grading system to assess disease severity through increasing grades of inflammation. Severity grading can then be utilized in risk-adjustment and stratification of patient outcomes for clinical benchmarking. We sought to validate the AAST appendicitis grading system by examining the ability of AAST grade to predict clinical outcomes used for clinical benchmarking.

METHODS

Surgical quality program data were prospectively collected on all adult patients undergoing appendectomy for acute appendicitis at our institution between December 2013 and May 2018. The AAST acute appendicitis grade from 1 to 5 was assigned for all patients undergoing open or laparoscopic appendectomy. Primary outcomes were occurrence of major complications, any complications, and index hospitalization length of stay. Multivariable models were constructed for each outcome without and with inclusion of the AAST grade as an ordinal variable. We also developed models using International Classification of Diseases, 9th or 10th Rev.-Clinical Modification codes to determine presence of perforation for comparison.

RESULTS

A total of 734 patients underwent appendectomy for acute appendicitis. The AAST score distribution included 561 (76%) in grade 1, 49 (6.7%) in grade 2, 79 (10.8%) in grade 3, 33 (4.5%) in grade 4, and 12 (1.6%) in grade 5. The mean age was 35.3 ± 14.7 years, 47% were female, 20% were nonwhite, and 69% had private insurance. Major complications, any complications, and hospital length of stay were all positively associated with AAST grade (p < 0.05). Risk-adjustment model fit improved after including AAST grade in the major complications, any complications, and length of stay multivariable regression models. The AAST grade was a better predictor than perforation status derived from diagnosis codes for all primary outcomes studied.

CONCLUSION

Increasing AAST grade is associated with higher complication rates and longer length of stay in patients with acute appendicitis. The AAST grade can be prospectively collected and improves risk-adjusted modeling of appendicitis outcomes.

LEVEL OF EVIDENCE

Prospective/Epidemiologic, Level III.

Validation of the American Association for the Surgery of Trauma grading system for acute mesenteric ischemia-More than anatomic severity is needed to determine risk of mortality

BACKGROUND

Acute mesenteric ischemia (AMI) is a highly morbid disease with a diverse etiology. The American Association for the Surgery of Trauma (AAST) proposed disease-specific grading scales intended to quantify severity based upon clinical, imaging, operative, and pathology findings. This grading scale has not been yet been validated for AMI. The goal of this study was to evaluate the correlation between the grading scale and complication severity.

METHODS

Patients for this single center retrospective chart review were identified using diagnosis codes for AMI (ICD10-K55.0, ICD9-557.0). Inpatients >17 years old from the years 2008 to 2015 were included. The AAST grades (1-5) were assigned after review of clinical, imaging (computed tomography), operative and pathology findings. Two raters applied the scales independently after dialog with consensus on a learning set of cases. Mortality and Clavien-Dindo complication severity were recorded.

RESULTS

A total of 221 patients were analyzed. Overall grade was only weakly correlated with Clavien-Dindo complication severity (rho = 0.27) and mortality (rho = 0.21). Computed tomography, pathology, and clinical grades did not correlate with mortality or outcome severity. There was poor interrater agreement between overall grade. A mortality prediction model of operative grade, use of vasopressors, preoperative serum creatinine and lactate levels showed excellent discrimination (c-index = 0.93).

CONCLUSION

In contrast to early application of other AAST disease severity scales, the AMI grading scale as published is not well correlated with outcome severity. The AAST operative grade, in conjunction with vasopressor use, creatinine, and lactate were strong predictors of mortality.

LEVEL OF EVIDENCE

Prognostic study, III.

Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines

BACKGROUND AND AIMS

Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.

METHODS

This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.

CONCLUSIONS

The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.

A simple classification of peritoneal contamination in perforated appendicitis predicts surgery-related complications

AIM

Perforated appendicitis has poorer clinical outcomes compared to non-perforated appendicitis. However, accurate outcome comparisons in research and clinical audits are challenged by its wide spectrum of manifestation. Previous attempts at the classification of severity have been complex and difficult to reproduce. In our study, we used another institution's (Jones et al., TX, USA) previously described simple classification system of peritoneal contamination and examined its usefulness in predicting outcomes.

METHODS

With ethical approval, we retrospectively reviewed the records of all paediatric patients operated at our institution for perforated appendicitis from 2016 to 2017. Patient demographics, intra-operative and histological findings, post-operative outcomes and length of stay were collected. Patients were categorised into group 1 (purulence in right lower quadrant only) and group 2 (contamination in two or more quadrants). Post-operative complications were defined as procedure-related (e.g. post-operative ileus, intra-abdominal abscess, visceral injury) and non-procedure-related (e.g. bronchospasm). Statistical analysis using χ² tests for categorical data and Mann-Whitney U-tests for non-parametric continuous variables was performed, with a significance of P < 0.05.

RESULTS

There were 134 eligible patients. We excluded 19 with incomplete data, leaving 115 for analysis, of which 69 (60%) were in group 2. Those in group 2 had a longer stay (P = 0.005) and more post-operative complications (P = 0.001), particularly procedure-related events (P = 0.006). There were no differences in age (P = 0.182), gender (P = 0.876), readmission rate (P = 0.317) and non-procedure-related post-operative complications (0.152).

CONCLUSION

This simple classification of perforated appendicitis appears to differentiate clinical outcomes well, particularly for iatrogenic morbidity, making it useful for operative preparation and outcomes research.

Implementing a surgeon-reported categorization of pediatric appendicitis severity

PURPOSE

The purpose of this study was to implement a novel surgeon-reported categorization (SRC) for pediatric appendicitis severity and determine if SRC was associated with outcomes.

METHODS

We conducted a retrospective review of appendectomies by 15 surgeons within a single center from January to December 2016. The SRC was defined as: simple (category 1), gangrenous or adherent (category 2A), perforation with localized abscess (category 2B), and perforation with gross contamination (category 2C). Logistic regression modeled the surgical site infections (SSI) and returns to the system. Cox proportional hazards analyses modeled the length of stay (LOS).

RESULTS

The cohort included 697 patients (mean age 10.7 years). Compliance with SRC documentation increased from 33.5 to 85.9%. Review of operative findings revealed 100% concordance with SRC. The combined morbidity (SSI and revisits) rate was 9.8%. Category 2C patients had the highest odds of SSI (odds ratio 3.37 95% confidence interval 1.07-10.59). Median LOS increased with each category (category 1 = 1d, category 2A = 2d, category 2B = 4d, category 2C = 6d). When modeling intra-abdominal abscess, SRC displayed an improved model calibration and discrimination compared to wound class.

CONCLUSION

SRC implementation is feasible and provides a granular assessment of appendicitis severity and outcomes. SRC may guide future quality improvement through development of grade-specific care pathways.

Application of the AAST EGS Grade for Adhesive Small Bowel Obstruction to a Multi-national Patient Population

BACKGROUND

The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) has demonstrated to be a valid tool in North American patient populations. Using a multi-national patient cohort, we retrospectively assessed the validity the AAST ASBO grading system and estimated disease severity in a global population in order to correlate with several key clinical outcomes.

METHODS

Multicenter retrospective review during 2012-2016 from four centers, Minnesota USA, Bologna Italy, Pietermaritzburg South Africa, and Bucharest Romania, was performed. Adult patients (age ≥ 18) with ASBO were identified. Baseline demographics, physiologic parameters, laboratory results, operative and imaging details, outcomes were collected. AAST ASBO grades were assigned by independent reviewers. Univariate and multivariable analyses with odds ratio (OR) and 95% confidence intervals (CIs) were performed.

RESULTS

There were 789 patients with a median [IQR] age of 58 [40-75] years; 47% were female. The AAST ASBO grades were I (n = 180, 23%), II (n = 443, 56%), III (n = 87, 11%), and IV (n = 79, 10%). Successful non-operative management was 58%. Conversion rate from laparoscopy to laparotomy was 33%. Overall mortality and complication and temporary abdominal closure rates were 2, 46, and 4.7%, respectively. On regression, independent predictors for mortality included grade III (OR 4.4 95%CI 1.1-7.3), grade IV (OR 7.4 95%CI 1.7-9.4), pneumonia (OR 5.6 95%CI 1.4-11.3), and failing non-operative management (OR 2.4 95%CI 1.3-6.7).

CONCLUSION

The AAST EGS grade can be assigned with ease at any surgical facility using operative or imaging findings. The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research. Disease severity and outcomes varied between countries.

LEVEL OF EVIDENCE III

Study type Retrospective multi-institutional cohort study.

The American Association for the Surgery of Trauma Emergency General Surgery Anatomic Severity Scoring System as a predictor of cost in appendicitis

BACKGROUND

The World Society for Emergency Surgery determined that for appendicitis managed with appendectomy, there is a paucity of evidence evaluating costs with respect to disease severity. The American Association for the Surgery of Trauma (AAST) disease severity grading system is valid and generalizable for appendicitis. We aimed to evaluate hospitalization costs incurred by patients with increasing disease severity as defined by the AAST. We hypothesized that increasing disease severity would be associated with greater cost.

METHODS

Single-institution review of adults (≥ 18 years old) undergoing appendectomy for acute appendicitis during 2010-2016. Demographics, comorbidities, operative details, hospital stay, complications, and institutional cost data were collected. AAST grades were assigned by two independent reviewers based on operative findings. Total cost was ascertained from billing data and normalized to median grade I cost. Non-parametric linear regression was utilized to assess the association of several covariates and cost.

RESULTS

Evaluated patients (n = 1187) had a median [interquartile range] age of 37 [26-55] and 45% (n = 542) were female. There were 747 (63%) patients with Grade I disease, 219 (19%) with Grade II, 126 (11%) with Grade III, 50 (4%) with Grade IV, and 45 (4%) with Grade V. The median normalized cost of hospitalization was 1 [0.9-1.2]. Increasing AAST grade was associated with increasing cost (ρ = 0.39; p < 0.0001). Length of stay exhibited the strongest association with cost (ρ = 0.5; p < 0.0001), followed by AAST grade (ρ = 0.39), Clavien-Dindo Index (ρ = 0.37; p < 0.0001), age-adjusted Charlson score (ρ = 0.31; p < 0.0001), and surgical wound classification (ρ = 0.3; p < 0.0001).

CONCLUSIONS

Increasing anatomic severity, as defined by AAST grade, is associated with increasing cost of hospitalization and clinical outcomes. The AAST grade compares favorably to other predictors of cost. Future analyses evaluating appendicitis reimbursement stand to benefit from utilization of the AAST grade.