International Journal of Scientific and Research Publications, Volume 2, Issue 10, October 2012 1 ISSN 2250-3153

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Acute Perforated Appendicitis: An Analysis of Risk

Factors to Guide Surgical Decision Making in Rural

India

Ugane S, Bhogawar S

Department of Surgery, GMC Miraj and PVPGH Sangli

Abstract- Introduction: Acute perforated appendicitis is

associated with increased post-operative morbidity and mortality.

Avoiding delays in surgery in these patients may play a role in

reducing observed morbidity. Objective: To analyze the clinico-

pathological profile and outcomes in a cohort of patients

undergoing emergency appendicectomies for suspected acute

appendicitis and to determine factors influencing the risk of

perforated appendicitis in order to aid better identification of

such patients and develop protocols for improved management of

this subset of patients. Materials and Methods: A retrospective

analysis of patients undergoing emergency appendicectomies

following presentation with acute appendicitis to the PVP Govt

Hosp, Sangli, India from March 2007 to April 2012 was

conducted. Statistical analyses were performed in SAS 9.2.

Results and Discussion: 506 patients underwent emergency

appendectomy for acute appendicitis which included equal

number of male and female patients with a median age of 25

years. Perforated appendicitis was found in 102 (20%) patients.

Post-operative morbidity was significantly higher in patients with

perforated appendicitis (28.4% vs 4.7%; P<0.0001). Male sex,

patients older than 60 years, along with raised neutrophil counts

and C-reactive protein levels were found to be significantly

associated with the risk of perforation (P<0.05). Conclusions:

Acute perforated appendicitis is associated with high morbidity.

The increased risk of perforation in males and elderly patients

appears unrelated to delays in presentation, diagnosis, or surgery.

Patients with clinically diagnosed acute appendicitis and an

elevation in neutrophil count and CRP level must be considered

candidates for early surgery as they are likely to have an

appendicular perforation.

Index Terms- Carcinoids, male, tumors

I. INTRODUCTION

he incidence of complicated acute appendicitis, including

perforated or gangrenous appendicitis, remains considerably

high (28-29%) [1],[2]

despite the availability of modern imaging

and the use of laparoscopic surgery, sometimes even as a

diagnostic tool for suspected appendicitis. [3]

And while

appendectomy for acute appendicitis is one of the most common

intra-abdominal surgical procedures performed by general

surgeons, [2],[4]

morbidity rates in the post-operative period

remain between 9% and 18%. [4]

There has been an increasing trend to delay

"uncomplicated" acute appendicitis cases that present after hours

to be performed the next morning [5]

in order to avoiding

disrupting operating room schedules and to reduce the number of

patients being operated on after hours on the premise that sleep

deprivation and fatigue were associated with technical errors. [6]

However, the importance of an urgent appendectomy cannot be

understated especially because of the disparity in morbidity and

mortality rates between perforated and non-perforated

appendicitis.

The aim of the current study was

1. to analyze the clinico-pathological profile and outcomes

in a cohort of patients undergoing emergency

appendectomies for suspected acute appendicitis, and

2. to determine the factors influencing the risk of

perforated appendicitis in order to aid better

identification of such patients so as to develop protocols

for improved management of this subset of patients.

II. MATERIALS AND METHODS

A retrospective search of a prospectively maintained

electronic database of the PVP Govt Hosp, Sangli, India was

undertaken. International Classification of Diseases (ICD) codes

for acute appendicitis for a 50-month period, from March 2007 to

April 2012 were analyzed with the aim of identifying all patients

admitted to the hospital with acute appendicitis who underwent

emergency appendectomies. This resulted in a total of 506

patients being identified. Each admission was reviewed within

the electronic database for patient admission details.

Patients presenting with right lower abdominal pain,

consistent examination findings, with supporting blood

investigations, such as raised white cell and neutrophil counts

and/or the inflammatory marker serum C-reactive protein (CRP)

levels, were considered to have acute appendicitis and proceeded

for an appendectomy (open, laparoscopic, and laparoscopic

converted to laparotomy).

In patients in whom the diagnosis was unclear, the use of

imaging (ultrasonography or computed tomography (CT) scan)

was considered prior to planning surgery. The use of

ultrasonography was preferred in children with an unclear

diagnosis owing to the larger relative size of appendix rendering

better visualization in them. Similarly, in young women,

ultrasonography was preferred as the initial investigation in

undifferentiated right lower abdominal pain. In the case of failure

to conclusively rule out appendicitis, a diagnostic laparoscopy

was preferred over the use of a CT scan. Antibiotics (usually a

T

International Journal of Scientific and Research Publications, Volume 2, Issue 10, October 2012 2

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cephalosporin) were administered at induction of surgery.

Laparoscopic appendectomies were performed using the

standard three port technique. In patients in whom the

laparoscopic procedure could not be completed safely, an audit

of surgical outcomes within the department found that a midline

laparotomy was the most effective approach for completing the

procedure-overriding the often unsuccessful use of the

McBurney incision. Hence, it is the department policy that in

patients in whom the appendectomy cannot be completed

laparoscopically by a trained laparoscopic surgeon, the surgeon

should then resort directly to a midline laparotomy. The choice

of surgical approach (laparoscopy versus open) in pediatric

patients was based on the actual size of the patient. In smaller

patients, the open approach via the McBurney incision was

preferred. Patients were labeled as having a perforated appendix

based on the findings of a perforation at the time of surgery and

confirmed on histopathology.

All appendectomy specimens were routinely submitted for

histopathological analysis as per the hospital protocol.

Post-operative morbidity was defined as any complication

(medical or surgical) encountered which prolonged the hospital

stay of the patient and/or complications occurring with 30-days

following surgery requiring re-admission.

Statistical analyses were performed in SAS 9.2. The

probability of perforation was modeled using separate logistic

regressions for each predictor. Then a multivariate logistic

regression model was considered. All analyses were tested for

significance at the 5% level. Unadjusted and adjusted odds ratios

and 95% confidence intervals for each predictor are presented.

III. RESULTS

Demographic profile

506 patients underwent emergency appendectomies in the

study period. These included 253 male (50%) and 253 female

(50%) patients with a median age of 25 years (range = 4-90). The

presenting complaint was right iliac fossa pain in all patients with

median duration of symptoms of 2 days (range: 0-30).

Surgical profile

418 patients (82%) underwent laparoscopic

appendectomies while 53 patients (11%) had an open procedure.

In 35 patients (7%), the procedure needed conversion from

laparoscopy to a laparotomy. The median duration of stay was 2

days (range: 0-21).

Pathological profile

Of the 506 patients, 455 patients (90%) had acute

appendicitis confirmed on histology. Thirty-five patients (7%)

had a histologically normal appendix while 16 patients had a

pathology other then appendicitis (3%). [Table 1] provides the

complete pathological profile of the histology. Hundred and two

patients (20%) had a perforated appendix noted at the time of

surgery.

Table 1: Pathological profile of the 506 patients who

underwent emergency appendectomy for suspected acute

appendicitis

Morbidity The overall post-operative morbidity rate was 9.4% (48

patients).). In patients with perforated appendicitis, the morbidity

rate was 28.4% (29 out of 102 patients) which was significantly

higher as compared to a rate of 4.7% (19 out of 404 patients)

without perforation (P<0.0001). The spectrum of complications

is listed in [Table 2]

Table 2: Post-operative morbidity (n=48)

Fourteen patients required re-surgery for complications.

These included 11 patients with collections (pelvic or other), 1

suprapubic port exploration, 2 diagnostic laparoscopies for

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abdominal pain (1 patient had a stump hematoma found which

was managed conservatively and the other patients had necrotic

mesoappendicular fat necessitating excision of the fat).

Fifteen patients (3%) required re-admission.

Risk factors predicting perforated appendicitis

A comparison of the demographic factors, symptom

duration, and blood investigations between the patients with a

perforated and non-perforated appendicitis is provided in [Table

3].

Table 3: Comparison of factors between patients with and

without perforation

The results of the univariate analysis for factors associated

with the likelihood of patients presenting with perforated

appendicitis have been summarized in [Table 4]. Males

(P<0.001) and patients older than 60 years (P<0.001) were found

to be at a significantly increased risk of developing perforated

appendicitis. Similarly, patients presenting after the second day

of onset of their symptoms were found to be at a significantly

increased risk with the risk increasing depending on whether they

presented between 2 and 3 days of onset of symptoms or 4 and 9

days following the onset of symptoms. While the white cell

count had no significance on the presence of perforated

appendicitis on univariate analysis, the neutrophil count was

found to have a significant effect on the probability of

perforation (P<0.001) with the risk of perforation increasing by

10% for every unit increase in the neutrophil count above

normal. Similarly, CRP levels were also found to have a

significant effect on the probability of perforation (P<0.001) with

the risk of perforation increasing by 1.4% for every unit increase

in the CRP level. Patients in the pediatric age group were less

likely to have a perforated appendicitis although this was not

statistically different from the patients aged 15 to 59 years.

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Table 4: Results from logistic regression analysis for factors associated with the risk for perforated appendicitis

On multivariate analysis, when all the terms were included

in the model of analysis, duration of symptoms was the only term

which was no longer significant at the 5% level (P=0.35).

IV. DISCUSSION

The present study on emergency appendectomies for acute

appendicitis conducted in a community teaching hospital in rural

India indicates that acute appendicitis is more common in the

young population affecting males and females, alike. The

findings of the study also indicate that the male sex and advanced

age (>60 years) are demographic factors associated with an

increased risk of perforation, while blood investigations at

admission such as neutrophil count and CRP levels were

independent predictors of risk of perforation. A combination of

an elevated neutrophil count and CRP level taken together were

also indicative of the risk of an underlying perforated appendix.

Perforated appendicitis was found to account for 20% of

the cases in this study which is not dissimilar to the rates reported

in other parts of the world. [2],[7]

The significantly increased

morbidity rate following surgery for perforated appendicitis has

been previously noted by Styrud et al. [8]

and remains a concern.

The impact of age and sex on the risk of perforation has

been previously reported.

Extremes of age and advancing age as well as the male

sex have been previously demonstrated to be linked to a risk of

perforation. [9],[10],[11],[12],[13]

Delays in diagnosis, and hence in the

surgical management, have been reported to be the likely causes.

In the pediatric age group, their inability to clearly communicate

symptoms, and in the elderly, confounding medical conditions

and a decreased index of suspicion have been linked to delays in

diagnosis. [11]

However, our own data has failed to demonstrate

an increased risk of perforation and its attendant morbidity in the

pediatric age group. The department policy of avoiding delays in

surgery once the diagnosis of acute appendicitis was made (as

observed by the lack of difference in the median duration of

symptoms to surgery in [Table 3]) could have accounted for the

observed the lower perforation rate noted even in the pediatric

age group. It, however, fails to explain the higher risk of

perforations encountered in the elderly (>60 years) and amongst

males. This indicates that there may be factors other than delays

in presentation, diagnosis, or surgery, which influence the risk of

perforation in these two groups. Males have been found to have a

higher incidence of appendicular faecoliths and calculi [14]

which

are in turn associated with an increased risk of perforation. This

could be one potential explanation for the increased risk of

perforation in males. Advanced age and male sex have been

found to be risk factors for perforation even in diverticular

disease. [15]

Changes in the colonic wall mechanical strength have

been noted with advancing age. [16]

These changes have been

postulated to be linked to the increased risk of diverticular

perforations noted in advancing age. While this has not been

previously studied in appendicular tissue, we can only

hypothesize that such changes may occur in the appendicular

wall, as well, increasing the susceptibility to perforation with

advancing age.

Blood investigations serve as an adjunct to clinical

findings in the diagnosis of acute appendicitis. [17]

The most

commonly performed blood investigations in patients presenting

with right lower quadrant pain are a complete blood count and

CRP. Our data confirm the added use of neutrophil counts and

CRP in predicting an appendicular perforation as a result of acute

appendicitis. In the rapidly changing surgical scenario wherein

patients with "uncomplicated" acute appendicitis, admitted after

hours, are delayed to the next morning, [5]

in a patient with

clinical signs of acute appendicitis and the findings of an

elevation in the blood parameters, namely neutrophil count and

CRP (which are associated with an increased risk of perforation)

such patients should be strongly considered as for an urgent

appendectomy even if this entails performing the surgery after

hours.

Our departmental policy of conversion directly from

laparoscopy to a midline laparotomy in patients in whom the

appendectomy cannot be completed laparoscopically by a trained

laparoscopic surgeon has helped us avoid an unnecessary

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additional wound/scar caused by the use of the McBurney

incision.

V. CONCLUSIONS

Acute perforated appendicitis is associated with a high

morbidity. The increased risk of perforation in males and elderly

patients appears to be unrelated to delays in presentation,

diagnosis, or surgery. Patients with clinically diagnosed acute

appendicitis and an elevation in two laboratory parameters,

namely neutrophil count and CRP level must be considered

candidates for early surgery as they are likely to have an

appendicular perforation.

REFERENCES

[1] Cueto J, D'Allemagne B, Vazquez-Frias JA, Gomez S, Delgado F, Trullenque L, et al. Morbidity of laparoscopic surgery for complicated appendicitis: An international study. Surg Endosc 2006;20:717-20.

[2] Yaghoubian A, de Virgilio C, Lee SL. Appendicitis outcomes are better at resident teaching institutions: A multi-institutional analysis. Am J Surg 2010;200:810-3.

[3] McGreevy JM, Finlayson SR, Alvarado R, Laycock WS, Birkmeyer CM, Birkmeyer JD. Laparoscopy may be lowering the threshold to operate on patients with suspected appendicitis. Surg Endosc 2002;16:1046-9.

[4] Gandy RC, Truskett PG, Wong SW, Smith S, Bennett MH, Parasyn AD. Outcomes of appendicectomy in an acute care surgery model. Med J Aust 2010;193:281-4.

[5] Abou-Nukta F, Bakhos C, Arroyo K, Koo Y, Martin J, Reinhold R, et al. Effects of delaying appendectomy for acute appendicitis for 12 to 24 hours. Arch Surg 2006;141:504-6.

[6] Eastridge BJ, Hamilton EC, O'Keefe GE, Rege RV, Valentine RJ, Jones DJ, et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am J Surg 2003;186:169-74.

[7] Styrud J, Eriksson S, Granstrom L. Treatment of perforated appendicitis: An analysis of 362 patients treated during 8 years. Dig Surg 1998;15:683-6.

[8] Stahlfeld K, Hower J, Homitsky S, Madden J. Is acute appendicitis a surgical emergency? Am Surg 2007;73:626-9.

[9] Andersson RE, Hugander A, Thulin AJ. Diagnostic accuracy and perforation rate in appendicitis: Association with age and sex of the patient and with appendicectomy rate. Eur J Surg 1992;158:37-41.

[10] Gurleyik G, Gurleyik E. Age-related clinical features in older patients with acute appendicitis. Eur J Emerg Med 2003;10:200-3.

[11] Hale DA, Molloy M, Pearl RH, Schutt DC, Jaques DP. Appendectomy: A contemporary appraisal. Ann Surg 1997;225:252-61.

[12] Shaw PA. The topographical and age distributions of neuroendocrine cells in the normal human appendix. J Pathol 1991;164:235-9.

[13] Storm-Dickerson TL, Horattas MC. What have we learned over the past 20 years about appendicitis in the elderly? Am J Surg 2003;185:198-201.

[14] Nitecki S, Karmeli R, Sarr MG. Appendiceal calculi and fecaliths as indications for appendectomy. Surg Gynecol Obstet 1990;171:185-8.

[15] Morris CR, Harvey IM, Stebbings WS, Speakman CT, Kennedy HJ, Hart AR. Epidemiology of perforated colonic diverticular disease. Postgrad Med J 2002;78:654-8.

[16] Wess L, Eastwood MA, Wess TJ, Busuttil A, Miller A. Cross linking of collagen is increased in colonic diverticulosis. Gut 1995;37:91-4.

[17] Markar SR, Karthikesalingam A, Falzon A, Kan Y. The diagnostic value of neutrophil: Lymphocyte ratio in adults with suspected acute appendicitis. Acta Chir Belg 2010;110:543-7.

AUTHORS

First Author – DR. SUBODH UGANE, MBBS, M.S (Gen

Surg), Assistant professor, Department of Gen Surg, Government

Medical College, Miraj and PVP Govt. Hospital, Sangli,

9921411355, ugane_subodh@yahoo.co.in

Second Author – DR. SUSHIL BHOGAWAR, MBBS,

M.S(Gen Surg 2nd yr), P. G. Student 2nd yr, Department of

Gen Surg, Government Medical College, Miraj and PVP Govt.

Hospital, Sangli., 8975209890, drsushilmsgsurg@gmail.com.

Correspondence Author – DR. SUSHIL BHOGAWAR,

MBBS, M.S(Gen Surg 2nd yr), P. G. Student 2nd yr,

Department of Gen Surg,, Government Medical College, Miraj

and PVP Govt. Hospital, Sangli., 8975209890,

drsushilmsgsurg@gmail.com