Increased anatomic severity in appendicitis is associated with outcomes in a South African population

Abstract

Background Severity of emergency general surgery diseases (EGS) has not been standardized until recently. The American Association for the Surgery of Trauma (AAST) proposed an anatomic severity grading system for EGS diseases to facilitate communication and quality comparisons between providers and hospitals. Previous work has demonstrated validity of the system for appendicitis in the United States. In order to demonstrate generalizability, we aim to externally validate this grading system in South African patients with appendicitis. Methods Patients with acute appendicitis during 2010–2016 were identified at multi institutional sites within South Africa. Baseline demographics and procedure types were recorded and AAST grades were assigned based on intraoperative findings. Outcomes included duration of stay, mortality, and Clavien-Dindo complications. Summary statistical univariate and nominal logistic regression analyses were performed to compare AAST grade and outcomes. Results A total of 1415 patients with a median [IQR] age of 19 years [14–28] were included (55% male). 100% underwent appendectomy: 63.5% completed via midline laparotomy, 36.5% via limited incision (31.8% via McBurney incision and 4.7% via laparoscopy). Overall 30-day mortality rate was 1.4% with an overall complication rate of 44%. Most common complications included: surgical site infection (n=147, 10.4%), pneumonia (n=105, 7.4%), and renal failure (n=64, 4.5%). Distribution of AAST grade is as follows: Grade 0 (10, 0.7%), Grade I (247, 17.4%), Grade II (280, 19.8%), Grade III (158, 11.3%), Grade IV (179, 12.6%), and Grade V (541, 38.2%). Increased median [IQR] AAST grades were recorded in patients with complications, 5 [3–5], compared to those without, 2 [1–3], p=0.001. Duration of stay was increased for patients with higher AAST grades: IV and V (10.6 ±5.9 days) versus I and II (3.6 ±4.3 days), p=0.001. AUROC analysis to predict presence of any complication based on AAST grade was 0.90. Conclusion The AAST EGS grading system is valid to predict important clinical outcomes in a South African population with an increased degree of severity on presentation. These results support generalizability of the AAST EGS grading system for appendicitis in a developing nation. Level of evidence Level 4 – Multi institutional retrospective study Study type Retrospective multi institutional study

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

“…This study is limited by retrospective disease severity assignment from operative findings. Previous work and that performed by others suggests this method is applicable and valid [31, 32]. The study findings may be limited due to clustering wherein the highest rates of disease severity were located in South Africa in comparison with other centers.…”

Systematic review of the use of big data to improve surgery in low- and middle-income countries

“…). Following assessment, 68 articles, involving 708 032 patients across 71 LMICs, were included in the review ( Tables S1 and S2 , supporting information). Country‐specific patient numbers were reported in 60 studies but were absent from six and two provided total LMIC patient numbers only.…”

“…Outcomes following cancer surgery were common topics, including breast, gastric, colorectal and prostate cancer, and hepatocellular carcinoma. Cardiac surgery, caesarean section and genitourinary fistula were also well represented in included articles, whereas clinical presentations included burn management, trauma, appendicitis, groin hernias and orthopaedic fracture management.…”

The necessity of abdominal drainage for patients with complicated appendicitis undergoing laparoscopic appendectomy: a retrospective cohort study

“…The American Association for the Surgery of Trauma (AAST) grade for acute appendicitis has been widely adopted for predicting complications, recovery, and hospital costs [ 13 , 14 ]. Complicated appendicitis is defined based on the severity of inflammation as follows: grade II (gangrenous appendix), III (perforated appendix with focal contamination), IV (perforation appendix with abscess formation), and V (perforated appendix with generalized peritonitis).…”