Increased anatomic severity predicts outcomes

Abstract

Background Determination and reporting of disease severity in emergency general surgery (EGS) lacks standardization. Recently, the American Association for the Surgery of Trauma (AAST) proposed an anatomic severity grading system. We aimed to validate this system in patients with appendicitis, and determine if cross sectional imaging correlates with disease severity at operation. Methods Patients 18 years or older undergoing treatment for acute appendicitis between 2013 and 2015 were identified. Baseline demographics, procedure types were recorded, and AAST grades were assigned based on intraoperative and radiologic findings. Outcomes including length of stay, 30 day mortality, and complications based on Clavien-Dindo categories and National Surgical Quality Improvement Program variables. Summary statistical univariate, nominal logistic and standard least squares analyses were performed comparing AAST grade with key outcomes. Bland-Altman analysis compared operative findings to preoperative cross sectional imaging to compare assigning grades. Results 334 patients with mean (±SD) age of 39.3 years (±16.5) were included (53% male) and all patients had cross sectional imaging. 299 underwent appendectomy, and 85% completed laparoscopic. 30 day mortality rate was 0.9%, complication rate 21%. Increased median [IQR] AAST grade was recorded in patients with complications 2 [1-4] compared to those without 1 [1-1], p=0.001. For operative management, a median [IQR] AAST grades were significantly associated with procedure type: laparoscopic 1 [1-1], open 4 [2-5] conversion to open 3 [1-4], p=0.001. Increased median [IQR] AAST grades were significantly associated in non-operative management: patients having a complication had a higher median AAST grade of 4 [3-5], compared to those without 3 [2-3], p=0.001. Bland Altman analysis comparing AAST grade and cross sectional imaging demonstrated no difference; −0.02 ±0.02 p = 0.2 coefficient of repeatability 0.9. Conclusions The AAST grading system is valid in our population. Increased AAST grade is associated with open procedures, complications, and length of stay. AAST EGS grade determined by preoperative imaging strongly correlated to operative findings.

An analysis of the consequences of acute appendicitis between urban and rural patients in Bangladesh

“…Rural patients were observed to have the worse outcomes or consequences from acute appendicitis than urban patients. This study's overall finding is similar to studies conducted in other low-and middle-income countries across different subclasses of patients (Elliott et al, 2019;Hernandez et al, 2017Hernandez et al, , 2018.…”

Defining burden and severity of disease for emergency general surgery

“…Similar work looking at the AAST grading scale for appendicitis has shown strong correlation between AAST severity grade assigned by preoperative cross-sectional imaging and intraoperative findings. 12 AAST severity grade also correlated well with outcomes in this study.…”

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

“…In 2017, Hernandez et al validated this system in a large cohort of patients with AA, showing that increased AAST grade was associated with open procedures, complications, and length of stay. AAST grade in emergency for AA determined by preoperative imaging strongly correlated with operative findings [ 189 ]. In 2018, the same researchers assessed whether the AAST grading system corresponded with AA outcomes in a US pediatric population.…”