Discordance of the pediatric surgeon's intraoperative assessment of pediatric appendicitis with the pathologists report

David Bliss, Julie McKee, David Cho, Sanjay Krishnaswami, Garret Zallen, Marvin Harrison, Mark Silen

Research output: Contribution to journalArticle

24 Citations (Scopus)

Abstract

Background/Purpose: The nature and duration of postoperative treatment in children with appendicitis is largely defined by the surgeon's intraoperative assessment of the degree of disease. Therefore, misclassification of patients could result in either inadequate or excessive duration of treatment. Materials/Methods: During the execution of an institutional review board-approved multicenter, randomized, prospective, single-blinded trial of laparoscopic versus open appendectomy in children, we tracked the attending pediatric surgeon's determination of the degree of appendicitis and compared it to the pathologists report. Postoperative care was determined, per protocol, by the surgeon's intraoperative classification. "Interval" appendectomies were excluded from the analysis. Statistical significance was analyzed using χ2 analyses. Results: A total of 133 patients were randomized into the open group, whereas 122 randomized to laparoscopy during the first 2 years of the study. The attending pediatric surgeons and pathologists were concordant in the determination of acute appendicitis in 90% of open patients and 93% of laparoscopic patients (P = not significant). When children were classified by the attending surgeon as having complicated appendicitis (gangrenous or ruptured), the concordance rate dropped to 38% and 52%, respectively (P = not significant). When open and laparoscopic patients were combined, the length of postoperative stay (LOS) of concordantly classified acute appendicitis patients was 35 ± 16 hours. Concordantly classified complicated appendicitis LOS was 118 ± 61 hours, and discordantly classified complicated appendicitis (pathology = acute) LOS was 85 ± 41 hours (P = .01). Wound infection rates in the concordant and discordant "complicated" appendicitis groups were 23% and 7%, respectively (P = .05). When the surgeons are grouped as "junior"(n = 2) and "senior" (n = 3), there is a trend toward greater concordance in the latter group (P = .08). Conclusions: In the 2 institutions studied, the 5 pediatric surgeon's intraoperative classification of appendicitis correlated with the pathologist's reading in a high percentage of those patients labeled "acute" but in only approximately one half of those defined as "complicated." These phenomena are independent of the operative approach but may correlate with surgeon experience. Interventions to improve the timeliness of pathologic diagnosis may improve the accuracy and efficiency of care of pediatric appendicitis.

Original languageEnglish (US)
Pages (from-to)1398-1403
Number of pages6
JournalJournal of Pediatric Surgery
Volume45
Issue number7
DOIs
StatePublished - 2010

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Appendicitis
Pediatrics
Length of Stay
Appendectomy
Surgeons
Pathologists
Postoperative Care
Research Ethics Committees
Wound Infection
Laparoscopy
Reading
Pathology

Keywords

  • Appendicitis
  • Laparoscopy

ASJC Scopus subject areas

  • Surgery
  • Pediatrics, Perinatology, and Child Health
  • Medicine(all)

Cite this

Discordance of the pediatric surgeon's intraoperative assessment of pediatric appendicitis with the pathologists report. / Bliss, David; McKee, Julie; Cho, David; Krishnaswami, Sanjay; Zallen, Garret; Harrison, Marvin; Silen, Mark.

In: Journal of Pediatric Surgery, Vol. 45, No. 7, 2010, p. 1398-1403.

Research output: Contribution to journalArticle

Bliss, David ; McKee, Julie ; Cho, David ; Krishnaswami, Sanjay ; Zallen, Garret ; Harrison, Marvin ; Silen, Mark. / Discordance of the pediatric surgeon's intraoperative assessment of pediatric appendicitis with the pathologists report. In: Journal of Pediatric Surgery. 2010 ; Vol. 45, No. 7. pp. 1398-1403.
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AU - McKee, Julie

AU - Cho, David

AU - Krishnaswami, Sanjay

AU - Zallen, Garret

AU - Harrison, Marvin

AU - Silen, Mark

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N2 - Background/Purpose: The nature and duration of postoperative treatment in children with appendicitis is largely defined by the surgeon's intraoperative assessment of the degree of disease. Therefore, misclassification of patients could result in either inadequate or excessive duration of treatment. Materials/Methods: During the execution of an institutional review board-approved multicenter, randomized, prospective, single-blinded trial of laparoscopic versus open appendectomy in children, we tracked the attending pediatric surgeon's determination of the degree of appendicitis and compared it to the pathologists report. Postoperative care was determined, per protocol, by the surgeon's intraoperative classification. "Interval" appendectomies were excluded from the analysis. Statistical significance was analyzed using χ2 analyses. Results: A total of 133 patients were randomized into the open group, whereas 122 randomized to laparoscopy during the first 2 years of the study. The attending pediatric surgeons and pathologists were concordant in the determination of acute appendicitis in 90% of open patients and 93% of laparoscopic patients (P = not significant). When children were classified by the attending surgeon as having complicated appendicitis (gangrenous or ruptured), the concordance rate dropped to 38% and 52%, respectively (P = not significant). When open and laparoscopic patients were combined, the length of postoperative stay (LOS) of concordantly classified acute appendicitis patients was 35 ± 16 hours. Concordantly classified complicated appendicitis LOS was 118 ± 61 hours, and discordantly classified complicated appendicitis (pathology = acute) LOS was 85 ± 41 hours (P = .01). Wound infection rates in the concordant and discordant "complicated" appendicitis groups were 23% and 7%, respectively (P = .05). When the surgeons are grouped as "junior"(n = 2) and "senior" (n = 3), there is a trend toward greater concordance in the latter group (P = .08). Conclusions: In the 2 institutions studied, the 5 pediatric surgeon's intraoperative classification of appendicitis correlated with the pathologist's reading in a high percentage of those patients labeled "acute" but in only approximately one half of those defined as "complicated." These phenomena are independent of the operative approach but may correlate with surgeon experience. Interventions to improve the timeliness of pathologic diagnosis may improve the accuracy and efficiency of care of pediatric appendicitis.

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