Appendiceal Phlegmon as an intraoperative finding: A retrospective analysis

doi:10.21203/rs.3.rs-2640598/v1

Background

Emergency procedures due to acute surgical abdomen correspond to a great part of emergency surgeries. Appendicitis is the most common abdominal surgical emergency in the world. Intraoperative findings can represent a challenging scenario for the surgical team and its decisions. Appendiceal phlegmon/plastron presents in 3.8-7% of patients with appendicitis and can be considered as a challenging surgical scenario where expertise may gain a fundamental value in terms of decision-making process. Therefore, we present clinical courses and outcomes of 40 patients that underwent emergency surgery with these intraoperative findings from 2016 to 2018.

Methods

Retrospective study with a prospective database in which we described patients with emergent need for surgical procedure due to peritoneal signs with surgical findings of appendiceal phlegmon. Multivariate analysis was performed to prove the relationship between obesity, diabetes, and surgeon experience with any complication and colonic resection.

Results

40 patients underwent surgical procedure due to peritoneal signs with intraoperative findings of appendiceal phlegmon. Mean age was 51.9 (± 20.4). Procedures were performed based on intraoperative findings being appendectomy the most frequent (85%), followed by right hemicolectomy (10%) and partial cecum resection (5%). Three patients required reintervention. No mortalities were documented. Surgeries performed by junior surgeons have a higher probability to require colonic resections (P = 0.05, OR 4.05 ,95% CI), also obesity is associated with complications (P = 0.04, OR 1.44, 95% CI).

Conclusion

Finding of appendiceal phlegmon constitute a challenging surgical scenario in daily practice. Our patient’s complication rates are similar to those described in literature despite its emergent circumstances. Surgeons' expertise appears to be associated with outcomes. Further studies are needed to give clear recommendations.

Appendicitis

appendiceal phlegmon

expertise

experience

acute abdomen

Acute surgical abdomen corresponds to a great part of emergency surgeries (1). Acute abdominal pain can represent a challenging scenario to the surgical team and its decisions (2). Acute abdomen encompasses a great number of pathologies that could require immediate surgical procedures, ranging from inflammatory diseases to neoplasms, and vascular problems [1, 2]. Given this broad spectrum, clinical presentation represents a challenge for the surgeon when faced with a patient with peritoneal signs that could lead to different therapeutic or diagnostic approaches that may delay the appropriate management. (1–3).

In general terms, acute appendicitis is the most common abdominal surgical emergency with a prevalence between 14–88% (depending on the patient's age), followed by bowel obstruction (5.5–45%), and benign biliary tract disease (13–25%) [1]. Appendiceal phlegmon, secondary to an inflammatory process on the appendix, presents in 2–10% of patients with appendicitis (4). Traditionally, patients with appendiceal phlegmon have been managed with non-surgical treatment followed by interval appendectomy to prevent recurrence (5). Nevertheless, a challenging surgical scenario takes place once patients present with peritoneal signs and underwent surgical procedures with an intraoperative finding of appendiceal phlegmon. Indeed, this happens since there is no consensus on appendiceal phlegmon management as an incidental intraoperative finding in the context of emergency surgery (6–8).

Among surgical approaches, laparoscopic appendectomy is considered the gold standard management for appendicitis, regardless of if it presents as an uncomplicated acute appendicitis case or an appendicular phlegmon with peritoneal signs (9). Superiority has been determined in terms of decrease of financial burden rates, readmission rate, ICU stay, overall mortality, and early diagnosis of underlying pathologies compared with open approaches (9,10). Despite the clear importance of laparoscopy in the management of emergency appendectomy, the challenge for our patients relies on the fact that diagnosis was made during surgery as an intraoperative finding. At this time, the surgeon is faced with a therapeutic challenge and must make decisions in a matter of seconds that may impact directly on patient outcomes, allowing the surgeon’s expertise as an important tool in the decision-making process.

Throughout surgical practice, different complex and challenging scenarios may be presented to the surgical team (11). These situations constitute a cornerstone in the continuous growth and expertise paradigm of the surgeon, contributing tools to enhance and enrich their progress (11). Hence, surgeons with richer experiences have a wider range of tools to use when making on-the-spot decisions when facing challenging scenarios, which may lead to better performance and fewer mistakes over time (11,12). Therefore, herein we present a retrospective analysis of 40 patients who underwent emergency surgery due to peritoneal signs with an incidental intraoperative finding of appendicular phlegmon. Likewise, we relate their outcomes to the level of expertise of the surgical team.

After Institutional Review Board approval (Research Ethics Committee) at Hospital Universitario Mayor Mederi, all patients undergoing surgical management for acute abdomen who had appendiceal phlegmon as an incidental intraoperative finding between January 2016 and December 2018, were included. Only patients over 18 years old were accepted into the study. Exclusion criteria involved patients with incomplete clinical history, previous conservative management, or patients who were intervened extra-institutionally. Preoperative data included patients' demographics and clinical history. The type of procedure performed, and its approach was included in the intraoperative data. Postoperative data included early and late complications. According to institutional protocol, all patients received at least 5 days of antibiotic postoperative care.

Descriptive statistics of all study parameters were provided. Data were analyzed using IBM SPSS Statistics 25 software. Continuous data were summarized by their ni mean, standard deviation, median, minimum, and maximum. Categorical data were summarized by their frequency and proportion. Bivariate analysis between qualitative and quantitative variables was performed using the Mann-Whitney test or t-test for independent samples. For associations between categorical variables, odds ratios with 95% confidence intervals were provided. The surgeon’s expertise cut-off was considered as 5 years of experience, we accepted a significant p-value ≤ 0.05.

From January 2016 to December 2018 a total of 48 patients with peritoneal signs underwent surgical management with intraoperative findings of appendiceal phlegmon. 8 patients were excluded due to previous extra-institutional management. The mean age of patients was 51.9 (± 20.4) years old with a mean BMI of 26.8 (± 4.5) Kg/m² (Table 1). 7.5% of all patients had a history of type II diabetes mellitus, 25 patients had a history of abdominal surgery, 20% had BMI > 30 Kg/m² and 5% were active smokers (Table 2). All patients had blood chemistry laboratories as an initial emergency department approach and 24 patients required additional diagnostic imagenological tests (Table 3). All patients underwent surgery, and the approach was selected by the surgical team. Procedures were performed based on intraoperative findings being appendectomy the most frequent (85%), followed by right hemicolectomy (10%) and partial cecum resection (5%) (Table 4).

Table 3. Diagnostic Criteria
Diagnostic Criteria	n	%
Clinical	16	40
CT	21	52,5
MRI	3	7,5
	Mean	Standard Deviation
Leucocytes	13423,7	5701,8
Neutrophils	10389,6	5257,6

Table 4. Procedure and Surgical Approach

Variables		n	%
Surgical Approach	Infraumbilical midline laparotomy	24	60
	Mc Burney	4	10
	Midline laparotomy	7	17,5
	Rockey-Davis	2	5
	Laparoscopic	2	5
	Hockey stick	1	2,5
Procedure performed	Appendectomy	34	85
	Right Hemicolectomy	4	10
	Partial Cecum Resection	2	5

Table. 5 Complications
	n	%
Superficial/ Deep Incisional SSI*	2	5
Ileus	6	15
Organ space SSI*	2	5
Evisceration	1	2,5
Anastomotic Leak	1	2,5
Organ space SSI* + Evisceration	1	2,5
None	27	67,5
*Surgical Site Infection (SSI)

Early complications were reported if they occurred within 30 days. Most patients had an uneventful follow-up (67.5%). 6 patients presented postoperative ileus that was managed successfully with hydration, early ambulation, and nasogastric tube placement. Reinterventions were required in 3 cases, including one anastomotic leak, with no need for additional procedures (Table 5). No mortality cases were reported. Surgical teams were divided in two according to surgeon experience, considering 5 years of experience as a cut-off point. 70% of procedures were performed by senior surgeons and four patients presented ileus as the only postoperative complication in this group. Three patients managed by junior attendings required reintervention, all with uneventful postoperative follow-up (Table 6). In the bivariate analysis, diabetes, obesity, and surgeon experience showed p-values < 0.05. ORs were calculated (Table 7).

In the bivariate analysis, diabetes, obesity, and surgeon experience showed p-values < 0.05. Our study found that postoperative complications are related to past history of diabetes with a significant statistical value (P = 0.04, 95% CI, OR 1.44). In addition, if the initial surgery was performed by a junior surgeon, our analysis reports a four times more chance of requiring colonic resections (P = 0.05, 95% CI, OR 4,05).

Acute abdomen represents 5–10% of the visits to the emergency room, with acute appendicitis being the most common abdominal surgical emergency in the world, with a prevalence that can be up to 90% among all causes of acute abdominal pain (1). Appendiceal phlegmon presents in up to 10% of patients with appendicitis (4). Early appendectomy and conservative management with or without interval appendectomy are both considered feasible options (5,13). Nevertheless, intraoperative incidental finding of appendiceal phlegmon in patients with peritoneal signs constitutes a challenging scenario that requires immediate solutions that impact patients’ outcomes and life quality.

Evidence for optimal appendiceal phlegmon management as an intraoperative incidental finding is scarce, with most of the studies focusing in the management of a before-surgery diagnosed appendiceal phlegmon (14,15). Even though the ideal approach of these patients is still unclear because of recurrence rates, conservative management with or without interval appendectomy appears to be more feasible and secure, considering possible complications as turning points while selecting adequate management (16–18). Nonetheless, in our study conservative management was not possible due to the nature of its detection as an intraoperative finding.

In terms of selecting the appropriate surgical approach, laparoscopic surgery has seemingly improved outcomes making it a feasible and safe surgical approach (9,10). In our study, the surgical management approach was selected following the first surgeon's preference, being infraumbilical laparotomy the most common (60%), only 2 cases were managed laparoscopically due to the nature of the surgical indication and in alignment to institutional guidelines.

Complication rate observed in our patients was 32,5%, similar to the rate described by Cheng et al (4) in a Cochrane review where they report an overall complications rate of 30% in the early appendectomy group. The majority of them were classified as grade I and II (ileus and superficial surgical site infection) according to Clavien-Dindo’s classification, as found in our patients (19). Ahmed et al (20) suggest that there must be a strict following process for patients in order to exclude the presence of hidden pathologies like colitis and even malignancies, especially in elderly patients (20,21). Nonetheless, in our population, no appendiceal, colonic neoplasms, or any other hidden pathologies were documented in pathology reports.

Complex and infrequent scenarios in the surgical room demand a fast-paced decision-making process in which expertise and experience gain relevance due to their relation to one's ability to adequately manage unexpected findings (22–24). Satkunasivam et al (23) in a Canadian retrospective cohort study of 1.159.676 patients undergoing emergent and elective procedures showed lower rates of 30-day mortality, readmission, and complications in patients treated by older surgeons compared with younger. This is similar to the results found in our population, where we documented a 32,5% overall rate of complications with junior surgeons having more severe ones, classified as type IIIb (Clavien-Dindo Classification) than senior surgeons. Additionally, we found an association between expertise and complications showing complication rates are 4,05 IC (3,5–6,9) (P 0,04) times more frequent in junior surgeons, similar to those reported by Mentula et al (8) where immediate laparoscopic surgery outperformed conservative management because almost all the procedures were performed by a single experienced surgeon with expertise in acute surgical conditions. Although our conclusions do not necessarily establish a causal relationship, severe complications are more frequently documented in inexperienced surgeons.

Exposure to challenging situations, such as acute abdomens and surgical practices can vary broadly among surgeons (25). Outcomes in the management of appendiceal phlegmon in the context of acute abdomen may be altered by surgeons’ expertise. Cristancho et al (24) proposed a model of intraoperative decision-making that consists of 3 steps: Assessing the situation and making an ideal plan, a reconciliation cycle where the findings are contrasted to what was expected, and implementing the planned course of action in the previous step (24). In spite of the demanding situation faced by our surgical teams, complication rates were similar to those reported in other studies in which surgical management was preferred by surgeons like those presented by Cheng et al (4). Thus, although the management of appendiceal phlegmon is debated and adequately described, there is no established consensus in the case of appendiceal phlegmon as an intraoperative incidental finding. Therefore, it will depend on the surgical criteria and the individual characteristics of each patient to define the appropriate approaches.

Among the limitations of this study are the relatively small number of patients, its retrospective nature, the lack of previous studies to compare our results in terms of expertise and experience of the surgical team. Further prospective studies are needed to validate our results.

Surgery in patients with peritoneal signs in the emergency context leads to increased challenges. We found that in patients who underwent surgery and had an incidental intraoperative finding of appendiceal phlegmon, emergency laparotomy followed by appendectomy had good outcomes, with no increase of complications. Our study suggests that surgery performed by junior surgeons has a higher probability to require colonic resections, and patients with any grade of obesity have an increased risk to present any complication. Further prospective studies are needed to confirm our results.

Ethical approval: All procedures performed involving human participants were in accordance with the ethical standards of the Institutional Review Board (Research Ethics Committee) at Hospital Universitario Mayor Mederi approval.

Ethical guidelines: All procedures were in accordance with the 1964 Helsinki Declaration and its later amendments. Also, in accordance with the current legislation on research Res. 008430-1993 and Res. 2378-2008 (Colombia) and the International Committee of Medical Journal Editors (ICMJE) were ensured under our Ethics and Research Institutional Committee (IRB) approval. Informed consent was filled out as required for the execution of this study.

Consent for publication: Consent for publication was obtained in order to publish this manuscript.

Availability of data and materials: The dataset generated is available from the corresponding author upon reasonable request.

Competing interests: None.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements: None.

CRediT authorship contribution statement:

Danny Conde: Study conception and design, interpretation of data, drafting of manuscript, critical revision of manuscript.

Lina Rodríguez: Study design, analysis and interpretation of data, drafting of manuscript, critical revision of manuscript.

David Venegas: Study conception and design, acquisition of data, analysis and interpretation of data, drafting of manuscript, critical revision of manuscript.

Carlos Rey: Study design, analysis and interpretation of data, drafting of manuscript, critical revision of manuscript.

Ricardo Núñez: Acquisition of data, drafting of manuscript, critical revision of manuscript.

Ricardo Nassar: Study conception, critical revision of manuscript.

Marco Venegas: Study design, drafting of manuscript, critical revision of manuscript.

Catalina Monsalve: Acquisition of data, drafting of manuscript, critical revision of manuscript.

Pablo Pinzon: Study conception and design, Analysis and interpretation of data and Critical revision of manuscript

Felipe Girón Arango: Study conception and design, acquisition of data, analysis and interpretation of data, drafting of manuscript, critical revision of manuscript.

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No competing interests reported.

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Appendiceal Phlegmon as an intraoperative finding: A retrospective analysis

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Abstract

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Background

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