M. Ruiz1, S. Huerta1,2 1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Dallas, TX, USA
Introduction: An open appendectomy used to be one of the most common cases performed by interns and physical exam dictated operative intervention. We hypothesize that the management of acute appendicitis has drastically changed from these previous practices.
Methods: This a retrospective, single institution analysis at the VA North Texas Health Care system (VANTHCS) between 7/05 to 6/17 for all patients who underwent an appendectomy (n=345). Patients who had an appendectomy for cancer, or incidentally for other reasons were excluded (n=35) as were patients with interval appendectomies (n=16) as well as patients with perforated appendicitis (n=14). Specific analysis for complications was performed by grouping residents as junior (PGY-1 to 3) and senior (PGY-4 and 5) to determine if there were differences in outcomes. Using postoperative complications as a dependent variable, univariate analysis was performed using Fisher’s Exact Test for categorical and Student’s T-Test for continuous variables. Significant variables were included in a multiple logistic regression model with postoperative complications as the dependent variable. Data are expressed as means ± SD and significance was established at a p≤0.05 (two-sided).
Results: There were 280 acute appendectomies during the study period (male=90%; age=46.0±15.7 y.o.; BMI=31.2±18.3 Kg/m2). Of these, only 8 were performed by interns, PGY-2=30, PGY-3=154, PGY-4=25, and PGY-5=63. There were 20 minor complications (7.1%) and 30-day mortality was zero. LOS was 3.7±4.3 days. On presentation, 91% of patients had a CT scan and 92% underwent a laparoscopic appendectomy. Conversion rate was 5%. Comparing patients operated by senior (PGY-4 and 5) to junior (PGY-1 to -3) residents: patients were of similar age, gender, BMI, ASA, and had similar co-morbid conditions, as well as similar WBC and blood pressure on initial presentation (all p’s > 0.05). However, OR time was longer (67.2±36.3 vs. 59.7±24.5 min) and EBL was higher (31.4±54.1 vs. 18.5±29.8 mL); both p’s <0.05. Patients also were more likely to have a gangrenous appendix if operated on by senior residents and had a higher heart rate on initial presentation (90.6±19.2 vs. 84.6±16.4; p=0.008). Complications were 10% and 6% for senior and junior residents; respectively (OR 1.1; 95% CI 1.0 to 1.1).
Conclusion: At the VANTHCS, most patients presenting with suspected appendicitis undergo a CT-scan. Most cases are performed laparoscopically. Only a small fraction of appendectomies are performed by interns. Senior residents undertake the most difficult laparoscopic cases and, therefore, have more complications.