A. Erickson1, K. E. Galicia1,2, L. Reidy2,3, M. Anstadt1, H. Ton-That1, R. Gonzalez1,2, J. Kubasiak1,2, P. Patel1 1Loyola University Medical Center, Department Of Surgery, Maywood, IL, USA 2Loyola University Chicago, Burn And Shock Trauma Research Institute, Maywood, IL, USA 3Loyola University Chicago, Stritch School Of Medicine, Maywood, IL, USA
Introduction: Resection of the normal appendix, also known as an incidental appendectomy (IA), is a frequent though non-standard addition to many elective operations. The rationale is to eliminate the risk of future appendicitis. Patients identified to have bowel injury and who undergo bowel repair or resection during trauma laparotomy are at significant risk of developing dense adhesions. Thus, there is potential benefit in performing an IA in this population. This study aims to determine the incidence and consequence of IA during trauma laparotomy with bowel injury.
Methods: The ACS-TQP-PUF database was queried for all adult trauma patients (>18 years) from 2017-2019. Using ICD-10 procedure codes, patients who underwent laparotomy with bowel repair or resection were identified and stratified into cohorts, those receiving IA and those who did not. Patients presenting dead on arrival or missing data were excluded. Chi-squared- and Student’s t-tests were used for demographic and clinical characteristic comparisons between cohorts. Outcome measures, including rate of surgical site infection (SSI), total ventilator days, intensive care unit length of stay (ICU LOS), hospital LOS, discharge to a facility, and in-hospital mortality were similarly compared. Multivariate regression was used to assess associations between IA and each outcome measure, adjusting for covariates. Analyses were conducted using RStudio (version 1.4.1717).
Results: A total of 11,949 patients were identified to have undergone trauma laparotomy with bowel resection or repair; 435 (3.6%) received an IA and 11,514 (96.4%) did not. Within the IA cohort, 321 (73.8%) were performed during the index laparotomy, while 114 (26.2%) were performed upon a subsequent return to the OR. The IA cohort was younger (34.4 years vs 36.8 years; p=0.002), though both cohorts were similar in sex and race (all p>0.05). Mechanism of trauma (blunt vs penetrating), injury severity score, GCS, and rates of hypotension were similar between cohorts (all p>0.05). The non-IA cohort was identified to be more comorbid via modified Charlson Comorbidity Index (0.4 vs 0.6; p<0.001). Multivariate regression analyses demonstrated that IA did not independently predict SSI (p>0.05), nor did it increase the likelihood of in-hospital mortality (OR=0.45; 95% CI, 0.25-0.76; p=0.005). In contrast, IA increased the likelihood of discharge to a facility (1.36; 1.07-1.73; p=0.012). Additionally, IA increased ICU LOS by 1.27 days (0.27-2.27; p=0.013) and hospital LOS by 2.48 days (0.85-4.12; p=0.003).
Conclusion: The data herein suggest that IA during trauma laparotomy with bowel repair or resection may be performed without added risk of SSI or mortality. Associated prolongations of ICU LOS and hospital LOS, as well as increased likelihood of discharge to a facility may be offset by eliminating the lifetime risk of acute appendicitis and circumventing post-operative complications associated with urgent appendectomy.