Cioffi Stefano Piero Bernardo, Granieri Stefano, Scaravilli Luca, Molteni Mattia, Altomare Michele, Spota Andrea, Virdis Francesco, Bini Roberto, Renzi Federica, Reitano Elisa, Ragozzino Roberta, Gupta Shailvi, Chiara Osvaldo, Cimbanassi Stefania
General Surgery and Trauma Team, ASST GOM Niguarda, Milano, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
Department of Surgical Sciences, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy.
Surg Endosc. 2023 Jan;37(1):729-740. doi: 10.1007/s00464-022-09674-0. Epub 2022 Oct 28.
Laparoscopic appendectomy (LA) for acute appendicitis (AA) is one of the most performed procedures. The effects of peritoneal lavage (PL) and the reasons to perform it have not been cleared and all meta-analyses didn't show a statistical advantage to prevent infectious complications. This study aims to investigate surgeons' perceptions during LA, comparing intraoperative findings with histological results, and exploring how surgeons' subjectivity influences the decision-making process on PL.
Data were extracted from the two-year data lock from REsiDENT-1 registry, a prospective resident-led multicentre observational trial. This study investigates the relationships between PL and postoperative intraabdominal abscesses (pIAA) introducing a classification for AA to standardize the intraoperative grading. We included pre, intra, and postoperative variables. We applied our classification proposal, used a five-point Likert scale (Ls) to assess subjective LA difficulty and ran a concordance analysis between the assessment of AA and histology. Subsequently, a multivariate logistic regression model was built to find factors influencing PL.
561 patients were enrolled from twenty-one hospitals and 51 residents. 542 procedures were included in the logistic regression analysis and 441 in the concordance analysis, due to missing data. PL was used in 222 LA (39, 6%). We discovered a moderate positive monotonic relationship between surgical evaluation and histology, p < 0.001. Despite this, the reliability of the surgeon's assessment of appendicitis is progressively lower for gangrenous and perforated forms. The increasing grade of contamination, the increasing grade of subjective difficulty and the intraoperative finding of a gangrenous or perforated appendicitis were independent predictors of PL.
This study shows how surgeons' evaluation of AA severity overestimated more than half of gangrenous or perforated appendices with the perception of a challenging procedure. These perceptions influenced the choice of PL. We proved that the evaluation during LA could be affected by subjectivity with a non-negligible impact on the decision-making process.
腹腔镜阑尾切除术（LA）治疗急性阑尾炎（AA）是最常开展的手术之一。腹腔灌洗（PL）的效果及其实施原因尚不明确，所有的荟萃分析均未显示其在预防感染性并发症方面具有统计学优势。本研究旨在调查LA手术过程中外科医生的认知，将术中发现与组织学结果进行比较，并探讨外科医生的主观性如何影响PL的决策过程。
数据来自REsiDENT-1注册研究的两年数据锁定，这是一项由住院医师主导的前瞻性多中心观察性试验。本研究通过引入AA分类来标准化术中分级，调查PL与术后腹腔内脓肿（pIAA）之间的关系。我们纳入了术前、术中和术后变量。我们应用了我们的分类方案，使用五点李克特量表（Ls）评估LA主观难度，并对AA评估与组织学进行一致性分析。随后，建立多变量逻辑回归模型以找出影响PL的因素。
来自21家医院的51名住院医师共纳入561例患者。由于数据缺失，逻辑回归分析纳入542例手术，一致性分析纳入441例。222例LA（39.6%）使用了PL。我们发现手术评估与组织学之间存在中度正单调关系，p < 0.001。尽管如此，对于坏疽性和穿孔性阑尾炎，外科医生对阑尾炎评估的可靠性逐渐降低。污染程度增加、主观难度增加以及术中发现坏疽性或穿孔性阑尾炎是PL的独立预测因素。
本研究表明，外科医生对AA严重程度的评估高估了超过一半的坏疽性或穿孔性阑尾，认为手术具有挑战性。这些认知影响了PL的选择。我们证明LA过程中的评估可能受到主观性影响，对决策过程产生不可忽视的影响。
