title: How good are surgeons at identifying appendicitis? Results from a multi-centre cohort study.
abstract: BACKGROUND
  Convincing arguments for either removing or leaving in-situ a macroscopically normal appendix have been made, but rely on surgeons' accurate intra-operative assessment of the appendix. This study aimed to determine the inter-rater reliability between surgeons and pathologists from a large, multicentre cohort of patients undergoing appendicectomy.
  
  
  METHODS
  The Multicentre Appendicectomy Audit recruited consecutive patients undergoing emergency appendicectomy during April and May 2012 from 95 centres. The primary endpoint was agreement between surgeon and pathologist and secondary endpoints were predictors of this disagreement.
  
  
  RESULTS
  The final study included 3138 patients with a documented pathological specimen. When surgeons assessed an appendix as normal (n = 496), histopathological assessment revealed pathology in a substantial proportion (n = 138, 27.8%). Where surgeons assessed the appendix as being inflamed (n = 2642), subsequent pathological assessment revealed a normal appendix in 254 (9.6%). There was overall disagreement in 392 cases (12.5%), leading to only moderate reliability (Kappa 0.571). The grade of surgeon had no significant impact on disagreement following clinically normal appendicectomy. Females were at the highest risk of false positives and false negatives and pre-operative computed tomography was associated with increased false positives.
  
  
  CONCLUSIONS
  This multi-centre study suggests that surgeons' judgements of the intra-operative macroscopic appearance of the appendix is inaccurate and does not improve with seniority and therefore supports removal at the time of surgery.
authors: Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK; Division of Surgery Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK; Severn and Peninsula Audit and Research Collaborative for Surgeons, UK. Electronic address: sean.strong@bristol.ac.uk.
authors: Sean
authors: S
authors: Strong
authors: Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK; Division of Surgery Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK; Severn and Peninsula Audit and Research Collaborative for Surgeons, UK.
authors: Natalie
authors: N
authors: Blencowe
authors: West Midlands Research Collaborative, Academic Department of Surgery, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK.
authors: Aneel
authors: A
authors: Bhangu
mesh_terms: D001062:Appendectomy / Q000379:methods; D001064:Appendicitis / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery*; D002983:Clinical Competence; D015331:Cohort Studies; D006801:Humans; D008485:Medical Audit; D015588:Observer Variation; D010336:Pathology / Q000592:standards; D015203:Reproducibility of Results; D066231:Surgeons / Q000592:standards
keywords: Appendicectomy; Emergency surgery