title: Determination of surgical priorities in appendicitis based on the probability of undetected appendiceal perforation.
abstract: OBJECTIVE
  To identify risk factors of actual appendiceal perforation when computed tomography (CT) scans suggest nonperforated appendicitis and accordingly determine surgical priority.
  
  
  METHODS
  We collected database of 1362 patients who underwent an appendectomy for acute appendicitis between 2006 and 2013. A single radiologist selected 1236 patients whose CT scans were suggestive of nonperforated appendicitis. Patients were divided into 2 groups: actual nonperforation group and actual perforation group according to intraoperative and pathologic features. Comparison of the 2 groups were made using binary logistic regression.
  
  
  RESULTS
  Of 1236 patients, 90 (7.3%) were found to have actual appendiceal perforation. Four risk factors related with actual appendiceal perforation were identified: body temperature≥37.6  °C (HR=1.912, 95%CI: 1.161-3.149; P=0.011), out-of-hospital symptom duration≥72 h (HR=2.454, 95%CI: 1.292-4.662; P=0.006), age≥35 years (HR=3.358, 95%CI: 1.968-5.728; P<0.001), and appendiceal diameter on CT scan≥8 mm (HR=4.294, 95%CI: 1.034-17.832; P=0.045). Actual appendiceal perforation group showed longer operation time, later initiation of diet, longer use of parenteral narcotics, longer hospital stay, and higher incidence of postoperative complications (P<0.05).
  
  
  CONCLUSIONS
  We proposed here new criteria to select patients with adverse clinical outcomes after appendectomy among the patients with radiologically nonperforated appendicitis. Surgical appendectomy outcomes could be improved by determining the surgical priority according to our criteria.
authors.affiliation: Sang Chul Lee, Byung-Jo Choi, Say-June Kim, Department of Surgery, Daejeon St. Mary's Hospital, the Catholic University of Korea, Daejeon 420-743, South Korea.
authors.forename: Sang Chul
authors.initials: SC
authors.lastname: Lee
authors.affiliation: Sang Chul Lee, Byung-Jo Choi, Say-June Kim, Department of Surgery, Daejeon St. Mary's Hospital, the Catholic University of Korea, Daejeon 420-743, South Korea.
authors.forename: Geon
authors.initials: G
authors.lastname: Park
authors.affiliation: Sang Chul Lee, Byung-Jo Choi, Say-June Kim, Department of Surgery, Daejeon St. Mary's Hospital, the Catholic University of Korea, Daejeon 420-743, South Korea.
authors.forename: Byung-Jo
authors.initials: BJ
authors.lastname: Choi
authors.affiliation: Sang Chul Lee, Byung-Jo Choi, Say-June Kim, Department of Surgery, Daejeon St. Mary's Hospital, the Catholic University of Korea, Daejeon 420-743, South Korea.
authors.forename: Say-June
authors.initials: SJ
authors.lastname: Kim
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D001062:Appendectomy / Q000009:adverse effects; D001064:Appendicitis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000601:surgery*; D001831:Body Temperature; D016009:Chi-Square Distribution; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D061646:Operative Time; D018579:Patient Selection; D011183:Postoperative Complications / Q000628:therapy; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult
keywords: Appendiceal perforation; Appendicitis; Operative priority; Practice guideline; Prognosis