Prospective evaluation of the Sunshine Appendicitis Grading System score.
BACKGROUND
Although there is a wealth of information predicting risk of post-operative intra-abdominal collection and guiding antibiotic therapy following appendicectomy, confusion remains because of lack of consensus on the clinical severity and definition of 'complicated' appendicitis. This study aimed to develop a standardized intra-operative grading system: Sunshine Appendicitis Grading System (SAGS) for acute appendicitis that correlates independently with the risk of intra-abdominal collections.


METHODS
Two-hundred and forty-six patients undergoing emergency laparoscopy for suspected appendicitis were prospectively scored according to the severity of appendicitis and followed up for complications including intra-abdominal collection. After termination of the study, the SAGS score was repeated by an independent surgeon based on operation notes and intra-operative photography to determine inter-rater agreement. The primary outcome measure was incidence of intra-abdominal collection, secondary outcome measures were all complications and length of stay.


RESULTS
SAGS score demonstrated good inter-rater agreement (kappa Kw0.869; 95% CI 0.796-0.941; P < 0.001). A risk ratio of 2.594 (95% CI 0.655-4.065; P < 0.001) for intra-abdominal collection was found using SAGS score as a predictor. The discriminative ability of SAGS score was supported by an area under the curve value of 0.850 (95% CI 0.799-0.892; P < 0.001).


CONCLUSIONS
SAGS score can be used to simply and accurately classify the severity of appendicitis and to independently predict the risk of intra-abdominal collection. It can therefore be used to stratify risk, guide antibiotic therapy, follow-up and standardize the definitions of appendicitis severity for future research.
Sunshine General Surgical Unit, Western Health, Sunshine Hospital, Melbourne, Victoria, Australia.|Department of Surgery, North West Academic Centre, The University of Melbourne, Melbourne, Victoria, Australia.
Fiona
F
Reid
Sunshine General Surgical Unit, Western Health, Sunshine Hospital, Melbourne, Victoria, Australia.|Department of Surgery, North West Academic Centre, The University of Melbourne, Melbourne, Victoria, Australia.
Julian
J
Choi
Sunshine General Surgical Unit, Western Health, Sunshine Hospital, Melbourne, Victoria, Australia.|Department of Surgery, North West Academic Centre, The University of Melbourne, Melbourne, Victoria, Australia.
Marli
M
Williams
Sunshine General Surgical Unit, Western Health, Sunshine Hospital, Melbourne, Victoria, Australia.|Department of Surgery, North West Academic Centre, The University of Melbourne, Melbourne, Victoria, Australia.
Steven
S
Chan
D000208:Acute Disease; D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use; D001062:Appendectomy / Q000009:adverse effects* / Q000379:methods; D001064:Appendicitis / Q000150:complications* / Q000188:drug therapy / Q000601:surgery; D005260:Female; D017408:Guidelines as Topic; D006801:Humans; D015994:Incidence; D059413:Intraabdominal Infections / Q000145:classification / Q000000981:diagnostic imaging / Q000453:epidemiology*; D010535:Laparoscopy / Q000009:adverse effects*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000453:epidemiology*; D011446:Prospective Studies; D012306:Risk; D012720:Severity of Illness Index; D015898:Tomography Scanners, X-Ray Computed / Q000592:standards; D014463:Ultrasonography / Q000592:standards
D000900:Anti-Bacterial Agents
appendicitis; intra-abdominal infection; laparoscopy; risk; severity of illness index