How good are surgeons at identifying appendicitis? Results from a multi-centre cohort study

Area of Science:

• Gastroenterology
• Surgical Pathology
• Clinical Audit

Background:

• Arguments exist for and against appendix removal when it appears normal during surgery.
• Accurate intra-operative assessment by surgeons is crucial for this decision.
• Inter-rater reliability between surgeons and pathologists regarding appendix assessment is not well-established.

Purpose of the Study:

• To determine the inter-rater reliability between surgeons and pathologists in assessing the appendix macroscopically.
• To identify predictors of disagreement in appendix assessment between surgeons and pathologists.

Main Methods:

• A multicentre audit (Multicentre Appendicectomy Audit) collected data from 95 centres during April-May 2012.
• Consecutive patients undergoing emergency appendicectomy were included.
• The primary endpoint was the agreement between surgeon and pathologist assessments; secondary endpoints investigated predictors of disagreement.

Main Results:

• Histopathological analysis revealed pathology in 27.8% of appendices surgeons assessed as normal (n=138/496).
• Pathologists found a normal appendix in 9.6% of cases surgeons assessed as inflamed (n=254/2642).
• Overall disagreement occurred in 12.5% of cases (n=392), indicating moderate reliability (Kappa 0.571). Females had higher false positive/negative rates, and CT scans increased false positives.

Conclusions:

• Surgeons' intra-operative macroscopic assessment of the appendix is unreliable.
• Surgical experience (grade) did not improve assessment accuracy.
• Findings support the routine removal of the appendix during surgery to avoid misdiagnosis.