Beyond Appendectomy: Predictive Factors for Major Resections in Adult Patients With Acute Appendicitis

Certain patients with acute appendicitis require more extensive resections due to an extensive inflammatory process. We aimed to identify predictive factors for major resections (MR) in patients undergoing laparoscopic appendectomy (LA) and determine its surgical outcomes.

We performed a retrospective analysis of a consecutive series of adult patients (> 16 years) undergoing LA from 2006 to 2023. The cohort was divided into two groups: LA only versus MR (i.e., partial cecectomy, ileocecectomy or right colectomy). Demographics, perioperative variables and postoperative outcomes were compared. Independent risk factors for MR were determined by multivariable logistic regression analysis.

A total of 2319 patients were included for analysis; 2279 (98.3%) underwent LA and 40 (1.7%) MR. Patients undergoing MR were significantly older (mean age 50.1 vs. 36.2 years, p < 0.0001). Obesity prevalence was higher in MR patients (20% vs. 7.0%, p = 0.02). The median interval time from symptom onset to medical consultation was also significantly higher in MR patients (99.4 vs. 40.7 h, p < 0.0001). The presence of pneumoperitoneum, free abdominal fluid, and cecal wall thickening in CT scan were significantly more frequent in MR patients (p < 0.0001). Conversion to open surgery was more common in MR patients (30% vs. 2.1%, p < 0.0001). Overall morbidity (52.5% vs. 13.5%, p < 0.0001), Clavien III-IV complications (22.5% vs. 3.9%, p < 0.0001) and median length of stay (6.6 vs. 1.6 days, p < 0.0001) were significantly higher in the MR group. Free abdominal fluid (OR 4.9 95% CI 2.1-11.1), pneumoperitoneum (OR 7.2 95% CI 1.6-31.9) and cecal wall thickening in CT scan (OR 6.2 95% CI 2.2-17.1) were identified as independent risk factors for MR.

Major resections for acute appendicitis are associated with significantly higher overall and major morbidity, as compared to LA. Clinical and imaging predictors of MR can help in improving surgical planning and informing patients about the higher risks of the operation.