Beyond the incision: What preoperative and intraoperative data could inform us on the outcomes of acute appendicitis

Aboo, Fatima Bibi

Beyond the incision: What preoperative and intraoperative data could inform us on the outcomes of acute appendicitis

Thesis / Dissertation

2026

Publisher

University of Cape Town

Department

Division of General Surgery

Faculty

Faculty of Health Sciences

Abstract

Background Acute appendicitis is one of the most common surgical emergencies worldwide, with significant morbidity and mortality, particularly in low- and middle-income countries (LMICs). Its management often serves as a proxy for the efficiency of surgical services, yet South African data remain limited, largely from single-centre retrospective studies. Standardised intraoperative grading systems can help assess severity, guide management, and predict outcomes, but interobserver variability and its impact on reproducibility are not well defined. This study therefore evaluated the Gomes grading system in the South African context, focusing on its reproducibility and prognostic utility in resource-limited settings. Methods A prospective cohort study was conducted across four hospitals in the Western Cape Metro. Patients aged 18 years and older who underwent surgical intervention for acute appendicitis between 1 February, and 31 July 2025 were enrolled. Demographic, intraoperative, and outcome data were collected anonymously and analysed in R (v4.5.0) using descriptive statistics, Wilcoxon rank-sum, Chi-square, and Fisher's Exact tests (p <0.05). All surgical units received training on the Gomes et al. (2015) grading system, which was used to capture intraoperative findings with photographic evidence, as videography was not feasible. Ethical approval was obtained and patient confidentiality was maintained. Results Ninety-eight patients were included, 46% male and 54% female, with a median age of 32 years. Patients with comorbidities were disproportionately represented in higher-grade disease. Preoperative predictors of complications included right iliac fossa tenderness (p <0.001), diffuse abdominal pain (OR 4.33, p <0.001), diarrhoea (OR 4.50, p =0.047), peritonitis (p =0.04), and elevated serum creatinine (p <0.001). White cell count and C-reactive protein were not predictive. Imaging was limited, with sonography performed in 25.5% and CT in 38.8%, neither yielding statistically significant findings. Intraoperative grading ranged from simple inflammation (24.5%) to perforated diffuse peritonitis (32.7%). Higher grades were strongly associated with complications (p <0.001), longer hospital stays (median 3-5.5 days), and open or converted procedures. Postoperative complications included deep surgical site infection (17.3%), superficial infection (11.2%), renal failure (6.1%), wound dehiscence (5.1%), nosocomial infection (4.1%), and fistula formation (1%). Mortality was 3.1%, occurring in patients with comorbidities, advanced intraoperative grades, elevated creatinine, and open laparotomy. ICU admission was required in 7.1%, predominantly for grade 4 disease. Interobserver agreement for intraoperative grading was fair (κ≈0.3), with consensus highest in lower grades and variability in transitional categories. The use of still images rather than videography limited reproducibility, contributing to variability in grading. Conclusion In this setting, preoperative clinical features and intraoperative severity were the strongest predictors of postoperative complications. The Gomes classification demonstrated strong prognostic value for complications and hospital stay, supporting its integration into routine documentation to guide escalation of care, rationalise resource use, and benchmark outcomes. Although interobserver agreement was only moderate, constrained by image quality, the study highlights the need for enhanced training and standardised visual aids in LMICs. Overall, the prognostic utility of intraoperative grading systems such as Gomes is reaffirmed, underscoring their potential to guide resource allocation and facilitate integration of LMICs into global outcome reporting.

Keywords

acute appendicits

surgery

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