Prospective evaluation of the Sunshine Appendicitis Grading System score

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Appendicitis is one of the most common surgical emergencies, yet controversies still remain regarding its management. Most common variations occur over duration of inpatient admission and length of antibiotic use.
The rationale for the use of post‐operative antibiotics is primarily to reduce the risk of post‐appendicectomy intra‐abdominal collection (IAC),1 which has a high morbidity usually requiring re‐admission and intervention. Conversely, there is a burden on the patient and population at large of inappropriate antibiotic use.2 Despite extensive research and meta‐analyses aimed at determining which patients are at higher risk of IAC (and therefore require post‐operative antibiotics), solid consensus guidance remains elusive.
A major contributing factor to the confusion surrounding treatment guidelines is the lack of consistency and terminology when describing the severity of appendicitis. Basic principles would indicate that the severity of intra‐abdominal contamination should correlate with the development of IAC and other complications. This theory has been well established in diverticulitis and has facilitated the recording of severity in this condition and therefore supported the generalizability of subsequent research.3 Currently, scoring systems for severity of appendicitis use preoperative biochemical markers, physiological markers or even imaging results to stratify severity.4 Many of these parameters are either unavailable (e.g. imaging) or expensive and arguably unnecessary (e.g. C‐reactive protein, CRP). A few use intra‐operative findings to establish severity including terms such as ‘gangrenous’, ‘necrotic’ and perforated without clear definitions of each or inter‐publication consistency.6
The Sunshine Appendicitis Grading System (SAGS) uses clinical principles to provide a very simple score based on intra‐operative findings to stratify severity of appendicitis. The hypothesis being that this simple score will accurately and independently predict the risk of intra‐abdominal collection.
The aims of the study were to validate the SAGS score as a reproducible intra‐operative tool and to determine if the SAGS score can independently predict development of intra‐abdominal collection.
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