2020 General Surgery Presentations

Daniel Baldor, MD1, Paul R Lewis, DO2, Matthew D Tadlock, MD1; 1Naval Medical Center San Diego, 23rd Medical Battalion

Objectives: Telemedicine modalities for remote surgical follow-up is associated with patient satisfaction and both health care system and patient cost savings.  For process improvement, we sought to determine if routine in-person follow-up after laparoscopic appendectomy alters management.

Methods: We retrospectively reviewed all adult patients who underwent a laparoscopic appendectomy over a 12-month period.  Patients with in-hospital complications, pregnancy, age less than 18 or inflammatory bowel disease were excluded. Primary endpoint was a change in management occurring during routine follow up. Secondary end-points included location (surgery or primary care clinic (PCC) or emergency department (ED)), and when patients with post-operative events (POE) presented in relation to their scheduled follow-up. Events were defined as any deviation from normal post-operative course within 6 weeks of surgery, including unexpected pathology results. Management changes were defined as unanticipated orders, procedures, referrals, admissions, or extended follow up. A logistic regression was performed to identify which patients benefitted from follow-up.

Results: A total of 176 laparoscopic appendectomies were performed with 148 meeting inclusion criteria. The median age was 27, 66.9% were male, 57.6 % white, 6.3% black, 5.6% Asian, and 29.9% were other/unknown. Four percent were takin antiplatelet medications, 16.3% had prior abdominal surgery and 10.1% were found to be perforated at operation. 

Of the 148 patients, only 11 (7.4%) had a change in post-operative management; 3 (2%) during routine follow up and 8 (5.4%) at another time or location.  A POE occurred in 24 (16.2%) patients with 80% presenting outside of routine follow-up; 48% before and 32% after their scheduled appointments. Most (57.77%) presented to the ED or PCC. Of the 24 POE, 11.5% were abscess, 7.7% surgical site infection, 7.7% incidental finding requiring follow-up, and 3.8% serous port-site drainage.  Persistent abdominal pain (54%) was the most common POE; of these most patients either re-assurance, or additional non-narcotic pain medications.

Perforated appendicitis was a significant, but weak predictor for post-operative events (OR 4.2, p=0.014, c-statistic 0.60). No variables were predictive of post-operative events requiring change in management.

Conclusions: Routine follow-up for laparoscopic appendectomy rarely changed management in our patient cohort. Eliminating points in the continuum of care that do not change management is likely safe.  A telemedicine approach may be a feasible alternative to routine clinic follow-up. Based on these results we plan to implement post-operative protocolized phone calls to answer any questions, review final pathology results, and to determine if further in-person evaluation is necessary.