Quality analysis of operative reports and referral data for appendiceal neoplasms with peritoneal dissemination

Published:November 13, 2020DOI:



      Peritoneal metastasis from appendiceal neoplasms is a rare disease usually found unexpectedly and is associated with deficits in quality reporting of findings.


      Retrospective review of our appendiceal peritoneal metastases carcinomatosis database evaluating quality of index operative and pathology reports. Operative report quality was graded by 2 standards; general quality, based on Royal College of Surgeons quality metrics and peritoneal metastases assessment. Pathology report quality was assessed by the accuracy of diagnosis.


      Three hundred and seventy-five index operative reports and 490 outside pathology reports were reviewed. General quality of the index operative reports was excellent, with nearly 80% of reports encompassing all the Royal College of Surgeons quality metrics. Peritoneal metastases assessment was poor. Forty-four percent of the reports performed no peritoneal evaluation, while 48.3% only involved partial peritoneal evaluation. Only 7.7% of the reports performed a complete evaluation. Of the pathology reports, 48.4% had discrepancies with final pathologic findings. Low-grade disease and high-grade disease were misdiagnosed 36.06% and 62.7% of the time, respectively. Discordant treatment occurred in 15.3% and 30.0% of cases for misdiagnosed low-grade and high-grade disease, respectively. Incomplete cytoreduction was attempted in nearly a third of referral cases, which was associated with a significantly increased risk for ultimate incomplete cytoreduction with an odds ratio of 4.72.


      This review finds that referral operative reports’ descriptions of the technical aspects of a procedure is usually complete. However, oncologic parameters and descriptions of peritoneal metastases are frequently incomplete. Further, pathology reports from outside institutions can lead to inappropriate clinical management decisions. We propose a simplified algorithm to assist nonperitoneal surface malignancy surgeons.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • McCusker M.E.
        • Coté T.R.
        • Clegg L.X.
        • Sobin L.H.
        Primary malignant neoplasms of the appendix: A population-based study from the surveillance, epidemiology and end-results program, 1973–1998.
        Cancer. 2002; 94: 3307-3312
        • Marmor S.
        • Portschy P.R.
        • Tuttle T.M.
        • Virnig B.A.
        The rise in appendiceal cancer incidence: 2000–2009.
        J Gastrointest Surg. 2015; 19: 743-750
        • Lietzen E.
        • Grönroos J.M.
        • Mecklin J.P.
        • et al.
        Appendiceal neoplasm risk associated with complicated acute appendicitis—a population based study.
        Int J Colorectal Dis. 2019; 34: 39-46
        • Trivedi A.N.
        • Levine E.A.
        • Mishra G.
        Adenocarcinoma of the appendix is rarely detected by colonoscopy.
        J Gastrointest Surg. 2009; 13: 668-675
        • Lyons T.F.
        • Payne B.C.
        The relationship of physicians' medical recording performance to their medical care performance.
        Med Care. 1974; 12: 463-469
        • Thomson D.R.
        • Baldwin M.J.
        • Bellini M.I.
        • Silva M.A.
        Improving the quality of operative notes for laparoscopic cholecystectomy: assessing the impact of a standardized operation note proforma.
        Int J Surg. 2016; 27: 17-20
        • Edhemovic I.
        • Temple W.J.
        • de Gara C.J.
        • Stuart G.C.
        The computer synoptic operative report—a leap forward in the science of surgery.
        Ann Surg Oncol. 2004; 11: 941-947
        • Royal College of Surgeons of England
        Good Surgical Practice.
        Royal College of Surgeons of England, London2008
        • Ghani Y.
        • Thakrar R.
        • Kosuge D.
        • Bates P.
        ‘Smart’ electronic operation notes in surgery: an innovative way to improve patient care.
        Int J Surg. 2014; 12: 30-32
        • Park J.
        • Pillarisetty V.G.
        • Brennan M.F.
        • et al.
        Electronic synoptic operative reporting: assessing the reliability and completeness of synoptic reports for pancreatic resection.
        J Am Coll Surg. 2010; 211: 308-315
        • Donahoe L.
        • Bennett S.
        • Temple W.
        • et al.
        Completeness of dictated operative reports in breast cancer—the case for synoptic reporting.
        J Surg Oncol. 2012; 106: 79-83
        • Hentzen J.E.K.R.
        • van der Plas W.Y.
        • Constansia R.D.N.
        • et al.
        Role of diagnostic laparoscopy in patients with suspicion of colorectal peritoneal metastases to evaluate suitability for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.
        BJS Open. 2019; 3: 812-821
        • Koh J.L.
        • Yan T.D.
        • Glenn D.
        • Morris D.L.
        Evaluation of preoperative computed tomography in estimating peritoneal cancer index in colorectal peritoneal carcinomatosis.
        Ann Surg Oncol. 2009; 16: 327-333
        • Esquivel J.
        • Chua T.C.
        • Stojadinovic A.
        • et al.
        Accuracy and clinical relevance of computed tomography scan interpretation of peritoneal cancer index in colorectal cancer peritoneal carcinomatosis: A multi-institutional study.
        J Surg Oncol. 2010; 102: 565-570
        • Hentzen J.E.K.R.
        • Constansia R.D.N.
        • Been L.B.
        • et al.
        Diagnostic laparoscopy as a selection tool for patients with colorectal peritoneal metastases to prevent a Non-therapeutic laparotomy during cytoreductive surgery.
        Ann Surg Oncol. 2020; 27: 1084-1093
        • Choudry H.A.
        • Pai R.K.
        • Parimi A.
        • et al.
        Discordant diagnostic terminology and pathologic grading of primary appendiceal mucinous neoplasms reviewed at a high-volume center.
        Ann Surg Oncol. 2019; 26: 2607-2614
        • Esquivel J.
        Management of peritoneal surface malignancies of appendiceal and colonic origin.
        in: Cameron J.L. Cameron A.M. Current Surgical Therapy. 12th edition. Elsevier, Inc, Philadelphia2017: 258-264
        • Bradley R.F.
        • Stewart 4th, J.H.
        • Russell G.B.
        • Levine E.A.
        • Geisinger K.R.
        Pseudomyxoma peritonei of appendiceal origin: a clinicopathologic analysis of 101 patients uniformly treated at a single institution, with literature review.
        Am J Surg Pathol. 2006; 30: 551-559
        • Harvey A.
        • Zhang H.
        • Nixon J.
        • Brown C.J.
        Comparison of data extraction from standardized versus traditional narrative operative reports for database-related research and quality control.
        Surgery. 2007; 141: 708-714
        • Lefter L.P.
        • Walker S.R.
        • Dewhurst F.
        • Turner R.W.L.
        An audit of operative notes: facts and ways to improve.
        ANZ J Surg. 2008; 78: 800-802
        • Stewart L.
        • Hunter J.G.
        • Wetter A.
        • Chin B.
        • Way L.W.
        Operative reports: form and function.
        Arch Surg. 2010; 145: 865-871
        • Wauben L.S.
        • Goossens R.H.
        • Lange J.F.
        Evaluation of operative notes concerning laparoscopic cholecystectomy: are standards being met?.
        World J Surg. 2010; 34: 903-909
        • Wauben L.S.
        • Grevenstein W.M.
        • Goossens R.H.
        • van der Meulen F.H.
        • Lange J.F.
        Operative notes do not reflect reality in laparoscopic cholecystectomy.
        Br J Surg. 2011; 98: 1431-1436
        • ten Broek R.P.
        • van den Beukel B.A.
        • van Goor H.
        Comparison of operative notes with real-time observation of adhesiolysis-related complications during surgery.
        Br J Surg. 2013; 100: 426-432
        • Arora V.
        • Johnson J.
        • Lovinger D.
        • Humphrey H.J.
        • Meltzer D.O.
        Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.
        Qual Saf Health Care. 2005; 14: 401-407
        • Riesenberg L.A.
        • Leitzsch J.
        • Massucci J.L.
        • et al.
        Residents’ and attending physicians’ handoffs: a systematic review of the literature.
        Acad Med. 2009; 84: 1775-1787
        • Apker J.
        • Mallak L.A.
        • Gibson S.C.
        Communicating in the “gray zone”: perceptions about emergency physician–hospitalist handoffs and patient safety.
        Acad Emerg Med. 2007; 14: 884-894
        • The American Board of Surgery
        SCORE--Surgical Council on Resident Education.
        (Accessed November 6, 2020)
        • Dromain C.
        • Leboulleux S.
        • Auperin A.
        • et al.
        Staging of peritoneal carcinomatosis: enhanced CT vs PET/CT.
        Abdom Imaging. 2008; 33: 87-93
        • Omohwo C.
        • Nieroda C.A.
        • Studeman K.D.
        • et al.
        Complete cytoreduction offers longterm survival in patients with peritoneal carcinomatosis from appendiceal tumors of unfavorable histology.
        J Am Coll Surg. 2009; 209: 308-312
        • Sugarbaker P.H.
        Epithelial appendiceal neoplasms.
        Cancer J. 2009; 15: 225-235
        • Elias D.
        • Gilly F.
        • Quenet F.
        • et al.
        • and the Association Francaise de Chirurgie
        Pseudomyxoma peritonei: a French multicentric study of 301 patients treated with cytoreductive surgery and intraperitoneal chemotherapy.
        Eur J Surg Oncol. 2010; 36: 456-462
        • El Halabi H.
        • Gushchin V.
        • Francis J.
        • et al.
        The role of cytoreductive surgery and heated intraperitoneal chemotherapy (CRS/HIPEC) in patients with high-grade appendiceal carcinoma and extensive peritoneal carcinomatosis.
        Ann Surg Oncol. 2012; 19: 110-114
        • Votanopoulos K.I.
        • Bartlett D.
        • Moran B.
        • et al.
        PCI is not predictive of survival after complete CRS/HIPEC in peritoneal dissemination from high-grade appendiceal primaries.
        Ann Surg Oncol. 2018; 25: 674-678
        • Stewart 4th, J.H.
        • Shen P.
        • Russell G.B.
        • et al.
        Appendiceal neoplasms with peritoneal dissemination: outcomes after cytoreductive surgery and intraperitoneal hyperthermic chemotherapy.
        Ann Surg Oncol. 2006; 13: 624-634
        • Moran B.
        • Baratti D.
        • Yan T.D.
        • Kusamura S.
        • Deraco M.
        Consensus statement on the loco-regional treatment of appendiceal mucinous neoplasms with peritoneal dissemination (pseudomyxoma peritonei).
        J Surg Oncol. 2008; 98: 277-282
        • Turner K.M.
        • Hanna N.N.
        • Zhu Y.
        • et al.
        Assessment of neoadjuvant chemotherapy on operative parameters and outcome in patients with peritoneal dissemination from high-grade appendiceal cancer.
        Ann Surg Oncol. 2013; : 201068-201073
        • Milovanov V.
        • Sardi A.
        • Ledakis P.
        • et al.
        Systemic chemotherapy (SC) before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in patients with peritoneal mucinous carcinomatosis of appendiceal origin (PMCA).
        Eur J Surg Oncol. 2015; 41: 707-712
        • Paul B.K.
        • Ihemelandu C.
        • Sugarbaker P.H.
        Prior surgical score: an analysis of the prognostic significance of an initial nondefinitive surgical intervention in patients with peritoneal carcinomatosis of a colorectal origin undergoing cytoreductive surgery and perioperative intraperitoneal chemotherapy.
        Dis Colon Rectum. 2018; 61: 347-354
        • Carr N.J.
        • Cecil T.D.
        • Mohamed F.
        • et al.
        and the Peritoneal Surface Oncology Group International. A consensus for classification and pathologic reporting of pseudomyxoma peritonei and associated appendiceal neoplasia: The results of the Peritoneal Surface Oncology Group International (PSOGI) Modified Delphi Process.
        Am J Surg Pathol. 2016; 40: 14-26