Preoperative Immature Granulocyte Count and Percentage for Acute Appendisitis
Preoperative Immature Granulocyte Count and Percentage for Acute Appendisitis
Appendectomy is the most effective treatment option for acute appendisitis, which is the most
 commen emergent surgical pathology. However with in time period, surgical treatment borders
 are narrowed. Especially in uncomplicated acute appendicitis cases, nonoperative management
 (NOM) with antibiotherapies becomes primary treatment option. The COVID-19 pandemic, which is
 caused by 2019 novel coronavirus (2019-nCoV) and we encountered in the current process, has
 led to the re-questioning of surgical elective and emergency cases. Serious complications and
 increased mortality rates of the 2019-nCoV creates a novel problems of patient selection for
 emergent surgery and health care workers faced with potential health problems. As the same as
 the other surgical procedures, in the uncomplicated acute appendisitis cases NOM become more
 mandantory. NOM of uncomplicated acute appendisitis doen't increase perforation risk and
 general practice for decreasing surgical complications in the COVID-19 pandemic period.
 Additionally complicated acute appendicitis accounts for 20 to 30% of the patients undergoing
 appendectomy and lead to increased risk of postoperative complications, delayed recovery and
 longer hospital stay. Therefore, early diagnosis of complicated acute appendicitis is
 important; however, the most appropriate and inexpensive diagnostic method to make this
 diagnosis has not been established yet. Although the use of imaging methods is widespread,
 these methods are not accessible in many rural hospitals due to the high costs and
 unavailability of specialists. Thus, the need for an inexpensive and effective diagnostic
 technique allowing to make a differential diagnosis has not been met yet. For this purpose,
 several inexpensive and easily accessible blood parameter tests have been proposed; including
 the white blood cell count, immature granulocyte (IG) percentage, C-reactive protein levels
 or the neutrophil-to-lymphocyte ratio.

 An increase in the IG count shows that the bone marrow is active. This parameter has been
 used as a prognostic factor in many infectious and non infectious diseases including sepsis,
 acute pancreatitis, and acute myocardial infarction. The Immature granulocyte (IG) fraction
 includes promyelocytes, myelocytes, and metamyelocytes but not band neutrophils or
 myeloblasts. The IG count and percentage has become an easy-to-use method, especially with
 the introduction of technological advances, as it can be easily determined using the results
 of a routine complete blood count.

 It is aimed to efficacy of IG count and percentage which are calculated automatically in CBC
 samples, to differatiate the complicated and uncomplicated acute appendicitis cases with a
 cheap, easily applicable and cost effective test, especially in rural areas without enough
 diagnostic tests in COVID-19 pandemy.
The data of 146 patients elder than 18 years, who admitted to the Emergency Department and
 General Surgery outpatient clinic with the complaint of abdominal pain diagnosed with acute
 appendicitis and who were operated by the same surgical team between June 2018 and June 2019
 were evaluated retrospectively after the approval of the local ethics committee. Patients'
 data were obtained by reviewing the patient follow charts, laboratory findings in the the
 electronic database of the hospital and epicrisis forms. Totally 76 patients excluded from
 the study; 22 patients were excluded because of the pathological diagnosis did not confirm
 acute appendicitis (negative appendectomies and appendiceal mucinous cystadenomas), 54
 patients who were operated by the other surgical team were excluded.

 The patients were assigned to the complicated acute appendicitis group (Group C) based on the
 preoperative imaging findings (periappendiceal abscess formation or significant
 periappendiceal fat tissue contamination in ultrasonography and computed tomography),
 intraoperative exploration findings (presence of gangrenous appendicitis, perforation or
 abscess formation), and pathological examination findings (acute phlegmonous appendicitis,
 acute gangrenous appendicitis or acute perforated appendicitis). The patients were assigned
 to the uncomplicated acute appendicitis group (Group UC) based on the increased diameter and
 wall thickness of the appendix and detection of minimal contamination in the surrounding fat
 tissue in the imaging tests; the presence of edema and the absence of gangrene, perforation
 or abscess in the the exploratory surgery of appendix, and confirmation of the diagnosis of
 acute appendicitis by the pathological examination findings [17-20].

 The WBC, IG count and IG percentage automatically calculated in the complete blood count
 (CBC) parameters. WBC count, neutrophil count, lymphocyte count, and IG% were measured using
 an automated hematological analyzer (XN 3000; Sysmex Corp., Kobe, Japan) from blood samples
 obtained at the initial admission to the emergency department . Neutrophyl and Lymphocyte
 counts were obtained from automatically from the CBC parameters and NLR was calculated
 manually.

 The demographic data (age, sex) of the patients, the white blood cell count (WBC), the
 neutrophil-to-lymphocyte ratio (NLR), and the IG count and percentage were evaluated
 retrospectively.

 Statistical Analysis Statistical analyses were performed with the IBM Statistical Package for
 Social Sciences (SPSS) version 20.0 software. The student t-test or Mann-Whitney U test were
 used for analyzing the quantitive values based on normality of the distrubution calculated
 with Shapiro Wilk Test. The chi-square test or Fischer's exact test was used for analyzing
 the categorical data. ROC analysis was used to determeine spesivity and sensitivity of the
 parameters. Binary logistic regression analysis was performed to determine the preoperative
 diagnostic accuracy of the parameters. The quantitive data were given mean ± standard
 deviation (minimum - maximum values) or median (minimum - maximum values). The qualitative
 values were given number of cases (n) and percentage (%). A p-value of <0.05 was considered
 statistically significant.
Inclusion Criteria:

 -  Age >18 years,

 -  Patients diagnosed as acute appenditicitis cases according to clinical (preoperative
 and peroperative) and preoperative laboratory findings and imaging modalities
 (ultrasound, computed tomography), and pathologic results

 -  Patients who were operated by the same surgical team of the Kahramanmaras Sutcu Imam
 University Hospital.

 Exclusion Criteria:

 -  Patients younger than 18 years,

 -  Negative appendectomies according to peroperative findings and pathologic findins

 -  Patients whose data were not available

 -  Patients who were operated by the other surgical team of the Kahramanmaras Sutcu Imam
 University.