MDCT for suspected appendicitis in the elderly: diagnostic performance and patient outcome

CT of acute abdomen in the elderly

Abdominal disorders represent 10 to 15% of all Emergency Department visits in elderly patients. This educational review focuses on acute abdomen pathologies specific to the elderly and on their imaging patterns and proposes a strategy for performing CT scans in this population. Bowel obstruction is the most common cause of emergency surgery in the elderly with a higher proportion of colonic obstructions, in particular obstructive colorectal cancer and sigmoid volvulus. Concerning abdominal inflammatory processes, such as cholecystitis, appendicitis, and diverticulitis, gangrenous cholecystitis and complicated appendicitis are relatively frequently encountered due to delayed diagnoses. Bowel ischemia, which includes acute mesenteric ischemia (AMI) and ischemic colitis (IC), is also much more common after the age of 80. Although ischemic colitis is mainly related to cardiovascular risk factors, it can also result from a persistent distension above a colonic cancer or from fecal impaction. Finally, extra-abdominal pathologies responsible for acute abdominal pain, such as inferior myocardial infarction, should not be overlooked. In clinical practice, when possible thanks to sufficient and appropriate radiological resources, we recommend a scan without injection of contrast and an injection depending on the results of the unenhanced scan, decided by the radiologist present at the CT scan room during the examination. CRITICAL RELEVANCE STATEMENT: CT is critical in the diagnosis and management of patients over 75 years old with an acute abdomen, given the difficulty of clinico-biological diagnosis, the frequency of complicated forms, and the morbidity induced by delayed diagnosis. KEY POINTS: The most common site and cause of bowel obstruction in the elderly is large bowel obstruction due to colon cancer. Discrepancy between a poor clinical examination and complicated forms on imaging, particularly for inflammation and infections, is responsible for late diagnosis and increased morbidity. Ischemia, including of the small bowel, colon, and gallbladder are common cause of acute abdomen in elderly. In patients with upper quadrant pain, consider extra-abdominal causes such as pneumonia or myocardial infarction.

Diagnosis and treatment of appendicitis: systematic review and meta-analysis

BACKGROUND

The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children.

METHODS

Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively.

RESULTS

2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04).

CONCLUSIONS

This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.

Diagnostic accuracy of computed tomography and ultrasound for the diagnosis of acute appendicitis: A systematic review and meta-analysis

INTRODUCTION

The diagnosis of acute appendicitis remains challenging. This review determined the current diagnostic accuracy of CT and ultrasound for suspected acute appendicitis in adults.

METHODS

This systematic review adhered to the PRISMA for diagnostic test accuracy guidelines. A systematic search was undertaken in appropriate databases. Screening of potential titles and abstracts, full-text retrieval, methodological quality assessment using QUADAS, and data extraction was performed. Meta-analyses were performed for relevant subgroups, and sensitivity analysis was completed to account for outliers. GRADE was utilized to assess the certainty of findings.

RESULTS

31 studies evaluating CT, 10 evaluating US, and six evaluating both were included. Pooled sensitivity and specificity for CT was 0.972 [0.958, 0.981] and 0.956 [0.941, 0.967] respectively, and 0.821 [0.738, 0.882] and 0.859 [0.727, 0.933] for US, respectively. When analyzing subgroups based on the use of contrast enhancement, sensitivity and specificity was highest for CT with intravenous and oral contrast (0.992 [0.965, 0.998], 0.974 [0.936, 0.99]), compared to CT with intravenous contrast (0.955 [0.922, 0.974], 0.942 [0.916, 0.960]). Low-Dose CT produced comparable values (0.934 [0.885,0.963], 0.937 [0.911, 0.955]) relative to these subgroups and standard dose non-contrast CT (0.877 [0.774,0.937], 0.914 [0.827, 0.959]). US studies which excluded equivocal findings demonstrated significantly greater values than the remainder of US studies (p < 0.0001).

CONCLUSION

The updated diagnostic test accuracies of CT, US and relevant subgroups should be implemented in light of factors such as dose, cost, and timing.

IMPLICATIONS FOR PRACTICE

For diagnosis of adult acute appendicitis: • CT with intravenous plus oral contrast enhancement yields statistically significantly greater diagnostic accuracy than CT with intravenous contrast alone. • Low-dose CT yields comparable sensitivity and specificity to standard-dose CT. • Ultrasound studies which exclude equivocal results may overinflate sensitivity and specificity.

An extremely rare clinical manifestation of acute appendicitis in a nonagenarian patient: lessons still to be learned

Abstract.

Risk factors for postoperative morbidity following appendectomy in the elderly: a nationwide prospective cohort study

BACKGROUND

A limited number of studies investigating perioperative risk factors associated with emergency appendectomy in elderly patients have been published to date. Whether older age may be associated with poorer outcomes following appendectomy is still a matter of debate. The primary aim of this study was to determine the predictors of postoperative morbidity following appendectomy in patients aged ≥ 65 years.

METHODS

Data regarding all elderly patients who underwent emergency appendectomy from January 2017 to June 2018 admitted 36 Italian surgical departments were prospectively collected and analyzed. Baseline demographics and perioperative variables were evaluated. Uni- and multivariate analyses adjusted for differences between groups were carried out to determine possible predictors of adverse outcomes after appendectomy.

RESULTS

Between January 2017 and June 2018, 135 patients aged ≥ 65 years with a diagnosis of AA met the study inclusion criteria. Twenty-six patients (19.3%) were diagnosed with some type of postoperative complication. Decreasing the preoperative hemoglobin level showed a statistically significant association with postoperative complications (OR 0.77, CI 0.61-0.97, P = 0.03). Preoperative creatinine level (P = 0.02, OR 2.04, CI 1.12-3.72), and open appendectomy (P = 0.03, OR 2.67, CI 1.11-6.38) were significantly associated with postoperative morbidity. After adjustment, the only independent predictor of postoperative morbidity was preoperative creatinine level (P = 0.04, OR 2.01, CI 1.05-3.89).

CONCLUSIONS

In elderly patients with AA, perioperative risk assessment in the emergency setting must be as accurate as possible to identify modifiable risk factors that can be addressed before surgery, such as preoperative hemoglobin and creatinine levels.

EAES rapid guideline: appendicitis in the elderly

BACKGROUND

There is a lack of trustworthy evidence-informed guidelines on the diagnosis and management of acute appendicitis in elderly patients.

METHODS

We developed a rapid guideline in accordance with GRADE and AGREE II standards. The steering group consisted of general surgeons, members of the EAES Research Committee/Guidelines Subcommittee with expertise and experience in guideline development, advanced medical statistics and evidence synthesis, biostatisticians, and a guideline methodologist. The guideline panel consisted of three general surgeons, an intensive care physician, a geriatrician and a patient advocate. We conducted systematic reviews and the results of evidence synthesis were summarized in evidence tables. Recommendations were authored and published through an online authoring and publication platform (MAGICapp), with the guideline panel making use of an evidence-to-decision framework and a Delphi process to arrive at consensus.

RESULTS

This rapid guideline provides a weak recommendation against the use of clinical scoring systems to replace cross-sectional imaging in the diagnostic approach of suspected appendicitis in elderly patients. It provides a weak recommendation against the use of antibiotics alone over surgical treatment in patients who are deemed fit for surgery, and a weak recommendation for laparoscopic over open surgery. Furthermore, it provides a summary of surgery-associated risks in elderly patients. The guidelines, with recommendations, evidence summaries and decision aids in user-friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/4494 .

CONCLUSIONS

This rapid guideline provides evidence-informed trustworthy recommendations on the diagnosis and management of acute appendicitis in elderly patients.

Geriatric patients undergoing appendectomy have increased risk of intraoperative perforation and/or abscess

BACKGROUND

The number of geriatric patients is expected to grow 3-fold over the next 30 years, and as many as 50% of the surgeries done in the United States may occur in geriatric patients. Geriatric patients often have increased comorbidities and more often present in a delayed manner for acute appendicitis. The aim of this study was to evaluate outcomes between geriatric patients and younger patients undergoing appendectomy, hypothesizing that geriatric patients will have a higher risk of abscess and/or perforation, conversion to open surgery, postoperative intra-abdominal abscess, and 30-day readmission.

METHODS

The 2016 to 2017 American College of Surgeons National Surgical Quality Improvement Program Procedure Targeted Appendectomy database was queried for patients with preoperative image findings consistent with acute appendicitis. Geriatric patients (age ≥65 years old) were compared with younger patients (age <65 years old). A multivariable logistic regression model was used for analysis.

RESULTS

From 21,586 patients undergoing appendectomy, 2,060 (9.5%) were geriatric patients. Compared with the younger cohort, geriatric patients were less likely to have leukocytosis (59.0% vs 65.8%, P < .001) and more likely to have a tumor and/or malignancy involving the appendix on final pathology (2.0% vs 0.8%, P < .001), an unplanned laparoscopic conversion to open surgery (4.2% vs 1.5%, P < .001), and 30-day readmission (7.0% vs 3.3%, P < .001). Geriatric patients had a longer median length of stay (2 vs 1 days, P < .001) and higher mortality rate (0.5% vs <0.1%, P < .001). After adjusting for covariates, there was an increased associated risk of intraoperative abscess and/or perforation (odds ratio 2.23, 2.01-2.48, P < .001) and postoperative intra-abdominal abscess (odds ratio 1.43, 1.12-1.83, P = .005) but no difference in associated risk for mortality (odds ratio 2.56, 0.79-8.25, P = .116), compared with the younger cohort.

CONCLUSION

Nearly 10% of laparoscopic appendectomies are done on geriatric patients with geriatric patients having a higher rate of conversion to open surgery and tumor and/or malignancy on final pathology. Geriatric patients have an associated increased risk of intraoperative perforation and/or abscess and postoperative intra-abdominal abscess but have similar risk for mortality compared with nongeriatric patients undergoing laparoscopic appendectomy.

The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition)

The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

Analysis of CT characteristics in the diagnosis of Schistosoma japonicum associated appendicitis with clinical and pathological correlation: a diagnostic accuracy study

PURPOSE

To clarify unique non-contrast CT (NCCT) characteristics for early recognition of Schistosomal associated appendicitis (SAA) differentiating from Non-schistosomal associated appendicitis (NSA).

MATERIAL AND METHODS

Clinical and pathological data of 50 cases with SAA and 60 cases with NSA who underwent emergency appendectomy were retrospectively compared to pre-surgical NCCT features such as direct and indirect signs of acute appendicitis as well as appendicoliths, colon calcifications as diagnostic criteria. Statistical methods such as Chi-square (χ²), t-tests, Principal component analysis (PCA), Binary Logistic regression (LR) and Factor Analysis (FA) were utilized to observe differences and isolate recognizable CT features of SAA. Pre and post hoc diagnostic performance of all criteria was calculated as sensitivity, specificity, and the Odds Ratio (OR).

RESULTS

Age > 50 years, diameter > 13 mm, pneumatosis, peri appendiceal abscess, focal wall defect, perforation; Orbital, linear and point types of appendicular wall calcifications; sigmoid colon and cecal curvilinear calcifications were observed as unique characteristics with a sensitivity of 84-95% and specificity of 91-98% in predicting SAA by OR of 6.2 times. Pre and post hoc hypothetical analysis did not show any significance for all other factors.

CONCLUSION

Factors such as elderly age, CT features such as larger appendicular diameter, appendicular wall calcifications along with sigmoid colon, and cecal calcifications, signs of perforation or abscess are characteristic for early recognition of SAA.

Computed tomography for diagnosis of acute appendicitis in adults

BACKGROUND

Diagnosing acute appendicitis (appendicitis) based on clinical evaluation, blood testing, and urinalysis can be difficult. Therefore, in persons with suspected appendicitis, abdominopelvic computed tomography (CT) is often used as an add-on test following the initial evaluation to reduce remaining diagnostic uncertainty. The aim of using CT is to assist the clinician in discriminating between persons who need surgery with appendicectomy and persons who do not.

OBJECTIVES

Primary objective Our primary objective was to evaluate the accuracy of CT for diagnosing appendicitis in adults with suspected appendicitis. Secondary objectives Our secondary objectives were to compare the accuracy of contrast-enhanced versus non-contrast-enhanced CT, to compare the accuracy of low-dose versus standard-dose CT, and to explore the influence of CT-scanner generation, radiologist experience, degree of clinical suspicion of appendicitis, and aspects of methodological quality on diagnostic accuracy.

SEARCH METHODS

We searched MEDLINE, Embase, and Science Citation Index until 16 June 2017. We also searched references lists. We did not exclude studies on the basis of language or publication status.

SELECTION CRITERIA

We included prospective studies that compared results of CT versus outcomes of a reference standard in adults (> 14 years of age) with suspected appendicitis. We excluded studies recruiting only pregnant women; studies in persons with abdominal pain at any location and with no particular suspicion of appendicitis; studies in which all participants had undergone ultrasonography (US) before CT and the decision to perform CT depended on the US outcome; studies using a case-control design; studies with fewer than 10 participants; and studies that did not report the numbers of true-positives, false-positives, false-negatives, and true-negatives. Two review authors independently screened and selected studies for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected the data from each study and evaluated methodological quality according to the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate random-effects model to obtain summary estimates of sensitivity and specificity.

MAIN RESULTS

We identified 64 studies including 71 separate study populations with a total of 10,280 participants (4583 with and 5697 without acute appendicitis). Estimates of sensitivity ranged from 0.72 to 1.0 and estimates of specificity ranged from 0.5 to 1.0 across the 71 study populations. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.93 to 0.96), and summary specificity was 0.94 (95% CI 0.92 to 0.95). At the median prevalence of appendicitis (0.43), the probability of having appendicitis following a positive CT result was 0.92 (95% CI 0.90 to 0.94), and the probability of having appendicitis following a negative CT result was 0.04 (95% CI 0.03 to 0.05). In subgroup analyses according to contrast enhancement, summary sensitivity was higher for CT with intravenous contrast (0.96, 95% CI 0.92 to 0.98), CT with rectal contrast (0.97, 95% CI 0.93 to 0.99), and CT with intravenous and oral contrast enhancement (0.96, 95% CI 0.93 to 0.98) than for unenhanced CT (0.91, 95% CI 0.87 to 0.93). Summary sensitivity of CT with oral contrast enhancement (0.89, 95% CI 0.81 to 0.94) and unenhanced CT was similar. Results show practically no differences in summary specificity, which varied from 0.93 (95% CI 0.90 to 0.95) to 0.95 (95% CI 0.90 to 0.98) between subgroups. Summary sensitivity for low-dose CT (0.94, 95% 0.90 to 0.97) was similar to summary sensitivity for standard-dose or unspecified-dose CT (0.95, 95% 0.93 to 0.96); summary specificity did not differ between low-dose and standard-dose or unspecified-dose CT. No studies had high methodological quality as evaluated by the QUADAS-2 tool. Major methodological problems were poor reference standards and partial verification primarily due to inadequate and incomplete follow-up in persons who did not have surgery.

AUTHORS' CONCLUSIONS

The sensitivity and specificity of CT for diagnosing appendicitis in adults are high. Unenhanced standard-dose CT appears to have lower sensitivity than standard-dose CT with intravenous, rectal, or oral and intravenous contrast enhancement. Use of different types of contrast enhancement or no enhancement does not appear to affect specificity. Differences in sensitivity and specificity between low-dose and standard-dose CT appear to be negligible. The results of this review should be interpreted with caution for two reasons. First, these results are based on studies of low methodological quality. Second, the comparisons between types of contrast enhancement and radiation dose may be unreliable because they are based on indirect comparisons that may be confounded by other factors.

Perforated vs. nonperforated acute appendicitis: evaluation of short-term surgical outcomes in an elderly population

BACKGROUND

Acute appendicitis is a common acute surgical abdominal condition and despite the majority of cases are observed in children and young adults, its occurrence in the elderly seems to be increasing, with a higher risk of perforation. The aim of this study was to evaluate the surgical outcomes following appendectomy for acute appendicitis in the elderly, making a comparison between perforated and nonperforated groups regarding operative time, hospital stay and postoperative complications.

METHODS

The medical records of 48 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis from January 2011 to December 2016 were retrospectively reviewed. Patients were grouped into those with perforated and those with non-perforated appendicitis (NPA) and a comparison was made between both groups regarding demography, operative time, length of hospital stay and postoperative complications.

RESULTS

From 48 patients over 60 years diagnosed with acute appendicitis, a PA was removed from 10 patients (20.8%). The PA group consisted of 3 males and 7 females, and their mean age was 71.6 years (range 65-84). The NPA group included 22 males and 16 females, and their mean age was 76.5 years (range 63-96). The mean operative time was 58±18.7 minutes and 43.3±9.9 minutes in the perforated and nonperforated groups respectively, with statistically significant difference (P=0.0013). The mean length of hospital stay was similar in the PA group and in the NPA group, being 6.5±1.8 days and 5.4±1.8 days respectively, but these differences were not statistically significant (P=0.093). The frequency of postoperative complications was similar in both groups as they were observed in 3 patients (30%) of the PA group and 10 patients (26%) of the NPA group (P=0.2488). No postoperative intraabdominal abscess was observed in both groups and there was no death after the surgery.

CONCLUSIONS

PA, despite requiring a longer mean operative time, in our series is not producing a longer hospital stay or more postoperative complications compared to NPA. The non-operative management of uncomplicated appendicitis is a reasonable option in frail patients in order to avoid the burden of morbidity related to operation, nevertheless surgery remains the standard of care in all age groups.

Abdominal Pain in the Geriatric Patient

Abdominal pain in the elderly can be a challenging and difficult condition to diagnose and treat. The geriatric population has significant comorbidities and often takes polypharmacy that can mask symptoms. The presentation of common conditions can be different than that in the younger population, often lacking the traditional indicators of disease, making it of pivotal importance for the clinician to consider a wide differential during their workup. It is also important to consider extra-abdominal abnormality that may manifest as abdominal pain.

ACR Appropriateness Criteria® Right Lower Quadrant Pain--Suspected Appendicitis

The most common cause of acute right lower quadrant (RLQ) pain requiring surgery is acute appendicitis (AA). This narrative's focus is on imaging procedures in the diagnosis of AA, with consideration of other diseases causing RLQ pain. In general, Computed Tomography (CT) is the most accurate imaging study for evaluating suspected AA and alternative etiologies of RLQ pain. Data favor intravenous contrast use for CT, but the need for enteric contrast when intravenous contrast is used is not strongly favored. Radiation exposure concerns from CT have led to increased investigation in minimizing CT radiation dose while maintaining diagnostic accuracy and in using algorithms with ultrasound as a first imaging examination followed by CT in inconclusive cases. In children, ultrasound is the preferred initial examination, as it is nearly as accurate as CT for the diagnosis of AA in this population and without ionizing radiation exposure. In pregnant women, ultrasound is preferred initially with MRI as a second imaging examination in inconclusive cases, which is the majority.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Emergency gastrointestinal surgery in the elderly

The main problem in management of elderly patients who present to the emergency department with abdominal pain is related to difficulties in establishing a diagnosis, because of frequently impaired communication as well as to unusual clinical and laboratory presentations, resulting in delayed management. Early use of pertinent imaging may reduce this delay. Surgical procedures in the elderly do not differ from those in younger patients, but their associated morbidity is different. Assessing co-morbidities and patient frailty, as well as taking into consideration the diagnosis, patients' wishes and status should help in decision-making. Therapeutic decisions should involve surgeons, anesthesiologists and geriatricians alike, both pre- and postoperatively, with the goal of optimizing patients' rehabilitation and offering good and appropriate care while ensuring the humane, social and financial aspects.

Perforated Appendicitis: Assessment With Multidetector Computed Tomography

Appendicitis is one of the most common abdominal surgical emergencies. In some cases, the correct diagnosis may be challenging, owing to different conditions that can mimic this pathology. In this context, abdominal computed tomography (CT) is the imaging modality of choice, leading to an accurate diagnosis and to a reduction in unnecessary laparotomies. The diagnosis of perforated appendix is crucial, but the detection of the perforation signs by CT may not be so simple in the early process. The aim of this article is to review the multiple detector CT signs of perforated appendicitis.

Mandatory imaging cuts costs and reduces the rate of unnecessary surgeries in the diagnostic work-up of patients suspected of having appendicitis

OBJECTIVE

To evaluate whether mandatory imaging is an effective strategy in suspected appendicitis for reducing unnecessary surgery and costs.

METHODS

In 2010, guidelines were implemented in The Netherlands recommending the mandatory use of preoperative imaging to confirm/refute clinically suspected appendicitis. This retrospective study included 1,556 consecutive patients with clinically suspected appendicitis in 2008-2009 (756 patients/group I) and 2011-2012 (800 patients/group II). Imaging use (none/US/CT and/or MRI) was recorded. Additional parameters were: complications, medical costs, surgical and histopathological findings. The primary study endpoint was the number of unnecessary surgeries before and after guideline implementation.

RESULTS

After clinical examination by a surgeon, 509/756 patients in group I and 540/800 patients in group II were still suspected of having appendicitis. In group I, 58.5% received preoperative imaging (42% US/12.8% CT/3.7% both), compared with 98.7% after the guidelines (61.6% US/4.4% CT/ 32.6% both). The percentage of unnecessary surgeries before the guidelines was 22.9%. After implementation, it dropped significantly to 6.2% (p<0.001). The surgical complication rate dropped from 19.9% to 14.2%. The average cost-per-patient decreased by 594 <euro> from 2,482 to 1,888 <euro> (CL:-1081; -143).

CONCLUSION

Increased use of imaging in the diagnostic work-up of patients with clinically suspected appendicitis reduced the rate of negative appendectomies, surgical complications and costs.

KEY POINTS

• The 2010 Dutch guidelines recommend mandatory imaging in the work-up of appendicitis. • This led to a considerable increase in the use of preoperative imaging. • Mandatory imaging led to reduction in unnecessary surgeries and surgical complications. • Use of mandatory imaging seems to reduce health care costs.

Negative Appendectomy: an Audit of Resident-Performed Surgery. How Can Its Incidence Be Minimized?

Negative appendectomy remains a concern in current surgical practice. Data from the developing world is scarce. Data of appendectomies during the last 5 years were analyzed. Interval and incidental appendectomies were excluded. The demographic details, presenting complaints, clinical signs, and investigations performed were recorded in a predesigned proforma. The data were critically analyzed. Six hundred eighty-five appendectomies were performed during the period. One hundred eighty-five patients with a normal appendix were identified on histopathology. Sixty-seven patients with incidental or interval appendectomies were excluded. Thus, 118 patients had appendectomies performed erroneously. All these patients with presumed diagnosis of acute appendicitis were operated on by resident surgeons. Records of 17 patients could not be retrieved. The most common symptom was abdominal pain (100 %), and the commonest sign was right iliac fossa tenderness (93 %). Most of the patients underwent USG to supplement the diagnosis. CT scan and diagnostic laparoscopy were not performed. The negative appendectomy rate was 17.2 % (12.4 % in males; 33.3 % in females). The highest incidence of negative appendectomy was in females aged 11-20 years (66.7 %). The rate of negative appendectomy at our institute is comparable with the world statistics. More diligence is required in making the clinical diagnosis of acute appendicitis, especially in young females. The use of C-reactive protein and CT scan may decrease the negative appendectomy rate.

Acute appendicitis in the elderly: risk factors for perforation

BACKGROUND

Acute appendicitis is the most common surgical emergency and becomes serious when it perforates. Perforation is more frequent in the elderly patients. The aim of this study was to identify the risk factors of perforation in elderly patients who presented with acute appendicitis.

METHODOLOGY

The medical records of 214 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis over a period of 10 years (2003-2013) were retrospectively reviewed. Patients were grouped into those with perforated and those with nonperforated appendicitis. Comparison was made between both groups in regard to demography, clinical presentation, and time delay to surgery, diagnosis, hospital stay and postoperative complications. Clinical assessment, Ultrasonography and Computerized tomography, in that order, were used for diagnosis. The incidence of perforation was also compared with a previous report from the same region 10 years earlier.

RESULTS

During the study period, a total of 214 patients over the age of 60 years had acute appendicitis, 103 males and 111 females. Appendix was found perforated in 87 (41%) patients, 46 (53%) males and 41 (47%) females. Of all patients, 31% were diagnosed by clinical assessment alone, 40% needed US and 29% CT scan. Of all the risk factors studied, the patient's pre-hospital time delay was the most important risk factor for perforation. Perforation rate was not dependent on the presence of comorbid diseases or in-hospital time delay. Post operative complications occurred in 44 (21%) patients and they were three times more common in the perforated group, 33 (75%) patients in the perforated and 11 (25%) in the nonperforated group. There were 6 deaths (3%), 4 in the perforated and 2 in the nonperforated group.

CONCLUSION

Acute appendicitis in elderly patients is a serious disease that requires early diagnosis and treatment. Appendiceal Perforation increases both mortality and morbidity. All elderly patients presented to the hospital with abdominal pain should be admitted and investigated. The early use of CT scan can cut short the way to the appropriate treatment.