Negative appendectomy experience in children

Negative appendectomy rate in the pediatric population: can we reach near-zero rates? An observational study

INTRODUCTION

Correct diagnosis of acute appendicitis may sometimes be challenging. The Negative appendectomy rate (NAR) has declined in the recent years in Europe and USA, in part due to better diagnostic imaging tools. The aim of this study was to examine the rates of negative appendectomy in our institution, investigate trends in its incidence, and identify possible predicting factors.

METHODS

A retrospective cohort study, including all patients younger than 18 years of age who underwent an appendectomy between 2007 and 2021 in a single tertiary medical center. Data regarding patient's demographics, laboratory and imaging results, pathological results and clinical outcome were collected.

RESULTS

Between 2007 and 2021, a total of 3937 pediatric patients underwent appendectomy due to a working diagnosis of acute appendicitis. Overall, 143 patients (3.6%) had normal appendix on pathological examination. However, in the last 5 years, the rate of normal appendix was 1.9%, together with an increased rate of pre-operative imaging (from 40% to nearly 100%).

CONCLUSION

Low NAR under 2% is an achievable benchmark in the era of accessible pre-operative imaging. In unequivocal cases, a secondary survey that includes repeated physical examination, blood work and imaging is recommended and may result in near-zero rates of NAR.

Contemporary Epidemiology of and Risk Factors Associated with Removal of a Pathologically Normal Appendix in Children with Suspected Appendicitis

BACKGROUND

The goal of this study was to characterize contemporary performance benchmarks and risk factors associated with negative appendectomy (NA) in children with suspected appendicitis.

METHODS

A multicenter retrospective cohort analysis of children undergoing appendectomy for suspected appendicitis was performed using data from the 2016-2021 NSQIP-Pediatric Appendectomy Targeted Public Use Files. Multivariable regression was used to evaluate the influence of year, age, sex, and WBC count on NA rate, and to generate rate estimates for NA based on different combinations of demographic characteristics and WBC profiles.

RESULTS

100,322 patients were included from 140 hospitals. The overall NA rate was 2.4%, and rates decreased significantly during the study period (2016: 3.1% vs. 2021: 2.3%, p < 0.001). In adjusted analyses, the highest risk for NA was associated with a normal WBC (<9000/mm3; OR 5.31 [95% CI: 4.87-5.80]), followed by female sex (OR 1.55 [95% CI: 1.42-1.68]) and age <5 years (OR 1.64 [95% CI 1.39, 1.94]). Model-estimated risk for NA varied significantly across demographic and WBC strata, with a 14.4-fold range in rates between subgroups with the lowest and highest predicted risk (males 13-17 years with elevated WBC [1.1%] vs. females 3-4 years with normal WBC [15.8%]).

CONCLUSIONS

Contemporary NA rates have decreased over time, however NA risk remains high in children without a leukocytosis, particularly for girls and children <5 years of age. These data provide contemporary performance benchmarks for NA in children with suspected appendicitis and identify high-risk populations where further efforts to mitigate NA risk should be targeted.

LEVEL OF EVIDENCE

III.

Blood routine examination: a simple way for differential diagnosis of immunoglobulin A vasculitis with abdominal involvement and appendicitis in children

To explore the value of blood routine examination indexes in the differential diagnosis of immunoglobulin A vasculitis (IgAV) with abdominal involvement and appendicitis in children. Forty-seven patients with IgAV and abdominal involvement, 95 cases with appendicitis, and 48 healthy children were enrolled in this study. Demographic and laboratory data were retrospectively recorded from medical files. The levels of serum percentage of lymphocytes (LYM%), percentage of eosinophils (E%), red cell volume distribution width (RDW) and platelet (PLT) count were higher, while blood cells (WBC) count, percentage of neutrophils (N%), percentage of monocytes (M%), mean platelet volume (MPV), platelet distribution width and C-reactive protein were lower in the group of IgAV with abdominal involvement compared to appendicitis group (P < 0.05). Multivariate logistic regression analysis showed LYM% (odds ratio (OR) = 1.34, P = 0.001) and RDW (OR = 2.96, P = 0.045) were independent risk factors for IgAV with abdominal involvement. N% (OR = 1.270, P = 0.006) and MPV (OR = 51.15, P = 0.042) were independently associated with appendicitis. Using receiver operating characteristic analysis, the optimal cut-off values (sensitivity and specificity) respectively were 42.17% (95.7%, 100.0%) for LYM%, 12.65% (83.0%, 83.2%) for RDW, 61.5% (91.6%, 97.9%) for NE% and 10.1fL (78.9%, 75.4%) for MPV, with the AUC values of 0.989, 0.881, 0.985, 0.810, respectively. Blood routine examination indices, especially the N%, LYM%, RDW, and MPV, can be used for simple differential diagnosis of IgAV with abdominal involvement and appendicitis.

Çocuklarda torakoport yardımlı laparoskopik apendektomi sonuçlarımız

Amaç: Açık, klasik multiport laparoskopi ve single insizyon laparoskopik cerrahinin (SILS) dezavantajlarının daha az olduğu torakoport yardımlı laparoskopik apendektomi deneyimlerimizi sunmayı amaçladık Yöntemler: Çalışmada 2018 Ocak ve 2019 Aralık yılları arasında Dicle Üniversitesi Tıp Fakültesi Çocuk Cerrahi kliniğinde akut apandisit nedeniyle apendektomi yapılan hastaların verileri geriye doğru incelendi. Hastaların cinsiyeti, yaşı, başvuru şikayetleri, tanı yöntemleri, laboratuvar tetkikleri, yapılan işlem, uygulanan tedavi yöntemleri ve hastanede kalış süreleri değerlendirildi. USG’ de net olarak ayırt edilemeyen şüpheli bulgular izlenen ve ek patolojiler olabileceği düşünülen hastalara kontrastlı Bilgisayarlı Tomografi (BT) istendi. Operasyondan bir gün sonra hastanın kliniği uygunsa oral başlandı. Takiplerde herhangi bir problemi olmayan hasta önerilerle taburcu edildi. Bir hafta sonra hastalar patoloji sonuçları ile kontrole çağırıldılar. Oluşan komplikasyonlar kaydedildi. Bulgular: Çalışmamızda 177’si (%63,7) erkek, 101’i (%36,3) kız olmak üzere toplam 278 hasta vardı. Hastaların yaş ortalaması 11.6 (2-17) idi. Hastaların başlıca semptomları: Karın ağrısı %93.1 (n:260), iştahsızlık %79,1 (n:220), bulantı %26,9 (n:75), kusma %16,9 (n:47) ve ateş %4 (n:12) idi. Hastaların laboratuvar tetkiklerinde 209 (%75,2) hastanın WBC’ si yüksekti. CRP yüksekliği 218 (%78,4) hastada tespit edildi. USG’ de 235 (%84) hastada anlamlı bulgular izlendi. BT çekilen 16 hastanın ise 14’ünde (%5,03) apandisitle uyumlu bulgular izlendi. Hastaların tamamına ameliyata torakoport yardımlı laparaskopi ile başlandı. İşlem 250 (%89,2) hastada torakoport yardımlı laparoskopik apendektomi olarak tamamlandı. Beş hastada 2. port, 10 hastada 3. port ihtiyacı oldu. On üç hastada laparoskopik işlem sonlandırıldı ve açık cerrahiye geçildi. Hastaların ortalama yatış süresi 1.7 (1-4) gün idi. Komplikasyon olarak 4 hastada brid ileus, 3 hastada yara yeri enfeksiyonu, 1 hastada umblikal herni gelişti ve cerrahi olarak düzeltildi. Brid ileus gelişen hastaların 3’ü konservatif olarak, birisi cerrahi olarak düzeltildi. Sonuç: Torakoport yardımlı laparaskopik apendektomi minimal invaziv bir yöntem olup kozmetik, maliyet, cerrahi işlemin kolaylığı, ağrı, hastanede yatış süresinin azlığı ve düşük komplikasyon gibi avantajları ile kullanılmasını önermekteyiz

Reference growth curves for normal appendiceal diameter in childhood

The aim of this study was to investigate the relationship between the appendiceal diameter (AD) and age, sex, height, and body weight in children and to verify how does the normal AD grows in childhood. We evaluated the AD of patients younger than 16 years of age who underwent laparoscopic surgery at our hospital. We statistically examined the relationship between the AD and the age, sex, height, and weight. A final cohort of 188 patients participated in the study. The median AD for the sample population was 5 mm (range, 3.2–8.1). There was no significant difference in the AD between males and females in the multivariate analysis (P = 0.500). There was a positive correlation between the age and the AD (R = 0.396, P < 0.001). The AD had a significant positive correlation with the height and weight (P < 0.001, P < 0.001, respectively). The reference curve with regard to the AD can be useful in clinical situations, although it should be kept in mind that the range of individual differences in AD is large, and the growth degree by age is not uniform during childhood.

Management of the normal-appearing appendix during laparoscopy for clinically suspected acute appendicitis in the pediatric population

PURPOSE

The widespread use of laparoscopy has brought forth the question of how to manage a macroscopically normal-appearing appendix in cases of clinically suspected appendicitis. This study aimed to determine the current practices of pediatric general surgeons in Canada regarding this matter.

METHODS

An online survey was created following the American Pediatric Surgical Association (APSA) guidelines and distributed via email to the Canadian Association of Pediatric Surgeons (CAPS) staff surgeons. The questions assessed clinician characteristics, standard practice, and rationale. Results were analyzed using descriptive statistics.

RESULTS

A total of 54/72 (75%) CAPS members practicing in Canada completed the survey. All (100%) agreed they would remove a normal-appearing appendix during laparoscopy for suspected acute appendicitis. The most common reasons were: possibility of microscopic appendicitis (39/54, 72.2%), avoiding future diagnostic confusion (28/54, 51.9%), and patient preference/consent discussion (21/54, 38.9%). Most (53/54, 98.1%) had performed a negative appendectomy and 49/54 (90.7%) agreed there were no sufficient guidelines.

CONCLUSIONS

The majority of pediatric surgeons agree sufficient guidelines do not exist to support decision making when a normal-appearing appendix is found during laparoscopy for suspected acute appendicitis. This survey shows that removal of the appendix in this case would be supported by the majority of Canadian pediatric surgeons.

TYPE OF STUDY

Survey LEVEL OF EVIDENCE: VII (Expert Opinion).

Can Fetuin-A, CRP, and WBC Levels Be Predictive Values in the Diagnosis of Acute Appendicitis in Children with Abdominal Pain?

Background: Acute appendicitis (AA) is the most common cause of emergency surgery. Therefore, perforation is common. Early diagnosis and new markers are needed. The aim of this study was to investigate the effects of plasma Fetuin-A (FA) levels in patients with an acute abdomen (AB). Material and Method: This prospective study included 107 patients younger than 16 years of age who were admitted to the emergency department for abdominal pain between January and December 2018. The patients who presented abdominal pain were divided into two groups as AA and other causes (OC) of AB. Patients with acute appendicitis; intraperitoneal, retrocolic/retrocecal, and appendicitis were divided into three groups. Additionally, the AA group was divided into two groups as perforated appendicitis and non-perforated appendicitis. Serum FA levels of the patients were evaluated in the emergency department. Results: In the AA group, C-reactive protein (CRP) and white blood cell (WBC) levels were higher, and FA levels were significantly lower than in the AB group. Intraperitoneal localization was 95.2% and perforation was frequent. When significant values in the univariate regression analysis for acute abdomen and perforation were compared in the multivariate regression analysis, CRP, WBC, and FA levels were found to be prognostic. Furthermore, decreased FA levels were associated with AA, while too greatly decreased FA levels were associated with the risk of perforation. Conclusion: Current diagnosis can be made by history, physical examination, laboratory, and imaging methods in appendicitis cases. While trying to diagnose AA in children, the FA, CRP, and WBC levels may be predictive values to identify risk factors.

Use of white blood cell count and negative appendectomy rate

BACKGROUND

Despite increased utilization of laboratory, radiologic imaging, and scoring systems, negative appendectomy (NA) rates in children remain above 3% nationwide. We reviewed the clinical data of patients undergoing appendectomy to further reduce our NA rate.

METHODS

A retrospective review was conducted of all appendectomies performed for suspected appendicitis at a tertiary children's hospital during a 42-month period. Preoperative clinical, laboratory, and radiographic data were collected. Variables absent or normal in more than half of NAs were further analyzed. Receiver operating characteristic curves were constructed for continuous variables by using appropriate cutoff points to determine sensitivity and false-positive rates. The results were validated by analyzing the 12 months immediately after the establishment of these rules.

RESULTS

Of 847 appendectomies performed, 22 (2.6%) had a pathologically normal appendix. The only variables found to be normal in more than half of NAs were white blood cell (WBC) count (89%) and neutrophil count (79%). A receiver operating characteristic curve indicates that using WBC cutoffs of 9000 and 8000 per µL yielded sensitivities of 92% and 95%, respectively, and reduction in NA rates by 77% and 36%, respectively. Results observed in the subsequent 12 months confirmed these expected sensitivities and specificities.

CONCLUSIONS

Absence of an elevated WBC count is a risk factor for NA. Withholding appendectomy for WBC counts <9000 and 8000 per µL reduces the NA rate to 0.6% and 1.2%, respectively. Missed true appendicitis in patients with normal WBC counts can be mitigated by a trial of observation in those presenting with early symptom onset.

Factors influencing the course of acute appendicitis in adults and children

PURPOSE

Our aim was to determine predictive factors for the diagnosis and postoperative complications of acute appendicitis.

MATERIALS AND PATIENTS

Data sets of 1,439 consecutive adults and children who had an appendectomy between 1999 and 2008 were retrospectively analyzed.

RESULTS

A mild acute appendicitis was present in 50 % (n = 722) and a severe acute appendicitis in 25 % (n = 355) of the patients. No signs of any pathology were found in 6 % (n = 82). Gender, white blood count (WBC), C-reactive protein (CRP), and ultrasound (US) examination were important indicators of mild acute and severe acute appendicitis in adults and children. Postoperative complications occurred in 16 % (237/1,439), mainly consisting of wound infections (8 %, n = 122) and bowel dysfunction (5 %, n = 76). Sixty-two patients (4.3 %) required reoperations. One patient died (1/1,439, 0.07 % mortality rate). Age, pathology, and the presence of bacteria in the intraoperative swab were important predictive factors for postoperative complications in adults and children. Time since onset of symptoms and type of operation were also associated with postoperative complications among adults. Complications developed in 21 and 9 % of the adults (155/754 and 10/125) who had open and laparoscopic surgery, respectively.

CONCLUSIONS

Besides history and clinical examination, WBC, CRP, and US examination remain important factors for diagnosing acute appendicitis. Complications are related to the pathology, presence of bacteria, and type of operation. Early diagnosis within 48 h may be important. A laparoscopic procedure in adults may also cause fewer wound infections.

Pediatric negative appendectomy rate: trend, predictors, and differentials

BACKGROUND

Appendectomy is one of the most commonly performed emergency operations in children. The diagnosis of appendicitis can be quite challenging, particularly in children. We set out to determine the accuracy of diagnosis of appendicitis by analyzing the trends in the negative appendectomy rate (NAR) using a national database.

MATERIALS AND METHODS

Analysis of the Kids Inpatient Database (KID) was performed for the years 2000, 2003, and 2006 on children with appendectomy, excluding incidental appendectomies. Children (<18 y) without appendicitis but who underwent appendectomies were classified as negative appendectomies (NA), and those with appendicitis as positive appendectomies (PA). Comparisons were made between those with PA versus NA by demographic characteristics. The subset of patients with NA was then further analyzed.

RESULTS

An estimated 250,783 appendectomies met the inclusion criteria. The NAR was 6.7%. Length of stay (LOS) was longer in NA versus PA (7 versus 3 d, P < 0.05). The NAR was increased in children under 5 y (21.1% versus 5.4% for among the 5-10 y versus 5.9% among the >10 y, P < 0.0001) and in females (9.3% versus 5.1%, P < 0.001). On multivariate analysis, increasing age was associated with lower odds of NA (OR = 0.92, P < 0.001). Females, rural hospitals, and Blacks were significantly more likely to experience NA.

CONCLUSIONS

Younger age, female gender, Black ethnicity and rural hospitals are independent predictors of NA. These factors can be incorporated into diagnostic algorithms to improve the accuracy of diagnosis of appendicitis in children.