Negative appendicectomy rate as a quality metric in the management of appendicitis: impact of computed tomography, Alvarado score and the definition of negative appendicectomy

Paediatric negative appendicectomy rates at a regional Western Australian Centre: a five-year cohort study

BACKGROUND

In acute appendicitis, decision-making around operative intervention for paediatric patients differs from adults due to a higher weight placed on clinical assessment and reduced rates of cross-sectional imaging. In regional settings, non-paediatric emergency doctors, general surgeons, and radiologists usually assess and manage this patient group. Differences have been observed in paediatric negative appendicectomy rates between general and paediatric centres.

METHODS

A retrospective cohort study was performed, identifying paediatric patients undergoing emergency appendicectomy at the Southwest Health Campus (Bunbury, Western Australia) from 2017 to 2021. The primary outcome measure was histopathology confirming the absence of transmural inflammation of the appendix. In addition, clinical, biochemical and radiological data were collected to identify predictors of negative appendicectomy (NA). Secondary outcome measures were hospital length-of-stay and post-operative complication rates.

RESULTS

Four hundred and twenty-one patients were identified, of which 44.9% had a negative appendicectomy. Statistically significant associations between female gender, white cell count less than 10 × 109 , neutrophil ratio less than 75%, low CRP and NA were observed. NA was not associated with a lower risk of re-admission or complications compared with appendicectomy for appendicitis.

CONCLUSIONS

Our centre's NA rate is higher than that observed in the literature at both non-paediatric and paediatric surgical centres. NA has similar morbidity risk to appendicectomy for uncomplicated appendicitis and offers a timely reminder that diagnostic laparoscopy in children is not benign.

The Rate of Negative Appendicectomy and Perforated Appendicitis As Quality Indicators of the General Surgical Service in a District General Hospital in Cavan, Republic of Ireland

Introduction Appendicitis is a common surgical condition that can be difficult to diagnose due to its varied clinical presentations. Surgical removal of the inflamed appendix is often necessary, and the appendix is sent for histopathological assessment to confirm the diagnosis. However, in some cases, the analysis may return a negative result for acute inflammation, known as a negative appendicectomy (NA). The definition of NA varies among experts. While negative appendicectomies are not ideal, they are accepted by surgeons to reduce the rate of perforated appendicitis, which can have severe consequences for patients. A study was conducted to investigate the rates of negative appendicectomies and their impact at a local district general hospital in Cavan, Republic of Ireland. Methods The study was conducted retrospectively from January 2014 to December 2019 on patients who were admitted with suspected appendicitis and underwent appendicectomy for appendicitis, regardless of age and sex. The researchers excluded patients who underwent elective, interval, and incidental appendicectomies. Data were collected on patient demographics, duration of symptoms prior to presentation, the intraoperative appearance of the appendix, and the histology results of the appendix specimens. Descriptive statistics and the Chi-squared test were used for data analysis with the help of IBM Statistical Package for the Social Sciences (SPSS) Version 26. Results The study retrospectively reviewed 876 patients who underwent an appendicectomy for suspected appendicitis between January 2014 and December 2019. The age distribution of patients was non-uniform, with 72% presenting before the third decade. The overall perforated appendicitis rate was 7.08%, and the overall negative appendicectomy (NA) rate was 21.3%. A subset analysis showed a statistically significant lower NA rate in females than in males. The NA rate decreased significantly over time and has been sustained since 2014 at around 10%, which is consistent with other published studies. The majority of the histology findings were uncomplicated appendicitis. Discussion This article discusses the challenges of diagnosing appendicitis and the need to reduce unnecessary surgeries. Laparoscopic appendectomy is the standard treatment, with an average cost of £2222.53 per patient in the UK. However, patients with negative appendicectomies (NA) have longer hospital stays and higher morbidity than uncomplicated cases, making it crucial to reduce unnecessary surgeries. The clinical diagnosis of appendicitis is not always straightforward, and the rate of perforated appendicitis increases with a longer duration of symptoms, particularly pain. The selective use of imaging in suspected appendicitis could reduce NA rates, but a statistical difference has not been proven. Scoring systems like the Alvarado score have limitations and cannot be relied upon alone. Retrospective studies have limitations, and biases and confounding variables must be considered. Conclusion The study found that a thorough investigation of patients, particularly with preoperative imaging, can decrease the rate of unnecessary appendectomies without increasing the rate of perforation. This could save costs and reduce harm to patients.

Trends and Predictors of Pediatric Negative Appendectomy Rates: A Single-Centre Retrospective Study

BACKGROUND

Appendectomy is still the standard treatment for acute appendicitis in the majority of centers. Despite all available diagnostic tools, the rates of negative appendectomies are still relatively high. This study aimed to determine negative appendectomy rates and to analyze the demographic and clinical data of the patients whose histopathology report was negative.

METHODS

All patients younger than 18 years who underwent appendectomy for suspected acute appendicitis in the period from 1 January 2012 to 31 December 2021 were included in the single-center retrospective study. Electronic records and archives of histopathology reports were reviewed for patients with negative appendectomy. The primary outcome of this study was a negative appendectomy rate. Secondary outcomes comprehended the rate of appendectomies and the association of age, sex, body mass index (BMI), values of laboratory markers, scoring systems, and ultrasound reports with negative histopathology reports.

RESULTS

During the study period, a total of 1646 appendectomies for suspected acute appendicitis were performed. In 244 patients, negative appendectomy was reported regarding the patients' pathohistology. In 39 of 244 patients, other pathologies were found, of which ovarian pathology (torsion and cysts) torsion of greater omentum and Meckel's diverticulitis were the most frequent. Finally, the ten-year negative appendectomy rate was 12.4% (205/1646). The median age was 12 years (interquartile range, IQR 9, 15). A slight female predominance was noted (52.5%). A significantly higher incidence of negative appendectomies was noted in girls, with a peak incidence between the ages of 10 and 15 years (p < 0.0001). Male children whose appendectomy was negative had significantly higher BMI values compared to female patients (p = 0.0004). The median values of white blood cell count, neutrophil count, and CRP in the patients with negative appendectomy were 10.4 × 10⁹/L, 75.9%, and 11 mg/dL, respectively. The median of Alvarado's score was 6 (IQR 4; 7.5), while the median of the AIR score was 5 (IQR 4, 7). The rate of children with negative appendectomy who underwent ultrasound was 34.4% (84/244), among which 47 (55.95%) concluded negative reports. The rates of negative appendectomies were not homogenous in terms of distribution regarding the season. The incidence of negative appendectomies was more frequent during the cold period of the year (55.3% vs. 44.7%; p = 0.042).

CONCLUSIONS

The majority of negative appendectomies were performed in children older than 9 years and most frequently in female children aged 10 to 15 years. In addition, female children have significantly lower BMI values compared to male children with negative appendectomy. An increase in the utilization of auxiliary diagnostic methods such as computed tomography could affect the reduction in the pediatric negative appendectomy rate.

A systematic review and meta-regression for validation of the Alvarado score as a tool for predicting acute appendicitis

The Alvarado score (AS) has not been widely used for diagnosing acute appendicitis although it has shown to be a good predictor for diagnosing appendicitis. The aim was to perform a systematic review of the available literature and synthesize the evidence.

Methods

A systematic review was performed as per the PRISMA guidelines using search engines like Ovid, PubMed, and Google Scholar with predefined, strict inclusion and exclusion criteria. The quality assessment of included studies was performed using the QUADAS 2 tool. Summary statistics were performed for all variables. A linear regression model was performed between dependent and independent variables using STATA software. Heterogeneity testing showed significant heterogeneity within the included studies; hence, a forest plot with pooled estimates could not be constructed, and therefore a meta-regression was performed.

Results

Seventeen full-text articles met inclusion and exclusion criteria. Ten of which were identified as low-risk studies. Five studies were included in final data pooling with total patients being 2239 and mean age of 31.9 years. (1) Linear regression demonstrated an association between 'histological appendicitis' and 'AS 7-0' with patients receiving intervention, with a significant P value of less than 0.005. (2) Meta-regression demonstrated a positive coefficient (0.298), a positive Z score of 2.20 with a significant P value of 0.028 for patients with 'high AS' who received interventions that were significantly proven to be 'histologically appendicitis', indicating a cause-and-effect relationship.

Conclusion

High AS (7 and above) is a significant predictor of acute appendicitis. The authors recommend further prospective randomized clinical trials to establish a cause-and-effect relationship.

Negative appendectomy rate in patients diagnosed with acute appendicitis

BACKGROUND

Acute appendicitis is the most common cause of acute lower abdominal pain leading patients to the emergency department. This study aims to find the negative appendectomy rate in patients diagnosed with acute appendicitis from 2015 to 2019.

METHODS

This study was a retrospective cohort study in the patients preoperatively diagnosed with acute appendicitis and underwent appendectomy from January 2015 to December 2019. Negative appendectomy is defined as the final pathologic results confirmed normal, congestion or peri-appendicitis.

RESULTS

The study population was 892 patients which was 54.3% female. The five-year negative appendectomy rate was 8.6% (n = 77) and 70% in female (n = 54). The factors associated with increasing the negative appendectomy rate were female (OR 2.23, P = 0.003), age ≤ 40 years old (OR 2.35, P = 0.003), and no history of diarrhea (OR 2.42, P = 0.017). Whereas the factors related to decline in the negative appendectomy rate were white blood cell count (WBC) [Formula: see text] 10,000 (OR 0.39, P = 0.016), neutrophil (N) [Formula: see text] 75% (OR 0.28, P < 0.001), and positive appendicitis from ultrasonography of abdomen (OR 0.04, P < 0.001) or computed tomography of abdomen (OR 0.07, P < 0.001).

CONCLUSION

The negative appendectomy rate was less than 10% in this study. Female, age 40 ≤ years old and history of diarrhea were related to increase in negative appendectomy. The factors that related to decline in negative appendectomy were leukocytosis with cells shift to the left, positive acute appendicitis from abdominal ultrasonography and CT scan. However, to request the further imaging studies to diagnose patients with suspected acute appendicitis depends on the risk and benefit to each patient and the choice of investigation.

Diagnostic Accuracy of Suspected Appendicitis: A Comparative Analysis of Misdiagnosed Appendicitis in Children

OBJECTIVE

When evaluating suspected appendicitis, limited data support quality benchmarks for negative appendectomy (NA); none exist for delayed diagnosis of appendicitis (DDA). The objectives of this study are the following: (1) to provide preliminary evidence supporting a quality benchmark for DDA and 2) to compare presenting features and diagnostic evaluations of children with NA and DDA with those with pathology-confirmed appendicitis (PCA) diagnosed during initial emergency department (ED) encounter.

METHODS

Secondary analysis of data from a QI project designed to reduce the use computed tomography when evaluating suspected appendicitis using a case-control design. Patients undergoing appendectomy in an academic tertiary care children's hospital system between January 1, 2015, and December 31, 2016 (n = 1,189) were eligible for inclusion in this case-control study. Negative appendectomy was defined as no pathologic change or findings consistent with a different diagnosis. Delayed diagnosis of appendicitis was defined as patients undergoing appendectomy within 7 days of a prior ED visit for a related complaint. Controls of PCA (n = 150) were randomly selected from all cases undergoing appendectomy.

RESULTS

There were 42 NA (3.5%) and 31 DDA (2.6%). Cases of PCA and NA exhibited similar histories, examination findings, and underwent comparable diagnostic evaluations. Cases of PCA more frequently demonstrated a white blood cell count greater than 10 × 103/μL (85% vs 67%; P = 0.01), a left-shift (77% vs 45%; P < 0.001), and an ultrasound interpretation with high probability for appendicitis (73% vs 54%; P = 0.03). Numerous significant differences in history, examination findings, and diagnostic tests performed existed between cases of PCA and DDA.

CONCLUSIONS

Children with PCA and NA present similarly and undergo comparable evaluations resulting in appendectomy. A 3% to 4% NA rate may be unavoidable given these similarities. Presenting features in DDA significantly differ from those of PCA. An irreducible proportion of appendicitis diagnoses may be delayed.

Negative Appendicectomy Rate: Incidence and Predictors

Introduction

Acute appendicitis is a common emergency surgical presentation. The gold standard treatment is surgery. Like any surgical procedure, appendicectomy is associated with complications. Negative appendicectomy (NA) can occur, and its incidence is 15%-39%. This study aimed to evaluate the rate and predictors of NA in a cohort.

Patients and methods

A retrospective study over a year through which data of patients who underwent emergency appendicectomies were collected and analyzed. The absence of inflammatory process and/or other significant pathology in the appendix was considered negative for appendicitis. An utter definition of NA was the absence of inflammatory cells in the appendix. The NA rate (NAR) was calculated using the standard criteria (NAR-SDC) and the strict criteria (NAR-STC). The routine laboratory parameters for diagnosing acute appendicitis on admission were collected. Increased inflammatory markers in the form of leucocytosis of total WBC > 11,000 per mm, elevated CPR > 5 mg/L, and isolated elevated total serum bilirubin > 20 µmol/L, were suggestive of acute appendicitis.

Results

Three hundred and seventy-two patients were included, 179 males and 193 females with a median age were 27 (5-94) years. The median duration of symptoms and waiting time to surgery were two days and one day, respectively. The mean admission WBC, C-reactive protein (CRP) and serum bilirubin levels were 12,600 (3,000-38,000)/mm³, 66.9 (1-323) mg/L and 12.7 (4-38) µmol/L respectively. Laparoscopic appendicectomy was performed in 93.5% of patients with a conversion rate of 4.6%. NAR-SDC was 10.2% and NAR-STC was 25.8%. NAR was significantly higher in females than males (39.4% versus 11.1%; p-value 0.0001). Patients with NA were younger (p-value 0.0001), had lower mean total WBC (p-value 0.014), CRP (p-value 0.0001) and total serum bilirubin (p-value 0.0001) levels on admission.

Conclusion

NA is still a major problem in the management of patients with acute right lower abdominal pain. Our NAR compared favourably with reported rates. Female gender, duration of symptoms more than three days, and lower total WBC were independent predictors of NA.

Computerized tomography scan in acute appendicitis with eventual negative appendectomy

Background and Aim:

Acute appendicitis (AA) is traditionally considered a clinical diagnosis and negative appendectomy (NA) rates vary across health-care systems. Computed tomography (CT) scans have been shown to aid in the reduction of NA rates. Our study aimed to determine the pre-operative imaging characteristics in patients undergoing appendectomy with eventual normal histology.

Materials and Methods:

An audit of all patients with a discharge diagnosis of AA was conducted from January 2011 to December 2015. Histology reports of all patients who underwent appendectomies were reviewed, and medical records of patients with NA were included in the study. To study the impact of CT scan reporting in NA patients, CT scan images of patients with NA were reviewed retrospectively by two blinded radiologists.

Results:

A total of 2603 patients underwent appendectomy for suspected AA, and NA rate was 3.34% (n=87). The mean age of patients with NA was 30.3 (14.8-69.8) years with no gender difference (51.7% male). Sixty-six (75.9%) patients had laparoscopic appendectomy with 3.5% open conversion rate. CT scans were done in 47 patients. Pre-operative CT scan report was more likely to report dilated appendix (n=26 [55.3%] vs. n=7 [14.9%], P=0.0001). Post-operative blinded radiology review was more like to report other pathology (n=27 [57.4%] vs. n=2 [4.3%], P=0.0001) and normal appendix (n=26 [55.3%] vs. n=5 (10.6%), P=0.0001).

Conclusion:

The NA rate is low. There needs to be standardized reporting for imaging features of prominent/dilated appendix.

Relevance for Patients:

Appendectomy must be avoided in patients with a normal CT scan and when another pathological diagnosis is established. Liberal imaging policy assists to reduce NA rates. Imaging features of prominent or dilated appendix can be subjective and international collaboration is needed to define thresholds for imaging diagnosis of AA.

The prevalence of right-sided colonic diverticulosis in a New Zealand population

BACKGROUND

Once considered to be a congenital condition, the epidemiology of right-sided colonic diverticulosis (RCD) is evolving. Acute diverticulitis (AD) is a complication of RCD which is frequently misdiagnosed as appendicitis, resulting in unnecessary surgery, as there is strong evidence supporting medical management for right-sided AD. In general, the incidence of AD correlates with the prevalence of RCD, which shows marked geographic variation. Few data reporting RCD prevalence come from Western countries, so the aim of this study is to define the prevalence of RCD in a New Zealand population.

METHODS

Independent review of the imaging from 1000 consecutive patients undergoing a computed tomography Kidney/Ureter/Bladder scan for suspected urolithiasis at Christchurch Hospital between January and November 2017 was undertaken, to determine the presence or absence, and distribution of colonic diverticulosis. Patients were excluded if they had a history of colonic resection, known IBD, or were less than 18-years old.

RESULTS

Thirty-one patients were excluded, leaving 969 eligible patients. Overall, 95 patients (9.8%) had RCD identified. The prevalence of RCD increased significantly with advancing age, being present in 2.3% of those aged 18-29, increasing to 20.3% in those greater than 70-years old (p < 0.001).

CONCLUSION

The prevalence of RCD in a New Zealand population is relatively high and increases significantly with age. This adds support to the role of cross-sectional imaging in the evaluation of suspected appendicitis, to exclude right-sided AD. The association with advancing age supports RCD being an acquired condition rather than a congenital condition as was previously thought.

Appendicitis during the COVID-19 pandemic: lessons learnt from a district general hospital

BACKGROUND

The COVID-19 pandemic dramatically influenced the delivery of healthcare. In line with the UK Royal Colleges' advice the management of acute appendicitis (AA) changed with greater consideration for non-operative management (NOM) or open appendicectomy when operative management (OM) was sought. We describe our experience of the presentation, management and outcomes for these patients to inform care for future viral pandemics.

METHODS

This retrospective, cohort study compared patients diagnosed with AA between March and July 2019 with those during the pandemic period of March to July 2020. Medical records were reviewed to obtain demographics, inflammatory markers, imaging, severity, management, histology, length of stay (LOS) and 90-day outcomes.

RESULTS

There were 149 and 125 patients in the 2019 and 2020 cohorts respectively. 14 patients (9.4%) had NOM in 2019 versus 31 (24.8%) in 2020 (p = 0.001). In the 2019 operative management (OM) group 125 patients (92.6%) had laparoscopic appendicectomy versus 65 (69.1%) in 2020. 59 patients (39.6%) had a CT in 2019 versus 70 (56%) in 2020. The median LOS was 4 days in 2019 and 3 days in 2020 (p = 0.03). Two patients in each year who received NOM had treatment failure (14.3% in 2019 and 6.5% in 2020). Three patients in 2019 who received OM had treatment failure (2.2%). Of 95 patients tested for COVID-19 all but one tested negative.

CONCLUSION

During the COVID-19 pandemic there was no observed increase in severity of AA, patients had a shorter LOS and were more likely to have imaging. NOM proportionally increased with no observed change in outcomes.

ACR Appropriateness Criteria® Suspected Appendicitis-Child

Acute appendicitis represents the most common abdominal surgical urgency/emergency in children. Imaging remains a central tool in the diagnosis of acute appendicitis and has been shown to facilitate management and decrease the rate of negative appendectomies. The initial consideration for imaging in a child with suspected acute appendicitis is based on clinical assessment, which can be facilitated with published scoring systems. The level of clinical risk (low, intermediate, high) and the clinical scenario (suspicion for complication) define the need for imaging and the optimal imaging modality. In some situations, no imaging is required, while in others ultrasound, CT, or MRI may be appropriate. This review frames the presentation of suspected acute appendicitis in terms of the clinical risk and also discusses the unique situations of the equivocal or nondiagnostic initial ultrasound examination and suspected appendicitis with suspicion for complication (eg, bowel obstruction). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Negative appendicectomy rates as a quality measure in a regional surgical unit: a retrospective review

INTRODUCTION

Historically, high negative appendicectomy rates (NAR) were acceptable to offset the risks of perforation, previously exceeding 20%. With improved imaging and clinical scoring algorithms, there is growing demand for lower negative appendicectomy rates. The objectives were to (1) establish the NAR in our institution and (2) correlate clinical parameters and imaging modalities with histological findings.

METHODS

Patients undergoing an appendicectomy between January 2012 and June 2018 were identified using a prospectively maintained pathology database. Histology findings were cross referenced against our radiology system, and anonymised data was collected for gender, age, WCC, Neutrophil and CRP level.

RESULTS

One thousand one hundred fifty-three patients met the inclusion criteria. Fifty-three percent were males (n = 610), with 81% (n = 933) of histology reports classified as appendicitis. Sixty patients had a histologically normal appendix equating to a 5.2% NAR. If lymphoid hyperplasia, fibrosis and atrophy are included, it equates to a NAR of 14.57%. (p < 0.0001). Sixty-six percent of patients had no pre-operative imaging. CT imaging demonstrated a higher sensitivity (93.33%) and positive predictive value (99.60%) compared to ultrasonography. WCC and CRP are statistically significant in predicting appendicitis (p < 0.0001).

CONCLUSION

There is no consensus on defining a negative appendicectomy or for imaging modality utilisation. CT imaging is the most sensitive and should be used in cases of diagnostic uncertainty. A standardised algorithm regarding the workup of patients with RIF pain along with a consensus on the use of imaging will further reduce negative appendicectomy rates.

Cohort study of 1241 patients to identify predictors of negative appendicectomy

BACKGROUND

Acute Appendicitis is the most common surgical presentation within Australia. Despite the increasing use of radiological investigations to aid clinical diagnosis, many appendectomies result in a histologically normal appendix. This study examines the histological negative appendicectomy rate (NAR) in a metropolitan hospital and determine factors associated with a negative appendicectomy (NA).

METHODS

Patients who underwent emergency appendicectomy for suspected acute appendicitis at Logan Hospital, Australia, between February 2016 and March 2019 inclusive were included. Clinicopathologic and imaging variables were analysed for associations with NA.

RESULTS

A total of 1241 patients underwent emergency appendicectomy of which 121 patients (9.8%) had a NA. The NAR for clinical diagnosis alone (no imaging) was 9.9%, 14.5% for ultrasonography alone and computed tomography scan alone was 4.9%. Univariate analysis revealed age <27 years (P < 0.001), absence of hypertension (P = 0.008), symptoms >48 hours (P < 0.001), absence of leucocytosis (P < 0.001), undergoing ultrasonography only (P < 0.001), undergoing computed tomography scan only (P < 0.001), macroscopically normal appendix (P < 0.001) and time to operation >24 hours (P < 0.001) were associated with NA. Multivariate analysis identified symptoms >48 h at presentation (odds ratio (OR) 1.98, 95% confidence interval (CI) 1.20-3.24; P = 0.007), absence of leucocytosis (OR 2.41, 95% CI 1.52-3.81; P < 0.001) and macroscopically normal appendix (OR 5.70, 95% CI 3.49-9.33; P < 0.001) to be associated with a NA.

CONCLUSION

The NAR reported is lowest in an Australian institution. The identified predictors of NA will be useful in identifying patients who would truly benefit from an appendicectomy versus those would have a higher rate of NA who may be suitable to be treated non-operatively to be spared the unnecessary morbidity of surgery.

The Results of Abdominopelvic Computed Tomography Interpreted via Remote Access for the Diagnosis of Acute Appendicitis

INTRODUCTION

Abdominal computed tomography (CT) is one of the imaging modalities for the diagnosis of acute appendicitis (AA). Today, CT scans can be interpreted via remote access called tele-radiology, besides conventional methods. The objective of this study was to evaluate the CT interpreted via tele-radiology for diagnosing AA.

METHODS

In this retrospective study, a total of 679 patients, who were interpreted via tele-radiology of CT due to suspicion of AA, were evaluated. Age, gender, CT findings, pathology results and intra-operative diagnosis of those with normal CT results were analysed. A sensitivity, specificity, accuracy, positive predictive values (PPV) and negative predictive values (NPV) of CT in the diagnosis of AA were calculated.

RESULTS

520 patients who were operated with pre-diagnosed AA were found. Of those, 441 patients (84.8%) were diagnosed with AA according to CT reports, out of which 368 (83.4%) were positive (true-positive) and 73 (16.6%) were negative (false-positive) in terms of pathology results. In the remaining operated 79 patients with normal CT results, 58 (73.4%) were positive for AA and 21 (26.6%) (negative laparotomy) were negative for AA in terms of pathological examination. The sensitivity, specificity, accuracy, PPV and NPV of CT in the diagnosis of AA were determined as 81.2%, 67.7%, 76.7%, 83.4% and 64.2%, respectively.

CONCLUSION

The sensitivity and PPV rates were found similar in both conventional and tele-radiological methods. However, specificity, accuracy and NPV rates were determined lower than in literature. Additionally, the negative laparotomy rate was higher than the conventional method.

Reducing the negative appendectomy rate with the laparoscopic appendicitis score; a multicenter prospective cohort and validation study

BACKGROUND

Approximately nine percent of all acute appendectomies are unintentionally performed on a normal appendix. Failure of treatment (negative appendectomy or missed appendicitis) is associated with higher morbidity and mortality when compared to appendectomy for uncomplicated appendicitis. The Laparoscopic APPendicitis (LAPP) score was developed in order to systematically evaluate the appendix for the presence of inflammation. This study aims to determine whether the LAPP score reduces the negative appendectomy rate without missing appendicitis.

METHODS

From September 2013 through May 2016, 322 adult patients presenting with a clinical suspicion of acute appendicitis and an indication for diagnostic laparoscopy were included and analyzed in this multicenter prospective validation study. Depending on the LAPP score, the appendix was either removed (n = 300) or left in situ (n = 22). These patients were compared to a historical control group of 584 patients treated at the same hospitals. The appendix was examined by a pathologist and the negative appendectomy rate was calculated.

RESULTS

The negative appendectomy rate was significantly lower when the LAPP score was used (4,7% vs. 8,4%; P = 0,034). None of the patients with a negative LAPP score, in which the appendix remained in situ, developed acute appendicitis within three months. There were no significant differences in operation time, complications, or readmissions. Using the LAPP score was associated with significantly higher rates of preoperative radiological imaging (98% vs. 70%; P < 0,001). After adjusting for covariables, including radiological imaging, use of the LAPP score led to fewer treatment failures when compared to not using the LAPP score (OR: 0,48, 95% C.I. 0,251 to 0,914; P = 0,025).

CONCLUSION

The LAPP score is a safe and simple tool to reduce the negative appendectomy rate during laparoscopic surgery without missing cases of acute appendicitis.

A five-year longitudinal observational study in morbidity and mortality of negative appendectomy in Sulaimani teaching Hospital/Kurdistan Region/Iraq

The most common surgical emergency is suspected acute appendicitis, the lifetime risk of acute appendicitis is estimated to be 8.6% for men and 6.7% for women, with a male to female ratio of 1.4:1; correct diagnosis can be made in 70–80% of patients after the operations about 32% of appendectomies revealed normal appendices and meanwhile appendectomy has a considerable morbidity and mortality. The aim is to explore potential morbidity and mortality associated with negative appendectomy. Prospective case series study, including 5847 patients, who were suspected to have acute appendicitis over a period of five years from 1st December 2013 to 30th November 2018, in emergency department of Sulaimani Teaching Hospital. All the collected data were collected, organized then analyzed by Statistical Package for the Social Sciences version 21. Morbidity in the patients with negative appendectomies occurred in patients in the form of 90 (01.91%) wound infection, 48 (01.02%) intestinal obstruction and last 15 (00.32%) patients developed septicemia. While mortality in negative appendectomy patients was 21, (00.45%). Negative appendectomies have high rates of morbidity and mortality, knowing real rates may help in considering various policies and may be helpful to elude avoidable complications and potential mortality.

Comparison of conservative treatment with appendectomy for acute uncomplicated pediatric appendicitis: a meta-analysis

Aim: We aimed to compare conservative treatment with surgery for uncomplicated pediatric appendicitis to estimate effectiveness and safety. Methods: Data recorded until September 2018 were searched, and relevant academic articles from PubMed, EMBASE, the Cochrane Library and other libraries were selected. STATA version 13.0 (Stata Corporation, TX, USA) was used for statistical analysis. Results: We identified nine eligible papers. The study reported a significant difference in the success rate of treatment in 1 month and in 1 year, and no difference in the incidence of complications. The patients with fecaliths showed low treatment efficacy in conservative treatment group (p < 0.05). Conclusion: Standardized conservative treatment as inpatients for pediatric appendicitis is safe and feasible. Appendectomy was the better choice for patients with fecaliths.

Laparoscopic Appendectomy in the Setting of Clinical Prediction Rules

PURPOSE

Acute appendicitis (AA) is the most frequent surgical entity in the emergency department, but its correct diagnosis remains challenging. To improve diagnosis, clinical prediction rules (CPRs) have been created to establish objective scores for the probability of suffering AA. In this study, we establish scores indicating whether laparoscopy would be superior to clinical observation or repeat diagnostic test.

METHODS

A retrospective observational study was conducted with 433 patients submitted to surgery for suspected AA using a laparoscopic approach. The Alvarado, Raja Isteri Pengiran Anak Saleha Appendicitis, appendicitis inflammatory response, and adult appendicitis score scales were applied in each case to establish a high, medium, or low probability of suffering AA.

RESULTS

Of the 433 patients analyzed, 381 (88.0%) had AA. Twelve (2.8%) were converted to open surgery, and complications were observed in 54 (12.5%) cases. The CPRs studied showed statistically significant differences between AA and negative appendectomies. However, in patients with intermediate probability scores, the diagnostic accuracy of the CPRs evaluated was not adequate.

CONCLUSIONS

Laparoscopic surgery can serve as a diagnostic tool for patients with intermediate AA probability scores because of its low associated morbidity and mortality and because it affords a direct diagnosis of the problem, allowing determination of the appropriate treatment.

Retrospective Multivariate Analysis of Data from Children with Suspected Appendicitis: A New Tool for Diagnosis

BACKGROUND

Decision-making for management may sometimes be difficult in acute appendicitis (AA). Various diagnostic scoring systems exist, but their sensitivity and specificity rates are far from ideal. In this study, the determination of the predictors and the effect of radiological data and developing a new scoring system were aimed.

METHODS

Medical records of patients who were hospitalized for AA between February 2012 and October 2016 were retrospectively reviewed. All data were compared between patients with and without appendicitis. The multivariate analysis was performed to define significant variables and to examine the sensitivity and specificity of each group of predictors including radiological data. A new scoring system (NSS) was formed and was compared with two existing scoring systems: pediatric appendicitis score (PAS) and Alvarado scoring system (ASS) by using reclassification method.

RESULTS

Negative appendectomy rate was 11.3%. Statistical analysis identified 21 independently significant variables. The heel drop test had the highest odds ratio. Sensitivity and specificity rates of clinical predictors were 84.6% and 94.8%, respectively. Radiological predictors increased the sensitivity rate to 86.9%. Sensitivity and specificity rates for PAS, ASS, and NSS were 86.8% and 83.9%, 84.7% and 81.6%, and 96.8% and 95.6%, respectively. The "re-assessed negative appendectomy rate" was 6.2% and false positive results were remarkably more common in patients with duration of symptoms less than 24 hours.

CONCLUSION

Radiological data improves the accuracy of diagnosis. Containing detailed clinical and radiological data, NSS performs superiorly to PAS and ASS, regarding sensitivity and specificity without any age limitation. The efficiency of NSS may be enhanced by determining different predictors for different phases of the inflammatory process.

Streptococcal Pharyngitis and Appendicitis in Children

BACKGROUND

Several pathologies, including pharyngitis, are associated with abdominal pain that can mimic appendicitis. We sought to further understand the link between appendicitis-like symptoms and streptococcal (strep) pharyngitis.

METHODS

All patients undergoing ultrasound imaging for appendicitis in our emergency department during 2013 were reviewed (n = 1572). A total of 207 patients were identified who underwent both ultrasound for appendicitis and testing for strep pharyngitis. Demographic and outcomes data between rule out appendicitis patients who underwent strep testing and those who did not were compared.

RESULTS

Strep testing was more common in younger patients (mean age = 8.26 vs 10.26 years P < .001) and evenly matched by gender (104 male, 103 female). Of the 207 patients tested for strep pharyngitis, 8 (3.9%) patients had appendicitis and 35 (16.9%) patients tested positive for strep pharyngitis. No cases of concurrent strep pharyngitis and appendicitis were identified. The negative appendectomy rate in the strep pharyngitis tested group was 38.5% (5/13), compared with 7.7% (23/296) ( P = .003) in the nontested group. The appendicitis rate among the strep tested group was 3.8% (8/207) compared with 20% (273/1365) in the nontested group ( P < .001).

CONCLUSIONS

Patients undergoing testing for strep pharyngitis were younger, had lower rates of appendicitis, and had a higher rate of negative appendectomy. A diagnosis of concurrent appendicitis and strep pharyngitis is rare. In cases of patients with sufficient symptoms to warrant testing for strep pharyngitis a diagnosis of appendicitis is less likely and surgical intervention leads to higher negative appendectomy rates.

Diagnosis of Acute Appendicitis Using Clinical Alvarado Scoring System and Computed Tomography (CT) Criteria in Patients Attending Gujarat Adani Institute of Medical Science - A Retrospective Study

Background

The aim was to evaluate the clinical Alvarado scoring system and computed tomography (CT) criteria for the diagnosis of acute appendicitis.

Material/Methods

The study was carried out retrospectively in patients who were referred to the Institute between March 2014 and January 2015. One hundred seventeen patients with acute abdominal pain who underwent abdominal CT were enrolled in this retrospective study. Patient demographics, clinical Alvarado scoring, CT images, and pathologic results of the patients were evaluated.

Results

Thirty nine of the 53 patients who were operated on had pathologically proven acute appendicitis. CT criteria of appendiceal diameter, presence of periappendiceal inflammation, fluid, appendicoliths, and white blood cell count (WBC) were significantly correlated with the inflammation of the appendix. The optimal cut-off value of the appendiceal diameter was 6.5 mm. The correlation between appendiceal diameter and WBC was 80% (P=0.01 <0.05). The correlation between appendiceal diameter and Alvarado score was 78.7% (P=0.01 <0.05).

Conclusions

Presence of appendiceal diameter above 6.5 mm on CT, periappendiceal inflammation, fluid, and appendicoliths should prompt the diagnosis of acute appendicitis. Since patients with acute appendicitis may not always show the typical signs and symptoms, CT is a helpful imaging modality for patients with relatively low Alvarado scores and leukocytosis, when physical examination is confusing.

The Accuracy of the Computed Tomography Diagnosis of Acute Appendicitis: Does the Experience of the Radiologist Matter?

Background and Aims:

To assess the accuracy of computed tomography in diagnosing acute appendicitis with a special reference to radiologist experience.

Material and Methods:

Data were collected prospectively in our randomized controlled trial comparing surgery and antibiotic treatment for uncomplicated acute appendicitis (APPAC trial, NCT01022567). We evaluated 1065 patients who underwent computed tomography for suspected appendicitis. The on-call radiologist preoperatively analyzed these computed tomography images. In this study, the radiologists were divided into experienced (consultants) and inexperienced (residents) ones, and the comparison of interpretations was made between these two radiologist groups.

Results:

Out of the 1065 patients, 714 had acute appendicitis and 351 had other or no diagnosis on computed tomography. There were 700 true-positive, 327 true-negative, 14 false-positive, and 24 false-negative cases. The sensitivity and the specificity of computed tomography were 96.7% (95% confidence interval, 95.1–97.8) and 95.9% (95% confidence interval, 93.2–97.5), respectively. The rate of false computed tomography diagnosis was 4.2% for experienced consultant radiologists and 2.2% for inexperienced resident radiologists (p = 0.071). Thus, the experience of the radiologist had no effect on the accuracy of computed tomography diagnosis.

Conclusion:

The accuracy of computed tomography in diagnosing acute appendicitis was high. The experience of the radiologist did not improve the diagnostic accuracy. The results emphasize the role of computed tomography as an accurate modality in daily routine diagnostics for acute appendicitis in all clinical emergency settings.

Predictors of positive esophagogastroduodenoscopy outcomes in children and adolescents: a single center experience

Background

Esophagogastroduodenoscopy (EGD) has become a key element in the diagnosis and therapy of many gastrointestinal diseases affecting children. The aim of this study was to evaluate predictors of positive outcomes in children undergoing their first diagnostic EGD with biopsies at a single center.

Results

This retrospective study was based on findings from existing EGD and histopathological reports. All procedures were performed between July 2006 and July 2013. Details of each patient’s clinical presentation and EGD were abstracted from medical records to determine the predictors of positive EGD outcomes. A total of 1133 records of patients between the ages of 0 and 18 years old were evaluated. Of these patients, 51.5% (n = 573) were female and 24.5% (n = 278) were younger than 4 years old. The mean age at the time of EGD was 9.6 ± 5.7 years (mean ± standard deviation). The most common indications for the procedure were abdominal pain (54.9%) and emesis (31.9%). The overall prevalence of any endoscopic abnormality was 54.5% and the overall prevalence of any histological abnormality was 59.1%. A multivariate logistic regression found that patients 12 years or older (odds ratio, OR = 1.46; 95% confidence interval, CI 1.31–1.63), African–American race (OR = 2.20; 95% CI 1.45–3.34), dysphagia (OR = 1.96; 95% CI 1.28–3.00) and positive celiac antibodies (OR = 2.25; 95% CI 1.52–3.34) were all significant independent predictors of a positive EGD outcome.

Conclusions

Several clinical variables were found to be independent predictors of positive EGD outcomes in children and adolescents. Prospective studies using standardized definitions of clinical variables and endoscopy outcomes are needed to further understand predictors of positive EGDs.

Emergency appendicectomy in Australia: findings from a multicentre, prospective study

BACKGROUND

Emergency appendicectomy is the most common emergency surgical procedure performed in Australia. Despite this frequency, there is a relative paucity of contemporary, broad-based, local data that examine how emergency appendicectomies are currently performed and what are the outcomes from these operations.

METHODS

A multicentre, prospective, observational study was performed. Patients were recruited by local investigators for a period of 2 months with 30-day follow-up. Patients were eligible for study inclusion if they underwent an emergency appendicectomy for suspected acute appendicitis. The primary outcome of the study was the negative appendicectomy rate (NAR), with secondary outcomes including 30-day complication rates, method of operation and conversion rates.

RESULTS

A total of 1189 patients were recruited across 27 centres. The NAR across all centres was 19.0%. 98.2% of appendicectomies were performed with a laparoscopic-first approach. The rate of conversion from laparoscopy to open operation was 2.4%. 9.4% of patients were recorded as having one or more of the following complications: readmission (6.6%), surgical site infection (1.9%), intra-abdominal abscess (2.7%) or further intervention (1.5%). Patients who had an open operation had higher rates of readmission and surgical site infection.

CONCLUSION

The NAR found in this study is within the traditional measures of acceptance; however, this rate is high when measured against modern international benchmarks.

Clinical and laboratory findings in the diagnosis of right lower quadrant abdominal pain: outcome analysis of the APPAC trial

BACKGROUND

The current research on acute appendicitis aims to improve the diagnostics and to clarify to whom antibiotic treatment might be the treatment of choice.

METHODS

The present study is a retrospective analysis of a prospectively collected data in our randomized multicenter trial comparing surgery and antibiotic treatment for acute uncomplicated appendicitis (APPAC trial, NCTO1022567). We evaluated 1321 patients with a clinical suspicion of acute appendicitis, who underwent computed tomography (CT). Age, gender, body temperature, pain scores, the duration of symptoms, white blood cell count (WBC) and C-reactive protein (CRP) were recorded on admission.

RESULTS

CT confirmed the diagnosis of acute appendicitis in 73% (n=970) and in 27% (n=351) it revealed no or other diagnosis. Acute appendicitis patients had significantly higher WBC levels than patients without appendicitis (median 12.2 and 10.0, respectively, p<0.0001), whereas CRP levels did not differ between the two groups. Ideal cut-off points were assessed with receiver operating characteristic (ROC) curves, but neither these markers or neither their combination nor any clinical characteristic could accurately differentiate between patients with acute appendicitis and those without. The proportion of patients with normal WBC count and CRP was significantly (p=0.0007) lower in patients with acute appendicitis than in patients without appendicitis.

CONCLUSIONS

Both clinical findings and laboratory tests are unable to reliably distinguish between patients with acute appendicitis and those without. If both WBC count and CRP are normal, acute appendicitis is very unlikely. The current results emphasize the role of CT imaging in patients with suspected acute appendicitis.

Negative Appendectomy: Clinical and Economic Implications

Historically, performing a negative appendectomy (NA) was justified to reduce the incidence of perforation. Furthermore, it is also believed that NA is associated with minimal morbidity and cost. The purpose of this study was to evaluate the frequency, clinical characteristics, and economic implications of NA. We reviewed the inpatient admissions on 274,405 patients who underwent nonincidental appendectomy as their primary procedure from the California State Inpatient Databases (2005–2011). Overall, 96.9 per cent had appendicitis (nonperforated = 73.1%, perforated = 23.8% and 3.1%) had NA. NA rates decreased steadily from 4.2 per cent in 2005 to 2.5 per cent in 2011 ( P < 0.01). The rates of appendectomy for perforated appendicitis rates also decreased slightly from 25.3 to 23.3 per cent during this time ( P = <0.01). Multivariate regression showed that female gender, African American race, and public insurance were all associated with increased NA rates. Compared with patients with appendectomy for nonperforated appendicitis, NA was associated with longer length of stay (NA = 3.2 days vs nonperforated = 1.7 days), higher median cost per admission (NA = $8626 vs nonperforated = $7605), and higher morbidity (4.7 vs 1.9%), all P < 0.01. Contrary to classic justification for NA, we did not find an inverse association of appendectomy for perforated appendicitis and NA at the hospital level. In conclusion, NA is associated with substantial clinical and financial burden, while having no apparent impact on lowering the rate of appendectomy for perforated appendicitis.

Is preoperative distinction between complicated and uncomplicated acute appendicitis feasible without imaging?

BACKGROUND

One of the main aims of appendicitis research is the differential diagnostics between complicated and uncomplicated acute appendicitis that enable provision of the optimal treatment for each patient.

METHODS

Data in the present study were collected prospectively in our randomized antibiotic treatment for uncomplicated acute appendicitis trial (APPAC) comparing surgery and antibiotic treatment for uncomplicated acute appendicitis (NCT01022567). We evaluated 705 patients who had acute appendicitis on computed tomography. Patients with uncomplicated acute appendicitis (n = 368) were compared with all complicated acute appendicitis patients (n = 337), and subgroup analyses were performed between uncomplicated acute appendicitis and an appendicolith appendicitis (CA1; n = 256) and uncomplicated acute appendicitis and perforation and/or abscess (CA2; n = 78). Age, sex, body temperature (°C), duration of symptoms, white blood cell count (E9/L), and C-reactive protein (mg/L) were recorded on admission. Receiver operating characteristic curves were calculated for white blood cell count, C-reactive protein, and temperature.

RESULTS

CA2 patients had significantly greater C-reactive protein levels (mean 122 and 47, respectively, P < .001) and longer duration of symptoms than uncomplicated acute appendicitis patients; 81% of CA2 patients and 38% of uncomplicated acute appendicitis patients had symptoms >24 hours before admission (P < .001). In receiver operating characteristic analysis, C-reactive protein and temperature had clinically significant results only in comparison with uncomplicated acute appendicitis and CA2 (area under the curve >0.7), but no optimum cutoff points could be identified.

CONCLUSION

In clinical decision making, neither clinical findings nor laboratory markers are reliable enough to estimate the severity of the acute appendicitis accurately or to determine the presence of an appendicolith. The current results emphasize the role of computed tomography in the differential diagnosis of complicated and uncomplicated acute appendicitis.

Evaluation of Clinical Alvarado Scoring System and CT Criteria in the Diagnosis of Acute Appendicitis

Aim. The aim was to evaluate the clinical Alvarado scoring system and computed tomography (CT) criteria for the diagnosis of acute appendicitis. Material and Methods. 117 patients with acute abdominal pain who underwent abdominal CT were enrolled in this retrospective study. Patient demographics, clinical Alvarado scoring, CT images, and pathologic results of the patients were evaluated. Results. 39 of the 53 patients who were operated on had pathologically proven acute appendicitis. CT criteria of appendiceal diameter, presence of periappendiceal inflammation, fluid, appendicolith, and white blood cell (WBC) count were significantly correlated with the inflammation of the appendix. The best cut-off value for appendiceal diameter was 6.5 mm. The correlation between appendiceal diameter and WBC count was 80% (P = 0.01 < 0.05). The correlation between appendiceal diameter and Alvarado score was 78.7% (P = 0.01 < 0.05). Conclusion. Presence of CT criteria of appendiceal diameter above 6.5 mm, periappendiceal inflammation, fluid, and appendicolith should prompt the diagnosis of acute appendicitis. Since patients with acute appendicitis may not always show the typical signs and symptoms, CT is a helpful imaging modality for patients with relatively low Alvarado score and leukocytosis and when physical examination is confusing.

Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis

Background

For more than a century, appendicectomy has been the treatment of choice for appendicitis. Recent trials have challenged this view. This study assessed the benefits and harms of antibiotic therapy compared with appendicectomy in patients with non‐perforated appendicitis.

Methods

A comprehensive search was conducted for randomized trials comparing antibiotic therapy with appendicectomy in patients with non‐perforated appendicitis. Key outcomes were analysed using random‐effects meta‐analysis, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

Five studies including 1116 patients reported major complications in 25 (4·9 per cent) of 510 patients in the antibiotic and 41 (8·4 per cent) of 489 in the appendicectomy group: risk difference −2·6 (95 per cent c.i. –6·3 to 1·1) per cent (low‐quality evidence). Minor complications occurred in 11 (2·2 per cent) of 510 and 61 (12·5 per cent) of 489 patients respectively: risk difference −7·2 (−18·1 to 3·8) per cent (very low‐quality evidence). Of 550 patients in the antibiotic group, 47 underwent appendicectomy within 1 month: pooled estimate 8·2 (95 per cent c.i. 5·2 to 11·8) per cent (high‐quality evidence). Within 1 year, appendicitis recurred in 114 of 510 patients in the antibiotic group: pooled estimate 22·6 (15·6 to 30·4) per cent (high‐quality evidence). For every 100 patients with non‐perforated appendicitis, initial antibiotic therapy compared with prompt appendicectomy may result in 92 fewer patients receiving surgery within the first month, and 23 more experiencing recurrent appendicitis within the first year.

Conclusion

The choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value‐ and preference‐dependent, suggesting a change in practice towards shared decision‐making is necessary.

Limitations of each evolving

Nonoperative treatment of acute appendicitis in children: A feasibility study

PURPOSE

Nonoperative treatment of acute appendicitis appears to be feasible in adults. It is unclear whether the same is true for children.

METHODS

Children 5-18 years with <48 h symptoms of acute appendicitis were offered nonoperative treatment: 2 doses of piperacillin IV, then ampicillin/clavulanate ×1 week. Treatment failure (worsening on therapy) and recurrence (after completion of therapy) were noted. Patients who declined enrollment were asked to participate as controls. Cost-utility analysis was performed using Pediatric Quality of Life Scale (PedsQL®) to calculate quality-adjusted life month (QALM) for study and control patients.

RESULTS

Twenty-four patients agreed to undergo nonoperative management, and 50 acted as controls. At a mean follow-up of 14 months, three of the 24 failed on therapy, and 2/21 returned with recurrent appendicitis at 43 and 52 days, respectively. Two patients elected to undergo an interval appendectomy despite absence of symptoms. Appendectomy-free rate at one year was therefore 71% (C.I. 50-87%). No patient developed perforation or other complications. Cost-utility analysis shows a 0.007-0.03 QALM increase and a $1359 savings from $4130 to $2771 per nonoperatively treated patient.

CONCLUSION

Despite occasional late recurrences, antibiotic-only treatment of early appendicitis in children is feasible, safe, cost-effective and is experienced more favorably by patients and parents.

Histopathological correlations of appendectomies: a clinical audit of a single center

BACKGROUND

Acute appendicitis is a common presentation in surgical assessment units and appendectomy accounts for a large number of emergency operations in the UK. Histopathological examination of the appendectomy specimens are routinely carried out. The aim of this study is to correlate the histological findings of appendectomy specimens with the clinical diagnosis of acute appendicitis.

METHODS

This is a retrospective analysis of 238 appendectomies carried out in a single UK center between January and December 2013. The Histopathology reports of appendectomy specimens were retrieved.

RESULTS

A total of 238 appendectomies were performed during the study period. The mean age of the patients was 32 years (range, 7-81 years). Adult patients (>16 years) represented 79.4% of the study population. The female sex accounted for 46.6% of all the patients. Of the 238 resected appendix, 211 (88.7%) had histopathology findings consistent with appendicitis. Approximately 1.7% of the 238 specimens were abnormal pathologies other than inflammation of the appendix. The negative appendectomy (normal appendix on histology) rate was 11.3%. The female sex accounted for 59.1% of the negative appendectomies. Adults (>16 years) represented 77.8% of the negative appendectomies.

CONCLUSIONS

The observed high rates of negative appendectomy in the female sex can be reduced by utilizing combined clinical assessment and diagnostic imaging modalities. The findings of abnormal pathologies on histopathological examination of the appendix which could potentially impact on the management of the patients justify the current practice of routine histopathological examination of resected appendix.

Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template

PURPOSE

Computed tomography (CT) for the diagnosis of appendicitis is associated with radiation exposure and increased cost. In an effort to reduce the diagnostic use of CT scans, we implemented a standardized ultrasound report template based on validated secondary signs of appendicitis.

METHODS

In September 2012, as part of a quality improvement project, we developed and introduced a four category standardized ultrasound report template for limited right lower quadrant abdominal ultrasounds. Outcomes for patients undergoing ultrasound or CT scan for appendicitis between 9/10/2012 and 12/31/2013 (Period 2, n=2033) were compared to the three months prior to implementation (Period 1, n=304).

RESULTS

In Period 1, 78 of 304 (25.7%) patients had appendicitis versus 385 of 2033 (18.9%) in Period 2 (p=0.006). Non-diagnostic exams decreased from 48% to 0.1% (p<0.001). Ultrasound sensitivity improved from 66.67% to 92.2% (p<0.001). Specificity did not significantly change (96.9% to 97.69%, p=0.46). CT utilization for appendicitis decreased from 44.3% in Period 1 to 14.5% at the end of Period 2 (p<0.001).

CONCLUSIONS

Implementation of a standardized ultrasound report template based on validated secondary signs of appendicitis nearly eliminated non-diagnostic exams, improved diagnostic accuracy, and resulted in a striking decrease in CT utilization.

Cost-effectiveness of diagnostic approaches to suspected appendicitis in children

BACKGROUND

Our group recently published a clinical pathway (Le Bonheur Clinical Pathway [LeB-P]) that used the Samuel Pediatric Appendicitis Score with selective use of ultrasonography (USG) for diagnosis of children at risk for appendicitis. The objective of this study was to model the cost-effectiveness of implementing the LeB-P compared with usual care.

STUDY DESIGN

We constructed a decision analytic model comparing hospital costs for the following diagnostic strategies for suspected appendicitis: emergency department clinician judgment alone, USG on all patients, CT on all patients, overnight observation with surgical evaluation without studies, and the LeB-P. Prevalence of disease, outcomes probabilities, and hospital and professional costs for each option were derived from published literature, national cost data, and our previous study results. Cost-effectiveness was calculated using these 3 sets of parameters.

RESULTS

In the base case model, USG was the preferred strategy over LeB-P and overnight observation with surgical evaluation without studies. Emergency department clinician judgment alone and CT were dominated by the other pathways, based on either lower diagnostic accuracy or increased costs. Compared with LeB-P, USG costs $337 less per patient evaluated, but increased the diagnostic error rate by 2%. Using LeB-P rather than USG would cost an institution an additional $17,206 to eliminate one misdiagnosis, which is known as the incremental cost-effectiveness ratio.

CONCLUSIONS

Although performing USG on all children with suspected appendicitis was determined to be the most cost-effective strategy, using the Pediatric Appendicitis Score with selective use of USG (LeB-P) improved diagnostic accuracy at a moderate increase in cost and decreased CT use.

The outcome of antibiotic therapy for uncomplicated appendicitis with diameters ≤ 10 mm

PURPOSE

Although many patients receive antibiotic therapy for uncomplicated appendicitis, the relatively high treatment failure and recurrence rates are problematic. We assumed that patients with appendicitis and appendiceal diameters ≤ 10 mm, have better outcomes. The purpose of this prospective non-randomized study was to assess the outcomes of antibiotic therapy in patients with uncomplicated appendicitis and appendiceal diameters ≤ 10 mm.

METHODS

Over 2 years, we enrolled 119 patients who initially received antibiotic therapy. The failure of antibiotic therapy was defined as the need for appendectomy and true appendicitis. Peritonitis was defined as either complicated appendicitis or intra-abdominal abscess postoperatively. We evaluated the rates of treatment failure, peritonitis, and recurrence.

RESULTS

Nine patients (7.6%) failed to respond to initial antibiotic therapy, and 6 had true appendicitis after subsequent surgery. Two patients had complicated appendicitis (peritonitis), but no patient displayed intra-abdominal abscess postoperatively. During a median follow-up period months of 14 months, 14 patients (12.7%) experienced recurrence.

CONCLUSIONS

Antibiotic therapy without surgery may be a safe treatment for uncomplicated appendicitis in select patients with appendiceal diameters ≤ 10 mm.

A simple algorithm reduces computed tomography use in the diagnosis of appendicitis in children

BACKGROUND

A diagnostic algorithm for appendicitis in children was created to reduce computed tomography (CT) use owing to the risk of cancer from radiation exposure and cost of CT. This study evaluates the impact of the algorithm on CT use and diagnostic accuracy of appendicitis.

METHODS

Patients ≤18 years who underwent appendectomy for suspected appendicitis after presenting to the emergency department for 2 years before and 3 years after algorithm implementation were identified. Clinical characteristics and outcomes, including use of CT and negative appendectomy rate, were compared between the pre- and post-implementation periods. Multivariable analysis was used to determine the impact of CT on negative appendectomy.

RESULTS

We identified 331 patients-41% in the pre- and 59% in the post-implementation period. CT utilization decreased from 39% to 18% (P < .001) after implementation. The negative appendectomy rate increased from 9% to 11% (P = .59). Use of CT did not impact the risk of negative appendectomy (P = .64).

CONCLUSION

Utilization of CT was significantly reduced after implementation of a diagnostic algorithm for appendicitis without impacting diagnostic accuracy. Given the concern for increased risk of cancer after CT, these results support use of an algorithm in children with suspected appendicitis.

Institutional review of patients presenting with suspected appendicitis

BACKGROUND

Appendicitis is a common gastrointestinal surgical emergency. Treatment balances the risks of negative appendicectomy (NA) against potential complicated appendicitis in determining clinical priority. This study reviewed the population characteristics, results of the diagnostic modalities and Alvarado score (AlvS) of patients with suspected appendicitis.

METHODS

A clinical audit of emergency appendicectomies was performed. Generalized linear models with a binomial distribution were used to evaluate the association between the age groups, gender, white cell count (WCC), neutrophil count (NC) and C-reactive protein (CRP) levels versus NAs and the different types of appendicitis. The utilization and accuracy of preoperative ultrasound and computed tomography (CT) and a preliminary analysis of AlvS were also evaluated.

RESULTS

Patients 17 to 24 years old had significantly higher odds of NA but lower odds of complicated appendicitis compared with patients above 40 years. Adult women and men had significantly higher odds of NA and suppurative appendicitis (SA), respectively. Only adults with SA and acute appendicitis had significantly higher odds of raised WCC, NC and CRP. The sensitivity of CT for adult females was high (100%). Patients who had CT and an AlvS of more than 7 did not have NAs.

CONCLUSION

Elevated WCC, NC and CRP were all associated with acute appendicitis and SA in adults only. CT is useful for refining the diagnosis in adult females. A combination of inflammatory markers, ultrasound and AlvS may be used selectively to complement or maximize the advantages of CT.

Prospective evaluation of a clinical pathway for suspected appendicitis

OBJECTIVE

To evaluate the diagnostic accuracy of a clinical pathway for suspected appendicitis combining the Samuel's pediatric appendicitis score (PAS) and selective use of ultrasonography (US) as the primary imaging modality.

METHODS

Prospective, observational cohort study conducted at an urban, academic pediatric emergency department. After initial evaluation, patients were determined to be at low (PAS 1-3), intermediate (PAS 4-7), or high (PAS 8-10) risk for appendicitis. Low-risk patients were discharged with telephone follow-up. High-risk patients received immediate surgical consultation. Patients at intermediate risk for appendicitis underwent US.

RESULTS

Of the 196 patients enrolled, 65 (33.2%) had appendicitis. An initial PAS of 1-3 was noted in 44 (22.4%), 4-7 in 119 (60.7%), and 8-10 in 33 (16.9%) patients. Ultrasonography was performed in 128 (65.3%) patients, and 48 (37.5%) were positive. An abdominal computed tomography scan was requested by the surgical consultants in 13 (6.6%) patients. The negative appendectomy rate was 3 of 68 (4.4%). Follow-up was established on 190 of 196 (96.9%) patients. Overall diagnostic accuracy of the pathway was 94% (95% confidence interval [CI] 91%-97%) with a sensitivity of 92.3% (95% CI 83.0%-97.5%), specificity of 94.7% (95% CI 89.3%-97.8%), likelihood ratio (+) 17.3 (95% CI 8.4-35.6) and likelihood ratio (-) 0.08 (95% CI 0.04-0.19).

CONCLUSIONS

Our protocol demonstrates high sensitivity and specificity for diagnosis of appendicitis in children. Institutions should consider investing in resources that increase the availability of expertise in pediatric US. Standardization of care may decrease radiation exposure associated with use of computed tomography scans.

Acute appendicitis: What is the gold standard of treatment?

McBurney’s procedure represented the gold-standard for acute appendicitis until 1981, but nowadays the number of laparoscopic appendectomies has progressively increased since it has been demonstrated to be a safe procedure, with excellent cosmetic results and it also allows a shorter hospitalization, a quicker and less painful postoperative recovery. The aim of this editorial was to perform a review of the literature in order to address controversial issues in the treatment of acute appendicitis.

Diagnostic yield of EGD in children: a retrospective single-center study of 1000 cases

BACKGROUND

Pediatric EGD is increasingly being used, but few studies have recently evaluated the diagnostic yield.

OBJECTIVE

To assess the association between presenting clinical symptoms and the likelihood of significant endoscopic and histologic abnormalities for initial diagnostic endoscopy.

DESIGN

Retrospective cohort study.

SETTING

Large, tertiary care children's hospital.

PATIENTS

One thousand patients, ages 1 month to 18 years, who underwent initial diagnostic EGD in 2009 and 2010.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Endoscopic and histologic abnormalities.

RESULTS

The most common primary indications for endoscopy were generalized abdominal pain (28.7%), gastroesophageal reflux (11.7%), and failure to thrive (9.5%). The overall prevalence of an endoscopic abnormality was 34.7% and of a histologic abnormality, 40.4%. The highest rates of endoscopic abnormalities were found in patients with strictures on upper GI radiology (100%), foreign body (88%), and GI bleeding (57%). The highest rates of histologic abnormalities were in patients with positive celiac screening (91%), foreign body (88%), dysphagia (51%), and GI bleeding (49%), and the lowest rates of histologic abnormalities were miscellaneous indications (17%), strictures on radiology (25%), and reflux (26%). Females and patients < 1 year of age had lower rates of abnormal histologic abnormalities.

LIMITATIONS

Retrospective nature of the study, limitation to a single tertiary care center, and simplification of complex patient presentations to a single indication.

CONCLUSIONS

Rates of endoscopic and histologic abnormalities from EGD vary based on age and indication for endoscopy, and this should be factored into the decision to proceed with initial endoscopy along with consideration of adverse event rates and effects of anesthesia.

Role of the faecolith in modern-day appendicitis

Introduction

The prevailing view on appendicitis is that the main aetiology is obstruction owing to faecoliths in adults and lymphoid hyperplasia in children. Faecoliths on imaging studies are believed to correlate well with appendicitis.

Methods

A retrospective chart review was conducted of 1,014 emergency appendicectomy patients between 2001 and 2011. Faecolith prevalence in adult and paediatric appendicectomy specimens with and without perforation was studied. The sensitivity and positive predictive value (PPV) of computed tomography (CT) for identifying faecoliths in the pathology specimen were examined.

Results

Overall, faecoliths were found in 18.1% (178/986) of appendicitis specimens and 28.6% (8/28) of negative appendicectomies. Faecolith prevalence for positive cases was 29.9% (79/264) in paediatric patients and 13.7% (99/722) in adults (p<0.05). Faecolith prevalence was 39.4% in perforated appendicitis but only 14.6% in non-perforated appendicitis (p<0.05). In adults, faecolith prevalence was 27.5% in perforated appendicitis and 12.0% in non-perforated appendicitis (p<0.05) while in paediatric patients, it was 56.1% in perforated appendicitis and 22.7% in non-perforated appendicitis (p=0.00). Sensitivity and PPV of preoperative CT in identifying faecoliths on pathology were 53.1% (86/162) and 44.8% (86/192) respectively.

Conclusions

Faecolith prevalence is too low to consider the faecolith the most common cause of non-perforated appendicitis. Faecoliths are more prevalent in paediatric appendicitis than in adult appendicitis. Preoperative CT is an unreliable predictor of faecoliths in pathology specimens.