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Lamm R, Kumar SS, Collings AT, Haskins IN, Abou-Setta A, Narula N, Nepal P, Hanna NM, Athanasiadis DI, Scholz S, Bradley JF, Train AT, Pucher PH, Quinteros F, Slater B. Diagnosis and treatment of appendicitis: systematic review and meta-analysis. Surg Endosc 2023; 37:8933-8990. [PMID: 37914953 DOI: 10.1007/s00464-023-10456-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 11/03/2023]
Abstract
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.
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Affiliation(s)
- Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Thomas Jefferson University, 1015 Walnut Street, 613 Curtis, Philadelphia, PA, 19107, USA.
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Nisha Narula
- Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Pramod Nepal
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joel F Bradley
- Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Philip H Pucher
- Department of Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago Medicine, Chicago, IL, USA
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Lyttle BD, Reppucci ML, Prendergast C, Ziogas IA, Tong S, Acker SN, Milla S, Tutman JJ, Rutherford A, Orsborn J, Bennett TD, DeCamp L, Diaz-Miron JL. Quality Improvement Campaign Improved Utilization of Rapid Sequence MRI for Diagnosis of Pediatric Appendicitis. J Pediatr Surg 2023; 58:2171-2180. [PMID: 37353392 DOI: 10.1016/j.jpedsurg.2023.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/10/2023] [Accepted: 05/28/2023] [Indexed: 06/25/2023]
Abstract
INTRODUCTION Appendicitis is the most common indication for emergency general surgery in the pediatric population. Computed tomography (CT) or magnetic resonance imaging (MRI) may be used for diagnosis when ultrasound findings are equivocal. However, CT involves unnecessary radiation exposure if MRI is available. After introducing a rapid sequence MRI (rsMRI) appendicitis protocol at our institution, CT was still preferentially used. We therefore implemented a quality improvement (QI) campaign to reduce the rate of CTs and increase the rate of rsMRI. Here, we assess the effectiveness of the QI campaign while evaluating potential barriers to using rsMRI. METHODS We conducted a mixed methods study, first performing stakeholder interviews which informed the design of a QI campaign initiated in May 2021 and a midway feedback survey in December 2021. A retrospective cohort study was then performed of children evaluated for appendicitis at our institution between January 1, 2016, and April 30, 2022. CT and rsMRI rates were compared before and after QI campaign implementation. RESULTS There was a significant decrease in rate of CTs and increase in rate of rsMRIs performed following the initiation of the QI campaign (p < 0.0001). The rate of CT scans decreased by a factor of 0.4 while the rate of rsMRI increased by a factor of 9.5. CONCLUSION A successful QI campaign was initiated at our institution, resulting in decreased utilization of CT and increased use of rsMRI for the evaluation of suspected appendicitis. These results highlight the potential impact of QI projects. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Bailey D Lyttle
- General Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Marina L Reppucci
- General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Connor Prendergast
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Ioannis A Ziogas
- General Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Suhong Tong
- Children's Hospital Center for Research in Outcomes for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States
| | - Shannon N Acker
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Sarah Milla
- Department of Pediatric Radiology, Children's Hospital Colorado, Aurora, CO, USA
| | - Jeffrey J Tutman
- Department of Pediatric Radiology, Children's Hospital Colorado, Aurora, CO, USA
| | - Amanda Rutherford
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Jonathan Orsborn
- Department of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Tellen D Bennett
- Departments of Biomedical Informatics and Pediatrics (Critical Care Medicine), University of Colorado School of Medicine, Aurora, CO, USA
| | - Lisa DeCamp
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Jose L Diaz-Miron
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
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Kim D, Woodham BL, Chen K, Kuganathan V, Edye MB. Rapid MRI Abdomen for Assessment of Clinically Suspected Acute Appendicitis in the General Adult Population: a Systematic Review. J Gastrointest Surg 2023; 27:1473-1485. [PMID: 37081221 PMCID: PMC10366263 DOI: 10.1007/s11605-023-05626-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 01/27/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVES To perform a systematic review on the use of magnetic resonance imaging (MRI) of the abdomen to evaluate clinically suspected appendicitis in the general adult population. We examined the diagnostic accuracy, the reported trends of MRI use, and the factors that affect the utility of MRI abdomen, including study duration and cost-benefits. METHODS We conducted a systematic literature search on PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library databases. We enrolled primary studies investigating the use of MRI in diagnosing appendicitis in the general adult population, excluding studies that predominantly reported on populations not representative of typical adult appendicitis presentations, such as those focusing on paediatric or pregnant populations. RESULTS Twenty-seven eligible primary studies and 6 secondary studies were included, totaling 2,044 patients from eight countries. The sensitivity and specificity of MRI for diagnosing appendicitis were 96% (95% CI: 93-97%) and 93% (95% CI: 80-98%), respectively. MRI can identify complicated appendicitis and accurately propose alternative diagnoses. The duration of MRI protocols in each primary study ranged between 2.26 and 30 minutes, and only one study used intravenous contrast agents in addition to the non-contrast sequences. Decision analysis suggests significant benefits for replacing computed tomography (CT) with MRI and a potential for cost reduction. Reported trends in MRI usage showed minimal utilisation in diagnostic settings even when MRI was available. CONCLUSIONS MRI accurately diagnoses appendicitis in the general adult population and improves the identification of complicated appendicitis or alternative diagnoses compared to other modalities using a single, rapid investigation.
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Affiliation(s)
- Dongchan Kim
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
| | - Benjamin Luke Woodham
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
- Department of General Surgery, Blacktown and Mount Druitt Hospitals, Blacktown Road, Blacktown, N.S.W. Australia
| | - Kathryn Chen
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
| | - Vinushan Kuganathan
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
| | - Michael Benjamin Edye
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
- Department of General Surgery, Blacktown and Mount Druitt Hospitals, Blacktown Road, Blacktown, N.S.W. Australia
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Afzal B, Cirocchi R, Dawani A, Desiderio J, Di Cintio A, Di Nardo D, Farinacci F, Fung J, Gemini A, Guerci L, Kam SYM, Lakunina S, Madi L, Mazzetti S, Nadyrshine B, Shams O, Ranucci MC, Ricci F, Sharmin A, Trastulli S, Yasin T, Bond-Smith G, Tebala GD. Is it possible to predict the severity of acute appendicitis? Reliability of predictive models based on easily available blood variables. World J Emerg Surg 2023; 18:10. [PMID: 36707812 PMCID: PMC9882741 DOI: 10.1186/s13017-023-00478-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 01/16/2023] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Recent evidence confirms that the treatment of acute appendicitis is not necessarily surgical, and selected patients with uncomplicated appendicitis can benefit from a non-operative management. Unfortunately, no cost-effective test has been proven to be able to effectively predict the degree of appendicular inflammation as yet, therefore, patient selection is too often left to the personal choice of the emergency surgeon. Our paper aims to clarify if basic and readily available blood tests can give reliable prognostic information to build up predictive models to help the decision-making process. METHODS Clinical notes of 2275 patients who underwent an appendicectomy with a presumptive diagnosis of acute appendicitis were reviewed, taking into consideration basic preoperative blood tests and histology reports on the surgical specimens. Variables were compared with univariate and multivariate analysis, and predictive models were created. RESULTS 18.2% of patients had a negative appendicectomy, 9.6% had mucosal only inflammation, 53% had transmural inflammation and 19.2% had gangrenous appendicitis. A strong correlation was found between degree of inflammation and lymphocytes count and CRP/Albumin ratio, both at univariate and multivariate analysis. A predictive model to identify cases of gangrenous appendicitis was developed. CONCLUSION Low lymphocyte count and high CRP/Albumin ratio combined into a predictive model may have a role in the selection of patients who deserve appendicectomy instead of non-operative management of acute appendicitis.
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Affiliation(s)
- Barza Afzal
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Roberto Cirocchi
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Aruna Dawani
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Jacopo Desiderio
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Antonio Di Cintio
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Domenico Di Nardo
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Federico Farinacci
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - James Fung
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Alessandro Gemini
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Lorenzo Guerci
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Sen Yin Melina Kam
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Svetlana Lakunina
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Lee Madi
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Stefano Mazzetti
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Bakhtiar Nadyrshine
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Ola Shams
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Maria Chiara Ranucci
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Francesco Ricci
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Afroza Sharmin
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Stefano Trastulli
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Tanzela Yasin
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Giles Bond-Smith
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Giovanni D. Tebala
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK ,grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
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Mezrich JL, Weinreb JC. Financial and medicolegal implications of focused/fast abdominopelvic MRI exams. Abdom Radiol (NY) 2022; 47:471-474. [PMID: 34713311 DOI: 10.1007/s00261-021-03328-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 09/28/2021] [Accepted: 10/18/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE Abbreviated MRI offers significant advantages in terms of MRI throughput, patient tolerance and expediency, and is being utilized for a variety of abdominopelvic imaging applications. However questions abound with respect to financial and medicolegal treatment of these relatively new protocols. METHODS A review of the relevant literature was performed. RESULTS There is no Current Procedural Terminology code for a "limited" MRI study, but it may not be appropriate to bill an abbreviated study the same as a more comprehensive study. With respect to medicolegal concerns, the risk of liability when missing or misinterpreting medically significant findings due to use of an abbreviated scan will turn on whether abbreviated MRI has become the standard of care. CONCLUSION In light of these ambiguities, it would behoove abdominopelvic imagers to advocate for their professional and subspecialty organizations to issue practice parameters/guidelines with respect to the utilization of abbreviated MRI protocols, and for the subspecialty to bill these abbreviated scans at objectively reasonable rates.
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Affiliation(s)
- Jonathan L Mezrich
- Department of Diagnostic Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, TE2, New Haven, CT, 06520, USA.
| | - Jeffrey C Weinreb
- Department of Diagnostic Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, TE2, New Haven, CT, 06520, USA
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