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Debnath P, Hayatghaibi S, Trout AT, Ayyala RS. Understanding Provider Cost of MRI for Appendicitis in Children: A Time-Driven Activity-Based Costing Analysis. J Am Coll Radiol 2024; 21:1668-1676. [PMID: 38880294 DOI: 10.1016/j.jacr.2024.05.008] [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: 03/07/2024] [Revised: 05/15/2024] [Accepted: 05/15/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE To use time driven activity-based costing to characterize the provider cost of rapid MRI for appendicitis compared to other MRI examinations billed with the same Current Procedural Terminology codes commonly used for MRI appendicitis examinations. METHODS Rapid MRI appendicitis examination was compared with MRI pelvis without intravenous contrast, MRI abdomen/pelvis without intravenous contrast, and MRI abdomen/pelvis with intravenous contrast. Process maps for each examination were created through direct shadowing of patient procedures (n = 20) and feedback from relevant health care professionals. Additional data were collected from the electronic medical record for 327 MRI examinations. Practical capacity cost rates were calculated for personnel, equipment, and facilities. The cost of each step was calculated by multiplying the capacity cost rate with the mean duration of each step. Stepwise costs were summed to generate a total cost for each MRI examination. RESULTS The mean duration and costs for MRI examination type were as follows: MRI appendicitis: 11 (range: 6-25) min, $20.03 (7.80-44.24); MRI pelvis without intravenous contrast: 55 (29-205) min, $105.99 (64.18-285.13); MRI abdomen/pelvis without intravenous contrast: 65 (26-173) min, $144.83 (61.16-196.50); MRI abdomen/pelvis with intravenous contrast: 128 (39-303) min, $236.99 (102.62-556.54). CONCLUSION The estimated cost of providing a rapid appendicitis MRI examination is significantly less than other MRI examinations billed using Current Procedural Terminology codes typically used for appendicitis MRI. Mechanisms to appropriately bill rapid MRI examinations with limited sequences are needed to improve cost efficiency for the patient and to enable wider use of limited MRI examinations in the pediatric population.
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Affiliation(s)
- Pradipta Debnath
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. https://twitter.com/pro_debnath
| | - Shireen Hayatghaibi
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. https://twitter.com/shireenhayati
| | - Andrew T Trout
- Professor of Radiology and Associate Professor of Pediatrics, Director of Clinical Research for Radiology, Director of Nuclear Medicine, Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. https://twitter.com/AndrewTroutMD
| | - Rama S Ayyala
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Associate Professor of Radiology, Associate Chief of Culture, Quality and Safety, Division Director of Thoracoabdominal Imaging, Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Debnath P, Trout AT, Ayyala RS. Partial visualization of appendix on ultrasound: What does it mean in the child with suspected appendicitis? Clin Imaging 2024; 111:110187. [PMID: 38754179 DOI: 10.1016/j.clinimag.2024.110187] [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: 02/23/2024] [Revised: 04/23/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Visualization of the entire appendix, including the tip, is thought, but has not been demonstrated, to be important for exclusion of appendicitis by ultrasound. OBJECTIVE To determine if incomplete visualization of the appendix has negative clinical ramifications including missed appendicitis. METHODS Under IRB approval we retrospectively reviewed right lower quadrant ultrasound reports from January 2017 to December 2020 to identify examinations with impressions of full visualization of the normal appendix, non-visualization of the appendix with and without secondary findings of appendicitis, and partial visualization of the appendix. Electronic health records were reviewed for follow-up imaging within 48 h, and surgery with pathology reports (if available). RESULTS 12,193 examinations were included. 4171 (34.2 %) had full visualization of a normal appendix, 5369 (44.0 %) had non-visualization with no secondary findings, and 234 (1.9 %) had non-visualization with secondary findings, The frequencies of appendicitis in these three groups were 34 (0.8 %), 283 (5.3 %), and 127 (54.3 %) respectively. The appendix was partially visualized in 338 (2.8 %) patients with secondary findings present in 53 (15.6 %). Partial visualization without secondary findings had a similar frequency (4.9 %, 14/285) of appendicitis to non-visualized appendix without secondary findings (p = 0.797) and a higher frequency than full visualization of a normal appendix (p < 0.0001). Partial visualization with secondary findings had similar rates (54.7 %, 29/53) to non-visualized appendix with secondary findings (p = 0.953). CONCLUSION Partial visualization of the appendix with ultrasound (with and without secondary findings) is associated with similar frequencies of appendicitis as non-visualization of appendix (with and without secondary findings).
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Affiliation(s)
- Pradipta Debnath
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America.
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America; Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America.
| | - Rama S Ayyala
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America; Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America.
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Roberts K, Moore H, Raju M, Gent R, Piotto L, Taranath A, Ee M, Linke R, Goh DW. Diagnostic Ultrasound for Acute Appendicitis: The Gold Standard. J Pediatr Surg 2024; 59:235-239. [PMID: 37985334 DOI: 10.1016/j.jpedsurg.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/11/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Acute appendicitis may present a diagnostic dilemma. The aim of this study was to review the accuracy of ultrasound in the diagnosis of paediatric acute appendicitis. METHOD Ultrasound studies performed for investigation of appendicitis during 2015-2021 were retrieved from a tertiary paediatric hospital database and reviewed. Medical records were reviewed to determine operative intervention, further imaging, and final diagnosis. Diagnostic accuracy was assessed by sensitivity, specificity, predictivity, and overall accuracy. All appendicectomy specimens underwent histopathological confirmation. This study was approved by the local Human Research Ethics Committee. RESULTS A total of 8555 consecutive ultrasound examinations were performed during the study period. Mean patient age was 10.8 years ( ± 3.7). Overall diagnostic accuracy was 96.1% (8221/8555) with a visualisation rate of 91.0%. Sensitivity and specificity were 96.2% (CI 95.3-97.0%) and 96.1% (CI 95.6-96.5%), respectively. When limited to positive/negative scans, sensitivity was 99.6% (CI 99.2-99.8%) and specificity 99.0% (CI 98.7-99.3%). Positive and negative predictive values were 96.9% and 99.9%, respectively. Repeat ultrasound following a non-diagnostic scan led to a definitive diagnosis in 76.1%. Negative appendicectomy rate was 5.5% overall in children who had undergone pre-operative ultrasound (107/1938), and 4.4% when other surgical pathologies were excluded. CONCLUSION Ultrasound examination provides gold-standard accuracy in the diagnosis of paediatric appendicitis and reduces rates of negative appendicectomy. Given the disadvantages of computed tomography and magnetic resonance imaging, ultrasound should be considered the first-line investigation of choice in the diagnosis of acute appendicitis in children. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kiera Roberts
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia.
| | - Hamish Moore
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia
| | - Mahima Raju
- Adelaide Medical School, the University of Adelaide, SA, Australia
| | - Roger Gent
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Lino Piotto
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Ajay Taranath
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Michael Ee
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia; College of Medicine and Public Health, Flinders University, SA, Australia
| | - Rebecca Linke
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Day Way Goh
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia; Discipline of Paediatrics, University of Adelaide, SA, Australia
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Proctor DW, Goodall R, Borsky K, Salciccioli JD, Marshall DC, Shanmugarajah K, Mohamed A, Shalhoub J. Trends in the mortality, incidence and disability-adjusted life-years of appendicitis in EU15+ countries: an observational study of the Global Burden of Disease Database, 1990-2019. Int J Surg 2023; 109:2608-2613. [PMID: 37232122 PMCID: PMC10498886 DOI: 10.1097/js9.0000000000000499] [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: 03/07/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Appendicitis places a substantial burden on healthcare systems, with acute appendicitis alone being the most common abdominal surgical emergency worldwide. Further characterisation of the disease burden in EU15+ countries may help optimise the distribution of healthcare resources. The aim of this observational study was to assess the trends in mortality, incidence and disability-adjusted life-years (DALYs) of appendicitis across European Union (EU) 15+ countries between the years 1990 and 2019, Supplemental Digital Content 3, http://links.lww.com/JS9/A589 . MATERIALS AND METHODS Age-standardised mortality rates (ASMRs), age-standardised incidence rates (ASIRs) and DALYs data for appendicitis in males and females were extracted from the 2019 Global Burden of Disease (GBD) study. Temporal trends within the study period were analysed using Joinpoint regression analysis. RESULTS The median ASMRs across EU15+ countries in 2019 were 0.08/100 000 and 0.13/100 000 for females and males, respectively. Between 1990 and 2019 the median percentage change in ASMR was -52.12% for females and -53.18% in males. The median ASIRs in 2019 for females and males were 251/100 000 and 278/100 000, respectively, with a median percentage change of +7.22% for females and +3.78% for males during the observation period. Decreasing trends in DALYs were observed over the 30-year study period, with median percentage changes of -23.57% and -33.81% for females and males, respectively, Supplemental Digital Content 3, http://links.lww.com/JS9/A589 . CONCLUSION Overall, a general trend of decreasing appendicitis ASMRs and DALYs was observed across EU15+ countries, despite small overall increases in appendicitis ASIRs, Supplemental Digital Content 3, http://links.lww.com/JS9/A589 . Variations in both diagnostic and management strategies over the study period are likely contributory to the changing trends.
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Affiliation(s)
| | | | - Kim Borsky
- Department of Plastic Surgery, Salisbury Hospital, Salisbury, UK
| | - Justin D. Salciccioli
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA
| | | | | | - Abdulla Mohamed
- Imperial College Healthcare NHS Trust
- Imperial College London, London
| | - Joseph Shalhoub
- Imperial College Healthcare NHS Trust
- Imperial College London, London
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5
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Aziz O, Nevin S, Serhan Y, Hakan B, Abdulkadir A. What is the margin of error of surgeons and radiological imaging in diagnosing acute appendicitis? Niger J Clin Pract 2023; 26:881-888. [PMID: 37635570 DOI: 10.4103/njcp.njcp_284_22] [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] [Indexed: 08/29/2023]
Abstract
Background Acute appendicitis is the most common emergency requiring surgical intervention in general surgery. Negative appendectomy is defined as the removal of a pathologically normal appendix. Aim In this study, we aimed to show our negative appendectomy rate. Materials and Methods This study was carried out among 2990 patients who were operated on for appendicitis between 2015-2020 at the Health Sciences University, İstanbul Kanuni Sultan Suleyman Training, and Research Hospital. Accrual and historical records of the patients were analyzed using NCSS (Number Cruncher Statistical System) 2007 Statistical Software (Utah, USA) package program. The results were evaluated at the significance level of P < 0.05. Results The mean age of all patients was 33. Of the patients, 1011 were women and 1979 were men. 27 of the women patients were pregnant. We requested a blood test (WBC count) and an abdominal ultrasound for all our patients who came with the complaint of abdominal pain in the right lower quadrant. Negative appendectomy was performed with ultrasonography in 622 patients with pathological diagnoses of lymphoid hyperplasia and fibrous obliteration (20.8%). We had abdominal computerized tomography (CT) for 285 patients and abdominal magnetic resonance imaging (MRI) for 16 of 27 pregnant women (59.25%) due to unclear clinical picture. Diagnostic laparoscopy was performed in 36 of the patients who underwent CT and 4 of the patients who underwent MRI since the diagnosis could not be made. We performed unnecessary appendectomy in 21.2% of the patients. Conclusion With the increasing clinical follow-up experience of surgeons and developing technology in radiology, our aim is to minimize the negative appendectomy rate as much as possible.
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Affiliation(s)
- O Aziz
- General Surgery Department, Health Sciences University, İstanbul Kanuni Sultan Suleyman Training and Research Hospital, İstanbul, Turkey
| | - S Nevin
- General Surgery Department, İstanbul Medipol University, İstanbul, Turkey
| | - Y Serhan
- General Surgery Department, Health Sciences University, İstanbul Kanuni Sultan Suleyman Training and Research Hospital, İstanbul, Turkey
| | - B Hakan
- General Surgery Department, Health Sciences University, İstanbul Kanuni Sultan Suleyman Training and Research Hospital, İstanbul, Turkey
| | - A Abdulkadir
- Radiology Department, Medipol Bahcelievler Hospital, İstanbul, Turkey
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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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Boccatonda A, D’Ardes D, Tallarico V, Vicari S, Bartoli E, Vidili G, Guagnano MT, Cocco G, Cipollone F, Schiavone C, Accogli E. Gastrointestinal Ultrasound in Emergency Setting. J Clin Med 2023; 12:jcm12030799. [PMID: 36769448 PMCID: PMC9917741 DOI: 10.3390/jcm12030799] [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: 12/17/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Acute bowel diseases are responsible for more than one third of subjects who were referred to the emergency department for acute abdominal pain and gastrointestinal evaluation. Gastrointestinal ultrasound (GIUS) is often employed as the first imaging method, with a good diagnostic accuracy in the setting of acute abdomen, and it can be an optimal diagnostic strategy in young females due to the radiation exposure related to X-ray and computed tomography methods. The physician can examine the gastrointestinal system in the area with the greatest tenderness by ultrasound, thus obtaining more information and data on the pathology than the standard physical examination. In this comprehensive review, we have reported the most relevant indications and advantages to using ultrasound in the investigation of abdominal acute pain.
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Affiliation(s)
- Andrea Boccatonda
- Internal Medicine, Bentivoglio Hospital, AUSL Bologna, Bentivoglio (BO), 40010 Bologna, Italy
- Correspondence: ; Tel.: +39-051-664-4111
| | - Damiano D’Ardes
- Department of Medicine and Aging Science, Institute of “Clinica Medica”, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Viola Tallarico
- Department of Internal Medicine, Bologna University, 40138 Bologna, Italy
| | - Susanna Vicari
- Internal Medicine, Bentivoglio Hospital, AUSL Bologna, Bentivoglio (BO), 40010 Bologna, Italy
| | - Elena Bartoli
- Internal Medicine, Bentivoglio Hospital, AUSL Bologna, Bentivoglio (BO), 40010 Bologna, Italy
| | - Gianpaolo Vidili
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
| | - Maria Teresa Guagnano
- Department of Medicine and Aging Science, Institute of “Clinica Medica”, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Giulio Cocco
- Internistic Ultrasound Unit, SS Annunziata Hospital, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Francesco Cipollone
- Department of Medicine and Aging Science, Institute of “Clinica Medica”, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Cosima Schiavone
- Internistic Ultrasound Unit, SS Annunziata Hospital, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Esterita Accogli
- Internal Medicine, Centre of Research and Learning in Ultrasound, Maggiore Hospital, 40133 Bologna, Italy
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Fawkner-Corbett D, Hayward G, Alkhmees M, Van Den Bruel A, Ordóñez-Mena JM, Holtman GA. Diagnostic accuracy of blood tests of inflammation in paediatric appendicitis: a systematic review and meta-analysis. BMJ Open 2022; 12:e056854. [PMID: 36328382 PMCID: PMC9639107 DOI: 10.1136/bmjopen-2021-056854] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Possible childhood appendicitis is a common emergency presentation. The exact value of blood tests is debated. This study sought to determine the diagnostic accuracy of four blood tests (white cell count (WCC), neutrophil(count or percentage), C reactive protein (CRP) and/or procalcitonin) for childhood appendicitis. DESIGN A systematic review and diagnostic meta-analysis. Data sources included MEDLINE, EMBASE, Central, Web of Science searched from inception-March 2022 with reference searching and authors contacted for missing/unclear data. Eligibility criteria was studies reporting the diagnostic accuracy of the four blood tests compared to the reference standard (histology or follow-up). Risk of bias was assessed (QUADAS-2), pooled sensitivity and specificity were generated for each test and commonly presented cut-offs. To provide insight into clinical impact, we present strategies using a hypothetical cohort. RESULTS 67 studies were included (34 839 children, 13 342 with appendicitis), all in the hospital setting. The most sensitive tests were WCC (≥10 000 cells/µL, 53 studies sensitivity 0.85 (95% CI 0.80 to 0.89)) and absolute neutrophil count (ANC) (≥7500 cells/µL, five studies sensitivity 0.90 (95% CI 0.85 to 0.94)). Combination of WCC or CRP increased sensitivity further(≥10 000 cells/µL or ≥10 mg/L, individual patient data (IPD) of 6 studies, 0.97 (95% CI 0.93 to 0.99)).Applying results to a hypothetical cohort(1000 children with appendicitis symptoms, of whom 400 have appendicitis) 60 and 40 children would be wrongly discharged based solely on WCC and ANC, respectively, 12 with combination of WCC or CRP.The most specific tests were CRP alone (≥50 mg/L, 38 studies, specificity 0.87 (95% CI 0.80 to 0.91)) or combined with WCC (≥10 000 cells/µL and ≥50 mg/L, IPD of six studies, 0.93 (95% CI 0.91 to 0.95)). CONCLUSIONS The best performing single blood tests for ruling-out paediatric appendicitis are WCC or ANC; with accuracy improved combining WCC and CRP. These tests could be used at the point of care in combination with clinical prediction rules. We provide insight into the best cut-offs for clinical application. PROSPERO REGISTRATION NUMBER CRD42017080036.
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Affiliation(s)
- David Fawkner-Corbett
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Academic Paediatric Surgery Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX3 9DU, UK
- MRC Weatherall Institute of Molecular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DS, UK
| | - Gail Hayward
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Mohammed Alkhmees
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ann Van Den Bruel
- EPI-Centre, Academic Centre for Primary Care, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
| | - Jose M Ordóñez-Mena
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Gea A Holtman
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Rafique U, Elfeky MA, Bhatti K, Siddique K. Does Diagnostic Laparoscopy Still Have a Role in the Evaluation of Right Iliac Fossa Pain Versus Imaging Techniques or Experience? Cureus 2022; 14:e30678. [PMID: 36439602 DOI: 10.7759/cureus.30678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
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10
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Lastunen KS, Leppäniemi AK, Mentula PJ. DIAgnostic iMaging or Observation in early equivocal appeNDicitis (DIAMOND): open-label, randomized clinical trial. Br J Surg 2022; 109:588-594. [PMID: 35482016 PMCID: PMC10364723 DOI: 10.1093/bjs/znac120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/08/2022] [Accepted: 03/24/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Mild appendicitis may resolve spontaneously. The use of CT may lead to an overdiagnosis of uncomplicated appendicitis. The aims of this study were to examine whether early imaging results in more patients being diagnosed with acute appendicitis than initial observation, and to study the safety and feasibility of score-based observation compared with imaging in patients with equivocal signs of appendicitis. METHODS Patients with suspected appendicitis with symptoms for fewer than 24 h and an Adult Appendicitis Score of 11-15 were eligible for this trial. After exclusions, patients were randomized openly into two equal-sized groups: imaging and observation. Patients in the imaging group had ultrasound imaging followed by CT when necessary, whereas those in the observation group were reassessed after 6-8 h with repeated scoring and managed accordingly. The primary outcome was the number of patients requiring treatment for acute appendicitis within 30 days. RESULTS Ninety-three patients were randomized to imaging and 92 to observation; after exclusions, 93 and 88 patients respectively were analysed. In the imaging group, more patients underwent treatment for acute appendicitis than in the observation group: 72 versus 57 per cent (difference 15 (95 per cent c.i. 1 to 29) per cent). This suggests that patients with spontaneously resolving appendicitis were not diagnosed or treated in the observation group. Some 55 per cent of patients in the observation group did not need diagnostic imaging within 30 days after randomization. There was no difference in the number of patients diagnosed with complicated appendicitis (4 versus 2 per cent) or negative appendicectomies (1 versus 1 per cent) in the imaging and observation groups. CONCLUSION Score-based observation of patients with early equivocal appendicitis results in fewer patients requiring treatment for appendicitis. Registration number: NCT02742402 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Kirsi S Lastunen
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ari K Leppäniemi
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Panu J Mentula
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Park JH, Salminen P, Tannaphai P, Lee KH. Low-Dose Abdominal CT for Evaluating Suspected Appendicitis in Adolescents and Young Adults: Review of Evidence. Korean J Radiol 2022; 23:517-528. [PMID: 35289145 PMCID: PMC9081692 DOI: 10.3348/kjr.2021.0596] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/18/2021] [Accepted: 11/21/2021] [Indexed: 11/15/2022] Open
Abstract
Due to its excellent diagnostic performance, CT is the mainstay of diagnostic test in adults with suspected acute appendicitis in many countries. Although debatable, extensive epidemiological studies have suggested that CT radiation is carcinogenic, at least in children and adolescents. Setting aside the debate over the carcinogenic risk of CT radiation, the value of judicious use of CT radiation cannot be overstated for the diagnosis of appendicitis, considering that appendicitis is a very common disease, and that the vast majority of patients with suspected acute appendicitis are adolescents and young adults with average life expectancies. Given the accumulated evidence justifying the use of low-dose CT (LDCT) of only 2 mSv, there is no reasonable basis to insist on using radiation dose of multi-purpose abdominal CT for the diagnosis of appendicitis, particularly in adolescents and young adults. Published data strongly suggest that LDCT is comparable to conventional dose CT in terms of clinical outcomes and diagnostic performance. In this narrative review, we will discuss such evidence for reducing CT radiation in adolescents and young adults with suspected appendicitis.
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Affiliation(s)
- Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland, Thailand
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland, Thailand
| | - Penampai Tannaphai
- Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, Korea
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12
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Haijanen J, Sippola S, Tammilehto V, Grönroos J, Mäntyoja S, Löyttyniemi E, Niiniviita H, Salminen P. Diagnostic accuracy using low-dose versus standard radiation dose CT in suspected acute appendicitis: prospective cohort study. Br J Surg 2021; 108:1483-1490. [PMID: 34761262 PMCID: PMC10364876 DOI: 10.1093/bjs/znab383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/05/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Contrast-enhanced CT is the reference standard used in diagnostic imaging for acute appendicitis in adults. The radiation dose has been of concern. This study aimed to assess whether a lower radiation dose would affect the diagnostic accuracy of CT. METHODS This was a prospective single-centre cohort study of patients (aged over 16 years) with suspected appendicitis evaluated for enrolment in concurrent APPAC II-III trials. The diagnostic accuracy of contrast-enhanced low- and standard-dose CT was compared with study protocols guiding imaging based on BMI; this enabled direct CT imaging comparison only in patients with a BMI below 30 kg/m2. The on-call CT diagnosis was compared with the final clinical diagnosis. RESULTS Among all 856 patients investigated, the accuracy of low-dose (454 patients) and standard-dose (402 patients) CT in identifying patients with and without appendicitis was 98·0 and 98·5 per cent respectively. In patients with a BMI under 30 kg/m2, respective values were 98·2 per cent (434 patients) and 98·6 per cent (210 patients) (P = 1·000). The corresponding accuracy for differentiating between uncomplicated and complicated acute appendicitis was 90·3 and 87·6 per cent in all patients, and 89·8 and 88·4 per cent respectively among those with a BMI below 30 kg/m2 (P = 0·663). The median radiation dose in the whole low- and standard-dose CT groups was 3 and 7 mSv respectively. In the group with BMI below 30 kg/m2, corresponding median doses were 3 and 5 mSv (P < 0·001). CONCLUSION Low- and standard-dose CT were accurate both in identifying appendicitis and in differentiating between uncomplicated and complicated acute appendicitis. Low-dose CT was associated with a significant radiation dose reduction, suggesting that it should be standard clinical practice at least in patients with a BMI below 30 kg/m2.
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Affiliation(s)
- Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland.,Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - Ville Tammilehto
- Department of Radiology, Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Siiri Mäntyoja
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | | | - Hannele Niiniviita
- Department of Radiology, Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland.,Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
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13
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Bracken RL, Harringa JB, Markhardt BK, Kim N, Park JK, Kitchin DR, Robbins JB, Ziemlewicz TJ, Birstler J, Ryan MJ, Hoang L, Pickhardt P, Reeder SB, Repplinger MD. Abdominal fellowship-trained versus generalist radiologist accuracy when interpreting MR and CT for the diagnosis of appendicitis. Eur Radiol 2021; 32:533-541. [PMID: 34268596 PMCID: PMC8665009 DOI: 10.1007/s00330-021-08163-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 06/12/2021] [Accepted: 06/24/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To compare the diagnostic accuracy of generalist radiologists working in a community setting against abdominal radiologists working in an academic setting for the interpretation of MR when diagnosing acute appendicitis among emergency department patients. METHODS This observational study examined MR image interpretation (non-contrast MR with diffusion-weighted imaging and intravenous contrast-enhanced MR) from a prospectively enrolled cohort at an academic hospital over 18 months. Eligible patients had an abdominopelvic CT ordered to evaluate for appendicitis and were > 11 years old. The reference standard was a combination of surgery and pathology results, phone follow-up, and chart review. Six radiologists blinded to clinical information, three each from community and academic practices, independently interpreted MR and CT images in random order. We calculated test characteristics for both individual and group (consensus) diagnostic accuracy then performed Chi-square tests to identify any differences between the subgroups. RESULTS Analysis included 198 patients (114 women) with a mean age of 31.6 years and an appendicitis prevalence of 32.3%. For generalist radiologists, the sensitivity and specificity (95% confidence interval) were 93.8% (84.6-98.0%) and 88.8% (82.2-93.2%) for MR and 96.9% (88.7-99.8%) and 91.8% (85.8-95.5%) for CT. For fellowship-trained radiologists, the sensitivity and specificity were 96.9% (88.2-99.5%) and 89.6% (82.8-94%) for MR and 98.4% (90.5-99.9%) and 93.3% (87.3-96.7%) for CT. No statistically significant differences were detected between radiologist groups (p = 1.0, p = 0.53, respectively) or when comparing MR to CT (p = 0.21, p = 0.17, respectively). CONCLUSIONS MR is a reliable, radiation-free imaging alternative to CT for the evaluation of appendicitis in community-based generalist radiology practices. KEY POINTS • There was no significant difference in MR image interpretation accuracy between generalist and abdominal fellowship-trained radiologists when evaluating sensitivity (p = 1.0) and specificity (p = 0.53). • There was no significant difference in accuracy comparing MR to CT imaging for diagnosing appendicitis for either sensitivity (p = 0.21) or specificity (p = 0.17). • With experience, generalist radiologists enhanced their MR interpretation accuracy as demonstrated by improved interpretation sensitivity (OR 2.89 CI 1.44-5.77, p = 0.003) and decreased mean interpretation time (5 to 3.89 min).
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Affiliation(s)
- Rebecca L Bracken
- BerbeeWalsh Department of Emergency Medicine, University of
Wisconsin-Madison, Madison, WI, USA
| | - John B Harringa
- BerbeeWalsh Department of Emergency Medicine, University of
Wisconsin-Madison, Madison, WI, USA
| | - B Keegan Markhardt
- Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA.,Department of Radiology, UnityPoint Health Meriter,
Madison, WI, USA
| | - Newrhee Kim
- Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA.,Department of Radiology, UnityPoint Health Meriter,
Madison, WI, USA
| | - John K Park
- Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA.,Department of Radiology, UnityPoint Health Meriter,
Madison, WI, USA
| | - Douglas R Kitchin
- Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA.,Madison Radiologists, Madison, WI, USA
| | - Jessica B Robbins
- Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA
| | | | - Jen Birstler
- Department of Biostatistics & Medical Informatics,
University of Wisconsin-Madison, Madison, WI, USA
| | - Michael J Ryan
- BerbeeWalsh Department of Emergency Medicine, University of
Wisconsin-Madison, Madison, WI, USA
| | - Ly Hoang
- BerbeeWalsh Department of Emergency Medicine, University of
Wisconsin-Madison, Madison, WI, USA
| | - Perry Pickhardt
- Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA
| | - Scott B Reeder
- BerbeeWalsh Department of Emergency Medicine, University of
Wisconsin-Madison, Madison, WI, USA.,Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of
Wisconsin-Madison, Madison, WI, USA.,Department of Radiology, University of Wisconsin-Madison,
Madison, WI, USA
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14
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Bom WJ, Scheijmans JCG, Salminen P, Boermeester MA. Diagnosis of Uncomplicated and Complicated Appendicitis in Adults. Scand J Surg 2021; 110:170-179. [PMID: 33851877 PMCID: PMC8258714 DOI: 10.1177/14574969211008330] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Diagnostic work-up of acute appendicitis remains challenging. While some guidelines advise to use a risk stratification based on clinical parameters, others use standard imaging in all patients. As non-operative management of uncomplicated appendicitis has been identified as feasible and safe, differentiation between uncomplicated and complicated appendicitis is of paramount importance. We reviewed the literature to describe the optimal strategy for diagnosis of acute appendicitis. Methods: A narrative review about the diagnosis of acute appendicitis in adult patients was conducted. Both diagnostic strategies and goals were analyzed. Results: For diagnosing acute appendicitis, both ruling in and ruling out the disease are important. Clinical and laboratory findings individually do not suffice, but when combined in a diagnostic score, a better risk prediction can be made for having acute appendicitis. However, for accurate diagnosis imaging seems obligatory in patients suspected for acute appendicitis. Scoring systems combining clinical and imaging features may differentiate between uncomplicated and complicated appendicitis and may enable ruling out complicated appendicitis. Within conservatively treated patients with uncomplicated appendicitis, predictive factors for non-responsiveness to antibiotics and recurrence of appendicitis need to be defined in order to optimize treatment outcomes. Conclusion: Standard imaging increases the diagnostic power for both ruling in and ruling out acute appendicitis. Incorporating imaging features in clinical scoring models may provide better differentiation between uncomplicated and complicated appendicitis. Optimizing patient selection for antibiotic treatment of appendicitis may minimize recurrence rates, resulting in better treatment outcomes.
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Affiliation(s)
- W J Bom
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - J C G Scheijmans
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - P Salminen
- Department of Surgery, University of Turku, Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - M A Boermeester
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
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15
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English W, Habib Bedwani N, Smith C, Doganay E, Marsden M, Muse S, Mak WK, Chana M, Eves J, Shatkar V. Suspected appendicitis and COVID-19, a change in investigation and management-a multicentre cohort study. Langenbecks Arch Surg 2020; 406:357-365. [PMID: 33169297 PMCID: PMC7652586 DOI: 10.1007/s00423-020-02023-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/02/2020] [Indexed: 12/14/2022]
Abstract
Purpose The COVID-19 pandemic has reformed global healthcare delivery. On 25 March 2020, Intercollegiate guidelines were published in the UK to promote safe surgical provision during the COVID-19 outbreak advocating non-operative management or avoidance of laparoscopy when surgery is essential. The effects of this on the investigation and management of appendicitis remain unknown. Methods We performed a multicentre, prospective, observational study from the start of the new guidelines to the 6th of May 2020. We included all patients referred to surgical teams with suspected appendicitis. A recent historical cohort was identified for comparison. The primary outcome was the impact of the COVID-19 pandemic on the use of non-operative management in appendicitis. Secondary outcomes included imaging, negative appendicectomy rate (NAR), length of stay (LOS) and 30-day complications. Results A total of 63/164 (38%) patients compared to 79/191 (41%) were diagnosed with appendicitis before and after the guidelines were introduced (p = 0.589). CT scanning increased (71/164 vs 105/191; p = 0.033) while ultrasound scanning decreased (71/164 vs 62/191; p = 0.037). Appendicitis was more likely to be managed non-operatively (11/63 vs 51/79; p < 0.001) and, of those managed surgically, with an open approach (3/52 vs 26/28 p < 0.001). The NAR also reduced (5/52 vs 0/28; p = 0.157). LOS was shorter in non-operatively managed patients (1 day vs 3 days; p < 0.001) without a difference in complications (10/51 vs 4/28; p = 0.760). Conclusion Introduction of the guidelines was associated with changes in practice. Despite these changes, short-term complications did not increase and LOS decreased. Questions remain on the longer-term complication rates in non-operatively managed patients. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-020-02023-6.
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Affiliation(s)
- W English
- Department of General Surgery, Queens Hospital, BHR NHS Trust, London, UK. .,National Bowel Research Centre, Blizard Institute, QMUL, London, UK.
| | - N Habib Bedwani
- Department of General Surgery, Queens Hospital, BHR NHS Trust, London, UK
| | - C Smith
- Department of General Surgery, Queens Hospital, BHR NHS Trust, London, UK
| | - E Doganay
- Department of General Surgery, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - M Marsden
- Department of General Surgery, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - S Muse
- Department of General Surgery, The Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - W K Mak
- Department of General Surgery, The Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - M Chana
- Department of General Surgery, The Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - J Eves
- Department of General Surgery, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - V Shatkar
- Department of General Surgery, Queens Hospital, BHR NHS Trust, London, UK
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16
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The Accuracy of Low-dose Computed Tomography Protocol in Patients With Suspected Acute Appendicitis: The OPTICAP Study. Ann Surg 2020; 271:332-338. [PMID: 30048324 DOI: 10.1097/sla.0000000000002976] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To compare diagnostic accuracy of contrast enhanced low-dose computed tomography (CT) accomplished in the OPTICAP trial phantom phase to standard CT in patients with suspected acute appendicitis. BACKGROUND Increasing use of CT as the gold standard in diagnosing acute appendicitis has raised concerns regarding radiation exposure. Unenhanced low-dose CT protocols have shown similar diagnostic accuracy with standard CT for diagnosing appendicitis. To our knowledge, there are no other trials in which the same patient with suspected acute appendicitis underwent both standard and low-dose CT allowing interpatient comparison. METHODS OPTICAP is an interpatient protocol sequence randomized noninferiority single-center trial performed at Turku University Hospital between November, 2015 and August, 2016. Sixty patients with suspected acute appendicitis and body mass index <30 kg/m were enrolled to undergo both standard and low-dose contrast enhanced CT scans, which were categorized as normal, uncomplicated or complicated appendicitis by 2 radiologists in blinded manner. All patients with CT confirmed appendicitis underwent appendectomy to obtain histopathology. RESULTS The low-dose protocol was not inferior to standard protocol in terms of diagnostic accuracy; 79% [95% confidence interval (CI) 66%-89%) accurate diagnosis in low-dose and 80% (95% CI 67%-90%) in standard CT by primary radiologist. Accuracy to categorize appendicitis severity was 79% for both protocols. The mean radiation dose of low-dose CT was significantly lower compared with standard CT (3.33 and 4.44 mSv, respectively). CONCLUSION Diagnostic accuracy of contrast enhanced low-dose CT was not inferior to standard CT in diagnosing acute appendicitis or distinguishing between uncomplicated and complicated acute appendicitis in patients with a high likelihood of acute appendicitis. Low-dose CT enabled significant radiation dose reduction.
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17
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Kyaw L, Pereira NK, Ang CX, Choo CSC, Nah SA. Parental preferences in treatment of acute uncomplicated appendicitis comparing surgery to conservative management with antibiotics and their views on research participation. Eur J Pediatr 2020; 179:735-742. [PMID: 31897841 DOI: 10.1007/s00431-019-03555-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 12/12/2019] [Accepted: 12/20/2019] [Indexed: 12/29/2022]
Abstract
Studies show that conservative management in acute uncomplicated appendicitis (AUA) is an alternative to surgery. This study aims to determine factors affecting parental preference in management of AUA and their decision for research participation. We conducted surveys on parents whose children were admitted with suspicion of appendicitis but later confirmed not to have appendicitis. Information on appendicectomy versus conservative treatment with antibiotics was provided using a fixed script and standard information leaflet. Questionnaires covered factors influencing decisions, opinions regarding research, treatment preference and demographic data. We excluded parents not fluent in English. Of 113 respondents, 71(62.8%) chose antibiotics, 39(34.5%) chose appendicectomy, and 3(2.7%) had no preference. Reasons given for choosing antibiotics were fear of surgical risks and preferring less invasive treatment. Those choosing appendicectomy expressed preference for definitive treatment and fear of recurrence. Majority were against randomisation (n = 89, 78.8%) and blinding (n = 90, 79.7%). Over half found difficulty involving their child in research (n = 65, 57.5%). Most thought that research is important (66.4%) and beneficial to others (59.3%). Parents who perceived their child as healthy found research riskier (p = 0.039). Educated parents were more likely to find research beneficial to others (p = 0.012) but less accepting of randomisation (p = 0.001).Conclusion: More parents appear to prefer conservative treatment for acute uncomplicated appendicitis. Researchers must consider parental concerns regarding randomisation and blinding.What is Known:• Conservative management of acute uncomplicated appendicitis in paediatric patients is safe and effective, sparing the child the need for an operation; however, neither conservative nor surgical management is proven to be superior.• Randomised controlled trials provide the highest level of evidence, but it is challenging to recruit paediatric patients as participants in such clinical trials.What is New:• More parents prefer conservative management of uncomplicated appendicitis over surgical management for their children due to fear of surgical risks and complications• Randomisation in trial design is significantly associated with a parent's decision to reject their child's participation in a clinical trial.
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Affiliation(s)
- Lin Kyaw
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Natalie Kate Pereira
- School of Applied Science, Temasek Polytechnic, 21 Tampines Ave 1, Singapore, 529757, Singapore
| | - Chen Xiang Ang
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Candy S C Choo
- Department of Paediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore. .,Division of Surgery, Duke-NUS Medical School, 8 College Rd, Singapore, 169857, Singapore. .,Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603, Malaysia.
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18
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Heye P, Saavedra JSM, Victoria T, Laje P. Accuracy of unenhanced, non-sedated MRI in the diagnosis of acute appendicitis in children. J Pediatr Surg 2020; 55:253-256. [PMID: 31706612 DOI: 10.1016/j.jpedsurg.2019.10.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 10/26/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Children with suspected appendicitis generally undergo an ultrasound (most commonly) or a CT scan (rarely) as the first imaging study. At our hospital, patients with non-diagnostic ultrasound or CT scan results undergo a non-contrast (unenhanced), non-sedated MRI. We aimed to determine the accuracy of this study for this purpose in a large cohort of children. METHODS A retrospective review of all unenhanced, non-sedated MRIs done for suspected appendicitis was performed from January 2014 to December 2018. MRI reports were correlated with pathology reports in cases that underwent appendectomy, and with clinical outcomes if no operation was done (clinical follow up: 30d). No patient was treated for appendicitis non-operatively. RESULTS Three hundred fifty unenhanced, non-sedated MRIs were done and reviewed with median age: 12 (3 to 18) years. Sixty-five (18.6%) MRIs were positive for appendicitis, and 62 of those underwent appendectomy (3 excluded clinically). Pathology was positive in 59/62 cases. 256 (73.1%) MRIs were negative for appendicitis. Six cases underwent appendectomy (persistent symptoms). Pathology was positive in 2/6 cases. The overall diagnostic accuracy was: sensitivity 96.7% (95% CI: 88.6-99.6), specificity 97.7% (95% CI: 95.0-99.1), PPV: 90.8% (95% CI: 81.6-95.6; false positives 6/65), and NPV: 99.2% (95% CI: 97.0-99.8; false negatives 2/254). Twenty-nine (8.3%) MRIs were non-diagnostic. None of those 29 cases had appendicitis (4 negative pathology, 25 excluded clinically). CONCLUSIONS The unenhanced, non-sedated MRI is highly accurate for the diagnosis of appendicitis in children. It should be considered as an alternative to CT in the work-up of patients with suspected appendicitis to eliminate the risks associated with ionizing radiation. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Pascal Heye
- Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Teresa Victoria
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Pablo Laje
- Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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19
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Bhangu A. Evaluation of appendicitis risk prediction models in adults with suspected appendicitis. Br J Surg 2020; 107:73-86. [PMID: 31797357 PMCID: PMC6972511 DOI: 10.1002/bjs.11440] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/12/2019] [Accepted: 10/29/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. METHODS A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16-45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). RESULTS Some 5345 patients across 154 UK hospitals were identified, of which two-thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut-off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut-off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). CONCLUSION Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision-making by identifying adults in the UK at low risk of appendicitis were identified.
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20
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Pedram A, Asadian F, Roshan N. Diagnostic Accuracy of Abdominal Ultrasonography in Pediatric Acute Appendicitis. Bull Emerg Trauma 2019; 7:278-283. [PMID: 31392228 PMCID: PMC6681883 DOI: 10.29252/beat-0703011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 06/06/2019] [Accepted: 06/26/2019] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of ultrasonography in pediatric acute appendicitis. METHODS In this cross-sectional study, 230 children aged 5-15 years with the diagnosis of acute appendicitis were studied. This study included the evaluation of demographic indices, ultrasound findings at diagnosis, and then comparing the results with the description of the patient's procedure and the pathology report of these patients. Patients who did not undergo ultrasound before surgery or their ultrasound did not include the evaluation of appendicitis or their pathologic report was not available were excluded. RESULTS Overall, we have included a total number of 230 children with clinical diagnosis of acute appendicitis among whom there were 121 (52.6%) girls and 109 (47.4%) boys with mean age of 11.44 ± 2.90 years. Preoperative ultrasound report showed that 51.3% were normal and 48.7% had acute appendicitis. 34.8% had normal appendix and 65.2% had a pathological diagnosis of acute appendicitis. The sensitivity and specificity of ultrasound in these children were 58% and 68%, respectively. Positive and negative predictive values were 77% and 46%, respectively. The area under curve (AUC) was 0.853 (CI 95% 0.788-0.917) indicating a test with moderate accuracy. CONCLUSION According to the obtained results, abdominal ultrasonography is of acceptable diagnostic accuracy in pediatric patients with acute appendicitis. The use of auxiliary techniques in ultrasound would increase the sensitivity and specificity in the diagnosis of acute appendicitis in children.
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Affiliation(s)
- Alireza Pedram
- International Branch, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Asadian
- Department of Medical Laboratory Sciences, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Naghmeh Roshan
- Shoashtari Hospital, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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21
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Tseng J, Cohen T, Melo N, Alban RF. Imaging utilization affects negative appendectomy rates in appendicitis: An ACS-NSQIP study. Am J Surg 2019; 217:1094-1098. [DOI: 10.1016/j.amjsurg.2018.12.072] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 10/17/2018] [Accepted: 12/29/2018] [Indexed: 12/29/2022]
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22
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de Burlet KJ, Ing AJ, Larsen PD, Dennett ER. Systematic review of diagnostic pathways for patients presenting with acute abdominal pain. Int J Qual Health Care 2019; 30:678-683. [PMID: 29668935 DOI: 10.1093/intqhc/mzy079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 04/03/2018] [Indexed: 12/12/2022] Open
Abstract
Purpose Abdominal pain is the most common reason for surgical referral. Imaging, aids early diagnosis and treatment. However unnecessary requests are associated with increased costs, radiation exposure and increased length of stay. Pathways can improve the quality of the diagnostic process. The aim of this systematic review was to identify the current evidence for diagnostic pathways and their use of imaging and effect on final outcomes. Data sources A systematic search of Embase, Medline and Cochrane databases was performed using keywords and MeSH terms for abdominal pain. Study selection All papers describing a pathway and published between January 2000 and January 2017 were included. Data extraction Data was obtained about the use of imaging, complications and length of stay. Quality assessment was performed using MINORS and Level of Evidence. Results Ten articles were included, each describing a different pathway. Five studies based the pathway on literature reviews alone and five studies on the results of their prospective study. Of the latter five studies, four showed that routine imaging increased diagnostic accuracy, but without showing a reduction in length of stay, complication rate or mortality. None of the studies included evaluated use of hospital resources or costs. Conclusion Pathways incorporating routine imaging will improve early diagnosis, but has not been proven to reduce complication rates or hospital length of stay. On the basis of this systematic review conclusions can therefore not be drawn about the pathways described and their benefit to the diagnostic process for patients presenting with abdominal pain.
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Affiliation(s)
- Kirsten J de Burlet
- Department of General Surgery, Capital and Coast DHB Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Andrew J Ing
- Department of General Surgery, Capital and Coast DHB Wellington, New Zealand
| | - Peter D Larsen
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Elizabeth R Dennett
- Department of General Surgery, Capital and Coast DHB Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
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Dillman JR, Trout AT. MRI for First-Line Evaluation of Children Suspected of Having Acute Appendicitis. Radiology 2019; 291:178-179. [DOI: 10.1148/radiol.2019190056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jonathan R. Dillman
- From the Department of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; and Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Andrew T. Trout
- From the Department of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; and Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Gómez López JR, Martín Del Olmo JC, Montenegro Martín MA, Concejo Cutoli P, Martín Esteban ML, Toledano Trincado M, López Mestanza IC, Vaquero Puerta C. Laparoscopic Appendectomy in the Setting of Clinical Prediction Rules. J Laparoendosc Adv Surg Tech A 2018; 29:184-191. [PMID: 30585754 DOI: 10.1089/lap.2018.0707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Haijanen J, Sippola S, Grönroos J, Rautio T, Nordström P, Rantanen T, Aarnio M, Ilves I, Hurme S, Marttila H, Virtanen J, Mattila A, Paajanen H, Salminen P. Optimising the antibiotic treatment of uncomplicated acute appendicitis: a protocol for a multicentre randomised clinical trial (APPAC II trial). BMC Surg 2018; 18:117. [PMID: 30558607 PMCID: PMC6296129 DOI: 10.1186/s12893-018-0451-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/28/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Based on epidemiological and clinical data acute appendicitis can present either as uncomplicated (70-80%) or complicated (20-30%) disease. Recent studies have shown that antibiotic therapy is both safe and cost-effective for a CT-scan confirmed uncomplicated acute appendicitis. However, based on the study protocols to ensure patient safety, these randomised studies used mainly broad-spectrum intravenous antibiotics requiring additional hospital resources and prolonged hospital stay. As we now know that antibiotic therapy for uncomplicated acute appendicitis is feasible and safe, further studies evaluating optimisation of the antibiotic treatment regarding both antibiotic spectrum and shorter hospital stay are needed to evaluate antibiotics as the first-line treatment for uncomplicated acute appendicitis. METHODS APPAC II trial is a multicentre, open-label, non-inferiority randomised controlled trial comparing per oral (p.o.) antibiotic monotherapy with intravenous (i.v.) antibiotic therapy followed by p.o. antibiotics in the treatment of CT-scan confirmed uncomplicated acute appendicitis. Adult patients with CT-scan diagnosed uncomplicated acute appendicitis will be enrolled in nine Finnish hospitals. The intended sample size is 552 patients. Primary endpoint is the success of the randomised treatment, defined as resolution of acute appendicitis resulting in discharge from the hospital without the need for surgical intervention and no recurrent appendicitis during one-year follow-up. Secondary endpoints include post-intervention complications, late recurrence of acute appendicitis after one year, duration of hospital stay, pain, quality of life, sick leave and treatment costs. Primary endpoint will be evaluated in two stages: point estimates with 95% confidence interval (CI) will be calculated for both groups and proportion difference between groups with 95% CI will be calculated and evaluated based on 6 percentage point non-inferiority margin. DISCUSSION To our knowledge, APPAC II trial is the first randomised controlled trial comparing per oral antibiotic monotherapy with intravenous antibiotic therapy continued by per oral antibiotics in the treatment of uncomplicated acute appendicitis. The APPAC II trial aims to add clinical evidence on the debated role of antibiotics as the first-line treatment for a CT-confirmed uncomplicated acute appendicitis as well as to optimise the non-operative treatment for uncomplicated acute appendicitis. TRIAL REGISTRATION Clinicaltrials.gov , NCT03236961, retrospectively registered on the 2nd of August 2017.
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Affiliation(s)
- J. Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Kiinanmyllynkatu 4-8, 20520 Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
- Department of Surgery, Satakunta Central Hospital, Pori, Finland
| | - S. Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Kiinanmyllynkatu 4-8, 20520 Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - J. Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Kiinanmyllynkatu 4-8, 20520 Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - T. Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - P. Nordström
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - T. Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - M. Aarnio
- Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - I. Ilves
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - S. Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - H. Marttila
- Department of Hospital Hygiene and Infection Control, Turku University Hospital, Turku, Finland
| | - J. Virtanen
- Department of Radiology, Turku University Hospital, University of Turku, Turku, Finland
| | - A. Mattila
- Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - H. Paajanen
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - P. Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Kiinanmyllynkatu 4-8, 20520 Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
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Sippola S, Grönroos J, Sallinen V, Rautio T, Nordström P, Rantanen T, Hurme S, Leppäniemi A, Meriläinen S, Laukkarinen J, Savolainen H, Virtanen J, Salminen P. A randomised placebo-controlled double-blind multicentre trial comparing antibiotic therapy with placebo in the treatment of uncomplicated acute appendicitis: APPAC III trial study protocol. BMJ Open 2018; 8:e023623. [PMID: 30391919 PMCID: PMC6231590 DOI: 10.1136/bmjopen-2018-023623] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 08/19/2018] [Accepted: 09/04/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Recent studies show that antibiotic therapy is safe and feasible for CT-confirmed uncomplicated acute appendicitis. Spontaneous resolution of acute appendicitis has already been observed over a hundred years ago. In CT-confirmed uncomplicated acute diverticulitis (left-sided appendicitis), studies have shown no benefit from antibiotics compared with symptomatic treatment, but this shift from antibiotics to symptomatic treatment has not yet been widely implemented in clinical practice. Recently, symptomatic treatment of uncomplicated acute appendicitis has been demonstrated in a Korean open-label study. However, a double-blinded placebo-controlled study to illustrate the role of antibiotics and spontaneous resolution of uncomplicated acute appendicitis is still lacking. METHODS AND ANALYSIS The APPAC III (APPendicitis ACuta III) trial is a multicentre, double-blind, placebo-controlled, superiority randomised study comparing antibiotic therapy with placebo in the treatment CT scan-confirmed uncomplicated acute appendicitis aiming to evaluate the role of antibiotics in the resolution of uncomplicated acute appendicitis. Adult patients (18-60 years) with CT scan-confirmed uncomplicated acute appendicitis (the absence of appendicolith, abscess, perforation and tumour) will be enrolled in five Finnish university hospitals.Primary endpoint is success of the randomised treatment, defined as resolution of acute appendicitis resulting in discharge from the hospital without surgical intervention within 10 days after initiating randomised treatment (treatment efficacy). Secondary endpoints include postintervention complications, recurrent symptoms after treatment up to 1 year, late recurrence of acute appendicitis after 1 year, duration of hospital stay, sick leave, treatment costs and quality of life. A decrease of 15 percentage points in success rate is considered clinically important difference. The superiority of antibiotic treatment compared with placebo will be analysed using Fisher's one-sided test and CI will be calculated for proportion difference. ETHICS AND DISSEMINATION This protocol has been approved by the Ethics Committee of Turku University Hospital and the Finnish Medicines Agency (FIMEA). The findings will be disseminated in peer-reviewed academic journals. TRIAL REGISTRATION NUMBER NCT03234296; Pre-results.
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Affiliation(s)
- Suvi Sippola
- Division of Digestive Surgery and
Urology, Turku University Hospital, Turku, Finland
- Department of Surgery,
University of Turku, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and
Urology, Turku University Hospital, Turku, Finland
- Department of Surgery,
University of Turku, Turku, Finland
| | - Ville Sallinen
- Department of Surgery,
Helsinki University Central Hospital, Helsinki, Finland
| | - Tero Rautio
- Department of Surgery,
Oulu University Hospital, Oulu, Finland
| | - Pia Nordström
- Division of Surgery, Gastroenterology and
Oncology, Tampere University Hospital, Tampere, Finland
| | - Tuomo Rantanen
- Department of Surgery,
Kuopio University Hospital, Kuopio, Finland
| | - Saija Hurme
- Department of Biostatistics,
University of Turku, Turku, Finland
| | - Ari Leppäniemi
- Department of Surgery,
Helsinki University Central Hospital, Helsinki, Finland
| | | | - Johanna Laukkarinen
- Division of Surgery, Gastroenterology and
Oncology, Tampere University Hospital, Tampere, Finland
| | - Heini Savolainen
- Department of Surgery,
Kuopio University Hospital, Kuopio, Finland
| | - Johanna Virtanen
- Department of Radiology,
Turku University Hospital, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and
Urology, Turku University Hospital, Turku, Finland
- Department of Surgery,
University of Turku, Turku, Finland
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de Castro SMM, Geerdink TH, Macco S, van Veen RN, Jensch S, Vrouenraets BC. Mandatory imaging in the work-up of children suspected of having appendicitis reduces the rate of unnecessary surgeries. J Pediatr Surg 2018. [PMID: 29540260 DOI: 10.1016/j.jpedsurg.2018.02.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE In children, the diagnosis “acute appendicitis” is difficult. In 2010, a new Dutch appendicitis guideline was published with the goal to reduce the negative appendectomy rate. The guideline recommended mandatory imaging (ultrasound first and CT or MRI when inconclusive) before surgery. This study examines whether the negative appendectomy rate in children has declined after the implementation of the guideline and if the number of ionising imaging procedures increased. METHODS In this cohort study, all consecutive patients aged 17 or younger, with the suspicion of appendicitis were included. Patients were divided into two groups. Those who presented between 2006 and 2010 (before the implementation) and those between 2011 and 2016 (after implementation). RESULTS In total, 748 children were enrolled, of which 363 children were seen before and 385 children after implementation of the guideline. Before implementation, 46% of the children with acute appendicitis underwent preoperative ultrasound compared with 95% in the post implementation group, p < 0.001. Any imaging was performed in 51% and 100%, respectively, p < 0.001. The percentage of negative appendectomy before implementation was 13% and 2.7% after implementation, p < 0.001. There was no significant increase in the number of CT scans before and after the implementation of the guideline, 3.6% versus 6.0%, respectively, p = 0.126. There was no increase in direct medical costs. CONCLUSIONS Mandatory preoperative imaging in children with the suspicion of acute appendicitis results in a significant decrease in negative appendectomies with no increase in the number of CT scans and without a substantial increase in costs.
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Affiliation(s)
| | | | - Sven Macco
- Department of Surgery, OLVG, Amsterdam, The Netherlands
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Imaging in pediatric appendicitis is key to a low normal appendix percentage: a national audit on the outcome of appendectomy for appendicitis in children. Pediatr Surg Int 2018; 34. [PMID: 29523946 PMCID: PMC5899113 DOI: 10.1007/s00383-018-4244-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE A laparoscopic approach for emergency appendectomy is increasingly used, in pediatric patients as well. The objective of this study is to audit the current state of diagnostic work-up, surgical techniques and its outcome in children with acute appendicitis. METHODS A prospective consecutive observational cohort study was carried out in a 2-month study period. All patients under 18 years that were operated for suspected acute appendicitis were included. Primary outcome was the infectious complication rate after open and laparoscopic approach; secondary outcomes were preoperative use of imaging and post-operative predictive value of imaging, normal appendix rate and children with a postoperative ileus. RESULTS A total of 541 children were operated for suspected acute appendicitis in 62 Dutch hospitals. Preoperative imaging was used in 98.9% of children. The normal appendix rate was 3.1%. In 523 children an appendectomy was performed. Laparoscopy was used in 61% of the patients and conversion rate was 1.7%. Complicated appendicitis was diagnosed in 29.4% of children. Overall 30-day complication rate was 11.9% and similar after open and laparoscopic. No difference was found in superficial surgical site infections, nor in intra-abdominal abscesses between the open and laparoscopic approach. Complicated appendicitis is an independent risk factor for infectious complications. CONCLUSION The laparoscopic approach is most frequently used, except for young children. Superficial surgical site infections are more frequent after open surgery only in patients with complicated appendicitis. The normal appendix rate is low, most likely because of routine preoperative imaging.
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Er S, Çomçalı B, Soykurt A, Cavit Yüksel B, Tez M. Diagnosis of Appendicitis in Patients with a Normal White Blood Cell Count; A Cross-Sectional Study. Bull Emerg Trauma 2018; 6:128-132. [PMID: 29719843 DOI: 10.29252/beat-060207] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Objective To investigate the clinical, imaging and laboratory findings for diagnosis of acute appendicitis (AA) in patients with a normal white blood cell count (WBCC). Methods This retrospective cross-sectional study was conducted in Ankara Numune Training and Research Hospital, Ankara, Turkey, during a 1-year period. To determine diagnostic factors in AA in patients with normal WBCC, medical records of eligible patients were reviewed for demographic and clinical variables, as well as patient outcome. Results A total of 105 patients that had undergone appendectomy and were found to have a normal WBCC were included in the study. Of these patients, 53 (50.5%) were men and 52 (49.5%) were women. The mean age of the patients was 34.2±12.3 (min 14, max 78). The negative exploration rate was identified as 19%. In the multivariate analysis, only the diameter of appendix was statistically significant (p=0.002). ROC analysis revealed the cut off appendiceal diameter as 8 mm. Conclusion In patients suspected of AA due to ≥8 mm appendiceal diameter determined by imaging, we recommend surgical treatment even if WBCC and neutrophil count are normal.
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Affiliation(s)
- Sadettin Er
- Department of Surgery, Ankara Numune Training and Research Hospital, Department of Surgery, Ankara, Turkey
| | - Bülent Çomçalı
- Department of Surgery, Ankara Numune Training and Research Hospital, Department of Surgery, Ankara, Turkey
| | - Ahmet Soykurt
- Department of Surgery, Ankara Numune Training and Research Hospital, Department of Surgery, Ankara, Turkey
| | - Bülent Cavit Yüksel
- Department of Surgery, Ankara Numune Training and Research Hospital, Department of Surgery, Ankara, Turkey
| | - Mesut Tez
- Department of Surgery, Ankara Numune Training and Research Hospital, Department of Surgery, Ankara, Turkey
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Niiniviita H, Salminen P, Grönroos JM, Rinta-Kiikka I, Hurme S, Kiljunen T, Kulmala J, Teräs M, Sippola S, Virtanen J. LOW-DOSE CT PROTOCOL OPTIMIZATION FOR THE ASSESSMENT OF ACUTE APPENDICITIS: THE OPTICAP PHANTOM STUDY. RADIATION PROTECTION DOSIMETRY 2018; 178:20-28. [PMID: 28591824 DOI: 10.1093/rpd/ncx070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/15/2017] [Indexed: 06/07/2023]
Abstract
UNLABELLED The aim was to evaluate effects of voltage, noise input (NI) and iterative reconstruction (IR) on radiation dose and image quality in order to establish a contrast enhanced low-dose protocol for assessment of acute appendicitis. An anthropomorphic abdominal phantom mimicking contrast enhanced abdomen was scanned with 80, 100 and 120 kV, standard and strong IR and 11 NIs (66 protocols). A total of 14 test tubes of increasing iodine dilutions and one tube with an appendicolith were evaluated within the phantom. The dose, HUs, noise, contrast-to-noise ratio (CNR) and figure of merit (FOM) were determined. Visual quality scores were assessed by two readers. A clinically used voltage-IR combination (120 kV, standard IR) was used as a reference. Overall, 100 kV with standard IR (p = 0.002) and 80 kV with both IRs (p < 0.001) showed higher CNR than the reference, but noise was most pronounced at 80 kV (p < 0.001). The highest FOM was found in the 100 kV protocols (p < 0.001). The reference and 100 kV with standard IR had highest image quality scores, where the 100 kV protocol enabled a distinct dose reduction. Lowering the voltage seems to be a more favorable tool than IR changes in optimizing the dose in contrast enhanced abdominal CT. TRIAL REGISTRATION ClinicalTrials.gov number, NCT01022567.
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Affiliation(s)
- Hannele Niiniviita
- Department of Medical Physics, Turku University Hospital and University of Turku, Kiinamyllynkatu 4-8, FI-20520 Turku, Finland
- Department of Radiology, Medical Imaging Center of Southwest Finland, Turku University Hospital, Kiinamyllynkatu 4-8, FI-20520 Turku, Finland
| | - Paulina Salminen
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinamyllynkatu 4-8, FI-20520 Turku, Finland
| | - Juha M Grönroos
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinamyllynkatu 4-8, FI-20520 Turku, Finland
| | - Irina Rinta-Kiikka
- Department of Radiology, Tampere University Hospital, Teiskontie 35, FI-33521 Tampere, Finland
| | - Saija Hurme
- Department of Biostatistics, University of Turku, Lemminkäisenkatu 1, FI-20520 Turku, Finland
| | - Timo Kiljunen
- Docrates Cancer Center, Saukonpaadenranta 2, FI-00180 Helsinki, Finland
| | - Jarmo Kulmala
- Department of Medical Physics, Turku University Hospital and University of Turku, Kiinamyllynkatu 4-8, FI-20520 Turku, Finland
| | - Mika Teräs
- Department of Medical Physics, Turku University Hospital and University of Turku, Kiinamyllynkatu 4-8, FI-20520 Turku, Finland
| | - Suvi Sippola
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinamyllynkatu 4-8, FI-20520 Turku, Finland
| | - Johanna Virtanen
- Department of Radiology, Medical Imaging Center of Southwest Finland, Turku University Hospital, Kiinamyllynkatu 4-8, FI-20520 Turku, Finland
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Mannil M, Polysopoulos C, Weishaupt D, Hansmann A. Clinical-radiological scoring system for enhanced diagnosis of acute appendicitis. Eur J Radiol 2018; 98:174-178. [DOI: 10.1016/j.ejrad.2017.11.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/23/2017] [Accepted: 11/27/2017] [Indexed: 10/18/2022]
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Anderson KT, Bartz-Kurycki M, Austin MT, Kawaguchi A, John SD, Kao LS, Tsao K. Approaching zero: Implications of a computed tomography reduction program for pediatric appendicitis evaluation. J Pediatr Surg 2017; 52:1909-1915. [PMID: 28927978 DOI: 10.1016/j.jpedsurg.2017.08.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/28/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE Because of awareness of iatrogenic radiation exposure, there is a national trend of diminishing computed tomography (CT) use for pediatric suspected appendicitis. The purpose of this study was to evaluate the effects of a CT reduction program for evaluation of appendicitis. METHODS A multidisciplinary group (emergency medicine, radiology, and surgery) at a children's hospital developed a reduction program which included: ultrasound (U/S) first (2012), magnetic resonance imaging (MRI) second (2014), and standardized U/S reports (2016). Imaging modality, negative appendectomy rate, time from first image to incision, and imaging costs were evaluated over time. RESULTS Of the 571 patients evaluated from 2012 to 2016, there was a significant decrease in CT use and increase U/S and MRI use over the study period (all p<0.01). CT use approached zero in 2016. Time from first image to incision (median 10.7h, IQR 5.6-15.5) and negative appendectomy rate (mean 3.7±0.2%) did not change. Median imaging costs ($88, IQR $52-$169) and radiology percent of total costs (range 0.8%-3.9%) increased over time (both p<0.01). CONCLUSION Approaching zero CT use for evaluation of pediatric appendicitis is possible through a multidisciplinary protocol without impacting clinical outcomes. However, increased MRI use led to higher costs. Cost-effectiveness of replacing CT with MRI warrants further study. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- K Tinsley Anderson
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Marisa Bartz-Kurycki
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Mary T Austin
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Akemi Kawaguchi
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Susan D John
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Lillian S Kao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - KuoJen Tsao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States.
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Acute appendicitis: implementing low-dose CT in clinical practice. Lancet Gastroenterol Hepatol 2017; 2:769-771. [DOI: 10.1016/s2468-1253(17)30282-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 09/04/2017] [Indexed: 11/17/2022]
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de Burlet KJ, Crane G, Cullinane R, Larsen PD, Dennett ER. Review of appendicectomies over a decade in a tertiary hospital in New Zealand. ANZ J Surg 2017; 88:1253-1257. [PMID: 28994178 DOI: 10.1111/ans.14203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 07/23/2017] [Accepted: 07/26/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute appendicectomy is the most common emergency operation for patients with abdominal pain. In the last decade, computed tomography (CT) scans have increasingly been used to aid in the diagnosis in order to reduce the negative appendicectomy rate. The aim of this study was to evaluate our institution's negative appendicectomy rate and the use of pre-operative imaging. METHODS A retrospective review was undertaken for all adult patients (>16 years), who underwent an appendicectomy on emergency basis in the years 2004, 2009 and 2014. Cases were identified from the hospital electronic theatre record system. Data were also obtained from the patients records and laboratory reports. RESULTS A total of 874 patients were included, 227 in 2004, 308 in 2009 and 339 in 2014. The negative appendicectomy rate was 29.1% in 2004, 20.1% in 2009 and 19.5% in 2014 (P = 0.014). Negative appendicectomies were more common in women (P = <0.001), patients between the ages of 16-30 years (P = <0.001) and were associated with low inflammatory markers (median white cell count of 10.2, C-reactive protein of 8, P = <0.001). The use of CT scan prior to operation increased between 2009 and 2014 (34 (11.0%) versus 64 (18.9%), P = <0.001). CONCLUSION Though the number of appendicectomies being performed in our institution has increased over the last decade, the negative appendicectomy rate remains fairly static and the increased use of CT scans did not further decrease the proportion of negative appendicectomies between 2009 and 2014.
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Affiliation(s)
- Kirsten J de Burlet
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Grant Crane
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Ruth Cullinane
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Peter D Larsen
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Elizabeth R Dennett
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
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Lietzén E, Salminen P, Rinta-Kiikka I, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Sand J, Mecklin JP, Jartti A, Virtanen J, Ohtonen P, Ånäs N, Grönroos JM. The Accuracy of the Computed Tomography Diagnosis of Acute Appendicitis: Does the Experience of the Radiologist Matter? Scand J Surg 2017; 107:43-47. [DOI: 10.1177/1457496917731189] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- E. Lietzén
- Division of Digestive Surgery and Urology, Department of Acute and Digestive Surgery, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - P. Salminen
- Division of Digestive Surgery and Urology, Department of Acute and Digestive Surgery, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - I. Rinta-Kiikka
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - H. Paajanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - T. Rautio
- Department of Surgery, Division of Gastroenterology, Oulu University Hospital, Oulu, Finland
- Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - P. Nordström
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - M. Aarnio
- Department of Surgery, Jyväskylä Central Hospital and University of Eastern Finland, Jyväskylä, Finland
| | - T. Rantanen
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - J. Sand
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - J.-P. Mecklin
- Department of Surgery, Jyväskylä Central Hospital and University of Eastern Finland, Jyväskylä, Finland
| | - A. Jartti
- Department of Radiology, Oulu University Hospital, Oulu, Finland
| | - J. Virtanen
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - P. Ohtonen
- Medical Research Center Oulu, University of Oulu, Oulu, Finland
- Division of Operative Care, Oulu University Hospital, Oulu, Finland
| | - N. Ånäs
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - J. M. Grönroos
- Division of Digestive Surgery and Urology, Department of Acute and Digestive Surgery, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
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36
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Sammalkorpi HE, Mentula P, Savolainen H, Leppäniemi A. The Introduction of Adult Appendicitis Score Reduced Negative Appendectomy Rate. Scand J Surg 2017; 106:196-201. [PMID: 28737110 DOI: 10.1177/1457496916683099] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Implementation of a clinical risk score into diagnostics of acute appendicitis may provide accurate diagnosis with selective use of imaging studies. The aim of this study was to prospectively validate recently described diagnostic scoring system, Adult Appendicitis Score, and evaluate its effects on negative appendectomy rate. MATERIAL AND METHODS Adult Appendicitis Score stratifies patients into three groups: high, intermediate, and low risk of appendicitis. The score was implemented in diagnostics of adult patients suspected of acute appendicitis in two university hospitals. We analyzed the effects of Adult Appendicitis Score on diagnostic accuracy, imaging studies, and treatment. The study population was compared with a reference population of 829 patients suspected of acute appendicitis originally enrolled for the study of construction of the Adult Appendicitis Score. RESULTS This study enrolled 908 patients of whom 432 (48%) had appendicitis. The score stratified 49% of all appendicitis patients into high-risk group with specificity of 93.3%. In the low-risk group, prevalence of appendicitis was 7%. The histologically confirmed negative appendectomy rate decreased from 18.2% to 8.7%, p<0.001, compared to the original dataset. CONCLUSION Adult Appendicitis Score is a reliable tool for stratification of patients into selective imaging, which results in low negative appendectomy rate.
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Affiliation(s)
- H E Sammalkorpi
- 1 Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland.,2 Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - P Mentula
- 1 Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - H Savolainen
- 3 Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - A Leppäniemi
- 1 Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
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37
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Sammalkorpi HE, Leppäniemi A, Lantto E, Mentula P. Performance of imaging studies in patients with suspected appendicitis after stratification with adult appendicitis score. World J Emerg Surg 2017; 12:6. [PMID: 28163774 PMCID: PMC5282904 DOI: 10.1186/s13017-017-0119-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 01/25/2017] [Indexed: 12/29/2022] Open
Abstract
Background Diagnostic scoring is used to stratify patients with suspected appendicitis into three groups: high, intermediate, and low probability of appendicitis. The stratification can be used for selective imaging to avoid the harms of radiation without compromising diagnostic accuracy. The aim was to study how stratification by Adult Appendicitis Score affects diagnostic performance of imaging studies. Methods Analysis of 822 patients who underwent diagnostic imaging for suspected appendicitis was made. Adult Appendicitis Score was used to stratify patients into groups of high, intermediate, and low probability of appendicitis. Diagnostic performance of computed tomography (CT) and ultrasound (US) was compared between these patient groups. Results After scoring, pre-test probability of appendicitis ranged from 9-16% in low probability group to 75-79% in high probability group in patients who underwent US or CT. Post-test probability of appendicitis after positive CT was 99, 91, and 75% in high probability, intermediate probability and low probability groups, respectively, p < 0.001. After positive US the respective probabilities were 95, 91 and 42%, p < 0.001. Conclusion Diagnostic imaging has limited value in patients with low probability of appendicitis according to Adult Appendicitis Score.
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Affiliation(s)
- Henna E Sammalkorpi
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland.,University of Helsinki, Medical Faculty, Helsinki, Finland
| | - Ari Leppäniemi
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Eila Lantto
- Department of Radiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Panu Mentula
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
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38
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Ahmed O, Rogers AC, Balfe P, Waldron BM, Pretorius F, McMonagle MP. Clinical utility of abdominal and pelvic ultrasound in the evaluation of right iliac fossa pain in females. Ir J Med Sci 2017; 186:775-779. [PMID: 28130666 DOI: 10.1007/s11845-017-1557-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/11/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Ultrasound (US) is often the imaging modality of choice in women with acute right iliac fossa (RIF) pain, identifying the appendix in up to 99% of patients. The literature, however, lacks clear guidelines on how ultrasonography should be performed to maximise sensitivity and specificity in such patients. Many centres perform untargeted abdomino-pelvic scans, including organs such as the liver and spleen, which unlikely contribute to the presenting complaint. AIMS We aimed to evaluate the clinical utility of unfocussed abdominal and pelvic US in women of reproductive age with acute RIF pain. METHODS This multicentre study describes 501 women between the ages of 12 and 50, over a 3-year period from three institutions, presenting acutely with RIF pain and investigated with US abdomen and pelvis. RESULTS 5.9% of cases confirmed appendicitis sonographically. A normal appendix was visualised in 0.2%. Over 10% identified gynaecological pathology, 41% relating to the right ovary. 10.4% incidental extra-pelvic findings were unrelated to the acute clinical presentation. 0.8% of patients had extra-pelvic findings meriting further clinical assessment. CONCLUSION The results herein reflect findings from high volume emergency surgical departments, demonstrating that unfocussed abdominal and pelvic ultrasounds are not an appropriate use of resources in reproductive women with RIF pain. Clinically relevant extra-pelvic US findings account for less than 1%, rarely contributing to the acute presentation. The appendix was only visualised in 6% of patients, suggesting that a focussed appendiceal and pelvic US would better assist diagnosis with a higher yield and increased sensitivity and specificity.
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Affiliation(s)
- O Ahmed
- Department of General Surgery, University Hospital Kerry, Tralee, County Kerry, Republic of Ireland.
| | - A C Rogers
- Department of General Surgery, University Hospital Kerry, Tralee, County Kerry, Republic of Ireland.,Department of General Surgery, University Hospital Waterford, Waterford, Republic of Ireland.,Department of General Surgery, St Luke's Hospital Kilkenny, Kilkenny, Republic of Ireland
| | - P Balfe
- Department of General Surgery, St Luke's Hospital Kilkenny, Kilkenny, Republic of Ireland
| | - B M Waldron
- Department of General Surgery, University Hospital Kerry, Tralee, County Kerry, Republic of Ireland
| | - F Pretorius
- Department of General Surgery, St Luke's Hospital Kilkenny, Kilkenny, Republic of Ireland
| | - M P McMonagle
- Department of General Surgery, University Hospital Waterford, Waterford, Republic of Ireland
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T1 bright appendix sign to exclude acute appendicitis in pregnant women. Eur Radiol 2017; 27:3310-3316. [PMID: 28097379 DOI: 10.1007/s00330-016-4727-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 12/05/2016] [Accepted: 12/22/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the diagnostic value of the T1 bright appendix sign for the diagnosis of acute appendicitis in pregnant women. MATERIAL AND METHODS This retrospective study included 125 pregnant women with suspected appendicitis who underwent magnetic resonance (MR) imaging. The T1 bright appendix sign was defined as a high intensity signal filling more than half length of the appendix on T1-weighted imaging. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the T1 bright appendix sign for normal appendix identification were calculated in all patients and in those with borderline-sized appendices (6-7 mm). RESULTS The T1 bright appendix sign was seen in 51% of patients with normal appendices, but only in 4.5% of patients with acute appendicitis. The overall sensitivity, specificity, PPV, and NPV of the T1 bright appendix sign for normal appendix diagnosis were 44.9%, 95.5%, 97.6%, and 30.0%, respectively. All four patients with borderline sized appendix with appendicitis showed negative T1 bright appendix sign. CONCLUSION The T1 bright appendix sign is a specific finding for the diagnosis of a normal appendix in pregnant women with suspected acute appendicitis. KEY POINTS • Magnetic resonance imaging is increasingly used in emergency settings. • Acute appendicitis is the most common cause of acute abdomen. • Magnetic resonance imaging is widely used in pregnant population. • T1 bright appendix sign can be a specific sign representing normal appendix.
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40
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Lamberts RW, Conti SL, Leppert JT, Elliott CS. Defining the Rate of Negative Ureteroscopy in the General Population Treated for Upper Tract Urinary Stone Disease. J Endourol 2017; 31:266-271. [PMID: 28049343 DOI: 10.1089/end.2016.0751] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Ureteroscopy is increasingly used to treat upper tract urinary stone disease. A negative ureteroscopy is a ureteroscopy performed with the intent of removing a kidney or ureteral stone, but in which ultimately no stone is removed. Negative ureteroscopy may occur when the stone is found to have already passed, or the presumed stone is found to be outside of the collecting system. We sought to determine the rate of negative ureteroscopy in a large population-based sample as well as factors associated with its use. PATIENTS AND METHODS We examined nonpublic data from the Office of Statewide Health Planning and Development (OSHPD) Database for all patients in California undergoing outpatient surgery from 2010 to 2012. We identified all patients with an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code for upper tract urinary stone disease, who underwent a ureteroscopic procedure. After excluding patients undergoing second look procedures or who had diagnosis codes for separate urologic pathology, the negative ureteroscopy rate was defined as the proportion of those ureteroscopy cases coded as a diagnostic ureteroscopy. We fit logistic regression models to evaluate patient factors associated with negative ureteroscopy. RESULTS During the years 2010 to 2012, 20,236 eligible patients underwent ureteroscopic procedures for upper tract stone disease. Of these, 1287 patients underwent diagnostic ureteroscopy and 19,039 underwent ureteroscopy with stone removal accounting for a negative ureteroscopy rate of 6.3%. The odds of receipt of a negative ureteroscopy rate were higher in females compared to males (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.25, 1.58) and lower in self-pay patients compared with insured patients (OR = 0.55, 95% CI 0.33, 0.91). CONCLUSIONS Negative ureteroscopy is common, occurring in nearly 1 in 16 procedures to treat urinary stone disease.
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Affiliation(s)
- Remy W Lamberts
- 1 Department of Urology, Stanford University School of Medicine , Stanford, California
| | - Simon L Conti
- 1 Department of Urology, Stanford University School of Medicine , Stanford, California.,2 Division of Urology, Veterans Affairs Palo Alto Health Care System , Palo Alto, California
| | - John T Leppert
- 1 Department of Urology, Stanford University School of Medicine , Stanford, California.,2 Division of Urology, Veterans Affairs Palo Alto Health Care System , Palo Alto, California
| | - Christopher S Elliott
- 1 Department of Urology, Stanford University School of Medicine , Stanford, California.,3 Division of Urology, Santa Clara Valley Medical Center , San Jose, California
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Lietzén E, Ilves I, Salminen P, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Kauko T, Jartti A, Sand J, Mecklin JP, Grönroos JM. Clinical and laboratory findings in the diagnosis of right lower quadrant abdominal pain: outcome analysis of the APPAC trial. Clin Chem Lab Med 2016; 54:1691-1697. [PMID: 27010776 DOI: 10.1515/cclm-2015-0981] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 02/15/2016] [Indexed: 10/03/2023]
Abstract
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.
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Al-Faouri AF, Ajarma KY, Al-Abbadi AM, Al-Omari AH, Almunaizel TS, Alzu'bi AA, Al-Jarrah RY, Abo-Zaiton OY. The Alvarado score versus computed tomography in the diagnosis of acute appendicitis: A prospective study. Med J Armed Forces India 2016; 72:332-337. [PMID: 27843179 DOI: 10.1016/j.mjafi.2016.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/21/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND To assess and compare performance of the Alvarado score and computed tomography scan in the diagnosis of acute appendicitis at King Hussein Medical Center. METHODS A total of 320 patients with suspected acute appendicitis were included in this study over a period of 2 years. The Alvarado score was calculated for all of these patients and 112 CT scans were requested selectively by surgeons caring for the patients. The histopathology diagnosis was used as the gold standard against which diagnostic performance of Alvarado score and CT scan were compared. RESULTS The complete data of 196 males and 124 females were analyzed at the end of the study period. The mean age was 26.1 ± 11.3 years. Appendectomy was performed in 263 patients with a negative appendectomy rate of 14.83% overall (12.28 in males and 19.56 in females). The remaining 57 patients were assumed to have no appendicitis. The diagnostic performance of CT scan was superior to that of Alvarado score with sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 94.2 versus 85.4%, 90 versus 65%, 9.42 versus 2.44, and 0.065 versus 0.224, respectively (p-value < 0.05). The overall diagnostic accuracy of CT scan was 92.6% compared to 77.5% for Alvarado score. CONCLUSION The Alvarado score was far from good and CT scan is more accurate in diagnosis of acute appendicitis in our patient population.
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Affiliation(s)
- Ashraf F Al-Faouri
- Senior Specialist, Department of Surgery, King Hussein Medical Center, Amman 11831, Jordan
| | - Khaled Y Ajarma
- Consultant, Department of Surgery, King Hussein Medical Center, Amman 11831, Jordan
| | | | - Abdullah H Al-Omari
- Consultant, Department of Radiology, King Hussein Medical Center, Amman 11831, Jordan
| | - Tariq S Almunaizel
- Specialist, Department of Surgery, King Hussein Medical Center, Amman 11831, Jordan
| | - Alaa A Alzu'bi
- Specialist, Department of Surgery, King Hussein Medical Center, Amman 11831, Jordan
| | - Ra'ed Y Al-Jarrah
- Specialist, Department of Surgery, King Hussein Medical Center, Amman 11831, Jordan
| | - Omar Y Abo-Zaiton
- Specialist, Department of Surgery, King Hussein Medical Center, Amman 11831, Jordan
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Lietzén E, Mällinen J, Grönroos JM, Rautio T, Paajanen H, Nordström P, Aarnio M, Rantanen T, Sand J, Mecklin JP, Jartti A, Virtanen J, Ohtonen P, Salminen P. Is preoperative distinction between complicated and uncomplicated acute appendicitis feasible without imaging? Surgery 2016; 160:789-95. [PMID: 27267549 DOI: 10.1016/j.surg.2016.04.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 04/14/2016] [Accepted: 04/20/2016] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Elina Lietzén
- Division of Digestive Surgery and Urology, Department of Acute and Digestive Surgery, Turku University Hospital, Turku, Finland; Department of Surgery, University of Turku, Turku, Finland.
| | - Jari Mällinen
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Juha M Grönroos
- Division of Digestive Surgery and Urology, Department of Acute and Digestive Surgery, Turku University Hospital, Turku, Finland; Department of Surgery, University of Turku, Turku, Finland
| | - Tero Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Hannu Paajanen
- Department of Surgery, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Pia Nordström
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - Markku Aarnio
- Department of Surgery, Jyväskylä Central Hospital and University of Eastern Finland, Jyväskylä, Finland
| | - Tuomo Rantanen
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Juhani Sand
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - Jukka-Pekka Mecklin
- Department of Surgery, Jyväskylä Central Hospital and University of Eastern Finland, Jyväskylä, Finland
| | - Airi Jartti
- Department of Radiology, Oulu University Hospital, Oulu, Finland
| | - Johanna Virtanen
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Pasi Ohtonen
- Division of Operative Care and Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Department of Acute and Digestive Surgery, Turku University Hospital, Turku, Finland; Department of Surgery, University of Turku, Turku, Finland
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44
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Sauvain MO, Slankamenac K, Muller MK, Wildi S, Metzger U, Schmid W, Wydler J, Clavien PA, Hahnloser D. Delaying surgery to perform CT scans for suspected appendicitis decreases the rate of negative appendectomies without increasing the rate of perforation nor postoperative complications. Langenbecks Arch Surg 2016; 401:643-9. [PMID: 27146319 DOI: 10.1007/s00423-016-1444-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/27/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE Negative appendectomies are costly and are embedded with unnecessary risks for the patients. A careful indication for surgery seems mandatory even more so, since conservative therapy emerges as a potential alternative to surgery. The aims of this population-based study were to analyze whether radiological examinations for suspected appendicitis decreased the rate of negative appendectomies without increasing the rate of perforation or worsening postoperative outcomes. METHOD This study is a retrospective analysis of a prospective population-based database. The data collection included preoperative investigations and intraoperative and postoperative outcomes. RESULTS Based on 2559 patients, the rate of negative appendectomies decreased significantly with the use of CT scan as compared to clinical evaluation only (9.3 vs 5 %, p = 0.019), whereas ultrasonography alone was not able to decrease this rate (9.3 vs 6.2 %, p = 0.074). Delaying surgery for radiological investigation did not increase the rate of perforation (18.1 vs 19.2 %; adjusted odds ratio (OR) 1.01; 0.8-1.3; p = 0.899). Postoperative complications (surgical reintervention, postoperative wound infection, postoperative hematoma, postoperative intra-abdominal abscess, postoperative ileus) were all comparable. CONCLUSION In this population-based study, CT scan was the only radiological modality that significantly reduced the rate of negative appendectomy. The delay induced by such additional imaging did not increase perforation nor complication rates. Abdominal CT scans for suspected appendicitis should therefore be more frequently used if clinical findings are unconclusive.
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Affiliation(s)
- M-O Sauvain
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland.,Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, Lausanne, 1011, Switzerland
| | - K Slankamenac
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland
| | - M K Muller
- Cantonal Hospital Frauenfeld, Frauenfeld, Switzerland
| | - S Wildi
- Department of Surgery, Waid Hospital, Zürich, Switzerland
| | - U Metzger
- Department of Surgery Triemli Hospital, Zürich, Switzerland
| | - W Schmid
- Hospital Zollikerberg, Zürich, Switzerland
| | - J Wydler
- Hospital Männedorf, Zürich, Switzerland
| | - P-A Clavien
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland
| | - D Hahnloser
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland. .,Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, Lausanne, 1011, Switzerland.
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45
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Debnath J, George RA, Ravikumar R. Imaging in acute appendicitis: What, when, and why? Med J Armed Forces India 2016; 73:74-79. [PMID: 28123249 DOI: 10.1016/j.mjafi.2016.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 02/18/2016] [Indexed: 02/07/2023] Open
Abstract
Acute appendicitis (AA) is the commonest cause of pain abdomen requiring surgical intervention. Diagnosis as well as management of acute appendicitis is mired in controversies and contradictions even today. Clinicians often face the dilemma of balancing negative appendectomy rate and perforation rate if the diagnosis is based on clinical scoring alone. Laboratory results are often non-specific. Imaging has an important role not only in diagnosing appendicitis and its complication but also suggesting alternate diagnosis in appropriate cases. However, there is no universally accepted diagnostic imaging algorithm for appendicitis. Imaging of acute appendicitis needs to be streamlined keeping pros and cons of the available investigative modalities. Radiography has practically no role today in the diagnosis and management of acute appendicitis. Ultrasonography (USG) should be the first line imaging modality for all ages, particularly for children and non-obese young adults including women of reproductive age group. If USG findings are unequivocal and correlate with clinical assessment, no further imaging is needed. In case of equivocal USG findings or clinico-radiological dissociation, follow-up/further imaging (computed tomography (CT) scan/magnetic resonance imaging (MRI)) is recommended. In pediatric and pregnant patients with inconclusive initial USG, MRI is the next option. Routine use of CT scan for diagnosis of AA needs to be discouraged. Our proposed version of a practical imaging algorithm, with USG first and always has been incorporated in the article.
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Affiliation(s)
- Jyotindu Debnath
- Professor, Department of Radiodiagnosis, Armed Forces Medical College, Pune 411040, India
| | - R A George
- Senior Adviser (Radiodiagnosis), Command Hospital (Air Force), Bengaluru, India
| | - R Ravikumar
- Professor & Head, Department of Radiodiagnosis, Armed Forces Medical College, Pune 411040, India
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Kearl YL, Claudius I, Behar S, Cooper J, Dollbaum R, Hardasmalani M, Hardiman K, Rose E, Santillanes G, Berdahl C. Accuracy of Magnetic Resonance Imaging and Ultrasound for Appendicitis in Diagnostic and Nondiagnostic Studies. Acad Emerg Med 2016; 23:179-85. [PMID: 26765503 DOI: 10.1111/acem.12873] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/24/2015] [Accepted: 09/22/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Suggestive radiographic studies with nonvisualization of the appendix can present a challenge to clinicians in the evaluation of pediatric abdominal pain. The primary objective of this study was to quantify the accuracy of magnetic resonance imaging (MRI) and of ultrasound (US) in the setting of nonvisualization of the appendix. Secondary objectives reported include sensitivity of MRI and US overall and correlation between MRI and US for diagnosis of appendicitis. METHODS Records of pediatric emergency department patients aged 3 to 21 years undergoing MRI and/or US for the evaluation of appendicitis were retrospectively reviewed. Radiographs were categorized as a normal appendix, neither demonstrating the appendix nor demonstrating abnormalities consistent with appendicitis; equivocal, not demonstrating the appendix but showing evidence of appendicitis; demonstrating an abnormal appendix consistent with appendicitis; or demonstrating an alternate pathology. The reading was compared with the final diagnosis for accuracy. RESULTS Of the 589 patients included, 146 had appendicitis. Diagnostic accuracy for studies with a nonvisualized appendix without secondary signs of appendicitis was 100% for MRI and 91.4% (95% CI = 87.3% to 94.2%) for US. Diagnostic accuracy for studies with a nonvisualized appendix with secondary signs of appendicitis was 50% (95% CI = 2.5% to 97.5%) for MRI and 38.9% (95% CI = 18.2% to 64.5%) for US. Appendicitis was ultimately diagnosed in 8.6% of patients with an otherwise negative right lower quadrant (RLQ) US that failed to directly identify the appendix. There was a moderate correlation between US and MRI (ρ = 0.573, p = 0.0001) when all studies were considered. CONCLUSIONS Magnetic resonance imaging without secondary signs of appendicitis is effective in excluding appendicitis regardless of whether the appendix is directly visualized, while otherwise negative RLQ US that fail to identify the appendix are less useful. Secondary signs of appendicitis without visualization of the appendix were not helpful regardless of radiographic modality. Results of MRI and US correlated moderately well.
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Affiliation(s)
- Y. Liza Kearl
- Department of Emergency Medicine; University of Southern California; Keck School of Medicine; Los Angeles CA
| | - Ilene Claudius
- Department of Emergency Medicine; University of Southern California; Keck School of Medicine; Los Angeles CA
| | - Sol Behar
- Department of Emergency Medicine; University of Southern California; Keck School of Medicine; Los Angeles CA
| | - John Cooper
- Department of Pediatrics; Los Angeles County and University of Southern California Hospital; Los Angeles CA
| | - Ryan Dollbaum
- University of Southern California; Keck School of Medicine; Los Angeles CA
| | - Madhu Hardasmalani
- Department of Emergency Medicine; University of Southern California; Keck School of Medicine; Los Angeles CA
| | - Kevin Hardiman
- Department of Emergency Medicine; Los Angeles County and University of Southern California Hospital; Los Angeles CA
| | - Emily Rose
- Department of Emergency Medicine; University of Southern California; Keck School of Medicine; Los Angeles CA
| | - Genevieve Santillanes
- Department of Emergency Medicine; University of Southern California; Keck School of Medicine; Los Angeles CA
| | - Carl Berdahl
- Department of Emergency Medicine; Los Angeles County and University of Southern California Hospital; Los Angeles CA
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