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Yang HB, Song HB, Han JW, Youn JK, Ko D, Ryu YJ, Kim JY, Kim HY. Clinical course in children with equivocal appendicitis on computed tomography: a retrospective cohort study. Ann Surg Treat Res 2023; 104:51-59. [PMID: 36685769 PMCID: PMC9830045 DOI: 10.4174/astr.2023.104.1.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 01/04/2023] Open
Abstract
Purpose Appendectomy is one of the most common surgeries in children. Although various radiological examinations are performed, they do not always reveal a definitive diagnosis of appendicitis. This study aimed to investigate the clinical course of equivocal appendicitis, identify the factors associated with appendectomy, and suggest appropriate management for these patients. Methods Patients younger than 19 years who visited Seoul National University Bundang Hospital with a differential diagnosis of appendicitis from January 2013 to December 2017 were included. All participants conducted 'appendiceal CT' with a scoring scale of 1-5. The higher the score, the higher the likelihood of a radiologic diagnosis of appendicitis. We defined the appendicitis CT score of 2-4 as equivocal appendicitis (n = 143). Medical records were reviewed retrospectively for demographics, further examination as abdominal ultrasonography, and appendectomy status (yes or no). The mean follow-up period was 15.6 ± 71 days. Results Equivocal appendicitis accounted for 16.7%. Additional ultrasonography test was performed in 24.5% (35 of 143). In total, 34 patients (23.8%) underwent appendectomy. Among the patients with appendiceal CT scores 2, 3, and 4, 4.9%, 50.0%, and 87.5% underwent appendectomy, respectively. Higher WBC count, higher appendicitis CT score, and readmission were significantly associated with appendectomy in patients with equivocal appendicitis. Conclusion Higher appendicitis CT score and WBC level were positively associated with appendectomy. Careful observation can be a treatment option in appendicitis CT score 2 or 3 groups. Appendectomy is the first-line treatment for patients with appendicitis score 4. Additional ultrasonography test is advisable to determine treatment modality for equivocal appendicitis.
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Affiliation(s)
- Hee-Beom Yang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Han-Byol Song
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji-Won Han
- Department of Surgery, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Joong Kee Youn
- Department of Pediatric Surgery, Seoul National University Children’s Hospital, Seoul, Korea
| | - Dayoung Ko
- Department of Pediatric Surgery, Seoul National University Children’s Hospital, Seoul, Korea
| | - Young Jin Ryu
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University Children’s Hospital, Seoul, Korea.,Department of Surgery, College of Medicine, Seoul National University, Seoul, Korea
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Chaochankit W, Boocha A, Samphao S. Negative appendectomy rate in patients diagnosed with acute appendicitis. BMC Surg 2022; 22:404. [PMID: 36419019 PMCID: PMC9682723 DOI: 10.1186/s12893-022-01852-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/13/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Acute appendicitis is the most common cause of acute lower abdominal pain leading patients to the emergency department. This study aims to find the negative appendectomy rate in patients diagnosed with acute appendicitis from 2015 to 2019. METHODS This study was a retrospective cohort study in the patients preoperatively diagnosed with acute appendicitis and underwent appendectomy from January 2015 to December 2019. Negative appendectomy is defined as the final pathologic results confirmed normal, congestion or peri-appendicitis. RESULTS The study population was 892 patients which was 54.3% female. The five-year negative appendectomy rate was 8.6% (n = 77) and 70% in female (n = 54). The factors associated with increasing the negative appendectomy rate were female (OR 2.23, P = 0.003), age ≤ 40 years old (OR 2.35, P = 0.003), and no history of diarrhea (OR 2.42, P = 0.017). Whereas the factors related to decline in the negative appendectomy rate were white blood cell count (WBC) [Formula: see text] 10,000 (OR 0.39, P = 0.016), neutrophil (N) [Formula: see text] 75% (OR 0.28, P < 0.001), and positive appendicitis from ultrasonography of abdomen (OR 0.04, P < 0.001) or computed tomography of abdomen (OR 0.07, P < 0.001). CONCLUSION The negative appendectomy rate was less than 10% in this study. Female, age 40 ≤ years old and history of diarrhea were related to increase in negative appendectomy. The factors that related to decline in negative appendectomy were leukocytosis with cells shift to the left, positive acute appendicitis from abdominal ultrasonography and CT scan. However, to request the further imaging studies to diagnose patients with suspected acute appendicitis depends on the risk and benefit to each patient and the choice of investigation.
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Affiliation(s)
- Wongsakorn Chaochankit
- grid.7130.50000 0004 0470 1162Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110 Thailand
| | - Aeraungkoon Boocha
- grid.7130.50000 0004 0470 1162Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110 Thailand
| | - Srila Samphao
- grid.7130.50000 0004 0470 1162Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110 Thailand
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Di Mitri M, Parente G, Bonfiglioli G, Thomas E, Bisanti C, Cordola C, Vastano M, Cravano S, Collautti E, Di Carmine A, D’Antonio S, Gargano T, Libri M, Lima M. IL-6 Serum Levels Can Enhance the Diagnostic Power of Standard Blood Tests for Acute Appendicitis. CHILDREN 2022; 9:children9101425. [PMID: 36291361 PMCID: PMC9600576 DOI: 10.3390/children9101425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/17/2022] [Accepted: 09/18/2022] [Indexed: 11/23/2022]
Abstract
Background: The diagnosis of acute appendicitis (AA) remains challenging, especially in pediatrics, because early symptoms are not specific, and the younger the patient the more difficult their interpretation is. There is a large degree of agreement between pediatric surgeons on the importance of an early diagnosis to avoid complicated acute appendicitis (CAA) and its consequences. The aim of this study is to assess if Interleukin 6 (IL-6) could enhance the sensitivity (Sn) and specificity (Sp) of the currently available and routinely performed diagnostic tools in case of suspected AA in pediatric patients. Materials and Methods: A prospective observational study was conducted including patients who underwent appendectomy between November 2020 and March 2022. We divided patients into three groups: not inflamed appendix (group NA), not complicated AA (group NCAA), and complicated AA (group CAA). We compared the mean values of white blood cells (WBC), neutrophils, fibrinogen, ferritin, aPTT, INR, C-reactive protein (CRP), IL-6, and CRP between the three groups. Then we evaluated Sn, Sp, and odds ratio (OR) of IL-6 and CRP alone and combined. Results: We enrolled 107 patients operated on for AA (22 in Group NA, 63 in Group NCAA, and 21 in group CAA). CRP levels resulted in a significant increase when comparing CAA with NA (p = 0.01) and CAA with NCAA (p = 0.01), whereas no significance was found between NA and NCAA (p = 0.38). A statistically significant increase in average IL-6 levels was found when comparing NCAA with NA (p = 0.04), CAA with NA (p = 0.04), and CAA with NCAA (p = 0.02). Considering CRP alone, its Sn, Sp, and OR in distinguishing NA from AA (both NCAA and CAA together) are 86%, 35%, and 33,17, respectively. Similarly, Sn, Sp, and OR of IL-6 alone are 82%, 54%, and 56, respectively. Combining CRP and IL-6 serum levels together, the Sn increases drastically to 100% with an Sp of 40% and OR of 77. Conclusions: Our study may suggest an important role of IL-6 in the detection of AA in its early stage, especially when coupled with CRP.
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Bourcier JE, Gallard E, Redonnet JP, Majourau M, Deshaie D, Bourgeois JM, Garnier D, Geeraerts T. Diagnostic performance of abdominal point of care ultrasound performed by an emergency physician in acute right iliac fossa pain. Crit Ultrasound J 2018; 10:31. [PMID: 30467798 PMCID: PMC6250608 DOI: 10.1186/s13089-018-0112-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 10/17/2018] [Indexed: 12/11/2022] Open
Abstract
Background Right iliac fossa abdominal pain is a common reason for emergency ward admissions, its etiology is difficult to diagnose. It can be facilitated by an imaging examination, such as a Computerized Tomography scan which exposes the patient to ionizing radiation and implies delays. A bedside ultrasound performed by emergency physicians could avoid these issues. The aim of our study was to assess the performance of ultrasound carried out at the patient’s bedside by an emergency physician compared with a clinical-laboratory examination for the diagnosis of a surgical pathology in right iliac fossa pain. Methods This is a single-center prospective cohort study conducted in an Emergency Department receiving 19,000 patients per year. All patients presenting pain in the right iliac fossa were included by four (out of ten) emergency physicians certified in an ultrasound examination. A full grid pattern scan ultrasound of the abdominal cavity with analysis of the right iliac fossa was performed. The primary outcome was to compare the diagnosis performance of bedside ultrasound and clinical-laboratory examination to detect a surgical pathology. Two emergency physicians who did not participate in the study made the final diagnosis (i.e., surgical or non-surgical pathology) by reviewing the entire medical chart of each patient. Results From January 2011 to July 2013, 158 patients with a median age of 17 [13–32] years were analyzed. The diagnosed cases were: appendicitis (53), non-specific abdominal pain (48), lymphadenitis (22), ileitis (11), complicated ovarian cysts (7), neoplasias (5), inflammatory or infectious colitis (5), inguinal herniations (3), bowel obstructions (2), and salpingitis (2). The accuracy of ultrasound diagnoses was 0.89 (95% CI 0.84–0.94) versus 0.70 (95% CI 0.57–0.82) for diagnoses based on clinical-laboratory examination only (p < 0.001). Conclusion Bedsides, ultrasound allows an accurate diagnosis of a surgical pathology in 89% of cases, which is more efficient than the clinical-laboratory examination.
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Affiliation(s)
- Jean-Eudes Bourcier
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France.
| | - Emeric Gallard
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Jean-Philippe Redonnet
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Magali Majourau
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Dominique Deshaie
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | | | - Didier Garnier
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Thomas Geeraerts
- Anesthesiology and Critical Care Department, Toulouse University Hospital, University Toulouse III Paul Sabatier, Toulouse, France
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Alhamdani YF, Rizk HA, Algethami MR, Algarawi AM, Albadawi RH, Faqih SN, Ahmed EH, Abukammas OJ. Negative Appendectomy Rate and Risk Factors That Influence Improper Diagnosis at King Abdulaziz University Hospital. Mater Sociomed 2018; 30:215-220. [PMID: 30515062 PMCID: PMC6195398 DOI: 10.5455/msm.2018.30.215-220] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 08/24/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Acute Appendicitis is the most common emergent abdominal surgery worldwide. diagnosis based on clinical assessment, laboratory and radiological investigations and appendectomy is the treatment of choice. Removing a normal appendix is a relatively common surgical issue, defined as negative appendectomy (NA). Multiple risk factors contribute to NA; female gender, normal WBC, normal CRP count, and CT scan unavailability. However, recently NA is decreasing in incidence after CT scan and Alvarado scoring. AIM We aimed to estimate the rate of negative appendectomy, and determine possible risk factors among King Abdulaziz University Hospital. PATIENTS AND METHODS Article has a retrospective character and included non-incidental 441 patients who undergo an appendectomy, during period 2008 to 2018. RESULTS Negative Appendectomy incidence (9.5%) was higher among females at (64.3%). Gynecological complaints were seen in (22.2%) of cases with a sign for Negative Appendectomy. Surgery reports documented (29.6%) of female ovarian cyst diseases. Alvarado scoring at presentation was less than 7 in (69%) of cases with statistical significance value. Normal WBC count (50%), for automated neutrophil (45.2%) was high, and same number were recorded with the normal neutrophil count, all of them have statically significant relation with NA. CONCLUSION Proper clinical evaluation involves documenting Alvarado score, using CRP, efficient radiological utilization. Also, considering more referrals to gynecological specialists of similar presentation especially females at reproductive age. Investing in time and equipment for proper clinical assessment can avoid the unnecessary burden and save our resources for better use.
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Affiliation(s)
| | - Hisham A. Rizk
- Department of General Surgery, University of Jeddah, Jeddah, Saudi Arabia
| | | | | | | | - Sofana N. Faqih
- King Abdulaziz University, Medical School, Jeddah, Saudi Arabia
| | - Elaf H. Ahmed
- King Abdulaziz University, Medical School, Jeddah, Saudi Arabia
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Ambe PC, Gödde D, Bönicke L, Papadakis M, Störkel S, Zirngibl H. Calprotectin could be a potential biomarker for acute appendicitis. J Transl Med 2016; 14:107. [PMID: 27118309 PMCID: PMC4847263 DOI: 10.1186/s12967-016-0863-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 04/12/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Acute appendicitis is a common cause for a visit to the emergency department and appendectomy represents the most common emergency procedure in surgery. The rate of negative appendectomy however has remained high despite modern diagnostic apparatus. Therefore, there is need for a better preoperative screening of patients with suspected appendicitis. Calprotectin represents a predominant protein in the cytosol of neutrophil granulocytes and has been extensively investigated with regard to bowel pathologies. This study investigates the expression of calprotectin in the lumen of the vermiform appendix of patients undergoing appendectomy for suspected appendicitis. METHODS Appendix specimens from patients undergoing emergency appendectomy for suspected acute appendicitis were examined. Acute appendicitis was confirmed on histopathology. The qualitative expression of calprotectin in the vermiform appendix specimens was analyzed using specific calprotectin antibodies. RESULTS Vermiform appendix specimens from 52 patients (22 female and 30 male) including 11 with uncomplicated and 41 with complicated appendicitis were analyzed. Strong immunostainings were achieved with calprotectin antibody in the lumen of all specimens irrespective of the extent of appendicitis. Immunostaining was negative in the uninflamed appendix. CONCLUSIONS High calprotectin activity could be demonstrated within the lumen of vermiform appendix specimens following appendectomy for acute appendicitis. The high luminal accumulation of calprotectin-carrying cells could be interpreted as an invitation to study the expression of calprotectin in stool as a new diagnostic aid in patients with suspected appendicitis.
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Affiliation(s)
- Peter C Ambe
- Department of Surgery, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany.
| | - Daniel Gödde
- Institute of Pathology and Molecular Pathology, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
| | - Lars Bönicke
- Department of Surgery, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
| | - Marios Papadakis
- Department of Surgery, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
| | - Stephan Störkel
- Institute of Pathology and Molecular Pathology, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
| | - Hubert Zirngibl
- Department of Surgery, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
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7
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Schuh S, Chan K, Langer JC, Kulik D, Preto-Zamperlini M, Aswad NA, Man C, Mohanta A, Stephens D, Doria AS. Properties of serial ultrasound clinical diagnostic pathway in suspected appendicitis and related computed tomography use. Acad Emerg Med 2015; 22:406-14. [PMID: 25808065 DOI: 10.1111/acem.12631] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/24/2014] [Accepted: 11/26/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The primary objective was to determine the diagnostic accuracy of a serial ultrasound (US) clinical diagnostic pathway to detect appendicitis in children presenting to the emergency department (ED). The secondary objective was to examine the diagnostic performance of the initial and interval US and to compare the accuracy of the pathway to that of the initial US. METHODS This was a prospective cohort study of 294 previously healthy children 4 to 17 years old with suspected appendicitis and baseline pediatric appendicitis scores of ≥2, who were managed with the serial US clinical diagnostic pathway. This pathway consisted of an initial US followed by a clinical reassessment in each patient and an interval US and surgical consultation in patients with equivocal initial US and persistent concern about appendicitis. The USs were interpreted by published criteria as positive, negative, or equivocal for appendicitis. Children in whom this pathway did not rule in or rule out appendicitis underwent computed tomography (CT). Cases with missed appendicitis, negative operations, and CTs after the pathway were considered inaccurate. The primary outcome was the diagnostic accuracy of the serial US clinical diagnostic pathway. The secondary outcomes included the test performance of the initial and interval US imaging studies. RESULTS Of the 294 study children, 111 (38%) had appendicitis. Using the serial US clinical diagnostic pathway, 274 of 294 children (93%, 95% confidence interval [CI] = 90% to 96%) had diagnostically accurate results: 108 of the 111 (97%) appendicitis cases were successfully identified by the pathway without CT scans (two missed and one CT), and 166 of the 183 (91%) negative cases were ruled out without CT scans (14 negative operations and three CTs). The sensitivity of this pathway was 108 of 111 (97%, 95% CI = 94% to 100%), specificity 166 of 183 (91%, 95% CI = 87% to 95%), positive predictive value 108 of 125 (86%; 95% CI = 79% to 92%), and negative predictive value 166 of 169 (98%, 95% CI = 96% to 100%). The diagnostic accuracy of the pathway was higher than that of the initial US alone (274 of 294 vs. 160 of 294; p < 0.0001). Of 123 patients with equivocal initial US, concern about appendicitis subsided on clinical reassessment in 73 (no surgery and no missed appendicitis). Of 50 children with persistent symptoms, 40 underwent interval US and 10 had surgical consultation alone. The interval US confirmed or ruled out appendicitis in 22 of 40 children (55.0%) with equivocal initial US, with one false-positive interval US. CONCLUSIONS The serial US clinical diagnostic pathway in suspected appendicitis has an acceptable diagnostic accuracy that is significantly higher than that of the initial US and results in few CT scans. This approach appears most useful in children with equivocal initial US, in whom the majority of negative cases were identified at clinical reassessment and appendicitis was diagnosed by interval US or surgical consultation in most study patients.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine; University of Toronto; Toronto Ontario Canada
- Department of Pediatrics; University of Toronto; Toronto Ontario Canada
- Research Institute; University of Toronto; Toronto Ontario Canada
| | - Kevin Chan
- Division of Pediatric Emergency Medicine; University of Toronto; Toronto Ontario Canada
| | - Jacob C. Langer
- Department of Surgery; University of Toronto; Toronto Ontario Canada
| | - Dina Kulik
- Division of Pediatric Emergency Medicine; University of Toronto; Toronto Ontario Canada
| | | | - Nadine Al Aswad
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Carina Man
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Arun Mohanta
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Derek Stephens
- Research Institute; University of Toronto; Toronto Ontario Canada
| | - Andrea S. Doria
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
- Research Institute; University of Toronto; Toronto Ontario Canada
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Pershad J, Waters TM, Langham MR, Li T, Huang EY. Cost-effectiveness of diagnostic approaches to suspected appendicitis in children. J Am Coll Surg 2014; 220:738-46. [PMID: 25667142 DOI: 10.1016/j.jamcollsurg.2014.12.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 12/15/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Our group recently published a clinical pathway (Le Bonheur Clinical Pathway [LeB-P]) that used the Samuel Pediatric Appendicitis Score with selective use of ultrasonography (USG) for diagnosis of children at risk for appendicitis. The objective of this study was to model the cost-effectiveness of implementing the LeB-P compared with usual care. STUDY DESIGN We constructed a decision analytic model comparing hospital costs for the following diagnostic strategies for suspected appendicitis: emergency department clinician judgment alone, USG on all patients, CT on all patients, overnight observation with surgical evaluation without studies, and the LeB-P. Prevalence of disease, outcomes probabilities, and hospital and professional costs for each option were derived from published literature, national cost data, and our previous study results. Cost-effectiveness was calculated using these 3 sets of parameters. RESULTS In the base case model, USG was the preferred strategy over LeB-P and overnight observation with surgical evaluation without studies. Emergency department clinician judgment alone and CT were dominated by the other pathways, based on either lower diagnostic accuracy or increased costs. Compared with LeB-P, USG costs $337 less per patient evaluated, but increased the diagnostic error rate by 2%. Using LeB-P rather than USG would cost an institution an additional $17,206 to eliminate one misdiagnosis, which is known as the incremental cost-effectiveness ratio. CONCLUSIONS Although performing USG on all children with suspected appendicitis was determined to be the most cost-effective strategy, using the Pediatric Appendicitis Score with selective use of USG (LeB-P) improved diagnostic accuracy at a moderate increase in cost and decreased CT use.
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Affiliation(s)
- Jay Pershad
- Department of Emergency Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Teresa M Waters
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Max R Langham
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Tao Li
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Eunice Y Huang
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN.
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Shah BR, Stewart J, Jeffrey RB, Olcott EW. Value of short-interval computed tomography when sonography fails to visualize the appendix and shows otherwise normal findings. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1589-1595. [PMID: 25154940 DOI: 10.7863/ultra.33.9.1589] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the type and incidence of disorders revealed by short-interval computed tomography (CT) in patients with suspected appendicitis after graded compression sonography fails to reveal the appendix and shows otherwise normal findings. METHODS Computed tomographic findings and clinical courses were assessed retrospectively for 318 patients identified consecutively in a searchable database who met inclusion criteria specifying that sonography was the initial imaging examination for suspected appendicitis; sonography revealed nonvisualization of the appendix and otherwise normal results; and abdominopelvic CT was performed within 48 hours after sonography. RESULTS Of the 318 patients, short-interval CT revealed normal findings in 250 (78.6%). Appendicitis was revealed in 52 (16.4%) others, of whom 7 had perforation and all of whom had pathologic results confirming these CT findings. Important alternative diagnoses other than appendicitis were revealed in 16 (5.0%) others, including 2 (0.6%) who required urgent surgery and 14 (4.4%) who did not. No significant differences were observed between adult patients (>18 years) and pediatric patients. CONCLUSIONS Most short-interval CT scans in this clinical setting reveal normal findings, and relatively few disclose appendicitis or disorders that require urgent surgery. In view of concerns regarding radiation exposure associated with CT, these observations argue for the development of clinical triage methods that differentiate patients who are likely to benefit from short-interval postsonography CT from those who are not.
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Affiliation(s)
- Bhavya R Shah
- Department of Radiology, Stanford University School of Medicine, Stanford, California USA (B.R.S., J.S., R.B.J., E.W.O.); and Radiology Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.W.O.)
| | - Jessica Stewart
- Department of Radiology, Stanford University School of Medicine, Stanford, California USA (B.R.S., J.S., R.B.J., E.W.O.); and Radiology Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.W.O.)
| | - R Brooke Jeffrey
- Department of Radiology, Stanford University School of Medicine, Stanford, California USA (B.R.S., J.S., R.B.J., E.W.O.); and Radiology Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.W.O.)
| | - Eric W Olcott
- Department of Radiology, Stanford University School of Medicine, Stanford, California USA (B.R.S., J.S., R.B.J., E.W.O.); and Radiology Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.W.O.).
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10
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Negative Appendectomy: an Audit of Resident-Performed Surgery. How Can Its Incidence Be Minimized? Indian J Surg 2014; 77:913-7. [PMID: 27011482 DOI: 10.1007/s12262-014-1063-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 03/27/2014] [Indexed: 12/29/2022] Open
Abstract
Negative appendectomy remains a concern in current surgical practice. Data from the developing world is scarce. Data of appendectomies during the last 5 years were analyzed. Interval and incidental appendectomies were excluded. The demographic details, presenting complaints, clinical signs, and investigations performed were recorded in a predesigned proforma. The data were critically analyzed. Six hundred eighty-five appendectomies were performed during the period. One hundred eighty-five patients with a normal appendix were identified on histopathology. Sixty-seven patients with incidental or interval appendectomies were excluded. Thus, 118 patients had appendectomies performed erroneously. All these patients with presumed diagnosis of acute appendicitis were operated on by resident surgeons. Records of 17 patients could not be retrieved. The most common symptom was abdominal pain (100 %), and the commonest sign was right iliac fossa tenderness (93 %). Most of the patients underwent USG to supplement the diagnosis. CT scan and diagnostic laparoscopy were not performed. The negative appendectomy rate was 17.2 % (12.4 % in males; 33.3 % in females). The highest incidence of negative appendectomy was in females aged 11-20 years (66.7 %). The rate of negative appendectomy at our institute is comparable with the world statistics. More diligence is required in making the clinical diagnosis of acute appendicitis, especially in young females. The use of C-reactive protein and CT scan may decrease the negative appendectomy rate.
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11
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Liu ZH, Li C, Zhang XW, Kang L, Wang JP. Meta-analysis of the therapeutic effects of antibiotic versus appendicectomy for the treatment of acute appendicitis. Exp Ther Med 2014; 7:1181-1186. [PMID: 24940408 PMCID: PMC3991548 DOI: 10.3892/etm.2014.1584] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 01/22/2014] [Indexed: 12/29/2022] Open
Abstract
Appendicectomy has been the gold standard treatment of acute appendicitis for more than a century, while nonoperative therapies, including antibiotics, have acquired increased interest in recent years. The present meta-analysis aimed to compare the therapeutic effects of antibiotics versus appendicectomy for the treatment of acute appendicitis. Medline, Embase and The Cochrane Library databases were searched. Prospective randomized controlled trials that compared antibiotic treatment with surgery were included. The outcomes evaluated included the time of hospital stay, complications and time to work. There were no statistically significant differences between the antibiotic and appendicectomy groups with regard to the time of hospital stay and complications. However, the time to work was significantly longer in the appendicectomy group when compared with the antibiotic group. In addition, the therapeutic effects of antibiotics and appendicectomy were comparable for the treatment of acute appendicitis.
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Affiliation(s)
- Zhi-Hua Liu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital to Sun Yat-Sen University, Guangzhou, Guangdong 510655, P.R. China
| | - Chao Li
- Department of Colorectal Surgery, The Sixth Affiliated Hospital to Sun Yat-Sen University, Guangzhou, Guangdong 510655, P.R. China
| | - Xing-Wei Zhang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital to Sun Yat-Sen University, Guangzhou, Guangdong 510655, P.R. China
| | - Liang Kang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital to Sun Yat-Sen University, Guangzhou, Guangdong 510655, P.R. China
| | - Jian-Ping Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital to Sun Yat-Sen University, Guangzhou, Guangdong 510655, P.R. China
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Bates MF, Khander A, Steigman SA, Tracy TF, Luks FI. Use of white blood cell count and negative appendectomy rate. Pediatrics 2014; 133:e39-44. [PMID: 24379236 DOI: 10.1542/peds.2013-2418] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Despite increased utilization of laboratory, radiologic imaging, and scoring systems, negative appendectomy (NA) rates in children remain above 3% nationwide. We reviewed the clinical data of patients undergoing appendectomy to further reduce our NA rate. METHODS A retrospective review was conducted of all appendectomies performed for suspected appendicitis at a tertiary children's hospital during a 42-month period. Preoperative clinical, laboratory, and radiographic data were collected. Variables absent or normal in more than half of NAs were further analyzed. Receiver operating characteristic curves were constructed for continuous variables by using appropriate cutoff points to determine sensitivity and false-positive rates. The results were validated by analyzing the 12 months immediately after the establishment of these rules. RESULTS Of 847 appendectomies performed, 22 (2.6%) had a pathologically normal appendix. The only variables found to be normal in more than half of NAs were white blood cell (WBC) count (89%) and neutrophil count (79%). A receiver operating characteristic curve indicates that using WBC cutoffs of 9000 and 8000 per µL yielded sensitivities of 92% and 95%, respectively, and reduction in NA rates by 77% and 36%, respectively. Results observed in the subsequent 12 months confirmed these expected sensitivities and specificities. CONCLUSIONS Absence of an elevated WBC count is a risk factor for NA. Withholding appendectomy for WBC counts <9000 and 8000 per µL reduces the NA rate to 0.6% and 1.2%, respectively. Missed true appendicitis in patients with normal WBC counts can be mitigated by a trial of observation in those presenting with early symptom onset.
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Affiliation(s)
- Maria F Bates
- Division of Pediatric Surgery, 2 Dudley St, Suite 190, Providence, RI 02905.
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Nataraja RM, Loukogeorgakis SP, Sherwood WJ, Clarke SA, Haddad MJ. The Incidence of Intraabdominal Abscess Formation Following Laparoscopic Appendicectomy in Children: A Systematic Review and Meta-analysis. J Laparoendosc Adv Surg Tech A 2013; 23:795-802. [DOI: 10.1089/lap.2012.0522] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Ramesh M. Nataraja
- Department of Paediatric Surgery, Chelsea and Westminster Hospital Foundation Trust, London, United Kingdom
| | - Stavros P. Loukogeorgakis
- Department of Paediatric Surgery, Chelsea and Westminster Hospital Foundation Trust, London, United Kingdom
| | - William J. Sherwood
- Department of Paediatric Surgery, Chelsea and Westminster Hospital Foundation Trust, London, United Kingdom
| | - Simon A. Clarke
- Department of Paediatric Surgery, Chelsea and Westminster Hospital Foundation Trust, London, United Kingdom
| | - Munther J. Haddad
- Department of Paediatric Surgery, Chelsea and Westminster Hospital Foundation Trust, London, United Kingdom
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Abstract
OBJECTIVE This study aimed to determine the outcome of children with unclear etiology for acute abdominal pain admitted to the emergency department observation unit (EDOU). METHODS This is a retrospective cohort study of children 18 years or younger who presented with acute abdominal pain to a tertiary pediatric ED and were observed in the EDOU. Children with alternative explanations for abdominal pain were excluded. Patients were classified based on disposition, and data were analyzed using χ tests. RESULTS There were 237 patients included in the study (median age, 9 years; 46% male). Mean length of stay in EDOU was 14.4 hours. Fifty-four percent were evaluated by surgery. Two hundred (84%) were discharged; 37 (16%) were admitted, of whom 22 (9%) underwent surgical intervention (13 appendectomies, 6 ovarian cystectomies, 2 small-bowel obstructions, 1 cholecystectomy). Eight had acute appendicitis on pathology reports. The duration of symptoms, the presence of fever, nausea/vomiting, right-lower-quadrant pain, rebound tenderness, or leukocytosis greater than 10,000 cells/μL did not predict admission. Patients with diarrhea were more likely to be discharged home (P = 0.02). Intravenous hydration (86%) and pain control (63%) were the most common interventions in the EDOU. Abdominal pain not otherwise specified and acute gastroenteritis were the 2 most common discharge diagnoses. Eight (4%) of the 200 discharged patients returned to the ED within 48 hours, and all were discharged home from the ED. CONCLUSIONS The majority of children admitted to the EDOU with abdominal pain have nonsurgical causes of abdominal pain. The EDOU provides a reasonable alternative for monitoring these patients pending disposition.
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Stewart JK, Olcott EW, Jeffrey RB. Sonography for appendicitis: nonvisualization of the appendix is an indication for active clinical observation rather than direct referral for computed tomography. JOURNAL OF CLINICAL ULTRASOUND : JCU 2012; 40:455-461. [PMID: 22638942 DOI: 10.1002/jcu.21928] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 03/16/2012] [Indexed: 06/01/2023]
Abstract
PURPOSE To determine the prevalence of perforated and nonperforated appendicitis in patients with nonvisualization of the appendix on ultrasound (US) performed for suspected appendicitis, and to evaluate the value of CT in these patients. METHODS We analyzed 400 consecutive patients undergoing US for suspected appendicitis. Of these patients, 260 had nonvisualization of the appendix, but otherwise normal scans. We analyzed the clinical outcome in these patients to determine the prevalence of appendicitis, referrals for CT, and the contribution of CT in these patients. RESULTS Of the 400 patients, 140 (35%) had either a normal (80 patients, 25%) or an abnormal appendix (60 patients, 15%); 260 (65%) had nonvisualization of the appendix. Overall 75 patients had appendicitis (18.8%) and 17 (4.3%) had appendicitis with perforation. Of the 260 patients with nonvisualization of the appendix, 14 patients (5.4%) had appendicitis and 2 were perforated (0.8%). The prevalence of perforated and nonperforated appendicitis in this group was significantly lower than the overall group (p < 0.001 and p < 0.01, respectively). Of these 260 patients, 101 patients (38.8%) had CT within 48 hours and 79 (78.2%) had normal scans. CONCLUSIONS Patients with nonvisualization of the appendix on US, but otherwise normal scans, are at significantly lower risk for appendicitis, either perforated or nonperforated. Active clinical observation should be considered in these patients, rather than direct referral for CT.
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Affiliation(s)
- Jessica K Stewart
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
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Abstract
BACKGROUND In recent years, there has been worldwide increase in childhood obesity. The diagnosis of acute appendicitis in very obese children can sometimes be difficult and challenging. The purpose of this study was to determine the incidence of histologically normal appendix in very obese and non-obese children undergoing emergency appendectomy for the clinical diagnosis of acute appendicitis. METHODS The hospital records of 1,228 consecutive patients, who underwent appendectomy for acute appendicitis between 2000 and 2008, were analyzed. 207 children (16.9%) were very obese. Very obese was defined as greater than 2 standard deviations above the standardized mean weight for age. Histological data was compared between very obese and non-obese children. Seventy-seven (37%) of 207 very obese and 398 (39%) of 1,021 non-obese children had ultrasound preoperatively. RESULTS The incidence of normal appendectomy was significantly higher in very obese children compared to non-obese children (24.6 vs. 9.9%, P < 0.001). The false positive rate of ultrasound was significantly higher in very obese children group compared to non-obese (26 vs. 6%, P < 0.05). The specificity, sensitivity, positive and negative predictive values of ultrasound were significantly lower (P < 0.05) in very obese children group compared to non-obese children. CONCLUSION Suspected appendicitis in childhood obesity is associated with increased incidence of normal appendectomy. Active observation in hospital in very obese children may reduce the rate of normal appendectomy without increasing the incidence of complicated appendicitis.
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Wu HP, Fu YC. Application with repeated serum biomarkers in pediatric appendicitis in clinical surgery. Pediatr Surg Int 2010; 26:161-166. [PMID: 19921211 DOI: 10.1007/s00383-009-2535-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2009] [Indexed: 11/25/2022]
Abstract
PURPOSE: To apply the repeated serum laboratory tests in diagnosing acute appendicitis in children with suspected appendicitis. METHODS: From 2005 to 2007, we prospectively collected 217 pediatric patients with clinically suspected appendicitis. The repeated serum laboratory tests were measured 6 h later and the changes in serum inflammatory biomarkers analyzed. Significant changes in serum parameters between primary and repeated examinations were selected as the discriminating variables. The receiver operating characteristic (ROC) curves were used to determine the cutoff values of the changes between two examinations in predicting appendicitis. RESULTS: Based on the ROC analysis, the change in the serum parameters could include simple appendicitis when the change in neutrophils (delta neutrophils) was >23.5% and delta C-reactive protein (CRP) was >118 mg/L; but for the exclusion of simple appendicitis, delta neutrophils was -44% or under and delta CRP was -10.0 mg/L or under. For perforated appendicitis, delta white blood cell counts, delta neutrophils, delta bands and delta CRP were all significant discriminators. However, based on analysis of the area under the ROC curve (AUC), only delta CRP had the greatest AUCs in predicting both simple and perforated appendicitis. The cutoff point of delta CRP was taken as 4.80 mg/L in distinguishing simple appendicitis from other acute abdominal diseases, and taken as 9.45 mg/L in predicting perforated appendicitis. CONCLUSIONS: Significant change between primary and repeated serum laboratory tests may serve as a helpful method in predicting acute appendicitis in children with suspected appendicitis.
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Affiliation(s)
- Han-Ping Wu
- Department of Pediatrics, Buddhist Tzu-Chi General Hospital, Taichung Branch, No. 66, Sec. 1, Fongsing Rd., Tanzih, Taichung, 42743, Taiwan,
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