Delaying surgery to perform CT scans for suspected appendicitis decreases the rate of negative appendectomies without increasing the rate of perforation nor postoperative complications

Safety of in-hospital delay of appendectomy - a propensity score-matched analysis of 4900 consecutive patients undergoing surgery for suspected appendicitis

BACKGROUND

Historically, urgent surgery was advocated in patients with suspected appendicitis because of the risk of perforation and possible complications. Although recent studies have shown that it is safe to delay surgery under certain circumstances, many studies do not report adjusted data and exclude patients based on risk factors. Furthermore, it is unclear whether an ultrasound-based diagnostic workup is sufficient to safely delay surgery. This large retrospective study aimed to analyze the risk-adjusted association between delayed appendectomy and perforation and complication rates.

METHODS

Data from consecutive patients who underwent appendectomy for suspected appendicitis at a single institution were reviewed and analyzed. The investigated outcomes were perforation and complication rates. Propensity score (PS) matching was used to create equal groups regarding confounding factors, and multivariate analysis was performed to control for risk factors and to calculate adjusted odds ratios (ORs) for in-hospital delay.

RESULTS

Between January 2008 and June 2023, 4900 patients underwent appendectomy for suspected appendicitis. Ultrasound imaging was performed in 4754 patients. Multivariate analysis of PS-matched data showed no association between a waiting time of >12 h and perforation rate (OR, 0.93; 95% CI, 0.67-1.31; P =.69) or complication rate (OR, 0.90; 95% CI, 0.62-1.30; P =.56). Similar results were obtained for a waiting time of 18 h and perforation rate (OR, 0.96; 95% CI, 0.48-1.56; P =.88) or complication rate (adjusted OR, 0.97; 95% CI, 0.57-1.68; P =.93).

CONCLUSION

This large PS-matched analysis showed that it is safe to delay surgery by 12 and 18 h, even when the diagnostic workup is based on ultrasound. In patients with risk factors for complications, postponement of the procedure can be considered if it can improve overall conditions or allow the procedure to be performed with a higher level of expertise.

Diagnosis and treatment of appendicitis: systematic review and meta-analysis

BACKGROUND

The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children.

METHODS

Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively.

RESULTS

2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04).

CONCLUSIONS

This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.

Diagnostic role of multislice spiral computed tomography combined with clinical manifestations and laboratory tests in acute appendicitis subtypes

The study aimed to investigate the diagnostic role of multislice spiral CT (MSCT) combined with clinical manifestations and laboratory tests in acute appendicitis subtypes. Patients diagnosed with acute appendicitis were included for retrospective analysis and their clinical manifestations and MSCT signs were analyzed. The clinical manifestations of different subtypes of acute appendicitis, including simple appendicitis, suppurative appendicitis and gangrenous appendicitis, were compared. The clinical manifestations were anorexia in 51.1% of patients, nausea and vomiting in 62.0%, shifting right lower abdominal pain in 51.1%, elevated body temperature in 31.2%, right lower quadrant abdominal tenderness in 91.4%, rebound tenderness in 91.4%, increased white cell count in 89.1%, high neutrophil count in 88.2%, increased appendiceal diameter enlargement in 100%, surrounding exudate in 95.0%, fecal stones in 51.6%, appendiceal wall thickening in 94.6%, lymph node in 82.8% and intestinal stasis in 18.6%. There were statistically significant differences in body temperature and neutrophil percentage among the subtypes of appendicitis and they were lowest in simple appendicitis and highest in gangrenous appendicitis. There were statistically significant differences in appendix diameter and the surrounding exudate among the subtypes of appendicitis and they were lowest in simple appendicitis and highest in gangrenous appendicitis. Clinical manifestations and MSCT signs, especially body temperature, percentage of neutrophils and the surrounding exudate, might have significant diagnostic value in acute appendicitis.

Routine Computed Tomography Versus Selective Imaging: An Audit of Negative Appendicectomy Rates in Two Hospitals

Introduction There are a variety of conflicting recommendations in the literature for pre-operative imaging in acute appendicitis. There is debate over what the ideal imaging protocol is to lower the negative appendicectomy rate (NAR) without increasing missed appendicitis. The aim of this study is to compare the audited NAR between two groups with different imaging approaches: (i) mandatory pre-operative computed tomography (CT) imaging and (ii) selective imaging with CT, ultrasound (US), or no imaging prior to appendicectomy. Materials and methods A retrospective chart audit was conducted of 400 patients who underwent an appendicectomy at two hospitals with different approaches to pre-operative imaging (hospital A and hospital B). The primary outcome measure was histologically confirmed appendicitis. It was also documented whether there was radiological (CT or US) evidence of appendicitis.  Results At hospital A, all 200 patients underwent CT imaging prior to appendicectomy. The total histologically confirmed NAR for this group was 9.5% (19/200). At hospital B, 97 (48.5%) patients underwent CT, 41 (25.5%) underwent US, 10 (5%) had both US and CT, and 52 (26%) had no imaging. The total NAR was 11.5% (23/200). Conclusion There was no statistically significant difference (p=0.62) in audited NARs when comparing clinician-guided selective imaging versus routine CT imaging for all patients undergoing appendicectomy.

DIAgnostic iMaging or Observation in early equivocal appeNDicitis (DIAMOND): open-label, randomized clinical trial

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).

Relationship Between Appendectomy Incidence and Computed Tomography Scans Based on Korean Nationwide Data, 2003-2017

BACKGROUND

Advances in medicine and changes in the medical environment can affect the diagnosis and treatment of diseases. The main purpose of the present study was to investigate whether the difference in accessibility to diagnosis and treatment facilities influenced the occurrence of appendectomy in Korea.

METHODS

We collected data on 183,531 appendectomy patients between 2003 and 2017 using the National Health Insurance Services claims. Retrospective analysis of relationship between the age-standardized rate (ASR) of appendectomy and clinical variables affecting medical accessibility was performed. Pearson's correlation analyses were used.

RESULTS

The incidence of appendectomy decreased from 30,164 cases in 2003 to 7,355 cases in 2017. The rate of computerized tomography (CT) scans for diagnosis of appendicitis increased from 4.73% in 2003 to 86.96% in 2017. The ASR of appendectomy in uncomplicated and complicated appendicitis decreased from 48.71 in 2005 to 13.40 in 2010 and 8.37 in 2005 to 2.96 in 2009, respectively. The ASR of appendectomy was higher in the high-income group. The proportion and ASR of appendectomy in older age group increased steadily with years. The total admission days continued to decrease from 6.02 days in 2003 to 4.96 days in 2017.

CONCLUSION

The incidence of appendectomy was seemingly associated with the rate of CT scan. In particular, the incidence of appendectomy in uncomplicated appendicitis was markedly reduced. Through enhanced accessibility to CT scans, accurate diagnosis and treatment of appendicitis can be facilitated.

Classification of acute appendicitis (CAA): treatment directed new classification based on imaging (ultrasound, computed tomography) and pathology

PURPOSE

Acute appendicitis (AA) is amongst the most common causes of acute abdominal pain. In spite of progress based on risk stratifications, "negative" appendectomies are performed in up to 30% of patients whilst the appendix perforates in others. Preoperative classification of AA based on imaging is therefore recommended. The aim was to classify AA based on imaging (ultrasound/US, computed tomography/CT), surgical pathology, and/or histopathology in order to differentiate between complicated and uncomplicated AA. A new classification of acute appendicitis (CAA) shall be illustrated by typical US and CT images and be employed in a diagnostic and therapeutic algorithm.

METHODS

Medline, Embase, and the Cochrane Library were searched. Any study after 1970, which investigated clinical scores, pathology, US, CT, magnetic resonance imaging, and treatment of AA, was included. Typical images were taken from the author's image database.

RESULTS

Five main types of AA are defined, normal appendix (type 0), nonvisualised appendix (type X), uncomplicated AA (type 1), complicated AA without perforation (type 2), and complicated AA with perforation (type 3). The imaging modality is indicated by an additional letter, e.g., type p3b for free perforation on pathology. Standardised reporting of the appendix evaluation by US and CT is presented, as well as algorithms for AA management. Imaging features indicating imminent perforation, as well as likely recurrence, were both classified as complicated AA.

CONCLUSION

Imaging is mandatory in suspected AA. The CAA clearly separates uncomplicated from complicated forms of AA allowing nonoperative management in selected patients with uncomplicated forms of AA.

Computerized tomography scan in acute appendicitis with eventual negative appendectomy

Background and Aim:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Relevance for Patients:

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

The usefulness and positive predictive value of ultrasonography and computed tomography in the diagnosis of acute appendicitis in adults: a retrospective study

OBJECTIVE

To analyze the evolution of the use of imaging tests (ultrasonography and computed tomography (CT)) in the diagnosis of acute appendicitis. To determine the positive predictive value of these tests and the percentage of negative and complicated appendectomies.

MATERIAL AND METHODS

This retrospective study compared adults who underwent appendectomy for suspected acute appendicitis at our tertiary hospital during 2015 versus similar patients at our center during 2007.

RESULTS

A total of 278 patients were included. The rate of negative appendectomies descended to 5%. The positive predictive value of ultrasonography increased to 97.4% in 2015, and the positive predictive value of CT and combined CT and ultrasonography was 100%. The rate of complicated appendicitis increased (23% in 2015).

CONCLUSIONS

The use of imaging tests increased, and the rate of "blind" laparotomies decreased. Nevertheless, the rate of complicated appendicitis increased.

The Accuracy of Low-dose Computed Tomography Protocol in Patients With Suspected Acute Appendicitis: The OPTICAP Study

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.

Diagnostic Accuracy of Abdominal Ultrasonography in Pediatric Acute Appendicitis

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.

Meta-analysis of in-hospital delay before surgery as a risk factor for complications in patients with acute appendicitis

Background

The traditional fear that every case of acute appendicitis will eventually perforate has led to the generally accepted emergency appendicectomy with minimized delay. However, emergency and thereby sometimes night‐time surgery is associated with several drawbacks, whereas the consequences of surgery after limited delay are unclear. This systematic review aimed to assess in‐hospital delay before surgery as risk factor for complicated appendicitis and postoperative morbidity in patients with acute appendicitis.

Methods

PubMed and EMBASE were searched from 1990 to 2016 for studies including patients who underwent appendicectomy for acute appendicitis, reported in two or more predefined time intervals. The primary outcome measure was complicated appendicitis after surgery (perforated or gangrenous appendicitis); other outcomes were postoperative surgical‐site infection and morbidity. Adjusted odds ratios (ORs) were pooled using forest plots if possible. Unadjusted data were pooled using generalized linear mixed models.

Results

Forty‐five studies with 152 314 patients were included. Pooled adjusted ORs revealed no significantly higher risk for complicated appendicitis when appendicectomy was delayed for 7–12 or 13–24 h (OR 1·07, 95 per cent c.i. 0·98 to 1·17, and OR 1·09, 0·95 to 1·24, respectively). Meta‐analysis of unadjusted data supported these findings by yielding no increased risk for complicated appendicitis or postoperative complications with a delay of 24–48 h.

Conclusion

This meta‐analysis demonstrates that delaying appendicectomy for presumed uncomplicated appendicitis for up to 24 h after admission does not appear to be a risk factor for complicated appendicitis, postoperative surgical‐site infection or morbidity. Delaying appendicectomy for up to 24 h may be an acceptable alternative for patients with no preoperative signs of complicated appendicitis.

Delay is safe

Time to appendectomy for acute appendicitis: A systematic review

OBJECTIVE

The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations regarding time to appendectomy for acute appendicitis in children within the context of preventing adverse events, reducing cost, and optimizing patient/parent satisfaction.

METHODS

The committee selected three questions that were addressed by searching MEDLINE, Embase, and the Cochrane Library databases for English language articles published between January 1, 1970 and November 3, 2016. Consensus recommendations for each question were made based on the best available evidence for both children and adults.

RESULTS

Based on level 3-4 evidence, appendectomy performed within 24h of admission in patients with acute appendicitis does not appear to be associated with increased perforation rates or other adverse events. Based on level 4 evidence, time from admission to appendectomy within 24h does not increase hospital cost or length of stay (LOS). Data are currently limited to determine an association between the timing of appendectomy and parent/patient satisfaction.

CONCLUSIONS

There is a paucity of high-quality evidence in the literature regarding timing of appendectomy for patients with acute appendicitis and its association with adverse events or resource utilization. Based on available evidence, appendectomy performed within the first 24h from presentation is not associated with an increased risk of perforation or adverse outcomes.

TYPE OF STUDY

Systematic Review of Level 1-4 studies.

Clinical Relevance of the Nonvisualized Appendix on Ultrasonography of the Abdomen in Children

OBJECTIVES

To evaluate the clinical relevance of the nonvisualized appendix on ultrasound imaging in children with right lower quadrant pain.

STUDY DESIGN

We reviewed 1359 children admitted for abdominal pain between January and December 2013 who had abdominal ultrasound imaging for right lower quadrant pain. Patients who had scans for genitourinary symptoms or intussusception were excluded from the study. When the appendix was not visualized, secondary signs indicating right lower quadrant inflammatory pathology were noted.

RESULTS

Of all admissions for abdominal pain, 810 had ultrasound scans. Thirty-eight did not evaluate the appendix and 131 were excluded for suspected intussusception, leaving 641 reports for children with a median age of 10.8 years (range, 1.3-21.3); 297 were boys (46.3%). There were 17 of 160 patients with a nonvisualized appendix (10.6%) who underwent appendectomy. Of these, 14 had secondary signs on ultrasound imaging and 3 (1.9%) had normal ultrasound reports. The 3 patients with normal ultrasound imaging had computed tomography imaging confirming appendicitis. There were 51 patients with a partially visualized appendix. The segment of appendix that could be seen was normal in 34 patients, none of whom had appendectomy. The remaining 17 had appendectomy, in whom the appendix seemed to be inflamed in 13 and equivocal in 4, all with histologically confirmed appendicitis. Overall, 232 children underwent appendectomy; 58 had no ultrasound imaging done, and 5 had a histologically normal appendix (overall negative appendectomy rate, 2.2%). Only 35 of 1359 patients (0.03%) had computed tomography scans.

CONCLUSION

In patients with a nonvisualized appendix on ultrasound imaging and no evidence of secondary inflammatory changes, the likelihood of appendicitis is less than 2%. Generous use of ultrasonography as an adjunct to clinical examination can achieve low negative appendectomy rates without underdiagnosis of acute appendicitis.