Predictive factors and outcomes of negative appendectomy

The Alvarado Score Is the Most Impactful Diagnostic Tool for Appendicitis: A Bibliometric Analysis

INTRODUCTION

The objective of this bibliometric analysis was to investigate the citation pattern of studies that have developed a diagnostic tool to diagnose appendicitis.

METHODS

We investigated characteristics of citations, publication frequency, evolution of citations, and fluctuation of previously highly cited studies. We analyzed which studies had been cited in the method section and identified impactful studies in this research field by a network visualization. We analyzed the differences in citations between diagnostic tools requiring a doctor to be present against the diagnostic tools not requiring doctors to be present, English language studies against non-English studies, and identified diagnostic tools targeting children.

RESULTS

There was an upward trend in publications in this research field, and between 1999-2021 the Alvarado score has been cited the most. In general, there was a high fluctuation, and 40 studies had been cited in the methods sections. There were significant differences in studies regarding diagnostic tools written in English compared to non-English studies, with more citations in the English-language studies. Furthermore, 22 studies had children as the target population.

CONCLUSIONS

The Alvarado score was the highest cited study since 1999, with 1086 citations, making it the most impactful study in this research field of diagnostic tools to diagnose appendicitis. Due to the diversity of target populations and settings for which diagnostic tools are developed, there is a need to expand research on diagnostic tools for appendicitis.

Diagnostic value of serum signal peptide-CUB-EGF-like domain-containing protein 1 levels in patients with acute appendicitis

OBJECTIVE

Acute appendicitis is one of the most common surgical causes of an acute abdomen among patients admitted to the emergency room due to abdominal pain. The clinical diagnosis of acute appendicitis is usually difficult and is made by evaluating the clinical, laboratory, and radiological findings together. The aim of this study was to investigate the diagnostic potential of signal peptide-CUB-EGF-like domain-containing protein 1 as a biomarker for acute appendicitis.

METHODS

A total of 67 adult patients without any comorbidities who presented to the emergency department with abdominal pain and were clinically diagnosed with acute appendicitis were included in the case group. The patients included in the study were classified into the negative appendectomy group and the acute appendicitis group according to their histopathological final diagnosis. In addition, 48 healthy volunteers without comorbidities were included in the control group. Signal peptide-CUB-EGF-like domain-containing protein 1 levels of patients and the control group were measured.

RESULTS

According to postoperative histopathological examinations of the patients, 7 (10.4%) patients were diagnosed with negative appendectomy, and 60 (89.6%) patients were diagnosed with acute appendicitis. Signal peptide-CUB-EGF-like domain-containing protein 1 levels were higher in the patients with acute appendicitis than in negative appendectomy patients (p=0.012). Signal peptide-CUB-EGF-like domain-containing protein 1 levels were also higher in the case group compared to the control group (p=0.001).

CONCLUSION

The admission signal peptide-CUB-EGF-like domain-containing protein 1 level was significantly higher in adults with acute appendicitis. The SCUBE1 level is a novel but promising biomarker that aids in the diagnosis of acute appendicitis.

Adult appendicitis score versus Alvarado score: A comparative study in the diagnosis of acute appendicitis

Background

Acute Appendicitis (AA) is the most common abdominal surgical emergency. It requires proper management to decrease mortality and morbidity. Clinical scoring systems for diagnosing AA aimed to decrease the use of radiological scans and the rate of negative appendectomies (NA). We aim to assess the adult appendicitis score (AAS) in the diagnosis prediction of AA.

Method

A retrospective study with 1303 cases of AA is performed. We compared the correlation of AAS and Alvarado scores to postoperative histopathology. Specificity, sensitivity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) were assessed. ROC was used.

Results

AAS risk stratification was applied to the study population. Group I for a low probability, and groups II and III for an intermediate and high probability of AA. We found that 159 patients were matched in group I, 505, and 639 were in groups II and III of AAS, respectively. The correlation between Alvarado and AAS with HP was significant. AAS ≥ 16 presented sensitivity and specificity of 50 % and 75.47 %, respectively, with PPV of 97.96 % and NPV of 6.02 %, with an accuracy of 51.04 %. Regarding AAS ≥ 11, the sensitivity was 88.96 %, specificity was 39.62 %, PPV was 97.2 %, NPV was 13.21 %, and accuracy was 86.95 %.

Conclusion

AAS is relatively more accurate than Alvarado's score, especially in selecting a safe candidate for discharge from an emergency. In addition, AAS is found to decrease the need for radiological images and NA rate more than Alvarado.

The Effect of Preoperative Imaging on the Negative Appendicectomy Rate

Background Appendicitis is one of the most common causes of acute abdominal pain and appendicectomy is one of the most frequently performed surgical procedures. The proliferation of radiological imaging has reduced the number of patients who have a normal appendix removed, i.e., a negative appendicectomy. We aimed to assess the effect of preoperative imaging on the negative appendicectomy rate (NAR). Methodology All emergency appendicectomies performed at a district general hospital in the United Kingdom over two separate one-year periods were retrospectively analysed using emergency theatre log books. The timeframes were chosen based on the introduction of a diagnostic pathway to reduce the number of appendicectomies performed on patients later found not to have appendicitis or alternative abnormality, i.e., a negative appendicectomy. This pathway involved a greater emphasis placed on preoperative imaging (CT or ultrasound) for patients with suspected appendicitis. The study excluded any patients who were found to have an alternative pathology during surgery. Information technology databases were used to collect data on patient demographics, date of surgery, histology, and any preoperative imaging that was performed. All histological findings showing acutely inflamed appendices and those positive for malignancy were categorised as positive, whereas all other findings were categorised as negative. Results During our initial data collection period (April 2018 to April 2019), we collected data on 207 patients who underwent an appendicectomy. The NAR was 17%. During our subsequent data collection period (August 2020 to August 2021), we collected data on 184 patients. The NAR was 16%. In our adult population, the NAR decreased from 13% to 9%. Discussion At first glance, the NAR does not seem to have improved. On closer look, all patients over the age of 21 years in our re-audit underwent pr-operative CT, and there was a reduction in the NAR in these patients. The issue arises with younger patients, in whom justifying the radiation associated with a CT scan may be difficult. Although ultrasound does not carry the same radiation risk, previous audits at our trust have that shown its sensitivity and specificity for appendicitis is approximately 60%. We may have to explore alternative imaging modalities such as MRI in the paediatric population or accept the higher NAR.

Varying negative appendectomy rates after laparoscopic appendectomy: a systematic review and meta-analysis

PURPOSE

Appendicitis is a common cause of acute abdominal pain, and treatment with laparoscopy has become increasingly common during the past two decades. Guidelines recommend that normal appendices are removed if operated for suspected acute appendicitis. It is unclear how many patients are affected by this recommendation. The aim of this study was to estimate the rate of negative appendectomies in patients undergoing laparoscopic surgery for suspected acute appendicitis.

METHODS

This study was reported following the PRISMA 2020 statement. A systematic search was conducted in PubMed and Embase for retrospective or prospective cohort studies (with n ≥ 100) including patients with suspected acute appendicitis. The primary outcome was the histopathologically confirmed negative appendectomy rate after a laparoscopic approach with a 95% confidence interval (CI). We performed subgroup analyses on geographical region, age, sex, and use of preoperative imaging or scoring systems. The risk of bias was assessed using the Newcastle-Ottawa Scale. Certainty of the evidence was assessed using GRADE.

RESULTS

In total, 74 studies were identified, summing up to 76,688 patients. The negative appendectomy rate varied from 0% to 46% in the included studies (interquartile range 4-20%). The meta-analysis estimated the negative appendectomy rate to be 13% (95% CI 12-14%) with large variations between the individual studies. Sensitivity analyses did not change the estimate. The certainty of evidence by GRADE was moderate due to inconsistency in point estimates.

CONCLUSION

The overall estimated negative appendectomy rate after laparoscopic surgery was 13% with moderate certainty of evidence. The negative appendectomy rate varied greatly between studies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Many diagnostic tools for appendicitis: a scoping review

BACKGROUND

We aimed to provide an overview of all diagnostic tools developed to diagnose appendicitis with their reported accuracy and to further characterize these including their need for diagnostic equipment.

METHODS

This scoping review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews and a protocol was registered at Open Science Framework. We performed a systematic literature search in PubMed, Embase, China National Knowledge Infrastructure, Índice Bibliográfico Espanhol de Ciências da Saúde, and Latin American and Caribbean Health Sciences Literature. We included original articles of all languages with the purpose to derive an accessible diagnostic tool. We extracted data regarding study- and diagnostic tool characteristics, and the accuracy of each diagnostic tool.

RESULTS

The search led to 6419 records, where 74 studies were included, yielding 82 diagnostic tools reported in seven different languages. Among these tools, 35% included patient characteristics, 85% symptoms, 93% physical examinations, 37% vital signs, 78% laboratory values, and 16% imaging. Among the diagnostic tools, 35% relied on a medical doctor/surgeon with access to a laboratory, and six diagnostic tools did not require a bedside medical doctor/surgeon. The median positive predictive value, negative predictive value, sensitivity, and specificity across diagnostic tools were 91%, 94%, 89%, and 86%, respectively.

CONCLUSIONS

We identified 82 diagnostic tools that most frequently were based on symptoms and physical examinations. Most diagnostic tools relied on a medical doctor/surgeon with access to laboratory values. The accuracy was high across the diagnostic tools.

Negative appendectomy rate in patients diagnosed with acute appendicitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Role of Alvarado Score in Predicting Acute Appendicitis and Its Severity in Correlation to Histopathology: A Retrospective Study in a Qatar Population

Background/objective

Acute appendicitis (AA) is one of the most common surgical emergencies that require a proper diagnosis to avoid a negative outcome in the case of missed or delayed diagnosis. Our study aims to assess the diagnostic power of the Alvarado score and the prediction of the severity of acute appendicitis in correlation to intraoperative findings and the final histopathology (HP) result.

Methods

This retrospective study was applied to 1,303 patients with clinically proven acute appendicitis (AA) and available HP results. We correlated Alvarado score to the gold standard HP and intraoperative findings. We selected the cutoff point of Alvarado at 5 and 7 as they were the most frequent cutoff value mentioned in the literature and based on the ROC curve in this study to assess sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

Results

The mean age of the study cohort is 33.3 ± 9.5 years, with a male predominance (75.8%). The negative appendectomy (NA) rate was 4%. The operative complication rate was 1.2%, and we recorded one mortality case (0.1%). The diagnostic evidence of AA was in 95.9% of cases. Alvarado score ≥ 7 presented sensitivity and specificity of 66.4% and 69.8%, respectively, with PPV of 98.1% and NPV of 8.1%, with an accuracy of 66.5%. For Alvarado score ≥ 5, the sensitivity was 91.2%, specificity was 22.6%, PPV was 96.5%, NPV was 9.8%, and accuracy was 88.4%. In addition, we demonstrated statistical significance between Alvarado risk stratification with HP and intraoperative grades (p = 0.001 each).

Conclusion

The Alvarado scoring system alone is not enough to diagnose AA with unsatisfactory sensitivity and specificity. However, it is a good indicator of the severity of AA that we can depend on to prioritize those patients waiting for surgery.

Endoscopic retrograde appendicitis therapy for acute appendicitis: a systematic review and meta-analysis

Background and study aims Endoscopic retrograde appendicitis therapy (ERAT) is an endoscopic procedure for management of patients with acute appendicitis (AA). In addition to being minimally invasive, it has the added advantages of preservation of appendix and simultaneous inspection of colon. We performed a systematic review and meta-analysis on ERAT in patients with AA.

Methods We conducted a comprehensive search of multiple electronic databases (from inception through January 2022) to identify studies reporting ERAT in AA. The primary outcome was to evaluate the overall clinical and technical success of ERAT. The secondary outcome was to study the total and individual adverse events (AEs). The meta-analysis was performed using Der Simonian and Laird random effect model.

Results Seven studies reporting on 298 patients were included. The majority of the patient population was male (55.3 %), with mean age of 31 ± 12.39 years. The pooled technical success rate was 99.36 % (95 % CI 97.61–100, I2 = 0) and the pooled clinical success rate was 99.29 % (95 % CI 97.48–100, I2 = 0). The pooled AE rate was 0.19 % (95 % CI 0–1.55, I2 = 0). The most common AE was perforation with 0.19 % (95 % CI 0–1.55, I2 = 0). The recurrence rate was 6.01 % (95 % CI 2.9–9.93, I2 = 20.10). Average length of procedure was 41.1 ± 7.16 min. Low heterogeneity was noted in in our meta-analysis.

Conclusions ERAT is a safe procedure with high rates of clinical and technical success in patients with AA. Further randomized controlled trials should be performed to assess the utility of ERAT in AA as compared to laparoscopic appendectomy.

Comparison of scoring systems regarding the gender as a parameter with the traditional scoring systems for predicting appendicitis

Although acute appendicitis remains the most common cause of acute abdomen in General Surgery practice, negative appendectomy rates are still high in particularly female patients. Appendicitis scoring systems considering gender can help the clinician to reduce negative appendectomy rates in females. This present study aims to compare the Lintula, Ripasa, Fenyo-Lindberg scoring systems, which use gender as a variable, with the Alvarado, Karaman, scoring systems to evaluate which CSS is more successful in the differential diagnosis of appendicitis in females. We analyzed the records of the patients operated on with a prediagnosis of acute appendicitis in our clinic between 2020 and 2021, retrospectively. Alvarado, adult appendicitis score (AAS), appendicitis inflammatory response score (AIRS), Ripasa, Karaman, Lintula, and Fenyo Lindberg scores were calculated for each patient. The patients were divided into two groups as male and female, according to gender. Receiver operator characteristic (ROC) curve analysis was used to identify the best cut-off value and assess the performance of the test score for appendicitis. Three hundred and sixty-three patients were included in the study. One hundred seventy-two (47.4%) of the patients were male, and 191 (52.6%) were female. Alvarado and AAS were the most valuable score in female (AUC: 0.805, sensitivity: 0.63, specificity: 0.83; and area under curve (AUC): 0.794, Sensitivity 0.71, Specificity: 0.76, respectively), male group (AUC: 0.828, Sensitivity: 0.71, Specificity: 0.83; and AUC: 0.834, Sensitivity 0.74, Specificity: 0.77, respectively), and when patients were not categorized by gender (AUC: 0.818, Sensitivity: 0.67 Specificity: 0.83; and AUC: 0.794, Sensitivity 0.71, Specificity: 0.76, respectively). Although the Alvarado scoring system is the first defined appendicitis scoring system, it seems as superior to the many scoring systems defined after it in predicting appendicitis, even in female patients.

Digital single-operator cholangioscope for endoscopic retrograde appendicitis therapy

BACKGROUND

This study aimed to investigate the diagnostic and therapeutic value of a digital single-operator cholangioscope (SOC) system for endoscopic management of acute appendicitis.

METHODS

14 patients with acute uncomplicated simple or supportive appendicitis were evaluated between November 2018 and September 2020. The diagnosis of acute appendicitis was confirmed by direct colonoscopy imaging and cholangioscope. The success rate of digital SOC-assisted endoscopic retrograde appendicitis therapy (ERAT), the procedure time, postoperative length of hospital stay, complications, and recurrence rate were recorded.

RESULTS

Technical success rate was 100 %, with high quality imaging of the appendiceal cavity achieved using SOC in all 14 patients. The mean procedure time was 37.8 (standard deviation [SD] 22) minutes. All patients experienced immediate relief from abdominal pain after the procedure. Mean postoperative hospitalization was 1.9 (SD 0.7) days. No recurrence occurred during 2-24 months of follow-up.

CONCLUSION

Digital SOC-assisted ERAT provided a feasible, safe, and effective alternative approach for diagnosis and management of acute uncomplicated appendicitis without the need for X-ray or ultrasonic guidance.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Negative Appendicectomy Rate: Incidence and Predictors

Introduction

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

Patients and methods

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

Results

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

Conclusion

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

Final diagnosis and patient disposition following equivocal results on 2-mSv CT vs. conventional-dose CT in adolescents and young adults with suspected appendicitis: a post hoc analysis of large pragmatic randomized trial data

OBJECTIVE

To compare 2-mSv CT and conventional-dose CT (CDCT, typically 7-8 mSv) regarding final diagnosis and patient disposition following equivocal CT results in adolescents and young adults with suspected appendicitis.

METHODS

In total, 3074 patients of 15-44 years (28 ± 9 years, 1672 women) from 20 hospitals were randomized to undergo contrast-enhanced 2-mSv CT (n = 1535) or CDCT (n = 1539) from December 2013 through August 2016. One hundred sixty-one radiologists prospectively rated the likelihood of appendicitis in a Likert scale (i.e., grades 1-5). The final diagnosis was based on CT image, surgical, pathologic, and clinical findings. Post hoc analysis was performed for final diagnosis, surgical procedure, and delay in patient management following equivocal results (i.e., grade 3).

RESULTS

The 2-mSv CT and CDCT groups were comparable for final diagnosis following equivocal results, including confirmed appendicitis (1.2% [18 patients] vs. 1.2% [19], p > 0.99), negative appendectomy (0.1% [2] vs. 0.3% [4], p = 0.53), and perforated appendicitis (0.1% [1] vs. 0.2% [3], p = 0.53). More patients were confirmed as not having appendicitis following equivocal results in the CDCT group than in the 2-mSv CT group (2.2% [34] vs. 1.0% [16], p = 0.016). The two groups were comparable for the need of appendectomy (1.4% [22] vs. 1.5% [23], p > 0.99), need of additional imaging tests (0.7% [11] vs. 1.1% [17], p = 0.35), and delay in patient management following equivocal results.

CONCLUSION

2-mSv CT is comparable to CDCT regarding final diagnosis and patient disposition following equivocal CT results.

KEY POINTS

• Our results strengthen evidence justifying the use of low-dose CT instead of conventional-dose CT (CDCT) in adolescents and young adults with suspected appendicitis. • The 2-mSv CT and CDCT groups were comparable for final diagnosis following equivocal CT results, including confirmed appendicitis (1.2% vs. 1.2%, p > 0.99), negative appendectomy (0.1% vs. 0.3%, p = 0.53), and perforated appendicitis (0.1% vs. 0.2%, p = 0.53). • The two groups were comparable for the need for appendectomy (1.4% vs. 1.5%, p > 0.99), need for additional imaging tests (0.7% vs. 1.1%, p = 0.35), and delay in patient management, following equivocal CT results.

Cohort study of 1241 patients to identify predictors of negative appendicectomy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Management of the normal-appearing appendix during laparoscopy for clinically suspected acute appendicitis in the pediatric population

PURPOSE

The widespread use of laparoscopy has brought forth the question of how to manage a macroscopically normal-appearing appendix in cases of clinically suspected appendicitis. This study aimed to determine the current practices of pediatric general surgeons in Canada regarding this matter.

METHODS

An online survey was created following the American Pediatric Surgical Association (APSA) guidelines and distributed via email to the Canadian Association of Pediatric Surgeons (CAPS) staff surgeons. The questions assessed clinician characteristics, standard practice, and rationale. Results were analyzed using descriptive statistics.

RESULTS

A total of 54/72 (75%) CAPS members practicing in Canada completed the survey. All (100%) agreed they would remove a normal-appearing appendix during laparoscopy for suspected acute appendicitis. The most common reasons were: possibility of microscopic appendicitis (39/54, 72.2%), avoiding future diagnostic confusion (28/54, 51.9%), and patient preference/consent discussion (21/54, 38.9%). Most (53/54, 98.1%) had performed a negative appendectomy and 49/54 (90.7%) agreed there were no sufficient guidelines.

CONCLUSIONS

The majority of pediatric surgeons agree sufficient guidelines do not exist to support decision making when a normal-appearing appendix is found during laparoscopy for suspected acute appendicitis. This survey shows that removal of the appendix in this case would be supported by the majority of Canadian pediatric surgeons.

TYPE OF STUDY

Survey LEVEL OF EVIDENCE: VII (Expert Opinion).

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

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

Diagnostic efficacy of serum procalcitonin, IL-6, IL-2, and D-dimer levels in an experimental acute appendicitis model

BACKGROUND/AIMS

Acute appendicitis is the most frequent cause of acute abdomen emergency surgery. It continues to be a problem today due to delayed diagnosis and its high perforation rate. For this reason, diagnostic tests continue to be developed. In this experimental study, the diagnostic significance of blood procalcitonin (PCT), interleukin (IL)-6, IL-2, and D-dimer levels in an acute appendicitis model in rabbits was investigated.

MATERIALS AND METHODS

A total of five groups were included: control group, sham group, and three different acute appendicitis groups. In the appendicitis groups, the appendix was ligated by laparotomy, and the blood PCT, IL-6, IL-2, and D-dimer levels were measured at 12 (group 3), 24 (group 4), and 48 h (group 5). Then, an appendectomy was performed.

RESULTS

In the present study, PCT and IL-6 levels increased in parallel with the inflammation of the appendix in all groups and were found to be statistically significant. IL-2 and D-dimer values were higher in the groups diagnosed with appendicitis but were not statistically significant.

CONCLUSION

In our experimental study, PCT and IL-6 levels were determined to be important in the early diagnosis of acute appendicitis, especially IL-6, and that these two parameters are more important markers than IL-2 and D-dimer.

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment of choice for acute appendicitis. However, in consequence of the evolution of endoscopic surgery, the operation can also be performed with minimally invasive surgery. Due to smaller incisions, the laparoscopic approach may be associated with reduced postoperative pain, reduced wound infection rate, and shorter time until return to normal activity.This is an update of the review published in 2010.

OBJECTIVES

To compare the effects of laparoscopic appendectomy (LA) and open appendectomy (OA) with regard to benefits and harms.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE and Embase (9 February 2018). We identified proposed and ongoing studies from World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and EU Clinical Trials Register (9 February 2018). We handsearched reference lists of identified studies and the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing LA versus OA in adults or children.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias, and extracted data. We performed the meta-analyses using Review Manager 5. We calculated the Peto odds ratio (OR) for very rare outcomes, and the mean difference (MD) for continuous outcomes (or standardised mean differences (SMD) if researchers used different scales such as quality of life) with 95% confidence intervals (CI). We used GRADE to rate the quality of the evidence.

MAIN RESULTS

We identified 85 studies involving 9765 participants. Seventy-five trials included 8520 adults and 10 trials included 1245 children. Most studies had risk of bias issues, with attrition bias being the largest source across studies due to incomplete outcome data.In adults, pain intensity on day one was reduced by 0.75 cm on a 10 cm VAS after LA (MD -0.75, 95% CI -1.04 to -0.45; 20 RCTs; 2421 participants; low-quality evidence). Wound infections were less likely after LA (Peto OR 0.42, 95% CI 0.35 to 0.51; 63 RCTs; 7612 participants; moderate-quality evidence), but the incidence of intra-abdominal abscesses was increased following LA (Peto OR 1.65, 95% CI 1.12 to 2.43; 53 RCTs; 6677 participants; moderate-quality evidence).The length of hospital stay was shortened by one day after LA (MD -0.96, 95% CI -1.23 to -0.70; 46 RCTs; 5127 participant; low-quality evidence). The time until return to normal activity occurred five days earlier after LA than after OA (MD -4.97, 95% CI -6.77 to -3.16; 17 RCTs; 1653 participants; low-quality evidence). Two studies showed better quality of life scores following LA, but used different scales, and therefore no pooled estimates were presented. One used the SF-36 questionnaire two weeks after surgery and the other used the Gastro-intestinal Quality of Life Index six weeks and six months after surgery (both low-quality evidence).In children, we found no differences in pain intensity on day one (MD -0.80, 95% CI -1.65 to 0.05; 1 RCT; 61 participants; low-quality evidence), intra-abdominal abscesses after LA (Peto OR 0.54, 95% CI 0.24 to 1.22; 9 RCTs; 1185 participants; low-quality evidence) or time until return to normal activity (MD -0.50, 95% CI -1.30 to 0.30; 1 RCT; 383 participants; moderate-quality evidence). However, wound infections were less likely after LA (Peto OR 0.25, 95% CI 0.15 to 0.42; 10 RCTs; 1245 participants; moderate-quality evidence) and the length of hospital stay was shortened by 0.8 days after LA (MD -0.81, 95% CI -1.01 to -0.62; 6 RCTs; 316 participants; low-quality evidence). Quality of life was not reported in any of the included studies.

AUTHORS' CONCLUSIONS

Except for a higher rate of intra-abdominal abscesses after LA in adults, LA showed advantages over OA in pain intensity on day one, wound infections, length of hospital stay and time until return to normal activity in adults. In contrast, LA showed advantages over OA in wound infections and length of hospital stay in children. Two studies reported better quality of life scores in adults. No study reported this outcome in children. However, the quality of evidence ranged from very low to moderate and some of the clinical effects of LA were small and of limited clinical relevance. Future studies with low risk of bias should investigate, in particular, the quality of life in children.

Diagnosis of Appendicitis in Patients with a Normal White Blood Cell Count; A Cross-Sectional Study

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.

Laparoscopic appendectomy for acute appendicitis: How to discourage surgeons using inadequate therapy

Acute appendicitis (AA) develops in a progressive and irreversible manner, even if the clinical course of AA can be temporarily modified by intentional medications. Reliable and real-time diagnosis of AA can be made based on findings of the white blood cell count and enhanced computed tomography. Emergent laparoscopic appendectomy (LA) is considered as the first therapeutic choice for AA. Interval/delayed appendectomy at 6-12 wk after disease onset is considered as unsafe with a high recurrent rate during the waiting time. However, this technique may have some advantages for avoiding unnecessary extended resection in patients with an appendiceal mass. Non-operative management of AA may be tolerated only in children. Postoperative complications increase according to the patient’s factors, and temporal avoidance of emergent general anesthesia may be beneficial for high-risk patients. The surgeon’s skill and cooperation of the hospital are important for successful LA. Delaying appendectomy for less than 24 h from diagnosis is safe. Additionally, a semi-elective manner (i.e., LA within 24 h after onset of symptoms) may be paradoxically acceptable, according to the factors of the patient, physician, and institution. Prompt LA is mandatory for AA. Fortunately, the Japanese government uses a universal health insurance system, which covers LA.