Readmission and reoperation rates following negative diagnostic laparoscopy for clinically suspected appendicitis: The "normal" appendix should not be removed - A retrospective cohort study

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.

Validity of the coding for appendicitis, appendectomy, and diagnostic laparoscopy in the Danish National Patient Registry

BACKGROUND AND OBJECTIVE

We aimed to validate the diagnostic accuracy of appendicitis, its severity, its description, and the surgical approach, including open or laparoscopic appendectomy and diagnostic laparoscopy, in the Danish National Patient Registry (DNPR) against information from the electronic medical records.

METHODS

A random sample of 1046 patients of all ages and sexes recorded in the DNPR from the Capital Region of Denmark during 2010-2015 was investigated. Patients' admission had to include a discharge code for appendicitis (K35-K379) according to the International Classification of Disease version 10 (ICD-10) alone or in combination with a surgical code for appendectomy or the surgical code for a diagnostic laparoscopy. We calculated the positive predictive values (PPVs) with 95% confidence intervals.

RESULTS

Data from a total of 1018 patients were available for data analysis. The ICD-10 codes for appendicitis resulted in a good PPV of >95% when combined with a surgical code. ICD-10 codes combined with the surgical codes could discriminate between uncomplicated and complicated appendicitis with some caution as the PPVs ranged from 68% to 93%. Only the surgical code for laparoscopic appendectomy yielded a good PPV (99%) for the actual surgical approach. The surgical code for a diagnostic laparoscopy alone did not cover a normal diagnostic laparoscopy.

CONCLUSIONS

The diagnostic accuracy of appendicitis and appendectomy in routinely collected administrative health data is good for ICD-10 codes for appendicitis in combination with a surgical code and especially for laparoscopic appendectomy. Uncomplicated and complicated appendicitis can be distinguished with some caution.

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.

Outcomes of the Macroscopically Normal Appendix Left in Situ in Patients with Suspected Appendicitis

BACKGROUND

Right iliac fossa (RIF) pain is a common indication for laparoscopy to diagnose and treat appendicitis. When a macroscopically normal appendix is found, there is no standard consensus regarding excision. Some surgeons remove the appendix due to the risk of microscopic inflammation and to avoid a future, repeat laparoscopy for possible appendicitis. Alternatively, others leave the appendix in situ to avoid morbidity from a potentially unnecessary procedure. We aimed to evaluate the outcomes of patients with macroscopically normal appendices left in situ.

METHODS

All emergency laparoscopies without appendicectomy between January 1st 2010- December 31st 2020 were identified from theatre records. All operative notes were individually evaluated and comments on the macroscopic appearance of the appendix and any intra-operative pathology were recorded. Only patients undergoing laparoscopy for suspected appendicitis with macroscopically normal appendices were included.

RESULTS

A total of 120 patients [median age 21.68 (range 9-90.8) years] were included. The cohort was predominantly female (n=105, 87.5%). Forty-eight patients (40.0%) had a positive finding during index laparoscopy. During a median duration of 94.5 (range 8-131) months' follow-up, 16 patients (13.33%) underwent a repeat laparoscopy for recurrent RIF pain. Thirteen (10.8% of total cohort) subsequently underwent an appendicectomy. Histology confirmed acute appendicitis in six cases (4.17% of entire cohort). On subanalysis of smaller cohort, index laparoscopies with no positive findings (n=72), nine patients (12.5%) underwent appendicectomy with two (2.7%) appendices demonstrating appendicitis on histological examination.

CONCLUSION

87% of the total cohort with a normal appendix at laparoscopy for RIF pain did not undergo further laparoscopy. Less than 5% of the total cohort and 2.7% of subanalysis cohort had an appendicectomy for histologically-proven appendicitis within the follow-up period. From the evidence in this study, we conclude that leaving the appendix in situ unless macroscopically inflamed is a viable alternative to excision.

MANAGEMENT OF ILEOCECAL CROHN'S DISEASE DURING SURGICAL TREATMENT FOR ACUTE APPENDICITIS: A SYSTEMATIC REVIEW

BACKGROUND

In many patients, the diagnosis of Crohn's disease (CD) is made during surgery for appendicitis in urgent settings. Intraoperative diagnosis can be challenging in certain cases, especially for less experienced surgeons.

OBJECTIVE

Review of the literature searching for scientific evidence that can guide surgeons through optimal management of ileocecal CD found incidentally in surgery for acute appendicitis (AA).

METHODS

Included studies were identified by electronic search in the PubMed database according to the Preferred Items of Reports for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The quality and bias assessments were performed by Methodological Index for Non-Randomized Studies (MINORS) criteria for non-randomized studies.

RESULTS

A total of 313 studies were initially identified, six of which were selected (all retrospective) for qualitative assessment (two studies were comparative and four only descriptive case series). Four studies identified a high rate of complications when appendectomy or ileocolectomy were performed and in only one, there was no increased risk of postoperative complications with appendectomy. In the sixth study, diarrhea, previous abdominal pain, preoperative anemia and thrombocytopenia were independent predictors for CD in patients previously operated for suspected AA.

CONCLUSION

Despite the paucity of data and low quality of evidence, a macroscopically normal appendix should be preserved in the absence of complicated disease when CD is suspected in surgery for AA. Ileocecal resections should be reserved for complicated disease (inflammatory mass, ischemia, perforation or obstruction). Further prospective studies are needed to confirm these claims.

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.

Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines

BACKGROUND AND AIMS

Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.

METHODS

This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.

CONCLUSIONS

The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.