The use of computed tomography versus clinical acumen in diagnosing appendicitis in children: A two-institution international study

Evaluation of the ability of laboratory, ultrasonography, and Doppler ultrasonography findings to distinguish between simple and complicated appendicitis

OBJECTIVE

To evaluate the utility of laboratory ultrasonographic and Doppler ultrasonographic findings in the differentiation of simple and complicated appendicitis.

METHODS

A prospective study was conducted, including pediatric patients who underwent surgery with the diagnosis of appendicitis.

RESULTS

Fifty patients, who were found to have appendicitis on ultrasonographic examination, were included. The mean age was found to be 12.80 ± 3.67 years, with 30% female and 70% male. The patients were histopathologically divided into two groups: simple appendicitis (Group 1, 41 patients, 82%) and complicated appendicitis (Group 2, 9 patients, 18%). CRP (C-reactive protein) levels (p = 0.004) and periappendiceal fatty tissue thickness (PFI) (p < 0.005) were found to be statistically significantly higher in Group 2 compared to Group 1. The portal vein (PV) diameter and peak systolic velocity (PSV) values were significantly higher in the study group compared to the control group (p = 0.033, p = 0.001).

CONCLUSION

Doppler ultrasonographic examination did not significantly differentiate complicated from simple appendicitis. The CRP value is an independent risk factor in the diagnosis of complicated appendicitis, and the presence of a significant increase in mesenteric tissue thickness is one of the important criteria for differentiating complicated appendicitis from simple appendicitis.

Quality Improvement Campaign Improved Utilization of Rapid Sequence MRI for Diagnosis of Pediatric Appendicitis

INTRODUCTION

Appendicitis is the most common indication for emergency general surgery in the pediatric population. Computed tomography (CT) or magnetic resonance imaging (MRI) may be used for diagnosis when ultrasound findings are equivocal. However, CT involves unnecessary radiation exposure if MRI is available. After introducing a rapid sequence MRI (rsMRI) appendicitis protocol at our institution, CT was still preferentially used. We therefore implemented a quality improvement (QI) campaign to reduce the rate of CTs and increase the rate of rsMRI. Here, we assess the effectiveness of the QI campaign while evaluating potential barriers to using rsMRI.

METHODS

We conducted a mixed methods study, first performing stakeholder interviews which informed the design of a QI campaign initiated in May 2021 and a midway feedback survey in December 2021. A retrospective cohort study was then performed of children evaluated for appendicitis at our institution between January 1, 2016, and April 30, 2022. CT and rsMRI rates were compared before and after QI campaign implementation.

RESULTS

There was a significant decrease in rate of CTs and increase in rate of rsMRIs performed following the initiation of the QI campaign (p < 0.0001). The rate of CT scans decreased by a factor of 0.4 while the rate of rsMRI increased by a factor of 9.5.

CONCLUSION

A successful QI campaign was initiated at our institution, resulting in decreased utilization of CT and increased use of rsMRI for the evaluation of suspected appendicitis. These results highlight the potential impact of QI projects.

LEVEL OF EVIDENCE

III.

Acute Appendicitis in Children: Evaluation of the Diagnostic Efficacy of Ultrasonography and Computed Tomography

OBJECTIVE

Acute appendicitis (AA), the most common cause of acute abdomen in childhood, can result in significant morbidity and mortality if not diagnosed and treated in a timely manner. Diagnosis of AA is more difficult in children due to the limited communication skills, in comparison to adults. The aim of this study is to evaluate the diagnostic accuracy of abdominal ultrasonography (US) and computed tomography (CT) in the diagnosis of AA in children.

MATERIALS AND METHODS

Pediatric patients who were operated on with the diagnosis of AA between January 2016 and December 2021 were retrospectively reviewed. Preoperative abdominal US and CT findings of the patients and postoperative pathology results were recorded.

RESULTS

A total of 263 patients with a mean age of 11.3 years were included in the study. There were 164 (62.3%) males and 99 (37.7%) females. Histopathology revealed AA in 215 (81.7%) patients. Preoperatively, US and CT were performed in 139 (52.8%) and 137 (54.5%), respectively. Both imaging methods were applied to 13 (5.1%) patients. US had a sensitivity and specificity rate of 77.2% and 52.6%, respectively. Positive predictive value (PPV) was found to be 81.2%, whereas negative predictive value (NPV) was 46.5% for US. The diagnostic accuracy rate of US was found as 70.5%. CT had a sensitivity and specificity rate of 88.1% and 57.1%, respectively. PPV was found to be 88.8%, whereas NPV was 55.1% for CT. The diagnostic accuracy rate of CT was found as 81.8%.

CONCLUSION

In case of suspicion of AA, US may be the first choice because it is inexpensive and easily accessible. However, considering patient incompatibility and subjective factors in children, US may sometimes be insufficient. We think that CT should be performed as an advanced examination method in cases where US is not compatible with the patient's condition, not clinic.

Other Pathologies Were Rarely Reported after Laparoscopic Surgery for Suspected Appendicitis: A Systematic Review and Meta-Analysis

BACKGROUND

Diagnostic laparoscopy is often used when a patient is suspected of having acute appendicitis. The aim of this study was to assess the rate of other pathologies found during diagnostic laparoscopy for suspected acute appendicitis.

METHODS

This systematic search included studies with ≥100 patients who received laparoscopy for suspected acute appendicitis and reported on the histopathologic and other intra-abdominal findings. We performed a meta-analysis estimating the rate of other pathologies, and a sensitivity analysis excluding smaller cohorts (≤500 patients). Age groups, sex, specific findings, and geographic regions were investigated. Certainty of evidence was assessed with GRADE.

RESULTS

A total of 27 studies were included covering 25,547 patients and of these 793 had an unexpected pathology. The findings were benign pathology in the appendix (34%), malignancy (30%), gynecologic pathology (5%), gastrointestinal pathology (4%), or unspecified (27%). Meta-analysis showed an overall rate of unexpected findings of 3.5% (95% CI 2.7-4.3; moderate certainty), and the sensitivity analysis showed similar results. Malignancy found in the appendix when treating suspected acute appendicitis was 1.0% (95% CI 0.8-1.3%; high certainty).

CONCLUSION

The rate of other histopathological findings in patients with suspected acute appendicitis was low and a malignancy in appendix was found in 1% of patients.

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.

Single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) for inguinal hernia with prolapsed ovary

BACKGROUND

Most studies reporting the outcomes of laparoscopic ovarian prolapsed hernia operations with large sample sizes are based on intracorporeal closure, while studies on extraperitoneal closure have limited sample sizes. We proactively used the single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) technique and obtained favorable outcomes, which we report in this paper.

METHODS

We retrospectively reviewed patients who had undergone laparoscopic surgery for inguinal hernia at our institution. They were retrospectively classified into two groups based on the pre- or intraoperative diagnosis of hernia with a prolapsed ovary, namely the prolapse group and the non-prolapse group, respectively. The data were statistically analyzed and p < 0.05 was considered statistically significant.

RESULTS

A total of 771 subjects underwent SILPEC during the study period, including 400 girls. Among them, 63 girls were diagnosed with an ovarian prolapsed hernia. SILPEC was successfully performed through a single port in all cases, with a single exception, in whom the forceps was inserted directly through the right lower quadrant to pull up the ovary. The duration of surgery in the prolapse group was not higher than that in the non-prolapse group. During the SILPEC surgery, the ovaries were successfully reverted into the abdominal cavity by external compression of the inguinal area alone in 38 of the 63 patients. In the remaining 25 cases, the ovaries were reverted into the abdominal cavity by external compression of the inguinal area and traction of the round ligament with forceps. None of these cases failed to return to the ovaries.

CONCLUSION

Our study results indicate that SILPEC may be performed safely for the treatment of ovarian prolapsed inguinal hernia. Since the ovary and fallopian tube are close to the internal inguinal ring due to the short round ligament, the procedure requires careful suturing with traction of the round ligament.

Laparoscopic iliopubic tract repair to treat recurrent pediatric inguinal hernia

BACKGROUND

Congenital defects, such as open processus vaginalis and the canal of Nuck, are common causes of primary pediatric inguinal hernia (PIH). However, in some patients, PIH occurs via acquired defects rather than congenital defects. The most representative cause of PIH is recurrent hernia. Recurrent PIH is treated with high ligation (HL), which is the same method that is used to treat primary PIH. However, the re-recurrence rate of recurrent PIH is high. This study aimed to compare laparoscopic iliopubic tract repair (IPTR) with laparoscopic HL for the treatment of recurrent PIH after primary PIH repair.

METHODS

From June 2013 to March 2019, 126 patients (< 10 years old) with recurrent PIH were retrospectively enrolled. Patients were divided into two groups according to the operative technique: laparoscopic HL (58 patients) and laparoscopic IPTR (68 patients). With HL, the hernial sac was removed and the peritoneum closed. With IPTR, iliopubic tract and transversalis fascia sutures were applied.

RESULTS

There were no cases of conversion to open surgery. Re-recurrence only occurred in the HL group; no patients in the IPTR group developed re-recurrence (8.6% [5/58] vs. 0.0% [0/68], respectively; p = 0.044). The mean duration from re-operation to re-recurrence in these five patients was 10.6 months. Other surgical outcomes and complications did not differ between the two groups.

CONCLUSIONS

Laparoscopic IPTR is an effective surgical treatment for reducing re-recurrence of recurrent PIH.