The Borderline-Size Appendix: Grayscale, Color Doppler, and Spectral Doppler Findings That Improve Specificity for the Sonographic Diagnosis of Acute Appendicitis

Diagnostic performance of spectral Doppler in acute appendicitis with an equivocal Alvarado score

PURPOSE

This study aims to evaluate the added value of duplex Doppler examination to the routinely graded compression grayscale ultrasound (US) for patients with suspected acute appendicitis (AA) in correlation with surgical management outcomes.

METHODS

The study lasted from January 2020 to March 2021. Throughout that period, patients who had suspected appendicitis were included with a visible appendix in the grayscale US. These patients were categorized clinically based on Alvarado's score. They underwent graded compression grayscale US of the appendix and duplex Doppler study. Subsequently, they were assigned for non-contrast multislice computed tomography (MSCT) according to Alvarado's score and underwent either emergency appendicectomy or conservative clinical management afterward. A Student's t-test was used to determine if there were significant differences in the mean values between the groups. The diagnostic performance of spectral Doppler US for the diagnosis of AA was depicted.

RESULTS

Eighty-four patients with visualized color flow in the appendicular Doppler US were enrolled, with 60 (71.4%) having AA, and 24 (28.6%) not having appendicitis. Spectral Doppler criterion of PSV greater than 8.6 cm/s demonstrated a high sensitivity of 91.67% and specificity of 77.78% for patients with Alvarado score ranging from 4 to 7, and appendiceal MOD ranging from 6 to 8 mm, while a discriminatory criterion of RI greater than 0.51 had a high sensitivity of 100% and a relatively lower specificity of 66.67%.

CONCLUSION

The patients with AA have significantly higher point PSV and point RI values than those without AA and are especially useful in equivocal patients whose MODs and Alvarado scores are in the diagnostically equivocal ranges of 6-8 mm and 4-7, respectively, with the point PSV and RI demonstrating negative predictive value 87.5% and 100%.

Is LigaSure Alone Sufficient for the Closure of the Appendix Stump?

PURPOSES

Closure of the appendix stump is necessary for laparoscopic appendectomy. Problems that occur during the appendix stump closure can cause severe morbidity. Several methods of stump closure have been described. This study aimed to investigate the adequacy of LigaSure alone in closing the appendix stump.

METHODS

Patients who were operated on with the diagnosis of acute appendicitis between October 2021 and January 2022 were evaluated retrospectively. The patients were divided into two groups according to the closure technique of the appendix stump hemoclip(group I) and LigaSure only(group II). In addition, demographic data (age, gender), body mass index (BMI), presence of comorbid disease, perioperative appendicitis classification, operation time, postoperative hospital stay, radiological and pathological appendix size of the patients included in the study were recorded. Clavien Dindo was used for postoperative complication assessment.

RESULT

The study included 77 patients. 48(62.3%) of the patients were in group I, and 29(37.7%) were in group II. There was no statistical difference between the groups regarding age, gender distribution, BMI, presence of comorbid disease (P > .05). The operation time of group I was longer than group II (P < .001). There was no difference between the groups in terms of both radiological and pathological appendix size. There was no statistical difference between the groups regarding postoperative complications and severity of complications (P = .76, P = .99, respectively).

CONCLUSION

Appendiceal stump closure can be performed with Ligasure, but it should be noted that this procedure can be performed on selected patients, as in the study group, not on all patients.

Added value of ratio of cross diameters of the appendix in ultrasound diagnosis of acute appendicitis

BACKGROUND

The maximum outer diameter (MOD) of the appendix is an essential parameter for diagnosing acute appendicitis, but there is space for improvement in ultrasound (US) diagnostic performance.

AIM

To investigate whether combining the ratio of the cross diameters (RATIO) of the appendix with MOD of the appendix can enhance the diagnostic performance of acute appendicitis.

METHODS

A retrospective study was conducted, and medical records of 233 patients with acute appendicitis and 112 patients with a normal appendix were reviewed. The MOD and RATIO of the appendix were calculated and tested for their diagnostic performance of acute appendicitis, both individually and in combination.

RESULTS

The RATIO for a normal appendix was 1.32 ± 0.16, while for acute appendicitis it was 1.09 ± 0.07. The cut-off value for RATIO was determined to be ≤ 1.18. The area under the receiver operating characteristic curve (AUC) for diagnosing acute appendicitis using RATIO ≤ 1.18 and MOD > 6 mm was 0.870 and 0.652, respectively. There was a significant difference in AUC between RATIO ≤ 1.18 and MOD > 6 mm (P < 0.0001). When comparing the combination of RATIO ≤ 1.18 and MOD > 6 mm with MOD > 6 mm alone, the combination showed increased specificity, positive predictive value (PPV), and AUC. However, the sensitivity and negative predictive value decreased.

CONCLUSION

Combining RATIO of the appendix ≤ 1.18 and MOD > 6 mm can significantly improve the specificity, PPV, and AUC in the US diagnosis of acute appendicitis.