Review of appendicectomies over a decade in a tertiary hospital in New Zealand

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.

Multicentre study of appendicitis management comparing a large South Island metropolitan hospital, to its referring regional and rural centres

BACKGROUND

Globally, patients presenting with acute surgical disease in rural areas have poorer outcomes when compared to urban areas; little data are available regarding outcomes for New Zealand (NZ) rural patients. This study aimed to compare the surgical management of appendicitis in a large metropolitan centre with its regional referral centres.

METHODS

In this retrospective cohort study, patient data were collated from the studied centres between November 2014 and October 2019. In addition to patient demographics, patterns of referral and presentation, the primary outcome was time to the theatre; secondary outcomes were perforation rates, length of stay and complications. Data are presented as medians (interquartile range).

RESULTS

A total of 3533 patients underwent appendicectomy over the period studied. For those presenting directly to the metropolitan centre, the median wait-time to the theatre was 16 h (9.2-23.2); if patients were transferred, they waited for 20.8 h (13.6-27). Patients presenting to regional centres waited for 7.6 h (4.5-15.4, P < 0.001). Perforation rates for transferred patients were 31% which was greater than for those presenting to the metropolitan (20%) or regional centres (17%, P = 0.014). Complications were also highest in transferred patients (20%) when compared to the metropolitan (17%) or regional centres (10%, P < 0.001).

CONCLUSION

Patients who were transferred to Christchurch Hospital from rural centres without surgical services had a longer wait-time than those who presented to Christchurch Hospital directly or were treated in regional centres. This was associated with higher rates of perforated appendicitis.

Impact of routine histopathological examination of appendectomy specimens on patient management: a study of 4012 appendectomy specimens

Objectives

For a suspected diagnosis of acute appendicitis, appendectomy is one of the most common emergency abdominal operations performed. However, the need for routine histopathological examination (HPE) of all appendectomy specimens has recently been questioned. The aim of this study was to assess whether a routine HPE of appendectomy specimens is needed and whether routine HPE has an impact on further management of patients.

Material and Methods

From January 2009 to June 2017, all histopathology reports of 4012 consecutive appendectomy specimens for a clinical suspicion of acute appendicitis were retrospectively analyzed in two university hospitals.

Results

Out of the 4012 cases, 3530 (88%) patients showed findings consistent with acute appendicitis on HPE. Perforation rate was 5.8% and was significantly higher in male patients (p <0.001) and higher in the > 30 years age group (p= 0.024). Negative appendectomy rate was 5.6% and was significantly higher in female patients (p <0.001). There were 256 (6.4%) patients who demonstrated unusual findings in their HPE, which included chronic appendicitis (n= 207; 5.2%) patients, Enterobius vermicularis (n= 14), Schistosoma (n= 8), Crohn's disease (n= 1), neuroma (n= 10), carcinoid tumour (n= 5) and mucinous cystadenoma (n= 5), mucocele (n= 4) and mucinous cystadenocarcinoma (n= 2).

Conclusion

HPE of the appendix does not only confirm the diagnosis of acute appendicitis, but also detects other unusual diagnoses that may have an impact on a patient's management. A number of patients with unusual histopathological findings require anti-helmentic treatment, colectomy, gastroenterology follow-up or periodic surveillance. Hence, all appendectomy specimens must be submitted for routine HPE.