An international survey of opinion regarding investigation of possible appendicitis and laparoscopic management of a macroscopically normal appendix

Clinical decision rules for appendicitis are not used by surgeons in training: A survey

BACKGROUNDS

We aimed to investigate surgeons in training knowledge of clinical decision rules (CDR) for diagnosing appendicitis and their attitudes toward implementing them.

METHODS

We included surgeons in training practicing in East Denmark who independently could decide to perform a diagnostic laparoscopy for suspected appendicitis. The survey was developed in Research Electronic Data Capture and face-validated before use. It consisted of three parts: (1) the characteristics of the surgeons, (2) their diagnostic approach, and (3) their knowledge and attitude toward introducing CDR in the clinic. Data were collected in January 2023.

RESULTS

We achieved 83 (90%) responses, and 52% of surgeons in training believed that appendicitis was difficult to diagnose. Their diagnostic approach mostly included symptoms and physical examinations for abdominal pain, and C-reactive protein. A total of 48% knew of at least one clinical decision rule, and 72% had never used a clinical decision rule. Regarding the necessity of CDR in clinical practice, surgeons in training options were divided into thirds: not needed, neither needed nor not needed, and needed. Surgeons in training indicated that CDR needed to be validated and easily applied before they would implement them.

CONCLUSION

Approximately 3/4 of surgeons in training had never utilized a clinical decision rule to diagnose appendicitis, and only half knew of their existence. The symptoms and findings incorporated in most CDR aligned with their diagnostic approach. They were conflicted if CDR needed to be implemented in clinical practice.

Diagnostic accuracy of computed tomography in adults with suspected acute appendicitis at the emergency department in a private tertiary hospital in Tanzania

INTRODUCTION

The increasing incidence of acute appendicitis in sub-Saharan Africa emphasizes the need for accurate and reliable diagnostic tools. However, the variability in the diagnostic performance of computed tomography for suspected acute appendicitis coupled with comparatively higher negative appendectomy rates in this setting highlight a possible concern regarding the diagnostic accuracy. This study evaluated the diagnostic accuracy of a computed tomography scan for suspected acute appendicitis at the emergency department in Tanzania.

METHODS

A retrospective diagnostic accuracy study was conducted from July to October 2020. All patients above 14 years of age who presented at the emergency department with right iliac fossa abdominal pain of fewer than ten days and underwent computed tomography for suspected acute appendicitis were evaluated, and the Alvarado score was computed. Histological diagnosis and clinical follow-up of 14 days were considered the reference standard. Ethical clearance was sought from the Aga Khan University Ethical review committee.

RESULTS

176 patients were included in this study. The sensitivity, specificity, and diagnostic accuracy were 100% (95% CI 91.8-100), 96.9% (95% CI 92.2-99.1), and 96.9% (95% CI 93.1-98.3), respectively. The mean Alvarado score in those without acute appendicitis was 4 (95% CI 3.7-4.3) compared to a mean score of 6.6 (95% CI 6.0-7.2) amongst those with acute appendicitis. The area under the receiver operator characteristics curve of computed tomography was 98.4%, and that of the Alvarado score was 84.1%.

CONCLUSIONS

The diagnostic performance of computed tomography in this study is similar to that established elsewhere. However, the Alvarado score is not routinely used for the initial screening of suspected acute appendicitis patients. A threshold of Alvarado score of 4 as a guide to conduct computed tomography for suspected acute appendicitis would have decreased computed tomography use by 50%, and missed 4 cases. Implementation studies that address Alvarado score use should be conducted.

Bilirubin as a Predictor of Complicated Appendicitis in a District General Hospital: A Retrospective Analysis

Aims

The objectives of the study were to establish the function of bilirubin as a novel diagnostic tool for predicting complex appendicitis and to compare the impact of other variables such as white blood cell count (WCC), C-reactive protein (CRP), and neutrophil.

Methods

This retrospective, single-center cohort analysis included all patients admitted to Torbay General Hospital in Torquay, United Kingdom, between January 2020 and December 2020 with a clinical diagnosis of acute appendicitis. In addition to serum CRP, WCC, and neutrophil, serum bilirubin and other liver enzymes were obtained from the patients’ blood on admission.

Results

The quantitative analysis included 174 patients from the group that remained. The large majority of the sample consisted of adults and males (77% and 51.7%, respectively). Overall, 49.4% of participants in the study were diagnosed with complicated appendicitis; 74.7% of adults had complicated appendicitis, with 58.6% being male. In 68.6% of cases, perforated appendicitis was the most prevalent form of complicated appendicitis. Patients with complicated appendicitis had significantly higher WCC, neutrophil, and CRP levels than those with uncomplicated appendicitis (14.15 vs. 12.88, p = 0.016; 11.63 vs. 10.19, p = 0.007; and (89.28 vs. 40.65, p = 0.0001, respectively).. The significantly greater alkaline phosphatase and total serum bilirubin discrepancies were observed in patients with complicated appendicitis. There were statistically significant differences in the means of the patients: (18.46 vs. 10.98, p = 0.0001 and 110.64 vs. 102.24, p = 0.033).

Conclusion

Serum bilirubin is a crucial diagnostic aid for determining the existence of complicated appendicitis.

Negative Appendicectomy Rates in Females of Childbearing Age: A Retrospective Analysis and Literature Review

Introduction

A negative appendicectomy rate (NAR) is defined as the portion of pathologically normal appendices removed surgically in patients suspected of having acute appendicitis. The lifetime risk of acute appendicitis is 8.6% for males and 6.7% for females; contrarily, the lifetime risk of appendicectomy is 12% for males and 23.1% for females. This study aims primarily to evaluate the true NAR in females of childbearing age to offer insight into potential strategies to reduce the number of unnecessary operative procedures carried out, along with their associated morbidity and mortality.

Methods

All emergency appendicectomies over a one-year period were retrospectively identified and collected from a single tertiary care centre. Preoperative clinical, laboratory and postoperative histopathological data were collected. The negative appendicectomy rate in subgroups divided by biomarkers and radiological imaging findings were analysed. The diagnostic value of these modalities in the context of acute appendicitis was found by calculating the sensitivity, specificity, positive predictive values, and negative predictive values.

Results

A total of 417 patients were included (median age 26; M:F, 0.7:1.0). The overall negative appendicectomy rate was 35.0% (146/417). Two-hundred sixty-one patients underwent an appendicectomy in the child-bearing age group. The NAR was significantly higher in those females with raised WBC and C-reactive protein (CRP) compared to their male counterparts (p-value -<0.001).

Conclusion

Women of childbearing age have a higher NAR of 43% when compared to the general population of 35%. Preoperative tests, including ultrasound scans, computed tomography and inflammatory markers in blood tests, help direct those who would benefit from surgery to the operating theatre, however, no test alone is suitably sensitive or specific. To reduce the NAR, management options include a return to observation and serial examination, increased use of low-dose CT or a commitment to improving the performance of ultrasonography.

Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis

BACKGROUND

This aim of this study was to provide an updated meta-analysis comparing antibiotic therapy with appendicectomy in adults (16 years or older) with uncomplicated acute appendicitis.

METHODS

A search for randomized clinical trials comparing antibiotic therapy with appendicectomy in adults with uncomplicated acute appendicitis from inception to 3 October 2021 in MEDLINE, Embase and CENTRAL with no language constraints was performed. Studies were excluded if they included paediatric participants or those with complicated appendicitis. Data on complications of treatment, treatment efficacy (defined in the antibiotic group as not undergoing appendicectomy within 1 year of enrolment, versus surgery without complications or no negative histology in the appendicectomy group), readmissions, and length of stay (LOS) were presented.

RESULTS

Eight RCTs involving 3203 participants (1613 antibiotics/1590 appendicectomy; 2041 males/1162 females) were included. There was no significant benefit of antibiotic treatment on complication rates (risk ratio (RR) 0.66, 95 per cent c.i. 0.41 to 1.04). Antibiotics had a reduced treatment efficacy compared with appendicectomy (RR 0.75, 95 per cent c.i. 0.63 to 0.89). Antibiotic treatment at 1 year was successful in 1016 of 1613 (62.9 per cent) participants. There was a six-fold increase in hospital readmissions within 1 year of enrolment in participants receiving antibiotic treatment (RR 6.28, 95 per cent c.i. 2.87 to 13.74). There was no difference in index admission LOS (mean difference 0.15 days (95 per cent c.i. -0.05 to 0.35)).

CONCLUSIONS

Earlier optimism regarding the benefits of antibiotic therapy for uncomplicated acute appendicitis does not persist at the same level now that further, large trials have been included. If antibiotic treatment is to be offered routinely as first-line therapy, patients should be counselled appropriately.

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.

Demographic factors associated with length of stay in hospital and histological diagnosis in adults undergoing appendicectomy

Objective: Appendicectomy remains of the most common emergency operations in the United Kingdom. The exact etiologies of appendicitis remain unclear with only potential causes suggested in the literature. Social deprivation and ethnicity have both been demonstrated to influence outcomes following many operations. There are currently no studies evaluating their roles with regards to severity and outcomes following appendicectomy.

Material and Methods: Demographic data were retrieved from health records for adult patients who underwent appendicectomy between 2010-2016 within a single NHS trust. To measure social deprivation, Indices of Multiple Deprivation (IMD) rankings were used. Histology reports were reviewed and diagnosis classified into predefined categories: non-inflamed appendix, uncomplicated appendicitis, complicated appendicitis and gangrenous appendicitis.

Results: Three thousand four hundred and forty-four patients were identified. Mean age was 37.8 years (range 73 years). Using a generalized linear model, South Asian ethnicity specifically was found to be independently predictive of increased length of stay following appendicectomy (p< 0.001). Amongst South Asian patients, social deprivation was found to be further predictive of longer hospital stay (p= 0.005). Deprivation was found to be a predictor of complicated appendicitis but not of gangrenous appendicitis (p= 0.01). Male gender and age were also independent predictors of positive histology for appendicitis (p< 0.001 and p= 0.021 respectively).

Conclusion: This study is the first to report an independent association between South Asian ethnicity and increased length of stay for patients undergoing appendicectomy in a single NHS trust. The associations reported in this study may be a result of differences in the pathophysiology of acute appendicitis or represent inequalities in healthcare provision across ethnic and socioeconomic groups.

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.

Low-Dose Abdominal CT for Evaluating Suspected Appendicitis in Adolescents and Young Adults: Review of Evidence

Due to its excellent diagnostic performance, CT is the mainstay of diagnostic test in adults with suspected acute appendicitis in many countries. Although debatable, extensive epidemiological studies have suggested that CT radiation is carcinogenic, at least in children and adolescents. Setting aside the debate over the carcinogenic risk of CT radiation, the value of judicious use of CT radiation cannot be overstated for the diagnosis of appendicitis, considering that appendicitis is a very common disease, and that the vast majority of patients with suspected acute appendicitis are adolescents and young adults with average life expectancies. Given the accumulated evidence justifying the use of low-dose CT (LDCT) of only 2 mSv, there is no reasonable basis to insist on using radiation dose of multi-purpose abdominal CT for the diagnosis of appendicitis, particularly in adolescents and young adults. Published data strongly suggest that LDCT is comparable to conventional dose CT in terms of clinical outcomes and diagnostic performance. In this narrative review, we will discuss such evidence for reducing CT radiation in adolescents and young adults with suspected appendicitis.

Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis

BACKGROUND

Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children.

OBJECTIVES

The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective.

SELECTION CRITERIA

We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies.

DATA COLLECTION AND ANALYSIS

We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity.

MAIN RESULTS

We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains.

AUTHORS' CONCLUSIONS

MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.

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).

Computed tomography for diagnosis of acute appendicitis in adults

BACKGROUND

Diagnosing acute appendicitis (appendicitis) based on clinical evaluation, blood testing, and urinalysis can be difficult. Therefore, in persons with suspected appendicitis, abdominopelvic computed tomography (CT) is often used as an add-on test following the initial evaluation to reduce remaining diagnostic uncertainty. The aim of using CT is to assist the clinician in discriminating between persons who need surgery with appendicectomy and persons who do not.

OBJECTIVES

Primary objective Our primary objective was to evaluate the accuracy of CT for diagnosing appendicitis in adults with suspected appendicitis. Secondary objectives Our secondary objectives were to compare the accuracy of contrast-enhanced versus non-contrast-enhanced CT, to compare the accuracy of low-dose versus standard-dose CT, and to explore the influence of CT-scanner generation, radiologist experience, degree of clinical suspicion of appendicitis, and aspects of methodological quality on diagnostic accuracy.

SEARCH METHODS

We searched MEDLINE, Embase, and Science Citation Index until 16 June 2017. We also searched references lists. We did not exclude studies on the basis of language or publication status.

SELECTION CRITERIA

We included prospective studies that compared results of CT versus outcomes of a reference standard in adults (> 14 years of age) with suspected appendicitis. We excluded studies recruiting only pregnant women; studies in persons with abdominal pain at any location and with no particular suspicion of appendicitis; studies in which all participants had undergone ultrasonography (US) before CT and the decision to perform CT depended on the US outcome; studies using a case-control design; studies with fewer than 10 participants; and studies that did not report the numbers of true-positives, false-positives, false-negatives, and true-negatives. Two review authors independently screened and selected studies for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected the data from each study and evaluated methodological quality according to the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate random-effects model to obtain summary estimates of sensitivity and specificity.

MAIN RESULTS

We identified 64 studies including 71 separate study populations with a total of 10,280 participants (4583 with and 5697 without acute appendicitis). Estimates of sensitivity ranged from 0.72 to 1.0 and estimates of specificity ranged from 0.5 to 1.0 across the 71 study populations. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.93 to 0.96), and summary specificity was 0.94 (95% CI 0.92 to 0.95). At the median prevalence of appendicitis (0.43), the probability of having appendicitis following a positive CT result was 0.92 (95% CI 0.90 to 0.94), and the probability of having appendicitis following a negative CT result was 0.04 (95% CI 0.03 to 0.05). In subgroup analyses according to contrast enhancement, summary sensitivity was higher for CT with intravenous contrast (0.96, 95% CI 0.92 to 0.98), CT with rectal contrast (0.97, 95% CI 0.93 to 0.99), and CT with intravenous and oral contrast enhancement (0.96, 95% CI 0.93 to 0.98) than for unenhanced CT (0.91, 95% CI 0.87 to 0.93). Summary sensitivity of CT with oral contrast enhancement (0.89, 95% CI 0.81 to 0.94) and unenhanced CT was similar. Results show practically no differences in summary specificity, which varied from 0.93 (95% CI 0.90 to 0.95) to 0.95 (95% CI 0.90 to 0.98) between subgroups. Summary sensitivity for low-dose CT (0.94, 95% 0.90 to 0.97) was similar to summary sensitivity for standard-dose or unspecified-dose CT (0.95, 95% 0.93 to 0.96); summary specificity did not differ between low-dose and standard-dose or unspecified-dose CT. No studies had high methodological quality as evaluated by the QUADAS-2 tool. Major methodological problems were poor reference standards and partial verification primarily due to inadequate and incomplete follow-up in persons who did not have surgery.

AUTHORS' CONCLUSIONS

The sensitivity and specificity of CT for diagnosing appendicitis in adults are high. Unenhanced standard-dose CT appears to have lower sensitivity than standard-dose CT with intravenous, rectal, or oral and intravenous contrast enhancement. Use of different types of contrast enhancement or no enhancement does not appear to affect specificity. Differences in sensitivity and specificity between low-dose and standard-dose CT appear to be negligible. The results of this review should be interpreted with caution for two reasons. First, these results are based on studies of low methodological quality. Second, the comparisons between types of contrast enhancement and radiation dose may be unreliable because they are based on indirect comparisons that may be confounded by other factors.

[Rational diagnostics of acute appendicitis]

Acute appendicitis is one of the most common abdominal emergencies. An accurate preoperative diagnosis is still a challenge in many cases. Patient history and clinical examination are the mainstay of diagnostics but other tools are also needed in order to reduce the number of misdiagnoses. Laboratory parameters and radiological imaging procedures are widely used and scoring systems can help in the risk stratification of patients with suspected appendicitis. In the USA most patients undergo preoperative computed tomography (CT) as the first-line examination, which can reduce the number of negative appendectomies to less than 5%; however, this practice results in substantial radiation exposure and is less accepted in Europe due to concerns about radiation-induced cancer in the often younger patients. Ultrasound is a valuable first-line imaging procedure and in experienced hands can achieve very good results. In patients with an equivocal diagnosis inpatient surveillance with close control of clinical and laboratory parameter represents a suitable method to reduce the number of negative explorations without resulting in an increase in the rate of perforation or morbidity.

Can Surgeons Identify Appendicitis Macroscopically? Results From a Multicentre Prospective Study

PURPOSE

The primary outcome was to investigate the accuracy of intraoperative macroscopic diagnosis by the operating surgeon with the results of the subsequent histopathologic examination. The secondary outcome was to identify the predictors of discrepancies between these 2 groups.

MATERIALS AND METHODS

A multicentre, prospective, observational study was conducted over a period of 2 months with a 30-day follow-up period. Patients who underwent surgery with the intention of appendicectomy were recruited in the study.

RESULTS

A total of 1169 patients were recruited. False negatives (FNs) were defined as a normal macroscopic diagnosis but histopathologically appendicitis, whereas false positive otherwise. Overall, FN rates were 22.4%, whereas false positive rates were 8.2%. The seniority of the operating surgeons did not affect the ability to accurately diagnose appendicitis macroscopically (P=0.069). However, consultant surgeons had the lowest FN rate of 15.6%. Females and preoperative ultrasound scan increased odds of FN, whereas preoperative computed tomography decreased the odds of FN appendicectomy.

CONCLUSION

Macroscopic identification intraoperatively is inaccurate with a FN rate of 22%.

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

BACKGROUND

In cases with clinically suspected appendicitis, there is controversy regarding the decision to remove a macroscopically normal appearing appendix during laparoscopy when no other intra-abdominal pathology is found. The aim of this study was to examine the rate of appendicitis, along with readmission and reoperation rates following diagnostic laparoscopy of clinically suspected appendicitis in patients where the appendix was not removed.

METHODS

We performed a retrospective cohort analysis of patients who underwent a diagnostic laparoscopy due to clinical suspicion of appendicitis where no other pathology was found and the appendix was not removed. The study period was from 2008 to 2013 and involved patients from two university hospitals in the Copenhagen area.

RESULTS

Of the 271 patients included (81.6% women, median age 27), 56 (20.7%) were readmitted with right iliac fossa pain after a median time of 10 months (range 1-84). Twenty-two patients (8.1%) underwent a new laparoscopic procedure. Appendix was removed in 18 patients, of which only one showed histological signs of inflammation. The median follow-up time was 5.6 years (range 1-109 months).

CONCLUSION

There was a low rate of appendicitis after a previous negative diagnostic laparoscopy. Therefore, based on results from the current study, we do not consider that it is necessary to remove a macroscopic normal appendix during laparoscopy for clinically suspected appendicitis. The high readmission rate warrants the need for further investigation or follow-up.

Endometriosis of the appendix presenting as acute appendicitis with unusual appearance

INTRODUCTION

Endometriosis of the appendix is an uncommon mimicker of acute appendicitis which makes for a diagnostic dilemma.

PRESENTATION OF CASE

We present a rare case of a menstruating woman presenting with classic symptoms of appendicitis, without the characteristic inflammatory changes seen on laparoscopy consistent with appendicitis. Instead, the appendix appeared unusually contracted on itself. Pathologic review of the appendix revealed microscopic findings of endometriosis.

DISCUSSION

We theorize the growth and shedding of the endometrial tissue during menstruation caused compression of the neural plexi in the wall of the appendix leading to the presentation mimicking acute appendicitis.

CONCLUSION

Given the potential for endometrial appendicitis, we propose appendectomy in reproductive age female patients with right lower quadrant pain, regardless of appendix appearance on laparoscopy.

Incidental appendectomy? Microscopy tells another story: A retrospective cohort study in patients presenting acute right lower quadrant abdominal pain

BACKGROUND

Optimal management of macroscopically normal appendix encountered during laparoscopy for acute abdominal pain is still unclear.

METHODS

164 acute abdominal pain cases in which laparoscopy showed a normal appendix were reviewed. No other intra-peritoneal acute disease was present in 50 patients (Group 1) whereas a miscellanea of intra-peritoneal conditions was identified in the other 114 (Group 2). All the patients underwent appendectomy with specimen examination.

RESULTS

Following incidental appendectomy significant microscopical changes were seen in 125 specimens (76%). Among these, inflammation was found in 122 and neuroendocrine tumors in 3. Appendices harbored pathological changes in n = 45 patients (90%) of Group 1 and in n = 34 patients (70%) of Group 2 patients (p < 0.05). Morbidity for incidental appendectomy was 2%.

CONCLUSION

This study supports an appendectomy in patients who are undergoing laparoscopy for acute right lower quadrant abdominal pain even when the appendix appears normal on visual inspection.

Hyperbilirubinaemia: its utility in non-perforated appendicitis

BACKGROUND

The diagnosis of acute appendicitis is made using clinical findings and investigations. Recent studies have suggested that serum bilirubin, a cheap and simple biochemical test, is a positive predictor in the diagnosis of appendiceal perforation and may be more specific than C-reactive protein (CRP) and white cell count (WCC). The aim of this study was to investigate the utility of the serum bilirubin level in patients with suspected acute but non-perforative appendicitis.

METHODS

A retrospective chart review of 213 patients who presented with suspected appendicitis in a 6-month period to Nambour General Hospital was performed. Serum bilirubin, WCC and CRP were recorded and analysed as to their utility in relation to the final diagnosis.

RESULTS

A total of 196 patients underwent an appendicectomy and 41 of these were negative. The specificity of hyperbilirubinaemia for appendicitis overall was 0.83 with a positive predictive value (PPV) of 0.86, compared with CRP (specificity 0.40, PPV 0.75) and WCC (specificity 0.67, PPV 0.85). The area under the receiver operating characteristic curve for bilirubin was 0.6289 compared to 0.6171 for CRP and 0.7219 for WCC. A subgroup analysis of those with complicated appendicitis demonstrated a PPV for bilirubin of 0.66 compared to 0.58 for WCC and 0.34 for CRP in agreement with the literature. Subgroup analysis of hyperbilirubinaemia in simple appendicitis demonstrated a PPV of 0.81 compared to CRP (0.71) and WCC (0.82).

CONCLUSION

Bilirubin had a higher specificity than CRP and WCC overall in patients with appendicitis. Hyperbilirubinaemia had a high PPV in patients with simple appendicitis.

How good are surgeons at identifying appendicitis? Results from a multi-centre cohort study

BACKGROUND

Convincing arguments for either removing or leaving in-situ a macroscopically normal appendix have been made, but rely on surgeons' accurate intra-operative assessment of the appendix. This study aimed to determine the inter-rater reliability between surgeons and pathologists from a large, multicentre cohort of patients undergoing appendicectomy.

MATERIALS AND METHODS

The Multicentre Appendicectomy Audit recruited consecutive patients undergoing emergency appendicectomy during April and May 2012 from 95 centres. The primary endpoint was agreement between surgeon and pathologist and secondary endpoints were predictors of this disagreement.

RESULTS

The final study included 3138 patients with a documented pathological specimen. When surgeons assessed an appendix as normal (n = 496), histopathological assessment revealed pathology in a substantial proportion (n = 138, 27.8%). Where surgeons assessed the appendix as being inflamed (n = 2642), subsequent pathological assessment revealed a normal appendix in 254 (9.6%). There was overall disagreement in 392 cases (12.5%), leading to only moderate reliability (Kappa 0.571). The grade of surgeon had no significant impact on disagreement following clinically normal appendicectomy. Females were at the highest risk of false positives and false negatives and pre-operative computed tomography was associated with increased false positives.

CONCLUSIONS

This multi-centre study suggests that surgeons' judgements of the intra-operative macroscopic appearance of the appendix is inaccurate and does not improve with seniority and therefore supports removal at the time of surgery.

The value of ultrasonography in the diagnosis of appendicitis

INTRODUCTION

Ultrasonography is a commonly used investigation in the UK for patients with right iliac fossa pain where the diagnosis of appendicitis is unclear. The published sensitivity and specificity of ultrasonography is higher than the results observed by clinicians in every day practice. The aim of this study was to elucidate the real-world value of ultrasonography in the diagnosis of appendicitis, and its impact on negative appendicectomy rates (NAR).

METHODS

A retrospective multicentre audit was conducted at three UK hospitals over a twelve month period in 2012.

RESULTS

573 patients underwent ultrasonography prior to appendicectomy. The appendix was not visualised in 45% of scans. The sensitivity and specificity of ultrasonography for the diagnosis of appendicitis was 51.8% and 81.4%. The mean NAR was 26.7%, or 18.3% after a positive ultrasound scan.

CONCLUSION

In clinical practice at UK centres, ultrasonography commonly does not visualise the appendix, and has a low sensitivity for appendicitis. To reduce the NAR, management options include a return to observation and serial examination, increased use of CT or a commitment to improving the performance of ultrasonography.

Population level analysis of diagnostic laparoscopy versus normal appendicectomy for acute lower abdominal pain

BACKGROUND

There is virtually no evidence to guide surgeons and patients when faced with an absence of pathology for acute lower abdominal pain. This study aimed to compare diagnostic laparoscopy alone to laparoscopic removal of a normal appendix in patients with acute lower abdominal pain but an absence of pathology.

METHOD

Retrospective analysis of routinely collected hospital data from all English acute hospitals performing emergency appendicectomy between 01/04/2002 and 31/03/2012. Patients admitted as emergencies with lower abdominal pain undergoing diagnostic laparoscopy (with no other procedure or associated diagnosis) were compared to those undergoing laparoscopic normal appendicectomy. The primary outcome measure was emergency readmission for abdominal pain during the 12 period after index surgery. Multivariable binary logistic regression was used to produce adjusted odds ratios (OR and bootstrapped 95% confidence intervals).

RESULT

10,072 patients undergoing diagnostic laparoscopy were compared to 9665 undergoing laparoscopic normal appendicectomy. Overall, 32.9% (n = 6499/19,737) were readmitted as an emergency for abdominal pain during the 12 months after index surgery. Following risk-adjustment, laparoscopic normal appendicectomy was associated with 44% reduced odds of readmission (adjusted OR 0.56, 0.50-61). In the diagnostic laparoscopy group, 2.1% of patients (213) required subsequent appendicectomy, which was abnormal in 47.4% (101/213) cases.

CONCLUSION

This study suggests that removal of a laparoscopically normal appendix, when no other pelvic pathology is visible, may reduce one-year readmission rates. Although limited through selection bias from routinely collected data, this study provides evidence for practicing surgeons and information for methodologists to power a future trial.

Clinical trial networks in orthopaedic surgery

The aim of this study was to review the role of clinical trial networks in orthopaedic surgery. A total of two electronic databases (MEDLINE and EMBASE) were searched from inception to September 2013 with no language restrictions. Articles related to randomised controlled trials (RCTs), research networks and orthopaedic research, were identified and reviewed. The usefulness of trainee-led research collaborations is reported and our knowledge of current clinical trial infrastructure further supplements the review. Searching yielded 818 titles and abstracts, of which 12 were suitable for this review. Results are summarised and presented narratively under the following headings: 1) identifying clinically relevant research questions; 2) education and training; 3) conduct of multicentre RCTs and 4) dissemination and adoption of trial results. This review confirms growing international awareness of the important role research networks play in supporting trials in orthopaedic surgery. Multidisciplinary collaboration and adequate investment in trial infrastructure are crucial for successful delivery of RCTs.

Cite this article: Bone Joint Res 2014;3:169–74.

Acute appendicitis: What is the gold standard of treatment?

McBurney’s procedure represented the gold-standard for acute appendicitis until 1981, but nowadays the number of laparoscopic appendectomies has progressively increased since it has been demonstrated to be a safe procedure, with excellent cosmetic results and it also allows a shorter hospitalization, a quicker and less painful postoperative recovery. The aim of this editorial was to perform a review of the literature in order to address controversial issues in the treatment of acute appendicitis.