Can imaging have a beneficial effect on reducing negative appendicectomy rates

Stephenson, James A.; Al-Nowfal, Ahmed; Khatiwada, Aagat Sharma; Lim, Zhia; Norwood, M. G. A.; Verma, Raman

doi:10.1016/j.crad.2018.07.181

Cited by 4 publications

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“…The acute appendicitis rate of 82.6% is consistent with the international literature, but recent studies suggest a slightly higher rate of negative appendectomies in the UK than in this current study [ 5 , 7 , 25 ]. A NAR of 17.4% is unacceptable.…”

Section: Discussionsupporting

confidence: 91%

Quality Outcomes in Appendicitis Care: Identifying Opportunities to Improve Care

Kabir

Bucholc

Walker³

et al. 2020

Life

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Introduction: Appendicitis is one of the most common causes of acute abdominal pain requiring surgical intervention, but the variability of diagnosis and management continue to challenge the surgeons. Aim: This study assessed patients undergoing appendectomy to identify opportunities to improve diagnostic accuracy and outcomes. Methods: An ethically approved retrospective cohort study was undertaken between March 2016 and March 2017 at a single university hospital of all consecutive adult and paediatric patients undergoing appendectomy. Demographic data including age, gender, co-morbidities, presentation and triage timings along with investigation, imaging and operative data were analysed. Appendicitis was defined as acute based on histology coupled with intraoperative grading with the American Association for the Surgery of Trauma (AAST) grades. Complications using the Clavien–Dindo classification along with 30-day re-admission rates and the negative appendectomy rates (NAR) were recorded and categorised greater and less than 25%. The use of scoring systems was assessed, and retrospective scoring performed to compare the Alvarado, Adult Appendicitis Score (AAS) and the Appendicitis Inflammatory Response (AIR) score. Results: A total of 201 patients were studied, 115 male and 86 females, of which 136/201 (67.6%) were adults and 65/201 (32.3%) paediatric. Of the adult group, 83 were male and 53 were female, and of the paediatric group, 32 were male and 33 were female. Median age was 20 years (range: 5 years to 81 years) and no patient below the age of 5 years had an appendectomy during our study period. All patients were admitted via the emergency department and median time from triage to surgical review was 2 h and 38 min, (range: 10 min to 26 h and 10 min). Median time from emergency department review to surgical review, 55 min (range: 5 min to 6 h and 43 min). Median time to operating theatre was 21 h from admission (range: 45 min to 140 h and 30 min). Out of the total patients, 173 (86.1%) underwent laparoscopic approach, 28 (13.9%) had an open approach and 12 (6.9%) of the 173 were converted to open. Acute appendicitis occurred in 166/201 (82.6%). There was no significant association between grade of appendicitis and surgeons’ categorical NAR rate (p = 0.07). Imaging was performed in 118/201 (58.7%); abdominal ultrasound (US) in 53 (26.4%), abdominal computed tomography (CT) in 59 (29.2%) and both US and CT in 6 (3%). The best cut-off point was 4 (sensitivity 84.3% and specificity of 65.7%) for AIR score, 9 (sensitivity of 74.7% and specificity of 68.6%) for AAS, and 7 (sensitivity of 77.7% and specificity of 71.4%) for the Alvarado score. Twenty-four (11.9%) were re-admitted, due to pain in 16 (58.3%), collections in 3 (25%), 1 (4.2%) wound abscess, 1 (4.2%) stump appendicitis, 1 (4.2%) small bowel obstruction and 1 (4.2%) fresh rectal bleeding. CT guided drainage was performed in 2 (8.3%). One patient had release of wound collection under general anaesthetic whereas another patient had laparoscopic drain placement. A laparotomy was undertaken in 3 (12.5%) patients with division of adhesions in 1, the appendicular stump removed in 1 and 1 had multiple collections drained. Conclusion: The negative appendectomy and re-admission rates were unacceptably high and need to be reduced. Minimising surgical variance with use of scoring systems and introduction of pathways may be a strategy to reduce NAR. New systems of feedback need to be introduced to improve outcomes.

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Section: Discussionsupporting

confidence: 91%

Quality Outcomes in Appendicitis Care: Identifying Opportunities to Improve Care

Kabir

Bucholc

Walker³

et al. 2020

Life

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“…Additionally, a Cochrane review published in 2019 found that in adults there was negligible difference in sensitivity or specificity between low-dose and standard-dose CT abdomen/ pelvis, and that contrast use was the only factor that increased sensitivity in diagnosing acute appendicitis [11]. Similar results regarding low-dose CT were also found in a 2004 study, then again in a 2018 study [12,13]. This is largely due to the advent multiplanar reformatting techniques.…”

Section: Discussionmentioning

confidence: 76%

Preoperative Imaging Continues to Lower Negative Appendicectomy Rates (NAR)-A Retrospective Analysis of a Tertiary Health Service in Australia

Corbitt¹

2022

OAJS

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To analyze the Negative Appendicectomy Rate (NAR) in a single tertiary health service, compare it to published data and analyze the impact of pre-operative imaging in acute appendicitis. Methods:A retrospective cohort study of a single health service was performed for a single year. Search terms included 'diagnostic laparoscopy' and 'appendicectomy ' (both laparoscopic and open). Demographic data was extracted. The primary outcome was NAR. Secondary outcomes included tumour incidence and imaging modality accuracy as defined by NAR. Data was excluded if there was no histopathological report available.Results: A total of 820 cases were identified, with 736 operations being performed for suspected appendicitis. A total of 633 booked laparoscopic appendicectomies were included for analysis, yielding an NAR of 11.2%. Overall tumour incidence was calculated at 1.5%. No preoperative imaging, or cases which utilized ultrasound as the only imaging modality, produced NARs of 19.3% and 17.4% respectively. Use of Computed Tomography (CT) in males under 40 was associated with lower NAR (3.0%, p=0.01) but no statistical difference was found between no imaging and ultrasound-only in this age group. Ultrasound-only was better than no imaging for females of all ages (p<0.001) and CT alone did not improve NAR in those under 40 years old (p>0.05). Preoperative CT was overall statistically significant at correctly identifying appendicitis (OR 2.80, p<0.001), giving an NAR of 7.1%. Conclusion:This study's NAR is better than accepted rates, however, is still high when compared internationally. There is great potential in the use of preoperative imaging to further guide correct diagnosis and operative patient selection.

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Impact of the COVID-19 pandemic on management and outcomes in acute appendicitis: Should these new practices be the norm?

et al. 2021

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Background In early 2020, the COVID‐19 pandemic significantly altered management of surgical patients globally. International guidelines recommended that non-operative management be implemented wherever possible (e.g. in proven uncomplicated appendicitis) to reduce pressure on healthcare services and reduce risk of peri-operative viral transmission. We sought to compare our management and outcomes of appendicitis during lockdown versus a non-pandemic period. Methods All presentations to our department with a clinical diagnosis of acute appendicitis between 12/03/2020 and 30/06/2020 were compared to the same 110-day period in 2019. Quantity and severity of presentations, use of radiological investigations, rate of operative intervention and histopathological findings were variables collected for comparison. Results There was a reduction in appendicitis presentations (from 74 to 56 cases), and an increase in radiological imaging (from 70.27% to 89.29%)( P =0.007) from 2019 to 2020. In 2019, 93.24% of patients had appendicectomy, compared to 71.42% in 2020(P<0.001). This decrease was most pronounced in uncomplicated cases, whose operative rates dropped from 90.32% to 62.5%( P =0.009). Post-operative histology confirmed appendicitis in 73.9% in 2019, compared to 97.5% in 2020 ( P =0.001). Normal appendiceal pathology was reported for 17 cases (24.64%) in 2019, compared to none in 2020 ( P <0.001) – a 0% negative appendicectomy rate (NAR). Discussion The 0% NAR in 2020 is due to a combination of increased CT imaging, a higher threshold to operate, and is impacted by increased disease severity due to delayed patient presentation. This study adds to growing literature promoting routine use of radiological imaging to confirm appendicitis diagnosis. As we enter a second lockdown, patients should be encouraged to avoid late presentations, and surgical departments should continue using radiological imaging more liberally in guiding appendicitis management.

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Can imaging have a beneficial effect on reducing negative appendicectomy rates

Cited by 4 publications

References 0 publications

Quality Outcomes in Appendicitis Care: Identifying Opportunities to Improve Care

Quality Outcomes in Appendicitis Care: Identifying Opportunities to Improve Care

Preoperative Imaging Continues to Lower Negative Appendicectomy Rates (NAR)-A Retrospective Analysis of a Tertiary Health Service in Australia

Impact of the COVID-19 pandemic on management and outcomes in acute appendicitis: Should these new practices be the norm?

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