DIALAPP: a prospective validation of a new diagnostic algorithm for acute appendicitis

Abstract

Purpose The management of patients with suspected appendicitis remains a challenge in daily clinical practice, and the optimal management algorithm is still being debated. Negative appendectomy rates (NAR) continue to range between 10 and 15%. This prospective study evaluated the accuracy of a diagnostic pathway in acute appendicitis using clinical risk stratification (Alvarado score), routine ultrasonography, gynecology consult for females, and selected CT after clinical reassessment. Methods Patients presenting with suspected appendicitis between November 2015 and September 2017 from age 18 years and above were included. Decision-making followed a clear management pathway. Patients were followed up for 6 months after discharge. The hypothesis was that the algorithm can reduce the NAR to a value of under 10%. Results A total of 183 patients were included. In 65 of 69 appendectomies, acute appendicitis was confirmed by histopathology, corresponding to a NAR of 5.8%. Notably, all 4 NAR appendectomies had other pathologies of the appendix. The perforation rate was 24.6%. Only 36 patients (19.7%) received a CT scan. The follow-up rate after 30 days achieved 69%, including no patients with missed appendicitis. The sensitivity and specificity of the diagnostic pathway was 100% and 96.6%, respectively. The potential saving in costs can be as much as 19.8 million €/100,000 cases presenting with the suspicion of appendicitis. Conclusion The risk-stratified diagnostic algorithm yields a high diagnostic accuracy for patients with suspicion of appendicitis. Its implementation can safely reduce the NAR, simultaneously minimizing the use of CT scans and optimizing healthcare-related costs in the treatment of acute appendicitis. Trial registration ClinicalTrials.gov Identifier: NCT02627781 (December 2015)

Conditional CT Strategy—An Effective Tool to Reduce Negative Appendectomy Rate and the Overuse of the CT

“…The conditional CT strategy there resulted in a similar sensitivity of 96% vs. 95% when compared with the direct CT group, but a lower specificity of 77% vs. 87%. A recent prospective study employed observation and the conditional CT strategy in patients with suspected AA [ 22 ]. They found that the sensitivity and specificity of TUS were 58.2% and 97.3%, respectively, and their model of conditional CT resulted in a low negative surgery rate of 5.8% and a CT scan rate of 19.7%.…”