Prospective Evaluation of the Added Value of Imaging within the Dutch National Diagnostic Appendicitis Guideline - Do we Forget our Clinical Eye?

Abstract

Background: Annually 16,000 appendectomies are performed in the Netherlands, of which 15-20% are negative. In 2010, to reduce this unacceptable percentage of superfluous appendectomies, the Dutch Association for Surgery introduced the ‘Appendicitis Guideline'. This guideline recommends the use of imaging. In this observational prospective study the added value of imaging in everyday clinical practice is evaluated. Methods: All patients with suspected appendicitis were included at the emergency department of a Dutch teaching hospital during the period from September 2011 to May 2012 (n = 350; 237 adults and 113 children under 18 years). Adherence to the guideline was evaluated. Results: 75 Patients (21%) were not referred for imaging because of a low suspicion or alternative diagnosis. In 16 patients (5%) the guideline was not followed. Of the 259 patients (74%) who underwent ultrasonography, 105 (30%) also underwent computed tomography (CT). 127 appendectomies were performed, showing appendicitis in 112 patients (88%); 15 appendectomies (12%) were negative. In the latter group, 12 were performed after false positive imaging results, and 3 following inconclusive imaging results. Conclusion: When using imaging in the diagnosis of appendicitis, the percentage of negative appendectomies remains close to the percentage declared as unacceptable by the publishers of the guideline.

Trends in the Management of Acute Appendicitis in a Single-Center Quality Register Cohort of 5,614 Patients

“…An increased proportion of uncomplicated cases could have indicated the overuse of surgery when additional radiology was used but this outcome was not found in our study. Other studies have also demonstrated 151 a decrease in the number of negative appendectomies with increased use of preoperative imaging [18,28,29]. An important benefit of reducing the number of negative appendectomies is avoiding complications from unnecessary surgery, which according to our data are comparable in number to that of OA.…”

Does the Use of Diagnostic Imaging Reduce the Rate of Negative Appendectomy ?

“…This leads to an enormous increase in costs purely for diagnosing appendicitis acuta. In the previously mentioned prospective study that was carried out in our hospital, it was found that computed tomography also sometimes gave false positive results in patients suspected of acute appendicitis (9). Although we were a little sceptical to increase the use of imaging for diagnosing acute appendicitis, as was proposed by the new guideline that was released in February 2010, our data show a significant decline in negative appendectomies.…”

Negative appendectomy rate during 5 years in Modarres Hospital of Tehran, Iran, and correlation with imaging

“…The most common misdiagnosis among men was diverticulitis of the colon. 7 Although in some studies, preoperative US and CT scan lower rates of negative appendectomy were reported, the results of the studies by Papes et al 8 and Schok et al 9 formed the opinion that diagnosis of appendicitis should still mainly be based on history, and clinical and laboratory data. 8 The study by Webb et al has shown that NAR was decreased for adult patients who underwent preoperative CT scan compared with patients with the lack of preoperative imaging.…”