Abstract
Purpose
Negative appendectomies are costly and are embedded with unnecessary risks for the patients. A careful indication for surgery seems mandatory even more so, since conservative therapy emerges as a potential alternative to surgery. The aims of this population-based study were to analyze whether radiological examinations for suspected appendicitis decreased the rate of negative appendectomies without increasing the rate of perforation or worsening postoperative outcomes.
Method
This study is a retrospective analysis of a prospective population-based database. The data collection included preoperative investigations and intraoperative and postoperative outcomes.
Results
Based on 2559 patients, the rate of negative appendectomies decreased significantly with the use of CT scan as compared to clinical evaluation only (9.3 vs 5 %, p = 0.019), whereas ultrasonography alone was not able to decrease this rate (9.3 vs 6.2 %, p = 0.074). Delaying surgery for radiological investigation did not increase the rate of perforation (18.1 vs 19.2 %; adjusted odds ratio (OR) 1.01; 0.8–1.3; p = 0.899). Postoperative complications (surgical reintervention, postoperative wound infection, postoperative hematoma, postoperative intra-abdominal abscess, postoperative ileus) were all comparable.
Conclusion
In this population-based study, CT scan was the only radiological modality that significantly reduced the rate of negative appendectomy. The delay induced by such additional imaging did not increase perforation nor complication rates. Abdominal CT scans for suspected appendicitis should therefore be more frequently used if clinical findings are unconclusive.
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References
Livingston EH, Woodward WA, Sarosi GA, Haley RW (2007) Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management. Ann Surg 245(6):886–892. doi:10.1097/01.sla.0000256391.05233.aa
Chandrasegaram MD, Rothwell LA, An EI, Miller RJ (2012) Pathologies of the appendix: a 10-year review of 4670 appendicectomy specimens. ANZ J Surg 82(11):844–847. doi:10.1111/j.1445-2197.2012.06185.x
Flum DR, Koepsell T (2002) The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg 137(7):799–804, discussion 804
Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B, Karoui M, Alves A, Dousset B, Valleur P, Falissard B, Franco D (2011) Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet 377(9777):1573–1579, 10.1016/S0140-6736(11)60410-8
Varadhan KK, Neal KR, Lobo DN (2012) Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials. BMJ 344, e2156. doi:10.1136/bmj.e2156
Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383
Busch M, Gutzwiller FS, Aellig S, Kuettel R, Metzger U, Zingg U (2011) In-hospital delay increases the risk of perforation in adults with appendicitis. World J Surg 35(7):1626–1633. doi:10.1007/s00268-011-1101-z
Coursey CA, Nelson RC, Patel MB, Cochran C, Dodd LG, Delong DM, Beam CA, Vaslef S (2010) Making the diagnosis of acute appendicitis: do more preoperative CT scans mean fewer negative appendectomies? A 10-year study. Radiology 254(2):460–468. doi:10.1148/radiol.09082298
Andersson MN, Andersson RE (2011) Causes of short-term mortality after appendectomy: a population-based case-controlled study. Ann Surg 254(1):103–107. doi:10.1097/SLA.0b013e31821ad9c4
Andersson RE (2013) Short and long-term mortality after appendectomy in Sweden 1987 to 2006. Influence of appendectomy diagnosis, sex, age, co-morbidity, surgical method, hospital volume, and time period. A national population-based cohort study. World J Surg 37(5):974–981. doi:10.1007/s00268-012-1856-x
Lahaye MJ, Lambregts DM, Mutsaers E, Essers BA, Breukink S, Cappendijk VC, Beets GL, Beets-Tan RG (2015) Mandatory imaging cuts costs and reduces the rate of unnecessary surgeries in the diagnostic work-up of patients suspected of having appendicitis. Eur Radiol. doi:10.1007/s00330-014-3531-0
Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ (1998) Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 338(3):141–146. doi:10.1056/NEJM199801153380301
Lee M, Paavana T, Mazari F, Wilson TR (2014) The morbidity of negative appendicectomy. Ann R Coll Surg Engl 96(7):517–520. doi:10.1308/003588414X13946184903801
Wu SC, Chen WT, Muo CH, Ke TW, Fang CW, Sung FC (2015) Association between appendectomy and subsequent colorectal cancer development: an Asian population study. PLoS One 10(2), e0118411. doi:10.1371/journal.pone.0118411
Kollár D, McCartan DP, Bourke M, Cross KS, Dowdall J (2015) Predicting acute appendicitis? a comparison of the Alvarado score, the appendicitis inflammatory response score and clinical assessment. World J Surg 39(1):104–109. doi:10.1007/s00268-014-2794-6
Collaborative NSR (2013) Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy. British J Surg 100(9):1240–1252. doi:10.1002/bjs.9201
Broder J, Warshauer DM (2006) Increasing utilization of computed tomography in the adult emergency department, 2000–2005. Emerg Radiol 13(1):25–30. doi:10.1007/s10140-006-0493-9
Reich B, Zalut T, Weiner SG (2011) An international evaluation of ultrasound vs. computed tomography in the diagnosis of appendicitis. International journal of emergency medicine 4:68. doi:10.1186/1865-1380-4-68
Lahaye MJ, Lambregts DM, Mutsaers E, Essers BA, Breukink S, Cappendijk VC, Beets GL, Beets-Tan RG (2015) Mandatory imaging cuts costs and reduces the rate of unnecessary surgeries in the diagnostic work-up of patients suspected of having appendicitis. Eur Radiol 25(5):1464–1470. doi:10.1007/s00330-014-3531-0
Terasawa T, Blackmore CC, Bent S, Kohlwes RJ (2004) Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med 141(7):537–546
Kim K, Kim YH, Kim SY, Kim S, Lee YJ, Kim KP, Lee HS, Ahn S, Kim T, Hwang SS, Song KJ, Kang SB, Kim DW, Park SH, Lee KH (2012) Low-dose abdominal CT for evaluating suspected appendicitis. N Engl J Med 366(17):1596–1605. doi:10.1056/NEJMoa1110734
Papandria D, Goldstein SD, Rhee D, Salazar JH, Arlikar J, Gorgy A, Ortega G, Zhang Y, Abdullah F (2013) Risk of perforation increases with delay in recognition and surgery for acute appendicitis. J Surg Res 184(2):723–729. doi:10.1016/j.jss.2012.12.008
Andersson RE (2007) The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J Surg 31(1):86–92. doi:10.1007/s00268-006-0056-y
Di Saverio S, Sibilio A, Giorgini E, Biscardi A, Villani S, Coccolini F, Smerieri N, Pisano M, Ansaloni L, Sartelli M, Catena F, Tugnoli G (2014) The NOTA Study (Non Operative Treatment for Acute Appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis. Annals of surgery 260 (1):109–117. doi:10.1097/sla.0000000000000560
Adams ML (1990) The medical management of acute appendicitis in a nonsurgical environment: a retrospective case review. Mil Med 155(8):345–347
Salminen P, Paajanen H, Rautio T, Nordstrom P, Aarnio M, Rantanen T, Tuominen R, Hurme S, Virtanen J, Mecklin JP, Sand J, Jartti A, Rinta-Kiikka I, Gronroos JM (2015) Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial. JAMA 313(23):2340–2348. doi:10.1001/jama.2015.6154
Marin D, Ho LM, Barnhart H, Neville AM, White RR, Paulson EK (2010) Percutaneous abscess drainage in patients with perforated acute appendicitis: effectiveness, safety, and prediction of outcome. AJR Am J Roentgenol 194(2):422–429. doi:10.2214/ajr.09.3098
Andersson RE, Petzold MG (2007) Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Ann Surg 246(5):741–748. doi:10.1097/SLA.0b013e31811f3f9f
Naeger DM, Chang SD, Kolli P, Shah V, Huang W, Thoeni RF (2011) Neutral vs positive oral contrast in diagnosing acute appendicitis with contrast-enhanced CT: sensitivity, specificity, reader confidence and interpretation time. Br J Radiol 84(1001):418–426. doi:10.1259/bjr/20854868
Authors’ contributions
M.-O. Sauvain: Study conception and design, analysis and interpretation of data, drafting of manuscript
K. Slankamenac: Analysis and interpretation of data
M. K. Muller: Critical revision of manuscript, drafting of manuscript
S. Wildi: Critical revision of manuscript
U. Metzger: Critical revision of manuscript
M. Decurtins: Critical revision of manuscript
W. Schmid: Critical revision of manuscript
J. Wydler: Critical revision of manuscript
P.-A. Clavien: Critical revision of manuscript
D. Hahnloser: Study conception and design, analysis and interpretation of data, drafting of manuscript
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Sauvain, MO., Slankamenac, K., Muller, M.K. et al. Delaying surgery to perform CT scans for suspected appendicitis decreases the rate of negative appendectomies without increasing the rate of perforation nor postoperative complications. Langenbecks Arch Surg 401, 643–649 (2016). https://doi.org/10.1007/s00423-016-1444-x
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DOI: https://doi.org/10.1007/s00423-016-1444-x