Neutrophil-to-lymphocyte ratio predicts acute appendicitis and distinguishes between complicated and uncomplicated appendicitis: A systematic review and meta-analysis

Objectivesto investigate whether Neutrophil-to-lymphocyte ratio (NLR) can predict acute appendicitis and whether it can distinguish between uncomplicated and complicated appendicitis.MethodsA search of electronic information sources was conducted to identify all studies reporting NLR in patients with clinical suspicion or confirmed diagnosis of acute appendicitis. We considered two comparisons:1) appendicitis versus no appendicitis; 2) uncomplicated appendicitis versus complicated appendicitis. ROC curve analysis was performed to determine cut-off values of NLR for appendicitis and complicated appendicitis.ResultsSeventeen studies, enrolling 8,914 patients were included. NLR of 4.7 was cut-off value for appendicitis with sensitivity of 88.89% and specificity of 90.91% with AUC of 0.96. NLR of 8.8 was cut-off value for complicated appendicitis with sensitivity of 76.92% and specificity 100% with AUC of 0.91. NLR >4.7 was predictor of acute appendicitis (OR:128,P < 0.0001) and, NLR >8.8 was predictor of complicated appendicitis (OR:43,P < 0.0001).ConclusionsNLR predicts both diagnosis and severity of appendicitis. This may have implications for prioritising cases for surgery, for monitoring conservatively treated patients and for patients who do not routinely undergo CT scan (pregnant or paediatric patients).     

Quantifying the effect of resident education on outcomes in pediatric appendicitis

Background/purposeSurgical residents are involved in the care of patients in a climate where quality of care is an important outcome measure. The purpose of this study was to evaluate the effect of resident involvement on appendectomy outcomes.MethodsWe retrospectively reviewed appendectomies, ages 0–18, from January 2016 to December 2018. Operative time, operative charges, and postoperative outcomes were evaluated for cases with and without a resident. Data were analyzed using Wilcoxon rank and Fisher's exact tests.ResultsOf 1842 appendectomies (1267 resident present and 575 no resident present), there was no difference in postoperative stay, abscess formation, readmission, or emergency room visits for simple or complex appendicitis. Operative time was significantly longer for cases of simple appendicitis by 10 min (p = < 0.0001) and charges significantly higher by $600 (p = < 0.0001) when a resident was involved in the case. These differences held true for complex appendicitis (time longer by 9 min, p = < 0.0001 and charges higher by $500, p = 0.03).ConclusionResident involvement results in an increase in operative time and charges, with no difference in length of stay or complications. These results highlight the cost of resident involvement, without an increase in complications experienced by patients.Level of evidenceLevel III evidence.     

Delta neutrophil index as an early predictor of acute appendicitis and acute complicated appendicitis in adults

Background

This retrospective study aimed to evaluate the ability of the delta neutrophil index (DNI) to predict histologically normal appendicitis preoperatively and to differentiate between simple and complicated appendicitis.

Methods

The data from 650 patients were divided into positive and negative appendectomy groups (histologically normal appendicitis). The patients in the acute appendicitis group were further sub-divided into simple and complicated appendicitis groups.

Results

The DNI was significantly higher in the positive group than in the negative appendectomy group (0.4 vs. ?0.4, p?<?0.001) as well as in the complicated group compared with that in the simple appendicitis group (1.2 vs. 0.3, p?<?0.001). The DNI independently predicted a positive appendectomy and an acute complicated appendicitis in multivariate logistic regression analysis [odds ratio (OR) 2.62, 95% confidence interval (CI) (1.11~6.16), p?=?0.028 and odds ratio (OR) 4.10, 95% confidence interval (CI) (2.94~5.80), p?<?0.001]. The optimum cut-off for a positive appendectomy and acute complicated appendicitis were 0.2 [area under curve (AUC) 0.709] and 0.6 (AUC 0.727).

Conclusions

We suggest that obtaining a preoperative DNI is a useful parameter to aid in the diagnosis of histologically normal appendicitis and to differentiate between simple and complicated appendicitis.

     

Evaluating the effectiveness of a discharge protocol for children with advanced appendicitis

BackgroundIn 2006, an evidence-based protocol for the management of children with appendicitis was established at our institution. Discharge criteria for patients with advanced appendicitis were based on a combination of clinical parameters and laboratory values. The purpose of this study is to evaluate the utility of laboratory values in guiding patient management with a discharge protocol for advanced appendicitis.Materials and methodsWe reviewed charts of patients with advanced appendicitis as defined by the surgeon intraoperatively from 2008–2009. We evaluated the sensitivity and specificity of the laboratory values at discharge for predicting postoperative intra-abdominal abscess (IAA) formation using a receiver operator curve. A logistic regression analysis was performed to identify predictors of IAA formation.ResultsWe identified 450 patients (mean age 8.9 ± 3.9 y). The postoperative IAA rate was 25%. The sensitivity and specificity for developing an abscess with a white blood cell count >12,000/UL were 52% and 82%, respectively (AUC 0.72, 95% CI 0.67–0.78, P < 0.001). The sensitivity and specificity for bands >3% were 47% and 70% (AUC 0.60, 95% CI 0.53–0.67, P = 0.002), respectively. On logistic regression analysis, an elevated white blood cell count was independently associated with an increased likelihood of a postoperative IAA (OR 1.27, 95% CI 1.19–1.35, P < 0.001).ConclusionsThe absence of leukocytosis is useful for identifying children with a decreased risk of postappendectomy IAA formation who otherwise meet clinical discharge parameters. A band count is not as predictive of risk. The use of laboratory evaluation as a component of discharge criteria in advanced appendicitis can stratify a subset of patients who are at increased IAA risk and may benefit from continued antibiotic therapy.     

Investigating the effect of discordant clinical and pathological diagnoses of complicated appendicitis on clinical outcomes

BackgroundFollowing appendectomy, management is often guided by surgeon determination of whether the appendicitis is uncomplicated or complicated. Our objectives were to determine the incidence of discordance between intraoperative and pathological findings and determine effect on outcomes.MethodsWe performed a retrospective five-year cohort analysis of adults who underwent appendectomy for acute appendicitis. Outcomes examined were length of stay (LOS), return to ED, and 30-day readmission. We reported p-values from logistic regression.ResultsOf 1479 cases, 36.4% were labeled complicated appendicitis, among which, 58.2% were discordant. When intraoperative findings underestimated pathological findings, there was a decreased LOS (p < 0.001) compared to concordant diagnoses. There was no significant difference for readmission (p = 0.592) or ED (p = 0.857).ConclusionOperative underestimation of appendicitis severity was associated with a shorter LOS. Discordance did not adversely affect hospital readmission or rate of return to ED. These findings suggest reliance on intraoperative findings is sufficient in guiding management.SummaryWe wanted determine the incidence of discordance between operative and pathological findings and determine effect on outcomes. Operative underestimation of appendicitis severity was associated with a shorter LOS. Discordance did not adversely affect hospital readmission or rate of return to ED. These findings suggest reliance on intraoperative findings is sufficient in guiding management.     

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

BackgroundIn 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 vs a non-pandemic period.MethodsAll 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.ResultsThere 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).DiscussionThe 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.     

The management of right iliac fossa pain – Is timing everything?

BackgroundRight iliac fossa (RIF) pain remains the commonest clinical dilemma encountered by general surgeons. We prospectively audited the management of acute RIF pain, examining the relationship between symptom duration, use of pre-operative radiological imaging and patient outcome.MethodsOver a six-month period, 302 patients, median age 18 years, 59% female, were admitted with RIF pain. Symptoms, clinical findings and laboratory results were documented. Patient management, timing of radiological investigations and operations, and outcome were recorded prospectively.ResultsNon-specific abdominal pain (26%), gynaecological (22%) and miscellaneous causes (14%) accounted for most admissions. Ultimately, 119 patients (39%) had appendicitis. Anorexia, tachycardia or rebound tenderness in the RIF significantly predicted a final diagnosis of appendicitis. Patients with perforated appendicitis (n = 29) had a longer duration of pre-hospital symptoms (median 50 h) compared to those with simple appendicitis (median 17 h) (p < 0.001). The use of pre-operative imaging resulted in an increased time to surgery but was not associated with increased post-operative morbidity or perforated appendicitis.ConclusionThe majority of patients presenting to hospital with RIF pain did not have appendicitis. Increased duration of pre-hospital symptoms was the main factor associated with perforated appendicitis. However, increased in-hospital time to theatre was not associated with perforated appendicitis or post-operative morbidity.     

It's time to deconstruct treatment-failure: A randomized controlled trial of nonoperative management of uncomplicated pediatric appendicitis with antibiotics alone

BackgroundPublished data demonstrate that management of uncomplicated pediatric appendicitis with antibiotics-alone is safe and frequently successful. Randomized controlled trials (RCT) comparing antibiotics-alone to appendectomy are lacking, alongside insight into drivers of failure. We sought to validate the antibiotics-alone approach and identify barriers to success using an RCT design.MethodsPatients aged 6–17 years with uncomplicated appendicitis were randomized to appendectomy or intravenous piperacillin/tazobactam for 24–48 h followed by 10 days of oral ciprofloxacin/metronidazole. Enrollment required symptoms <48 h, WBC<18, appendiceal diameter <11 mm, and radiographic absence of perforation. Lack of clinical improvement or persistently elevated WBC resulted in appendectomy. Primary outcomes were 1-year success rate of antibiotics-alone and quality-of-life measures.ResultsAmong 39 children enrolled over 31 months, 20 were randomized to antibiotics-alone and 19 to surgery. At 1 year, 6 nonoperative patients underwent appendectomy (70% success). Four cases were not true antibiotic failures but instead reflected “pragmatic” challenges to executing nonoperative algorithms. Only 2 cases represented recurrent/refractory appendicitis, suggesting a 90% adjusted 1-year success rate. Parental PedsQL? scores were similar between treatment cohorts (91.3 vs 90.2, P = 0.32). Children treated with antibiotics-alone had faster return to activity (2.0 vs 12 days, P = 0.001) and fewer parental missed work days (0.0 vs 2.5, P = 0.03).ConclusionsThese data corroborate findings from non-randomized studies suggesting 70–90% of uncomplicated pediatric appendicitis can be treated with antibiotics-alone, with fewer disability days. Failures appear multifactorial, often reflecting practical hurdles and not antibiotic limitations. As surgeons consider nonoperative protocols for uncomplicated appendicitis, these data further inform the variability of treatment success.Level of evidence1; randomized controlled trial.     

Impact of a Clinical Pathway and Standardization of Treatment for Acute Appendicitis

Purpose: Acute appendicitis is one of the most common surgical diseases. Simple and precise guidelines for treating acute appendicitis are necessary for improving the treatment outcome of this disease. The purpose of this study was to determine the impact of a clinical pathway and standardization of treatment for acute appendicitis at our hospital. Methods: The clinical pathway and standardization of treatment for acute appendicitis were introduced to our hospital in January 2000. We compared the length of hospitalization, postoperative stay, hospital costs, and operation time during the years before and the years after their introduction. Results: There was no significant difference in the clinical characteristics of the 73 patients in the control group and the 112 patients in the pathway group. There were 6 (8.2%) and 24 (21.4%) cases of perforated appendicitis in the respective groups. The mean length of hospitalization (P < 0.001), postoperative stay (P < 0.001), and hospital costs (P < 0.01) were significantly less in the patients in the pathway group who underwent surgery. Conclusion: Our clinical pathway and standardization of treatment for acute appendicitis proved effective for treating patients with acute appendicitis and minimizing costs without compromising patient care. Received: February 19, 2002 / Accepted: November 19, 2002 Reprint requests to: K. Takegami (address 2)     

Response-based therapy for ruptured appendicitis reduces resource utilization

PurposeWe examined the effectiveness of a postoperative ruptured appendicitis protocol that eliminated Pseudomonas coverage and based the duration of IV antibiotic treatment and length of hospital stay on the patient’s clinical response.MethodsIn our new protocol, IV antibiotics were administered until the patient met discharge criteria: adequate oral intake, pain control with oral medications, and afebrile for 24 h. We collected data on all patients with ruptured appendicitis at our institution following protocol implementation (May 1, 2012, to April 30, 2013) and compared them to a control group.Results306 patients were treated (154 prior protocol, 152 new protocol). The new clinical response-based protocol led to a decrease in hospital stay from 134 h (SD 66.1) to 94.5 h (SD 61.7) (p < 0.001) and total cost of care per patient also decreased from $13,610 (SD $6859) to $9870 (SD $5670) (p < 0.001).ConclusionOur clinical response-based protocol for pediatric patients with ruptured appendicitis decreased LOS, cost, and IV antibiotics use without significant changes in adverse events.     

Hyponatremia as a predictor of perforated acute appendicitis in pediatric population: A prospective study

BackgroundThe aim of this study was to investigate hyponatremia as a new biochemical marker associated with complicated appendicitis in the pediatric population.MethodsPediatric patients (n = 184) with acute appendicitis confirmed by histopathology were enrolled in a prospective cohort study from January 2019 to May 2020. Medical history, demographic and clinical data were recorded in the study protocol. Blood samples for biochemical analysis, electrolytes and acute inflammatory markers were taken before surgery.Patients were further divided in two groups, those with non-perforated (n = 148; 79%) and perforated appendicitis (n = 38; 21%).ResultsThe mean serum sodium level in patients with complicated appendicitis was significantly lower compared to patients with non-complicated appendicitis (132.2 mmol/L vs. 139.2 mmol/L, p < 0.001). The receiver operating characteristic curve of plasma sodium concentration in patients who were diagnosed with perforated acute appendicitis showed an area under the curve of 0.983 (95% CI, 0.963–1.00). A cut-off-value of plasma sodium concentration of ≤ 135 mmol/L was shown to give the best possible sensitivity and specificity, 94.7% (95% CI: 82.2–99.3) and 88.5% (95% CI: 88.2–93.2) respectively (p < 0.001). Patients with complicated appendicitis were more likely to be younger than five years of age (10.5% vs. 1.4%, p = 0.005), have a duration of symptoms for > 24 h (97.4% vs. 59.6%, p < 0.001), sodium serum concentration ≤ 135 mmol/L (89.5% vs. 5.5%, p < 0.001), body temperature > 38.5 °C (47.4% vs. 11.0%, p < 0.001) and CRP serum concentration > 62 mg/L (26% vs. 2%, p < 0.001).ConclusionHyponatremia is a novel and very discriminative marker of complicated appendicitis in the pediatric population, and is therefore recommended in appendicitis diagnostic and treatment planning.Type of studyProspective comparative studyLevel of evidenceII     

sTREM-1 as a diagnostic biomarker for acute appendicitis in children

BackgroundThe typical history of acute appendicitis is observed in less than 60% of cases. Therefore, searching for a surrogate marker is mandatory. Our goal was to determine whether the soluble triggering receptor expressed on myeloid cells (sTREM-1) is an efficient biomarker for acute appendicitis.MethodssTREM-1 serum levels were measured in addition to carrying out routine diagnostic tests (urine dipstick, complete blood count and CRP) in children admitted to the Emergency Department with suspected appendicitis. Statistical analysis was performed in order to examine whether sTREM-1 was a significant predictor of appendicitis.ResultsFifty three of 134 children enrolled in the study were diagnosed with appendicitis. There was no significant difference in serum sTREM-1 levels (p = 0.111) between children with or without appendicitis (n = 81). Leukocytes, neutrophils and CRP were significantly elevated in the appendicitis group (p < 0.001). The appendix diameter was significantly larger and the Alvarado score significantly higher in the appendicitis group (p < 0.001).Conclusionserum sTREM-1 is not a good marker for acute appendicitis. Customary tests in addition to a proper patient history and physical examination are still the most effective methods to diagnose acute appendicitis.     

Characterization of acute appendicitis in diabetic children

PurposeChildren with diabetes mellitus (DM) who develop acute appendicitis can present a diagnostic and clinical challenge. No studies have examined this population since the advent of multiple dose insulin therapy, computed tomography, and laparoscopic surgery. We sought to characterize these children to identify their differences and how to best care for them.MethodsWe retrospectively examined the medical records of children with a preexisting diagnosis of DM treated for acute appendicitis. Values are presented as the mean ± the standard error of the mean, and Student's t-test was used for statistical comparison.ResultsWe identified 18 diabetic children treated for acute appendicitis, making this the largest series of its kind. These children had similar presentations compared to non-diabetics, with the exception of often presenting without fever (83.3% with an initial temperature < 38 C). All children developed significant postoperative hyperglycemia (average high 382 ± 18 mg/dL), and most had glycemic control for ≤ 50% of the hospitalization (14/18, 77.8%), but they otherwise had typical postoperative courses.ConclusionsDiabetic children with appendicitis are often afebrile at presentation and have serum glucose levels that are difficult to control. Collaboration with pediatric endocrinologists is needed to appropriately manage these children during their hospitalization.     

Complicated appendicitis are common during the epidemic period of 2019 novel coronavirus (2019-nCoV)

ObjectivesTo assess the prevalence of complicated appendicitis (including gangrene, abscess and perforation) after the outbreak of the 2019-nCoV epidemic and to identify the risk factors associated with complicated appendicitis.MethodsTwo groups were established in the study consisting of: one group for cases of acute appendicitis before the 2019-nCoV epidemic (before January 1, 2020; pre-epidemic group) and another group for those after the epidemic outbreak (after January 1, 2020; epidemic group). These two groups were compared in terms of demographic and clinical characteristics, prevalence of complicated appendicitis, and treatment intention. A multivariate analysis model using binary logistic regression was constructed.ResultsA total of 163 patients were included in this study, with 105 in the pre-epidemic group and 58 in the epidemic group. In the epidemic group, the interval from the onset of symptoms to admission was 65.0 h, which is significantly longer than the 17.3 h interval noted in the pre-epidemic group (P < 0.001). The prevalence of complicated appendicitis after the epidemic outbreak was significantly higher than before the outbreak (51.7% vs. 12.4%, P < 0.001). In addition, the epidemic group had a lower score of patient’s intention to seek treatment than the pre-epidemic group (9.5 ± 2.7 vs. 3.4 ± 2.6, P < 0.001). Based on the multivariate analysis, the risk factors for complicated appendicitis included the time from symptoms onset to admission (OR = 1.075) and the patients’ intention to receive treatment (OR = 0.541).ConclusionComplicated appendicitis was more common in patients with acute appendicitis after the outbreak of the 2019-nCoV epidemic.     

Predicting short- and long-term renal function following partial and radical nephrectomy

ObjectivesTo externally validate the previously published Mayo clinic model for the prediction of early (<30 days) postoperative renal failure, which relies solely on preoperative estimated glomerular filtration rate (eGFR) and develop a novel model for the prediction of long-term (>30 days) renal function after partial nephrectomy (PN) and radical nephrectomy (RN), including patient factors and nephrometry scores.Patients and methodsRetrospective, single-center cohort study on patients who underwent PN or RN for a unilateral renal tumor between 2003 and 2019 with a preoperative eGFR of at least 15 ml/min/1.73m². Early postoperative renal failure was defined as eGFR <15 ml/min/1.73 m² or receipt of dialysis within 30 days. We determined the area under the receiver operating characteristics curve (AUC) to assess the Mayo clinic model's discriminative power. We used hierarchical linear mixed models with backward selection of candidate variables to develop a prediction model for long-term eGFR following PN and RN, separately. Their predictive ability was quantified using the marginal and conditional R²_GLMM and an internal validation.ResultsWe included 421 patients (7,548 eGFR observations) who underwent PN and 271 patients (6,530 eGFR observations) who underwent RN. The Mayo clinic model for prediction of early postoperative renal failure following PN and RN showed an AUC of 0.816 (95% CI 0.718–0.920) and 0.825 (95% CI 0.688–0.962), respectively.In multivariable models, long-term eGFR following PN was associated with age, diabetes, the presence of a solitary kidney, tumor diameter and preoperative eGFR, while long-term eGFR following RN was associated with age, body mass index, RENAL nephrometry score and preoperative eGFR. Marginal and conditional R²_GLMM were 0.591 and 0.855 for the PN model, and 0.363 and 0.849 for the RN model, respectively.ConclusionsThe Mayo clinic model for short-term renal failure prediction showed good accuracy on external validation. Our long-term eGFR prediction models depend mostly on host factors as opposed to tumor complexity and can aid in decision-making when considering PN vs. RN.     

The Role of D-Lactate in Differential Diagnosis of Acute Appendicitis

ABSTRACT

Introduction: Early diagnosis of acute appendicitis, known as the most frequent cause of acute surgical abdominal pathologies, dramatically decreases the related complications. D-lactate, produced by intestinal bacteria as a fermentation product, may be useful in diagnosing acute abdominal pathologies. The aim of this study was to investigate whether the presence of d-lactate would be a significant indicator in the early diagnosis of acute appendicitis. Methods: Eighty consecutive patients were prospectively included in this study. The patients were divided into four groups: acute appendicitis (group 1), perforated acute appendicitis (group 2), nonspecific abdominal pain (group 3), and acute abdomen other than acute appendicitis (group 4). For the control group, blood samples were taken in the same manner from 20 healthy subjects. Results: There was no significant difference in blood d-lactate levels between the simple acute appendicitis and acute perforated appendicitis groups (p > .05). The blood d-lactate levels in groups 1 and 2 were significantly higher than those in groups 3 and 4, and the control group (p < .001). The reliability of d-lactate was determined as 97% sensitivity, 93% specificity, 90% positive predictive and 95% negative predictive values, and 95% accuracy. Conclusions: Based on findings in this study, blood d-lactate level may be a valuable diagnostic marker for the diagnosis of acute appendicitis.     

Spatial–temporal clusters of pediatric perforated appendicitis in California

BackgroundPerforated appendicitis is a well-documented child health disparity. Geographic patterns in perforated appendicitis exist in several United States regions, but such patterns have not been described in California. We aimed to analyze spatial–temporal patterns of pediatric perforated appendicitis and identify population characteristics contributing to these cluster patterns.MethodsWe geocoded risk-adjusted perforated appendicitis rates per 1000 appendicitis cases in patients 1–17 years from 2005–2015 in California. We performed a space-time cube analysis to identify hot spot trends. We performed logistic regression to estimate rural classification associated with spatial–temporal hot spots and multivariate analysis to assess effects of socioeconomic factors.ResultsIn 2005–2015, 43,888 cases of pediatric perforated appendicitis occurred in California. Median risk-adjusted perforated appendicitis rate was 312 per 1000 appendicitis cases. We identified 11 spatial–temporal hot spots of perforated appendicitis. Rural micropolitan counties had 14 times higher odds of being classified as a hot spot (p<0.05, 95% CI 1–185). Poverty was a significant predictor of high perforated appendicitis median risk-adjusted rate (p<0.004).ConclusionsWe identified 11 California hot spots of perforated appendicitis that persisted across a ten-year time span. Incorporating geography alongside our understanding of socioeconomic factors is a critical step in addressing this important child health disparity.     

Pediatric laparoscopic appendectomy: a population-based study of trends,associations, and outcomes

PurposeWe performed a population-based study to analyze the trends, associations, and outcomes of laparoscopic appendectomy (LA) in the Canadian universal health care setting.MethodsChildren younger than 18 years coded for urgent appendectomy in the discharge abstract database of the Canadian Institute of Health Information during 2004–2010 were analyzed. The Cochran–Armitage test, logistic regression, and quintile regression were used to perform the necessary analyses.Results41,405 children were studied. LA incidence steadily increased from 28.8% to 66.4%, p < .0001. Conversion rates significantly decreased, while LA for perforated appendicitis significantly increased. LA occurred significantly less in younger patients [OR 0.24 (< 5 years), OR 0.45 (6–11 years)], males [OR 0.79], and operations by a general surgeon [OR 0.33]. Rural domicile, socioeconomic status, and hospital type had no effect. LA decreased hospital stay for simple appendicitis by one day beginning in 2006, and by variable durations for perforated appendicitis throughout the study period.ConclusionsThe incidence of LA in Canada has more than doubled. Older children, females, and patients treated by pediatric surgeons are more likely to receive LA, while domicile, socioeconomic status, and hospital type have no effect. LA reduced hospital stay for both simple and perforated appendicitis.     

Absolute neutrophil count as a diagnostic guide for the use of MRI in the workup of suspected appendicitis in children

Background/PurposeTo assess the additive value of magnetic resonance imaging (MRI) in the setting of an equivocal US (Eq-US) with or without an elevated absolute neutrophil count (ANC).MethodsSingle-institution, retrospective review of children ages 5–18 years who presented to the ER with suspected appendicitis from 9/2015 to 8/2016. US, ANC, and MRI results were reviewed. Imaging was identified as positive/suspicious, normal, or equivocal and ANC < 8000/mm³ was defined as normal.Results738 patients with a median age of 11 years (IQR 8–14) met inclusion criteria. US was equivocal in 61.4%. Among 304 (67.1%) patients with an Eq-US and normal ANC, only 5 (1.6%) had acute appendicitis. In contrast, 28 of 149 patients (18.8%) with Eq-US and elevated ANC had appendicitis. MRI was performed in 125 patients with Eq-US and was positive/suspicious in 2.9% (2/69) with normal ANC and 25.0% (14/56) with elevated ANC. MRI had 94.7% sensitivity and 100% specificity for acute appendicitis in patients with an Eq-US.ConclusionsMRI has high sensitivity and specificity for diagnosing acute appendicitis in children. Patients with Eq-US plus a normal ANC have a very low likelihood of appendicitis and do not typically require further imaging. MRI may have utility for children with Eq-US and elevated ANC.Level of EvidenceLevel III.     

Contemporary Epidemiology of and Risk Factors Associated with Removal of a Pathologically Normal Appendix in Children with Suspected Appendicitis

BackgroundThe goal of this study was to characterize contemporary performance benchmarks and risk factors associated with negative appendectomy (NA) in children with suspected appendicitis.MethodsA multicenter retrospective cohort analysis of children undergoing appendectomy for suspected appendicitis was performed using data from the 2016–2021 NSQIP-Pediatric Appendectomy Targeted Public Use Files. Multivariable regression was used to evaluate the influence of year, age, sex, and WBC count on NA rate, and to generate rate estimates for NA based on different combinations of demographic characteristics and WBC profiles.Results100,322 patients were included from 140 hospitals. The overall NA rate was 2.4%, and rates decreased significantly during the study period (2016: 3.1% vs. 2021: 2.3%, p < 0.001). In adjusted analyses, the highest risk for NA was associated with a normal WBC (<9000/mm³; OR 5.31 [95% CI: 4.87–5.80]), followed by female sex (OR 1.55 [95% CI: 1.42–1.68]) and age <5 years (OR 1.64 [95% CI 1.39, 1.94]). Model-estimated risk for NA varied significantly across demographic and WBC strata, with a 14.4-fold range in rates between subgroups with the lowest and highest predicted risk (males 13–17 years with elevated WBC [1.1%] vs. females 3–4 years with normal WBC [15.8%]).ConclusionsContemporary NA rates have decreased over time, however NA risk remains high in children without a leukocytosis, particularly for girls and children <5 years of age. These data provide contemporary performance benchmarks for NA in children with suspected appendicitis and identify high-risk populations where further efforts to mitigate NA risk should be targeted.Level of EvidenceIII.