DIALAPP: a prospective validation of a new diagnostic algorithm for acute appendicitis
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ORIGINAL ARTICLE
DIALAPP: a prospective validation of a new diagnostic algorithm for acute appendicitis Patrizia Malkomes 1 & Franziska Edmaier 1 & Juliane Liese 2 & Alexander Reinisch-Liese 3 & Hanan El Youzouri 1 & Teresa Schreckenbach 1 & Andreas M. Bucher 4 & Wolf Otto Bechstein 1 & Andreas A. Schnitzbauer 1 Received: 10 August 2020 / Accepted: 1 November 2020 # The Author(s) 2020
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) Keywords Acute appendicitis . Diagnostic algorithm . Risk-stratification . Negative appendectomy rate . Clinical trial
Introduction Wolf Otto Bechstein and Andreas A. Schnitzbauer contributed equally to this work. * Patrizia Malkomes [email protected] 1
Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
2
Department of General, Abdominal, Thoracic and Transplant Surgery, University Hospital of Giessen, Giessen, Germany
3
Department of General, Visceral and Oncological Surgery, Wetzlar Clinic, Wetzlar, Germany
4
Department of Radiology, Institute for Diagnostic and Interventional Radiology, Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
With an incidence of 120 per 100,000 inhabitants, appendiciti
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