Negative appendicectomy rates as a quality measure in a regional surgical unit: a retrospective review
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ORIGINAL ARTICLE
Negative appendicectomy rates as a quality measure in a regional surgical unit: a retrospective review Noel E. Donlon 1,2 & Michael E. Kelly 1,2 & Andrew Sheppard 2 & Maria Davern 2 & Tim S. Nugent 1,2 & Patrick A. Boland 1 & Kevin Corless 1 & Waqar Khan 1 & Iqbal Khan 1 & Ronan Waldron 1 & Kevin Barry 1,3 Received: 25 April 2020 / Accepted: 31 August 2020 # Royal Academy of Medicine in Ireland 2020
Abstract Introduction Historically, high negative appendicectomy rates (NAR) were acceptable to offset the risks of perforation, previously exceeding 20%. With improved imaging and clinical scoring algorithms, there is growing demand for lower negative appendicectomy rates. The objectives were to (1) establish the NAR in our institution and (2) correlate clinical parameters and imaging modalities with histological findings. Methods Patients undergoing an appendicectomy between January 2012 and June 2018 were identified using a prospectively maintained pathology database. Histology findings were cross referenced against our radiology system, and anonymised data was collected for gender, age, WCC, Neutrophil and CRP level. Results One thousand one hundred fifty-three patients met the inclusion criteria. Fifty-three percent were males (n = 610), with 81% (n = 933) of histology reports classified as appendicitis. Sixty patients had a histologically normal appendix equating to a 5.2% NAR. If lymphoid hyperplasia, fibrosis and atrophy are included, it equates to a NAR of 14.57%. (p < 0.0001). Sixty-six percent of patients had no pre-operative imaging. CT imaging demonstrated a higher sensitivity (93.33%) and positive predictive value (99.60%) compared to ultrasonography. WCC and CRP are statistically significant in predicting appendicitis (p < 0.0001). Conclusion There is no consensus on defining a negative appendicectomy or for imaging modality utilisation. CT imaging is the most sensitive and should be used in cases of diagnostic uncertainty. A standardised algorithm regarding the workup of patients with RIF pain along with a consensus on the use of imaging will further reduce negative appendicectomy rates. Keywords Appendicitis . Clinical parameters . Computed tomography (CT) . Negative appendicectomy rate (NAR) . Pathology . Ultrasound (US)
Introduction Acute appendicitis is the most common abdominal surgical emergency, with a lifetime risk of 8.6 percent in males and 6.9 percent in females, and a worldwide incidence of 86 cases annually/100,000 population. [1, 2]. Unfortunately, over a
* Noel E. Donlon [email protected] 1
Department of General Surgery, Mayo University Hospital, Castlebar, Mayo, Ireland
2
Department of General Surgery, St. James’ Hospital, Dublin 8, Ireland
3
Discipline of Surgery, National University of Ireland, Galway, Ireland
century since Fitz’s initial description of ‘Perforating Inflammation of the Vermiform Appendix’, the diagnosis as well as management of acute appendicitis is mired in controversies and contradictions [3]. Conventional wisdom in the management of appendicit
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