BACKGROUND: Acute appendicitis (AA) is the most common emergency general surgical condition worldwide. Diagnosis is challenging and incorporates clinical, biochemical and radiological investigations. Our aim was to provide data from routine practice investigating widely utilised diagnostic methods from a single centre within the United Kingdom.
METHODS: We conducted a retrospective observational cohort study of patients who underwent a laparoscopic appendicectomy for AA between April 2022 and March 2023. AA was defined as the presence of transmural polymorphonuclear leukocytes in histology. Subgroup analysis was performed on paediatric patients. Factors associated with AA were investigated, and the diagnostic utility of biochemical and radiological investigations was examined.
RESULTS: A total of 330 appendicectomies were analysed. We found an overall negative appendicectomy rate (NAR) of 38% and 48% in paediatric patients. Independent factors associated with AA on the multivariate analysis included elevated neutrophil counts (>7 × 109/L) (OR 4.04), elevated CRP (>5 mg/L) (OR 3.04) and a radiological diagnosis (OR 8.0). Computerised tomography (CT) and ultrasound had sensitivity/specificity of 98%/47% and 35%/86%, respectively. The positive-predictive values were 85% for CT and 50% for ultrasound, and the negative-predictive values were 86% for CT and 77% for ultrasound.
CONCLUSIONS: Our study has highlighted the importance of utilising a combination of factors to improve the diagnostic certainty of AA. However, our routine practice data have shown different sensitivities and specificities of imaging in comparison to existing literature, resulting in a high NAR. Further real-world data are needed to understand whether these differences from the existing data are seen in other clinical settings.

Background The clinical diagnosis of acute appendicitis (AA) can be challenging. This study aimed to evaluate the significance of this diagnosis amidst technological progress. It compared clinical diagnosis to radiology-aided diagnostic outcomes and negative appendicectomy rates (NAR). Methodology This study conducted a single-center retrospective and prospective cohort observational study on all adult patients presenting with suspected AA in 2018 at a major tertiary teaching hospital in Perth, Western Australia. Key demographics, clinicopathological, radiology, and operative reports were reviewed. Data were analyzed using SPSS v.27. Results Of 418 patients with suspected AA, 234 (56%) were in the retrospective group. The median age was 35 (IQR=26), and 224 (54%) were female. The overall NAR was 18.6% (95% CI (14.8-22.4)) and 20.8% for clinical diagnosis. Notably, the NAR for ultrasound (USS)-reported AA (false positive) was 17.6% (95% CI (10.6-27.4)). Three-quarters of the patients, 298 (71.3%), had radiological imaging. The most common modality was CT 176 (59.1%), and 33 (7.9%) had both CT and USS imaging performed. Compared with final histopathology, no significant difference was found in the accuracy of clinically diagnosed and USS-diagnosed cases, with rates of 83.5% and 82.5%, respectively (p=0.230). CT had the best positive predictive value at 82.1%. Single-modality imaging did not cause a significant surgical delay (p=0.914), but multi-modal imaging showed a non-significant trend toward delay (p=0.065). When surgeons assessed an appendix as normal, 54 (12.9%), the histopathological assessment revealed pathology in 28 (51.9%). The inter-observer agreement was only fair to moderate, Kappa=0.46 (95% CI (0.33-0.58); p<0.001). The intraoperative identification of a normal appendix inversely correlated to the grade of the primary surgeon, which was likely related to the number of surgical personnel in the theater (p<0.001). Conclusion This study showed that clinical diagnosis matches the diagnostic accuracy of imaging technologies. Utilizing diagnostic imaging methods promptly and appropriately did not lead to considerable delays in surgery. Surgeons\' capability to diagnose appendicitis during surgery is moderately accurate. Most patients underwent imaging, with CT scans being the most common. Moving forward, practitioners must minimize excessive reliance on imaging techniques as this can be resource-intensive, especially in developing countries. Future clinical practice should balance embracing technological advancements and preserving essential clinical diagnostic expertise, for medicine is both a science and an art.

UNASSIGNED: Acute appendicitis (AA) is treated primarily surgically with histopathology being the gold standard for confirmation of appendicitis and reported rates of negative appendicectomies (NA) ranging between 3.2% and 19% worldwide and 15.9-20.6% in the UK. NA rates are frequently used to identify poor performing centers as part of a Model Health System and form an integral part of appendicitis scoring systems. This study aims to evaluate the prevalence of negative appendicectomies within our institution and critically analyze the appropriateness of its use as a quality metric and its impact on clinical practice and research.
UNASSIGNED: Data analysis from a prospective dataset of pediatric appendicitis patients between 2015 and 2021 in a tertiary center in the UK was performed. Detailed analysis of negative appendicectomies was performed and further stratified by two distinct age and gender groups looking at the incidence of NA and the classification of non-histologically normal appendix specimens.
UNASSIGNED: In our series, 819 patients met inclusion criteria, 736 (89.9%) had acute appendicitis. Our overall institutional negative appendicectomy rate was 10.1% (83 patients) with the breakdown as follows: 65 histologically normal appendix (7.9%), 10 Enterobius vermicularis, 3 eosinophilic appendicitis, 2 neoplasms, 1 isolated faecolith, 1 fibrous obliteration of the lumen, and 1 peri-appendiceal inflammation.
UNASSIGNED: Our negative appendicectomy rate is below established UK pediatric NA rates. This rate ranges from 7.9% to 10.1% depending on the definition of NA utilized. A single standard pathological definition for histological acute appendicitis is required when being used as a comparative quality metric. Centers engaged in clinical research should be aware of variations in NA definitions both in scoring systems and individual centers to avoid skewing derived results.

Background and objectives Appendicitis is a frequent cause of abdominal pain. Because of the limited availability of imaging services in many medical centers and an urge to reduce the substantial number of unnecessary appendectomies, several clinical diagnostic tools have been constructed. A novel diagnostic tool, referred to as the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score, has been created to assist in identifying acute appendicitis (AA) in Asian nations. The study aimed to assess the correlation between RIPASA scores and the severity of appendicitis as determined by pathological examination. Materials and methods The study was a prospective observational investigation undertaken in the Department of General Surgery at Muslim education society (MES) Medical College Perinthalmanna over 12 months. The study included all patients who had been diagnosed with AA and underwent appendectomy, provided they satisfied both the inclusion and exclusion criteria. An analysis was conducted on a convenience sample of 225 individuals using a prestructured proforma. The RIPASA scores were estimated before their surgery, taking into account their age, gender, symptoms, physical examination findings, and laboratory findings. These scores were subsequently contrasted with the histopathological results obtained after the appendectomy. The individuals were categorized into three groups according to their RIPASA scores. The lower-score category, scores between 4 and 7. The intermediate-score category consists of scores ranging from 7.5 to 11.5, while the higher-score category includes scores of 12 and above. These scores are correlated with the histopathology report (HPR) to determine the presence of appendicitis, perforated appendix, appendicular abscess, or the absence of pathology observed. Results The study population comprised of 137 (60.9%) males and 88 (39.1%) females. Among these, 177 individuals (78.7%) were younger than 40 years, while 48 individuals (21.3%) were older than 40 years. Out of 225 cases, 146 cases were AA (64.9%), 27 (12%) appendicular abscess cases, and 41 (18.2%) appendicular perforation cases. The normal appendix was noted in 11 out of 225 cases in the low-score group. The association between the histopathological report and RIPASA score was found to be statistically highly significant (p=0.000). In the low-score group, there were 14 cases of appendicitis (53.8%), one case of appendicular abscess (3.8%), a total of 11 cases without pathology observed (42.3%), and no reported instances of appendicular perforation. In the intermediate-score category, there were 121 cases of appendicitis (89.6%), 12 cases of appendicular abscess (8.9%), 2 cases of appendicular perforation (1.5%), and no reported cases in the non-pathology category. Among the high-score category, there were 11 cases of appendicitis (17.2%), 14 cases of appendicular abscess (21.9%), 39 cases of appendicular perforation (60.9%), and no reported instances of negative appendectomy. Conclusion The study has shown that the RIPASA scoring system had a high diagnostic efficacy in identifying AA. This scoring system is an effective, dependable, cost-effective, noninvasive, reproducible, and safe diagnostic technique that does not require additional expenses or concerns.

Acute appendicitis is one of the most common causes of right iliac fossa pain which often warrants surgical management. In many cases, abdominal ultrasonography (USS) is done to confirm the diagnosis however negative appendicectomy is common due to atypical presentations and different visualisation rate. The unnecessary operative intervention can result in complications. The aim of this study was to compare the efficacy between clinical diagnosis and USS in diagnosing acute appendicitis to avoid negative appendicectomy and prevent further complications.
UNASSIGNED: A retrospective cohort study was conducted in a district general hospital which 1046 cases of laparoscopic appendicectomy were included and examined for the use of USS or clinical diagnosis. The sensitivity, specificity, negative and positive predictive value in USS and data in clinical evaluation were analysed for their accuracy in the diagnosis of acute appendicitis based on the histology results post appendicectomy.
UNASSIGNED: Clinical diagnosis without preoperative imaging was found to have a significantly lower negative appendicectomy rate of 27.20% compared with 42.67% in those who underwent ultrasound. 44.64% of the patients were misdiagnosed with a normal USS result who had a subsequent positive histology of appendicitis.
UNASSIGNED: USS has been shown to be less sensitive for diagnosing acute appendicitis which results in high negative appendicectomy and misdiagnosis rate. With an increasing burden of health budget and resources, cautious and appropriate use of USS would avoid the misdiagnosis and prevent further complications. Thorough clinical evaluation remains an important first step and role in the diagnosis of acute appendicitis.

In acute appendicitis, decision-making around operative intervention for paediatric patients differs from adults due to a higher weight placed on clinical assessment and reduced rates of cross-sectional imaging. In regional settings, non-paediatric emergency doctors, general surgeons, and radiologists usually assess and manage this patient group. Differences have been observed in paediatric negative appendicectomy rates between general and paediatric centres.
A retrospective cohort study was performed, identifying paediatric patients undergoing emergency appendicectomy at the Southwest Health Campus (Bunbury, Western Australia) from 2017 to 2021. The primary outcome measure was histopathology confirming the absence of transmural inflammation of the appendix. In addition, clinical, biochemical and radiological data were collected to identify predictors of negative appendicectomy (NA). Secondary outcome measures were hospital length-of-stay and post-operative complication rates.
Four hundred and twenty-one patients were identified, of which 44.9% had a negative appendicectomy. Statistically significant associations between female gender, white cell count less than 10 × 109 , neutrophil ratio less than 75%, low CRP and NA were observed. NA was not associated with a lower risk of re-admission or complications compared with appendicectomy for appendicitis.
Our centre\'s NA rate is higher than that observed in the literature at both non-paediatric and paediatric surgical centres. NA has similar morbidity risk to appendicectomy for uncomplicated appendicitis and offers a timely reminder that diagnostic laparoscopy in children is not benign.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has posed significant challenges to the provision of elective and emergency general surgical care. Patterns of presentation have changed and management pathways have also been adapted, moving to more non-operative management (NOM) for some conditions. We investigated how COVID-19 changed the volume of emergency general surgery operating in our district general hospital (DGH). We aimed to evaluate the impact of NOM on outcomes in acute appendicitis.
METHODS: A retrospective case review of operating lists, patient handover lists, and patient notes was undertaken for patients presented between 1st January 2020 and 3rd June 2020. The study period was divided into two, with the period between 1st January 2020 and 23rd March 2020 representing the pre-COVID cohort.
RESULTS: Some 393 emergency general surgery operations were performed in the study period. There was a clear reduction in operating volume after 23rd March 2020. During that same period, 325 patients were assessed with right iliac fossa (RIF) pain. Median age was 21 (range 5-87) and 201 patients were female (61.8%). The rate of NOM for suspected acute appendicitis was 8.8% in the pre-COVID group, which increased to 36.4% in the COVID group. The incidence of normal histology following appendicectomy did not change with this difference in management (16.1% compared to 17.9%, p = 0.78).
CONCLUSIONS: This study summarizes the changes brought to the provision of emergency general surgery in the setting of a DGH by the COVID-19 pandemic. In particular, NOM was the preferred option for acute appendicitis but this did not alter the negative appendicectomy rate.

OBJECTIVE: To report the impact of the SARS-CoV-2 pandemic on management and outcomes of paediatric appendicitis in the UK and Ireland.
METHODS: Prospective, multicentre observational cohort study at general surgical and specialist paediatric surgical centres in the United Kingdom and Ireland from 1st April to 31st July 2020. Primary outcome was treatment strategy used for acute appendicitis.
RESULTS: This study includes 2002 children treated for acute appendicitis of a median age of 10 (range 1-15) years and 605 children from a similar data set pre pandemic from 2017. In the pandemic cohort 560/2002(28%) were initially treated non operatively of whom 125/560(22%) proceeded to appendicectomy within initial hospital admission. Non operative treatment wasn\'t used in the pre pandemic cohort. Diagnostic imaging use was greater during the pandemic compared to pre pandemic (54vs31%; p < 0.00001) but overall use of laparoscopy was similar during both time periods (62.4vs66.6%). Hospital readmission rate was lower (8.7vs13.9%; p = 0.0002) during the pandemic than pre pandemic and Re-intervention rate was similar (2.9vs2.6%;p = 0.42). In cases treated operatively negative appendicectomy rate was lower during the pandemic than pre pandemic (4.4vs15.4%; p =0.0001), and during the pandemic was amongst the lowest ever reported in the UK.
CONCLUSIONS: COVID-19 has had a significant impact on the management of children with appendicitis in the UK and Ireland. The rate of imaging and the use of non operative management increased, whilst the negative appendicectomy rate reduced. Overall, patient outcomes have not been adversely impacted by change in management during the pandemic.
CONCLUSIONS: Level I.
METHODS: Prognosis study.

Introduction Acute appendicitis is a common emergency surgical presentation. The gold standard treatment is surgery. Like any surgical procedure, appendicectomy is associated with complications. Negative appendicectomy (NA) can occur, and its incidence is 15%-39%. This study aimed to evaluate the rate and predictors of NA in a cohort. Patients and methods A retrospective study over a year through which data of patients who underwent emergency appendicectomies were collected and analyzed. The absence of inflammatory process and/or other significant pathology in the appendix was considered negative for appendicitis. An utter definition of NA was the absence of inflammatory cells in the appendix. The NA rate (NAR) was calculated using the standard criteria (NAR-SDC) and the strict criteria (NAR-STC). The routine laboratory parameters for diagnosing acute appendicitis on admission were collected. Increased inflammatory markers in the form of leucocytosis of total WBC > 11,000 per mm, elevated CPR > 5 mg/L, and isolated elevated total serum bilirubin > 20 µmol/L, were suggestive of acute appendicitis. Results Three hundred and seventy-two patients were included, 179 males and 193 females with a median age were 27 (5-94) years. The median duration of symptoms and waiting time to surgery were two days and one day, respectively. The mean admission WBC, C-reactive protein (CRP) and serum bilirubin levels were 12,600 (3,000-38,000)/mm3, 66.9 (1-323) mg/L and 12.7 (4-38) µmol/L respectively. Laparoscopic appendicectomy was performed in 93.5% of patients with a conversion rate of 4.6%. NAR-SDC was 10.2% and NAR-STC was 25.8%. NAR was significantly higher in females than males (39.4% versus 11.1%; p-value 0.0001). Patients with NA were younger (p-value 0.0001), had lower mean total WBC (p-value 0.014), CRP (p-value 0.0001) and total serum bilirubin (p-value 0.0001) levels on admission. Conclusion NA is still a major problem in the management of patients with acute right lower abdominal pain. Our NAR compared favourably with reported rates. Female gender, duration of symptoms more than three days, and lower total WBC were independent predictors of NA.

BACKGROUND: Appendicitis accounts for the most frequent surgical emergencies in childhood. The guidance from the Royal College of Surgeons and poor post operative outcomes in surgical patients during the pandemic, it would be expected that only children who had clinical signs of appendicitis and were unwell, would have undergone surgery. Hence, the negative appendicectomy rate during the pandemic should have decreased.The aim of this retrospective study was to assess the rate of negative appendicectomy amongst children <16 years of age during the first wave of the pandemic, from the announcement of the lockdown and determine if there was a true difference by comparing the rate with the same time period in 2019.
METHODS: Data of all children aged<16 years who were operated for appendicitis between 23/3/2020 and 30/06/2020 was collected retrospectively and compared with that of children operated during the same time period in 2019 for the rate of negative appendicectomy.Data were analysed using the two-tailed t-test for continuous data and χ2 or Fishers exact tests for categorical data with p value of <0.05 considered significant.
RESULTS: Twenty three paediatric patients presenting with acute appendicitis underwent appendicectomy during the COVID-19 pandemic and 35 patients during 2019.Overall 17.39% patients underwent laparoscopic appendicectomy in 2020 while 54.29% in 2019. The negative appendicectomy rate was zero during the pandemic while it was 17.14% in 2019. There was no difference in the median length of hospital stay during the two time periods. There was no significant difference in complication or re-admission rate.
CONCLUSIONS: This study has the lowest reported incidence of negative appendicectomy rate during the pandemic following wider use of pre operative imaging and early senior involvement in decision making. The increased number of complicated appendicitis during the pandemic did not translate to worse clinical outcomes.