Normal Appendix Research Articles

Perforated Meckel’s Diverticulum: A Case Report

Meckel’s diverticulum is a true diverticulum that consists of all layers of bowel normally found in a normal small bowel wall. The three most common presentations in children are intestinal bleeding (30–56%), intestinal obstruction (14–42%), and diverticular inflammation (6–14%). Complications result in more severe symptoms, such as acute abdomen and signs of peritonitis. These presentations are not specific to Meckel’s diverticulum and can be found in many other conditions, making the diagnosis difficult. A five-year-old child came to the emergency department with complaint of acute abdominal pain, especially in the right lower quadrant. The pain was accompanied by vomiting. On physical examination, patient was febrile and signs of peritonitis were found. Abdominal plain film revealed the probability of focal inflammation in the right lower region of the abdomen, with partial intestinal obstruction. Ultrasonography showed a presence of a mass in right iliac region with the size of 24x20x23 mm, with normal appendix. During exploratory laparotomy, a necrotic and perforated Meckel’s diverticulum was found, with associated purulent matter. Diverticulectomy with segmental resection of ileum followed by end-to-end anastomosis were done. Diagnosis of Meckel’s diverticulum requires a high index of suspicion, especially in the pediatric population. It is important for clinicians to be aware of unusual presentations of Meckel’s diverticulum.

Borderline tumours of the ovary: A 37-year experience at a tertiary referral centre.

Borderline ovarian tumours (BOT) are a common epithelial ovarian tumours. Typically diagnosed at an early stage with a good prognosis, many BOT are treated conservatively. Recurrence is common. This update to our last audit in 1997 represents one of the largest audits of BOT to date. All patients with BOT managed at 'the hospital' from 1984 to 2021 were included. Expert pathology review was available. There were 549 cases included. The recurrence rate was 5% (n = 29/549) with 1.4% (n = 8/549) undergoing malignant transformation. Three of the eight women who recurred as cancer died from their disease. Frozen section was predictive of histologic diagnosis in 92% (n = 55/60) of serous tumours (SBOT), but only 62% (n = 54/87) of mucinous tumours (MBOT). In MBOT where the appendix appeared normal intra-operatively, it was histologically benign in all cases (n = 63). In SBOT, the recurrence rate was 5/23 (22%), 12/52 (23%), 1/29 (3%) and 3% (P = <0.01) for unilateral cystectomy, unilateral oophorectomy ± cystectomy, bilateral oophorectomy, and bilateral oophorectomy with hysterectomy, respectively, as index procedure. In MBOT this correlated to 2/20 (10%), 3/93 (3%), 0 and 1/58 (2%), respectively. This study describes important information correlating first surgical procedure and fertility-sparing surgery to recurrence and malignant transformation. For all BOT subtypes, fertility-preserving surgery increased the risk of recurrence and hysterectomy was not superior to removal of both ovaries. In MBOT, frozen section is of limited utility and the macroscopically normal appendix is very unlikely to be anything but benign, if MBOT is the true histologic diagnosis.

Using a sum of the cross diameters of the appendix measured on ultrasonographyas a criterion can more effectively predict acute appendicitis.

To investigate whether usingasum of the cross diameters on the transverse section of the appendix as a criterioncan improve the diagnosis of acute appendicitis (AA). In this retrospective study, 433 patients with AA and 207 patients with a normal appendix were assigned to the training and validation groups in a proportion of 7:3. Each group was divided into subgroups consisting of patients with AA and a normal appendix. The training group included 144 patients with a normal appendix and 302 patients with AA, while the validation group comprised 63 patients with a normal appendix and 131 patients with AA. Graded compression ultrasound was performed to evaluate the appendix, and the cross diameters on the transverse section were measured, with one of them used as the maximum outer diameter (MOD). The cut-off value of the sum of cross diameters for predicting AA was 13.5 mm or more. When it was applied to evaluate the appendix in the training group, a sensitivity of 98.7%, specificity of 99.3%, positive predictive value of 99.7%, negative predictive value of 97.3%, and an area under the receiver operating characteristic curve of 0.990 were achieved. Which were significantly higher than those (except for a sensitivity of 99.3%) obtained using the criteria of MOD ≥ 6 mm. Similar results were obtained in the validation group. Using a sum of cross diameters of the appendix of 13.5 mm or more as a criterionto diagnose AA can yield excellent diagnostic performance, and can replace the current criteria of MOD of 6 mm or more. Question A MOD of the appendix ≥ 6 mm is a recommended criterion for diagnosing AA, but often results in a false-positive diagnosis. Findings Using the sum of the cross diameters of the appendix ≥ 13.5 mm as acriterionyielded significantly higher diagnostic performance than the recommended criteria. Clinical relevance The sum of the cross diameters of the appendix is a better criterion for the evaluation of patients with suspected AA, exhibiting significantly higher diagnostic performance than the MOD of the appendix.

EP198 - Negative appendicectomy: A cohort study

Abstract Aims Negative appendectomy is charaterized as removal of normal appendix histopatholigically. Diagnosis of appendicitis remains a challenge, despites improved diagnostic algorithms (including scoring systems, serological &amp; radiological tests), negative appendectomy rate remains &amp;lt; 20%. The aim of the study is to assess negative appendicectomy at a single centre. Methods Cohort study was carried out on all appendicectomies from Mar’2020 to Jan’2024. Descriptive demography &amp; post-operative outcomes were evaluated for negative appendicectomies (Histopathological HPA confirmed normal appendix), all other appendicectomies (HPA confirmed appendicitis) were recruited as controls. Results Normal HPA(n = 41) Appendicitis HPA(n = 477) Mann-Whitney U(p value) Age(yrs) 26.4 36.7 &amp;lt; 0.005 Sex(M : F) 16 : 25 235 : 242 NS BMI(kg/m2) 24.7 25.5 NS GP 8 135 NS A &amp; E 33 342 NS WCC(x109/L) 10.7 13.5 &amp;lt; 0.0001 CRP(mg/L) 43.4 ± 10.5 68.3 ± 3.9 &amp;lt; 0.005 Open(n) 0 8 NS Lap(n) 41 469 NS ASA(median) 1 1 NS Diagnostic(n) Clinical 0 33 USS scan 23 117 &amp;lt; 0.001 CT scan 18 327 &amp;lt; 0.01 AB (days) Inpatient 2 ± 0.5 2 ± 1 NS Discharge 0 ± 2 ± 2.5 &amp;lt; 0.005 Operation time (mins) 66.2 75.7 &amp;lt; 0.01 LOS (days) (med) 2 2 NS Appendix HPA (mm) Length 62.4 67.0 NS Diameter 8.6 11.5 &amp;lt; 0.0001 Cost (£) 3376 4341 &amp;lt; 0.05 Conclusions Despite radiological diagnostics, the negative appendicectomy rate was 7.9 %. Laparoscopy offers an additional diagnostic modality especially in women &amp; post op recovery is quicker. The negative appendicectomy rate has been declining in recent years, but cannot be abolished. A negative appendicectomy rate of &amp;lt; 10 % must be deemed acceptable, to achieve a 90 % therapeutic appendectomy (HPA confirmed appendicitis) rate.

WP8.5 - Operative Documentation of Laparoscopic Appendicectomies at FVRH based on GIRFT - An Audit

Abstract Introduction Laparoscopic appendicectomy (LA) is the most performed abdominal surgery in the UK. Clear documentation is required to ensure safe and effective patient care. Aims To assess compliance with LA operative documentation at Forth Valley Royal Hospital using Getting It Right First Time (GIRFT) guidelines. Methods 27 data points selected from GIRFT Guidelines were examined retrospectively for 172 LA procedures between 01/08/2022 and 29/09/2023. Completed numbers and percentages for each data point were calculated. Results Most consistently documented data points were intra-operative findings 168 (98%), details of closure 168 (98%) and method to secure appendix stump 161 (94%). Least consistently documented were drain insertion 7 (4%), estimated blood loss 5 (3%) and instructions for suture removal 6 (3%). 6 (37%) operative notes explicitly confirmed whether the appendix was removed in those with a macroscopically normal appendix. Conclusion Many data points had a high completion rate, whilst others had a low completion rate. We have highlighted discrepancies in documentation between surgeons which the department is hoping to streamline to avoid any gaps that could have patient care, legal or cost implications in the future.

SP2.2 - A Retrospective Audit: Evaluating Changes in Negative Appendicectomy Rates from 2019 Before the Establishment of the Emergency General Surgery Service at a Tertiary Centre to 2022

Abstract Introduction and Aim Negative surgical exploration for suspected acute appendicitis remains prevalent, with a reported 20% rate in the UK Right Iliac Fossa Pain Treatment (RIFT) study. WSES guidelines endorse structured diagnostic pathways to decrease negative appendicectomy rates. To enhance acute surgery care, a dedicated Emergency General Surgery (EGS) service was established at a tertiary centre in 2020. This retrospective audit compares the negative appendicectomy rates between 2019 and 2022, therefore the main aim is to assess whether the introduction of a consultant-led EGS service influenced overall negative appendectomy rates. Methodology Appendicectomy numbers and histology results from 2019 and 2022 were analyzed. Histologically normal appendix cases were deemed negative appendicectomies, excluding unclear, other conditions, or missing reports. A retrospective review was conducted pre- and post-EGS service implementation. Results In 2019, 479 appendicectomies were audited, with a mean age of 34; 51% were female, and 20% were negative. Negative cases averaged 28 years, with 67% females. In 2022, 420 cases had a mean age of 40; 45% were female, 55% male, and negative rates reduced to 13%. Negative cases averaged 29 years, with 62% females. Conclusions Between 2019 and 2022, age groups were comparable. Negative cases in both years were more likely to be younger females compared to positive and total groups. The EGS service introduction demonstrated a notable decrease in negative appendectomy rates from 20% to 13% within two years, suggesting that consultant-led EGS services effectively reduce negative appendicectomy rates.

A Comparison of the Alvarado Score and the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) Score in the Diagnosis of Acute Appendicitis: A Prospective Cohort Study.

Background Diagnosing acute appendicitis remains a problem, especially in teenagers with right lower quadrant pain.Imaging studies aid in accurate diagnosis but have limitations such as cost and availability. The Modified Alvarado Scoring System (MASS) is simple and cost-effective with fewer parameters. The Raja Isteri Pengiran Anak Saleha Appendicitisscoring system (RIPASA), designed for Asian populations, includes more parameters. This study compares the effectiveness of RIPASA and Alvarado scores in diagnosing acute appendicitis in a specific clinical setting. Objectives To compare the scoring systems of RIPASA and Alvarado in the diagnosis of acute appendicitis at a tertiary care hospital. Methods Data has been collected from all patients who attended the NRI general hospital emergency department and outpatient wing with acute appendicitis, admitted as inpatients based on clinical history and relevant investigations. Patients satisfying inclusion and exclusion criteria were selected and the basic investigations were done. Summary statistics were done using mean, standard deviation and proportions. Inferential statistics were done by using an independent t-test, kappa statistic, sensitivity and specificity with a 95% confidence interval (CI). All the measurements are done using the statistical package for the social sciences (SPSS) software version 21.0 (IBM Corp., Armonk, NY, USA) and open epidemiological (OpenEpi) software 3.01. A probability (p) <0.05 is considered as statistically significant. Results A total of 110 patients were analyzed for this study with a majority (39%) of them in the 21-30 age group. In our study, females (53%) outnumbered males (47%). Ultrasound findings in our cohort were acute appendicitis (93%), chronic appendicitis (2%) and normal appendix (5%). However, histopathology reported acute appendicitis (75%), chronic appendicitis (9%) and negative/non-specific (15%). The probability of appendicitis as predicted by Alvarado and RIPASA were 40% and 51% respectively. Definitive diagnosis of appendicitis was made in 16.4% with RIPASA whereas only 5.5% with Alvarado. When comparing the Alvarado and RIPASA scores, the sensitivity or true positive rate was higher for RIPASA (73.63%) than for Alvarado (50.55%). Conclusion There was a significant difference between the mean scores in Alvarado and RIPASA inpatients with scores suggestive of appendicitis and no appendicitis. Diagnostic accuracy was higher in RIPASA scoring compared to ALVARDO scoring. There was a significant statistical difference between the two scoring systems. When it comes to diagnosing in low-resource countries the study recommends a combination of Alvarado and RIPASA scoring systems.

Interobserver agreement of an ED PoCUS video training dataset of normal appendix and appendicitis in children

BackgroundEducational video datasets can be an effective method for training in emergency department (ED) point-of-care ultrasound (PoCUS). A video dataset for normal appendix and appendicitis in children using ED PoCUS images was developed to assess interobserver agreement, as measured by Cohen’s Kappa on key sonographic findings.MethodsThree sets of 25 ED PoCUS videos were selected and curated from pediatric patients with normal appendix and acute appendicitis. Four participant ED sonologist-physicians were trained on the first set of 25 videos showing normal appendix or normal bowel in patients without appendicitis to note if normal appendix was seen in any part or in it’s entirety from tip-to-cecum. They were then tested on the second set of similar videos. A third set of 25 videos from patients who had appendicitis where participant sonologists were asked to note if appendicitis was present or absent, with and without appendicolith or perforation. Cohen’s Kappa was calculated in aggregate and stratified by experience vs. novice against a senior sonologist-physician aware of all patient outcomes for visualization of: 1. any part of normal appendix, 2. normal appendix visualized from tip to cecum 3. any part of appendicitis, 4. appendicolith, 5. appendiceal perforation.ResultsCohen’s Kappa for any part of normal appendix, 0.71, 95% CI (0.58–0.85); normal appendix tip-to-cecum, 0.43, 95% CI (0.19–0.67), appendicitis, 0.53, 95%CI (0.34–0.70), appendicolith, 0.63, 95%CI (0.43–0.84), perforated appendicitis, 0.46, 95%CI (0.22–0.70). Stratified by experienced vs. novice: any part of normal appendix, 0.75 vs. 0.68; normal appendix tip-to-cecum, 0.50 vs. 0.36; appendicitis, 0.78 vs. 0.31; appendicolith, 0.75 vs. 0.5; perforated appendicitis, 0.5 vs 0.42.ConclusionsThis educational video dataset may be used to train sonologist-physicians in ED PoCUS scanning for normal appendix and appendicitis in children. Sonologist experience affected interobserver agreement with respect to visualization of entire normal appendix and appendicitis.

What do you do with a normal appearing appendix? A national study of Pediatric Surgeons.

Surgeons may encounter a grossly normal appearing appendix in a patient with clinically suspected appendicitis. The purpose of this study is to determine the practice of pediatric surgeons in Saudi Arabia when this is encountered, and determine the reasons behind their decision making. An electronic survey was sent to all pediatric surgeons in Saudi Arabia. Data points collected included demographics, peri-operative imaging preference, and personal practice when managing an intra-operative grossly normal appendix in symptomatic children. A total of 105 responses were obtained yielding a response rate of 33.8% The majority of respondents, 88 (87.1%) would remove the appendix while 13 (12.9%) would leave it in situ. The most common reason for removing the appendix was the possibility of microscopic/Endo appendicitis 71 (34.8%) while the most common reason for leaving the appendix in situ was the possible usage of the appendix for reconstructive benefits in the future 11 (50%). The overwhelming majority 87 (86.1%) felt that there were no sufficient guidelines on removal of the normal appearing appendix at the time of surgery for suspected acute appendicitis. The majority of pediatric surgeons in Saudi Arabia would proceed with an appendectomy when an intra-operative grossly normal appendix is seen in patients suspected to have acute appendicitis. There is a clear lack of published pediatric guidelines and large studies to guide the correct course of action.

Patients' attitudes toward negative appendectomies and surgery for suspected appendicitis: a qualitative interview study.

From a surgeon's perspective, appendicitis is treated with appendectomy and sometimes a normal appendix is removed. This study aimed to investigate the patients' perspectives on having surgery but not appendicitis and their involvement in treatment decisions. This study is reported according to the COnsolidated criteria for REporting Qualitative research (COREQ) guideline. Eligible participants either had a normal diagnostic laparoscopy with no resection of the appendix or a negative appendectomy confirmed by histopathology. Interviews were conducted using a semi-structured interview guide and transcribed verbatim. Data were analyzed using content analysis. This study consisted of 15 interviews. Analysis of the interviews resulted in the formulation of four categories: (1) discovering the results of the histopathology report, (2) thoughts on having a normal appendix removed or left in situ, (3) the scarce use of shared decision-making, and (4) general anesthesia and the risk of a burst appendix made the participants nervous. The amount of information communicated to the patients before and after surgery was sparse. The participants were not aware of the histopathology results and the participants were not involved in decision-making and were generally anxious about anesthesia and a burst appendix.

Study of pediatric appendicitis scores and management strategies: A prospective observational feasibility study.

The objective was to investigate the feasibility of prospectively validating multiple clinical prediction scores (CPSs) for pediatric appendicitis in an Australian pediatric emergency department (ED). A literature search was conducted to identify potential CPSs and a single-center prospective observational feasibility study was performed between November 2022 and May 2023 to evaluate the performance of identified CPSs. Children 5-15 years presenting with acute right-sided or generalized abdominal pain and clinician suspicion of appendicitis were included. CPSs were calculated by the study team from prospectively clinician-collected data and/or review of medical records. Accuracy of CPSs were assessed by area under the receiver operating characteristic curve (AUC) and proportions correctly identifiable as either low-risk or high-risk with the best performing CPS compared to clinician gestalt. Final diagnosis of appendicitis was confirmed on histopathology or by telephone/email follow-up for those discharged directly from ED. Thirty CPSs were identified in the literature search and 481 patients were enrolled in the study. A total of 150 (31.2%) patients underwent appendectomy with three (2.0%) having a normal appendix on histopathology. All identified CPSs were calculable for at least 50% of the patient cohort. The pediatric Appendicitis Risk Calculator for pediatric EDs (pARC-ED; n = 317) was the best performing CPS with AUC 0.90 (95% confidence interval [CI] 0.86-0.94) and specificity 99.0% (95% CI 96.4%-99.7%) in diagnosing high-risk cases and a misclassification rate of 4.5% for low-risk cases. The study identified 30 CPSs that could be validated in a majority of patients to compare their ability to assess risk of pediatric appendicitis. The pARC-ED had the highest predictive accuracy and can potentially assist in risk stratification of children with suspected appendicitis in pediatric EDs. A multicenter study is now under way to evaluate the potential of these CPSs in a broader range of EDs to aid clinical decision making in more varied settings.

The Role of Vascular Cell Adhesion Molecule-1 (VCAM-1) in Predicting Complicated Appendicitis in Children.

Acute appendicitis is a common abdominal emergency observed in emergency departments (ED). Distinguishing between uncomplicated and complicated appendicitis is important in determining a treatment strategy. Serum soluble vascular cell adhesion molecule-1 (VCAM-1) is an inflammatory biomarker. We aimed to determine the role of VCAM-1 in predicting complicated appendicitis in children. Pediatric patients with suspected appendicitis admitted to the ED were enrolled in this prospective study. Pre-surgical serum VCAM-1 was tested in children with acute appendicitis within 72 h of symptoms (from day 1 to day 3). Serum VCAM-1 levels were further analyzed and compared between patients with and without complicated appendicitis. Among the 226 pediatric appendicitis patients, 70 had uncomplicated appendicitis, 138 had complicated appendicitis, and 18 had normal appendices. The mean serum VCAM-1 levels in patients with perforated appendicitis were higher than in those with simple appendicitis (p < 0.001). On day 1 to day 3, the mean VCAM-1 levels in patients with complicated appendicitis were all significantly higher than in those with uncomplicated appendicitis (all p < 0.001). Serum VCAM-1 levels may be helpful in differentiating uncomplicated and complicated appendicitis in children and could predict appendiceal perforation.

Introducing the ratio of cross diameters of the appendix for ultrasound diagnosis of acute appendicitis can significantly increase specificity.

To validate whether the introduction of the ratio of the cross diameters on the transverse section of the appendix (RATIO) ≤ 1.18 is useful for improving the ultrasound diagnosis of acute appendicitis (AA). Data from 220 patients with AA and 110 patients with a normal appendix were retrospectively studied. The RATIO ≤ 1.18, maximal outer diameter (MOD) > 6mm, and a combination of RATIO ≤ 1.18 and MOD > 6mm were used for predicting AA. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated. The RATIO ≤ 1.18, MOD > 6mm, and a combination of RATIO ≤ 1.18 and MOD > 6mm for predicting AA showed a sensitivity of 90, 100, and 90%; specificity of 79.1, 27.3, and 88.2%; and AUC of 0.845, 0.636, and 0.891, respectively. When comparing the outcomes between MOD > 6mm and a combination of MOD > 6mm and RATIO ≤ 1.18, the specificity and PPV increased from 27.3 to 88.2% and 73.3 to 93.8%, respectively (all P < 0.0001). The sensitivity and NPV decreased from 100 to 90% and 100 to 81.5%, respectively (all P < 0.0001). The AUC increased from 0.636 to 0.891 (P < 0.0001). When comparing the AUC of MOD > 6mm, and a combination of RATIO ≤ 1.18 and MOD > 6mm for predicting AA with the AUC in a previous study, there were no significant differences between each other (all P > 0.05). Introducing the RATIO ≤ 1.18 for the evaluation of AA can improve the diagnostic performance and significantly increase specificity.

Exploring the seasonal impact on appendectomy: incidence, patterns, predictors, and healthcare implication of appendectomy at Prince Ali military hospital

Background: This study at Prince Ali military hospital in Al Karak, Jordan, investigates seasonal variations in appendicitis incidence and outcomes, assessing diagnostic and treatment strategies across different seasons. The aim is to understand how seasonal changes influence appendicitis rates and to evaluate the effectiveness of diagnostic methods and treatment approaches. Methods: A retrospective observational study was conducted on 321 confirmed cases of inflamed or perforated appendicitis from March 2021 to February 2024. Patient demographics, dates of surgery, surgical interventions, and postoperative complications were analyzed, with a focus on seasonal trends. Results: Out of 394 reviewed cases, 321 (81.47%) met the inclusion criteria, showing significant seasonal variations in appendicitis incidence. Autumn saw the highest rate of appendicitis cases at 32.09% while the lowest was in Winter (22.12%). Regarding normal appendix, the highest rate was in winter (21.98%), and the lowest was in summer (13.09%). The mean patient age was 25.20 years, with a majority being male (66.36%). Open surgeries were the most common, comprising 91.9% of cases, compared to 8.1% for laparoscopic procedures. Diagnostic analysis revealed a very strong correlation between CT findings and histopathological outcomes (p=3.23×10^-11) and a significant but less strong correlation for ultrasound findings (p=0.000446). These results suggest that both diagnostic methods are effective, with CT scans showing a stronger correlation. The distribution of cases across seasons was 32.087% in autumn, 23.05% in spring, 22.741% in summer, and 22.118% in winter. Conclusions: Significant seasonal peaks in appendicitis are evident, particularly in autumn, driven by changes in diet and viral infections. The superior effectiveness of CT scans during winter highlights the need for adaptive diagnostic strategies across seasons. These findings advocate for healthcare systems to seasonally adjust resources and diagnostics to optimize appendicitis management, with further research needed to expand these insights globally.

Changes in Levels of Serum Cytokines and Chemokines in Perforated Appendicitis in Children.

Appendicitis is primarily diagnosed based on intraoperative or histopathological findings, and few studies have explored pre-operative markers of a perforated appendix. This study aimed to identify systemic biomarkers to predict pediatric appendicitis at various time points. The study group comprised pediatric patients with clinically suspected appendicitis between 2016 and 2019. Pre-surgical serum interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), intercellular cell-adhesion molecule-1 (ICAM-1), and endothelial selectin (E-selectin) levels were tested from day 1 to day 3 of the disease course. The biomarker values were analyzed and compared between children with normal appendices and appendicitis and those with perforated appendicitis (PA) and non-perforated appendicitis. Among 226 pediatric patients, 106 had non-perforated appendicitis, 102 had PA, and 18 had normal appendices. The levels of all serum proinflammatory biomarkers were elevated in children with acute appendicitis compared with those in children with normal appendices. In addition, the serum IL-6 and TNF-α levels in children with PA were significantly higher, with an elevation in TNF-α levels from days 1 and 2. In addition, serum IL-6 levels increased significantly from days 2 and 3 (both p < 0.05). Serum ICAM-1 and E-selectin levels were elevated in the PA group, with consistently elevated levels within the first three days of admission (all p < 0.05). These results indicate that increased serum levels of proinflammatory biomarkers including IL-6, TNF-α, ICAM-1, and E-selectin could be used as parameters in the prediction and early diagnosis of acute appendicitis, especially in children with PA.

Finding Waldo: Sonographic systematic approach to localize the appendix in children.

To describe a systematic scanning approach using anatomical landmarks followed by an assessment of radiology trainees' ability to identify the normal appendix in healthy children. Uncontrolled pre and post study assessing radiology residents' sonographic skills in detecting the normal appendix in healthy children. Initial questionnaire for the trainees' demographics, perceptions and experiences in detecting the appendix with ultrasound in children followed by a precourse test on healthy volunteers. Hands-on training was conducted by describing a systematic sonographic approach to identify the appendix using anatomical landmarks, and then a postcourse test was carried out. The primary outcome was unprompted ability to identify the appendix. Subjective self-scoring of confidence was also recorded. A three-hour hands-on workshop was conducted. Sixteen radiology trainees participated and were randomly distributed to four stations, each with different ultrasound machines and healthy volunteers. Fifteen had a precourse assessment, and 12 completed the postcourse assessment. Before the course, 3/15 (20%) identified the appendix, while 10/12 (83%) identified the appendix afterward. After the course, participants perceived finding the appendix easier than before. There was no statistically significant difference in the participants' perceived confidence in detecting the appendix. With the described scanning technique, most of the participants were able to identify the normal appendix after receiving short hands-on training. This highlights the importance of targeted training of radiology trainees and nonradiologists.

Should an appendicectomy be performed in the presence of a macroscopically healthy appendix, during laparoscopic exploration?

Introduction: In contrast to the conventional laparotomy approach, the decision to perform an appendicectomy or not in the presence of a macroscopically normal appendix remains contentious during laparoscopic procedures. Our objective is to assess the rate of appendix conservation and conduct a literature review on the management of a macroscopically normal appendix intraoperatively. Materials and Methods: This was a descriptive, prospective, evaluative study involving 337 patients undergoing laparoscopic surgery for non-traumatic acute abdominal emergencies. Results: Of the 337 patients operated on, 190 were females (56.4%), with a mean age of 38 years ± 15 years (range 15 to 82 years). In 7 patients (2.1%), the appendix appeared macroscopically normal intraoperatively, despite preoperative diagnosis favoring acute appendicitis. These 7 patients (6 females and 1 male) all underwent thorough clinical examination and preoperative ultrasound, although CT scans were performed in only 3 patients. Among these 7 patients, 2 had ovarian cyst torsions, 2 had ruptured hemorrhagic ovarian cysts, 1 case was diagnosed as retrocaecal internal hernia, and in 2 patients, no etiology was identified. The appendix was preserved in all 7 cases. All patients received postoperative antibiotic therapy. No postoperative complications or surgical reinterventions were recorded. Conclusion: Our study demonstrates that a macroscopically normal appendix can be left in situ without postoperative complications or need for surgical reintervention.

Emphasizing the Clinical Diagnosis of Acute Appendicitis Amidst Technological Advancements.

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.

Partial visualization of appendix on ultrasound: What does it mean in the child with suspected appendicitis?

BackgroundVisualization of the entire appendix, including the tip, is thought, but has not been demonstrated, to be important for exclusion of appendicitis by ultrasound. ObjectiveTo determine if incomplete visualization of the appendix has negative clinical ramifications including missed appendicitis. MethodsUnder IRB approval we retrospectively reviewed right lower quadrant ultrasound reports from January 2017 to December 2020 to identify examinations with impressions of full visualization of the normal appendix, non-visualization of the appendix with and without secondary findings of appendicitis, and partial visualization of the appendix. Electronic health records were reviewed for follow-up imaging within 48 h, and surgery with pathology reports (if available). Results12,193 examinations were included. 4171 (34.2 %) had full visualization of a normal appendix, 5369 (44.0 %) had non-visualization with no secondary findings, and 234 (1.9 %) had non-visualization with secondary findings, The frequencies of appendicitis in these three groups were 34 (0.8 %), 283 (5.3 %), and 127 (54.3 %) respectively.The appendix was partially visualized in 338 (2.8 %) patients with secondary findings present in 53 (15.6 %). Partial visualization without secondary findings had a similar frequency (4.9 %, 14/285) of appendicitis to non-visualized appendix without secondary findings (p = 0.797) and a higher frequency than full visualization of a normal appendix (p < 0.0001). Partial visualization with secondary findings had similar rates (54.7 %, 29/53) to non-visualized appendix with secondary findings (p = 0.953). ConclusionPartial visualization of the appendix with ultrasound (with and without secondary findings) is associated with similar frequencies of appendicitis as non-visualization of appendix (with and without secondary findings).

Effectiveness of Ultrasonography and Computed Tomography in the Diagnosis of Acute Appendicitis

Background: Acute appendicitis is the acute inflammation of the appendix vermiformis and is one of the leading emergency intra-abdominal surgeries. In the study; To investigate the effectiveness of preoperative USG and CT in the diagnosis of acute appendicitis. Materials and Methods: The records of 332 patients who underwent appendectomy between March 2018 and March 2023 were retrospectively examined. Gender, age, USG and CT reports and patho-logy results of the patients were recorded. Sensitivity, specificity, positive predictive value and negative predictive values of USG and CT in the diagnosis of acute appendicitis were calculated separately. Results: The pathology result was reported as acute appendicitis in 312 of the patients, and was evaluated as normal in 20 of them. The pathology result of 254 of 261 patients, whose CT results were evaluated as compatible with acute appendicitis, was reported as acute appendicitis. In 7 patients, it was found to be normal appendicitis. Of 28 patients whose CT results were incompatible with acute appendicitis, the pathology result was positive in 18 and negative in 10. Pathology results of 96 patients whose USG results were compatible with acute appendicitis; Acute appendicitis was found in 90 patients and normal appendix in 6 patients. Pathology results of 41 patients whose USG results were evaluated as negative; It was reported to be compatible with acute appendicitis in 36 cases and normal in 5 cases. Conclusions: In our study, both the sensitivity and specificity of CT were found to be superior to USG, consistent with the literature. Researching IT effectiveness; We think that prospective studies com-paring teleradiology reports and the reports of radiologists working in hospitals would be useful.