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*Corresponding Author: Aliya Ishaq, Department of General Surgery, Dubai Hospital, United Arab Emirates, Liaquat National Hospital and Medical College, Karachi, Pakistan.
Citation: Ishaq A, Naureen S, Amin Y, Jamshaid H Khan, Latif A, Anwar S and Esaaf H Ghazi.(2021) “Negative appendectomy rate and its correlation with use of radiology; A clinical audit of our department”. J. Surg Case Repo and Imag. 4(5); DOI:10.31579/2690-1897/079
Copyright: © 2021 Aliya Ishaq, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 08 May 2021 | Accepted: 15 May 2021 | Published: 28 May 2021
Keywords: radiology; negative appendectomy
Introduction; Appendectomy is the most common surgical emergency and negative appendectomy is a one of recognized consequence of appendectomy. Recently an increased use of radiology is seen in diagnosing appendicitis and it has significantly decreased the rate of negative appendectomy.
Every effort should be made to establish an exact diagnosis. If, however, this is impossible and a suspicion of appendicitis exists, exploration is mandatory. It is far better to subject a moderate number of patients to a theoretically unnecessary operation than to let one patient suffer perforation.
Aim; Recently we have seen an increased use of radiology in our department for diagnosing appendicitis. The idea of conducting this audit was to calculate our negative appendectomy rate by correlating it with use of radiology and to compare it with international figures and to set up guide lines for use of radiology in diagnosing appendicitis on basis of results of our audit .
Methods; Records of all patients who underwent appendectomy in Dubai Hospital, UAE from jan 2018 to jan 2019 were retrospectively analyzed using electronic record system. Clinical diagnosis and radiological findings were compared with histopathology as gold standard for negative appendectomy rate. The sensitivity and specificity of different radiological procedures was calculated as well.
Results; Total 165 patients underwent appendectomy in specified duration. Over all negative appendectomy rate was 17 % with male being 9.7 % and female rate 31% . CTSCAN was found to be 100% specific and 91.4 % sensitive in diagnosing appendicitis while clinical diagnosis was accurate in 88.5 % cases.
Appendicitis is the most common cause of an acute surgical abdomen, with an estimated lifetime prevalence of 7–8 %. Despite advances in diagnosis and treatment, it is still associated with significant morbidity (10 %) and mortality (1–5 %) (1). This rapidly progressing inflammatory process requires prompt removal of the appendix to prevent life-threatening complications such as ruptured appendix and peritonitis and hence accurate and quick diagnosis is important. Traditionally the diagnosis of acute appendicitis is based on clinical features and physical examination .Over the past two decades, the use of dedicated pre-operative ultrasonography (US) and computed tomography (CT) techniques for the evaluation of patients clinically suspected of acute appendicitis has led to improved diagnostic accuracy (1)
Negative appendectomy rate, a recognized consequence of appendectomy varies between 6% to 40% in the literature. The suggested acceptable rate of negative appendectomy is 20%.
This rate is considered acceptable to avoid missing cases of appendicitis and possible sequela of appendicitis such as perforation, peritonitis, access formation and sepsis, and also to avoid prolonged hospital stay and financial consequences (1).
However, it can further be reduced by utilizing combined clinical assessment with diagnostic modalities.
We did a retrospective audit for negative appendectomy rate of general surgery department Dubai Hospital, UAE for a duration of one year by correlating the clinical diagnosis of appendicitis with histopathology being gold standard. We also correlated histopathological diagnosis with radiological diagnosis and hence calculated specificity and sensitivity of different radiological procedures in diagnosing appendicitis.
Setting: Department of General Surgery Dubai Hospital,UAE
Duration of Study: FROM JAN 2018 TO Jan 2019
Sample Size: total 165 patients who underwent appendectomy during the specified duration were included in audit .
Sampling Technique: continuous sampling
Data Collection:
Medical records of all the patients were reviewed retrospectively using electronic medical records used in our hospital from jan 2018 to jan 2019.
Data Analysis:
All analysis will be conducted by using the Statistical package for social sciences (SPSS) version 24. p Value is used for changes in quantitative viable for significant changes and numbers and percentage are used for descriptive variables.
Total 165 appendectomies were performed between Jan 2018 till Jan 2019.
Mean age was 23 years.
For sex data;
Frequency Table
Male patients in audit 107/165 – 64.8%
Female patients in audit 58/165 –35.2 %
Histopathological findings;
They were acute inflammation, acute supportive appendicitis, Tran’s mural inflammation of appendix with or without fecalith and gangrenous perforated appendix.
8 cases of fibrous obliteration of lumen of appendix with neuroma of tip without inflammation reported
137 out of 165 showed that its appendicitis ie 83%
28/165 showed negative appendectomy ie – 17%
Negative appendectomy rate is 17 %
Ct scan findings;
Ct scan abdomen and pelvis was done in 63.0 % patients
Us abdomen done in 5.4
Several recent papers have cited a declining negative appendectomy rate( NAR) , including several large database studies and meta analyses with NARs as low as 6–8% and single institution studies with NARs as low as 1.7–7%, coinciding with the increased use of computed tomography (CT) and laparoscopy[i]. While CT is often credited with lowering the NAR, a definitive causal relationship has not been established and lingering questions about proper usage remain. Routine CT is unnecessary for male patients with clinical diagnosis of appendicitis. Mild appendicitis may resolve without surgery and CT may contribute to unnecessary surgery (2).
.Over the past two decades, the use of dedicated pre-operative ultrasonography (US) and computed tomography (CT) techniques for the evaluation of patients clinically suspected of acute appendicitis has led to improved diagnostic accuracy[ii] . In light of this, in 2010 the Dutch College of Surgeons introduced a guideline entitled ‘‘diagnostics and treatment in acute appendicitis’’ with recommendations concerning pre-operative imaging in the diagnosis and treatment of acute appendicitis. The guideline states that in every patient with clinically suspected acute appendicitis an ultrasonography or CT scan is advised to confirm diagnosis before surgery (3).
When compared with patients with appendicitis, negative appendectomy was associated with a significantly longer length of stay (5.8 vs. 3.6 days, P<0>vs. 1.8%, P<0>vs. 0.2%, P<0>vs. 10,584, P<0>
Higher NAR in the female sex compared to the male sex have been reported by multiple studies. Seetha et al(3) in a 10-year review of a nationally representative sample of 475,651 cases of appendectomy reported that women accounted for 71.6% of the negative appendectomies. This is consistent with the findings of this study in which females accounted for approximately 60% of the negative appendectomies. Reasons adduced for this observation includes the gynecological conditions that could mimic the presentation of acute appendicitis. Ovarian cysts, leiomyoma, endometriosis, benign ovarian neoplasms, malignant ovarian disease, pelvic adhesions have been reportedly misdiagnosed as acute appendicitis in women (10) (11).
Our audit showed an overall negative appendectomy rate of 17 % while it is 9.7% in male and 31% in female patients. Imaging was used over all in 68.4
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