Some surgeons use nonoperative management with or without interval appendectomy for patients who present with perforated appendicitis. These strategies depend on accurately delineating perforation by computed tomography (CT). Since 2005, our institution has used an evidence-based definition for perforation as a hole in the appendix or fecalith in the abdomen. This has been shown to clearly separate those with a high risk of abscess from those without. To quantify the ability of CT to identify which patients would meet these criteria for perforation, we tested 6 surgeons and 2 radiologists who evaluated blinded CT scans.
A junior and senior surgical residents, 2 staff interventional radiologists, and 4 attending pediatric surgeons with 3 to 30 years of experience reviewed 200 CT scans of pediatric patients who had undergone a laparoscopic appendectomy. All CT scans were reviewed electronically, and the reviewers were blinded to the results, outcome, and intraoperative findings. None of the patients had a well-formed abscess on CT. The reviewers were asked to decide only on perforated or nonperforated appendicitis according to our intraoperative definition. Clinical admission data were reviewed and compared between groups.
In total, the reviewers were correct 72% of the time with an overall sensitivity of 62% and a specificity of 81%. The overall positive predictive value was 67%, and the negative predictive value was 77%.
This study shows that in the absence of a well-formed abscess, the triage of patient care based on a preoperative diagnosis of perforation from CT may be imprudent and subject a portion of the population to an unnecessarily prolonged course of care.
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- Is interval appendectomy necessary after rupture of an appendiceal mass?.J Pediatr Surg. 1996; 31: 849-850
- Routine interval appendectomy in children is not indicated.J Pediatr Surg. 2007; 42: 1500-1503
- Current practice patterns in the treatment of perforated appendicitis in children.J Am Coll Surg. 2003; 196: 212-221
- The association of elevated percent bands on admission with failure and complications of interval appendectomy.J Pediatr Surg. 2001; 36: 165-168
- Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences.J Pediatr Surg. 2007; 42: 934-938
- Nonoperative management of perforated appendicitis in children: can CT predict outcome?.Pediatr Radiol. 2007; 37: 251-255
- Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children.JAMA. 1999; 282: 1041-1046
- Unenhanced limited CT of the abdomen in the diagnosis of appendicitis in children: comparison with sonography.AJR Am J Roentgenol. 2001; 176: 31-35
- A prospective trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient.Am J Surg. 2000; 179: 379-381
- Imaging evaluation of suspected appendicitis in a pediatric population: Effectiveness of sonography versus CT.AJR Am J Roentgenol. 2000; 175: 977-980
- An evidence-based definition for perforated appendicitis derived from a prospective randomized trial.J Pediatr Surg. 2008; 43: 2242-2245
- The use of a computed tomography scan to rule out appendicitis in women of childbearing age is as accurate as clinical examination: a prospective randomized trial.Am Surg. 2007; 73: 1232-1236
- Management of pediatric acute appendicitis in the computed tomographic era.J Surg Res. 2008; 147: 221-224
- Imaging of acute appendicitis and its impact on negative appendectomy and perforation rates: the St. Paul's experience.Can Assoc Radiol J. 2007; 58: 220-224
- Negative appendectomy and imaging accuracy in the Washington State Surgical Care and Outcomes Assessment Program.Ann Surg. 2008; 248: 557-563
- Effect of cross-sectional imaging on negative appendectomy and perforation rates in children.Radiology. 2001; 220: 103-107
- Introduction of appendiceal CT: impact on negative appendectomy and appendiceal perforation rates.Ann Surg. 1999; 229: 344-349
- Imaging for suspected appendicitis: negative appendectomy and perforation rates.Radiology. 2002; 225: 131-136
- Evaluation of perforated and nonperforated appendicitis with CT.Clin Imaging. 2004; 28: 422-427
- Differentiation of perforated from nonperforated appendicitis at CT.Radiology. 2003; 227: 46-51
- Differentiation of nonperforated from perforated appendicitis: accuracy of CT diagnosis and relationship of CT findings to length of hospital stay.Radiology. 2005; 235: 89-96
- CT is useful for identifying patients with complicated appendicitis.Dig Liver Dis. 2004; 36: 195-198
- Histologic severity of appendicitis can be predicted by computed tomography.Arch Surg. 2004; 139: 1304-1308
- Computed tomography scanning for the diagnosis of perforated appendicitis.Am Surg. 1999; 65: 959-964
- A retrospective study of CT findings in cases undergoing appendectomy at a single hospital.Clin Imaging. 2007; 31: 239-243
- Perforated versus nonperforated acute appendicitis: accuracy of multidetector CT detection.Radiology. 2006; 241: 780-786
- Perforated and nonperforated appendicitis: defect in enhancing appendiceal wall—depiction with multi-detector row CT.Radiology. 2008; 246: 142-147
Accepted: October 6, 2009
Received: October 5, 2009
Presented at the 40th Annual Meeting of the American Pediatric Surgical Association, Fajardo, Puerto Rico, May 28-June 1, 2009.
© 2010 Elsevier Inc. Published by Elsevier Inc. All rights reserved.