Congruence of histological diagnosis with imaging and operation diagnosis in acute appendicitis

Česká verzia

Authors: K. Šuta Kimle; K. Chrz; J. Ulrych; E. Šimůnková; D. Michalský
Authors place of work: I. chirurgická klinika 1. lékařské fakulty Univerzity Karlovy a Všeobecné fakultní nemocnice v Praze
Published in the journal: Rozhl. Chir., 2019, roč. 98, č. 11, s. 457-461.
Category: Původní práce
doi: https://doi.org/10.33699/PIS.2019.98.11.457–461

Summary

Introduction: The diagnostic process of acute appendicitis is based on clinical symptoms, evaluation of laboratory biomarkers of inflammation and imaging examinations results. Accurate preoperative diagnosis is a key factor in reducing the number of so-called negative appendectomies. The aim of our study was to evaluate the importance of ultrasound in the diagnostic algorithm of acute appendicitis. We also compared the accuracy of the intraoperative diagnosis evaluated by the surgeon with the histopathological findings.

Methods: We performed a retrospective analysis of patients operated for acute appendicitis at our surgical department in time period from 2015 to 2017. We compared the results of preoperative imaging examinations (ultrasound, CT) and intraoperative diagnosis (from the surgical record) with final histopathological findings.

Results: 386 patients were operated on for acute appendicitis. Histopathological examination revealed 33 patients (9%) with no signs of inflammation, 309 patients (80%) with inflammatory changes, 37 cases (10%) with chronic appendicitis and 7 other histological findings (2%). Ultrasound was performed in 382 patients (99%). False negative ultrasound was obtained in 18 (6%) of 309 patients with histologically confirmed inflammation. Ultrasound gave a false positive finding in 16 (48%) of 33 patients whose histology revealed no signs of inflammation. Equivocal ultrasound was obtained in 104 patients (27%). Intraoperative diagnosis of appendix without inflammation was described by the surgeon in 27 patients (7%). Of these, 12 cases (44%) were histologically non-inflammatory, 7 cases (26%) with acute inflammation, 7 cases (26%) with chronic inflammation and 1 other finding (4%).

Conclusion: Ultrasound is a suitable imaging method to confirm the diagnosis of acute appendicitis but not to rule it out. Intraoperative assessment of the appendix by the surgeon is not reliable. Any appendix intraoperatively evaluated as showing no signs of inflammation should be removed.

Keywords:

ultrasound – acute appendicitis – histopathology – appendectomy

Zdroje

Holloway JJ, Lett LA, Kim DY, et al. Investigating the effect of discordant clinical and pathological diagnoses of complicated appendicitis on clinical outcomes. The American Journal of Surgery 2019;16:78–82. doi:10.1016/j.amjsurg.2019.05.004.
Liang KM, Andersson RE, Jaffe BM, et al. The appendix. In: Schwartz’s principles of surgery. 10^th edition. New York, McGraw-Hill Education 2014:124–62. ISBN 978-0-07179674-3.
Tomography (CT) criteria in patients attending Gujarat Adani Institute of Medical Science – a retrospective study. Pol J Radiol. 2017;82:726–30. doi: 10.126559/PJR.902246.
Mostbeck G, Adam EJ, Nielsen MB, et al. How to diagnose acute appendicitis: ultrasound first. Insights Imaging 2016;7:255–63. doi:10.1007/s13244-016-0469-6.
Šmíd D, Skalický T, Třeška V. Přínos ultrasonografie břicha v diagnostice akutní apendicitidy – naše zkušenosti. Rozhl Chir. 2009;88:466–46.
Bhangu A, Søreide K, Di Saverio S, et al.Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015;386:1278–87. doi:10.1016/S0140-6736(15)00275-5.
Kabir SA, Kabir SI, Sun R, et al. How to diagnose an acutely inflamed appendix; a systematic review of the latest evidence. Int J Surg. 2017;40:155–62. doi:10.3748/wjg.v23.i32.5849.
Körner H, Söndenaa K, Söreide JA, et al. Incidence of acute nonperforated and perforated appendicitis: age-specific and sex-specific analysis. World J Surg. 1997;21:313–7. doi:10.1007/s002689900235.
Tayfur M, Balci MG. Pathological changes in appendectomy specimens including the role of parasites: A retrospective study of 2400 cases of acute appendicitis. Niger J Clin Pract. 2019;22:270–5. doi:10.4103/njcp.njcp_271_18.
Partecke LI, Thiele A, Schmidt-Wankel F, et al. Appendicopathy—a clinical and diagnostic dilemma. Int J Colorectal Dis. 2013;28:1081–9. doi.org/10.1007/s00384-013-1677-x.
Kim D, Butterworth SA, Goldman RD. Chronic appendicitis in children. Can Fam Physician 2016;62:e304–e305.
Rao P, Rhea J, Novelline R, et al. The computed tomography appearance of recurrent and chronic appendicitis. Am J Emerg Med. 1998;16:26–33.doi:10.1016/s0735-6757(98)90060-2.
Sartelli M, Baiocchi GL, Di Saverio S, et al. Prospective Observational Study on Acute Appendicitis Worldwide (POSAW). World J Emerg Surg. 2018;13:19. doi:10.1186/s13017-018-0179-0.
Gorter RR, Eker HH, Gorter-Stam MA, et al. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc. 2016;30:4668–90. doi:10.1007/s00464-016-5245-7.
Korndorffer JR Jr, Fellinger E, Reed W. SAGES guideline for laparoscopic appendectomy. Surgical Endoscopy 2010;24:757–61. doi:10.1007/s00464-009-0632-y.
Gómez López JR, Martín Del Olmo JC, Montenegro Martín MA, et al. Laparoscopic appendectomy in the setting of clinical prediction rules. The American Journal of Surgery 2019;29:184–91. doi:10.1089/lap.2018.0707.
Sartelli M, Viale P, Catena F, et al. 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2013;8:3. doi:10.1186/1749-7922-8-3.
Bliss D, McKee J, Cho D, et al. Discordance of the pediatric surgeon’s intraoperative assessment of pediatric appendicitis with the pathologists report. J Pediatr Surg. 2010;45:1398–403, doi:10.1016/j.jpedsurg.2010.02.048.
Acharya A, Markar SR, Ni M, Hanna GB. Biomarkers of acute appendicitis: systematic review and cost–benefit trade-off analysis. Surgical Endoscopy 2017;31:1022–31. doi:10.1007/s00464-016-5109-1.
D’Souza N, Marsden M, Bottomley S, et al. Cost-effectiveness of routine imaging of suspected appendicitis. Ann R Coll Surg Engl. 2018;100:47–51. doi:10.1308/rcsann.2017.0132.
Slotboom T, Hamminga JTH, Hofker HS, et al. Intraoperative motive for performing a laparoscopic appendectomy on a postoperative histological proven normal appendix. Scandinavian Journal of Surgery 2014;103:245–8. doi:10.1177/1457496913519771.
Strong S, Blencowe N, Bhangu A. How good are surgeons at identifying appendicitis? Results from a multi-centre cohort study. International Journal of Surgery 2015;15:107–12. doi:10.1016/j.ijsu.2015.01.032.
Pham H, Devadas M, Howle J. Effect of surgical experience on the macroscopic diagnosis of appendicitis: A retrospective cohort study. International Journal of Surgery 2015;16:78–82. doi:10.1016/j.ijsu.2015.02.019.
Thong DW, Crouch S, Morgan S, Arthur T. Can surgeons identify appendicitis macroscopically? Results from a multicentre prospective study. Journal of Pediatric Surgery 2019;15:107–12. doi:10.1097/SLE.0000000000000687.