Acute appendicitis or not: Facts and suggestions to reduce valueless surgery

BackgroundFor suspected acute appendicitis (AA), risk stratification with clinical tools and supplemental imaging is useful for reducing unnecessary surgery and radiation exposure without increased appendicitis rupture.PurposeIn patients receiving surgery for suspected AA, we compared adults versus children, and patients with versus without AA. Based on these facts and the benefits of surgery in patients without AA, we recommend a way to reduce unnecessary surgery.MethodsWe retrieved the records of patients who underwent surgery for presumed appendicitis from January 2009 to December 2011. Risks of AA were assessed using the Alvarado score or the pediatric appendicitis score. We compared the adult and pediatric patients, and the patients with and without AA. The value of surgery for non-AA patients was evaluated by experts using the Delphi method.ResultsWe enrolled 314 patients, which comprised 258 adults and 56 children. Adult patients had higher percentages of migratory abdominal pain and local tenderness. Pediatric patients had higher frequencies of anorexia, nausea, vomiting, and leukocytosis. Our pediatric patients had higher clinical scores than adults (p < 0.001). The arrival-to-surgery time was shorter in children (p = 0.040), whereas no significant difference was found in symptom-to-emergency department time or length of hospital stay. There were 15 adults and one child without AA. The non-AA adults had a lower percentage of local tenderness (p = 0.040) and longer arrival-to-surgery times (p = 0.015) and hospital stays (p = 0.020). In the valuing of surgery, of the 16 patients eight were evaluated as indicated, six as helpful, and two as not helpful.ConclusionPreoperative imaging studies should be considered in moderate-risk patients, especially when the clinical manifestations are ambiguous. More workups, or even a prolonged observation, but not rushing to the operation theater, should be undertaken for patients with unremarkable imaging. In high-risk patients, surgery was valuable for patients without preoperative imaging, or with suggestive but inconclusive imaging results.