Journal Club: Appendicitis in 2021

The RIFT study prospectively evaluated 15 different clinical prediction models in children with right iliac fossa pain to determine their accuracy.

The Shira score had an area under the curve of 0.84 and a failure rate of 3%, making it effective for ruling out appendicitis.

Introduction of a standardized ultrasound reporting template reduced equivocal reports from 27% to 9%.

The standardized ultrasound reporting template reduced CT scan utilization from 19% to 9% without affecting negative laparotomy rates.

In a pilot RCT comparing laparoscopic surgery versus antibiotics for acute non-perforated appendicitis in children, the surgical failure rate was 0% and the medical failure rate was 45%.

The pilot RCT on non-operative management had 26 patients in one arm and 24 in the other arm.

A large retrospective cohort study based on NSQIP database showed a 90% reduction in surgical site infection when using ceftriaxone plus metronidazole compared to cefoxitin for non-complicated appendicitis.

Doctor Sean Saint Peter and Whitt Holcomb in 2005 defined perforated appendicitis as a hole in the appendix or fecal material in the abdomen.

A 2008 study validated that a hole in the appendix and stool in the abdomen predict abscess rates.

A retrospective cohort study of 5000 patients identified four intraoperative findings that correlate with complicated postoperative course: visible hole, abscess, fecal material, and diffuse fibrinopurulent exudate outside the right iliac fossa or pelvis.

These four intraoperative findings were associated with higher adverse effects, higher length of stay, higher emergency visits, and higher use of hospital and patient resources after adjusting for all variables.

The recent study differs from Saint Peter's study in that pus in the abdomen was found to be a predictor of abscess, whereas in Sean's study it was not.

A double-blinded RCT of 243 patients comparing two doses of postoperative IV antibiotics versus placebo after laparoscopic appendectomy for simple appendicitis found a significant reduction in skin infection rate from 6.6% to 0.8%.

A 6% baseline infection rate for simple appendicitis seems too high.

A pre-post intervention study that eliminated opioid prescriptions after non-perforated appendectomy showed no increase in self-reported pain or extra medication use after discharge.

Patients do well with Tylenol and/or Motrin after appendectomy and do not typically return asking for opiates.