Journal Club: Appendicitis in 2021

The RIFT study prospectively evaluated 15 different clinical prediction models in children with right iliac fossa pain by calculating area under the curve and failure rates.

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

A standardized ultrasound reporting template reduced equivocal reports from 27% to 9%.

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

In a pilot RCT of non-perforated appendicitis, surgical failure rate was 0% versus 45% medical failure rate, with failure defined as requiring laparoscopic appendectomy during follow-up.

The non-operative versus appendectomy study randomized 26 patients to surgery and 24 to antibiotics.

Ceftriaxone plus metronidazole showed a 90% reduction in surgical site infection compared to cefoxitin for non-complicated appendicitis in a large NSQIP-based retrospective cohort study published in Annals of Surgery in 2020.

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

Four intraoperative findings correlate with complicated postoperative course for appendicitis: 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.

Pus in the abdomen is a predictor of abscess in the recent study, which differs from Sean Saint Peter's study where it was not a predictor.

A double-blind RCT of 243 patients randomized to two doses of postoperative antibiotics versus placebo found a significant reduction in skin infection rate from 6.6% to 0.8% for simple appendicitis.

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

A pre-post intervention study completely eliminated opioid prescriptions after non-perforated appendectomy and found no increase in self-reported pain or extra medication use via phone interviews and surgical follow-up.

After converting from opiates to Tylenol and/or Motrin for post-appendectomy pain, patients are fine and do not come back asking for opiates.