Y. R. Yu1,2, E. H. Rosenfeld1,2, S. Dadjoo1,2, M. E. Lopez1,2, S. R. Shah1,2, B. J. Naik-Mathuria1,2 1Texas Children’s Hospital,Pediatric Surgery,Houston, TX, USA 2Baylor College Of Medicine,Surgery,Houston, TX, USA
Introduction:
Non-operative management (NOM) of simple appendicitis is a proposed alternative to traditional appendectomy. This study assessed the accuracy of surgeons’ prediction of appendicitis severity.
Methods:
From February to August 2016, pediatric surgeons prospectively predicted whether patients had simple or complex appendicitis before the operation based on clinical data, imaging, and general assessment at a single tertiary care pediatric hospital. Surgeon confidence in their prediction using a 5-point Likert scale was documented. Results were analyzed using receiver operating characteristic (ROC) curves to determine area under the curve (AUC) and optimal cut-off points of clinical findings for diagnosing simple appendicitis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) were also calculated. Predictions were compared to findings using χ2 . A p-value < 0.05 was considered statistically significant.
Results:
Of 125 cases, 73 (58%) were male and the median age was 9 years (range 1-18 years). Simple appendicitis was predicted in 77 (62%) and complex appendicitis in 48 (38%). Surgeons were generally confident of their predictions (simple: 87% certainty, complex: 88% certainty). Predictions were accurate in 59 (77%) of simple cases and 45 (94%) of complex cases. Although surgeon prediction was more accurate than individual imaging or clinical findings and was highly sensitive (95%) for diagnosing simple appendicitis, specificity was only 71% (Table).
Eighteen cases (14%) were inaccurately predicted as simple when they were actually complex. Of these, 6 (33%) were gangrenous, 17 (94%) had focal/no abdominal tenderness, 15 (83%) were well-appearing, 11 (61%) had ultrasound reported as simple appendicitis, 11 (61%) had ≤ 2 days of symptoms, and 8 (44%) were afebrile (<100.4 oF).
Lower WBC (<15.5×103/uL, AUC 0.61, p=0.05), afebrile (<100.4 oF, AUC 0.86, p<0.01), and shorter symptom duration (≤ 1.5 days, AUC 0.71, p<0.001) were associated with simple appendicitis.
Conclusion:
Successful NOM for appendicitis works best in patients with simple appendicitis. While surgeon prediction of simple appendicitis is more accurate than ultrasound or clinical data alone, a significant error rate still exists.
