Computed Tomography-Based Clinical Diagnostic Pathway for Acute Appendicitis: Prospective Validation - 09/08/11
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, Louis Rivera, MD , Bret J. Langenberg, DO , George Hahm, MD , Michael A. Favata, MD †, Carlos V.R. Brown, MD, FACS Department of Surgery, Naval Medical Center San Diego, San Diego, CA Correspondence address: Jared Antevil, MD, 1004 Tower Pl, Nashville, TN 37204.Résumé |
Background |
Despite our regular use of CT for suspected appendicitis, a recent study at our institution demonstrated a negative appendectomy (NA) rate similar to our rate 15 years earlier. Based on analysis of this data, a diagnostic pathway was implemented prospectively for adult patients with possible appendicitis.
Study design |
Rates of CT, NA, and perforation for nonpregnant patients over 14 years of age undergoing appendectomy between August 2001 and August 2002 (PRE) were compared with prospectively collected pathway data (PATH, August 2004 to August 2005). All PATH patients were evaluated by a surgeon before CT. All females underwent CT. CT was obtained in male patients with low suspicion or pain for longer than 48 hours. After negative CT, patients were discharged from the emergency department or admitted for observation.
Results |
There was a substantial decrease in NA rate after implementation of the pathway (4% PATH [8 of 183] versus 16% PRE [31 of 196], p < 0.001), without a change in the rate of perforation (11% PATH [20 of 175] versus 8% PRE [13 of 165], p = 0.28) or frequency of preoperative CT (59% PATH [108 of 183] versus 60% PRE [118 of 196], p = 0.84).
Conclusions |
Frequent appendiceal CT alone does not ensure surgical diagnostic accuracy. CT need not be used in all patients to achieve very low NA rates. An evidence-based diagnostic algorithm incorporating early surgical evaluation, objective criteria for preoperative CT, deterrence of early operation after negative CT, and use of CT to facilitate safe discharge led to substantial improvements in the care of our adult population presenting with possible appendicitis.
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| Competing Interests Declared: None. The Chief, Bureau of Medicine and Surgery, Navy Department, Washington, DC, Clinical Investigation Program sponsored this report no. S-04-035 as required by NSHSBETHINST 6000.41A. The article represents the personal viewpoint of the authors and cannot be construed as a statement of official Department of the Navy, Department of Defense, or the United States Government policy. |
Vol 203 - N° 6
P. 849-856 - décembre 2006 Retour au numéro
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