Department of General Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey.
Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
BJS Open. 2024 Sep 3;8(5). doi: 10.1093/bjsopen/zrae120.
Appendicitis is the most prevalent surgical emergency. The negative appendicectomy rate and diagnostic uncertainty are important concerns. This study aimed to assess the effectiveness of current appendicitis risk prediction models in patients with acute right iliac fossa pain.
A nationwide prospective observational study was conducted, including all consecutive adult patients who presented with right iliac fossa pain. Diagnostic, clinical and negative appendicectomy rate data were recorded. The Alvarado score, Appendicitis Inflammatory Response (AIR), Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Adult Appendicitis Score systems were calculated with collected data to classify patients into risk categories. Diagnostic value and categorization performance were evaluated, with use of risk category-based metrics including 'true positive rate' (percentage of appendicitis patients in the highest risk category), 'failure rate' (percentage of patients with appendicitis in the lowest risk category) and 'categorization resolution' (true positive rate/failure rate).
A total of 3358 patients from 84 centres were included. Female patients were less likely to undergo surgery than men (71.5% versus 82.5% respectively; relative risk 0.866, 95% c.i. 0.834 to 0.901, P < 0.001); with a three-fold higher negative appendicectomy rate (11.3% versus 4.1% respectively; relative risk 2.744, 95% c.i. 2.047 to 3.677, P < 0.001). Ultrasonography was utilized in 56.8% and computed tomography in 75.2% of all patients. The Adult Appendicitis Score had the best diagnostic performance for the whole population; however, only RIPASA was significant in men. All scoring systems were successful in females patients, but Adult Appendicitis Score had the highest area under the receiver operating characteristic curve value. The RIPASA and the Adult Appendicitis Score had the best categorization resolution values, complemented by their exceedingly low failure rates in both male and female patients. Alvarado and AIR had extremely high failure rates in men.
The negative appendicectomy rate was low overall, but women had an almost three-fold higher negative appendicectomy rate despite lower likelihood to undergo surgery. The overuse of imaging tests, best exemplified by the 75.2% frequency of patients undergoing computed tomography, may lead to increased costs. Risk-scoring systems such as RIPASA and Adult Appendicitis Score appear to be superior to Alvarado and AIR.
阑尾炎是最常见的外科急症。阴性阑尾切除术率和诊断不确定性是重要关注点。本研究旨在评估当前阑尾炎风险预测模型在急性右髂窝疼痛患者中的有效性。
进行了一项全国性前瞻性观察研究，纳入所有连续出现右髂窝疼痛的成年患者。记录诊断、临床和阴性阑尾切除术率数据。使用收集的数据计算 Alvarado 评分、阑尾炎症反应 (AIR)、Raja Isteri Pengiran Anak Saleha 阑尾炎 (RIPASA) 和成人阑尾炎评分系统，将患者分类为风险类别。使用基于风险类别的指标评估诊断价值和分类性能，包括“真阳性率”（最高风险类别中阑尾炎患者的百分比）、“失败率”（最低风险类别中阑尾炎患者的百分比）和“分类分辨率”（真阳性率/失败率）。
共纳入 84 个中心的 3358 例患者。女性患者接受手术的可能性低于男性（分别为 71.5%和 82.5%；相对风险 0.866，95%置信区间 0.834 至 0.901，P<0.001）；阴性阑尾切除术率高 3 倍（分别为 11.3%和 4.1%；相对风险 2.744，95%置信区间 2.047 至 3.677，P<0.001）。所有患者中 56.8%接受了超声检查，75.2%接受了计算机断层扫描。成人阑尾炎评分在整个人群中具有最佳的诊断性能；然而，只有 RIPASA 在男性中具有统计学意义。所有评分系统在女性患者中均有效，但成人阑尾炎评分的受试者工作特征曲线下面积值最高。RIPASA 和成人阑尾炎评分的分类分辨率值最佳，且在男性和女性患者中失败率极低。Alvarado 和 AIR 在男性患者中的失败率极高。
总体而言，阴性阑尾切除术率较低，但女性尽管手术可能性较低，但其阴性阑尾切除术率却高 3 倍。影像学检查的过度使用，最明显的是 75.2%的患者接受了计算机断层扫描，可能导致成本增加。RIPASA 和成人阑尾炎评分等风险评分系统似乎优于 Alvarado 和 AIR。
