Mariadason J G, Bhattarai P, Shah S, Mitaszka K, Belmonte A, Matari H, Chiechi M, Wallack M K
Chief of Sub-Division of General Surgery, Metropolitan Hospital Center, Associate Professor of Surgery, New York Medical College at Metropolitan Hospital, 12th Floor, Metropolitan Hospital, 1901 First Ave, New York, NY, 10029, United States.
Surgery Department, Metropolitan Hospital Center, New York, NY, United States.
Surg Pract Sci. 2022 Jul 17;10:100113. doi: 10.1016/j.sipas.2022.100113. eCollection 2022 Sep.
Both the CODA trial and the 2020 WSES Jerusalem guidelines concluded that nonoperative management of appendicitis (NOMA) was non-inferior for uncomplicated appendicitis but appendicoliths increase risk for complications. Thus "Appendicoliths on CT" are a relative contraindication to NOMA but accuracy of CT in identifying appendicoliths is just assumed.
We conducted an EMR review of 1552 appendectomy patients, who had pre-operative CT scans for suspected acute appendicitis from 2001-2019. Two radiologists reinterpreted images from 2011 and 2019 for presence of appendicoliths. Appendicoliths identified on CT were compared to appendicoliths in corresponding pathology specimens. Cohorts A (2001-10) & B (2011-19) were created on account of changes in CT scanners. PPV, NPV, sensitivity and specificity rates were calculated for contemporaneous readings and for 2011 and 2019 reinterpretations.
397 CT scans were read as positive for appendicoliths; 167 for A, 230 for B. 246 corresponding specimens had appendicoliths. PPV was 62% overall; 69% for A, 57% for B. 1155 scans were negative for appendicoliths. 191 corresponding specimens had appendicoliths; NPV was 83% overall; 80% for A, 87% for B. 447 specimens had appendicoliths; only 246 were identified by CT. Sensitivity was 55% overall; 48% for A, 66% for B. Specificity was 86% overall (964/1115); 91% for A, 82% for B. Radiologist accuracies varied.
Complicated appendicitis is often associated with appendicoliths. The assumption that CT identification of appendicoliths is reliable is unsupported by this study. CT finding of an appendicolith should not be used to exclude patients from antibiotics treatment but rather used in the shared decision-making conversation about management with patients.
CODA试验和2020年WSES耶路撒冷指南均得出结论，对于单纯性阑尾炎，非手术治疗（NOMA）并不逊色，但阑尾粪石会增加并发症风险。因此，“CT上的阑尾粪石”是NOMA的相对禁忌证，但CT识别阑尾粪石的准确性只是一种假设。
我们对1552例接受阑尾切除术的患者进行了电子病历回顾，这些患者在2001年至2019年期间因疑似急性阑尾炎进行了术前CT扫描。两名放射科医生重新解读了2011年和2019年的图像，以确定是否存在阑尾粪石。将CT上识别出的阑尾粪石与相应病理标本中的阑尾粪石进行比较。根据CT扫描仪的变化创建了队列A（2001 - 10年）和队列B（2011 - 19年）。计算了同期读数以及2011年和2019年重新解读的阳性预测值（PPV）、阴性预测值（NPV）、敏感性和特异性率。
397例CT扫描被解读为阑尾粪石阳性；队列A中有167例，队列B中有230例。246个相应标本中有阑尾粪石。总体PPV为62%；队列A为69%，队列B为57%。1155例扫描阑尾粪石为阴性。191个相应标本中有阑尾粪石；总体NPV为83%；队列A为80%，队列B为87%。447个标本中有阑尾粪石；CT仅识别出246个。总体敏感性为55%；队列A为48%，队列B为66%。特异性总体为86%（964/1115）；队列A为91%，队列B为82%。放射科医生的准确性各不相同。
复杂性阑尾炎常与阑尾粪石相关。本研究不支持CT识别阑尾粪石可靠这一假设。CT发现阑尾粪石不应被用于排除患者接受抗生素治疗，而应用于与患者进行关于治疗管理的共同决策讨论中。
