Diagnostic Indexes Findings in Early Stages of Appendicitis (DIFESA Study): a reanalysis from the POSAW study database

Carlos Augusto Gomes1*, Luis Pordeus Shafee1, Ana Luíza de Castro Carvalho1, Lucas Machado de Souza Vicente2, Felipe Couto Gomes2, Mauro Podda3, Belinda de Simone4, Massimo Sartelli5, Fausto Catena6

1Department of Surgery, Hospital Universitário, Universidade Federal de Juiz de Fora. MG, Brasil. 2Hospital Universitário Terezinha de jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de FORA, MG, Brasil. 3Department of Surgical Science University of Cagliari (Italy). 4Unit of Metabolic, Digestive and Emergency Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, France. 5General and Emergency Surgery, Macerata Hospital, Macerata, Italy. 6Bufalini Hospital Cesena Italy.

Purpose: The resection of a normal-looking appendix during laparoscopic appendicectomy (LA) remains a dilemma. The optimal approach requires reliable macroscopic judgment by the surgeons. The aim of this study is to assess the surgeon’s ability to laparoscopically diagnose acute appendicitis (AA) in its initial uncomplicated grades.

Method: Subgroup analysis from the POSAW study, 2016. Patients diagnosed with initial grades of AA (0 – 1) who underwent LA were included (n=718). The median age was 29.4 years, and 52% were female. The accuracy of the macroscopic intraoperative diagnosis was assessed with the histopathological examination of the resected specimens, and the agreement between the surgeon’s and the pathologist’s judgment was established.

Results: Of the 79 appendices classified intraoperatively as normal-looking, 18 (22.8%) had some inflammation degree. Of the 639 appendices classified intraoperatively as inflamed, 101 (15.8%) were normal. The intraoperative surgeon’s judgment had an accuracy of 83.4% and a moderate to low agreement (Kappa 0.42). The sensitivity and specificity values were 96.8% and 37.7%, and the positive and negative predictive values were 84.2% and 77.2%, respectively.

Conclusion: The surgeon’s intraoperative diagnosis of uncomplicated AA’s initial grades is not sufficiently accurate to establish good reliability for appendicectomy. The surgeon overestimates the presence of appendicular inflammation.

Keywords: Appendicitis; Appendectomy; Laparoscopy, Diagnosis.

Free Full-text PDF

How to cite this article:

Carlos Augusto Gomes, Luis Pordeus Shafee, Ana Luíza de Castro Carvalho, Lucas Machado de Souza Vicente, Felipe Couto Gomes, Mauro Podda, Belinda de Simone Massimo Sartelli, Fausto Catena. Diagnostic Indexes Findings in Early Stages of Appendicitis (DIFESA Study): a reanalysis from the POSAW study database. American Journal of Surgical Research and Reviews, 2021, 4:35. DOI:10.28933/ajsrr-2021-10-0305


1. Ferris M, Quan S, Kaplan BS, et al. The Global Inci-dence of Appendicitis: A Systematic Review of Population-based Studies. Ann Surg. 2017;266(2):237–241. https://doi.org/10.1097/sla.0000000000002188
2. Wagner M, Tubre DJ, Asensio JA. Evolution and Current Trends in the Management of Acute Appen-dicitis. Surg Clin North Am. 2018;98(5):1005-1023. https://doi.org/10.1016/j.suc.2018.05.006
3. Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015 Sep 26;386(10000):1278-1287. doi: 10.1016/S0140-6736(15)00275-5. Erratum in: Lancet. 2017 Oct 14;390(10104):1736. PMID: 26460662. https://doi.org/10.1016/s0140-6736(15)00275-5
4. Di Saverio S, Podda M, De Simone B, et al. diag-nosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15(1):27. Published 2020 Apr 15. https://doi.org/10.1186/s13017-020-00306-3
5. Leeuwenburgh MM, Wiezer MJ, Wiarda BM, Bouma WH, Phoa SS, Stockmann HB, Jensch S, Bossuyt PM, Boermeester MA, Stoker J; OPTIMAP study group. Accuracy of MRI compared with ultrasound imaging and selective use of CT to discriminate simple from perforated appendicitis. Br J Surg. 2014 Jan;101(1):e147-55. https://doi.org/10.1002/bjs.9350
6. Podda M, Andersson R, Boermeester M, Coccolini F, Sartelli M, Moore EE, Sugrue M, Abu-Zidan F, To-lonen M, Damaskos D, Kluger Y, Soreide K, Pisanu A, Augustin G, Latifi R, Kelly M, Leppaniemi A, Fraga GP, Ten Broek R, Tan E, Van Goor H, Chiara O, Maier RV, Pata F, De Simone B, Ordoñez CA, Ansaloni L, Catena F, Di Saverio S. Do young patients with high clinical suspicion of appendicitis really need cross sectional imaging? Proceedings from a highly con-troversial debate among the experts’ panel of 2020 WSES Jerusalem Guidelines. J Trauma Acute Care Surg. 2021 Jan 25. https://doi.org/10.1097/ta.0000000000003097
7. Poillucci G, Mortola L, Podda M, et al. Laparoscopic appendectomy vs antibiotic therapy for acute ap-pendicitis: a propensity score-matched analysis from a multicenter cohort study. Updates Surg. 2017;69(4):531-540. https://doi.org/10.1007/s13304-017-0499-8
8. Gomes CA, Sartelli M, Podda M, et al. Laparoscopic versus open approach for diffuse peritonitis from appendicitis ethiology: a subgroup analysis from the Physiological parameters for Prognosis in Ab-dominal Sepsis (PIPAS) study. Updates Surg. 2020;72(1): 185-191. https://doi.org/10.1007/s13304-020-00711-y
9. Jaschinski T, Mosch C, Eikermann M, Neugebauer EA. Laparoscopic versus open appendectomy in patients with suspected appendicitis: a systematic review of meta-analyses of randomised controlled trials. BMC Gastroenterol. 2015;15:48. Published 2015 Apr 15. https://doi.org/10.1186/s12876-015-0277-3
10. Podda M, Gerardi C, Cillara N, Fearnhead N, Gomes CA, Birindelli A, Mulliri A, Davies RJ, Di Saverio S. Antibiotic Treatment and Appendectomy for Un-complicated Acute Appendicitis in Adults and Chil-dren: A Systematic Review and Meta-analysis. Ann Surg. 2019 Dec;270(6):1028-1040. PMID: 30720508. https://doi.org/10.1097/sla.0000000000003225
11. Slotboom T, Hamminga JT, Hofker HS, Heineman E, Haveman JW; Apple Study Group Appendicitis and Laparoscopic Evaluation. Intraoperative motive for performing a laparoscopic appendectomy on a postoperative histological proven normal appendix. Scand J Surg. 2014;103(4):245-248. https://doi.org/10.1177/1457496913519771
12. Thong DW, Crouch S, Morgan S, Arthur T; QUEST Collaboration. Can Surgeons Identify Appendicitis Macroscopically? Results From a Multicentre Pro-spective Study. SurgLaparoscEndoscPercutan Tech. 2019 Oct;29(5):344-348. https://doi.org/10.1097/sle.0000000000000687
13. Strong S, Blencowe N, Bhangu A. How good are surgeons at identifying appendicitis? Results from a multicentre cohort study. Int J Surg. 2015;15:107–12. https://doi.org/10.1016/j.ijsu.2015.01.032
14. Van den Boom AL, de Wijkerslooth EML, Mauff KAL, et al. Interobserver variability in the classification of appendicitis during laparoscopy: Interobserver var-iability in classification of appendicitis during lapa-roscopy. Br J Surg. 2018;105:1014–9. https://doi.org/10.1002/bjs.10837
15. Sartelli M, Baiocchi GL, Di Saverio S, et al. Pro-spective Observational Study on acute Appendicitis Worldwide (POSAW). World J EmergSurg. 2018;13:19. https://doi.org/10.1186/s13017-018-0179-0
16. Gomes CA, Sartelli M, Di Saverio S, et al. Acute appendicitis: proposal of a new comprehensive grading system based on clinical, imaging and lap-aroscopic findings. World J Emerg Surg. 2015;10:60. https://doi.org/10.1186/s13017-015-0053-2
17. Gorter RR, Eker HH, Gorter-Stam MA, et al. diagnosis and management of acute appendicitis. EAES consensus development conference 2015. SurgEn-dosc. 2016; 30(11): 4668-4690. https://doi.org/10.1007/s00464-016-5245-7
18. Chaudhary P, Nabi I, Arora MP. Periappendicitis: our 13 year experience. Int J Surg. 2014;12(9):1010-3. https://doi.org/10.1016/j.ijsu.2014.07.265
19. Carr NJ. The pathology of acute appendicitis. Ann DiagnPathol. 2000;4(1):46-58. https://doi.org/10.1016/s1092-9134(00)90011-x
20. Bastiaenen VP, Allema WM, Klaver CEL, et al. Rou-tine histopathologic examination of the appendix after appendectomy for presumed appendicitis: Is it really necessary? A systematic review and me-ta-analysis.Surgery. 2020;168(2):305-312.https://doi.org/10.1016/j.surg.2020.03.032
21. Landis RJ, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–174. PMID: 843571
22. McHugh ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb). 2012;22(3):276-82. PMID: 23092060
23. Zosimas D, Lykoudis PM, Burke J, Strano G, Leung P, Shatkar V. Postoperative outcomes in laparo-scopic appendicectomies with histopathologically normal appendix. Ann Ital Chir. 2019;90:72-77. PMID: 30467271
24. Šuta Kimle K, Chrz K, Ulrych J, Šimůnková E, Michalský D. Congruence of histological diagnosis with imaging and operation diagnosis in acute ap-pendicitis. RozhlChir. 2019 Winter;98(11):457-461. https://doi.org/10.33699/pis.2019.98.11.457-461
25. Jones AE, Phillips AW, Jarvis JR, Sargen K (2007) The value of routine histopathological examination of appendicectomy specimens. BMC Surg 7(1):17. https://doi.org/10.1186/1471-2482-7-17
26. Cho J, Lee D, Sung K, Baek J, Lee J. Clinical im-plication of discrepancies between surgical and pathologic diagnoses of acute appendicitis. Ann Surg Treat Res. 2017; 93(1): 43-49. https://doi.org/10.4174/astr.2017.93.1.43
27. Correa J, Jimeno J, Vallverdu H, et al. Correlation between intraoperative surgical diagnosis of com-plicated acute appendicitis and the pathology report: clinical implications. Surg Infect (Larchmt). 2015;16(1):41-44. https://doi.org/10.1089/sur.2013.155
28. Mariadason JG, Wang WN, Wallack MK, Belmonte A, Matari H. Negative appendicectomy rate as a quality metric in the management of appendicitis: impact of computed tomography, Alvarado score and the definition of negative appendicectomy. Ann R Coll Surg Engl. 2012 Sep;94(6):395-401.
29. Bhangu A; RIFT Study Group on behalf of the West Midlands Research Collaborative. Evaluation of appendicitis risk prediction models in adults with suspected appendicitis. Br J Surg. 2020 Jan;107(1):73-86. doi: 10.1002/bjs.11440. Epub 2019 Dec 3. PMID: 31797357; PMCID: PMC6972511. https://doi.org/10.1002/bjs.11440
30. Charfi S, Sellami A, Affes A, Yaïch K, Mzali R, Boudawara TS. Histopathological findings in ap-pendectomy specimens: a study of 24,697 cases. Int J Colorectal Dis. 2014 Aug;29(8):1009-12. https://doi.org/10.1007/s00384-014-1934-7
31. Allaway MGR, Eslick GD, Cox MR. The Unacceptable Morbidity of Negative Laparoscopic Appendicec-tomy. World J Surg. 2019 Feb; 43(2): 405-414. https://doi.org/10.1007/s00268-018-4784-6
32. Güller U, Rosella L, McCall J, Brügger LE, Candinas D. Negative appendicectomy and perforation rates in patients undergoing laparoscopic surgery for sus-pected appendicitis. Br J Surg. 2011 Apr;98(4):589-95. https://doi.org/10.1002/bjs.7395
33. Chandrasegaram MD, Rothwell LA, An EI, Miller RJ. Pathologies of the appendix: a 10-year review of 4670 appendicectomy specimens. ANZ J Surg. 2012 Nov; 82(11): 844-7. https://doi.org/10.1111/j.1445-2197.2012.06185.x
34. Sarr MG. CT scan in complicated appendicitis di-agnosis: a very costly option. Dig LiverDis. 2004 Mar;36(3):174. https://doi.org/10.1016/j.dld.2003.12.007
35. Lee M, Paavana T, Mazari F, Wilson TR (2014). The morbidity of negative apendicectomy. Ann R Coll SurgEngl 96 (7): 517-520. https://doi.org/10.1308/003588414×13946184903801
36. Sørensen AK, Bang-Nielsen A, Levic-Souzani K, et al. Readmission and reoperation rates following nega-tive diagnostic laparoscopy for clinically suspected appendicitis: The “normal” appendix should not be removed – A retrospective cohort study published correction appears in Int J Surg. 2020 Jul;79:154.. Int J Surg. 2019;64:1-4.
37. Bijnen CL, Van Den Broek WT, Bijnen AB, De Ruiter P, Gouma DJ. Implications of removing a normal ap-pendix. Dig Surg. 2003;20(2):115-21. PMID: 12686778. https://doi.org/10.1159/000069386
38. Das MK, Gautam D, Roy H, Mukherjee A, Gaurav R, Sen S. Unnecessary appendicectomy in suspected cases of acute appendicitis. J Indian Med Assoc. 20
09 Jun;107(6):354, 356-7. PMID: 19886373.
39. Vitetta L, Chen J, Clarke S. The vermiform appendix: an immunological organ sustaining a microbiome inoculum. Clin Sci (Lond). 2019 Jan 3;133(1):1-8. https://doi.org/10.1042/cs20180956
40. Pham H, Devadas M, Howle J. Effect of surgical experience on the macroscopic diagnosis of ap-pendicitis: a retrospective cohort study. Int J Surg. 2015 Apr;16(Pt A):78-82.

Terms of Use/Privacy Policy/ Disclaimer/ Other Policies:
You agree that by using our site, you have read, understood, and agreed to be bound by all of our terms of use/privacy policy/ disclaimer/ other policies (click here for details).

This work and its PDF file(s) are licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.