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. 2021 Feb;406(1):141-152.
doi: 10.1007/s00423-020-02022-7. Epub 2020 Nov 19.

DIALAPP: a prospective validation of a new diagnostic algorithm for acute appendicitis

Patrizia Malkomes  1 , Franziska Edmaier  2 , Juliane Liese  3 , Alexander Reinisch-Liese  4 , Hanan El Youzouri  2 , Teresa Schreckenbach  2 , Andreas M Bucher  5 , Wolf Otto Bechstein #  2 , Andreas A Schnitzbauer #  2
Affiliations

DIALAPP: a prospective validation of a new diagnostic algorithm for acute appendicitis

Patrizia Malkomes et al. Langenbecks Arch Surg. 2021 Feb.

Abstract

Purpose: The management of patients with suspected appendicitis remains a challenge in daily clinical practice, and the optimal management algorithm is still being debated. Negative appendectomy rates (NAR) continue to range between 10 and 15%. This prospective study evaluated the accuracy of a diagnostic pathway in acute appendicitis using clinical risk stratification (Alvarado score), routine ultrasonography, gynecology consult for females, and selected CT after clinical reassessment.

Methods: Patients presenting with suspected appendicitis between November 2015 and September 2017 from age 18 years and above were included. Decision-making followed a clear management pathway. Patients were followed up for 6 months after discharge. The hypothesis was that the algorithm can reduce the NAR to a value of under 10%.

Results: A total of 183 patients were included. In 65 of 69 appendectomies, acute appendicitis was confirmed by histopathology, corresponding to a NAR of 5.8%. Notably, all 4 NAR appendectomies had other pathologies of the appendix. The perforation rate was 24.6%. Only 36 patients (19.7%) received a CT scan. The follow-up rate after 30 days achieved 69%, including no patients with missed appendicitis. The sensitivity and specificity of the diagnostic pathway was 100% and 96.6%, respectively. The potential saving in costs can be as much as 19.8 million €/100,000 cases presenting with the suspicion of appendicitis.

Conclusion: The risk-stratified diagnostic algorithm yields a high diagnostic accuracy for patients with suspicion of appendicitis. Its implementation can safely reduce the NAR, simultaneously minimizing the use of CT scans and optimizing healthcare-related costs in the treatment of acute appendicitis.

Trial registration: ClinicalTrials.gov Identifier: NCT02627781 (December 2015).

Keywords: Acute appendicitis; Clinical trial; Diagnostic algorithm; Negative appendectomy rate; Risk-stratification.

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Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Learning circle of the DIALAPP study. Starting with the formation of a learning community in order to minimize the rate of negative appendectomies and CT scans in the diagnosis of acute appendicitis. After the analysis of our institutional retrospective data of Liese et al. (data to knowledge), a diagnostic pathway was implemented and prospectively evaluated as part of the DIALAPP study (knowledge to practice). As a result, we found a reduction in the NAR and CT rate (practice to data) (NAR, negative appendectomy rate)
Fig. 2
Fig. 2
Flowchart and management course of study cohort. Implementation of the proposed diagnostic algorithm in 183 patients with suspected appendicitis (AA, acute appendicitis; US, ultrasound)
Fig. 3
Fig. 3
ROC curve. ROC (receiver operating characteristic) curve of sensitivity and specificity of the Alvarado score for diagnosis of acute appendicitis
See this image and copyright information in PMC

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