The Journal of Emergency Medicine, Vol. -, No. -, p. 1, 2016 Ó 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
Letter to the Editor , PREOPERATIVE IMAGING DOES NOT PREDICT RUPTURE IN ACUTE APPENDICITIS
assessment or the efficacy of the antibiotic regimen at the authors’ institution. The supposition that the appendix perforated within 24 h despite adequate antibiotics is therefore misleading and inaccurate. While important factors can potentially contribute to children presenting with appendiceal perforation (including younger age and duration of symptoms), it is erroneous to conclude that a >9 h duration before operative intervention increases the rate of perforation without the backing of a well-conducted randomized clinical trial.
, To the Editor: We read with interest the article by Bonadio et al. in the July 2015 issue of the Journal (1). Using their institutional data, the authors investigated the impact of timing to appendectomy on perforation rates in pediatric appendicitis, concluding that a delay of >9 h in previous computed tomography (CT)–confirmed nonperforated appendicitis led to a higher rate of perforation. While we applaud the authors’ attempt to determine the timing to surgery of an otherwise prevalent condition in children and an outcome with significantly worse morbidity, the methodology contains some fundamental flaws. The use of CT scan as a predictor of appendiceal perforation is highly misleading. The 2006 Bixby et al. study quoted by the authors concluded that multidetector CT imaging had very poor sensitivity for perforated appendicitis (2). In 2010, Fraser et al. found that the positive predictive accuracy of detecting appendiceal perforation by CT scan was 67% based on the review of 200 CT scans obtained for appendicitis (3).The study concluded that the triage of patients based on preoperative CT scans was highly imprudent. The authors also concluded that the use of antibiotics did not prevent progression of appendicitis, with rates of perforation as high as 41% within 24 h! This finding contradicts research studies, including well-conducted prospective, randomized trials on the role of antibiotics in the treatment of uncomplicated appendicitis (4,5). This brings into question the validity of the initial CT
Tolulope A. Oyetunji, MD Rebecca Maria Rentea, MD Katrina L. Weaver, MD Richard J. Hendrickson, MD Children’s Mercy Hospital Kansas City, Missouri http://dx.doi.org/10.1016/j.jemermed.2016.02.035 REFERENCES 1. Bonadio W, Brazg J, Telt N, et al. Impact of in-hospital timing to appendectomy on perforation rates in children with appendicitis. J Emerg Med 2015;49:597–604. 2. Bixby SD, Lucey BC, Soto JA, Theysohn JM, Ozonoff A, Varghese JC. Perforated versus nonperforated acute appendicitis: accuracy of multidetector CT detection. Radiology 2006;241:780–6. 3. Fraser JD, Aguayo P, Sharp SW, et al. Accuracy of computed tomography in predicting appendiceal perforation. J Pediatr Surg 2010;45: 231–4. 4. Gorter RR, van der Lee JH, Cense HA, et al. Initial antibiotic treatment for acute simple appendicitis in children is safe: short-term results from a multicenter, prospective cohort study. Surgery 2015;157: 916–23. 5. Minneci PC, Sulkowski JP, Nacion KM, et al. Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children. J Am Coll Surg 2014;219:272–9.