EP.FRI.101 Paediatric Appendicitis Score (PAS): A local trial of a risk prediction pathway

Introduction Right iliac fossa (RIF) pain remains the commonest acute general surgical presentation in children. Our centre had been an outlier compared with the national average in terms of negative appendicectomy rates. Thus, we designed and implemented a local pathway for risk stratification and management of children with RIF pain. Methods The first phase was a retrospective analysis of all appendicectomies performed between April 2018 and March 2019, in children aged five to seventeen years old. Pre-operative inflammatory markers, clinical signs, and histology findings were analyzed. Second phase involved designing a pathway utilizing Paediatric Appendicitis Score (PAS), a ten-point scoring system when assessing children with RIF pain. The final phase was a prospective analysis of appendicectomy results performed between August and November 2019, after implementing PAS pathway. Results 92 cases were recruited in the first phase (mean age 12.3). 22 cases were analyzed in the final phase after implementing PAS pathway (mean age 10.9). Our negative appendicectomy rates had reduced from 25% to 15.4%. In addition, we found that 96% of positive appendicectomies had either raised inflammatory markers (WCC or CRP), raised PAS (Score of ≥ 4), or both. Conclusion There is noticeable difference in our negative appendicectomy rates since the introduction of PAS pathway. A diagnosis of appendicitis in a child with normal inflammatory markers and PAS score seemed unlikely. Our goal is to continue utilizing the PAS pathway in our department in order to reduce unnecessary surgeries in children.

TP9.2.1Evaluating the incidence, the predictors and the outcomes of patients with negative appendicectomy

Introduction Negative appendicectomy (NA) is still a major issue following appendicectomy. We evaluated the rate and predictors of negative appendicectomy in a cohort. Patients and Methods Data of patients who underwent emergency appendicectomies over a year was collected and analysed. The absence of inflammation and/or other significant pathology in the appendix was considered negative by standard definition. A stricter definition of NA was the absence of inflammatory cells in the appendix. Negative appendicectomy rate (NAR) was calculated using the standard criteria (NAR-SDC) and the strict criteria (NAR-STC). Results 372 patients were included, 179 males and 193 females with a median age of 27 (5-94) years. Median duration of symptoms and waiting time to surgery were 2 days and 1 day respectively. The mean admission WBC and CRP were 12,600 (3000-38000)/mm3 and 66.9 (1-323) mg/L respectively. Laparoscopic appendicectomy was performed in 93.5% of patients with a conversion rate of 4.6%. NAR-SDC was 10.2% and NAR-STC was 25.8%. NAR was significantly higher in females than males (39.4% versus 11.1%; p-value 0.0001). Patients with NA were younger (p-value 0.0001), had lower mean total WBC (p-value 0.014) and CRP (p-value 0.0001) on admission. Independent predictors of negative appendicectomy are female gender, duration of symptoms more than 3 days, and lower total WBC. Conclusion NA is still a major problem in the management of patients with acute right lower abdominal pain. Our NAR compared favourably with reported rates. Female gender, symptoms duration more than 3 days, lower WBC are independent predictors of NA.

EP.FRI.615 Assessing the reliability of the Adult Appendicitis Score in managing patients with suspected acute appendicitis

Aims To evaluate the effectiveness of using a clinical prediction tool in the management of suspected acute appendicitis Methods Retrospective data was collected on patients undergoing appendicectomy at a single tertiary centre from November 2019 to June 2020. Inclusion criteria were all patients aged 18 and above undergoing diagnostic laparoscopy for suspected appendicitis. Exclusion criteria were all patients that had a pathological finding other than appendicitis at laparoscopy. The pre operative AAS score at first presentation was calculated and patients grouped into low(0-10), intermediate(11-15), and high(16 and above) risk. These groups were then compared to the histological findings. Results A total of 74 patients were included, 44 male and 30 female. The age range was from 18 to 83, with a median age of 36. Of 10 patients in the low risk group, 4 (40%) had appendicitis on histology. 36 out of 40 (90%) patients in the intermediate risk group had appendicitis and 100% of the 24 patients in the high risk group. Pearson’s coefficient showed a significant correlation between the AAS risk (low, intermediate, and high) and the histological diagnosis of appendicitis (r = 0.48, p = 0.000016). Conclusions Our study did show a positive correlation between the AAS risk stratification and histological diagnosis. Based on our findings we would recommend the adoption of this score in assessing patients with suspected acute appendicitis and minimising the negative appendicectomy rate.

EP.FRI.479 Clinical accuracy of u/sound combined with inflammatory markers in Acute Appendicitis

Traditionally acute appendicitis has been a clinical diagnosis based on patients' history and physical examination, but the accuracy of clinical diagnosis ranges from 70-95%. Pre-operative diagnosis of acute appendicitis still remains an enigmatic challenge, because no single test alone can reduce the rate of negative appendectomy. Hence some authors have recommended a combination of two or more investigations to increase accuracy and therefore the use of imaging is gaining support. The objective of the study was to determine the clinical accuracy of ultrasound, combined with inflammatory markers such as CRP, WBC, and neutrophilia keeping histopathology as the gold standard. Methods The study was conducted in a Tertiary care hospital in Peshawar from September 2014 to March 2015 on 250 patients who were clinically diagnosed with acute appendicitis. All these patients underwent u/sound scanning in addition to blood tests. Findings In this study, WBC had the highest sensitivity (77.68%) followed by neutrophil% (69.96%), CRP(67.10%), and U/Sound (62.96%) respectively. While U/Sound had the highest specificity (70.59%) followed by CRP and TLC (64.71% each) and neutrophil% (58.82%) respectively. When all the four tests were combined the sensitivity, specificity, (99.17% and 98.45%) increased significantly. When all four tests were negative, appendicitis could be safely ruled out. Conclusion Acute appendicitis is very unlikely and surgery can be safely deferred in these patients when all tests are negative thereby reducing the negative appendicectomy rates.

TP9.2.19Factors Associated with Multiple Presentations Prior to Appendicectomy in Children Presenting with Suspected Appendicitis

Aims Appendicectomy is amongst the most common emergency operations in children. We aim to audit the rate of re-presentation within 30-days prior to appendicectomy in children presenting to the emergency department (ED) with suspected appendicitis and identify the factors associated with re-presentations. Methods Retrospective review of the medical notes of all children that had an emergency appendicectomies between June 2016 and June 2019. Results A total of 231 appendicectomies were performed, all presented through ED, with 8.2%(n = 19) re-presenting within 30-days prior to appendicectomy. Negative appendicectomy rates were similar in those that had appendectomy at initial presentation or when they re-presented (13.2(n = 28)%vs.15.8%(n = 3), p = 0.752), respectively. Of those that re-presented, 84.2%(n = 16) were not reviewed by the surgical team at the index presentation. Female patients accounted for 62.5%(n = 10) of those that re-presented, compared with 31%(n = 57) of those that presented once(p = 0.010). Pyrexia(p = 0.029), Rovsing's sign(p = 0.032), nausea or vomiting(p = 0.012) was associated with histological appendicitis. Absence of migratory pain(p = 0.005), anorexia(p = 0.004), right iliac fossa tenderness(p < 0.001) or guarding(p < 0.001) was associated with higher successful discharge rate. Among those re-presented, there was significant CRP rise between first and second presentation (median(Q1,Q3): 6(1.25,28.5)vs.95.5(27,176.5), p = 0.016) however, white cell count was comparable (median(Q1,Q3): 14.6(11.98,16.05)vs.14.0(11.02,18.58), p = 0.815). Conclusion Clinical symptoms and signs correlated with histological appendicitis. A significant proportion of those that re-presented were not assessed by the surgical team at initial presentation. Early surgical consultation at initial presentation may reduce rates of re-presentation.

EP.FRI.1012 One plus one equals four: how NELA inspired a quality improvement programme that produced 4 distinct positive outcomes

Aim To describe how NELA inspired an ‘improving emergency surgery’ quality improvement programme that produced improvements in 4 distinct areas of surgical practice. Methods This paper describes how Kotter's improvement methodology was implemented in a district general hospital to achieve NELA targets, reduce the negative appendicectomy rate in children, implement NICE guidance on early laparoscopic cholecystectomy for acute cholecystitis and consistently deliver the 'S' and 'A' of SAFER within the surgery department. Results As a result of a systematic quality improvement approach, Conclusions Incorporating NELA into a local 'improving emergency surgery' quality improvement programme has delivered important and wide-ranging benefits beyond emergency laparotomy, and protected the service from 'crowding out behaviour' where focus on a single quality improvement can come at the expense of quality in other areas.

EP.FRI.229 The Role of Ultrasound in the Diagnosis of Paediatric Appendicitis

Background Acute appendicitis remains the most common acute surgical presentation among children and adults. Ultrasonography is a commonly used investigation for patients with right iliac fossa pain were the diagnosis is unclear, however in a district general hospital (DGH), appropriate radiologists are not often readily available. The aim of this study was to determine the value of ultrasonography in the diagnosis of appendicitis in children. Methods A retrospective review was carried out of all paediatric patients (aged 5-16), who underwent an appendicectomy in a single acute surgical unit, over a 6 month period. An institutional database and up to date electronic care records were used to record preoperative ultrasound results, intraoperative findings and histopathology results. Results A total of 59 patients were admitted with possible appendicitis within the audit window, 31 of which underwent an appendicectomy, 58% performed laparoscopically. 38.7% underwent pre- operative ultrasound, 33.3% of which identified an acutely inflamed appendix. The remaining patients who did not proceed to theatre were successfully discharged with no re-attendance following a period of observation. Following histopathological confirmation, ultrasonography was found to have a sensitivity and specificity of 100%. Negative appendicectomy rate returned at 6.7%. Conclusion Ultrasonography is a low cost, highly sensitive diagnostic tool in appendicitis, where provisions are in place to do so. Visualising the appendix on ultrasound can reduce negative pathology rates. This is a small study within a DGH and access to ultrasound is limited. Better utilisation or the development of a protected ultrasound slot should be sought.

TP6.2.3 Abnormal liver function tests: A helpful diagnostic test and a predictor of severity in acute appendicitis

Aim: Acute appendicitis (AA) is the commonest surgical emergency worldwide. The diagnosis usually is clinical but imaging and bloods tests are helpful. The study aims to establish the role of abnormalities in liver function tests (LFTs) in the diagnosis and in predicting the severity of AA. Methods Retrospective, observational study performed in district general hospital between June 2018 and June 2019. Patients with abdominal pain and appendicectomy (excluding children <16 years with isolated ALP rise) were categorized into two groups based on presence (Group-A) or absence (Group-B) of abnormal LFTs. Demographics data, diagnosis and severity of appendicitis, hospital stay and postoperative complications were analysed. Results Two hundred and seventy nine patients were included: Group-A (n = 146, mean age 37.5 years, M: F 1.3/1.0) and Group-B (n = 133, mean age 29.7 years, M:F 1.0/1.8). Appendicitis occurred in 85.6% of Group-A (125/146) and in 62.4% (83/133) of Group-B with positive predictive value 85.6%. The appendix was normal in 14.4% of Group-A (21/146) and in 37.6% of Group-B (50/133) with specificity of 70%. Laparotomy was required in 6.1% in Group-A (9/146) compared to 1.5% in Group-B (2/133). Average hospital stay was 4.7 days (range: 1-21) in Group-A versus 2.7 days (range 1-14) in Group-B. Readmission rate due to a postoperative complication was 16.4% in Group-A (24/146) compared to 6% in Group-B (8/ 133). Conclusion: Deranged LFTs is an additional diagnostic tool in AA and a good predictor of its severity. This may help to decrease the negative appendicectomy rate and guide surgeon in the decision-making process.

TP9.2.5Routine ultrasound in paediatric appendicitis is highly accurate and substantially reduces negative appendicectomy rate

Aims Our centre routinely uses ultrasound in adults to confirm diagnosis of appendicitis. This study investigated its use in the diagnosis of suspected appendicitis in children and its impact on management. Methods Retrospective cohort study of children (5-16 years) managed by general surgeons with suspected appendicitis during 2019. Primary outcomes were ultrasound use. Secondary outcomes were diagnosis, length of stay, complications and negative appendicectomy rate. Results A total of 193 children were admitted with suspected appendicitis. The majority underwent an ultrasound scan (169/193 [88%]) which identified an inflammed appendix or secondary-inflammation in nearly all cases of appendicitis (65/71 [91%] and 5/71 [7%] respectively). A normal appendix was identified in more than half of children not diagnosed with appendicitis (53/95 [56%]), with the rest showing an ovarian pathology (3/95 [3%]) or normal scan (39/95 [41%]). Ultrasound had high sensitivity (92% [CI 83-97%]) and specificity (100% [CI 96-100%]) for appendicitis. The majority of children diagnosed with appendicitis were treated with laparoscopic appendicectomy (75/85 [88%]) and a minority medically-managed (10/75 [12%]). One appendix mass was medically-managed, and two Meckels Diverticulitis underwent a laparoscopic small bowel resection. Negative appendicectomy rate was extremely low (2/77 [2.5%]). Post-operative complication rate was low (6%). Median length of stay was short for appendicitis and all other diagnoses (2days [IQR 2.2] and 1day [IQR 0] respectively). Discussion The majority of children with suspected appendicitis underwent pre-operative ultrasound, which was highly sensitive and specific for appendicitis. Negative appendicectomy rate was extremely low, and likely related to routine pre-operative imaging.

EP.FRI.60 A complete audit cycle into the paediatric negative appendicectomy rate for children presenting to A&E with suspected appendicitis at a District General Hospital

Aim Determine compliance rate with a local policy implemented in 2017, and whether interventions from audit cycle 1 were successful. The policy stated that all children aged 6-18 with acute abdominal pain must initially be reviewed by the ED registrar/consultant and have a documented Alvarado score. Method A closed loop audit on adherence to the 2017 policy and negative appendicectomy rate in children aged 6 to 18, with suspected appendicitis. The data were collected and analysed. Areas for improvement were discussed at the M&M meeting, alongside methods to achieve these improvements. Results The study included 67 patients aged 6-18 who underwent an appendicectomy in 2019. The study found that the Alvarado score had only 14.29% specificity. There was poor adherence to the 2017 protocol as only 36% had a documented Alvarado score and 55% had a senior ED review. Audit cycle 1 recommended improvement of ultrasound quality and increased use of CT scanning to reduce the negative appendicectomy rate. We found that only 2 patients had a CT. The negative appendicectomy rate in patients with and without an ultrasound remained at 8%, indicating no quality improvement. Nevertheless, our primary outcome showed that negative appendicectomy rates reduced from 28% to 11%. Conclusion These results demonstrate negligible impact of ultrasound and Alvarado scores. Good history-taking and clinical examination skills are key in reducing the negative appendicectomy rate. A specific ambulatory care pathway for children with suspected appendicitis has been implemented to lower inpatient stays and cost impact of unnecessary laparoscopies.