Complementary Computed Tomography to Inconclusive Ultrasonography in Children with Suspected Acute Appendicitis: A...

Area of Science:

• Pediatric Surgery
• Diagnostic Imaging
• Evidence-Based Medicine

Background:

• The optimal diagnostic approach for pediatric acute appendicitis (AA) following non-diagnostic ultrasonography (US) remains debated, particularly concerning the role of computed tomography (CT).
• High rates of negative appendectomy and radiation exposure are concerns in pediatric AA diagnosis.

Purpose of the Study:

• To compare negative appendectomy rates between a US-only diagnostic pathway and a pathway involving CT after an initial non-diagnostic US in children.
• To evaluate the impact of diagnostic strategies on unnecessary surgeries and radiation exposure in pediatric AA.

Main Methods:

• Systematic review and meta-analysis following PRISMA guidelines, searching 6 databases through July 2024.
• Inclusion of longitudinal studies comparing US-only vs. US-followed-by-CT pathways for pediatric AA.
• Risk of bias assessment (ROBINS-I, Newcastle-Ottawa Scale) and certainty of evidence evaluation (GRADE).
• Fixed-effects meta-analysis to calculate pooled odds ratios (ORs) for negative appendectomy rates.

Main Results:

• A US-only pathway was associated with significantly lower odds of negative appendectomy compared to the US-followed-by-CT pathway (OR 0.44; 95% CI 0.21-0.90; P = 0.02).
• The protective association was stronger in the subgroup with initially inconclusive US (OR 0.22; 95% CI 0.05-0.89; P = 0.03).

Conclusions:

• A US-only diagnostic pathway is linked to significantly reduced negative appendectomy rates in children with suspected AA after a non-diagnostic US.
• These findings support prioritizing clinical re-evaluation and repeat US to decrease unnecessary surgeries and radiation exposure.
• Clinical judgment remains crucial due to the low certainty of the evidence.