Korean Journal of Radiology

The Korean Society of Radiology (대한영상의학회)
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Computed Tomography Findings Associated with Treatment Failure after Antibiotic Therapy for Acute Appendicitis

  • Wonju Hong (Department of Radiology, Hallym University Sacred Heart Hospital) ;
  • Min-Jeong Kim (Department of Radiology, Hallym University Sacred Heart Hospital) ;
  • Sang Min Lee (Department of Radiology, Hallym University Sacred Heart Hospital) ;
  • Hong Il Ha (Department of Radiology, Hallym University Sacred Heart Hospital) ;
  • Hyoung-Chul Park (Center for Colorectal Cancer, National Cancer Center) ;
  • Seung-Gu Yeo (Department of Radiation Oncology, Soonchunhyang University Cheonan Hospital)
  • Received : 2019.11.04
  • Accepted : 2020.05.24
  • Published : 2021.01.01
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Abstract

Objective: To identify the CT findings associated with treatment failure after antibiotic therapy for acute appendicitis. Materials and Methods: Altogether, 198 patients who received antibiotic therapy for appendicitis were identified by searching the hospital's surgery database. Selection criteria for antibiotic therapy were uncomplicated appendicitis with an appendiceal diameter equal to or less than 11 mm. The 86 patients included in the study were divided into a treatment success group and a treatment failure group. Treatment failure was defined as a resistance to antibiotic therapy or recurrent appendicitis during a 1-year follow-up period. Two radiologists independently evaluated the following CT findings: appendix-location, involved extent, maximal diameter, thickness, wall enhancement, focal wall defect, periappendiceal fat infiltration, and so on. For the quantitative analysis, two readers independently measured the CT values at the least attenuated wall of the appendix by drawing a round region of interest on the enhanced CT (HUpost) and non-enhanced CT (HUpre). The degree of appendiceal wall enhancement (HUsub) was calculated as the subtracted value between HUpost and HUpre. A logistic regression analysis was used to identify the CT findings associated with treatment failure. Results: Sixty-four of 86 (74.4%) patients were successfully treated with antibiotic therapy, with treatment failure occurring in the remaining 22 (25.5%). The treatment failure group showed a higher frequency of hypoenhancement of the appendiceal wall than the success group (31.8% vs. 7.8%; p = 0.005). Upon quantitative analysis, both HUpost (46.7 ± 21.3 HU vs. 58.9 ± 22.0 HU; p = 0.027) and HUsub (26.9 ± 17.3 HU vs. 35.4 ± 16.6 HU; p = 0.042) values were significantly lower in the treatment failure group than in the success group. Conclusion: Hypoenhancement of the appendiceal wall was significantly associated with treatment failure after antibiotic therapy for acute appendicitis.

Keywords

Acknowledgement

We would like to thank Editage (www.editage.co.kr) for English language editing.

References

  1. Sartelli M, Viale P, Catena F, Ansaloni L, Moore E, Malangoni M, et al. 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg 2013;8:3 
  2. Brugger L, Rosella L, Candinas D, Guller U. Improving outcomes after laparoscopic appendectomy: a population-based, 12-year trend analysis of 7446 patients. Ann Surg 2011;253:309-313  https://doi.org/10.1097/SLA.0b013e3181fc9d53
  3. Kouhia ST, Heiskanen JT, Huttunen R, Ahtola HI, Kiviniemi VV, Hakala T. Long-term follow-up of a randomized clinical trial of open versus laparoscopic appendicectomy. Br J Surg 2010;97:1395-1400  https://doi.org/10.1002/bjs.7114
  4. Eriksson S, Granstrom L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg 1995;82:166-169  https://doi.org/10.1002/bjs.1800820207
  5. Styrud J, Eriksson S, Nilsson I, Ahlberg G, Haapaniemi S, Neovius G, et al. Appendectomy versus antibiotic treatment in acute appendicitis. A prospective multicenter randomized controlled trial. World J Surg 2006;30:1033-1037  https://doi.org/10.1007/s00268-005-0304-6
  6. Hansson J, Korner U, Khorram-Manesh A, Solberg A, Lundholm K. Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg 2009;96:473-481  https://doi.org/10.1002/bjs.6482
  7. Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet 2011;377:1573-1579  https://doi.org/10.1016/S0140-6736(11)60410-8
  8. Salminen P, Paajanen H, Rautio T, Nordstrom P, Aarnio M, Rantanen T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial. JAMA 2015;313:2340-2348  https://doi.org/10.1001/jama.2015.6154
  9. Simillis C, Symeonides P, Shorthouse AJ, Tekkis PP. A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery 2010;147:818-829  https://doi.org/10.1016/j.surg.2009.11.013
  10. Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials. BMJ 2012;344:e2156 
  11. Sallinen V, Akl EA, You JJ, Agarwal A, Shoucair S, Vandvik PO, et al. Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis. Br J Surg 2016;103:656-667  https://doi.org/10.1002/bjs.10147
  12. Allievi N, Harbi A, Ceresoli M, Montori G, Poiasina E, Coccolini F, et al. Acute appendicitis: still a surgical disease? results from a propensity score-based outcome analysis of conservative versus surgical management from a prospective database. World J Surg 2017;41:2697-2705  https://doi.org/10.1007/s00268-017-4094-4
  13. Hanson AL, Crosby RD, Basson MD. Patient preferences for surgery or antibiotics for the treatment of acute appendicitis. JAMA Surg 2018;153:471-478  https://doi.org/10.1001/jamasurg.2017.5310
  14. Park HC, Kim MJ, Lee BH. The outcome of antibiotic therapy for uncomplicated appendicitis with diameters ≤ 10 mm. Int J Surg 2014;12:897-900  https://doi.org/10.1016/j.ijsu.2014.07.011
  15. Park HC, Kim MJ, Lee BH. Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis. Br J Surg 2017;104:1785-1790  https://doi.org/10.1002/bjs.10660
  16. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull 1979;86:420-428  https://doi.org/10.1037/0033-2909.86.2.420
  17. Avanesov M, Wiese NJ, Karul M, Guerreiro H, Keller S, Busch P, et al. Diagnostic prediction of complicated appendicitis by combined clinical and radiological appendicitis severity index (APSI). Eur Radiol 2018;28:3601-3610  https://doi.org/10.1007/s00330-018-5339-9
  18. Kim HY, Park JH, Lee YJ, Lee SS, Jeon JJ, Lee KH. Systematic review and meta-analysis of CT features for differentiating complicated and uncomplicated appendicitis. Radiology 2018;287:104-115  https://doi.org/10.1148/radiol.2017171260
  19. Bhangu A, Soreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015;386:1278-1287  https://doi.org/10.1016/S0140-6736(15)00275-5
  20. Jang KM, Min K, Kim MJ, Koh SH, Jeon EY, Kim IG, et al. Diagnostic performance of CT in the detection of intestinal ischemia associated with small-bowel obstruction using maximal attenuation of region of interest. AJR Am J Roentgenol 2010;194:957-963  https://doi.org/10.2214/AJR.09.2702
  21. Horrow MM, White DS, Horrow JC. Differentiation of perforated from nonperforated appendicitis at CT. Radiology 2003;227:46-51  https://doi.org/10.1148/radiol.2272020223
  22. Bixby SD, Lucey BC, Soto JA, Theysohn JM, Ozonoff A, Varghese JC. Perforated versus nonperforated acute appendicitis: accuracy of multidetector CT detection. Radiology 2006;241:780-786  https://doi.org/10.1148/radiol.2413051896
  23. Tsuboi M, Takase K, Kaneda I, Ishibashi T, Yamada T, Kitami M, et al. Perforated and nonperforated appendicitis: defect in enhancing appendiceal wall--depiction with multi-detector row CT. Radiology 2008;246:142-147  https://doi.org/10.1148/radiol.2461051760
  24. Pinto Leite N, Pereira JM, Cunha R, Pinto P, Sirlin C. CT evaluation of appendicitis and its complications: imaging techniques and key diagnostic findings. AJR Am J Roentgenol 2005;185:406-417  https://doi.org/10.2214/ajr.185.2.01850406
  25. Antonopoulos P, Konstantinidis F, Dalamarinis K, Petroulakis A, Konstantinidou E, Karanikas I, et al. Acute gangrenous appendicitis-diagnosis by spiral CT. Ann Gastroenterol 2006;19:72-76 
  26. Elbanna KY, Mohammed MF, Chahal T, Khosa F, Ali IT, Berger FH, et al. Dual-energy CT in differentiating nonperforated gangrenous appendicitis from uncomplicated appendicitis. AJR Am J Roentgenol 2018;211:776-782 https://doi.org/10.2214/AJR.17.19274