Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

Novel Management of Complicated Renal Artery Aneurysm: Laparoscopic Nephrectomy and Ex-Vivo

Background and Purpose: Renal artery aneurysm (RAA) is an infrequently seen disease entity but one with the potential for significant morbidity and mortality. Complications related to RAA include pain, hematuria, hypertension, and, rarely, rupture. Management is often based on symptomatology or, if symptoms are not present, the potential for rupture with increased size. Treatment options include observation, endovascular methods, or open surgical approaches, including aneurysm repair or nephrectomy. Complex cases often preclude endovascular approaches. We report our initial experience with laparoscopic nephrectomy, ex vivo back-table repair of the aneurysm, and iliac fossa autotransplant in cases of complex RAA. Patients and Methods: Two patients underwent laparoscopic nephrectomy with RAA repair and heterotopic autotransplant from May 2006 to November 2008. Etiology of the RAA was atherosclerosis in one patient and idiopathic in the second. Laparoscopic nephrectomy and back-table arterial reconstruction was performed, including aneurysmectomy and ostial closure. Patient 2 needed a gonadal vein graft for arterial reconstruction. Both patients had autotransplant into the right iliac fossa. Results: Both patients were women. Mean age was 52.5 years (range 39–66 yrs). Mean operative blood loss was 550 mL (range 350–750 mL). Mean length of stay was 5.5 days (range 5–6 d). Mean discharge creatinine level was 0.8 mg/dL (range 0.5–1.1 mg/dL). No perioperative complications were reported. At last follow-up, all patients are alive with functioning autotransplant and no evidence of functional impairment. Conclusion: Management of complex RAA with laparoscopic nephrectomy, extracorporeal repair, and autotransplant is a feasible and successful method with minimal morbidity

Influence function analysis applied to partial least squares

Partial least squares, Influence function analysis, Outliers,