Journal of Pediatric Surgery 54 (2019) 2274–2278

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Journal of Pediatric Surgery

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Accuracy of surgeon prediction of appendicitis severity in

pediatric patients☆
Yangyang R. Yu a,b,⁎, Eric H. Rosenfeld a,b, Shaahin Dadjoo a,b, Robert C. Orth c, Monica E. Lopez a,b,
Sohail R. Shah a,b, Bindi J. Naik-Mathuria a,b
a
The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030
b
Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030
c
Division of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street Suite 470, Houston, TX 77030

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Clinical prediction of disease severity is important as one considers nonoperative management of simple
Received 29 October 2018 appendicitis. This study assesses the accuracy of surgeons' prediction of appendicitis severity.
Received in revised form 8 March 2019 Methods: From February to August 2016, pediatric surgeons at a single institution were asked to predict whether
Accepted 16 April 2019 patients had simple or complex appendicitis preoperatively based on clinical data, imaging, and general assess-
ment. Receiver operating characteristic curves were generated to determine area under the curve (AUC) and op-
Key words:
timal cutoff points of clinical findings for diagnosing simple appendicitis. Outcomes included sensitivity and
Pediatric
Appendicitis
specificity of variables to identify simple appendicitis. Predictions were compared to operative findings using
Nonoperative management χ2. A p-valueb0.05 was considered statistically significant.
Accuracy Results: Of 125 cases (median age 9 years [IQR 7–13], 58% male), simple appendicitis was predicted in 77 (62%)
Diagnostic study and complex appendicitis in 48 (38%). Predictions were accurate in 59 (77%) simple cases and 45 (94%) complex
cases. Although surgeon prediction was more accurate than individual imaging or clinical findings and was highly
sensitive (95%) for diagnosing simple appendicitis, specificity was only 71%.
Lower WBC (b 15.5 × 103/μL, AUC 0.61, p = 0.05), afebrile (b100.4 °F, AUC 0.86, p b 0.01), and shorter symptom
duration (≤ 1.5 days, AUC 0.71, p b 0.001) were associated with simple appendicitis. Of 18 complex cases (14%)
inaccurately predicted as simple, 17 (94%) lacked diffuse tenderness, 15 (83%) were well-appearing, 11 (61%)
had ultrasound findings of simple appendicitis, 11 (61%) had ≤2 days of symptoms, and 8 (44%) were afebrile
(b 100.4 °F).
Conclusion: While surgeon prediction of simple appendicitis is more accurate than ultrasound or clinical data
alone, diagnostic accuracy is still limited.
Type of study: Prospective survey.
Level of evidence: II
© 2019 Elsevier Inc. All rights reserved.

1. Background
Appendicitis is the most common pediatric surgical emergency with
the standard of care currently laparoscopic appendectomy in children
[1,2]. Recently, there has been a growing interest in managing patients
with acute appendicitis nonoperatively. One of the reasons contributing
to this has been improved imaging capabilities resulting in increased di-
agnostic accuracy. Computed tomography (CT) has high sensitivity
☆ Disclosures: The authors report no conflict of interest concerning the materials or
methods used in this study or the findings specified in this paper.
⁎ Corresponding author at: Texas Children's Hospital / Baylor College of Medicine, 6701
Fannin Suite 1210, Houston, TX 77030. Tel.: +1 832 822 3135; fax: +1 832 825 3141.
E-mail address: yxyangya@texaschildrens.org (Y.R. Yu).
(87–100%) and specificity (89%–99%) making it one of the most com-
monly used imaging modalities to diagnose appendicitis [3] However,
concerns of long-term impacts owing to radiation exposure in children
have led the American College of Radiology to adopt practices to reduce
radiation dosages and utilize targeted CT scans to reduce anatomic cov-
erage [4]. As a result, many children's hospitals have decreased use of CT
scans in favor of ultrasonography (US). Diagnostic accuracy of imaging
modalities from a recent meta-analysis found pooled sensitivity of ul-
trasound to be 89% and pooled specificity of 97% compared to 95% sen-
sitivity and 92% specificity seen for CT [5].
Although there is a body of literature in the adult population
supporting short-term feasibility and safety of nonoperative
management (NOM) of appendicitis [6–10], there have only been a
handful of small studies in the pediatric population assessing nonop-
erative management of uncomplicated appendicitis [11–15]. Even

https://doi.org/10.1016/j.jpedsurg.2019.04.007
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 Y.R. Yu et al. / Journal of Pediatric Surgery 54 (2019) 2274–2278 2275

though initial hospital success rates are high (92–99%), a consider-

able number of patients experienced treatment failure after at least
1 year (24–29%) [11,12,14,15]. These studies all rely on different di-
agnostic criteria such as symptom duration, imaging and laboratory
findings to identify patients with acute or uncomplicated appendici-
tis. Patient selection and miscategorization of complex appendicitis
as uncomplicated appendicitis may contribute to some of the vari-
ability in failure rates of NOM reported. Despite technological ad-
vancements, appendicitis can be diagnosed clinically with a
thorough history and physical examination [16,17]. In cases of equiv-
ocal appendicitis, the surgeon's physical examination often is critical
in the ultimate management decision.
Clinical scores such as the Alvarado or Pediatric Appendicitis
Score are also helpful [18,19]. Low scores can be used to exclude
patients with a low likelihood of having appendicitis [20]. In order
to minimize failures of nonoperative management of acute appendi-
citis, careful selection of patients with simple or uncomplicated ap-
pendicitis is of key importance [21]. The purpose of this study is to
assess the accuracy of pediatric surgeons' prediction of appendicitis
severity in children. We hypothesize that pediatric surgeon's physi-
cal examination supplementing historical, imaging and laboratory
parameters, can accurately predict whether a child has simple ap-
pendicitis prior to appendectomy.

2. Methods

2.1. Study design

Following IRB-approval, a prospective survey was administered to

17 pediatric surgeons, with experience ranging between 3 and 35
years of practice, at a tertiary care pediatric hospital between February
2016 and August 2016. Children less than 18 years of age who were
scheduled for laparoscopic appendectomy for acute appendicitis were
included. Cases of complicated appendicitis for whom interval appen-
dectomy was planned were excluded. All subjects were screened for
study eligibility by the first author (YRY) prior to study entry. This
was a convenience sample of children with appendicitis who were en-
rolled when study investigators were present to administer the survey.
Surgeons reviewed the imaging and laboratory findings, examined the
patient, and then completed the survey prior to the operation.
2.2. Appendicitis severity surveys
The administered survey is shown in Fig. 1. Clinical variables such as
age at time of surgery, white blood cell count (WBC), highest reported
or recorded temperature, number of days of symptoms and ultrasound
findings were filled out by the clinical research team from the admission
history and physical. At our institution, we have developed an ultra-
sound scoring system (Appy-Score) to facilitate consistent, reliable
communication among providers and risk-stratify children with
suspected appendicitis [22]. Score breakdown is as follows: 1 = normal
completely visualized appendix, 2 = normal partially visualized appen-
dix, 3 = nonvisualized appendix, 4 = equivocal, 5a = nonperforated
appendicitis, 5b = perforated appendicitis. The operating surgeon was
asked to complete four questions on the survey. The first question eval-
uated the presence and extent of peritonitis on physical examination
(none, focal, or diffuse). The second question assessed the general ap-
pearance of the patient (well-appearing vs ill-appearing). The third
question asked for a prediction of either simple or complex appendicitis
based on a synthesis of the imaging data, clinical data and physical ex-
amination. Finally, the surgeon reported his/her certainty of the predic-
tion on a 5-point Likert scale. At the end of the case, the operating
surgeon completed the operative report and intraoperative findings
using a standardized operative template in our electronic medical re-
cord (Epic Systems Software, Verona, WI). The research investigators
reviewed the operative report and collected data on intraoperative
Fig. 1. Survey administered to pediatric surgeons prior to surgery.
findings. Disease severity classification for appendicitis has been stan-
dardized for all surgeons in our group with the use of pictorial pam-
phlets in the operating room with standard definitions to ensure
accurate description and coding in the electronic medical record. Simple
appendicitis was defined as an acutely inflamed or suppurative appen-
dix, and complex appendicitis as a gangrenous (ischemic/necrotic/
microperforation) or perforated appendix (hole in appendix, fecalith
outside appendix, complex free fluid, presence of abscess). Operative
findings were used as the reference standard instead of histopathologi-
cal diagnosis as it has been shown that operative findings are more pre-
dictive of clinical outcomes [22,23].
2.3. Statistical analysis
Statistical analysis was performed using SPSS (version 24, IBM SPSS).
Descriptive analysis of patient demographics and clinical variables was
performed using counts and proportions for categorical variables and
medians with interquartile ranges (IQR) for continuous variables. Re-
ceiver operating characteristic (ROC) analysis was performed for con-
tinuous variables and optimal cutoff points of clinical variables for
distinguishing simple appendicitis from complex appendicitis were de-
termined based on maximum value of the Youden's J statistic calculated
for each point on the ROC curve. Sensitivity, specificity, accuracy, posi-
tive predictive value, and negative predictive value were calculated for
each clinical variable and combinations of clinical variables, as well as
surgeon's predictions, for simple appendicitis compared to operative
findings of simple appendicitis. While sensitivity evaluates the ability
to correctly identify simple appendicitis cases and specificity evaluates
the ability to correctly identify complex appendicitis cases, accuracy
evaluates the ability to differentiate both simple and complex cases cor-
rectly. Preoperative predictions for simple appendicitis were compared
to intraoperative findings using χ 2 analysis and Fisher's exact test. An
alpha b 0.05 was used to determine significance.

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2276 Y.R. Yu et al. / Journal of Pediatric Surgery 54 (2019) 2274–2278
3. Results
3.1. Patient characteristics
A total of 125 laparoscopic appendectomy cases were included. There
were 73 (58%) male patients and median age at time of laparoscopic ap-
pendectomy was 9 years (IQR 7–13 years). Of 116 patients with white
blood cell (WBC) count recorded, median WBC was 15.9 × 10 3/μL (IQR
12.1–20.0 × 103/μL). Reference range for WBC at our institution is
4.5–13.5 × 103/μL. Eight patients reported subjective fevers without ele-
vated temperature recorded at the hospital. Of the remaining 117 pa-
tients, median temperature was 100.2 °F (IQR 99.1–101.9 °F) prior to
surgery. The majority (51%, n = 64) of patients reported just one day of
symptoms (IQR 1–3 days). There were 89 patients who underwent ultra-
sonography to diagnosis appendicitis. Four patients were found to have
Appy-Score of 3. Of these, 2 underwent subsequent CT scan to confirm ap-
pendicitis (perforated appendicitis and early appendicitis on CT). Two pa-
tients had Appy-Score of 4, 60 had Appy-Score of 5a, and 23 had Appy-
Score of 5b. There were 36 patients who were diagnosed with CT. As CT
is not first-line imaging modality at our institution, and infrequently per-
formed at our institution in the diagnosis of appendicitis, these patients
were initially evaluated at a community hospital and transferred to our
institution with CT scans already performed. Overall, 30% of patients
were diagnosed by CT and 70% with ultrasound in this cohort. In terms
of physical examination, 13 patients did not have peritonitis, 88 patients
had focal peritonitis, and 23 patients had diffuse peritonitis. Sixty-five
percent (n = 81) of patients were described as well-appearing.
3.2. Surgeon predictions and confidence
Surgeons predicted that 77/125 patients (62%) had simple appendi-
citis; 87% of predictions were either “somewhat certain” (n = 26) or
“very certain” (n = 41), 3% (n = 2) were “equivocal”, 8% (n = 6)
were “somewhat uncertain”, and 3% (n = 2) were “very uncertain”.
Forty-eight cases were predicted to be complex appendicitis: 52%
(n = 25) were “very certain”, 35% (n = 17) were “somewhat certain”,
4% (n = 2) “equivocal”, 6% (n = 3) were “somewhat uncertain”, and
2% (n = 1) “very uncertain”. Intraoperative findings confirmed 62
simple appendicitis cases and 63 complex appendicitis cases. Of the 77
simple predictions, 18 (23%) were found to be complex appendicitis in
the operating room. Of the 48 complex predictions, 3 (6%) were found
to be simple appendicitis in the operating room. Of the 109 predictions
made with “somewhat certain” or “very certain” confidence, 93 (85%) of
predictions were correct. In comparison, of the 12 predictions made
with “somewhat uncertain” or “very uncertain” confidence, 8 (67%)
predictions were correct.
Of note, although there was a significantly higher rate of complex
appendicitis in children less than 7 years of age compared to children
7 years and older (83% vs 43%, p b 0.001), there was no difference in sur-
geon prediction accuracy in younger children compared to older chil-
dren (87% vs 82%, p = 0.76).
3.3. ROC analysis and optimal cutoffs for clinical values
Receiver operating characteristic curves demonstrated WBC count
(AUC 0.61, p = 0.05), symptom duration (AUC 0.71, p b 0.001) and
maximum temperature (AUC 0.86, p b 0.01) have significant diagnostic
ability to discriminate simple appendicitis from complex appendicitis
[Fig. 2]. Additionally, maximum Youden's J statistic for all points on
each curve yielded an optimal cutoff value for greatest discriminatory
ability of each diagnostic variable to identify simple from complex
appendicitis of 15.5 × 103/μL for WBC (Youden's J 0.23), 1.5 days symp-
tom duration (Youden's J 0.35), and 100.4 °F maximum temperature
(Youden's J 0.58).
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3.4. Comparison of surgeon predictions to alternative diagnostic features
Imaging studies had a sensitivity of 95%–100% and specificity of
48%–75% for simple appendicitis. CT scan was more sensitive (100% vs.
95%), specific (75% vs 48%) and accurate (89% vs 70%) in diagnosing
simple appendicitis from complex appendicitis compared to ultrasound
[Table 1]. Clinical variables such as WBC, maximum temperature and
symptom duration had lower sensitivity compared to imaging studies.
Temperature less than 100.4 °F had the highest sensitivity for simple ap-
pendicitis compared to the other clinical variables. Accuracy of clinical
variables was 60–79%. Presence of a combination of clinical variables re-
sulted in high specificity (97%) and positive predictive value (91%);
however, it lacked sensitivity (32%). Patients with focal or no abdominal
peritonitis had 97% sensitivity for simple appendicitis; however, speci-
ficity was only 33%. Similarly, patients who were described as well-
appearing had a sensitivity of 90% and specificity of 40% for simple ap-
pendicitis. Accuracy of physical examination findings was 65%. Surgeon
prediction resulted in an 83% accuracy rate, 95% sensitivity, and 71%
specificity. Surgeon prediction had higher negative predictive value
(94%) than positive predictive value (77%).
There were 18 patients who surgeons predicted to have simple ap-
pendicitis who were found to have complex appendicitis during sur-
gery. A closer look at the features of these patients revealed that the
majority (94%) had focal or no peritonitis and 83% were classified as
well-appearing. In 61% of these patients the ultrasound diagnosis was
simple appendicitis (score 5a). The majority of patients (61%) also had
two or fewer days of symptoms. Notably, 33% of these complex cases
had gangrenous appendicitis (ischemic, necrotic, microperforation).
Gangrenous appendicitis was difficult to differentiate on ultrasound
from simple appendicitis, given the lack of simple or complex
periappendiceal fluid, appendicolith, and/or enlarged appendiceal di-
ameter, the presence of which are all features associated with perfo-
rated appendicitis [24]. Of the 16 patients found to have gangrenous
appendicitis at the time of surgery, 11 underwent preoperative ultra-
sound. Eight (73%) were diagnosed as simple (Appy-Score 5a) while 2
(18%) were diagnosed as complex (Appy-Score 5b) and in one patient
the appendix was not visualized (Appy-Score 3) on ultrasound. In addi-
tion, patients with gangrenous appendicitis had average 2.2 days of
symptoms compared to 1.6 days for simple appendicitis and 3.7 days
for perforated appendicitis.
4. Discussion
Nonoperative management of appendicitis is a highly debated topic
in the surgical and nonsurgical medical community currently. This man-
agement strategy is proposed for the least severe cases of acute appen-
dicitis; specifically children with simple appendicitis. However, there is
currently no standard clinical algorithm for identifying these patients
accurately. While we continue to explore the safety and efficacy of
NOM for simple appendicitis, we need to also identify risk factors for
failure of NOM. One major contributing factor may be inappropriate pa-
tient selection, where patients with more advanced disease are
misidentified as having acute simple appendicitis. In this survey of ex-
perienced pediatric surgeons at a single tertiary care institution with
an annual appendectomy volume of N 1000 cases, we found that the
surgeon's prediction of a patient having simple appendicitis had greater
accuracy than relying on imaging findings, clinical variables, or physical
examination findings alone. Despite this improvement in accuracy, a
23% error rate was observed. Disease severity in appendicitis falls on a
spectrum [25,26]. Gangrenous appendicitis appears to lie somewhere
in between simple appendicitis and perforated appendicitis. At our in-
stitution, gangrenous appendicitis is considered complex appendicitis
based on its typical disease course. Although lacking visible perforation,
gangrenous appendicitis often has greater bacterial spillage and poten-
tially higher complication rates than the standard simple appendicitis.
Preoperative identification of patients with gangrenous appendicitis
 Y.R. Yu et al. / Journal of Pediatric Surgery 54 (2019) 2274–2278 2277

explains the 36 (29%) patients in our study with CT scans performed

to diagnose appendicitis.
Over the years a number of interventions have been proposed to im-
prove diagnostic accuracy in pediatric appendicitis. Diagnostic algo-
rithms have been gaining popularity. These algorithms include various
diagnostic modalities to create a standardized pathway for the diagnosis
and management of appendicitis. Use of these clinical pathways has
been shown to increase sensitivity and specificity for the diagnosis of
pediatric appendicitis [30]. Interventions targeting ultrasounds have
also been explored. Although ultrasound is a noninvasive imaging mo-
dality, it is limited by its operator dependence and availability at referral
centers. Some proposed ways to improve reliability of ultrasonography
are to increase its use at institutions [31] and implement a standardized
ultrasound reporting template [22,32,33]. At our institution, ultrasound
is utilized as an adjunct to clinical diagnosis for the majority of appendi-
citis cases. With the high volume of appendicitis cases, the ultrasound
technicians are experienced in obtaining high quality images, and de-
velopment of the Appy-Score template has resulted in a sensitivity
and specificity of 93% for diagnosing acute appendicitis compared to pa-
tients without appendicitis [22]. We recently studied ultrasound char-
acteristics predictive of perforation in an attempt to improve the
Youden’s J
AUC P-value Optimal cut-off diagnostic utility of ultrasound for this patient population in our institu-
index
1. Maximum tion. In the current study, sensitivity and specificity of ultrasound for dif-
0.86 <0.01 0.58 100.4o F
Temperature ferentiating simple from complex appendicitis were 95% and 48%,
2. Symptom
0.71 <0.01 0.35 1.5 days respectively, which are similar to prior data published from our institu-
duration tion of 93% sensitivity and 44% specificity [24]. Compared to ultra-
3. WBC 0.61 <0.05 0.23 15.5x103/uL
sounds, our study shows surgeon prediction has equivalent sensitivity
for differentiating simple from complex appendicitis (95%), but greater
Fig. 2. Receiver operating characteristic (ROC) analysis for distinguishing simple
appendicitis from complex appendicitis and optimal cutoff points of diagnostic tests.
specificity than ultrasound (71% versus 48%).
To date, only a handful of studies of nonoperative appendicitis man-
agement have been performed in children. In 2012, Svensson et al. per-
may not be possible owing to its often subtle, intermediary presentation formed a pilot randomized controlled trial including 26 patients
of signs and symptoms. Gangrenous appendicitis accounted for 1/3 of randomized to surgery and 24 patients to nonoperative treatment
the errors in the simple appendicitis predictions. with intravenous (IV) antibiotics for at least 48 hours. They report a suc-
Better imaging technology has led to increased diagnostic accuracy. cess rate of 92% at discharge and 62% at 1 year [11]. Mudri et al. per-
While CT is the gold standard diagnostic imaging modality in adults to formed a retrospective review of 26 children treated nonoperatively
diagnose acute appendicitis, many pediatric centers have moved away with acute appendicitis and found significantly longer total length of
from CT owing to concerns from the ionizing radiation exposure. The stay and a 35% failure rate of nonoperative management. Although initial
American College of Radiology has recommended ultrasound as the pre- costs were lower in the nonoperative cohort, median total hospital costs
ferred initial consideration for imaging children with suspected appen- over a 3-year period were similar for both groups [34]. Minneci et al. re-
dicitis, with CT reserved for equivocal cases, while recognizing expertise port their findings in a prospective patient choice trial in the United
and access may vary in community settings [27]. Reported use of CT in States enrolling children between 7 and 18 years of age meeting specific
pediatric institutions for the diagnosis of appendicitis is as low as clinical inclusion criteria: age 7–17 years, ≤48 hours of abdominal pain,
under 10% [28,29]. At our institution, CT usage is b6% and almost all of WBC b 18,000/μL, imaging study with nonruptured appendicitis, and sur-
our patients receive an abdominal ultrasound as the first-line imaging gical evaluation to confirm diagnosis. In the 37 patients choosing nonop-
modality. However, 36% of appendectomies are transfers from referral erative management with antibiotics, in-hospital success rate was high at
facilities with 87% diagnosed by CT [28]. This combination of referrals 94% but decreased over time to 89% in 30 days, and 76% at one year [14]. A

Table 1
The extent clinical variables are able to predict simple appendicitis compared to surgeon's prediction. Max temp = maximum temperature.

Variables to predict simple appendicitis Sensitivity Specificity NPV PPV Accuracy p-value

Imaging studies
Ultrasound (5a vs. 5b)a 95% 48% 91% 62% 70% b0.001
CTb 100% 75% 100% 83% 89% b0.001
Clinical variables
WBC b15.5 57% 63% 61% 59% 60% 0.03
Max temp b100.4 84% 75% 83% 76% 79% b0.001
Symptom duration b1.5 days 73% 70% 72% 70% 71% b0.001
WBC b15.5, Symptoms b1.5 days, and Max temp b100.4 32% 97% 59% 91% 65% b0.001
Physical Examination findings
Focal or no peritonitis 97% 33% 91% 58% 65% b0.001
Well-appearing 90% 40% 81% 60% 65% b0.001
Focal or no abdominal peritonitis and well-appearing 100% 29% 100% 58% 64% b0.001
Surgeon prediction 95% 71% 94% 77% 83% b0.001
a
n = 83, 6 patients with Appy-Scores of 3 or 4
b
n = 36.

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2278 Y.R. Yu et al. / Journal of Pediatric Surgery 54 (2019) 2274–2278
recent meta-analysis by Huang et al. included 5 studies (404 patients)
comparing antibiotic therapy and appendectomy for acute uncomplicated
appendicitis in children. They found a high initial success rate of antibiotic
treatment (91%); however, 27% underwent interval appendectomy
within 1 year. Notably, the 23% error rate found in our study is similar
to the overall failure rate within 1-year of presentation (24–38%) of
these studies. Accurate assessment of disease severity is necessary to min-
imize treatment failures. Some nonoperative treatment failures may
occur in patients who clinically and pathologically have simple appendici-
tis. Further investigation to help us determine which of these patients will
fail nonoperative management is needed.
This study had several limitations. Bias in surgeon prediction may
have been introduced by variable experience levels and variable clinical
judgment. This information is difficult to assess and was not collected in
this study. However, in this study there did not appear to be a significant
correlation between accuracy of surgeons' predictions based on their
level of experience (p = 0.41, r = 0.25). Another limitation of this
study is the retrospective determination of intraoperative findings and
the subjective nature of categorizing disease severity in a large practice.
However, this was adjudicated based on standardized operative note
templates and standard classification of disease severity adopted by
our group. Pictorial pamphlets depicting each class of appendicitis as
well as the appropriate billing codes for each were placed at each oper-
ating room computer station to ensure consistent reporting.
Additionally, we excluded patients who underwent delayed or inter-
val appendectomies. This subset is typically perforated appendicitis
cases with prolonged symptom duration resulting in well-formed ab-
scesses and is thus initially treated by catheter drainage. Exclusion of
these most obviously perforated cases may have resulted in lower diag-
nostic accuracy values reported in this study. Another limitation of this
study is its generalizability to community centers where levels of exper-
tise and diagnostic imaging modalities may be limited. Our study high-
lights the importance of clinical judgement in not only diagnosing
appendicitis but distinguishing appendicitis of differing severity. Until
these community centers assess their own diagnostic accuracies, appli-
cation of nonoperative management of patients identified solely by
meeting clinical criteria should be done with caution. Imaging modality
experience and availability differ at different centers. We do not include
data on MRI diagnostic accuracy in this study as currently we do not uti-
lize MRIs in the diagnosis of acute appendicitis in our institution.
5. Conclusion
The ability to distinguish pediatric patients with simple and complex
appendicitis is necessary for appropriate patient selection for nonoper-
ative treatment of appendicitis and to guide patient and family expecta-
tions on the expected postoperative course and clinical outcomes. Given
that a significant error rate exists in diagnosing simple appendicitis even
when experienced surgeons synthesize clinical data, additional studies
are needed to elucidate which patient population will benefit the
most from a nonoperative approach to acute appendicitis.
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