title: Use of white blood cell count and negative appendectomy rate.
abstract: BACKGROUND
  Despite increased utilization of laboratory, radiologic imaging, and scoring systems, negative appendectomy (NA) rates in children remain above 3% nationwide. We reviewed the clinical data of patients undergoing appendectomy to further reduce our NA rate.
  
  
  METHODS
  A retrospective review was conducted of all appendectomies performed for suspected appendicitis at a tertiary children's hospital during a 42-month period. Preoperative clinical, laboratory, and radiographic data were collected. Variables absent or normal in more than half of NAs were further analyzed. Receiver operating characteristic curves were constructed for continuous variables by using appropriate cutoff points to determine sensitivity and false-positive rates. The results were validated by analyzing the 12 months immediately after the establishment of these rules.
  
  
  RESULTS
  Of 847 appendectomies performed, 22 (2.6%) had a pathologically normal appendix. The only variables found to be normal in more than half of NAs were white blood cell (WBC) count (89%) and neutrophil count (79%). A receiver operating characteristic curve indicates that using WBC cutoffs of 9000 and 8000 per µL yielded sensitivities of 92% and 95%, respectively, and reduction in NA rates by 77% and 36%, respectively. Results observed in the subsequent 12 months confirmed these expected sensitivities and specificities.
  
  
  CONCLUSIONS
  Absence of an elevated WBC count is a risk factor for NA. Withholding appendectomy for WBC counts <9000 and 8000 per µL reduces the NA rate to 0.6% and 1.2%, respectively. Missed true appendicitis in patients with normal WBC counts can be mitigated by a trial of observation in those presenting with early symptom onset.
authors.affiliation: Division of Pediatric Surgery, 2 Dudley St, Suite 190, Providence, RI 02905. francois_luks@brown.edu.
authors.forename: Maria F
authors.initials: MF
authors.lastname: Bates
authors.forename: Amrin
authors.initials: A
authors.lastname: Khander
authors.forename: Shaun A
authors.initials: SA
authors.lastname: Steigman
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Tracy
authors.forename: Francois I
authors.initials: FI
authors.lastname: Luks
mesh_terms: D000293:Adolescent; D001062:Appendectomy / Q000706:statistics & numerical data*; D001064:Appendicitis / Q000097:blood / Q000150:complications / Q000175:diagnosis* / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D003661:Decision Support Techniques; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D007223:Infant; D007958:Leukocyte Count; D007964:Leukocytosis / Q000097:blood / Q000175:diagnosis / Q000209:etiology*; D008297:Male; D009504:Neutrophils; D012372:ROC Curve; D012189:Retrospective Studies; D012680:Sensitivity and Specificity
keywords: appendectomy; appendicitis; diagnosis; differential; leukocyte count; negative appendectomy