Development and Validation of the Scoring System of Appendicitis Severity 2.0
Authors: Scheijmans Jochem C. G. , Bom Wouter J. , Ghori Umme Habiba , van Geloven Anna A. W. , Hannink Gerjon , van Rossem Charles C. , van de Wouw Lieke , Huisman Peter M. , van Hemert Annemiek , Franken Rutger J. , Oosterling Steven J. , Rosman Camiel , Koens Lianne , Stoker Jaap , Dijkgraaf Marcel G. W. , Boermeester Marja A. ,   SAS Collaborative Group, Alberts F , Bachiri S , den Bakker MA , Bisschops B , Boersma E , Bolmers MDM , Bosman WM , Bril H , Buurman C , Courrech Staal EFW , Davids P , Deniz RS , Detering R , Dijkstra BL , Drillenburg P , Dinaux A , van Duijvendijk P , van Eden WJ , Gans S , Gaspersz M , van Geel AM , Gerhards MF , Gratama JWC , Groenendijk I , Hellebrekers P , Henebiens M , Heydari H , in ’t Hof K , Hoogteijling TJ , van Ingen G , Jensch S , Jonker AM , Joosten F , Kraaijvanger N , Kuijpers KC , Le Large TYS , Linzel D , Loos MHJ , Lopes Cardozo AMF , Meijer-Jorna LB , Mulder M , Mullaart N , Oudejans J , Pappot T , Peeters S , Pleiter C , de Roos MA , Scheurkogel MM , Scholten L , Schut T , Tiddens OWT , Ubels S , de Vries FEE , Walraven LFJ , Wiegerinck EMA , Wiggers JK , Witt M , Wolfhagen N 
Published: March 2024

ImportanceWhen considering nonoperative treatment in a patient with acute appendicitis, it is crucial to accurately rule out complicated appendicitis. The Atema score, also referred to as the Scoring System of Appendicitis Severity (SAS), has been designed to differentiate between uncomplicated and complicated appendicitis but has not been prospectively externally validated.ObjectiveTo externally validate the SAS and, in case of failure, to develop an improved SAS (2.0) for estimating the probability of complicated appendicitis.Design, Setting, and ParticipantsThis prospective study included adult patients who underwent operations for suspected acute appendicitis at 11 hospitals in the Netherlands between January 2020 and August 2021.Main Outcomes and MeasuresAppendicitis severity was predicted according to the SAS in 795 patients and its sensitivity and negative predictive value (NPV) for complicated appendicitis were calculated. Since the predefined targets of 95% for both were not met, the SAS 2.0 was developed using the same cohort. This clinical prediction model was developed with multivariable regression using clinical, biochemical, and imaging findings. The SAS 2.0 was externally validated in a temporal validation cohort consisting of 565 patients.ResultsIn total, 1360 patients were included, 463 of whom (34.5%) had complicated appendicitis. Validation of the SAS resulted in a sensitivity of 83.6% (95% CI, 78.8-87.6) and an NPV of 85.0% (95% CI, 80.6-88.8), meaning that the predefined targets were not achieved. Therefore, the SAS 2.0 was developed, internally validated (C statistic, 0.87; 95% CI, 0.84-0.89), and subsequently externally validated (C statistic, 0.86; 95% CI, 0.82-0.89). The SAS 2.0 was designed to calculate a patient’s individual probability of having complicated appendicitis along with a 95% CI.Conclusions and RelevanceIn this study, external validation of the SAS fell short in accurately distinguishing complicated from uncomplicated appendicitis. The newly developed and externally validated SAS 2.0 was able to assess an individual patient’s probability of having complicated appendicitis with high accuracy in patients with acute appendicitis. Use of this patient-specific risk assessment tool can be helpful when considering and discussing nonoperative treatment of acute appendicitis with patients.