Pediatric appendectomy

Transumbilical laparoscopically assisted appendectomy: an alternative minimally invasive technique in pediatric patients

INTRODUCTION

Transumbilical laparoscopically assisted appendectomy (TULAA) has been reported in the literature as an alternative to traditional three-port laparoscopic appendectomy (LA). Our study compares outcomes between LA and the one-trocar transumbilical technique in a single institution over a concurrent time frame for all cases of pediatric appendicitis.

METHODS

An Institutional Review Board-approved retrospective chart review of all appendectomies from July 2007 through June 2009 was performed. All appendectomies were performed either laparoscopically or transumbilically. One surgeon predominantly used the TULAA method, whereas the other 2 surgeons used strictly the LA method. No cases were converted to open. Categorization of specimens as normal, acute, or ruptured was based on pathology reports. Outcomes analyzed for each group included surgical duration, cost, length of stay, fever (>101.5F), wound infection, ileus, and postoperative abdominal-pelvic abscess.

RESULTS

A total of 131 appendectomies were performed by 3 surgeons, 83 were LA and 48 were TULAA. For all stages of appendicitis, outcomes differed significantly only for operating room cost, with the TULAA being significantly less expensive. All other outcomes were similar between the two techniques.

CONCLUSION

Our study suggests that TULAA is a reasonable alternative to the standard minimally invasive technique for appendicitis in both acute and ruptured situations. All analyzed complications were similar between the groups, suggesting that TULAA is an acceptable surgical method in pediatric patients for all stages of appendicitis.

Evidence-based adjustment of antibiotic in pediatric complicated appendicitis in the era of antibiotic resistance

INTRODUCTION

Antibiotic resistance is a global issue especially in developed areas. With the emergence of antibiotic resistant-bacteria, the traditional choice of broad spectrum antibiotics may not be effective in complicated appendicitis. We herein report the bacteriology and antibiotic susceptibility of intra-operative peritoneal culture in children with acute appendicitis in Hong Kong. This may guide us to adjust the choice of antibiotics with evidence.

METHODS

A retrospective review of all cases of children who underwent laparoscopic appendicectomy from 2003 to 2007 was performed. Data including histology of appendixes, the choice of antibiotics, bacteriology, and antibiotic susceptibility of the intra-operative peritoneal cultures were analyzed.

RESULTS

Over a 5-year period, 250 children were included in this study. 41 children had gangrenous- and 77 had ruptured appendicitis, respectively. Peritoneal swab was taken in 158 children. Common bacteria isolated including E. coli, Streptococcus, and Bacteroides. Ampicillin, cefuroxime, and metronidazole were our choice of antibiotics. 26% of children with gangrenous and 25% with ruptured appendicitis were insensitive to the current regime. Using 3 antibiotics regime by switching cefuroxime to ceftazidime, it covered 77% resistant bacteria. Using 4 antibiotics regime by adding gentamycin, it covered 96% resistant bacteria.

CONCLUSIONS

One-fourth of children with gangrenous or ruptured appendicitis were insensitive to the current regime. This study provides evidence-based information on the choice of antibiotics.

Do not rush into operating and just observe actively if you are not sure about the diagnosis of appendicitis

PURPOSE

The aim of this study was to determine whether the admission and active observation of children where the diagnosis of acute appendicitis is uncertain is a safe and effective way to improve the diagnostic accuracy of appendicitis and safely reduce the incidence of negative laparotomies without increasing complications.

METHODS

We performed a retrospective cohort study of children who presented with a complaint of right lower quadrant pain and were hospitalized with a diagnosis of appendicitis or suspected appendicitis from 1 January to 31 December 2007.

RESULTS

A total of 569 patients were included in the study. The mean age was 9.5 +/- 3.2 (range 1.1-17) years. The number of patients directly operated on with a diagnosis of appendicitis was 186 (32%) from the total of 575 while 389 patients (68%) were observed in the surgical ward as the examination and/or investigation findings were equivocal. Of the 383 patients admitted for observation, 173 (45%) were operated on with a suspicion of appendicitis after 14.4 +/- 6.7 h while 210 (55%) were discharged after 1.1 +/- 1.2 days as there seemed to have no surgical problem. Our total negative appendectomy rate was 4% (14/350) and total perforation rate was 37.4% (131/350). The patients operated on directly and those operated on after observation were similar, and there was no difference for the preoperative duration of symptom, histopathological diagnosis, postoperative complication rate, postoperative inpatient days and hospital charges. Total hospitalization duration was significantly longer and the hospital charges significantly higher in the negative appendectomy group.

CONCLUSION

Both the features and results and the complication rates and costs of the group operated on after observation were the same as the directly operated on group. However, patients undergoing a negative appendectomy stayed as inpatients longer than only observation patients with higher treatment charges. We could therefore decrease the negative appendectomy rate, the associated cost and duration of hospitalization without causing extra complications if we observe and investigate patients with right lower quadrant pain with a doubtful diagnosis and did not operate on them directly.

Appendicitis in children: a comparative study between a specialist paediatric centre and a district general hospital

PURPOSE

The study aimed to compare paediatric appendicectomy practice in a specialist paediatric centre (SPC) with a district general hospital (DGH).

METHODS

This was a retrospective study of children younger than 16 years treated between January 1, 2005, and September 30, 2007.

RESULTS

Two hundred seven patients (SPC) and 264 (DGH) had an operation for suspected appendicitis. Thirty-one percent of SPC patients were female vs 41% in the DGH (P = .03). Median age (range) was 10.3 years (1.2-15.9 years) in the SPC and 11.8 (3.3-16.0 years) in the DGH (P < or = .0001). The negative appendicectomy rate was 4% at the SPC and 20% at the DGH (P < or = .0001). Perforated appendicitis was found in 37% of children at the SPC compared with only 18% at the DGH (P < or = .0001). Median (range) length of stay was 5 days at the SPC (1-21 days) compared with 2 days at the DGH (1-21 days) (P < or = .0001).

CONCLUSION

Our findings have important implications for local practice in our 2 centres but may also have wider implications for the national organisation of the surgical care of children and for the training of general surgeons.

Acute appendicitis in young children: cost-effectiveness of US versus CT in diagnosis--a Markov decision analytic model

PURPOSE

To compare the cost-effectiveness of different imaging strategies in the diagnosis of pediatric appendicitis by using a decision analytic model.

MATERIALS AND METHODS

Approval for this retrospective study based on literature review was not required by the institutional Research Ethics Board. A Markov decision model was constructed by using costs, utilities, and probabilities from the literature. The risk of radiation-induced cancer was modeled by using the Biological Effects of Ionizing Radiation VII report, which is based primarily on data from atomic bomb survivors. The three imaging strategies were ultrasonography (US), computed tomography (CT), and US followed by CT if the initial US study was negative. The model simulated the short-term and long-term outcomes of the patients, calculating the average quality-adjusted life span and health care costs.

RESULTS

For a single abdominal CT study in a 5-year-old child, the lifetime risk of radiation-induced cancer would be 26.1 per 100,000 in female and 20.4 per 100,000 in male patients. In the base-case analysis, US followed by CT was the most costly and most effective strategy, CT was the second-most costly and second-most effective strategy, and US was the least costly and least effective strategy. The incremental cost-effectiveness ratios (ICERs) of CT to US and of US followed by CT to US were both well below the societal willingness-to-pay threshold of $50,000 (in U.S. dollars). The ICER of US followed by CT to CT was less than $10,000 in both male and female patients.

CONCLUSION

In a Markov-based decision model of pediatric appendicitis, the most cost-effective method of imaging pediatric appendicitis was to start with a US study and follow each negative US study with a CT examination.

Prospective validation of the pediatric appendicitis score

OBJECTIVE

To prospectively validate the Pediatric Appendicitis Score (PAS), developed on a cohort of children with abdominal pain suggestive of appendicitis, in unselected children with abdominal pain who present to the emergency department.

STUDY DESIGN

Over a 19-month period, we prospectively recruited children 1 to 17 years old who came to our tertiary pediatric emergency department, with a chief complaint of abdominal pain of duration less than 7 days. PAS components included fever >38 degrees C, anorexia, nausea/vomiting, cough/percussion/hopping tenderness (2 points), right-lower-quadrant tenderness (2 points), migration of pain, leukocytosis >10 000 cells/mm(3), and polymorphonuclear neutrophilia > 7500 cells/mm(3). A follow-up call was made to verify final outcome. Sensitivity, specificity, and the receiver operating characteristic curve of the PAS with respect to diagnosis of appendicitis were calculated.

RESULTS

We collected data on 849 children. 123 (14.5%) had pathologic study-proven appendicitis. Mean (median, range) score for children with appendicitis and without appendicitis was 7.0 (7, 2-10) and 1.9 (1, 0-9), respectively. If a cutoff PAS of <or=2 was used to discharge patients without further investigation, only 3 (2.4%) with appendicitis would be sent home. If a PAS of >or=7 was used to take children to the operating room without further investigation, only 29 (4%) would not have appendicitis. For the PAS the area under the receiver operator curve was 0.95.

CONCLUSIONS

The PAS is useful, because a value <or=2 (found in 73% of children without appendicitis) has high validity for ruling out appendicitis, and a score >or=7 (found in 61% of children with appendicitis) has a high validity for predicting the presence of appendicitis. Children with PAS of 3 to 6 (37% with appendicitis and 23% without appendicitis in this study) should undergo further investigation such as observation, ultrasonography, or computed tomography.

Antibiotic Therapy and Interval Appendectomy for Perforated Appendicitis in Children: A Selective Approach

The role of initial nonoperative treatment in pediatric perforated appendicitis remains controversial. We examined our outcomes after using this approach in a selective manner. Children with perforated appendicitis treated during a 28-month period were retrospectively reviewed. Antibiotics and delayed appendectomy were used if there were more than 3 days of symptoms, absence of bowel obstruction, absence of diffuse peritonitis, and an appendiceal mass. Of 221 patients with perforated appendicitis, 32 (14%) were treated with this approach. Average age was 7.4 ± 4.2 years. Twenty-eight patients (88%) were successfully managed and 26 (81%) underwent appendectomy 8.6 ± 4.2 weeks after first presentation. Two patients did not respond completely, and underwent appendectomy during the same admission. Two patients initially responded, but had recurrent symptoms necessitating earlier appendectomy. There were no complications. Average total hospital stay was 7.2 ± 3.0 days. Initial nonoperative treatment is highly successful in selected children who meet specific criteria. Failure is not associated with increased morbidity.

Does this child have appendicitis?

CONTEXT

Evaluation of abdominal pain in children can be difficult. Rapid, accurate diagnosis of appendicitis in children reduces the morbidity of this common cause of pediatric abdominal pain. Clinical evaluation may help identify (1) which children with abdominal pain and a likely diagnosis of appendicitis should undergo immediate surgical consultation for potential appendectomy and (2) which children with equivocal presentations of appendicitis should undergo further diagnostic evaluation.

OBJECTIVE

To systematically assess the precision and accuracy of symptoms, signs, and basic laboratory test results for evaluating children with possible appendicitis.

DATA SOURCES

We searched English-language articles in MEDLINE (January 1966-March 2007) and the Cochrane Database, as well as physical examination textbooks and bibliographies of retrieved articles, yielding 2521 potentially relevant articles.

STUDY SELECTION

Studies were included if they (1) provided primary data on children aged 18 years or younger in whom the diagnosis of appendicitis was considered; (2) presented medical history data, physical examination findings, or basic laboratory data; and (3) confirmed or excluded appendicitis by surgical pathologic findings, clinical observation, or follow-up. Of 256 full-text articles examined, 42 met inclusion criteria.

DATA EXTRACTION

Twenty-five of 42 studies were assigned a quality level of 3 or better. Data from these studies were independently extracted by 2 reviewers.

RESULTS

In children with abdominal pain, fever was the single most useful sign associated with appendicitis; a fever increases the likelihood of appendicitis (likelihood ratio [LR], 3.4; 95% confidence interval [CI], 2.4-4.8) and conversely, its absence decreases the chance of appendicitis (LR, 0.32; 95% CI, 0.16-0.64). In select groups of children, in whom the diagnosis of appendicitis is suspected and evaluation undertaken, rebound tenderness triples the odds of appendicitis (summary LR, 3.0; 95% CI, 2.3-3.9), while its absence reduces the likelihood (summary LR, 0.28; 95% CI, 0.14-0.55). Midabdominal pain migrating to the right lower quadrant (LR range, 1.9-3.1) increases the risk of appendicitis more than right lower quadrant pain itself (summary LR, 1.2; 95% CI, 1.0-1.5). A white blood cell count of less than 10,000/microL decreases the likelihood of appendicitis (summary LR, 0.22; 95% CI, 0.17-0.30), as does an absolute neutrophil count of 6750/microL or lower (LR, 0.06; 95% CI, 0.03-0.16). Symptoms and signs are most useful in combination, particularly for identifying children who do not require further evaluation or intervention.

CONCLUSIONS

Although the clinical examination does not establish a diagnosis of appendicitis with certainty, it is useful in determining which children with abdominal pain warrant immediate surgical evaluation for consideration of appendectomy and which children may warrant further diagnostic evaluation. More child-specific, age-stratified data are needed to improve the utility of the clinical examination for diagnosing appendicitis in children.

Aminoglycoside-based triple-antibiotic therapy versus monotherapy for children with ruptured appendicitis

OBJECTIVE

We conducted a retrospective cohort study to compare the use of triple therapy versus monotherapy for children and adolescents with perforated appendicitis and to determine whether there has been a transition to monotherapy within the freestanding children's hospitals that contribute to the Pediatric Health Information System database.

METHODS

We used the Pediatric Health Information System database, which includes billing and discharge data for 32 children's hospitals in the United States, to examine the trend in antibiotic usage and whether the postappendectomy antibiotic regimen was associated with differences in complication-related readmissions, length of stay, or charges in a population of children and adolescents with ruptured appendicitis and discharge dates between March 1, 1999, and September 30, 2004. Pairwise regression analyses were performed to compare the most common monotherapy regimens with the triple therapy.

RESULTS

A total of 8545 patients met the inclusion criteria, of whom 58%, over the entire study period, received the aminoglycoside-based triple antibiotic therapy on postoperative day 1. There was, however, a notable transition over this 6-year period, from 69% to 52% of surgeons using aminoglycoside-based combination therapy. There were no significant differences in the odds of readmission at 30 days except for the group receiving ceftriaxone, which was associated with significantly decreased odds. The subgroup receiving piperacillin/tazobactam monotherapy demonstrated significantly decreased length of stay (-0.90 days) and total hospital charges, and the group receiving cefoxitin demonstrated significantly decreased length of stay (-1.89 days), as well as decreased pharmacy and total hospital charges.

CONCLUSIONS

Single-agent antibiotic therapy in the treatment of perforated appendicitis is being used with increasing frequency, is at least equal in efficacy to the traditional aminoglycoside-based combination therapy, and may offer improvements in terms of length of stay, pharmacy charges, and hospital charges.

Laparoscopic appendectomy is a favorable alternative for complicated appendicitis in children

Laparoscopic appendectomy in children is a generally accepted procedure for the treatment of non-complicated acute appendicitis. Nevertheless, the role of laparoscopy in complicated appendicitis is more controversial. The objective of this study was to examine the safety, efficacy and complications of laparoscopy in children with complicated appendicitis. This is a retrospective review of the children who underwent laparoscopic appendectomy for complicated appendicitis at King Khalid University Hospital, Riyadh, Saudi Arabia between January 1998 and March 2006. Complicated appendicitis includes perforated appendicitis, gangrenous appendicitis and appendicular masses found intra-operatively. Data collected include demographic, duration of symptoms, operative time, analgesia, complications, length of hospitalization and histopathology. Laparoscopic appendectomy was done by three trocar technique in all cases. During the study period, 59 children aged 3-12 years underwent laparoscopic appendectomy for complicated appendicitis. There were 34 patients with perforated appendicitis, 12 patients with gangrenous appendicitis and 13 patients with appendicular mass. The average operating time was 62 min. The average length of hospitalization was 5 days. The post-operative narcotic analgesic requirement was minimal. Laparoscopy was converted to open surgery in two patients (3.38%). These two cases were excluded from further analysis. Four out of 57 patients (7.01%) had post-operative complications. Three patients (5.26%) developed wound infection. One patient (1.75%) developed haematoma at umbilical port site. There was no post-operative intra-abdominal collection. Laparoscopic appendectomy is a safe alternative for the treatment of complicated appendicitis. It does not increase the incidence of complications even with complicated appendicitis. Contrary to the previous studies, we did not have increased incidence of intra-abdominal collection in this review. However, prospective randomized controlled trials are needed to verify these findings.

Appendicitis in children treated by pediatric versus general surgeons

BACKGROUND

Pediatric appendicitis is treated by both pediatric and general surgeons. We investigated whether specialty-dependent differences existed in patients' characteristics and outcomes.

STUDY DESIGN

A retrospective chart review of 465 consecutive children treated for appendicitis at a university-affiliated children's hospital during a 28-month period was performed. Characteristics and outcomes of patients treated by pediatric surgeons were compared with those treated by general surgeons. Rates of misdiagnosis, postoperative readmission, wound infection, intraabdominal infection, and duration of hospital stay were considered primary outcomes and analyzed by chi-square, Fisher's exact test, or Student's t-test where appropriate. Hospital charges were considered secondary outcomes and analyzed by Wilcoxon rank sum test.

RESULTS

Three hundred four children (65%) were treated by pediatric surgeons and 161 (35%) by general surgeons. Pediatric-surgeon patients were younger (8.3 +/- 3.6 versus 13.2 +/- 3.1 years, p < 0.001), and more likely to have gangrenous or perforated appendicitis (54% versus 33%, p < 0.001). There was no significant difference in the normal appendix rate (pediatric surgeon, 4.3% versus general surgeon, 5.6%, p = 0.53). In patients with simple and complicated appendicitis, there were no significant differences between pediatric and general surgeons in readmissions, postoperative complications, or hospital stay. Median hospital charges were not significantly different for complicated appendicitis, but were lower for pediatric-surgeon patients with simple appendicitis (10,735 dollars versus 11,613 dollars, p = 0.005).

CONCLUSIONS

Pediatric surgeons treat younger children with more severe appendicitis. There are no specialty-dependent differences in clinical outcomes for simple or complicated appendicitis. Hospital charges are lower for simple appendicitis treated by pediatric surgeons.

Peritoneal adhesions and intestinal obstructions in patients with familial Mediterranean fever--are they more frequent?

OBJECTIVE

Familial Mediterranean fever (FMF) is characterized by recurrent episodes of peritonitis. A controversy exists as to whether intestinal obstruction due to peritoneal adhesions is more common among FMF patients compared with healthy controls. The aim of the study was to estimate the rate of spontaneous or postsurgical small-bowel obstruction (SBO) in FMF patients.

METHODS

We reviewed the charts of 560 FMF patients followed in our clinic for the occurrence of spontaneous SBO. We also assessed the occurrence of postappendectomy intestinal obstruction among 89 FMF patients compared with 417 individuals without FMF who underwent an appendectomy without other abdominal surgery in the same medical center.

RESULTS

Ten of 471 FMF patients (2.1%) developed spontaneous SBO, 8 of whom required laparotomy and adhesiolysis. Six of 89 FMF patients (6.7%) who underwent appendectomy developed SBO. None of the non-FMF patients developed SBO.

CONCLUSIONS

Our retrospective study showed that FMF patients are at a higher risk than healthy individuals for developing SBO either spontaneously or as a postsurgical complication. Physicians should be alert to this possible complication when FMF patients arrive at the emergency room.

Pathology of the appendix in children: an institutional experience and review of the literature

BACKGROUND

The appendix can be affected by a variety of congenital and acquired diseases, but acute appendicitis is the most common pathology found in the pediatric population.

OBJECTIVE

This is a retrospective review of all appendectomies performed during a 2-year period at a major children's hospital with a review of the literature regarding the most common pathologic findings.

MATERIALS AND METHODS

The pathology database was reviewed for appendectomy specimens, and patient medical records were evaluated to determine the age, gender, race and operative diagnosis. All slides were reviewed and the histologic findings were recorded.

RESULTS

A total of 392 appendectomies were performed, including 68 incidental appendectomies and 324 performed for clinical suspicion of acute appendicitis. In 247 of the latter, acute appendicitis was confirmed histologically, and of the remainder 14 were interval appendectomies, 2 had findings suspicious for Crohn disease, 1 confirmed diverticulitis and 60 were histologically negative for appendicitis.

CONCLUSION

Acute appendicitis is the most common pathologic cause of appendectomy, but various other pathologic entities are found in children. Examination of the appendix is warranted even when it appears normal on exploration.

Pitfalls in Paediatric Appendicitis: Highlighting Common Clinical Features of Missed Cases

OBJECTIVE

Missed cases of paediatric appendicitis lead to a delay in diagnosis and increased complications during the subsequent surgery. We aim to identify the common clinical features of such cases at the time of first hospital attendance.

METHODS

Case records of patients with a missed diagnosis were reviewed retrospectively, documenting the presentation, preliminary investigations, initial diagnosis and eventual outcome.

RESULTS

Thirty-nine patients fitted our criteria over a 2-year and 5-month period. The rate of "missed appendicitis" was 7%. The commonest symptoms and signs were that of nausea and vomiting (74.4%), abdominal pain (74.4%) and fever (61.5%). The site of abdominal pain was rarely in the right iliac fossa (5.1%). The two commonest diagnoses made at first presentation was that of gastroenteritis (51.3%) and constipation (25.6%). Twenty patients (51.3%) were initially discharged home. Compared to those initially admitted, more of those initially discharged home underwent surgery delayed beyond 24 hours from first presentation.

CONCLUSION

The paucity of symptoms and signs in the right lower quadrant does not exclude appendicitis. Gastroenteritis and colic constipation are the greatest masqueraders of paediatric appendicitis. A high index of suspicion, therefore, is necessary to avoid wrongful discharge altogether.

What are the True Advantages of a Pediatric Appendicitis Clinical Pathway?

Multiple protocols have been described for pediatric appendicitis, but few have been compared with off-protocol treatment. We performed such a comparison. Children treated for appendicitis by three pediatric surgeons over a 28-month period were studied. A protocol of primary wound closure without drains, standardized use of antibiotics, and patient discharge according to predetermined clinical criteria was compared with individualized drain use, antibiotic selection, and discharge timing. Three hundred ninety-seven children were treated, 43 per cent on pathway (Group I) and 57 per cent off pathway (Group II). The two groups showed similar incidence of acute (45% vs 46%), complicated (50% vs 49%), and normal (5%) appendix. Among patients with simple appendicitis, Group I had less postoperative antibiotic use (16% vs 80% P < 0.001), shorter hospital stays (1.44 vs 1.89 days, P = 0.001), and decreased hospital charges ($9,289 vs $10,751, P = 0.001). Among patients with complicated appendicitis, Group I had less drain placement (4% vs 27%, P < 0.001), less use of discharge antibiotics (13% vs 39%, P < 0.001), and no readmission (0% vs 5%, P = 0.05). Infectious complications were similar between the two groups. A clinical pathway decreases the use of unnecessary antibiotics, hospital stay, and charges for simple appendicitis. It decreases the use of unnecessary drains, and eliminates readmissions after complicated appendicitis.

Acute appendicitis: is there a difference between children and adults?

Historically, the lack of classic symptoms and delay in presentation make diagnosing acute appendicitis more difficult in children, resulting in a higher perforation rate. Despite this, the morbidity of acute appendicitis is usually lower in children. We evaluated the current differences in clinical presentation, diagnostic clues, and the outcomes of acute appendicitis between the two age groups. A retrospective review of 210 consecutive cases of pediatric appendectomy and 744 adult cases for suspected acute appendicitis from January 1995 to December 2000. Pediatric patients were defined as being 13 years and younger. Pediatric patients were similar to adult patients with respect to duration of pain before presentation (2.4 +/- 4.3 days vs 2.5 +/- 7.3 days), number of patients previously evaluated (22.0 vs 17.7%), number of imaging tests (computed tomography or ultrasound; 32.9 vs 40.2%), and number of patients observed (16.7 vs 17.2%). However, pediatric patients required less time for emergency room evaluation (4.0 +/- 2.7 hours vs 5.7 +/- 4.9 hours, P = 0.0001). In children and adults, a history of classic, migrating pain had the highest positive predictive value (94.2 vs 89.6%), followed by a white blood cell count > or =12 x 109/L (91.5 vs 84.3%). The overall negative appendectomy rate was 10.0 per cent for children and 19.0 per cent for adults (P = 0.003); the perforation rate was 19.0 per cent and 13.8 per cent, respectively (P > 0.05). The perforation rate in children was not associated with a delay in presentation (perforated cases, 2.9 +/- 3.3 days compared with nonperforated cases, 2.3 +/- 4.6 days). Mortality and morbidity, including wound infection rate and intra-abdominal abscess rate, were similar. Contrary to traditional teaching, diagnosing acute appendicitis in children is similar to that in adults. A history of migratory pain together with physical findings and leukocytosis remain accurate diagnostic clues for children and adults. Perforation rate and morbidity in children is similar to those in adults. The outcomes of acute appendicitis in children are not associated with a delay in presentation or delay in diagnosis.

Laparoscopic appendectomy for perforated appendicitis: a comparison with open appendectomy

BACKGROUND

The role of laparoscopic appendectomy for perforated appendicitis remains controversial. This study aimed to compare laparoscopic and open appendectomy outcomes for children with perforated appendicitis.

METHODS

Over a 36-month period, 111 children with perforated appendicitis were analyzed in a retrospective review. These children were treated with either laparoscopic (n = 59) or open appendectomy. The primary outcome measures were operative time, length of hospital stay, time to adequate oral intake, wound infection, intraabdominal abscess formation, and bowel obstruction.

RESULTS

The demographic data, presenting symptoms, preoperative laboratory values, and operative times (laparoscopic group, 61 +/- 3 min; open group, 57 +/- 3 were similar for the two groups (p = 0.3). The time to adequate oral intake was 104 +/- 7 h for the laparoscopic group and 127 +/- 12 h for the open group (p = 0.08). The hospitalization time was 189 +/- 14 h for the laparoscopic group, as compared with 210 +/- 15 h for the open group (p = 0.3). The wound infection rate was 6.8% for the laparoscopic group and 23% for the open group (p < 0.05). The wounds of another 29% of the patients were left open at the time of surgery. The postoperative intraabdominal abscess formation rate was 13.6% for the laparoscopic group and 15.4% for the open group. One patient in each group experienced bowel obstruction.

CONCLUSIONS

Laparoscopic appendectomy for the children with perforated appendicitis in this study was associated with a significant decrease in the rate of wound infection. Furthermore, on the average, the children who underwent laparoscopic appendectomy tolerated enteral feedings and were discharged from the hospital approximately 24 h earlier than those who had open appendectomy.

Emergent vs urgent appendectomy in children: a study of outcomes

BACKGROUND

Emergent appendectomy (EA) in children is still considered surgical dogma and continues to be recommended as a standard of care. This study examined whether emergent operation has any outcome advantages over urgent operation.

METHODS

The charts of children treated for appendicitis during a recent 28-month period at 2 children's hospitals, where appendectomies are not performed between midnight and 7 am, were reviewed. Outcomes were compared between patients who underwent EA (within 8 hours of presentation) vs those who underwent urgent appendectomy (UA, after 8 hours).

RESULTS

Three hundred sixty-five children met the criteria for the study. One hundred sixty-one (44%) were in the EA group (5.3 +/- 2.1 hours), and 204 (56%) were in the UA group (16.8 +/- 9.7 hours). The incidence of gangrenous or perforated appendicitis was significantly higher in the EA group (47% vs 36%, P = .04). There were no significant differences between EA and UA in postoperative outcomes, including readmissions (3.7% vs 1.0%, P = .08), wound infections (0.6% vs 2.4%, P = .17), or postoperative abscesses (1.9% vs 1.5%, P = .77). There were no significant differences in average hospital stay or average hospital charges between EA and UA (3.2 days for both, 14,775 dollars vs 14,850 dollars), respectively.

CONCLUSIONS

Emergent appendectomy in children has no advantages over UA with respect to gangrene and perforation rates, readmissions, postoperative complications, hospital stay, or hospital charges. Performance of a UA at a time convenient to the surgeon should be considered within the standard of care.

Estado atual do diagnóstico e tratamento da apendicite aguda na criança: avaliação de 300 casos

OBJETIVOS: Avaliar o estado atual do diagnóstico e tratamento da apendicite aguda em crianças operadas em dois grandes hospitais quaternários da cidade de São Paulo, no período de 30 meses. MÉTODO: Nossa casuística constou de 300 crianças operadas por apendicite aguda no período de 1998 a 2000 (65% do sexo masculino e 35% feminino). Foram analisadas as variáveis idade, sexo, manifestações clínicas, tempo gasto para o diagnóstico, achados de exame físico, laboratoriais e cirúrgicos, antimicrobianos administrados, complicações pós-operatórias e tempo de internação. Utilizou-se o teste t de Student para avaliar duas variantes e Análise de Variâncias quando mais de duas. RESULTADOS: Diagnosticou-se inicialmente apendicite aguda em apenas 63% dos casos, tendo os 35% restantes, diagnóstico de abdome agudo cirúrgico. O tempo decorrido na realização do diagnóstico foi superior a 24 horas em 57,4% dos casos, denotando retardo importante na sua elaboração. Dor abdominal (85,3%) e irritação peritoneal (82%) em fossa ilíaca direita foram os sinais e sintomas mais freqüentes. Identificou-se leucocitose em 83% dos pacientes e leucocitúria em 39,7 %. Em 92,4% das radiografias simples de abdome encontramos imagens sugestivas de apendicite aguda. A ultra-sonografia abdominal foi diagnóstica em 80,1% dos casos. Utilizaram-se esquemas antimicrobianos especialmente para agentes gram-negativos e anaeróbicos. A principal complicação foi infecção da ferida cirúrgica, não tendo sido observada mortalidade no grupo. A média de internação foi de 5.2 e 6,0 dias para meninos e meninas respectivamente. CONCLUSÃO: Mesmo com melhor conhecimento sobre apendicite aguda, refinamento técnico, laboratorial, radiológico e uso de antibioticoterapia adequada, o tempo de para diagnóstico e a morbidade ainda se mantém alta na idade pediátrica.

The influence of advanced radiographic imaging on the treatment of pediatric appendicitis

PURPOSE

Since 1998, the use of advanced radiographic imaging with computed tomography (CT) and/or diagnostic ultrasound (US) has increased dramatically for the diagnosis of acute appendicitis in children. This study investigates the impact of this imaging on the evaluation, management, and outcome of pediatric patients who underwent appendectomy for suspected appendicitis.

METHODS

Retrospective review of 197 consecutive children with a preoperative diagnosis of acute appendicitis, from January 2002 through May 2004, undergoing appendectomy at a university-affiliated community hospital by pediatric and general surgeons.

RESULTS

Patients were divided into two groups: imaged (n = 106; 54%) and nonimaged (n = 91; 46%). Groups were similar with respect to age, sex, temperature, white blood count, and insurance status. Ninety-seven imaged patients had CT, 6 had US, and 3 had both CT and US. Seventy-one percent of imaging studies were ordered by emergency department physicians and 24% by treating surgeons. Average wait from emergency department triage to operative incision for the imaged and nonimaged groups was 12.1 and 5.4 hours, respectively (P < .0001). Both groups had similar perforation rates (imaged: 15.1%, nonimaged: 14.6%). Negative appendectomy rates were 10.4% (imaged) and 4.4% (nonimaged). Average hospital charges were 11,791 dollars (imaged) and 9360 dollars (nonimaged) (P = .001). Time on antibiotics, complication rates, and length of stay were similar for both groups.

CONCLUSIONS

More than half of pediatric patients with suspected appendicitis now undergo advanced imaging and experience a significant delay in surgical treatment with a 26% increase in hospital charges and no clear-cut improvement in diagnostic accuracy nor outcome, when compared with evaluation by the treating surgeons.

Pediatric appendicitis rupture rate: a national indicator of disparities in healthcare access

Background

The U.S. National Healthcare Disparities Report is a recent effort to measure and monitor racial and ethnic disparities in health and healthcare. The Report is a work in progress and includes few indicators specific to children. An indicator worthy of consideration is racial/ethnic differences in the rate of bad outcomes for pediatric acute appendicitis. Bad outcomes for this condition are indicative of poor access to healthcare, which is amenable to social and healthcare policy changes.

Methods

We analyzed the KID Inpatient Database, a nationally representative sample of pediatric hospitalization, to compare rates of appendicitis rupture between white, African American, Hispanic and Asian children. We ran weighted logistic regression models to obtain national estimates of relative odds of rupture rate for the four groups, adjusted for developmental, biological, socioeconomic, health services and hospital factors that might influence disease outcome.

Results

Rupture was a much more burdensome outcome than timely surgery and rupture avoidance. Rupture cases had 97% higher hospital charges and 175% longer hospital stays than non-rupture cases on average. These burdens disproportionately affected minority children, who had 24% – 38% higher odds of appendicitis rupture than white children, adjusting for age and gender. These differences were reduced, but remained significant after adjusting for other factors.

Conclusion

The racial/ethnic disparities in pediatric appendicitis outcome are large and are preventable with timely diagnosis and surgery for all children. Furthermore, estimating this disparity using the KID survey is a relatively straightforward process. Therefore pediatric appendicitis rupture rate is a good candidate for inclusion in the National Healthcare Disparities Report. As with most other health and healthcare disparities, efforts to reduce disparities in income, wealth and access to care will most likely improve the odds of favorable outcome for this condition as well.

Effects of race, insurance status, and hospital volume on perforated appendicitis in children

OBJECTIVE

Previous research suggests that perforated appendicitis is more common in Medicaid patients, but the roles of minority race and hospital volume remain largely unstudied. We sought to investigate the association of perforated appendicitis in children with minority race, insurance status, and hospital volume.

METHODS

We conducted a retrospective, population-based cohort study of 33184 children who had an International Classification of Diseases, Ninth Revision diagnosis code for acute appendicitis in The Kids' Inpatient Database, a pediatric database from 22 states in 1997. A multivariate logistic regression model was developed to determine patient and hospital characteristics predictive of perforated appendicitis.

RESULTS

Of 33184 children with acute appendicitis, 10777 (32.5%) were perforated. In multivariate analysis, black (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 1.10-1.39) and Hispanic (OR: 1.19; 95% CI: 1.10-1.29) children were more likely to have perforated appendicitis than white children. Perforation was also more likely in Medicaid patients (OR: 1.30; 95% CI 1.22-1.39) compared with privately insured children. Annual hospital volume of cases of appendicitis was not significantly associated with perforation in multivariate analysis.

CONCLUSIONS

Perforated appendicitis disproportionately affected both children of minority race and children insured by Medicaid. No effect of hospital volume was observed. To reduce this racial disparity, efforts should focus on the causes of delayed diagnosis and the treatment of appendicitis in children of minority race.

A diagnostic score for children with suspected appendicitis

BACKGROUND/PURPOSE

Appendicectomy is an operation that is often performed without certainty of diagnosis. This study aimed to construct and to validate a prognostic score for the diagnosis of acute appendicitis in children.

METHODS

Data for 35 symptoms and signs were prospectively recorded for 131 consecutive children with suspected appendicitis. Logistic regression analysis of the variables yielded a diagnostic score: gender (male 2 points, female 0) + intensity of abdominal pain (severe 2, mild or moderate 0) + relocation of pain (yes 4, no 0) + vomiting (yes 2, no 0) + pain in the right lower abdominal quadrant (yes 4, no 0) + fever (yes 3, no 0) + guarding (yes 4, no 0) + bowel sounds (abnormal 4, normal 0) + rebound tenderness (yes 7, no 0). The cut-off level for recommendation of appendicectomy was > or =21, and the cut-off level for non-appendicitis was < or =15. The score was prospectively validated on 109 children.

RESULTS

In the validation sample, based on clinical judgment, unnecessary appendicectomy was performed in ten (27%) children, and one (4%) child was misdiagnosed as not having appendicitis. By application of the score, unnecessary appendicectomies would have been reduced to four (13%), and three children (11%) with appendicitis would have been discharged.

CONCLUSION

The use of a predictive mathematical model may facilitate the diagnosis of appendicitis to avoid unnecessary operations.

Minimum postoperative antibiotic duration in advanced appendicitis in children: a review

The suitable duration of antibiotic use following appendectomy for advanced appendicitis in children is still debated. A systematic review was performed, including published experimental and observational data of antibiotic use in children who had undergone appendectomy for advanced appendicitis. Data were extracted and analyzed according to predefined criteria. Twenty-eight studies were selected that included 2,284 patients. There was no consistency among the protocols regarding length of antibiotic use, discharge criteria, or use of home antibiotics following discharge. Limiting duration of antibiotic use to 3 days did not appear to be associated with higher rates of intraabdominal abscess or wound infection. In the absence of higher-level evidence, shortening of antibiotic regimens following surgery for pediatric complicated appendicitis appears to be safe.

Is mini-laparoscopic appendectomy feasible for children

Mini-laparoscopic appendectomy (mini-LA) can be performed safely and efficiently. It is the first treatment choice for patients with acute, uncomplicated appendicitis in our hospital. To evaluate the feasibility of mini-LA for simple and ruptured appendicitis in children, we retrospectively compared the outcomes between mini-LA and open appendectomy for appendicitis in children. From October 1998 to August 2000, the medical records of 585 patients with appendicitis were retrospectively reviewed. Children were defined as patients younger than 15 years of age. The percentage of mini-LA, operation time, time to first flatus passage, duration of hospital stay, and demand for intra-muscular pethidine injection were compared between the mini-LA and open appendectomy. The complications among simple and ruptured appendicitis and the cost of mini-LA and open appendectomy were also analyzed. The operation was performed with one infra-umbilical 10-mm incision, and pneumoperitoneum was established at 12 to 15 mm Hg. A 2-mm laparoscope was inserted via the supra-pubic port, and another 2-mm working port was set-up between the other two ports. Statistical testing using the Whitney-Mann U test and Fisher exact test was performed as appropriate. Of the 585 patients, there were 100 children. The youngest patient was 4 years of age and only 7 patients were younger than 5 years. Among children, 18% had a perforated appendix. Mini-LA accounted for 83% of appendectomies in the pediatric group, but it increased yearly (from 41.7% in 1998 to 92.5% in 2000). The operation time of mini-LA and open appendectomy were 57.32 minutes and 49.12 minutes. There was significant improvement in mini-LA from 1998 to 1999. Flatus passage, hospital stay, and pethidine use all favored the mini-LA. For pediatric appendicitis involving a ruptured appendix, postoperative ileus and length of hospital stay were significantly shortened in the mini-LA group. The postoperative complication was not significantly different between mini-LA and open appendicitis. Mini-LA can be safely performed in pediatric patients and it provides early postoperative recovery and short hospital stay. Even for a ruptured appendix, the mini-LA can be the treatment of choice in a well-equipped hospital with well-trained surgeons.

The management of pediatric appendicitis: a survey of North American Pediatric Surgeons

BACKGROUND/PURPOSE

Variation exists among pediatric surgeons in the management of pediatric appendicitis. The goal of this study was to determine current practice patterns and provide a foundation for evidence-based outcome studies that would standardize patient care.

METHODS

Members of the American Pediatric Surgical Association (APSA) were surveyed. Data included preference of imaging, timing of operation, and opinions on interval appendectomy. Intraoperative principles surveyed included use of cultures, antibiotic irrigation, transperitoneal drains, and method of wound closure. Spectrum and duration of antibiotic coverage were assessed, as were discharge criteria.

RESULTS

Survey response was 70%. A majority prefers computerized tomographic (CT) imaging and favors interval appendectomy in appropriate candidates. Seventy percent indicate a stable child with suspected appendicitis would be operated on in a semiurgent manner rather than emergently in their practice. Discrepancy exists in the type and duration of antibiotic coverage, impact of clinical parameters on antibiotic use, and utility of discharge criteria.

CONCLUSIONS

This study consolidates current opinions on appropriate management of pediatric appendicitis, providing a foundation for evidence-based outcome studies capable of bringing conformity to the management of this surgical disease. Such studies would establish clinical practice guidelines that optimize resource utilization while maintaining quality care.

CT scans may not reduce the negative appendectomy rate in children

BACKGROUND/PURPOSE

Concern about an increased lifetime risk of cancer in children who have undergone a single computed tomography (CT) scan prompted us to review utilization of this diagnostic test in our appendicitis population.

METHODS

From 1998 to 2001, the records of 720 children admitted to our hospital with a diagnosis of appendicitis were reviewed for adjunct diagnostic modalities, including ultrasonography (USG) and CT scanning. Negative appendectomy rates were determined by the final pathologic report. Statistical comparisons were made using the chi(2) test, and significance was assigned at P <.05.

RESULTS

The use of ultrasound scan for diagnosing appendicitis decreased from 20.0% in 1998 to 7.0% in 2001 (P <.01). Conversely, the use of CT scans increased from 17.6% in 1998 to 51.3% in 2001 (P <.001). During this time period the difference in the negative appendectomy rate was not statistically significant (P < 0.20). Of the negative appendectomies, 11 of these patients had a USG interpreted as positive for appendicitis (22.0%), and 9 had a CT scan interpreted as positive (18.0%).

CONCLUSIONS

Liberal use of CT scans in diagnosing appendicitis in children has not resulted in a decreased negative appendectomy rate. Potentially harmful radiation exposure should prompt pediatric surgeons to reevaluate the role of CT scanning in the management of children with suspected appendicitis.

Laparoscopic Appendectomy in Children: Technically Feasible and Safe in All Stages of Acute Appendicitis

This is a retrospective outcomes analysis of pediatric open and laparoscopic appendectomy in a children's hospital. One hundred three children underwent appendectomy for appendicitis by two pediatric surgeons from August 1998 to December 2002. Patients were divided into two groups, laparoscopic appendectomy (LAP) and open appendectomy (OAP), and were further subdivided by diagnosis: normal (NL), acute (AA), and ruptured (RA). There were no differences in age, sex, race, or zip codes between groups. Median age was 10 years. In the acute phase, 28 patients underwent OAP and 65 underwent LAP whereas 10 patients underwent interval appendectomy (IA) 6 weeks after percutaneous drainage of established abscesses (eight were LAP vs two OAP). In the remaining patients, the appendix was normal in 17 (18.4%) and ruptured in 24 (25.8%) pathologically. LAP took longer to perform (57 minutes vs 34.5 minutes) at higher cost ($3718 vs $1858) than OAP. Overall complications were lower in the LAP group (17% vs 29%), and LAP for RA had significantly fewer total complications (25% vs 62.5%). Intra-abdominal abscess increased following LAP: 9.2 per cent versus 3.6 per cent. Length of stay was shorter for LAP versus OAP in both AA (2.0 vs 2.5 days) and RA (5.5 vs 7 days).

Diagnosis of acute appendicitis in children using a clinical practice guideline

PURPOSE

In October 2000, our institution implemented a clinical practice guideline (CPG) utilizing selective computed tomography (CT) and ultrasound scan (US) for the evaluation of children with suspected appendicitis. The authors sought to determine surgical outcomes and diagnostic accuracy in the CPG period.

METHODS

The authors retrospectively analyzed the medical records of patients evaluated under the CPG at their institution between January 1 and December 31, 2001. Depending on a patient's clinical presentation, the CPG recommends immediate surgery or further evaluation with CT or US. CPG patients were identified if they received an appendectomy or a CT or US for suspected appendicitis. Negative appendectomy and perforation rates, as well as admissions for inpatient observation were compared with control patients treated for suspected appendicitis at our hospital in 1997, before frequent utilization of imaging studies.

RESULTS

In the CPG period, 571 patients were evaluated for acute appendicitis, with 272 undergoing an appendectomy. Whereas 513 patients (90%) received a CT or US, only 34 patients (6%) were admitted to the surgical service for serial examinations. Patients with a histologically normal appendix decreased from 27 of 255 (10.6%) in 1997 to 15 of 272 (5.5%) in 2001 (P =.03). Fifty-seven patients (22.2%) in 2001 had a perforated appendix compared with 65 (28.5%) in 1997 (P =.11). The CPG, incorporating clinical judgment and selected imaging, had a sensitivity of 98.8%, a specificity of 95.2%, and positive and negative predictive values of 94.4% and 99.0%, respectively.

CONCLUSIONS

A clinical practice guideline selectively utilizing CT and US is highly accurate in the diagnosis of acute appendicitis, minimizing the need for inpatient admission for serial examinations.

The diagnosis of appendicitis in children: outcomes of a strategy based on pediatric surgical evaluation

OBJECTIVE

To determine the accuracy of a protocol for diagnosis of appendicitis in children based on clinical evaluation by a pediatric surgeon with selective use of diagnostic imaging studies. We performed this study because 1) current reports in the medical, pediatric, emergency medical, and surgical literature advocate imaging, particularly computed tomography (CT), as the gold standard for diagnosis of appendicitis, and 2) the value of pediatric surgical evaluation early in the management of the child with possible appendicitis has rarely been emphasized. METHODS, DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of 356 children (mean age: 9.6 years; range: 1-18 years) referred to a regional pediatric surgical center for possible appendicitis from 1999 through 2001.

INTERVENTIONS

Initial pediatric surgical evaluation consisted of history, physical examination, white blood cell count, differential count, and urinalysis. Children diagnosed with appendicitis underwent appendectomy without additional studies; those with equivocal findings received intravenous fluids, rest, and reevaluation after 4 to 6 hours. Imaging was used selectively by the pediatric surgeon.

OUTCOME MEASURES

Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the protocol based on final diagnoses; rate of appendiceal perforation; and rate of negative appendectomy.

RESULTS

Of 356 children evaluated for appendicitis, 220 (62%) had an appendectomy. Two-hundred nine (95%) had histologically proven appendicitis, and 11 (5%) had a normal appendix. Of the 209 children with appendicitis, 139 (66%) had acute appendicitis, 34 (16%) had advanced appendicitis without perforation, and 36 (17%) had advanced appendicitis with perforation. Appendectomy was performed after initial evaluation in 195 (89%) of the 220 children and after a period of supportive care and observation in 25 (11%) of 220. One hundred thirty-six children (38%) did not have an appendectomy and were discharged with other diagnoses. The sensitivity of this protocol was 99%, specificity was 92%, positive predictive value was 95%, and negative predictive value was 99%. The accuracy was 97% compared with an accuracy of 82% for ultrasound alone and 90% for CT scan alone.

CONCLUSIONS

These data show that a protocol based on clinical evaluation by a pediatric surgeon with selective use of imaging was highly accurate for the diagnosis of appendicitis in children. Low rates of negative appendectomy (5%) and perforation (17%) were achieved without the potential costs and radiation exposure of excess imaging.

The effect of hospital volume of pediatric appendectomies on the misdiagnosis of appendicitis in children

BACKGROUND

Although appendicitis is a common pediatric surgical condition, it is often misdiagnosed. Because higher hospital volume has been associated with improved outcome for many surgical procedures, the current study investigates whether hospital volume of pediatric appendectomies is associated with misdiagnosis of appendicitis in children.

METHODS

The Kids' Inpatient Database is a national sample of pediatric discharges from 2521 hospitals in 22 states in 1997. In this study, misdiagnosis was defined as a patient with a principal International Classification of Diseases, Ninth Revision procedure code for nonincidental appendectomy without a corresponding diagnosis code for appendicitis. Hospitals were stratified into 5 groups based on the number of nonincidental appendectomies performed on children in 1997: lowest (<1 per month), low (>or=1 per month but <1 per week), medium (1-2 per week), high (2-3 per week), and highest (>or=3 per week). Using generalized estimating equations to control for clustering within hospitals, we developed a logistic regression model of the effect of hospital volume on misdiagnosis while adjusting for patient age, gender, race, and insurance status.

RESULTS

In the database, 37,109 nonincidental appendectomies were performed on children 1 to 18 years old in 1997. Of those, 3103 (8.4%) were misdiagnosed. Of all appendectomies, 24,655 (66.4%) were performed at lowest- or low-volume hospitals. After adjusting for patient characteristics, lowest- (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.0-2.2) and low- (OR: 1.6; 95% CI: 1.1-2.3) volume hospitals had a significantly increased likelihood of misdiagnosis compared with highest-volume hospitals. Misdiagnosis at medium- (OR: 1.5; 95% CI: 1.0-2.2) and high- (OR: 1.4; 95% CI: 0.9-2.2) volume hospitals was similar to misdiagnosis at lower-volume hospitals, although not statistically different from highest-volume hospitals.

CONCLUSIONS

Almost two thirds of pediatric appendectomies are performed at hospitals performing <1 pediatric appendectomy per week. Lower hospital volume of pediatric appendectomies is associated with a significantly increased likelihood of misdiagnosis of appendicitis in children.

Getting residents in the game: an evaluation of general surgery residents' participation in pediatric laparoscopic surgery

PURPOSE

In a large children's hospital, the authors evaluated general surgery residents' experience with pediatric laparoscopic procedures and the impact of their participation on patient outcome.

METHODS

The records of all children who underwent laparoscopic appendectomy, splenectomy, fundoplication, or pyloromyotomy were reviewed. The level of participation by general surgery residents in each of these operations was determined. Outcome was assessed for these procedures in terms of intraoperative and postoperative complications.

RESULTS

A resident was the operating surgeon in 164 of 174 laparoscopic appendectomies (94%), 37 of 38 laparoscopic splenectomies (97%), 78 of 104 laparoscopic fundoplications (75%), and 72 of 97 laparoscopic pyloromyotomies (74%). Adverse outcomes in the cases in which a resident was surgeon were limited to 4 postappendectomy infectious complications, 3 cases of recurrent reflux after fundoplication, and one incomplete myotomy and one mucosal injury after laparoscopic pyloromyotomy.

CONCLUSIONS

The authors have shown that well-supervised general surgery residents can perform common, pediatric laparoscopic operations with excellent results. Although it is essential for established pediatric surgeons and fellows in pediatric surgery to acquire expertise in minimally invasive surgery, once they have confidence in their own skills they may safely permit qualified general surgery residents to perform laparoscopic procedures in children.

Perforated appendicitis in children: is there a best treatment?

PURPOSE

This study was performed to provide outcome data for the development of evidenced-based management techniques for children with appendicitis in the authors' hospital.

METHODS

This is a retrospective analysis of 1,196 consecutive children with appendicitis over a 5-year period (1996 to 2001) at a metropolitan hospital.

RESULTS

The median age was 9 years (7 months to 18 years). The perforation rate was 38.9%, and the nonappendicitis rate was 5.6%. Predictors of perforation included age less than 8 years, Hispanic ethnicity, generalized abdominal tenderness, rebound tenderness, and increased number of bands. In perforated cases, the median length of stay was 5 days, and the complication rate was 13.5%. There was no difference in complication rates related to type or timing of antibiotics or related to the individual surgeon. There was no difference in infection rates related to type of wound management.

CONCLUSIONS

Children with perforated appendicitis are treated effectively by a less expensive broad-spectrum antibiotic regimen, expeditious operation by open or laparoscopic technique, primary wound closure, and postoperative intravenous antibiotics until they are afebrile for 24 hours and have a white blood cell count of less than 12,000/mm3. This approach is to be used in our prospective, randomized analysis of children treated on or off a clinical pathway.

Increased CT scan utilization does not improve the diagnostic accuracy of appendicitis in children

BACKGROUND/PURPOSE

Appendicitis continues to present a diagnostic dilemma in children of all ages leading to increased utilization of radiographic studies. Focused computed tomography (CT) scanning has become the diagnostic test of choice in many hospitals. The purpose of this study was to critically evaluate the use of radiographic studies for the evaluation of acute appendicitis in children and to determine if diagnostic accuracy has improved.

METHODS

Children undergoing appendectomy for acute appendicitis were reviewed from 1997 to 2001. Diagnostic workup (CT scan, ultrasound [US], or no radiographic study) was recorded as were the final pathology results.

RESULTS

Six hundred sixteen appendectomies were performed. Mean age was 10.4 +/- 4.1 years, and 60% were boys. Overall, 184 children (30%) underwent CT scanning, 104 (17%) had US performed, and 310 (50%) had no radiographic study (18 patients had both CT and US performed). A pathologically normal appendix was removed in 7% (14 of 202) of CT patients, 11% (14 of 122) of US patients, and 8% (26 of 310) of patients without a study. The frequency of CT scanning increased from 1.3% of all children in 1997 to 58% in 2001, whereas utilization of US decreased from 40% to 7%. Over the same period, the overall negative appendectomy rate did not change significantly from 8% to 7%.

CONCLUSIONS

With increased utilization of focused CT scanning, the negative appendectomy rate has remained unchanged. History and physical examination by an experienced surgeon is as accurate as CT in correctly diagnosing acute appendicitis in children.

Appendicitis in children: a ten-year update of therapeutic recommendations

BACKGROUND/PURPOSE

In 1990, the authors reported excellent outcomes using a standard protocol to treat pediatric appendicitis. This protocol has been simplified further and a large retrospective review was conducted to assess current outcomes.

METHODS

All patients treated for presumed appendicitis between April 1997 and December 1999 were reviewed. All patients received preoperative gentamicin and clindamycin. Patients with complicated appendicitis received postoperative ampicillin, gentamicin, and clindamycin or metronidazole. All wounds were closed primarily without drains. Patients with complicated appendicitis were discharged when their ileus resolved, they remained afebrile for 24 hours, and had a normal leukocyte count.

RESULTS

A total of 648 patients were reviewed. A total of 9.4% of appendices were pathologically normal, 55.6% were simple acute, 15.7% were gangrenous, and 19.3% were perforated. Hospital stay was 2.21 +/- 2.04 days for normal, 1.39 +/-.89 for simple acute, 2.97 +/- 1.25 for gangrenous, and 6.31 +/- 3.51 days for perforated appendices. There were no wound infections in patients with normal or simple acute appendices. Two minor intraabdominal infections (0.56%) occurred in patients with simple appendicitis. Patients with complicated appendicitis (gangrenous or perforated) had wound infection and intraabdominal infection rates of 2.6% and 4.4%, respectively.

CONCLUSIONS

The authors' current protocol results in reasonable hospital stays and good outcomes. It serves as an evidence-based standard of care for the treatment of pediatric appendicitis.

Laparoscopy in children with complicated appendicitis

BACKGROUND/PURPOSE

Laparoscopic appendectomy is an accepted way of dealing with suspected uncomplicated appendicitis in children. The role of laparoscopy in complicated acute appendicitis is more controversial. The purpose of this trial was to compare laparoscopic appendectomy with open appendectomy in children with complicated appendicitis.

METHODS

A total of 102 children with suspected acute appendicitis were selected randomly to undergo either a laparoscopic or an open appendectomy. The outcomes of 25 children with complicated appendicitis, 13 in the laparoscopic group and 12 in the open appendectomy group, were analyzed. Children, their parents, and research nurses were blinded to which procedure had been performed and remained blinded until the control visit 7 days after the operation. All 25 children completed a 30-day follow-up.

RESULTS

There were no differences in terms of patients' age, sex, weight, height, and appendiceal histology between the 2 groups. All laparoscopic procedures were completed without conversion. The mean (+/-SD) operating time was 63 (+/-31) minutes in the laparoscopic group and 37 (+/-18) minutes in the open appendectomy group (mean difference 26 minutes, 95% CI 5 to 47 minutes, P =.02). There were 2 major complications in the laparoscopic group in children with appendiceal masses. One child had an entero-cutaneous fistula of the residual appendiceal tip that needed open reoperation. Another child had a pelvic abscess that resolved with antibiotic treatment. Superficial wound infections were encountered in 2 patients in the open appendectomy group.

CONCLUSIONS

Laparoscopic appendectomy is an alternative to open procedure in children with complicated appendicitis. Good surgical judgement is necessary in patients with an established appendiceal abscess.

Pediatric appendicitis score

BACKGROUND/PURPOSE

Morbidity in children treated with appendicitis results either from late diagnosis or negative appendectomy. A Prospective analysis of efficacy of Pediatric Appendicitis Score for early diagnosis of appendicitis in children was conducted.

METHODS

In the last 5 years, 1,170 children aged 4 to 15 years with abdominal pain suggestive of acute appendicitis were evaluated prospectively. Group 1 (734) were patients with appendicitis and group 2 (436) nonappendicitis. Multiple linear logistic regression analysis of all clinical and investigative parameters was performed for a model comprising 8 variables to form a diagnostic score.

RESULTS

Logistic regression analysis yielded a model comprising 8 variables, all statistically significant, P <.001. These variables in order of their diagnostic index were (1) cough/percussion/hopping tenderness in the right lower quadrant of the abdomen (0.96), (2) anorexia (0.88), (3) pyrexia (0.87), (4) nausea/emesis (0.86), (5) tenderness over the right iliac fossa (0.84), (6) leukocytosis (0.81), (7) polymorphonuclear neutrophilia (0.80) and (8) migration of pain (0.80). Each of these variables was assigned a score of 1, except for physical signs (1 and 5), which were scored 2 to obtain a total of 10. The Pediatric Appendicitis Score had a sensitivity of 1, specificity of 0.92, positive predictive value of 0.96, and negative predictive value of 0.99.

CONCLUSION

Pediatric appendicitis score is a simple, relatively accurate diagnostic tool for accessing an acute abdomen and diagnosing appendicitis in children.

Common abdominal emergencies in children

Because young children often present to EDs with abdominal complaints, emergency physicians must have a high index of suspicion for the common abdominal emergencies that have serious sequelae. At the same time, they must realize that less serious causes of abdominal symptoms (e.g., constipation or gastroenteritis) are also seen. A gentle yet thorough and complete history and physical examination are the most important diagnostic tools for the emergency physician. Repeated examinations and observation are useful tools. Physicians should listen carefully to parents and their children, respect their concerns, and honor their complaints. Ancillary tests are inconsistent in their value in assessing these complaints. Abdominal radiographs can be normal in children with intussusception and even malrotation and early volvulus. Unlike the classic symptoms seen in adults, young children can display only lethargy or poor feeding in cases of appendicitis or can appear happy and playful between paroxysmal bouts of intussusception. The emergency physician therefore, must maintain a high index of suspicion for serious pathology in pediatric patients with abdominal complaints. Eventually, all significant abdominal emergencies reveal their true nature, and if one can be patient with the child and repeat the examinations when the child is quiet, one will be rewarded with the correct diagnosis.

99m Tc anti-CD 15 monoclonal antibody (LeuTech) imaging improves diagnostic accuracy and clinical management in patients with equivocal presentation of appendicitis

BACKGROUND

Appendicitis frequently presents in an atypical fashion leading to misdiagnosis or a delay in diagnosis. This is particularly true in early cases where the patient may be erroneously discharged from an emergency department and will invariably return with perforated appendicitis. The standard of care is hospital admission for observation or early operation. Adjunctive imaging tests have been used with mixed results in this equivocal patient population. The authors studied a promising new monoclonal antibody, 99mTc-labeled anti-CD 15 (LeuTech; Palatin Technologies, Inc., Princeton, NJ), which specifically targets neutrophils and may be used for imaging appendicitis. This prospective, multicenter, open-label study evaluated the diagnostic efficacy and clinical impact of LeuTech scintigraphy for detecting appendicitis in patients with an equivocal presentation.

METHODS

A total of 200 patients (121 females, 79 males; age range 5-86 years; mean age 30.5 +/- 16.5 years) completed the study. Management plan was formulated before and reassessed following LeuTech imaging to determine impact on management. Following intravenous injection of LeuTech, the abdomen was imaged with a standard gamma camera for 30 to 90 minutes.

RESULTS

Fifty-nine patients had a histopathologic diagnosis of acute appendicitis. LeuTech identified 53 of 59 patients with appendicitis (90% sensitivity) and was negative in 122 of 141 patients without appendicitis (87% specificity). Accuracy, positive predictive value, and negative predictive value were 88%, 74%, and 95%, respectively. Diagnostic efficacy was unchanged in a subgroup of 48 pediatric patients (5-17 years). Diagnostic images for appendicitis were achieved within 8 minutes postinjection in 50% of patients and within 47 minutes in 90% of patients. Significant shifts in patient management decisions were evident following LeuTech results. LeuTech was well tolerated with no serious adverse events reported.

CONCLUSION

LeuTech is a convenient, safe, rapid, and sensitive imaging test for diagnosis of appendicitis and favorably impacts patient management in adult and pediatric patients with equivocal signs and symptoms.

Tratamento não-cirúrgico de abscessos intra-cavitários pós-apendicectomia

OBJETIVOS: avaliar a eficácia do tratamento não cirúrgico em crianças que desenvolveram abscessos intra-cavitários pós-apendicectomia, no Instituto Materno Infantil de Pernambuco, Recife, Brasil, e comparar os resultados obtidos com dois esquemas antimicrobianos (Cefoxitina versus Amicacina com Metronidazol) utilizados. MÉTODOS: o estudo corresponde ao período de janeiro de 1997 a janeiro de 2000 no qual 427 crianças foram apendicectomizadas; 41 delas desenvolveram abscessos intra-cavitários sendo 39 incluídas no estudo. O diagnóstico dos abscessos intra-cavitários baseou-se em sinais clínicos e exames complementares. RESULTADOS: A incidência de abscessos intra-cavitários pós-apendicectomias foi de 9,6%. 89,7% dos pacientes obtiveram sucesso com o tratamento. Não houve diferença entre os percentuais de cura obtidos com os dois esquemas antimicrobianos. CONCLUSÕES: o tratamento não cirúrgico de abscessos intra-cavitários pós-apendicectomias, baseado na antibioticoterapia endovenosa é uma opção segura e eficaz. Os esquemas antimicrobianos com Cefo-xitina e associação de Amicacina com Metronidazol têm eficácia semelhantes. A associação Amicacina com Metronidazol é recomenda pelo seu menor custo.

Suspected appendicitis in children: focused CT technique for evaluation

PURPOSE

To determine the accuracy of a focused computed tomographic (CT) technique with oral and intravenous contrast materials for the diagnosis of appendicitis.

MATERIALS AND METHODS

Ninety-three abdominal-pelvic contrast material-enhanced CT scans obtained during 6 years in 54 girls and 39 boys (age range, 1-18 years) with right lower quadrant pain were retrospectively reviewed. The detected abnormal findings were recorded as being in the region above the upper pole of the right kidney, between the upper pole of the right kidney and the lower pole of the right kidney (RLP), or below the iliac crest. Sensitivity, specificity, and positive and negative predictive values were calculated. chi(2) analysis was performed to determine whether there were significant differences among patient groups according to region of detected disease.

RESULTS

Fifty-five scans were abnormal: 38 showed appendicitis; and 17, other diseases. No scans, except two that showed pneumonia, had key findings above the RLP. Nineteen scans showed key findings between the RLP and the iliac crest. Thirty-three scans had diagnostic findings only below the iliac crest. The sensitivity (97%), specificity (93%), positive predictive value (90%), and negative predictive value (98%) of interpretation with all images for the diagnosis of appendicitis were the same as those of interpretation with only the focused images.

CONCLUSION

CT performed to diagnose appendicitis can be limited to the region below the RLP.

Appendicectomy in Western Australia: profile and trends, 1981-1997

OBJECTIVE

To measure and describe changes in the incidence of appendicectomy in the population of Western Australia (WA) for 1981-1997.

DESIGN

Population-based incidence study using hospital discharge data.

SETTING

All hospitals in WA (1981-1997).

PATIENTS

All patients who underwent an appendicectomy in WA hospitals.

MAIN OUTCOME MEASURES

Changes in the incidence of appendicectomy procedures over time; age-standardised rates and age-sex profiles of four appendicectomy subgroups: (1) acute emergency admission, (2) other emergency admission, (3) incidental appendicectomy and (4) other appendicectomy.

RESULTS

From 1981 to 1997, there were 59,749 appendicectomies in WA hospitals. The age-standardised rate of appendicectomy declined by 63% in metropolitan females, by 44% in non-metropolitan females, by 41% in metropolitan males and by 21% in non-metropolitan males. The rate of decline was significantly greater in females and in metropolitan patients. From 1988 to 1997, acute emergency admission for appendicectomy was the most common admission status and was more common in males than females (122 v 103 per 100,000 person-years) and in non-metropolitan areas. The rate of incidental appendicectomy was higher among females than males (20 v 7 per 100,000 person-years). From 1988 to 1997, recorded diagnosis coding for appendicitis became more specific, with a marked reduction in the use of the "unspecified" appendicitis code.

CONCLUSIONS

The overall incidence of appendicectomy has declined markedly in WA and includes a decline in the practice of incidental appendicectomy. The trend was greatest in the metropolitan hospitals.

Evidence of an Inflammatory Pathologic Condition in “Normal” Appendices Following Emergency Appendectomy

Background.—Appendices removed from patients with suspected appendicitis often appear normal on histologic examination.

Objective.—To study appendix specimens for the expression of inflammatory markers as an indicator of presence of an inflammatory response in this subgroup of patients.

Methods.—Cyclooxygenase 1 and 2, prostaglandin E2, inducible nitric oxide synthase, and major histocompatibility complex class II were investigated by immunofluorohistochemistry using confocal laser microscopy in 15 acutely inflamed appendix specimens, 39 histologically classified “normal” appendices, and 11 negative control specimens.

Results.—Strong expressions of all the inflammatory mediators were found in the mucosa of inflamed appendices, in approximately 50% of histologically normal appendices from patients with a clinical diagnosis of appendicitis, and in none of the normal control specimens.

Conclusion.—This study confirms the existence of a subgroup of appendicitis within the so-called histologically normal appendices in which evidence of an inflammatory pathologic condition is only obvious at a molecular level. The initiating signal for this and all other forms of clinical appendicitis still remains elusive.

The impact of ultrasound examinations on the management of children with suspected appendicitis: a 3-year analysis

BACKGROUND/PURPOSE

The aim of this study was to evaluate the usefulness of ultrasonography in the routine management of children with suspected appendicitis in a children's hospital.

METHODS

Data from surgical, radiologic, and pathologic databases were cross referenced retrospectively to allow for review of all children undergoing appendectomy and all children undergoing an ultrasound scan to rule out appendicitis in the 3-year period August 1, 1996 to July 31, 1999.

RESULTS

Pathology reports were available for 1,007 of 1,032 patients undergoing appendectomy. Eighty-four percent had acute appendicitis (26% of these were perforated). Fifty-eight percent of all children undergoing appendectomy had at least 1 preoperative ultrasound scan. Eighty-six percent of those having ultrasound scans had acute appendicitis compared with 82% of those who did not have an ultrasound scan (P <.05 chi(2) Test). During the same period, 2,056 ultrasound examinations were performed by staff radiologists who were available 24 hours a day to rule out appendicitis. Ultrasonography in this setting had a sensitivity of 89%, specificity of 95%, positive predictive value of 86%, and a negative predictive value of 96% (true-positives, n = 496; false-positive, n = 81; true-negative, n = 1,417; false-negative, n = 62). An alternate ultrasound diagnosis was offered in 157 children.

CONCLUSIONS

Ultrasound scan improves diagnostic accuracy in children with suspected appendicitis. The high negative predictive value of ultrasound scan, especially when used repeatedly, may reduce the need for admission to hospital for clinical observation to rule out appendicitis.

Laparoscopic appendectomy for simple and perforated appendicitis in children: the procedure of choice?

BACKGROUND/PURPOSE

Whether laparoscopic appendectomy (LA) is superior to open appendectomy (OA) for simple (SA) and perforated appendicitis (PA) in children is debatable. The operative experience of 4 senior pediatric surgeons at a single institution was studied over a 6-year period during a transition from OA in all cases to LA in all cases, to answer this question.

METHODS

All appendectomies from December 1993 to December 1999 were reviewed for operative technique (OA, LA), presence of perforation (SA, PA), operating time (OT), length of stay (LOS), morbidity, and mortality.

RESULTS

There were 1,128 appendectomies in children aged 14 months to 19 years, including 955 LA (653 in SA, 302 in PA) and 173 OA (86 in SA, 87 in PA). OT was equal for LA and OA in SA (52 minutes), but has dropped to less than 40 minutes for LA in the past year. OT in PA was slightly longer in LA versus OA (68 v. 58 minutes; P < .001) but recently has dropped in LA to less than 60 minutes. LOS in SA was 2 days for LA and 3 days for OA; in PA, LOS was 7 days in both LA and OA, but has dropped to 5 days for LA recently. Postoperative abscess rates and incidence of bowel obstruction did not differ between LA and OA in either group. There was no mortality.

CONCLUSIONS

LA is at least as safe and effective as, if not superior to, OA for both simple and perforated appendicitis. Postoperative pain is less, and recovery is faster, thereby reducing LOS and overall cost. The growing demand for this procedure can be satisfied without increase in cost, morbidity, or mortality. Laparoscopic appendectomy is our procedure of choice in children.