Pediatric appendectomy: the outcome differences between pediatric surgeons and general surgeons

Associations between Hospital Setting and Outcomes after Pediatric Appendectomy

Prior studies of associations between hospital location and outcomes for pediatric appendectomy have not adjusted for significant differences in patient and treatment patterns between settings. This was a cross-sectional analysis of pediatric appendectomies in the 2016 Kids' Inpatient Database (KID). Weighted multiple linear and logistic regression models compared hospital location (urban or rural) and academic status against total admission cost (TAC), length of stay (LOS), and postoperative complications. Patients were stratified by laparoscopic (LA) or open (OA) appendectomy. Among 54,836 patients, 39,454 (73%) were performed at an urban academic center, 11,642 (21%) were performed at an urban non-academic center, and 3740 (7%) were performed at a rural center. LA was utilized for 49,011 (89%) of all 54,386 patients: 36,049 (91%) of 39,454 patients at urban academic hospitals, 10,191 (87%) of 11,642 patients at urban non-academic centers, and 2771 (74%) of 3740 patients at rural centers (p < 0.001). On adjusted analysis, urban academic centers were associated with an 18% decreased TAC (95% CI -0.193--0.165; p < 0.001) despite an 11% increased LOS (95% CI 0.087-0.134; p < 0.001) compared to rural centers. Urban academic centers were associated with a decreased odds of complication among patients who underwent LA (OR 0.787, 95% CI 0.650-0.952) but not after OA. After adjusting for relevant patient and disease-related factors, urban academic centers were associated with lower costs despite longer lengths of stay compared to rural centers. Urban academic centers utilized LA more frequently and were associated with decreased odds of postoperative complications after LA.

Contemporary Epidemiology of and Risk Factors Associated with Removal of a Pathologically Normal Appendix in Children with Suspected Appendicitis

BACKGROUND

The goal of this study was to characterize contemporary performance benchmarks and risk factors associated with negative appendectomy (NA) in children with suspected appendicitis.

METHODS

A multicenter retrospective cohort analysis of children undergoing appendectomy for suspected appendicitis was performed using data from the 2016-2021 NSQIP-Pediatric Appendectomy Targeted Public Use Files. Multivariable regression was used to evaluate the influence of year, age, sex, and WBC count on NA rate, and to generate rate estimates for NA based on different combinations of demographic characteristics and WBC profiles.

RESULTS

100,322 patients were included from 140 hospitals. The overall NA rate was 2.4%, and rates decreased significantly during the study period (2016: 3.1% vs. 2021: 2.3%, p < 0.001). In adjusted analyses, the highest risk for NA was associated with a normal WBC (<9000/mm3; OR 5.31 [95% CI: 4.87-5.80]), followed by female sex (OR 1.55 [95% CI: 1.42-1.68]) and age <5 years (OR 1.64 [95% CI 1.39, 1.94]). Model-estimated risk for NA varied significantly across demographic and WBC strata, with a 14.4-fold range in rates between subgroups with the lowest and highest predicted risk (males 13-17 years with elevated WBC [1.1%] vs. females 3-4 years with normal WBC [15.8%]).

CONCLUSIONS

Contemporary NA rates have decreased over time, however NA risk remains high in children without a leukocytosis, particularly for girls and children <5 years of age. These data provide contemporary performance benchmarks for NA in children with suspected appendicitis and identify high-risk populations where further efforts to mitigate NA risk should be targeted.

LEVEL OF EVIDENCE

III.

Difference in Postoperative Outcomes and Perioperative Resource Utilization Between General Surgeons and Pediatric Surgeons: A Systematic Review

Background: Both general surgeons (GS) and pediatric surgeons (PS) perform a high volume of appendectomies in pediatric patients, but there is a paucity of data on these outcomes based on surgeon training. We performed a systematic review and meta-analysis to compare postoperative outcomes and perioperative resource utilization for pediatric appendectomies.Methods: We searched PubMed to identify articles examining the association between surgeon specialization and outcomes for pediatric patients undergoing appendectomies. Study selection, data extraction, risk of bias assessment, and quality assessment were performed by one reviewer, with another reviewer to resolve discrepancies.Results: We identified 4799 articles, with 98.4% (4724/2799) concordance after initial review. Following resolution of discrepancies, 16 studies met inclusion criteria. Of the studies that reported each outcome, GS and PS demonstrated similar rates of readmission within 30 days (pooled RR 1.61 95% CI 0.66, 2.55) wound infections (pooled RR 1.07, 95% CI .55, 1.60), use of laparoscopic surgery (pooled RR 1.87, 95% CI .21, 3.53), postoperative complications (pooled RR 1.40, 95% CI .83, 1.97), use of preoperative imaging (pooled RR .98,95% CI .90, 1.05), and intra-abdominal abscesses (pooled RR .80, 95% CI .03, 1.58). Patients treated by GS did have a significantly higher risk of negative appendectomies (pooled RR 1.47, 95% CI 1.10, 1.84) when compared to PS.Discussion: This is the first meta-analysis to compare outcomes for pediatric appendectomies performed by GS compared to PS. Patient outcomes and resource utilization were similar among PS and GS, except for negative appendectomies were significantly more likely with GS.

Quality metrics for emergency abdominal surgery in children: a systematic review

BACKGROUND

There is variation in care quality and outcomes for children undergoing emergency abdominal surgery, such as appedectomy. Addressing this requires paediatric-specific quality metrics. The aim of this study was to identify perioperative structure and process measures that are associated with improved outcomes for these children.

METHODS

We performed a systematic review searching MEDLINE, Embase, CINAHL, Cochrane Library, and Google Scholar for articles published between January 1, 1980 and September 29, 2020 about the perioperative care of children undergoing emergency abdominal surgery. We also conducted secondary searching of references and citations, and we included international professional publications.

RESULTS

We identified and analysed 383 peer-reviewed articles and 18 grey literature publications. High-grade evidence pertaining to the perioperative care of this patient group is limited. Most of the evidence available relates to improving diagnostic accuracy using preoperative blood testing, imaging, and clinical decision tools. Processes associated with clinical outcomes include time lapse between time of presentation or initial assessment and surgery, and the use of particular analgesia and antibiotic protocols. Structural factors identified include hospital and surgeon caseload and the use of perioperative care pathways.

CONCLUSIONS

This review summarises the structural and process measures associated with outcome in paediatric emergency abdominal surgery. Such measures provide a means of evaluating care and identifying areas of practice that require quality improvement, especially in children with appendicitis.

CLINICAL TRIAL REGISTRATION

PROSPERO CRD42017055285.

The Burden of Disease and Pathology at a Rapidly Expanding Tertiary Paediatric Surgical Unit in South Africa

BACKGROUND

The precise burden of paediatric surgical care in South Africa is unknown. In the absence of epidemiological data, hospital-based study is a first step to gauge the burden and profile of paediatric surgical disease. We aim to describe the profile of pathology, pattern of referrals, and complications of paediatric surgical care at Chris Hani Baragwanath Academic Hospital (CHBAH).

METHODS

A 1-year retrospective record review for the period 3/1/2019 to 1/1/2020 was conducted by evaluation of the morbidity and mortality databases of the Department of Paediatric Surgery (DPS). Number of admissions, consultations, complications, and surgeries performed were analysed and classified.

RESULTS

A total of 11,932 unique patient encounters occurred. Emergencies (79%, 1841/2329) accounted for the majority of admissions. Trauma accounted for 49% (896/1841) of emergency admissions. Elective surgery constituted 52% (1202/2316) and emergency surgery 48% (1114/2316) of all procedures performed. The emergency department (55%, 1271/2329), outpatients department (19%, 447/2329), and peripheral hospitals (16%, 378/2329) were the source of the majority of admissions. A complication rate of 9% (208/2316) was observed.

CONCLUSION

The high-volume subspecialist environment at CHBAH presents the ideal environment for delivery of specialist paediatric surgical services and training. Injury prevention, optimal use of existing resources, and additional physical, human and financial resources are required to meet the existing and predicted future burden of paediatric surgical disease.

Rates of Complications After Appendectomy in Children and Adolescents: Pediatric Surgical Compared to General Surgical Hospitals

BACKGROUND

Appendectomies in children and adolescents are performed in Germany in pediatric surgical (PS) or general surgical hospitals (GS). The aim of this study is to evaluate whether the surgery in a PS or GS hospital has an influence on the postoperative course after appendectomy in children and adolescents.

MATERIALS AND METHODS

Nationwide routine data from children and adolescents aged 1-17 y insured by the Local Health Insurance Fund who underwent appendectomy between 2014 and 2016 were analyzed (cohort study). Descriptive statistics were calculated both overall and in the two groups (PS and GS). Patients were additionally examined by age (1-5, 6-12, and 13-17 y), treatment (laparoscopic, open surgical, and conversion), and appendicitis type (nonacute: K36/K37/K38/R10, acute simple: K35.30/K35.8, and acute complex: K35.2/K35.31/K35.32). The influence of surgeon specialization on 90-d secondary surgery and 90-d general complications was assessed by multiple logistic regression.

RESULTS

Altogether, 25,065 patients who underwent surgery in 83 PS and 906 GS hospitals were included. Logistic regression analysis revealed that PS was associated with a reduced risk of interventions in the 1-5- and 6-12-y age groups (odds ratio: 0.44, 0.62). Acute complex appendicitis, comorbidities, and open surgery significantly increased the risk for reintervention. PS was associated with an increased risk for complications in the 13-17-y age group (odds ratio: 1.66).

CONCLUSIONS

PS and GS hospitals provided safe appendectomies in children and adolescents with low reintervention and complication rates. PS hospitals demonstrated advantages for patients in the 1-5- and 6-12-y age groups and GS hospitals for patients 13-17 y.

The Right Child/Right Surgeon initiative: A position statement on pediatric surgical training, sub-specialization, and continuous certification from the American Pediatric Surgical Association

The past 50 years have witnessed profound changes in the specialty of pediatric surgery in North America. There has been a marked increase in the number of both pediatric surgical training programs and practicing pediatric general and thoracic surgeons. Despite this trend, the population of children in the United States and the birth rate have recently remained relatively flat. Some pediatric surgeons have become "super specialists", concentrating their practices in oncology or colorectal surgery. This has the potential to result in a dilution of experience for both pediatric surgical trainees and practicing pediatric surgeons, thus limiting their ability to acquire and maintain expertise, respectively. Coincident with this, there has been a relative paradigm shift in recognition that "quality of life" is based more on maintaining a creative balance in lifestyle and is not "all about work". There has been a parallel growth in the number of practicing pediatric general and thoracic surgeons in urban settings, but we have not appreciated as much growth in rural and underserved areas, where access to pediatric surgical care remains limited and fewer pediatric general and thoracic surgeons practice. This is a complex issue, as some underserved areas are economically depressed and geographically sparse, but others are just underserved with adult providers taking care of children in settings that are often under resourced for pediatric surgical care. This problem may extend beyond the boundaries of pediatric general and thoracic surgery to other specialties. As the premier association representing all pediatric surgeons in the United States, the American Pediatric Surgical Association (APSA) has concluded that the quality of pediatric surgical care will likely decline should the status quo be allowed to continue. Therefore, APSA has initiated a Right Child/Right Surgeon initiative to consider these issues and propose some potential solutions. What follows is a brief statement of intent.

The Provision of Acute Pediatric Surgical Care by Adult Acute Care General Surgeons : Is There a Learning Curve?

BACKGROUND

At our hospital, acute surgical care of children aged 6 and older is managed by adult acute care surgeons. Previously published data from a 10-year experience with this model demonstrated no differences in outcomes when compared with pediatric surgical benchmark data. This study assesses for the effects of a learning curve in the care of pediatric patients by comparing outcomes of patients treated in the first three years with those treated in the last 3 years during a 10-year experience with this model.

DESIGN

This was a retrospective study of pediatric patients aged 6 and older who underwent an emergent or urgent, nontrauma surgical procedure by a general surgeon. Data was obtained via chart review and descriptive statistics were compared between patients operated on between January 1, 2009-January 1, 2012 and January 1, 2016-January 1, 2019.

RESULTS

In all, 208 cases were performed in the early cohort and 192 cases in the late cohort. Appendectomy was the most common procedure in both intervals (88% early, 94.8% late). Although there was a significant decrease in open procedures in the later cohort (22.6% vs 4.7%, P < .001), there was no significant change in disease-specific complications or negative appendectomies. No consults to a fellowship-trained pediatric surgeon were required during either time period, although one was available if needed.

CONCLUSIONS

Our data demonstrated a decrease in the number of open procedures in the later cohort. This may be due to an increased comfort level with pediatric laparoscopy over time. However, no significant changes in outcomes were observed. This study supports that acute care general surgeons can provide comparable care to pediatric patients within this age demographic and that although a learning curve, appears to exist with respect to pediatric laparoscopy, it is insignificant in terms of its effect on overall outcomes.

Population-based cohort study of the correlation between provision of care and the risk for complications after appendectomy in children

PURPOSE

To investigate the impact of hospital administrative level and caseload of pediatric appendectomies on the morbidity and mortality after appendectomy in a population-based cohort of Swedish children.

METHODS

Population-based cohort study including all Swedish children less than 15 years of age that underwent appendectomy for suspected appendicitis, 1987-2009. Patient characteristics and data on postoperative morbidity and mortality were collected from the Swedish National Patient Register and the Swedish Death Register. Primary endpoints were postoperative morbidity and mortality. Two explanatory variables were investigated: hospital administrative level and hospital annual caseload of pediatric appendectomies. Data were analyzed in regression models adjusting for available confounders.

RESULTS

The cohort comprised 55,591 children. The risk for postoperative complications was reduced in specialized pediatric surgical centers and in high caseload centers, compared to other hospitals. There were only seven postoperative deaths within 90 days of appendectomy.

CONCLUSIONS

We found clinically relevant risk reductions for reoperation and for readmission after appendectomy in specialized pediatric surgical centers. Importantly, the risk for postoperative complications was also reduced with increased hospital caseload, indicating that the merit from centralizing the management of pediatric appendectomies to specialized pediatric surgical centers may also be achieved by increasing hospital caseload of pediatric appendectomies in non-pediatric surgical units.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level II.

Optimizing postoperative follow-up in pediatric surgery (OFIPS)

BACKGROUND/PURPOSE

The purpose of the study was to determine variables associated with attending postoperative clinic follow-up (POFU) in pediatric surgical patients, predictors of clinical value, and visit cost estimates.

METHODS

POFU patterns of children undergoing eight common pediatric surgical procedures over one year at a tertiary pediatric hospital were examined retrospectively. Variables associated with attending POFU and associated with predetermined measures of clinical value and cost were determined. Driving distance to hospital was chosen as a proxy measure of cost to the family.

RESULTS

Six-hundred-thirty-three patients were included, and 58% attended POFU. Variables independently associated with attending follow-up included: procedure type (orchidopexy, complicated appendicitis), living close to the hospital, having a defined follow-up order, individual surgeon attending. Clinical value was identified in 16.4% of patient visits and associated with orchidopexies, having required an earlier urgent postoperative visit and longer cases considered "complex". Significant costs to the health care system (~$125,000) and families (~$15,000) could be estimated from follow-up cases that had no clinical issues identified nor required an intervention.

CONCLUSION

POFU of common pediatric surgical procedures may have limited clinical value while coming at significant costs to families and the health care system. Further study is needed to define optimal needs and means of follow-up of these common pediatric surgical procedures.

LEVEL OF EVIDENCE

Level III.

Jejunal perforation as an unusual presentation of total colonic aganglionosis in a neonate: A case report

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Untreated distal bowel obstruction eventually leads to perforation near the obstruction.

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Total colonic aganglionosis can present as a proximal jejunal perforation.

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Distal bowel should also be sought in cases of proximal bowel perforation.

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Appendiceal biopsy can be a reliable tool for suspecting total colonic aganglionosis.

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Multiple colon and rectal biopsies are necessary to diagnose total colonic aganglionosis.

Introduction

Neonatal intestinal perforation usually occurs at distal small bowel secondary to distal bowel obstruction. The aim of this report is to describe an unusual case of total colonic aganglionosis with an initial presentation of proximal jejunal perforation.

Presentation of case

A male newborn presented with jejunal perforation on the fifth day of life and was treated by laparoscopic primary repair. Abdominal distention persisted postoperatively, and radiological examination revealed an obstruction near the terminal ileum. Laparotomy showed a transition zone 30-cm proximal to the ileocecal valve, and diverting ileostomy and appendiceal biopsy was performed. Permanent section demonstrated the complete absence of ganglion cells in the appendix and total colonic aganglionosis was strongly suspected.

Discussion

Contrary to the classic teaching, proximal bowel perforation can occur in case of far distal obstruction, and careful distal evaluation would direct more appropriate surgical treatment option.

Conclusions

Total colonic aganglionosis can present as a proximal bowel perforation. Careful distal evaluation can provide diagnostic clues in cases of proximal intestinal perforation. Appendiceal biopsy is a reliable tool for evaluating suspected total colonic aganglionosis, but multiple colonic and rectal biopsies should be obtained to confirm the diagnosis.