Appendicoliths and appendectomy in the pediatric population

The Impact of Pathological Criteria on Pediatric Negative Appendectomy Rate

INTRODUCTION

Negative appendectomy rate (NAR) is a quality metric used in the surgical management of appendicitis. The rates of negative appendectomy (NA) in children range anywhere from 1% to 40% in the literature. Many reports do not provide clear pathological definitions for either appendicitis or NA on which they base their calculation of NAR. We reviewed our experience with pediatric appendectomy and the pathological spectrum encompassed within our definition of a NA and examined how the pathologic definition impacts our hospital's NAR.

METHODS

A retrospective review from 2012 to 2016 in a single institution identified 1676 children that underwent appendectomy. Average age was 11.4 (2-18 years). Patient demographics, clinical outcomes and pathological findings were collected. At our institution, appendicitis is defined as the presence of transmural acute inflammation in the appendix and those patients without this finding have been considered to have had a negative appendectomy.

RESULTS

1435 patients underwent appendectomy for presumed appendicitis. The rate of pathologically diagnosed appendicitis was 91.1% (1307/1435) and as such, the NAR was 8.9% (128/1435). Review of the pathology of the NA cohort identified 67/128 (52.3%) patients with completely normal pathology. The remaining 61 patients displayed some sort of pathological abnormality including malignancy (n = 2), fecaliths (n = 9), pinworms (n = 3), granuloma (n = 2), fibrous obliteration (n = 4), isolated periappendiceal inflammation (n = 1), and acute inflammation confined to the mucosa (n = 40). Exclusion of these patients with abnormal pathology decreased the NAR to 4.6%. Patients with pathological abnormalities of the appendix other than transmural inflammation had a higher rate of 30-day readmission than patients with acute appendicitis (8.2% versus 4.5% p < 0.01).

CONCLUSION

Pediatric NAR is dependent upon the pathological definition of appendicitis and negative appendectomy. Institutional variation in definition may explain discrepancies in the literature. By example, including only those that show "the absence of inflammation or other appendiceal pathology" would decrease our NAR by 50%. This study calls into question the interpretation of interhospital NAR and the use of NAR as a quality metric in the management of appendicitis. Retrospective comparative study: Level III evidence.

Impact of Percutaneous Drainage on Outcome of Intra-abdominal Infection Associated With Pediatric Perforated Appendicitis

BACKGROUND

Perforated appendicitis can result in potentially serious complications requiring prolonged medical care. The optimal approach to successfully managing this condition is controversial.

METHODS

Review of 80 consecutive cases of pediatric acute perforated appendicitis with intra-abdominal infection (IAI) medically managed with parenteral antibiotics and percutaneous drainage (PD) during a 7-year period.

RESULTS

All patients received broad spectrum parenteral antibiotic therapy. One-third were hospitalized for >2 weeks. IAI was identified on admission in 60% compared with developing during hospitalization in 40% of cases. Before performing PD, the mean duration of antibiotic therapy in those who developed IAI during hospitalization was 6 days. IAI cultures yielded 127 bacterial isolates; polymicrobial infection occurred in 65% of cases. Only 7% of aspirates were sterile. The most common pathogens were Escherichia coli (82%), of which 5 isolates exhibited extended-spectrum β-lactamase production, and streptococci (40%). At the time of PD, 60% were febrile (mean duration of in-hospital fever, 7.5 days); 67% defervesced within 24 hours after the procedure. Posthospitalization abdominal complications (recurrent IAI or appendicitis) occurred in one-third of patients.

CONCLUSIONS

Children with perforated appendicitis and IAI often have a complicated and prolonged clinical course. Medical management consisting solely of parenteral antibiotic therapy is frequently ineffective in resolving IAI. Rapid clinical improvement commonly follows PD.

Perihepatic abscess caused by dropped appendicoliths following laparoscopic appendectomy: sonographic findings

We report the case of a 6-year-old girl presenting with acute appendicitis complicated by perforated appendix, followed by perihepatic abscess associated with ectopic appendicoliths. CT findings were initially suspicious for an intrahepatic abscess with internal calcifications. However, on sonography the abscess appeared to be in a perihepatic location. Perihepatic abscess associated with a dropped or retained appendicolith has been rarely reported. Awareness of the possibility of a perihepatic abscess as a complication of laparoscopic appendectomy and use of sonography should result in optimal management of this rare complication.

Intraluminal air within an obstructed appendix: a CT sign of perforated or necrotic appendicitis

RATIONALE AND OBJECTIVES

The aim of this study was to evaluate the predictive value of intraluminal air for appendiceal necrosis and/or perforation when not apparent on imaging. Additional factors of intraluminal appendicoliths, age, and gender were also assessed.

MATERIALS AND METHODS

Patients with pathologically proven appendicitis who underwent multidetector computed tomographic imaging over a 3-year period (n = 487) were retrospectively reviewed. Those with imaging evidence for perforation were excluded to create a study population of apparent uncomplicated acute appendicitis (n = 374). Each scan was assessed for intraluminal appendiceal air and appendicoliths on multidetector computed tomography and compared against surgical and pathologic results for appendiceal necrosis and/or perforation.

RESULTS

Image-occult necrosis or perforation was present in 17.4% (65 or 374) of the study cohort. Intraluminal air and appendicoliths were predictive variables by univariate logistic regression (P = .001 and P ≤ .001, respectively), with odds ratios of 2.64 (95% confidence interval, 1.48-4.73) for intraluminal air and 2.67 (95% confidence interval, 1.55-4.61) for appendicoliths. Both remained independent variables on multivariate modeling despite multicollinearity. Increasing age was also predictive (odds ratio, 1.25; 95% confidence interval, 1.09-1.44; P = .002), whereas gender was not (P = .472).

CONCLUSIONS

Intraluminal appendiceal air in the setting of acute appendicitis is a marker of perforated or necrotic appendicitis. Recognition of this finding in otherwise uncomplicated appendicitis at imaging should raise suspicion for image-occult perforation or necrosis.