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Behrendorff N, Palan R, McKitterick T, Cover J. Paediatric negative appendicectomy rates at a regional Western Australian Centre: a five-year cohort study. ANZ J Surg 2023; 93:1987-1992. [PMID: 36994911 DOI: 10.1111/ans.18446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND In acute appendicitis, decision-making around operative intervention for paediatric patients differs from adults due to a higher weight placed on clinical assessment and reduced rates of cross-sectional imaging. In regional settings, non-paediatric emergency doctors, general surgeons, and radiologists usually assess and manage this patient group. Differences have been observed in paediatric negative appendicectomy rates between general and paediatric centres. METHODS A retrospective cohort study was performed, identifying paediatric patients undergoing emergency appendicectomy at the Southwest Health Campus (Bunbury, Western Australia) from 2017 to 2021. The primary outcome measure was histopathology confirming the absence of transmural inflammation of the appendix. In addition, clinical, biochemical and radiological data were collected to identify predictors of negative appendicectomy (NA). Secondary outcome measures were hospital length-of-stay and post-operative complication rates. RESULTS Four hundred and twenty-one patients were identified, of which 44.9% had a negative appendicectomy. Statistically significant associations between female gender, white cell count less than 10 × 109 , neutrophil ratio less than 75%, low CRP and NA were observed. NA was not associated with a lower risk of re-admission or complications compared with appendicectomy for appendicitis. CONCLUSIONS Our centre's NA rate is higher than that observed in the literature at both non-paediatric and paediatric surgical centres. NA has similar morbidity risk to appendicectomy for uncomplicated appendicitis and offers a timely reminder that diagnostic laparoscopy in children is not benign.
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Affiliation(s)
- Natasha Behrendorff
- General Surgery Department, South West Health Campus, Western Australia Country Health Service, Bunbury, Western Australia, Australia
| | - Ranesh Palan
- General Surgery Department, South West Health Campus, Western Australia Country Health Service, Bunbury, Western Australia, Australia
| | - Tommy McKitterick
- General Surgery Department, South West Health Campus, Western Australia Country Health Service, Bunbury, Western Australia, Australia
| | - Jacinta Cover
- General Surgery Department, South West Health Campus, Western Australia Country Health Service, Bunbury, Western Australia, Australia
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Bhaskar K, Clarke S, Moore LSP, Hughes S. Bacterial peritonitis in paediatric appendicitis; microbial epidemiology and antimicrobial management. Ann Clin Microbiol Antimicrob 2023; 22:45. [PMID: 37270568 DOI: 10.1186/s12941-023-00591-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/27/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Appendicitis remains a common surgical emergency in children. Empirical antibacterial treatment is indicated to reduce infective complications. We investigate the bacterial pathogens identified intra-operatively during appendectomies in children to guide empirical surgical antimicrobial prophylaxis options. METHODS A retrospective analysis of patients (< 18 years old) undergoing an appendectomy across a multisite London hospital (Nov 2019-March 2022) was undertaken. Patient-related outcomes including length of hospital stay (LOS), days of antibacterial therapy (DOT), intra-operative microbiology and post-operative radiology reports were interrogated. RESULTS 304 patients underwent an appendectomy during this period; 39.1% of patients had intraoperative samples cultured. Bacterial pathogens were found in 73/119 (61.3%) cases; the most common isolates being Escherichia coli (42.0%), Pseudomonas aeruginosa (21.0%), milleri Streptococcus spp. (14.3%) and Bacteroides fragilis (5.9%). Polymicrobial infection was common (32/73). Isolation of Pseudomonas spp. from intra-operative sampling was associated with a greater LOS (7.0 vs. 5.0 days; p = 0.011) but nil effect on the incidence of postoperative collections. Presence of milleri Streptococcus spp. was associated with longer LOS (7.0 vs. 5.0 day; p = 0.007), DOT (12.0 vs. 8.5 day; p = 0.007) but had no observed outcome on postoperative collections (29.4% vs. 18.6%; p = 0.330). 48% of E. coli positive cultures were co-amoxiclav resistant and prolonged LOS compared to the non-resistant group (7.0 vs. 5.0 days; p = 0.040) but had no difference in post-operative collections (29.2% vs. 17.9%; p = 0.260). CONCLUSION A high proportion of children with appendicitis have Pseudomonas spp. isolated, leading to a prolonged LOS. Evolving Enterobacterales resistance and the presence of Pseudomonas spp. necessitate extended antibacterial coverage for paediatric appendectomies with evidence of peritonitis.
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Affiliation(s)
- Keir Bhaskar
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
- Department of Medicine, Imperial College London, Exhibition Road, South Kensington, London, SW7 2BX, England, UK
| | - Simon Clarke
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Luke S P Moore
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK.
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.
- Department of Medicine, Imperial College London, Exhibition Road, South Kensington, London, SW7 2BX, England, UK.
| | - Stephen Hughes
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
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Ott KC, McMahon MA, Vacek JC, Zeineddin S, Hu YY, Raval MV, Goldstein SD. The costs and benefits of emergent surgical workflow for acute appendicitis in children. J Pediatr Surg 2022; 57:896-901. [PMID: 35934527 DOI: 10.1016/j.jpedsurg.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/09/2022] [Accepted: 06/29/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Controversy exists regarding how operative timing affects patient safety and resource utilization for acute appendicitis. Over 3 years, our institution trialed efforts to optimize appendectomy workflow. Our aim is to describe the ramifications of expediting appendectomy and implementing standardized protocols relative to historic controls. METHODS Patient records at a freestanding children's hospital were reviewed from synchronized 6-month periods from 2019 to 2021. During Year 1 (historic), no standardized workflows existed. In Year 2 (expedited), appendicitis management was protocoled using a clinical quality improvement bundle, which included performing appendectomies within two hours of diagnosis. In Year 3 (QI), operative timing was relaxed to the same calendar day while all prior QI initiatives continued. Descriptive statistics were performed, using hospital length of stay (LOS) as the primary outcome. RESULTS 298 patients underwent appendectomy for acute appendicitis. The median expedited workflow LOS was 15.3 hours shorter (p = 0.003) than historic controls; however, this was sustained despite relaxation of surgical urgency in the QI workflow. No differences in perforation rates were observed. During the expedited workflow, OR overtime staffing expense increased by $90,000 with no significant change in hospital costs. In multivariate regression, perforation was the only variable associated with LOS. CONCLUSION Hospital LOS can be shortened by expediting appendectomy. However, in our institution this did not decrease hospital costs and was furthermore balanced by higher personnel expenses. A sustained decrease in LOS after relaxing operative urgency standards implies that concurrent QI initiatives represent a more effective and cost-efficient strategy to decrease hospital resource utilization. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Katherine C Ott
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States.
| | - Maxwell A McMahon
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Jonathan C Vacek
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
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Larocca V, Oltean I, Grandpierre V, Nasr A. Development and evaluation of a patient decision aid for pediatric interval appendectomy. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000466. [DOI: 10.1136/wjps-2022-000466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022] Open
Abstract
ObjectiveOne option for the treatment of perforated appendicitis in pediatric patients is interval appendectomy (IA). A patient decision aid (PDA) can be useful in the decision-making process regarding IA. The purpose of this study was to evaluate parents’ decisional conflict before and after engaging with a developed PDA.MethodsParticipants included (a) parents who are considering IA surgery for their child, (b) have not yet had their follow-up appointment postdischarge, and (c) were fluent in either the official languages of English or French. This study used a pretest and post-test design to measure participants’ decisional conflict and treatment option choice. Perceptions and acceptability of the PDA were also assessed.ResultsA total of 18 participants completed the study (16 mothers). Major findings include significant decreases in all Decisional Conflict Scale items from pre-PDA to post-PDA engagement, except for one item. The majority of participants perceived the PDA to be useful, easy to find information regarding risks and provided enough information to help them make a decision regarding their child’s treatment.ConclusionsThis is the first study to develop and evaluate a PDA among parents who are making a decision regarding IA surgery. The results showed a significant decrease in decisional conflict after using the PDA. The results also showed that the PDA was generally accepted among parents and had positive perceptions regarding length, content, and balance. The use of PDA for this population can help ease feelings of decisional conflict and equip parents with the information to make informed decisions.
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Takirambudde S, Ruffolo LI, Wakeman DS, Dale BS, Arca MJ, Wilson NA. Social Determinants of Health are Associated With Postoperative Outcomes in Children With Complicated Appendicitis. J Surg Res 2022; 279:692-701. [PMID: 35940047 DOI: 10.1016/j.jss.2022.06.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Socioeconomic disadvantage has been associated with increased complicated appendicitis rates. Our purpose was to analyze the complex interactions between social determinants of health (SDOH) and postoperative outcomes in pediatric appendicitis. MATERIALS AND METHODS Children who underwent appendectomy at our institution (1/2015-12/2020) were retrospectively reviewed. We used home addresses to determine composite measures of neighborhood/area-level socioeconomic advantage (Area Deprivation Index [ADI] and Social Deprivation Index [SDI]), and other area-level indicators. We created a novel, composite outcome score computed as a weighted average of eight outcome measures. Feature selection and exploratory factor analysis were used to create a multivariate model predictive of outcomes. RESULTS Of 1117 children with appendicitis, 20.59% had complicated (perforated) appendicitis. Factor analysis identified two multivariate latent factors; Factor 1 contained SDI, ADI, and % unemployed in the population, and Factor 2 contained % Hispanic and % foreign-born in the population. Low Factor 2 scores (communities with more Hispanic/foreign-born residents) were associated with increased length of stay, more frequent postoperative percutaneous drainage, and increased postoperative imaging. CONCLUSIONS Interactions between SDOH and pediatric surgical care go beyond the individual patient and suggest that vulnerable populations are exposed to contextual conditions that may impact outcomes. Specifically, neighborhood-level factors, including the prevalence of Hispanic ethnicity and foreign-born individuals, are associated with outcomes in pediatric patients with complicated appendicitis. Reducing disparities in complicated appendicitis outcomes may involve addressing neighborhood-level SDOH through strategic reallocation of healthcare resources and developing targeted interventions to improve access to pediatric surgical care in underserved communities.
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Affiliation(s)
- Sanyu Takirambudde
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Luis I Ruffolo
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Derek S Wakeman
- Division of Pediatric Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Benjamin S Dale
- Department of Biomedical Engineering, University of Rochester, Rochester, New York
| | - Marjorie J Arca
- Division of Pediatric Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Nicole A Wilson
- Division of Pediatric Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York; Department of Biomedical Engineering, University of Rochester, Rochester, New York.
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Grandpierre V, Duba K, Toupin April K, Oltean I, Weir A, Nasr A. Needs assessment of parents for a patient decision aid in pediatric interval appendectomy via the qualitative interview method. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000371. [DOI: 10.1136/wjps-2021-000371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/15/2021] [Indexed: 11/03/2022] Open
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Studies of Diagnostic Test Accuracy: Partial Verification Bias and Test Result-Based Sampling. J Clin Epidemiol 2022; 145:179-182. [DOI: 10.1016/j.jclinepi.2022.01.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 01/30/2022] [Accepted: 01/31/2022] [Indexed: 11/23/2022]
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Ribeiro AM, Romero I, Pereira CC, Soares F, Gonçalves Á, Costa S, da Silva JB. Inflammatory parameters as predictive factors for complicated appendicitis: A retrospective cohort study. Ann Med Surg (Lond) 2022; 74:103266. [PMID: 35106154 PMCID: PMC8784622 DOI: 10.1016/j.amsu.2022.103266] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 01/08/2023] Open
Abstract
Introduction Acute appendicitis is a major cause of acute abdomen. Although its diagnosis is clinical, it is often supported by complementary diagnostic tests. Sometimes, delay in diagnosis can lead to worsening of the clinical picture, resulting in a complicated acute appendicitis. Some series have studied some clinical and analytical parameters as possible predictors of complicated acute appendicitis. Study design A retrospective analysis of patients admitted for acute appendicitis and undergoing appendectomy between January 2014 and December 2017 was performed in order to assess the possible existence of preoperative analytical predictive factors for complicated acute appendicitis (such as leukocytosis, C-reactive protein and ratio between neutrophils and lymphocytes). Results 841 patients underwent emergency appendectomy during the analysed period. This initial sample was divided into two groups: Group 1 with patients with uncomplicated acute appendicitis and Group 2 with patients with complicated acute appendicitis. Group 2's presentation age, duration of symptoms and hospital stay was significantly higher than Group 1. Regarding analytical parameters, the measurement of leukocytes, C-reactive protein and ratio between neutrophils and lymphocytes was significantly higher in patients with complicated acute appendicitis. After a multivariate analysis, it was found that only C-reactive protein was a good predictor of complicated acute appendicitis. Conclusion Several publications have studied and demonstrated the possible use of certain analytical parameters as predictors of complicated acute appendicitis. In our study, C-reactive protein proved to be a good independent predictor of complicated acute appendicitis and, therefore, when an assay of this protein exceeds 63.3 mg/L, faster surgical approach should be considered due to the high probability of the presence of a complicated picture of this clinical entity. Preoperative distinction of the severity of appendicitis can be challenging. Biochemical markers can help the surgeon to understand its severity and emergency. C-reactive protein shows to be a good predictor of complicated acute appendicitis.
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Affiliation(s)
- Ana Matos Ribeiro
- Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
- Corresponding author. Rua Dom João V, número 223, 2° esquerdo, 4560, Penafiel, Portugal.
| | - Inês Romero
- Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | | | | | | | - Susana Costa
- Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
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Ergün E, Sözduyar S, Gurbanova A, Serttürk F, Çiftçi E, Özdemir H, Arga G, Konca HK, Çınar G, Akdemir Kalkan İ, Gülten E, Selvi Can Ö, Şen Akova B, Suat Fitöz Ö, Vatansever G, Tekin D, Göllü G, Bingöl-Koloğlu M, Yağmurlu A, Çakmak M, Ateş U. An indirect effect of COVID-19 pandemic: Increased pediatric perforated appendicitis rate due to delayed admission. Turk J Surg 2021; 37:318-323. [PMID: 35677491 PMCID: PMC9130943 DOI: 10.47717/turkjsurg.2021.5277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 10/06/2021] [Indexed: 11/23/2022]
Abstract
Objectives Appendicitis is a common surgical emergency among children. The coronavirus pandemic affected the system of hospitals more than any other field, and great amount of people were concerned about visiting the hospitals for any reason. In this study, it was aimed to evaluate the profile of appendicitis by emphasizing perforated and acute appendicitis in the pandemic period and to compare the rates with previous three years. Material and Methods Charts of the children who underwent laparoscopic appendectomy due to appendicitis between March 11-September 30 between 2017-2020 were retrospectively analyzed in terms of demographic data, duration of symptoms, duration between hospital admission and surgery, radiologic imaging and perioperative outcomes. Results This study includes 467 children who underwent laparoscopic appendectomy. There were 97 procedures in 2020, 111 in 2019, 146 in 2018 and 113 in 2017. Multiple comparison tests revealed that age did not show difference; but onset of symptoms in admission (p= 0.004), hospitalization time before surgery (p <0.001), total hospitalization time (p <0.001) showed statistically significant difference between years. Pairwise comparisons showed that these parameters were increased in 2020 compared to other years. Perforated appendicitis rate was significantly increased in 2020 when compared to previous years. Conclusion Although there is no direct relation between appendicitis and COVID-19 infection in the current knowledge, perforated appendicitis was found to be increased in children during the COVID pandemic. Reason of the higher rate of perforated appendicitis may be multifactorial; however, the pandemic appears to have a role in increased morbidity in children with appendicitis indirectly due to delay of hospital admissions.
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Affiliation(s)
- Ergun Ergün
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Sümeyye Sözduyar
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Aynur Gurbanova
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Fırat Serttürk
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ergin Çiftçi
- Division of Pediatric Infectious Disease, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Halil Özdemir
- Division of Pediatric Infectious Disease, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gül Arga
- Division of Pediatric Infectious Disease, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hatice Kübra Konca
- Division of Pediatric Infectious Disease, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Güle Çınar
- Department of Infectious Diseases and Clinical Microbiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - İrem Akdemir Kalkan
- Department of Infectious Diseases and Clinical Microbiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ezgi Gülten
- Department of Infectious Diseases and Clinical Microbiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Özlem Selvi Can
- Department of Anesthesia and Reanimation, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Birsel Şen Akova
- Division of Pediatric Radiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ömer Suat Fitöz
- Division of Pediatric Radiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Göksel Vatansever
- Division of Pediatric Emergency, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Deniz Tekin
- Division of Pediatric Emergency, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gülnur Göllü
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Meltem Bingöl-Koloğlu
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Aydın Yağmurlu
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Murat Çakmak
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ufuk Ateş
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
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Brief Report: Association of Complicated Appendicitis in Children with Autism Spectrum Disorders. J Autism Dev Disord 2020; 50:4535-4540. [PMID: 32297124 DOI: 10.1007/s10803-020-04499-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Sakellaris G, Dimopoulou D, Niniraki M, Dimopoulou A, Alegakis A, Symvoulakis EK, Kostaki D, Blevrakis E, Kolivaki S, Chryssos E. The role of blood inflammatory markers in the diagnosis of appendicitis in children: a prospective study from a University Hospital in Greece. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2020. [DOI: 10.23736/s0393-3660.18.03636-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Wong DC, Relton SD, Lane V, Ismail M, Goss V, Bytheway J, West RM, Deuchars J, Sutcliffe J. Bedside breath tests in children with abdominal pain: a prospective pilot feasibility study. Pilot Feasibility Stud 2019; 5:121. [PMID: 31720000 PMCID: PMC6833160 DOI: 10.1186/s40814-019-0502-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 09/16/2019] [Indexed: 01/30/2023] Open
Abstract
Background There is no definitive method of accurately diagnosing appendicitis before surgery. We evaluated the feasibility of collecting breath samples in children with abdominal pain and gathered preliminary data on the accuracy of breath tests. Methods We conducted a prospective pilot study at a large tertiary referral paediatric hospital in the UK. We recruited 50 participants with suspected appendicitis, aged between 5 and 15 years. Five had primary diagnosis of appendicitis. The primary outcome was the number of breath samples collected. We also measured the number of samples processed within 2 h and had CO2 ≥ 3.5%. Usability was assessed by patient-reported pain pre- and post-sampling and user-reported sampling difficulty. Logistic regression analysis was used to predict appendicitis and evaluated using the area under the receiver operator characteristic curve (AUROC). Results Samples were collected from all participants. Of the 45 samples, 36 were processed within 2 h. Of the 49 samples, 19 had %CO2 ≥ 3.5%. No difference in patient-reported pain was observed (p = 0.24). Sampling difficulty was associated with patient age (p = 0.004). The logistic regression model had AUROC = 0.86. Conclusions Breath tests are feasible and acceptable to patients presenting with abdominal pain in clinical settings. We demonstrated adequate data collection with no evidence of harm to patients. The AUROC was better than a random classifier; more specific sensors are likely to improve diagnostic performance. Trial registration ClinicalTrials.gov, NCT03248102. Registered 14 Aug 2017.
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Affiliation(s)
- David C Wong
- 1Centre for Health Informatics, University of Manchester, Manchester, UK
| | - Samuel D Relton
- 2Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Mohamed Ismail
- 2Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Victoria Goss
- 4Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Robert M West
- 2Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Jim Deuchars
- 6School of Biomedical Sciences, University of Leeds, Leeds, UK
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Intravenous versus intravenous/oral antibiotics for perforated appendicitis in pediatric patients: a systematic review and meta-analysis. BMC Pediatr 2019; 19:407. [PMID: 31684906 PMCID: PMC6827245 DOI: 10.1186/s12887-019-1799-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 10/23/2019] [Indexed: 02/07/2023] Open
Abstract
Background The use of oral (PO) antibiotics following a course of certain intravenous (IV) antibiotics is proposed in order to avoid the complications of IV medications and to decrease the cost. However, the efficacy and safety of sequential IV/PO antibiotics is unclear and requires further study. Methods The databases, including PubMed, EMBASE and Cochrane Library, were searched. Studies comparing outcomes in patients with perforated appendicitis receiving sequential IV/PO and PO antibiotics therapy were screened. The Newcastle-Ottawa Scale (NOS) and the Jadad score were used to evaluate the quality of the cohort and the randomized controlled portions of the trial, respectively. Statistical heterogeneity was assessed using the I2 value. A fixed or random-effect model was applied according to the I2 value. Results Five controlled studies including a total of 580 patients were evaluated. The pooled estimates revealed that sequential IV/PO antibiotic therapy did not increase the risk of complications, with a risk ratio (RR) of 0.97 (95% CI 0.51–1.83, P = 0.93) for postoperative abscess, 1.04 (95% CI 0.25–4.36, P = 0.96) for wound infection and 0.62 (95% CI 0.33–1.16, P = 0.13) for readmission. Conclusions Our study demonstrates that sequential IV/PO antibiotic therapy is noninferior to IV antibiotic therapy regarding postoperative abscess, wound infection and readmission.
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Greer D, Bennett P, Wagstaff B, Croaker D. Lymphopaenia in the diagnosis of paediatric appendicitis: a false sense of security? ANZ J Surg 2019; 89:1122-1125. [PMID: 31452301 DOI: 10.1111/ans.15394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/08/2019] [Accepted: 07/10/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Appendicitis is a common indication for emergent surgery in children; however, it is a small proportion of presentations with abdominal pain. As viral illness is a common differential diagnosis, lymphopaenia is used by some as a predictor against appendicitis. Furthermore, neutrophil-lymphocyte ratio (NLR) has been found to predict appendicitis. We aimed to verify if lymphopaenia predicted against appendicitis in children. METHODS Retrospective review was conducted for all patients aged 15 years and under presenting with abdominal pain to our institution in 2017, and data including age, white cell count, neutrophil and lymphocyte count, NLR, C-reactive protein and diagnosis of appendicitis were recorded. Statistical analysis was performed using Stata©. Receiver operating characteristic curves for various tests were formed and areas under curve (AUC) compared using regression, P < 0.05 was considered significant. RESULTS A total of 1263 patients were presented, of whom 546 had their blood performed and were included, 86 had appendicitis and 460 did not. Neutrophilia was the best predictor for appendicitis (AUC = 0.86), significantly higher than NLR (0.81), P < 0.05. Lymphopaenia was a poor negative predictor of appendicitis (AUC = 0.46), and while isolated lymphopaenia was more predictive (AUC = 0.23) this was inferior to the positive prediction of neutrophilia, P < 0.05. CONCLUSION The value of isolated lymphopaenia to predict against appendicitis is largely accounted for inherently normal neutrophils, independently lymphopaenia has little value. NLR, while predictive, is a weaker predictor than neutrophilia.
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Affiliation(s)
- Douglas Greer
- Division of Paediatrics and Child Health, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Peter Bennett
- Division of Paediatrics and Child Health, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Benjamin Wagstaff
- Division of Paediatrics and Child Health, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - David Croaker
- Division of Paediatrics and Child Health, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
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Esparaz JR, McGovern GC, Mowrer AR, Nierstedt RT, Biesboer EA, Elger BM, Pearl RH, Aprahamian CJ. A simple algorithm to improve quality while reducing resource utilization in evaluation of suspected appendicitis in children. Am J Surg 2018; 217:469-472. [PMID: 30454838 DOI: 10.1016/j.amjsurg.2018.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND With similar effectiveness of ultrasonography, our institution replaced CT imaging with ultrasound for diagnosing appendicitis in children. An unexpected consequence was the overutilization of ultrasound. Our objective was to establish measures that could help prevent this overuse. METHODS A retrospective chart review of 327 consecutive pediatric patients evaluated for appendicitis between October 2014 and September 2015 at our institution was performed. Data on clinical, radiographic, and histopathologic findings were reviewed. Diagnostic accuracy of US and white blood cell (WBC) values was determined. An algorithm was created. RESULTS 327 (100%) patients received an ultrasound for suspected appendicitis. WBC of 10,000/μl was determined to be the primary discriminant for management and ultrasound utilization. If a WBC ≥10,000/μL had been utilized as criteria for imaging, 49.5% fewer patients would have received an ultrasound. CONCLUSIONS Clinical exam, WBC count, and surgery consultation prior to ultrasonography can lessen then need for ultrasound utilization in children with suspected appendicitis.
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Affiliation(s)
- Joseph R Esparaz
- Department of Surgery, University of Illinois College of Medicine, Peoria, IL, USA.
| | - Greg C McGovern
- Department of Surgery, University of Illinois College of Medicine, Peoria, IL, USA.
| | - Alyssa R Mowrer
- Department of Surgery, University of Illinois College of Medicine, Peoria, IL, USA.
| | - Ryan T Nierstedt
- Children's Hospital of Illinois at OSF Saint Francis Medical Center, Peoria, IL, USA.
| | | | - Breanna M Elger
- Children's Hospital of Illinois at OSF Saint Francis Medical Center, Peoria, IL, USA.
| | - Richard H Pearl
- Department of Surgery, University of Illinois College of Medicine, Peoria, IL, USA; Children's Hospital of Illinois at OSF Saint Francis Medical Center, Peoria, IL, USA.
| | - Charles J Aprahamian
- Department of Surgery, University of Illinois College of Medicine, Peoria, IL, USA; Children's Hospital of Illinois at OSF Saint Francis Medical Center, Peoria, IL, USA.
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16
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Negative appendicectomy rates in adolescent girls compared with boys. ANNALS OF PEDIATRIC SURGERY 2018. [DOI: 10.1097/01.xps.0000535043.44631.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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17
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Affiliation(s)
- Yangyang R Yu
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, TX 77030, USA
| | - Sohail R Shah
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, TX 77030, USA.
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18
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Affiliation(s)
- Rebecca M Rentea
- Deparment of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Pediatric Surgical Fellowship and Scholars Programs, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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19
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Benabbas R, Hanna M, Shah J, Sinert R. Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of-care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2017; 24:523-551. [PMID: 28214369 DOI: 10.1111/acem.13181] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 01/17/2017] [Accepted: 02/06/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute appendicitis (AA) is the most common surgical emergency in children. Accurate and timely diagnosis is crucial but challenging due to atypical presentations and the inherent difficulty of obtaining a reliable history and physical examination in younger children. OBJECTIVES The aim of this study was to determine the utility of history, physical examination, laboratory tests, Pediatric Appendicitis Score (PAS) and Emergency Department Point-of-Care Ultrasound (ED-POCUS) in the diagnosis of AA in ED pediatric patients. We performed a systematic review and meta-analysis and used a test-treatment threshold model to identify diagnostic findings that could rule in/out AA and obviate the need for further imaging studies, specifically computed tomography (CT) scan, magnetic resonance imaging (MRI), and radiology department ultrasound (RUS). METHODS We searched PubMed, EMBASE, and SCOPUS up to October 2016 for studies on ED pediatric patients with abdominal pain. Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality and applicability of included studies. Positive and negative likelihood ratios (LR+ and LR-) for diagnostic modalities were calculated and when appropriate data was pooled using Meta-DiSc. Based on the available literature on the test characteristics of different imaging modalities and applying the Pauker-Kassirer method we developed a test-treatment threshold model. RESULTS Twenty-one studies were included encompassing 8,605 patients with weighted AA prevalence of 39.2%. Studies had variable quality using the QUADAS-2 tool with most studies at high risk of partial verification bias. We divided studies based on their inclusion criteria into two groups of "undifferentiated abdominal pain" and abdominal pain "suspected of AA." In patients with undifferentiated abdominal pain, history of "pain migration to right lower quadrant (RLQ)" (LR+ = 4.81, 95% confidence interval [CI] = 3.59-6.44) and presence of "cough/hop pain" in the physical examination (LR+ = 7.64, 95% CI = 5.94-9.83) were most strongly associated with AA. In patients suspected of AA none of the history or laboratory findings were strongly associated with AA. Rovsing's sign was the physical examination finding most strongly associated with AA (LR+ = 3.52, 95% CI = 2.65-4.68). Among different PAS cutoff points, PAS ≥ 9 (LR+ = 5.26, 95% CI = 3.34-8.29) was most associated with AA. None of the history, physical examination, laboratory tests findings, or PAS alone could rule in or rule out AA in patients with undifferentiated abdominal pain or those suspected of AA. ED-POCUS had LR+ of 9.24 (95% CI = 6.24-13.28) and LR- of 0.17 (95% CI = 0.09-0.30). Using our test-treatment threshold model, positive ED-POCUS could rule in AA without the use of CT and MRI, but negative ED-POCUS could not rule out AA. CONCLUSION Presence of AA is more likely in patients with undifferentiated abdominal pain migrating to the RLQ or when cough/hop pain is present in the physical examination. Once AA is suspected, no single history, physical examination, laboratory finding, or score attained on PAS can eliminate the need for imaging studies. Operating characteristics of ED-POCUS are similar to those reported for RUS in literature for diagnosis of AA. In ED patients suspected of AA, a positive ED-POCUS is diagnostic and obviates the need for CT or MRI while negative ED-POCUS is not enough to rule out AA.
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Affiliation(s)
- Roshanak Benabbas
- Department of Emergency Medicine; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
| | - Mark Hanna
- Department of Pediatrics; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Pediatrics; Kings County Hospital Center; Brooklyn NY
| | - Jay Shah
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
| | - Richard Sinert
- Department of Emergency Medicine; State University of New York/SUNY Downstate Medical Center; Brooklyn NY
- Department of Emergency Medicine; Kings County Hospital Center; Brooklyn NY
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Abstract
Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.
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Affiliation(s)
- Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA.
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA
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21
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Abstract
Appendicitis is one of the most common surgical pathologies in children. It can present with right lower quadrant pain. Scoring systems in combination with selective imaging and surgical examination will diagnose most children with appendicitis. Clinical pathways should be used. Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated. Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis. This article discusses the workup and management, modes of treatment, and continued areas of controversy in pediatric appendicitis.
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Affiliation(s)
- Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Pediatric Surgical Fellowship and Scholars Programs, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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Bosak Versic A, Glavan N, Bukvic N, Tomasic Z, Nikolic H. Does elevated urinary 5-hydroxyindole acetic acid level predict acute appendicitis in children? Emerg Med J 2016; 33:848-852. [PMID: 27466348 DOI: 10.1136/emermed-2015-205559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 06/07/2016] [Accepted: 07/07/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Acute appendicitis is the most common abdominal surgical emergency in children, and appendectomy is the most frequent acute abdominal operation. Prompt diagnosis and surgical treatment are required to reduce the risk of perforation and prevent complications, especially in small children. Enterochromaffin cells that contain large amounts of serotonin are mostly located in the distal appendix. Serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) could therefore be a marker for acute appendicitis. OBJECTIVE We tested urinary 5-HIAA concentrations in spot urine samples from children with acute appendicitis. METHODS We enrolled 93 patients who underwent surgery for suspicion of acute appendicitis. The diagnosis was made intraoperatively and confirmed histopathologically. Additionally, urine samples from 102 healthy children were collected as controls. Their 5-HIAA was measured using high-performance liquid chromatography. RESULTS Acute appendicitis was diagnosed in 81 patients, whereas there were other explanations for abdominal pain in the remaining 12 patients in the non-appendicitis group. The control group comprised 102 healthy children. Considering the median of all measured 5-HIAA values as the cut-off, we analysed the proportions of patients with elevated values in all the groups. Our analysis showed that statistically there was no significant difference in the distribution of percentages among the groups. The area under the curve for 5-HIAA was 0.55 (95% CI 0.47 to 0.62) with sensitivity and specificity 60.4% and 48.9%, respectively. CONCLUSIONS Urine 5-HIAA concentration measured in spot samples is not a reliable method for diagnosing acute appendicitis in children.
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Affiliation(s)
- Ana Bosak Versic
- Pediatric Surgery Clinic, University Hospital Center Rijeka, Rijeka, Croatia
| | - Nedeljka Glavan
- Pediatric Surgery Clinic, University Hospital Center Rijeka, Rijeka, Croatia
| | - Nado Bukvic
- Pediatric Surgery Clinic, University Hospital Center Rijeka, Rijeka, Croatia
| | - Zlatko Tomasic
- Pediatric Surgery Clinic, University Hospital Center Rijeka, Rijeka, Croatia
| | - Harry Nikolic
- Pediatric Surgery Clinic, University Hospital Center Rijeka, Rijeka, Croatia
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23
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Cox M, Gould SW, Podberesky DJ, Epelman M. Magnetic resonance imaging of acquired disorders of the pediatric female pelvis other than neoplasm. Pediatr Radiol 2016; 46:806-17. [PMID: 27229499 DOI: 10.1007/s00247-016-3595-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 01/29/2016] [Accepted: 02/19/2016] [Indexed: 02/04/2023]
Abstract
Transabdominal US remains the primary screening imaging modality of the pediatric female pelvis. However, MRI has become an invaluable adjunct to US in recent years. MRI offers superb soft-tissue contrast resolution that allows for detailed evaluation, particularly of the ovaries and their associated pathology. MRI can yield diagnostic information that is similar to or even better than that of US, especially in nonsexually active girls in whom transvaginal US would be contraindicated. MRI is generally a second-line examination and is preferred over CT because it does not involve the use of ionizing radiation. MRI might be underutilized in this population, particularly in differentiating surgical from nonsurgical conditions. This article reviews the relevant anatomy and discusses imaging of acquired conditions that involve the pediatric female genital tract, illustrating associated pathology with case examples.
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Affiliation(s)
- Mougnyan Cox
- Department of Medical Imaging, Nemours Children's Health System/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sharon W Gould
- Department of Medical Imaging, Nemours Children's Health System/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Daniel J Podberesky
- Department of Medical Imaging/Radiology, Nemours Children's Health System/Nemours Children's Hospital, 13535 Nemours Parkway, Orlando, FL, 32827, USA
| | - Monica Epelman
- Department of Medical Imaging/Radiology, Nemours Children's Health System/Nemours Children's Hospital, 13535 Nemours Parkway, Orlando, FL, 32827, USA.
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24
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Naderan M, Babaki AES, Shoar S, Mahmoodzadeh H, Nasiri S, Khorgami Z. Risk factors for the development of complicated appendicitis in adults. ULUSAL CERRAHI DERGISI 2016; 32:37-42. [PMID: 26985166 DOI: 10.5152/ucd.2015.3031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 02/06/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To investigate the patient's history and physical examination information to find out risk factors associated with complicated appendicitis. MATERIAL AND METHODS Two hundred patients who were admitted with complicated appendicitis (including abscess, phlegmon, and generalized peritonitis) were retrieved from our database. Two hundred patients with non-complicated acute appendicitis were randomly selected from the same period. These two groups were compared in terms of demographic characteristics, past medical history, and presenting symptoms. We made a multivariate analysis model using binary logistic regression and backward stepwise elimination. RESULTS Based on multivariate analysis, risk factors for complicated appendicitis included presenting with epigastric pain (OR=3.44), diarrhea (OR=23.4) or malaise (OR=49.7), history of RLQ pain within the past 6 months (OR=4.93), older age (OR=1.04), being married (OR=2.52), lack of anorexia (OR=4.63) and longer interval between onset of symptoms and admission (OR=1.46). Conversely, higher (academic) education was associated with decreased odds for complicated appendicitis (OR=0.26). CONCLUSION Our findings suggest that a surgeon's clinical assessment is more reliable to make a judgment. "Bedside evaluation" is a useful, cheap, quick and readily available method for identifying those at risk for developing complicated acute appendicitis.
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Affiliation(s)
- Mohammad Naderan
- Department of Surgery, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
| | | | - Saeed Shoar
- Department of Surgery, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
| | - Hossein Mahmoodzadeh
- Department of Surgery, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
| | - Shirzad Nasiri
- Department of Surgery, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
| | - Zhamak Khorgami
- Department of Surgery, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
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25
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Gregory S, Kuntz K, Sainfort F, Kharbanda A. Cost-Effectiveness of Integrating a Clinical Decision Rule and Staged Imaging Protocol for Diagnosis of Appendicitis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:28-35. [PMID: 26797233 DOI: 10.1016/j.jval.2015.10.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 09/28/2015] [Accepted: 10/07/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of a diagnostic protocol for appendicitis in children, the use of a validated clinical decision rule (CDR) and a staged imaging protocol, compared with usual care. METHODS We estimated the cost-effectiveness of the three competing strategies using parameters from existing literature as well as a Markov model developed to simulate the effects of exposure to ionizing radiation from a single computed tomography (CT) study in the course of diagnosis. The simulation model was applied to a hypothetical cohort of 100,000 boys and girls, age 10 years, presenting with acute abdominal pain to emergency departments in the United States. RESULTS The integrated strategy, the CDR followed by staged imaging, was found to be the most cost-effective approach. Cost savings accrued from the reduction in CT utilization for low-risk patients compared with the other two strategies. The addition of ultrasound (US) to the CDR strategy reduced CT utilization by an additional 10.9%, its main cost advantage, with negligible change in net health benefits from false-negative US results, and associated morbidity or mortality. CONCLUSIONS Results suggest that the integration of staged imaging with the CDR for the diagnosis of appendicitis in children is a cost-effective and cost-saving approach. The model estimates a further 10.9% reduction in the number of CTs from the incorporation of US for patients scoring high or medium risk, in excess of the 19.5% reduction estimated in the CDR validation study.
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Affiliation(s)
- Sean Gregory
- Department of Health Policy and Management, College of Public Health, and Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Karen Kuntz
- Department of Health Policy and Management, School of Public Health, University of Minnesota, Delaware, MN, USA
| | - François Sainfort
- Department of Health Policy and Management, School of Public Health, University of Minnesota, Delaware, MN, USA
| | - Anupam Kharbanda
- Pediatric Emergency Medicine, Children's Hospital and Clinics of Minnesota, Minneapolis, MN
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Obayashi J, Ohyama K, Manabe S, Tanaka K, Nagae H, Shima H, Furuta S, Wakisaka M, Kawase H, Kitagawa H. Are there reliable indicators predicting post-operative complications in acute appendicitis? Pediatr Surg Int 2015; 31:1189-93. [PMID: 26310685 DOI: 10.1007/s00383-015-3786-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE To clarify the predictors of post-operative complications of pediatric acute appendicitis. METHODS The medical records of 485 patients with acute appendicitis operated on between January 2006 and November 2014 were retrospectively reviewed. Age, sex, preoperative WBC, CRP, and appendix maximum short diameter on diagnostic imaging (AMSD) were compared retrospectively with the complications group (Group C) vs the non-complication group (Group NC) by Student's T test, Fisher exact test and Multivariate analysis. Regression analysis with p less than 0.01 was considered significant. We analyzed the most recent 314 laparoscopic appendectomy patients similarly. RESULTS Complications were found in 29 of the 485 appendectomies (6.0%). Comparing Group C to Group NC, preoperative WBC (×10(3)/μl) 16.4 ± 5.6 vs 14.1 ± 4.1 (p < 0.01), CRP (mg/dl) 8.3 ± 7.1 vs 3.3 ± 4.6 (p < 0.01), AMSD (mm) was 12.1 ± 3.7 vs 9.9 ± 2.8 (p < 0.01). The CRP was significantly different by Multivariate analysis, but the WBC and AMSD wasn't. The results following laparoscopic appendicectomy data were identical. CONCLUSION Preoperative WBC, CPR and AMSD all indicated an increased risk of complications. If WBC (/μl) >16,500, CRP >3.1 mg/dl and AMSD >11.4 mm, complications increased sixfold.
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Affiliation(s)
- Juma Obayashi
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kei Ohyama
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Shutaro Manabe
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kunihide Tanaka
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hideki Nagae
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hideki Shima
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Shigeyuki Furuta
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Munechika Wakisaka
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hirokazu Kawase
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hiroaki Kitagawa
- Division of Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan.
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Song RY, Jung K. Drain insertion after appendectomy in children with perforated appendicitis based on a single-center experience. Ann Surg Treat Res 2015; 88:341-4. [PMID: 26029680 PMCID: PMC4443266 DOI: 10.4174/astr.2015.88.6.341] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/12/2014] [Accepted: 12/22/2014] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Management of appendicitis in children has always been an issue in pediatric surgery. Both diagnostic methods and treatment vary significantly among medical centers, and little consensus exists in many aspects of the care for patients with appendicitis. Here, we assessed the value of drain insertion after appendectomy in children. METHODS This study is a retrospective review of pediatric patients who underwent appendectomy for perforated appendicitis at a tertiary medical center between 2003 and 2012. Patients who had a peritoneal drain inserted after appendectomy were compared with patients without drains regarding preoperative features and postoperative outcomes. Statistical analyses included a 2-tailed Student t-test and a chi-square or Fisher exact test. RESULTS In total, 958 patients were reviewed. Of 342 patients with perforated appendicitis, 108 (31.6%) had Jackson-Pratt (JP) drains inserted. The JP group had a longer hospital stay compared with the non-JP group (6.38 ± 3.59 days vs. 3.87 ± 2.38 days, P < 0.001). The JP group also had higher complication rates (22.2% vs. 6.8%, P = 0.003), including the formation of intra-abdominal abscesses. CONCLUSION According to our results, there seems to be little evidence to support peritoneal drain insertion after appendectomy, even in perforated appendicitis cases.
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Affiliation(s)
- Ra-Yeong Song
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyuwhan Jung
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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Angalakuditi M, Sunderland VB, Roberts MJ, Turner S, Lilley BJ. Impact of an Educational Program on Antibiotic Use in Paediatric Appendectomy Procedures. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2005.tb00295.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | - Sean Turner
- Princess Margaret Hospital for Children; Subiaco Western Australia
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Obinwa O, Peirce C, Cassidy M, Fahey T, Flynn J. A model predicting perforation and complications in paediatric appendicectomy. Int J Colorectal Dis 2015; 30:559-65. [PMID: 25608495 DOI: 10.1007/s00384-015-2120-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/01/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE To analyse the diagnostic value of simple clinical measurements in ensuring an early and accurate detection of advanced appendicitis (perforation, mass and peri-appendicular abscess) and possible complications. METHODS A retrospective, single-centre study of all paediatric (age 0-14 years) appendicectomies was conducted over a 14-year period. Preoperative symptoms, signs and laboratory results, intra-operative findings and postoperative complications were analyzed. Receiver operating characteristic (ROC) curves were used to estimate sensitivity and specificity of significant (p ≤ 0.05) predictor variables based on multivariate logistic regression models. RESULTS One thousand and thirty-seven patients were included. Perforations were seen in 88 (8.5%) cases, and abscesses were seen in 35 (3.4%) cases. Of all the clinical variables evaluated, preoperative temperature ≥37.5 °C was most discriminatory for advanced appendicitis. Significant other discriminatory clinical variables were WBC count ≥15,100/μL, preoperative anorexia and rebound tenderness. Postoperative complications occurred in 74 (7.1%) patients and were associated with pre-operative temperature ≥37.5 °C and advanced appendicitis. CONCLUSION Independent clinical predictors of advanced appendicitis exist but lack individual accuracy. In this study, preoperative pyrexia is shown to be highly associated with both advanced appendicitis and development of postoperative complications. This independent factor may point to early need for antibiotic treatment, urgent imaging and subsequent intervention in patients with appendicitis.
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Affiliation(s)
- Obinna Obinwa
- Department of Surgery, Portiuncula Hospital, Ballinasloe, County Galway, Ireland,
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Shbat L, Emil S, Elkady S, Baird R, Laberge JM, Puligandla P, Shaw K. Benefits of an abridged antibiotic protocol for treatment of gangrenous appendicitis. J Pediatr Surg 2014; 49:1723-5. [PMID: 25487469 DOI: 10.1016/j.jpedsurg.2014.09.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 09/05/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND We previously reported a validated, objective definition of gangrenous, nonperforated appendicitis. In this study, we compared a cohort of children with gangrenous appendicitis treated with abridged antibiotics (AA) to another treated with prolonged antibiotics (PA). METHODS In 2012, our service changed its standard of care for gangrenous appendicitis from PA to AA. In PA, patients received postoperative triple antibiotics until ileus resolved, they were afebrile (<37.5°C) for 24hours, and achieved a normal WBC count. In AA, patients received two doses of postoperative triple antibiotics. A PA cohort during a 12-month period (February 2010-January 2011) was compared to an AA cohort during another 12-month period (April 2012-March 2013). RESULTS Twenty patients were treated with AA and 38 patients with PA. AA patients had a significantly shorter overall length of stay (2.1±1.58 vs. 3.18±1.09days, p=0.003), as well as a significantly shorter postoperative stay (1.85±1.42 vs. 2.95±1.14days, p=0.002). There were no differences between the AA and PA cohorts in wound infections (0%), intraabdominal infections (0%), or appendicitis-related readmissions (0%). CONCLUSIONS Abridged postoperative antibiotics for gangrenous appendicitis significantly shorten hospital stay without increasing complications.
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Affiliation(s)
- Layla Shbat
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sherif Emil
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Sherif Elkady
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Robert Baird
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean-Martin Laberge
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Pramod Puligandla
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kenneth Shaw
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Furuya T, Inoue M, Sugito K, Goto S, Kawashima H, Kaneda H, Masuko T, Ohashi K, Ikeda T, Koshinaga T. Effectiveness of Interval Appendectomy After Conservative Treatment of Pediatric Ruptured Appendicitis with Abscess. Indian J Surg 2014; 77:1041-4. [PMID: 27011507 DOI: 10.1007/s12262-014-1121-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 06/09/2014] [Indexed: 12/27/2022] Open
Abstract
The management of patients with acute perforated appendicitis with abscess is controversial. The aim of the present study was to assess the outcomes of treatment in patients with this condition. We retrospectively analyzed 31 patients (16 men and 15 women with a mean age of 8.4 years) with appendicitis presenting with abscess. Patients were divided into two groups (emergency operation group and interval operation group), and clinical characteristics and outcomes of treatment were investigated. On presentation, no differences in gender, age, body weight, duration of symptoms, temperature, white blood cell count, C-reactive protein level, or maximum size of the abscess in the axial view were detected between the two groups. Fifteen patients (48.4 %) underwent emergency surgery. The remaining 16 patients (51.6 %) were initially treated conservatively with antibiotics. All 16 patients underwent planned operations after receiving conservative treatment, and two (12.5 %) of these patients underwent appendectomy before the planned operation day because of recurrent appendicitis without abscess. There were no differences in the length of hospital stay. In the emergency operation group, six (40 %) patients presented with wound infection and four (26.7 %) developed a postoperative intra-abdominal abscess. No infective complications were reported in the interval operation group. Interval appendectomy after conservative treatment of pediatric ruptured appendicitis with abscess significantly reduced postoperative infection rates.
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Affiliation(s)
- Takeshi Furuya
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo 173-8610 Japan
| | - Mikiya Inoue
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo 173-8610 Japan ; Department of Pediatric Surgery, Teikyo University School of Medicine, Itabashi, Japan
| | - Kiminobu Sugito
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo 173-8610 Japan
| | - Shumpei Goto
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo 173-8610 Japan
| | - Hiroyuki Kawashima
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo 173-8610 Japan
| | - Hide Kaneda
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo 173-8610 Japan
| | - Takayuki Masuko
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo 173-8610 Japan
| | - Kensuke Ohashi
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo 173-8610 Japan
| | - Taro Ikeda
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo 173-8610 Japan
| | - Tsugumichi Koshinaga
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1, Ohyaguchi-Kamicho, Itabashi-ku, Tokyo 173-8610 Japan
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Kohn MA, Carpenter CR, Newman TB. Understanding the direction of bias in studies of diagnostic test accuracy. Acad Emerg Med 2013; 20:1194-206. [PMID: 24238322 DOI: 10.1111/acem.12255] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 06/09/2013] [Accepted: 06/16/2013] [Indexed: 11/28/2022]
Abstract
Ordering and interpreting diagnostic tests is a critical part of emergency medicine (EM). In evaluating a study of diagnostic test accuracy, emergency physicians (EPs) need to recognize whether the study uses case-control or cross-sectional sampling and account for common biases. The authors group biases in studies of test accuracy into five categories: incorporation bias, partial verification bias, differential verification bias, imperfect gold standard bias, and spectrum bias. Other named biases are either equivalent to these biases or subtypes within these broader categories. The authors go beyond identifying a bias and predict the direction of its effect on sensitivity and specificity, providing numerical examples from published test accuracy studies. Understanding the direction of a bias may permit useful inferences from even a flawed study of test accuracy.
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Affiliation(s)
- Michael A. Kohn
- Department of Epidemiology and Biostatistics; University of California at San Francisco; San Francisco CA
- The Emergency Department; Mills-Peninsula Medical Center; Burlingame CA
| | | | - Thomas B. Newman
- Department of Epidemiology and Biostatistics; University of California at San Francisco; San Francisco CA
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Nataraja RM, Loukogeorgakis SP, Sherwood WJ, Clarke SA, Haddad MJ. The Incidence of Intraabdominal Abscess Formation Following Laparoscopic Appendicectomy in Children: A Systematic Review and Meta-analysis. J Laparoendosc Adv Surg Tech A 2013; 23:795-802. [DOI: 10.1089/lap.2012.0522] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Ramesh M. Nataraja
- Department of Paediatric Surgery, Chelsea and Westminster Hospital Foundation Trust, London, United Kingdom
| | - Stavros P. Loukogeorgakis
- Department of Paediatric Surgery, Chelsea and Westminster Hospital Foundation Trust, London, United Kingdom
| | - William J. Sherwood
- Department of Paediatric Surgery, Chelsea and Westminster Hospital Foundation Trust, London, United Kingdom
| | - Simon A. Clarke
- Department of Paediatric Surgery, Chelsea and Westminster Hospital Foundation Trust, London, United Kingdom
| | - Munther J. Haddad
- Department of Paediatric Surgery, Chelsea and Westminster Hospital Foundation Trust, London, United Kingdom
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Ein SH, Nasr A, Ein A. Open appendectomy for pediatric ruptured appendicitis: a historical clinical review of the prophylaxis of wound infection and postoperative intra-abdominal abscess. Can J Surg 2013; 56:E7-E12. [PMID: 23706859 DOI: 10.1503/cjs.001912] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND We conducted a 3-decade clinical review of prophylaxis for wound infection and postoperative intra-abdominal abscess after open appendectomy for pediatric ruptured appendicitis. METHODS We reviewed the charts of patients with ruptured appendicitis who underwent open appendectomy performed by the same pediatric surgeon at the Hospital for Sick Children, Toronto, Canada, between 1969 and 2003, inclusive. We evaluated 3 types of prophylaxis: subcutaneous (SC) antibiotic powder, peritoneal wound drain and intravenous (IV) antibiotics. We divided the sample into 4 treatment groups: peritoneal wound drain alone (group 1); peritoneal wound drain, SC antibiotic powder and IV antibiotics (group 2); SC antibiotic powder and IV antibiotics (group 3); and IV antibiotics alone (group 4). We used the χ(2) test with Bonferroni correction for multiple comparisons. RESULTS There were 496 patients: 348 (70%) boys and 148 (30%) girls, with a mean age of 7 (range newborn to 17) years. There were 90 (18%) wound infections. Compared with the current standard of practice, IV antibiotics alone (group 4), peritoneal wound drain (group 1) was associated with the lowest number of wound infections (7 [7%], p = 0.023). There were 43 (9%) postoperative intra-abdominal abscesses. Compared with IV antibiotics alone, SC antibiotic powder with IV antibiotics (group 3) was associated with the lowest number of postoperative intra-abdominal abscesses (14 [6%], p = 0.06). CONCLUSION Over a 35-year period of open appendectomy for pediatric ruptured appendicitis, wound infection was least frequent in patients who received prophylactic peritoneal wound drain, and postoperative intra-abdominal abscess was least frequent in those who received prophylactic SC antibiotic powder and IV antibiotics.
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Affiliation(s)
- Sigmund H Ein
- The Division of Pediatric Surgery, Hospital for Sick Children, Toronto, Ont., Canada.
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Cappiello CD, Guzzetta PC, Qureshi FG. Appendicitis is like a box of chocolates. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2013. [DOI: 10.1016/j.epsc.2013.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Zhang HL, Bai YZ, Zhou X, Wang WL. Nonoperative management of appendiceal phlegmon or abscess with an appendicolith in children. J Gastrointest Surg 2013; 17:766-70. [PMID: 23315049 DOI: 10.1007/s11605-013-2143-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 01/02/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal treatment of appendiceal phlegmon or abscess with an appendicolith is controversial. This study aimed to evaluate outcomes and prognosis of nonoperative management of appendiceal phlegmon or abscess with an appendicolith in children. METHODS From 2007 to 2011, 105 children with appendiceal phlegmon or abscess who were treated nonoperatively without interval appendectomy were reviewed. Average follow-up of subjects was 2.4 years. Data were compared between subjects with and without an appendicolith or persistent presence and disappearance of an appendicolith. RESULTS The success rate for nonoperative therapy for appendiceal phlegmon or abscess with appendicolith was 95.9 %. The risk of recurrent appendicitis in appendiceal phlegmon or abscess with appendicolith (19.1 %) was higher than that without appendicolith (8.9 %, P = 0.132). The rate of appendicolith disappearance during follow-up was 80.9 %. The persistent presence of an appendicolith was associated with a significantly higher recurrence rate (66.7 %) compared with appendicolith disappearance (7.9 %, P < 0.05). CONCLUSION Appendiceal phlegmon or abscess with an appendicolith can be managed nonoperatively, and most appendicoliths can be resolved. Persistent presence of an appendicolith is a significant risk factor for recurrent appendicitis. Interval appendectomy is recommended for persistent presence of appendicolith, but is not indicated in cases without appendicolith or appendicolith disappearance.
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Affiliation(s)
- Hai-Lan Zhang
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, No. 36 Sanhao St, Heping District, Shenyang, China, 110004
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The Analysis of Mean Platelet Volume and Platelet Distribution Width Levels in Appendicitis. Indian J Surg 2013; 77:495-500. [PMID: 26730052 DOI: 10.1007/s12262-013-0891-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 02/20/2013] [Indexed: 02/08/2023] Open
Abstract
We aimed to analyze the diagnostic value of mean platelet volume and platelet distribution width, which are also known as the markers of platelet count, in acute and perforated appendicitis. The data of 202 patients who applied to general surgery clinic in Mustafa Kemal University Hospital from 2007 to 2012 with acute appendicitis were analyzed retrospectively. The findings were separated to two groups due to the perforation status (perforated vs. non-perforated). Age, sex, leukocyte, hemoglobin, hematocrit, mean platelet volume, and platelet distribution width were examined. The mean age of the patients was 35.8. Twenty-one of all cases were perforated appendicitis (10.4 %), and the rest was acute appendicitis (non-perforated) (n = 181, 89.6 %). The mean platelet volume value was 9.8 ± 2.1 fL; mean thrombocyte count, 340.9 × 10(9)/L; and mean platelet distribution width value, 18.3 %. There were statistically significant differences between sex and age, hemoglobin, hematocrit, leukocyte, mean platelet volume, and platelet distribution width. There was a positive correlation between mean platelet volume, platelet distribution width, and platelet. Age, leukocyte, platelet, mean platelet volume, and platelet distribution width were higher in cases with perforation as a comparison with non-perforated cases. We think that mean platelet volume and platelet distribution width may be valuable markers to detect the risk of perforation in early periods of acute appendicitis.
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Noh H, Chang SJ, Han A. The diagnostic values of preoperative laboratory markers in children with complicated appendicitis. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2012; 83:237-41. [PMID: 23091796 PMCID: PMC3467390 DOI: 10.4174/jkss.2012.83.4.237] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 07/23/2012] [Accepted: 08/05/2012] [Indexed: 12/29/2022]
Abstract
Purpose Accurate diagnosis and optimal management of acute appendicitis, despite being the most common surgical emergency encountered in emergency departments, is often delayed in pediatric patients due to nonspecific symptoms and communication barriers, often leading to more complicated cases. The aim of this study is to investigate the diagnostic significance of common laboratory markers. Methods A total of 421 patients aged 15 and younger underwent surgical treatment for acute appendicitis. We conducted a retrospective analysis for white blood cell (WBC), C-reactive protein (CRP) and bilirubin. All patients were classified into simple or complicated appendicitis groups based on postoperative histology. Results The mean age of the patients in the complicated appendicitis group was younger than that in the simple group (P = 0.005). WBC, CRP and bilirubin levels were significantly higher in the complicated appendicitis group (P < 0.001, <0.001, 0.002). The relative risk for complicated appendicitis was calculated using age, WBC, CRP and bilirubin. Elevated CRP levels were associated with the highest risk for complicated appendicitis (hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.38 to 4.65) followed by WBC (HR, 2.42; 95% CI, 1.07 to 5.46) and bilirubin (HR, 2.04; 95% CI, 1.09 to 3.82). The most sensitive markers for diagnosing complicated appendicitis were WBC (95.2%) and CRP (86.3%). Bilirubin levels showed the highest specificity at 74.8%. Conclusion The risk of complicated appendicitis was significantly higher in patients younger than 10 years old. Preoperative WBC, CRP and bilirubin have clinical value in diagnosing complicated appendicitis with a HR of 2.0 to 2.5. Our results suggest that the utilization of WBC, CRP, and bilirubin can assist in the diagnosis of complicated appendicitis in pediatric patients, allowing prompt diagnosis and optimal management.
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Affiliation(s)
- Hany Noh
- Department of General Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
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Pepper VK, Stanfill AB, Pearl RH. Diagnosis and management of pediatric appendicitis, intussusception, and Meckel diverticulum. Surg Clin North Am 2012; 92:505-26, vii. [PMID: 22595706 DOI: 10.1016/j.suc.2012.03.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Three of the most common causes of surgical abdominal pain in pediatric patients include appendicitis, Meckel diverticulum, and intussusception. All 3 can present with right lower quadrant pain, and can lead to significant morbidity and even mortality. Although ultrasound is the preferred method of diagnosis with appendicitis and intussusception, considerable variety exists in the modalities needed in the diagnosis of Meckel diverticulum. This article discusses the pathways to diagnosis, the modes of treatment, and the continued areas of controversy.
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Affiliation(s)
- Victoria K Pepper
- Section of Pediatric Surgery, Department of Surgery, University of Illinois College of Medicine at Peoria, Children's Hospital of Illinois, Peoria, IL, USA
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Bansal V, Altermatt S, Nadal D, Berger C. Lack of benefit of preoperative antimicrobial prophylaxis in children with acute appendicitis: a prospective cohort study. Infection 2012; 40:635-41. [PMID: 22810888 DOI: 10.1007/s15010-012-0297-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Accepted: 06/28/2012] [Indexed: 12/01/2022]
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Emil S, Gaied F, Lo A, Laberge JM, Puligandla P, Shaw K, Baird R, Bernard C, Blumenkrantz M, Nguyen VH. Gangrenous appendicitis in children: a prospective evaluation of definition, bacteriology, histopathology, and outcomes. J Surg Res 2012; 177:123-6. [PMID: 22482763 DOI: 10.1016/j.jss.2012.03.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 02/27/2012] [Accepted: 03/08/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The definition and treatment of gangrenous appendicitis are not agreed upon. We performed a prospective study in children to evaluate an objective definition of gangrenous appendicitis, as well as associated bacteriology, histopathology, and outcomes. METHODS Five staff pediatric surgeons prospectively enrolled patients in the study at the time of appendectomy if the following five criteria were met: gray or black discoloration of the appendiceal wall; absence of fecalith outside the appendix; absence of visible hole in the appendix; absence of gross purulence or fibrinous exudate remote from the appendix; and absence of intraoperative appendiceal leak. Peritoneal fluid was cultured, and a standard histopathologic review was undertaken. Persistence of fever (>37.5°C) and ileus was documented daily. Patients were continued postoperatively on ampicillin, gentamicin, and metronidazole until they tolerated diet, manifested a 24-h afebrile period, and had a normal leukocyte count. Hospital stay, readmissions, and infectious complications were recorded. The study took place over a 12-mo period. RESULTS Thirty-eight patients were enrolled, representing 17% of all patients with appendicitis treated during the year. Average age was 10.8 ± 3.5 y. Peritoneal cultures were positive in 53% of cases. Gangrene was documented histologically in 61% of specimens. Hospital stay was 3.2 ± 1.1 d. There were no postoperative infectious complications or readmissions related to the disease. Neither culture results nor histologic gangrene had a statistically significant effect on hospital stay. CONCLUSIONS An objective definition of gangrenous appendicitis is reproducible and has good histopathologic association. Recovery from gangrenous appendicitis is not influenced by culture or pathology results, and postoperative complications are rare. Limiting postoperative antibiotics to 24 h in gangrenous appendicitis may significantly decrease the cost of treatment without increasing morbidity.
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Affiliation(s)
- Sherif Emil
- Division of Pediatric General Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
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External validation of Lintula score in Turkish acute appendicitis patients. Int J Surg 2012; 10:25-7. [DOI: 10.1016/j.ijsu.2011.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 10/23/2011] [Accepted: 11/17/2011] [Indexed: 12/29/2022]
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Zakaria O, Sultan TA, Khalil TH, Wahba T. Role of clinical judgment and tissue harmonic imaging ultrasonography in diagnosis of paediatric acute appendicitis. World J Emerg Surg 2011; 6:39. [PMID: 22087573 PMCID: PMC3285058 DOI: 10.1186/1749-7922-6-39] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 11/16/2011] [Indexed: 02/08/2023] Open
Abstract
Background Appendicitis is the most common surgical emergency in children; yet, diagnosis of equivocal presentations continues to challenge clinicians. Aim The objective of this study was to investigate the hypothesis that the use of a modified clinical practice and harmonic ultrasonographic grading scores (MCPGS) may improve the accuracy in diagnosing acute appendicitis in the pediatric population. Patients & Methods Results The Number of appendectomies declined from 200 (75.5%) in our previous CPGS to 187 (70.6%) in the MCPGS (P > 0.05). Specificity was significantly higher when applying MCPGS (90.7%) in this study compared to 70.47% in our previous work when CPGS was applied (P < 0.01). Furthermore, the positive predictive value (PPV) was significantly higher (95.72%) than in our previous study (82.88%), (P < 0.01). Overall agreement (accuracy) of MCPGS was 96.98%. Kappa = 0.929 (P < 0.001). Negative predictive power was 100%. And the Overall agreement (accuracy) was 96.98%. Conclusions MCPGS tends to help in reduce the numbers of avoidable and unnecessary appendectomies in suspected cases of pediatric acute appendicitis that may help in saving hospital resources.
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Affiliation(s)
- Ossama Zakaria
- Division of Pediatric Surgery, Departments of Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.
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Narsule CK, Kahle EJ, Kim DS, Anderson AC, Luks FI. Effect of delay in presentation on rate of perforation in children with appendicitis. Am J Emerg Med 2011; 29:890-3. [PMID: 20627213 DOI: 10.1016/j.ajem.2010.04.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Revised: 03/16/2010] [Accepted: 04/11/2010] [Indexed: 10/19/2022] Open
Affiliation(s)
- Chaitan K Narsule
- Division of Pediatric Surgery, Hasbro Children's Hospital and Warren Alpert Medical School of Brown University, Providence, RI 02905, USA
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Abstract
BACKGROUND A large service and distant geographical area can make the process of diagnosing and treating appendicitis a challenge. METHODS Hospital records of children treated for appendicitis between 2007 and 2009 were retrospectively analyzed, including time from emergency (ER) to operating room (OR), diagnostic imaging (DI) utilization, preoperative antibiotic usage, operating time, length of stay (LOS), and perforation rate. RESULTS The perforation rate was 34%, with longer LOS. Transfer time to the children's hospital between ER inside and outside the city was not different. ER to OR time was significantly shorter for patients assessed at the children's hospital directly. Ultrasound remained the most used DI modality (55%). Preoperative antibiotics were only fully administered in 42% of the cases. CONCLUSION A clinical pathway for pediatric appendicitis may address the challenges of the process of pre-ER, ER to OR, and OR care to maintain an acceptable perforation rate.
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Adibe OO, Muensterer OJ, Georgeson KE, Harmon CM. Severity of appendicitis correlates with the pediatric appendicitis score. Pediatr Surg Int 2011; 27:655-8. [PMID: 20936475 DOI: 10.1007/s00383-010-2744-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2010] [Indexed: 12/29/2022]
Abstract
PURPOSE The pediatric appendicitis score (PAS) has been used as a diagnostic tool for the assessment of acute abdominal pain. Our institution has utilized this scoring system as part of a clinical pathway for acute appendicitis. We sought to discover if the PAS could also serve as a prognostic indicator. METHODS Patients treated within the clinical pathway were divided into three groups (A, B, and C) based on the PAS assigned on admission. Data pertaining to intraoperative findings and length of hospital stay were collected prospectively. RESULTS In 4 months, 112 patients were enrolled in the study (median age 10.5, range 1-18). 69 of these patients underwent early laparoscopic appendectomy. For group A, 75% had simple appendicitis and 5% were complex. For group B, 68.4% patients had simple appendicitis and 26.3% were complex. For group C, 27.3% were simple and 63.6% were complex. Mean length of hospital stay increased from 1.63 ± 0.34 for patients in group A to 5.9 ± 1.37 for patients in group C. CONCLUSION Our observational data suggests that the PAS may be a prognostic tool for acute appendicitis. It thereby may impact on preoperative management and postoperative clinical pathways. A larger cohort is necessary to validate our findings.
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Affiliation(s)
- Obinna O Adibe
- Division of Pediatric Surgery, The Children's Hospital of Alabama, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA.
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Shindholimath VV, Thinakaran K, Rao TN, Veerappa YV. Laparoscopic management of appendicular mass. J Minim Access Surg 2011; 7:136-40. [PMID: 21523236 PMCID: PMC3078476 DOI: 10.4103/0972-9941.78345] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Accepted: 10/13/2010] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Laparoscopic appendectomy is becoming the preferred technique for treating acute appendicitis. However, its role in the treatment of complicated appendicitis is controversial. This study was undertaken to assess the feasibility of laparoscopic appendectomy for appendicular mass. MATERIALS AND METHODS A retrospective review was performed of all the patients who were treated laparoscopically for appendicular mass from March 2007 to October 2009. SETTING Tertiary care hospital. RESULTS A total of 120 patients were treated for appendicitis. A retrospective review of the patients' records demonstrated that 19 patients (15.8%) had appendicular mass at the time of admission. The average operative time was 95 minutes (range 45-140 minutes). Pathological evidence of appendicitis was present in all the patients. The average length of hospital stay was six days (rang 6-9 days). Three patients (15.7%) had post- operative complications. Two patients developed wound infections and one patient was re-admitted with pain and a lump below the umbilical port. CONCLUSION The findings suggest that laparoscopic appendectomy is feasible in patients with appendicular mass. The authors propose a prospective, randomized trial to verify this finding.
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Affiliation(s)
- Vishwanath V Shindholimath
- Department of Surgery, PES Institute of Medical Sciences and Research, Kuppam, 517 425, District Chittoor, Andhra Pradesh, India
| | - K Thinakaran
- Department of Surgery, PES Institute of Medical Sciences and Research, Kuppam, 517 425, District Chittoor, Andhra Pradesh, India
| | - T Narayana Rao
- Department of Surgery, PES Institute of Medical Sciences and Research, Kuppam, 517 425, District Chittoor, Andhra Pradesh, India
| | - Yenni Veerabhadrappa Veerappa
- Department of Pathology, PES Institute of Medical Sciences and Research, Kuppam, 517 425, District Chittoor, Andhra Pradesh, India
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An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children. J Pediatr Surg 2011; 46:192-6. [PMID: 21238665 DOI: 10.1016/j.jpedsurg.2010.09.087] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2010] [Accepted: 09/30/2010] [Indexed: 11/22/2022]
Abstract
PURPOSE The increased use of computed tomography (CT) to diagnose appendicitis in children has led to a concern for the possibility of increased CT-related cancer morbidity. We designed a clinical protocol for the diagnosis and treatment of appendicitis in children in an attempt to decrease the use of CT scans at our institution. METHODS Patients who had surgical consultation for suspected appendicitis were placed on the clinical protocol. Data concerning diagnosis and treatment were collected prospectively. Retrospective data from patients admitted to our institution with acute appendicitis before the clinical protocol were collected as historical controls. RESULTS One hundred twelve patients were diagnosed and treated by our protocol between June and November 2009. Of these, 100 patients underwent an appendectomy for acute appendicitis. They were compared with 146 patients from 2007. In-house CT use decreased from 71.2% to 51.7% (P = .01). Preoperative ultrasound use increased from 2.7% to 21% (P < .001). The negative appendectomy rate increased (6.8% vs 11%, P = .25). CONCLUSIONS Our findings suggest that the implementation of an evidence-based clinical protocol for the diagnosis and treatment of acute appendicitis in children may safely decrease the use of CT scans and increase the use of ultrasound.
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Computed Tomography Criterion for the Diagnosis of Appendicitis Without Periappendiceal Inflammation in Children Using the Maximum Depth of Intraluminal Appendiceal Fluid. J Comput Assist Tomogr 2010; 34:907-14. [PMID: 21084908 DOI: 10.1097/rct.0b013e3181ec05fe] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ben Dhaou M, Ghorbel S, Chouikh T, Charieg A, Nouira F, Ben Khalifa S, Khemakhem R, Jlidi S, Chaouachi B. Conservative management of post-appendicectomy intra-abdominal abscesses. Ital J Pediatr 2010; 36:68. [PMID: 20946659 PMCID: PMC2976736 DOI: 10.1186/1824-7288-36-68] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 10/14/2010] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Appendicitis is the most common abdominal inflammatory process in children which were sometimes followed by complications including intra-abdominal abscess. This later needs classically a surgical drainage. We evaluated the efficacy of antibiotic treatment and surgical drainage. METHODS Hospital records of children treated in our unit for intra-abdominal post appendectomy abscesses over a 6 years period were reviewed retrospectively. RESULTS This study investigates a series of 14 children from 2 to 13 years of age with one or many abscesses after appendectomy, treated between 2002 and 2007. Seven underwent surgery and the others were treated with triple antibiotherapy. The two groups were comparable. For the 7 patients who receive medical treatment alone, it was considered efficient in 6 cases (85%) with clinical, biological and radiological recovery of the abscess. There was one failure (14%). The duration of hospitalization from the day of diagnosis of intra-abdominal abscess was approximately 10.28 days (range 7 to 14 days). In the other group, the efficacy of treatment was considered satisfactory in all cases. The duration of hospitalization was about 13 days (range: 9 to 20). CONCLUSION Compared to surgical drainage, antibiotic management of intra-abdominal abscesses was a no invasive treatment with shorter hospitalization.
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Affiliation(s)
- Mahdi Ben Dhaou
- Department of paediatric surgery B, Children Hospital of Tunis, 1007 Tunis, Tunisia
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