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Lamm R, Kumar SS, Collings AT, Haskins IN, Abou-Setta A, Narula N, Nepal P, Hanna NM, Athanasiadis DI, Scholz S, Bradley JF, Train AT, Pucher PH, Quinteros F, Slater B. Diagnosis and treatment of appendicitis: systematic review and meta-analysis. Surg Endosc 2023; 37:8933-8990. [PMID: 37914953 DOI: 10.1007/s00464-023-10456-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children. METHODS Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively. RESULTS 2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04). CONCLUSIONS This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.
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Affiliation(s)
- Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Thomas Jefferson University, 1015 Walnut Street, 613 Curtis, Philadelphia, PA, 19107, USA.
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Nisha Narula
- Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Pramod Nepal
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joel F Bradley
- Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Philip H Pucher
- Department of Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago Medicine, Chicago, IL, USA
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Labs Do Not Predict Postoperative Intra-abdominal Abscess in Pediatric Perforated Appendicitis. J Surg Res 2023; 285:20-25. [PMID: 36638551 DOI: 10.1016/j.jss.2022.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 12/27/2022] [Accepted: 12/27/2022] [Indexed: 01/13/2023]
Abstract
INTRODUCTION We aim to evaluate the utility of postoperative labs in predicting the development of an intra-abdominal abscess (IAA) in pediatric patients with perforated appendicitis. We hypothesize that postoperative labs are not predictive of IAA development. METHODS This was a single-institution retrospective cohort study that included pediatric patients (n = 61) who underwent surgery for perforated appendicitis from January 1, 2019 to December 1, 2020. Patients were stratified into those who developed a postoperative IAA (n = 22) and those who did not (n = 39). Postoperative labs (white blood cell [WBC] count, absolute neutrophil count, platelet count, C-reactive protein) were examined. Mann-Whitney U tests and chi-square tests were used to assess for differences between groups. RESULTS There was extensive heterogeneity and overlap in postoperative lab values between patients who developed an IAA and those who did not. Almost all patients who developed an IAA had clinical signs that were indicative of abscess formation regardless of their postoperative WBC count or change in WBC count. While patients who developed an IAA had a higher postoperative median WBC count (10.8 versus 8.4, P = 0.003) and a smaller WBC count decrease (-4.9 versus -7.4, P = 0.01), no cutoff value for any of the examined lab values specifically predicted abscess formation. Postoperative median absolute neutrophil count (7.4 versus 4.0, P = 0.15), platelet count (360 versus 353, P = 0.98), and C-reactive protein (8.20 versus 5.32, P = 0.06) did not differ significantly. CONCLUSIONS We conclude that postoperative labs have limited clinical utility in evaluating IAA development in children with perforated appendicitis.
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Theodorou CM, Lee SY, Lawrence Y, Saadai P, Hirose S, Brown EG. The Utility of Discharge Antibiotics in Pediatric Perforated Appendicitis Without Leukocytosis. J Surg Res 2022; 275:48-55. [PMID: 35219251 PMCID: PMC10032146 DOI: 10.1016/j.jss.2022.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/14/2021] [Accepted: 01/26/2022] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Optimal management of pediatric perforated appendicitis remains a topic of active investigation. Our institutional clinical practice guidelines (CPGs) were modified to discontinue antibiotics on discharge for patients with normal white blood cell count (WBC) without left shift. We hypothesized that patients would receive fewer antibiotics without increased complications. METHODS Patients <18 y old with perforated appendicitis who underwent laparoscopic appendectomy between November 1, 2016 and May 31, 2021 at a tertiary care children's hospital were included. Primary outcome was adverse events: postdischarge surgical site infection (SSI), 30-day emergency department (ED) visits, or readmissions. Outcomes were compared before and after CPG modification. Multivariable regression was performed to identify factors associated with SSI. RESULTS There were 113 patients pre- and 97 patients post-CPG modification. 23.1% of patients in the pre-cohort had an elevated discharge WBC or left shift compared to 18.9% of patients in the post-cohort (P = 0.48). Significantly fewer patients were prescribed antibiotics on discharge in the post-cohort (70.8% pre versus 14.4% post, P < 0.0001) and for fewer days (2 pre versus 0 post, P < 0.0001). Total antibiotic days decreased significantly (6.1 pre versus 4.6 post, P < 0.0001). There was an increase in postdischarge SSIs on univariate analysis (1.8% pre versus 9.3% post, P = 0.03), ED visits (9.7% pre versus 19.6% post, P = 0.04), and readmissions (5.3% pre versus 11.3% post, P = 0.13). On multivariable analysis, being in the post-cohort was not significantly associated with post-discharge SSIs after adjusting for sex, symptom duration, initial WBC, and discharge antibiotic duration (OR 0.25, 95% CI 0.04-1.4, P = 0.11). CONCLUSIONS Modification of a pediatric perforated appendicitis clinical practice guideline to discontinue antibiotics on discharge with a normal WBC without left shift was effective in decreasing antibiotic duration. This was associated with an increase in SSIs on univariate analysis, which did not persist on multivariable analysis and requires further investigation.
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Affiliation(s)
- Christina M Theodorou
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California.
| | - Su Yeon Lee
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
| | - Yemi Lawrence
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
| | - Payam Saadai
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
| | - Shinjiro Hirose
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
| | - Erin G Brown
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
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Plattner AS, Newland JG, Wallendorf MJ, Shakhsheer BA. Management and Microbiology of Perforated Appendicitis in Pediatric Patients: A 5-Year Retrospective Study. Infect Dis Ther 2021; 10:2247-2257. [PMID: 34287780 PMCID: PMC8572942 DOI: 10.1007/s40121-021-00502-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/12/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION This study aims to assess the current epidemiology and microbiology of perforated appendicitis, how antibiotic choice and duration correlate with meaningful clinical outcomes, and whether serial white blood cell (WBC) counts provide clinical value. METHODS Five-year retrospective cohort study, 2015-2019, among 333 consecutive children, ages 0-18 years, treated at St. Louis Children's Hospital for perforated appendicitis. Main outcomes included length of stay (LOS), postoperative abscess formation, and readmission. Statistical analysis was performed with uni- and multi-variate analyses. RESULTS Intra-abdominal cultures most commonly grew Bacteroides fragilis (52%) and Escherichia coli (50%). Patients who initially received broad-spectrum antibiotics (meropenem, piperacillin-tazobactam, fourth-generation cephalosporins) for perforated appendicitis had greater rates of postoperative abscess formation (25% vs. 12%, p < 0.01) and LOS (7.0 vs. 5.7 days, p < 0.01). Similarly, antibiotics at time of discharge were associated with greater postoperative abscess formation (22% vs. 9%, p < 0.01) and LOS (6.4 vs. 5.6 days, p = 0.02). However, discharge with strictly oral antibiotics was not correlated with greater LOS, postoperative abscess formation, or readmission rates compared to discharge without antibiotics. Serial WBC counts had no predictive value for LOS, postoperative abscess formation, or readmission. CONCLUSIONS Bacteroides fragilis and E. coli were the most common intra-abdominal microbes for perforated appendicitis among our cohort. In non-critically ill children, the routine use of broad-spectrum antibiotics or continuation of antibiotics beyond discharge was not correlated with improved clinical outcomes. Additionally, WBC counts were not correlated with meaningful clinical outcomes.
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Affiliation(s)
- Alex S Plattner
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Jason G Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Michael J Wallendorf
- Division of Biostatistics, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Baddr A Shakhsheer
- Division of Pediatric Surgery, Department of Surgery, Washington University in St Louis School of Medicine, 1 Children's Place, Suite 6110-CB 8235, St Louis, MO, 63110, USA.
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Ketha B, Stephenson KJ, Dassinger MS, Smith SD, Burford JM. Eliminating Use of Home Oral Antibiotics in Pediatric Complicated Appendicitis. J Surg Res 2021; 263:151-154. [PMID: 33652177 DOI: 10.1016/j.jss.2020.12.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 12/15/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Postoperative oral antibiotic management at discharge for perforated appendicitis varies by institution. A prior study at our institution led to a decrease in antibiotic therapy in patients without leukocytosis. A subsequent protocol change eliminated the white blood cell count check and oral antibiotics if discharge criteria were met by postoperative day seven. We hypothesized this change could be made without an increase in abscess or readmission rates. METHODS We conducted a retrospective review of patients with perforated appendicitis over two 1-year periods after institutional review board approval (262061). In the pre-protocol group, a white blood cell count was checked at discharge and patients with leukocytosis were prescribed oral antibiotics to complete a total of 7 d. In the post-protocol group, no white blood cell count was checked and patients were discharged home without antibiotics. RESULTS There were a total of 174 patients with complicated appendicitis in the two 1-year periods with 129 (74%) patients with perforated appendicitis discharged before postoperative day seven. The pre-protocol group included 71 children, and post-protocol included 58 children. There were no differences between mean postoperative days to discharge (2.57 versus 3, P = 0.0896), postoperative abscess rate (12.7% versus 12.1%, P = 1.0000), or readmission rate (12.7% versus 17.2%, P = 0.6184). None of the patients in the post-protocol group were discharged home with oral antibiotics compared with 22.5% in the pre-protocol group (P < 0.001). CONCLUSIONS For pediatric patients with perforated appendicitis discharged before postoperative day seven, stopping antibiotics at the time of discharge significantly decreased our home antibiotic use without an increase in postoperative morbidity.
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Affiliation(s)
- Bavana Ketha
- Arkansas Children's Hospital, Division of Pediatric Surgery, Little Rock, Arkansas.
| | - Krista J Stephenson
- Arkansas Children's Hospital, Division of Pediatric Surgery, Little Rock, Arkansas
| | - Melvin S Dassinger
- Arkansas Children's Hospital, Division of Pediatric Surgery, Little Rock, Arkansas
| | - Samuel D Smith
- Arkansas Children's Hospital, Division of Pediatric Surgery, Little Rock, Arkansas
| | - Jeffrey M Burford
- Arkansas Children's Hospital, Division of Pediatric Surgery, Little Rock, Arkansas
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