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Becker G, Fuhrer AE, Kremer K, Hochschild A, Kammar H, Sukhotnik I. Age as an Exclusion Criterion for Nonoperative Management in Simple Acute Appendicitis in Children. Eur J Pediatr Surg 2024; 34:102-106. [PMID: 37591255 DOI: 10.1055/a-2155-7642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
OBJECTIVE Nonoperative management (NOM) for simple acute appendicitis (SAA) is an acceptable mode of treatment in healthy children. Previous studies of NOM routinely excluded young children (< 5 years); however, the effect of age on NOM failure has not been directly assessed. Efficiency of NOM in young adults is questionable. Therefore, adolescents may also be at greater risk of NOM failure. Our aim was to investigate the effect of age on NOM failure. METHODS This is a retrospective analysis of children with SAA who received NOM between January 1, 2019, and June 30, 2021, at our institution. NOM failure was defined by subsequent appendectomy. Age was assessed as a continuous variable, and we also compared different age subgroups. RESULTS In this study, 151 children were included (60% male), mean age 11.2 ± 3.2 years (range: 5-17). Overall, 66 children (44%) failed NOM, 90% of them within the first year (median 7 weeks). Ten percent of the cohort were younger than 6 years of age and 33% of them failed NOM (p = 0.39). Per 1 year increase in age, the odds of NOM failure increased by 12% (p = 0.027). Children over 14 years of age had 2.46 times higher odds to fail NOM (p = 0.03). These higher odds remained after adjusting for appendiceal diameter and appendicolith. Linear regression showed a decrease by a factor of 12 at the time of NOM failure with every 1-year increase in age (β = -12, p = 0.09). CONCLUSION The risk of NOM failure in children increases with age; therefore, age should be considered when deciding on the optimal management of SAA, especially in adolescents. Effectiveness of NOM in children younger than 6 years is noninferior to older children and therefore should not be excluded.
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Affiliation(s)
- Gal Becker
- Department of Pediatric Surgery, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Audelia Eshel Fuhrer
- Department of Pediatric Surgery, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Keren Kremer
- Department of Pediatric Surgery, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Annabella Hochschild
- Department of Pediatric Surgery, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Haguy Kammar
- Department of Pediatric Surgery, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Igor Sukhotnik
- Department of Pediatric Surgery, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Patterson KN, Deans KJ, Minneci PC. Shared decision-making in pediatric surgery: An overview of its application for the treatment of uncomplicated appendicitis. J Pediatr Surg 2023; 58:729-734. [PMID: 36379750 DOI: 10.1016/j.jpedsurg.2022.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/17/2022] [Accepted: 10/12/2022] [Indexed: 11/15/2022]
Abstract
Nonoperative management (NOM) of uncomplicated appendicitis is a safe and effective treatment alternative to surgery that may be preferred by some families. Surgery and NOM differ significantly in their associated risks and benefits. Choosing a treatment for acute appendicitis requires patients and their caregivers to make timely, informed decisions that allow for incorporation of personal perspectives, values, and preferences. This article will address the concept of shared decision-making and establish its role in patient-centered care. It will demonstrate the effectiveness of shared decision-making in a high acuity surgical setting for children and highlight how the choice for management of acute appendicitis may be impacted by patients' and families' individualized circumstances and values.
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Affiliation(s)
- Kelli N Patterson
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Katherine J Deans
- Department of Surgery, Nemours Children's Health Delaware, 1600 Rockland Rd, Wilimington, DE 19803, USA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
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Ferreira J, Patel P, Guadagno E, Ow N, Wray J, Emil S, Poenaru D. Patient experience or patient satisfaction? A systematic review of child- and family-reported experience measures in pediatric surgery. J Pediatr Surg 2023; 58:862-870. [PMID: 36797113 DOI: 10.1016/j.jpedsurg.2023.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/02/2023] [Indexed: 01/21/2023]
Abstract
PURPOSE Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are increasingly recognized as important health care quality indicators. PREMs measure patients' perception of the care they have received, differing from satisfaction ratings, which measure their expectations. The use of PREMs in pediatric surgery is limited, prompting this systematic review to assess their characteristics and identify areas for improvement. METHODS A search was conducted in eight databases from inception until January 12, 2022, to identify PREMs used with pediatric surgical patients, with no language restrictions. We focused on studies of patient experience but also included studies that assessed satisfaction and sampled experience domains. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool. RESULTS Following title and abstract screening of 2633 studies, 51 were included for full-text review, of which 22 were subsequently excluded because they measured only patient satisfaction rather than experience, and 14 were excluded for a range of other reasons. Out of the 15 included studies, questionnaires used in 12 studies were proxy-reported by parents and in 3 by both parents and children; none focused only on the child. Most instruments were developed in-house for each specific study, without patients' involvement in the process, and were not validated. CONCLUSIONS Although PROMs are increasingly used in pediatric surgery, PREMs are not yet in use, being typically substituted by satisfaction surveys. Significant efforts are needed to develop and implement PREMs in pediatric surgical care, in order to effectively capture children's and families' voices. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Julia Ferreira
- McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada; Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Prachikumari Patel
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Elena Guadagno
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Nikki Ow
- Department of Occupational Science and Occupational Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jo Wray
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sherif Emil
- McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada; Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Dan Poenaru
- McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada; Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada.
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Nepomuceno H, Pearson EG. Nonoperative management of appendicitis in children. Transl Gastroenterol Hepatol 2021; 6:47. [PMID: 34423168 DOI: 10.21037/tgh-20-191] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/23/2020] [Indexed: 11/06/2022] Open
Abstract
Appendicitis is a common condition in childhood and adolescence that frequently requires urgent surgical intervention. For almost two centuries appendicitis has been recognized as a medical problem with a surgical solution. Currently the appendix can be removed with a minimally invasive approach, low anesthetic and surgical risk, and swift hospital discharge. Despite these advances, surgery and anesthesia have associated risks including postoperative infection, bleeding, hernia and organ injury among others. In addition, surgery requires time off of school and work to recover and associated healthcare costs can be significant. In both adult and pediatric populations, quality data suggesting a nonoperative approach is suggesting a change to the traditional surgical paradigm. Adults studies have demonstrated both safety and efficacy in the nonoperative management of acute appendicitis. In selected children with uncomplicated appendicitis, initial nonoperative management has been shown to be safe with fewer complications, fewer disability days and less healthcare costs while avoiding the risks inherent to surgery. Ongoing randomized controlled clinical trials in both the United States and Europe seek to further demonstrate the safety of nonoperative management and assist physicians with educating patients about the risk profile of their treatment decision. In complicated appendicitis presenting with abscess or acute appendiceal phlegmon, an initial nonoperative strategy with or without abscess drainage followed by interval appendectomy is the current state of the art though the utility of interval appendectomy is questioned.
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Affiliation(s)
- Helene Nepomuceno
- Department of Pediatric Surgery, Sunrise Children's Hospital, Las Vegas, NV, USA
| | - Erik G Pearson
- Department of Pediatric Surgery, Sunrise Children's Hospital, Las Vegas, NV, USA
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Kvasnovsky CL, Shi Y, Rich BS, Glick RD, Soffer SZ, Lipskar AM, Dolgin S, Bagrodia N, Hong A, Prince JM, James DE, Sathya C. Limiting hospital resources for acute appendicitis in children: Lessons learned from the U.S. epicenter of the COVID-19 pandemic. J Pediatr Surg 2021; 56:900-904. [PMID: 32620267 PMCID: PMC7309720 DOI: 10.1016/j.jpedsurg.2020.06.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/06/2020] [Accepted: 06/14/2020] [Indexed: 01/22/2023]
Abstract
INTRODUCTION The COVID-19 pandemic resulted in the suspension of nonemergent surgeries throughout New York. Our tertiary care children's hospital pivoted towards a brief trial of intravenous (IV) antibiotic therapy in all patients in order to limit operating room (OR) utilization and avoid prolonged hospital stays. We describe our pandemic-based strategy for non-operative management (NOM) of appendicitis but with a limited duration of IV antibiotics. METHODS We performed a retrospective study of children treated for acute appendicitis at our center from 3/31/2020 to 5/3/2020 during the peak of the New York pandemic. We compared appendicitis volume to similar months in prior years. We evaluated failure of NOM, length of stay, and compared characteristics of children we successfully treated with our expanded NOM protocol to previously published inclusion criteria for NOM. RESULTS 45.5% of children (25/55) with acute appendicitis underwent NOM. Of the 30 who underwent surgery, 13 had complicated appendicitis while 17 had simple appendicitis. Three patients were COVID-positive, although none had respiratory symptoms. The majority of patients presenting with acute appendicitis (78.2%) did not meet previously published criteria for NOM. CONCLUSIONS We treated a similar volume of children with acute appendicitis during the pandemic compared to prior years. We applied non-operative management to nearly half our patients, even as we expanded inclusion criteria for NOM to reduce OR utilization, but limited the duration of the antibiotic trial to avoid prolonged hospital stays. TYPE OF STUDY Retrospective study. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Charlotte L Kvasnovsky
- Cohen Children's Medical Center, Division of Pediatric Surgery, New Hyde Park, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
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Nonsurgical Management of Acute Appendicitis in Sickle Cell Disease. J Pediatr Hematol Oncol 2021; 43:28-30. [PMID: 32134840 DOI: 10.1097/mph.0000000000001774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 9-year-old child with sickle cell disease (sickle beta zero thalassemia) was diagnosed to have acute appendicitis during a hospitalization for pain, acute chest syndrome, and exacerbation of asthma. Because of his high surgical risk, his appendicitis was treated nonsurgically, successfully deferring his appendectomy. He remains well after 1 year. This approach should be considered at least in other sickle cell patients with appendicitis, and perhaps other high-risk populations, if not all children with appendicitis.
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Minneci PC, Hade EM, Lawrence AE, Sebastião YV, Saito JM, Mak GZ, Fox C, Hirschl RB, Gadepalli S, Helmrath MA, Kohler JE, Leys CM, Sato TT, Lal DR, Landman MP, Kabre R, Fallat ME, Cooper JN, Deans KJ. Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis. JAMA 2020; 324:581-593. [PMID: 32730561 PMCID: PMC7385674 DOI: 10.1001/jama.2020.10888] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Nonoperative management with antibiotics alone has the potential to treat uncomplicated pediatric appendicitis with fewer disability days than surgery. Objective To determine the success rate of nonoperative management and compare differences in treatment-related disability, satisfaction, health-related quality of life, and complications between nonoperative management and surgery in children with uncomplicated appendicitis. Design, Setting, and Participants Multi-institutional nonrandomized controlled intervention study of 1068 children aged 7 through 17 years with uncomplicated appendicitis treated at 10 tertiary children's hospitals across 7 US states between May 2015 and October 2018 with 1-year follow-up through October 2019. Of the 1209 eligible patients approached, 1068 enrolled in the study. Interventions Patient and family selection of nonoperative management with antibiotics alone (nonoperative group, n = 370) or urgent (≤12 hours of admission) laparoscopic appendectomy (surgery group, n = 698). Main Outcomes and Measures The 2 primary outcomes assessed at 1 year were disability days, defined as the total number of days the child was not able to participate in all of his/her normal activities secondary to appendicitis-related care (expected difference, 5 days), and success rate of nonoperative management, defined as the proportion of patients initially managed nonoperatively who did not undergo appendectomy by 1 year (lowest acceptable success rate, ≥70%). Inverse probability of treatment weighting (IPTW) was used to adjust for differences between treatment groups for all outcome assessments. Results Among 1068 patients who were enrolled (median age, 12.4 years; 38% girls), 370 (35%) chose nonoperative management and 698 (65%) chose surgery. A total of 806 (75%) had complete follow-up: 284 (77%) in the nonoperative group; 522 (75%) in the surgery group. Patients in the nonoperative group were more often younger (median age, 12.3 years vs 12.5 years), Black (9.6% vs 4.9%) or other race (14.6% vs 8.7%), had caregivers with a bachelor's degree (29.8% vs 23.5%), and underwent diagnostic ultrasound (79.7% vs 74.5%). After IPTW, the success rate of nonoperative management at 1 year was 67.1% (96% CI, 61.5%-72.31%; P = .86). Nonoperative management was associated with significantly fewer patient disability days at 1 year than did surgery (adjusted mean, 6.6 vs 10.9 days; mean difference, -4.3 days (99% CI, -6.17 to -2.43; P < .001). Of 16 other prespecified secondary end points, 10 showed no significant difference. Conclusion and Relevance Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year. However, there was substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not met. Trial Registration ClinicalTrials.gov Identifier: NCT02271932.
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Affiliation(s)
- Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Erinn M Hade
- Departments of Biomedical Informatics and Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Amy E Lawrence
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Yuri V Sebastião
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jacqueline M Saito
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Grace Z Mak
- Section of Pediatric Surgery, Department of Surgery, University of Chicago Medicine and Biologic Sciences, Chicago, Illinois
| | - Christa Fox
- Section of Pediatric Surgery, Department of Surgery, University of Chicago Medicine and Biologic Sciences, Chicago, Illinois
| | - Ronald B Hirschl
- Division of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor
| | - Samir Gadepalli
- Division of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor
| | - Michael A Helmrath
- Division of Pediatric Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan E Kohler
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Thomas T Sato
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Matthew P Landman
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Rashmi Kabre
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mary E Fallat
- Division of Pediatric Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
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Padula WV, McQueen RB. Expanding the Role of the Patient-Centered Outcomes Research Institute: Reauthorization and Facilitating Value Assessments. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:757-759. [PMID: 31586307 PMCID: PMC6885497 DOI: 10.1007/s40258-019-00525-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- William V Padula
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, USA
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - R Brett McQueen
- Department of Clinical Pharmacy, Center for Pharmaceutical Outcomes Research (CePOR), Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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