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Abu-Ashour W, Emil S, Poenaru D. Using Artificial Intelligence to Label Free-Text Operative and Ultrasound Reports for Grading Pediatric Appendicitis. J Pediatr Surg 2024; 59:783-790. [PMID: 38383177 DOI: 10.1016/j.jpedsurg.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 01/22/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE Data science approaches personalizing pediatric appendicitis management are hampered by small datasets and unstructured electronic medical records (EMR). Artificial intelligence (AI) chatbots based on large language models can structure free-text EMR data. We compare data extraction quality between ChatGPT-4 and human data collectors. METHODS To train AI models to grade pediatric appendicitis preoperatively, several data collectors extracted detailed preoperative and operative data from 2100 children operated for acute appendicitis. Collectors were trained for the task based on satisfactory Kappa scores. ChatGPT-4 was prompted to structure free text from 103 random anonymized ultrasound and operative records in the dataset using the set variables and coding options, and to estimate appendicitis severity grade from the operative report. A pediatric surgeon then adjudicated all data, identifying errors in each method. RESULTS Within the 44 ultrasound (42.7%) and 32 operative reports (31.1%) discordant in at least one field, 98% of the errors were found in the manual data extraction. The appendicitis grade was erroneously assigned manually in 29 patients (28.2%), and by ChatGPT-4 in 3 (2.9%). Across datasets, the use of the AI chatbot was able to avoid misclassification in 59.2% of the records including both reports and extracted data approximately 40 times faster. CONCLUSION AI chatbot significantly outperformed manual data extraction in accuracy for ultrasound and operative reports, and correctly assigned the appendicitis grade. While wider validation is required and data safety concerns must be addressed, these AI tools show significant promise in improving the accuracy and efficiency of research data collection. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Waseem Abu-Ashour
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; McGill University Health Centre Research Institute, Montreal, Quebec, Canada.
| | - Sherif Emil
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; McGill University Health Centre Research Institute, Montreal, Quebec, Canada
| | - Dan Poenaru
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; McGill University Health Centre Research Institute, Montreal, Quebec, Canada
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Yang J, Yang L, Zheng S, Miyasaka EA. Lack of Routine Postoperative Labs Not Associated With Complications in Pediatric Perforated Appendicitis. J Surg Res 2024; 295:655-659. [PMID: 38103323 DOI: 10.1016/j.jss.2023.11.027] [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: 02/27/2023] [Revised: 10/03/2023] [Accepted: 11/12/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Postoperative (postop) management of pediatric perforated appendicitis varies significantly, and postop intra-abdominal abscesses (IAA) remain a significant issue. Between 2019 and 2020, our standardized protocol included routine postop labs after an appendectomy for perforated appendicitis. However, given the lack of predictive utility of these routine labs, we discontinued this practice in 2021. We hypothesize that discontinuing routine postop labs will not be associated with an increase in complication rates after an appendectomy for pediatric perforated appendicitis. METHODS A single-institution, retrospective review of all pediatric appendectomies for perforated appendicitis from January 2019 to December 2021 was conducted at University Hospitals Rainbow Babies and Children's Hospital in Cleveland, Ohio. Data were collected on rate of complications (IAA development, re-admissions, bowel obstructions, superficial surgical site infections, intensive care unit transfers, Clostridium difficile infections, allergic reactions, and transfusions), postop imaging, postop interventions, and length of stay. Statistical analysis was completed using Fisher's exact test and Mann-Whitney U-test. RESULTS A total of 109 patients (2019-2020 n = 61, 2021 n = 48) were included in the study. All 61 patients from 2019 to 2020 had postop labs compared to only eight patients in 2021. There was no statistically significant difference between the two groups in overall complication rates, but there was a decrease in IAAs reported in 2021 (P = 0.03). There were no statistically significant differences in other complications, postop imaging usage, or postop interventions. The median length of stay was 4.5 d in 2021 compared to 6.0 d in 2019-2020 (P = 0.009). CONCLUSIONS Discontinuing routine postop labs is not associated with an increase in overall complications rates. Further studies are needed to determine whether routine postop labs can be safely removed in pediatric patients with perforated appendicitis, which would reduce patient discomfort and care costs.
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Affiliation(s)
- Jennifer Yang
- Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Lucy Yang
- Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Susan Zheng
- Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Eiichi A Miyasaka
- Case Western Reserve University, School of Medicine, Cleveland, Ohio; Division of Pediatric Surgery, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio.
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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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Buonpane CL, Vacek J, Harris CJ, Salazar Osuna JH, Van Arendonk KJ, Hunter CJ, Goldstein SD. Controversy in the classification of appendicitis and utilization of postoperative antibiotics. Surgery 2021; 171:1022-1026. [PMID: 34774292 DOI: 10.1016/j.surg.2021.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 07/26/2021] [Accepted: 10/04/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is wide variability and considerable controversy regarding the classification of appendicitis and the need for postoperative antibiotics. This study aimed to assess interrater agreement with respect to the classification of appendicitis and its influence on the use of postoperative antibiotics amongst surgeons and surgical trainees. METHODS A survey comprising 15 intraoperative images captured during appendectomy was distributed to surgeons and surgical trainees. Participants were asked to classify severity of disease (normal, inflamed, purulent, gangrenous, perforated) and whether they would prescribe postoperative antibiotics. Statistical analysis included percent agreement, Krippendorff's alpha for interrater agreement, and logistic regression. RESULTS In total, 562 respondents completed the survey: 206 surgical trainees, 217 adult surgeons, and 139 pediatric surgeons. For classification of appendicitis, the statistical interrater agreement was highest for categorization as gangrenous/perforated versus nongangrenous/nonperforated (Krippendorff's alpha = 0.73) and lowest for perforated versus nonperforated (Krippendorff's alpha = 0.45). Fourteen percent of survey respondents would administer postoperative antibiotics for an inflamed appendix, 44% for suppurative, 75% for gangrenous, and 97% for perforated appendicitis. Interrater agreement of postoperative antibiotic use was low (Krippendorff's alpha = 0.28). The only significant factor associated with postoperative antibiotic utilization was 16 or more years in practice. CONCLUSIONS Surgeon agreement is poor with respect to both subjective appendicitis classification and objective utilization of postoperative antibiotics. This survey demonstrates that a large proportion (59%) of surgeons prescribe antibiotics after nongangrenous or nonperforated appendectomy, despite a lack of evidence basis for this practice. These findings highlight the need for further consensus to enable standardized research and avoid overtreatment with unnecessary antibiotics.
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Affiliation(s)
- Christie L Buonpane
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL; Geisinger Medical Center, Danville, PA.
| | - Jonathan Vacek
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL. https://twitter.com/JonathanVacek
| | - Courtney J Harris
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL. https://twitter.com/courtneyjharris
| | | | - Kyle J Van Arendonk
- Children's Hospital of Wisconsin, Milwaukee, WI. https://twitter.com/KyleVanArendonk
| | - Catherine J Hunter
- The Children's Hospital, Oklahoma City, OK. https://twitter.com/CJHunter18
| | - Seth D Goldstein
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL. https://twitter.com/sethgoldsteinmd
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Ingram MC, Harris CJ, Studer A, Martin S, Berman L, Alder A, Raval MV. Distilling the Key Elements of Pediatric Appendicitis Clinical Practice Guidelines. J Surg Res 2021; 258:105-112. [PMID: 33010554 PMCID: PMC7736270 DOI: 10.1016/j.jss.2020.08.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/17/2020] [Accepted: 08/25/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Use of clinical practice guidelines (CPGs) have been shown to reduce care delays, optimize resource utilization, and improve patient outcomes. We conducted a systematized review to identify key elements that should be included in an evidence-based CPG for pediatric appendicitis. METHODS We characterized key decision points and content areas from CPGs developed from 2000 to 2019 that were identified using publicly available platforms and manual search/personal communications. RESULTS Twenty-seven CPGs were reviewed with content saturation achieved after reviewing eight. We found 16 key elements spanning from triage to postoperative care. Elements with high accord among CPGs included use of laparoscopy and delay of postoperative imaging for abscess screening until postoperative day seven. For simple appendicitis, all CPGs endorsed antibiotic cessation, diet advancement, and early activity, and 11 CPGs included same-day discharge. Elements with heterogeneity in decision-making included antibiotic selection/duration for perforated appendicitis, criteria defining perforation, and utility of postoperative laboratory evaluations. CONCLUSIONS Development of an evidence-based CPGs for pediatric appendicitis requires attention to a finite number of key decision points and content areas. Existing literature demonstrates improved patient outcomes with CPG implementation.
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Affiliation(s)
- Martha-Conley Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Courtney J Harris
- Division of Pediatric Surgery, Department of Surgery, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Abbey Studer
- Division of Pediatric Surgery, Department of Surgery, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Sarah Martin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Loren Berman
- Division of Pediatric Surgery, Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Nemours Al duPont Hospital for Children, Wilmington, Delware
| | - Adam Alder
- Division of Pediatric Surgery, University of Texas Southwestern, Dallas, Texas
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Vaos G, Zavras N, Dimopoulou A, Iakomidis E, Pantalos G, Passalides A. Safety assessment of open appendectomies for complicated acute appendicitis in children: a comparison of trainees and specialists. Pediatr Surg Int 2020; 36:1181-1187. [PMID: 32676829 DOI: 10.1007/s00383-020-04713-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this study was to compare the outcome of children with complicated acute appendicitis (CAA) who underwent open appendectomy (OA) performed either by trainees under the direct supervision of an SPS, or an SPS. METHODS Two hundred thirty eight patients with CAA were reviewed operated on either by a junior trainee (JT) or a senior trainee (ST) under the direct supervision of an SPS or by an SPS. The outcome measures were the overall rate of complications, operative time (OT), length of hospital stay (LHS) and 30-day readmission rate. RESULTS No statistical differences were observed between the three groups regarding the overall complication rates and 30-day readmission rate. Although, no statistical differences were observed in the mean OT between the three groups, the mean OT for perforated appendicitis (PA) performed by JTs was significantly longer than when performed by SPSs (p 0.012). Furthermore, there was a statistically significant difference between JTs and SPSs in terms of LHS for patients with PA (p 0.028). CONCLUSION This study suggests that no statistical differences were observed between the supervised trainees and SPSs regarding the overall complication rate and 30-readmission rate when they performed OA for GA or PA except of a longer OT and LHS for PA performed by JTs.
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Affiliation(s)
- George Vaos
- Department of Pediatric Surgery, "ATTIKON" University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Nick Zavras
- Department of Pediatric Surgery, "ATTIKON" University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Dimopoulou
- Department of Pediatric Surgery, "ATTIKON" University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Emmanouil Iakomidis
- Department of Pediatric Surgery, "ATTIKON" University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - George Pantalos
- Second Department of Pediatric Surgery, P & A Kyriakou Children's Hospital, Thivon & Levadias Str, 11527, Athens, Greece
| | - Alexander Passalides
- Second Department of Pediatric Surgery, P & A Kyriakou Children's Hospital, Thivon & Levadias Str, 11527, Athens, Greece
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Rodríguez E, Valero J, Jaramillo L, Vallejo-Ortega MT, Lagos L. Evaluation of concordance among surgeons and pathologists regarding the diagnosis and classification of acute appendicitis in children. J Pediatr Surg 2020; 55:1503-1506. [PMID: 31718870 DOI: 10.1016/j.jpedsurg.2019.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/27/2019] [Accepted: 09/25/2019] [Indexed: 11/17/2022]
Abstract
UNLABELLED Acute appendicitis is the most frequent urgent abdominal surgical pathology in children. Therapeutic decisions in patients who have undergone an appendectomy are made based on the macroscopic findings at the moment of surgery. There is high variability between surgical and histopathological findings. METHOD Concordance among surgeons and pathologists regarding the diagnosis and classification of acute appendicitis was assessed in children who have undergone an appendectomy. Surgical site infection (SSI) incidence was measured for both the surgical and pathological classification. RESULTS The statistical analysis included 1092 children. The pathologists confirmed the presence of appendicitis in 90.4% of the patients. Concordance in the diagnosis of appendicitis among surgeons and pathologists was weak (kappa 0.57), while concordance in the classification of perforated or non-perforated appendicitis was moderate (kappa 0.7). There were no significant differences in these findings determined by the surgeons' experience or the open or laparoscopic approach. In the discordant group of 70 patients in which the surgeon classified the appendicitis as non-perforated but the pathologist classified as perforated, just one patient developed an intra-abdominal abscess. CONCLUSIONS The classification of appendicitis as perforated or non-perforated shows moderate concordance between the surgical and histopathological diagnosis. This concordance is not determined by the surgeons' experience or the surgical approach. TYPE OF STUDY Diagnostic Test LEVEL OF EVIDENCE: Level II.
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Affiliation(s)
- Eliana Rodríguez
- Resident of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Universidad Nacional de Colombia, Colombia.
| | - Juan Valero
- Pediatric Surgeon, Fundación Hospital Pediátrico la Misericordia. Assistant Professor, Department of Surgery, Faculty of Medicine, Universidad Nacional de Colombia, Colombia
| | - Lina Jaramillo
- Pathologist, Fundación Hospital Pediátrico la Misericordia. Tenur Proffessor, Department of Pathology, Faculty of Medicine, Universidad Nacional de Colombia, Colombia
| | | | - Luisa Lagos
- Resident of Pediatrics, Department of Pediatrics, Faculty of Medicine, Universidad Nacional de Colombia, Colombia
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Management of appendiceal mass and abscess in children; early appendectomy or initial non-operative treatment? A systematic review and meta-analysis. Surg Endosc 2020; 34:5234-5249. [PMID: 32710216 PMCID: PMC7644542 DOI: 10.1007/s00464-020-07822-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/10/2020] [Indexed: 12/26/2022]
Abstract
Background Appendiceal mass and abscess and its treatment are associated with significant morbidity and high costs. Still, the optimal treatment strategy is the point of debate. Therefore, this systematic review and meta-analysis aimed to compare overall complications between initial non-operative treatment (NOT) and early appendectomy (EA) in children with appendiceal mass and/or abscess. Methods Pubmed and Embase were searched. Only randomized controlled trials and prospective or historical cohort studies that compared NOT with EA in children with appendiceal mass or abscess in terms of complications were eligible for inclusion. Risk of bias was assessed. Primary outcome was the overall complication rate. Secondary, length of stay and readmission rate were investigated. A meta-analysis of overall complications associated with both treatment strategies was performed. Results 14 of 7083 screened studies were selected, including 1022 children in the NOT group and 333 in the EA group. Duration of follow-up ranged between four weeks and 12 years. Risk of bias was moderate in four and serious in 10 studies. NOT was associated with a lower overall complication rate (risk ratio (RR) 0.37 [95% confidence interval (CI) 0.21–0.65]). However, NOT led to increased length of stay (mean difference varied between 0.2 and 8.4 days) and higher readmission rate (RR 1.75 [95%CI 0.79–3.89]), although not significantly. Interval appendectomy after NOT was performed as a routine procedure in all but one study. This study found a recurrence rate of 34% in a group of 38 patients during a follow-up period of 3.4 ± 1.7 years. Conclusion NOT may reduce the overall complication rate compared to EA, but the evidence is very uncertain. As evidence is scarce, and of low level, and heterogeneity between studies is substantial, the results should be interpreted with caution. Large prospective studies are needed to determine the optimal treatment strategy for children with appendiceal mass and/or abscess. Electronic supplementary material The online version of this article (10.1007/s00464-020-07822-y) contains supplementary material, which is available to authorized users.
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9
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Wee JJ, Park CJ, Lee YT, Cheong YL, Rai R, Nah SA. A simple classification of peritoneal contamination in perforated appendicitis predicts surgery-related complications. J Paediatr Child Health 2020; 56:272-275. [PMID: 31410904 DOI: 10.1111/jpc.14591] [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: 06/28/2019] [Revised: 07/24/2019] [Accepted: 07/28/2019] [Indexed: 11/28/2022]
Abstract
AIM Perforated appendicitis has poorer clinical outcomes compared to non-perforated appendicitis. However, accurate outcome comparisons in research and clinical audits are challenged by its wide spectrum of manifestation. Previous attempts at the classification of severity have been complex and difficult to reproduce. In our study, we used another institution's (Jones et al., TX, USA) previously described simple classification system of peritoneal contamination and examined its usefulness in predicting outcomes. METHODS With ethical approval, we retrospectively reviewed the records of all paediatric patients operated at our institution for perforated appendicitis from 2016 to 2017. Patient demographics, intra-operative and histological findings, post-operative outcomes and length of stay were collected. Patients were categorised into group 1 (purulence in right lower quadrant only) and group 2 (contamination in two or more quadrants). Post-operative complications were defined as procedure-related (e.g. post-operative ileus, intra-abdominal abscess, visceral injury) and non-procedure-related (e.g. bronchospasm). Statistical analysis using χ2 tests for categorical data and Mann-Whitney U-tests for non-parametric continuous variables was performed, with a significance of P < 0.05. RESULTS There were 134 eligible patients. We excluded 19 with incomplete data, leaving 115 for analysis, of which 69 (60%) were in group 2. Those in group 2 had a longer stay (P = 0.005) and more post-operative complications (P = 0.001), particularly procedure-related events (P = 0.006). There were no differences in age (P = 0.182), gender (P = 0.876), readmission rate (P = 0.317) and non-procedure-related post-operative complications (0.152). CONCLUSION This simple classification of perforated appendicitis appears to differentiate clinical outcomes well, particularly for iatrogenic morbidity, making it useful for operative preparation and outcomes research.
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Affiliation(s)
- Jia J Wee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chang J Park
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - York T Lee
- Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Yee L Cheong
- Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Rambha Rai
- Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Shireen A Nah
- Paediatric Surgery, KK Women's and Children's Hospital, Singapore.,Division of Surgery, Duke-NUS Medical School, Singapore
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Bailey K, Choynowski M, Kabir SMU, Lawler J, Badrin A, Sugrue M. Meta-analysis of unplanned readmission to hospital post-appendectomy: an opportunity for a new benchmark. ANZ J Surg 2019; 89:1386-1391. [PMID: 31364257 DOI: 10.1111/ans.15362] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/03/2019] [Accepted: 06/10/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. While many studies report readmission, a meta-analysis of readmission post-appendectomy has not been published. This meta-analysis was undertaken to determine rates and predictors of hospital readmission following appendectomy and to potentially provide a metric benchmark. METHODS An ethically approved PROSPERO-registered (ID CRD42017069040) meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using databases PubMed and Scopus, was undertaken for studies published between January 2012 and June 2017. Articles relating to outcomes and readmissions after appendectomy were identified. Those scoring >15 for comparative studies and >10 for non-comparative studies, using Methodological Index for Non-Randomized Studies criteria were included in the final analysis. The odds ratios (OR) using random-effects, Mantel-Haenszel method with 95% confidence intervals (CI), were computed for each risk factor with RevMan5. RESULTS A total of 1757 articles reviewed were reduced to 45 qualifying studies for a final analysis of 836 921 appendectomies. 4.3% (range 0.0-14.4%) of patients were readmitted within 30 days. Significant preoperative patient factors for increased readmission were diabetes mellitus (OR 1.93, CI 1.63-2.28, P < 0.00001), complicated appendicitis (OR 3.6, CI 2.43-5.34, P < 0.00001) and open surgical technique (OR 1.39, CI 1.08-1.79, P < 0.00001). Increased readmission was not associated with gender, obesity or paediatric versus general surgeons or centres. CONCLUSION This meta-analysis identified that readmission is not uncommon post-appendectomy, occurring in one in 25 cases. The mean readmission rate of 4.3% may act as a quality benchmark for improving emergency surgical care. Targeting high-risk groups with diabetes or complicated appendicitis and increasing use of laparoscopic technique may help reduce readmission rates.
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Affiliation(s)
- Kate Bailey
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | - Michelle Choynowski
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | - Syed Mohammad Umar Kabir
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland.,Department of Surgery, Letterkenny University Hospital, Letterkenny, Ireland
| | - Jack Lawler
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | - Adibah Badrin
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | - Michael Sugrue
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland.,Department of Surgery, Letterkenny University Hospital, Letterkenny, Ireland.,EU INTERREG Centre for Personalised Medicine Project, Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Magee Campus, Londonderry, Northern Ireland
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Do‐Wyeld M, Rogerson T, Court‐Kowalski S, Cundy TP, Khurana S. Fast‐track surgery for acute appendicitis in children: a systematic review of protocol‐based care. ANZ J Surg 2019; 89:1379-1385. [PMID: 30989778 DOI: 10.1111/ans.15125] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/08/2019] [Accepted: 01/25/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Montgommery Do‐Wyeld
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
| | - Thomas Rogerson
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
| | - Stefan Court‐Kowalski
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
- Discipline of SurgeryThe University of Adelaide Adelaide South Australia Australia
| | - Thomas P. Cundy
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
- Discipline of SurgeryThe University of Adelaide Adelaide South Australia Australia
| | - Sanjeev Khurana
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
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12
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Nordin AB, Diefenbach K, Sales SP, Christensen J, Besner GE, Kenney BD. Gangrenous appendicitis: No longer complicated. J Pediatr Surg 2019; 54:718-722. [PMID: 30551843 DOI: 10.1016/j.jpedsurg.2018.10.064] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 10/10/2018] [Accepted: 10/21/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Appendicitis presents on a spectrum ranging from inflammation to gangrene to perforation. Studies suggest that gangrenous appendicitis has lower postoperative infection rates relative to perforated cases. We hypothesized that gangrenous appendicitis could be successfully treated as simple appendicitis, reducing length of stay (LOS) and antibiotic usage without increasing postoperative infections. METHODS In February 2016, we strictly defined complex appendicitis as a hole in the appendix, extraluminal fecalith, diffuse pus or a well-formed abscess. We switched gangrenous appendicitis to a simple pathway and reviewed all patients undergoing laparoscopic appendectomy for 12 months before (Group 1) and 12 months after (Group 2) the protocol change. Data collected included demographics, appendicitis classification, LOS, presence of a postoperative infection, and 30-day readmissions. RESULTS Patients in Group 1 and Group 2 were similar, but more cases of simple appendicitis occurred in Group 2. Average LOS for gangrenous appendicitis patients decreased from 2.5 to 1.4 days (p < 0.001) and antibiotic doses decreased from 5.2 to 1.3 (p < 0.001). Only one gangrenous appendicitis patient required readmission, and one patient in each group developed a superficial infection; there were no postoperative abscesses. CONCLUSIONS Gangrenous appendicitis can be safely treated as simple appendicitis without increasing postoperative infections or readmissions. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Andrew B Nordin
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH, 43205; State University of New York University at Buffalo, Department of General Surgery, 100 High St, Buffalo, NY 14203.
| | - Karen Diefenbach
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH, 43205; The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210.
| | - Stephen P Sales
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH, 43205.
| | - Jeff Christensen
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH, 43205.
| | - Gail E Besner
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH, 43205; The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210.
| | - Brian D Kenney
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH, 43205; The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210.
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Prospective evaluation of a clinical response directed pathway for complicated appendicitis. J Pediatr Surg 2019; 54:272-275. [PMID: 30528202 DOI: 10.1016/j.jpedsurg.2018.10.082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 10/30/2018] [Indexed: 11/20/2022]
Abstract
AIM Despite evidence to suggest shorter durations of antibiotics are safe in complicated appendicitis, the practice has not been widely adopted in the UK. Our aim was to determine whether a clinical pathway that tailors antibiotics to clinical condition was safe and effective. METHODS A new post-operative pathway (NewPath) was devised that reduced mandatory intravenous antibiotics for complicated appendicitis (perforated or gangrenous) from 5 to 3 days post-operatively, provided the child was apyrexial for >12 h and tolerating oral diet. Oral antibiotics were only given if white-blood-cell counts were raised. Data were collected prospectively (NewPath) and compared to 100 cases immediately prior. Data are presented as median [IQR]. Comparisons used the Fisher's exact or Mann Whitney U tests as appropriate. Significance was defined as p < 0.05. RESULTS One hundred sixty-four children completed the NewPath over 11 months. Age and normal appendicectomy rate were similar [NewPath vs. control, 9y (6-12) vs. 10y (7-13) and 19/164 (12%) vs.15/100 (15%)]. Complicated appendicitis rates were 88/164 [54%] vs. 42/100 [42%]; p = 0.08. Length of stay was shorter for the NewPath [5 (4-7) vs. 7 (6-8) days; p = 0.009], and fewer required oral antibiotics [35/88 (40%) vs. 26/42 (62%); p = 0.01]. Readmissions within 28 days [24/88 (27%) vs. 8/42 (19%), p = 0.39) and intra-abdominal collections [20/88 (23%) vs. 6/42 (14%), p = 0.35] were similar. CONCLUSIONS Post-operative appendicitis care guided by clinical progress and white-blood-cell count can reduce hospital stay and antibiotic use without increasing complications. Pathways such as this could save considerable health resource and contribute to important antimicrobial stewardship initiatives. LEVEL OF EVIDENCE Level III.
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14
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Mariage M, Sabbagh C, Grelpois G, Prevot F, Darmon I, Regimbeau JM. Surgeon's Definition of Complicated Appendicitis: A Prospective Video Survey Study. Euroasian J Hepatogastroenterol 2019; 9:1-4. [PMID: 31988858 PMCID: PMC6969325 DOI: 10.5005/jp-journals-10018-1286] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim Definition of the type of appendicitis is based on examination of the peritoneum and appendix. Gomes et al. proposed a laparoscopic grading system of acute appendicitis (grades 1 and 2, noncomplicated appendicitis, grade 3-5 complicated appendicitis). The aim of this study was to evaluate the reproducibility of this score. Patients and methods All patients managed for acute appendicitis between January 2016 and June 2016 were included in this single-center prospective study. Laparoscopic appendectomy procedures were filmed by analogy to Sugerbaker's peritoneal carcinomatosis score (9 quadrants, all of the abdomen was filmed). The videos were then analyzed by seven staff surgeons blinded to each other and the operative report. The primary endpoint was to determine the concordance between staff surgeons for grading of appendicitis using the laparoscopic grading system of acute appendicitis described by Gomes et al. Results A total of 40 patients were included in this study. A concordance was observed between the seven staff surgeons in 85% of cases. For regional peritonitis, the mean ± (SD) number of quadrants in which the staff surgeons reported signs of peritonitis was 1.44 ± 0.63. For diffuse peritonitis, the mean (SD) number of quadrants in which the staff surgeons reported signs of peritonitis was 2.59 ± 0.51. On ROC curve analysis, two quadrants was the best cut-off between grade 4B (local peritonitis) and five (diffuse peritonitis) acute appendicitis (AUC = 0.92, Se = 100%, Sp = 92%, p = 0.005). Conclusion The classification used to determine the type of appendicitis is reproducible. Clinical significance To give a definition of complicated appendicitis. How to cite this article Mariage M, Sabbagh C, et al. Surgeon's Definition of Complicated Appendicitis: A Prospective Video Survey Study. Euroasian J Hepatogastroenterol 2019;9(1):1-4.
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Affiliation(s)
- Maxime Mariage
- Department of Digestive Surgery, University Hospital of Amiens, Amiens, Hautsde France, France
| | - Charles Sabbagh
- Department of Digestive Surgery, University Hospital of Amiens, Amiens, Hautsde France, France
| | - Gerard Grelpois
- Department of Digestive Surgery, University Hospital of Amiens, Amiens, Hautsde France, France
| | - Flavien Prevot
- Department of Digestive Surgery, University Hospital of Amiens, Amiens, Hautsde France, France
| | - Ilan Darmon
- Department of Digestive Surgery, University Hospital of Amiens, Amiens, Hautsde France, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, University Hospital of Amiens, Amiens, Hautsde France, France
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15
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Implementing a surgeon-reported categorization of pediatric appendicitis severity. Pediatr Surg Int 2018; 34:1281-1286. [PMID: 30317376 DOI: 10.1007/s00383-018-4364-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2018] [Indexed: 01/11/2023]
Abstract
PURPOSE The purpose of this study was to implement a novel surgeon-reported categorization (SRC) for pediatric appendicitis severity and determine if SRC was associated with outcomes. METHODS We conducted a retrospective review of appendectomies by 15 surgeons within a single center from January to December 2016. The SRC was defined as: simple (category 1), gangrenous or adherent (category 2A), perforation with localized abscess (category 2B), and perforation with gross contamination (category 2C). Logistic regression modeled the surgical site infections (SSI) and returns to the system. Cox proportional hazards analyses modeled the length of stay (LOS). RESULTS The cohort included 697 patients (mean age 10.7 years). Compliance with SRC documentation increased from 33.5 to 85.9%. Review of operative findings revealed 100% concordance with SRC. The combined morbidity (SSI and revisits) rate was 9.8%. Category 2C patients had the highest odds of SSI (odds ratio 3.37 95% confidence interval 1.07-10.59). Median LOS increased with each category (category 1 = 1d, category 2A = 2d, category 2B = 4d, category 2C = 6d). When modeling intra-abdominal abscess, SRC displayed an improved model calibration and discrimination compared to wound class. CONCLUSION SRC implementation is feasible and provides a granular assessment of appendicitis severity and outcomes. SRC may guide future quality improvement through development of grade-specific care pathways.
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Hernandez MC, Kong VY, Bruce JL, Aho JM, Laing GL, Zielinski MD, Clarke DL. Pediatric Appendicitis Severity in KwaZulu-Natal, South Africa: A Retrospective Cohort Analysis. World J Surg 2018; 42:3785-3791. [PMID: 29777269 DOI: 10.1007/s00268-018-4677-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute appendicitis is a common pediatric surgical emergency; however, there are few grading systems to assign disease severity. The American Association for the Surgery of Trauma (AAST) recently developed a grading system for a variety of emergency surgical conditions, including appendicitis. The severity of acute appendicitis in younger patients in KwaZulu-Natal (South Africa) is unknown. We aimed to describe the disease severity in this patient population using the AAST grading system hypothesizing that the AAST grade would correlate with morbidity, management type, and duration of stay. MATERIALS Single institutional review of patients <18 years old with a final diagnosis of acute appendicitis during 2010-2016 in KwaZulu-Natal, South Africa, was performed. Demographics, physiologic and symptom data, procedural details, postoperative complications, and Clavien-Dindo classification were abstracted. AAST grades were generated based on intraoperative findings. Summary, univariate, and nominal logistic regression analyses were performed to compare AAST grade and outcomes. RESULTS A total of 401 patients were identified with median [IQR] age of 11 [5-13], 65% male. Appendectomy was performed in all patients; 2.4% laparoscopic, 37.6% limited incision, and 60% midline laparotomy. Complications occurred in 41.6%, most commonly unplanned relaparotomy (22.4%), surgical site infection (8.9%), pneumonia (7.2%), and acute renal failure (2.9%). Complication rate and median length of stay increased with greater AAST grade (all p < 0.001). AAST grade was independently associated with increased risk of complications. CONCLUSION Pediatric appendicitis is a morbid disease in a developing middle-income country. The AAST grading system is generalizable and accurately corresponds with management strategies as well as key clinical outcomes. LEVEL OF EVIDENCE Retrospective study, Level IV. STUDY TYPE Retrospective single institutional study.
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Affiliation(s)
- Matthew C Hernandez
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Victor Y Kong
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - John L Bruce
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Johnathon M Aho
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Grant L Laing
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Martin D Zielinski
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Damian L Clarke
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa
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17
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Anderson KT, Bartz-Kurycki MA, Kawaguchi AL, Austin MT, Holzmann-Pazgal G, Kao LS, Lally KP, Tsao K. Home Antibiotics at Discharge for Pediatric Complicated Appendicitis: Friend or Foe? J Am Coll Surg 2018; 227:247-254. [PMID: 29680415 DOI: 10.1016/j.jamcollsurg.2018.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
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18
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Litz CN, Asuncion JB, Danielson PD, Chandler NM. Timing of antimicrobial prophylaxis and infectious complications in pediatric patients undergoing appendectomy. J Pediatr Surg 2018; 53:449-451. [PMID: 28528712 DOI: 10.1016/j.jpedsurg.2017.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/26/2017] [Accepted: 05/04/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE Antibiotic administration within one hour prior to incision is a common quality metric; however, antibiotics are typically started at the time of diagnosis in pediatric patients with acute appendicitis. The purpose was to determine if antibiotic administration within one hour prior to incision reduces the incidence of surgical site infections (SSI) in pediatric patients with acute appendicitis started on parenteral antibiotics upon diagnosis. METHODS A retrospective review was performed of 478 patients aged 0-18years who underwent appendectomy for acute appendicitis from 7/2013 to 4/2015. Patients were categorized based on timing of antibiotic administration; there were 198 patients in Group A (<60min before) and 280 in Group B (>60min before). RESULTS Demographics and operative time (A: 30.5±9.9 vs B: 30.8±12.2min, p=0.51) were similar. Procedures were performed laparoscopically and the groups had similar proportions of single-incision operations (A: 53% vs B: 55%, p=0.64). There was no difference in the incidence of superficial SSI (A: 2.0% vs B: 2.1%, p=1.0) or intraabdominal abscess (A: 4.0% vs B: 3.6%, p=0.81) and this remained true when stratified by intraoperative classification. CONCLUSION Antibiotic administration within one hour of appendectomy in pediatric patients with acute appendicitis who receive antibiotics at diagnosis did not change the incidence of postoperative infectious complications. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Cristen N Litz
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, United States.
| | - Jessica B Asuncion
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, United States.
| | - Paul D Danielson
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, United States.
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, United States.
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19
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Yousef Y, Youssef F, Dinh T, Pandya K, Stagg H, Homsy M, Baird R, Laberge JM, Poenaru D, Puligandla P, Shaw K, Emil S. Risk stratification in pediatric perforated appendicitis: Prospective correlation with outcomes and resource utilization. J Pediatr Surg 2018; 53:250-255. [PMID: 29223673 DOI: 10.1016/j.jpedsurg.2017.11.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 11/08/2017] [Indexed: 01/25/2023]
Abstract
PURPOSE Despite a wide spectrum of severity, perforated appendicitis in children is typically considered a single entity in outcomes studies. We performed a prospective cohort study to define a risk stratification system that correlates with outcomes and resource utilization. METHODS A prospective study was conducted of all children operated for perforated appendicitis between May 2015 and December 2016 at a tertiary free-standing university children's hospital. Surgical findings were classified into one of four grades of perforation: I. localized or contained perforation, II. Contained abscess with no generalized peritonitis, III. Generalized peritonitis with no dominant abscess, IV. Generalized peritonitis with one or more dominant abscesses. All patients were treated on a clinical pathway that involved all points of care from admission to final follow-up. Outcomes and resource utilization measures were analyzed using Fisher's exact test, Kruskal-Wallis test, One-way ANOVA, and logistic regression. RESULTS During the study period, 122 patients completed treatment, and 100% had documented follow-up at a median of 25days after operation. Grades of perforation were: I, 20.5%; II, 37.7%; III, 10.7%; IV, 31.1%. Postoperative abscesses occurred in 12 (9.8%) of patients, almost exclusively in Grade IV perforations. Hospital stay, duration of antibiotics, TPN utilization, and the incidence of postoperative imaging significantly increased with increasing grade of perforation. CONCLUSION Outcomes and resource utilization strongly correlate with increasing grade of perforated appendicitis. Postoperative abscesses, additional imaging, and additional invasive procedures occur disproportionately in patients who present with diffuse peritonitis and abscess formation. The current stratification allows risk-adjusted outcome reporting and appropriate assignment of resource burden. LEVEL OF EVIDENCE I (Prognosis Study).
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Affiliation(s)
- Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Fouad Youssef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Trish Dinh
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kartikey Pandya
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Hayden Stagg
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Michael Homsy
- 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
| | - Dan Poenaru
- 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
| | - Sherif Emil
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
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Hernandez MC, Polites SF, Aho JM, Haddad NN, Kong VY, Saleem H, Bruce JL, Laing GL, Clarke DL, Zielinski MD. Measuring Anatomic Severity in Pediatric Appendicitis: Validation of the American Association for the Surgery of Trauma Appendicitis Severity Grade. J Pediatr 2018; 192:229-233. [PMID: 29106922 DOI: 10.1016/j.jpeds.2017.09.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/29/2017] [Accepted: 09/08/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To assess whether the American Association for the Surgery of Trauma (AAST) grading system accurately corresponds with appendicitis outcomes in a US pediatric population. STUDY DESIGN This single-institution retrospective review included patients <18 years of age (n = 331) who underwent appendectomy for acute appendicitis from 2008 to 2012. Demographic, clinical, procedural, and follow-up data (primary outcome was measured as Clavien-Dindo grade of complication severity) were abstracted. AAST grades were generated based on intraoperative findings. Summary, univariate, and multivariable regression analyses were performed to compare AAST grade and outcomes. RESULTS Overall, 331 patients (46% female) were identified with a median age of 12 (IQR, 8-15) years. Appendectomy was laparoscopic in 90% and open in 10%. AAST grades included: Normal (n = 13, 4%), I (n = 152, 46%), II (n = 90, 27%), III (n = 43, 13%), IV (n = 24 7.3%), and V (n = 9 2.7%). Increased AAST grade was associated with increased Clavien-Dindo severity, P =.001. The overall complication rate was 13.6% and was comprised by superficial surgical site infection (n = 13, 3.9%), organ space infection (n = 15, 4.5%), and readmission (n = 17, 5.1%). Median duration of stay increased with AAST grade (P < .0001). Nominal logistic regression identified the following as predictors of any complication (P < .05): AAST grade and febrile temperature at admission. CONCLUSIONS The AAST appendicitis grading system is valid in a single-institution pediatric population. Increasing AAST grade incrementally corresponds with patient outcomes including increased risk of complications and severity of complications. Determination of the generalizability of this grading system is required.
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Affiliation(s)
- Matthew C Hernandez
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.
| | - Stephanie F Polites
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Johnathon M Aho
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN; Biomedical Engineering and Physiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Nadeem N Haddad
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Victor Y Kong
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of Kwa-Zulu Natal, South Africa
| | - Humza Saleem
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - John L Bruce
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of Kwa-Zulu Natal, South Africa
| | - Grant L Laing
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of Kwa-Zulu Natal, South Africa
| | - Damian L Clarke
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of Kwa-Zulu Natal, South Africa
| | - Martin D Zielinski
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
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Yousef Y, Youssef F, Homsy M, Dinh T, Pandya K, Stagg H, Baird R, Laberge JM, Poenaru D, Puligandla P, Shaw K, Emil S. Standardization of care for pediatric perforated appendicitis improves outcomes. J Pediatr Surg 2017; 52:1916-1920. [PMID: 28935397 DOI: 10.1016/j.jpedsurg.2017.08.054] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 08/28/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND The treatment of perforated appendicitis in children is characterized by significant variability in care, morbidity, resource utilization, and outcomes. We prospectively studied how minimization of care variability affects outcomes. METHODS A clinical pathway for perforated appendicitis, in use for three decades, was further standardized in May 2015 by initiation of a disease severity classification, refinement of discharge criteria, standardization of the operation, and establishment of criteria for use of postoperative total parenteral nutrition, imaging, and invasive procedures. Prospective evaluation of all children treated for 20months on the new fully standardized protocol was conducted and compared to a retrospective cohort treated over 58months prior to standardization. Differences between outcomes before and after standardization were analyzed using regression analysis techniques to adjust for disease severity. RESULTS Median follow-up time post discharge was 25 and 14days in the post- and prestandardization groups, respectively. Standardization significantly reduced postoperative abscess (9.8% vs. 17.4%, p=0.001) and hospital stay (p=0.002). Standardization reduced the odds of developing a postoperative abscess by four fold. CONCLUSION Minimizing variability of care at all points in the treatment of perforated appendicitis significantly improves outcomes. TYPE OF STUDY Prospective Cohort Study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Fouad Youssef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Michael Homsy
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Trish Dinh
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kartikey Pandya
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Hayden Stagg
- 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
| | - Dan Poenaru
- 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
| | - Sherif Emil
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
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22
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Dickinson CM, Coppersmith NA, Luks FI. Early Predictors of Abscess Development after Perforated Pediatric Appendicitis. Surg Infect (Larchmt) 2017; 18:886-889. [PMID: 29016242 DOI: 10.1089/sur.2017.134] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Approximately one-third of children with appendicitis present with advanced disease or perforation. Whereas this increases the risk for post-operative complications and re-admission, it is not yet possible to predict early on who will develop an abdominal abscess. We sought to identify specific risk factors for this complication, in an attempt to streamline post-operative care. PATIENTS AND METHODS We reviewed the records of all cases of perforated appendicitis over a 12-month period at a tertiary children's hospital. All patients who developed an abscess despite treatment minimum of seven days of antibiotic therapy were identified. Patients who presented or were re-admitted with an abscess were excluded from analysis. Records were reviewed for demographics, laboratory results, progression of oral intake, and vital signs. RESULTS Of 273 patients with appendicitis, we identified 59 cases of perforated appendicitis. Fifteen patients were excluded. Eight of the remaining 44 patients (18.2%) developed an abscess during their initial admission. Their mean length of stay was longer than that of patients without an abscess (13.4 ± 7.1 vs. 6.9 ± 1.9 d, p < 0.0001). Gender, leukocytosis, or diarrhea at presentation, maximum temperature on post-operative day 3, and maximum heart rate on post-operative day 3 were not statistically different. Diet progression was different between the two groups: none of the 21 patients who were tolerating a regular diet by post-operative day 3 developed an abscess, compared with 8 of the 23 patients who were not yet eating a regular diet on post-operative day 3 (p < 0.01). Late leukocytosis also correlated with the presence of an abscess: 7 of the 8 patients with an abscess had persistent leukocytosis at days 5 through 7, compared with 3 of 31 patients without abscess (p < 0.05). An ultrasound was obtained for these 3 patients and proved normal. CONCLUSIONS Tolerating a regular diet three days after appendectomy for perforated appendicitis decreased the likelihood of a post-operative abscess. No other parameter was predictive of this complication early in the post-operative period. If confirmed in a larger prospective study, this finding may help decrease the length of stay for low-risk patients, and identify abscesses in high-risk patients in a timely fashion.
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Affiliation(s)
- Catherine M Dickinson
- 1 Department of Surgery, Warren Alpert Medical School of Brown University , Rhode Island Hospital, Providence, Rhode Island
| | | | - Francois I Luks
- 3 Department of Surgery, Division of Pediatric Surgery, Warren Alpert Medical School of Brown University , Providence, Rhode Island.,4 Division of Pediatric Surgery, Hasbro Children's Hospital , Providence, Rhode Island
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Hernandez MC, Shafi S, Zielinski MD. A classification system to grade all appendicitis. J Pediatr Surg 2017; 52:665. [PMID: 28065720 DOI: 10.1016/j.jpedsurg.2016.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 12/15/2016] [Indexed: 11/15/2022]
Affiliation(s)
- Matthew C Hernandez
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA.
| | - Shahid Shafi
- Baylor Scott & White Health System, Office of Chief Quality Officer, Dallas, TX 75061, USA
| | - Martin D Zielinski
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA.
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