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Zouari M, Hbaieb M, Issaoui A, Krichen E, Safi F, Dhaou MB, Mhiri R. Ultrasound Assessment in Children With Suspected Appendicitis: Time to Revise Diagnostic Criteria: A Prospective Cohort Study. Surg Infect (Larchmt) 2024. [PMID: 38625002 DOI: 10.1089/sur.2023.370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Background: Although ultrasound is considered the gold standard for the evaluation of children with suspected appendicitis, there is still much debate about the most accurate ultrasound findings. The purpose of this study was to define the best ultrasound signs that could ultimately improve the diagnostic accuracy of ultrasound for diagnosing pediatric acute appendicitis, and to differentiate between simple appendicitis and complicated appendicitis. Patients and Methods: After approval by our Institutional Review Board, a prospective study was carried out from January 1, 2022, to July 31, 2023, in a pediatric emergency department. We included all patients aged under 14 years with suspected appendicitis and ultrasound-visualized appendix. Results: A total of 550 patients presented with suspected appendicitis during the study period. Of these children, 411 had an ultrasound-visualized appendix. Our patients' mean age was 9.4 years. The best positive predictive value of ultrasound was found for appendiceal diameter ≥7.5 mm. The combination of an appendiceal diameter <6 mm and the lack of peri-appendiceal free fluid on ultrasound rules out the diagnosis of appendicitis. The best diagnostic accuracy of ultrasound, which was 92%, was achieved for appendix diameters ≥6.5 mm. The sonographic sign giving the best ultrasound accuracy for diagnosing complicated appendicitis was an appendix diameter ≥9 mm. Conclusions: In conclusion, our present study demonstrated that appendiceal diameter ≥6.5 mm is the gold standard for diagnosing appendicitis in pediatric patients. The combination of an appendiceal diameter <6 mm and the lack of peri-appendiceal free fluid on ultrasound would rule out appendicitis.
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Affiliation(s)
- Mohamed Zouari
- Research Laboratory "Developmental and Induced Diseases" (LR19ES12), Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia
- Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Manar Hbaieb
- Research Laboratory "Developmental and Induced Diseases" (LR19ES12), Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia
- Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Asma Issaoui
- Research Laboratory "Developmental and Induced Diseases" (LR19ES12), Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia
- Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Emna Krichen
- Research Laboratory "Developmental and Induced Diseases" (LR19ES12), Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia
- Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Faiza Safi
- Department of Pediatrics, Hedi Chaker Hospital, Sfax, Tunisia
| | - Mahdi Ben Dhaou
- Research Laboratory "Developmental and Induced Diseases" (LR19ES12), Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia
- Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Riadh Mhiri
- Research Laboratory "Developmental and Induced Diseases" (LR19ES12), Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia
- Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
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Imaging of Right Lower Quadrant Pain in Children and Adolescents: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2022; 220:767-779. [PMID: 36416395 DOI: 10.2214/ajr.22.28358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Right lower quadrant (RLQ) pain is a common clinical presentation in children, and accurate clinical diagnosis remains challenging given that this nonspecific presentation is associated with numerous surgical and nonsurgical conditions. The broad differential diagnosis varies by patient age and sex. Important considerations in the selection of a diagnostic imaging strategy include the sequencing, performance, and cost of tests. This article provides a comprehensive narrative review of the diagnostic imaging of RLQ pain in children and adolescents, including a discussion of the complementary roles of ultrasound, CT, and MRI; description of key imaging findings based on available evidence; and presentation of salient differential diagnoses. Subspecialized pediatric emergency medicine and surgical perspectives are also provided as further clinical insight into this common, but often challenging, scenario. Finally, the current status of imaging of RLQ pain in children and adolescents is summarized on the basis of expert consensus.
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Mundell BF, Fattahi S, Traynor MD, Blazejak D, Puig C, Roskos P, Heying J, Sunnock W, Hunchis J, Dholakia R, Borah B, Mannenbach M, Klinkner DB. The appendicitis algorithm five years later: Variability remains. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Whitehead A, Fullerton K, Miller HC. Minimizing Ionizing Radiation in Evaluating Suspected Appendicitis in Children Before and After the Release of the ACEP Clinical Policy. Pediatr Emerg Care 2021; 37:e1434-e1438. [PMID: 32097377 DOI: 10.1097/pec.0000000000002068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE The aim of this study was to examine the impact of the ACEP (American College of Emergency Physicians) clinical policy regarding diagnosis of suspected appendicitis on changing practice in the pediatric emergency department (ED) in the absence of a formal departmental protocol. METHODS This was a retrospective chart review in a pediatric ED in which patients aged 2 to 18 years were evaluated for appendicitis via ultrasound, computed tomography (CT), or both, over a 7-year study period. We compared rates of CT utilization in the period before the release of the ACEP clinical policy regarding diagnosis and treatment of appendicitis (2008-2009) and the period after (2010-2014). Other metrics of interest were ultrasound results and physician response to results, as well as surrogate markers for quality of care. RESULTS Seven hundred pediatric ED visits were included, with 200 prepolicy release and 500 postrelease. Computed tomography utilization decreased significantly postpolicy release from 43.5% (95% confidence interval [CI], 36.6%-50.3%) to 22.2% (95% CI, 18.5%-25.8%). The proportion of ultrasounds with indeterminate results also decreased, with 71.5% (95% CI, 65.1%-77.9%) and 55.1% (95% CI, 50.7%-59.5%) in the pre and post groups, respectively. Physicians ordered fewer CTs after indeterminate ultrasounds, decreasing from 63.7% (95% CI, 56.9%-70.5%) to 48.3%% (95% CI, 43.9%-52.7%). CONCLUSIONS After the release of the clinical policy, CT utilization decreased significantly suggesting possible effectiveness of the policy in bringing about change in practice. Subsequently, there was an increase in the definitiveness in the ultrasound results. Physicians also evolved in their response to indeterminate ultrasound results, with fewer CTs ordered reflexively after indeterminate results.
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Affiliation(s)
| | - Katherine Fullerton
- Department of Pediatrics, Inova Fairfax Hospital for Children, Falls Church, VA
| | - Helen C Miller
- George Washington University School of Medicine and Health Sciences, Washington, DC
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Lentz B, Fong T, Rhyne R, Risko N. A systematic review of the cost-effectiveness of ultrasound in emergency care settings. Ultrasound J 2021; 13:16. [PMID: 33687607 PMCID: PMC7943664 DOI: 10.1186/s13089-021-00216-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/19/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The use of ultrasound (US) in emergency departments (ED) has become widespread. This includes both traditional US scans performed by radiology departments as well as point-of-care US (POCUS) performed by bedside clinicians. There has been significant interest in better understanding the appropriate use of imaging and where opportunities to enhance cost-effectiveness may exist. The purpose of this systematic review is to identify published evidence surrounding the cost-effectiveness of US in the ED and to grade the quality of that evidence. METHODS We performed a systematic review of the literature following Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Studies were considered for inclusion if they were: (1) economic evaluations, (2) studied the clinical use of ultrasound, and (3) took place in an emergency care setting. Included studies were critically appraised using the Consolidated Health Economic Evaluation Reporting Standards checklist. RESULTS We identified 631 potentially relevant articles. Of these, 35 studies met all inclusion criteria and were eligible for data abstraction. In general, studies were supportive of the use of US. In particular, 11 studies formed a strong consensus that US enhanced cost-effectiveness in the investigation of pediatric appendicitis and 6 studies supported enhancements in the evaluation of abdominal trauma. Across the studies, weaknesses in methodology and reporting were common, such as lack of sensitivity analyses and inconsistent reporting of incremental cost-effectiveness ratios. CONCLUSIONS The body of existing evidence, though limited, generally demonstrates that the inclusion of US in emergency care settings allows for more cost-effective care. The most definitive evidence for improvements in cost-effectiveness surround the evaluation of pediatric appendicitis, followed by the evaluation of abdominal trauma. POCUS outside of trauma has had mixed results.
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Affiliation(s)
- Brian Lentz
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, 1411 E. 31st Street, QIC 22123, Oakland, CA, 94602, USA
| | - Tiffany Fong
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Randall Rhyne
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Nicholas Risko
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD, 21287, USA.
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Kharbanda AB, Vazquez-Benitez G, Ballard DW, Vinson DR, Chettipally UK, Dehmer SP, Ekstrom H, Rauchwerger AS, McMichael B, Cotton DM, Kene MV, Simon LE, Zhu J, Warton EM, O’Connor PJ, Kharbanda EO. Effect of Clinical Decision Support on Diagnostic Imaging for Pediatric Appendicitis: A Cluster Randomized Trial. JAMA Netw Open 2021; 4:e2036344. [PMID: 33560426 PMCID: PMC7873779 DOI: 10.1001/jamanetworkopen.2020.36344] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE Appendicitis is the most common pediatric surgical emergency. Efforts to improve efficiency and quality of care have increased reliance on computed tomography (CT) and ultrasonography (US) in children with suspected appendicitis. OBJECTIVE To evaluate the effectiveness of an electronic health record-linked clinical decision support intervention, AppyCDS, on diagnostic imaging, health care costs, and safety outcomes for patients with suspected appendicitis. DESIGN, SETTING, AND PARTICIPANTS In this parallel, cluster randomized trial, 17 community-based general emergency departments (EDs) in California, Minnesota, and Wisconsin were randomized to the AppyCDS intervention group or usual care (UC) group. Patients were aged 5 to 20 years, presenting for an ED visit with right-sided or diffuse abdominal pain lasting 5 days or less. We excluded pregnant patients, those with a prior appendectomy, those with selected comorbidities, and those with traumatic injuries. The trial was conducted from October 2016 to July 2019. INTERVENTIONS AppyCDS prompted data entry at the point of care to estimate appendicitis risk using the pediatric appendicitis risk calculator (pARC). Based on pARC estimates, AppyCDS recommended next steps in care. MAIN OUTCOMES AND MEASURES Primary outcomes were CT, US, or any imaging (CT or US) during the index ED visit. Safety outcomes were perforations, negative appendectomies, and missed appendicitis. Costs were a secondary outcome. Ratio of ratios (RORs) for primary and safety outcomes and differences by group in cost were used to evaluate effectiveness of the clinical decision support tool. RESULTS We enrolled 3161 patients at intervention EDs and 2779 patients at UC EDs. The mean age of patients was 11.9 (4.6) years and 2614 (44.0%) were boys or young men. RORs for CT (0.94; 95% CI, 0.75-1.19), US (0.98; 95% CI, 0.84-1.14), and any imaging (0.96; 95% CI, 0.86-1.07) did not differ by study group. In an exploratory analysis conducted in 1 health system, AppyCDS was associated with a reduction in any imaging (ROR, 0.82; 95% CI, 0.73- 0.93) for patients with pARC score of 15% or less and a reduction in CT (ROR, 0.58; 95% CI, 0.45-0.74) for patients with a pARC score of 16% to 50%. Perforations, negative appendectomies, and cases of missed appendicitis by study phase did not differ significantly by study group. Costs did not differ overall by study group. CONCLUSIONS AND RELEVANCE In this study, AppyCDS was not associated with overall reductions in diagnostic imaging; exploratory analysis revealed more appropriate use of imaging in patients with a low pARC score. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02633735.
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Affiliation(s)
- Anupam B. Kharbanda
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | | | - Dustin W. Ballard
- The Permanente Medical Group, Oakland, California
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | - David R. Vinson
- The Permanente Medical Group, Oakland, California
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | | | - Steven P. Dehmer
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - Heidi Ekstrom
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - Adina S. Rauchwerger
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Brianna McMichael
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | | | | | - Laura E. Simon
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Jingyi Zhu
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - E. Margaret Warton
- The Kaiser Permanente Northern California Division of Research, Oakland, California
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Hao TK, Chung NT, Huy HQ, Linh NTM, Xuan NT. Combining Ultrasound with a Pediatric Appendicitis Score to Distinguish Complicated from Uncomplicated Appendicitis in a Pediatric Population. Acta Inform Med 2020; 28:114-118. [PMID: 32742063 PMCID: PMC7382774 DOI: 10.5455/aim.2020.28.114-118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: The accurate diagnosis of complicated appendicitis has been improved by using various diagnostic modalities. However, no preoperative diagnostic method could completely confirm the results. Therefore, preoperative diagnosis of complicated appendicitis to have the right management is still a huge challenge. Objectives: The aim of this study was to evaluate the diagnostic value of ultrasound combined with pediatric appendicitis score for differentiation between acute uncomplicated appendicitis and acute complicated appendicitis in a pediatric population. Methods: We prospectively evaluated 120 pediatric patients who underwent surgery for acute appendicitis from November 2017 to June 2019. Pediatric appendicitis score (PAS) was calculated and ultrasound (US) was performed before surgery. The histopathology of phlegmonous appendicitis corresponds to uncomplicated appendicitis (AUA), while gangrenous appendicitis and perforation are classified as complicated appendicitis (ACA). Results: Histopathologically, the results provided a diagnosis of acute appendicitis including 86 (71.7%) patients with AUA and 34 (28.3%) children with ACA. US findings showed a sensitivity of 23.5%, the specificity of 95.4%, PPV of 66.7%, NPV of 75.9%, and an accuracy of 75%. PAS of 8 was found to be the most appropriate cutoff point compatible with ACA; it resulted in a sensitivity of 76.5% and a specificity of 84.1%. Combining ultrasound with a pediatric appendicitis score resulted in a higher specificity to distinguish complicated from uncomplicated appendicitis when compared with ultrasound or PAS solely. Conclusions: the US is highly specific but nonsensitive for detecting complicated pediatric appendicitis. Combining ultrasound with pediatric appendicitis is a very good concept to distinguish complicated from uncomplicated appendicitis in a pediatric population.
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Affiliation(s)
| | - Nguyen Tien Chung
- Department of Internal Medicine, University Of Traditional Medicine, Ha Noi, Vietnam
| | - Huynh Quang Huy
- Department of Radiology, Pham Ngoc Thach University of Medicine, Vietnam
| | | | - Nguyen Thanh Xuan
- Department of Abdominal Emergency and Pediatric Surgery, Hue Central Hospital, Vietnam
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Dhatt S, Sabhaney V, Bray H, Skarsgard ED. Improving the diagnostic accuracy of appendicitis using a multidisciplinary pathway. J Pediatr Surg 2020; 55:889-892. [PMID: 32067806 DOI: 10.1016/j.jpedsurg.2020.01.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 01/25/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Improvement opportunities exist in the accuracy and timeliness of the diagnosis of childhood appendicitis. The purpose of our study was to conduct a post-implementation audit of a diagnostic pathway for children with suspected appendicitis presenting to our pediatric emergency department. METHODS We adopted a diagnostic pathway that utilized a validated risk of appendicitis stratification tool (Alvarado Score) with protocolized use of abdominal ultrasound for moderate risk patients. We conducted a 10% convenience sample audit of pathway patients treated over the subsequent 18-month period. Outcome measures included false negative and positive rates, sensitivity, specificity, and overall pathway accuracy. RESULTS One hundred thirty-four pathway patients, of which 22 (16.4%) had appendicitis confirmed pathologically, were evaluated. The risk group distribution of patients was: low risk (29%), moderate risk (60%), and high risk (11%). The negative appendectomy rate was 4.4% (reduced from 14% pre-pathway), and the false negative (missed appendicitis) rate was 3.0%. No patients received CT scans. Pathway sensitivity was 81.8%% (95% CI 59.7% to 94.8%), specificity-92.9%% (95% CI 86.4%-96.9%), and overall accuracy-91.0% (95% CI 84.9%-95.3%). CONCLUSION Implementation of a diagnostic pathway achieved a high level of accuracy and reduced our institutional negative appendectomy rate by 67%. The audit identified additional pathway improvement opportunities. LEVELS OF EVIDENCE Level IV.
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Affiliation(s)
- Saroop Dhatt
- University of British Columbia, Faculty of Medicine, British Columbia Children's Hospital, Vancouver, Canada
| | - Vikram Sabhaney
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Heather Bray
- Department of Radiology, University of British Columbia, Vancouver, Canada
| | - Erik D Skarsgard
- Department of Surgery, University of British Columbia, Vancouver, Canada.
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Utilization of computed tomography imaging in the pediatric emergency department. Pediatr Radiol 2020; 50:470-475. [PMID: 31807854 DOI: 10.1007/s00247-019-04564-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/30/2019] [Accepted: 10/21/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND In recent years, there has been a movement toward more judicious use of computed tomography (CT) imaging in an attempt to limit exposure of pediatric patients to ionizing radiation. The Image Gently Alliance and like-minded movements began advocating for safe and high-quality pediatric imaging worldwide in the late 2000s. OBJECTIVE In the context of these efforts, we evaluate CT utilization rates in the pediatric emergency department at a major academic medical center. MATERIALS AND METHODS We tracked utilization in several categories of CT, magnetic resonance imaging (MRI) and ultrasonography (US) between July 2008 and June 2017 and compared them with utilization rates from 2000 to 2006. RESULTS A total of 4,955 pediatric patients underwent a total of 5,973 CT scans, 2,775 US studies and 293 MRI scans while in the pediatric emergency department during the 2008-2017 study period. We observed decreases in CT scans across all categories, ranging from a 19% decrease in abdominal CT to a 66% decrease in chest CT. Relatively greater decreases in CT scans were observed in patients younger than 3 years of age as compared to older children and adolescents. Abdominal and pelvic US increased. Brain MRI also increased over the final two years of the study. CONCLUSION CT utilization decreased throughout the 2008-2017 study period.
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Anderson KT, Bartz-Kurycki MA, Austin MT, Kawaguchi AL, Kao LS, Lally KP, Tsao K. Hospital type predicts computed tomography use for pediatric appendicitis. J Pediatr Surg 2019; 54:723-727. [PMID: 29925468 DOI: 10.1016/j.jpedsurg.2018.05.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/23/2018] [Accepted: 05/23/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evidence-based guidelines recommend ultrasound (US) over computed tomography (CT) as the primary imaging modality for suspected pediatric appendicitis. Continued high rates of CT use may result in significant unnecessary radiation exposure in children. The purpose of this study was to evaluate variables associated with preoperative CT use in pediatric appendectomy patients. METHODS A retrospective cohort study of pediatric patients who underwent appendectomy for acute appendicitis in 2015-2016 at National Surgical Quality Improvement Program for Pediatrics (NSQIP-P) hospitals was conducted. Pediatric (<18 years old) patients who underwent appendectomy for acute appendicitis in an NSQIP-P hospital from 2015 to 2016 were included. Patients were excluded if they underwent interval or incidental appendectomy or did not have a final diagnosis of appendicitis. Variables associated with imaging evaluation, including age, body mass index (BMI), race/ethnicity, gender and hospital of presentation (NSQIP-P vs. non-NSQIP-P hospital) were evaluated. The primary outcome was receipt of preoperative CT. Secondary outcomes include reimaging practices and trends over time. RESULTS 22,333 children underwent appendectomies, of which almost all were imaged preoperatively (96.5%) and 36% of whom presented initially to a non-NSQIP-P hospital. Overall, US only was the most common imaging modality (52%), followed by CT only (27%), US+CT (16%), no imaging (3%), MRI +/- CT/US (1%) and MRI only (<1%). On regression, older age (>11 years), obesity (BMI >95th percentile for age), and female gender were associated with increased odds of receiving a CT scan. However, initial presentation to a non-NSQIP-P hospital was the strongest predictor of CT use (OR 9.4, 95% CI 8.1-10.8). Reimaging after transfer was common, especially after US and MRI at a non-NSQIP-P hospital. CT use decreased between 2015 and 2016 in non-NSQIP-P hospitals but remained the same (25%) in NSQIP-P facilities. CONCLUSIONS Though patient characteristics were associated with different imaging practices, presentation at a referral, nonchildren's hospital is the strongest predictor of CT use in children with appendicitis. NSQIP-P hospitals frequently reimage transferred patients and have not reduced their CT use. Novel strategies are required for all hospital types in order to sustain reduction in CT use and mitigate unnecessary imaging. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative study.
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Affiliation(s)
- Kathryn Tinsley Anderson
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX.
| | - Marisa A Bartz-Kurycki
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Mary T Austin
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Akemi L Kawaguchi
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Lillian S Kao
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Kevin P Lally
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Kuojen Tsao
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
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Bonasso PC, Dassinger MS, Wyrick DL, Gurien LA, Burford JM, Smith SD. Review of bedside surgeon-performed ultrasound in pediatric patients. J Pediatr Surg 2018; 53:2279-2289. [PMID: 29807830 DOI: 10.1016/j.jpedsurg.2018.04.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 03/21/2018] [Accepted: 04/28/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE Pediatric surgeon performed bedside ultrasound (PSPBUS) is a targeted examination that is diagnostic or therapeutic. The aim of this paper is to review literature involving PSPBUS. METHODS PSPBUS practices reviewed in this paper include central venous catheter placement, physiologic assessment (volume status and echocardiography), hypertrophic pyloric stenosis diagnosis, appendicitis diagnosis, the Focused Assessment with Sonography for Trauma (FAST), thoracic evaluation, and soft tissue infection evaluation. RESULTS There are no standards for the practice of PSPBUS. CONCLUSIONS As the role of the pediatric surgeon continues to evolve, PSPBUS will influence practice patterns, disease diagnosis, and patient management. TYPE OF STUDY Review Article. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Patrick C Bonasso
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202.
| | - Melvin S Dassinger
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Deidre L Wyrick
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Lori A Gurien
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Jeffrey M Burford
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Samuel D Smith
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
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Kharbanda AB, Christensen EW, Dudley NC, Bajaj L, Stevenson MD, Macias CG, Mittal MK, Bachur RG, Bennett JE, Sinclair K, McMichael B, Dayan PS. Economic Analysis of Diagnostic Imaging in Pediatric Patients With Suspected Appendicitis. Acad Emerg Med 2018; 25:785-794. [PMID: 29427374 DOI: 10.1111/acem.13387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/01/2018] [Accepted: 02/05/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (EDs). This study compares the cost of diagnosing and treating suspected appendicitis across a multicenter network of children's hospitals. METHODS This study is a secondary analysis using deidentified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3 to 18 years old who presented to the ED with acute abdominal pain of <96 hours' duration. RESULTS Our data set contained 2,300 cases across nine sites. There was an appendicitis rate of 31.8% and perforation rate of 25.7%. Sites correctly diagnosed appendicitis in over 95% of cases. The negative appendicitis rate ranged from 2.5% to 4.7% while the missed appendicitis rate ranged from 0.3% to 1.1% with no significant differences in these rates across site. Across sites, we found a strong positive correlation (0.95) between CT rate and total cost per case and a strong negative correlation (-0.71) between US rate and cost. The cost per case at US sites was 5.2% ($367) less than at CT sites (p < 0.001). Similarly, costs per case at mixed sites were 3.4% ($244) less than at CT sites (p < 0.001). Comparing costs among CT sites or among US sites, the cost per case generally increased as the images per case increased among both CT sites and US sites, but the costs were universally higher at CT sites. CONCLUSIONS Our results provide support for US as the primary imaging modality for appendicitis. Sites that preferentially utilized US had lower costs per case than sites that primarily used CT. Imaging rates across sites varied due to practice patterns and resulted in a significant cost consequence without higher rates for negative appendectomies or missed appendicitis cases.
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Affiliation(s)
- Anupam B Kharbanda
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Eric W Christensen
- Health Services Management, College of Continuing and Professional Studies, University of Minnesota, Minneapolis, MN
| | - Nanette C Dudley
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado School of Medicine, Denver, CO
| | | | - Charles G Macias
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Manoj K Mittal
- Department of Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jonathan E Bennett
- Department of Pediatrics, Alfred I. duPont Hospital for Children, Jefferson Medical College, Wilmington, DE
| | - Kelly Sinclair
- Division of Emergency Medicine, Children's Mercy Hospital, Kansas City, MO
| | - Brianna McMichael
- Children's Minnesota Research Institute, Children's Minnesota, Minneapolis, MN
| | - Peter S Dayan
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY
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13
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The Alvarado score should be used to reduce emergency department length of stay and radiation exposure in select patients with abdominal pain. J Trauma Acute Care Surg 2018. [PMID: 29521805 DOI: 10.1097/ta.0000000000001885] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Parikh PP, Tashiro J, Wagenaar AE, Curbelo M, Perez EA, Neville HL, Hogan AR, Sola JE. Looped suture versus stapler device in pediatric laparoscopic appendectomy: a comparative outcomes and intraoperative cost analysis. J Pediatr Surg 2018; 53:616-619. [PMID: 28550935 DOI: 10.1016/j.jpedsurg.2017.05.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/10/2017] [Accepted: 05/15/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Appendiceal ligation during pediatric laparoscopic appendectomy (LA) may be performed using looped suture versus stapler. Controversy regarding the utility of either method exists. Clinical outcomes and cost analysis of LA with both methods were compared. METHODS All pediatric LA were performed from fiscal years 2013 and 2014 by two pediatric surgeons. While one surgeon used looped suture, the other used stapler exclusively. chi-Square tests were performed to analyze associations. RESULTS Two hundred thirty-eight cases were analyzed where looped suture versus stapler LA was performed in 46% and 54% of patients, respectively. Operating room costs were $317.10 and $707.12/person for looped suture and stapler LA, respectively (P<0.0001). Difference in cost of $390.02/person was attributed solely to ligation type. On bivariate analysis, rate of in-hospital complications, length of stay, return-to-ER and readmission within 30 days did not significantly differ between groups. CONCLUSION A comparative analysis of looped suture versus stapler device during LA for pediatric appendicitis revealed that postoperative complications, length of stay, ER visits and readmissions were not significantly different. Looped suture LA was significantly more cost efficient than stapler LA. In pediatric appendicitis, appendiceal ligation during LA may be performed safely and cost effectively with looped suture versus stapler. TYPE OF STUDY Cost effectiveness LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Punam P Parikh
- DeWitt-Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL.
| | - Jun Tashiro
- DeWitt-Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Amy E Wagenaar
- DeWitt-Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Miosotys Curbelo
- DeWitt-Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Eduardo A Perez
- DeWitt-Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Holly L Neville
- DeWitt-Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Anthony R Hogan
- DeWitt-Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Juan E Sola
- DeWitt-Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL
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15
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Nishizawa T, Maeda S, Goldman RD, Hayashi H. Predicting need for additional CT scan in children with a non-diagnostic ultrasound for appendicitis in the emergency department. Am J Emerg Med 2018; 36:49-55. [DOI: 10.1016/j.ajem.2017.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 07/01/2017] [Accepted: 07/02/2017] [Indexed: 12/19/2022] Open
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16
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Anderson KT, Bartz-Kurycki M, Austin MT, Kawaguchi A, John SD, Kao LS, Tsao K. Approaching zero: Implications of a computed tomography reduction program for pediatric appendicitis evaluation. J Pediatr Surg 2017; 52:1909-1915. [PMID: 28927978 DOI: 10.1016/j.jpedsurg.2017.08.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/28/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE Because of awareness of iatrogenic radiation exposure, there is a national trend of diminishing computed tomography (CT) use for pediatric suspected appendicitis. The purpose of this study was to evaluate the effects of a CT reduction program for evaluation of appendicitis. METHODS A multidisciplinary group (emergency medicine, radiology, and surgery) at a children's hospital developed a reduction program which included: ultrasound (U/S) first (2012), magnetic resonance imaging (MRI) second (2014), and standardized U/S reports (2016). Imaging modality, negative appendectomy rate, time from first image to incision, and imaging costs were evaluated over time. RESULTS Of the 571 patients evaluated from 2012 to 2016, there was a significant decrease in CT use and increase U/S and MRI use over the study period (all p<0.01). CT use approached zero in 2016. Time from first image to incision (median 10.7h, IQR 5.6-15.5) and negative appendectomy rate (mean 3.7±0.2%) did not change. Median imaging costs ($88, IQR $52-$169) and radiology percent of total costs (range 0.8%-3.9%) increased over time (both p<0.01). CONCLUSION Approaching zero CT use for evaluation of pediatric appendicitis is possible through a multidisciplinary protocol without impacting clinical outcomes. However, increased MRI use led to higher costs. Cost-effectiveness of replacing CT with MRI warrants further study. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- K Tinsley Anderson
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Marisa Bartz-Kurycki
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Mary T Austin
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Akemi Kawaguchi
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Susan D John
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Lillian S Kao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - KuoJen Tsao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States.
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17
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Abstract
Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.
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Affiliation(s)
- Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA.
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA
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18
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Carpenter JL, Orth RC, Zhang W, Lopez ME, Mangona KL, Guillerman RP. Diagnostic Performance of US for Differentiating Perforated from Nonperforated Pediatric Appendicitis: A Prospective Cohort Study. Radiology 2017; 282:835-841. [DOI: 10.1148/radiol.2016160175] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jennifer L. Carpenter
- From the Division of Pediatric Surgery (J.L.C., M.E.L.), Department of Pediatric Radiology (R.C.O., K.L.M., R.P.G.), and Surgical Outcomes Center (W.Z.), Texas Children’s Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030; and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex (J.L.C., M.E.L.)
| | - Robert C. Orth
- From the Division of Pediatric Surgery (J.L.C., M.E.L.), Department of Pediatric Radiology (R.C.O., K.L.M., R.P.G.), and Surgical Outcomes Center (W.Z.), Texas Children’s Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030; and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex (J.L.C., M.E.L.)
| | - Wei Zhang
- From the Division of Pediatric Surgery (J.L.C., M.E.L.), Department of Pediatric Radiology (R.C.O., K.L.M., R.P.G.), and Surgical Outcomes Center (W.Z.), Texas Children’s Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030; and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex (J.L.C., M.E.L.)
| | - Monica E. Lopez
- From the Division of Pediatric Surgery (J.L.C., M.E.L.), Department of Pediatric Radiology (R.C.O., K.L.M., R.P.G.), and Surgical Outcomes Center (W.Z.), Texas Children’s Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030; and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex (J.L.C., M.E.L.)
| | - Kate L. Mangona
- From the Division of Pediatric Surgery (J.L.C., M.E.L.), Department of Pediatric Radiology (R.C.O., K.L.M., R.P.G.), and Surgical Outcomes Center (W.Z.), Texas Children’s Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030; and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex (J.L.C., M.E.L.)
| | - R. Paul Guillerman
- From the Division of Pediatric Surgery (J.L.C., M.E.L.), Department of Pediatric Radiology (R.C.O., K.L.M., R.P.G.), and Surgical Outcomes Center (W.Z.), Texas Children’s Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030; and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex (J.L.C., M.E.L.)
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Sammalkorpi HE, Mentula P, Savolainen H, Leppäniemi A. The Introduction of Adult Appendicitis Score Reduced Negative Appendectomy Rate. Scand J Surg 2017; 106:196-201. [PMID: 28737110 DOI: 10.1177/1457496916683099] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Implementation of a clinical risk score into diagnostics of acute appendicitis may provide accurate diagnosis with selective use of imaging studies. The aim of this study was to prospectively validate recently described diagnostic scoring system, Adult Appendicitis Score, and evaluate its effects on negative appendectomy rate. MATERIAL AND METHODS Adult Appendicitis Score stratifies patients into three groups: high, intermediate, and low risk of appendicitis. The score was implemented in diagnostics of adult patients suspected of acute appendicitis in two university hospitals. We analyzed the effects of Adult Appendicitis Score on diagnostic accuracy, imaging studies, and treatment. The study population was compared with a reference population of 829 patients suspected of acute appendicitis originally enrolled for the study of construction of the Adult Appendicitis Score. RESULTS This study enrolled 908 patients of whom 432 (48%) had appendicitis. The score stratified 49% of all appendicitis patients into high-risk group with specificity of 93.3%. In the low-risk group, prevalence of appendicitis was 7%. The histologically confirmed negative appendectomy rate decreased from 18.2% to 8.7%, p<0.001, compared to the original dataset. CONCLUSION Adult Appendicitis Score is a reliable tool for stratification of patients into selective imaging, which results in low negative appendectomy rate.
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Affiliation(s)
- H E Sammalkorpi
- 1 Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland.,2 Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - P Mentula
- 1 Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - H Savolainen
- 3 Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - A Leppäniemi
- 1 Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
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20
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Otero HJ, Crowder L. Imaging Utilization for the Diagnosis of Appendicitis in Stand-Alone Children's Hospitals in the United States: Trends and Costs. J Am Coll Radiol 2017; 14:603-608. [PMID: 28223114 DOI: 10.1016/j.jacr.2016.12.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe the imaging utilization patterns for the diagnosis of appendicitis among children's hospitals in the United States over the last 10 years (2005-2014). METHODS All patients with a primary discharge diagnosis of appendicitis included in a large administrative database of 45 pediatric institutions in the United States between 2005 and 2014 were selected. Demographics, imaging utilization, and costs were described. RESULTS In all, 96,786 children with appendicitis (59% boys, 41% girls; mean age: 9.9 years) were studied. The average length of stay decreased from 5.0 days in 2005 to 3.4 days in 2014 (P < .01). The percentage of patients undergoing CT increased between 2005 and 2007 from 59.1% to 62.6%, respectively, followed by a decrease from 62.6% to 32.7% in 2014 (r2 = 0.93). Radiograph utilization decreased from 14.2% in 2005 to 3.6% in 2014 (r2 = 0.93), and ultrasound and MRI increased from 25% and 0.03% in 2005 to 61% and 1.0% in 2014 (r2 = 0.97 and 0.64), respectively. The mean total hospital costs increased from $11,700 in 2005 to $16,500 in 2014; imaging costs increased only slightly from $3,205 to $3,259. The imaging fraction of hospital costs decreased from 27.5% to 19.8%. CONCLUSION There has been a significant decrease in utilization of CT and radiographs for the management of appendicitis in children, and ultrasound has continued to increase. Imaging costs have remained stable in comparison to rising hospital costs, generating a drop in the fraction of costs related to imaging.
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Affiliation(s)
- Hansel J Otero
- Department of Diagnostic Imaging and Radiology, Children's National Health System, Washington, DC.
| | - Lauren Crowder
- Department of Diagnostic Imaging and Radiology, Children's National Health System, Washington, DC
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Abstract
Acute appendicitis is the most common cause of emergent surgery in children. Historically, surgical dogma dictated emergent appendectomy due to concern for impending perforation. Recently, however, there has been a paradigm shift in both the understanding of its pathophysiology as well as its treatment to more nonoperative management. No longer is it considered a spectrum from uncomplicated appendicitis inevitably progressing to complicated appendicitis over time. Rather, uncomplicated and complicated appendicitis are now considered two distinct pathophysiologic entities. This change requires not only educating the patients and their families but also the general practitioners who will be managing treatment expectations and caring for patients long term. In this article, we review the pathophysiology of appendicitis, including the differentiation between uncomplicated and complicated appendicitis, as well as the new treatment paradigms. [Pediatr Ann. 2016;45(7):e235-e240.].
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How to diagnose acute appendicitis: ultrasound first. Insights Imaging 2016; 7:255-63. [PMID: 26883138 PMCID: PMC4805616 DOI: 10.1007/s13244-016-0469-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 01/18/2016] [Accepted: 01/25/2016] [Indexed: 12/24/2022] Open
Abstract
Acute appendicitis (AA) is a common abdominal emergency with a lifetime prevalence of about 7 %. As the clinical diagnosis of AA remains a challenge to emergency physicians and surgeons, imaging modalities have gained major importance in the diagnostic work-up of patients with suspected AA in order to keep both the negative appendectomy rate and the perforation rate low. Introduced in 1986, graded-compression ultrasound (US) has well-established direct and indirect signs for diagnosing AA. In our opinion, US should be the first-line imaging modality, as graded-compression US has excellent specificity both in the paediatric and adult patient populations. As US sensitivity is limited, and non-diagnostic US examinations with non-visualization of the appendix are more a rule than an exception, diagnostic strategies and algorithms after non-diagnostic US should focus on clinical reassessment and complementary imaging with MRI/CT if indicated. Accordingly, both ionizing radiation to our patients and cost of pre-therapeutic diagnosis of AA will be low, with low negative appendectomy and perforation rates. Main Messages • Ultrasound (US) should be the first imaging modality for diagnosing acute appendicitis (AA). • Primary US for AA diagnosis will decrease ionizing radiation and cost. • Sensitivity of US to diagnose AA is lower than of CT/MRI. • Non-visualization of the appendix should lead to clinical reassessment. • Complementary MRI or CT may be performed if diagnosis remains unclear.
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