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Greene AC, Mankarious MM, Matzelle-Zywicki M, Patel A, Reyes L, Tsai AY, Santos MC, Moore MM, Kulaylat AN. A Magnetic Resonance Imaging Protocol for the Evaluation of Pediatric Postappendectomy Abscess: A Quality Improvement Project. J Surg Res 2024; 293:587-595. [PMID: 37837813 DOI: 10.1016/j.jss.2023.09.029] [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: 06/01/2023] [Revised: 09/07/2023] [Accepted: 09/12/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Computed tomography (CT) scans are often used when cross-sectional imaging is required for evaluation of postappendectomy abscess, exposing children to a source of ionizing radiation. Our aim was to decrease the use of CT scans in pediatric postappendectomy patients by 50% in 12 mo and to sustain those results for 1 y. METHODS A comprehensive magnetic resonance imaging protocol was introduced in 2018 at a tertiary children's hospital within a general health system to replace CT scans in suspected pediatric postappendectomy abscess. Diagnostic and clinical outcomes were compared preprotocol (2015-2017) and postprotocol (2018-2022) implementation using standard univariate statistics. P < 0.05 was considered significant. Quality improvement methodology was used to design and implement the protocol. RESULTS Sixty eight pediatric postappendectomy patients received cross-sectional imaging during the study period. Overall, CT scans were used exclusively (100%, n = 27) in the preimplementation period compared to 31.7% (n = 13) of cross-sectional imaging in the postimplementation period. However, in the first year of protocol implementation, CT scan use only decreased to 78% of cross-sectional studies performed. The majority of protocol deviations (54%) also occurred in this time period. With improved education and reinforcement, CT scan utilization decreased to approximately 24% of cross-sectional studies annually. Missed abscess rate, time to diagnosis, drainage procedure type, readmission, and reoperation were similar between preimplementation and postimplementation periods. CONCLUSIONS Implementation of a postappendectomy abscess magnetic resonance imaging protocol was associated with decreased CT utilization in the pediatric population, while maintaining comparable diagnostic evaluation and clinical outcomes. Adherence to quality improvement principles facilitated achieving goals and sustaining gains.
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Affiliation(s)
- Alicia C Greene
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Marc M Mankarious
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | | | - Akshilkumar Patel
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Lilia Reyes
- Division of Pediatric Emergency Medicine, Penn State Children's Hospital, Hershey, Pennsylvania
| | - Anthony Y Tsai
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, Pennsylvania
| | - Mary C Santos
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, Pennsylvania
| | - Michael M Moore
- Department of Radiology, Nemours Children's Hospital, Wilmington, Delaware
| | - Afif N Kulaylat
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, Pennsylvania.
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Greene AC, Mankarious MM, Patel A, Matzelle-Zywicki M, Kwon EG, Reyes L, Tsai AY, Santos MC, Moore MM, Kulaylat AN. Can magnetic resonance imaging replace computed tomography scans in the evaluation of pediatric post-appendectomy abscess? Surgery 2023; 174:703-708. [PMID: 37365084 DOI: 10.1016/j.surg.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/03/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Computed tomography scans have been used when cross-axial imaging is required to evaluate pediatric post-appendectomy abscesses. To reduce a source of radiation exposure, our institution converted to using contrast-enhanced magnetic resonance imaging to replace computed tomography scans in this clinical context. Our aim is to evaluate the performance of magnetic resonance imaging compared to computed tomography scans and associated clinical outcomes in this patient population. METHODS A contrast-enhanced comprehensive magnetic resonance imaging protocol was implemented to evaluate a post-appendectomy abscess in 2018. A retrospective chart review was performed from 2015 to 2022 for pediatric patients (<18 years old) with prior appendectomy and subsequent cross-sectional imaging to evaluate for an intraabdominal abscess. Patient characteristics and clinical parameters between the 2 modalities were abstracted and compared using standard univariate statistics. RESULTS There were a total of 72 post-appendectomy patients who received cross-axial imaging, which included 43 computed tomography scans and 29 magnetic resonance imaging during the study interval. Patient demographics were comparable between cohorts and rates of perforated appendicitis at the index operation (computed tomography: 79.1% vs magnetic resonance imaging: 86.2%). Missed abscess rate, abscess size, management technique, drainage culture results, readmission, and reoperation were similar between imaging modalities. Median request to scan time was longer for magnetic resonance imaging than computed tomography (191.5 vs 108 minutes, P = .04). The median duration of a comprehensive magnetic resonance imaging scan was 32 minutes (interquartile range 28-50.5 minutes). CONCLUSION Contrast-enhanced magnetic resonance imaging provides an alternative cross-sectional imaging modality to computed tomography scans to evaluate pediatric post-appendectomy abscesses.
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Affiliation(s)
- Alicia C Greene
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA. https://twitter.com/AliciaGreeneDO
| | - Marc M Mankarious
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA. https://twitter.com/MarcMMankarious
| | - Akshilkumar Patel
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA
| | - Madeline Matzelle-Zywicki
- The Pennsylvania State University College of Medicine, Hershey, PA. https://twitter.com/maddie_mzywicki
| | - Eustina G Kwon
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA. https://twitter.com/eustina_k
| | - Lilia Reyes
- Division of Pediatric Emergency Medicine, Penn State Children's Hospital, Hershey, PA
| | - Anthony Y Tsai
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, PA. https://twitter.com/antsai
| | - Mary C Santos
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, PA
| | - Michael M Moore
- Department of Radiology, Nemours Children's Hospital, Wilmington, DE
| | - Afif N Kulaylat
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, PA.
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Affiliation(s)
- Katherine He
- Department of General Surgery, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street CA-034, Boston, MA 02115, USA
| | - Shawn J Rangel
- Department of Pediatric & Thoracic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue - Fegan 3, Boston, MA 02115, USA.
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Utilization and Performance Benchmarking for Postoperative Imaging in Children With Complicated Appendicitis. Ann Surg 2020; 275:816-823. [PMID: 32657938 DOI: 10.1097/sla.0000000000004250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gibson CR, Amirabadi A, Goman S, Armstrong NC, Langer JC, Amaral JG, Temple MJ, Parra D, John PR, Connolly BL. Use of Tissue Plasminogen Activator in Abdominal Abscesses in Children-A Single-Center Randomized Control Trial. Can Assoc Radiol J 2020; 72:577-584. [PMID: 32281404 DOI: 10.1177/0846537120914263] [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: 11/17/2022] Open
Abstract
PURPOSE To establish the efficacy of once-per-day intracavitary tissue plasminogen activator (tPA) in the treatment of pediatric intra-abdominal abscesses. METHODS A single-center prospective, double-blinded, randomized controlled trial of the use of intracavitary tPA in abdominal abscesses in children. Patients were randomized to either tPA-treatment or saline-treatment groups. Primary outcome was drainage catheter dwell (hours). Secondary outcomes were length of hospital stay, times to discharge, clinical and sonographic resolution, and adverse events (AEs). RESULTS Twenty-eight children were randomized to either group (n = 14 each). Demographics between groups were not significantly different (age P = .28; weight P = .40; gender P = .44). There were significantly more abscesses in the tPA-treated group (P = .03). Abscesses were secondary to perforated appendicitis (n = 25) or postappendectomy (n = 3). Thirty-four abscesses were drained, 4 aspirated, 3 neither drained/aspirated. There was no significant difference in number of drains (P = .14), drain size (P = .19), primary outcome (P = .077), or secondary outcomes found. No procedural or intervention drug-related AEs occurred. No patient in the saline-treated group required to be switched/treated with tPA. CONCLUSION No significant difference in the length of catheter dwell time, procedure time to discharge, or time to resolution was found. Intracavitary tPA was not associated with morbidity or mortality. The results neither support nor negate routine use of tPA in the drainage of intra-abdominal abscess in children. It is possible that a multicentre study with a larger number of patients may answer this question more definitively.
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Affiliation(s)
- Craig R Gibson
- Image Guided Therapy, Diagnostic Imaging, 7979The Hospital for Sick Children, Toronto, Ontario, Canada.,Perth Children's Hospital, Nedlands, Australia
| | - Afsaneh Amirabadi
- Diagnostic Imaging, 7979The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Simal Goman
- Image Guided Therapy, Diagnostic Imaging, 7979The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicholas C Armstrong
- Image Guided Therapy, Diagnostic Imaging, 7979The Hospital for Sick Children, Toronto, Ontario, Canada.,8808University of Limerick, Graduate Entry Medical School, Limerick, Ireland
| | - Jacob C Langer
- Division of General and Thoracic Surgery, 7979The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Ontario, Canada
| | - Joao G Amaral
- Image Guided Therapy, Diagnostic Imaging, 7979The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Ontario, Canada
| | - Michael J Temple
- Image Guided Therapy, Diagnostic Imaging, 7979The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Ontario, Canada
| | - Dimitri Parra
- Image Guided Therapy, Diagnostic Imaging, 7979The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Ontario, Canada
| | - Philip R John
- Image Guided Therapy, Diagnostic Imaging, 7979The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Ontario, Canada
| | - Bairbre L Connolly
- Image Guided Therapy, Diagnostic Imaging, 7979The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Ontario, Canada
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Dariushnia SR, Mitchell JW, Chaudry G, Hogan MJ. Society of Interventional Radiology Quality Improvement Standards for Image-Guided Percutaneous Drainage and Aspiration of Abscesses and Fluid Collections. J Vasc Interv Radiol 2020; 31:662-666.e4. [PMID: 32061521 DOI: 10.1016/j.jvir.2019.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/02/2019] [Indexed: 12/26/2022] Open
Affiliation(s)
- Sean R Dariushnia
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University School of Medicine, Atlanta, Georgia.
| | - Jason W Mitchell
- Department of Radiology, Capital Regional Medical Center, Tallahassee, Florida
| | - Gulraiz Chaudry
- Division of Interventional Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Mark J Hogan
- Department of Radiology, Section of Vascular and Interventional Radiology, Nationwide Children's Hospital, Columbus, Ohio
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Abstract
There has been an increasing demand in image-guided minimally invasive procedures and these have become an integral part of present-day clinical practice. Basic interventional radiology (IR) procedures have greatly reduced the need for invasive procedures for sampling as well as treating conditions like abscess and fluid collections. Owing to their minimally invasive nature, most of these procedures may be performed on the outpatient patients as daycare procedures. Some of these procedures in critically ill patients may be lifesaving. Basic interventional radiology (IR) procedures consist of image-guided fine-needle aspiration cytology and biopsy, tru-cut (core) biopsy, needle aspiration/drainage and percutaneous catheter drainage. This review aims to provide practice requisites for basic IR procedures.
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Affiliation(s)
- Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Krishna Bhardwaj
- Department of Radiology, VMMC and Safdarjung Hospital, Ansari Nagar, New Delhi, India
| | - Chander Mohan
- Department of Interventional Radiology, BLK Superspecialty Hospital, Pusa Raod, New Delhi, India
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Abstract
The normal peritoneal structures, including the mesenteries and the omenta, are only a few cell layers thick and are visible on imaging based upon the tissues (e.g., fat) and structures (e.g., blood vessels and lymph nodes) contained within them. These structures become more visible and change in appearance when involved by pathological processes. In this pictorial essay, we discuss the normal anatomy of the various abdominopelvic peritoneal structures and illustrate numerous developmental and acquired diagnoses that involve these structures in the pediatric and young adult population.
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Farach SM, Danielson PD, Chandler NM. Preprocedural Coagulation Studies in Pediatric Patients Undergoing Percutaneous Intervention for Appendiceal Abscesses. Am Surg 2015. [DOI: 10.1177/000313481508100917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The literature reports poor correlation between coagulation screening and prediction of bleeding risk in children. Our aim is to determine whether there is a role for coagulation studies in children undergoing percutaneous intervention for appendiceal abscesses. A retrospective review of 1805 patients presenting with a diagnosis of appendicitis from September 2008 to September 2013 was performed. Patients presenting with appendiceal abscess who underwent percutaneous intervention were selected for further review (n = 131). A total of 76 patients (58%) had normal coagulation studies, whereas 55 (42%) had elevated values. An international normalized ratio ≥ 1.3 was found in 26 patients. Patients with normal coagulation values had an incidence of bleeding of 1.3 per cent. In the abnormal coagulation group, 8 patients received fresh frozen plasma before intervention, whereas 47 did not. There was one hematoma noted in each group with an incidence of bleeding of 3.6 per cent. The overall incidence of hematoma was 2.3 per cent with no significant difference in bleeding risk between the normal and abnormal coagulation groups. In conclusion, although many patients are found to have elevated coagulation studies, most do not have bleeding complications after intervention. There is poor correlation between coagulation screening and postprocedural outcomes evidenced by the low risk of bleeding.
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Affiliation(s)
- Sandra M. Farach
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Saint Petersburg, Florida
| | - Paul D. Danielson
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Saint Petersburg, Florida
| | - Nicole M. Chandler
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Saint Petersburg, Florida
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Sutcliffe J, Briggs J, Little M, McCarthy E, Wigham A, Bratby M, Tapping C, Anthony S, Patel R, Phillips-Hughes J, Boardman P, Uberoi R. Antibiotics in interventional radiology. Clin Radiol 2015; 70:223-34. [DOI: 10.1016/j.crad.2014.09.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Revised: 09/28/2014] [Accepted: 09/30/2014] [Indexed: 12/18/2022]
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Crowley JJ, Hogan MJ, Towbin RB, Saad WE, Baskin KM, Marie Cahill A, Caplin DM, Connolly BL, Kalva SP, Krishnamurthy V, Marshalleck FE, Roebuck DJ, Saad NE, Salazar GM, Stokes LS, Temple MJ, Gregory Walker T, Nikolic B. Quality improvement guidelines for pediatric gastrostomy and gastrojejunostomy tube placement. J Vasc Interv Radiol 2014; 25:1983-91. [PMID: 25439676 DOI: 10.1016/j.jvir.2014.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 08/01/2014] [Indexed: 01/20/2023] Open
Affiliation(s)
- John J Crowley
- Department of Radiology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark J Hogan
- Department of Vascular and Interventional Radiology, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Richard B Towbin
- Department of Radiology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Wael E Saad
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, 1500 E. Medical Drive, SPC 5868, Cardiovascular Center, #5588, Ann Arbor, MI 48109-5868.
| | - Kevin M Baskin
- Advanced Interventional Institute, Pittsburgh, Pennsylvania
| | - Anne Marie Cahill
- Department of Interventional Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Drew M Caplin
- Department of Radiology, Division of Interventional Radiology, Northshore University Hospital, Manhasset, New York
| | - Bairbre L Connolly
- Centre for Image Guided Therapy, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Venkataramu Krishnamurthy
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, 1500 E. Medical Drive, SPC 5868, Cardiovascular Center, #5588, Ann Arbor, MI 48109-5868
| | - Francis E Marshalleck
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Derek J Roebuck
- Department of Radiology, Great Ormond Street Hospital, London, United Kingdom
| | - Nael E Saad
- Department of Radiology, Division of Vascular and Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri; Department of Surgery, Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Gloria M Salazar
- Department of Radiology, Division of Vascular Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts
| | - Leann S Stokes
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael J Temple
- Centre for Image Guided Therapy, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - T Gregory Walker
- Department of Radiology, Division of Vascular Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts
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Abstract
Peritonitis is a progressive disease leading inexorably from local peritoneal irritation to overwhelming sepsis and death unless this trajectory is interrupted by timely and effective therapy. In children peritonitis is usually secondary to intraperitoneal disease, the nature of which varies around the world. In rich countries, appendicitis is the principal cause whilst in poor countries diseases such as typhoid must be considered in the differential diagnosis. Where resources are limited, the clinical diagnosis of peritonitis mandates laparotomy for diagnosis and source control. In regions with unlimited resources, radiological investigation, ultrasound, CT scan or MRI may be used to select patients for non-operative management. For patients with appendicitis, laparoscopic surgery has achieved results comparable to open operation; however, in many centres open operation remains the standard. In complicated peritonitis "damage control surgery" may be appropriate wherein source control is undertaken as an emergency with definitive repair or reconstruction awaiting improvement in the patient's general condition. Awareness of abdominal compartment syndrome is essential. Primary peritonitis in rich countries is seen in high-risk groups, such as steroid-dependent nephrotic syndrome patients, whilst in poor countries the at-risk population is less well defined and the diagnosis is often made at surgery.
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Affiliation(s)
- G P Hadley
- Department of Paediatric Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag, Congella 4013, Durban 17039, South Africa.
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