1
|
Rey R, Gualtieri R, La Scala G, Posfay Barbe K. Artificial Intelligence in the Diagnosis and Management of Appendicitis in Pediatric Departments: A Systematic Review. Eur J Pediatr Surg 2024. [PMID: 38290564 DOI: 10.1055/a-2257-5122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Artificial intelligence (AI) is a growing field in medical research that could potentially help in the challenging diagnosis of acute appendicitis (AA) in children. However, usefulness of AI in clinical settings remains unclear. Our aim was to assess the accuracy of AIs in the diagnosis of AA in the pediatric population through a systematic literature review. METHODS PubMed, Embase, and Web of Science were searched using the following keywords: "pediatric," "artificial intelligence," "standard practices," and "appendicitis," up to September 2023. The risk of bias was assessed using PROBAST. RESULTS A total of 302 articles were identified and nine articles were included in the final review. Two studies had prospective validation, seven were retrospective, and no randomized control trials were found. All studies developed their own algorithms and had an accuracy greater than 90% or area under the curve >0.9. All studies were rated as a "high risk" concerning their overall risk of bias. CONCLUSION We analyzed the current status of AI in the diagnosis of appendicitis in children. The application of AI shows promising potential, but the need for more rigor in study design, reporting, and transparency is urgent to facilitate its clinical implementation.
Collapse
Affiliation(s)
- Robin Rey
- Department of Human Medicine, Faculty of Medicine, University of Geneva, Genève, Switzerland
| | - Renato Gualtieri
- Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Genève, Switzerland
| | - Giorgio La Scala
- Division of Pediatric Surgery, Hôpital des enfants, Geneva University Hospitals, Genève, Switzerland
| | - Klara Posfay Barbe
- Division of General Pediatrics, Hôpital des enfants, Geneva University Hospitals, Genève, Switzerland
| |
Collapse
|
2
|
Chidiac C, Liu O, Gorijavolu R, Rhee DS, Garcia AV. Ethnic disparities in pediatric appendicitis: the impact of hispanic ethnicity on presentation, complications, and postoperative outcomes. Int J Colorectal Dis 2024; 39:29. [PMID: 38386177 PMCID: PMC10884102 DOI: 10.1007/s00384-024-04598-8] [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] [Accepted: 01/25/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE Our study investigates ethnic disparities in pediatric appendicitis, focusing on the impact of Hispanic ethnicity on presentation, complications, and postoperative outcomes. METHODS We conducted a retrospective analysis of pediatric patients undergoing appendectomy for acute appendicitis from 2015 to 2020 using the National Surgical Quality Improvement Program-Pediatric database. We compared 30-day postoperative complications, postoperative length of stay, and postoperative interventions between Hispanic and non-Hispanic White patients. RESULTS 65,976 patients were included, of which 23,462 (35.56%) were Hispanic and 42,514 (64.44%) non-Hispanic White. Hispanic children were more likely to present to the hospital with complicated appendicitis (31.75% vs. 25.15%, P < 0.0001) and sepsis (25.22% vs. 19.02%, P < 0.0001) compared to non-Hispanic White. Hispanics had higher rates of serious complications (4.06% vs. 3.55%, P = 0.001) but not overall complications (5.37% vs. 5.09%, P = 0.12). However, after multivariate analysis, Hispanic ethnicity was not associated with an increased rate of serious postoperative complications (OR 0.93, CI 0.85-1.01, P = 0.088); it was associated with less overall complications (OR 0.88, CI 0.81-0.96, P = 0.003) but a longer postoperative length of stay (OR 1.09, CI 1.04-1.14, P < 0.0001). CONCLUSION Hispanic children are more likely to present with complicated appendicitis, contributing to increased postoperative complications. Notably, upon adjustment for the impact of complicated appendicitis, our findings suggest potentially favorable outcomes for Hispanic ethnicity. This emphasizes the need to understand delays in presentation to improve outcomes in the Hispanic population.
Collapse
Affiliation(s)
- Charbel Chidiac
- Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St Suite 7335, Baltimore, MD, 21287, USA
| | - Olivia Liu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Daniel S Rhee
- Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St Suite 7335, Baltimore, MD, 21287, USA
| | - Alejandro V Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St Suite 7335, Baltimore, MD, 21287, USA.
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Baykara AS. Acute Appendicitis in Children: Evaluation of the Diagnostic Efficacy of Ultrasonography and Computed Tomography. Cureus 2023; 15:e43860. [PMID: 37736458 PMCID: PMC10511028 DOI: 10.7759/cureus.43860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2023] [Indexed: 09/23/2023] Open
Abstract
OBJECTIVE Acute appendicitis (AA), the most common cause of acute abdomen in childhood, can result in significant morbidity and mortality if not diagnosed and treated in a timely manner. Diagnosis of AA is more difficult in children due to the limited communication skills, in comparison to adults. The aim of this study is to evaluate the diagnostic accuracy of abdominal ultrasonography (US) and computed tomography (CT) in the diagnosis of AA in children. MATERIALS AND METHODS Pediatric patients who were operated on with the diagnosis of AA between January 2016 and December 2021 were retrospectively reviewed. Preoperative abdominal US and CT findings of the patients and postoperative pathology results were recorded. RESULTS A total of 263 patients with a mean age of 11.3 years were included in the study. There were 164 (62.3%) males and 99 (37.7%) females. Histopathology revealed AA in 215 (81.7%) patients. Preoperatively, US and CT were performed in 139 (52.8%) and 137 (54.5%), respectively. Both imaging methods were applied to 13 (5.1%) patients. US had a sensitivity and specificity rate of 77.2% and 52.6%, respectively. Positive predictive value (PPV) was found to be 81.2%, whereas negative predictive value (NPV) was 46.5% for US. The diagnostic accuracy rate of US was found as 70.5%. CT had a sensitivity and specificity rate of 88.1% and 57.1%, respectively. PPV was found to be 88.8%, whereas NPV was 55.1% for CT. The diagnostic accuracy rate of CT was found as 81.8%. CONCLUSION In case of suspicion of AA, US may be the first choice because it is inexpensive and easily accessible. However, considering patient incompatibility and subjective factors in children, US may sometimes be insufficient. We think that CT should be performed as an advanced examination method in cases where US is not compatible with the patient's condition, not clinic.
Collapse
Affiliation(s)
- Aziz Serhat Baykara
- Pediatric Surgery, Health Sciences University, Eskisehir City Hospital, Eskisehir, TUR
| |
Collapse
|
5
|
Reduced Computed Tomography for Appendicitis in Children after Implementation of Next-day Surgery Clinic Follow-up. Pediatr Qual Saf 2023; 8:e641. [PMID: 36926215 PMCID: PMC10013624 DOI: 10.1097/pq9.0000000000000641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 02/27/2023] [Indexed: 03/15/2023] Open
Abstract
The use of computed tomography (CT) in the emergency department (ED) evaluation of pediatric patients for suspected appendicitis can be safely reduced. However, published examples of reduced CT use also report increased MRI utilization, ED length of stay, hospitalization rates, and in-ED surgical consultation. In addition, previous studies recommended follow-up for undifferentiated abdominal pain, yet none with pediatric surgeons. Therefore, we implemented a diagnostic algorithm that includes an option for next-day surgery clinic follow-up in cases where uncertainty remains after appendix ultrasound (US) to reduce CT utilization without increasing hospital-based resources. Methods We implemented a diagnostic algorithm in January 2014. We retrospectively identified 4,577 patients who underwent an evaluation for suspected appendicitis from January 2012 to September 2015. CT utilization was compared before and after implementation using Statistical Process Control. In addition, we evaluated secondary outcomes, including US utilization, hospital admission, surgery clinic follow-up, ED surgery consultation, ED return visits within 7 days, and ED length of stay. Results Following the implementation of the algorithm, CT utilization decreased significantly from 13.8% to 6%. Forty-eight patients were evaluated the next day in the optional pediatric surgery clinic for 21 months after implementation. There was no significant change in US utilization, hospital admission, ED surgery consultation, ED return visits within 7 days, or ED length of stay. Conclusion We achieved decreased CT utilization without an increase in the utilization of other hospital-based resources after implementing a pediatric appendicitis evaluation algorithm that includes the option for next-day pediatric surgery clinic follow-up.
Collapse
|
6
|
Adams UC, Herb JN, Akinkuotu AC, Gallaher JR, Charles AG, Phillips MR. Nonoperative Management Versus Laparoscopic Appendectomy in Children: A Cost-Effectiveness Analysis. J Surg Res 2023; 283:929-936. [PMID: 36915021 DOI: 10.1016/j.jss.2022.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/07/2022] [Accepted: 10/16/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Nonoperative management (NOM) of acute appendicitis in the pediatric population is highly debated with uncertain cost-effectiveness. We performed a decision tree cost-effectiveness analysis of NOM versus early laparoscopic appendectomy (LA) for acute appendicitis in children. METHODS We created a decision tree model for a simulated cohort of 49,000 patients, the number of uncomplicated appendectomies performed annually, comparing NOM and LA. We included postoperative complications, recurrent appendicitis, and antibiotic-related complications. We used the payer perspective with a 1-year time horizon. Model uncertainty was analyzed using a probabilistic sensitivity analysis. Event probabilities, health-state utilities, and costs were obtained from literature review, Healthcare Cost and Utilization Project, and Medicare fee schedules. RESULTS In the base-case analysis, NOM costs $6530/patient and LA costs $9278/patient on average at 1 y. Quality-adjusted life year (QALY) differences minimally favored NOM compared to LA with 0.997 versus 0.996 QALYs/patient. The incremental cost-effectiveness ratio for NOM over LA was $4,791,149.52/QALY. NOM was dominant in 97.4% of simulations, outperforming in cost and QALYs. A probabilistic sensitivity analysis showed NOM was 99.6% likely to be cost-effective at a willingness-to-pay threshold of $100,000/QALY. CONCLUSIONS Our model demonstrates that NOM is a dominant strategy to LA over a 1-year horizon. We use recent trial data demonstrating higher rates of early and late NOM failures. However, we also incorporate a shorter length of index hospitalizations with NOM, reflecting a contemporary approach to NOM and ultimately driving cost-effectiveness. Long-term follow-up data are needed in this population to assess the cost-effectiveness of NOM over longer time horizons, where healthcare utilization and recurrence rates may be higher.
Collapse
Affiliation(s)
- Ursula C Adams
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joshua N Herb
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Adesola C Akinkuotu
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jared R Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anthony G Charles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael R Phillips
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| |
Collapse
|
7
|
Stackievicz R, Milner R, Werner M, Arnon S, Steiner Z. Follow-up ultrasonographic findings among children treated conservatively for uncomplicated acute appendicitis. Pediatr Radiol 2023; 53:223-234. [PMID: 36112194 PMCID: PMC9483395 DOI: 10.1007/s00247-022-05497-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/29/2022] [Accepted: 08/25/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ultrasound is an accurate tool for diagnosing acute appendicitis. Conservative treatment for uncomplicated acute appendicitis is feasible and safe in children. However, no sonographic follow-up results from children with nonoperatively managed acute appendicitis have been reported. OBJECTIVE To describe the sonographic appearance of the appendix at follow-up ultrasound and to attempt to identify signs predictive of recurrent acute appendicitis. MATERIALS AND METHODS Children diagnosed with uncomplicated acute appendicitis and treated conservatively in our hospital from 2014 to 2019, and who presented for follow-up ultrasound at 3, 6 and 9 months, were included in our study. Clinical, laboratory and ultrasound data were recorded. RESULTS By the end of follow-up, 29 (14.2%) of 204 children in the cohort had developed recurrent acute appendicitis and 175 had recovered uneventfully. On follow-up ultrasound, appendiceal diameter measured > 6 mm in 56/204 (27.5%) cases at 3 months and in 9/26 (34.5%) at 6 months. After 3 months, 102/204 (50%) children had normal appendiceal diameter on ultrasound. Appendiceal diameter > 6 mm was associated with intraluminal fluid or sludge in the appendiceal lumen at 3- and 6-month follow-up (P < 0.001, P = 0.002, respectively). Comparing cases with and without recurrence, at 3-month follow-up, appendiceal diameter > 6 mm was found in 17/29 (58.6%) cases vs. 39/175 (22.3%), respectively (P < 0.001). Appendiceal diameter returned to normal in 12/19 (63.2%) cases in the nonrecurrent acute appendicitis group compared with 2/7 (28.6%) in the recurrent acute appendicitis group (P = 0.05) at the 6-month follow-up. Intraluminal fluid or sludge was detected more frequently in the recurrent acute appendicitis versus the nonrecurrent acute appendicitis group at 3- (P < 0.001) and 6-month (P = 0.001) follow-up. CONCLUSION Progressive normalization of appendiceal diameter was noted on follow-up ultrasound. The prevalence of both appendiceal diameter > 6 mm and intraluminal fluid or sludge were found to be increased in children who later developed recurrent acute appendicitis. Ultrasound appears to be a useful tool for follow-up in children with conservatively treated uncomplicated acute appendicitis and possibly might help predict recurrence.
Collapse
Affiliation(s)
- Rodica Stackievicz
- Department of Radiology, Meir Medical Center, 59 Tchernichovsky St., Kfar Saba, 4428164, Israel. .,Department of Radiology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Rotem Milner
- Department of Radiology, Meir Medical Center, 59 Tchernichovsky St., Kfar Saba, 4428164, Israel
| | - Myriam Werner
- Department of Radiology, Meir Medical Center, 59 Tchernichovsky St., Kfar Saba, 4428164, Israel.,Department of Radiology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shmuel Arnon
- Department of Neonatology, Meir Medical Center, Kfar Saba, Israel.,Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Steiner
- Department of Pediatric Surgery, Meir Medical Center, Kfar Saba, Israel.,Department of Pediatric Surgery, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
8
|
Structured coaching as a means to improve sonographic visualization of the appendix: a quality improvement initiative. Emerg Radiol 2023; 30:161-166. [PMID: 36598657 DOI: 10.1007/s10140-022-02106-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/28/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Ultrasound of the right lower quadrant for appendicitis requires specific training and practice. Improved visualization of the appendix can result in decreased utilization of computed tomography. Increasing the sensitivity of ultrasound for appendicitis thus decreases radiation exposure, reduces cost, and improves the patient healthcare experience in accordance with the three principles of the triple aim designated by the Institute for Healthcare Improvement. The purpose of this study was to examine the effect of a structured training program supplemented by technologist feedback on sonographic visualization of the appendix in a large pediatric health system. METHODS The baseline ultrasound visualization frequency was computed for 20 ultrasound technologists in a large pediatric health system. Following this, technologists were informed of their individual and relative performance. Those with visualization frequencies less than 75% were provided structured training by a designated sonographer with an appendix visualization frequency above 75% while those with greater than 75% visualization continued to be monitored and informed of their monthly frequency. Following this structured training, appendix visualization frequencies were monitored over the next 5 months. RESULTS There was no significant effect of sonographer career experience on the baseline appendix visualization frequency. Fourteen of 20 technologists demonstrated improved visualization frequencies post-intervention. The composite visualization frequency among these 20 technologists improved from 66.55 to 69.14%. This resulted in a potential savings of 38 CT scans during the post-intervention period. CONCLUSION An appendix visualization rate monitoring program coupled with structured training was successful in improving the appendix visualization rate throughout a large pediatric health system. This program demonstrates the positive effect that monitoring and targeted intervention can have on a quality improvement program. The program continues to be carried out as part of a plan-study-do-act cycle.
Collapse
|
9
|
Unglert AK, Lehnick D, Szavay PO, Zundel S. A Novel Tool to Predict Postoperative Opioid Need after Laparoscopic Appendectomy in Children: A Step toward Evidence-Based Pain Management. Eur J Pediatr Surg 2022; 32:529-535. [PMID: 35263775 DOI: 10.1055/s-0042-1744148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Optimizing postoperative pain treatment is essential to minimize morbidity, lower costs, and ensure patient and parent satisfaction. This study aims at identifying pre- and intraoperative parameters predicting opioid needs after laparoscopic appendectomy to enable timely and adequate postoperative pain control. MATERIALS AND METHODS A retrospective analysis of patients treated with laparoscopic appendectomy for appendicitis between January 2018 and March 2019 was performed. Multiple logistic regression was applied to identify predictors of opioid demand. RESULTS Based on our analysis, we developed a prediction tool for opioid requirements after laparoscopic appendectomies in children. The integrated parameters are: presence of turbid fluid, age, white-blood-cell count, symptom duration, and body temperature. CONCLUSION We developed an algorithm-based predictor tool that has the potential to better anticipate postoperative pain and, thereby, optimize pain management following laparoscopic appendectomies in children. The proposed predictor tool will need validation through further prospective studies.
Collapse
Affiliation(s)
- Ann-Katrin Unglert
- Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Dirk Lehnick
- Department of Health Sciences and Health Policy, Universitat Luzern Kultur- und Sozialwissenschaftliche Fakultat, Luzern, Switzerland
| | - Philipp O Szavay
- Department of Pediatric Surgery, Luzerner Kantonsspital Kinderspital, Spitalstrasse, Lucerne, Switzerland
| | - Sabine Zundel
- Department of Pediatric Surgery, Luzerner Kantonsspital Kinderspital, Spitalstrasse, Lucerne, Switzerland
| |
Collapse
|
10
|
Fawkner-Corbett D, Hayward G, Alkhmees M, Van Den Bruel A, Ordóñez-Mena JM, Holtman GA. Diagnostic accuracy of blood tests of inflammation in paediatric appendicitis: a systematic review and meta-analysis. BMJ Open 2022; 12:e056854. [PMID: 36328382 PMCID: PMC9639107 DOI: 10.1136/bmjopen-2021-056854] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Possible childhood appendicitis is a common emergency presentation. The exact value of blood tests is debated. This study sought to determine the diagnostic accuracy of four blood tests (white cell count (WCC), neutrophil(count or percentage), C reactive protein (CRP) and/or procalcitonin) for childhood appendicitis. DESIGN A systematic review and diagnostic meta-analysis. Data sources included MEDLINE, EMBASE, Central, Web of Science searched from inception-March 2022 with reference searching and authors contacted for missing/unclear data. Eligibility criteria was studies reporting the diagnostic accuracy of the four blood tests compared to the reference standard (histology or follow-up). Risk of bias was assessed (QUADAS-2), pooled sensitivity and specificity were generated for each test and commonly presented cut-offs. To provide insight into clinical impact, we present strategies using a hypothetical cohort. RESULTS 67 studies were included (34 839 children, 13 342 with appendicitis), all in the hospital setting. The most sensitive tests were WCC (≥10 000 cells/µL, 53 studies sensitivity 0.85 (95% CI 0.80 to 0.89)) and absolute neutrophil count (ANC) (≥7500 cells/µL, five studies sensitivity 0.90 (95% CI 0.85 to 0.94)). Combination of WCC or CRP increased sensitivity further(≥10 000 cells/µL or ≥10 mg/L, individual patient data (IPD) of 6 studies, 0.97 (95% CI 0.93 to 0.99)).Applying results to a hypothetical cohort(1000 children with appendicitis symptoms, of whom 400 have appendicitis) 60 and 40 children would be wrongly discharged based solely on WCC and ANC, respectively, 12 with combination of WCC or CRP.The most specific tests were CRP alone (≥50 mg/L, 38 studies, specificity 0.87 (95% CI 0.80 to 0.91)) or combined with WCC (≥10 000 cells/µL and ≥50 mg/L, IPD of six studies, 0.93 (95% CI 0.91 to 0.95)). CONCLUSIONS The best performing single blood tests for ruling-out paediatric appendicitis are WCC or ANC; with accuracy improved combining WCC and CRP. These tests could be used at the point of care in combination with clinical prediction rules. We provide insight into the best cut-offs for clinical application. PROSPERO REGISTRATION NUMBER CRD42017080036.
Collapse
Affiliation(s)
- David Fawkner-Corbett
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Academic Paediatric Surgery Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX3 9DU, UK
- MRC Weatherall Institute of Molecular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DS, UK
| | - Gail Hayward
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Mohammed Alkhmees
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ann Van Den Bruel
- EPI-Centre, Academic Centre for Primary Care, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
| | - Jose M Ordóñez-Mena
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Gea A Holtman
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
11
|
Juan HL, Nicolas AM, Daniela CNL, Lineth ORM, María RHA, Camila RQM, Gabriela TPP, Felipe CVL, Catalina C. Use of a bipolar device (LigaSure) to seal the appendiceal stump in pediatric laparoscopic appendectomy: 10-year Latin-American experience. J Pediatr Surg 2022:S0022-3468(22)00677-7. [PMID: 36396473 DOI: 10.1016/j.jpedsurg.2022.10.005] [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: 07/15/2022] [Revised: 08/24/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Closure of the appendiceal stump is a critical step during an appendectomy. There is a lack of knowledge about the feasibility of using electrosurgical devices for the occlusion of the appendix. This study aims to determine the safety of this technique in pediatric patients. METHODS We performed a cross-sectional analytical study in patients less than 18 years of age treated at Hospital Militar Central Colombia between 2012 and 2021. Our institution's ethics committee approved the study. We analyzed the data using SPSS 22 statistical program. We present frequencies for qualitative variables and measures of central tendency or dispersion for quantitative variables depending on the distribution measured by the Kolmogorov-Smirnov test. In addition, we measured the association of nominal variables with the Chi-square test or Fisher's exact test. For numerical variables, the difference of means with the Student's t-test or the difference of medians with the Mann-Whitney U test. RESULTS We treated 209 patients. One hundred sixteen (55.5%) were boys, and the mean age was 9.7 years (SD 3.2). The median intraoperative time was 60 min, and the hospital stay was 2.8 days on average. There were no cases of stump leakage, and only two patients (1%) had an organ-space surgical site infection, which was unrelated to the closure technique. We found no association between procedural complications and appendicular status (p = 0.450). CONCLUSIONS Our research suggests that using a bipolar sealing device (Ligasure, Medtronic, USA) for appendiceal stump closure in pediatric patients undergoing laparoscopic appendectomy is feasible and should be further studied. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Cabrera-Vargas Luis Felipe
- Hospital Militar Central. Tv 3c # 49-02, Bogota, Colombia; Universidad Militar Nueva Granada. Transversal 3A No 49-00, Bogota, Colombia
| | | |
Collapse
|
12
|
Camacho-Cruz J, Padilla PO, Sánchez DG, Mongui DM, Hoyos LK, Porras ML, Hoyos PV, Polo F, Castro CA. Outcomes of acute appendicitis in patients younger than age 4: a descriptive study. ANNALS OF PEDIATRIC SURGERY 2022. [DOI: 10.1186/s43159-022-00196-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Acute appendicitis is an infrequent pathology in children under 4 years of age, and its diagnosis is a clinical challenge that can lead to late detection. The intention of this study is to describe the clinical and surgical findings and to explore factors and outcomes associated with appendiceal perforation in patients under 4 years of age with histologically confirmed acute appendicitis. Cross-sectional study of historical data is on patients with a pathologic diagnosis of appendicitis. Clinical, surgical, and pathological variables were described. The relationship between the presence of perforation and associated factors and outcomes was explored using odds ratios (OR) and 95% confidence intervals.
Results
Seventy-five patients were found between 2013 and 2019. Seventy-four cases presented with pain on palpation, 56 (75%) with signs of peritoneal irritation, and 70 (93%) with sepsis on admission to the emergency room. An ultrasound was done on 57 patients (76%), and only 26 (45%) were suggestive of appendicitis. Forty-one (55%) cases were operated on by open surgery and 34 (45%) by laparoscopy. In 61 (81%), they were perforated, and 48 (64%) presented peritonitis. Perforation was associated with increased hospital days (OR = 2.54 [1.60−4.03]), days of antibiotics (OR = 4.40 [2.09−9.25]), and admission to intensive care (OR = 9.65 [1.18−78.57]).
Conclusions
Abdominal pain reported by parents, pain on abdominal palpation, and clinical criteria of sepsis on admission to the emergency room are common features. Acute appendicitis complicated by perforation leads to high morbidity due to longer antibiotic treatment, hospitalization days, admission to PICU, and postoperative ileus.
Collapse
|
13
|
Castro P, Rincón J, Sánchez C, Molina I, Buitrago G. Presurgical time and associated factors as predictors of acute perforated appendicitis: a prospective cohort study in a teaching pediatric hospital in Colombia. BMC Pediatr 2022; 22:49. [PMID: 35057783 PMCID: PMC8772156 DOI: 10.1186/s12887-022-03121-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background We aim to determine the association between out and in-hospital factors with time, from the beginning of the symptoms to the surgery, in patients with acute appendicitis treated at Fundación Hospital Pediatrico La Misericordia (HOMI) in Colombia. Methods Eleven month prospective cohort study of pediatric patients at HOMI with acute appendicitis diagnosis taken to surgery. Data from the out-of-hospital phase was collected by surveying parents, and the data regarding the in-hospital phase was completed with medical records. We analyzed the association between the time from the beginning of the symptoms to the surgery, and out and in-hospital factors associated with this time using generalized linear models. Results Eight hundred three patients were included in the study. Total pre-surgical time was longer in perforated appendicitis (PA) group (2.65 days, standard deviation (SD) 1.88 vs. 2.04 days, SD 1.45) (p < 0.01). Factors associated with longer total and out-of-hospital presurgical times were age under 4 years old, lower socioeconomic status, father as a caregiver, self-medication, and underestimating disease severity. Conclusions Out-of-hospital timing determines the longer pre-surgical time in complicated appendicitis. Younger age and lower socioeconomic status affect time significantly. We suggest the implementation of strategies in order to lower prehospital time, rates, and costs of complicated appendicitis. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03121-8.
Collapse
|
14
|
Antic J, Jokic R, Bukarica S, Lukic I. Postoperative recovery assessment after appendectomy in children - laparoscopic versus open technique. SRP ARK CELOK LEK 2022. [DOI: 10.2298/sarh210710015a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction/Objective. Surgery is a ?gold standard? in treating the acute
appendicitis in pediatric patients. The aim of the study was to determine
the effect of open and laparoscopic appendectomy on postoperative recovery,
return to everyday activities and quality of life in patients operated for
the acute appendicitis. Methods. This prospective study was performed at
the Institute for Children and Youth Healthcare of Vojvodina, during a
period of ten months. This study was approved by Ethic committee of the
Institute. All patients treated for the acute appendicitis by surgery were
divided into two basic groups: open or laparoscopic appendectomy and into
three subgroups, depending on the degree of appendicitis. We analyzed length
of surgery, oral intake, establishing peristalsis, hospital stay, return to
everyday activities and quality of life after surgery. Results.
Laparoscopic technique was performed in 60 patients (48%), and the open
method in 65 (52%). In laparoscopically treated patients (66.7%),
peristalsis occurred earlier (p < 0.001), length of hospital stay was
shorter (5.95 ? 1.21 days) (Z = -3.054; p = 0.002), the total score of daily
activities showed a statistically significantly better score (Z = -7.667; p
= 0.000), and they achieved a high level of quality of life significantly
earlier (t = 2.773; p = 0.007). Conclusion. The advantage of minimally
invasive surgery in the treatment of acute appendicitis in children is
reflected in the faster re-establishment of every day functioning, faster
recovery, and a good quality of life.
Collapse
Affiliation(s)
- Jelena Antic
- University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia + Institute for Child and Youth Health Care of Vojvodina, Clinic of Pediatric Surgery, Novi Sad, Serbia
| | - Radoica Jokic
- University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia + Institute for Child and Youth Health Care of Vojvodina, Clinic of Pediatric Surgery, Novi Sad, Serbia
| | - Svetlana Bukarica
- University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia + Institute for Child and Youth Health Care of Vojvodina, Clinic of Pediatric Surgery, Novi Sad, Serbia
| | - Ivana Lukic
- University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia + Institute for Child and Youth Health Care of Vojvodina, Clinic of Pediatric Surgery, Novi Sad, Serbia
| |
Collapse
|
15
|
Arredondo Montero J, Antona G, Rivero Marcotegui A, Bardají Pascual C, Bronte Anaut M, Ros Briones R, Fernández-Celis A, López-Andrés N, Martín-Calvo N. Discriminatory capacity of serum interleukin-6 between complicated and uncomplicated acute appendicitis in children: a prospective validation study. World J Pediatr 2022; 18:810-817. [PMID: 36114365 PMCID: PMC9617836 DOI: 10.1007/s12519-022-00598-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/19/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Serum interleukin-6 (IL-6) has a moderate diagnostic performance in pediatric acute appendicitis (PAA). The evidence regarding its capacity to discern between complicated and uncomplicated PAA is scarce. METHODS We designed a prospective observational study to validate serum IL-6 as a marker for diagnostic classification between complicated and uncomplicated PAA. This study included 205 patients divided into three groups: (1) patients who underwent major outpatient surgery (n = 57); (2) patients with non-surgical abdominal pain (NSAP) in whom the diagnosis of PAA was excluded (n = 53), and (3) patients with a confirmed diagnosis of PAA (n = 95). The PAA patients were further classified as uncomplicated or complicated PAA. IL-6 concentration was determined in all patients at diagnosis. Comparative statistical analysis was performed using the Mann-Whitney U test, the Fisher exact test and the Kruskall Wallis test. The area under the receiver operating characteristic curves (AUC) were calculated. RESULTS Median (interquartile range, IQR) serum IL-6 values were 2 pg/mL (2.0-3.4) in group 1, 3.9 pg/mL (2.4-11.9) in group 2, and 23.9 pg/mL (11.1-61.0) in group 3 (P < 0.001). Among the participants in group 3, those with uncomplicated PAA had median (IQR) serum IL-6 values of 17.2 pg/mL (8.5-36.8), and those with complicated PAA had 60.25 pg/mL (27.1-169) serum IL-6 (P < 0.001). At the cut-off point of 19.55 pg/mL, the AUC for the discrimination between patients in group 2 vs. 3 was 0.83 [95% confidence interval (CI) 0.76-0.90], with a sensitivity of 61.3% and a specificity of 86.8. The AUC for the discrimination between patients with uncomplicated and complicated PAA was 0.77 (95% CI 0.68-0.86) and the cut-off point was 25.90 pg/mL, with a sensitivity and specificity of 84.6% and 65.6%, respectively. CONCLUSIONS Serum IL-6 has a good performance in discerning between complicated and uncomplicated PAA. A score including clinical and radiological variables may increase the diagnostic performance of this molecule.
Collapse
Affiliation(s)
- Javier Arredondo Montero
- Pediatric Surgery Department, Hospital Universitario de Navarra, Irunlarrea 3, 31008, Pamplona, Spain.
- School of Medicine, Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain.
| | - Giuseppa Antona
- Pediatric Surgery Department, Hospital Universitario de Navarra, Irunlarrea 3, 31008, Pamplona, Spain
| | | | - Carlos Bardají Pascual
- Pediatric Surgery Department, Hospital Universitario de Navarra, Irunlarrea 3, 31008, Pamplona, Spain
| | | | - Raquel Ros Briones
- Pediatric Surgery Department, Hospital Universitario de Navarra, Irunlarrea 3, 31008, Pamplona, Spain
| | - Amaya Fernández-Celis
- Cardiovascular Translational Research, NavarraBiomed (Miguel Servet Foundation), Hospital Universitario de Navarra, Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Natalia López-Andrés
- Cardiovascular Translational Research, NavarraBiomed (Miguel Servet Foundation), Hospital Universitario de Navarra, Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Nerea Martín-Calvo
- School of Medicine, Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Health Institute Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria de Navarra, IdiSNA, Pamplona, Navarra, Spain
| |
Collapse
|
16
|
Body mass index as a predictor of sonographic visualization of the pediatric appendix. Pediatr Radiol 2022; 52:42-49. [PMID: 34524472 DOI: 10.1007/s00247-021-05176-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 07/16/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Appendicitis is a common condition that is often confirmed with imaging. Ultrasound (US) is recommended as the first radiologic test in the work-up of appendicitis in children. Increased body mass index (BMI) has been implicated as a limiting factor to the sensitivity of US. This has drastic public health ramifications, as pediatric obesity has been increasing at alarming rates. OBJECTIVE The purpose of this study is to compare age-adjusted BMI z-scores to the frequency of sonographic visualization of the appendix. MATERIALS AND METHODS A retrospective review of 500 consecutive reports of US exams ordered for appendicitis in patients with a documented BMI was performed. Patients were stratified by BMI z-score based on, and the visualization frequency of the appendix was compared to the BMI z-score group. A logistic regression analysis generated the odds of visualization of the appendix by BMI z-score group. Primary home language, ethnicity, sex and insurance status were included in the logistic regression model to assess these characteristics as potential effect modifiers. RESULTS Of the 500 patients, 52.4% were male, 56.4% were Hispanic and 62.0% had government insurance. BMI z-score distribution groups were as follows: 4.2% were <-2, 8.0% were -2 to -1, 49.8% were -1 to 1, 26.4% were 1 to 2 and 11.6% were >2. The visualization frequency was 61.1% for boys and 46.2% for girls (P<0.05). Visualization frequency by BMI z-score group was as follows: 85.7% for <2, 72.5% for -2 to -1, 57.4% for -1 to 1, 47.7% for 1 to 2 and 29.3% for >2. Children with a BMI z-score greater than 2 were less likely to have a US with visualization of the appendix compared to children with a BMI z-score between -1 and 1 (adjusted odds ratio [aOR]: 0.21, 95% CI: 0.11-0.40, P<0.0001). Boys were more likely than girls to have a US with visualization of the appendix (aOR: 1.90, 95% CI: 1.29-2.80, P=0.001). There was no effect from insurance status, ethnicity or primary home language. CONCLUSION Findings show that as the BMI z-score increased, sonographic visualization of the appendix decreased even after adjusting for demographic differences. These findings have implications for pediatric radiology practice in light of the worsening obesity epidemic.
Collapse
|
17
|
Hannan MJ, Parveen MK, Hoque MM, Chowdhury TK, Hasan MS, Nandy A. Management of Acute Appendicitis in Children During COVID-19 and Perspectives of Pediatric Surgeons From South Asia: Survey Study. JMIR Perioper Med 2021; 4:e26613. [PMID: 34818209 PMCID: PMC8691415 DOI: 10.2196/26613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/26/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Nonoperative treatment (NOT) of pediatric appendicitis as opposed to surgery elicits great debate and is potentially influenced by physician preferences. Owing to the effects of the COVID-19 pandemic on health care, the practice of NOT has generally increased by necessity and may, in a post-COVID-19 world, change surgeons' perceptions of NOT. OBJECTIVE The aim of this study was to determine whether the use of NOT has increased in South Asia and whether these levels of practice would be sustained after the pandemic subsides. METHODS A survey was conducted among pediatric surgeons regarding their position, institute, and country; the number of appendicitis cases they managed; and their mode of treatment between identical time periods in 2019 and 2020 (April 1 to August 31). The survey also directly posed the question as to whether they would continue with the COVID-19-imposed level of NOT after the effect of the pandemic diminishes. RESULTS A total of 134 responses were collected out of 200 (67.0%). A significant increase in the practice of NOT was observed for the entire cohort, although no effect was observed when grouped by country or institute. When grouped by position, senior physicians increased the practice of NOT the most, while junior physicians reported the least change. The data suggest that only professors would be inclined to maintain the COVID-19-level of NOT practice after the pandemic. CONCLUSIONS Increased practice of NOT during the COVID-19 pandemic was observed in South Asia, particularly by senior surgeons. Only professors appeared inclined to consider maintaining this increased level of practice in the post-COVID-19 world.
Collapse
Affiliation(s)
- Md Jafrul Hannan
- Department of Pediatric Surgery, South Point Hospital, Chittagong, Bangladesh
| | | | - Md Mozammel Hoque
- Department of Pediatric Surgery, Chattagram Maa-O-Shishu Hospital Medical College, Chittagong, Bangladesh
| | | | - Md Samiul Hasan
- Department of Pediatric Surgery, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Alak Nandy
- Department of Anesthesiology, Chattgram Maa-O-Shishu Hospital Medical College, Chittagong, Bangladesh
| |
Collapse
|
18
|
Ergün E, Sözduyar S, Gurbanova A, Serttürk F, Çiftçi E, Özdemir H, Arga G, Konca HK, Çınar G, Akdemir Kalkan İ, Gülten E, Selvi Can Ö, Şen Akova B, Suat Fitöz Ö, Vatansever G, Tekin D, Göllü G, Bingöl-Koloğlu M, Yağmurlu A, Çakmak M, Ateş U. An indirect effect of COVID-19 pandemic: Increased pediatric perforated appendicitis rate due to delayed admission. Turk J Surg 2021; 37:318-323. [PMID: 35677491 PMCID: PMC9130943 DOI: 10.47717/turkjsurg.2021.5277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 10/06/2021] [Indexed: 11/23/2022]
Abstract
Objectives Appendicitis is a common surgical emergency among children. The coronavirus pandemic affected the system of hospitals more than any other field, and great amount of people were concerned about visiting the hospitals for any reason. In this study, it was aimed to evaluate the profile of appendicitis by emphasizing perforated and acute appendicitis in the pandemic period and to compare the rates with previous three years. Material and Methods Charts of the children who underwent laparoscopic appendectomy due to appendicitis between March 11-September 30 between 2017-2020 were retrospectively analyzed in terms of demographic data, duration of symptoms, duration between hospital admission and surgery, radiologic imaging and perioperative outcomes. Results This study includes 467 children who underwent laparoscopic appendectomy. There were 97 procedures in 2020, 111 in 2019, 146 in 2018 and 113 in 2017. Multiple comparison tests revealed that age did not show difference; but onset of symptoms in admission (p= 0.004), hospitalization time before surgery (p <0.001), total hospitalization time (p <0.001) showed statistically significant difference between years. Pairwise comparisons showed that these parameters were increased in 2020 compared to other years. Perforated appendicitis rate was significantly increased in 2020 when compared to previous years. Conclusion Although there is no direct relation between appendicitis and COVID-19 infection in the current knowledge, perforated appendicitis was found to be increased in children during the COVID pandemic. Reason of the higher rate of perforated appendicitis may be multifactorial; however, the pandemic appears to have a role in increased morbidity in children with appendicitis indirectly due to delay of hospital admissions.
Collapse
Affiliation(s)
- Ergun Ergün
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Sümeyye Sözduyar
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Aynur Gurbanova
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Fırat Serttürk
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ergin Çiftçi
- Division of Pediatric Infectious Disease, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Halil Özdemir
- Division of Pediatric Infectious Disease, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gül Arga
- Division of Pediatric Infectious Disease, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hatice Kübra Konca
- Division of Pediatric Infectious Disease, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Güle Çınar
- Department of Infectious Diseases and Clinical Microbiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - İrem Akdemir Kalkan
- Department of Infectious Diseases and Clinical Microbiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ezgi Gülten
- Department of Infectious Diseases and Clinical Microbiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Özlem Selvi Can
- Department of Anesthesia and Reanimation, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Birsel Şen Akova
- Division of Pediatric Radiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ömer Suat Fitöz
- Division of Pediatric Radiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Göksel Vatansever
- Division of Pediatric Emergency, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Deniz Tekin
- Division of Pediatric Emergency, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gülnur Göllü
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Meltem Bingöl-Koloğlu
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Aydın Yağmurlu
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Murat Çakmak
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ufuk Ateş
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
19
|
Kim HHR, Hull NC, Lee EY, Phillips GS. Pediatric Abdominal Masses: Imaging Guidelines and Recommendations. Radiol Clin North Am 2021; 60:113-129. [PMID: 34836559 DOI: 10.1016/j.rcl.2021.08.008] [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] [Indexed: 11/17/2022]
Abstract
Pediatric abdominal masses are commonly encountered in the pediatric population, with a broad differential diagnosis that encompasses benign and malignant entities. The primary role of abdominal imaging in the setting of a suspected pediatric abdominal mass is to establish its presence, as nonneoplastic entities can mimic an abdominal mass, and to identify characteristic imaging features that narrow the differential diagnosis. In the setting of a neoplasm, various imaging modalities play an important role to characterize the mass, stage extent of disease, and assist in presurgical planning. The purpose of this article is to discuss a practical imaging algorithm for suspected pediatric abdominal masses and to describe typical radiological findings of the commonly encountered abdominal masses in neonates and children with emphasis on imaging guidelines and recommendations.
Collapse
Affiliation(s)
- Helen H R Kim
- Department of Radiology, Seattle Children's Hospital and University of Washington, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA.
| | - Nathan C Hull
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 330 Longwood Avenue, Boston, MA 02115, USA
| | - Grace S Phillips
- Department of Radiology, Seattle Children's Hospital and University of Washington, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA
| |
Collapse
|
20
|
Nepomuceno H, Pearson EG. Nonoperative management of appendicitis in children. Transl Gastroenterol Hepatol 2021; 6:47. [PMID: 34423168 DOI: 10.21037/tgh-20-191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/23/2020] [Indexed: 11/06/2022] Open
Abstract
Appendicitis is a common condition in childhood and adolescence that frequently requires urgent surgical intervention. For almost two centuries appendicitis has been recognized as a medical problem with a surgical solution. Currently the appendix can be removed with a minimally invasive approach, low anesthetic and surgical risk, and swift hospital discharge. Despite these advances, surgery and anesthesia have associated risks including postoperative infection, bleeding, hernia and organ injury among others. In addition, surgery requires time off of school and work to recover and associated healthcare costs can be significant. In both adult and pediatric populations, quality data suggesting a nonoperative approach is suggesting a change to the traditional surgical paradigm. Adults studies have demonstrated both safety and efficacy in the nonoperative management of acute appendicitis. In selected children with uncomplicated appendicitis, initial nonoperative management has been shown to be safe with fewer complications, fewer disability days and less healthcare costs while avoiding the risks inherent to surgery. Ongoing randomized controlled clinical trials in both the United States and Europe seek to further demonstrate the safety of nonoperative management and assist physicians with educating patients about the risk profile of their treatment decision. In complicated appendicitis presenting with abscess or acute appendiceal phlegmon, an initial nonoperative strategy with or without abscess drainage followed by interval appendectomy is the current state of the art though the utility of interval appendectomy is questioned.
Collapse
Affiliation(s)
- Helene Nepomuceno
- Department of Pediatric Surgery, Sunrise Children's Hospital, Las Vegas, NV, USA
| | - Erik G Pearson
- Department of Pediatric Surgery, Sunrise Children's Hospital, Las Vegas, NV, USA
| |
Collapse
|
21
|
Hodge SV, Mickiewicz B, Lau M, Jenne CN, Thompson GC. Novel molecular biomarkers and diagnosis of acute appendicitis in children. Biomark Med 2021; 15:1055-1065. [PMID: 34284638 DOI: 10.2217/bmm-2021-0108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Reliable and efficient diagnosis of pediatric appendicitis is essential for the establishment of a clinical management plan and improvement of patient outcomes. Current strategies used to diagnose a child presenting with a suspected appendicitis include laboratory studies, clinical scores and diagnostic imaging. Although these modalities work in conjunction with each other, one optimal diagnostic strategy has yet to be agreed upon. The recent introduction of precision medicine techniques such as genomics, transcriptomics, proteomics and metabolomics has increased both the diagnostic sensitivity and specificity of appendicitis. Using these novel strategies, the integration of precision medicine into clinical practice via point-of-care technologies is a plausible future. These technologies would assist in the screening, diagnosis and prognosis of pediatric appendicitis.
Collapse
Affiliation(s)
- Sarah Vl Hodge
- Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Beata Mickiewicz
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Matthew Lau
- Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Craig N Jenne
- Department of Microbiology, Immunology & Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Graham C Thompson
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada.,Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| |
Collapse
|
22
|
Güngör A, Göktuğ A, Güneylioğlu MM, Yaradılmış RM, Bodur I, Öztürk B, Karaman İ, Karacan CD, Tuygun N. Utility of biomarkers in predicting complicated appendicitis: can immature granulocyte percentage and C-reactive protein be used? Postgrad Med 2021; 133:817-821. [PMID: 34165049 DOI: 10.1080/00325481.2021.1948306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Acute appendicitis is the most common reason for abdominal surgery in children. The aim of this study was to evaluate the utility of biomarkers in predicting complicated appendicitis (CA). METHODS Patients having a diagnosis of acute appendicitis who underwent operations were retrospectively determined, and the utility of biomarkers in predicting CA was evaluated. RESULTS A total of 251 patients were included in the study. The mean age was 130.9 ± 48.8 months, 148 of the cases (59%) were simple appendicitis, and 103 (41%) were CA. The C-reactive protein (CRP) levels, immature granulocyte (IG) percentage, white blood cell counts, and absolute neutrophil counts were significantly higher in the CA patients. The bilirubin levels and neutrophil to lymphocyte ratios were not useful for predicting CA. The best area under the curve (AUC) values to predict CA were with the IG percentage and CRP level (0.82), the IG percentage [odds ratio (OR) 9.36, 95% CI (4.94-17.75), p < 0.001] and CRP [OR 8.42, 95% CI (4.72-15.02), p < 0.001] were the best marker in predicting CA. The sensitivity of the IG percentage and CRP level were higher than other markers. CONCLUSION To predict CA, the best AUC values were associated with the IG percentage and the CRP level. Because it is easy, fast to measure, does not require taking extra blood, and does not lead to additional costs, IG percentage may be preferred in the diagnosis of patients with CA.
Collapse
Affiliation(s)
- Ali Güngör
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Aytaç Göktuğ
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Muhammed Mustafa Güneylioğlu
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Raziye Merve Yaradılmış
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Ilknur Bodur
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Betül Öztürk
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - İbrahim Karaman
- Department of Pediatric Surgery, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Can Demir Karacan
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Nilden Tuygun
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
23
|
Postuma R, Vajcner G, Postuma RB, Keijzer R. Bedside pressure-pain threshold algometry to measure abdominal tenderness in childhood appendicitis: A retrospective cohort study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
24
|
Mitigating disparity in children with acute appendicitis: Impact of patient-driven protocols. J Pediatr Surg 2021; 56:663-667. [PMID: 33183744 DOI: 10.1016/j.jpedsurg.2020.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/29/2020] [Accepted: 10/02/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE Previous reports in the literature demonstrate racial and ethnic disparities for children diagnosed with acute appendicitis, with minorities experiencing worse outcomes. At our institution, we have developed an evidence based patient driven protocol for children following laparoscopic appendectomy. However, the influence of such protocol on mitigating racial and ethnic disparities in outcomes remains unknown. The purpose of our study is to assess the impact of our protocol by evaluating the influence of race and ethnicity on surgical outcomes among children treated for acute appendicitis. MATERIAL AND METHODS A retrospective review of prospectively collected data was conducted. Children undergoing a laparoscopic appendectomy at our freestanding children's hospital between December 2015 and July 2017 were included. Demographic data, post-operative length of stay, same day discharge rates and hospital readmission rates were abstracted from patient medical records. Patients were classified by their race and ethnic background. Comparative analysis was performed in STATA with a p value <.05 determined as significant. RESULTS A total of 786 children were included, with the majority being either White (70%, n = 547), Black (8%, n = 62) or Hispanic (17%, n = 133); 569 patients (72%) were found to have non-perforated appendicitis. There was no statistically significant difference in the rates of same day discharge among White, Black or Hispanic children respectively (88% vs. 77% vs. 86%, p = .126). Of the 217 children with perforated appendicitis, Hispanic children had increased rates of perforation (41%, n = 55) compared to White and Black children respectively (23%, n = 128 and 29%, n = 18, p = .001). However, average post-operative length of stay were similar among White, Black and Hispanic children (96 h vs. 95 h vs. 98 h, p = .015). On multivariate analysis, the only significant risk factor for an elevated post-operative length of stay was the presence of a perforation. CONCLUSION Our evidence based patient driven protocol effectively mitigates racial and ethnic disparities found in children with acute appendicitis. Further prospective investigation into the role of such patient-driven protocols to mitigate healthcare disparities is warranted. LEVELS OF EVIDENCE Therapeutic study; Level 3.
Collapse
|
25
|
Devin CL, D'Cruz R, Linden AF, English S, Vinocur CD, Reichard KW, Berman L. Reducing resource utilization for patients with uncomplicated appendicitis through use of same-day discharge and elimination of postoperative antibiotics. J Pediatr Surg 2020; 55:2591-2595. [PMID: 32482411 DOI: 10.1016/j.jpedsurg.2020.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/11/2020] [Accepted: 04/06/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND There is controversy over certain aspects of post-appendectomy care for children with uncomplicated appendicitis. Some institutions have embraced the practice of same-day discharge after appendectomy, while others are hesitant due to concerns about increased readmissions or emergency department (ED) visits. Similarly, some surgeons have transitioned to treating gangrenous appendicitis with a single perioperative dose, while others are concerned about increased risk of infection in this population. METHODS We developed a pathway for the management of patients undergoing appendectomy for uncomplicated acute appendicitis which included same-day discharge and elimination of postoperative antibiotics for patients with gangrenous appendicitis. We compared outcomes for children treated at our institution before and after implementation of the protocol. RESULTS We identified 575 patients undergoing appendectomy for uncomplicated appendicitis (307 pre- and 268 post-protocol). We observed a significant decrease in postoperative length-of stay (10.6 to 2.6 h, p < 0.0001). There were no increases in postoperative complications, such as superficial (2.6% vs 1.1%, p = 0.19) or organ-space surgical-site infection (1.6% vs 0.4%, p = 0.14), percutaneous drain placement (1.3% vs 0%, p = 0.06), postoperative ED visits (5.5% vs 5.2%, p = 0.87) or readmission (3.3% vs 1.5%, p = 0.17). CONCLUSIONS These findings suggest that incorporating same-day discharge for simple appendicitis and eliminating postoperative antibiotics for children with gangrenous appendicitis does not increase complication rates. Implementation of similar pathways across institutions has the potential to significantly reduce resource utilization for children undergoing appendectomy for uncomplicated appendicitis. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Courtney L Devin
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA.
| | - Roshan D'Cruz
- Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Allison F Linden
- Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Sharon English
- Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Charles D Vinocur
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA; Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Kirk W Reichard
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA; Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Loren Berman
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA; Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| |
Collapse
|
26
|
Saha B, Aoyama K, Petre MA, Englesakis M, Robertson J, Levine M. Pericardial disease as a rare complication of pediatric appendicitis: a systematic literature search. JA Clin Rep 2020; 6:89. [PMID: 33165640 PMCID: PMC7652975 DOI: 10.1186/s40981-020-00395-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Classic symptoms of acute appendicitis are well known but are uncommon and often misinterpreted in pediatric patients, potentially delaying diagnosis and resulting in rare sequelae. METHODS We conducted a comprehensive systematic literature search of case reports detailing pericardial disease as a rare complication of pediatric appendicitis through MEDLINE, Embase, and Cochrane Databases. Inclusion criteria was that the patient must be < 18 years old and present with both pericardial disease and appendicitis. RESULTS Our search yielded 7 cases with an average age of 10.3 ± 3.9 years old. The cases involved cardiac tamponade, pericarditis, and/or pericardial effusion. Five cases were diagnosed with appendicitis before complicated by pericardial disease. Most cases had an infectious component, but a majority had negative pericardial fluid cultures. Pleural effusion and abdominal abscesses were other common complications of pediatric appendicitis. CONCLUSION Awareness of this uncommon relationship may have prognostic value as this may facilitate appropriate management of pericardial effusions, tamponade, and/or appendicitis.
Collapse
Affiliation(s)
- Bibek Saha
- John A. Burns School of Medicine, University of Hawaii at Manoa, 651 Ilalo St, Honolulu, HI, 96813, USA.,Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, #2211, Toronto, ON, M5G 1X8, Canada
| | - Kazuyoshi Aoyama
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, #2211, Toronto, ON, M5G 1X8, Canada. .,Program in Clinical Health Evaluative Sciences, The SickKids Research Institute, 555 University Ave, #2211, Toronto, ON, M5G 1X8, Canada.
| | - Maria-Alexandra Petre
- Department of Pediatric Anesthesia, Montreal Children's Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - James Robertson
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, #2211, Toronto, ON, M5G 1X8, Canada
| | - Mark Levine
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, #2211, Toronto, ON, M5G 1X8, Canada
| |
Collapse
|
27
|
An Administrative Data-based Surrogate Definition Identifies Children Evaluated Beyond Physical Examination for Suspected Appendicitis. Pediatr Qual Saf 2020; 5:e343. [PMID: 33575519 PMCID: PMC7870269 DOI: 10.1097/pq9.0000000000000343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 07/09/2020] [Indexed: 11/27/2022] Open
Abstract
Previous studies have reported on the evaluation of patients diagnosed with appendicitis. Very little is known about all patients evaluated for suspected appendicitis. Patients evaluated beyond physical examination with laboratory and imaging testing, then found not to have appendicitis, are more difficult to identify. Data readily available in administrative databases may be used to identify these patients.
Collapse
|
28
|
Simon LE, Kene MV, Warton EM, Rauchwerger AS, Vinson DR, Reed ME, Chettipally UK, Mark DG, Sax DR, McLachlan DI, Cotton DM, Lin JS, Vazquez-Benitez G, Kharbanda AB, Kharbanda EO, Ballard DW. Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years. Acad Emerg Med 2020; 27:821-831. [PMID: 32239713 PMCID: PMC8310728 DOI: 10.1111/acem.13931] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/31/2020] [Accepted: 02/01/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions. METHODS This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5 days of right-sided or diffuse abdominal pain using a Web-based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c-statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates. RESULTS Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c-statistic = 0.83, 95% confidence interval = 0.81 to 0.85), performing particularly well in the low-risk strata (appendicitis rate = 1.1% in gestalt 1%-10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5 years since medical school graduation demonstrated improved gestalt performance over those with less experience (p = 0.007). All clinical characteristics tested, except pain <24 hours, were significantly associated with physician gestalt value (p < 0.05). CONCLUSION Physician gestalt for acute appendicitis diagnosis performed well, especially in low-risk patients and when employed by experienced physicians.
Collapse
Affiliation(s)
- Laura E. Simon
- Division of Research, Kaiser Permanente, Oakland, CA
- University of California San Diego School of Medicine, La Jolla, CA
| | - Mamata V. Kene
- The Permanente Medical Group, Kaiser Permanente San Leandro Medical Center, San Leandro, CA
| | | | | | - David R. Vinson
- Division of Research, Kaiser Permanente, Oakland, CA
- The Permanente Medical Group, Kaiser Permanente Roseville Medical Center, Roseville, CA
| | - Mary E. Reed
- Division of Research, Kaiser Permanente, Oakland, CA
| | - Uli K. Chettipally
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Dustin G. Mark
- Division of Research, Kaiser Permanente, Oakland, CA
- The Permanente Medical Group, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Dana R. Sax
- The Permanente Medical Group, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - D. Ian McLachlan
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Dale M. Cotton
- The Permanente Medical Group, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA
| | - James S. Lin
- The Permanente Medical Group, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | | | | | | | - Dustin W. Ballard
- Division of Research, Kaiser Permanente, Oakland, CA
- The Permanente Medical Group, Kaiser Permanente San Rafael Medical Center, San Rafael, CA
| |
Collapse
|
29
|
Abstract
Acute abdominal pain is a common complaint in pediatrics. Although age and location of pain can help focus differential diagnosis, imaging plays an essential role in clinical evaluation. In this review, we discuss the optimal imaging approach to pediatric patients with acute abdominal pain and important imaging findings in the most common causes of abdominal pain in the pediatric population. [Pediatr Ann. 2020;49(9):e380-e388.].
Collapse
|
30
|
New Oxidative Stress Markers Useful in the Diagnosis of Acute Appendicitis in Children: Thiol/Disulfide Homeostasis and the Asymmetric Dimethylarginine Level. Pediatr Emerg Care 2020; 36:362-367. [PMID: 29135899 DOI: 10.1097/pec.0000000000001339] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate 2 new oxidative stress markers, thiol/disulfide homeostasis status and the asymmetric dimethylarginine (ADMA) level, in children with acute appendicitis (AA) and to evaluate their diagnostic utility. METHODS This case-control study included 45 patients with AA and 35 healthy children. Age, sex, white blood cell count, neutrophil-to-lymphocyte ratio, high-sensitivity C-reactive protein (hs-CRP) level, ultrasonographic findings, thiol/disulfide homeostasis parameters (native and total thiol levels, native thiol/total thiol ratios [antioxidant parameters], and disulfide, disulfide/native thiol, and disulfide/total thiol ratios [oxidant parameters]), and the ADMA level were compared between the 2 groups. RESULTS The native and total thiol levels, and the native thiol/total thiol ratio, were significantly lower, and the disulfide level and disulfide/native thiol and disulfide/total thiol ratios significantly higher, in the AA compared with the control group (all P < 0.001). The ADMA level was significantly higher in a perforated versus nonperforated subgroup of AA patients, but the thiol/disulfide homeostasis parameters did not differ significantly between the two subgroups. In addition, the hs-CRP level and appendiceal wall thickness were higher in the perforated subgroup. The thiol/disulfide antioxidant parameters and ADMA level correlated negatively with the white blood cell count, the neutrophil-to-lymphocyte ratio, and the hs-CRP level, in the AA group, but correlated positively with oxidant parameters. The sensitivity and specificity of the disulfide/native thiol and disulfide/total thiol ratios were high when used to diagnose AA, whereas the sensitivity of the ADMA level was high when used to diagnose perforated appendicitis. CONCLUSIONS Thiol/disulfide homeostasis and the ADMA level, together with certain other parameters, may be useful biomarkers of AA in children.
Collapse
|
31
|
Ingram MCE, Calabro K, Polites S, McCracken C, Aspelund G, Rich BS, Ricca RL, Dasgupta R, Rothstein DH, Raval MV. Systematic Review of Disparities in Care and Outcomes in Pediatric Appendectomy. J Surg Res 2020; 249:42-49. [PMID: 31918329 DOI: 10.1016/j.jss.2019.12.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 11/13/2019] [Accepted: 12/11/2019] [Indexed: 12/21/2022]
|
32
|
Chiang JJY, Angus MI, Nah SA, Jacobsen AS, Low Y, Choo CSC, Yap TL, Chen Y. Time course response of inflammatory markers in pediatric appendicitis. Pediatr Surg Int 2020; 36:493-500. [PMID: 32088741 DOI: 10.1007/s00383-020-04620-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE We aim to evaluate the diagnostic value and time course response of the triple inflammatory markers: white blood cell count (WBC), neutrophil percentage (Neu), and C-reactive protein (CRP) in pediatric acute appendicitis. METHODS A retrospective review of clinical data pertaining to 1391 patients admitted with suspicion for pediatric appendicitis from 2012 to 2017 was conducted. Triple inflammatory markers were acquired upon admission. Appendicitis was confirmed histologically post-appendectomy. The diagnostic value and time course response of these markers was trended in relation to the duration of abdominal pain on admission. RESULTS 718 patients had histologically confirmed appendicitis. WBC and Neu demonstrate high sensitivity for early appendicitis at 94.6% and 80.0% at Day 1, while CRP demonstrates highest sensitivity of 97.9% at Day 4. The triple markers had poor overall diagnostic value when interpreted individually, however, had a high combined sensitivity of 99.7% and negative predictive value of 98.7% regardless of duration of disease. Overall negative appendectomy rate was 6.7% (n = 52). Among 19 patients with triple markers negative who underwent appendectomy, 17 (89.5%) were histologically normal. CONCLUSIONS The triple inflammatory markers have limited diagnostic value when interpreted individually, but are strong discriminators of pediatric appendicitis when combined. Their high sensitivity and negative predictive value could potentially help patients avoid unnecessary admissions or costly imaging studies, and reduce negative appendectomy rates. In addition, their objective nature confers an advantage over existing clinical scoring systems which comprise subjective elements.
Collapse
Affiliation(s)
- Jayne J Y Chiang
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Mark Ian Angus
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Shireen A Nah
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.,Division of Surgery, Duke-NUS Medical School, Singapore, Singapore
| | - Anette S Jacobsen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.,Division of Surgery, Duke-NUS Medical School, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yee Low
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.,Division of Surgery, Duke-NUS Medical School, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Candy S C Choo
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Te-Lu Yap
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore. .,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| | - Yong Chen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore. .,Division of Surgery, Duke-NUS Medical School, Singapore, Singapore.
| |
Collapse
|
33
|
Cardiac tamponade as a rare complication of pediatric perforated appendicitis. Can J Anaesth 2019; 67:609-611. [PMID: 31728852 DOI: 10.1007/s12630-019-01529-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/05/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022] Open
|
34
|
Jiang J, Wu Y, Tang Y, Shen Z, Chen G, Huang Y, Zheng S, Zheng Y, Dong R. A novel nomogram for the differential diagnosis between advanced and early appendicitis in pediatric patients. Biomark Med 2019; 13:1157-1173. [PMID: 31559834 DOI: 10.2217/bmm-2019-0036] [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: 11/21/2022] Open
Abstract
Aim: To develop a nomogram for differential diagnosis between advanced and early pediatric appendicitis (PA). Patients & methods: We retrospectively studied 669 PA patients. Patient characteristics and 24 serum markers were subjected to univariate and multivariate analysis, based on which the nomogram was constructed. Results: Fibrin degradation product, CRP and Na+ differed significantly between the advanced and early PA. The value of area under the receiver operating characteristic curve (AUC) was 0.8602, which was greater than that of a single serum marker. Furthermore, the nomogram showed better discriminative ability than the biomarker alone. Notably, validation indicated high stability and reproducibility. Conclusion: The nomogram is superior to the serum marker alone, and may hold promise in clinical application.
Collapse
Affiliation(s)
- Jingying Jiang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Ying Wu
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Yue Tang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Zhen Shen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Gong Chen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Yanlei Huang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Shan Zheng
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Yijie Zheng
- Department of Medical Scientific Affairs, Wuxi Diagnosis, Wuxi Apptec, Shanghai, PR China
| | - Rui Dong
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| |
Collapse
|
35
|
Bi LW, Yan BL, Yang QY, Cui HL. Comparison of conservative treatment with appendectomy for acute uncomplicated pediatric appendicitis: a meta-analysis. J Comp Eff Res 2019; 8:767-780. [PMID: 31137951 DOI: 10.2217/cer-2019-0036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: We aimed to compare conservative treatment with surgery for uncomplicated pediatric appendicitis to estimate effectiveness and safety. Methods: Data recorded until September 2018 were searched, and relevant academic articles from PubMed, EMBASE, the Cochrane Library and other libraries were selected. STATA version 13.0 (Stata Corporation, TX, USA) was used for statistical analysis. Results: We identified nine eligible papers. The study reported a significant difference in the success rate of treatment in 1 month and in 1 year, and no difference in the incidence of complications. The patients with fecaliths showed low treatment efficacy in conservative treatment group (p < 0.05). Conclusion: Standardized conservative treatment as inpatients for pediatric appendicitis is safe and feasible. Appendectomy was the better choice for patients with fecaliths.
Collapse
Affiliation(s)
- Le-Wee Bi
- Department of the Graduate School, Tianjin Medical University, Tianjin, PR China
| | - Bei-Lei Yan
- Department of the Graduate School, Tianjin Medical University, Tianjin, PR China
| | - Qian-Yu Yang
- Department of the Graduate School, Tianjin Medical University, Tianjin, PR China
| | - Hua-Lei Cui
- Department of General Surgery, Tianjin Children's Hospital, Tianjin, PR China
| |
Collapse
|
36
|
Isani MA, Jackson J, Barry WE, Mallicote MU, Rosenberg D, Stein JE, Jensen AR, Kim ES. Non-Operative Management is More Cost-Effective than Immediate Operation in Perforated Appendicitis Patients with Seven or More Days of Symptoms. J Surg Res 2019; 240:70-79. [PMID: 30909067 DOI: 10.1016/j.jss.2019.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/15/2019] [Accepted: 02/21/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Management of perforated appendicitis in children remains controversial. Nonoperative (NO) and immediate operative (IO) strategies are used with varying outcomes. We hypothesized that IO intervention for patients with perforated appendicitis would be more cost-effective than NO management. METHODS A retrospective chart review of all patients with appendicitis from 2012 to 2015 was performed. Patients with perforated appendicitis were defined by evidence of perforation on imaging. We excluded patients who presented with sepsis, organ failure, and ventriculoperitoneal shunts. NO management was determined by surgeon preference. Univariate and multivariate analyses were performed. RESULTS IO was performed on 145 patients with perforated appendicitis, whereas 83 were treated with NO management. Compared to IO patients, NO patients incurred higher overall costs, greater length of stay, more readmissions, complications, peripherally inserted central venous catheter lines, interventional radiology drains, and unplanned clinic and emergency department visits (P < 0.0001 for all). Multivariate analysis adjusting for age, days of symptoms, admission C-reactive protein and white blood cell count revealed that NO management was independently associated with increased costs (OR 1.35, 1.12-1.62, 95% CI). Cost curves demonstrated that total cost for IO surpasses that of NO management when patients present with greater than 6.3 d of symptoms (P = 0.01). CONCLUSIONS Our data suggest that IO is more cost-effective than NO management for patients with perforated appendicitis who present with less than 6.3 d of symptoms, after which point, NO management is more cost-effective. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Mubina A Isani
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Jeremy Jackson
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Wesley E Barry
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Michael U Mallicote
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - David Rosenberg
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - James E Stein
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Aaron R Jensen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Eugene S Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.
| |
Collapse
|
37
|
Wang A, Prieto JM, Ward E, Bickler S, Henry M, Kling K, Thangarajah H, Ignacio R. Operative treatment for intussusception: Should an incidental appendectomy be performed? J Pediatr Surg 2019; 54:495-499. [PMID: 30583859 DOI: 10.1016/j.jpedsurg.2018.10.099] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/17/2018] [Accepted: 10/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES An incidental appendectomy is performed by some surgeons during operative treatment for intussusception to eliminate future appendicitis as a diagnostic consideration. However, an appendectomy can increase the risk of infection and other noninfectious complications making an incidental appendectomy controversial. We examined outcomes for surgical intervention for intussusception with appendectomy (SWA) compared to surgical reduction alone (SRA). METHODS The Pediatric Health Information System database, 8/2008-9/2015, was retrospectively analyzed for patients under the age of five who required an operative intervention for intussusception without bowel resection. Demographic data and postoperative outcomes were analyzed. Available data included need for postoperative enema, subsequent small bowel obstruction, recurrent intussusception, length of stay (LOS), and adjusted total cost (ATC). RESULTS Fifty-seven percent (748/1312) of patients had appendectomy performed during surgical reduction, 564 (43%) did not. ATC ($10,594 vs. $8939, p < 0.001) and LOS (3.0 vs. 2.48, p < 0.001) are higher in the SWA group. Rates of readmission are similar, but post-operative small bowel obstruction may be higher in the SWA group (1.3% vs. 0.35%, p = 0.06). CONCLUSION There is a higher mean LOS and ATC in the SWA group. This study suggests that appendectomy during surgery for uncomplicated intussusception should be reconsidered and requires further investigation. TYPE OF STUDY retrospective comparative study. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Andrew Wang
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - James M Prieto
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Erin Ward
- Department of Surgery, School of Medicine, University of California, La Jolla, CA 92093, USA
| | - Stephen Bickler
- Division of Pediatric Surgery, Rady Children's Hospital, San Diego, CA 92123, USA
| | - Marion Henry
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Karen Kling
- Division of Pediatric Surgery, Rady Children's Hospital, San Diego, CA 92123, USA
| | | | - Romeo Ignacio
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA.
| |
Collapse
|
38
|
Aneurysmal dilation of bowel mimicking an abscess in pediatric primary gastrointestinal lymphoma. Radiol Case Rep 2019; 14:52-54. [PMID: 30338011 PMCID: PMC6187092 DOI: 10.1016/j.radcr.2018.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 09/17/2018] [Indexed: 12/26/2022] Open
Abstract
Primary gastrointestinal lymphoma, though rare, is the most common gastrointestinal malignancy in children. Signs and symptoms are nonspecific, and include abdominal pain, nausea, emesis, and a palpable abdominal mass. Imaging is therefore typically required to differentiate gastrointestinal lymphoma from other abdominal conditions. We present a pediatric case of primary gastrointestinal lymphoma involving the distal bowel that was initially misdiagnosed as an intra-abdominal abscess. This case highlights the imaging findings of primary gastrointestinal lymphoma, potential pitfalls in imaging diagnosis, and the role of accurate imaging diagnosis in expediting patient management to reduce associated morbidity and mortality.
Collapse
|
39
|
Howell EC, Dubina ED, Lee SL. Perforation risk in pediatric appendicitis: assessment and management. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2018; 9:135-145. [PMID: 30464677 PMCID: PMC6209076 DOI: 10.2147/phmt.s155302] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Perforated appendicitis, as defined by a visible hole in the appendix or an appendicolith free within the abdomen, carries significant morbidity in the pediatric population. Accurate diagnosis is challenging as there is no single symptom or sign that accurately predicts perforated appendicitis. Younger patients and those with increased duration of symptoms are at higher risk of perforated appendicitis. Elevated leukocytosis, bandemia, high C-reactive protein, hyponatremia, ultrasound, and CT are all useful tools in diagnosis. Distinguishing patients with perforation from those without is important given the influence of a perforation diagnosis on the management of the patient. Treatment for perforated appendicitis remains controversial as several options exist, each with its indications and merits, illustrating the complexity of this disease process. Patients may be managed non-operatively with antibiotics, with or without interval appendectomy. Patients may also undergo appendectomy early in the course of their index hospitalization. Factors known to predict failure of non-operative management include appendicolith, leukocytosis greater than 15,000 white blood cells per microliter, increased bands, and CT evidence of disease beyond the right lower quadrant. In this review, the indications and benefits of each treatment strategy will be discussed and an algorithm to guide treatment decisions will be proposed.
Collapse
Affiliation(s)
- Erin C Howell
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Emily D Dubina
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA, .,Division of Pediatric Surgery, UCLA Mattel Children's Hospital, Los Angeles, CA, USA,
| |
Collapse
|
40
|
Same-Day Discharge for Nonperforated Appendicitis in Children: An Updated Institutional Protocol. J Surg Res 2018; 232:346-350. [PMID: 30463740 DOI: 10.1016/j.jss.2018.06.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/13/2018] [Accepted: 06/19/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The evolving demands of our current health care system for enhanced efficiency and safety while decreasing hospital length of stay has led to our institutional protocol for same-day discharge (SDD) after laparoscopic appendectomy. We have previously demonstrated a 28% rate of SDD in children with nonperforated appendicitis. The purpose of our study is to assess the effectiveness of a mature protocol for SDD by evaluating discharge success, duration of hospital stay, and readmission rates. MATERIALS AND METHODS A retrospective review of prospectively collected data was conducted. All children undergoing a laparoscopic appendectomy for nonperforated appendicitis at Children's Mercy Hospital between December 2015 and July 2017 were included. Patients were classified according to whether they were discharged home the same day as their operation or had an overnight stay. Demographic data, time of day the procedure was completed, postoperative length of stay, and readmission rates were abstracted from patient medical records. Comparative analysis was performed in STATA using chi-squared or Fisher exact tests for categorical variables and t-test or Wilcoxon rank sum test for continuous variables. RESULTS A total of 569 children were included, with 87% (n = 495) discharged home the same day as their appendectomy. Of the patients discharged home the same day of surgery, their median length of postoperative stay was 4 h (IQR: 3, 5) compared with 19 h for the patients who stayed overnight (IQR: 15, 25, P < 0.0001). Approximately two-thirds of patients who had their appendectomies after 6 PM stayed overnight. In addition, patients discharged home the same day had similar hospital readmission rates compared with patients who stayed overnight (2% vs. 4%, P = 0.155). CONCLUSIONS After laparoscopic appendectomy in children with nonperforated appendicitis, SDD not only reduces postoperative length of stay but also is not associated with higher hospital readmission rates.
Collapse
|