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Eakes AM, Burkbauer L, Purcell LN, Akinkuotu AC, McLean SE, Charles AG, Phillips MR. Difference in Postoperative Outcomes and Perioperative Resource Utilization Between General Surgeons and Pediatric Surgeons: A Systematic Review. Am Surg 2023; 89:3739-3744. [PMID: 37150834 DOI: 10.1177/00031348231173943] [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: 05/09/2023]
Abstract
Background: Both general surgeons (GS) and pediatric surgeons (PS) perform a high volume of appendectomies in pediatric patients, but there is a paucity of data on these outcomes based on surgeon training. We performed a systematic review and meta-analysis to compare postoperative outcomes and perioperative resource utilization for pediatric appendectomies.Methods: We searched PubMed to identify articles examining the association between surgeon specialization and outcomes for pediatric patients undergoing appendectomies. Study selection, data extraction, risk of bias assessment, and quality assessment were performed by one reviewer, with another reviewer to resolve discrepancies.Results: We identified 4799 articles, with 98.4% (4724/2799) concordance after initial review. Following resolution of discrepancies, 16 studies met inclusion criteria. Of the studies that reported each outcome, GS and PS demonstrated similar rates of readmission within 30 days (pooled RR 1.61 95% CI 0.66, 2.55) wound infections (pooled RR 1.07, 95% CI .55, 1.60), use of laparoscopic surgery (pooled RR 1.87, 95% CI .21, 3.53), postoperative complications (pooled RR 1.40, 95% CI .83, 1.97), use of preoperative imaging (pooled RR .98,95% CI .90, 1.05), and intra-abdominal abscesses (pooled RR .80, 95% CI .03, 1.58). Patients treated by GS did have a significantly higher risk of negative appendectomies (pooled RR 1.47, 95% CI 1.10, 1.84) when compared to PS.Discussion: This is the first meta-analysis to compare outcomes for pediatric appendectomies performed by GS compared to PS. Patient outcomes and resource utilization were similar among PS and GS, except for negative appendectomies were significantly more likely with GS.
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Affiliation(s)
- Ali M Eakes
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura Burkbauer
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura N Purcell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adesola C Akinkuotu
- Department of Surgery, Division of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sean E McLean
- Department of Surgery, Division of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anthony G Charles
- Department of Surgery, Division of General and Acute Care Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael R Phillips
- Department of Surgery, Division of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Georgeades C, Farazi MR, Gainer H, Flynn-O'Brien KT, Leys CM, Gourlay D, Van Arendonk KJ. Distribution of acute appendicitis care in children: A statewide assessment of the surgeons and facilities providing surgical care. Surgery 2023; 173:765-773. [PMID: 36244816 DOI: 10.1016/j.surg.2022.06.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/06/2022] [Accepted: 06/21/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Pediatric appendicitis is managed by general and pediatric surgeons at both children's hospitals and non-children's hospitals. A statewide assessment of surgeons and facilities providing appendicitis care was performed to identify factors associated with location of surgical care. METHODS Children aged <18 years undergoing appendectomy for appendicitis in Wisconsin from 2018-2020 were identified through the International Classification of Diseases, 10th revision, and Current Procedural Terminology codes using Wisconsin Hospital Association data. Patient residence and hospital locations were used to determine travel distance, rurality, and neighborhood-level socioeconomic status. RESULTS Among 3,604 children with appendicitis, 36.0% and 12.8% had an appendectomy at 2 major children's hospitals and 4 other children's hospitals, respectively, and 51.2% had an appendectomy at 99 non-children's hospitals. Pediatric surgeons performed 76.1% of appendectomies at children's hospitals and 2.9% at non-children's hospitals. Only 32.2% of patients received care at the hospital closest to their homes. Non-children's hospitals disproportionally cared for older, non-Hispanic White, and privately insured children, those with uncomplicated appendicitis, and those living in rural areas, in mid-socioeconomic status neighborhoods, and greater distances from children's hospitals (all P < .001). After multivariable adjustment, receipt of care at children's hospitals was associated with younger age, minority race, complicated appendicitis, shorter distance to children's hospitals, and urban residence. CONCLUSION Over half of surgical care for pediatric appendicitis occurred at non-children's hospitals, especially among older children and those living in rural areas far from children's hospitals. Future work is necessary to determine which children benefit most from care at children's hospitals and which can safely receive care at non-children's hospitals to avoid unnecessary time and resource utilization associated with travel to children's hospitals.
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Affiliation(s)
- Christina Georgeades
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
| | - Manzur R Farazi
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Hailey Gainer
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, WI
| | - David Gourlay
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Kyle J Van Arendonk
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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Sogbodjor LA, Singleton G, Davenport M, Walker S, Moonesinghe SR. Quality metrics for emergency abdominal surgery in children: a systematic review. Br J Anaesth 2021; 128:522-534. [PMID: 34895715 DOI: 10.1016/j.bja.2021.10.045] [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: 07/27/2021] [Revised: 10/07/2021] [Accepted: 10/13/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND There is variation in care quality and outcomes for children undergoing emergency abdominal surgery, such as appedectomy. Addressing this requires paediatric-specific quality metrics. The aim of this study was to identify perioperative structure and process measures that are associated with improved outcomes for these children. METHODS We performed a systematic review searching MEDLINE, Embase, CINAHL, Cochrane Library, and Google Scholar for articles published between January 1, 1980 and September 29, 2020 about the perioperative care of children undergoing emergency abdominal surgery. We also conducted secondary searching of references and citations, and we included international professional publications. RESULTS We identified and analysed 383 peer-reviewed articles and 18 grey literature publications. High-grade evidence pertaining to the perioperative care of this patient group is limited. Most of the evidence available relates to improving diagnostic accuracy using preoperative blood testing, imaging, and clinical decision tools. Processes associated with clinical outcomes include time lapse between time of presentation or initial assessment and surgery, and the use of particular analgesia and antibiotic protocols. Structural factors identified include hospital and surgeon caseload and the use of perioperative care pathways. CONCLUSIONS This review summarises the structural and process measures associated with outcome in paediatric emergency abdominal surgery. Such measures provide a means of evaluating care and identifying areas of practice that require quality improvement, especially in children with appendicitis. CLINICAL TRIAL REGISTRATION PROSPERO CRD42017055285.
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Affiliation(s)
- Lisa A Sogbodjor
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK; Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
| | - Georgina Singleton
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | - Suellen Walker
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond St Institute of Child Health, London, UK
| | - S Ramani Moonesinghe
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
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Rolle U, Fahlenbach C, Heidecke CD, Heller G, Meyer HJ, Schuler E, Waibel B, Jeschke E, Günster C, Maneck M. Rates of Complications After Appendectomy in Children and Adolescents: Pediatric Surgical Compared to General Surgical Hospitals. J Surg Res 2020; 260:467-474. [PMID: 33272597 DOI: 10.1016/j.jss.2020.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/08/2020] [Accepted: 11/01/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Appendectomies in children and adolescents are performed in Germany in pediatric surgical (PS) or general surgical hospitals (GS). The aim of this study is to evaluate whether the surgery in a PS or GS hospital has an influence on the postoperative course after appendectomy in children and adolescents. MATERIALS AND METHODS Nationwide routine data from children and adolescents aged 1-17 y insured by the Local Health Insurance Fund who underwent appendectomy between 2014 and 2016 were analyzed (cohort study). Descriptive statistics were calculated both overall and in the two groups (PS and GS). Patients were additionally examined by age (1-5, 6-12, and 13-17 y), treatment (laparoscopic, open surgical, and conversion), and appendicitis type (nonacute: K36/K37/K38/R10, acute simple: K35.30/K35.8, and acute complex: K35.2/K35.31/K35.32). The influence of surgeon specialization on 90-d secondary surgery and 90-d general complications was assessed by multiple logistic regression. RESULTS Altogether, 25,065 patients who underwent surgery in 83 PS and 906 GS hospitals were included. Logistic regression analysis revealed that PS was associated with a reduced risk of interventions in the 1-5- and 6-12-y age groups (odds ratio: 0.44, 0.62). Acute complex appendicitis, comorbidities, and open surgery significantly increased the risk for reintervention. PS was associated with an increased risk for complications in the 13-17-y age group (odds ratio: 1.66). CONCLUSIONS PS and GS hospitals provided safe appendectomies in children and adolescents with low reintervention and complication rates. PS hospitals demonstrated advantages for patients in the 1-5- and 6-12-y age groups and GS hospitals for patients 13-17 y.
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Affiliation(s)
- Udo Rolle
- Department of Paediatric Surgery and Paediatric Urology, University Hospital, Goethe University, Frankfurt/Main, Germany.
| | | | - Claus-Dieter Heidecke
- Department of General, Visceral, Thoracic and Vascular Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Günther Heller
- Department of Medicine, University Marburg, Marburg, Germany
| | | | - Ekkehard Schuler
- Department of Quality Management, Helios Hospital, Berlin, Germany
| | - Beate Waibel
- Medical Review Board of the Social Health Insurance Funds, Freiburg, Germany
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Bailey K, Choynowski M, Kabir SMU, Lawler J, Badrin A, Sugrue M. Meta-analysis of unplanned readmission to hospital post-appendectomy: an opportunity for a new benchmark. ANZ J Surg 2019; 89:1386-1391. [PMID: 31364257 DOI: 10.1111/ans.15362] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/03/2019] [Accepted: 06/10/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. While many studies report readmission, a meta-analysis of readmission post-appendectomy has not been published. This meta-analysis was undertaken to determine rates and predictors of hospital readmission following appendectomy and to potentially provide a metric benchmark. METHODS An ethically approved PROSPERO-registered (ID CRD42017069040) meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using databases PubMed and Scopus, was undertaken for studies published between January 2012 and June 2017. Articles relating to outcomes and readmissions after appendectomy were identified. Those scoring >15 for comparative studies and >10 for non-comparative studies, using Methodological Index for Non-Randomized Studies criteria were included in the final analysis. The odds ratios (OR) using random-effects, Mantel-Haenszel method with 95% confidence intervals (CI), were computed for each risk factor with RevMan5. RESULTS A total of 1757 articles reviewed were reduced to 45 qualifying studies for a final analysis of 836 921 appendectomies. 4.3% (range 0.0-14.4%) of patients were readmitted within 30 days. Significant preoperative patient factors for increased readmission were diabetes mellitus (OR 1.93, CI 1.63-2.28, P < 0.00001), complicated appendicitis (OR 3.6, CI 2.43-5.34, P < 0.00001) and open surgical technique (OR 1.39, CI 1.08-1.79, P < 0.00001). Increased readmission was not associated with gender, obesity or paediatric versus general surgeons or centres. CONCLUSION This meta-analysis identified that readmission is not uncommon post-appendectomy, occurring in one in 25 cases. The mean readmission rate of 4.3% may act as a quality benchmark for improving emergency surgical care. Targeting high-risk groups with diabetes or complicated appendicitis and increasing use of laparoscopic technique may help reduce readmission rates.
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Affiliation(s)
- Kate Bailey
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | - Michelle Choynowski
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | - Syed Mohammad Umar Kabir
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland.,Department of Surgery, Letterkenny University Hospital, Letterkenny, Ireland
| | - Jack Lawler
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | - Adibah Badrin
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | - Michael Sugrue
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland.,Department of Surgery, Letterkenny University Hospital, Letterkenny, Ireland.,EU INTERREG Centre for Personalised Medicine Project, Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Magee Campus, Londonderry, Northern Ireland
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Bos C, Doumouras AG, Akhtar-Danesh GG, Flageole H, Hong D. A population-based cohort examining factors affecting all-cause morbidity and cost after pediatric appendectomy: Does annual adult procedure volume matter? Am J Surg 2018; 218:619-623. [PMID: 30580933 DOI: 10.1016/j.amjsurg.2018.12.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/04/2018] [Accepted: 12/13/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to examine factors affecting morbidity and cost after pediatric appendectomy and particularly the role of adult surgical volume. MATERIALS AND METHODS This was population-based study including all pediatric patients who underwent appendectomy for appendicitis in Canada (excluding Quebec) from 2008 to 2015. All-cause morbidity was the main outcome of interest. Cost of the index admission (in 2014 Canadian dollars) was a secondary outcome. Hierarchal linear and logistic regressions were used to model the outcomes. RESULTS Overall, 41,512 patients were identified. After adjustment, younger patients (OR = 0.98/year, 95%CI 0.97-0.99, p < 0.001), patients with comorbidities (OR = 2.20, 95%CI 1.96-2.46, p < 0.001), and those with perforated appendicitis (OR = 5.95, 95%CI 5.44-6.50, p < 0.001) were more susceptible to morbidity. Annual pediatric appendectomy volume was a significant predictor of reduced morbidity (OR = 0.85/20 cases, 95%CI 0.76-0.93, p < 0.001) as was the use of laparoscopy (OR = 0.81, 95%CI 0.72-0.91, p = 0.001). Conversely, annual adult appendectomy volume conferred no benefit nor did pediatric surgery specialty training. CONCLUSION Outcomes after pediatric appendectomy are influenced by pediatric case volume, regardless of specialty training, but extra adult surgical volume confers no benefit.
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Affiliation(s)
- Cecily Bos
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Helene Flageole
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dennis Hong
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada.
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Abstract
Acute appendicitis is the most common cause of emergent surgery in children. Historically, surgical dogma dictated emergent appendectomy due to concern for impending perforation. Recently, however, there has been a paradigm shift in both the understanding of its pathophysiology as well as its treatment to more nonoperative management. No longer is it considered a spectrum from uncomplicated appendicitis inevitably progressing to complicated appendicitis over time. Rather, uncomplicated and complicated appendicitis are now considered two distinct pathophysiologic entities. This change requires not only educating the patients and their families but also the general practitioners who will be managing treatment expectations and caring for patients long term. In this article, we review the pathophysiology of appendicitis, including the differentiation between uncomplicated and complicated appendicitis, as well as the new treatment paradigms. [Pediatr Ann. 2016;45(7):e235-e240.].
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