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Smith CB, Marapese KD, Charles AG. Management of acute appendicitis in low- and middle-income countries. Curr Probl Surg 2024; 61:101444. [PMID: 38548428 DOI: 10.1016/j.cpsurg.2024.101444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 04/02/2024]
Affiliation(s)
| | | | - Anthony G Charles
- School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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Roberts K, Moore H, Raju M, Gent R, Piotto L, Taranath A, Ee M, Linke R, Goh DW. Diagnostic Ultrasound for Acute Appendicitis: The Gold Standard. J Pediatr Surg 2024; 59:235-239. [PMID: 37985334 DOI: 10.1016/j.jpedsurg.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/11/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Acute appendicitis may present a diagnostic dilemma. The aim of this study was to review the accuracy of ultrasound in the diagnosis of paediatric acute appendicitis. METHOD Ultrasound studies performed for investigation of appendicitis during 2015-2021 were retrieved from a tertiary paediatric hospital database and reviewed. Medical records were reviewed to determine operative intervention, further imaging, and final diagnosis. Diagnostic accuracy was assessed by sensitivity, specificity, predictivity, and overall accuracy. All appendicectomy specimens underwent histopathological confirmation. This study was approved by the local Human Research Ethics Committee. RESULTS A total of 8555 consecutive ultrasound examinations were performed during the study period. Mean patient age was 10.8 years ( ± 3.7). Overall diagnostic accuracy was 96.1% (8221/8555) with a visualisation rate of 91.0%. Sensitivity and specificity were 96.2% (CI 95.3-97.0%) and 96.1% (CI 95.6-96.5%), respectively. When limited to positive/negative scans, sensitivity was 99.6% (CI 99.2-99.8%) and specificity 99.0% (CI 98.7-99.3%). Positive and negative predictive values were 96.9% and 99.9%, respectively. Repeat ultrasound following a non-diagnostic scan led to a definitive diagnosis in 76.1%. Negative appendicectomy rate was 5.5% overall in children who had undergone pre-operative ultrasound (107/1938), and 4.4% when other surgical pathologies were excluded. CONCLUSION Ultrasound examination provides gold-standard accuracy in the diagnosis of paediatric appendicitis and reduces rates of negative appendicectomy. Given the disadvantages of computed tomography and magnetic resonance imaging, ultrasound should be considered the first-line investigation of choice in the diagnosis of acute appendicitis in children. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kiera Roberts
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia.
| | - Hamish Moore
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia
| | - Mahima Raju
- Adelaide Medical School, the University of Adelaide, SA, Australia
| | - Roger Gent
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Lino Piotto
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Ajay Taranath
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Michael Ee
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia; College of Medicine and Public Health, Flinders University, SA, Australia
| | - Rebecca Linke
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Day Way Goh
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia; Discipline of Paediatrics, University of Adelaide, SA, Australia
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Cironi K, Albuck AL, McLafferty B, Mortemore AK, McCarthy C, Hussein M, Issa PP, Metz T, Herrera M, Toraih E, Taghavi S, Kandil E, Turner J. Risk Factors for Postoperative Infections Following Appendectomy of Complicated Appendicitis: A Meta-analysis and Retrospective Single-institutional Study. Surg Laparosc Endosc Percutan Tech 2024; 34:20-28. [PMID: 37852230 DOI: 10.1097/sle.0000000000001234] [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: 06/01/2023] [Accepted: 08/22/2023] [Indexed: 10/20/2023]
Abstract
Patients with complicated appendicitis have an increased risk for postoperative infections. Potential risk factors for postoperative infections through a meta-analysis and retrospective chart review are discussed. A meta-analysis consisting of 35 studies analyzing complicated appendicitis treated with an appendectomy noting at least 1 postoperative infection was performed. A retrospective review was then conducted in patients diagnosed with complicated appendicitis after appendectomy. Of 5326 patients in total, 15.4% developed postoperative infections. Laparoscopic surgery and perioperative hyperoxygenation were found to be protective factors for the development of infection. Retrospectively, 53.2% of patients presented with complicated appendicitis. Patients with complicated appendicitis were more likely to be older in age and have an increased length of stay. Patient demographics, operative time, and comorbid status had no effect on postoperative infection or readmission rate. Physicians should strongly consider minimally invasive techniques to treat all cases of complicated appendicitis irrespective of comorbidities, age, sex, or body mass index.
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Affiliation(s)
| | | | | | | | | | | | - Peter P Issa
- Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA
| | | | | | - Eman Toraih
- Department of Surgery, Division of Endocrine and Oncologic Surgery
- Department of Genetics, Histology and Cell Biology, Suez Canal University Faculty of Medicine, Ismailia, Egypt
| | - Sharven Taghavi
- Department of Surgery, Division of Trauma and Critical Care, Tulane University School of Medicine
| | - Emad Kandil
- Department of Surgery, Division of Endocrine and Oncologic Surgery
| | - Jacquelyn Turner
- Department of Surgery, Division of Endocrine and Oncologic Surgery
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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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Purcell LN, Eakes A, Ricketts T, McLean SE, Akinkuotu A, Hayes AA, Charles AG, Phillips MR. Appendectomy by Pediatric Surgeons in North Carolina is Associated With Higher Charge Than General Surgeons. J Surg Res 2023; 281:299-306. [PMID: 36228340 DOI: 10.1016/j.jss.2022.08.022] [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: 05/16/2022] [Revised: 08/03/2022] [Accepted: 08/20/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION The delivery of pediatric surgical care for acute appendicitis involves general surgeons (GS) and pediatric surgeons (PS), but the differences in clinical practice are primarily undescribed. We examined charge differences between GS and PS for the treatment of pediatric acute appendicitis. METHODS We performed a retrospective review of the North Carolina hospital discharge database (2013-2017) in pediatric patients (≤18 y) who had surgery for appendiceal pathology (acute or chronic appendicitis and other appendiceal pathology). We performed a bivariate analysis of surgical charges over the type of surgical providers (GS, PS, other specialty, and unassigned surgeons). RESULTS Over the study period, 21,049 patients had appendicitis or other diseases of the appendix, and 15,230 (72.4%) underwent appendectomy. Patients who were operated on by PS were younger (10 y, interquartile range (IQR): 6-13 versus 13 y, IQR: 9-16, P < 0.001). Acute appendicitis was diagnosed in 2860 (44.3%) and 3173 (49.2%) of the PS and GS cohorts, respectively, P = 0.008. PS compared to GS performed a higher percentage of laparoscopic (n = 2,697, 89.4% versus n = 2,178, 65.5%) than open appendectomies (n = 280, 9.3% versus n = 1,118, 33.6%), P < 0.001. The overall hospital charges were $28,081 (IQR: $21,706-$37,431) and $24,322 (IQR: $17,906-$32,226) for PS and GS, respectively, P < 0.001. Surgical charges where higher for PS than GS, $12,566 (IQR: $9802-$17,462) and $8051 (IQR: $5872-$2331), respectively. When controlling for diagnosis, surgical approach, emergent status, age, and surgical cost of appendiceal surgery, and hospital charges following appendiceal surgery were $4280 higher for PS than GS (95% CI: 3874-4687). CONCLUSIONS The total charge for operations for appendiceal disease is significantly higher for PS compared to GS. Pediatric surgeons had increased surgical charges compared to GS but decreased radiology charges. The specific reasons for these differences are not clearly delineated in this data set and persist after controlling for relevant covariates. However, these data demonstrate that increasing value in pediatric appendicitis may require specialty-based targets.
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Affiliation(s)
- Laura N Purcell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ali Eakes
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Thomas Ricketts
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sean E McLean
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Adesola Akinkuotu
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Andrea A Hayes
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anthony G Charles
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael R Phillips
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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Raffa A, Abduljabbar A, Alharthy A. Comparison of Ultrasound and Computed Tomography Scanning Accuracy in Diagnosing Acute Appendicitis at King Abdulaziz University Hospital. Cureus 2022; 14:e31880. [PMCID: PMC9693829 DOI: 10.7759/cureus.31880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2022] [Indexed: 11/26/2022] Open
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Larocca V, Oltean I, Grandpierre V, Nasr A. Development and evaluation of a patient decision aid for pediatric interval appendectomy. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000466. [DOI: 10.1136/wjps-2022-000466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022] Open
Abstract
ObjectiveOne option for the treatment of perforated appendicitis in pediatric patients is interval appendectomy (IA). A patient decision aid (PDA) can be useful in the decision-making process regarding IA. The purpose of this study was to evaluate parents’ decisional conflict before and after engaging with a developed PDA.MethodsParticipants included (a) parents who are considering IA surgery for their child, (b) have not yet had their follow-up appointment postdischarge, and (c) were fluent in either the official languages of English or French. This study used a pretest and post-test design to measure participants’ decisional conflict and treatment option choice. Perceptions and acceptability of the PDA were also assessed.ResultsA total of 18 participants completed the study (16 mothers). Major findings include significant decreases in all Decisional Conflict Scale items from pre-PDA to post-PDA engagement, except for one item. The majority of participants perceived the PDA to be useful, easy to find information regarding risks and provided enough information to help them make a decision regarding their child’s treatment.ConclusionsThis is the first study to develop and evaluate a PDA among parents who are making a decision regarding IA surgery. The results showed a significant decrease in decisional conflict after using the PDA. The results also showed that the PDA was generally accepted among parents and had positive perceptions regarding length, content, and balance. The use of PDA for this population can help ease feelings of decisional conflict and equip parents with the information to make informed decisions.
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Acute appendicitis in children: Reexamining indications for conservative treatment - A large prospective analysis. J Pediatr Surg 2022; 57:373-379. [PMID: 34991866 DOI: 10.1016/j.jpedsurg.2021.12.012] [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: 08/11/2021] [Revised: 12/04/2021] [Accepted: 12/07/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Conservative antibiotic treatment (CAT) for uncomplicated acute appendicitis (AUA) in children has been proven safe and efficacious. However, as data accumulate, high rates of recurrent appendicitis and subsequent appendectomy have been reported. This prospective longitudinal study evaluated risk-factors for recurrent AUA after CAT in a large cohort, with long-term follow-up. MATERIALS AND METHODS Children ages 5 to 16 years admitted to the Department of Pediatric Surgery from 2014 through 2018, diagnosed with AUA were eligible for CAT. We recorded their age, appendix outer diameter, white blood cell counts, C-reactive protein and other related signs and symptoms associated with AUA. Clinical and ultrasonographic follow-up was carried out until follow-up data collection ceased according to the study design (2014-2019). RESULTS The cohort included 646 children who were initially treated successfully with CAT. Among them, 180 (28%) were readmitted for recurrent acute appendicitis during the follow-up period and 138 (21%) eventually had appendectomy. Overall success of 79% for CAT was recorded in this cohort. A multivariable model including; age, sex, appendiceal diameter, WBC and CRP, found the factors of older age, larger outer appendiceal diameter and high WBC counts significantly related to appendectomy during the follow-up period. We offer a decision tree model to predict appendectomy probabilities for patients based on their prognostic measurements. CONCLUSION CAT in AUA in children should consider older age, larger outer appendiceal diameter and high WBC counts as risk-factors for recurrent AUA and subsequent appendectomy. The proposed decision tree model may help both clinicians and parents before CAT is chosen. LEVEL OF EVIDENCE Level 2.
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Di Mitri M, Parente G, Bonfiglioli G, Thomas E, Bisanti C, Cordola C, Vastano M, Cravano S, Collautti E, Di Carmine A, D’Antonio S, Gargano T, Libri M, Lima M. IL-6 Serum Levels Can Enhance the Diagnostic Power of Standard Blood Tests for Acute Appendicitis. CHILDREN 2022; 9:children9101425. [PMID: 36291361 PMCID: PMC9600576 DOI: 10.3390/children9101425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/17/2022] [Accepted: 09/18/2022] [Indexed: 11/23/2022]
Abstract
Background: The diagnosis of acute appendicitis (AA) remains challenging, especially in pediatrics, because early symptoms are not specific, and the younger the patient the more difficult their interpretation is. There is a large degree of agreement between pediatric surgeons on the importance of an early diagnosis to avoid complicated acute appendicitis (CAA) and its consequences. The aim of this study is to assess if Interleukin 6 (IL-6) could enhance the sensitivity (Sn) and specificity (Sp) of the currently available and routinely performed diagnostic tools in case of suspected AA in pediatric patients. Materials and Methods: A prospective observational study was conducted including patients who underwent appendectomy between November 2020 and March 2022. We divided patients into three groups: not inflamed appendix (group NA), not complicated AA (group NCAA), and complicated AA (group CAA). We compared the mean values of white blood cells (WBC), neutrophils, fibrinogen, ferritin, aPTT, INR, C-reactive protein (CRP), IL-6, and CRP between the three groups. Then we evaluated Sn, Sp, and odds ratio (OR) of IL-6 and CRP alone and combined. Results: We enrolled 107 patients operated on for AA (22 in Group NA, 63 in Group NCAA, and 21 in group CAA). CRP levels resulted in a significant increase when comparing CAA with NA (p = 0.01) and CAA with NCAA (p = 0.01), whereas no significance was found between NA and NCAA (p = 0.38). A statistically significant increase in average IL-6 levels was found when comparing NCAA with NA (p = 0.04), CAA with NA (p = 0.04), and CAA with NCAA (p = 0.02). Considering CRP alone, its Sn, Sp, and OR in distinguishing NA from AA (both NCAA and CAA together) are 86%, 35%, and 33,17, respectively. Similarly, Sn, Sp, and OR of IL-6 alone are 82%, 54%, and 56, respectively. Combining CRP and IL-6 serum levels together, the Sn increases drastically to 100% with an Sp of 40% and OR of 77. Conclusions: Our study may suggest an important role of IL-6 in the detection of AA in its early stage, especially when coupled with CRP.
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Hu A, Li J, Vacek J, Bouchard M, Ingram MC, McMahon M, Mithal LB, Raval MV, Reynolds M, Goldstein S. Antibiotic resistance is common in the cultures of intraabdominal abscess drainage after appendectomy. J Pediatr Surg 2022; 57:102-106. [PMID: 34991867 DOI: 10.1016/j.jpedsurg.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/14/2021] [Accepted: 12/04/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Intraabdominal abscesses (IAA) are a common complication following appendectomy. Empiric antibiotic regimens may fail to prevent IAA due to changes in bacterial resistance. We aim to describe the bacteriology of pediatric patients requiring drainage of an IAA after an appendectomy for appendicitis. METHODS We performed a retrospective study of patients ≤18 years who underwent percutaneous drainage of an IAA following appendectomy a single U.S. children's hospital between 2015 and 2018. Patient demographics, appendicitis characteristics, antibiotic regimens, and culture data were collected. RESULTS In total, 71 patients required drainage of an IAA of which 48 (67%) were male, the average age was 9.81 (SD 3.31) years and 68 (95.7%) having complicated appendicitis. Ceftriaxone/metronidazole was the most common empiric regimen prior to IAA drainage occurring in 64 (90.1%) patients. IAA cultures isolated organisms in 34 (47.9%) patients. Of those with positive cultures, 17 (50%) cases demonstrated an antimicrobial resistant organism. Most notably, 20% of Escherichia coli was resistant to the empiric regimen. Empiric antimicrobial regimens did not appropriately cover 92.3% of Pseudomonas aeruginosa cultures or 100% of Enterococcus species cultures. Antimicrobial regimens were changed following IAA drainage in 30 (42.2%) instances with 23 (32.4%) instances due to resistance in culture results or lack of appropriate empiric antimicrobial coverage. CONCLUSIONS IAA culture data following appendectomy for appendicitis frequently demonstrates resistance to or lack of appropriate coverage by empiric antimicrobial regimens. These data support close review of IAA culture results to identify prevalent resistant pathogens along with local changes in resistance. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Jennifer Li
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jonathan Vacek
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Megan Bouchard
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Martha-Conley Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Maxwell McMahon
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Division of Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Leena B Mithal
- Division of Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Marleta Reynolds
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Seth Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Grandpierre V, Duba K, Toupin April K, Oltean I, Weir A, Nasr A. Needs assessment of parents for a patient decision aid in pediatric interval appendectomy via the qualitative interview method. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000371. [DOI: 10.1136/wjps-2021-000371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/15/2021] [Indexed: 11/03/2022] Open
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12
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Burini G, Cianci MC, Coccetta M, Spizzirri A, Di Saverio S, Coletta R, Sapienza P, Mingoli A, Cirocchi R, Morabito A. Aspiration versus peritoneal lavage in appendicitis: a meta-analysis. World J Emerg Surg 2021; 16:44. [PMID: 34488825 PMCID: PMC8419906 DOI: 10.1186/s13017-021-00391-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/19/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Acute appendicitis is one of the most frequent abdominal surgical emergencies. Intra-abdominal abscess is a frequent post-operative complication. The aim of this meta-analysis was to compare peritoneal irrigation and suction versus suction only when performing appendectomy for complicated appendicitis. METHODS According to PRISMA guidelines, a systematic review was conducted and registered into the Prospero register (CRD42020186848). The risk of bias was defined to be from low to moderate. RESULTS Seventeen studies (9 RCTs and 8 CCTs) were selected, including 5315 patients. There was no statistical significance in post-operative intra-abdominal abscess in open (RR 1.27, 95% CI 0.75-2.15; I2 = 74%) and laparoscopic group (RR 1.51, 95% CI 0.73-3.13; I2 = 83%). No statistical significance in reoperation rate in open (RR 1.27, 95% CI 0.04-2.49; I2 = 18%) and laparoscopic group (RR 1.42, 95% CI 0.64-2.49; I2 = 18%). In both open and laparoscopic groups, operative time was lower in the suction group (RR 7.13, 95% CI 3.14-11.12); no statistical significance was found for hospital stay (MD - 0.39, 95% CI - 1.07 to 0.30; I2 = 91%) and the rate of wound infection (MD 1.16, 95% CI 0.56-2.38; I2 = 71%). CONCLUSIONS This systematic review has failed to demonstrate the statistical superiority of employing intra-operative peritoneal irrigation and suction over suction-only to reduce the rate of post-operative complications after appendectomy, but all the articles report clinical superiority in terms of post-operative abscess, wound infection and operative times in suction-only group.
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Affiliation(s)
- Gloria Burini
- General and Emergency Surgical Clinic of Ancona, Ancona, Italy
| | - Maria Chiara Cianci
- Department of Pediatric Surgery, Meyer Children’s Hospital, University of Florence, Florence, Italy
| | | | | | - Salomone Di Saverio
- Department of Colorectal Surgery, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ UK
| | - Riccardo Coletta
- Department of Pediatric Surgery, Meyer Children’s Hospital, School of Environment and Life Science, University of Salford, Salford, UK
| | - Paolo Sapienza
- Department of Surgery, University of Rome, Sapienza, Italy
| | - Andrea Mingoli
- Department of Surgery, University of Rome, Sapienza, Italy
| | - Roberto Cirocchi
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Antonino Morabito
- Department of Pediatric Surgery, Meyer Children’s Hospital, Department of Neurofarba, University of Florence, Florence, Italy
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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.
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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
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14
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Hosokawa T, Tanami Y, Sato Y, Ishimaru T, Kawashima H, Oguma E. Association between the computed tomography findings and operative time for interval appendectomy in children. Afr J Paediatr Surg 2021; 18:73-78. [PMID: 33642402 PMCID: PMC8232362 DOI: 10.4103/ajps.ajps_94_20] [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] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The purpose was to evaluate the association between operative time and findings noted on computed tomography (CT) immediately before interval appendectomy. MATERIALS AND METHODS Forty-two children who underwent CT before interval appendectomy were included. We evaluated the association between operative time and these image findings: (1) appendicolith, (2) increased intra-abdominal fat density around the appendix, (3) location of the appendix, (4) ascites, (5) abscess formation and (6) maximum appendix outer wall diameter. Appendix location was classified as (#1) just below the anterior abdominal wall; (#2) retrocaecal or retro-ascending colon and (#3) pelvic. Results were analysed using Pearson's correlation coefficient or Mann-Whitney U test. RESULTS The mean patient age and operative time were 116.24 ± 38.66 months (range, 31-195) and 67.76 ± 31.23 min (range, 30-179), respectively. Ascites was detected in only one case, and no abscess occurred in any patient; therefore, these findings were not analysed. Factors that significantly prolonged the operative time included increased intra-abdominal fat density around the appendix (absent, 59.43 ± 22.14 [range, 30-108] vs. present, 84.43 ± 40.13 [range, 32-179] min; P = 0.03) and retrocaecal or retro-ascending colon appendix (location 1, 40.83 ± 8.35 [range, 30-50]; location 2, 99.25 ± 18.56 [range, 74-135]; location 3, 64.54 ± 30.22 [range, 30-179] min; P < 0.01). There was a weak but significant association between maximum appendix outer wall diameter and operative time (R = 0.353; P = 0.02). CONCLUSION These pre-operative CT findings are important predictors of operative time for interval appendectomy. Radiologists and surgeons should use these specific image findings to predict the operative time and need for additional procedures during an interval appendectomy.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Tetsuya Ishimaru
- Department of Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroshi Kawashima
- Department of Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
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15
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Outcomes following adoption of a standardized protocol for abscess drain management in pediatric appendicitis. J Pediatr Surg 2021; 56:43-46. [PMID: 33143877 DOI: 10.1016/j.jpedsurg.2020.09.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 09/22/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND/PURPOSE Though evidence-based clinical pathways for the diagnosis and treatment of pediatric appendicitis have been established, protocols guiding management of percutaneous abscess drains are lacking. We hypothesized a drain management protocol utilizing drain output and clinical factors instead of fluoroscopic drain studies would reduce interventional radiologic procedures without adversely impacting clinical outcomes. METHODS A standardized protocol was uniformly adopted at a tertiary-care children's hospital in April 2016. A retrospective chart review included all cases of appendicitis requiring abscess drainage by interventional radiology three years pre- and postprotocol implementation. RESULTS Fifty-eight patients (preprotocol = 39, postprotocol = 19) underwent percutaneous abscess drainage, of whom 52 (preprotocol = 34, postprotocol = 18) required a drain. Baseline demographics and clinical presentation were similar across groups. Following protocol implementation, total number of IR procedures decreased from 2.4 to 1.3 per patient (p = 0.004). There was no significant difference in the number of postprocedure diagnostic imaging studies, readmissions, or inpatient days, and there was a trend towards a decrease in number of drain days (10.7 to 5.7, p = 0.067). CONCLUSION A standardized protocol for management of abscess drains for complicated appendicitis reduced the number of IR procedures without a negative impact on clinical outcomes or increase in alternative imaging studies. This approach may decrease radiation exposure, anesthetic administration, and resource utilization. TYPE OF STUDY Treatment study (retrospective comparative study). LEVEL OF EVIDENCE Level III.
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16
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Patel A, Levine M, Dickman E, Haines L, Homel P, Likourezos A, Pushkar I, Drapkin J, Arroyo A. Does Orally-Administered Radiocontrast Impair Ultrasound Image Quality in Pediatric Patients? West J Emerg Med 2020; 21:359-364. [PMID: 32191194 PMCID: PMC7081863 DOI: 10.5811/westjem.2019.10.44104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 10/25/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction It is commonly assumed that orally-administered radiocontrast material (ORC) preceding abdominal ultrasound (US) performance can obscure image quality and potentially impair diagnostic accuracy when assessing patients with abdominal pain. Due to this concern, ORC administration per protocol for computed tomography (CT) is often delayed until after US performance, potentially contributing to prolonged length of stay in the emergency department (ED) in patients with concern for abdominal pathology. The objective of this study was to evaluate whether early administration of ORC in children with abdominal pain receiving abdominal CT for possible appendicitis obscures subsequent abdominal US image quality. Methods We designed a prospective observational study of children <18 years of age presenting to a pediatric ED with abdominal pain who were set to receive ORC prior to obtaining an abdominal CT. These patients received a point-of-care ultrasound (POCUS) of the abdomen to assess the abdominal aorta and right lower quadrant (RLQ) structures (psoas muscle and iliac vessels) pre- and post-ORC administration. Images were compared independently by two blinded emergency US-certified physician-assessors for quality, specifically to determine whether ORC obscured the anatomical structures in question. Results A total of 17 subjects were enrolled, and each subject had two POCUS studies of the abdomen, one pre- and one post-ORC administration looking to visualize the anatomy of the RLQ and abdominal aorta in both studies. Statistical analysis showed no significant differences in mean values of POCUS image quality scoring by two blinded US-trained physician-assessors for either RLQ structures or abdominal aorta when performed pre- and post-administration of ORC. Conclusion Early ORC administration in children with abdominal pain does not adversely affect image quality of a subsequently performed abdominal US. Patients who may require abdominal CT to determine the etiology of abdominal pain can receive early administration of ORC prior to US performance to help minimize ED length of stay without impairing US diagnostic accuracy.
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Affiliation(s)
- Amit Patel
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Marla Levine
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Eitan Dickman
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Lawrence Haines
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Peter Homel
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Antonios Likourezos
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Illya Pushkar
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Jefferson Drapkin
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Alexander Arroyo
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
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17
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La Pergola E, Sgrò A, Rebosio F, Vavassori D, Fava G, Codrich D, Montanaro B, Leva E, Schleef J, Cheli M, Pelizzo G, Gamba P, Alberti D, Betalli P. Appendicitis in Children in a Large Italian COVID-19 Pandemic Area. Front Pediatr 2020; 8:600320. [PMID: 33363065 PMCID: PMC7755995 DOI: 10.3389/fped.2020.600320] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/09/2020] [Indexed: 12/26/2022] Open
Abstract
Introduction: The coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the routine activities of pediatric surgical centers, and it determined the reduction of admissions in the pediatric emergency departments (PED). We reviewed the records of patients affected by acute appendicitis (AA) during the COVID-19 pandemic period in a large Italian COVID-19 pandemic area. Methods: Data regarding demographics, age, macroscopic and microscopic findings, and time between symptom onset and PED admission of patients affected by confirmed AA in the period between March and April 2020 were considered. The data were compared with those obtained during the same period of 2019, 2018, and 2017 in the included centers. Data were quoted as median (range) or absolute number. Non-parametric statistical tests were used to compare groups. A p ≤ 0.05 was regarded as significant. Since only anonymous data have been used and the data storage meets current data protection regulations, ethical committee approval was not required for this study. Results: Eighty-six patients underwent surgical appendectomy for AA between February 20th, 2020 and April 20th, 2020; 32.5% were complicated appendicitis and 67.5% were uncomplicated. Fifty-three patients were males and 33 were females. Patients' age ranged from 3 to 17 years and the median age was 10 years. The median time between the onset of symptoms and the admission in PED was 1.85 days. The average time between the symptom onset and PED admission was 1.8 days. Conclusions: Although fear from the COVID-19 pandemic determined a delayed diagnosis of serious pediatric diseases, the increasing prevalence and severity of AA were not demonstrated in the most COVID-19-affected areas of Italy.
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Affiliation(s)
- Enrico La Pergola
- Paediatric Surgery Unit, Ospedale dei Bambini V. Buzzi, Milan, Italy
| | - Alberto Sgrò
- Paediatric Surgery Unit, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Federico Rebosio
- Paediatric Surgery Unit, Ospedale dei Bambini V. Buzzi, Milan, Italy.,Department of Paediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy
| | - Daniele Vavassori
- Department of Paediatric Surgery, Papa Giovanni XXIII, Bergamo, Italy
| | - Giorgio Fava
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniela Codrich
- Department of Paediatric Surgery, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Beatrice Montanaro
- Department of Paediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jurgen Schleef
- Department of Paediatric Surgery, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - M Cheli
- Department of Paediatric Surgery, Papa Giovanni XXIII, Bergamo, Italy
| | - Gloria Pelizzo
- Paediatric Surgery Unit, Ospedale dei Bambini V. Buzzi, Milan, Italy
| | - Piergiorgio Gamba
- Paediatric Surgery Unit, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Daniele Alberti
- Department of Paediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy
| | - Pietro Betalli
- Department of Paediatric Surgery, Papa Giovanni XXIII, Bergamo, Italy
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18
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Bi LW, Yan BL, Yang QY, Cui HL. Peritoneal irrigation vs suction alone during pediatric appendectomy for perforated appendicitis: A meta-analysis. Medicine (Baltimore) 2019; 98:e18047. [PMID: 31852066 PMCID: PMC6922395 DOI: 10.1097/md.0000000000018047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND There currently exists no substantial evidence reporting the efficacy of peritoneal irrigation in reducing the incidence of postoperative intra-abdominal abscess in pediatric patients. The purpose of our study was to perform a meta-analysis to compare rates of intra-abdominal abscess after appendectomy between irrigation and suction alone groups. METHODS We identified studies by a systematic search in EMBASE, PubMed, Web of Science, and the Cochrane Library to recognize randomized controlled trials and case control studies from the 1950 to May 2019. We limited the English language studies. We checked the reference list of studies to recognize other potentially qualified trials. We analyzed the merged data with use of the Review Manager 5.3. RESULTS We identified 6 eligible papers enrolling a total of 1633 participants. We found no significant difference in the incidence of postoperative intraabdominal abscess, wound infection, and the length of hospitalization between 2 group, but duration of surgery is longer in irrigation group (MD = 6.76, 95% CI = 4.64 to 8.87, P < .001; heterogeneity, I = 25%, P = .26). CONCLUSION Our meta-analysis did not provide strong evidence allowing definite conclusions to be drawn, but suggested that peritoneal irrigation during appendectomy did not decrease the incidence of postoperative IAA. This meta-analysis also indicated the need for more high-quality trials to identify methods to decrease the incidence of postoperative IAA in pediatric perforated appendicitis patients.Trial registration number Standardization of endoscopic treatment of acute abdomen in children: 14RCGFSY00150.
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Affiliation(s)
- Le-Wee Bi
- Department of the Graduate School, Tianjin Medical University
| | - Bei-Lei Yan
- Department of the Graduate School, Tianjin Medical University
| | - Qian-Yu Yang
- Department of the Graduate School, Tianjin Medical University
| | - Hua-Lei Cui
- Department of General Surgery, Tianjin Children's Hospital, Tianjin
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19
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Holguín-Sanabria DA, Perilla-López MÁ, Castañeda-Espinosa S, Jaimes-de La Hoz P, Aragón S, Valero JJ, Molina ID, Fierro-Ávila F. Prevalence of organ-space surgical site infections after appendectomy for ruptured appendix in children. REVISTA DE LA FACULTAD DE MEDICINA 2019. [DOI: 10.15446/revfacmed.v67n4.64434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: Appendicitis can be classified as non-perforated and perforated; based on such classification, the reported organ-space surgical site infection (OS-SSI) rate is 0.8% and 18%, respectively.Objective: To establish the prevalence of OS-SSI in patients with perforated appendicitis treated in a pediatric hospital in 2012.Materials and methods: Retrospective, observational and descriptive study conducted at Fundación Hospital Pediátrico La Misericordia, with a random sample of 200 patients, of which 160 met the inclusion criteria.Results: 20 patients (12.5%) presented with OS-SSI and all of them received antibiotic treatment; 70% did not require abscess drainage. Patients ≥8 years of age had 5 times more abscesses than younger ones (17.6% vs. 3.4%). OS-SSI was found in 33% of patients with free fecalith and in 50% of the patients who required postoperative management at the ICU vs. 9.5% of the patients who received management in the intermediate care unit and the inpatient hospital floors. The total rate of surgical site infection was 24.3% (11.8% superficial, 0% deep and 12.5% organ-space).Conclusions: The prevalence of OS-SSI found here is lower than what has been reported in the literature. Being 8 years or older and having free fecalith are risk factors to develop this type of infection. The higher frequency of OS-SSI in patients treated at the ICU during the post-operative period observed here suggests that this condition may be associated with septic shock.
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20
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Associations Between Sonographic Findings and Operative Time of Transumbilical Laparoscopic-Assisted Appendectomy for Acute Appendicitis in Children. AJR Am J Roentgenol 2019; 213:191-199. [DOI: 10.2214/ajr.18.20937] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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21
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Vaos G, Dimopoulou A, Gkioka E, Zavras N. Immediate surgery or conservative treatment for complicated acute appendicitis in children? A meta-analysis. J Pediatr Surg 2019; 54:1365-1371. [PMID: 30115448 DOI: 10.1016/j.jpedsurg.2018.07.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/19/2018] [Accepted: 07/20/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE This study carried out a meta-analysis to compare immediate surgery (IS) with conservative treatment (CT) of complicated acute appendicitis (CAA) in children. METHODS Systematic literature research was performed for relevant studies published from 1969 to date. Trials of IS compared with CT were included. Outcomes of interest were postoperative morbidity and length of hospital stay (LOS). RESULTS Fifteen trials were studied (1.243 patients). CT achieved better rates of any complication type (odds ratio [OR] 0.22, [95% confidence interval (CI): 0.14, 0.38], p = 0.001) and wound infection (OR: 0.40 [95% CI: 0.17, 0.96], p = 0.041). Neither intraabdominal abscess (OR: 1.03 [95% CI: 0.31, 3.37], p = 0.958) nor postoperative ileus (OR: 0.29 [95% CI: 0.06, 1.44], p = 0.130) was affected by the treatment option. The polled difference in LOS showed a trend for shorter LOS in the IS group (standard mean difference [SMD]: 0.25 [95% CI: 0.07, -0.43], p = 0.007). CONCLUSIONS IS was associated with shorter LOS, while overall complication rates and wound infection declined significantly with CT. The development of intraabdominal abscess and postoperative ileus was not affected by the treatment of choice. The heterogeneity of most studies depicts the need for randomized controlled trials (RCTs) to discover safe management of CAA in children. LEVEL OF EVIDENCE III: Type of study: Meta-analysis.
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Affiliation(s)
- George Vaos
- Department of Paediatric Surgery, Attikon University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
| | - Anastasia Dimopoulou
- Department of Paediatric Surgery, Attikon University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Eleana Gkioka
- Second Department of Paediatrics, Athens Medical Center, Athens, Greece
| | - Nick Zavras
- Department of Paediatric Surgery, Attikon University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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22
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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: 39] [Impact Index Per Article: 6.5] [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.
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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,
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23
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Koomalsingh KJ, Mokadam NA. Don't you want me? J Thorac Cardiovasc Surg 2018; 156:586-587. [PMID: 29703407 DOI: 10.1016/j.jtcvs.2018.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 03/09/2018] [Indexed: 11/25/2022]
Affiliation(s)
| | - Nahush A Mokadam
- Division of Cardiothoracic Surgery, University of Washington, Seattle, Wash.
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Zárate-Suárez LA, Urquiza-Suárez YL, García CF, Padilla-Mantilla DA, Mendoza MC. Acute abdomen and perforated duodenal ulcer in an adolescent: case report. REVISTA DE LA FACULTAD DE MEDICINA 2018. [DOI: 10.15446/revfacmed.v66n2.59798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
El dolor abdominal agudo es uno de los principales motivos de consulta en los servicios de urgencias, sus causas son diversas y se dividen en quirúrgicas y médicas. En este artículo se hace mención a las causas quirúrgicas que pueden ser de tipo traumático, obstructivo o inflamatorio. En esta última categoría se encuentra la perforación de víscera hueca como complicación de ulcera duodenal, entidad poco frecuente en la edad pediátrica.Se presenta el caso de un adolescente de 14 años, previamente sano, quien consultó a urgencias de medicina general por dolor abdominal de inicio súbito y de rápido progreso en hipocondrio derecho, con irradiación a zona lumbar del mismo lado, asociado a síntomas vaso vágales. Se da manejo primario como urolitiasis.Ante el deterioro clínico y los signos evidentes de peritonitis generalizada, el paciente es llevado a laparoscopia diagnóstica que requiere conversión a laparotomía por cirugía pediátrica. El hallazgo quirúrgico es úlcera duodenal perforada como causa del cuadro clínico. Este reporte pretende mostrar la experiencia de los casos clínicos en los que se da un error diagnóstico inicial e incluir a la ulcera duodenal complicada como diagnóstico diferencial.
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Prada Arias M, Salgado Barreira A, Montero Sánchez M, Fernández Eire P, García Saavedra S, Gómez Veiras J, Fernández Lorenzo JR. Appendicitis versus non-specific acute abdominal pain: Paediatric Appendicitis Score evaluation. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2017.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Serres SK, Graham DA, Glass CC, Cameron DB, Anandalwar SP, Rangel SJ. Influence of Time to Appendectomy and Operative Duration on Hospital Cost in Children with Uncomplicated Appendicitis. J Am Coll Surg 2017; 226:1014-1021. [PMID: 29155269 DOI: 10.1016/j.jamcollsurg.2017.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/01/2017] [Accepted: 11/03/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND The goal of this study was to examine the influence of time to appendectomy (TTA) and operative duration (OD) on hospital cost as surrogate measures of perioperative efficiency. STUDY DESIGN We conducted a retrospective cohort analysis of 2,116 children undergoing appendectomy for uncomplicated appendicitis at 16 children's hospitals from January 2013 to December 2014. Time to appendectomy (emergency department presentation to incision) and OD were obtained from the NSQIP Pediatric Appendectomy Pilot Database and merged with cost data from the Pediatric Health Information System Database. Multivariate regression was used to examine the influence of TTA and OD (categorized by quartiles of hospital-level means) on hospital cost, adjusting for patient and hospital-level characteristics. RESULTS Median TTA and OD across all patients was 7.3 hours (interquartile range 4.4 to 12.4 hours) and 36 minutes (interquartile range 26 to 49 minutes), respectively. The longest quartile of OD was associated with 38% higher total cost ($2,512/case; rate ratio [RR] 1.38; 95% CI 1.27 to 1.5; p < 0.001) and 27% higher operating room-associated cost ($960/case; RR 1.27; 95% CI 1.22 to 1.34; p < 0.001) compared with the shortest quartile. The longest quartile of TTA was associated with 23% higher total cost ($1,589/case; RR 1.23; 95% CI 1.14 to 1.32; p < 0.001) and 53% higher room-associated cost ($906/case; RR 1.53; 95% CI 1.35 to 1.74; p < 0.001) compared with the shortest quartile. The influence of TTA and OD were independent but potentiating effects, with median cost for hospitals in both the longest quartiles of TTA and OD being 79% higher than those in the shortest quartiles. CONCLUSIONS Longer TTA and OD were independently associated with increased hospital cost, with OD being the most significant driver of cost variation across hospitals. Identification of best practices from high-efficiency hospitals might provide a high-yield strategy for improving value in appendicitis care.
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Affiliation(s)
- Stephanie K Serres
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Dionne A Graham
- Center for Applied Quality Analytics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Charity C Glass
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Danielle B Cameron
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Seema P Anandalwar
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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Andrade LAM, Muñoz FYP, Báez MVJ, Collazos SS, de Los Angeles Martinez Ferretiz M, Ruiz B, Montes O, Woolf S, Noriega JG, Aparicio UM, Gonzalez IG. Appendectomy Skin Closure Technique, Randomized Controlled Trial: Changing Paradigms (ASC). World J Surg 2017; 40:2603-2610. [PMID: 27283187 DOI: 10.1007/s00268-016-3607-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Appendectomy is the most frequent and urgent gastrointestinal surgery. Overtime, the surgical techniques have been improved upon, in order to reduce complications, get better cosmetic results, and limit the discomfort associated with this procedure, by its high impact in the surgery departments. The traditional skin closure is associated with a poor cosmetic result and it requires stitches removal, alongside the pain associated with this procedure, and no benefits were demonstrated in the literature regarding separated stitches over intradermic stitch. This is a randomized controlled trial, and our objective is to compare two different skin closure techniques in open appendectomy. METHODS A prospective randomized trial method was used, with a total number of 208 patients participating in the study, after acute appendicitis diagnosis in the emergency department. They were randomized into two groups: patients who would receive skin closure with a unique absorbable intradermic stitch (Group A) and another group that would receive the traditional closure technique, consistent in non-absorbable separated stitches (Group B). General characteristics like gender, age, Body Mass Index (BMI), comorbidities, and allergies were registered. Days of Evolution (DOE) until surgery, previous use of antibiotics, complicated or uncomplicated appendicitis, surgical time, and wound complications like skin infection, dehiscence, seroma or abscess were also registered in each case. RESULTS 8 patients were excluded due to negative appendicitis during surgery and lack of follow-up. Two groups, each containing 100 patients, were formed. General characteristics and parity were compared, and no statistically significant differences were observed. Difference in the surgical time (Group A: 47.35 min vs Group B: 54.13 min, p < .001) and cases with complicated appendicitis (Group A: 58 and Group B:38, p = .005) were found to be statistically significant. Four wound complications were reported, and the incidence of seroma (Group A:0 and Group B:5, p = .02) and abscess (Group A:2 and Group B:8, p = .05) were found to have some statistical significant difference. In a multivariate analysis, a relationship was observed between BMI > 25 kg/m2 and seroma (p = .006), BMI > 25 kg/m2 and abscess (p = .02), surgical time >50 min and seroma (p < .001), >2 DOE and abscess (p = .001), and complicated appendicitis with seroma development (p = .03). CONCLUSION Open appendectomy skin closure with a unique absorbable intradermic stitch is safe, with a reduced seroma and abscess incidence, compared to traditional closure, and an equivalent dehiscence and superficial infection incidence, allowing a lower hospital attention cost and length of hospital stay for treatment of complications. The relative risk of complications with traditional skin closure is 2.91 higher, compared to this new technique.
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Affiliation(s)
- Luis Angel Medina Andrade
- Instituto Mexicano del Seguro Social, Hospital General Regional No. 17, General Surgery Department, Quintana Roo University, Av. Politécnico Manzana 1 Lote 1 Región 509, C.P. 55750, Cancún, Quintana Roo, Mexico.
| | - Franz Yeudiel Pérez Muñoz
- Instituto Mexicano del Seguro Social, Hospital General Regional No. 17, General Surgery Department, Quintana Roo University, Av. Politécnico Manzana 1 Lote 1 Región 509, C.P. 55750, Cancún, Quintana Roo, Mexico
| | - María Valeria Jiménez Báez
- Health Research Department, Quintana Roo, Instituto Mexicano del Seguro Social, Av. Politécnico Manzana 1 Lote 1 Región 509, C.P. 55750, Cancún, Quintana Roo, Mexico
| | - Stephanie Serrano Collazos
- Instituto Mexicano del Seguro Social, Hospital General Regional No. 17, General Surgery Department, Quintana Roo University, Av. Politécnico Manzana 1 Lote 1 Región 509, C.P. 55750, Cancún, Quintana Roo, Mexico
| | - Maria de Los Angeles Martinez Ferretiz
- Instituto Mexicano del Seguro Social, Hospital General Regional No. 17, General Surgery Department, Quintana Roo University, Av. Politécnico Manzana 1 Lote 1 Región 509, C.P. 55750, Cancún, Quintana Roo, Mexico
| | - Brenda Ruiz
- Instituto Mexicano del Seguro Social, Hospital General Regional No. 17, General Surgery Department, Quintana Roo University, Av. Politécnico Manzana 1 Lote 1 Región 509, C.P. 55750, Cancún, Quintana Roo, Mexico
| | - Oscar Montes
- Instituto Mexicano del Seguro Social, Hospital General Regional No. 17, General Surgery Department, Quintana Roo University, Av. Politécnico Manzana 1 Lote 1 Región 509, C.P. 55750, Cancún, Quintana Roo, Mexico
| | - Stephanie Woolf
- Instituto Mexicano del Seguro Social, Hospital General Regional No. 17, General Surgery Department, Quintana Roo University, Av. Politécnico Manzana 1 Lote 1 Región 509, C.P. 55750, Cancún, Quintana Roo, Mexico
| | - Jessica Gonzalez Noriega
- Hospital General de Zona #1. Instituto Mexicano del Seguro Social, Universidad Nacional Autónoma de México, 5 de Febrero, Col. Pueblo Nuevo, La Paz, Baja California Sur, Mexico
| | - Uriel Maldonado Aparicio
- Hospital General de Zona #1. Instituto Mexicano del Seguro Social, Universidad Nacional Autónoma de México, 5 de Febrero, Col. Pueblo Nuevo, La Paz, Baja California Sur, Mexico
| | - Israel Gonzalez Gonzalez
- General Surgery Department, The American British Cowdray Medical Center I.A.P, Universidad Nacional Autonoma de Mexico, Sur 136 #116, Col. Las Americas, Alvaro Obregon, C.P. 01120, Distrito Federal, Mexico
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Affiliation(s)
- Rebecca M Rentea
- Deparment of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Pediatric Surgical Fellowship and Scholars Programs, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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Serres SK, Cameron DB, Glass CC, Graham DA, Zurakowski D, Karki M, Anandalwar SP, Rangel SJ. Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children. JAMA Pediatr 2017; 171. [PMID: 28628705 PMCID: PMC5710637 DOI: 10.1001/jamapediatrics.2017.0885] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Management of appendicitis as an urgent rather than emergency procedure has become an increasingly common practice in children. Controversy remains as to whether this practice is associated with increased risk of complicated appendicitis and adverse events. OBJECTIVE To examine the association between time to appendectomy (TTA) and risk of complicated appendicitis and postoperative complications. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study using the Pediatric National Surgical Quality Improvement Program appendectomy pilot database, 2429 children younger than 18 years who underwent appendectomy within 24 hours of presentation at 23 children's hospitals from January 1, 2013, through December 31, 2014, were studied. EXPOSURES The main exposure was TTA, defined as the time from emergency department presentation to appendectomy. Patients were further categorized into early and late TTA groups based on whether their TTA was shorter or longer than their hospital's median TTA. Exposures were defined in this manner to compare rates of complicated appendicitis within a time frame sensitive to each hospital's existing infrastructure and diagnostic practices. MAIN OUTCOMES AND MEASURES The primary outcome was complicated appendicitis documented at operation. The association between treatment delay and complicated appendicitis was examined across all hospitals by using TTA as a continuous variable and at the level of individual hospitals by using TTA as a categorical variable comparing outcomes between late and early TTA groups. Secondary outcomes included length of stay (LOS) and postoperative complications (incisional and organ space infections, percutaneous drainage procedures, unplanned reoperation, and hospital revisits). RESULTS Of the 6767 patients who met the inclusion criteria, 2429 were included in the analysis (median age, 10 years; interquartile range, 8-13 years; 1467 [60.4%] male). Median hospital TTA was 7.4 hours (range, 5.0-19.2 hours), and 574 patients (23.6%) were diagnosed with complicated appendicitis (range, 5.2%-51.1% across hospitals). In multivariable analyses, increasing TTA was not associated with risk of complicated appendicitis (odds ratio per 1-hour increase in TTA, 0.99; 95% CI, 0.97-1.02). The odds ratios of complicated appendicitis for late vs early TTA across hospitals ranged from 0.39 to 9.63, and only 1 of the 23 hospitals had a statistically significant increase in their late TTA group (odds ratio, 9.63; 95% CI, 1.08-86.17; P = .03). Increasing TTA was associated with longer LOS (increase in mean LOS for each additional hour of TTA, 0.06 days; 95% CI, 0.03-0.08 days; P < .001) but was not associated with increased risk of any of the other secondary outcomes. CONCLUSIONS AND RELEVANCE Delay of appendectomy within 24 hours of presentation was not associated with increased risk of complicated appendicitis or adverse outcomes. These results support the premise that appendectomy can be safely performed as an urgent rather than emergency procedure.
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Affiliation(s)
- Stephanie K. Serres
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Danielle B. Cameron
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Charity C. Glass
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dionne A. Graham
- Center for Applied Quality Analytics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- Department of Anesthesiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mahima Karki
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Seema P. Anandalwar
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shawn J. Rangel
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Church JT, Klein EJ, Carr BD, Bruch SW. Early appendectomy reduces costs in children with perforated appendicitis. J Surg Res 2017; 220:119-124. [PMID: 29180172 DOI: 10.1016/j.jss.2017.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/14/2017] [Accepted: 07/03/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Perforated appendicitis can be managed with early appendectomy, or nonoperative management followed by interval appendectomy. We aimed to identify the strategy with the lowest health care utilization and cost. METHODS We retrospectively reviewed the medical records of all children ≤18 years old with perforated appendicitis admitted to a single institution between January 2009 and March 2016. After excluding immunosuppressed patients and transfers from outside hospitals, we grouped the remaining patients by early or interval appendectomy. Cost accounting data were obtained from our institutional database. The primary outcome was total hospital cost over 2 y from initial admission for appendicitis. Other outcomes analyzed included initial admission costs, number of admissions, emergency room and clinic visits, percutaneous procedures, cross-sectional and overall imaging studies, and length of stay. RESULTS A total of 203 children with perforated appendicitis were identified. After exclusion of immunosuppressed patients and outside hospital transfers, 94 patients were included in the study. Thirty-nine underwent early appendectomy and 55 initial nonoperative management; of these, 54 underwent elective interval appendectomy. Five of 55 patients (9%) failed initial nonoperative management and required earlier-than-planned appendectomy. Total cost over 2 y was significantly lower with early appendectomy than initial nonoperative management ($19,300 ± 14,300 versus $26,000 ± 17,500; P = 0.05). Early appendectomy resulted in fewer hospital admissions, clinic visits, invasive procedures, and imaging studies. CONCLUSIONS Early appendectomy results in lower hospital costs and less health care utilization compared with initial nonoperative management with elective interval appendectomy. A prospective study will shed more light on this question and can assess the role of nonoperative management without interval appendectomy in children with perforated appendicitis.
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Affiliation(s)
- Joseph T Church
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan.
| | - Edwin J Klein
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Benjamin D Carr
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Steven W Bruch
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
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Blumfield E, Yang D, Grossman J. Scoring system for differentiating perforated and non-perforated pediatric appendicitis. Emerg Radiol 2017; 24:547-554. [PMID: 28685263 DOI: 10.1007/s10140-017-1535-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 06/21/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Appendicitis is the most common indication for emergency pediatric surgery and its most significant complication is perforation. Perforated appendicitis (PA) may be managed conservatively, whereas non-perforated appendicitis (NP) is managed surgically. Recent studies have shown that ultrasound (US) is effective for differentiating between PA and NP, and does not expose pediatric patients to ionizing radiation. The purpose of this study is to enhance the accuracy of differentiation with a novel scoring system based on clinical, laboratory, and US findings. METHODS This retrospective study included 243 patients aged 2-17 years who presented between 2006 and 2013 with surgically proven appendicitis, of whom 60 had perforation. Clinical and laboratory data were collected and US images evaluated by a pediatric radiologist. To create the scoring system, point values were assigned to each parameter. A randomly selected training sample of 137 subjects was used to create a scoring prediction model. The model was tested on the remaining 106 patients. RESULTS Scores of ≥6, ≥11, and ≥15 yielded specificities of 64, 91, and 99%, and sensitivities of 96, 61, and 29%, respectively (p < 0.001). CONCLUSIONS We have designed a scoring system incorporating clinical, laboratory, and sonographic findings which can differentiate PA from NP with high specificity.
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Affiliation(s)
- Einat Blumfield
- Department of Radiology, Albert Einstein College of Medicine/Jacobi Medical Center, 1400 Pelham Parkway South, Bronx, NY, USA
| | - Daniel Yang
- Department of Radiology, Albert Einstein College of Medicine/Jacobi Medical Center, 1400 Pelham Parkway South, Bronx, NY, USA.
| | - Joshua Grossman
- Department of Pediatrics, Albert Einstein College of Medicine/Montefiore Medical Center, 111 East 210th Street, Bronx, NY, USA
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Prada Arias M, Salgado Barreira A, Montero Sánchez M, Fernández Eire P, García Saavedra S, Gómez Veiras J, Fernández Lorenzo JR. [Appendicitis versus non-specific acute abdominal pain: Paediatric Appendicitis Score evaluation]. An Pediatr (Barc) 2017; 88:32-38. [PMID: 28254168 DOI: 10.1016/j.anpedi.2017.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 01/15/2017] [Accepted: 01/17/2017] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Non-specific acute abdominal pain is the most common process requiring differential diagnosis with appendicitis in clinical practice. The aim of this study was to assess the Paediatric Appendicitis Score in differentiating between these two entities. MATERIAL AND METHODS All patients admitted due to suspicion of appendicitis were prospectively evaluated in our hospital over a two-year period. Cases of non-specific acute abdominal pain and appendicitis were enrolled in the study. Several variables were collected, including Score variables and C-reactive protein levels. Descriptive, univariate and multivariate analyses and diagnostic accuracy studies (ROC curves) were performed. RESULTS A total of 275 patients were studied, in which there were 143 cases of non-specific acute abdominal pain and 132 cases of appendicitis. Temperature and right iliac fossa tenderness on palpation were the variables without statistically significant differences, and with no discrimination power between groups. Pain on coughing, hopping, and/or percussion tenderness in the right lower quadrant was the variable with greater association with appendicitis. The Score correctly stratified the patients into risk groups. Substitution of temperature for C-reactive protein in the Score increased diagnostic accuracy, although with no statistically significant differences. CONCLUSIONS The Paediatric Appendicitis Score helps in differential diagnosis between appendicitis and non-specific acute abdominal pain. It would be advisable to replace the temperature in the Score, since it has no discrimination power between these groups. C-reactive protein at a cut-off value of 25.5mg/L value could be used instead.
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Affiliation(s)
- Marcos Prada Arias
- Sección de Cirugía Pediátrica, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España; Instituto de Investigación Sanitaria Galicia Sur, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España.
| | - Angel Salgado Barreira
- Unidad de apoyo a la Investigación, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España; Instituto de Investigación Sanitaria Galicia Sur, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España
| | - Margarita Montero Sánchez
- Sección de Cirugía Pediátrica, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España; Instituto de Investigación Sanitaria Galicia Sur, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España
| | - Pilar Fernández Eire
- Sección de Cirugía Pediátrica, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España; Instituto de Investigación Sanitaria Galicia Sur, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España
| | - Silvia García Saavedra
- Sección de Cirugía Pediátrica, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España
| | - Javier Gómez Veiras
- Sección de Cirugía Pediátrica, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España
| | - José Ramón Fernández Lorenzo
- Servicio de Pediatría, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España; Instituto de Investigación Sanitaria Galicia Sur, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España
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The role of 256-slice CT in differentiation between non-perforated and perforated appendicitis. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2017. [DOI: 10.1016/j.ejrnm.2016.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
Appendicitis is one of the most common surgical pathologies in children. It can present with right lower quadrant pain. Scoring systems in combination with selective imaging and surgical examination will diagnose most children with appendicitis. Clinical pathways should be used. Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated. Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis. This article discusses the workup and management, modes of treatment, and continued areas of controversy in pediatric appendicitis.
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Affiliation(s)
- Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Pediatric Surgical Fellowship and Scholars Programs, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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Prada-Arias M, Vázquez JL, Salgado-Barreira Á, Gómez-Veiras J, Montero-Sánchez M, Fernández-Lorenzo JR. Diagnostic accuracy of fibrinogen to differentiate appendicitis from nonspecific abdominal pain in children. Am J Emerg Med 2017; 35:66-70. [PMID: 27760719 DOI: 10.1016/j.ajem.2016.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 09/07/2016] [Accepted: 10/03/2016] [Indexed: 12/29/2022] Open
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Lodwick DL, Cooper JN, Kenney B, Deans KJ, Minneci PC, Thakkar RK. Lymphocyte depression as a predictor of postoperative intraabdominal abscess after appendectomy in children. J Pediatr Surg 2017; 52:93-97. [PMID: 27836359 DOI: 10.1016/j.jpedsurg.2016.10.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 10/20/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study evaluated the efficacy of lymphopenia to predict postappendectomy intraabdominal abscess (IAA) in pediatric complex appendicitis. METHODS This single-center retrospective cohort study included appendectomy patients with complex appendicitis from 4/2012 to 10/2014. IAA was diagnosed based on imaging or undergoing a drainage procedure. Labs were used from the closest day prior to abscess diagnosis or day of discharge from index admission. Lymphocyte percentage was categorized based on age-specific cutoffs with lymphopenia defined as a low percentage. Comparisons were made using chi-square or Fisher exact tests for categorical variables and Mann-Whitney U-tests for continuous variables. RESULTS Of 611 appendectomy patients with complicated appendicitis, 551 had WBC and differential. IAA was identified in 79 (12.9%) patients. There were no significant differences in demographics between IAA and non-IAA groups. Patients with IAA had higher rates of leukocytosis (44.3% versus 12.3%, p<0.001) and higher rates of age-based lymphopenia (84% vs. 46%, p<0.001). IAA was independently associated with leukocytosis (OR 3.65, p<0.001) and lymphopenia (OR 4.46, p<0.001). Patients with leukocytosis and lymphopenia had the highest abscess rate (36%), and those with normal labs had the lowest (3%, p<0.001). CONCLUSIONS Lymphocyte depression is a useful adjunct to predict postoperative IAA in patients with complicated appendicitis. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Daniel L Lodwick
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Brian Kenney
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Katherine J Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Rajan K Thakkar
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH.
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Cundy TP, Gent R, Frauenfelder C, Lukic L, Linke RJ, Goh DW. Benchmarking the value of ultrasound for acute appendicitis in children. J Pediatr Surg 2016; 51:1939-1943. [PMID: 27670963 DOI: 10.1016/j.jpedsurg.2016.09.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 09/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND This study appraises the diagnostic quality of ultrasound for acute appendicitis in children and consequently challenges the perception of inferior accuracy and suitability compared to computed tomography (CT). METHODS Radiologist reports for consecutive "query appendicitis" ultrasound studies were retrieved from a hospital database for the study period 2009-2014. Children who subsequently underwent appendicectomy were identified. Corresponding operative and histopathology findings were evaluated. Diagnostic accuracy of ultrasound was determined by analyzing overall accuracy, sensitivity, specificity, predictivity, and likelihood ratios. RESULTS A total of 3799 ultrasound examinations were evaluated. Mean age was 11.5±3.8years. The proportion of patients investigated with preoperative ultrasound was 59.9% (1103/1840). Appendix visualization rate was 91.7%. Overall diagnostic accuracy was 95.5%. Sensitivity and specificity values were 97.1% (95.9-98.1; 95% CI) and 94.8% (93.9-95.6; 95% CI), respectively. Separate analysis of only ultrasound positive and negative examinations (i.e., excluding nondiagnostic examinations) confirmed sensitivity and specificity values of 98.8% and 98.3%. CONCLUSION In this largest reported single institution series of ultrasound examinations for appendicitis, we report benchmark standard quality of diagnostic accuracy and visualization rates. Given the radiation and cost implications of CT, there is a strong argument to recommend ultrasound as the primary imaging modality. Diagnostic Study-Level II.
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Affiliation(s)
- Thomas P Cundy
- Department of Paediatric Surgery, Women's and Children's Hospital, South Australia; Discipline of Surgery, University of Adelaide, South Australia.
| | - Roger Gent
- Department of Radiology, Women's and Children's Hospital, South Australia
| | - Claire Frauenfelder
- Department of Paediatric Surgery, Women's and Children's Hospital, South Australia
| | - Laura Lukic
- Department of Radiology, Women's and Children's Hospital, South Australia
| | - Rebecca J Linke
- Department of Radiology, Women's and Children's Hospital, South Australia
| | - Day Way Goh
- Department of Paediatric Surgery, Women's and Children's Hospital, South Australia; Discipline of Paediatrics, School of Medicine, University of Adelaide, South Australia
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The contribution of practice variation to length of stay for children with perforated appendicitis. J Pediatr Surg 2016; 51:1292-7. [PMID: 26891834 DOI: 10.1016/j.jpedsurg.2016.01.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/19/2016] [Accepted: 01/20/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Postoperative length of stay (pLOS) is an easily tracked outcome that reflects health care efficiency and resource utilization. The purpose of this study was to determine the contribution of practice variation on pLOS for children with perforated appendicitis. METHODS Children ages 2-18years with appendectomy for complicated appendicitis were selected from the National Surgical Quality Improvement Program-Pediatric. Extended pLOS (EpLOS) was defined as ≥7days (75th percentile). The contribution of comorbidities, operative traits, and postoperative complications to EpLOS was evaluated using regression models and matched subgroup analyses. RESULTS Of 2585 children with complicated appendicitis in our study, 835 had EpLOS. Regression analysis found that EpLOS was associated with extended operative time (odds ratio (OR) 1.99; 95% confidence interval (CI) 1.63-2.44), dehiscence (OR 13.19; 95% CI 1.52-114.23), wound infection (OR 7.39; 95% CI 2.63-20.80), organ space infection (OR 92.51; 95% CI 34.03-251.50), and pneumonia (OR 4.55; 95% CI 1.06-19.44). Over three-fourths of the variation in pLOS could not be explained by preoperative, intraoperative, or postoperative factors. CONCLUSIONS There is significant variation in pLOS for children undergoing appendectomy that is not accounted for by comorbidities, operative traits, or complications indicating an opportunity to improve outcomes through modifying practice patterns.
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Abstract
Appendectomy has been the standard of care for appendicitis since the late 1800s, and remains one of the most common operations performed in children. The advent of data-driven medicine has led to questions about every aspect of the operation-whether appendectomy is even necessary, when it should be performed (timing), how the procedure is done (laparoscopic variants versus open and irrigation versus no irrigation), length of hospital stay, and antibiotic duration. The goal of this analysis is to review the current status of, and available data regarding, the surgical management of appendicitis in children.
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Affiliation(s)
- Shawn D St Peter
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, Missouri 64108.
| | - Charles L Snyder
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, Missouri 64108
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40
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Abstract
Appendicitis represents the most common abdominal surgical emergency in the pediatric age group. Despite being a relatively common condition, the diagnosis of appendicitis in children can prove to be challenging in many cases. The goal of this article is to review the predictive utility for presenting signs and symptoms, laboratory tests, and imaging studies in the diagnostic work-up of appendicitis. Furthermore, we sought to explore the predictive utility of composite measures based on multiple sources of diagnostic information, as well as the utility of clinical pathways as a means to streamline the diagnostic process.
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Affiliation(s)
- Charity C Glass
- Department of Surgery, Children׳s Hospital Boston, Harvard Medical School, 300 Longwood Ave. Fegan-3, Boston, MA 02115
| | - Shawn J Rangel
- Department of Surgery, Children׳s Hospital Boston, Harvard Medical School, 300 Longwood Ave. Fegan-3, Boston, MA 02115.
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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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Abstract
• On the basis of class B evidence and consensus, acute appendicitis in children can often be diagnosed clinically with only selective use of imaging. (13)(14)(15)(16) • On the basis of class B evidence and consensus, ultrasonography is the test of choice when acute appendicitis is suspected but is unclear based on history, physical examination, and laboratory results. (17)(18)(19) • On the basis of class B evidence and consensus, the use of computed tomography scan should be limited to cases of suspected complex appendicitis with abscess or when there is clinical suspicion for acute appendicitis but ultrasonography results are not helpful. (16) • On the basis of class C evidence and consensus, children with possible appendicitis ideally should be treated in medical centers that have skilled sonographic personnel. (21) • On the basis of class B evidence and consensus, simple appendicitis should be treated by appendectomy during normal operating hours. Preoperative treatment with intravenous antibiotics and fluids during the overnight hours halts disease progression and allows for the safest surgery with the benefit of a full and rested staff. (24)(25)(26) • On the basis of class B evidence and consensus, complex appendicitis with a well-defined abscess can be treated nonoperatively initially, with the option of an interval appendectomy after recovery from the acute infection. (29)(30) (31)(32)(33)
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Affiliation(s)
- Laura W Hansen
- Department of Surgery, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY
| | - Stephen E Dolgin
- Department of Surgery, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY. Division of Pediatric Surgery, Cohen Children's Medical Center of New York, New Hyde Park, NY
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Pediatric appendiceal ultrasound: accuracy, determinacy and clinical outcomes. Pediatr Radiol 2015; 45:1934-44. [PMID: 26280637 DOI: 10.1007/s00247-015-3432-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 05/08/2015] [Accepted: 07/07/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ultrasonography is considered the most appropriate initial imaging study in the evaluation of acute appendicitis in children but has recently come under criticism with reports of low specificity and high indeterminate study rates, particularly when used in obese patients and patients early in the course of their disease, or when performed by sonographers with limited experience. OBJECTIVE To (1) assess the impact of patient factors (gender, age, body mass index, and symptom duration) and system factors (call status or year of exam) on pediatric appendiceal US accuracy and indeterminate study rate, (2) assess the impact of indeterminate study results on follow-up CT and negative laparotomy rates and (3) present strategies to reduce the rate of indeterminate US studies and improve accuracy. MATERIALS AND METHODS We retrospectively reviewed all US reports performed for the assessment of acute appendicitis in children <18 years old at Mayo Clinic Rochester from January 2010 to June 2014. RESULTS A total of 790 US examinations were performed in 452 girls (57%) and 338 boys (43%). The prevalence of appendicitis was 18.5% (146/790). There were 109 true-positive, 440 true-negative, 17 false-positive, 6 false-negative, 218 equivocal and 41 technically inadequate US studies. A definitive interpretation was made in 72% of the studies, with an accuracy, sensitivity and specificity of 0.960, 0.948 and 0.963, respectively. No patient or system factors significantly affected US accuracy. Indeterminate studies (28%) had significantly higher CT utilization (46% vs. 11%) and normal appendectomy rates (6.9% vs. 3.5%). CONCLUSION US should be the initial imaging study of choice for pediatric appendicitis. When a definitive interpretation was given, the accuracy was 96%, was independent of patient and system factors and resulted in reduced follow-up CTs and negative laparotomies. Accuracy can be increased by requiring the presence of periappendiceal inflammatory changes prior to interpreting a mildly distended appendix as positive for acute appendicitis. The indeterminate study rate can be reduced by not requiring visualization of the normal appendix for the exclusion of acute appendicitis.
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Hashizume N, Iinuma Y, Hirayama Y, Nitta K, Iida H, Shiotani M, Shibuya H, Yagi M. Contrast-enhanced multidetector-row computed tomography can predict pathological findings of acute appendicitis in children. Acute Med Surg 2015; 3:21-25. [PMID: 29123743 DOI: 10.1002/ams2.131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/17/2015] [Indexed: 11/07/2022] Open
Abstract
Aims To retrospectively evaluate the correlation between multidetector-row computed tomography findings of acute appendicitis and the pathological status of acute appendicitis, and evaluate the capability of multidetector-row computed tomography to predict the pathological status of acute appendicitis in children. Methods The presence of a distended appendix (>6 mm in transverse diameter) was used as a primary sign to indicate the presence of appendiceal inflammation. The presence of appendiceal wall thickening (>1 mm) and enhanced appendiceal wall continuity were also used as predictive findings to reflect the degree of progression of acute appendicitis on multidetector-row computed tomography findings. The findings of each individual case were classified into four grades. The final pathological diagnosis was classified into four groups: normal findings, only mucosal inflammation, inflammation with intramural spreading, and gangrenous. The relationship between the pathological grades and computed tomography grades was analyzed using Spearman's rank correlation test. Results Four of six cases in Grade 0 reflected normal appendiceal findings (66.7%) and 3 of 5 cases in Grade I reflected only mucosal inflammation status (60.0%). Forty-four of 51 cases in Grade II reflected intramural inflammation status (86.3%), and 40 of 57 cases in Grade III reflected gangrenous status (70.2%). The multidetector-row computed tomography grade was significantly correlated to the pathological grade with Spearman's rank correlation coefficient of 0.689 (P < 0.001). Conclusions There was a close relationship between the multidetector-row computed tomography imaging findings and the pathological findings. This preoperative information is extremely useful for decision-making in the treatment strategy for acute appendicitis in children.
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Affiliation(s)
- Naoki Hashizume
- Department of Pediatric Surgery Niigata City General Hospital Niigata City Fukuoka Japan
- Department of Pediatric Surgery Kurume University School of Medicine Kurume Fukuoka Japan
| | - Yasushi Iinuma
- Department of Pediatric Surgery Niigata City General Hospital Niigata City Fukuoka Japan
| | - Yutaka Hirayama
- Department of Pediatric Surgery Niigata City General Hospital Niigata City Fukuoka Japan
| | - Kohju Nitta
- Department of Pediatric Surgery Niigata City General Hospital Niigata City Fukuoka Japan
| | - Hisataka Iida
- Department of Pediatric Surgery Niigata City General Hospital Niigata City Fukuoka Japan
| | - Motoi Shiotani
- Department of Radiology Niigata City General Hospital Niigata City Fukuoka Japan
| | - Hiroyuki Shibuya
- Department of Pathology Niigata City General Hospita lNiigata City Fukuoka Japan
| | - Minoru Yagi
- Department of Pediatric Surgery Kurume University School of Medicine Kurume Fukuoka Japan
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Obinwa O, Peirce C, Cassidy M, Fahey T, Flynn J. A model predicting perforation and complications in paediatric appendicectomy. Int J Colorectal Dis 2015; 30:559-65. [PMID: 25608495 DOI: 10.1007/s00384-015-2120-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/01/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE To analyse the diagnostic value of simple clinical measurements in ensuring an early and accurate detection of advanced appendicitis (perforation, mass and peri-appendicular abscess) and possible complications. METHODS A retrospective, single-centre study of all paediatric (age 0-14 years) appendicectomies was conducted over a 14-year period. Preoperative symptoms, signs and laboratory results, intra-operative findings and postoperative complications were analyzed. Receiver operating characteristic (ROC) curves were used to estimate sensitivity and specificity of significant (p ≤ 0.05) predictor variables based on multivariate logistic regression models. RESULTS One thousand and thirty-seven patients were included. Perforations were seen in 88 (8.5%) cases, and abscesses were seen in 35 (3.4%) cases. Of all the clinical variables evaluated, preoperative temperature ≥37.5 °C was most discriminatory for advanced appendicitis. Significant other discriminatory clinical variables were WBC count ≥15,100/μL, preoperative anorexia and rebound tenderness. Postoperative complications occurred in 74 (7.1%) patients and were associated with pre-operative temperature ≥37.5 °C and advanced appendicitis. CONCLUSION Independent clinical predictors of advanced appendicitis exist but lack individual accuracy. In this study, preoperative pyrexia is shown to be highly associated with both advanced appendicitis and development of postoperative complications. This independent factor may point to early need for antibiotic treatment, urgent imaging and subsequent intervention in patients with appendicitis.
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Affiliation(s)
- Obinna Obinwa
- Department of Surgery, Portiuncula Hospital, Ballinasloe, County Galway, Ireland,
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St Peter SD, Shah SR, Adibe OO, Sharp SW, Reading B, Cully B, Holcomb GW, Rivard DC. Saline vs Tissue Plasminogen Activator Irrigations after Drain Placement for Appendicitis-Associated Abscess: A Prospective Randomized Trial. J Am Coll Surg 2015; 221:390-6. [PMID: 26141467 DOI: 10.1016/j.jamcollsurg.2015.03.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 03/20/2015] [Accepted: 03/22/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Emerging data suggest instillation of tissue plasminogen activator (tPA) is safe and potentially efficacious in the treatment of intra-abdominal abscess. To date, prospective comparative data are lacking in children. Therefore, we conducted a randomized trial comparing abscess irrigation with tPA and irrigation with saline alone. STUDY DESIGN After IRB approval, children with an abscess secondary to perforated appendicitis who had a percutaneous drain placed for treatment were randomized to twice-daily instillation of 13 mL 10% tPA or 13 mL normal saline. All patients were treated with once-daily dosing of ceftriaxone and metronidazole throughout their course. The primary end point variable was duration of hospitalization after drain placement. Using a power of 0.8 and an α of 0.05, a sample size of 62 patients was calculated. RESULTS Sixty-two patients were enrolled between January 2009 and February 2013. There were no differences in demographics, abscess size, abscess number, admission WBC, or duration of symptoms. Duration of hospitalization after drainage was considerably longer with the use of tPA. There was no difference in total duration of hospitalization, days of drainage, or days of antibiotics. However, medication charges were higher with tPA. CONCLUSIONS There are no advantages to routine tPA flushes in the treatment of abdominal abscess secondary to perforated appendicitis in children.
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Affiliation(s)
- Shawn D St Peter
- Department of Surgery, The Center for Prospective Clinical Trials, The Children's Mercy Hospital, Kansas City, MO.
| | - Sohail R Shah
- Department of Surgery, The Center for Prospective Clinical Trials, The Children's Mercy Hospital, Kansas City, MO
| | - Obinna O Adibe
- Department of Surgery, The Center for Prospective Clinical Trials, The Children's Mercy Hospital, Kansas City, MO
| | - Susan W Sharp
- Department of Surgery, The Center for Prospective Clinical Trials, The Children's Mercy Hospital, Kansas City, MO
| | - Brent Reading
- Department of Radiology, The Center for Prospective Clinical Trials, The Children's Mercy Hospital, Kansas City, MO
| | - Brent Cully
- Department of Radiology, The Center for Prospective Clinical Trials, The Children's Mercy Hospital, Kansas City, MO
| | - George W Holcomb
- Department of Surgery, The Center for Prospective Clinical Trials, The Children's Mercy Hospital, Kansas City, MO
| | - Douglas C Rivard
- Department of Radiology, The Center for Prospective Clinical Trials, The Children's Mercy Hospital, Kansas City, MO
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Gorter RR, van der Lee JH, Cense HA, Kneepkens CMF, Wijnen MHWA, In 't Hof KH, Offringa M, Heij HA. Initial antibiotic treatment for acute simple appendicitis in children is safe: Short-term results from a multicenter, prospective cohort study. Surgery 2015; 157:916-23. [PMID: 25791031 DOI: 10.1016/j.surg.2015.01.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 12/30/2014] [Accepted: 01/11/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Initial antibiotic treatment for acute appendicitis has been shown to be safe in adults; so far, not much is known about the safety and efficacy of this treatment in children. The aims of this study were to investigate the feasibility of a randomized controlled trial (RCT) evaluating initial antibiotic treatment for acute appendectomy in children with acute simple appendicitis and to evaluate the safety of this approach. METHODS In a multicenter, prospective cohort study patients aged 7-17 years with a radiologically confirmed simple appendicitis were eligible. Intravenous antibiotics (amoxicillin/clavulanic acid 250/25 mg/kg 4 times daily; maximum 6,000/600 mg/d and gentamicin 7 mg/kg once daily) were administered for 48-72 hours. Clinical reevaluation every 6 hours, daily blood samples, and ultrasound follow-up after 48 hours was performed. In case of improvement after 48 hours, oral antibiotics were given for a total of 7 days. At any time, in case of clinical deterioration or non-improvement after 72 hours, an appendectomy could be performed. Follow-up continued until 8 weeks after discharge. Adverse events were defined as major complications of antibiotic treatment, such as allergic reactions, perforated appendicitis, and recurrent appendicitis. RESULTS Of 44 eligible patients, 25 participated (inclusion rate, 57%; 95% CI, 42%-70%). Delayed appendectomy was performed in 2, and the other 23 were without symptoms at the 8 weeks follow-up. Minor complications occurred in three patients. None of the patients suffered from an adverse event or a recurrent appendicitis. CONCLUSION Our study shows that an RCT comparing initial antibiotic treatment strategy with urgent appendectomy is feasible in children; the intervention seems to be safe.
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Affiliation(s)
- Ramon R Gorter
- Paediatric Surgical Centre of Amsterdam, Emma Children's Hospital AMC & VU University Medical Centre, Amsterdam, The Netherlands; Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands.
| | - Johanna H van der Lee
- Paediatric Clinical Research Office Division Woman and Child, Academic Medical Centre, Amsterdam, The Netherlands
| | - Huibert A Cense
- Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands
| | - C M Frank Kneepkens
- Department of Paediatric Gastroenterology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Marc H W A Wijnen
- Department of Paediatric Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Martin Offringa
- Child Health Evaluative Sciences (CHES), The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Hugo A Heij
- Paediatric Surgical Centre of Amsterdam, Emma Children's Hospital AMC & VU University Medical Centre, Amsterdam, The Netherlands
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Nazarey PP, Stylianos S, Velis E, Triana J, Diana-Zerpa J, Pasaron R, Stylianos V, Malvezzi L, Knight C, Burnweit C. Treatment of suspected acute perforated appendicitis with antibiotics and interval appendectomy. J Pediatr Surg 2014; 49:447-50. [PMID: 24650475 DOI: 10.1016/j.jpedsurg.2013.10.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 10/03/2013] [Accepted: 10/04/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Initial antibiotics with planned interval appendectomy (interval AP) have been used to treat patients with complicated perforated appendicitis; however, little experience exists with this approach in children with suspected acute perforated appendicitis (SAPA). We sought to determine the outcome of initial antibiotics and interval AP in children with SAPA. METHODS Over an 18-month period, 751 consecutive patients underwent appendectomy including 105 patients with SAPA who were treated with initial intravenous antibiotics and planned interval AP ≥ 8 weeks after presentation. All SAPA patients had symptoms for ≤ 96 hours. Primary outcome variables were rates of readmission, abscess formation, and need for interval AP prior to the planned ≥ 8 weeks. RESULTS Intraabdominal abscess rate was 27%. Appendectomy prior to planned interval AP was 11% and readmission occurred in 34%. All patients underwent eventual appendectomy with pathologic confirmation confirming the previous appendiceal inflammation. White blood cell (WBC) count >15,000, WBC >15,000 plus fecalith on imaging, and WBC >15,000 plus duration of symptoms >48 hours were all significantly associated with higher rates of readmission (p=0.01, p=0.04, p=0.02) and need for interval AP prior to the planned ≥ 8 weeks (p=0.003, p=0.05, p=0.03). CONCLUSIONS Treatment of SAPA with antibiotics and planned interval AP is successful in the majority of patients; however, complications such as abscess formation and/or readmission prior to planned interval AP occur in up to one-third of patients. Certain clinical variables are associated with increased treatment complications.
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Affiliation(s)
- Pradeep P Nazarey
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA.
| | - Steven Stylianos
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA; FIU College of Medicine, Miami, FL, USA
| | - Evelio Velis
- College of Health Sciences, Barry University, Miami, FL, USA
| | - Jason Triana
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA
| | | | - Raquel Pasaron
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA
| | - Vanessa Stylianos
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA
| | - Leopoldo Malvezzi
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA
| | - Colin Knight
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA
| | - Cathy Burnweit
- Department of Pediatric Surgery, Miami Children's Hospital, Miami, FL, USA
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Jo HS, Boo YJ, Lee EH, Lee JS. Comparison of Surgical Infection and Readmission Rates after Laparoscopy in Pediatric Complicated Appendicitis. ACTA ACUST UNITED AC 2014. [DOI: 10.13029/jkaps.2014.20.2.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Hey Sung Jo
- Division of Pediatric Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Yoon Jung Boo
- Division of Pediatric Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Eun Hee Lee
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Ji Sung Lee
- Department of Medical Statistics, Korea University College of Medicine, Seoul, Korea
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Knott EM, Thomas P, Sharp NE, Gasior AC, St Peter SD. Reduced use of computed tomography in patients treated with interval appendectomy after implementing a protocol from a prospective, randomized trial. Pediatr Surg Int 2013; 29:1293-6. [PMID: 23892423 DOI: 10.1007/s00383-013-3349-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND In 2009, we instituted a protocol to standardize care for patients undergoing interval appendectomy based on results from a prospective trial that demonstrated a reduction in the mean number of computed tomography (CT) scans performed. The goal of this study was to determine if our current practice now resulted in fewer CT scans as a result of this trial. METHODS A retrospective review of all patients undergoing interval appendectomy for perforated appendicitis from March 2009 to March 2011 was performed. Demographics and outcomes were compared to previously collected data from a retrospective study prior to institution of the protocol and to the prospective trial. RESULTS During the study period, 45 patients underwent interval appendectomy. There were no differences in demographics among the three studies. Similar numbers of patients underwent aspiration or percutaneous drainage. There continues to be a significant reduction in the number of CT scans (3.5 ± 2.0 vs. 2.1 ± 1.3, P = 0.0001) and health care visits (7.6 ± 2.8 vs. 4.5 ± 1.4, P = 0.0001) when comparing management prior to the prospective trial to management since its completion. CONCLUSION A protocol for management of patients undergoing interval appendectomy care results in fewer health care visits and CT scans.
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Affiliation(s)
- E Marty Knott
- Department of Surgery, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO, 64108, USA
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