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Elisa Z, Camilla P, Giulia M, Nicola Z, Daniela C, Francesca G, Marco G, Claudio C, Alessandro P, Fabio B, Antoniello LM, Piergiorgio G. Concordance in Intraoperative Surgeons' Opinion in the Diagnosis and Management of Acute Appendicitis: The Role of Training. JOURNAL OF SURGICAL EDUCATION 2024:S1931-7204(24)00232-0. [PMID: 38908992 DOI: 10.1016/j.jsurg.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 04/24/2024] [Accepted: 05/07/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE Acute appendicitis is a wide spectrum disease, from simple inflammation to evident intestinal perforation. The correct interpretation of the degree of inflammation is crucial to guarantee appropriate treatment and adherence to protocols and guidelines. In order to investigate this concordance, the authors compared the definition of appendicitis and the predicted treatment among all surgeons affiliated to a single Pediatric Surgery School (consisting of 8 different centers). DESIGN Twenty-two short recordings of intra-operative manipulation of appendices were shown to 56 surgeons, blindly to clinical information. Four items were collected and analyzed: classification of appendicitis, type and length of predicted antibiotic therapy, day of re-alimentation. Data were analyzed to identify the concordance kappa coefficient, stratified according to expertise of the responding surgeon. RESULTS The 1232 evaluations obtained in all valued items low overall concordance. Subgroup analysis identified a good agreement between younger surgeons only in the choice of antibiotic (k 0.47). However, if the centers were divided between University and non-University Hospitals, a strong agreement was found in the former both for classification (k 0.45 vs 0.32) and type of antibiotic (k 0.42 vs 0.24). CONCLUSIONS The overall concordance between surgeons in different centers in the diagnostic classification and predicted treatment of appendicitis is quite low. University Hospital have a highest concordance in both items at all levels of expertise; it might be postulated that teaching to younger surgeon increase the comparison between experts and finally the concordance and adherence to protocols within the center.
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Affiliation(s)
- Zambaiti Elisa
- Pediatric Surgery Unit, Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Torino, TO, Italy.
| | - Pagliara Camilla
- Pediatric Surgery Unit, Azienda Ospedaliero Universitaria di Padova, Padova, PD, Italy; Department of Pediatric Surgery, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, TS, Italy
| | - Mottadelli Giulia
- Pediatric Surgery Unit, Azienda Ospedaliero Universitaria di Padova, Padova, PD, Italy; Umberto Bosio Center for Digestive Diseases, Pediatric Surgery Unit, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, AL, Italy
| | - Zampieri Nicola
- Department of Surgery, Policlinico G.B.Rossi, University of Verona, Verona, VR, Italy
| | - Codrich Daniela
- Department of Pediatric Surgery, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, TS, Italy
| | - Grandi Francesca
- Complex Operative Unit-Pediatric Surgery, Hospital of Bolzano, Bolzano, BZ, Italy
| | - Gasparella Marco
- Pediatric Surgery Unit, Ca' Foncello Hospital, Treviso, TV, Italy
| | - Carlini Claudio
- Umberto Bosio Center for Digestive Diseases, Pediatric Surgery Unit, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, AL, Italy
| | - Pane Alessandro
- Pediatric Surgery Unit, Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Torino, TO, Italy
| | - Beretta Fabio
- Pediatric Surgery Unit, Presidio Ospedaliero Santa Chiara, Trento, TN, Italy
| | - Luca Maria Antoniello
- Pediatric Surgery Unit, Azienda Ospedaliero Universitaria di Padova, Padova, PD, Italy
| | - Gamba Piergiorgio
- Pediatric Surgery Unit, Azienda Ospedaliero Universitaria di Padova, Padova, PD, Italy
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Becker G, Fuhrer AE, Kremer K, Hochschild A, Kammar H, Sukhotnik I. Age as an Exclusion Criterion for Nonoperative Management in Simple Acute Appendicitis in Children. Eur J Pediatr Surg 2024; 34:102-106. [PMID: 37591255 DOI: 10.1055/a-2155-7642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
OBJECTIVE Nonoperative management (NOM) for simple acute appendicitis (SAA) is an acceptable mode of treatment in healthy children. Previous studies of NOM routinely excluded young children (< 5 years); however, the effect of age on NOM failure has not been directly assessed. Efficiency of NOM in young adults is questionable. Therefore, adolescents may also be at greater risk of NOM failure. Our aim was to investigate the effect of age on NOM failure. METHODS This is a retrospective analysis of children with SAA who received NOM between January 1, 2019, and June 30, 2021, at our institution. NOM failure was defined by subsequent appendectomy. Age was assessed as a continuous variable, and we also compared different age subgroups. RESULTS In this study, 151 children were included (60% male), mean age 11.2 ± 3.2 years (range: 5-17). Overall, 66 children (44%) failed NOM, 90% of them within the first year (median 7 weeks). Ten percent of the cohort were younger than 6 years of age and 33% of them failed NOM (p = 0.39). Per 1 year increase in age, the odds of NOM failure increased by 12% (p = 0.027). Children over 14 years of age had 2.46 times higher odds to fail NOM (p = 0.03). These higher odds remained after adjusting for appendiceal diameter and appendicolith. Linear regression showed a decrease by a factor of 12 at the time of NOM failure with every 1-year increase in age (β = -12, p = 0.09). CONCLUSION The risk of NOM failure in children increases with age; therefore, age should be considered when deciding on the optimal management of SAA, especially in adolescents. Effectiveness of NOM in children younger than 6 years is noninferior to older children and therefore should not be excluded.
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Affiliation(s)
- Gal Becker
- Department of Pediatric Surgery, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Audelia Eshel Fuhrer
- Department of Pediatric Surgery, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Keren Kremer
- Department of Pediatric Surgery, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Annabella Hochschild
- Department of Pediatric Surgery, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Haguy Kammar
- Department of Pediatric Surgery, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Igor Sukhotnik
- Department of Pediatric Surgery, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Lipsett SC, Monuteaux MC, Shanahan KH, Bachur RG. Nonoperative Management of Uncomplicated Appendicitis. Pediatrics 2022; 149:186782. [PMID: 35434736 DOI: 10.1542/peds.2021-054693] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Several studies have revealed the success of nonoperative management (NOM) of uncomplicated appendicitis in children. Large studies of current NOM utilization and its outcomes in children are lacking. METHODS We queried the Pediatric Health Information System database to identify children <19 years of age with a diagnosis code for appendicitis. We used linear trend analysis to assess the subsequent utilization and outcomes of NOM in children with nonperforated appendicitis over time. We calculated the proportion of children experiencing treatment failure, defined as either a subsequent appendectomy or hospitalization with a diagnosis code of perforated appendicitis. RESULTS We identified 117 705 children with appendicitis over the 9-year study period. Of the 73 544 children with nonperforated appendicitis, 10 394 (14.1%) underwent NOM. The odds of NOM significantly increased (odds ratio 1.10 per study quarter, 95% confidence interval [CI] 1.05-1.15). The 1-year and 5-year failure rates were 18.6% and 23.3%, respectively. Children who experienced failure of NOM had higher rates of perforation at the time of failure than did the general cohort at the time of initial presentation (45.7% vs 37.5%, P < .001). Patients undergoing NOM had higher rates of subsequent related emergency department visits (8.0% vs 5.1%, P < .001) and hospitalizations (4.2% vs 1.4%, P < .001) over a 12-month follow-up period. CONCLUSIONS NOM of nonperforated appendicitis in children is increasing. Although the majority of children who undergo NOM remain recurrence-free years later, they carry a substantial risk of perforation at the time of recurrence and may experience a higher rate of postoperative complications than children undergoing an immediate appendectomy.
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Affiliation(s)
- Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Pediatrics.,Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kristen H Shanahan
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Pediatrics.,Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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