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Kulasekere DA, Royan R, Shan Y, Reyes AM, Thomas AC, Lundberg AL, Feinglass JM, Stey AM. Appendicitis Hospitalization Care Costs Among Patients With Delayed Diagnosis of Appendicitis. JAMA Netw Open 2024; 7:e246721. [PMID: 38619839 PMCID: PMC11019393 DOI: 10.1001/jamanetworkopen.2024.6721] [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] [Received: 09/13/2023] [Accepted: 02/17/2024] [Indexed: 04/16/2024] Open
Abstract
Importance Delayed appendicitis diagnosis is associated with worse outcomes. Appendicitis hospital care costs associated with delayed diagnosis are unknown. Objective To determine whether delayed appendicitis diagnosis was associated with increased appendicitis hospital care costs. Design, Setting, and Participants This cohort study used data from patients receiving an appendectomy aged 18 to 64 years in 5 states (Florida, Maryland, Massachusetts, New York, Wisconsin) that were captured in the Healthcare Cost and Utilization Project State Inpatient and Emergency Department databases for the years 2016 and 2017 with no additional follow-up. Data were analyzed January through April 2023. Exposures Delayed diagnosis was defined as a previous emergency department or inpatient hospital encounter with an abdominal diagnosis other than appendicitis, and no intervention 7 days prior to appendectomy encounter. Main Outcomes and Measures The main outcome was appendicitis hospital care costs. This was calculated from aggregated charges of encounters 7 days prior to appendectomy, the appendectomy encounter, and 30 days postoperatively. Cost-to-charge ratios were applied to charges to obtain costs, which were then adjusted for wage index, inflation to 2022 US dollar, and with extreme outliers winsorized. A multivariable Poisson regression estimated appendicitis hospital care costs associated with a delayed diagnosis while controlling for age, sex, race and ethnicity, insurance status, care discontinuity, income quartile, hospital size, teaching status, medical school affiliation, percentage of Black and Hispanic patient discharges, core-based statistical area, and state. Results There were 76 183 patients (38 939 female [51.1%]; 2192 Asian or Pacific Islander [2.9%], 14 132 Hispanic [18.5%], 8195 non-Hispanic Black [10.8%], 46 949 non-Hispanic White [61.6%]) underwent appendectomy, and 2045 (2.7%) had a delayed diagnosis. Delayed diagnosis patients had median (IQR) unadjusted cost of $11 099 ($6752-$17 740) compared with $9177 ($5575-$14 481) for nondelayed (P < .001). Patients with delayed diagnosis had 1.23 times (95% CI, 1.16-1.28 times) adjusted increased appendicitis hospital care costs. The mean marginal cost of delayed diagnosis was $2712 (95% CI, $2083-$3342). Even controlling for delayed diagnosis, non-Hispanic Black patients had 1.22 times (95% CI, 1.17-1.28 times) the adjusted increased appendicitis hospital care costs compared with non-Hispanic White patients. Conclusions and Relevance In this cohort study, delayed diagnosis of appendicitis was associated with increased hospital care costs.
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Affiliation(s)
| | - Regina Royan
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Ying Shan
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ana M. Reyes
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | | | - Alexander L. Lundberg
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Joe M. Feinglass
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Anne M. Stey
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Fransvea P, Puccioni C, Altieri G, D'Agostino L, Costa G, Tropeano G, La Greca A, Brisinda G, Sganga G. Beyond acute appendicitis: a single-institution experience of unexpected pathology findings after 989 consecutive emergency appendectomy. Langenbecks Arch Surg 2024; 409:87. [PMID: 38441707 DOI: 10.1007/s00423-024-03277-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/27/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Appendiceal neoplasms (ANs) are rare, with an estimated incidence of around 1%: neuroendocrine tumours (NETs) and low-grade appendiceal mucinous neoplasms (LAMNs) comprise most cases. Most tumours are cured by appendectomy alone, although some require right hemicolectomy and intra-operative chemotherapy. The aim of the present study is to evaluate our institution's experience in terms of the prevalence of AN, their histological types, treatment and outcomes in adult patients undergoing emergency appendectomy. MATERIAL AND METHODS Single-centre retrospective cohort analysis of patients treated for acute appendicitis at a large academic medical centre. Patients with a diagnosis of acute appendicitis (AA) where further compared with patients with acute appendicitis and a histologically confirmed diagnosis of appendiceal neoplasm (AN). RESULTS A diagnosis of acute appendicitis was made in 1200 patients. Of these, 989 patients underwent emergency appendectomy. The overall incidence of appendiceal neoplasm was 9.3% (92 patients). AN rate increased with increasing age. Patients under the age of 30 had a 3.8% (14/367 patients) rate of occult neoplasm, whereas patients between 40 and 89 years and older had a 13.0% rate of neoplasm. No difference was found in clinical presentations and type of approach while we found a lower complicated appendicitis rate in the AN group. CONCLUSION ANs are less rare with respect to the literature; however, clinically, there are no specific signs of suspicious and simple appendicectomy appears to be curative in most cases. However, age plays an important role; older patients are at higher risk for AN. ANs still challenge the non-operative management concept introduced into the surgical literature.
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Affiliation(s)
- Pietro Fransvea
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy.
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy.
| | - Caterina Puccioni
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy
| | - Gaia Altieri
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Luca D'Agostino
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Gianluca Costa
- Surgery Center, Colorectal Surgery Clinical and Research Unit - Fondazione Policlinico Universitario Campus Bio-Medico, University Campus Bio-Medico of Rome, Rome, Italy
| | - Giuseppe Tropeano
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Antonio La Greca
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy
| | - Giuseppe Brisinda
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
- Università Cattolica del Sacro Cuore Roma Italia, Rome, Italy
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3
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Rey R, Gualtieri R, La Scala G, Posfay Barbe K. Artificial Intelligence in the Diagnosis and Management of Appendicitis in Pediatric Departments: A Systematic Review. Eur J Pediatr Surg 2024. [PMID: 38290564 DOI: 10.1055/a-2257-5122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Artificial intelligence (AI) is a growing field in medical research that could potentially help in the challenging diagnosis of acute appendicitis (AA) in children. However, usefulness of AI in clinical settings remains unclear. Our aim was to assess the accuracy of AIs in the diagnosis of AA in the pediatric population through a systematic literature review. METHODS PubMed, Embase, and Web of Science were searched using the following keywords: "pediatric," "artificial intelligence," "standard practices," and "appendicitis," up to September 2023. The risk of bias was assessed using PROBAST. RESULTS A total of 302 articles were identified and nine articles were included in the final review. Two studies had prospective validation, seven were retrospective, and no randomized control trials were found. All studies developed their own algorithms and had an accuracy greater than 90% or area under the curve >0.9. All studies were rated as a "high risk" concerning their overall risk of bias. CONCLUSION We analyzed the current status of AI in the diagnosis of appendicitis in children. The application of AI shows promising potential, but the need for more rigor in study design, reporting, and transparency is urgent to facilitate its clinical implementation.
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Affiliation(s)
- Robin Rey
- Department of Human Medicine, Faculty of Medicine, University of Geneva, Genève, Switzerland
| | - Renato Gualtieri
- Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Genève, Switzerland
| | - Giorgio La Scala
- Division of Pediatric Surgery, Hôpital des enfants, Geneva University Hospitals, Genève, Switzerland
| | - Klara Posfay Barbe
- Division of General Pediatrics, Hôpital des enfants, Geneva University Hospitals, Genève, Switzerland
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4
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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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5
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Brucchi F, Bracchetti G, Fugazzola P, Viganò J, Filisetti C, Ansaloni L, Dal Mas F, Cobianchi L, Danelli P. A meta-analysis and trial sequential analysis comparing nonoperative versus operative management for uncomplicated appendicitis: a focus on randomized controlled trials. World J Emerg Surg 2024; 19:2. [PMID: 38218862 PMCID: PMC10787963 DOI: 10.1186/s13017-023-00531-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/20/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND The aim of this study is to provide a meta-analysis of randomized controlled trials (RCT) comparing conservative and surgical treatment in a population of adults with uncomplicated acute appendicitis. METHODS A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL. We have exclusively incorporated randomized controlled trials (RCTs). Studies involving participants with complicated appendicitis or children were excluded. The variables considered are as follows: treatment complications, complication-free treatment success at index admission and at 1 year follow-up, length of hospital stay (LOS), quality of life (QoL) and costs. RESULTS Eight RCTs involving 3213 participants (1615 antibiotics/1598 appendectomy) were included. There was no significant difference between the two treatments in terms of complication rates (RR = 0.66; 95% CI 0.61-1.04, P = 0.07, I2 = 69%). Antibiotics had a reduced treatment efficacy compared with appendectomy (RR = 0.80; 95% CI 0.71 to 0.90, p < 0.00001, I2 = 87%) and at 1 year was successful in 540 out of 837 (64.6%, RR = 0.69, 95% confidence interval 0.61 to 0.77, p < 0.00001, I2 = 81%) participants. There was no difference in LOS (mean difference - 0.58 days 95% confidence interval - 1.59 to 0.43, p = 0.26, I2 = 99%). The trial sequential analysis has revealed that, concerning the three primary outcomes, it is improbable that forthcoming RCTs will significantly alter the existing body of evidence. CONCLUSIONS As further large-scale trials have been conducted, antibiotic therapy proved to be safe, less expensive, but also less effective than surgical treatment. In order to ensure well-informed decisions, further research is needed to explore patient preferences and quality of life outcomes.
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Affiliation(s)
- Francesco Brucchi
- University of Milan, Via Festa Del Perdono 7, 20122, Milan, Italy.
- , Milan, Italy.
| | - Greta Bracchetti
- University of Milan, Via Festa Del Perdono 7, 20122, Milan, Italy
| | - Paola Fugazzola
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Jacopo Viganò
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Claudia Filisetti
- Department of Pediatric Surgery, Buzzi Children's Hospital, 20154, Milan, Italy
| | - Luca Ansaloni
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
| | - Francesca Dal Mas
- Department of Management, Università Ca' Foscari, Dorsoduro 3246, 30123, Venezia, Italy
| | - Lorenzo Cobianchi
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Piergiorgio Danelli
- Division of General Surgery, Department of Biomedical and Clinical Sciences, University of Milan, L. Sacco University Hospital, 20157, Milan, Italy
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Zhang A, Zhang Y, Fan N, Hui Y, Zhou Y, Zeng L, Wang C, Shang L, Qi K, He X, Lin Y, Jiang X. Modified endoscopic retrograde appendicitis therapy vs. laparoscopic appendectomy for uncomplicated acute appendicitis in children. Dig Endosc 2024. [PMID: 38173187 DOI: 10.1111/den.14753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/27/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES Modified endoscopic retrograde appendicitis therapy (mERAT) has been proposed as an alternative to laparoscopic appendectomy for the treatment of appendicitis. However, data from children in large samples are lacking. The aim of this article is to evaluate the efficacy between mERAT and laparoscopic appendectomy (LA) in children with uncomplicated appendicitis. METHOD We retrospectively analyzed 594 patients with suspected uncomplicated appendicitis from October 2018 to May 2021. A pool of 294 consecutive patients who met the inclusion criteria were ultimately enrolled in this study (228 and 66 patients in mERAT and LA, respectively). Given the differences in baseline clinical data (gender, age), the regression equation including differences in clinical baseline, grouping factor, and white blood cell count was established to address the influence of potential confounding factors. RESULT The initial success rate of mERAT management was 96.9%, and the recurrence rate was 6.9% in the mERAT group and 1.7% in the LA group within 1 year, which was no significant difference. But the mERAT group had a lower rate of adverse events. Finally, those results indicated that the treatment modalities, LA or mERAT, had no significant effect on initial success rate (P = 0.99) or recurrence rate (P = 0.17) within 1 year, but a significant effect on the adverse events rate during hospitalization (P = 0.01) in the multivariate regression analysis. CONCLUSION Among children with uncomplicated appendicitis, an initial mERAT management strategy had a success rate of 96.9%, which was similar to the LA group at 1 year. This follow-up supports the feasibility of mERAT alone as an alternative to surgery for uncomplicated appendicitis.
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Affiliation(s)
- Anding Zhang
- Department of Pediatrics, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), Xi'an, China
| | - Yalong Zhang
- Department of Pediatrics, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), Xi'an, China
| | - Na Fan
- Department of Pediatrics, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), Xi'an, China
| | - Yaxing Hui
- Department of Pediatrics, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), Xi'an, China
| | - Ying Zhou
- Department of Pediatrics, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), Xi'an, China
| | - Lingchao Zeng
- Department of Pediatrics, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), Xi'an, China
| | - Chunhui Wang
- Department of Pediatrics, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), Xi'an, China
| | - Lei Shang
- Department of Health Statistics, School of Preventive Medicine, Fourth Military Medical University (Air Force Medical University), Xi'an, China
| | - Ke Qi
- Department of Pediatrics, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), Xi'an, China
| | - Xiaobao He
- Department of Pediatrics, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), Xi'an, China
| | - Yan Lin
- Department of Pediatrics, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), Xi'an, China
| | - Xun Jiang
- Department of Pediatrics, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), Xi'an, China
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7
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Lamm R, Kumar SS, Collings AT, Haskins IN, Abou-Setta A, Narula N, Nepal P, Hanna NM, Athanasiadis DI, Scholz S, Bradley JF, Train AT, Pucher PH, Quinteros F, Slater B. Diagnosis and treatment of appendicitis: systematic review and meta-analysis. Surg Endosc 2023; 37:8933-8990. [PMID: 37914953 DOI: 10.1007/s00464-023-10456-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children. METHODS Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively. RESULTS 2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04). CONCLUSIONS This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.
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Affiliation(s)
- Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Thomas Jefferson University, 1015 Walnut Street, 613 Curtis, Philadelphia, PA, 19107, USA.
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Nisha Narula
- Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Pramod Nepal
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joel F Bradley
- Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Philip H Pucher
- Department of Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago Medicine, Chicago, IL, USA
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Wondemagegnehu BD. Presentation management and outcome of phlegmonous and inflammed appendicitis in children in Ethiopia: retrospective review. BMC Surg 2023; 23:278. [PMID: 37710191 PMCID: PMC10503200 DOI: 10.1186/s12893-023-02191-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/08/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Acute appendicitis is the leading cause of emergency pediatric surgical admissions in the world. The diagnosis is may be difficult and is often dependent on clinical parameters. This study was aimed at reviewing the clinical presentations, the management and outcomes in children with inflamed and phlegmonous appendicitis with reference to the operative findings. METHODS The records of 211 children 5 to 15 years of age who were operated for acute appendicitis with intra operative findings of inflamed or phlegmonous appendicitis who met inclusion criteria were entered and analyzed using SPSS (IBM) V.26. Descriptive and regression tests were done with p < 0.05 considered statistically significant. RESULTS Of 211 children with inflamed and phlegmonous appendicitis, the M: F was 1.48:1 with a median age of 11 years. 58.3% of them presented within 24 h with the commonest symptoms being right lower abdominal pain, anorexia, and vomiting (96.2%,96.2%, 85.3%,) respectively. 96.7% of them had right lower abdominal tenderness. 73% had neutrophils ≥ 75%, and of 171 patients who had abdominal ultrasound scan, 97.7% showed appendiceal diameter ≥ 6 mm. Intraoperatively 56.4% of them were found to have phlegmonous appendicitis. In a retrospective Pediatric Appendiceal Score, only 52.6% of patients fall into the high-risk category, who could be confirmed on preoperative clinical assessment. Postoperatively 90% of them discharged improved with a mean hospital stay of 2.26(SD = 0.9) days. There was no association between the sex of the child and the intraoperative finding of inflamed or phlegmonous appendicitis (p = 0.77). CONCLUSION Pediatric appendicitis affects more male children in their second decade of life. Most had phlegmonous appendicitis and presented within 24 h. Duration of illness has little effect on the progress of appendicitis. Surgical management is safe for inflamed and phlegmonous appendicitis with a reasonable hospital stay and a low rate of complications.
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9
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Gil LA, Deans KJ, Minneci PC. Appendicitis in Children. Adv Pediatr 2023; 70:105-122. [PMID: 37422289 DOI: 10.1016/j.yapd.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
The management of pediatric appendicitis continues to advance with the development of evidence-based treatment algorithms and a recent shift toward patient-centered treatment approaches. Further research should focus on development of standardized institution-specific diagnostic algorithms to minimize rates of missed diagnosis and appendiceal perforation and refinement of evidence-based clinical treatment pathways that reduce complication rates and minimize health care resource utilization.
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Affiliation(s)
- Lindsay A Gil
- Pediatric Surgery Research Fellow, Nationwide Children's Hospital, The Ohio State University Wexner Medical Center, 700 Children's Drive, Columbus, OH 43206, USA
| | - Katherine J Deans
- Department of Surgery, Nemours Children's Health, Delaware Valley, 1600 Rockland Road, Wilmington, DE 19803, USA
| | - Peter C Minneci
- Division of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University Wexner Medical Center, 611 East Livingston Avenue, Columbus, OH 43206, USA.
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10
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Fincher KA, Bakeer MR. Left-Sided Laparoscopic Appendectomy in a Pediatric Patient With Situs Inversus Totalis. Cureus 2023; 15:e35844. [PMID: 37033503 PMCID: PMC10076207 DOI: 10.7759/cureus.35844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/04/2023] [Indexed: 03/08/2023] Open
Abstract
Acute appendicitis classically presents as periumbilical pain that migrates to the right lower quadrant. Rarely, left-sided appendicitis can occur, but it is not commonly considered in the differential of left lower quadrant pain. This report intends to raise awareness of left-sided appendicitis, in this case, due to situs inversus totalis, and to emphasize the need to perform a thorough patient evaluation. Here, we discuss the case of a 10-year-old male with known situs inversus totalis and primary ciliary dyskinesia (suspected Kartagener's syndrome) who presented to the emergency room with a one-day history of left lower quadrant pain and associated nausea and vomiting. His white blood cell (WBC) count was elevated, and a contrast-enhanced computed tomography (CT) scan revealed acute tip appendicitis in the left lower quadrant. The surgeon performed a laparoscopic appendectomy with modifications. The patient tolerated the procedure well but experienced difficulty weaning off oxygen postoperatively. An airway management plan was initiated, which allowed for the discontinuation of oxygen. The patient was discharged on postoperative day two and was seen in the clinic approximately two weeks later with no postoperative complications. Pathology confirmed acute suppurative appendicitis.
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11
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Reyes AM, Royan R, Feinglass J, Thomas AC, Stey AM. Patient and Hospital Characteristics Associated With Delayed Diagnosis of Appendicitis. JAMA Surg 2023; 158:e227055. [PMID: 36652227 PMCID: PMC9857818 DOI: 10.1001/jamasurg.2022.7055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Importance Racial disparities in timely diagnosis and treatment of surgical conditions exist; however, it is poorly understood whether there are hospital structural measures or patient-level characteristics that modify this phenomenon. Objective To assess whether patient race and ethnicity are associated with delayed appendicitis diagnosis and postoperative 30-day hospital use and whether there are patient- or systems-level factors that modify this association. Design, Setting, and Participants This population-based, retrospective cohort study used data from the Healthcare Cost and Utilization Project's state inpatient and emergency department (ED) databases from 4 states (Florida, Maryland, New York, and Wisconsin) for patients aged 18 to 64 years who underwent appendectomy from January 7, 2016, to December 1, 2017. Data were analyzed from January 1, 2016, to December 31, 2017. Exposure Delayed diagnosis of appendicitis, defined as an initial ED presentation with an abdominal diagnosis other than appendicitis followed by re-presentation within a week for appendectomy. Main Outcomes and Measures A mixed-effects multivariable Poisson regression model was used to estimate the association of delayed diagnosis of appendicitis with race and ethnicity while controlling for patient and hospital variables. A second mixed-effects multivariable Poisson regression model quantified the association of delayed diagnosis of appendicitis with postoperative 30-day hospital use. Results Of 80 312 patients who received an appendectomy during the study period (median age, 38 years [IQR, 27-50 years]; 50.8% female), 2013 (2.5%) experienced delayed diagnosis. In the entire cohort, 2.9% of patients were Asian or Pacific Islander, 18.8% were Hispanic, 10.9% were non-Hispanic Black, 60.8% were non-Hispanic White, and 6.6% were other race and ethnicity; most were privately insured (60.2%). Non-Hispanic Black patients had a 1.41 (95% CI, 1.21-1.63) times higher adjusted rate of delayed diagnosis compared with non-Hispanic White patients. Patients at hospitals with a more than 50% Black or Hispanic population had a 0.73 (95% CI, 0.59-0.91) decreased adjusted rate of delayed appendicitis diagnosis compared with hospitals with a less than 25% Black or Hispanic population. Conversely, patients at hospitals with more than 50% of discharges of Medicaid patients had a 3.51 (95% CI, 1.69-7.28) higher adjusted rate of delayed diagnosis compared with hospitals with less than 10% of discharges of Medicaid patients. Additional factors associated with delayed diagnosis included female sex, higher levels of patient comorbidity, and living in a low-income zip code. Delayed diagnosis was associated with a 1.38 (95% CI, 1.36-1.61) increased adjusted rate of postoperative 30-day hospital use. Conclusions and Relevance In this cohort study, non-Hispanic Black patients had higher rates of delayed appendicitis diagnosis and 30-day hospital use than White patients. Patients presenting to hospitals with a greater than 50% Black and Hispanic population were less likely to experience delayed diagnosis, suggesting that seeking care at a hospital that serves a diverse patient population may help mitigate the increased rate of delayed diagnosis observed for non-Hispanic Black patients.
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Affiliation(s)
- Ana M Reyes
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Surgery, University of Miami and Jackson Memorial Hospital, Miami, Florida
| | - Regina Royan
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Joe Feinglass
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Arielle C Thomas
- Department of Surgery, Medical College of Wisconsin, Milwaukee.,American College of Surgeons, Chicago, Illinois
| | - Anne M Stey
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Minneci PC, Talan DA, Deans KJ. Result Interpretation in Nonoperative Management of Uncomplicated Appendicitis. Pediatrics 2022; 150:189800. [PMID: 36305234 DOI: 10.1542/peds.2022-059372a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 11/05/2022] Open
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Snyder CL. Weighing the Risks and Benefits of Nonoperative Management of Appendicitis. Pediatrics 2022; 149:186780. [PMID: 35434743 DOI: 10.1542/peds.2021-056034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/24/2022] Open
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