Pediatric appendectomy

doi:10.1016/0022-3468(95)90556-1

Journal of Pediatric Surgery

Volume 30, Issue 2, February 1995, Pages 173-181

https://doi.org/10.1016/0022-3468(95)90556-1 Get rights and content

Abstract

Purpose: To define patterns of care and outcome for pediatric appendectomy. Methods: A study was designed to evaluate all pediatric appendectomies performed in the 147 Department of Defense hospitals worldwide. Cases of nonincidental appendectomy were identified through discharge diagnoses and operative logs, and 98.6% of the charts were retrieved for review. All charts were abstracted, and data were entered into a 127-field database for analysis. Results: Over a 12-month period, ending January 1993, appendectomy was performed on 1,366 pediatric patients in the Department of Defense hospital system. The patients' median age was 12 years (range, 6 months to 18 years); 59% were male. The diagnosis was normal appendix for 157 patients (12%), acute nonperforated appendicitis for 930 (68%), and perforated appendicitis for 279 (20%). Age ≤ 8 years was predictive (P < .001) of a higher rate of perforated appendicitis (33% v 18%) but was not predictive of normal pathology (13% v 11%). Female gender was associated with a significantly higher rate of normal pathology (17% v 8%; P < .001) but not of perforation (18% v 22%). Temperature elevation and right lower quadrant pain and tenderness did not clinically distinguish between diagnostic groups. Sixty-two percent of patients with a normal appendix had a white blood cell count of more than 10,000/mm³, as did 91% of patients with acute or perforated appendicitis. Those with perforated appendicitis received pre- and postoperative anti-biotics, primarily ampicillin/gentamicin/clindamycin or Flagyl (41%), cefoxitin (34%), or Unasyn (15%). In 77% of this subgroup, intraoperative cultures were positive, with isolates for Escherichia coli (76%) Enterococcus (30%), Bacteroides (24%), and Pseudomonas (20%) predominating. There were no deaths. Major complications occurred in 1.2% of patients with acute appendicitis and in 6.4% of those with perforated appendicitis; there were no major complications in the group with normal appendectomies. The hospitalization period was more than 7 days for 1.6%, 40%, and 3.8%, respectively. Conclusion: This large series, from a large number of hospitals, with multiple practitioners, can serve as a community standard for pediatric appendectomy in the 1990s.

References (28)

MW Harrison et al.
Acute appendicitis in children: Factors affecting morbidity
Am J Surg
(1984)
IB David et al.
Rational use of antibiotics for perforated appendicitis in childhood
J Pediatr Surg
(1982)
IR Neilson et al.
Appendicitis in children: Current therapeutic recommendations
J Pediatr Surg
(1990)
TJ Curran et al.
The treatment of complicated appendicitis in children using peritoneal drainage: Results from a public hospital
J Pediatr Surg
(1993)
MJ Bell et al.
Appendectomy in childhood: Analysis of 105 negative explorations
Am J Surg
(1982)
DM Mosdell et al.
Peritoneal cultures and antibiotic therapy in pediatric perforated appendicitis
Am J Surg
(1994)
G Stringel
Appendicitis in children: A systematic approach for a low incidence of complications
Am J Surg
(1987)
DN Linz et al.
Does the current health care environment contribute to the morbidity and mortality of acute appendicitis in children?
J Pediatr Surg
(1993)
DT Cloud
Appendicitis
PK Kottmeier
Appendicitis

DP Lund et al.

Management of perforated appendicitis in children: A decade of aggressive therapy

JS Janik et al.

Pediatric appendicitis: A 20-year study of 1,640 children at Cook County (Illinois) Hospital

Arch Surg

(1979)

SL Samelson et al.

Management of perforated appendicitis in children—Revisited

Arch Surg

(1987)

MZ Schwartz et al.

Management of perforated appendicitis in children: The controversy continues

Ann Surg

(1983)

Cited by (166)

The costs and benefits of emergent surgical workflow for acute appendicitis in children
2022, Journal of Pediatric Surgery
Controversy exists regarding how operative timing affects patient safety and resource utilization for acute appendicitis. Over 3 years, our institution trialed efforts to optimize appendectomy workflow. Our aim is to describe the ramifications of expediting appendectomy and implementing standardized protocols relative to historic controls.
Patient records at a freestanding children's hospital were reviewed from synchronized 6-month periods from 2019 to 2021. During Year 1 (historic), no standardized workflows existed. In Year 2 (expedited), appendicitis management was protocoled using a clinical quality improvement bundle, which included performing appendectomies within two hours of diagnosis. In Year 3 (QI), operative timing was relaxed to the same calendar day while all prior QI initiatives continued. Descriptive statistics were performed, using hospital length of stay (LOS) as the primary outcome.
298 patients underwent appendectomy for acute appendicitis. The median expedited workflow LOS was 15.3 hours shorter (p = 0.003) than historic controls; however, this was sustained despite relaxation of surgical urgency in the QI workflow. No differences in perforation rates were observed. During the expedited workflow, OR overtime staffing expense increased by $90,000 with no significant change in hospital costs. In multivariate regression, perforation was the only variable associated with LOS.
Hospital LOS can be shortened by expediting appendectomy. However, in our institution this did not decrease hospital costs and was furthermore balanced by higher personnel expenses. A sustained decrease in LOS after relaxing operative urgency standards implies that concurrent QI initiatives represent a more effective and cost-efficient strategy to decrease hospital resource utilization.
Level III
Social Determinants of Health are Associated With Postoperative Outcomes in Children With Complicated Appendicitis
2022, Journal of Surgical Research
Socioeconomic disadvantage has been associated with increased complicated appendicitis rates. Our purpose was to analyze the complex interactions between social determinants of health (SDOH) and postoperative outcomes in pediatric appendicitis.
Children who underwent appendectomy at our institution (1/2015-12/2020) were retrospectively reviewed. We used home addresses to determine composite measures of neighborhood/area-level socioeconomic advantage (Area Deprivation Index [ADI] and Social Deprivation Index [SDI]), and other area-level indicators. We created a novel, composite outcome score computed as a weighted average of eight outcome measures. Feature selection and exploratory factor analysis were used to create a multivariate model predictive of outcomes.
Of 1117 children with appendicitis, 20.59% had complicated (perforated) appendicitis. Factor analysis identified two multivariate latent factors; Factor 1 contained SDI, ADI, and % unemployed in the population, and Factor 2 contained % Hispanic and % foreign-born in the population. Low Factor 2 scores (communities with more Hispanic/foreign-born residents) were associated with increased length of stay, more frequent postoperative percutaneous drainage, and increased postoperative imaging.
Interactions between SDOH and pediatric surgical care go beyond the individual patient and suggest that vulnerable populations are exposed to contextual conditions that may impact outcomes. Specifically, neighborhood-level factors, including the prevalence of Hispanic ethnicity and foreign-born individuals, are associated with outcomes in pediatric patients with complicated appendicitis. Reducing disparities in complicated appendicitis outcomes may involve addressing neighborhood-level SDOH through strategic reallocation of healthcare resources and developing targeted interventions to improve access to pediatric surgical care in underserved communities.
Studies of diagnostic test accuracy: Partial verification bias and test result-based sampling
2022, Journal of Clinical Epidemiology
Partial verification bias occurs in studies assessing the accuracy of existing diagnostic tests when a positive index test makes application of the reference standard more likely.
This article first describes alternative sampling frames for a diagnostic test accuracy study then discusses partial verification bias.
One approach to avoiding partial verification bias is to apply the reference standard to all individuals who are positive on the index test and a random sample of those who are negative. Estimating sensitivity and specificity then requires adjusting for the sampling fraction in the test-negative group.
If a finding was already used to determine who should get the definitive test, one can't look at those who got the definitive test to determine the usefulness of the finding.
Inflammatory parameters as predictive factors for complicated appendicitis: A retrospective cohort study
2022, Annals of Medicine and Surgery
Acute appendicitis is a major cause of acute abdomen. Although its diagnosis is clinical, it is often supported by complementary diagnostic tests. Sometimes, delay in diagnosis can lead to worsening of the clinical picture, resulting in a complicated acute appendicitis. Some series have studied some clinical and analytical parameters as possible predictors of complicated acute appendicitis.
A retrospective analysis of patients admitted for acute appendicitis and undergoing appendectomy between January 2014 and December 2017 was performed in order to assess the possible existence of preoperative analytical predictive factors for complicated acute appendicitis (such as leukocytosis, C-reactive protein and ratio between neutrophils and lymphocytes).
841 patients underwent emergency appendectomy during the analysed period. This initial sample was divided into two groups: Group 1 with patients with uncomplicated acute appendicitis and Group 2 with patients with complicated acute appendicitis. Group 2's presentation age, duration of symptoms and hospital stay was significantly higher than Group 1. Regarding analytical parameters, the measurement of leukocytes, C-reactive protein and ratio between neutrophils and lymphocytes was significantly higher in patients with complicated acute appendicitis. After a multivariate analysis, it was found that only C-reactive protein was a good predictor of complicated acute appendicitis.
Several publications have studied and demonstrated the possible use of certain analytical parameters as predictors of complicated acute appendicitis. In our study, C-reactive protein proved to be a good independent predictor of complicated acute appendicitis and, therefore, when an assay of this protein exceeds 63.3 mg/L, faster surgical approach should be considered due to the high probability of the presence of a complicated picture of this clinical entity.
Appendicitis
2020, Pediatric Gastrointestinal and Liver Disease, Sixth Edition
Acute appendicitis is one of the most common surgical conditions afflicting children and adults. Approximately 250,000 cases occur annually in the United States, with the highest incidence in patients 10 to 19 years of age. The lifetime risk of developing appendicitis has been estimated at 8.6% for males and 6.7% for females, with a lifetime risk of undergoing an appendectomy estimated at 12% for males and 23% for females. Appendiceal perforation in the pediatric population is more common than in adults, occurring in up to 50% of patients. In children younger than 5 years of age, the perforation rate is 65%, and 95% in children younger than 2 years of age. A thorough understanding of this common surgical condition is important for all health care providers, who should be able to recognize and refer patients with possible appendicitis to be further evaluated promptly in order to avoid complications related to delayed diagnosis.
A simple algorithm to improve quality while reducing resource utilization in evaluation of suspected appendicitis in children
2019, American Journal of Surgery
Citation Excerpt :
As with any ideal diagnostic test, the initial screening must be affordable, quick, easy to interpret, and accurate. Pearl et al., stated that 91% of acute or perforated appendicitis had a leukocytosis of more than 10,000/mm3 on admission.12 We focused on this white blood cell count.
With similar effectiveness of ultrasonography, our institution replaced CT imaging with ultrasound for diagnosing appendicitis in children. An unexpected consequence was the overutilization of ultrasound. Our objective was to establish measures that could help prevent this overuse.
A retrospective chart review of 327 consecutive pediatric patients evaluated for appendicitis between October 2014 and September 2015 at our institution was performed. Data on clinical, radiographic, and histopathologic findings were reviewed. Diagnostic accuracy of US and white blood cell (WBC) values was determined. An algorithm was created.
327 (100%) patients received an ultrasound for suspected appendicitis. WBC of 10,000/μl was determined to be the primary discriminant for management and ultrasound utilization. If a WBC ≥10,000/μL had been utilized as criteria for imaging, 49.5% fewer patients would have received an ultrasound.
Clinical exam, WBC count, and surgery consultation prior to ultrasonography can lessen then need for ultrasound utilization in children with suspected appendicitis.

View all citing articles on Scopus

^☆: Presented at the 25th Annual Meeting of the American Pediatric Surgical Association, Tucson, Arizona, May 14–17, 1994.

View full text

Pediatric appendectomy☆

Abstract

Am J Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Am J Surg

Am J Surg

Am J Surg

J Pediatr Surg

Appendicitis

Appendicitis

Management of perforated appendicitis in children: A decade of aggressive therapy

Pediatric appendicitis: A 20-year study of 1,640 children at Cook County (Illinois) Hospital

Arch Surg

Management of perforated appendicitis in children—Revisited

Arch Surg

Management of perforated appendicitis in children: The controversy continues

Ann Surg