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Lim KZ, Nataraja RM, Pacilli M. Triple Versus Double Antibiotic Therapy in Children Undergoing Laparoscopic Appendicectomy for Complicated Appendicitis: A Case-Control Study. Surg Infect (Larchmt) 2025. [PMID: 40304248 DOI: 10.1089/sur.2024.322] [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: 05/02/2025] Open
Abstract
Background and Objectives: Historically, a triple-antibiotic (TA) regimen (ampicillin, gentamicin, metronidazole) has been used for children with complicated appendicitis (CA) at our institution. We implemented a double-antibiotic (DA) regimen (ceftriaxone, metronidazole) in November 2018. The aim of this study was to compare the post-operative outcomes between the two groups. Patients and Methods: Clinical and laboratory data were collected from the medical records of children who underwent laparoscopic appendicectomy (LA) for CA between November 2017 and 2019. Data, reported as number of cases (%) and median with interquartile range or 95% confidence interval (CI), were analyzed with Fisher exact test and Mann-Whitney U test; p values <0.05 were considered significant. Results: One hundred and ninety-seven patients were identified; 99 treated with the TA regimen and 98 with the DA regimen. The groups had similar demographics. Post-operative complications were similar between the two groups: intra-abdominal abscess (IAA) 12 (12.1%) in TA versus 10 (10.2%) in DA (p = 0.82); surgical site infections 1 (1.0%) in TA versus 2 (2.2%) in DA (p = 0.62). Time to defervescence in the first 5 post-operative days was substantially longer in the TA group: 72 (95% CI 72-96) versus 48 (95% CI 48-72) hours (p = 0.003). Among patients without post-operative IAA, the DA group had a shorter post-operative hospital stay (5 [5-6] vs. 5.5 [5-6] days; p = 0.04). The cost of DA regimen was substantially lower (p < 0.0001). Conclusions: The DA regimen provided better post-operative temperature control and a quicker overall recovery, without increasing the incidence of IAA and surgical site infection in children following LA for CA.
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Affiliation(s)
- Kai-Zheong Lim
- Department of Paediatric Surgery, Monash Children's Hospital, Clayton, Victoria, Australia
- Department of Paediatrics, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Ramesh M Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, Clayton, Victoria, Australia
- Department of Paediatrics, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Department of Surgery, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Maurizio Pacilli
- Department of Paediatric Surgery, Monash Children's Hospital, Clayton, Victoria, Australia
- Department of Paediatrics, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Department of Surgery, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
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Krinock DJ, Stephenson K, Irby D, Akmyradov C, Barker M, Waldrip Z, Burdine M, Wolf LL, Dassinger MS, Wyrick D. Intra-peritoneal Povidone-iodine Irrigation Decreases Abscesses in a Perforated Appendicitis Murine Model. J Pediatr Surg 2025; 60:162081. [PMID: 39657362 DOI: 10.1016/j.jpedsurg.2024.162081] [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: 08/22/2024] [Revised: 11/12/2024] [Accepted: 11/25/2024] [Indexed: 12/12/2024]
Abstract
BACKGROUND Children with perforated appendicitis frequently form post-operative intra-abdominal abscesses (IAA). Intra-peritoneal irrigation for prevention remains controversial. Using a perforated appendicitis murine model, we sought to determine the effect of intra-peritoneal irrigation on post-operative IAA and adhesion formation. METHODS A survival operation was performed where cecal ligation and puncture was used to simulate perforated appendicitis. After 72 h, mice underwent a second operation where a distal cecectomy and intra-peritoneal irrigation was performed. Mice were assigned to a no irrigation group or one of four irrigation groups: normal saline, povidone-iodine (PVI), tacrolimus, or PVI followed by tacrolimus. At 2-weeks or 2-months after the second survival operation, mice were euthanized and IAAs were counted, measured, and cultured. Intra-peritoneal adhesion severity was graded on a 4-point scale. Statistical analysis compared IAA numbers and adhesion grade between the irrigation groups. RESULTS In the 2-week cohort, prevalence of IAA was 78 % (n = 129). Type of irrigation solution was associated with abscess development (p < 0.001). Pairwise comparisons demonstrated PVI alone decreased abscess count. PVI irrigation caused more severe adhesions while tacrolimus decreased adhesions and adhesion grade was dependent on irrigation solution (p < 0.001). In the 2-month cohort, similar responses were observed with decreased abscess numbers in the PVI group (p = 0.006) but increased adhesion burden (p = 0.002). CONCLUSION Povidone-iodine irrigation decreases intra-abdominal abscess formation, but increases adhesion formation. LEVEL OF EVIDENCE: 1
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Affiliation(s)
- Derek J Krinock
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Krista Stephenson
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - David Irby
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Chary Akmyradov
- Biostatistics Core, Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Melanie Barker
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Zachary Waldrip
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Marie Burdine
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lindsey L Wolf
- Division of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Melvin S Dassinger
- Division of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Deidre Wyrick
- Division of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, AR, USA
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Keane OA, Motley T, Robinson J, Smith A, Short HL, Santore MT. Standardization of Antibiotic Management and Reduction of Opioid Prescribing in Pediatric Complicated Appendicitis: A Quality Improvement Initiative. J Pediatr Surg 2024; 59:1058-1065. [PMID: 38030531 DOI: 10.1016/j.jpedsurg.2023.11.001] [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: 09/01/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Appendicitis is one of the most common pediatric surgical procedures in the United States. However, wide variation remains in antibiotic prescribing and pain management across and within institutions. We aimed to minimize variation in antibiotic usage and decrease opioid prescribing at discharge for children with complicated appendicitis by implementation of a quality improvement (QI) initiative. METHODS On December 1st, 2021, a QI initiative standardizing postoperative care for complicated appendicitis was implemented across a tertiary pediatric healthcare system with two main surgical centers. QI initiative focused on antibiotic and pain management. An extensive literature search was performed and a total of 20 articles matching our patient population were critically appraised to determine the best evidence-based interventions to implement. Antibiotic regimen included: IV or PO ceftriaxone/metronidazole immediately post-operatively and transition to PO amoxicillin-clavulanic acid for completion of 7-day total course at discharge. Discharge pain control regimen included acetaminophen, ibuprofen, as needed gabapentin, and no opioid prescription. Guideline compliance were closely monitored for the first six months following implementation. RESULTS In the first 6-months post-implementation, compliance with use of ceftriaxone/metronidazole as initial post-operative antibiotics was 75.6 %. Transition to PO amoxicillin-clavulanic acid prior to discharge increased from 13.7 % pre-implementation to 73.7 % 6-months post-implementation (p < 0.001). Compliance with a 7-day course of antibiotics within the first 6-months post-implementation was 60 % across both sites. After QI intervention, overall opioid prescribing remained at 0 % at one surgical site and decreased from 17.6 % to 0 % at the second surgical site over the study timeframe (p < 0.001). CONCLUSION Antibiotic use can be standardized and opioid prescribing minimized in children with complicated appendicitis using QI principles. Continued monitoring of the complicated appendicitis guideline is needed to assess for further progress in the standardization of post-operative care. STUDY TYPE Quality improvement. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Olivia A Keane
- Department of Surgery, Emory University, Atlanta, GA, USA.
| | - Theresa Motley
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jenny Robinson
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Alexis Smith
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Matthew T Santore
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Cramm SL, Graham DA, Blakely ML, Chandler NM, Cowles RA, Kunisaki SM, Russell RT, Allukian M, DeFazio JR, Griggs CL, Santore MT, Scholz S, Aronowitz DI, Campbell BT, Collins DT, Commander SJ, Engwall-Gill A, Esparaz JR, Feng C, Gerall C, Hanna DN, Keane OA, Lamoshi A, Lipskar AM, Orlas Bolanos CP, Pace E, Regan MD, Tracy ET, Williams S, Zhang L, Rangel SJ. Outcomes and Resource Utilization Associated with Use of Routine Pre-Discharge White Blood Cell Count for Clinical Decision-Making in Children with Complicated Appendicitis: A Multicenter Hospital-Level Analysis. J Pediatr Surg 2023; 58:1178-1184. [PMID: 37030979 DOI: 10.1016/j.jpedsurg.2023.02.039] [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: 01/27/2023] [Accepted: 02/10/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND The objective was to explore the hospital-level relationship between routine pre-discharge WBC utilization (RPD-WBC) and outcomes in children with complicated appendicitis. METHODS Multicenter analysis of NSQIP-Pediatric data from 14 consortium hospitals augmented with RPD-WBC data. WBC were considered routine if obtained within one day of discharge in children who did not develop an organ space infection (OSI) or fever during the index admission. Hospital-level observed-to-expected ratios (O/E) for 30-day outcomes (antibiotic days, imaging utilization, healthcare days, and OSI) were calculated after adjusting for appendicitis severity and patient characteristics. Spearman correlation was used to explore the relationship between hospital-level RPD-WBC utilization and O/E's for each outcome. RESULTS 1528 children were included. Significant variation was found across hospitals in RPD-WBC use (range: 0.7-100%; p < 0.01) and all outcomes (mean antibiotic days: 9.9 [O/E range: 0.56-1.44, p < 0.01]; imaging: 21.9% [O/E range: 0.40-2.75, p < 0.01]; mean healthcare visit days: 5.7 [O/E 0.74-1.27, p < 0.01]); OSI: 14.1% [O/E range: 0.43-3.64, p < 0.01]). No correlation was found between RPD-WBC use and antibiotic days (r = +0.14, p = 0.64), imaging (r = -0.07, p = 0.82), healthcare days (r = +0.35, p = 0.23) or OSI (r = -0.13, p = 0.65). CONCLUSIONS Increased RPD-WBC utilization in pediatric complicated appendicitis did not correlate with improved outcomes or resource utilization at the hospital level. LEVEL OF EVIDENCE III. TYPE OF STUDY Clinical Research.
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Affiliation(s)
- Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Dionne A Graham
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA, USA
| | - Martin L Blakely
- Department of Surgery, Vanderbilt Children's Hospital, Vanderbilt School of Medicine, Nashville, TN, USA
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkin's All Children's Hospital, St. Petersburg, FL, USA
| | - Robert A Cowles
- Department of Pediatric Surgery, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Robert T Russell
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's of Alabama
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer R DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York, NY, USA
| | - Cornelia L Griggs
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew T Santore
- Department of Surgery, Division of Pediatric Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Stefan Scholz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Danielle I Aronowitz
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brendan T Campbell
- Department of Surgery, Connecticut Children's Hospital, Hartford, CT, USA
| | - Devon T Collins
- Department of Surgery, Children's National Hospital, Washington, D.C, USA
| | - Sarah J Commander
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC, USA
| | - Abigail Engwall-Gill
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Joseph R Esparaz
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Christina Feng
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC, USA
| | - Claire Gerall
- Department of Surgery, UT Health San Antonio, San Antonio, TX, USA
| | - David N Hanna
- Department of Surgery, Vanderbilt Children's Hospital, Nashville, TN, USA
| | - Olivia A Keane
- Department of Surgery, Division of Pediatric Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Abdulraouf Lamoshi
- Division of Pediatric Surgery, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Aaron M Lipskar
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Claudia P Orlas Bolanos
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth Pace
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maia D Regan
- Department of Surgery, Children's National Hospital, Washington, D.C, USA
| | - Elisabeth T Tracy
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC, USA
| | - Sacha Williams
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Lucy Zhang
- Department of Pediatric Surgery, Yale New Haven Children's Hospital, New Haven, CT, USA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Zhou Q, Meng W, Ren Y, Li Q, Boermeester MA, Nthumba PM, Rickard J, Zheng B, Liu H, Shi Q, Zhao S, Wang Z, Liu X, Luo Z, Yang K, Chen Y, Sawyer RG. Effectiveness of intraoperative peritoneal lavage with saline in patient with intra-abdominal infections: a systematic review and meta-analysis. World J Emerg Surg 2023; 18:24. [PMID: 36991507 DOI: 10.1186/s13017-023-00496-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Abstract
Background
Intraoperative peritoneal lavage (IOPL) with saline has been widely used in surgical practice. However, the effectiveness of IOPL with saline in patients with intra-abdominal infections (IAIs) remains controversial. This study aims to systematically review randomized controlled trials (RCTs) evaluating the effectiveness of IOPL in patients with IAIs.
Methods
The databases of PubMed, Embase, Web of Science, Cochrane library, CNKI, WanFang, and CBM databases were searched from inception to December 31, 2022. Random-effects models were used to calculate the risk ratio (RR), mean difference, and standardized mean difference. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to rate the quality of the evidence.
Results
Ten RCTs with 1318 participants were included, of which eight studies on appendicitis and two studies on peritonitis. Moderate-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (0% vs. 1.1%; RR, 0.31 [95% CI, 0.02–6.39]), intra-abdominal abscess (12.3% vs. 11.8%; RR, 1.02 [95% CI, 0.70–1.48]; I2 = 24%), incisional surgical site infections (3.3% vs. 3.8%; RR, 0.72 [95% CI, 0.18–2.86]; I2 = 50%), postoperative complication (11.0% vs. 13.2%; RR, 0.74 [95% CI, 0.39–1.41]; I2 = 64%), reoperation (2.9% vs. 1.7%; RR,1.71 [95% CI, 0.74–3.93]; I2 = 0%) and readmission (5.2% vs. 6.6%; RR, 0.95 [95% CI, 0.48–1.87]; I2 = 7%) in patients with appendicitis when compared to non-IOPL. Low-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (22.7% vs. 23.3%; RR, 0.97 [95% CI, 0.45–2.09], I2 = 0%) and intra-abdominal abscess (5.1% vs. 5.0%; RR, 1.05 [95% CI, 0.16–6.98], I2 = 0%) in patients with peritonitis when compared to non-IOPL.
Conclusion
IOPL with saline use in patients with appendicitis was not associated with significantly decreased risk of mortality, intra-abdominal abscess, incisional surgical site infection, postoperative complication, reoperation, and readmission compared with non-IOPL. These findings do not support the routine use of IOPL with saline in patients with appendicitis. The benefits of IOPL for IAI caused by other types of abdominal infections need to be investigated.
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Skertich NJ, Sullivan GA, Wiegmann AL, Becerra AZ, Madonna MB, Pillai S, Shah AN, Gulack BC. A shortened course of Amoxicillin/Clavulanate is the preferred antibiotic treatment after surgery for perforated appendicitis in children. J Pediatr Surg 2023; 58:558-563. [PMID: 35490055 DOI: 10.1016/j.jpedsurg.2022.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 03/22/2022] [Accepted: 03/29/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Despite evidence supporting short course outpatient antibiotic treatment following appendectomy for perforated appendicitis, evidence of real-world implementation and consensus for antibiotic choice is lacking. We therefore aimed to compare outpatient antibiotic treatment regimens in a national cohort. METHODS We identified children who underwent surgery for perforated appendicitis between 2010 and 2018 using the PearlDiver database and compared 45-day disease-specific readmission between children who received shortened (5-8 days) versus prolonged (10-14 day) total antibiotic courses (inpatient intravenous and/or oral) completed with outpatient Amoxicillin/Clavulanate versus Ciprofloxacin/Metronidazole, and compared antibiotic type (5-14 days) to each other. RESULTS 4916 children were identified, 2001 (90.0%) treated with Amoxicillin/Clavulanate (5-14 days), 381 (19.0%) with shortened (5-8 days), 1464 (73.2%) with prolonged (10-14 days) courses. 222 (10.0%) were treated with Ciprofloxacin/Metronidazole, 44 (19.8%) with shortened, 174 (78.4%) with prolonged courses. Freedom from readmission was not different between prolonged and shortened course whether they received Amoxicillin/Clavulanate (adjusted hazard ratio [AHR] 1.54, 95%CI 0.95-2.5) or Ciprofloxacin/Metronidazole (AHR 3.49, 95%CI 0.45-27.3). Antibiotic type did not affect readmission rate (Amoxicillin/Clavulanate versus Ciprofloxacin/Metronidazole, AHR 1.21, 95%CI 0.71-2.05). CONCLUSION Prolonged antibiotic regimens are routinely prescribed despite evidence suggesting shorter courses and antibiotic choice are not associated with greater treatment failure. As it is better tolerated, we recommend a shortened course of Amoxicillin/Clavulanate for oral management of perforated appendicitis. STUDY DESIGN Retrospective. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Nicholas J Skertich
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States.
| | - Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States
| | - Aaron L Wiegmann
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States
| | - Adan Z Becerra
- Department of Surgery, Rush University Medical Center, Chicago, IL 60612, United States
| | - Mary Beth Madonna
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States
| | - Srikumar Pillai
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States
| | - Brian C Gulack
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States
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Postoperative Antibiotics for Complicated Appendicitis in Children: Piperacillin/Tazobactam versus Ceftriaxone with Metronidazole. J Pediatr Surg 2023; 58:1128-1132. [PMID: 36931937 DOI: 10.1016/j.jpedsurg.2023.02.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/10/2023] [Indexed: 02/19/2023]
Abstract
INTRODUCTION Recent studies are discordant regarding postoperative use of piperacillin/tazobactam (PT) versus ceftriaxone/metronidazole (CM) for pediatric complicated appendicitis. Some argue that the broader spectrum PT decreases intraabdominal abscess formation; however, antibiotic stewardship, and once-a-day dosing favor CM. We aim to compare outcomes of postoperative antibiotic utilization using a large administrative database. METHODS We queried the Pediatric Health Information System for patients 2-18 years old who underwent laparoscopic appendectomy for complicated appendicitis between 2016 and 2021. Patients were grouped into PT, CM, or other using the first postoperative day antibiotics. Adverse events and antibiotic use trends were evaluated. RESULTS We included 29,015 children from 45 hospitals. CM was used in 51.9% and 31.3% received PT. Wide variation was seen among hospitals with PT use decreasing over the years. Overall rate of abscess was 9.2%. On multivariable regression, PT was associated with higher risk for abscess formation (RR 1.35, 99% CI 1.04-1.75) and readmission (RR 1.38, 99% CI 1.13-1.68) compared to the CM group. However, following adjustment for hospitals with high CM prevalence, these associations were no longer significant. CONCLUSION Postoperative use of PT for complicated appendicitis is associated with higher rates of readmissions and intraabdominal abscess when compared to CM. However, this effect is mitigated when adjusting for common practice patterns. LEVEL OF EVIDENCE Level III. STUDY TYPE Retrospective Comparative Study.
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Ott KC, Vacek JC, McMahon MA, Moeckel CM, Hu YY, Raval MV, Goldstein SD. Expedited Surgical Care of Appendicitis is Associated With Improved Resource Utilization. J Surg Res 2023; 282:93-100. [PMID: 36265430 DOI: 10.1016/j.jss.2022.08.012] [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: 12/27/2021] [Revised: 07/24/2022] [Accepted: 08/18/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Appendectomy for acute appendicitis is the most common pediatric intra-abdominal operation. Current literature supports the notion that modest in-hospital, preoperative delays are not associated with greater patient morbidity. However, there is less certainty regarding the role that hour-of-presentation plays in determining the timing of surgery. Thus, we aimed to evaluate how after-hours presentation may relate to the timing of surgery and to assess the outcomes and resource utilization associated with expedited appendectomy compared to nonexpedited. METHODS Patient records for children who underwent an appendectomy at a freestanding pediatric hospital from 2015 to 2019 were reviewed. Business hour presentations were defined as arrival at the emergency department from 7 AM to 6 PM. Primary outcomes were hospital length of stay (LOS), cost derived from the Pediatric Health Information System database, perforation, surgical complications, and 30-day readmissions. RESULTS Nine hundred forty-two patients underwent appendectomy over the study period. The median time to OR was 2.0 h in the expedited cohort and 9.8 h in the nonexpedited group. Presentation during business hours was associated with 4.4 higher odds (P < 0.001) of expedited workflow. Expedited appendectomies were associated with shorter hospital LOS (11.5 h, P < 0.001), less costly admissions ($1,155, P < 0.001); LOS measured in midnights, perforation and readmission rates were similar between groups. CONCLUSIONS We found reduced resource utilization associated with expedited appendectomy. Additionally, the demonstrated association between the time of presentation to the emergency department (ED) and the timing of surgery may be utilized to inform staffing and resource deployment decisions. Further research regarding the generalizability and sustainability of an expedited presurgical workflow in pediatric appendectomy is certainly indicated.
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Affiliation(s)
- Katherine C Ott
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Jonathan C Vacek
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maxwell A McMahon
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Camille M Moeckel
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Bălănescu R, Bălănescu L, Kadar AM, Enache T, Moga A. The Management of Pediatric Acute Appendicitis-Survey among Pediatric Surgeons in Romania. Medicina (B Aires) 2022; 58:medicina58121737. [PMID: 36556939 PMCID: PMC9781247 DOI: 10.3390/medicina58121737] [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: 10/02/2022] [Revised: 11/21/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
Background and Objectives: To assess the current practice pattern in the management of pediatric acute appendicitis in Romania. Materials and Methods: A questionnaire was emailed to all the members of the Romanian Society of Pediatric Surgery between June-July 2022. Results: 118 answers were received, 79.7% responses being from permanent staff members. In the diagnosis of appendicitis, complete blood count, C-reactive protein and abdominal ultrasound are the most commonly used diagnostic tools, while appendicitis scores are not widely used (25% of surgeons). In the case of simple appendicitis, 49.2% of surgeons prefer the conservative approach-oral/intravenous antibiotics. Those who choose the operative approach begin preoperative antibiotics in 56.7% of patients. In case of a stable patient, only 16.7% of surgeons will operate during the night. Laparoscopic approach is chosen by 51.7% of surgeons. In the case of a complicated appendicitis, 92.4% of surgeons will perform the appendectomy, prescribing preoperative antibiotics in 94% of the cases and continuing the therapy postoperatively in 98.2%. Laparoscopic approach is used by 28.8% of surgeons in case of complicated appendicitis. In presence of appendicular mass, 80% prefer a conservative approach with a delayed appendectomy within 6 months. Appendicular abscesses are managed operatively in 82.2% of the cases. The appendix is sent for histological analysis by 95.8% of surgeons. If the peritoneal cavity is contaminated, 95% of the respondents will take a sample for microbiological analysis, 71% will always place a drainage and 44% will always irrigate (71.9%-saline). Conclusions: Clearly, there seems to be a lack of consensus regarding several aspects of the management of acute appendicitis in children. In addition, minimally invasive surgery is not as widely used as reported, despite literature support.
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Affiliation(s)
- Radu Bălănescu
- Pediatric Surgery Department, “Grigore Alexandrescu” Clinical Emergency Hospital for Children, 011743 Bucharest, Romania
- Department of Pediatric Surgery and Orthopedics, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Laura Bălănescu
- Pediatric Surgery Department, “Grigore Alexandrescu” Clinical Emergency Hospital for Children, 011743 Bucharest, Romania
- Department of Pediatric Surgery and Orthopedics, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Correspondence: ; Tel.: +40-722984347
| | - Anna Maria Kadar
- Department of Pediatric Surgery and Orthopedics, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Pediatric Surgery Department, “M.S. Curie” Clinical Emergency Hospital for Children, 077120 Bucharest, Romania
| | - Tudor Enache
- Pediatric Surgery Department, “Grigore Alexandrescu” Clinical Emergency Hospital for Children, 011743 Bucharest, Romania
| | - Andreea Moga
- Pediatric Surgery Department, “Grigore Alexandrescu” Clinical Emergency Hospital for Children, 011743 Bucharest, Romania
- Department of Pediatric Surgery and Orthopedics, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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10
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Roberts BK, Alonso D, Terp K, Metellus B, Calisto JL, Malvezzi L, Burnweit CA, Alkhoury F. Using NSQIP to improve perforated appendicitis protocol and better resource allocation. SURGERY IN PRACTICE AND SCIENCE 2022; 9:100074. [PMID: 39845064 PMCID: PMC11749822 DOI: 10.1016/j.sipas.2022.100074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022] Open
Abstract
•NSQIP is a useful tool for drawing attention to areas for quality improvement.•NSQIP is not sufficient to evaluate institutional practices and requires supplemental review.•Evaluating and adjusting protocols is important for continued benefit in patient outcomes.•Resource utilization should be considered when considering quality improvement studies.
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Affiliation(s)
- Bailey K Roberts
- Northwell Health, Department of Surgery, New Hyde Park, NY, United States
| | - Dailen Alonso
- Nicklaus Children's Hospital, Department of Pediatric Surgery, Florida International University Herbert Wertheim College of Medicine, Miami, FL, United States
| | - Kristy Terp
- Nicklaus Children's Hospital, Department of Pediatric Surgery, Florida International University Herbert Wertheim College of Medicine, Miami, FL, United States
| | - Betsy Metellus
- Nicklaus Children's Hospital, Department of Pediatric Surgery, Florida International University Herbert Wertheim College of Medicine, Miami, FL, United States
| | - Juan L Calisto
- Nicklaus Children's Hospital, Department of Pediatric Surgery, Florida International University Herbert Wertheim College of Medicine, Miami, FL, United States
| | - Leopoldo Malvezzi
- Nicklaus Children's Hospital, Department of Pediatric Surgery, Florida International University Herbert Wertheim College of Medicine, Miami, FL, United States
| | - Cathy A Burnweit
- Nicklaus Children's Hospital, Department of Pediatric Surgery, Florida International University Herbert Wertheim College of Medicine, Miami, FL, United States
| | - Fuad Alkhoury
- Nicklaus Children's Hospital, Department of Pediatric Surgery, Florida International University Herbert Wertheim College of Medicine, Miami, FL, United States
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11
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Ferguson DM, Arshad SA, Avritscher EB, Li LT, Austin MT, Kawaguchi AL, Lally KP, Tsao K. Costs associated with postoperative intra-abdominal abscess in pediatric perforated appendicitis: A retrospective cohort study. Surgery 2022; 172:212-218. [PMID: 35279294 DOI: 10.1016/j.surg.2022.01.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/18/2021] [Accepted: 01/28/2022] [Indexed: 12/29/2022]
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12
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Shaughnessy MP, Maassel NL, Yung N, Solomon DG, Cowles RA. Laparoscopy is increasingly used for pediatric inguinal hernia repair. J Pediatr Surg 2021; 56:2016-2021. [PMID: 33549307 DOI: 10.1016/j.jpedsurg.2021.01.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Inguinal hernia repairs (IHR) are commonly performed by pediatric surgeons in the United States. The operative approach depends on surgeon preference with no definitive prospective studies comparing laparoscopic inguinal hernia repair (LIHR) versus traditional inguinal hernia repair (TIHR). We aim to assess current practice, hypothesizing that laparoscopy is increasingly used for pediatric IHR. MATERIAL & METHODS The Children's Hospital Association (CHA) Pediatric Health Information System was queried for IHRs performed between 01/01/2009 and 12/31/2018. Demographics, procedure type, hernia laterality, and cost were obtained. Patients were grouped by procedure type (laparoscopic/traditional). RESULTS 125,249 IHRs were performed at 32 CHA hospitals during the ten-year study period. 115,782 (92.4%) were TIHR and 9467 (7.6%) LIHR. Use of laparoscopy increased 5-fold from 3% to 15% over the study period. When comparing laparoscopic to traditional IHR groups, there were more females (28.3% vs 12.6%), African-Americans (19.7% vs 14.4%), government-insured (50% vs 45.2%), younger patients (4.2 vs 4.4 years), bilateral IHRs (11.4% vs 7.9%), and higher adjusted total hospital cost ($3,791 vs $2995) in the laparoscopic group (p<0.0001, all comparisons). CONCLUSIONS Laparoscopy for pediatric IHR is increasing at CHA hospitals where nearly 1 in 6 children currently undergoes a laparoscopic repair. The long-term outcomes with laparoscopic repair are worthy of future study.
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Affiliation(s)
- Matthew P Shaughnessy
- Department of Surgery, Division of Pediatric Surgery at Yale University, 333 Cedar St, FMB 131, New Haven, CT, United States
| | - Nathan L Maassel
- Department of Surgery, Division of Pediatric Surgery at Yale University, 333 Cedar St, FMB 131, New Haven, CT, United States
| | - Nicholas Yung
- Department of Surgery, Division of Pediatric Surgery at Yale University, 333 Cedar St, FMB 131, New Haven, CT, United States
| | - Daniel G Solomon
- Department of Surgery, Division of Pediatric Surgery at Yale University, 333 Cedar St, FMB 131, New Haven, CT, United States
| | - Robert A Cowles
- Department of Surgery, Division of Pediatric Surgery at Yale University, 333 Cedar St, FMB 131, New Haven, CT, United States.
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13
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IMPPACT (Intravenous Monotherapy for Postoperative Perforated Appendicitis in Children Trial): Randomized Clinical Trial of Monotherapy Versus Multi-drug Antibiotic Therapy. Ann Surg 2021; 274:406-410. [PMID: 34132703 DOI: 10.1097/sla.0000000000005006] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Perforated appendicitis is the most common cause of intraabdominal abscess (IAA) in children. The optimal postoperative antibiotic regimen to reduce IAA has evolved in the last decade from triple-drug to 2-drug therapy (CM). Recent retrospective studies show decreased infectious complications with monotherapy PT. To date prospective comparative data are lacking. Therefore, a prospective randomized trial comparing PT versus CM was conducted. METHODS A multi-institutional prospective randomized trial was performed in children with perforated appendicitis comparing postoperative antibiotic regimens PT or CM. The primary outcome was 30-day postoperative IAA formation. Perforation was strictly defined as a hole in the appendix or fecalith in the abdomen, documented with intraoperative photographs. RESULTS One hundred sixty-two patients were enrolled during the study period. No differences in age, weight, or duration of presenting symptoms were identified. In addition, length of stay, duration of intravenous antibiotic treatment, discharge oral antibiotic treatment, and antibiotic-related complications did not differ between groups. Compared to the CM group, the PT group had significantly lower IAA rate [6.1% vs 23.8%, odd ratio (OR) 4.80, P = 0.002], lower postoperative computed tomography imaging rate (13.9% vs 29.3%, OR 2.57, P = 0.030), and fewer emergency room visits (8.8% vs 26.4%, OR 3.73, P = 0.022). Multivariate logistic regression analysis found the use of CM versus PT (OR 9.21, P = 0.021) to be the most significant predictor for developing IAA. CONCLUSIONS In children with perforated appendicitis, postoperative monotherapy with PT is superior to standard 2-drug therapy with CM and does not increase antibiotic-related complications or antibiotic exposure duration.
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14
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Do-Wyeld M, Cundy TP, Court-Kowalski S, Dandie L, Cooper C, Burgoyne L, Cooksey R, Khurana S. Improving quality and efficiency of care for advanced appendicitis in children. ANZ J Surg 2021; 91:1497-1503. [PMID: 34013543 DOI: 10.1111/ans.16929] [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: 01/05/2020] [Revised: 04/04/2021] [Accepted: 04/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Complicated appendicitis encompasses a spectrum of severity with heterogeneity in definition and substantial variation in care. Enhanced recovery after surgery or 'fast-track' protocols aim to reduce practice variation by standardizing care. These initiatives may improve quality and efficiency of care, preserve resources and expedite discharge. This study aims to evaluate the impact of a standardized Enhanced Recovery Pathway (ERP) on the post-operative recovery of children with a subset of complicated appendicitis termed 'advanced' appendicitis. METHODS We defined advanced appendicitis as gangrenous or suppurative appendicitis without perforation, contained iatrogenic perforation, or localized purulent fluid. Children with operative findings reflecting these criteria were enrolled in the ERP protocol. Key protocol components include early upgrade of diet, avoidance of intravenous analgesia, abridged intravenous antibiotics, early ambulation and standardized discharge criteria. The study period was May 2018 to June 2019. A historical cohort was used as the comparator group. RESULTS Outcomes for 44 children treated under the ERP were compared to 44 historical controls. There was a 20% reduction in median post-operative length of stay (1.80 vs. 2.24 days, p = 0.02). Intravenous analgesia was received by fewer patients (6.8% vs. 36.4%, p = 0.01) with significant reduction in antiemetic requirement (p = 0.03). No significant difference in 30-day complication rates was observed. CONCLUSION Reduced post-operative length of stay and reduction in practice variation were achieved after implementation of a 'fast-track' protocol for children with advanced appendicitis. Additional benefits of this protocol include reduced provision of intravenous morphine analgesia, decreased resource use and cost savings.
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Affiliation(s)
- Montgommery Do-Wyeld
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Thomas P Cundy
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
| | - Stefan Court-Kowalski
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
| | - Lynda Dandie
- Health Information and Decision Support, Women's and Children's Health Network, Adelaide, South Australia, Australia
| | - Celia Cooper
- Department of Infectious Diseases, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Laura Burgoyne
- Department of Children's Anaesthesia, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Rebecca Cooksey
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Sanjeev Khurana
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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15
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Ferguson DM, Anderson KT, Arshad SA, Garcia EI, Hebballi NB, Li LT, Kawaguchi AL, Lally KP, Tsao K. Prophylactic intraabdominal drains do not confer benefit in pediatric perforated appendicitis: Results from a quality improvement initiative. J Pediatr Surg 2021; 56:727-732. [PMID: 32709531 DOI: 10.1016/j.jpedsurg.2020.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/29/2020] [Accepted: 06/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND/PURPOSE Prophylactic, intraabdominal drains have been used to prevent intraabdominal abscess (IAA) after perforated appendicitis. We hypothesized that routine drain placement would reduce the IAA rate in pediatric perforated appendicitis. METHODS A 27-month quality improvement (QI) initiative was conducted: closed-suction, intraabdominal drains were placed intraoperatively in pediatric (age < 18) perforated appendicitis patients. QI patients were compared to controls admitted during the preceding 8 months and following 4 months. The primary outcome was 30-day IAA rate. Univariate and multivariate analyses were performed. RESULTS Two hundred seventy QI patients were compared to 109 controls. There was 100% compliance during 21 of 27 months of the QI initiative; only 7 QI patients did not receive drains. IAA occurred in 20.0% of QI patients and 22.9% of control (p = 0.52). After adjustment, the QI initiative was not associated with reduced odds of IAA (OR 0.83, 95% CI 0.48-1.44). Median length of stay was longer in QI patients during the index admission (p = 0.03) and over 30 postoperative days (p = 0.03), but these relationships did not persist after adjustment. CONCLUSIONS A QI initiative investigating prophylactic, intraabdominal drain placement in perforated appendicitis did not reduce the IAA rate. We recommend against routine drain placement in pediatric perforated appendicitis. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Dalya M Ferguson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - K Tinsley Anderson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Seyed A Arshad
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Elisa I Garcia
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Nutan B Hebballi
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Linda T Li
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Akemi L Kawaguchi
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States.
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16
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Timeliness of pediatric surgical appendicitis care is associated with time of hospital admission. Surgery 2021; 170:224-231. [PMID: 33568332 DOI: 10.1016/j.surg.2020.12.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/03/2020] [Accepted: 12/23/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Despite the frequency of acute appendicitis in children, there is no evidence-based consensus surrounding the urgency of the operation if a diagnosis is made after regular business hours. Although a modest delay in time to operation does not increase disease severity, postponing cases to the next calendar day may be associated with higher resource utilization. We aimed to evaluate the trend of delaying appendectomies to the next calendar day and its associated outcomes. METHODS We queried the Pediatric Health Information System to analyze appendectomy patients younger than 18 y of age from 2010 to 2018. Same-day appendectomy and next-day appendectomy cohorts were created using admission hour and operative day. Healthcare cost, length of stay, surgical complications, and 30-day readmission rates were collected. Bivariate analyses and multivariable regressions were used to evaluate groups stratified by time of presentation. RESULTS During the study period, 113,662 appendectomies were performed, comprising 88,715 (78.1%) same-day appendectomies and 24,947 (21.9%) next-day appendectomies. A higher proportion of same-day appendectomies (80.5%) were performed during hours 12:00am to 5:00pm and 19.5% were performed during hours 6:00pm to 11:00pm. The trend of next-day appendectomies increased during the study period from 13.9% to 20.2%. This was primarily evident in the 6:00pm to 11:00pm period. The 5:00pm cutoff was most predictive of a next-day appendectomy. Next-day appendectomies had similar rates of surgical complications; however, they were associated with higher costs, longer lengths of stay, and higher readmission rates. CONCLUSION As the understanding of appendicitis urgency has changed, a more tempered approach of delivering surgical care has trended. Although short delays appear safe, postponement to the next calendar day is associated with higher resource utilization.
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17
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Burjonrappa S. Study of social disparities in pediatric laparoscopic appendectomy outcomes and cost. SAGE Open Med 2021; 9:2050312121989627. [PMID: 33552518 PMCID: PMC7841672 DOI: 10.1177/2050312121989627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 12/30/2020] [Indexed: 11/28/2022] Open
Abstract
Purpose: There is an increasing focus on racial and social disparities in health care. There have been several studies that have documented disparities in outcome between racial groups in the adult literature. Not much is known about disparities in outcomes after surgical procedures in children. The purpose of this study was to investigate the effect of race on complications (outcomes) and costs after laparoscopic appendectomy. Methods: This study is a single-center retrospective chart review of 248 pediatric patients who underwent appendectomies for uncomplicated acute appendicitis from 2015 to 2017. Patients were divided into minority (Africa American or Hispanic) and non-minority groups, and length of stay, preoperative and postoperative factors, and total costs were compared. Results: Of 185 eligible patients, 45.9% (n = 85) were of Hispanic or African American ethnicity and 54.1% (n = 100) were Caucasian. About 11.8% of minority patients had comorbidities and 12% of majority patients had comorbidities (p = 1). Readmission rate for minority group patients was 3.5% (n = 3) and 2% (n = 2) for majority patients (p = 0.7). The average cost of hospital stay for minority patients was $30,900 and for majority patients was $31,111 (p = 0.59). Conclusions: Standardization of care protocols has reduced social/racial disparities in surgical outcomes. In the most common pediatric surgery emergency procedure, laparoscopic appendectomy, there were no differences in outcomes or costs between minority (Hispanic/Africa American) and Caucasian ethnic groups. Level of evidence: Level III Type of study: Clinical Study
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Affiliation(s)
- Sathyaprasad Burjonrappa
- Winthrop University Hospitals, Mineola, NY, USA.,Rutgers State University of New Jersey, Bristol Myers Squibb Children's Hospital, New Brunswick, NJ, USA
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18
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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: 0.5] [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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Khan S, Siow VS, Lewis A, Butler G, Narr M, Srinivasan S, Michaels M, Mollen K. An Evidence-Based Care Protocol Improves Outcomes and Decreases Cost in Pediatric Appendicitis. J Surg Res 2020; 256:390-396. [PMID: 32771703 PMCID: PMC7864993 DOI: 10.1016/j.jss.2020.05.067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/20/2020] [Accepted: 05/03/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Appendicitis is a common indication for urgent abdominal surgery in the pediatric population. The postoperative management varies significantly in time to discharge and cost of care. The objective of this study was to investigate whether implementation of an evidence-based protocol after an appendectomy would lead to decreased length of stay and cost of care. METHODS In 2014 at the Children's Hospital of Pittsburgh, an initiative to develop an evidenced-based protocol to treat appendicitis was undertaken. A work group was formed of pediatric surgeons and other important personnel to determine best practices. Treatment pathways were created. Pathways differed with recommendation on postoperative antibiotic choice and duration, diet initiation, and discharge criteria. Data were prospectively gathered from all patients (ages 0-18 y) with acute appendicitis from January 2015 to December 2016. Primary outcomes were length of stay and cost of care. Secondary outcomes were surgical site infection, readmission rate, and duration of postoperative antibiotics. RESULTS Among the 1289 patients, 481 patients were in the preprotocol cohort and 808 patients were in the postprotocol cohort. 27% of patients had an intraoperative diagnosis of complicated appendicitis. There was a significantly shorter length of stay in the postprotocol cohort (P < 0.001). Median costs for the whole cohort decreased 0.6% and 24.6% for patients with complicated appendicitis after protocol initiation (P < 0.01). CONCLUSIONS This study has demonstrated that introduction of an evidence-based clinical care protocol for pediatric patients with appendicitis leads to shorter hospital stay and decreased hospital costs.
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Affiliation(s)
- Sidrah Khan
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Vei Shaun Siow
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anthony Lewis
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gabriella Butler
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marissa Narr
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Suresh Srinivasan
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marian Michaels
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kevin Mollen
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.
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Devin CL, D'Cruz R, Linden AF, English S, Vinocur CD, Reichard KW, Berman L. Reducing resource utilization for patients with uncomplicated appendicitis through use of same-day discharge and elimination of postoperative antibiotics. J Pediatr Surg 2020; 55:2591-2595. [PMID: 32482411 DOI: 10.1016/j.jpedsurg.2020.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/11/2020] [Accepted: 04/06/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND There is controversy over certain aspects of post-appendectomy care for children with uncomplicated appendicitis. Some institutions have embraced the practice of same-day discharge after appendectomy, while others are hesitant due to concerns about increased readmissions or emergency department (ED) visits. Similarly, some surgeons have transitioned to treating gangrenous appendicitis with a single perioperative dose, while others are concerned about increased risk of infection in this population. METHODS We developed a pathway for the management of patients undergoing appendectomy for uncomplicated acute appendicitis which included same-day discharge and elimination of postoperative antibiotics for patients with gangrenous appendicitis. We compared outcomes for children treated at our institution before and after implementation of the protocol. RESULTS We identified 575 patients undergoing appendectomy for uncomplicated appendicitis (307 pre- and 268 post-protocol). We observed a significant decrease in postoperative length-of stay (10.6 to 2.6 h, p < 0.0001). There were no increases in postoperative complications, such as superficial (2.6% vs 1.1%, p = 0.19) or organ-space surgical-site infection (1.6% vs 0.4%, p = 0.14), percutaneous drain placement (1.3% vs 0%, p = 0.06), postoperative ED visits (5.5% vs 5.2%, p = 0.87) or readmission (3.3% vs 1.5%, p = 0.17). CONCLUSIONS These findings suggest that incorporating same-day discharge for simple appendicitis and eliminating postoperative antibiotics for children with gangrenous appendicitis does not increase complication rates. Implementation of similar pathways across institutions has the potential to significantly reduce resource utilization for children undergoing appendectomy for uncomplicated appendicitis. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Courtney L Devin
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA.
| | - Roshan D'Cruz
- Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Allison F Linden
- Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Sharon English
- Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Charles D Vinocur
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA; Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Kirk W Reichard
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA; Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Loren Berman
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA; Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
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A Standardized Protocol for the Management of Appendicitis in Children Reduces Resource Utilization. Pediatr Qual Saf 2020; 5:e357. [PMID: 33134759 PMCID: PMC7591119 DOI: 10.1097/pq9.0000000000000357] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/03/2020] [Indexed: 11/26/2022] Open
Abstract
Appendicitis is the most common condition requiring emergency surgery in children. We implemented a standardized protocol (SP) for treating children with appendicitis to provide more uniform care and reduce resource utilization.
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Rossidis AC, Brown EG, Payton KJ, Mattei P. Implementation of an evidence-based protocol after appendectomy reduces unnecessary antibiotics. J Pediatr Surg 2020; 55:2379-2386. [PMID: 32753275 DOI: 10.1016/j.jpedsurg.2020.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 06/29/2020] [Accepted: 07/02/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Children with acute appendicitis have historically received intravenous antibiotics before and after appendectomy, yet recent literature supports minimizing postoperative antibiotics. In this study, we examined the impact of a standardized protocol that eliminates postoperative antibiotics for nonperforated appendicitis and discontinues antibiotics at discharge for perforated appendicitis. METHODS A retrospective review of all pediatric patients who underwent laparoscopic appendectomy for acute appendicitis between May 2013 and March 2017 was performed. Preprotocol patients (5/1/2013-3/31/2015) were compared to postprotocol patients (5/1/2015-3/31/2017), excluding those who underwent surgery during the month of protocol introduction (4/2015). Primary outcomes were postoperative antibiotic doses for nonperforated cases and antibiotics after discharge for perforated cases. Mann-Whitney and Fisher's exact tests were performed. RESULTS Laparoscopic appendectomy was performed in 748 children before (PRE) and in 814 children after (POST) protocol implementation. Perforation rates were similar (POST 21.5 vs. PRE 21.8%, p=0.90). For nonperforated appendicitis, postoperative antibiotics were reduced (median 0 [IQR 0-0] vs. 3 [0-5] doses, p<0.001), and more patients were discharged less than 24 h after surgery (65.7 vs. 40.9%, p<0.001). Fewer patients with perforated appendicitis underwent PICC placement (8.6 vs. 21.0%, p=0.002), and fewer patients were prescribed antibiotics on discharge (33.7 vs. 89.0%, p<0.001). There were no differences between groups for complication, readmission, or return to ED rates. CONCLUSION For children with acute appendicitis, a standardized protocol can safely reduce unnecessary antibiotics and decrease length of stay. Furthermore, the judicious use of antibiotics does not increase SSI, readmission, or overall complication rates. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Avery C Rossidis
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - Erin G Brown
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - K Joy Payton
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - Peter Mattei
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104.
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Ferguson DM, Ferrante AB, Orr HA, Arshad SA, Curbo ME, Parker TD, Chang ML, Tsao K. Clinical Practice Guideline Nonadherence and Patient Outcomes in Pediatric Appendicitis. J Surg Res 2020; 257:135-141. [PMID: 32828996 DOI: 10.1016/j.jss.2020.07.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 06/19/2020] [Accepted: 07/11/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Clinical practice guidelines (CPGs) have been associated with improved patient outcomes. We aimed to evaluate institutional CPG adherence and hypothesized that adherence would be associated with fewer complications in pediatric appendicitis. METHODS A retrospective review was conducted of pediatric (<18 y) appendicitis patients who underwent appendectomy (6/1/2017-5/30/2018). Patients were managed using an institutional pediatric appendicitis CPG. The primary outcome was CPG adherence, defined as receipt of preoperative antibiotics at diagnosis, surgical prophylaxis before incision, and, in perforated/gangrenous appendicitis, continued postoperative antibiotics, and prescription for discharge antibiotics. Univariate and multivariate analyzes were performed. RESULTS Among 399 patients, the baseline characteristics were similar between CPG-adherent and nonadherent patients. Overall CPG adherence was low at 55% (n = 221). Only 58% of patients received preoperative antibiotics per protocol (n = 233). Patients with simple appendicitis were more likely to proceed to surgery without receiving any preoperative antibiotics (35% vs. 21%, P = 0.004). Surgical prophylaxis compliance was high at 97% (n = 389). CPG violation was associated with reoperation (n = 5 versus 0, P = 0.02). After adjusting for age and admission white blood cell count, the association between CPG adherence and postoperative surgical site infection or intra-abdominal abscess remained nonsignificant (OR: 1.2, 95% CI: 0.5-2.5). CONCLUSIONS Despite a long-standing pediatric appendicitis CPG, adherence with antibiotic components of the CPG was poor. CPG violation was significantly associated with reoperation, but was not associated with other postoperative complications. Regular audits of CPG adherence are necessary to ascertain reasons for noncompliance and identify ways to improve adherence.
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Affiliation(s)
- Dalya M Ferguson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| | | | - Hillary A Orr
- Children's Memorial Hermann Hospital, Houston, Texas
| | - Seyed A Arshad
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - Maile E Curbo
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Tayler D Parker
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Michael L Chang
- Children's Memorial Hermann Hospital, Houston, Texas; Division of Pediatric Infectious Diseases, Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
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Mennie N, Panabokke G, Chang A, Tanny ST, Cheng W, Pacilli M, Ferguson P, Nataraja RM. Are Postoperative Intravenous Antibiotics Indicated After Laparoscopic Appendicectomy for Simple Appendicitis? A Prospective Double-blinded Randomized Controlled Trial. Ann Surg 2020; 272:248-252. [PMID: 32675537 DOI: 10.1097/sla.0000000000003732] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND There is limited evidence for the use of postoperative antibiotics for simple appendicitis (SA) in children. Our aim was to conduct a prospective double-blinded randomized controlled trial to investigate this after a laparoscopic appendicectomy. METHODS Following ethical approval, children (≤16 years) undergoing appendicectomy were recruited at a single institution. Patients were randomized intraoperatively to receive either 2 postoperative intravenous doses of placebo or antibiotics (Abx). All patients received a dose of Abx at induction of anesthesia. Primary outcome was the incidence of postoperative wound infection (WI), and secondary outcome was the incidence of intra-abdominal abscess formation. Data are reported as number of cases (%), median (range), relative risk, and analyzed using Mann Whitney U test, Chi-square test, as appropriate, a P-value ≤0.05 was considered significant. RESULTS A total of 304 patients were randomized. Sixty-one were subsequently excluded due to protocol violations or recruitment errors; therefore, 243 were included in the final analysis. One hundred twenty-two patients received placebo and 121 Intravenous Abx. There was no difference between the sex (50F/72 M vs 47F/74 M, P = 0.8), median age (12.4 vs 12.2 years, P = 0.5), and postoperative length of stay in a hospital (27.2 vs 25.6 hours, P = 0.7). There was also no difference in the preoperative blood results. A total of 9 WIs occurred: 8/122 (6.6%) placebo versus 1/121 (0.8%) Abx, P = 0.01 [relative risk for WI 7.9 (95% confidence interval: 1.0-62.4)]. There were no intra-abdominal abscess in either groups. CONCLUSIONS This prospective randomized double blinded randomized controlled trial has revealed a significant decrease in WI rates by giving 2 postoperative intravenous doses of Abx, suggesting postoperative Abx are of benefit in SA.
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Affiliation(s)
- Nicole Mennie
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
| | - Gayathri Panabokke
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
| | - Annette Chang
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
| | - Sharman Tan Tanny
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
| | - Wei Cheng
- Department of Pediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- New Century Healthcare, Hong Kong
| | - Maurizio Pacilli
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
- Department of Pediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Peter Ferguson
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
| | - Ramesh M Nataraja
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
- Department of Pediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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Prolonged In-hospital Time to Appendectomy is Associated With Increased Complicated Appendicitis in Children. Ann Surg 2020; 275:1200-1205. [PMID: 32740232 DOI: 10.1097/sla.0000000000004316] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the association between prolonged in-hospital time to appendectomy (TTA) and the risk of complicated appendicitis. SUMMARY BACKGROUND DATA Historically, acute appendicitis was treated with emergency appendectomy. More recently, practice patterns have shifted to urgent appendectomy, with acceptable in-hospital delays of up to 24 hours. However, the consequences of prolonged TTA remain poorly understood. Herein, we present the largest individual analysis to date of outcomes associated with prolonged in-hospital delay before appendectomy in children. METHODS Data from patients who underwent appendectomy within 24 hours of hospital presentation were obtained from the American College of Surgeons Pediatric National Surgical Quality Improvement Program Procedure Targeted Appendectomy database from 2016 to 2018. Appendectomy within 16 hours of presentation was considered early, whereas those between 16 to 24 hours were defined as late. The primary outcome was operative findings of complicated appendicitis. Secondary outcomes included 30-day complications and resource utilization. RESULTS This study consisted of 18,927 patients, with 20.6% undergoing late appendectomy. The rate of complicated appendicitis was significantly higher in the late group (Early: 26.3%, Late: 30.3%, P < 0.05). Additionally, the late group had longer operative times, increased need for postoperative percutaneous drainage, antibiotics at discharge, parenteral nutrition, and an extended hospital length of stay (P < 0.05). On multivariate analysis, late appendectomy remained a predictor of complicated disease (odds ratio 1.17 [95% confidence interval, 1.08-1.27]). CONCLUSIONS A significant proportion of pediatric patients with acute appendicitis experience prolonged in-hospital delays before appendectomy, which are associated with modestly increased rates of complicated appendicitis. Although this does not indicate appendectomy needs to be done emergently, prolonged in-hospital TTA should be avoided whenever possible.
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Ferguson DM, Parker TD, Arshad SA, Garcia EI, Hebballi NB, Tsao K. Standardized Discharge Antibiotics May Reduce Readmissions in Pediatric Perforated Appendicitis. J Surg Res 2020; 255:388-395. [PMID: 32615311 DOI: 10.1016/j.jss.2020.05.086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/21/2020] [Accepted: 05/24/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Based on limited evidence, the American Pediatric Surgical Association recommends 5-7 d of postoperative antibiotics in perforated appendicitis for preventing intra-abdominal abscess (IAA). In 2015, our institutional clinical practice guideline was modified to standardize prescription for 7 additional days of oral antibiotics after discharge. We hypothesized that prescribing oral antibiotics after discharge would be associated with fewer complications in perforated appendicitis. MATERIALS AND METHODS A retrospective cohort study was conducted of pediatric (younger than 18 y) patients who underwent laparoscopic appendectomy for perforated appendicitis (August 1, 2012-April 30, 2019). Patients diagnosed with IAA before discharge or with a postoperative length of stay ≥8 d were excluded. Patient outcomes were compared prestandardization and poststandardization of discharge antibiotics. RESULTS Of 617 patients, 212 (34.5%) were admitted prestandardization and 404 (65.5%) poststandardization. Overall, 409 patients (66.3%) received discharge antibiotics. The median total postoperative antibiotic duration was 4 d (interquartile range, 3-5) prestandardization versus 11 d (interquartile range, 10-12) poststandardization (P < 0.001). Prestandardization patients had a higher rate of IAA (8.9% versus 4.5%, P = 0.03) and were readmitted more frequently (13.1% versus 6.4%, P = 0.005). On adjusted analysis, admission poststandardization was associated with reduced odds of IAA (odds ratio, 0.51; 95% confidence interval, 0.25-1.06), but the relationship was imprecise. Admission poststandardization was significantly associated with reduced adjusted odds of readmission (odds ratio, 0.46; 95% confidence interval, 0.25-0.85). CONCLUSIONS Prescription for seven additional days of oral antibiotics after discharge was associated with reduced odds of readmission in pediatric perforated appendicitis. This population may benefit from a longer postoperative antibiotic course than currently recommended.
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Affiliation(s)
- Dalya M Ferguson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - Tayler D Parker
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Seyed A Arshad
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - Elisa I Garcia
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Nutan B Hebballi
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
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Pogorelić Z, Silov N, Jukić M, Elezović Baloević S, Poklepović Peričić T, Jerončić A. Ertapenem Monotherapy versus Gentamicin Plus Metronidazole for Perforated Appendicitis in Pediatric Patients. Surg Infect (Larchmt) 2019; 20:625-630. [PMID: 31099712 DOI: 10.1089/sur.2019.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Zenon Pogorelić
- Department of Pediatric Surgery, University Hospital of Split, Split, Croatia
- University of Split School of Medicine, Split, Croatia
| | - Nikica Silov
- University of Split School of Medicine, Split, Croatia
| | - Miro Jukić
- Department of Pediatric Surgery, University Hospital of Split, Split, Croatia
| | | | - Tina Poklepović Peričić
- Department of Research in Biomedicine and Health, University of Split School of Medicine, Split, Croatia
| | - Ana Jerončić
- Department of Research in Biomedicine and Health, University of Split School of Medicine, Split, Croatia
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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: 1.7] [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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Savoie KB, Shelby RD, Dykes MW, Diefenbach KA, Besner GE, Kenney BD. Volume of Irrigation Does Not Affect Rate of Abscess in Perforated Appendicitis. J Laparoendosc Adv Surg Tech A 2019; 29:1232-1238. [PMID: 31524565 DOI: 10.1089/lap.2019.0183] [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: 11/13/2022] Open
Abstract
Background: Although previous studies have evaluated whether use of irrigation decreases postoperative intraabdominal abscess (PO-IAA) formation, these studies treated irrigation as a dichotomous variable and concluded that no irrigation resulted in a decreased incidence of PO-IAA formation. However, a recent study found decreased incidence with small aliquots to a total volume of 6 L. We hypothesized that higher volumes of irrigation would result in a lower incidence of PO-IAA. Materials and Methods: A postoperative template was developed as a quality improvement initiative and included descriptors for complex appendicitis and volume of irrigation. Data were prospectively collected from February 2016 to December 2018. Patients with complex appendicitis (fibropurulent exudate, extraluminal fecalith, well-formed abscess, visible hole in the appendix) were identified and analyzed by using standard statistical analysis. Volume of irrigation was categorized for analysis. Results: Two thousand three hundred six appendicitis patients were identified; 408 had complex appendicitis (17.7%). Three hundred eighty-four patients with complex appendicitis had documented irrigation volumes. The overall incidence of PO-IAA was 13.8%. Irrigation was commonly used (92.7%). The median amount of irrigation was 1000 mL (500 mL, 2500 mL), but it ranged from none to 9000 mL. There was no overall difference in the volume of irrigation used between those who developed a PO-IAA and those who did not (P = .34). No specific intraoperative finding was associated with the development of PO-IAA. Increasing volume of irrigation did not lower PO-IAA incidence (P = .24). Conclusions: The volume of irrigation did not appear to affect the rate of PO-IAA formation. The use of irrigation should be left to the discretion of the operating surgeon.
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Affiliation(s)
- Kate B Savoie
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Rita D Shelby
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Michael W Dykes
- Department of Quality Improvement, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Gail E Besner
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Brian D Kenney
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio
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Jones RE, Gee KM, Preston SC, Babb JL, Beres AL. Diagnostic Utilization and Accuracy of Pediatric Appendicitis Imaging at Adult and Pediatric Centers. J Surg Res 2019; 240:97-103. [DOI: 10.1016/j.jss.2019.02.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/29/2019] [Accepted: 02/22/2019] [Indexed: 12/29/2022]
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Abstract
Background Data on common practice in the management of patients with complex appendicitis are scarce, especially for the adult population. Variation in the definition of complex appendicitis, indications for and the type of prolonged antibiotic prophylaxis have not been well studied yet. The aim of this study was to document current practice of the classification and postoperative management of complex appendicitis on an international level. Methods An online survey was dispersed among practicing surgeons and surgical residents. Survey questions pertained to the definition of a complex appendicitis, indications for antibiotic prophylaxis after appendectomy, the duration, route of administration and antibiotic agents used. Results A total of 137 survey responses were eligible for analysis. Most respondents were from Northern or Western Europe and were specialized in gastrointestinal surgery. Opinion varied substantially regarding the management of appendicitis, in particular for phlegmonous appendicitis with localized pus, gangrenous appendicitis and iatrogenic rupture of appendicitis. The most common duration of postoperative antibiotics was evenly spread over <3, 3, 5 and 7 days. Whereas most respondents indicated a combined intravenous and oral route of administration was common practice, 28% answered a completely intravenous route of administration was standard practice. Conclusion Current practice patterns in the classification and postoperative management of complex appendicitis are highly variable. Electronic supplementary material The online version of this article (10.1007/s00268-018-4806-4) contains supplementary material, which is available to authorized users.
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Bonasso PC, Dassinger MS, Wyrick DL, Smith SD, Burford JM. Evaluation of white blood cell count at time of discharge is associated with limited oral antibiotic therapy in children with complicated appendicitis. Am J Surg 2019; 217:1099-1101. [PMID: 30639131 DOI: 10.1016/j.amjsurg.2018.12.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 12/20/2018] [Accepted: 12/29/2018] [Indexed: 10/27/2022]
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Gee KM, Jones RE, Babb JL, Preston SC, Beres AL. Clinical and Imaging Correlates of Pediatric Mucosal Appendicitis. J Surg Res 2019; 242:111-117. [PMID: 31075655 DOI: 10.1016/j.jss.2019.04.039] [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: 12/06/2018] [Revised: 03/20/2019] [Accepted: 04/09/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Mucosal appendicitis is a controversial entity that is histologically distinct from transmural appendicitis. There is mixed opinion regarding mucosal inflammation as a spectrum of appendicitis versus a negative appendectomy. The ability to distinguish these diagnoses preoperatively is of importance to prevent unnecessary surgery. We hypothesize that patients with mucosal appendicitis can be discriminated from those with transmural disease based on specific preoperative clinical and imaging findings. MATERIALS AND METHODS After IRB approval, all patients who underwent laparoscopic appendectomy at our institution during 2015 were reviewed in the electronic medical record. Patients with mucosal appendicitis were identified and matched 2:1 to a random cohort of nonperforated transmural appendicitis cases. Demographic and clinical data were collected, including history, examination, laboratory, and imaging findings. Preoperative factors associated with mucosal appendicitis were modeled using binomial logistic regression analysis. RESULTS Of 1153 appendectomies performed during 2015, 103 patients had pathologic diagnosis of mucosal appendicitis. When compared with patients with mucosal infection, leukocytosis >10,000 per microliter led to 5.9 times higher likelihood of transmural pathology (P = 0.000). Noncompressibility on ultrasound was associated with 7.3 times higher likelihood of transmural disease (P = 0.015). Echogenic changes were predictive of transmural appendicitis, conferring 3.9 times the risk (P = 0.007). Presence of free fluid led to 2.3 times the rate of transmural pathology (P = 0.007). Finally, for every millimeter decrease in appendiceal diameter, patients were half as likely to exhibit transmural disease (P = 0.000). Together, these variables can successfully predict presence of mucosal appendicitis on final pathology report at a rate of 82.1%, and explain 60% of the variance in diagnosis of mucosal versus transmural appendicitis (P = 0.000). CONCLUSIONS Mucosal appendicitis remains a controversial pathologic entity, but is not associated with greater complications compared with transmural appendicitis when treated with laparoscopic appendectomy. Transmural disease can be predicted by leukocytosis, noncompressible appendix, presence of free fluid, larger appendiceal diameter and echogenicity.
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Affiliation(s)
- Kristin M Gee
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ruth Ellen Jones
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jacqueline L Babb
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stephanie C Preston
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alana L Beres
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Surgery, Children's Health, Dallas, Texas.
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Lala SV, Strubel N, Nocera N, Bittman ME, Fefferman NR. Visualization of the normal appendix in children: feasibility of a single contrast-enhanced radial gradient recalled echo MRI sequence. Pediatr Radiol 2019; 49:770-776. [PMID: 30783687 DOI: 10.1007/s00247-019-04352-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 01/03/2019] [Accepted: 02/04/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) assessment for appendicitis is limited by exam time and patient cooperation. The radially sampled 3-dimensional (3-D) T1-weighted, gradient recalled echo sequence (radial GRE) is a free-breathing, motion robust sequence that may be useful in evaluating appendicitis in children. OBJECTIVE To compare the rate of detection of the normal appendix with contrast-enhanced radial GRE versus contrast-enhanced 3-D GRE and a multi-sequence study including contrast-enhanced radial GRE. MATERIALS AND METHODS This was a retrospective study of patients ages 7-18 years undergoing abdominal-pelvic contrast-enhanced MRI between Jan. 1, 2012, and April 1, 2016. Visualization of the appendix was assessed by consensus between two pediatric radiologists. The rate of detection of the appendix for each sequence and combination of sequences was compared using a McNemar test. RESULTS The rate of detection of the normal appendix on contrast-enhanced radial GRE was significantly higher than on contrast-enhanced 3-D GRE (76% vs. 57.3%, P=0.003). The rate of detection of the normal appendix with multi-sequence MRI including contrast-enhanced radial GRE was significantly higher than on contrast-enhanced 3-D GRE (81.3% vs. 57%, P<0.001). There was no significant difference between the rate of detection of the normal appendix on contrast-enhanced radial GRE alone and multi-sequence MRI including contrast-enhanced radial GRE (76% vs. 81.3%, P=0.267). CONCLUSION Contrast-enhanced radial GRE allows superior detection of the normal appendix compared to contrast-enhanced 3-D GRE. The rate of detection of the normal appendix on contrast-enhanced radial GRE alone is nearly as good as when the contrast-enhanced radial GRE is interpreted with additional sequences.
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Affiliation(s)
- Shailee V Lala
- Department of Radiology, New York University School of Medicine, 660 First Ave., New York, NY, 10016, USA.
| | - Naomi Strubel
- Department of Radiology, New York University School of Medicine, 660 First Ave., New York, NY, 10016, USA
| | - Nicole Nocera
- Department of Radiology, New York University School of Medicine, 660 First Ave., New York, NY, 10016, USA
| | - Mark E Bittman
- Department of Radiology, New York University School of Medicine, 660 First Ave., New York, NY, 10016, USA
| | - Nancy R Fefferman
- Department of Radiology, New York University School of Medicine, 660 First Ave., New York, NY, 10016, USA
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Do‐Wyeld M, Rogerson T, Court‐Kowalski S, Cundy TP, Khurana S. Fast‐track surgery for acute appendicitis in children: a systematic review of protocol‐based care. ANZ J Surg 2019; 89:1379-1385. [PMID: 30989778 DOI: 10.1111/ans.15125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/08/2019] [Accepted: 01/25/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Montgommery Do‐Wyeld
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
| | - Thomas Rogerson
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
| | - Stefan Court‐Kowalski
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
- Discipline of SurgeryThe University of Adelaide Adelaide South Australia Australia
| | - Thomas P. Cundy
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
- Discipline of SurgeryThe University of Adelaide Adelaide South Australia Australia
| | - Sanjeev Khurana
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
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LaPlant MB, Saltzman DA, Rosen JI, Acton RD, Segura BJ, Hess DJ. Standardized irrigation technique reduces intraabdominal abscess after appendectomy. J Pediatr Surg 2019; 54:728-732. [PMID: 30025605 DOI: 10.1016/j.jpedsurg.2018.06.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/26/2018] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The utility of irrigation at the time of appendectomy for acute appendicitis has been debated, with recent studies showing no benefit to irrigation. In our practice, two techniques have been used; one in which irrigation was at the discretion of the surgeon, and one in which irrigation was standardized. The standardized irrigation technique involved large volume (3-12 l) irrigation in small, focused, directed aliquots to achieve optimal dilution. We sought to retrospectively assess whether the standardized large volume irrigation technique was associated with measurably reduced intraabdominal infection. We hypothesized that there would be no difference in intraabdominal infection rate. METHODS Medical records for cases of appendectomies performed for acute appendicitis, years 2007 through 2017, were reviewed (n = 432). Rate of subsequent abdominal infection was compared between patients who underwent the standardized large volume irrigation technique compared to those who did not using Fisher's exact test; p < 0.05 was considered significant. RESULTS For patients that underwent the standardized large volume irrigation technique there were no (0/140) subsequent abdominal infections within the study period, compared with a rate of 6.2% (18/292) for all other patients (p value 0.001). Among cases that had a perforated appendix (n = 105), the rates were 0% (0/31) compared to 18.9% (14/74; p value 0.009). CONCLUSIONS Utilization of a standardized large volume irrigation technique with the objective of serial dilution is associated with a significantly lower rate of subsequent abdominal infection, even among cases with a perforated appendix. Prospective studies are needed to evaluate this technique. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Treatment study.
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Affiliation(s)
- Melanie B LaPlant
- Department of Surgery, Division of Pediatric Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Daniel A Saltzman
- Department of Surgery, Division of Pediatric Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Jocelyn I Rosen
- Department of Surgery, Division of Pediatric Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Robert D Acton
- Department of Surgery, Division of Pediatric Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Bradley J Segura
- Department of Surgery, Division of Pediatric Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Donavon J Hess
- Department of Surgery, Division of Pediatric Surgery, University of Minnesota, Minneapolis, MN, United States.
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Anderson KT, Bartz-Kurycki MA, Austin MT, Kawaguchi AL, Kao LS, Lally KP, Tsao K. Hospital type predicts computed tomography use for pediatric appendicitis. J Pediatr Surg 2019; 54:723-727. [PMID: 29925468 DOI: 10.1016/j.jpedsurg.2018.05.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/23/2018] [Accepted: 05/23/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evidence-based guidelines recommend ultrasound (US) over computed tomography (CT) as the primary imaging modality for suspected pediatric appendicitis. Continued high rates of CT use may result in significant unnecessary radiation exposure in children. The purpose of this study was to evaluate variables associated with preoperative CT use in pediatric appendectomy patients. METHODS A retrospective cohort study of pediatric patients who underwent appendectomy for acute appendicitis in 2015-2016 at National Surgical Quality Improvement Program for Pediatrics (NSQIP-P) hospitals was conducted. Pediatric (<18 years old) patients who underwent appendectomy for acute appendicitis in an NSQIP-P hospital from 2015 to 2016 were included. Patients were excluded if they underwent interval or incidental appendectomy or did not have a final diagnosis of appendicitis. Variables associated with imaging evaluation, including age, body mass index (BMI), race/ethnicity, gender and hospital of presentation (NSQIP-P vs. non-NSQIP-P hospital) were evaluated. The primary outcome was receipt of preoperative CT. Secondary outcomes include reimaging practices and trends over time. RESULTS 22,333 children underwent appendectomies, of which almost all were imaged preoperatively (96.5%) and 36% of whom presented initially to a non-NSQIP-P hospital. Overall, US only was the most common imaging modality (52%), followed by CT only (27%), US+CT (16%), no imaging (3%), MRI +/- CT/US (1%) and MRI only (<1%). On regression, older age (>11 years), obesity (BMI >95th percentile for age), and female gender were associated with increased odds of receiving a CT scan. However, initial presentation to a non-NSQIP-P hospital was the strongest predictor of CT use (OR 9.4, 95% CI 8.1-10.8). Reimaging after transfer was common, especially after US and MRI at a non-NSQIP-P hospital. CT use decreased between 2015 and 2016 in non-NSQIP-P hospitals but remained the same (25%) in NSQIP-P facilities. CONCLUSIONS Though patient characteristics were associated with different imaging practices, presentation at a referral, nonchildren's hospital is the strongest predictor of CT use in children with appendicitis. NSQIP-P hospitals frequently reimage transferred patients and have not reduced their CT use. Novel strategies are required for all hospital types in order to sustain reduction in CT use and mitigate unnecessary imaging. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative study.
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Affiliation(s)
- Kathryn Tinsley Anderson
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX.
| | - Marisa A Bartz-Kurycki
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Mary T Austin
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Akemi L Kawaguchi
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Lillian S Kao
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Kevin P Lally
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Kuojen Tsao
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
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Badru F, Piening N, Greenspon J, Chatoorgoon K, Fitzpatrick C, Villalona GA. Extended Antibiotic Course Prior to Interval Appendectomy in Children with Complicated Appendicitis Offers No Significant Advantage. Surg Infect (Larchmt) 2019; 20:197-201. [PMID: 30526419 DOI: 10.1089/sur.2018.172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Faidah Badru
- Cardinal Glennon Children's Medical Center, St. Louis, Missouri
- Saint Louis University School of Medicine, St. Louis, Missouri
| | | | - Jose Greenspon
- Cardinal Glennon Children's Medical Center, St. Louis, Missouri
- Saint Louis University School of Medicine, St. Louis, Missouri
| | - Kaveer Chatoorgoon
- Cardinal Glennon Children's Medical Center, St. Louis, Missouri
- Saint Louis University School of Medicine, St. Louis, Missouri
| | - Colleen Fitzpatrick
- Cardinal Glennon Children's Medical Center, St. Louis, Missouri
- Saint Louis University School of Medicine, St. Louis, Missouri
| | - Gustavo A. Villalona
- Cardinal Glennon Children's Medical Center, St. Louis, Missouri
- Saint Louis University School of Medicine, St. Louis, Missouri
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Association of postoperative organ space infection after intraoperative irrigation in appendicitis. J Trauma Acute Care Surg 2019; 84:628-635. [PMID: 29271870 DOI: 10.1097/ta.0000000000001773] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The benefit of intraoperative irrigation on postoperative abscess rates compared to suction alone is unclear. The American Association for the Surgery of Trauma grading system provides distinct disease severity stratification to determine if prior analyses were biased by anatomic severity. We hypothesized that for increasing appendicitis severity, patients receiving (high, ≥2 L) intraoperative irrigation would have increased postoperative organ space infection (OSI) rate compared to (low, <2 L) irrigation. METHODS Single-institution review of adults (>18 years) undergoing appendectomy for appendicitis during 2010-2016. Demographics, operative details, irrigation volumes, duration of stay, and complications (Clavien-Dindo classification) were collected. American Association for the Surgery of Trauma grades were assigned by two independent reviewers based on operative findings. Summary, univariate, and area under the receiver operating curve analyses were performed. RESULTS Patients (n = 1187) were identified with a mean (SD) age of 41.6 (18.4) years (45% female). Operative approach included laparoscopy (n = 1122 [94.5%]), McBurney incision (n = 10 [0.8%]), midline laparotomy (n = 16 [1.3 %]), and laparoscopy converted to laparotomy (n = 39 [3.4%)]. The mean (SD) volume of intraoperative irrigation was 410 (1200) mL. Complication rate was 26.1%. Median volume of intraoperative irrigation in patients who developed postoperative OSI was 3 [0-4] compared to 0 [0-0] in those without infection (p < 0.0001). Area under the receiver operating curve analysis determined that 2 or more liters of irrigation was associated with postoperative OSI (c statistic: 0.83, 95% confidence interval, 0.76-0.89; p < 0.001). CONCLUSION Irrigation is used for increasingly severe appendicitis with wide variation. Irrigation volumes of 2 L or greater are associated with postoperative OSI. Improving standardization of irrigation volume (<2 L) may prevent morbidity associated with this high-volume disease. LEVEL OF EVIDENCE Therapeutic, level IV.
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Arnold MR, Wormer BA, Kao AM, Klima DA, Colavita PD, Cosper GH, Heniford BT, Schulman AM. Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial. Pediatr Surg Int 2018; 34:1257-1268. [PMID: 30218170 DOI: 10.1007/s00383-018-4343-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis. METHODS This was a randomized controlled trial of patients aged 4-17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I-contained perforation, II-localized contamination to right gutter/pelvis, and III-diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin-clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared. RESULTS Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3 ± 3.6 versus 10.1 ± 3.6, p < 0.05) with higher BMI (20.9 ± 5.8 versus 17.9 ± 3.5, p < 0.05). There were no differences in gender, comorbidities, or perforation grade (I-20.4% vs. 26.3%, II-36.4% vs. 34.2%, III-43.2% vs. 39.5%, all p > 0.05). Comparing IV to oral, there was no difference in length of stay (4.4 ± 1.5 versus 4.4 ± 2.0 days, p > 0.05), postoperative abscess rate (11.6% vs. 8.1%, p > 0.05), or readmission rate (14.0% vs. 16.2%, p > 0.05). Hospital and outpatient charges were higher in the IV group (p < 0.0001). CONCLUSION Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.
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Affiliation(s)
- Michael R Arnold
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Blair A Wormer
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Angela M Kao
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - David A Klima
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Paul D Colavita
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Graham H Cosper
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA.,Hemby Children's Hospital, Novant Health, 200 Hawthorne Ln., Charlotte, NC, 28204, USA.,Pediatric Surgical Associates, 1900 Randolph Road, Suite 210, Charlotte, NC, 28207, USA
| | - Brant Todd Heniford
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Andrew M Schulman
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA. .,Hemby Children's Hospital, Novant Health, 200 Hawthorne Ln., Charlotte, NC, 28204, USA. .,Pediatric Surgical Associates, 1900 Randolph Road, Suite 210, Charlotte, NC, 28207, USA.
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Importance of Compliance Audits for a Pediatric Complicated Appendicitis Clinical Practice Guideline. J Med Syst 2018; 42:257. [PMID: 30406316 DOI: 10.1007/s10916-018-1117-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/02/2018] [Indexed: 11/25/2022]
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Kelly BS, Bollard SM, Weir A, O'Brien C, Mullen D, Kerin M, McCarthy P. Improving diagnostic accuracy in clinically ambiguous paediatric appendicitis: a retrospective review of ultrasound and pathology findings with focus on the non-visualised appendix. Br J Radiol 2018; 92:20180585. [PMID: 30102564 DOI: 10.1259/bjr.20180585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To compare pre-operative ultrasound to histopathological results and retrospectively assess the diagnostic accuracy of ultrasound in paediatric appendicitis. METHODS 5 year review of all appendectomies performed in patients <16 years old in a tertiary referral university hospital. 983 patients had an appendicectomy over the time period while 189 patients had a preoperative ultrasound. We retrospectively reviewed all of the preoperative imaging in conjunction with the reports for the 189 patients; our aim was to determine the sensitivity of preoperative ultrasound for the diagnosis of acute appendicitis. RESULTS Of the 189 patients who had an ultrasound, 102 had histology positive for appendicitis and 87 had normal histology. Sensitivity overall was 72.55% [95% confidence interval (CI) 62.82 to 80.92] and specificity was 77.01% (95% CI 66.75 to 85.36). A suggested ultrasound diagnosis of appendicitis made positive pathology three times more likely and a normal ultrasound made positive pathology three times less likely [positive-predictive value 3.16 (95% CI 2.11 to 4.72) negative predictive value 0.36 (95% CI 0.25 to 0.50)]. 77% (67/87) of the patients whose pathology was ultimately normal had an ultrasound which was either normal or suggested an alternative diagnosis. However, in the 33 (17%) of patients with a non-visualised appendix, no secondary signs of inflammation or alternative diagnosis 16 (48%) had pathologically confirmed appendicitis. CONCLUSION Ultrasound has the potential to improve diagnostic accuracy in clinically ambiguous appendicitis. ADVANCES IN KNOWLEDGE This paper furthers the evidence on the efficacy of ultrasound as a diagnostic tool in acute appendicitis in children, especially when the diagnosis is clinically equivocal. It also sheds further light on the "non-visualized appendix" with almost half of these patients having pathologically confirmed appendicitis; meaning advanced imaging with CT or MR may be indicated in this cohort.
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Affiliation(s)
- B S Kelly
- Department of Radiology, Galway University Hospital, Galway, Ireland.,Departmentof Radiology, St Vincents University Hospital, Elm park, Dublin, Ireland
| | - S M Bollard
- Department of Surgery, Galway University Hospital, Galway, Ireland
| | - A Weir
- Department of Radiology, Galway University Hospital, Galway, Ireland.,Departmentof Radiology, St Vincents University Hospital, Elm park, Dublin, Ireland
| | - C O'Brien
- Departmentof Radiology, St Vincents University Hospital, Elm park, Dublin, Ireland
| | - D Mullen
- Department of Pathology, Galway University Hospital, Galway, Ireland
| | - M Kerin
- Department of Surgery, Galway University Hospital, Galway, Ireland
| | - P McCarthy
- Department of Radiology, Galway University Hospital, Galway, Ireland
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Baumann LM, Williams K, Oyetunji TA, Grabowski J, Lautz TB. Optimal Timing of Postoperative Imaging for Complicated Appendicitis. J Laparoendosc Adv Surg Tech A 2018; 28:1248-1252. [PMID: 29870297 DOI: 10.1089/lap.2018.0121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Approximately one quarter of children with complicated appendicitis develop postoperative abscess, leading to additional procedures and increased length of stay (LOS), but the optimal timing of postoperative imaging to detect abscess is unknown. METHODS The Pediatric Health Information System database was reviewed, and children who underwent laparoscopic appendectomy in 2013-2014 with postoperative LOS ≥5 days were included. Demographics, imaging, drainage procedures, LOS, and 30-day readmission were analyzed. Chi-squared analysis was performed. RESULTS A total of 21,985 patients underwent laparoscopic appendectomy and 3332 met inclusion criteria. A total of 1174 (35.2%) patients underwent postoperative imaging, among whom 38.4% underwent ultrasound and 75.0% underwent computed tomography scan. Timing of first imaging varied significantly between hospitals, ranging from 0% to 76% on postoperative day (POD) 5. Initial imaging was performed on POD 5, 6, and 7 in 19.7%, 31.3%, and 36.2%, respectively. Imaging on POD 5 compared with POD 7 was associated with shorter LOS (10.6 ± 5.7 versus 11.8 ± 4.4 days), but also lower rates of intervention (42.4% versus 50.8%), increased repeat imaging (10.8% versus 5.2%), and higher readmission rates (35.9% versus 28.2%) (P < .05). CONCLUSION Timing of postoperative imaging for complicated appendicitis is variable across hospitals. While earlier imaging was associated with a decreased LOS, these children also had lower rates of subsequent intervention coupled with higher rates of repeat imaging and readmission. These findings suggest that delaying imaging until at least POD 6 may maximize the diagnostic yield of imaging while decreasing radiation exposure and readmission. Prospective investigation should be undertaken to guide the development of standardized clinical practice guidelines for the management of perforated appendicitis.
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Affiliation(s)
- Lauren M Baumann
- 1 Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital , Chicago, Illinois.,2 Department of Surgery, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Kibileri Williams
- 1 Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital , Chicago, Illinois.,2 Department of Surgery, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Tolulope A Oyetunji
- 3 Department of Surgery, Children's Mercy Kansas City , Kansas City, Missouri
| | - Julia Grabowski
- 1 Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital , Chicago, Illinois
| | - Timothy B Lautz
- 1 Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital , Chicago, Illinois.,2 Department of Surgery, Northwestern University Feinberg School of Medicine , Chicago, Illinois
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Abstract
BACKGROUND Complicated appendicitis, characterized by perforation and/or peritonitis, is common in children, and late infectious complications are frequent. The best antibiotic treatment approach is unknown, resulting in substantial variation in care. We evaluated the effects of 2 successive interventions, an antimicrobial stewardship program (ASP) and a condition-specific clinical practice guideline (CPG), on antimicrobial utilization and patient outcomes in these patients. METHODS The ASP at our institution was begun in March 2012. The CPG, a standardized antibiotic treatment, was implemented in July 2013. We reviewed every case of complicated appendicitis managed with early appendectomy between January 2011 and October 2014. Patients were thus divided into 3 eras based on their exposure to the following: (1) neither intervention, (2) ASP only or (3) both ASP and CPG. We compared measures of antibiotic utilization and clinical outcomes among the 3 eras. RESULTS A total of 313 patients were included in the study: 91 exposed to neither intervention; 100 exposed to only the ASP; and 122 exposed to both interventions. With ASP implementation, there were declines in the use of unnecessarily broad or toxic antibiotic regimens. With CPG implementation, there was a decrease in total antibiotic utilization and discharges with intravenous antibiotics. Compliance with CPG-recommended antibiotics exceeded 90%. There was no significant change in overall adverse events; there was a decline in the incidence of surgical-site infections in patients exposed to both interventions. CONCLUSIONS Complicated appendicitis is an important target for antimicrobial stewardship and quality improvement efforts. A condition-specific CPG can improve both antimicrobial utilization and clinical outcomes.
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Irrigation Versus Suction Alone in Laparoscopic Appendectomy: Is Dilution the Solution to Pollution? A Systematic Review and Meta-Analysis. Surg Innov 2018; 25:174-182. [DOI: 10.1177/1553350617753244] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Yousef Y, Youssef F, Homsy M, Dinh T, Pandya K, Stagg H, Baird R, Laberge JM, Poenaru D, Puligandla P, Shaw K, Emil S. Standardization of care for pediatric perforated appendicitis improves outcomes. J Pediatr Surg 2017; 52:1916-1920. [PMID: 28935397 DOI: 10.1016/j.jpedsurg.2017.08.054] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 08/28/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND The treatment of perforated appendicitis in children is characterized by significant variability in care, morbidity, resource utilization, and outcomes. We prospectively studied how minimization of care variability affects outcomes. METHODS A clinical pathway for perforated appendicitis, in use for three decades, was further standardized in May 2015 by initiation of a disease severity classification, refinement of discharge criteria, standardization of the operation, and establishment of criteria for use of postoperative total parenteral nutrition, imaging, and invasive procedures. Prospective evaluation of all children treated for 20months on the new fully standardized protocol was conducted and compared to a retrospective cohort treated over 58months prior to standardization. Differences between outcomes before and after standardization were analyzed using regression analysis techniques to adjust for disease severity. RESULTS Median follow-up time post discharge was 25 and 14days in the post- and prestandardization groups, respectively. Standardization significantly reduced postoperative abscess (9.8% vs. 17.4%, p=0.001) and hospital stay (p=0.002). Standardization reduced the odds of developing a postoperative abscess by four fold. CONCLUSION Minimizing variability of care at all points in the treatment of perforated appendicitis significantly improves outcomes. TYPE OF STUDY Prospective Cohort Study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Fouad Youssef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Michael Homsy
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Trish Dinh
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kartikey Pandya
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Hayden Stagg
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Robert Baird
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean-Martin Laberge
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dan Poenaru
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Pramod Puligandla
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kenneth Shaw
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sherif Emil
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
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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: 0.9] [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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Buicko JL, Parreco J, Abel SN, Lopez MA, Sola JE, Perez EA. Pediatric laparoscopic appendectomy, risk factors, and costs associated with nationwide readmissions. J Surg Res 2017; 215:245-249. [DOI: 10.1016/j.jss.2017.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 03/09/2017] [Accepted: 04/11/2017] [Indexed: 01/07/2023]
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