Appendiceal Perforation Research Articles

The diagnostic value of a panel of serological markers in acute appendicitis.

Appendicitis is a frequent reason for hospital admissions. Elevated C-reactive protein, white blood cell count, and serum bilirubin have been suggested as individual markers for appendicitis and appendiceal perforation. The aim of this study was to analyze if a combination of serologic markers could increase the prognostic accuracy of diagnosing non-perforated and perforated appendicitis. Demographic data, histological findings, blood tests, and clinical symptoms were collected on all patients who underwent a diagnostic laparoscopy, a laparoscopic appendectomy, or conventional (open) appendectomy between May 2009 and May 2012 from a surgical department. The patients were grouped into those with either perforated appendicitis, non-perforated appendicitis, or differential diagnosis. Univariate and multivariate models were used to identify which markers were useful in predicting acute and perforated appendicitis, and receiving operating characteristics curves were used to find the specificity, sensitivity, and the negative and positive predictive values. A total of 1008 patients were operated under suspicion of appendicitis. From these, 700 patients had a pathologically verified inflamed appendix and 190 had a perforated appendix. Patients with acute appendicitis had significantly higher blood levels of white blood cell, bilirubin, C-reactive protein, and alanine transaminase than patients without appendicitis. Patients with perforated appendicitis had significantly higher levels of white blood cell, bilirubin, and C-reactive protein than patients with non-perforated appendicitis. The highest positive predictive value to discriminate between acute appendicitis and non-appendicitis was of a linear regression model combining white blood cell count, bilirubin, and alanine transaminase. C-reactive protein levels and a linear regression model, including white blood cell count, bilirubin, and C-reactive protein levels as variables, had the highest negative predictive values when discriminating between perforated and non-perforated appendicitis. Combining blood markers was useful in predicting appendicitis and perforated appendicitis. In addition to C-reactive protein and white cell count, blood levels of bilirubin, and alanine transaminase may be useful.

Effect of Hispanic Ethnicity and Language Barriers on Appendiceal Perforation Rates and Imaging in Children

To determine the association between Hispanic ethnicity and limited English proficiency (LEP) and the rates of appendiceal perforation and advanced radiologic imaging (computed tomography and ultrasound) in children with abdominal pain. We performed a secondary analysis of a prospective, cross-sectional, multicenter study of children aged 3-18 years presenting with abdominal pain concerning for appendicitis between March 2009 and April 2010 at 10 tertiary care pediatric emergency departments in the US. Appendiceal perforation and advanced imaging rates were compared between ethnic and language proficiency groups using simple and multivariate regression models. Of 2590 patients enrolled, 1001 (38%) had appendicitis, including 36% of non-Hispanics and 44% of Hispanics. In multivariate modeling, Hispanics with LEP had a significantly greater odds of appendiceal perforation (OR, 1.44; 95% CI, 1.20-1.74). Hispanics with LEP with appendiceal perforation of moderate clinical severity were less likely to undergo advanced imaging compared with English-speaking non-Hispanics (OR, 0.64; 95% CI, 0.43-0.95). Hispanic ethnicity with LEP is an important risk factor for appendiceal perforation in pediatric patients brought to the emergency department with possible appendicitis. Among patients with moderate clinical severity, Hispanic ethnicity with LEP appears to be associated with lower imaging rates. This effect of English proficiency and Hispanic ethnicity warrants further investigation to understand and overcome barriers, which may lead to increased appendiceal perforation rates and differential diagnostic evaluation.

Predictors of appendiceal perforation in an equal access system

BackgroundDiscrepancies in socioeconomic factors have been associated with higher rates of perforated appendicitis. As an equal-access health care system theoretically removes these barriers, we aimed to determine if remaining differences in demographics, education, and pay result in disparate outcomes in the rate of perforated appendicitis. Materials and methodsAll patients undergoing appendectomy for acute appendicitis (November 2004–October 2009) at a tertiary care equal access institution were categorized by demographics and perioperative data. Rank of the sponsor was used as a surrogate for economic status. A multivariate logistic regression model was performed to determine patient and clinical characteristics associated with perforated appendicitis. ResultsA total of 680 patients (mean age 30 ± 16 y; 37% female) were included. The majority were Caucasian (56.4% [n = 384]; African Americans 5.6% [n = 38]; Asians 1.9% [n = 13]; and other 48.9% [n = 245]) and enlisted (87.2%). Overall, 6.4% presented with perforation, with rates of 6.6%, 5.8%, and 6.7% (P = 0.96) for officers, enlisted soldiers, and contractors, respectively. There was no difference in perforation when stratified by junior or senior status for either officers or enlisted (9.3% junior versus 4.40% senior officers, P = 0.273; 6.60% junior versus 5.50% senior enlisted, P = 0.369). On multivariate analysis, parameters such as leukocytosis and temperature, as well as race and rank were not associated with perforation (P = 0.7). Only age had a correlation, with individuals aged 66–75 y having higher perforation rates (odds ratio, 1.04; 95% confidence interval, 1.02–1.05; P < 0.001). ConclusionsIn an equal-access health care system, older age, not socioeconomic factors, correlated with increased appendiceal perforation rates.

Appendiceal Mucinous Cystadenoma Intussuscepted into the Cecum on a Patient with Rectal Carcinoma: A Case Report

Appendiceal mucinous cystadenoma intussusception is rare but is readily ruptured and may form pseudomyxoma peritonei [1–3]. This condition is difficult to diagnose preoperatively due to its similarity to appendicitis or to atypical symptoms. A computed tomography (CT) scan, radioscopy, or colonoscopy can differentiate appendiceal mucinous cystadenoma intussusception from a cecal polyp or mass [4, 5]. Misdiagnosis may lead to treatment with false-polypectomy colonoscopy, which can result in appendiceal perforation and mucinous cystadenoma rupture. Etiologies include anatomical variations of the appendix and pathological conditions [6]. Especially in patients with rectal cancer, pseudomyxoma peritonei is difficult to detect.

Gynecologic and Surgical Complications in Type IV Ehlers-Danlos Syndrome

Although type IV Ehlers-Danlos syndrome is a rare condition, it is critical that physicians be aware of this disease because it presents unique management challenges. We present a young woman who was admitted with a pelvic abscess after having a miscarriage and an appendiceal perforation. She had an exploratory laparotomy secondary to a persistent pelvic abscess and endured multiple postoperative complications. Based on her family history and physical characteristics, type IV Ehlers-Danlos syndrome was diagnosed. The decision to proceed with surgery should be weighed against tissue fragility in patients with type IV Ehlers-Danlos syndrome. A conservative, multidisciplinary team approach addresses whether to proceed with surgery and minimize postoperative complications if surgery is performed.

Acute appendicitis in the elderly: risk factors for perforation

BackgroundAcute appendicitis is the most common surgical emergency and becomes serious when it perforates. Perforation is more frequent in the elderly patients. The aim of this study was to identify the risk factors of perforation in elderly patients who presented with acute appendicitis.MethodologyThe medical records of 214 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis over a period of 10 years (2003-2013) were retrospectively reviewed. Patients were grouped into those with perforated and those with nonperforated appendicitis. Comparison was made between both groups in regard to demography, clinical presentation, and time delay to surgery, diagnosis, hospital stay and postoperative complications. Clinical assessment, Ultrasonography and Computerized tomography, in that order, were used for diagnosis. The incidence of perforation was also compared with a previous report from the same region 10 years earlier.ResultsDuring the study period, a total of 214 patients over the age of 60 years had acute appendicitis, 103 males and 111 females. Appendix was found perforated in 87 (41%) patients, 46 (53%) males and 41 (47%) females. Of all patients, 31% were diagnosed by clinical assessment alone, 40% needed US and 29% CT scan. Of all the risk factors studied, the patient’s pre-hospital time delay was the most important risk factor for perforation. Perforation rate was not dependent on the presence of comorbid diseases or in-hospital time delay. Post operative complications occurred in 44 (21%) patients and they were three times more common in the perforated group, 33 (75%) patients in the perforated and 11 (25%) in the nonperforated group. There were 6 deaths (3%), 4 in the perforated and 2 in the nonperforated group.ConclusionAcute appendicitis in elderly patients is a serious disease that requires early diagnosis and treatment. Appendiceal Perforation increases both mortality and morbidity. All elderly patients presented to the hospital with abdominal pain should be admitted and investigated. The early use of CT scan can cut short the way to the appropriate treatment.

Socioeconomic Predictors of Appendiceal Perforation in an Equal-Open Access Healthcare System

Socioeconomic Predictors of Appendiceal Perforation in an Equal-Open Access Healthcare System

Hyperbilirubinemia, C-reactive protein and ultrasonography as predictors of appendiceal perforation: A prospective study

Background: Acute appendicitis is the most common cause of acute abdomen and subsequent surgery. The diagnosis is essentially based on the clinical grounds and as a result misdiagnosis is a common and crucial problem in general surgery. Delayed or wrong diagnosis in patients with appendicitis can result in perforation and consequently increased morbidity and mortality. Serum bilirubin and C-reactive protein (CRP) have been shown to indicate perforation in appendicitis. Aim: The purpose of this study was to evaluate the role of hyperbilirubinemia, CRP and ultrasonography (USG) as predictors for appendiceal perforation. Materials and Methods: This study consisted of patients admitted with the clinical suspicion of acute appendicitis. The study finally included a group of those 100 patients who had histologically proven appendicitis. Subsequent to hospital admission all patients underwent thorough physical examination and routine lab exams. Preultrasound clinical diagnosis was made based on medical history, physical examination as well as laboratory findings. Real-time, high-resolution (5 MHz, 7.5 MHz) graded compression ultrasound examination was performed by a senior radiologist after a clinical diagnosis was made. Results: Serum bilirubin and CRP were raised in significant number of patients with appendiceal perforation compared to the patients of appendicitis without perforation. Thirty-three of 42 patients with perforated appendix had bilirubin ≥1.5 mg/dl (P < 0.0001). Sensitivity of serum bilirubin in predicting perforation was 78.57%, while as specificity was 89%. Thirty-five of 42 patients with perforated acute appendicitis had raised CRP levels (P < 0.0001). Sensitivity and specificity of CRP in predicting perforation were 83% and 74%, respectively. Abdominal USG in patients with diagnosis of perforated acute appendicitis has a sensitivity of 64.28% and specificity of 79.3% (P < 0.0001). Conclusion: Bilirubin, CRP and ultrasound are effective for differentiation of perforated from nonperforated appendicitis. Bilirubin, CRP and USG are important preoperative biochemical and sonographic markers of perforation, respectively in appendicitis.

A Case of Peritonitis due to Appendiceal Perforation with an Incarcerated Inguinal Hernia

A Case of Peritonitis due to Appendiceal Perforation with an Incarcerated Inguinal Hernia

Red Blood cell distribution width: an emerging diagnostic factor of acute appendicitis?

Acute appendicitis is the most common surgical abdominal emergency. Immidiate diagnosis of this disease is crucial, because this condition can lead to appendiceal perforation, potential peritonitis, and even death. We read with great interest the article ‘The role of red cell distribution width (RDW) in the diagnosis of acute appendicitis: a retrospective case-controlled study’ by Narci et al. and wanted to discuss whether RDW alone provide certain information about the inflammatory status of the patient with acute appendicitis.

Introduction of a New Policy of no Nighttime Appendectomies: Impact on Appendiceal Perforation Rates and Postoperative Morbidity

Working hour limitations and tight health care budgets have posed significant challenges to emergency surgical services. Since 1 January 2010, surgical interventions at Berne University Hospital between 23:00 and 08:00 h have been restricted to patients with an expected serious adverse outcome if not operated on within 6 h. This study was designed to assess the safety of this new policy that restricts nighttime appendectomies (AEs). The patients that underwent AE from 1 January 2010 to 31 December 2011 ("2010-2011 group") were compared retrospectively with patients that underwent AE before introduction of the new policy (1 January 2006-31 December 2009; "2006-2009 group"). Overall, 390 patients were analyzed. There were 255 patients in the 2006-2009 group and 135 patients in the 2010-2011 group. Patients' demographics did not differ statistically between the two study groups; however, 45.9 % of the 2006-2009 group and 18.5 % of the 2010-2011 group were operated between 23:00 and 08:00 h (p < 0.001). The rates of appendiceal perforations and surgical site infections did not differ statistically between the 2006-2009 group and the 2010-2011 group (20 vs. 18.5 %, p = 0.725 and 2 vs. 0 %, p = 0.102). Additionally, no difference was found for the hospital length of stay (3.9 ± 7.4 vs. 3.4 ± 6.0 days, p = 0.586). However, the proportion of patients with an in-hospital delay of >12 h was significantly greater in the 2010-2011 group than in the 2006-2009 group [55.6 vs. 43.5 %, p = 0.024, odds ratio (95 % confidence interval 1.62 (1.1-2.47)]. Restricting AEs from 23:00 to 08:00 h does not increase the perforation rates and occurrence of clinical outcomes. Therefore, these results suggest that appendicitis may be managed safely in a semielective manner.

Assessing quality in pediatric surgery — the limited role of appendectomy as the optimal target

BackgroundAppendectomy is one of the highest volume procedures in children performed across a variety of hospital types in the U.S. potentially making it the ideal procedure to target when assessing hospital and surgeon quality. Though appendiceal perforation rate has been identified as a potential quality target reflecting primary care access, perforation rates have little association with hospital or surgeon quality. The utility and reliability of appendectomy as a target procedure to judge hospital quality based on outcomes beyond perforation rates are unknown. MethodsUsing the 2008 Nationwide Inpatient Sample, hospital pediatric appendectomy volumes were determined. Based on literature review, a variety of complication rate thresholds to identify hospital outlier status were determined using sample size calculations. The percent of U.S. hospitals that could exceed volume thresholds in order to be reliably compared was determined. ResultsSeveral complication rates of interest were identified ranging from mortality at 0.19% to a composite overall morbidity at 6.44%. Minimum hospital caseloads required to detect a doubling of complication rates included 127 cases for a composite overall morbidity, 276 cases for wound infection, 285 cases for negative appendectomy, 335 cases for intra-abdominal abscess, 438 cases for postoperative ileus, and 4,729 cases for mortality. Based on annual volumes, only 22% of hospitals met the minimum volume thresholds for a composite overall morbidity. In order to use other outcomes to assess quality, multiple year aggregate data are needed in order to generate volumes sufficient for comparison. Even with 5year aggregate data less than 2% of hospitals could be compared based on mortality. ConclusionsFor the vast majority of complications very few hospitals accrue enough procedure specific volume with appendectomy to judge quality even with multiple years of data collection. In order to best assess hospital quality in children’s surgery alternate targets beyond procedure specific traditional outcomes warrant exploration.

Laparoscopic accuracy in prediction of appendiceal pathology: oncologic and inflammatory aspects

BackgroundIn the prelaparoscopy era, macroscopically normal appendices were routinely resected. The aim of this study was to evaluate the accuracy of laparoscopy. MethodsA review of 1,899 patients who underwent appendectomy with multivariate analysis was conducted. ResultsLaparoscopic and open approaches had similar false-positive rates, false-negative rates, accuracy, and sensitivity. The study population included 17 false-negative cases (11% of all macroscopically normal appendices). Tumors were found in 1.1% of our study population. Female gender (1.9% vs .5%; odds ratio, 4; 95% confidence interval, 1.5 to 11; P < .005) and appendiceal perforation were independent risk factors for harboring a tumor. ConclusionsIt is suggested that laparoscopy has diagnostic quality similar to that of the open approach. Until randomized trials evaluate the fate of patients who receive false-negative diagnoses, routine appendectomy is recommended. Special attention should be paid to female patients and to patients with perforations, who have a 4-fold increased risk for harboring a tumor.

Appendicitis: What does really make the difference between private and public hospitals?

BackgroundAppendicitis is one of the most common surgical emergencies and is also a time-sensitive condition. Delays in treatment increase the risk of appendiceal perforation (AP), and thus AP rates have been used as a proxy to measure access to surgical care. It is very well known that in Brazil there are big differences between the public and private healthcare systems. Those differences can reflect in the treatment of what are considered simple cases, like appendicitis. As far as we know, it has no known links to behavioral or social risk factors, and has only one treatment option – appendectomy. The purpose of this study was to compare treatment received by Brazilian people, both by those who depend on the public and private healthcare system, and how it affects their outcome.MethodsData was collected from the records of all patients submitted to appendectomy, in a public and in a private Sao Paulo city’s hospitals, during January to April of 2010.ResultsPatients admitted by the public hospital present symptoms for a longer period of time than those treated by the private one. It took a significantly higher amount of time for the patients from the public hospital undergo surgery, and their length of stay is also significantly higher.ConclusionsAppendicitis in a public scenario is associated with increased time from onset of symptoms to operative intervention and the main reason is the delayed presentation. Clinical polices for abdominal pain should be instituted by the public healthcare system, based on population education, healthcare professionals training and establishment of strategies that can speed the diagnosis process up.

Duration of Postoperative Intravenous Antibiotics in Childhood Complicated Appendicitis: A Propensity Score-Matched Comparison Study

Postoperative antibiotics complement surgery in managing childhood-complicated appendicitis. However, there is limited evidence to guide clinicians on appropriate duration of therapy. A comparison cohort study was performed to determine whether tailoring duration of inpatient intravenous (IV) antibiotic therapy to patient response, assessed using a set of clinical criteria, leads to shortened hospital length of stay (LOS) without compromising patient outcomes. Over a 6-month period, 47 children (aged 5-14 years) with complicated appendicitis were treated with postoperative IV antibiotics until each satisfied a set of bedside clinical parameters suggesting resolved intraperitoneal infection (core temperature < 38°C for 24 hours, tolerated two consecutive meals, mobilizing independently, requiring only oral analgesia). Complicated appendicitis was defined as the presence of generalized peritonitis, appendiceal perforation or gangrene, and/or abscess. Postoperative recovery parameters were prospectively recorded and compared with those of 47 historical control patients, matched by propensity scores, who received 5 days minimum of postoperative IV antibiotics. Sample size was determined by a priori power calculation based on reduction in LOS. Severity of postoperative complications was graded using the Clavien-Dindo system. Study group variables were comparable including patient demographics, duration of presenting symptoms, severity of presenting disease, preoperative antibiotics received, length of operation, seniority of primary surgeon, surgical approach taken, and intraoperative findings. The prospective cohort had a significantly shorter median LOS compared with the historical control cohort (5 vs. 6 nights, p = 0.010) while readmission rates and the incidence and severity of complications were similar, including incidence of postoperative intra-abdominal infections (6 vs. 8 cases, p = 0.562). Using bedside clinical parameters indicative of resolved intraperitoneal infection to tailor duration of postoperative IV antibiotics for children with complicated appendicitis shortens LOS without apparent compromise to patient outcomes.

Hyperbilirubinemia as a Predictor for Appendiceal Perforation: A Systematic Review

Delayed or wrong diagnosis in patients with appendicitis can result in perforation and consequently increased morbidity and mortality. Serum bilirubin may be a useful marker for appendiceal perforation. The purpose of this systematic review was to evaluate studies investigating elevated serum bilirubin as a predictor for appendiceal perforation. Medline, Embase, and Cochrane databases were searched for studies evaluating elevated bilirubin in the diagnosis of perforated appendicitis. Study selection criteria included English language papers evaluating serum bilirubin as a marker of appendiceal perforation in humans. A total of 189 abstracts were screened for eligibility, of which five clinical studies were included in this study. Bilirubin was significantly higher in patients with appendiceal perforation compared with patients with appendicitis without perforation. Elevated serum bilirubin had a sensitivity ranging from 0.38 to 0.77 and a specificity ranging from 0.70 to 0.87 in predicting appendiceal perforation. Elevated serum bilirubin for determining the risk of perforation in appendicitis has low sensitivity but higher specificity. This measure can therefore be used as a supplement in the diagnostic process.

Reply to Dr. Meyers et al regarding ‘Beyond acute appendicitis: imaging of additional pathologies of the pediatric appendix’

Sir, We would like to thank Dr. Meyers et al. [1] for their comments and question regarding our recently published article discussing alternative pathologies of the appendix beyond primary acute appendicitis [2]. When evaluating the appendix, we believe two main clinically relevant decision points must be addressed. The first is to determine whether or not the appendix is normal. If it is abnormal, the radiologist should look for any findings that would preclude urgent surgical intervention. The most frequent and straightforward such finding is that of appendiceal perforation with an associated abscess, whereby an abscess drainage procedure performed by interventional radiology staff may supplant urgent appendectomy as the primary intervention. However, as discussed in our article, there are other entities that can mimic acute bacterial appendicitis, such as cystic fibrosis and inflammatory bowel disease [2], where careful analysis of the clinical details and the imaged periappendiceal structures may provide clues that an urgent appendectomy is not warranted and that markedly different clinical management is required. Although viral appendicitis has been described, there are not sufficient data to show that it can be readily differentiated from early bacterial appendicitis by imaging [3, 4]. Therefore if the appendix appears inflamed by imaging, even if mild, and there are no clear clinical, laboratory or imaging clues to suggest that it may not be caused by acute bacterial appendicitis, an appendectomy is generally indicated, though this may be tempered by clinical examination from experienced surgical staff. Therefore the possibility of viral appendicitis does not affect the imaging algorithm at our institution (i.e. we do not think the radiologist has a role in suggesting this entity for which non-surgical management has been proposed [3]). In our standardized, structured reports for US exam of the appendix [5], we list an indeterminate category among our impression choices. This option may be employed when findings are not clear (e.g., the appendix is mildly dilated without compression but compresses normally with only mild tenderness and surrounding fluid but without adjacent fat induration) and may trigger a surgical consult, overnight monitoring or further imaging depending on the clinical scenario. This being said, we have certainly encountered cases where imaging and operative exploration both suggested mild appendiceal inflammation yet, after resection, the appendix was interpreted to be normal by the examining pathologist. Given that our pathologists are not routinely making assessments of the appendix detailed toward the exclusion of viral appendicitis, it is possible that these seemingly discordant cases could be caused by viral appendicitis. Whether a viral appendicitis can cause a clinical syndrome below the threshold of routine radiologic and histological interrogations is a different matter and cannot be addressed based on the current literature. K. R. Dietz Department of Radiology, University of Minnesota Amplatz Children’s Hospital, Minneapolis, MN, USA

JOURNAL CLUB: Ultrasound for Differentiation Between Perforated and Nonperforated Appendicitis in Pediatric Patients

Acute appendicitis is the most common condition requiring emergency surgery in children. Differentiation of perforated from nonperforated appendicitis is important because perforated appendicitis may initially be managed conservatively whereas nonperforated appendicitis requires immediate surgical intervention. CT has been proved effective in identifying appendiceal perforation. The purpose of this study was to determine whether perforated and nonperforated appendicitis in children can be similarly differentiated with ultrasound. This retrospective study included 161 consecutively registered children from two centers who had acute appendicitis and had undergone ultra-sound and appendectomy. Ultrasound images were reviewed for appendiceal size, appearance of the appendiceal wall, changes in periappendiceal fat, and presence of free fluid, abscess, or appendicolith. The surgical report served as the reference standard for determining whether perforation was present. The specificity and sensitivity of each ultrasound finding were determined, and binary models were generated. The patients included were 94 boys and 67 girls (age range, 1-20 years; mean, 11 ± 4.4 [SD] years) The appendiceal perforation rate was significantly higher in children younger than 8 years (62.5%) compared with older children (29.5%). Sonographic findings associated with perforation included abscess (sensitivity, 36.2%; specificity, 99%), loss of the echogenic submucosal layer of the appendix in a child younger than 8 years (sensitivity, 100%; specificity, 72.7%), and presence of an appendicolith in a child younger than 8 years (sensitivity, 68.4%; specificity, 91.7%). Ultrasound is effective for differentiation of perforated from nonperforated appendicitis in children.

Current Status of Laparoscopic Appendectomy in Children: A Nation Wide Survey in Germany

Management of appendicitis in children has changed remarkably over the last decade. The proven benefits of laparoscopic appendectomy (LA) over the open operation have made LA increasingly popular for pediatric patients. To date, no national clinical practice guideline is available for pediatric LA in Germany and the operation is not standardized. Thus, the aim of our study was to evaluate the current status of pediatric LA in Germany. An internet-based survey was conducted on pediatric LA among all 98 registered pediatric surgical units in Germany, comprising 22 questions with regard to utilization and subjective appraisal of LA, technical standards, perioperative treatment, and training aspects. The survey was completed by 71 of the 98 units (72%). Technical infrastructure for LA was provided in all units, but only in 79% of the units was LA, the standard approach for appendectomy. Overall quality of LA was rated better compared with open appendectomy by 52% units, equivalent by 38% and worse by 3%. The three-port technique was used by 90% of the units; 10% used a single-port approach. Dissection of the mesoappendix was done with bipolar coagulation in 55%, monopolar coagulation in 24%, harmonic knife in 6%, and endostaplers in 11% of the units. Closure of the appendiceal stump was performed using endoloops in 57%, ligations in 3%, endostaplers in 39%, and harmonic knife in 1%. Removal of the appendix was done through the port by 79%, using a retrieval bag by 18%, whereas in 3% it was removed directly through laparotomy. In case of appendiceal perforation, an intra-abdominal drain was placed in 65%. Perioperative antibiotic treatment for nonperforated appendicitis was given as a single shot in 33% of the units, for 24 hours in 17%, for 3 days in 39%, and for 5 to 7 days in 11%. LA was performed by a trainee under supervision in 87%, by a board approved pediatric surgeon in 2%, by an attending pediatric surgeon in 7%, and by the surgeon-in-chief in 4% of the units. For 93% of the sample, LA was an essential part of pediatric surgical training. LA is the favored surgical method for pediatric appendectomy in Germany. However, technical details, perioperative therapy and implementation into training programs remain inconsistent. An effort has to be made to establish national clinical practice guidelines to achieve standardization of LA.

Using appendiceal perforation rates to measure impact of a disaster on healthcare system effectiveness.

To understand baseline inequities in appendiceal perforation rates and the impact of hurricane destruction on the healthcare system with respect to perforation rates and racial disparities. We used claims data extracted from Medicaid Analytic Extract files to identify appendicitis diagnoses in children and adolescents based on International Classification of Diseases-9 codes and appendectomy procedures based on Current Procedural Terminology codes in the hurricane-affected states of Mississippi and Louisiana. County-level summary data obtained from 2005 Area Resource Files were used to determine high and low hurricane-affected areas. We estimated logistic regression models, mutually adjusting for race, sex, and age, to examine disparities and mixed logistic regression models to determine whether county-level effects contributed to perforation rates. There were nine counties in the high-impact area and 133 counties in the low-impact area. Living in the high- or low-impact area was not associated with a statistically different rate of perforation before or after Hurricane Katrina; however, living in the high-impact area was associated with a change from a lower risk (odds ratio [OR] 0.62) of perforation prehurricane to a higher risk (OR 1.14) posthurricane compared with those living in the low-impact areas. African Americans had statistically higher perforation rates than whites in the high-impact areas both before (OR 1.46) and after (OR 1.71) Hurricane Katrina. Health professionals and hospital systems were able to maintain effective levels of care before and after Hurricane Katrina; however, perforation rates in African Americans suggest ongoing racial disparities during disasters.