Treatment Of Pediatric Appendicitis Research Articles

Outcomes following adoption of a standardized protocol for abscess drain management in pediatric appendicitis

Background/purposeThough 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. MethodsA 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. ResultsFifty-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). ConclusionA 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 studyTreatment study (retrospective comparative study). Level of evidenceLevel III.

Occurrence and Treatment of Pediatric Appendicitis in Finland 2004-2014

BackgroundWe aimed to investigate the trends in occurrence and the treatment approaches of appendicitis in Finnish children. Material and methodsAll patients aged <16 y hospitalized for appendicitis in Finland in 2004-2014 were included. Data were retrospectively collected from the Finnish Care Register for Health Care and Statistics Finland. ResultsAltogether 8494 children were hospitalized for appendicitis, with standardized incidence rate of 80.7 (95% confidence interval 79.0-82.0)/100,000 person years. The incidence rate of appendicitis decreased by 3.3% per year during the study period. Appendicitis was more common with increasing age, in boys compared to girls at 8 to 15 y of age, and during the summer compared to the other seasons. Most children (83.2%) were treated with conventional open appendectomy, but laparoscopic appendectomies were slowly increasing during the study period. The length of hospital stay (LOS) was shorter in boys than girls, in those treated laparoscopically, and in those with uncomplicated appendicitis. There was no significant seasonal variation in the LOS. However, the LOS decreased during the study period. ConclusionsThe incidence of pediatric appendicitis is decreasing, and there is a decreasing trend in LOS. While still relatively rare in the Finnish pediatric surgical centers, the use of laparoscopic appendectomy is increasing.

Cefoxitin vs. Piperacillin/Tazobactam for Acute Appendicitis in Pediatric Patients

BackgroundAppendicitis is a medical emergency that usually necessitates surgery and antibiotics in pediatric patients. There is a lack of consensus regarding optimal antibiotics for pediatric appendicitis, with varying recommendations in guidelines and literature. Recent studies have shown that narrow-spectrum and broad-spectrum antibiotics produce similar outcomes in the treatment of pediatric appendicitis. At our institution, cefoxitin has replaced piperacillin/tazobactam for the management of pediatric appendicitis. We compared patient outcomes, including readmission rates, among patients treated with cefoxitin or piperacillin/tazobactam for surgically managed appendicitis.MethodsWe retrospectively reviewed medical charts of surgically managed pediatric appendicitis patients between the ages of 3 to 18 years who received piperacillin/tazobactam or cefoxitin. Those who received piperacillin/tazobactam from 2014–2015 were compared with those who received cefoxitin from 2015–2016. Patients were excluded if they received antibiotics for other indications or if they were initiated prior to hospital admission. Data collection included age, gender, race, days of antibiotics, length of stay, days of fever and readmission within 30 days. The primary outcome was treatment failure defined as inpatient readmission for any complication within 30 days of discharge. Secondary outcomes were hospital length of stay and days of fever.ResultsAfter screening 564 patient charts, 315 were included in the study with 174 in the piperacillin/tazobactam and 141 in the cefoxitin arm. Similar rates of perforations were observed in both groups. In the piperacillin/tazobactam group, there were 4 patients readmitted within 30 days of discharge compared with 2 in the cefoxitin arm, which was not statistically significant. Longer hospital length of stay and days of antibiotics in the piperacillin/tazobactam arm compared with cefoxitin was found to be statistically significant.ConclusionCefoxitin was found to be non-inferior to piperacillin/tazobactam for the treatment of surgically managed acute appendicitis in pediatric patients at our institution.Disclosures All authors: No reported disclosures.

Delays in Treatment of Pediatric Appendicitis: A More Accurate Variable for Measuring Pediatric Healthcare Inequalities?

Racial and socioeconomic factors may cause barriers to healthcare access that result in delayed treatment. Because perforated appendicitis (PA) in children is thought to result from delays in treatment, it is often used as an index of barrier to access. Recent literature suggests that PA is not an inevitable consequence of delayed treatment, so it may not be the best marker for evaluating such barriers. Therefore we investigated whether racial and socioeconomic factors led directly to delays in treatment. We performed a retrospective study of 667 children undergoing appendectomy in a tertiary care center over 12.5 years. Univariate and multivariable regression analyses were used to determine if racial and socioeconomic variables were associated with increased risk of PA and increased risk of symptom duration greater than 48 hours. Hispanic children have higher rates of PA regardless of delays in treatment whereas black children had higher PA rates likely due to delays in treatment. These differences were not from socioeconomic factors in our cohort. PA, a heterogeneous disease whose course is determined by multiple factors, is not a good metric for evaluation healthcare disparities in the pediatric population. Delays in treatment may be a more appropriate measure of healthcare inequalities in children.

Appendizitis

BackgroundOver the last 10–15 years the management of appendicitis in childhood has changed with regard to diagnosis and therapy.ManagementThe implementation of ultrasound, scoring systems to support the surgical indication and minimally invasive techniques for surgery ranging from conventional laparoscopy to single port surgery have had a major impact in the treatment of appendicitis. In addition, the non-operative management of appendicitis has gained new importance. The goal of this article is to provide pediatricians and pediatric surgeons an update for their daily clinical work.ConclusionPractical clinical guidelines for the current modern treatment of pediatric appendicitis are proposed in this article.

Experience of Single-Incision Laparoscopic Appendectomy in the Treatment of Pediatric Appendicitis

Experience of Single-Incision Laparoscopic Appendectomy in the Treatment of Pediatric Appendicitis

Hospital readmission after management of appendicitis at freestanding children's hospitals: contemporary trends and financial implications

IntroductionThe purpose of this study was to characterize epidemiologic trends and cost implications of hospital readmission after treatment of pediatric appendicitis. MethodsWe conducted a 5-year retrospective cohort analysis of 30-day readmission rates for 52,054 patients admitted with appendicitis at 38 children's hospitals participating in the Pediatric Health Information System database. Patients were categorized as “uncomplicated” (postoperative length of stay [LOS] ≤2 days) or “complicated” (LOS ≥3 days and ≥4 consecutive days of antibiotics) and analyzed for demographic data, treatment received during the index admission, readmission rates, and excess LOS and hospital-related costs attributable to readmission encounters. ResultsThe aggregate 30-day readmission rate was 8.7%, and this varied significantly by disease severity and management approach (uncomplicated appendectomy, 5.6%; complicated appendectomy, 12.8%; drainage, 22.6%; antibiotics only, 24.6%; P < .0001). The median hospital cost per case attributable to readmission was $3401 (reflecting a 44% relative increase in cumulative treatment-related cost), and this varied significantly by disease severity and management approach (uncomplicated appendectomy, $1946 [31% relative increase]; complicated appendectomy, $6524 [53% increase]; drainage, $6827 [48% increase]; antibiotics only, $5835 [58% increase]; P < .0001). ConclusionIn freestanding children's hospitals, readmission after treatment of pediatric appendicitis is a relatively common and costly occurrence. Collaborative efforts are needed to characterize patient, treatment, and hospital-related risk factors as a basis for developing preventative strategies.

Missed opportunities in the treatment of pediatric appendicitis

This study sought to evaluate the outcomes of in-hospital delay and determine associated co-morbidities in the treatment of pediatric acute appendicitis. This was a retrospective analysis of the national inpatient sample from 2000 to 2008. Immediate treatment was defined as treatment in hospital day 0 or 1. Delay in treatment was defined as treatment in hospital day 2 and beyond. During the study period, 683,016 pediatric appendicitis were identified. 17,737 (2.6%) experienced a delay in treatment. Multivariate analysis identified associated co-morbidities for delay in treatment: ALL (OR 12.84, CI 11.04-14.94), AML (OR 9.41, CI 7.58-11.68), neutropenia (OR 5.53, CI 4.60-6.65), and ovarian cyst without torsion (OR 3.17, CI 2.94-3.42). Surgical management included more than 13-fold increase in drainage procedures (5.5 vs. 0.4%), sixfold increase in cecectomy (1.2 vs. 0.2%), 14-fold increase in hemicolectomy (1.4 vs. 0.1%), 11-fold increase in small bowel laceration suture repair (1.1 vs. 0.1%), and 15-fold increase in small bowel resection (1.5 vs. 0.1%). In-hospital delay beyond 2 days is associated with significant negative outcomes with regard to complications, economic burden, and subsequent surgical management. Using the co-morbidity index, high-risk co-morbidities with associated delay in treatment were identified.

The influence of advanced radiographic imaging on the treatment of pediatric appendicitis

Purpose Since 1998, the use of advanced radiographic imaging with computed tomography (CT) and/or diagnostic ultrasound (US) has increased dramatically for the diagnosis of acute appendicitis in children. This study investigates the impact of this imaging on the evaluation, management, and outcome of pediatric patients who underwent appendectomy for suspected appendicitis. Methods Retrospective review of 197 consecutive children with a preoperative diagnosis of acute appendicitis, from January 2002 through May 2004, undergoing appendectomy at a university-affiliated community hospital by pediatric and general surgeons. Results Patients were divided into two groups: imaged (n = 106; 54%) and nonimaged (n = 91; 46%). Groups were similar with respect to age, sex, temperature, white blood count, and insurance status. Ninety-seven imaged patients had CT, 6 had US, and 3 had both CT and US. Seventy-one percent of imaging studies were ordered by emergency department physicians and 24% by treating surgeons. Average wait from emergency department triage to operative incision for the imaged and nonimaged groups was 12.1 and 5.4 hours, respectively ( P < .0001). Both groups had similar perforation rates (imaged: 15.1%, nonimaged: 14.6%). Negative appendectomy rates were 10.4% (imaged) and 4.4% (nonimaged). Average hospital charges were $11,791 (imaged) and $9360 (nonimaged) ( P = .001). Time on antibiotics, complication rates, and length of stay were similar for both groups. Conclusions More than half of pediatric patients with suspected appendicitis now undergo advanced imaging and experience a significant delay in surgical treatment with a 26% increase in hospital charges and no clear-cut improvement in diagnostic accuracy nor outcome, when compared with evaluation by the treating surgeons.

Comparison of Laparoscopic Appendectomy with open appendectomy in Treating Children with Appendicitis.

Objective:To analyze feasibility and curative effect of laparoscopic appendectomy in the treatment of pediatric appendicitis and compare it with open appendectomy.Methods:Two hundred and sixty patients were selected for this study and randomly divided into open appendectomy group (130 cases) and laparoscopic appendectomy group (130 cases). Patients in open appendectomy group underwent traditional open appendectomy, while patients in laparoscopic appendectomy were treated with laparoscopic appendectomy. Incision length, blood loss during operation, duration of operation, time to leave bed, anus exhausting time, time to take food, catheter drainage time, urinary catheterization time, time of using antibiotics, use of pain killer and incidence of complications such as incision infection, residual abscess and intestinal obstruction were compared between two groups.Results:We found relevant indexes including length of incision, amount of bleeding and duration of operation in laparoscopic appendectomy group were better than open appendectomy group after surgery; and differences were statistically significant (P<0.05). Indexes such as time to out of bed, time to take food, exhaust time, drainage time, catheterization time and application time and use of antibiotics in laparoscopic appendectomy group were all superior to open appendectomy group, and differences had statistical significance (P<0.05). Incidence of complications in laparoscopic appendectomy group was much lower than open appendectomy group and the difference was statistically significant (P<0.05).Conclusion:Laparoscopic appendectomy has advantages of small trauma, sound curative effect, low incidence of complications and rapid recovery and can effectively relieve pain of children suffering from appendicitis. Hence it is worth promotion and should be preferred.