Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences

Introduction

The initial nonoperative management of perforated appendicitis fails in 15% to 25% of children. These children have complications and increased hospitalization. The purpose of this study was to identify predictors of failure.

Methods

Children with perforated appendicitis treated with antibiotics and intent for nonoperative management over a 4-year period were reviewed. Seventy-five children were identified and included in the study. Failure was defined as undergoing appendectomy before the initially planned interval.

Results

Nine (12%) of the patients required appendectomy sooner than initially planned. Age, presenting symptoms, physical examination findings, and white blood cell (WBC) count were similar in both success and failure groups. Absence of abscess and presence of appendicolith were both predictors of failure in a multivariate analysis, which included the presence of small bowel obstruction. The failed group had a longer median total length of stay (18 days [range, 4-67] vs 8 days [range, 4-31]; P = .002) and underwent 3 times as many computed tomography scans as successes (3 [range, 2-7] vs 1 [range, 0-5]; P < .001).

Conclusion

Lack of abscess and presence of an appendicolith predict failure of nonoperative management of perforated appendicitis in children even when the effect of small bowel obstruction is accounted for. Children with these characteristics may benefit from alternative management strategies.     

Dollars and sense of interval appendectomy in children: a cost analysis

Purpose

Although initial nonoperative management of focal, perforated appendicitis in children is increasingly practiced, the need for subsequent interval appendectomy remains debated. We hypothesized that cost comparison would favor continued nonoperative management over routine interval appendectomy.

Methods

Decision tree analysis was used to compare continued nonoperative management with routine interval appendectomy after initial success with nonoperative management of perforated appendicitis. Outcome probabilities were obtained from literature review and cost estimates from the Kid's Inpatient Database. Sensitivity analyses were performed on the 2 most influential variables in the model, the probability of successful nonoperative management and the costs associated with successful observation. Monte Carlo simulation was performed using the range of cost estimates.

Results

Costs for continued nonoperative observation were estimated at $3080.78 as compared to $5034.58 for the interval appendectomy. Sensitivity analysis confirms a cost savings for nonoperative management as long as the likelihood of successful observation exceeds 60%. As the cost of nonoperative management increased, the required probability for its success also increased. Using wide distributions for both probability estimates as well as costs, Monte Carlo simulation favored continued observation in 75% of scenarios.

Conclusion

Continued nonoperative management has a cost advantage over routine interval appendectomy after initial success with conservative management in children with focal, perforated appendicitis.     

Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

Objective

The aim of the study was to review evidence-based data regarding the use of antibiotics for the treatment of appendicitis in children.

Data Source

Data were obtained from PubMed, MEDLINE, and citation review.

Study Selection

We conducted a literature search using “appendicitis” combined with “antibiotics” with children as the target patient population. Studies were selected based on relevance for the following questions:

(1)

What perioperative antibiotics should be used for pediatric patients with nonperforated appendicitis?

(2)

For patients with perforated appendicitis treated with appendectomy:

a.

What perioperative intravenous antibiotics should be used?

b.

How long should perioperative intravenous antibiotics be used?

c.

Should oral antibiotics be used?

(3)

For patients with perforated appendicitis treated with initial nonoperative management, what antibiotics should be used in the initial management?

Results

Children with nonperforated appendicitis should receive preoperative, broad-spectrum antibiotics. In children with perforated appendicitis who had undergone appendectomy, intravenous antibiotic duration should be based on clinical criteria. Furthermore, broad-spectrum, single, or double agent therapy is as equally efficacious as but is more cost-effective than triple agent therapy. If intravenous antibiotics are administered for less than 5 days, oral antibiotics should be administered for a total antibiotic course of 7 days. For children with perforated appendicitis who did not initially undergo an appendectomy, the duration of broad-spectrum, intravenous antibiotics should be based on clinical symptoms.

Conclusions

Current evidence supports the use of guidelines as described above for antibiotic therapy in children with acute and perforated appendicitis.     

Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis

Background

The role of nonoperative therapy vs immediate appendectomy in the management of children with perforated appendicitis remains undefined. The objective of this study was to rigorously compare these management options in groups of patients with matched clinical characteristics.

Methods

Multicenter case-control study was conducted from 1998 to 2003. We compared patients treated nonoperatively vs those undergoing appendectomy to identify differences in 12 clinical parameters. We then generated a second control group of patients matched for these variables and compared the following outcomes in these clinically similar groups: complication rate, abscess rate, and length of stay (LOS). Analysis was performed according to intention-to-treat principles, using χ², Fisher exact, and Student t tests.

Results

The only significant difference between patients treated nonoperatively and those treated by appendectomy was the duration of pain on presentation (6.8 vs 3.1 days of pain).We created a second control group of patients undergoing immediate appendectomy matched on duration of pain on presentation to patients treated nonoperatively. These groups continued to be clinically comparable for the other 11 parameters. Compared to this matched control group, the nonoperative group had fewer complications (19% vs 43%, P < .01), fewer abscesses (4% vs 24%, P < .01), and a trend for shorter LOS (6.5 ± 5.7 vs 8.8 ± 6.7 days, P = .08).

Conclusions

When nonoperative management for perforated appendicitis was studied using appropriately matched clinical controls, we found that it resulted in a lower complication rate and shorter LOS in the subset of patients presenting with a long duration of pain. Our data suggest that nonoperative management should be prospectively evaluated in children with perforated appendicitis presenting with a history of pain exceeding 5 days.     

Early decisions in perforated appendicitis in children: lessons from a study of nonoperative management

Background

In nonoperative management of perforated appendicitis, some children do not respond to treatment. This study sought early identifiers of failure to help in surgical decision making.

Methods

Fifty-eight patients with computed tomographic (CT)-proven perforated appendicitis were treated according to a nonoperative protocol. Patients who recovered were considered “successes;” those who did not improve underwent appendectomy and were scored as “failures” of nonoperative treatment.

Results

Thirty-six (62%) of 58 patients responded to treatment and 22 (38%) failed. Three parameters distinguished the 2 groups: the number of band forms on the admission white blood cell count, the body temperature response after 24 hours of treatment, and the areas of the abdomen involved in the CT scan. Patients in whom nonoperative treatment failed stayed in the hospital longer (17 vs 9 days) and had more complications (46% vs 0%).

Conclusions

Because failure of nonoperative management is associated with a high complication rate, it is important to make an early decision about appendectomy. Persistence of fever after 24 hours of treatment, bandemia on admission, and multisector involvement on CT scan identify most patients who fail nonoperative management. When combined with clinical judgment, these are useful indicators to guide early decisions.     

Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial

Introduction

Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamicin, and clindamycin (AGC) has been used postoperatively for perforated appendicitis. A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens.

Methods

After internal review board approval (IRB no. 04 12-149), children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (2 total doses per day) or standard dosing of AGC (11 total doses per day). Perforation was defined as an identifiable hole in the appendix. The operative approach (laparoscopic), length of antibiotic use, and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary end point, a sample size of 100 patients was calculated for an α of .5 and a power of 0.82.

Results

One hundred patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptoms, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. The CM group resulted in significantly less antibiotic charges then the AGC group.

Conclusions

Once daily dosing with the 2-drug regimen (CM) offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen.     

Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial

Introduction

Perforated appendicitis is a common condition in children, which, in a small number of patients, may be complicated by a well-formed abscess. Initial nonoperative management with percutaneous drainage/aspiration of the abscess followed by intravenous antibiotics usually allows for an uneventful interval appendectomy. Although this strategy has become well accepted, there are no published data comparing initial nonoperative management (drainage/interval appendectomy) to appendectomy upon presentation with an abscess. Therefore, we conducted a randomized trial comparing these 2 management strategies.

Methods

After internal review board approval (#06 11-164), children who presented with a well-defined abdominal abscess by computed tomographic imaging were randomized on admission to laparoscopic appendectomy or intravenous antibiotics with percutaneous drainage of the abscess (when possible), followed by interval laparoscopic appendectomy approximately 10 weeks later. This was a pilot study with a sample size of 40, which was based on our recent volume of patients presenting with appendicitis and abscess.

Results

On presentation, there were no differences between the 2 groups regarding age, weight, body mass index, sex distribution, temperature, leukocyte count, number of abscesses, or greatest 2-dimensional area of abscess in the axial view. Regarding outcomes, there were no differences in length of total hospitalization, recurrent abscess rates, or overall charges. There was a trend toward a longer operating time in patients undergoing initial appendectomy (61 minutes versus 42 minutes mean, P = .06).

Conclusions

Although initial laparoscopic appendectomy trends toward a requiring longer operative time, there seems to be no advantages between these strategies in terms of total hospitalization, recurrent abscess rate, or total charges.     

Accuracy of computed tomography in predicting appendiceal perforation

Background

Some surgeons use nonoperative management with or without interval appendectomy for patients who present with perforated appendicitis. These strategies depend on accurately delineating perforation by computed tomography (CT). Since 2005, our institution has used an evidence-based definition for perforation as a hole in the appendix or fecalith in the abdomen. This has been shown to clearly separate those with a high risk of abscess from those without. To quantify the ability of CT to identify which patients would meet these criteria for perforation, we tested 6 surgeons and 2 radiologists who evaluated blinded CT scans.

Methods

A junior and senior surgical residents, 2 staff interventional radiologists, and 4 attending pediatric surgeons with 3 to 30 years of experience reviewed 200 CT scans of pediatric patients who had undergone a laparoscopic appendectomy. All CT scans were reviewed electronically, and the reviewers were blinded to the results, outcome, and intraoperative findings. None of the patients had a well-formed abscess on CT. The reviewers were asked to decide only on perforated or nonperforated appendicitis according to our intraoperative definition. Clinical admission data were reviewed and compared between groups.

Results

In total, the reviewers were correct 72% of the time with an overall sensitivity of 62% and a specificity of 81%. The overall positive predictive value was 67%, and the negative predictive value was 77%.

Conclusions

This study shows that in the absence of a well-formed abscess, the triage of patient care based on a preoperative diagnosis of perforation from CT may be imprudent and subject a portion of the population to an unnecessarily prolonged course of care.     

Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach

Introduction

Adhesive small bowel obstruction (SBO) is a common postoperative complication. Published data in the pediatric literature characterizing SBO are scant. Furthermore, the relationship between the risk of SBO for a given procedure is not well described. To evaluate these parameters, we reviewed the incidence of SBO after laparoscopic appendectomy (LA) and open appendectomy (OA) performed at our institution.

Methods

With institutional review board approval, all patients that developed SBO after appendectomy for appendicitis from January 1998 to June 2005 were investigated. Hospital records were reviewed to identify the details of their postappendectomy SBO. The incidences of SBO after LA and OA were compared with χ² analysis using Yates correction.

Results

During the study period, 1105 appendectomies were performed: 477 OAs (8 converted to OA during laparoscopy) and 628 LAs. After OA, 7 (6 perforated appendicitis) patients later developed SBO of which 6 required adhesiolysis. In contrast, a patient with perforated appendicitis developed SBO after LA requiring adhesiolysis (P = .01). The mean time from appendectomy to the development of intestinal obstruction for the entire group was 46 ± 32 days.

Conclusions

The overall risk of SBO after appendectomy in children is low (0.7%) and is significantly related to perforated appendicitis. Small bowel obstruction after LA appears statistically less common than OA. Laparoscopic appendectomy remains our preferred approach for both perforated and nonperforated appendectomy.     

Nonoperative management of pediatric ruptured appendix with inflammatory mass or abscess: presence of an appendicolith predicts recurrent appendicitis

Aim of Study

The aim of this study was to determine if the presence of an appendicolith is associated with an increased risk for recurrent appendicitis after nonoperative treatment of pediatric ruptured appendix with inflammatory mass or abscess.

Methods

Ninety-six pediatric patients (52 girls, 44 boys), aged 16 months to 17 years (average, 7 years), were managed between 1980 and 2003. All were treated nonoperatively with intravenous triple antibiotics for 5 to 21 days. All children had at least a 2-year follow-up. This study was approved by the hospital research ethics board.

Main Results

Six children (6%) who became worse and 41 (46%) who had an interval appendectomy were eliminated from the study. The other 49 patients comprised the study group and received no further treatment. Twenty-eight (57%) had no recurrence, and 21 (43%) had a recurrence within 1 month to 2 years (average, 3 months). In the study group, 31 (63%) children had no appendicolith on radiological imaging and 18 (37%) had. Presence of an appendicolith was associated with a 72% rate of recurrent appendicitis compared with a recurrence rate of 26% in those with no appendicolith (χ² test, P < .004).

Conclusion

We conclude that the patients with appendicolith should have an interval appendectomy.     

Outcome of laparoscopic appendectomy for perforated appendicitis in children

Background

The aim of this study was to evaluate the outcome of laparoscopic (LA) vs open appendectomy (OA) in patients with perforated appendicitis in our center.

Methods

Retrospective review from July 2002 to April 2007 (institutional review board-approved), evaluating 281 patients with perforated appendicitis based on surgical approach. We compared demographics, mean operative time, length of stay (LOS), infectious complications, and follow-up in patients with OA (n = 213) and LA (n = 68).

Results

Laparoscopic appendectomy patients were significantly older (12 vs 9.4 years), heavier (51.8 vs 36.6 kg) and more frequently girls (47.8% vs 34.3%). Mean operative time was longer in LA (72.6 vs 50.2 minutes). Median LOS was 5 days in LA and 6 days in OA. Few patients in each group required a drainage procedure for a persistent abscess (LA 4.4%, OA 4.7%; P = 1.000). Laparoscopic appendectomy patients had fewer wound infections (1.5% vs 9.5%; P = .034), and less follow-up visits were needed (>2 clinic visits 4.5% vs 16.4%; P = .013).

Conclusion

Laparoscopic appendectomy has a shorter median LOS, a trend toward less postoperative infectious complications, and fewer clinic visits than OA, which makes it a safe and effective procedure for patients with perforated appendicitis.     

Quality of life assessment between laparoscopic appendectomy at presentation and interval appendectomy for perforated appendicitis with abscess: analysis of a prospective randomized trial

Purpose

The current study examined the impact of immediate laparoscopic surgery vs nonoperative initial management followed by interval appendectomy for appendicitis with abscess on child and family psychosocial well-being.

Methods

After obtaining Internal Review Board approval, 40 patients presenting with a perforated appendicitis and a well-formed abscess were randomized to surgical condition. Parents were asked to complete child quality of life and parenting stress ratings at presentation, at 2 weeks postadmission, and at approximately 12 weeks postadmission (2 weeks postoperation for the interval appendectomy group).

Results

Children in the interval arm experienced trends toward poorer quality of life at 2 and 12 weeks postadmission. However, no group differences in parenting stress were observed at 2 weeks postoperation. At 12 weeks postadmission, participants in the interval condition demonstrated significant impairment in both frequency and difficulty of problems contributing to parenting distress.

Conclusion

Families experience significant parenting distress related to the child's functioning and disruption in the child's quality of life that may be because of the delay in fully resolving the child's medical condition. In addition, parents experience negative consequences to their own stress as a result of the delay before the child's appendectomy.     

A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial

Introduction

In a previous prospective randomized trial, we found a once-a-day regimen of ceftriaxone and metronidazole to be an efficient, cost-effective treatment for children with perforated appendicitis. In this study, we evaluated the safety of discharging patients to complete an oral course of antibiotics.

Methods

Children found to have perforated appendicitis at the time of laparoscopic appendectomy were enrolled in the study. Perforation was defined as a hole in the appendix or fecalith in the abdomen. Patients were randomized to antibiotic treatment with either once daily dosing of ceftriaxone and metronidazole for a minimum of 5 days (intravenous [IV] arm) or discharge to home on oral amoxicillin/clavulanate when tolerating a regular diet (IV/PO arm) to complete 7 days.

Results

One hundred two patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in age, weight, sex distribution, days of symptoms, maximum temperature, or leukocyte count between the 2 groups. There was no difference in the postoperative abscess rate between the two treatment groups. Discharge was possible before day 5 in 42% of the patients in the IV/PO arm.

Conclusions

When patients are able to tolerate a regular diet, completing the course of antibiotics orally decreases hospitalization with no effect on the risk of postoperative abscess formation.     

Postoperative bowel obstruction after laparoscopic and open appendectomy in children: a 15-year experience

Purpose

The purpose of the study was to determine and evaluate the incidence of postoperative bowel obstruction (PBO) after laparoscopic and open appendectomy in children.

Material and Methods

The medical files of children who have undergone an appendectomy, either via the laparoscopic or open approach, at our department from 1992 until 2007 were reviewed. Collected data included age at appendectomy, initial surgical approach, time interval to PBO, and type of definitive treatment. The incidences of PBO after laparoscopic and open appendectomy were compared with the χ² analysis.

Results

From the 1684 children who were found, 1371 had nonperforated appendicitis and 313 had perforated appendicitis. Laparoscopic appendectomy was performed in 954 patients of the nonperforated group and in 221 of the perforated group. Open appendectomy was performed in 417 and 92 patients of the 2 groups, respectively. Overall, the incidence of PBO development was 2.2%. In the laparoscopic appendectomy population, a significantly low incidence of 1.19% of PBO development was detected, compared with the 4.51% of the open appendectomy group (P < .0001).

Conclusion

Laparoscopic appendectomy diminishes the potential of PBO development. The overall incidence of PBO is not related to the severity of the disease but only to the initial operative approach.     

Risk of perforation increases with delay in recognition and surgery for acute appendicitis

Background

Appendicitis remains a common indication for urgent surgical intervention in the United States, and early appendectomy has long been advocated to mitigate the risk of appendiceal perforation. To better quantify the risk of perforation associated with delayed operative timing, this study examines the impact of length of inpatient stay preceding surgery on rates of perforated appendicitis in both adults and children.

Methods

This study was a cross-sectional analysis using the National Inpatient Sample and Kids’ Inpatient Database from 1988–2008. We selected patients with a discharge diagnosis of acute appendicitis (perforated or nonperforated) and receiving appendectomy within 7 d after admission. Patients electively admitted or receiving drainage procedures before appendectomy were excluded. We analyzed perforation rates as a function of both age and length of inpatient hospitalization before appendectomy.

Results

Of 683,590 patients with a discharge diagnosis of appendicitis, 30.3% were recorded as perforated. Over 80% of patients underwent appendectomy on the day of admission, approximately 18% of operations were performed on hospital days 2–4, and later operations accounted for <1% of cases. During appendectomy on the day of admission, the perforation rate was 28.8%; this increased to 33.3% for surgeries on hospital day 2 and 78.8% by hospital day 8 (P < 0.001). Adjusted for patient, procedure, and hospital characteristics, odds of perforation increased from 1.20 for adults and 1.08 for children on hospital day 2 to 4.76 for adults and 15.42 for children by hospital day 8 (P < 0.001).

Conclusions

Greater inpatient delay before appendectomy is associated with increased perforation rates for children and adults within this population-based study. These findings align with previous studies and with the conventional progressive pathophysiologic appendicitis model. Randomized prospective studies are needed to determine which patients benefit from nonoperative versus surgically aggressive management strategies for acute appendicitis.     

Is it necessary to drain all postoperative fluid collections after appendectomy for perforated appendicitis?

Purpose

Children treated for perforated appendicitis can have significant morbidity. Management often includes looking for and draining postoperative fluid collections. We sought to determine if drainage hastens recovery.

Methods

Children with perforated appendicitis treated with appendectomy from 2006 to 2009 were reviewed. Patients with postoperative fluid that was drained were compared with patients with undrained fluid with regard to preoperative features and postoperative outcomes. Statistical analyses included paired Student's t tests, Mann-Whitney U test, and linear regression.

Results

Five hundred ninety-one patients were reviewed. Seventy-one patients had postoperative fluid, of whom 36 had a drainage procedure and 35 did not. There was no significant difference in white blood cell count at the time of assessment for drainage (16.4 ± 4.0 vs 14.6 ± 4.9, P = .14), days with fever (3.5 ± 3.0 vs 2.9 ± 2.5, P = .35), or readmission rate (19% vs 31%, P = .28). After multivariate linear regression, larger fluid volumes were associated with prolonged length of stay (LOS) (P = .03). For fluid collections between 30-100 mL, there was no significant difference in LOS between the drain and no-drain groups (9.8 ± 3.5 vs 10.9 ± 5.2 days, P = .51).

Conclusion

After appendectomy for perforated appendicitis, larger postoperative fluid collections are associated with prolonged LOS. Drainage of collections less than 100 mL may not hasten recovery.     

Appendiceal fecalith is associated with early perforation in pediatric patients

Purpose

A fecalith is a fecal concretion that can obstruct the appendix leading to acute appendicitis. We hypothesized that the presence of a fecalith would lead to an earlier appendiceal perforation.

Methods

Between January 2001 and December 2005, the charts of all patients younger than 18 years old who underwent appendectomy at our institution were reviewed. Duration of symptoms and timing between presentation and operation were noted along with radiologic, operative, and pathologic findings.

Results

There were 388 patients who met the study criteria. A fecalith was present in 31% of patients (n = 121). The appendix was perforated in 57% of patients who had a fecalith vs 36% in patients without a fecalith (P < .001). The overall rate of interval appendectomies was 12%. A fecalith was present on the initial radiologic studies of 36% of the patients who had interval appendectomies, and the appendix was perforated significantly sooner in these patients when compared to those without a fecalith (91 vs 150 hours; P = .036).

Conclusion

The presence of fecalith is associated with earlier and higher rates of appendiceal perforation in pediatric patients with acute appendicitis. An expedient appendectomy should therefore be performed in the pediatric patient with a radiologic evidence of fecalith.     

Tip appendicitis: clinical implications and management

Background

Tip appendicitis describes a rare condition involving inflammatory changes of the distal appendix. We discuss the significance and management of this entity when it is identified on computed tomography (CT) imaging.

Methods

CT scans performed at our institution between 2003 and 2007 were reviewed to identify cases of tip appendicitis. Patients were divided into 2 groups, determined by the confirmation of appendicitis on histopathology. Radiological findings and the clinical courses of both groups were documented and compared using univariate analysis.

Results

Of 18 patients with the CT finding of tip appendicitis, appendicitis was ultimately confirmed in 39%. Patients in this group had a higher rate of right lower quadrant (RLQ) tenderness (100% vs 55%, P = .04), leukocytosis (14.2 vs 10.5, P = .03), and clinical suspicion for acute appendicitis (43% vs 0%, P = .02). There were no complications or re-admissions.

Conclusions

The CT finding of tip appendicitis can be managed conservatively in a subset of patients with low clinical suspicion for acute appendicitis.     

Comparison of pediatric appendicitis outcomes between teaching and nonteaching hospitals

Purpose

The aim of the study was to determine the outcomes of pediatric appendicitis between a teaching and nonteaching institution.

Methods

A retrospective review of all patients younger than 18 years treated for appendicitis between 1998 and 2007 was performed. The teaching institution has its own general surgery residency program, and the nonteaching institution has no surgical resident involvement. Both hospitals are part of a larger system and were similar except for resident involvement. Study outcomes included postoperative morbidity and length of hospitalization (LOH). Patients with perforated appendicitis treated nonoperatively were excluded. Data were analyzed using Wilcoxon rank sum test and χ² analysis with P < .01 considered significant.

Results

Seven hundred ninety-two patients were treated at the teaching institution (mean age, 10.9 years; 62% male) and 1670 at the nonteaching institution (mean age, 11 years; 61% male). The perforated appendicitis rate was 31% at the teaching institution and 26% at the nonteaching institution (P = .008). Forty-five patients at the teaching institution and 14 at the nonteaching institution with perforated appendicitis were treated nonoperatively and excluded. For nonperforated appendicitis, despite similar rates of postoperative wound infection, abscess drainage, and readmission within 30 days between the 2 institutions, LOH was shorter in the teaching institution (1.4 ± 1.0 vs 1.8 ± 1.4 days; P < .0001). For perforated appendicitis, LOH and rates of wound infection, abscess drainage, and readmission within 30 days were similar between the 2 institutions.

Conclusions

Children with nonperforated appendicitis cared for at a teaching institution had similar postoperative morbidity and shorter LOH compared to a nonteaching institution. In patients with perforated appendicitis, postoperative morbidity and LOH were similar between teaching and nonteaching institutions. Overall, the presence of surgical trainees did not adversely impact on the quality of care for children with appendicitis.     

An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children

Purpose

The increased use of computed tomography (CT) to diagnose appendicitis in children has led to a concern for the possibility of increased CT-related cancer morbidity. We designed a clinical protocol for the diagnosis and treatment of appendicitis in children in an attempt to decrease the use of CT scans at our institution.

Methods

Patients who had surgical consultation for suspected appendicitis were placed on the clinical protocol. Data concerning diagnosis and treatment were collected prospectively. Retrospective data from patients admitted to our institution with acute appendicitis before the clinical protocol were collected as historical controls.

Results

One hundred twelve patients were diagnosed and treated by our protocol between June and November 2009. Of these, 100 patients underwent an appendectomy for acute appendicitis. They were compared with 146 patients from 2007. In-house CT use decreased from 71.2% to 51.7% (P = .01). Preoperative ultrasound use increased from 2.7% to 21% (P < .001). The negative appendectomy rate increased (6.8% vs 11%, P = .25).

Conclusions

Our findings suggest that the implementation of an evidence-based clinical protocol for the diagnosis and treatment of acute appendicitis in children may safely decrease the use of CT scans and increase the use of ultrasound.