Appendicitis in children: a comparative study between a specialist paediatric centre and a district general hospital

Paediatric negative appendicectomy rates at a regional Western Australian Centre: a five-year cohort study

BACKGROUND

In acute appendicitis, decision-making around operative intervention for paediatric patients differs from adults due to a higher weight placed on clinical assessment and reduced rates of cross-sectional imaging. In regional settings, non-paediatric emergency doctors, general surgeons, and radiologists usually assess and manage this patient group. Differences have been observed in paediatric negative appendicectomy rates between general and paediatric centres.

METHODS

A retrospective cohort study was performed, identifying paediatric patients undergoing emergency appendicectomy at the Southwest Health Campus (Bunbury, Western Australia) from 2017 to 2021. The primary outcome measure was histopathology confirming the absence of transmural inflammation of the appendix. In addition, clinical, biochemical and radiological data were collected to identify predictors of negative appendicectomy (NA). Secondary outcome measures were hospital length-of-stay and post-operative complication rates.

RESULTS

Four hundred and twenty-one patients were identified, of which 44.9% had a negative appendicectomy. Statistically significant associations between female gender, white cell count less than 10 × 109 , neutrophil ratio less than 75%, low CRP and NA were observed. NA was not associated with a lower risk of re-admission or complications compared with appendicectomy for appendicitis.

CONCLUSIONS

Our centre's NA rate is higher than that observed in the literature at both non-paediatric and paediatric surgical centres. NA has similar morbidity risk to appendicectomy for uncomplicated appendicitis and offers a timely reminder that diagnostic laparoscopy in children is not benign.

Quality metrics for emergency abdominal surgery in children: a systematic review

BACKGROUND

There is variation in care quality and outcomes for children undergoing emergency abdominal surgery, such as appedectomy. Addressing this requires paediatric-specific quality metrics. The aim of this study was to identify perioperative structure and process measures that are associated with improved outcomes for these children.

METHODS

We performed a systematic review searching MEDLINE, Embase, CINAHL, Cochrane Library, and Google Scholar for articles published between January 1, 1980 and September 29, 2020 about the perioperative care of children undergoing emergency abdominal surgery. We also conducted secondary searching of references and citations, and we included international professional publications.

RESULTS

We identified and analysed 383 peer-reviewed articles and 18 grey literature publications. High-grade evidence pertaining to the perioperative care of this patient group is limited. Most of the evidence available relates to improving diagnostic accuracy using preoperative blood testing, imaging, and clinical decision tools. Processes associated with clinical outcomes include time lapse between time of presentation or initial assessment and surgery, and the use of particular analgesia and antibiotic protocols. Structural factors identified include hospital and surgeon caseload and the use of perioperative care pathways.

CONCLUSIONS

This review summarises the structural and process measures associated with outcome in paediatric emergency abdominal surgery. Such measures provide a means of evaluating care and identifying areas of practice that require quality improvement, especially in children with appendicitis.

CLINICAL TRIAL REGISTRATION

PROSPERO CRD42017055285.

Estimation of age of transition from paediatric to adult healthcare for young people with long term conditions using linked routinely collected healthcare data

Introduction

Healthcare transitions, including from paediatric to adult services, can be disruptive and cause a lack of continuity in care. Existing research on the paediatric-adult healthcare transition often uses a simple age cut-off to assign transition status. This risks misclassification bias, reducing observed changes at transition (adults are included in the paediatric group and vice versa) possibly to differing extents between groups that transition at different ages.

Objective

To develop and assess methods for estimating the transition point from paediatric to adult healthcare from routine healthcare records.

Methods

A retrospective cohort of young people (12 to 23 years) with long term conditions was constructed from linked primary and secondary care data in England. Inpatient and outpatient records were classified as paediatric or adult based on treatment and clinician specialities. Transition point was estimated using three methods based on record classification (First Adult: the date of first adult record; Last Paediatric: date of last paediatric record; Fitted: a date determined by statistical fitting). Estimated transition age was compared between methods. A simulation explored impacts of estimation approaches compared to a simple age cut-off when assessing associations between transition status and healthcare events.

Results

Simulations showed using an age-based cut-off at 16 or 18 years as transition point, common in research on transition, may underestimate transition-associated changes. Many health records for those aged <14 years were classified as adult, limiting utility of the First Adult approach. The Last Paediatric approach is least sensitive to this possible misclassification and may best reflect experience of the transition.

Conclusions

Estimating transition point from routine healthcare data is possible and offers advantages over a simple age cut-off. These methods, adapted as necessary for data from other countries, should be used to reduce risk of misclassification bias in studies of transition in nationally representative data.

Should all paediatric appendicectomies be performed in a specialist or high-volume setting?

INTRODUCTION

Acute appendicitis is a common surgical emergency in children. The majority of appendicectomies in children are performed by general surgeons, rather than specialist paediatric surgeons.

AIM

To assess the impact of hospital specialization, hospital volume, and surgeon volume on outcomes for children undergoing appendicectomy in Ireland.

METHODS

NQAIS (National Quality Assurance and Improvement System) data for all appendicectomies performed on children in Ireland between January 2014 and November 2017 was examined. Hospitals were categorized as specialist paediatric centres (SPCs), high-volume general (HVGHs), moderate-volume general (MVGHs), or low-volume general (LVGHs) by annual case volume. Similarly, surgeons were categorized as high-volume (HVSs), moderate-volume (MVSs), or low-volume (LVSs) by annual volume. Data relating to patient demographics, type of surgery (open/laparoscopic/laparoscopic converted to open), length of stay (LOS), mortality, admission to critical care, and readmission rates were collected and analysed.

RESULTS

About 9593 appendicectomies were performed in 21 hospitals by 134 surgeons. Patients in SPCs had lowest overall rates of laparoscopic surgery (48% v 66% (HVGHs) v 70% (MVGHs) v 57%(LVGHs), p < 0.001). In SPCs 30-day readmission rates were lower for younger children (5.3% for 5-8-year olds v 6.7% (HVGHs) v 7.3%(MVGHs) v 10.5% (LVGHs), p = 0.023). HVSs performed more laparoscopic appendicectomies on younger patients (0-4 years: 40% v 6% (MVSs) v 17%(LVSs), p < 0.001) but performed the least on older children (13-16 years: 76% v 82%(MVSs) v 82%(LVSs), p < 0.001).

CONCLUSION

Children younger than 8 years undergoing appendicectomy in HVGHs or SPCs, or by HVSs, have marginally better outcomes. In older children, marginally shorter in-hospital stays and higher laparoscopic rates are seen in those looked after outside of high-volume or specialist units. Our results show that nonspecialist centres provide an essential, and safe, service to paediatric patients with acute appendicitis.

Pediatric appendicitis: Is referral to a regional pediatric center necessary?

BACKGROUND

Acute appendicitis is the most common emergent surgical procedure performed among children in the United States, with an incidence exceeding 80,000 cases per year. Appendectomies are often performed by both pediatric surgeons and adult general/trauma and acute care (TACS) surgeons. We hypothesized that children undergoing appendectomy for acute appendicitis have equivalent outcomes whether a pediatric surgeon or a TACS surgeon performs the operation.

METHODS

A retrospective chart review was performed for patients 6 to 18 years of age, who underwent appendectomy at either a regional children's hospital (Children's Hospital of Colorado [CHCO], n = 241) or an urban safety-net hospital (n = 347) between July 2010 and June 2015. The population of patients operated on at the urban safety-net hospital was further subdivided into those operated on by pediatric surgeons (Denver Health Medical Center [DHMC] pediatric surgeons, n = 68) and those operated on by adult TACS surgeons (DHMC TACS, n = 279). Baseline characteristics and operative outcomes were compared between these patient populations utilizing one-way analysis of variance and χ test for independence.

RESULTS

When comparing the CHCO and DHMC TACS groups, there were no differences in the proportion of patients with perforated appendicitis, operative time, rate of operative complications, rate of postoperative infectious complications, or rate of 30-day readmission. Length of stay was significantly shorter for the DHMC TACS group than that for the CHCO group.

CONCLUSIONS

Our data demonstrate that among children older than 5 years undergoing appendectomy, length of stay, risk of infectious complications, and risk of readmission do not differ regardless of whether they are operated on by pediatric surgeons or adult TACS surgeons, suggesting resources currently consumed by transferring children to hospitals with access to pediatric surgeons could be allocated elsewhere.

LEVEL OF EVIDENCE

Therapeutic/Care management, level III.

Outcomes and costs of pediatric appendectomies at rural hospitals

BACKGROUND/PURPOSE

Despite policy efforts to support rural hospitals, little is known about the quality and safety of pediatric surgical care in geographically remote areas. Our aim was to determine the outcomes and costs of appendectomies at rural hospitals.

METHODS

The Kids' Inpatient Database (2003-2012) was queried for appendectomies in children <18 years at urban and rural hospitals. Outcomes (disease severity, laparoscopy, complications, length of stay (LOS), cost) were analyzed with bivariate and multivariable regression analysis.

RESULTS

Rural hospitals performed 13.6% of appendectomies. On multivariable analysis, rural hospitals were associated with higher negative appendectomy rates (OR 1.49, 95% CI 1.39-1.60, p < 0.001), decreased appendiceal perforation rates (OR 0.86, 95% CI 0.83-0.89, p < 0.001), less laparoscopy use (OR 0.48, 95% CI 0.47-0.50, p < 0.001), higher complication rates (OR 1.29, 95% CI 1.19-1.39, p < 0.001), shorter LOS (IRR 0.90, 95% CI 0.89-0.91, p < 0.001), and slightly increased costs (exponentiated log$ 1.02, 95% CI 1.01-1.02, p < 0.001) CONCLUSIONS: Rural hospitals care for fewer patients with advanced appendicitis but are associated with higher negative appendectomy rates, lower laparoscopy use, and higher complication rates. Additional studies are needed to identify factors that drive this disparity to improve the quality of pediatric surgical care in rural settings.

TYPE OF STUDY

Treatment/Cost Study (Outcomes).

LEVEL OF EVIDENCE

Level III.

Outcomes and Costs of Common Surgical Procedures at Children's and Nonchildren's Hospitals

BACKGROUND

Variations in the management of pediatric patients at children's hospitals (CHs) and non-CHs (NCHs) have been well described, especially within the trauma literature. However, little is known about the outcomes and costs of common general surgical procedures at NCHs. The purpose of this study was to evaluate the effect of CH designation on the outcomes and costs of appendectomy and cholecystectomy.

METHODS

The Kids' Inpatient Database (2003-2012) was queried for patients aged under 18 y who underwent appendectomy or cholecystectomy at CHs and NCHs. Outcomes analyzed included disease severity, complications, laparoscopy, length of stay (LOS), and cost.

RESULTS

Most of appendectomies and cholecystectomies were performed at NCHs. Overall, CHs cared for younger children were more likely to be teaching hospitals, had higher costs, and longer LOS. On multivariate analysis for appendectomies, CHs were associated with higher rates of perforated appendicitis (OR = 1.53, 95% CI = 1.42-1.66, P < 0.001), less complications (OR = 0.68, 95% CI = 0.61-0.75, P < 0.001), increased laparoscopy (OR = 2.93, 95% CI = 2.36-3.64, P < 0.001), longer LOS (RR = 1.13, 95% CI = 1.09-1.17, P < 0.001), and higher costs (exponentiated log $ = 1.19, 95% CI = 1.13-1.24, P < 0.001). Multivariate analysis for cholecystectomies revealed that CHs were associated with less laparoscopy (OR = 0.58, 95% CI = 0.50-0.67, P < 0.001), longer LOS (RR = 1.26, 95% CI = 1.19-1.34, P < 0.001), and higher costs (exponentiated log $ = 1.29, 95% CI = 1.22-1.37, P < 0.001) with similar complications. Independent predictors of LOS and cost included CH designation, negative appendectomy, perforated appendicitis, complications, younger age, black patients, and public insurance.

CONCLUSIONS

Variations in surgical management, outcomes, and costs after appendectomy and cholecystectomy exist between CHs and NCHs. CHs excelled in treating complicated appendicitis. NCHs effectively performed cholecystectomies. These differences in outcomes require further investigation to identify modifiable factors to optimize care across all hospitals for these common surgical diseases.

Is there still a role for the adult general surgeon in general paediatric surgery within a District General Hospital setting? National questionnaire amongst adult general surgical trainees

INTRODUCTION

In recent years there has been a trend towards centralisation of services for general paediatric surgery in the United Kingdom. Fewer District General Hospitals supply provision of paediatric surgery, placing a strain on Specialist Centres. The cause behind the decline is unclear but lack of interest from general surgical trainees may be a contributing factor. A survey was conducted across current higher surgical trainees to review this.

MATERIALS AND METHODS

A short online survey (Typeform) was sent nationally to higher general surgical trainees. The results were analysed using SPSS Version 21.

RESULTS

121 trainees responded to the survey. Only 29% trainees expressed an interest in pursuing general paediatric surgery as part of their future chosen specialty. The main concerns of trainees in regards to paediatric surgery was a limited training time, perception that a paediatric consultant would be unwilling to train a general surgical trainee, and a concern that ISCP requirements were unattainable in six months. There was no significant difference in opinion between those who had/not completed a paediatric surgical placement.

CONCLUSION

There is a growing disinterest of general surgical trainees to pursue paediatric surgery within their future chosen specialty. This is resulting in fewer consultants being qualified to provide the service within a District General Hospital. Trainees often have negative preconceived ideas about the specialty, which may be modified by a positive experience within the specialty.

Effect of hospital type on the treatment of acute appendicitis in teenagers

BACKGROUND

Teenagers receive appendicitis care at both adult and pediatric facilities. The purpose of this study was to evaluate outcomes following treatment of acute appendicitis in teenagers based on the type of hospital facility.

METHODS

Patients aged 13-17years with acute appendicitis who were discharged from acute care hospitals from 2009 to 2014 were identified using a statewide discharge dataset. Hospitals were classified as pediatric or adult and outcomes were compared.

RESULTS

There were 5585 patients treated in adult hospitals and 1625 in pediatric hospitals. Fewer patients at adult hospitals had complicated appendicitis (20.4% vs. 33.0%, p<0.01). Open appendectomy occurred more often in adult hospitals compared to pediatric hospitals (12.6% vs. 6.0%, p<0.01). Pediatric hospitals had higher rates of non-operative management (10% vs. 3.4%, p<0.01) and percutaneous drain placement (1.2% vs. 0.4%, p<0.01). Postoperative complication rates did not significantly differ between hospital types.

CONCLUSION

Most teenagers undergo appendectomy at adult facilities; however, a greater proportion of younger patients and patients with complicated appendicitis is treated at pediatric hospitals. Treatment at a freestanding children's hospital results in lower rates of open procedures and no difference in complications. Opportunities may exist to standardize care across treating facilities to optimize outcomes and resource use.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

II.

Comparison of Appendectomy Outcomes Between Senior General Surgeons and General Surgery Residents

Importance

In some centers, the presence of a senior general surgeon (SGS) is obligatory in every procedure, including appendectomy, while in others it is not. There is a relative paucity in the literature of reports comparing the outcomes of appendectomies performed by unsupervised general surgery residents (GSRs) with those performed in the presence of an SGS.

Objective

To compare the outcomes of appendectomies performed by SGSs with those performed by GSRs.

Design, Setting, and Participants

A retrospective analysis was performed of all patients 16 years or older operated on for assumed acute appendicitis between January 1, 2008, and December 31, 2015. The cohort study compared appendectomies performed by SGSs and GSRs in the general surgical department of a teaching hospital.

Main Outcomes and Measures

The primary outcome measured was the postoperative early and late complication rates. Secondary outcomes included time from emergency department to operating room, length of surgery, surgical technique (open or laparoscopic), use of laparoscopic staplers, and overall duration of postoperative antibiotic treatment.

Results

Among 1649 appendectomy procedures (mean [SD] patient age, 33.7 [13.3] years; 612 female [37.1%]), 1101 were performed by SGSs and 548 by GSRs. Analysis demonstrated no significant difference between the SGS group and the GSR group in overall postoperative early and late complication rates, the use of imaging techniques, time from emergency department to operating room, percentage of complicated appendicitis, postoperative length of hospital stay, and overall duration of postoperative antibiotic treatment. However, length of surgery was significantly shorter in the SGS group than in the GSR group (mean [SD], 39.9 [20.9] vs 48.6 [20.2] minutes; P < .001).

Conclusions and Relevance

This study demonstrates that unsupervised surgical residents may safely perform appendectomies, with no difference in postoperative early and late complication rates compared with those performed in the presence of an SGS.

Staged intraperitoneal brachytherapy and hyperthermic intraperitoneal chemotherapy in an adolescent: novel anesthetic challenges for pediatric anesthetists

Newer techniques that have found a place in cancer management in adults are offered far less commonly in pediatric patients. We present a case of a patient with recurrent Wilms' tumor managed with a novel combination of cytoreductive surgery, intraperitoneal brachytherapy, and subsequent hyperthermic intraperitoneal chemotherapy. Each stage presents challenges that the pediatric anesthetist is unlikely to have faced before. Such cases require flexibility and thorough planning to manage the combination of major surgery, remote anesthesia with brachytherapy and hyperthermic chemotherapy with its potential for metabolic derangement, significant fluid shifts, analgesic care, and potential exposure of staff to cytotoxic agents. Comprehensive care can be offered in pediatric centers.

Influence of hospital and patient location on early postoperative outcomes after appendectomy and pyloromyotomy

BACKGROUND

The effects of hospital location and designation on postoperative pediatric outcomes remain unclear. We hypothesized that urban hospital outcomes would be superior to rural hospitals, and that outcomes at urban centers would differ for children from rural versus urban counties.

METHODS

Retrospective cohort study of children undergoing appendectomy (n=129,507) and pyloromyotomy (n=13,452) using the 2006/2009 KID databases. Hospitals were characterized by specialty designation and classified as urban/rural. County of residence was classified as urban/rural. Outcomes included complications and length of stay. Multivariate regression models were used to adjust for confounding.

RESULTS

Among appendectomy patients, treatment at urban hospitals was associated with reduced odds of any postoperative complication (OR=0.77, 95% C.I. 0.70-0.85) and anesthesia-related complications (OR=0.72, 95% C.I. 0.57-0.91). This association was strongest in the youngest children (<5 years) and at children's hospitals. For pyloromyotomy patients, urban hospitals were associated with reduced odds of any complication (OR=0.43, 95% C.I. 0.24-0.75), anesthesia-related complications (OR=0.14, 95% C.I. 0.05-0.37), and duodenal perforation (OR=0.46, 95% C.I. 0.19-1.07). These associations were most significant at children's hospitals.

CONCLUSIONS

Postoperative outcomes appear to be improved at urban specialty hospitals relative to rural hospitals for certain common pediatric procedures. Identification of the factors driving this association may help inform resource optimization efforts in pediatric surgery.

The Integration of Adult Acute Care Surgeons into Pediatric Surgical Care Models Supplements the Workforce without Compromising Quality of Care

Acute care of children remains a challenge due to a shortage of pediatric surgeons, particularly in rural areas. In our institutional norm, all cases in patients age six and older are managed by dedicated general surgeons. The provision of care to these children by these surgeons alleviates the impact of such shortages. We conducted a five-year retrospective analysis of all acute care pediatric surgical cases performed in patients aged 6 to 17 years by a dedicated group of adult general surgeons in a rural tertiary care hospital. Demographics, procedure, complications, outcomes, length of stay, and time of consultation/operation were obtained via chart review. Elective, trauma related, or procedures performed by a pediatric surgeon were excluded. Descriptive statistics are reported. A total of 397 cases were performed by six dedicated general surgeons during the study period. Mean age was 11.5 ± 3.1 years. In all, 100 (25.2%) were transferred from outlying facilities and 52.6 per cent of consultations/operations occurred at night (7P–7A), of which 33.2 per cent occurred during late night hours (11P–7A). On weekends, 34.0 per cent occurred. Appendectomy was the most commonly performed operation (n = 357,89.9%), of which 311 were laparoscopic (87.1%). Others included incision/drainage (4.5%), laparoscopic cholecystectomy (2.0%), bowel resection (1.5%), incarcerated hernia (0.5%), small bowel obstruction (0.5%), intraabdominal abscess drainage (0.3%), resection of intussusception (0.3%), Graham patch (0.3%), and resection omental torsion (0.3%). Median length of stay was two days. Complications occurred in 23 patients (5.8%), of which 22(5.5%) were the result of the disease process. These results parallel those published by pediatric surgeons in this age group and for the diagnoses treated. Models integrating dedicated general surgeons into pediatric call rotations can be designed such that quality of pediatric care is maintained while providing relief to an overburdened pediatric surgical workforce.

Systematic Review and Meta-Analysis on the Influence of Surgeon Specialization on Outcomes Following Appendicectomy in Children

The aim of this study is to assess the influence of surgeon specialization on outcomes following appendicectomy in children.General surgeons and pediatric surgeons manage appendicitis in children; however, the influence of subspecialization on outcomes remains unclear.Two authors searched Medline and Embase to identify relevant studies. Eligible studies were comparative and provided data on children who had appendicectomy while under the care of general or pediatric surgical teams. Two authors initially screened titles and abstracts and then full text manuscripts were evaluated. Data were extracted by 2 authors using an electronic spreadsheet. Pooled risk ratios and pooled mean differences were used in analyses.We identified 9 relevant studies involving 50,963 children who were managed by general surgery teams and 15,032 children who were managed by pediatric surgery teams. A normal appendix was removed in 4660/48,105 children treated by general surgery units and in 889/14,760 children treated by pediatric units (pooled risk ratio 1.79; 95% confidence interval [CI] 1.26-2.54; P = 0.001). Children managed in general units had shorter mean hospital stays compared with children managed in pediatric units (pooled mean difference -0.70 days; 95%CI -1.09 to -0.30; P = 0.0005). There were no significant differences regarding wound infections, intra-abdominal abscesses, readmissions, or mortality.We found that children who were managed by specialized pediatric surgery teams had lower rates of negative appendicectomy although mean length of stay was longer. Our article is based upon a group of heterogeneous and mostly retrospective studies and therefore there is little external validity. Further studies are needed.

The impact of children's hospital designation on outcomes in children with malrotation

BACKGROUND

The benefit of Ladd's procedure for malrotation at a Children's Hospital (CH) has not previously been established. Our aim was to characterize the potential variations in management and outcomes between CH and Non-Children's Hospitals (NCH) in the treatment of malrotation with Ladd's procedure.

METHODS

There were 2827 children identified with malrotation and complete information from the Kids' Inpatient Database (2003, 2006, 2009). Outcomes were compared between CH and NCH and evaluated with logistic and linear regressions. Additional propensity score matching was used to balance covariates between CH and NCH.

RESULTS

There were 2261 (80.0%) children with malrotation undergoing Ladd's procedures treated at CH; 566 (20.0%) were treated at NCH. In multivariate analysis, CH was associated with a 39% lower odds of resection (p=0.004), with no differences observed for mortality, morbidity and LOS. Comparison of a propensity score matched cohort confirmed these findings, as well as demonstrated no significant differences in associated costs.

CONCLUSIONS

The majority of pediatric intestinal malrotation is managed at CH. While measured outcomes of mortality, morbidity, LOS, and costs were not different at NCH, CH was less likely to perform intestinal resection during Ladd's procedure.

Article Commentary: Rural Pediatric Surgery

Published outcome studies support regionalization of pediatric surgery, in which all children suspected of having surgical disease are transferred to a specialty center. Transfer to specialty centers, however, is an expensive approach to quality, both in direct costs of hospitalization and the expense incurred by families. A related question is the role of well-trained rural surgeons in an adequately resourced facility in the surgical care of infants and children. Local community facilities provide measurably equivalent results for straightforward emergencies in older children such as appendicitis. With education, training, and support such as telemedicine consultation, rural surgeons and hospitals may be able to care for many more children such as single-system trauma and other cases for which they have training such as pyloric stenosis. They can recognize surgical disease at earlier stages and initiate appropriate treatment before transfer so that patients are in better shape for surgery when they arrive for definitive care. Rural and community facilities would be linked in a pediatric surgery system that covers the spectrum of pediatric surgical conditions for a geographical region.

Optimizing resources for the surgical care of children: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee consensus statement

The United States' healthcare system is facing unprecedented pressures: the healthcare cost curve is not sustainable while the bar of standards and expectations for the quality of care continues to rise. Systems committed to the surgical treatment of children will likely require changes and reorganization. Regardless of these mounting pressures, hospitals must remain focused on providing the best possible care to each child at every encounter. Available clinical expertise and hospital resources should be optimized to match the complexity of the treated condition. Although precise criteria are lacking, there is a growing consensus that the optimal combination of clinical experience and hospital resources must be defined, and efforts toward this goal have been supported by the Regents of the American College of Surgeons, the members of the American Pediatric Surgical Association, and the Society for Pediatric Anesthesia (SPA) Board of Directors. The topic of optimizing outcomes and the discussion of the concepts involved have unfortunately become divisive. Our goals, therefore, are 1) to provide a review of the literature that can provide context for the discussion of regionalization, volume, and optimal resources and promote mutual understanding of these important terms, 2) to review the evidence that has been published to date in pediatric surgery associated with regionalization, volume, and resource, 3) to focus on a specific resource (anesthesia), and the association that this may have with outcomes, and 4) to provide a framework for future research and policy efforts.

Outcome of appendicectomy in children performed in paediatric surgery units compared with general surgery units

BACKGROUND

Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units.

METHODS

This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures.

RESULTS

Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0.37, 95 per cent confidence interval 0.23 to 0.59; P < 0.001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0.34, 0.21 to 0.57; P < 0.001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1.90, 1.18 to 3.06; P = 0.011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1.59, 0.93 to 2.73; P = 0.091).

CONCLUSION

The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.

Pediatric surgeon vs general surgeon: does subspecialty training affect the outcome of appendicitis?

BACKGROUND

The absence of pediatric surgeons in many centers results in restriction of patient access to pediatric subspecialty care. The aim of this study was to compare the outcomes of children treated for appendicitis by pediatric surgeons (PS) and by general surgeons (GS).

METHODS

This was a retrospective review of the charts of all consecutive patients <16 years old who underwent appendectomy during 2 years The primary outcome measure was the overall rate of complications. Secondary outcome measures included length of hospital stay (LOS), symptom duration, time from emergency department diagnosis to surgery, and readmission rate within 30 days.

RESULTS

A total of 94 patients (PS group, n = 66; GS group, n = 28) were included. PS patients were younger. For patients with complicated appendicitis, complications were significantly more prevalent in the GS group (57% vs 15%; P = 0.0001). Median LOS was not significantly different between the two groups for complicated appendicitis, but patients with non-complicated appendicitis had a significant longer LOS when treated by PS (3.74 ± 1.5 vs 2.57 ± 1.21 days; P = 0.0041). Patients in the PS group had a prolonged use of antibiotics (2 vs 4 days; P = 0.001), and longer LOS (3 vs 4 days; P = 0.0018).

CONCLUSIONS

Overall complication rates were similar between PS and GS. Complications were significantly more prevalent in patients with complicated appendicitis who were treated by GS.

Shifts towards pediatric specialists in the treatment of appendicitis and pyloric stenosis: trends and outcomes

BACKGROUND

Little data exists on temporal changes in the care of children with common surgical conditions. We hypothesized that an increasing proportion of procedures are performed at pediatric hospitals over time, and that outcomes are superior at these centers.

METHODS

We conducted a retrospective cohort study using Washington State discharge records for children 0-17years old undergoing appendectomy (n=39,472) or pyloromyotomy (n=3,500). Pediatric hospitals were defined as centers with full-time pediatric surgeons. Outcomes were examined for two time periods (1987-2000, 2001-2009).

RESULTS

From 1987 to 2009, the proportion of procedures performed at pediatric hospitals steadily increased. The percentage for appendectomies increased from 17% to 32%, and that for pyloromyotomies increased from 57% to 99%. For pyloromyotomy, care at a pediatric hospital was associated with decreased risk of postoperative complications (OR=0.36, p<0.001) for both time periods. Appendectomy outcomes did not differ significantly in the early time period, but in the later time period specialist care was associated with lower risk of complications in children <5years (OR=0.54, p=0.03).

CONCLUSION

There has been a shift towards pediatric hospitals for certain procedures, with a widening disparity in outcomes for younger children. These results suggest that procedures in younger patients may best be performed by providers familiar with these patient populations.

Appendicectomy at a children's hospital: what has changed over a decade?

BACKGROUND

Appendicectomy remains the most common abdominal emergency procedure performed by surgeons. We reviewed appendicectomies for the calendar years 1999 and 2009 to assess any changes in the referral, presentation and management at a tertiary paediatric institution.

METHODS

We performed a retrospective chart review on all appendicectomies at our institution in 1999 and 2009. Patients were identified using the International Classification of Diseases 9 and 10 Australian Modification codes. A P-value of <0.05 was considered significant.

RESULTS

The number of emergency appendicectomies more than doubled from 126 to 296 between 1999 and 2009. The rate of laparoscopic appendicectomy increased from <1% in 1999 to 70.3% in 2009. Overall, the mean patient age increased from 8.6 years in 1999 to 9.68 in 2009 (P = 0.005). There was an increase in the proportion (19.8% versus 39.5%, P < 0.001) and age (5.3 versus 8.8, P < 0.0001) of patients referred via inter-hospital transfers between the two time periods. In 2009, laparoscopic surgery required on average 13.6 min longer than open surgery. This increase in surgical duration was offset by a decrease in the length of stay (5.0 ± 0.7 versus 3.5 ± 0.3, P < 0.0001).

CONCLUSIONS

Our institution has experienced an extraordinary rise in the number of appendicectomies performed, which cannot be explained by an increase in the local paediatric population alone. There appears to have been dramatic shift in the surgical care of children to our tertiary paediatric centre. The majority of appendicectomies in 2009 were laparoscopic, with a reduced length of stay despite longer operative times.

Comparison of pediatric appendectomy outcomes between pediatric surgeons and general surgery residents

BACKGROUND

Appendectomy is the most common urgent procedure in children, and surgical outcomes may be affected by the surgeon's experience. This study's aim is to compare appendectomy outcomes performed by pediatric surgeons (PSs) and general surgery residents (GSRs).

MATERIALS AND METHODS

A retrospective review of all patients younger than 16y treated for appendicitis at two different campuses of the same institution during the years 2008-2009 was performed. Appendectomies were performed by PS in one campus and GSR in the other. Primary end points included postoperative morbidity and hospital length of stay.

RESULTS

During the study period, 246 (61%) patients were operated by senior GSR (postgraduate year 5-7) versus 157 (39%) patients by PS. There was no significant difference in patients' characteristics at presentation to the emergency room and the rate of appendeceal perforation (11% versus 15%, P=0.32), and noninfectious appendicitis (5% versus 5% P=0.78) also was similar. Laparoscopic surgery was performed more commonly by GSR (16% versus 9%, P=0.02) with shorter operating time (54±1.5 versus 60±2.1, P=0.01). Interestingly, the emergency room to operating room time was shorter for GSR group (419±14 versus 529±24min, P<0.001). The hospital length of stay was shorter for the GSR group (4.0±0.2 versus 4.5±0.2, P=0.03), and broad-spectrum antibiotics were used less commonly (20% versus 53%, P<0.0001) and so was home antibiotics continuation (13% versus 30%, P<0.0001). Nevertheless, postoperative complication rate was similar (5% versus 7%, P=0.29) and so was the rate of readmissions (2% versus 5%, P=0.52).

CONCLUSIONS

The results of this study suggest that the presence of a PS does not affect the outcomes of appendectomies.

The effect of surgical training and hospital characteristics on patient outcomes after pediatric surgery: a systematic review

BACKGROUND/PURPOSE

A systematic review aimed to compare patient outcomes after (1) appendicectomy and (2) pyloromyotomy performed by different surgical specialties, surgeons with different annual volumes, and in different hospital types, to inform the debate surrounding children's surgery provision.

METHODS

Embase, Medline, Cochrane Library, and Health Management Information Consortium were searched from January 1990 to February 2010 to identify relevant articles. Further literature was sought by contacting experts, citation searching, and hand-searching appropriate journals.

RESULTS

Seventeen relevant articles were identified. These showed that (1) rates of wrongly diagnosed appendicitis were higher among general surgeons, but there were little differences in other outcomes and (2) outcomes after pyloromyotomy were superior in patients treated by specialist surgeons. Surgical specialty was a better predictor of morbidity than hospital type, and surgeons with higher operative volumes had better results.

CONCLUSIONS

Existing evidence is largely observational and potentially subject to selection bias, but general pediatric surgery outcomes were clearly dependent on operative volumes. Published evidence suggests that (1) pediatric appendicectomy should not be centralized because children can be managed effectively by general surgeons; (2) pyloromyotomy need not be centralized but should be carried out in children's units by appropriately trained surgeons who expect to see more than 4 cases per year.

Diagnostic accuracy of white cell count and C-reactive protein for assessing the severity of paediatric appendicitis

OBJECTIVES

Simple investigations like white cell count (WCC) and C-reactive protein (CRP) may help to improve the accuracy of diagnosis in paediatric appendicitis. We evaluated the diagnostic accuracy of WCC and CRP for the severity of acute appendicitis in children.

DESIGN

Cross-sectional study.

SETTING

This study was conducted on all children who underwent open appendectomy from January 2007 to December 2008 at a District General Hospital. Data regarding demographics, WCC, CRP, histology and postoperative complications were analysed.

PARTICIPANTS

All children who underwent open appendectomy during the study period.

MAIN OUTCOME MEASURES

Diagnostic accuracy of WCC and CRP for simple acute appendicitis and a perforated appendix.

RESULTS

Out of 204 patients, 112 (54.9%) were girls. At surgery, appendix was grossly inflamed in 175 of which 32 had perforation. Histology revealed simple acute appendicitis in 135 (66.2%) and gangrenous appendicitis in 32 (15.7%). The rest were normal. The duration of symptoms, temperature, length of stay, WCC and CRP were significantly worse in the perforated group (P value <0.05). Postoperative complications included wound infection (n = 18), pelvic collection (n = 5) and intestinal obstruction (n = 6); and were more common among patients with a perforated appendix (P value <0.05). WCC had a higher diagnostic accuracy and higher sensitivity than CRP in diagnosing simple acute appendicitis. The combined sensitivity of WCC and CRP increased to 95% and 100% for the diagnosis of simple acute appendicitis and a perforated appendix, respectively.

CONCLUSION

Accuracy of WCC is higher than CRP for diagnosing simple acute appendicitis. The combined sensitivity of WCC and CRP increases for simple acute appendicitis as well as a perforated appendix.

Comparison of childhood appendicitis management in the regional paediatric surgery unit and the district general hospital

BACKGROUND/PURPOSE

Ongoing debate surrounds the future provision of general paediatric surgery. The aim of this study was to compare outcomes for childhood appendicitis managed in a district general hospital (DGH) and a regional paediatric surgical unit (RU).

METHODS

Data collected retrospectively for a 2-year period in a DGH were compared with data collected prospectively for 1 year in an RU, where appendicitis management is guided by a care pathway. Children aged 6 to 15 years were included.

RESULTS

Four hundred and two patients were included (DGH ,196; RU, 206). There were more cases of gangrenous/perforated appendicitis in the RU (P < .0001). In the DGH, fewer patients received preoperative antibiotics (P < .0001) or underwent preoperative pain scoring (P < .0001). When adjusted for case mix, the relative risk of complications for a child managed at the DGH was 1.76 (95% confidence interval, 1.44-2.16; P < .0001) and that of readmission was 1.76 (95% confidence interval, 1.43-2.16; P < .0001) when compared with the RU.

CONCLUSIONS

Patients with appendicitis managed in the DGH had a higher risk of complications and readmission. However, this appears to be related to the use of a care pathway at the RU. Introduction of a care pathway in the DGH may improve outcomes and thus support the ongoing provision of general paediatric surgery.