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Kumar SS, Collings AT, Lamm R, Haskins IN, Scholz S, Nepal P, Train AT, Athanasiadis DI, Pucher PH, Bradley JF, Hanna NM, Quinteros F, Narula N, Slater BJ. SAGES guideline for the diagnosis and treatment of appendicitis. Surg Endosc 2024; 38:2974-2994. [PMID: 38740595 DOI: 10.1007/s00464-024-10813-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/21/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis. METHODS A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. RESULTS Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty. CONCLUSIONS These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.
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Affiliation(s)
- Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pramod Nepal
- Division of Colon & Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | | | - Philip H Pucher
- School of Pharmacy and Biosciences, University of Portsmouth & Department of General Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Joel F Bradley
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Nisha Narula
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Bethany J Slater
- University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, USA.
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Zhou S, Cheng Y, Cheng N, Gong J, Tu B. Early versus delayed appendicectomy for appendiceal phlegmon or abscess. Cochrane Database Syst Rev 2024; 5:CD011670. [PMID: 38695830 PMCID: PMC11064883 DOI: 10.1002/14651858.cd011670.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
BACKGROUND This is an update of a Cochrane review first published in 2017. Acute appendicitis (inflammation of the appendix) can be simple or complicated. Appendiceal phlegmon and appendiceal abscess are examples of complicated appendicitis. Appendiceal phlegmon is a diffuse inflammation in the bottom right of the appendix, while appendiceal abscess is a discrete inflamed mass in the abdomen that contains pus. Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms (e.g. abdominal pain, loss of appetite, nausea, and vomiting) and avoid complications (e.g. peritonitis (infection of abdominal lining)). Surgery for people with appendiceal phlegmon or abscess may be early (immediately after hospital admission or within a few days of admission), or delayed (several weeks later in a subsequent hospital admission). The optimal timing of appendicectomy for appendiceal phlegmon or abscess is debated. OBJECTIVES To assess the effects of early appendicectomy compared to delayed appendicectomy on overall morbidity and mortality in people with appendiceal phlegmon or abscess. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers on 11 June 2023, together with reference checking to identify additional studies. SELECTION CRITERIA We included all individual and cluster-randomised controlled trials (RCTs), irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included eight RCTs that randomised 828 participants to early or delayed appendicectomy for appendiceal phlegmon (7 trials) or appendiceal abscess (1 trial). The studies were conducted in the USA, India, Nepal, and Pakistan. All RCTs were at high risk of bias because of lack of blinding and lack of published protocols. They were also unclear about methods of randomisation and length of follow-up. 1. Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon We included seven trials involving 788 paediatric and adult participants with appendiceal phlegmon: 394 of the participants were randomised to the early appendicectomy group (open or laparoscopic appendicectomy as soon as the appendiceal mass resolved within the same admission), and 394 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed open or laparoscopic appendicectomy several weeks later). There was no mortality in either group. The evidence is very uncertain about the effect of early appendicectomy on overall morbidity (risk ratio (RR) 0.74, 95% confidence interval (CI) 0.19 to 2.86; 3 trials, 146 participants; very low-certainty evidence), the proportion of participants who developed wound infections (RR 0.99, 95% CI 0.48 to 2.02; 7 trials, 788 participants), and the proportion of participants who developed faecal fistulas (RR 1.75, 95% CI 0.36 to 8.49; 5 trials, 388 participants). Early appendicectomy may reduce the abdominal abscess rate (RR 0.26, 95% CI 0.08 to 0.80; 4 trials, 626 participants; very low-certainty evidence), reduce the total length of hospital stay by about two days (mean difference (MD) -2.02 days, 95% CI -3.13 to -0.91; 5 trials, 680 participants), and increase the time away from normal activities by about five days (MD 5.00 days; 95% CI 1.52 to 8.48; 1 trial, 40 participants), but the evidence is very uncertain. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscess We included one trial involving 40 paediatric participants with appendiceal abscess: 20 were randomised to the early appendicectomy group (emergent laparoscopic appendicectomy), and 20 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed laparoscopic appendicectomy 10 weeks later). There was no mortality in either group. The trial did not report on overall morbidity, various complications, or time away from normal activities. The evidence is very uncertain about the effect of early appendicectomy on the total length of hospital stay (MD -0.20 days, 95% CI -3.54 to 3.14; very low-certainty evidence). AUTHORS' CONCLUSIONS For the comparison of early versus delayed open or laparoscopic appendicectomy for paediatric and adult participants with appendiceal phlegmon, very low-certainty evidence suggests that early appendicectomy may reduce the abdominal abscess rate. The evidence is very uncertain whether early appendicectomy prevents overall morbidity or other complications. Early appendicectomy may reduce the total length of hospital stay and increase the time away from normal activities, but the evidence is very uncertain. For the comparison of early versus delayed laparoscopic appendicectomy for paediatric participants with appendiceal abscess, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy. Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery, and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities and length of hospital stay.
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Affiliation(s)
- Shiyi Zhou
- Department of Pharmacy, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Nansheng Cheng
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jianping Gong
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Bing Tu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Lamm R, Kumar SS, Collings AT, Haskins IN, Abou-Setta A, Narula N, Nepal P, Hanna NM, Athanasiadis DI, Scholz S, Bradley JF, Train AT, Pucher PH, Quinteros F, Slater B. Diagnosis and treatment of appendicitis: systematic review and meta-analysis. Surg Endosc 2023; 37:8933-8990. [PMID: 37914953 DOI: 10.1007/s00464-023-10456-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children. METHODS Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively. RESULTS 2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04). CONCLUSIONS This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.
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Affiliation(s)
- Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Thomas Jefferson University, 1015 Walnut Street, 613 Curtis, Philadelphia, PA, 19107, USA.
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Nisha Narula
- Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Pramod Nepal
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joel F Bradley
- Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Philip H Pucher
- Department of Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago Medicine, Chicago, IL, USA
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Lascano D, Kelley-Quon LI. Management of Postoperative Complications Following Common Pediatric Operations. Surg Clin North Am 2021; 101:799-812. [PMID: 34537144 DOI: 10.1016/j.suc.2021.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This review discusses complications unique to pediatric surgical populations. Here the authors focus primarily on five of the most common procedures performed in children: appendectomy, central venous catheterization, pyloromyotomy, gastrostomy, and inguinal/umbilical hernia repair.
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Affiliation(s)
- Danny Lascano
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA 90027, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA 90027, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA; Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA.
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Tatsuta K, Miyazaki S, Ogiku M, Harada T, Yoshiro N. Defining treatment strategy for uncomplicated appendicitis based on patient satisfaction feedback: A cross-sectional study. Asian J Surg 2021; 45:167-171. [PMID: 33966963 DOI: 10.1016/j.asjsur.2021.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/03/2020] [Accepted: 04/15/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Two surgical strategies are available for appendicitis: emergency laparoscopic appendectomy and interval laparoscopic appendectomy. However, timing of surgical intervention remains debatable. This study aimed to compare the surgical outcomes of emergency laparoscopic appendectomy and interval laparoscopic appendectomy and conduct a questionnaire survey to investigate the use of emergency laparoscopic appendectomy and patient satisfaction with regard to treatment. METHODS We included 162 patients who underwent laparoscopic appendectomy at our hospital. Outcomes were assessed by operation time, blood loss, postoperative fasting time, length of hospital stay, and complication rate. Patient satisfaction was measured by questionnaire addressing degree of satisfaction, presurgery anxiety, and length of hospital stay. RESULTS Of 162 patients, 74 (46%) and 88 (54%) received emergency and interval laparoscopic appendectomy, respectively. No significant difference was observed in the operation time, blood loss, length of hospital stay, or complication rate. Among 66 patients who responded to the questionnaire (28 emergency, 38 interval), a significant difference was observed only in the degree of satisfaction regarding the timing of the surgical intervention (p = 0.04). CONCLUSION Surgical outcomes of emergency and interval appendectomy were equivalent; however, patient satisfaction favored emergency appendectomy, suggesting it is a preferable approach for the treatment of uncomplicated appendicitis.
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Affiliation(s)
- Kyota Tatsuta
- Department of Gastroenterological Surgery, Hamamatsu Medical Center, 328 Tomitsuka, Nakaku, Shizuoka, 432-8580, Japan.
| | - Shinichiro Miyazaki
- Department of Gastroenterological Surgery, Hamamatsu Medical Center, 328 Tomitsuka, Nakaku, Shizuoka, 432-8580, Japan
| | - Masahito Ogiku
- Department of Gastroenterological Surgery, Hamamatsu Medical Center, 328 Tomitsuka, Nakaku, Shizuoka, 432-8580, Japan
| | - Takashi Harada
- Department of Gastroenterological Surgery, Hamamatsu Medical Center, 328 Tomitsuka, Nakaku, Shizuoka, 432-8580, Japan
| | - Nishiwaki Yoshiro
- Department of Gastroenterological Surgery, Hamamatsu Medical Center, 328 Tomitsuka, Nakaku, Shizuoka, 432-8580, Japan
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Takahashi Y, Obata S, Matsuura T, Kawano Y, Yanagi Y, Yoshimaru K, Izaki T, Taguchi T. The experiences of interval appendectomy for inflammatory appendiceal mass. Pediatr Int 2021; 63:88-93. [PMID: 32568432 DOI: 10.1111/ped.14358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/23/2020] [Accepted: 06/17/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Interval appendectomy (IA) is a common treatment of acute appendicitis (AA) with inflammatory appendiceal mass (IAM). However, the management of patients with IAM is still controversial. The aim of this study was to assess the outcomes in patients with this condition. METHODS We retrospectively evaluated 244 patients with AA for their clinical characteristics and outcomes. RESULTS Forty-three patients had IAM at the first medical examination. The mean age was significantly younger and the C-reactive protein level significantly higher (12.6 vs 3.1 mg/dL) in patients with IAM. Thirty-four patients received IA, and nine received emergency appendectomy (EA). In the IA group, the diameter of the abscess was larger than in the EA group (31.4 vs 16.1 mm). The total length of hospitalization was longer in the IA group than the EA group (20.6 vs 7.0 days), although the operative time was longer in the EA group because of adhesion (101.1 vs 192.1 min). Furthermore, most IA patients received a reduced-port appendectomy (74% vs 11%). Recurrence occurred in approximately 15% of patients awaiting IA. There were no complications in either group. CONCLUSIONS Although each treatment approach has its advantages and disadvantages, both IA and EA can be the first option for the treatment of AA with IAM.
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Affiliation(s)
- Yoshiaki Takahashi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Satoshi Obata
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshiharu Matsuura
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuki Kawano
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yusuke Yanagi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichiro Yoshimaru
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoko Izaki
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Rahman MAM, Chowdhury TK, Chowdhury MZ, Farooq MAA. Early appendectomy for appendicular mass: operative findings and outcome in 220 children—a developing country perspective. ANNALS OF PEDIATRIC SURGERY 2020. [DOI: 10.1186/s43159-020-00051-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Abstract
Background
Lump or mass formation due to delayed presentation after appendicitis is common, and it is frequently complicated by perforation, gangrene, pus, or abscess formation. Care of patients and management vary between developed world and developing country. The aim of the study is to analyze outcome of early surgery for appendicular mass from a developing country perspective. 220 patients of appendicular mass who underwent early appendectomy over a period of 5 years in the Department of Pediatric Surgery, at author’s institute were retrospectively reviewed. Early appendectomy was defined as appendectomy done within 24 h of admission. Presentation, examination findings, investigations, type of surgery, operative findings, post-operative complications, and hospital stay were analyzed.
Results
Age of patients ranged from 2 to 12 years (mean 9.04 ± 2.54 years) and male to female ratio was 2:1. Abdominal pain was the most common presentation followed by vomiting and fever. Mean pain duration was 4.35 ± 4.23 days. There was raised temperature in 140 (63.64%) patients, 154 (74.04%) had tachycardia, and 75.86% had raised WBC count. Laparoscopic appendectomy was done in 31 (14.09%) patients, and the rest 189 (85.91%) patients underwent open surgery. Perforated appendix was the most common (171 patients, 77.73%) peri-operative finding followed by formation of pus (135 patients, 61%). Pus was found more in patients less than 5 years old (18 patients out of 23) than patients more than 5 years old (114 patients out of 197) (P = 0.045). Younger patients also had significantly more complications (39.13% vs 17.26%, P = .000) and hospital stays (mean 15.61 days vs 9.87 days, P = 0.014) than older boys. Complications developed in 42 (19.09%) patients, and wound dehiscence (26 patients, 11.82%) was the most common complication.
Conclusion
Early appendectomy for appendicular mass is a feasible option in the developing world, and laparoscopic appendectomy has good prospect.
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Yang K, Li Y, Gong GW, Lamont G. Laparoscopic treatment of appendiceal abscess in children. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Mima K, Miyanari N, Itoyama R, Nakao Y, Kato R, Shigaki H, Kurashige J, Inoue M, Iwagami S, Mizumoto T, Kubota T, Baba H. Interval laparoscopic appendectomy after antibiotic therapy for appendiceal abscess in elderly patients. Asian J Endosc Surg 2020; 13:311-318. [PMID: 31621202 DOI: 10.1111/ases.12758] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 08/29/2019] [Accepted: 09/01/2019] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate the safety and efficacy of interval laparoscopic appendectomy after antibiotic therapy in elderly patients with appendiceal abscess. METHODS We retrospectively analyzed data for 50 patients with appendiceal abscess aged ≥18 years who had initially planned to undergo interval laparoscopic appendectomy after antibiotic therapy and 50 patients with appendicitis aged ≥70 years who had undergone early laparoscopic appendectomy. All patients were treated at the National Hospital Organization Kumamoto Medical Center between 2012 and 2018. We compared perioperative outcomes after interval appendectomy between patients aged <70 years and ≥70 years. RESULTS Clinical progression of appendicitis during antibiotic therapy developed in one patient (2.0%), and recurrent appendicitis after antibiotic therapy for appendiceal abscess occurred in two patients (4.0%). Pathological findings confirmed appendiceal neoplasms in four patients (8.0%). Postoperative infectious complications occurred in 1 of 47 patients (2.1%) who had undergone successful interval laparoscopic appendectomy, and the median length of postoperative hospital stay was 4 days (interquartile range, 3-5 days). There were no significant differences in outcomes after interval appendectomy between patients aged <70 years and ≥70 years. In the secondary analysis, the median length of postoperative hospital stay after interval laparoscopic appendectomy for appendiceal abscess (4 days) was significantly shorter than that after early laparoscopic appendectomy for uncomplicated appendicitis (7 days; P < .001). CONCLUSIONS Interval laparoscopic appendectomy for appendiceal abscess may be safe and effective in elderly patients without severe comorbidities. Interval appendectomy may be necessary for determining the underlying cause of appendiceal abscess in adults.
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Affiliation(s)
- Kosuke Mima
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Nobutomo Miyanari
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Rumi Itoyama
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Yosuke Nakao
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Rikako Kato
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Hironobu Shigaki
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Junji Kurashige
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Mitsuhiro Inoue
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Shiro Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Takao Mizumoto
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Tatsuo Kubota
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
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Young children with perforated appendicitis benefit from prompt appendectomy. J Pediatr Surg 2019; 54:1809-1814. [PMID: 30638663 DOI: 10.1016/j.jpedsurg.2018.10.107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/26/2018] [Accepted: 10/31/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND/PURPOSE To identify factors associated with nonoperative treatment failure in pediatric perforated appendicitis compared to immediate appendectomy. METHODS After IRB approval, between September 2016 and August 2017, prospective data were recorded for children (age: 1-18 years) with completed appendectomies and pathologist-confirmed perforations. Children were treated according to clinician-designated preference. Nonoperative treatment was considered failed if a nonresolving obstruction developed or any return of symptoms before the planned interval. The median time from pain onset to treatment initiation was 3 days (range: 1-14). Presentation on days 1 or 2 (early) was compared to day 3 or after(late). The nonoperatives were compared to appendectomies stratified by presentation time. Variables were compared by chi-square, Fisher exact or t-tests. Logistic regression evaluated for independence. RESULTS Of 201 suspected perforations, 176 were included, 101 (57%) immediate appendectomies and 75 (43%) nonoperatives. Of 75, 24 (32%) failed; 6 (25%) in hospital, 18 (75%) after discharge. In 51 (68%), nonoperative treatment succeeded. Significantly younger children failed nonoperative treatment (p = 0.03). Failure was independently associated with treatment initiation within 2.75 days from pain onset (OR: 0.07, 95% CI: 0.57-0.98) (p = 0.010) and lower WBC at presentation (OR: 0.03, 95% CI: 0.81-0.98) (p = 0.014). When compared to immediate appendectomy, nonoperatives had more morbidity. CONCLUSION Younger children fail nonoperative treatment, perforate rapidly and have a significantly lower WBC, but benefit from immediate appendectomy. LEVEL OF EVIDENCE Treatment Study Level II.
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Minneci PC, Hade EM, Lawrence AE, Saito JM, Mak GZ, Hirschl RB, Gadepalli S, Helmrath MA, Leys CM, Sato TT, Lal DR, Landman MP, Kabre R, Fallat ME, Fischer BA, Cooper JN, Deans KJ. Multi-institutional trial of non-operative management and surgery for uncomplicated appendicitis in children: Design and rationale. Contemp Clin Trials 2019; 83:10-17. [PMID: 31254670 PMCID: PMC7073001 DOI: 10.1016/j.cct.2019.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/17/2019] [Accepted: 06/25/2019] [Indexed: 12/29/2022]
Abstract
Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children's hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a "successful" treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.
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Affiliation(s)
- Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Erinn M Hade
- Departments of Biomedical Informatics and Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Amy E Lawrence
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jacqueline M Saito
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Grace Z Mak
- Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine and Biologic Sciences, Chicago, IL, USA
| | - Ronald B Hirschl
- Division of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Samir Gadepalli
- Division of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Michael A Helmrath
- Division of Pediatric Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Thomas T Sato
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Matthew P Landman
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rashmi Kabre
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mary E Fallat
- Division of Pediatric Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Beth A Fischer
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Katherine J Deans
- Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
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Minneci PC, Cooper JN, Leonhart K, Nacion K, Sulkowski J, Porter K, Wei L, Deans KJ. Effects of a Patient Activation Tool on Decision Making Between Surgery and Nonoperative Management for Pediatric Appendicitis: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e195009. [PMID: 31173118 PMCID: PMC6563561 DOI: 10.1001/jamanetworkopen.2019.5009] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Strategies to activate and engage patients and caregivers in shared decision making in the acute care setting may result in improved outcomes. OBJECTIVE To determine whether a patient activation tool (PAT) can improve decision-making and patient-centered outcomes among pediatric patients and their caregivers who choose between surgery and nonoperative management for their child's appendicitis. DESIGN, SETTING, AND PARTICIPANTS This single-blind, randomized clinical trial collected data from a single tertiary children's hospital from March 1, 2014, through April 30, 2016, with 1-year follow-up completed on May 1, 2017. Two hundred of 236 eligible children and adolescents aged 7 to 17 years with uncomplicated appendicitis enrolled with their caregivers. After receiving the randomized clinical intervention, caregivers chose surgery or nonoperative management. Data were analyzed from March 1, 2014, through May 1, 2017. INTERVENTIONS Randomization to a scripted standardized surgical consultation that emphasized patient choice or a scripted standardized surgical consultation plus the PAT (a tablet-based tool that presents each treatment, encourages participation in medical decision making, and aims at alleviating decisional uncertainty). MAIN OUTCOMES AND MEASURES Decisional self-efficacy immediately after treatment decision, health care satisfaction at discharge, and disability days for the child at 1-year follow-up. RESULTS Among 200 participants (median age, 12 years [interquartile range (IQR), 9-15 years]; 120 [60.0%] male), 98 were randomized to the PAT and 102 to the standardized consultation groups. The percentages choosing nonoperative management were similar (standardized consultation group, 42 of 102 [41.2%]; PAT group, 31 of 98 [31.6%]; P = .19). Immediate decisional self-efficacy was similar in the standardized consultation and PAT groups (median score, 100 [IQR, 97.7-100] vs 100 [IQR, 95.5-100]; P = .03), which was not significant at the planned significance level of P = .02. Total scores on health care satisfaction at discharge were similar (median, 99 [IQR, 94.7-100] vs 98 [IQR, 91.7-100]; P = .27). Disability days at 1-year follow-up were also similar (median, 6 [IQR, 2-11] vs 5 [IQR, 2-15]; P = .67). No difference in the failure rate of nonoperative management at 1 year (13 of 38 [34.2%] vs 11 of 30 [36.7%]; P > .99) or in the rate of complicated appendicitis 30 days after discharge (7 of 68 [10.3%] vs 9 of 71 [12.7%]; P = .79) occurred. CONCLUSIONS AND RELEVANCE In this study, a technology-based PAT did not improve measures of decision making for pediatric patients and caregivers needing to make an urgent treatment decision between surgery and nonoperative management for appendicitis. However, the overall high scores in both groups suggest that pediatric patients and caregivers can process information in the acute care setting and effectively participate in an informed shared decision-making process around the need for surgery. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02110485.
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Affiliation(s)
- Peter C. Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Jennifer N. Cooper
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Karen Leonhart
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Kristine Nacion
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Jason Sulkowski
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Kyle Porter
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus
| | - Lai Wei
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
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Howell EC, Dubina ED, Lee SL. Perforation risk in pediatric appendicitis: assessment and management. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2018; 9:135-145. [PMID: 30464677 PMCID: PMC6209076 DOI: 10.2147/phmt.s155302] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Perforated appendicitis, as defined by a visible hole in the appendix or an appendicolith free within the abdomen, carries significant morbidity in the pediatric population. Accurate diagnosis is challenging as there is no single symptom or sign that accurately predicts perforated appendicitis. Younger patients and those with increased duration of symptoms are at higher risk of perforated appendicitis. Elevated leukocytosis, bandemia, high C-reactive protein, hyponatremia, ultrasound, and CT are all useful tools in diagnosis. Distinguishing patients with perforation from those without is important given the influence of a perforation diagnosis on the management of the patient. Treatment for perforated appendicitis remains controversial as several options exist, each with its indications and merits, illustrating the complexity of this disease process. Patients may be managed non-operatively with antibiotics, with or without interval appendectomy. Patients may also undergo appendectomy early in the course of their index hospitalization. Factors known to predict failure of non-operative management include appendicolith, leukocytosis greater than 15,000 white blood cells per microliter, increased bands, and CT evidence of disease beyond the right lower quadrant. In this review, the indications and benefits of each treatment strategy will be discussed and an algorithm to guide treatment decisions will be proposed.
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Affiliation(s)
- Erin C Howell
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Emily D Dubina
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA, .,Division of Pediatric Surgery, UCLA Mattel Children's Hospital, Los Angeles, CA, USA,
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14
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Wagner M, Tubre DJ, Asensio JA. Evolution and Current Trends in the Management of Acute Appendicitis. Surg Clin North Am 2018; 98:1005-1023. [DOI: 10.1016/j.suc.2018.05.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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15
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Early versus late surgical management of complicated appendicitis in children: A statewide database analysis with one-year follow-up. J Pediatr Surg 2018; 53:1339-1344. [PMID: 29032983 DOI: 10.1016/j.jpedsurg.2017.09.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 08/27/2017] [Accepted: 09/02/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Complicated appendicitis is common in children, yet the timing of surgical management remains controversial. Some support initial antibiotics with delayed operation whereas others support immediate operation. While a few randomized trials have evaluated this question, they have been small, single-center trials with limited follow-up. We present a database analysis of outcomes in early versus late surgical management of complicated appendicitis with one-year follow-up. METHODS We conducted a retrospective review of children with complicated appendicitis presenting between 2000 and 2013, utilizing a New York State database. We compare children undergoing later versus early appendectomy with a primary outcome measure of any complication within one year as determined from ICD-9 codes. RESULTS 8840 children were included in the analysis, 7708 of whom underwent early appendectomy. Patients with late appendectomy were significantly more likely to have at least one complication when compared to those undergoing early appendectomy (34.6% vs 26.7%, p<0.01). CONCLUSIONS We present the first population-level study evaluating early versus late appendectomy in children with complicated appendicitis with a one-year follow-up period. Children undergoing late appendectomy were more likely to have a complication than those undergoing early appendectomy. These data corroborated previous studies supporting early operative management. LEVEL OF EVIDENCE This study provides level III evidence of a treatment study.
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16
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The cost-effectiveness of nonoperative management versus laparoscopic appendectomy for the treatment of acute, uncomplicated appendicitis in children. J Pediatr Surg 2017; 52:1135-1140. [PMID: 27836368 DOI: 10.1016/j.jpedsurg.2016.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 09/01/2016] [Accepted: 10/11/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Several studies have demonstrated the safety and short-term success of nonoperative management in children with acute, uncomplicated appendicitis. Nonoperative management spares the patients and their family the upfront cost and discomfort of surgery, but also risks recurrent appendicitis. METHODS Using decision-tree software, we evaluated the cost-effectiveness of nonoperative management versus routine laparoscopic appendectomy. Model variables were abstracted from a review of the literature, Healthcare Cost and Utilization Project, and Medicare Physician Fee schedule. Model uncertainty was assessed using both one-way and probabilistic sensitivity analyses. We used a $100,000 per quality adjusted life year (QALY) threshold for cost-effectiveness. RESULTS Operative management cost $11,119 and yielded 23.56 quality-adjusted life months (QALMs). Nonoperative management cost $2277 less than operative management, but yielded 0.03 fewer QALMs. The incremental cost-to-effectiveness ratio of routine laparoscopic appendectomy was $910,800 per QALY gained. This greatly exceeds the $100,000/QALY threshold and was not cost-effective. One-way sensitivity analysis found that operative management would become cost-effective if the 1-year recurrence rate of acute appendicitis exceeded 39.8%. Probabilistic sensitivity analysis indicated that nonoperative management was cost-effective in 92% of simulations. CONCLUSIONS Based on our model, nonoperative management is more cost-effective than routine laparoscopic appendectomy for children with acute, uncomplicated appendicitis. LEVEL OF EVIDENCE Cost-Effectiveness Study: Level II.
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17
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Cheng Y, Xiong X, Lu J, Wu S, Zhou R, Cheng N. Early versus delayed appendicectomy for appendiceal phlegmon or abscess. Cochrane Database Syst Rev 2017; 6:CD011670. [PMID: 28574593 PMCID: PMC6481778 DOI: 10.1002/14651858.cd011670.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms and avoid complications. The timing of appendicectomy for appendiceal phlegmon or abscess is controversial. OBJECTIVES To assess the effects of early versus delayed appendicectomy for appendiceal phlegmon or abscess, in terms of overall morbidity and mortality. SEARCH METHODS We searched the Cochrane Library (CENTRAL; 2016, Issue 7), MEDLINE Ovid (1950 to 23 August 2016), Embase Ovid (1974 to 23 August 2016), Science Citation Index Expanded (1900 to 23 August 2016), and the Chinese Biomedical Literature Database (CBM) (1978 to 23 August 2016). We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform search portal (23 August 2016) and ClinicalTrials.gov (23 August 2016) for ongoing trials. SELECTION CRITERIA We included all individual and cluster-randomised controlled trials, irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). MAIN RESULTS We included two randomised controlled trials with a total of 80 participants in this review. 1. Early versus delayed open appendicectomy for appendiceal phlegmonForty participants (paediatric and adults) with appendiceal phlegmon were randomised either to early appendicectomy (appendicectomy as soon as appendiceal mass resolved within the same admission) (n = 20), or to delayed appendicectomy (initial conservative treatment followed by interval appendicectomy six weeks later) (n = 20). The trial was at high risk of bias. There was no mortality in either group. There is insufficient evidence to determine the effect of using either early or delayed open appendicectomy onoverall morbidity (RR 13.00; 95% CI 0.78 to 216.39; very low-quality evidence), the proportion of participants who developed wound infection (RR 9.00; 95% CI 0.52 to 156.91; very low quality evidence) or faecal fistula (RR 3.00; 95% CI 0.13 to 69.52; very low quality evidence). The quality of evidence for increased length of hospital stay and time away from normal activities in the early appendicectomy group (MD 6.70 days; 95% CI 2.76 to 10.64, and MD 5.00 days; 95% CI 1.52 to 8.48, respectively) is very low quality evidence. The trial reported neither quality of life nor pain outcomes. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscessForty paediatric participants with appendiceal abscess were randomised either to early appendicectomy (emergent laparoscopic appendicectomy) (n = 20) or to delayed appendicectomy (initial conservative treatment followed by interval laparoscopic appendicectomy 10 weeks later) (n = 20). The trial was at high risk of bias. The trial did not report on overall morbidity or complications. There was no mortality in either group. We do not have sufficient evidence to determine the effects of using either early or delayed laparoscopic appendicectomy for outcomes relating to hospital stay between the groups (MD -0.20 days; 95% CI -3.54 to 3.14; very low quality of evidence). Health-related quality of life was measured with the Pediatric Quality of Life Scale-Version 4.0 questionnaire (a scale of 0 to 100 with higher values indicating a better quality of life). Health-related quality of life score measured at 12 weeks after appendicectomy was higher in the early appendicectomy group than in the delayed appendicectomy group (MD 12.40 points; 95% CI 9.78 to 15.02) but the quality of evidence was very low. This trial reported neither the pain nor the time away from normal activities. AUTHORS' CONCLUSIONS It is unclear whether early appendicectomy prevents complications compared to delayed appendicectomy for people with appendiceal phlegmon or abscess. The evidence indicating increased length of hospital stay and time away from normal activities in people with early open appendicectomy is of very low quality. The evidence for better health-related quality of life following early laparoscopic appendicectomy compared with delayed appendicectomy is based on very low quality evidence. For both comparisons addressed in this review, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy.Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities, quality of life and the length of hospital stay.
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Affiliation(s)
- Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Xianze Xiong
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Jiong Lu
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Sijia Wu
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Rongxing Zhou
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
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18
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Tanaka Y, Uchida H, Kawashima H, Fujiogi M, Suzuki K, Takazawa S, Deie K, Amano H, Iwanaka T. More than one-third of successfully nonoperatively treated patients with complicated appendicitis experienced recurrent appendicitis: Is interval appendectomy necessary? J Pediatr Surg 2016; 51:1957-1961. [PMID: 27666007 DOI: 10.1016/j.jpedsurg.2016.09.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 09/12/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although nonoperative treatment (non-OPT) for complicated appendicitis is performed widely, the long-term outcomes and merits of interval appendectomy (IA) need to be evaluated. METHODS Between April 2007 and December 2013, all appendicitis patients with well-circumscribed abscess or phlegmon were required to select either laparoscopic surgery (OPT) or non-OPT with optional IA on admission. Optional IA was planned at ≥3months after non-OPT. For non-OPT, intravenous injection of antibiotics was continued until the serum C-reactive protein concentration decreased to <0.5mg/dL, with occasional drainage of abscesses. RESULTS Thirty-three patients chose OPT, and 55 chose non-OPT. Among non-OPT patients, 16 selected IA. The success rate of non-OPT was 98.2%. Recurrence occurred in 13 (34.2%) of the 38 non-IA group patients. Although the non-IA group patients frequently had perforated appendicitis at recurrence, they visited the hospital earlier than at the initial appendicitis and had less inflammation. Readmission rate or complications in patients undergoing IA were not different compared with those of the patients in the non-IA group, who had recurrence at ≥3months, or with those of patients in the OPT group. CONCLUSION Although many patients experienced recurrent appendicitis after successful nonoperative treatment, IA may not be necessary after non-OPT. LEVEL OF EVIDENCE Prospective comparative study, level II.
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Affiliation(s)
- Yujiro Tanaka
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama 339-8551, Japan; Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan.
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Hiroshi Kawashima
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama 339-8551, Japan
| | - Michimasa Fujiogi
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama 339-8551, Japan
| | - Keisuke Suzuki
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama 339-8551, Japan
| | - Shinya Takazawa
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama 339-8551, Japan; Department of Pediatric Surgery, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Kyoichi Deie
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama 339-8551, Japan; Department of Pediatric Surgery, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Hizuru Amano
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama 339-8551, Japan
| | - Tadashi Iwanaka
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama 339-8551, Japan
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19
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Stevens DJ, Blencowe NS, McElnay PJ, Macefield RC, Savović J, Avery KNL, Blazeby JM. A Systematic Review of Patient-reported Outcomes in Randomized Controlled Trials of Unplanned General Surgery. World J Surg 2016; 40:267-76. [PMID: 26573174 PMCID: PMC4709380 DOI: 10.1007/s00268-015-3292-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Unplanned general surgery represents a major workload and requires comprehensive evaluation with appropriate outcomes. This study aimed to summarize current reporting of patient-reported outcomes (PROs) in randomized clinical trials (RCTs) in unplanned general surgery. A systematic review identified RCTs reporting PROs in the commonest six areas of unplanned general surgery. Details of the PRO measures were examined using the CONSORT extension for PRO reporting in RCTs. Extracted information about each PRO domain included the reporting of baseline PROs, rationale for PRO selection and whether PRO findings were used in conjunction with clinical outcomes to inform treatment recommendations. The internal validity of included studies was assessed using the Cochrane risk of bias tool. 12,519 abstracts were screened and 20 RCTs containing data from 2037 patients included. Included studies used 14 separate PRO measures covering 35 different health domains. A visual analogue assessment of pain was most frequently reported (n = 13). Reporting of baseline PRO data was uncommon (11/35 PRO domains). The rationale for PRO data collection and a PRO-specific hypothesis were provided for 9 (25.7 %) and 5 (14.3 %) domains, respectively. Seventeen RCTs (85.0 %) used the PRO data alongside clinical outcomes to inform treatment recommendations. Of the 116 risk of bias assessments, 77 (66.0 %) were judged as high or unclear. There is a lack of well designed, and conducted RCTs in unplanned general surgery that include PROs. Future work to define relevant PROs and methods for optimal assessment are needed to inform health care decision-making.
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Affiliation(s)
- Daniel J Stevens
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK.
| | - Natalie S Blencowe
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK.,Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK
| | - Philip J McElnay
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK
| | - Rhiannon C Macefield
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK
| | - Jelena Savović
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK
| | - Kerry N L Avery
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK
| | - Jane M Blazeby
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK. .,Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK.
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20
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Abstract
Appendectomy has been the standard of care for appendicitis since the late 1800s, and remains one of the most common operations performed in children. The advent of data-driven medicine has led to questions about every aspect of the operation-whether appendectomy is even necessary, when it should be performed (timing), how the procedure is done (laparoscopic variants versus open and irrigation versus no irrigation), length of hospital stay, and antibiotic duration. The goal of this analysis is to review the current status of, and available data regarding, the surgical management of appendicitis in children.
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Affiliation(s)
- Shawn D St Peter
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, Missouri 64108.
| | - Charles L Snyder
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, Missouri 64108
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21
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Kim IY. Minimally Invasive Interval Appendectomy for Perforated Appendicitis With a Periappendiceal Abscess. Ann Coloproctol 2016; 32:88-9. [PMID: 27437388 PMCID: PMC4942530 DOI: 10.3393/ac.2016.32.3.88] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Ik Yong Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Korea
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22
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Hall NJ, Kapadia MZ, Eaton S, Chan WWY, Nickel C, Pierro A, Offringa M. Outcome reporting in randomised controlled trials and meta-analyses of appendicitis treatments in children: a systematic review. Trials 2015; 16:275. [PMID: 26081254 PMCID: PMC4499220 DOI: 10.1186/s13063-015-0783-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 05/28/2015] [Indexed: 01/07/2023] Open
Abstract
Background Acute appendicitis is the most common surgical emergency in children. Despite this, there is no core outcome set (COS) described for randomised controlled trials (RCTs) in children with appendicitis and hence no consensus regarding outcome selection, definition and reporting. We aimed to identify outcomes currently reported in studies of paediatric appendicitis. Methods Using a defined, sensitive search strategy, we identified RCTs and systematic reviews (SRs) of treatment interventions in children with appendicitis. Included studies were all in English and investigated the effect of one or more treatment interventions in children with acute appendicitis or undergoing appendicectomy for presumed acute appendicitis. Studies were reviewed and data extracted by two reviewers. Primary (if defined) and all other outcomes were recorded and assigned to the core areas ‘Death’, ‘Pathophysiological Manifestations’, ‘Life Impact’, ‘Resource Use’ and ‘Adverse Events’, using OMERACT Filter 2.0. Results A total of 63 studies met the inclusion criteria reporting outcomes from 51 RCTs and nine SRs. Only 25 RCTs and four SRs defined a primary outcome. A total of 115 unique and different outcomes were identified. RCTs reported a median of nine outcomes each (range 1 to 14). The most frequently reported outcomes were wound infection (43 RCTs, nine SRs), intra-peritoneal abscess (41 RCTs, seven SRs) and length of stay (35 RCTs, six SRs) yet all three were reported in just 25 RCTs and five SRs. Common outcomes had multiple different definitions or were frequently not defined. Although outcomes were reported within all core areas, just one RCT and no SR reported outcomes for all core areas. Outcomes assigned to the ‘Death’ and ‘Life Impact’ core areas were reported least frequently (in six and 15 RCTs respectively). Conclusions There is a wide heterogeneity in the selection and definition of outcomes in paediatric appendicitis, and little overlap in outcomes used across studies. A paucity of studies report patient relevant outcomes within the ‘Life Impact’ core area. These factors preclude meaningful evidence synthesis, and pose challenges to designing prospective clinical trials and cohort studies. The development of a COS for paediatric appendicitis is warranted. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0783-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nigel J Hall
- Faculty of Medicine, University of Southampton, Southampton, UK. .,Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.
| | - Mufiza Z Kapadia
- Toronto Outcomes Research in Child Health (TORCH), SickKids Research Institute, Toronto, Canada.
| | - Simon Eaton
- Developmental Biology Programme, UCL Institute of Child Health, London, UK.
| | - Winnie W Y Chan
- Toronto Outcomes Research in Child Health (TORCH), SickKids Research Institute, Toronto, Canada.
| | - Cheri Nickel
- Hospital Library and Archives, The Hospital for Sick Children, Toronto, Canada.
| | - Agostino Pierro
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada.
| | - Martin Offringa
- Toronto Outcomes Research in Child Health (TORCH), SickKids Research Institute, Toronto, Canada.
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23
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Guida E, Pederiva F, Grazia MD, Codrich D, Lembo MA, Scarpa MG, Rigamonti W. Perforated appendix with abscess: Immediate or interval appendectomy? Some examples to explain our choice. Int J Surg Case Rep 2015; 12:15-8. [PMID: 25985296 PMCID: PMC4485681 DOI: 10.1016/j.ijscr.2015.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 05/04/2015] [Accepted: 05/04/2015] [Indexed: 11/28/2022] Open
Abstract
There are no clear guidelines in the treatment of a perforated appendicitis associated with localized abscess. Our team’s therapeutic choice, also with presence of coprolith, is the initial conservative case management followed by a routine interval appendectomy. Interval appendectomy should be performed not later than 4 months after discharge.
Introduction There are no clear guidelines in the treatment of a perforated appendicitis associated with periappendiceal abscess without generalized peritonitis. Presentation of cases We retrospectively studied six examples of treated children in order to discuss the reasons of our team’s therapeutic approach. Some children were treated with a conservative antibiotic therapy to solve acute abdomen pain, planning a routine interval appendectomy after some months. Others, instead, underwent an immediate appendectomy. Discussion By examining these examples we wanted to highlight how the first approach may be associated with shorter surgery time, fewer overall hospital days, faster refeeding and minor complications. Conclusion Our team’s therapeutic choice, in the case of a perforated appendicitis with an abscess and coprolith is an initial conservative case management followed by a routine interval appendectomy performed not later than 4 months after discharge.
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Affiliation(s)
- Edoardo Guida
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy.
| | - Federica Pederiva
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | | | - Daniela Codrich
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | | | - Maria Grazia Scarpa
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Waifro Rigamonti
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy; University of Trieste, Italy
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24
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Polites SF, Habermann EB, Zarroug AE, Wagie AE, Cima RR, Wiskerchen R, Moir CR, Ishitani MB. A comparison of two quality measurement tools in pediatric surgery--the American College of Surgeons National Surgical Quality Improvement Program-Pediatric versus the Agency for Healthcare Research and Quality Pediatric Quality Indicators. J Pediatr Surg 2015; 50:586-90. [PMID: 25840068 DOI: 10.1016/j.jpedsurg.2014.10.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 10/15/2014] [Accepted: 10/15/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE Identifying quality in pediatric surgery can be difficult given the low frequency of postoperative complications. We compared postoperative events following pediatric surgical procedures at a single institution identified by ACS-NSQIP Pediatric (ACS NSQIP-P) methodology and AHRQ Pediatric Quality Indicators (AHRQ PDIs), an administrative tool. METHODS AHRQ PDI algorithms were run on inpatient hospital discharge abstracts for 1257 children in the 2010 to 2013 ACS NSQIP-P at our institution. Four events-pulmonary complications, postoperative sepsis, wound dehiscence and bleeding-were matched between ACS NSQIP-P and AHRQ PDI. RESULTS Events were identified by ACS NSQIP-P in 7.9% of children and by AHRQ PDI in 8.0%. The four matched events were identified in 5.5% and 3.7%, respectively. Specificities of AHRQ PDI ranged from 97% to 100% and sensitivities from 0 to 2%. The largest discrepancy was in bleeding, where AHRQ PDI captured 1 of the 54 events identified by ACS NSQIP-P. None of the 41 pulmonary, sepsis, and wound dehiscence events identified by AHRQ PDI were clinically relevant according to ACS NSQIP-P. CONCLUSIONS Adverse events following pediatric surgery are infrequent; thus, additional measures of quality to supplement postoperative adverse events are needed. AHRQ PDIs are inadequate for assessing quality in pediatric surgery.
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Affiliation(s)
| | - Elizabeth B Habermann
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Abdalla E Zarroug
- Division of Pediatric Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amy E Wagie
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, United States
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, United States
| | | | - Christopher R Moir
- Division of Pediatric Surgery, Mayo Clinic, Rochester, MN, United States
| | - Michael B Ishitani
- Division of Pediatric Surgery, Mayo Clinic, Rochester, MN, United States.
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25
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Lin HF, Lai HS, Lai IR. Laparoscopic treatment of perforated appendicitis. World J Gastroenterol 2014; 20:14338-14347. [PMID: 25339821 PMCID: PMC4202363 DOI: 10.3748/wjg.v20.i39.14338] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 12/18/2013] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
The use of laparoscopy has been established in improving perioperative and postoperative outcomes for patients with simple appendicitis. Laparoscopic appendectomy is associated with less wound pain, less wound infection, a shorter hospital stay, and faster overall recovery when compared to the open appendectomy for uncomplicated cases. In the past two decades, the use of laparoscopy for the treatment of perforated appendicitis to take the advantages of minimally invasiveness has increased. This article reviewed the prevalence, approaches, safety disclaimers, perioperative and postoperative outcomes of the laparoscopic appendectomy in the treatment of patients with perforated appendicitis. Special issues including the conversion, interval appendectomy, laparoscopic approach for elderly or obese patient are also discussed to define the role of laparoscopic treatment for patients with perforated appendicitis.
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26
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Knott EM, Thomas P, Sharp NE, Gasior AC, St Peter SD. Reduced use of computed tomography in patients treated with interval appendectomy after implementing a protocol from a prospective, randomized trial. Pediatr Surg Int 2013; 29:1293-6. [PMID: 23892423 DOI: 10.1007/s00383-013-3349-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND In 2009, we instituted a protocol to standardize care for patients undergoing interval appendectomy based on results from a prospective trial that demonstrated a reduction in the mean number of computed tomography (CT) scans performed. The goal of this study was to determine if our current practice now resulted in fewer CT scans as a result of this trial. METHODS A retrospective review of all patients undergoing interval appendectomy for perforated appendicitis from March 2009 to March 2011 was performed. Demographics and outcomes were compared to previously collected data from a retrospective study prior to institution of the protocol and to the prospective trial. RESULTS During the study period, 45 patients underwent interval appendectomy. There were no differences in demographics among the three studies. Similar numbers of patients underwent aspiration or percutaneous drainage. There continues to be a significant reduction in the number of CT scans (3.5 ± 2.0 vs. 2.1 ± 1.3, P = 0.0001) and health care visits (7.6 ± 2.8 vs. 4.5 ± 1.4, P = 0.0001) when comparing management prior to the prospective trial to management since its completion. CONCLUSION A protocol for management of patients undergoing interval appendectomy care results in fewer health care visits and CT scans.
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Affiliation(s)
- E Marty Knott
- Department of Surgery, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO, 64108, USA
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27
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Uchida K, Kawamata A, Hashimoto K, Inoue M, Otake K, Koike Y, Matsushita K, Fujikawa H, Okita Y, Araki T, Tanaka K, Kusunoki M. Self-reported assessment of health-related quality of life in children who underwent restorative proctocolectomy with ileal J-pouch anal anastomosis for ulcerative colitis. Pediatr Surg Int 2013. [PMID: 23184266 DOI: 10.1007/s00383-012-3224-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To clarify health-related quality of life (HRQOL) by self-evaluation after restorative proctocolectomy with ileal J-pouch anal anastomosis (IPAA) in children with ulcerative colitis, a questionnaire using the Pediatric Quality of Life Inventory™ 4.0 (PedsQL) was administered. METHODS The PedsQL was administered to 13 consecutive children (mean age 14.5 years) who underwent IPAA between 2005 and 2010 in our hospital and age-matched healthy controls. The mean duration after IPAA was 2.5 years (range 0.08-6 years) at the time of this study. Healthy children completed the same questionnaire by retrospective imaging during the past 1 month by the PedsQL evaluation policy. RESULTS Patients' total score and each functioning score after IPAA reached the same levels as those in healthy controls. Soiling, pouchitis occurrence, and bowel movements had no significant relationship to the PedsQL total score and each functioning score. CONCLUSIONS Interference of physical activity, emotional status, and social life caused by refractory ulcerative colitis (UC) worsens patients' HRQOL. IPAA could resolve these problems in children with UC and result in an HRQOL comparable with that in healthy children.
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Affiliation(s)
- Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.
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28
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Dennett KV, Tracy S, Zurakowski D, Calvert CE, Chen C. Impact on family of management strategies for perforated appendicitis in children. J Pediatr Surg 2012; 47:1900-6. [PMID: 23084204 DOI: 10.1016/j.jpedsurg.2012.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 06/04/2012] [Accepted: 06/08/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to examine the impact on the family of immediate appendectomy compared with initial nonoperative management for perforated appendicitis in children. METHODS Sixty-six prospectively identified families of children with perforated appendicitis completed a daily activity journal and the Impact on Family Scale at presentation and at completion of therapy. RESULTS There were no significant differences in postoperative surgical site infections or number of missed school or employment days between the immediate appendectomy group (n = 40) and the initial nonoperative management group (n = 26). Impact on Family Scale total scores decreased over time for both groups, but this improvement over time was significant only in the initial nonoperative management group (P < .01). CONCLUSIONS Immediate appendectomy or initial nonoperative management can effectively manage perforated appendicitis in children with no statistically significant differences in the number of missed school or employment days. Greater improvements in family impact are associated with initial nonoperative management as measured by the Impact on Family Scale at completion of therapy.
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Affiliation(s)
- Kate V Dennett
- Department of Surgery, Children's Hospital Boston, Boston, MA 02115, USA
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29
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Interval appendectomy after perforated appendicitis: what are the operative risks and luminal patency rates? J Surg Res 2012; 177:127-30. [PMID: 22482752 DOI: 10.1016/j.jss.2012.03.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 02/22/2012] [Accepted: 03/08/2012] [Indexed: 01/20/2023]
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30
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Hospital readmission after management of appendicitis at freestanding children's hospitals: contemporary trends and financial implications. J Pediatr Surg 2012; 47:1170-6. [PMID: 22703789 DOI: 10.1016/j.jpedsurg.2012.03.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Accepted: 03/06/2012] [Indexed: 01/09/2023]
Abstract
INTRODUCTION The purpose of this study was to characterize epidemiologic trends and cost implications of hospital readmission after treatment of pediatric appendicitis. METHODS We 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. RESULTS The 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). CONCLUSION In 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.
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