Postoperative timing of computed tomography scans for abscess in pediatric appendicitis

Risk Factors for Postoperative Intra-Abdominal Abscess in Pediatric Perforated Appendicitis Following Laparoscopic Appendectomy: A Multicenter Analysis

BACKGROUND

Perforated appendicitis in children is a frequently encountered and significant surgical condition. The treatment of choice is laparoscopic appendectomy, but this carries a risk of postoperative intra-abdominal abscess (IAA). The purpose of this study was to determine risk factors linked to the occurrence of IAA following laparoscopic surgery in pediatric perforated appendicitis.

METHODS

This retrospective cohort study analyzed 137 children with perforated appendicitis who received laparoscopic appendectomy at four tertiary hospitals between March 2018 and December 2022. Data on patient demographics, preoperative clinical characteristics, and surgical details were collected. Independent risk factors for IAA formation were determined using logistic regression analysis.

RESULTS

The overall incidence of postoperative IAA was 10.9%. Prolonged symptom duration and elevated CRP levels were associated with higher IAA rates. Patients who developed IAAs experienced prolonged postoperative fevers and longer hospital stays. Significant risk factors for IAA identified through multivariable analysis included a higher severity grade of appendicitis (≥Grade IV, OR 5.9, p = 0.034) and the presence of a free appendicolith during surgery (OR 5.549, p = 0.01). Of the patients who developed IAAs, nine (60%) improved with conservative treatment, while six (40%) required invasive procedures.

CONCLUSIONS

A higher severity grade of appendicitis (≥Grade IV) and the presence of a free appendicolith are significant predictors of postoperative IAAs in pediatric perforated appendicitis. Recognizing these factors can help guide clinical management and postoperative care, potentially reducing the incidence of this complication.

2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Diagnostic Imaging of Suspected Acute Intra-abdominal Abscess in Adults, Children, and Pregnant People

This article is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America. In this article, the panel provides recommendations for diagnostic imaging of suspected acute intra-abdominal abscess. The panel's recommendations are based on evidence derived from systematic literature reviews and adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach.

Reducing Postoperative CT Imaging for Children With Complicated Appendicitis: A Pediatric Surgical Quality Collaborative Quality Improvement Project

BACKGROUND

Despite widespread initiatives to reduce ionizing radiation for appendicitis diagnosis, computed tomography (CT) scanning postoperatively remains common. The Pediatric Surgery Quality Collaborative (PSQC) aimed to identify differences between children's hospitals with high and low postoperative CT usage for complicated appendicitis.

METHODS

Using National Surgery Quality Improvement Program Pediatric data from PSQC children's hospitals, we compared postoperative CT imaging for complicated appendicitis (April 2020-March 2021). Key stakeholders from 11 hospitals (5 low CT utilization, 6 high CT utilization) participated in semi-structured interviews regarding postoperative imaging. Qualitative analysis of transcripts was performed deductively and inductively based on the Theoretical Domains Framework (TDF).

RESULTS

Five of twelve TDF domains were most prominent in influencing CT use: skills, beliefs about capabilities, intentions/goals, memory and decision processes, and environment. Children's hospitals with lower rates of postoperative CT use tended to: trust and educate the ultrasound technicians; believe US strengths outweigh weaknesses; image no sooner than 7 days postoperatively; have access to sufficient quality improvement resources; maintain trusting relationships between specialties; and prioritize radiation stewardship.

CONCLUSION

Hospitals at extremes of postoperative CT use for complicated appendicitis reveal strategies for improvement, which include imaging protocol development and adherence, quality improvement resource availability, interdisciplinary collaboration, and promoting radiation stewardship.

LEVEL OF EVIDENCE

Level V.

A Magnetic Resonance Imaging Protocol for the Evaluation of Pediatric Postappendectomy Abscess: A Quality Improvement Project

INTRODUCTION

Computed tomography (CT) scans are often used when cross-sectional imaging is required for evaluation of postappendectomy abscess, exposing children to a source of ionizing radiation. Our aim was to decrease the use of CT scans in pediatric postappendectomy patients by 50% in 12 mo and to sustain those results for 1 y.

METHODS

A comprehensive magnetic resonance imaging protocol was introduced in 2018 at a tertiary children's hospital within a general health system to replace CT scans in suspected pediatric postappendectomy abscess. Diagnostic and clinical outcomes were compared preprotocol (2015-2017) and postprotocol (2018-2022) implementation using standard univariate statistics. P < 0.05 was considered significant. Quality improvement methodology was used to design and implement the protocol.

RESULTS

Sixty eight pediatric postappendectomy patients received cross-sectional imaging during the study period. Overall, CT scans were used exclusively (100%, n = 27) in the preimplementation period compared to 31.7% (n = 13) of cross-sectional imaging in the postimplementation period. However, in the first year of protocol implementation, CT scan use only decreased to 78% of cross-sectional studies performed. The majority of protocol deviations (54%) also occurred in this time period. With improved education and reinforcement, CT scan utilization decreased to approximately 24% of cross-sectional studies annually. Missed abscess rate, time to diagnosis, drainage procedure type, readmission, and reoperation were similar between preimplementation and postimplementation periods.

CONCLUSIONS

Implementation of a postappendectomy abscess magnetic resonance imaging protocol was associated with decreased CT utilization in the pediatric population, while maintaining comparable diagnostic evaluation and clinical outcomes. Adherence to quality improvement principles facilitated achieving goals and sustaining gains.

Association between the computed tomography findings and operative time for interval appendectomy in children

PURPOSE

The purpose was to evaluate the association between operative time and findings noted on computed tomography (CT) immediately before interval appendectomy.

MATERIALS AND METHODS

Forty-two children who underwent CT before interval appendectomy were included. We evaluated the association between operative time and these image findings: (1) appendicolith, (2) increased intra-abdominal fat density around the appendix, (3) location of the appendix, (4) ascites, (5) abscess formation and (6) maximum appendix outer wall diameter. Appendix location was classified as (#1) just below the anterior abdominal wall; (#2) retrocaecal or retro-ascending colon and (#3) pelvic. Results were analysed using Pearson's correlation coefficient or Mann-Whitney U test.

RESULTS

The mean patient age and operative time were 116.24 ± 38.66 months (range, 31-195) and 67.76 ± 31.23 min (range, 30-179), respectively. Ascites was detected in only one case, and no abscess occurred in any patient; therefore, these findings were not analysed. Factors that significantly prolonged the operative time included increased intra-abdominal fat density around the appendix (absent, 59.43 ± 22.14 [range, 30-108] vs. present, 84.43 ± 40.13 [range, 32-179] min; P = 0.03) and retrocaecal or retro-ascending colon appendix (location 1, 40.83 ± 8.35 [range, 30-50]; location 2, 99.25 ± 18.56 [range, 74-135]; location 3, 64.54 ± 30.22 [range, 30-179] min; P < 0.01). There was a weak but significant association between maximum appendix outer wall diameter and operative time (R = 0.353; P = 0.02).

CONCLUSION

These pre-operative CT findings are important predictors of operative time for interval appendectomy. Radiologists and surgeons should use these specific image findings to predict the operative time and need for additional procedures during an interval appendectomy.

Intra-abdominal Abscess After Appendectomy-Are Drains Necessary in All Patients?

BACKGROUND

Research has shown that patients who develop a postoperative intra-abdominal abscess (PIAA) after appendectomy have a greater number of health care visits with drain placement. Our institution developed an algorithm to limit drain placement for only abscesses with a size >20 cm². We sought to determine the adherence to and effectiveness of this algorithm.

METHODS

This prospective observational study included patients aged 2-18 y old who developed a PIAA from September 2017 to June 2019. Outcomes were compared between patients with a small or large abscess. Analysis was performed in STATA; P < 0.05 was significant.

RESULTS

Thirty patients were included. The median age was 10.6 y (7, 11.7); 60% were men, and 60% were Caucasian. The median duration of symptoms before diagnosis of appendicitis was 3 d (2, 6). Thirteen patients (43%) were diagnosed with a PIAA while still inpatient, and 17 (57%) were readmitted at a later date. After algorithm implementation, 95% (n = 19) of patients with a large abscess had aspiration ± drain placement, whereas 30% (n = 3) with a small abscess underwent drainage. Length of stay after abscess diagnosis, total duration of antibiotics, and number of health care visits were the same between groups. One patient with a small abscess required reoperation for an obstruction, whereas one patient with a large abscess that was drained was readmitted for a recurrent abscess.

CONCLUSIONS

Small PIAA can be successfully managed without intervention. Our proposed algorithm can assist in determining which patients can be treated with antibiotics alone.

Utility of standardized discharge criteria after appendectomy to identify pediatric patients requiring intervention after postoperative imaging

BACKGROUND

The purposes of this study were to evaluate the efficacy of failure-of-discharge criteria and identify the cohort of pediatric patients after appendectomy in whom postoperative imaging would impact management.

METHODS

Pediatric patients who underwent an appendectomy from July 2009 to May 2017 were included. Complicated appendicitis was defined based on the intraoperative diagnosis. Postoperative imaging was recommended at postoperative days 5-7 for patients who met at least one criterion of failure of standard management: fever (>38°C), leukocytosis (white blood cell count >12,000/mm³), diet intolerance, or uncontrolled pain by oral analgesics at postoperative day 5. Primary outcomes included any intervention (reoperation, drainage procedures, or change in antibiotics).

RESULTS

In all, 3,276 pediatric patients undergoing appendectomy were identified. Of these patients, 12% met at least 1 discharge criterion of failure Most discharge failures (79%) underwent postoperative imaging, such as computed tomography (68%), ultrasonography then computed tomography (20%), or ultrasonography only (12%); 39% of imaging patients required intervention. On multiple logistic regression, 3 criteria (diet intolerance, fever, and leukocytosis), complicated disease, and age were associated with the need for intervention after imaging. The type of imaging modality did not discriminate need for intervention.

CONCLUSION

Standardized criteria identifying failure of ability to discharge the patient after appendectomy limits the need for unnecessary imaging. In the management of pediatric appendicitis, a selective approach resulted in a high yield of complications requiring intervention after obtaining postoperative imaging.

Optimal Timing of Postoperative Imaging for Complicated Appendicitis

PURPOSE

Approximately one quarter of children with complicated appendicitis develop postoperative abscess, leading to additional procedures and increased length of stay (LOS), but the optimal timing of postoperative imaging to detect abscess is unknown.

METHODS

The Pediatric Health Information System database was reviewed, and children who underwent laparoscopic appendectomy in 2013-2014 with postoperative LOS ≥5 days were included. Demographics, imaging, drainage procedures, LOS, and 30-day readmission were analyzed. Chi-squared analysis was performed.

RESULTS

A total of 21,985 patients underwent laparoscopic appendectomy and 3332 met inclusion criteria. A total of 1174 (35.2%) patients underwent postoperative imaging, among whom 38.4% underwent ultrasound and 75.0% underwent computed tomography scan. Timing of first imaging varied significantly between hospitals, ranging from 0% to 76% on postoperative day (POD) 5. Initial imaging was performed on POD 5, 6, and 7 in 19.7%, 31.3%, and 36.2%, respectively. Imaging on POD 5 compared with POD 7 was associated with shorter LOS (10.6 ± 5.7 versus 11.8 ± 4.4 days), but also lower rates of intervention (42.4% versus 50.8%), increased repeat imaging (10.8% versus 5.2%), and higher readmission rates (35.9% versus 28.2%) (P < .05).

CONCLUSION

Timing of postoperative imaging for complicated appendicitis is variable across hospitals. While earlier imaging was associated with a decreased LOS, these children also had lower rates of subsequent intervention coupled with higher rates of repeat imaging and readmission. These findings suggest that delaying imaging until at least POD 6 may maximize the diagnostic yield of imaging while decreasing radiation exposure and readmission. Prospective investigation should be undertaken to guide the development of standardized clinical practice guidelines for the management of perforated appendicitis.

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

BACKGROUND

Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.

METHODS

Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.

RESULTS

This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.

SUMMARY

The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

Pediatric appendicitis: state of the art review

Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.