Facilitating factors in same-day discharge after pediatric laparoscopic appendectomy

Same-Day Discharge after Laparoscopic Appendectomy for Simple Appendicitis in Pediatric Patients—Is It Possible?

(1) Background: One-day surgery has been widely adopted for many elective laparoscopic procedures in pediatric patients. Recently, the same protocol has been investigated for some emergency procedures, such as laparoscopic appendectomy. This study aimed to evaluate the safety and effectiveness of discharge from hospital within 24 h in pediatric patients who received laparoscopic appendectomy for uncomplicated acute appendicitis. (2) Methods: From 1 March 2021 to 1 May 2022, a total of 180 pediatric patients who were discharged from hospital within 24 h after laparoscopic appendectomy for uncomplicated appendicitis were included in this prospective single-center study. The primary outcome of this study was the safety of discharge from hospital within 24 h after laparoscopic appendectomy for uncomplicated appendicitis, as well as the parental satisfaction with this protocol. Secondary outcomes included the rate of readmission or unplanned return to the operating room, the complication rate and a cost-effectiveness analysis. For each patient, demographic data, preoperative evaluation (physical examination, laboratory data, imaging), duration of surgery, intraoperative and postoperative complications, length of hospital stay and pain levels, as well as parental satisfaction with this protocol, were recorded. (3) Results: The median age was 11 years (interquartile range (IQR) 10, 14). The majority of the patients (63.8%) were males. The median length of hospital stay after surgery was 15 h (IQR 12, 19). The highest level of satisfaction, at discharge, was recorded in most of the respondents (n = 155, 86.1%), while the remaining 25 (13.9%) expressed moderate levels of satisfaction. The median pain levels according to a visual analogue scale for all postoperative days were low (range 0–4). In four patients (2.2%), unplanned readmission before the seventh postoperative day because of postoperative intraabdominal abscess was recorded. All patients with abscess formation were treated conservatively. The majority of the parents (n = 175; 97.2%) expressed the highest level of satisfaction during the outpatient follow-up examination on the seventh postoperative day. (4) Conclusions: Same-day discharge after laparoscopic appendectomy for simple appendicitis in pediatric patients was safe and feasible. Parental satisfaction with this protocol was very high. With the right protocol and parent education, pediatric patients who underwent laparoscopic appendectomy because of non-complicated acute appendicitis may be successfully treated in this way.

Criteria-led discharge for simple appendicitis in children: A pilot study

AIM

Criteria-led discharge (CLD) protocols have been suggested to increase efficiency of discharge from hospital following surgical interventions. Our aim was to assess the feasibility, clinical outcomes and parental satisfaction following the introduction of a pilot CLD for simple appendicitis (SA) in children.

METHODS

A prospective pilot cohort study was conducted including paediatric patients with SA who were managed with CLD and a control group who were managed with standard discharge procedures. A CLD pro forma was developed, standardising care guidelines and clinical criteria indicators to be met for children to be discharged post-operatively. A post-discharge parent survey was also utilised. The primary outcome measure was post-operative length of stay (pLOS), with secondary outcomes of post-operative complication rates and parental satisfaction.

RESULTS

The control group consisted of 31 patients and CLD group 35 patients. There was no difference in the median pLOS (24 [16.7-44.6] vs. 25.3 [19.1-50.1] h, P = 0.3). Furthermore, there were no significant differences on any of the secondary outcomes. Parental confidence with time of discharge was very high in both control (85.7%) and CLD (88.2%) groups (P = 1.0).

CONCLUSION

The introduction of CLD is safe and feasible. Whilst this pilot has not demonstrated a reduction in pLOS, our data suggest that it is well accepted by the parents.

Feasibility of Same-Day Discharge After Appendectomy in Pediatric Patients: A Systematic Review and Meta-Analysis

BACKGROUND

To compare the readmission rate, rate of urgent/unplanned visits to emergency, complication rate along with cost of health care among children and adolescents who were discharged the same day following a laparoscopic appendectomy and those who were not discharged on the same day.

METHODS

A systematic search was performed in the PubMed, Embase, and Scopus databases. Randomized controlled trials and studies, observational in design, were considered for inclusion. The included studies were conducted in children and adolescents with uncomplicated appendicitis undergoing laparoscopic appendectomy and compared outcomes of interest between patients that were discharged the same day (SDD group) following the operation and patients that were discharged within 2 days post-operatively (non-SSD group). Statistical analysis was performed using STATA software. Effect sizes were reported as pooled odds ratio (OR) or weighted mean difference (WMD) with 95% confidence intervals.

RESULTS

A total of 13 studies with 32,021 children and adolescents were included. There was no significant difference in the risks of unplanned visit to the emergency department (OR 1.07, 95% CI: 0.78, 1.47), readmission (OR 0.83, 95% CI: 0.66, 1.05), reoperation/re-intervention (OR 1.73, 95% CI: 0.19, 16.2) and complications (OR 0.84, 95% CI: 0.67, 1.06) in both groups of patients. Patients in the SDD group had slightly lower risk of wound infection/complication (OR 0.74, 95% CI: 0.57, 0.96) compared to patients in the non-SDD group. Those with SDD had to incur comparatively lesser hospital expense (in USD) compared to those with no SDD (WMD -2587.4, 95% CI: -4628.3, -546.6).

CONCLUSION

In children and adolescents with uncomplicated acute appendicitis undergoing laparoscopic appendectomy, same-day discharge is not associated with increased readmission risk, unplanned visits to emergency, and complications. Further, SDD is associated with lower cost of hospital care. Adoption of SDD in this subset of children and adolescents may be encouraged.

SYSTEMATIC REVIEW REGISTRATION

[www.crd.york.ac.uk/prospero], identifier [CRD420 22320539].

Same-day discharge after laparoscopic appendectomy for non-perforated appendicitis is safe and cost effective

AIM OF THE STUDY

To compare the outcomes and hospital charges of patients who underwent laparoscopic appendectomy for non-perforated appendicitis and were discharged home either shortly after the operation after being admitted for overnight observation.

METHODS

Postoperative (30-day) emergency department (ED) visits, hospital readmissions, and reoperations were compared between patients who were discharged shortly after surgery (same-day discharge [SDD] group) and patients who were discharged after spending one night in the hospital (overnight observation group).

STUDY PERIOD

July/2015 to June/2019. Patients with perforated appendicitis and/or who spent > 1 night in the hospital were excluded from the study.

RESULTS

We did 1957 laparoscopic appendectomies within the 4-year study period. After excluding all non-eligible cases, 930 patients were included in the overnight observation group, and 511 in the SDD group. Mean age and mean operative time were similar in both groups: 11.5 (SD 3.6)/11.8 (SD 3.5) years, and 35 (SD 13)/33 (SD 12) minutes, respectively. There were 24 (2.6%) ED visits within the overnight observation group. Sixteen patients (1.7%) were discharged from the ED, and 8 (0.9%) required a re-admission. There were 11 (2.1%; P = 0.61) ED visits within the SDD group. Six patients (1.1%; P = 0.41) were discharged from the ED, and 5 (1%; P = 0.82) required a readmission. Six of the 11 ED visits within the SDD group occurred on the 5th postoperative day or later, whereas five (1%) occurred within the first 3 days post appendectomy. These five patients would have likely benefited from an overnight admission and were erroneously discharged on the same day of the appendectomy. There were no reoperations in the overnight observation group, but there were 3 reoperations in the SDD group (0.6%, P = 0.01). The reasons for the reoperations (two bowel obstructions and one bowel perforation) were in no way related to the time of the original discharge. The mean hospital charges per patient in the SDD group and the overnight observation group were significantly different: $32,450 and $35,420, respectively (> 9% margin, P < 0.01).

CONCLUSION

Healthy children who undergo laparoscopic appendectomy for non-perforated appendicitis can be discharged home during the same day of the operation after a short period of observation. This approach is safe and does not result in more postoperative ED visits or hospital readmissions. In addition, there is a significant financial benefit when patients are discharged early.

LEVEL-OF-EVIDENCE

Level III-retrospective comparative treatment study.

Study of social disparities in pediatric laparoscopic appendectomy outcomes and cost

Purpose:

There is an increasing focus on racial and social disparities in health care. There have been several studies that have documented disparities in outcome between racial groups in the adult literature. Not much is known about disparities in outcomes after surgical procedures in children. The purpose of this study was to investigate the effect of race on complications (outcomes) and costs after laparoscopic appendectomy.

Methods:

This study is a single-center retrospective chart review of 248 pediatric patients who underwent appendectomies for uncomplicated acute appendicitis from 2015 to 2017. Patients were divided into minority (Africa American or Hispanic) and non-minority groups, and length of stay, preoperative and postoperative factors, and total costs were compared.

Results:

Of 185 eligible patients, 45.9% (n = 85) were of Hispanic or African American ethnicity and 54.1% (n = 100) were Caucasian. About 11.8% of minority patients had comorbidities and 12% of majority patients had comorbidities (p = 1). Readmission rate for minority group patients was 3.5% (n = 3) and 2% (n = 2) for majority patients (p = 0.7). The average cost of hospital stay for minority patients was $30,900 and for majority patients was $31,111 (p = 0.59).

Conclusions:

Standardization of care protocols has reduced social/racial disparities in surgical outcomes. In the most common pediatric surgery emergency procedure, laparoscopic appendectomy, there were no differences in outcomes or costs between minority (Hispanic/Africa American) and Caucasian ethnic groups.

Level of evidence:

Level III

Type of study:

Clinical Study

Reducing resource utilization for patients with uncomplicated appendicitis through use of same-day discharge and elimination of postoperative antibiotics

BACKGROUND

There is controversy over certain aspects of post-appendectomy care for children with uncomplicated appendicitis. Some institutions have embraced the practice of same-day discharge after appendectomy, while others are hesitant due to concerns about increased readmissions or emergency department (ED) visits. Similarly, some surgeons have transitioned to treating gangrenous appendicitis with a single perioperative dose, while others are concerned about increased risk of infection in this population.

METHODS

We developed a pathway for the management of patients undergoing appendectomy for uncomplicated acute appendicitis which included same-day discharge and elimination of postoperative antibiotics for patients with gangrenous appendicitis. We compared outcomes for children treated at our institution before and after implementation of the protocol.

RESULTS

We identified 575 patients undergoing appendectomy for uncomplicated appendicitis (307 pre- and 268 post-protocol). We observed a significant decrease in postoperative length-of stay (10.6 to 2.6 h, p < 0.0001). There were no increases in postoperative complications, such as superficial (2.6% vs 1.1%, p = 0.19) or organ-space surgical-site infection (1.6% vs 0.4%, p = 0.14), percutaneous drain placement (1.3% vs 0%, p = 0.06), postoperative ED visits (5.5% vs 5.2%, p = 0.87) or readmission (3.3% vs 1.5%, p = 0.17).

CONCLUSIONS

These findings suggest that incorporating same-day discharge for simple appendicitis and eliminating postoperative antibiotics for children with gangrenous appendicitis does not increase complication rates. Implementation of similar pathways across institutions has the potential to significantly reduce resource utilization for children undergoing appendectomy for uncomplicated appendicitis.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Implementation of an evidence-based protocol after appendectomy reduces unnecessary antibiotics

BACKGROUND

Children with acute appendicitis have historically received intravenous antibiotics before and after appendectomy, yet recent literature supports minimizing postoperative antibiotics. In this study, we examined the impact of a standardized protocol that eliminates postoperative antibiotics for nonperforated appendicitis and discontinues antibiotics at discharge for perforated appendicitis.

METHODS

A retrospective review of all pediatric patients who underwent laparoscopic appendectomy for acute appendicitis between May 2013 and March 2017 was performed. Preprotocol patients (5/1/2013-3/31/2015) were compared to postprotocol patients (5/1/2015-3/31/2017), excluding those who underwent surgery during the month of protocol introduction (4/2015). Primary outcomes were postoperative antibiotic doses for nonperforated cases and antibiotics after discharge for perforated cases. Mann-Whitney and Fisher's exact tests were performed.

RESULTS

Laparoscopic appendectomy was performed in 748 children before (PRE) and in 814 children after (POST) protocol implementation. Perforation rates were similar (POST 21.5 vs. PRE 21.8%, p=0.90). For nonperforated appendicitis, postoperative antibiotics were reduced (median 0 [IQR 0-0] vs. 3 [0-5] doses, p<0.001), and more patients were discharged less than 24 h after surgery (65.7 vs. 40.9%, p<0.001). Fewer patients with perforated appendicitis underwent PICC placement (8.6 vs. 21.0%, p=0.002), and fewer patients were prescribed antibiotics on discharge (33.7 vs. 89.0%, p<0.001). There were no differences between groups for complication, readmission, or return to ED rates.

CONCLUSION

For children with acute appendicitis, a standardized protocol can safely reduce unnecessary antibiotics and decrease length of stay. Furthermore, the judicious use of antibiotics does not increase SSI, readmission, or overall complication rates.

LEVEL OF EVIDENCE

III.

Post operative pediatric appendicitis nurse-driven discharge: Patient outcomes and nursing perspectives

BACKGROUND

Nurse-driven discharge pathways following pediatric appendectomies have proven effective in children's hospitals; studies in general hospital settings are lacking. Additionally, despite the central role of nursing in such pathways, nursing perspectives aren't investigated in the literature.

METHODS

Data from all pediatric acute uncomplicated appendicitis patients who underwent laparoscopic appendectomy in the 12 months following institution of a nurse-driven discharge pathway (intervention, n = 67) were compared to those treated in the preceding year (control, n = 64). Surveys on the pathway were distributed to pediatric ward nurses.

RESULTS

Postoperative length of stay (POLOS) decreased by 37% in the intervention group, about 6 h, (0.44 days ± 0.22 vs 0.7 days ± 0.27, p-value 0.0001), without a significant increase in related readmissions. Same day discharges increased from 10.9% to 46.3%, (P-value 0.0001). Nurse surveys revealed a high approval of the pathway (7-10/10) and yielded valuable feedback.

CONCLUSION

A nurse-driven discharge pathway decreased POLOS without increasing readmission following pediatric laparoscopic appendectomy in a general hospital setting. Valuable insight into nursing perspectives on this pathway was acquired.

Intermediate-term evaluation of interval appendectomy in the pediatric population

BACKGROUND

Initial non-operative management of children with complicated appendicitis has been well studied but when comparing emergency procedures the long-term effectiveness of interval appendectomy remains undefined. This study aimed to determine the effects of interval appendectomy from the perspective of long-term follow-up.

METHODS

A retrospective review of patients with complicated appendicitis between 2010 and 2017 was performed. The medical records of 471 patients with initial non-operative therapy and 377 patients treated with emergency appendectomy who served as controls were reviewed. Propensity score matching was performed to adjust for any potential selection bias in the two strategies. A comparison of the clinical outcomes, including short- and long-term postoperative complications, was conducted in the 348 matched patients.

RESULTS

On presentation, there were no differences in age, weight, sex distribution, white blood cell (WBC), or procalcitonin (PCT) between the two groups, except for days of symptoms. The patients undergoing emergency appendectomy had a high American Society of Anesthesiology (ASA) score (p = 0.002). The patients who underwent initial non-operative therapy had a lower complication rate, including surgical wound infection [odds ratio (OR), 3.77; 95% CI 2.59-5.50; p < 0.001) and postoperative peritonitis or abscess (OR, 3.81; 95% CI 1.79-8.12; p < 0.001) than those who underwent emergency appendectomy. Furthermore, the incidence of adhesive small bowel obstruction (ASBO) was lower in patients who underwent initial non-operative therapy than in patients who underwent emergency appendectomy (OR, 4.6; 95% CI 0.99-21.41; p = 0.032).

CONCLUSIONS

Initial non-operative therapy with interval appendectomy was feasible for most patients with appendiceal abscesses and had advantages in terms of postoperative complications, especially regarding long-term obstruction events. Therefore, initial non-operative therapy with interval appendectomy should be considered the first treatment of choice for pediatric patients with complicated appendicitis.

Clinical effects of warmed humidified carbon dioxide insufflation in infants undergoing major laparoscopic surgery

PURPOSE

Some studies have reported that warmed humidified carbon dioxide (CO2) insufflation in adult laparoscopic surgery could reduce pain and improve the core body temperature (CBT). However, similar studies are lacking in infants. Thus, this study aimed to investigate the clinical effects of warmed, humidified CO2 insufflation in pediatric patients undergoing major laparoscopic surgeries.

METHODS

From January 2015 to December 2017, infants who underwent major laparoscopic surgeries in Ningbo Women and Children's Hospital were randomized to Group A (standard CO2 insufflation) or Group B (warmed humidified CO2 insufflation, 35°C, 95% relative humidity). Change in CBT at the end of surgery was the primary outcome. Secondary outcomes included surgery time, intraoperative blood loss, oxygen saturation (SO2), and Face, Legs, Activity, Cry and Consolability (FLACC) scale. These variables were compared between the 2 groups.

RESULTS

Sixty-three infants (38 females, 25 males) were included; 30 patients were in Group A and 33 in Group B. The diseases treated with the laparoscopic approach included congenital megacolon, congenital diaphragmatic hernia, and intestinal malrotation. No deaths were noted. CBT was significantly higher in Group B at the end of surgery (P = .021). The occurrence of postoperative shivering (P = .02), hypothermia (P = .032), bowel movement (P = .044), and hospital stay (P = .038) was significantly different between the 2 groups; Group B had less shivering and hypothermia occurrence after surgery. Moreover, Group B demonstrated a more rapid postoperative recovery of bowel movement and shortened hospital stay than Group A. There was no statistical difference in operative time (P = .162), intraoperative blood loss (P = .541), SO2 (P = .59), and FLACC scale (P = .65) between the 2 groups.

CONCLUSION

The use of warmed humidified CO2 insufflation in infants undergoing major laparoscopic surgery was helpful for maintaining normothermia and was associated with several positive postoperative outcomes, including less shivering and hypothermia, faster recovery of bowel movement, and shortened hospital stay.