Time From Emergency Department Evaluation to Operation and Appendiceal Perforation

Is language a barrier in the management of acute appendicitis?

BACKGROUND

Language preference is a contributing factor for prolonged time from symptom onset to appendectomy within pediatrics, but is poorly characterized in adults. We aimed to investigate associations between language barriers and delays in assessment and treatment for adults with acute appendicitis.

METHODS

In a multiethnic community, patients aged ≥18 years old who underwent appendectomy were identified between January 2017 and August 2022 at a single institution. Negative binomial regression was used to compare interval wait times to imaging, medication administration, and surgical evaluation between patients with limited English proficiency and those who are English proficient.

RESULTS

Of the 1469 patients included, 48% (n = 699) were with limited English proficiency. Average age was higher for patients with limited English proficiency (45 vs 36, P < .001). Most of them were Asian (54%) and without private insurance (65%, P < .001). Symptom duration, incidence of septic shock, and date/time of presentation to the emergency department were similar. Patients with limited English proficiency presented more frequently with gangrenous appendicitis (20% vs 15%, P = .013) but not perforated (23% vs 20%, P = .065). They experienced longer wait times for surgical evaluation (376 vs 348 min, incidence rate ratio [IRR], 1.08; P = .002) but similar times for imaging, and medications administered. After controlling for demographics, triage acuity, and hospital factors, significantly longer wait times for surgical evaluation persisted (IRR adjusted, 1.07; P = .038). There was no significant difference in hospital length-of-stay, postoperative infection, or 30-day readmission rate.

CONCLUSION

Adult patients with limited English proficiency may experience longer wait times for surgical evaluation for acute appendicitis, but this may not result in clinically significant delays in the initiation of treatment.

Non-operative management of uncomplicated appendicitis in children: a randomized, controlled, non-inferiority study evaluating safety and efficacy

BACKGROUND

Appendicitis is the commonest paediatric surgical emergency. Adult studies suggest non-operative management (NOM) may have a place in care. There have been no adequately powered randomized controlled trials in children.

OBJECTIVE

to determine the safety and efficacy of NOM for paediatric simple appendicitis.

METHODS

A non-inferiority randomized controlled trial was conducted comparing operative (OM) to NOM of SA in children aged five-15 years. Primary outcome was treatment success (no unplanned or unnecessary operation, or complication) at 30 days and 12 months, with a non-inferiority margin of 15%. (anzctr.org.au: ACTRN12616000788471).

RESULTS

From 11 June 2016 to 30 November 2020, 222 children were randomized: 94 (42.34%) to OM and 128 (57.66%) to NOM. Non-inferiority of NOM was not demonstrated at either time point, with 45.67% of NOM patients subsequently undergoing operation. There was no significant difference in complications.

CONCLUSIONS

While noninferiority was not shown, NOM was safe, with no difference in adverse outcomes between the two groups. Further research to refine the place of NOM of simple appendicitis in children is required, including nuanced patient selection, longer term evaluation, the place of choice, and the acceptability of the treatment for children and their carers.

Potential causes of delays in paediatric perforated appendicitis: A prospective interview study

AIM

Delays in care may be a driver of inequities in perforated appendicitis rates. The goal of this study was to explore potential causes of delay in care for children with perforated appendicitis.

METHODS

We conducted an interview study of caregivers of children admitted with perforated appendicitis to a children's hospital between December 2022 and March 2023. Semi-structured interviews based on an iteratively revised interview guide were conducted in-person during the child's admission. All interviews were transcribed, coded and underwent a process of thematic analysis.

RESULTS

We reached thematic saturation after 12 interviews. The median age for children was 13.5 years, 50% were male, 83% of caregivers self-identified as White, and one interview required an interpreter. Through thematic analysis, four major themes for potential causes of delay emerged. The first theme of symptom recognition includes delays related to recognising the symptoms, their severity and the need for medical evaluation. The second theme - accessing care - describes delays that occur after a decision was made to seek care until the child was evaluated. The third theme includes delays that occur in making the diagnosis after evaluation. The last theme captures potential delays in definitive treatment after a diagnosis of appendicitis is made.

CONCLUSION

We identify four major themes from the patient and family perspective, each with multiple sub-themes, for potential delays in definitive care for children with perforated appendicitis. Additional research is needed to further characterise these potential delays and quantify their role in contributing to inequities in perforation rates.

Expedited Surgical Care of Appendicitis is Associated With Improved Resource Utilization

INTRODUCTION

Appendectomy for acute appendicitis is the most common pediatric intra-abdominal operation. Current literature supports the notion that modest in-hospital, preoperative delays are not associated with greater patient morbidity. However, there is less certainty regarding the role that hour-of-presentation plays in determining the timing of surgery. Thus, we aimed to evaluate how after-hours presentation may relate to the timing of surgery and to assess the outcomes and resource utilization associated with expedited appendectomy compared to nonexpedited.

METHODS

Patient records for children who underwent an appendectomy at a freestanding pediatric hospital from 2015 to 2019 were reviewed. Business hour presentations were defined as arrival at the emergency department from 7 AM to 6 PM. Primary outcomes were hospital length of stay (LOS), cost derived from the Pediatric Health Information System database, perforation, surgical complications, and 30-day readmissions.

RESULTS

Nine hundred forty-two patients underwent appendectomy over the study period. The median time to OR was 2.0 h in the expedited cohort and 9.8 h in the nonexpedited group. Presentation during business hours was associated with 4.4 higher odds (P < 0.001) of expedited workflow. Expedited appendectomies were associated with shorter hospital LOS (11.5 h, P < 0.001), less costly admissions ($1,155, P < 0.001); LOS measured in midnights, perforation and readmission rates were similar between groups.

CONCLUSIONS

We found reduced resource utilization associated with expedited appendectomy. Additionally, the demonstrated association between the time of presentation to the emergency department (ED) and the timing of surgery may be utilized to inform staffing and resource deployment decisions. Further research regarding the generalizability and sustainability of an expedited presurgical workflow in pediatric appendectomy is certainly indicated.

Time between onset of symptoms and definitive treatment in children with acute appendicitis: How it affects length of hospital stay?

PURPOSE

Any delay in treatment of acute appendicitis (AA) could lead to complications increasing morbidity and length of hospital stay (LHS). The aim of this study was to determine the time interval between onset of symptoms and seeking medical attention and definitive treatment in children with AA and its impact on LHS.

MATERIALS AND METHODS

A prospective study was conducted from December 2017 to March 2018. All patients diagnosed with AA and who underwent surgical procedure were enrolled. A questionnaire leaflet completed by parents was used to collect clinical data and information about seeking medical attention and children's management. Time was divided into six different intervals (1-2 h, 3-6 h, 7-12 h, 13-24 h, >24 h and >48 h) to estimate the time between onset of symptoms and seeking medical attention and time between hospital admission and surgical procedure. LHS was recorded.

RESULTS

During the study period, 125 children were enrolled. Over half of the patients sought for medical assistance relatively soon (3-12 h) after the onset of symptoms, whereas 17.6% sought late healthcare (>24 h). The time between the medical examination and surgical procedure was <24 h in approximately 80% of the children. LHS was affected by time between onset of symptoms and seeking medical attention and time between medical examination and surgical procedure (P = 0.001 and P = 0.017, respectively).

CONCLUSIONS

The majority of the children with AA admitted to hospital were treated relatively soon after the onset of symptoms. However, a significant proportion of children delayed to seek medical advice and undergo appendectomy, increasing LHS.

Predictive scoring systems to differentiate between simple and complex appendicitis in children (PRE-APP study)

BACKGROUND

Several clinical prediction rules have been developed for preoperative differentiation between simple and complex appendicitis in children, as potential treatment strategies differ. This study aimed to externally validate applicable clinical prediction rules that could be used to differentiate between simple and complex appendicitis in children.

METHODS

Potential clinical prediction rules were identified by a scoping review of the literature. Clinical prediction rules applicable in our daily practice were subsequently externally validated in a multicenter historical cohort consisting of 1 tertiary center and 1 large teaching hospital. All children (<18 years old) with histopathologically confirmed acute appendicitis between 2013 and 2020 were included. Test results of clinical prediction rules were compared to the gold standard of either simple or complex appendicitis consisting of predefined perioperative and histopathological criteria. Areas under the receiver operating characteristic curves were determined for the selected clinical prediction rules. Areas under the receiver operating characteristic curve >0.7 were considered acceptable and potentially useful.

RESULTS

In total, 31 clinical prediction rules were identified, of which 12 could be evaluated in our cohort consisting of 550 children. The main reason to exclude clinical prediction rules was the use of variables that were not routinely measured in our cohort. In our cohort, 208/550 (38%) were diagnosed with complex appendicitis according to the gold standard. Clinical prediction rules with areas under the receiver operating characteristic curve >0.7 were: Gorter (0.81), Bogaard (0.79), Bröker (0.79), Graham (0.77), Hansson (0.76), BADCF (0.76), and Eddama (0.75).

CONCLUSION

In this study, clinical prediction rules consisting of a combination of clinical and objective variables had the highest discriminative ability. External validation showed that 7 clinical prediction rules were potentially useful. Integration of these clinical prediction rules in daily practice is proposed to guide decision making regarding treatment strategies.

Revisiting delayed appendectomy in patients with acute appendicitis

Acute appendicitis (AA) is the most common acute abdomen, and appendectomy is the most common nonelective surgery performed worldwide. Despite the long history of understanding this disease and enhancements to medical care, many challenges remain in the diagnosis and treatment of AA. One of these challenges is the timing of appendectomy. In recent decades, extensive studies focused on this topic have been conducted, but there have been no conclusive answers. From the onset of symptoms to appendectomy, many factors can cause delay in the surgical intervention. Some are inevitable, and some can be modified and improved. The favorable and unfavorable results of these factors vary according to different situations. The purpose of this review is to discuss the causes of appendectomy delay and its risk-related costs. This review also explores strategies to balance the positive and negative effects of delayed appendectomy.

Plasma Fibrinogen: An Independent Predictor of Pediatric Appendicitis

Aims

Appendicitis, in spite of all the diagnostic advances, achieving an accurate and timely diagnosis of this common condition in children remains a challenge. Plasma fibrinogen (FB) is an acute inflammatory mediator and has been proposed and evaluated as an adjunct laboratory marker for improving diagnostic accuracy. The study evaluates the plasma values of Se FB along with other serum markers in pediatric appendicitis patients, to determine their diagnostic accuracy.

Methods

Prospective observational study on 120 patients between the age group of 5 and 12 years. All eligible enrolled cases underwent total leukocyte count (TLC), plasma FB, C reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), absolute neutrophil count (ANC), and erythrocyte sedimentation rate on admission along with pediatric appendicitis score. Final confirmation of diagnosis and allotment of cohort was made by intra operative findings and histopathological confirmation. Two groups were defined: (1) Histopathologically confirmed acute appendicitis-Cases (2) Nonspecific abdominal pain-Controls. Laboratory results were statistically analyzed between the case and the control groups for diagnostic accuracy.

Results

Study reflected strong statistical significance in terms of leukocyte count, ANC, NLR, CRP, and FB levels. However, plasma FB (value above 4.02 g/L) had the highest diagnostic accuracy rate of 82.50% compared to other laboratory values (TLC-70.83%, CRP-70.00%).

Conclusion

Plasma FB has emerged as an accurate diagnostic tool and its diagnostic accuracy is superior to all other laboratory parameter studied (TLC, CRP, NLR, and ANC). Plasma FB values above 4.02 g/L is an independent predictor of appendicitis and can help in reducing negative laparotomy in pediatric age group.

Acute Appendicitis in Children During the COVID-19 Pandemic: Neither Delayed Diagnosis Nor Worse Outcomes

AIM

The aim of this study was to describe the incidence of complicated appendicitis during the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic lockdown.

METHODS

This was a retrospective study of pediatric patients diagnosed with acute appendicitis in a single pediatric institution that assumed care responsibility for most of the pediatric emergencies during the lockdown period in Madrid (Spain). A control group was made up of the same number of patients diagnosed the previous year.

RESULTS

One hundred fifty-one patients diagnosed with acute appendicitis were included (77 during self-quarantine and 74 during the previous year). The incidence of complicated appendicitis was 38.9% versus 28.3%, showing no significant differences. The 2 groups were homogeneous, with no differences in time elapsed between symptom onset and first emergency department visit, laboratory test results, median length of stay, intensive care admissions, or patients correctly diagnosed on their first visit.

CONCLUSIONS

COVID-19 (coronavirus disease 2019) self-quarantine has not increased the incidence of complicated appendicitis, and children who developed complicated appendicitis did not have worse clinical outcomes. Parents did not delay presenting for medical attention, and emergency department pediatricians did not fail to diagnose this condition. Reorganization of hospital resources, fast-track treatment protocols for noncomplicated appendicitis, and extended use of home-stay hospitalization for complicated appendicitis could have contributed to these favorable outcomes.

Timeliness of pediatric surgical appendicitis care is associated with time of hospital admission

BACKGROUND

Despite the frequency of acute appendicitis in children, there is no evidence-based consensus surrounding the urgency of the operation if a diagnosis is made after regular business hours. Although a modest delay in time to operation does not increase disease severity, postponing cases to the next calendar day may be associated with higher resource utilization. We aimed to evaluate the trend of delaying appendectomies to the next calendar day and its associated outcomes.

METHODS

We queried the Pediatric Health Information System to analyze appendectomy patients younger than 18 y of age from 2010 to 2018. Same-day appendectomy and next-day appendectomy cohorts were created using admission hour and operative day. Healthcare cost, length of stay, surgical complications, and 30-day readmission rates were collected. Bivariate analyses and multivariable regressions were used to evaluate groups stratified by time of presentation.

RESULTS

During the study period, 113,662 appendectomies were performed, comprising 88,715 (78.1%) same-day appendectomies and 24,947 (21.9%) next-day appendectomies. A higher proportion of same-day appendectomies (80.5%) were performed during hours 12:00am to 5:00pm and 19.5% were performed during hours 6:00pm to 11:00pm. The trend of next-day appendectomies increased during the study period from 13.9% to 20.2%. This was primarily evident in the 6:00pm to 11:00pm period. The 5:00pm cutoff was most predictive of a next-day appendectomy. Next-day appendectomies had similar rates of surgical complications; however, they were associated with higher costs, longer lengths of stay, and higher readmission rates.

CONCLUSION

As the understanding of appendicitis urgency has changed, a more tempered approach of delivering surgical care has trended. Although short delays appear safe, postponement to the next calendar day is associated with higher resource utilization.

Inflammatory Markers and Duration of Symptoms Have a Close Connection With Diagnosis and Staging of Acute Appendicitis in Children

Background: For children with acute appendicitis (AA), a clear diagnosis is a challenge. The purpose of this study is to explore whether inflammatory markers in the blood combined with symptom duration are helpful in the diagnosis of acute appendicitis and in predicting the severity of acute appendicitis. Methods: All the selected patients underwent appendectomy between November 10, 2011 and November 15, 2019, in whom preoperative WBCC, CRP, and NE% had been measured in a short time. All patients were divided into two groups: uncomplicated AA and complicated AA, postoperatively. Results: For our standards, 813 patients were selected, 442 of them had complicated AA. The mean [standard deviation (SD)] age for the uncomplicated AA group was 9.78 ± 2.02 years and for the complicated AA group was 9.69 ± 2.16 years (P = 0.55). Elevated WBCC, CRP, and NE% had a higher relatively sensitivity in complicated AA than uncomplicated AA especially when WBCC, CRP, and NE% were at normal levels, which had a sensitivity of 100% in uncomplicated AA, but this only applied to nine patients. CRP values were significantly different in three time groups, whether uncomplicated or complicated AA. Conclusion: The combination of WBCC, CRP, and NE% values is very sensitive for the diagnosis of acute appendicitis, and when we predict complicated AA using the CRP value, we also need to consider the time of symptom onset.

[Impact of COVID-19 on the presentation and course of acute appendicitis in paediatrics]

Introducción

La apendicitis aguda (AA) es la patología quirúrgica urgente más frecuente en pediatría. La pandemia por la COVID-19 ha generado un descenso en las consultas a urgencias, pudiendo conllevar un retraso en la atención sanitaria y un aumento en la gravedad de las patologías. El objetivo es analizar la tasa de AA complicadas durante la pandemia, en comparación con el mismo periodo del año anterior.

Material y métodos

Estudio retrospectivo observacional de cohortes unicéntrico que incluyó a pacientes menores de 14 años atendidos en urgencias con diagnóstico de AA durante los meses de marzo a mayo de 2019 (no pandemia) y 2020 (pandemia).

Resultados

Se incluyeron 90 pacientes (41 en no pandemia y 49 en pandemia). No se encontraron diferencias en el tiempo desde el inicio de la clínica hasta la consulta en urgencias entre los dos periodos (37 h vs. 38 h, p = 0,881), pero sí en el tiempo desde la llegada a urgencias hasta la intervención quirúrgica (7:00 h vs. 10:30 h; p = 0,004). La diferencia se acentuó al comparar el mes de marzo con abril-mayo de 2020 (6 h vs. 12 h; p = 0,001). No se observaron diferencias significativas en la tasa de AA complicadas en el diagnóstico intraoperatorio (35% vs. 33%; p = 0,870) ni anatomopatológico (35% vs. 48%; p = 0,222), ni tampoco en el número de complicaciones postoperatorias, duración de ingreso y reingresos. Se objetivó un aumento del diagnóstico anatomopatológico de AA con periapendicitis (47% vs. 81%; p = 0,001).

Conclusión

Durante la pandemia se observó una demora desde la llegada a urgencias hasta la intervención quirúrgica en niños diagnosticados de AA. Esta demora se tradujo en un incremento del diagnóstico de AA evolucionadas histológicamente, pero sin objetivarse un aumento de las complicaciones de la enfermedad.

Effect of Delay to Operation on Outcomes in Patients with Acute Appendicitis: a Systematic Review and Meta-analysis

BACKGROUND

Many studies have investigated the association between time interval and incidence of complicated appendicitis and post-operative surgical site infection (SSI), but the results are controversial.

METHODS

A systematic search of the electronic databases identified studies that investigated the association of appendectomy delay with complicated appendicitis and SSI among patients with acute appendicitis. Qualitative and quantitative meta-analysis of the results was conducted.

RESULTS

Twenty-one studies were included in the final analysis. Meta-analysis showed no significant difference in complicated appendicitis incidence between patients in the 6-12 h, > 12 and < 6 h groups (OR 1.07, 95% CI 0.89-1.30, p = 0.47; OR 1.04, 95% CI 0.88-1.22, p = 0.64). Comparison of the 6-12 h category with the < 6 h category of in-hospital delay revealed significant associations between longer in-hospital delay and increased risk of post-operative SSI (OR 1.40, 95% CI 1.11-1.77, p = 0.004). Patients in the 24-48 h category had 1.99- and 1.84-fold (p < 0.05) higher odds of developing complicated appendicitis compared to patients in the < 24 h category for pre-hospital delay and total delay, respectively (OR 1.99, 95% CI 1.35-2.94, p = 0.0006; OR 1.84, 95% CI 1.05-3.21, p = 0.03). When pre-hospital and total delay time extended to more than 48 h, the odds of risk increased 4.62- and 7.57-fold, respectively (OR 4.62, 95% CI 2.99-7.13, p < 0.00001; OR 7.57, 95% CI 6.14-9.35, p = < 0.00001).

CONCLUSION

Complicated appendicitis incidence was associated with overall elapsed time from symptom onset to admission or operation; short appendectomy in-hospital delay did not increase the risk of complicated appendicitis but was associated with a slightly increased risk of SSI. Prompt surgical intervention is warranted to avoid additional morbidity, enabling quicker recovery in this population.

Practical Imaging Strategies for Acute Appendicitis in Children

OBJECTIVE

Diagnosing pediatric appendicitis is difficult because clinical findings are nonspecific. Improved accuracy can be obtained with ultrasound (US), CT, or MRI, despite considerable variation in their use at different institutions. This article reviews the evidence for best practices in imaging pediatric appendicitis.

CONCLUSION

When each modality is optimally used, a stepwise imaging approach that begins with graded compression US and proceeds to CT or MRI in select cases is currently best practice.

Acute appendicitis in childhood: oral contrast does not improve CT diagnosis

INTRODUCTION

We compared the diagnostic accuracy of CT performed without and with oral contrast for suspected appendicitis in children.

METHODS

In this retrospective cohort study, we reviewed abdomen/pelvis CT scans with IV contrast performed between 2011 and 2015 for suspected appendicitis. Oral contrast was used routinely before August 2013 and eliminated from the CT protocol thereafter. Diagnostic accuracy of CT was compared with operative/pathology reports, and included a 30-day follow-up period for non-surgical patients. For a secondary analysis, the oral contrast group was subdivided into "complete" (contrast extending into the cecum) or "partial" contrast. We also compared groups for CT turnaround time, the frequency of appendiceal perforation and abscess, and the potential influence of a prior appendix ultrasound.

RESULTS

Five hundred fifty-eight patients were included: 51.6% (n = 288) without oral contrast and 48.4% (n = 270) with oral contrast (of which 52% (n = 140/270) had "complete" contrast). There was no difference in diagnostic accuracy between the oral contrast and non-contrast groups (p = 0.903), with sensitivity/specificity of 93.8% (95% CI 84.8-98.3)/98.5% (CI 95.8-99.7) and 94.6% (CI 84.9-98.9)/98.3% (CI 95.7-99.5), respectively. Similarly, there was no difference in accuracy when comparing only "complete" contrast vs. non-contrast groups (p = 0.755). CT turnaround time for the non-contrast group was significantly faster (43.8 ± 37.6 min), on average, than the oral contrast group (137.4 ± 47.5 min).

CONCLUSION

For children evaluated by CT with IV contrast for suspected appendicitis, administering oral contrast increased wait time by > 90 min, did not reach the cecum in 48% of cases, and did not improve diagnostic accuracy. Oral contrast for pediatric CT appendicitis evaluation is not warranted.

Influence of Time to Appendectomy and Operative Duration on Hospital Cost in Children with Uncomplicated Appendicitis

BACKGROUND

The goal of this study was to examine the influence of time to appendectomy (TTA) and operative duration (OD) on hospital cost as surrogate measures of perioperative efficiency.

STUDY DESIGN

We conducted a retrospective cohort analysis of 2,116 children undergoing appendectomy for uncomplicated appendicitis at 16 children's hospitals from January 2013 to December 2014. Time to appendectomy (emergency department presentation to incision) and OD were obtained from the NSQIP Pediatric Appendectomy Pilot Database and merged with cost data from the Pediatric Health Information System Database. Multivariate regression was used to examine the influence of TTA and OD (categorized by quartiles of hospital-level means) on hospital cost, adjusting for patient and hospital-level characteristics.

RESULTS

Median TTA and OD across all patients was 7.3 hours (interquartile range 4.4 to 12.4 hours) and 36 minutes (interquartile range 26 to 49 minutes), respectively. The longest quartile of OD was associated with 38% higher total cost ($2,512/case; rate ratio [RR] 1.38; 95% CI 1.27 to 1.5; p < 0.001) and 27% higher operating room-associated cost ($960/case; RR 1.27; 95% CI 1.22 to 1.34; p < 0.001) compared with the shortest quartile. The longest quartile of TTA was associated with 23% higher total cost ($1,589/case; RR 1.23; 95% CI 1.14 to 1.32; p < 0.001) and 53% higher room-associated cost ($906/case; RR 1.53; 95% CI 1.35 to 1.74; p < 0.001) compared with the shortest quartile. The influence of TTA and OD were independent but potentiating effects, with median cost for hospitals in both the longest quartiles of TTA and OD being 79% higher than those in the shortest quartiles.

CONCLUSIONS

Longer TTA and OD were independently associated with increased hospital cost, with OD being the most significant driver of cost variation across hospitals. Identification of best practices from high-efficiency hospitals might provide a high-yield strategy for improving value in appendicitis care.