A. C. Alder1,2, M. M. Hagopian2, R. I. Renkes1, L. Burkhalter1, R. P. Foglia1,2 1Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA 2University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA
Introduction:
Appendicitis is a common ailment in children. Treatment requires a tremendous allocation of resources especially for complicated cases. Initial non-operative management (NOM) has gained favor in selected cases of complicated appendicitis. Variations in this NOM approach include percutaneous drain placement or aspiration of intra-abdominal abscesses. We set out to review the effects of this variation on our population of patients with complicated appendicitis treated without initial appendectomy.
Methods:
All patients with appendicitis were reviewed between June 2009 and December 2012. Among these patients those who were treated with antibiotics +/- adjuncts and no appendectomy during the initial hospital stay were identified. Demographic and clinical data were collected with specific interest in data related to treatment variation (imaging technique, drain placement, antibiotic type, etc) and clinically relevant outcomes (length of stay (LOS), time to tolerating oral diet, etc). Data were analyzed using univariate and multivariate techniques as well as time to event tests.
Results:
Among 3491 patients found to have appendicitis, 101 patients were noted to have complicated appendicitis and were selected for NOM. All patients were given antibiotics. The mean age was 9 years with a slight majority of female patients. All patients had imaging – either CT, ultrasound or both. Patients with fever had a trend to a longer time to oral intake, a significantly longer time to tolerance of regular diet and no difference in LOS. Patients with a fecalith had a significantly longer LOS, no difference in first oral intake and a trend toward a longer time to tolerance of a regular diet. A change in antibiotics, use of TPN and an ICU stay were associated with an increased LOS and a longer time to tolerance of regular diet. Only ICU stays were associated with a longer time to first oral intake. Abscesses were found on imaging in over 90% of all patients. Drains were placed in 74/101 patients. Placement of a drain was associated with a longer LOS and prolonged time to tolerance of a regular diet when compared to aspiration and antibiotics alone. Aspiration was associated with a significantly lower LOS, but no difference in first or tolerance of a diet. Time to event analysis confirmed that the patients who were drained had a significantly longer time to tolerance of the regular diet but no difference in time to first oral intake.
Conclusion:
In this large series we found it surprising that patients with complicated appendicitis who underwent drainage of an abdominal abscess had a longer LOS. They were as quick to start a diet, but took longer to tolerate a regular diet. This effect may be related to the management style of the surgical team, but may also be related to the intra-abdominal process. This differs from previously published reports which indicate a quicker time to recovery when the abscess was amenable to drainage. We believe this warrants further research into the best use of resources in the management of complicated appendicitis.