J. W. Nielsen1, K. Kurtovic1, B. Kenney1, K. Diefenbach1 1Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA
Introduction: Appendicitis is a common surgical problem in pediatric patients. Many pediatric patients present to the hospital with gangrenous or ruptured appendicitis and despite surgical and medical management they form intra-abdominal abscesses with associated morbidity. Although some have suggested that imaging for patients with suspected abscess be delayed until one week the optimal timing is a subject of debate.
Methods: Our institutional pediatric appendicitis database was reviewed for all complex appendicitis patients (ruptured or gangrenous) who were not discharged before post-op day (POD) #5 from April 2012 to February 2014. Patients were stratified into 2 groups: those who had a CT scan before POD #7 (Group 1, n=23) and those who did not (Group 2, n=109). Patients who did not have a CT scan before POD #7 were further stratified into those who were afebrile (<37.5° Celsius)(Group 2a, n=68) or febrile (Group 2b, n=41) at POD #5. Outcomes including abscess formation, number of additional CT scans, and culture data were compared.
Results: A total of 133 patients were identified who were not discharged before POD #5. The majority of patients were male (54%) with a mean age of 10.1 years. The drainage rate was higher for patients who underwent early CT scans: Group 1, 69.6% vs. Group 2b 42.1%, p=0.07. No difference was found in the rate of culture positivity between Group 1 and Group 2b (73.3% vs. 72.7%, p=1.0). Of the 23 patients in Group 1 who underwent CT scanning early, 5 patients ended up getting 2 additional CT scans compared to only 4 patients in Group 2b who got 1 additional scan each. Twenty one of the 41 (51.2%) patients who were still febrile after POD #5 in Group 2b had a resolution of symptoms with antibiotics alone and did not need scanning or drainage. The 68 patients in Group 2a who were afebrile but still admitted to the hospital due to other symptoms were all discharged with a resolution of symptoms without CT scanning. In total, 89 of the 109 (81.6%) patients in Group 2 had a resolution of symptoms prior to discharge without needing a CT scan or drainage procedure with readmission of only 3 patients (3.4%) for subsequent abscess development.
Conclusions: CT scanning post-operative appendectomy patients earlier than POD #7 was associated with a higher number of repeat CT scans and an increased number of drainage procedures. The vast majority of complex appendicitis patients who were still admitted at POD #5 had a resolution of fevers or other symptoms without CT scanning or drainage procedures and they had a low readmission rate. Our results suggest important patient benefits in decreased CT scans and avoidance of unnecessary procedures from waiting until POD #7 or later before performing a CT scan to look for an abscess.