R. L. Massoumi1, C. P. Childers1,3, J. Q. Dworsky1,3, R. Shenoy1, M. Maggard-Gibbons1, S. L. Lee2, M. M. Russell1,4 1David Geffen School Of Medicine, University Of California At Los Angeles,General Surgery,Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles,Pediatric Surgery,Los Angeles, CA, USA 3University Of California – Los Angeles,Health Policy & Management,Los Angeles, CA, USA 4Veterans Affairs Greater Los Angeles,Surgery,Los Angeles, CA, USA
Introduction:
Appendicitis is the most common cause of emergency general surgery in children. Despite improvements in the outcomes of children undergoing surgery, there remain challenges such as overutilization of computed tomography (CT), and poor outcomes such as negative appendectomy and postoperative morbidity. Contemporary data are needed to inform patient and family expectations, identify areas for improvement, and support the design of nonoperative appendicitis trials. Our objective was to provide contemporary data for the pre-, peri-, and postoperative management and outcomes for children undergoing surgery for acute uncomplicated appendicitis.
Methods:
We performed a retrospective cohort review of children (<18y/o) undergoing appendectomy in the 2016 National Surgical Quality Improvement Program Pediatric appendectomy-targeted file. To focus on cases of uncomplicated appendicitis, we excluded patients undergoing: (1) elective surgery, (2) surgery for an indication other than acute abdominal pain (eg, interval appendectomy), (3) surgery performed on or after hospital day 2, (4) surgery performed by a provider other than a pediatric or general surgeon (eg, gynecology), and (5) complicated appendicitis (eg, perforation) based on the surgeon’s operative note. Primary outcomes included rates of CT, negative appendectomy, and 30-day morbidity. Covariates included patient (eg, age and sex), provider (eg, approach and specialty), and system (transferred in vs. locally managed) variables. Multivariable models were fit using conceptually-driven covariates of interest for each outcome.
Results:
The final sample included 8,017 appendectomies for acute uncomplicated appendicitis. The population was predominantly male (60.1%) and 6-12 y/o (55.6%). Only 3.1% (245/8017) of patients did not have imaging before surgery. Overall, 40.2% (3224/8017) received a CT scan, however, patients transferred with imaging received CT scans at 3.4 times the rate of those with only local (i.e. operating hospital) imaging (Rate ratio 3.4 [CI 3.2-3.7], p<0.001). Negative appendectomy and complication rates were 3.6% (277/7655) and 2.4% (195/8017), respectively. Children ≤5 y/o had over twice the odds of negative appendectomy (Odds ratio[OR] 2.6 [CI 1.9-3.7], p<0.001) and complications (OR 2.2 [CI 1.4-3.3], p<0.001) than children 6-17 y/o, after controlling for confounders.
Conclusion:
Despite guidelines against their use, almost half of children in this cohort received a CT scan prior to surgery, driven predominantly by transferring hospitals. Children ≤5 y/o have not been included in many nonoperative trials, yet, with increased rate of negative appendectomy and complications, they may have the most to gain.