Subscribe to RSS
A Nationwide Cohort Study of Outcome after Pediatric AppendicitisFunding This study has been funded by Anna Lisa & Sven-Eric Lundgren Foundation for Medical Research; Skåne Region ALF Educational grants to E.O. and Project grants to L.H.; and Svenska Läkaresällskapet Research grants for young investigators.
Introduction Children with appendicitis often present with complicated disease. The aim of this study was to describe the clinical management of pediatric appendicitis, and to report how disease severity and operative modality are associated with short- and long-term risks of adverse outcome.
Materials and Methods A nationwide retrospective cohort study of all Swedish children (<18 years) diagnosed with appendicitis, 2001 to 2014 (n = 38,939). Primary and secondary outcomes were length of stay, surgical site infections, readmissions, 30-day mortality, and long-term risk of surgery for small bowel obstruction (SBO). Implications of complicated disease and operative modality were assessed with adjustment for age, gender, and trends over time.
Results Complicated appendicitis was associated with longer hospital stay (4 vs. 2 days, p < 0.001), increased risk of surgical site infection (5.9 vs. 2.3%, adjusted odds ratio [aOR]: 2.64 [95% confidence interval, CI: 2.18–3.18], p < 0.001), readmission (5.5 vs. 1.2, aOR: 4.74 [95% CI: 4.08–5.53], p < 0.001), as well as long-term risk of surgery for SBO (0.7 vs. 0.2%, adjusted hazard ratio [aHR]: 3.89 [95% CI: 2.61–5.78], p < 0.001). Intended laparoscopic approach was associated with reduced risk of surgical site infections (2.3 vs. 3.1%, aOR: 0.74 [95% CI: 0.62–0.89], p = 0.001), but no overall reduction in risk for SBO; however, successful laparoscopic appendectomy was associated with less SBO during follow-up compared with open appendectomy (aHR: 0.27 [95% CI: 0.11–0.63], p = 0.002).
Conclusion Children treated for complicated appendicitis are at risk of substantial short- and long-term morbidities. Fewer surgical site infections were seen after intended laparoscopic appendectomy, compared with open appendectomy, also when converted procedures were accounted for.
Keywordspediatric appendicitis - complications - surgical site infection - small bowel obstruction - laparoscopic
Received: 19 November 2019
Accepted: 16 April 2020
26 June 2020 (online)
© 2020. Thieme. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
- 1 Henderson J, Goldacre MJ, Fairweather JM, Marcovitch H. Conditions accounting for substantial time spent in hospital in children aged 1-14 years. Arch Dis Child 1992; 67 (01) 83-86
- 2 Guthery SL, Hutchings C, Dean JM, Hoff C. National estimates of hospital utilization by children with gastrointestinal disorders: analysis of the 1997 kids' inpatient database. J Pediatr 2004; 144 (05) 589-594
- 3 Cameron DB, Graham DA, Milliren CE. et al. Quantifying the burden of interhospital cost variation in pediatric surgery implications for the prioritization of comparative effectiveness research. JAMA Pediatr 2017; 171 (02) e163926
- 4 Lund DP, Murphy EU. Management of perforated appendicitis in children: a decade of aggressive treatment. J Pediatr Surg 1994; 29 (08) 1130-1133
- 5 Anandalwar SP, Cameron DB, Graham DA. et al. Association of intraoperative findings with outcomes and resource use in children with complicated appendicitis. JAMA Surg 2018; 153 (11) 1021-1027
- 6 Shepherd JA. Acute appendicitis: a historical survey. Lancet 1954; 267 (6833): 299-302
- 7 Omling E, Salö M, Saluja S. et al. Nationwide study of appendicitis in children. Br J Surg 2019; 106 (12) 1623-1631
- 8 Almström M, Svensson JF, Patkova B, Svenningsson A, Wester T. In-hospital surgical delay does not increase the risk for perforated appendicitis in children. Ann Surg 2017; 265 (03) 616-621
- 9 Almström M, Svensson JF, Svenningsson A, Hagel E, Wester T. Population-based cohort study on the epidemiology of acute appendicitis in children in Sweden in 1987-2013. BJS Open 2018; 2 (03) 142-150
- 10 Tingstedt B, Johansson J, Nehez L, Andersson R. Late abdominal complaints after appendectomy--readmissions during long-term follow-up. Dig Surg 2004; 21 (01) 23-27
- 11 Andersson RE. Small bowel obstruction after appendicectomy. Br J Surg 2001; 88 (10) 1387-1391
- 12 Tsao KJ, St Peter SD, Valusek PA. et al. Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach. J Pediatr Surg 2007; 42 (06) 939-942
- 13 Kaselas C, Molinaro F, Lacreuse I, Becmeur F. Postoperative bowel obstruction after laparoscopic and open appendectomy in children: a 15-year experience. J Pediatr Surg 2009; 44 (08) 1581-1585
- 14 Svensson JF, Patkova B, Almström M, Eaton S, Wester T. Outcome after introduction of laparoscopic appendectomy in children: a cohort study. J Pediatr Surg 2016; 51 (03) 449-453
- 15 Ludvigsson JF, Andersson E, Ekbom A. et al. External review and validation of the Swedish National Inpatient Register. BMC Public Health 2011; 11 (01) 450
- 16 Nordic Medico-Statistical Committee. NOMESCO Classification of Surgical Procedures (NCSP), version 1.16. 2011:1–301
- 17 VanderWeele TJ, Ding P. Sensitivity analysis in observational research: introducing the E-value. Ann Intern Med 2017; 167 (04) 268-274
- 18 Sceats LA, Trickey AW, Morris AM, Kin C, Staudenmayer KL. Nonoperative management of uncomplicated appendicitis among privately insured patients. JAMA Surg 2019; 154 (02) 141-149
- 19 Won RP, Friedlander S, Lee SL. Outcomes and costs of managing appendicitis at safety-net hospitals. JAMA Surg 2017; 152 (11) 1001-1006
- 20 Sippola S, Grönroos J, Tuominen R. et al. Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial. Br J Surg 2017; 104 (10) 1355-1361
- 21 Blomqvist PG, Andersson RE, Granath F, Lambe MP, Ekbom AR. Mortality after appendectomy in Sweden, 1987-1996. Ann Surg 2001; 233 (04) 455-460
- 22 Humes DJ, Simpson J. Acute appendicitis. BMJ 2006; 333 (7567): 530-534
- 23 Blakely ML, Williams R, Dassinger MS. et al. Early vs interval appendectomy for children with perforated appendicitis. Arch Surg 2011; 146 (06) 660-665
- 24 Putnam LR, Ostovar-Kermani TG, Le Blanc A. et al. Surgical site infection reporting: more than meets the agar. J Pediatr Surg 2017; 52 (01) 156-160
- 25 Lawson EH, Louie R, Zingmond DS. et al. A comparison of clinical registry versus administrative claims data for reporting of 30-day surgical complications. Ann Surg 2012; 256 (06) 973-981
- 26 Gasior AC, St Peter SD, Knott EM, Hall M, Ostlie DJ, Snyder CL. National trends in approach and outcomes with appendicitis in children. J Pediatr Surg 2012; 47 (12) 2264-2267
- 27 Dingemann J, Metzelder ML, Szavay PO. Current status of laparoscopic appendectomy in children: a nation wide survey in Germany. Eur J Pediatr Surg 2013; 23 (03) 226-233
- 28 Drake TM, Camilleri-Brennan J, Tabiri S. et al; GlobalSurg Collaborative. Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study. Surg Endosc 2018; 32 (08) 3450-3466
- 29 Gomes CA, Abu-Zidan FM, Sartelli M. et al. Management of appendicitis globally based on income of countries (MAGIC) study. World J Surg 2018; 42 (12) 3903-3910
- 30 Salö M, Gudjonsdottir J, Omling E, Hagander L, Stenström P. Association of IgE-mediated allergy with risk of complicated appendicitis in a pediatric population. JAMA Pediatr 2018; 172 (10) 943-948