A Nationwide Cohort Study of Outcome after Pediatric Appendicitis

Abstract

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.

Implemented Interventions in Preventing Surgical Site Infection in Pediatric Appendicitis Patients: A Scoping Review

“…In pediatric patients, two operative modalities, namely open appendectomy and laparoscopic appendectomy, have been widely used for the management of appendicitis. Of the six studies [44][45][46][47][48][49] that compared the SSI rates between open appendectomy and laparoscopic appendectomy, four of them found laparoscopic appendectomy had a significantly lower risk of developing SSIs compared to open appendectomy 45,[47][48][49] . In contrast, two studies 44,46 found no statistically significant association between the operative techniques (open/laparoscopic appendectomy) and SSIs.…”

Associations between Th1-related cytokines and complicated pediatric appendicitis

“…In addition to elucidating its pathogenesis, a biomarker for complicated appendicitis in children could aid in clinical diagnostics which, in turn, would lead to better resource utility and health outcomes. Children with uncomplicated appendicitis could receive non-operative management 18 , thereby avoiding short- and long-term risks associated with surgery such as surgical site infections and small bowel obstructions 19 , 20 . In contrast, children with complicated appendicitis would be prioritized for timely surgical intervention.…”

Clinical, Laboratory and Radiographic Features Associated With Prolonged Hospitalization in Children With Complicated Appendicitis

“…Complicated appendicitis is associated with an increased risk of abscess formation, prolonged hospitalization, and wound infection in the short term ( 3 – 5 ) and small bowel obstruction requiring surgical intervention as a long term complication ( 6 ). There has been a growing body of literature around the distinction between complicated and uncomplicated appendicitis to help guide management decisions in children ( 7 , 8 ).…”