Fast‐track surgery for acute appendicitis in children: a systematic review of protocol‐based care

Abstract

Background ‘Fast‐track’ surgery protocols aim to standardize and rationalize post‐operative care, with evidence of safety and efficacy in both uncomplicated and complicated childhood appendicitis. Generalization for broader adoption has been limited by variation in protocol design, including specific antibiotic choice, discharge criteria, post‐operative monitoring and patient selection. Methods A systematic review of the literature was performed to evaluate the current evidence underpinning fast‐track protocols for childhood appendicitis and identify areas of consensus and controversy. Results About 33 studies met the inclusion criteria, including four prospective observational studies, 20 case–control studies, seven cohort studies and two randomized controlled trials studying uncomplicated (n = 9), complicated (n = 18) and mixed cohorts (n = 6). Reduction in length of hospital stay was almost universally reported, with equivalent or improved complication rates. Key themes of protocols included antibiotic choice and duration, discharge criteria and post‐operative laboratory and radiographic testing. Rationalized analgesia is an underexplored aspect of protocol design, and a standardized definition of complicated appendicitis remains elusive. Conclusion Standardized care of childhood appendicitis has been shown to be safe and effective in several local and international centres. Next steps include investigation of a complicated appendicitis protocol that integrates rationalized analgesia in appendicectomy recovery, and development of a consistent classification scheme for complicated disease to aid in identification of amenable cohorts.

Improving quality and efficiency of care for advanced appendicitis in children

“…Standardized care protocols have previously been reported for complicated appendicitis in children 6–10,22–26 . The scale of our results is comparable to many of these studies, reinforcing the validity of standardized care in this setting.…”

“…The ERP was designed following the systematic review of related literature 10 and examination of benchmark outcomes from other similar hospitals. Our definition of ‘advanced’ appendicitis, eligibility criteria for the pathway as well as post‐operative milestones were agreed by consensus among a multi‐disciplinary group of paediatric surgeons, anaesthetists, infectious diseases physicians and nursing staff at our hospital.…”

“…Descriptive content in the operative note, including any captured laparoscopic photographs were used to assess eligibility for assignment. The case–control study design was based on review of the literature previously published by the authors, 10 with the vast majority of relevant studies to date using a similar case–control protocol (i.e. use of comparable historical controls).…”

“…Initial experiences in the standardization of care for complicated appendicitis in children have been encouraging 6–9 . Protocol elements include antibiotics (selection, duration and timing of transition to oral agents), laboratory tests and imaging, diet and discharge criteria 10 . Case–control and cohort studies of protocolized care have so far observed length of stay reduction with equivalent or even reduced post‐operative complication rate 8,11 .…”

Application of enhanced recovery after surgery during the perioperative period in children with Meckel’s diverticulum–a single-center prospective clinical trial

“…In the late 1990s, Danish surgeon Kehlet first proposed the concept of ERAS ( 10 ). ERAS program is mainly achieved through preoperative, intraoperative, and postoperative measures ( 11 ). Preoperative measures mainly include perioperative counseling, minimized preoperative fasting; Intraoperative measures mainly include optimal anesthesia, minimally invasive techniques, temperature management, infusion management; Postoperative measures mainly include minimized postoperative fasting, early postoperative mobilization, limited intravenous fluids, and early removal of surgical tubes ( 12 , 13 ).…”