Optimizing pediatric histrelin implantation to improve success rates in clinic without sedation.

OBJECTIVES: The purpose of this study was to review our success rate performing the histrelin implant procedure in clinic without sedation. METHODS: A retrospective study was performed for histrelin implant procedures done at our institution from 2008 to 2020. Wilcoxon rank-sum test or Fisher's exact test was utilized to identify significant differences (p<0.05). RESULTS: A total of 73 patients underwent 184 histrelin implant procedures from 2008 to 2020. In the past few years, there has been a decrease in procedures for precocious puberty and an increase for gender dysphoria. The majority of procedures were performed in clinic without sedation (82%). The only risk factor associated with requiring sedation was younger age (median 9 vs. 10 years; p<0.003). Complications (i.e. implant fracture or need for counter-incision) were noted in 10 of the procedures (5%). The only risk factor identified for a procedural complication during implant removal/replacement was interval time from insertion (21 vs. 13 months; p<0.01). The only documented wound problem reported was dermatitis in 1 patient (no suture granuloma, dehiscence, or implant extravasation). CONCLUSIONS: Procedural refinements and distraction therapy have enabled us to perform the majority of procedures in clinic without sedation. In our experience, procedural difficulty and complications appear to increase with prolonged implant duration. Histrelin implantation is increasingly being performed for gender dysphoria.

Underrepresentation of pediatric operations in the relative value unit updating process.

BACKGROUND: The Relative Value Unit (RVU) system was designed and implemented by Medicare to standardize physician payments for a given service. Because Medicare primarily cares for older adults, RVU assignments and updates may not consider pediatric-specific procedures, despite the fact that private insurers and Medicaid often base their payments on these RVU valuations. METHODS: The CPT codes of index pediatric operations were retrieved from the ACGME. We categorized these procedures into "Peds-specific" (eg, Ladd Procedure) versus those that could be performed in both children and adults, or "Non-specific" (eg, fundoplication). We merged these codes with RVU information from publicly available CMS files and the Resource-based Relative Value Scale Data Manager. Variables included were the date of last RVU update and the vignette used by survey respondents when asked to update the RVU valuation. RESULTS: Among 85 procedures, nearly three-quarters were Peds-specific (74%), with the remainder Non-specific. Approximately half of the 85 procedures (52%) had never been updated. Compared to Non-specific CPT codes, Peds-specific CPT codes were less likely to have been updated (38% vs. 91%, p < 0.001) and, among those that were updated, were updated more remotely (median year 2000 vs. 2005, p = 0.02). Among updated Non-specific CPT codes, the vignette written to justify the valuation was based on an adult patient in 85% of cases. CONCLUSIONS: Peds-specific surgical CPT codes have either never been updated or have not been updated in decades. Procedures performed in both children and adults have been updated more often and more recently, but the vignette on which this valuation is based on is typically an adult patient. In order to remain relevant and reimburse pediatric surgeons accurately, the RVUs for pediatric procedures need to also be prioritized for revision and updating.

The impact of removing global periods on pediatric surgeon reimbursement.

PURPOSE: CMS has proposed removing postoperative care from the global periods for surgical procedures and instead requiring surgeons to bill for postoperative visits using evaluation & management (E&M) codes. This policy may alter reimbursement to pediatric surgeons. METHODS: To assess the impact of this policy, NSQIP-pediatric data were used to calculate median LOS for high-volume procedures with 10 or 90 day global periods. We then merged these data with CMS physician work time and RVU files. A CMS LOS variable was created by counting the number of hospital-based E&M codes built into the global period based on the fact that if global periods are removed, surgeons may only bill one E&M code per postoperative day. We then compared the CMS and NSQIP LOS values. RESULTS: The dataset included 201 CPT codes with NSQIP LOS estimates derived from a median of 137 operations. Twenty-nine procedures (14.4%) had higher, 24 (16.9%) had the same, and 138 (68.7%) had lower NSQIP median LOS than current CMS values. On average, NSQIP values were 40.0% (95% confidence interval [95CI] -50.0, -29.9%) lower than CMS values. Based on a daily average work RVU per postoperative E&M code of 1.09 (95% CI 1.05, 1.12), and $35.78 per RVU (2017 rate), surgeons in this sample would experience a cumulative annual reduction in reimbursement of approximately $3.4 M following the policy change. CONCLUSIONS: Most pediatric surgical procedures have RVU valuations that include more hospital-based E&M codes than the current median number of postoperative days. Holding all else equal, the removal of global periods would therefore reduce reimbursement for pediatric surgeons. The downstream effects of this policy change, such as the impact on the quality of clinical care, are uncertain and warrant further investigation. TYPE OF STUDY: Clinical research paper. LEVEL OF EVIDENCE: Level II.

Chance to cut: defining a negative exploration rate in patients with suspected necrotizing soft tissue infection.

BACKGROUND: Necrotizing soft tissue infections (NSTI) are aggressive infections associated with significant morbidity and mortality. Despite multiple predictive models for the identification of NSTI, a subset of patients will not have an NSTI at the time of surgical exploration. We hypothesized there is a subset of patients without NSTI who are clinically indistinguishable from those with NSTI. We aimed to characterize the differences between NSTI and non-NSTI patients and describe a negative exploration rate for this disease process. METHODS: We conducted a retrospective review of adult patients undergoing surgical exploration for suspected NSTI at our county-funded, academic-affiliated medical center between 2008 and 2015. Patients were identified as having NSTI or not (non-NSTI) based on surgical findings at the initial operation. Pathology reports were reviewed to confirm diagnosis. The NSTI and non-NSTI patients were compared using χ2 test, Fisher's exact test, and Wilcoxon rank-sum test as appropriate. A p value <0.05 was considered significant. RESULTS: Of 295 patients undergoing operation for suspected NSTI, 232 (79%) were diagnosed with NSTI at the initial operation and 63 (21%) were not. Of these 63 patients, 5 (7.9%) had an abscess and 58 (92%) had cellulitis resulting in a total of 237 patients (80%) with a surgical disease process. Patients with NSTI had higher white cell counts (18.5 vs. 14.9 k/mm3, p=0.02) and glucose levels (244 vs. 114 mg/dL, p<0.0001), but lower sodium values (130 vs. 134 mmol/L, p≤0.0001) and less violaceous skin changes (9.2% vs. 23.8%, p=0.004). Eight patients (14%) initially diagnosed with cellulitis had an NSTI diagnosed on return to the operating room for failure to improve. CONCLUSIONS: Clinical differences between NSTI and non-NSTI patients are subtle. We found a 20% negative exploration rate for suspected NSTI. Close postoperative attention to this cohort is warranted as a small subset may progress. LEVEL OF EVIDENCE: Retrospective cohort study, level III.

The contemporary appendectomy for acute uncomplicated appendicitis in children.

BACKGROUND: National, procedure-specific clinical registries are increasingly available in surgery, although data about children have lagged behind. Data related to the surgical management of appendicitis in children have become available recently and can be used to inform patient and family expectations and to identify clinical areas in need of ongoing improvement. METHODS: Cases of acute, uncomplicated appendicitis in children (<18 years of age) were extracted from the 2017 pediatric appendectomy-targeted file of the American College of Surgeons National Surgical Quality Improvement Program. Epidemiologic data were generated across 5 domains: (1) patient characteristics/severity, (2) preoperative imaging patterns, (3) characteristics of the operation, (4) pathologic outcomes, and (5) postoperative morbidity and mortality. RESULTS: The final sample included 9,507 appendectomies for acute, uncomplicated appendicitis performed at 106 hospitals. The population was predominantly male (60.6%), involving children 6 to 12 years of age (55.3%). Only 2.9% of patients did not have imaging before their appendectomy. Overall, 38.2% received a computed tomography; however, patients transferred with imaging received computed tomography at 3.8 times the rate of those with only local (ie, operating hospital) imaging. Laparoscopy was used in 94.6% of cases, with 1.1% converted to open. Negative appendectomy and complication rates were 3.3% and 2.1%, respectively. Children ≤5 years of age had 2.3 greater odds of negative appendectomy than children 6 to 17 years of age. CONCLUSION: Children undergoing operation for acute, uncomplicated appendicitis have excellent clinical outcomes, although children ≤5 years of age have an increased risk of negative appendectomy. Despite guidelines against their use, more than one-third of children received a computed tomography before operation, driven predominantly by transferring hospitals.

Assessing outcomes and costs of appendectomies performed at rural hospitals.

BACKGROUND: The purpose of our study was to assess the outcomes and costs of appendectomies performed at rural and urban hospitals. METHODS: The National Inpatient Sample (2001-2012) was queried for appendectomies at urban and rural hospitals. Outcomes (disease severity, laparoscopy, complications, length of stay (LOS), and cost) were analyzed. RESULTS: Rural patients were more likely to be older, male, white, and have Medicaid or no insurance. Rural hospitals were associated with higher negative appendectomy rates (OR = 1.26,95%CI = 1.18-1.34,p < 0.01), less laparoscopy use (OR = 0.65,95%CI = 0.58-0.72,p < 0.01), and slightly shorter LOS (OR = 0.98,95%CI = 0.97-0.99,p < 0.01). There was no consistent association with perforated appendicitis and no difference in complications or costs after adjusting for hospital volume. Yearly trends showed a significant increase in the cases utilizing laparoscopy each year at rural hospitals. CONCLUSIONS: Rural appendectomies are associated with increased negative appendectomy rates and less laparoscopy use with no difference in complications or costs compared to urban hospitals.

Outcomes and costs of pediatric appendectomies at rural hospitals.

BACKGROUND/PURPOSE: Despite policy efforts to support rural hospitals, little is known about the quality and safety of pediatric surgical care in geographically remote areas. Our aim was to determine the outcomes and costs of appendectomies at rural hospitals. METHODS: The Kids' Inpatient Database (2003-2012) was queried for appendectomies in children <18 years at urban and rural hospitals. Outcomes (disease severity, laparoscopy, complications, length of stay (LOS), cost) were analyzed with bivariate and multivariable regression analysis. RESULTS: Rural hospitals performed 13.6% of appendectomies. On multivariable analysis, rural hospitals were associated with higher negative appendectomy rates (OR 1.49, 95% CI 1.39-1.60, p < 0.001), decreased appendiceal perforation rates (OR 0.86, 95% CI 0.83-0.89, p < 0.001), less laparoscopy use (OR 0.48, 95% CI 0.47-0.50, p < 0.001), higher complication rates (OR 1.29, 95% CI 1.19-1.39, p < 0.001), shorter LOS (IRR 0.90, 95% CI 0.89-0.91, p < 0.001), and slightly increased costs (exponentiated log$ 1.02, 95% CI 1.01-1.02, p < 0.001) CONCLUSIONS: Rural hospitals care for fewer patients with advanced appendicitis but are associated with higher negative appendectomy rates, lower laparoscopy use, and higher complication rates. Additional studies are needed to identify factors that drive this disparity to improve the quality of pediatric surgical care in rural settings. TYPE OF STUDY: Treatment/Cost Study (Outcomes). LEVEL OF EVIDENCE: Level III.

Outcomes and Costs of Common Surgical Procedures at Children's and Nonchildren's Hospitals.

BACKGROUND: Variations in the management of pediatric patients at children's hospitals (CHs) and non-CHs (NCHs) have been well described, especially within the trauma literature. However, little is known about the outcomes and costs of common general surgical procedures at NCHs. The purpose of this study was to evaluate the effect of CH designation on the outcomes and costs of appendectomy and cholecystectomy. METHODS: The Kids' Inpatient Database (2003-2012) was queried for patients aged under 18 y who underwent appendectomy or cholecystectomy at CHs and NCHs. Outcomes analyzed included disease severity, complications, laparoscopy, length of stay (LOS), and cost. RESULTS: Most of appendectomies and cholecystectomies were performed at NCHs. Overall, CHs cared for younger children were more likely to be teaching hospitals, had higher costs, and longer LOS. On multivariate analysis for appendectomies, CHs were associated with higher rates of perforated appendicitis (OR = 1.53, 95% CI = 1.42-1.66, P < 0.001), less complications (OR = 0.68, 95% CI = 0.61-0.75, P < 0.001), increased laparoscopy (OR = 2.93, 95% CI = 2.36-3.64, P < 0.001), longer LOS (RR = 1.13, 95% CI = 1.09-1.17, P < 0.001), and higher costs (exponentiated log $ = 1.19, 95% CI = 1.13-1.24, P < 0.001). Multivariate analysis for cholecystectomies revealed that CHs were associated with less laparoscopy (OR = 0.58, 95% CI = 0.50-0.67, P < 0.001), longer LOS (RR = 1.26, 95% CI = 1.19-1.34, P < 0.001), and higher costs (exponentiated log $ = 1.29, 95% CI = 1.22-1.37, P < 0.001) with similar complications. Independent predictors of LOS and cost included CH designation, negative appendectomy, perforated appendicitis, complications, younger age, black patients, and public insurance. CONCLUSIONS: Variations in surgical management, outcomes, and costs after appendectomy and cholecystectomy exist between CHs and NCHs. CHs excelled in treating complicated appendicitis. NCHs effectively performed cholecystectomies. These differences in outcomes require further investigation to identify modifiable factors to optimize care across all hospitals for these common surgical diseases.

Expanding the inclusion criteria for nonoperative management of uncomplicated appendicitis: Outcomes and cost.

BACKGROUND: Carefully selected children with early appendicitis may be managed nonoperatively. However, it is unknown whether nonoperative management (NOM) is applicable to all patients with uncomplicated appendicitis. The purpose of this study was to evaluate the outcomes of NOM of uncomplicated appendicitis with expanded inclusion criteria. METHODS: A prospective, nonrandomized patient-preference study comparing NOM versus laparoscopic appendectomy (LA) was performed in children with radiographic/clinical evidence of uncomplicated appendicitis. RESULTS: Demographics, laboratory values, and clinical presentation were similar between the NOM (n=51) and LA (n=32) groups. Initial failure rate was 31%. The outcomes were similar between groups, except that NOM had fewer days of pain medication. Patients who failed NOM had a longer duration of symptoms prior to admission. Patients with appendicolith had a failure rate of 50% compared to 24% without appendicolith. The recurrence rate was 26%. Overall, 51% avoided appendectomy. Costs were similar between NOM and LA. CONCLUSIONS: When expanding the inclusion criteria for children with presumed uncomplicated appendicitis, NOM was associated with high failure and recurrence rates. These high rates may be because of the inclusion of patients with complicated appendicitis and patients with an appendicolith. Even in this setting of less-restrictive exclusion criteria, NOM remained cost neutral. LEVEL OF EVIDENCE: LEVEL II (Treatment Study: Prospective Comparative Study).

Clinical and socioeconomic factors associated with negative pediatric appendicitis.

BACKGROUND: Misdiagnosing appendicitis may lead to unnecessary surgery. The study evaluates the risk factors for negative appendectomies, as well as the clinical and socioeconomic consequences of negative appendectomy across three states. MATERIALS AND METHODS: Data were obtained from the California, New York, and Florida State Inpatient Databases 2005-2011. Patients (<18 years) who underwent nonincidental appendectomies (n = 156,660) were evaluated with hierarchical and multivariate negative binomial regression analyses on outcomes including hospital cost, length of stay (LOS), and associated morbidity. RESULTS: From 2005 to 2011, there was a decrease in the rate of negative appendicitis and perforated appendicitis, whereas the rate of true acute nonperforated appendicitis increased. Whites, females, and privately insured patients were associated with higher negative appendicitis rates, whereas those at an increased risk for perforated appendicitis were African-Americans, males, and those with public or no insurance. Compared to patients with acute nonperforated appendicitis, those with negative appendicitis have significantly higher morbidity (2.5% versus 1.3%), longer LOS (3.4 versus 1.8 d), and greater hospital costs averaged over time ($6926 versus $6492 per patient). CONCLUSIONS: Despite a low incidence, negative appendicitis is associated with greater morbidity, longer LOS, and higher cost than acute nonperforated appendicitis. Certain subpopulations are at higher risk for undergoing surgery for negative appendicitis, whereas others are at greater risk for presenting with perforated appendicitis. Further research is needed to understand what drives such disparities and to inform efforts to improve quality of hospital care across all groups of patients.

Addressing the quality and cost of cholecystectomy at a safety net hospital.

BACKGROUND: The aim of this study was to evaluate the effects of safety-net burden on outcomes of a common, urgent operation like cholecystectomy. METHODS: We identified all cholecystectomies performed from 2005 to 2011 in the California State Inpatient Database and separated them into three cohorts based on the performing hospital's safety-net burden. Hierarchical multivariable regression analyses were performed with outcomes including laparoscopy, advanced disease, morbidity, length of hospitalization, and cost. RESULTS: Safety-net hospitals had similar rates of laparoscopy, overall advanced disease, and post-operative morbidity. Yet, they were able to maintain lower overall costs (cost difference -5592, 95% CI -8928, -2256, p < 0.01), despite having similar lengths of stay. CONCLUSION: Safety-net hospitals performed cholecystectomy with similar rates of laparoscopy and morbidity, while achieving lower costs. Safety-net hospitals may be well equipped to perform common, urgent operations like cholecystectomy.

Association of General Surgery Resident Remediation and Program Director Attitudes With Resident Attrition.

IMPORTANCE: Previous studies of resident attrition have variably included preliminary residents and likely overestimated categorical resident attrition. Whether program director attitudes affect attrition has been unclear. OBJECTIVES: To determine whether program director attitudes are associated with resident attrition and to measure the categorical resident attrition rate. DESIGN, SETTING, AND PARTICIPANTS: This multicenter study surveyed 21 US program directors in general surgery about their opinions regarding resident education and attrition. Data on total resident complement, demographic information, and annual attrition were collected from the program directors for the study period of July 1, 2010, to June 30, 2015. The general surgery programs were chosen on the basis of their geographic location, previous collaboration with some coauthors, prior work in surgical education and research, or a program director willing to participate. Only categorical surgical residents were included in the study; thus, program directors were specifically instructed to exclude any preliminary residents in their responses. MAIN OUTCOMES AND MEASURES: Five-year attrition rates (2010-2011 to 2014-2015 academic years) as well as first-time pass rates on the General Surgery Qualifying Examination and General Surgery Certifying Examination of the American Board of Surgery (ABS) were collected. High- and low-attrition programs were compared. RESULTS: The 21 programs represented different geographic locations and 12 university-based, 3 university-affiliated, and 6 independent program types. Programs had a median (interquartile range [IQR]) number of 30 (20-48) categorical residents, and few of those residents were women (median [IQR], 12 [5-17]). Overall, 85 of 966 residents (8.8%) left training during the study period: 15 (17.6%) left after postgraduate year 1, 34 (40.0%) after postgraduate year 2, and 36 (42.4%) after postgraduate year 3 or later. Forty-four residents (51.8%) left general surgery for another surgical discipline, 21 (24.7%) transferred to a different surgery program, and 18 (21.2%) exited graduate medical education altogether. Each program had an annual attrition rate ranging from 0.73% to 6.0% (median [IQR], 2.5% [1.5%-3.4%]). Low-attrition programs were more likely than high-attrition programs to use resident remediation (21.0% vs 6.8%; P < .001). Median (IQR) Qualifying Examination pass rates (93% [90%-98%] vs 92% [86%-100%]; P = .92) and Certifying Examination pass rates (83% [68%-84%] vs 81% [71%-86%]; P = .47) were similar. Program directors at high-attrition programs were more likely than their counterparts at low-attrition programs to agree with this statement: "I feel that it is my responsibility as a program director to redirect residents who should not be surgeons." CONCLUSIONS AND RELEVANCE: The overall 5-year attrition rate of 8.8% was significantly lower than previously reported. Program directors at low-attrition programs were more likely to use resident remediation. Variations in attrition may be explained by program director attitudes, although larger studies are needed to further define program factors affecting attrition.

Outcomes and Costs of Managing Appendicitis at Safety-Net Hospitals.

IMPORTANCE: Safety-net hospitals serve vulnerable populations with limited resources. Although complex, elective operations performed at safety-net hospitals have been associated with inferior outcomes and higher costs, it is unclear whether a similar association has been seen with common emergency general surgery performed at safety-net hospitals. OBJECTIVE: To evaluate the association of safety-net burden with the outcomes of appendectomy. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review was conducted of all nonfederally funded hospitals in the California state inpatient database that performed appendectomies from January 1, 2005, to December 31, 2011. A total of 349 hospitals performing 274 405 nonincidental appendectomies were stratified based on safety-net burden; low-burden hospitals had the lowest quartile of patients who either had Medicaid or were uninsured (0%-14%), medium-burden hospitals had the middle 2 quartiles (15%-41%), and high-burden hospitals had the highest quartile (>42%). Data analysis was performed from August 27 to September 8, 2016. MAIN OUTCOMES AND MEASURES: Rates of laparoscopy, perforation, negative appendectomy, morbidity, length of stay, and cost. RESULTS: Among the 349 hospitals in the study, high-burden hospitals treated a larger proportion of black patients than did medium- and low-burden hospitals (4.5% vs 2.4% vs 2.9%; P = .01), as well as Hispanic patients (64.8% vs 27.0% vs 22.0%; P < .001) and patients with perforated appendicitis (27.6% vs 23.6% vs 23.6%; P = .005). High-burden hospitals were less likely than medium- or low-burden hospitals to use laparoscopy (51.6% vs 60.7% vs 71.9%; P < .001). There were no differences in morbidity, length of stay, or cost. Multivariable regression analysis confirmed that high-burden hospitals were more likely than low-burden hospitals to treat perforated appendicitis (log %, 0.07; 95% CI, 0.03-0.12; P = .04) and less likely to use laparoscopy (-16.9% difference; 95% CI, -26.1% to -7.6%; P < .001), while achieving similar complication rates. Multivariable analysis also confirmed that high-burden hospitals have similar costs, despite being associated with longer length of stay (relative risk, 1.17; 95% CI, 1.09-1.26; P < .001). CONCLUSIONS AND RELEVANCE: Safety-net hospitals treat a disproportionate number of patients with advanced appendicitis while falling behind in the use of laparoscopy. Nonetheless, safety-net hospitals treat this common surgical emergency with morbidity and cost similar to that seen at other hospitals. Additional research is needed to evaluate how these outcomes are achieved to improve all surgical outcomes at underresourced hospitals.

The cost-effectiveness of nonoperative management versus laparoscopic appendectomy for the treatment of acute, uncomplicated appendicitis in children.

BACKGROUND: Several studies have demonstrated the safety and short-term success of nonoperative management in children with acute, uncomplicated appendicitis. Nonoperative management spares the patients and their family the upfront cost and discomfort of surgery, but also risks recurrent appendicitis. METHODS: Using decision-tree software, we evaluated the cost-effectiveness of nonoperative management versus routine laparoscopic appendectomy. Model variables were abstracted from a review of the literature, Healthcare Cost and Utilization Project, and Medicare Physician Fee schedule. Model uncertainty was assessed using both one-way and probabilistic sensitivity analyses. We used a $100,000 per quality adjusted life year (QALY) threshold for cost-effectiveness. RESULTS: Operative management cost $11,119 and yielded 23.56 quality-adjusted life months (QALMs). Nonoperative management cost $2277 less than operative management, but yielded 0.03 fewer QALMs. The incremental cost-to-effectiveness ratio of routine laparoscopic appendectomy was $910,800 per QALY gained. This greatly exceeds the $100,000/QALY threshold and was not cost-effective. One-way sensitivity analysis found that operative management would become cost-effective if the 1-year recurrence rate of acute appendicitis exceeded 39.8%. Probabilistic sensitivity analysis indicated that nonoperative management was cost-effective in 92% of simulations. CONCLUSIONS: Based on our model, nonoperative management is more cost-effective than routine laparoscopic appendectomy for children with acute, uncomplicated appendicitis. LEVEL OF EVIDENCE: Cost-Effectiveness Study: Level II.

Factors predictive of complicated appendicitis in children.

BACKGROUND: The ability to predict whether a child has complicated appendicitis at initial presentation may influence clinical management. However, whether complicated appendicitis is associated with prehospital or inhospital factors is not clear. We also investigate whether hyponatremia may be a novel prehospital factor associated with complicated appendicitis. MATERIALS AND METHODS: A retrospective review of all pediatric patients (≤12 y) with appendicitis treated with appendectomy from 2000 to 2013 was performed. The main outcome measure was intraoperative confirmation of gangrenous or perforated appendicitis. A multivariable analysis was performed, and the main predictors of interest were age <5 y, symptom duration >24 h, leukocytosis (white blood cell count >12 × 103/mL), hyponatremia (sodium ≤135 mEq/L), and time from admission to appendectomy. RESULTS: Of 392 patients, 179 (46%) had complicated appendicitis at the time of operation. Univariate analysis demonstrated that patients with complicated appendicitis were younger, had a longer duration of symptoms, higher white blood cell count, and lower sodium levels than patients with noncomplicated appendicitis. Multivariable analysis confirmed that symptom duration >24 h (odds ratio [OR] = 5.5, 95% confidence interval [CI] = 3.5-8.9, P < 0.01), hyponatremia (OR = 3.1, 95% CI = 2.0-4.9, P < 0.01), age <5 y (OR = 2.3, 95% CI = 1.3-4.0, P < 0.01), and leukocytosis (OR = 1.9, 95% CI = 1.0-3.5, P = 0.04) were independent predictors of complicated appendicitis. Increased time from admission to appendectomy was not a predictor of complicated appendicitis (OR = 0.8, 95% CI = 0.5-1.2, P = 0.2). CONCLUSIONS: Prehospital factors can predict complicated appendicitis in children with suspected appendicitis. Hyponatremia is a novel marker associated with complicated appendicitis. Delaying appendectomy does not increase the risk of complicated appendicitis once intravenous antibiotics are administered. This information may help guide resource/personnel allocation, timing of appendectomy, and decision for nonoperative management of appendicitis in children.

Misdiagnosing adult appendicitis: clinical, cost, and socioeconomic implications of negative appendectomy.

BACKGROUND: The aim of this study was to evaluate the clinical, financial, and socioeconomic factors associated with negative appendectomy (NA). METHODS: Data were obtained from the California State Inpatient Database (2005 to 2011). Patients (≥18 years) who underwent nonincidental appendectomies (n = 180,958) were evaluated with multivariate regression analyses. RESULTS: NA rates decreased from 4.5% in 2005 to 2.8% in 2011 (P < .01). Compared with patients with nonperforated appendicitis, NA was associated with longer length of stay, higher morbidity, and higher hospital costs. Multivariate regression demonstrated that African Americans, younger age (18 to 29 years), and females were predictors of NA. Hispanics and patients with public or no insurance were associated with a lower NA rate; however, perforation rates were higher. CONCLUSIONS: NA was associated with higher cost, longer length of stay, and higher morbidity compared with nonperforated appendicitis. Lower NA rates but higher perforation rates in some populations suggest a delay in presentation. Further research is needed to understand these disparities and to improve quality of care among low-income minority patients.

Routine intraoperative cholangiography is unnecessary in patients with mild gallstone pancreatitis and normalizing bilirubin levels.

BACKGROUND: The benefit of intraoperative cholangiography (IOC) is controversial in patients with gallstone pancreatitis whose bilirubin levels are normalizing. IOC with subsequent endoscopic retrograde cholangiopancreatography may lengthen duration of surgery and length of stay, whereas failure to clear the common bile duct may result in recurrent pancreatitis. METHODS: We performed a 6-year retrospective cohort analysis of consecutive adult patients with mild gallstone pancreatitis undergoing same-admission cholecystectomy at 2 university-affiliated medical centers. Institution A routinely performed IOC, whereas institution B did not. The primary outcome was readmission within 30 days for recurrent pancreatitis. RESULTS: Of 520 patients evaluated, 246 (47%) were managed at institution A (routine IOC) and 274 (53%) were managed at institution B (restricted IOC). Patients at institution B had a shorter duration of surgery (1.0 vs 1.6 hours, P < .001), shorter length of stay (4 vs 5 days, P < .001), and fewer postoperative endoscopic retrograde cholangiopancreatographies performed (1.8% vs 21%, P < .001), without a difference in readmissions (1.5% vs 0%, P = .12). CONCLUSIONS: Routine IOC is not necessary in the setting of mild gallstone pancreatitis with normalizing bilirubin values.