Protocolized management of pediatric complicated appendicitis leads to improved outcomes.

PURPOSE: We aimed to evaluate a complicated appendicitis clinical practice guideline at our institution. METHODS: Records were compared before and after protocol implementation. We standardized an ED consult pathway, antibiotic use and need for early appendectomy (EA) versus interval appendectomy (IA). We evaluated demographics, clinical characteristics, and outcomes. Subgroup analysis was performed to compare patients with small abscess treated with IA pre-protocol versus similar patients treated by EA post-protocol. RESULTS: In total 246 patients were reviewed (Pre-protocol = 152, Post-protocol = 94). Pre-protocol early appendectomy rate was 51% versus 82% on post-protocol patients. There were no differences in demographics. Post-protocol the use of preoperative imaging significantly decreased (Pre 92% vs. 56%, p = 0.0001), as well as the use of discharge antibiotics (Pre 93% vs. Post 27%, p = 0.0001) with no change in abscess rate. Overall, post-protocol patients had fewer total CT scans performed (Pre 40% vs. Post 28%, p = 0.03) and decreased total length of stay (Pre 7.7 vs. Post 6.5 days, p = 0.049). On subgroup analysis, post-protocol EA with no or small abscess had lower median number of admissions, decreased total LOS (Pre IA 9 days vs. Post EA 5 days, p = 0.00001) and fewer complications (Pre IA 42% vs. EA 22%, p = 0.022). CONCLUSION: The establishment of a standardized pediatric complicated appendicitis protocol may lead to improved outcomes and resource utilization. Patients presenting with no or small abscess may be the least likely to benefit from interval appendectomy. LEVEL OF EVIDENCE: Level III.

Screening Laboratory Testing in Asymptomatic Minor Pediatric Blunt Trauma Leads to Unnecessary Needle Sticks.

OBJECTIVE: Screening blood work after minor injuries is common in pediatric trauma. The risk of missed injuries versus diagnostic necessity in an asymptomatic patient remains an ongoing debate. We evaluated the clinical utility of screening blood work in carefully selected asymptomatic children after minor trauma. METHODS: Patients seen at a level 1 pediatric center with "minor trauma" for blunt trauma between 2010 and 2015 were retrospectively reviewed. Exclusion criteria were age <4 of >18 years, a Glasgow Coma Scale score of <15, penetrating trauma, nonaccidental trauma, hemodynamic instability, abdominal findings (pain, distension, bruising, tenderness), hematuria, pelvic/femur fracture, multiple fractures, and operative intervention. Data abstraction included demographics, blood work, interventions, and disposition. RESULT: A total of 1308 patients were treated during the study period. Four hundred thirty-three (33%) met inclusion criteria. Mean ± SD age was 12.7 ± 4 years (range, 4-18 years), and 59% were male. Seventy-eight percent were discharged home from the emergency department. All patients had blood work. Twenty-eight percent had at least one abnormal laboratory value. The most common abnormal blood work was leukocytosis (16%). Thirty percent had an intervention, and none prompted by abnormal blood work. One patient had an intra-abdominal finding (psoas hematoma). CONCLUSION: When appropriately selected, screening laboratory testing in asymptomatic minor pediatric blunt trauma patients leads to unnecessary needle sticks without significant advantage.

Imaging for acute appendicitis at nonpediatric centers exposes children to excess radiation.

BACKGROUND: Radiation exposure is the reason for the decreased utilization of computed tomography (CT) in pediatric centers (PCs). We sought to compare the radiation dose exposure of CT imaging performed at outside hospitals (OH) versus PC in pediatric patients with acute appendicitis (AA). MATERIAL AND METHODS: A retrospective review of all patients managed at our PC for AA from January 2011 to March 2016 was performed. Patients who had CT imaging for AA at OH were compared to those who underwent CT for appendicitis at our PC. Radiation dosing was compared using the dose index (CTDI [mGY]) and dose length product (DLP [mGYcm]). Independent t-test samples were used to compare means for radiation dose. RESULTS: 379 patients met inclusion criteria. There were 59.4% (225) patients imaged at our PC and 40.6% (154) patients were transferred from an OH. When performed at OH, 6.5% of CTs were considered inadequate as they were done without intravenous contrast compared to 1.3% in our PC. Mean CTDI was 6.9 at our PC and 11.8 at OH (P < 0.0001). Mean DLP at PC was 296.2 versus 456.8 at OH (P < 0.0001). An excess radiation dose of 4.9 mGY and 160.5 mGYcm was noted when CT scan was performed at OH versus PC. CONCLUSIONS: Using DLP as a gauge of radiation exposure, CT imaging performed at OH has a 44% higher radiation rate relative to the exposure at PC. In cases of suspected AA at a facility without pediatric surgeons, early transfer to PC prior to imaging is advocated.

Optimal timing of cholecystectomy in children with gallstone pancreatitis.

BACKGROUND: Little data exist regarding the recurrence of pancreatitis in pediatric patients with gallstone pancreatitis awaiting cholecystectomy. This study evaluates the recurrence rate of pancreatitis after acute gallstone pancreatitis based on the timing of cholecystectomy in pediatric patients. MATERIALS AND METHODS: A retrospective chart review of all patients admitted with gallstone pancreatitis from 2007 to 2015 was performed. Children were divided into the following five groups. Group 1 had surgery during the index admission. Group 2 had surgery within 2 wk of discharge. Group 3 had surgery between 2 and 6 wk postdischarge. Group 4 had surgery 6 wk after discharge, and group 5 patients had no surgery. The recurrence rates of pancreatitis were calculated for all groups. RESULTS: Forty-eight patients with gallstone pancreatitis were identified in this study. The 19 patients in group 1 had no recurrence of their pancreatitis. Of the remaining 29 patients, nine (31%) had recurrence of pancreatitis or required readmission for abdominal pain prior to their cholecystectomy. In group 2, two of the eight patients (25%) had recurrent pancreatitis. In group 3, three of eight patients (37.5%) developed recurrent pancreatitis. In group 4, three of five patients (60%), and in group 5, one of eight. No children in group 5 had demonstrable gallstones at presentation, only sludge in their gallbladder. CONCLUSIONS: Cholecystectomy during the index admission is associated with no recurrence or readmission for pancreatitis. Therefore, we recommend that cholecystectomy be performed after resolution of an episode of gallstone pancreatitis during index admission.

Multicenter retrospective comparison of spontaneous intestinal perforation outcomes between primary peritoneal drain and primary laparotomy.

PURPOSE: The purpose of our study was to compare outcomes of infants with spontaneous intestinal perforation (SIP) treated with primary peritoneal drain versus primary laparotomy. METHODS: We performed a multi-institution retrospective review of infants with diagnosis of SIP from 2012 to 2016. Clinical characteristics and outcomes were compared between infants treated with primary peritoneal drain vs infants treated with laparotomy. RESULTS: We identified 171 patients treated for SIP (drain n = 110 vs. laparotomy n = 61). There were no differences in maternal or prenatal characteristics. There were no clinically significant differences in vital signs, white blood cell or platelet measures, up to 48 h after intervention. Patients who were treated primarily with a drain were more premature (24.9 vs. 27.2 weeks, p < 0.001) and had lower median birth weight (710 g vs. 896 g, p < 0.001). No significant differences were found in complications, time to full feeds, length of stay (LOS) or mortality between the groups. Primary laparotomy group had more procedures (median number 1 vs. 2, p = 0.002). There were 32 (29%) primary drain failures whereby a laparotomy was ultimately needed. CONCLUSIONS: SIP treated with primary drain is successful in the majority of patients with no significant differences in outcomes when compared to laparotomy with stoma. THE LEVEL OF EVIDENCE: III.

Extended Antibiotic Course Prior to Interval Appendectomy in Children with Complicated Appendicitis Offers No Significant Advantage.

BACKGROUND: No consensus exists regarding duration of antibiotic therapy for complicated appendicitis treated with interval appendectomy. We hypothesized that more than two weeks of antibiotic therapy does not decrease complication rates in asymptomatic patients. PATIENTS AND METHODS: A retrospective review of all patients with complicated appendicitis treated with interval appendectomy from 2010-2015 was performed. We divided the patients in two groups (group 1, ≤2 weeks of antibiotics; group 2: >2 weeks of antibiotics). Demographics, antibiotic agents, and complications were collected. Pearson χ analysis and Student t-test analysis was performed with significance of p < 0.05. RESULTS: Total of 158 patients met inclusion criteria (group 1 [47.4%] vs. group 2 [52.5%]). Mean length of stay was 7.5 days. Abscess on admission was 26% (n = 41). The groups were demographically similar. Total complication rate was 39.2% (abscess development, n = 19; re-admissions, n = 16; interval appendectomy <28 days, n = 13; unplanned emergency department visits, n = 7; fistula, n = 4, wound infection/dehiscence, n = 3; and conversion to open surgery, n = 4). All fistulas and conversions occurred in the less than two-week group. Mean course of antibiotics was 4.1 weeks. There was no significant difference in the complication rates based on duration or type of antibiotics (p = 1.0). CONCLUSION: Treatment with more than two weeks of antibiotic therapy for complicated appendicitis does not confer any clinical benefit prior to interval appendectomy. Complications were not reduced by a prolonged course of antibiotic therapy.

Abscess and symptoms duration upon presentation should guide decision algorithms for early versus interval appendectomy in children.

BACKGROUND: To compare outcomes for complicated appendicitis treated with early versus interval appendectomy and to identify which patients would likely benefit from early appendectomy. METHODS: A retrospective review of complicated appendicitis was performed from 2010 to 2015. Patients were divided into early (EA) versus interval appendectomy (IA) groups. We compared demographics, complications and outcomes. Pearson's Chi square analysis and Student's T test analysis were performed. RESULTS: We identified 316 patients (EA group 53% vs. IA group 47%). Interval appendectomy group had longer symptom duration [IA 3.8 vs. EA 2.3 days (p = 0.0001)], increased leukocytosis [IA 18.7 vs. EA 17.2 (p = 0.008)], more initial abscesses [IA 35% vs. EA 13% (p = 0.0001)], more complications [IA 30% vs. EA 19%, (p = 0.013) and prolonged total length of stay [(LOS), p = 0.009]. Subgroup analysis of all patients revealed 80% of patients presented with ≤3 cm abscess and duration of symptoms (DOS) ≤5 days. Interval appendectomy patients with DOS ≤5 days and or ≤3 cm abscess on admission had no differences in clinical presentation. However, these patients had prolonged total LOS (IA 7.7 vs. EA 6.3 days, p = 0.01) and increased complications (IA 29% vs. EA 19%, p = 0.04). CONCLUSION: The majority of patients with complicated appendicitis in children present with small abscess (≤3 cm) and short symptom duration (≤5 days). This subset of patients might benefit from early appendectomy due to decreased LOS, resource utilization and reduced complications.

Laparoscopic Peritoneal Dialysis Catheter Placement with Chest Wall Exit Site for Neonate with Stoma.

Neonates requiring peritoneal dialysis (PD) catheters have been shown to have complication rates up to 70%. The presence of a concurrent stoma significantly increases the risk of peritonitis, exit-site infection, and catheter failure. As such, multiple techniques have been proposed to reduce these risks, including a chest wall exit site. In this case, the patient was born with bilateral hypoplastic kidneys and an anorectal malformation, requiring a colostomy soon after birth. At 4 weeks of life, he required placement of a PD catheter for dialysis. Given the high risk of infection, a laparoscopic-assisted PD catheter placement with a chest wall exit remote from the colostomy was performed. This report describes the operative technique including omentectomy, placement of a percutaneous stitch between the catheter cuffs, and fibrin glue injection around the catheter. The patient had no catheter-related infections. Laparoscopic-assisted PD catheter placement with chest wall exit site is a safe alternative in patients with any type of abdominal stoma.

Peritoneal Nodules in a Pediatric Patient with Benign Teratoma. A Case Report and Review of Literature.

BACKGROUND: Mature ovarian teratomas are common in children. These well differentiated tumors are typically confined to the ovary. In rare cases, they can rupture leading to granulomatous peritonitis that mimics carcinomatosis. Ovarian tumors with peritoneal/omental implants suggest malignant pathology with a different prognosis. CASE: A 15-year-old girl presented with 5 months of abdominal pain, and weight loss. Computed tomography (CT) imaging of the abdomen revealed a large mass filling the abdomen. Slightly elevated lactate dehydrogenase (LDH) and carcinoma antigen 125 (CA125). On laparotomy an ovarian tumor with peritoneal and omental implants was identified. Left salpingo-oophorectomy, omentectomy, and peritoneal washing were performed. Pathology revealed a benign cystic teratoma. SUMMARY AND CONCLUSION: Although ovarian teratomas are typically benign, they might mimic carcinomatosis. In patients with unexpected finding of peritoneal implants, histologic diagnosis is recommended before proceeding with a full oncologic ovarian resection.