Journal of Pediatric Surgery xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Pediatric patients transferred for operative management of appendicitis: are they at a disadvantage? Sandra M. Farach ⁎, Paul D. Danielson 1, N. Elizabeth Walford 1, Richard P. Harmel Jr. 1, Nicole M. Chandler 1 Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Saint Petersburg, FL, USA
a r t i c l e
i n f o
Article history: Received 6 November 2014 Received in revised form 8 March 2015 Accepted 10 March 2015 Available online xxxx Key words: Pediatric Appendicitis Appendectomy Transfer
a b s t r a c t Purpose: Many pediatric patients are initially diagnosed with appendicitis at referring hospitals and are subsequently transferred to pediatric facilities. We aimed to compare outcomes of patients transferred to a pediatric referral center to those who present primarily for operative management of appendicitis. Methods: A retrospective review of 326 patients with operative appendicitis from July 2012 to July 2013 was performed. Demographic data, clinical parameters, and outcomes were analyzed. Results: Transferred (n = 222, 68%) and primary patients (n = 104, 32%) were similar except for mean age (primary 12.4 vs. transferred 11.2 years, p b 0.01). Computed tomography scans were performed in 80% of transferred compared to 40% of primary patients. Primary patients were more likely to present between the hours of 09:00 and 17:59 (52%), while transferred arrived equally across all hours. Both groups were more likely to present with acute appendicitis (primary 56% vs. transfer 61%, p = NS). There was no difference in time of diagnosis to time of appendectomy, length of hospital stay, or 30 day complications (primary 8.6% vs. transfer 5.8%, p = NS). Conclusions: Patients transferred for definitive care of appendicitis are not found to have more advanced disease or have increased complications; however, they are exposed to significantly more ionizing radiation during evaluation for appendicitis. © 2015 Elsevier Inc. All rights reserved.
Appendicitis has been described as a progressive inflammatory process induced by luminal obstruction that ultimately leads to infection, ischemic necrosis, and perforation [1–3]. Given this progression, appendicitis is usually considered a disease requiring timely surgical management. It is believed that a delay in diagnosis contributes to a higher perforation rate and in turn increased morbidity, hospital length of stay, and health care costs [4]. One report found a linear relationship between duration of symptoms of appendicitis and risk of perforation in children, rising from 10% at 18 hours to greater than 40% at 48 hours [5]. A second study found that an in-hospital delay greater than 12 hours was associated with a significantly higher perforation rate and longer hospital stay [6]. Many pediatric patients are initially evaluated at non-pediatric hospitals and subsequently transferred to pediatric tertiary referral hospitals. This may be for further work up if there is a concern for appendicitis or further management if there is a confirmed diagnosis of appendicitis. This process may lead to a delay in either diagnosis or treatment in this patient population. While recent studies have demonstrated that a short delay to appendectomy yield the same result as immediate ⁎ Corresponding author at: All Children's Hospital, Outpatient Care Center, 601 5th Street South, Dept 70-6600, 3rd Floor, St. Petersburg, FL 33701. Tel.: +1 727 767 2205; fax: +1 727 767 4346. E-mail addresses: [email protected] (S.M. Farach), [email protected] (P.D. Danielson), [email protected] (N.E. Walford), [email protected] (R.P. Harmel), [email protected] (N.M. Chandler). 1 All Children’s Hospital, Outpatient Care Center, 601 5th Street South, Dept 70-6600, 3rd Floor, St. Petersburg, FL 33701. Tel.: +1 727 767 4170; fax: +1 727 767 4346.
appendectomy, it is believed that this is dependent on timely, correct diagnosis with the initiation of appropriate antibiotic coverage [7,8]. The purpose of this study is to compare outcomes of patients transferred to a pediatric tertiary referral center to those who present primarily to the pediatric hospital for operative management of appendicitis. 1. Material and methods After Institutional Review Board approval (IRB # 13-0601), a retrospective analysis of 326 patients who underwent appendectomy at a free-standing, tertiary children's hospital from July 2012 to July 2013 was performed. Patients who presented primarily for initial evaluation and patients who were transferred from referring hospitals were included. As a tertiary children's hospital, our institution has a large geographic catchment area. While many patients are transferred for definitive care after a diagnosis of appendicitis, other patients are transferred for further workup to rule out possible appendicitis. Our institution has 24 hour ultrasound capability performed by technicians who are specialized in pediatric ultrasonography. One of four attending pediatric surgeons performed all appendectomies on a rotating basis determined by call schedule with the aid of a pediatric surgery fellow or mid-level provider. Our operating suite has an add-on room that is available for cases that are booked overnight or on an ongoing basis during the day. All patients received preoperative antibiotics prior to appendectomy. Antibiotics are started once the diagnosis of appendicitis is made, and they are continued at the appropriate dosing and timing based on patient age and type of antibiotic
http://dx.doi.org/10.1016/j.jpedsurg.2015.03.041 0022-3468/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Farach SM, et al, Pediatric patients transferred for operative management of appendicitis: are they at a disadvantage?, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.03.041
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S.M. Farach et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
administered. Appendectomy was performed by an open, multi-port laparoscopic, or single incision laparoscopic technique based on surgeon preference. Pre-operative, peri-operative, and post-operative care is standardized at our institution regardless of the operative technique utilized for appendectomy. During the study period, patients with intraoperative findings of acute appendicitis were admitted following appendectomy, without further antibiotic treatment and discharged once discharge criteria were met. Patients with intraoperative findings of suppurative, gangrenous, or perforated appendicitis were also admitted following appendectomy, however they were continued on intravenous antibiotic treatment until discharge criteria were met. Discharge criteria included temperature b 38.5 °C, tolerating an adequate liquid diet, and pain control with oral pain medication. Patients were grouped into “primary” (those who presented to our institution for initial evaluation) and “transferred” (those who were transferred from referring hospitals). Demographic data were obtained on age, weight, gender, category of appendicitis, surgical procedure utilized, and time of arrival to our emergency center (EC). Quality and outcome measures including time from EC diagnosis at our institution to operating room arrival, modality for diagnosis, post-operative length of stay, and 30-day complications were analyzed. Complications were defined as any event or occurrence that is a departure from the standard course of events following appendectomy. This included events occurring pre-operatively, intraoperatively, post-operatively, and/or within 30 days of surgery. The patient medical records were reviewed by one of two reviewers thoroughly to ensure the same definitions for complications were applied. Surgical site infection was defined as the presence of any localized swelling, erythema, calor, or wound drainage requiring treatment with antibiotics or open drainage by the surgeon. Intraabdominal abscess was defined as the presence of an intraabdominal collection following appendectomy diagnosed by ultrasound or computed tomography scan. Post-operative ileus was defined as a delay in return of bowel function prolonging a patient's hospital course or requiring re-admission. Descriptive data are reported as mean ± standard deviation and range where appropriate. Statistical analysis was performed using Student's t-test for continuous variables and Fisher's exact test for categorical variables. Significance was set at p b 0.05. 2. Results During the study period, a total of 326 patients underwent appendectomy. Two hundred twenty-two (67.7%) patients presented as transfers from referring hospitals, while 104 (31.9%) presented as primary patients for initial evaluation at our institution. Demographic, quality, and outcome measures are described in detail in Table 1. Primary patients were found to be significantly older compared to transferred patients (12.4 vs. 11.2 years, p b 0.05). Gender, weight, white blood cell count, and C-reactive protein were similar for both groups and found to be non-significant. The duration of abdominal pain was not significantly different between the two groups (1.39 vs. 1.42 days, p = NS). There were significantly more patients with private insurance and significantly less patients with Medicaid presenting to our institution primarily compared to those transferred. Of the 222 patients who were transferred, 131 (59%) received intravenous antibiotic treatment prior to their transfer. The most commonly administered antibiotics included cephalosporins (35.9%) and broad spectrum, beta-lactamase inhibiting penicillins (62.6%). The remaining 91 patients who were not treated with antibiotics did not have a definitive diagnosis of appendicitis prior to their transfer. For patients who presented for initial evaluation at out institution, 77.9% received Cefoxitin, 12.5% received Zosyn, 5.8% received Ciprofloxacin and Flagyl, and 3.8% received other antibiotics. The time of arrival to our institution's emergency center was evaluated for all patients. These were divided into three separate time frames: 01:00–08:59, 09:00–17:59, and 18:00–00:59 hours. It was noted that primary patients were more likely to arrive between the hours of 09:00 and 17:59 (51.9%), while those transferred arrived between all
Table 1 Demographics and outcomes of primary and transferred patient groups. Demographics and outcomes
Number of patients Age (years)a Males (%) Weight (kg)a Insurance status Private insurance Medicaid Self-pay Race Asian Black Caucasian Hispanic Other White blood cell counta C-reactive proteina Abdominal pain duration (days)a Modality for diagnosis Ultrasound (US) Computed tomography (CT) US + CT OR findings Acute (%) Complex (%) Time of diagnosis to OR (hours)a Hospital length of stay (hours)a Complications a
Primary
Transferred
p-Value
104 (31.9%) 12.5 ± 3.9 (2.7–20.6) 60 (57.7%) 48.8 ± 21.2 (13–109)
222 (67.7%) 11.2 ± 3.7 (1.5–20.5) 137 (61.7%) 45.2 ± 20.8 (11.7–124)
0.004 0.543 0.15
52 (50%) 47 (45.2%) 5 (4.8%)
81 (36.5%) 134 (60.4%) 7 (3.2%)
0.022 0.012 0.53
3 (2.9%) 12 (11.5%) 74 (71.2%) 13 (12.5%) 2 (1.9%) 14.9 ± 5.2 (2.4–30.7) 5.8 ± 7.1 (0.5–30.2) 1.39 ± 1.1 (0.5–7)
2 (0.9%) 10 (4.5%) 137 (61.7%) 62 (28%) 11 (4.9%) 14.9 ± 4.9 (3.8–28.3) 4.5 ± 5.7 (0.05–33.7) 1.42 ± 1.1 (0.5–7)
0.332 0.163 0.107 0.002 0.239 0.981 0.131 0.525
63 (60.6%) 22 (21.2%)
47 (21.2%) 143 (64.4%)
0.0001 0.0001
19 (18.2%)
32 (14.4%)
0.414 0.397
58 (55.8%) 46 (44.2%) 5.9 ± 5.2 (0.6–26)
136 (61.3%) 86 (38.7%) 5.5 ± 4.3 (0.4–31.1)
0.515
46.4 ± 63.7 (3.4–341)
38.8 ± 70.1 (2.6–760)
0.353
9 (8.6%)
13 (5.8%)
0.352
Values are reported at mean ± standard deviation and (range).
hours equally (Fig. 1). When comparing the two groups, primary patients were significantly more likely to arrive between the hours of 09:00 and 17:59 when compared to the transferred patients (51.9 vs. 30.7%, p b 0.05); while transferred patients were significantly more likely more likely to arrive between the hours of 01:00 and 08:59 when compared to the primary patients (32.4 vs. 13.5%, p b 0.05). When evaluating the modality for diagnosis of appendicitis, transferred patients were more likely to have undergone computed tomography (CT) scans compared to patients who presented primarily (78.8 vs. 39.4%, p b 0.05) (Fig. 2). Patients who presented primarily were significantly more likely to undergo ultrasound alone for diagnosis of appendicitis compared to transferred patients (60.6 vs. 21.2%, p b 0.05).
Fig. 1. Number of patients presenting to the emergency department in each group over three time periods. Percentages are listed within the bars.
Please cite this article as: Farach SM, et al, Pediatric patients transferred for operative management of appendicitis: are they at a disadvantage?, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.03.041
S.M. Farach et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
Fig. 2. A comparison of the total number of computed tomography scans performed in the primary group versus the transferred group.
Operative findings at the time of appendectomy were grouped into acute appendicitis and complex appendicitis. Complex appendicitis included suppurative, gangrenous, and perforated appendicitis. When comparing operative findings between the primary and transferred groups, it was noted that patients in both groups more likely to present with acute appendicitis overall. Transferred patients were not found to have a significantly higher incidence of complex appendicitis when compared to the primary group (44.2 vs. 38.7%, p = NS) (Table 1). When comparing the time of EC diagnosis to time of arrival to the operating room between the two groups, there was no significant difference appreciated (primary 5.9 hours vs. transferred 5.5 hours, p = NS). Total hospital length of stay was also similar between the two groups and found to be non-significant (primary 46.4 hours vs. transferred 38.8 hours, p = NS). Complications and re-admissions for primary and transferred groups are listed in Table 2. There was no significant difference in the 30-day complication or re-admission rates between primary or transferred patients.
3. Discussion While it is generally accepted that appendicitis is a progressive disease requiring timely surgical management to avoid increased morbidity associated with perforated appendicitis, this historical concept has been challenged. Many reports have demonstrated no difference in outcomes with a short delay in operative intervention [5,9–12], suggesting that after initiation of antibiotic therapy, appendicitis can be managed in a more urgent or semi-elective manner [7,12–14]. This has led to a significant shift in surgical practice for appendicitis. A recent survey of 484 pediatric surgeons revealed that only 3.8% believed non-perforated appendicitis to be a surgical emergency, with the majority (92%) preferring to postpone overnight appendectomy [14].
Table 2 Comparison of complications and re-admission between the primary and transferred groups. Complications
Surgical site infection Intra-abdominal abscess Ileus/bowel obstruction Other Total Re-admissions
Primary
Transferred
p-Value
3 3 2 1 9 (8.6%) 3 (2.9%)
5 3 3 2 13 (5.8%) 5 (2.3%)
0.713 0.388 0.656 1.000 0.352 0.713
3
There remains large variability in the literature with regards to the outcomes resulting from delay to appendectomy. A number of reports have shown that a short delay to appendectomy, ranging from 6 to 24 hours, does not result in increased perforation rates or worse outcomes [2,5,7,9–12,15–17]. Other reports, however, have attributed delays in operative intervention for appendicitis to increased rates of perforation [3,6,18]. In a retrospective review of 1081 patients who underwent appendectomy, Ditillo et al. noted that the prevalence of advanced appendiceal pathology correlated positively with prolonged total interval to surgical intervention. They did, however, note that pre-hospital delays were more profoundly related to worsening pathology when compared to in-hospital delays [3]. Pittman-Waller et al. examined 5755 consecutive appendectomies and found an overall rate of complicated appendicitis of 32% and concluded that patient delay in presentation was the only significant factor determining the incidence of complicated appendicitis [15]. Over a 1 year period, 67.7% of patients presenting to our pediatric tertiary referral center with appendicitis were transferred from a referring facility. We sought to determine if this patient population had increased rates of appendiceal perforation or worse outcomes when compared to those who presented to our institution primarily given the potential for delay in treatment. We found that the majority of patients in both groups presented with acute appendicitis, 55.8 and 61.3% respectively, and there was no significant increase in the rates of complicated appendicitis in transferred patients. A study of 223 patients aged 15 to 50 evaluating the effect of transfer on outcomes in patient with appendicitis found that transferred patients were less likely to be ruptured at the time of operation [10]. In our analysis, we found that the duration of abdominal pain was not significantly different between the two groups (1.39 vs. 1.42 days, p = NS). It was also noted that the time of EC diagnosis to time of appendectomy was similar between the two groups, with mean time of less than 6 hours for both primary and transferred patients. Prior studies have shown no increase in perforation rates with in-hospital delay to appendectomy of less than 6 hours [2,6,7,12,16,19]. Transferred patients in our study were not found to have an increased incidence of perforation and this may be attributed to the fact that the mean time to appendectomy from EC diagnosis was less than 6 hours. We found no increase in the incidence of complications or readmission rates between the two groups. Studies on the topic of surgical site infection (SSI) rates with delayed appendectomy remain variable. Teixeira et al. demonstrated an increase in SSI when surgery was delayed longer than 6 hours from the time of admission to appendectomy [13]. Boomer et al. found no significant increase in the risk of SSI related to delay in appendectomy when evaluating emergency department triage to appendectomy and admission to appendectomy time in their analysis of 1388 pediatric patients [20]. They did, however, note an increase in SSI as the length of time between the start of symptoms and appendectomy increased [20]. A recent systematic review and metaanalysis demonstrated delays beyond 48 hours to be associated with an increase rate of wound infection [12]. We found no significant difference between primary and transferred patients with regards to SSI. Again, this may be attributed to the fact that the mean time to appendectomy from emergency department arrival was less than 6 hours for both groups. Another important finding in our results was the significantly higher number of computed tomography scans noted in transferred patients when compared to primary patients. Recent literature has expressed concerns regarding the increasing number of CT scans performed and subsequent increase in radiation exposure to patients in this population. The radiation exposure from an abdominopelvic CT scan is equivalent to approximately 100 to 250 chest radiographs [21]. One report estimated the development of approximately one fatal cancer for every 1000 CT scans performed in children [22]. A study evaluating whether established guidelines for CT scanning are being utilized at non-pediatric facilities prior to transfer of children with suspected appendicitis to tertiary
Please cite this article as: Farach SM, et al, Pediatric patients transferred for operative management of appendicitis: are they at a disadvantage?, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.03.041
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pediatric centers found that only 17% were performed according to published best-practice guidelines [23]. We therefore encourage other institutions to investigate their own CT imaging practices and to take a proactive approach in minimizing radiation exposure in the children. There may be a benefit to transferring patients with suspected appendicitis to institutions that specialize in pediatric ultrasound. The major limitations of this study include its retrospective design, single institutional data, and relatively small number of patients. This limits the ability to access more specific demographic, qualitative, and quantitative data. While we are able to assess the length of time of patient symptoms prior to presentation, this is very difficult to measure and subject to bias with regards to patient recall. We are unable to determine if there was a specific reason for a patient's delay in presentation, which again will have an impact on the disease severity. We are unable to determine the time of arrival to the referring facility, the amount of time at the referring facility, or the time to transfer as these data were not available for analysis. This again is another area of potential delay to definitive care for the patient and, thus, may affect severity and outcome. The amount of time at the referring facility and time to transfer would be a useful area for future investigation that may be best studied prospectively. While most patients younger than 18 are referred to our pediatric hospital for surgical care, there may be a subset of patients that undergo appendectomy at non-pediatric hospitals.
4. Conclusion Patients who are evaluated and diagnosed with appendicitis at a referring facility and transferred to a pediatric hospital for definitive care are not found to have more advanced disease or have increased complications compared to patient who initially present to a pediatric hospital. This may be attributed to the administration of antibiotics once the diagnosis of appendicitis is made as well as a semi-elective approach with a mean time of less than 6 hours to appendectomy for both groups. Given the majority of studies reporting no increased risk of complications with a short delay in appendectomy, this allows for pediatric patients to be transferred to specialized pediatric centers for definitive treatment without concerns for more advanced disease or worse outcomes. Patients transferred from referring hospitals were found to be exposed to significantly more ionizing radiation during evaluation for abdominal pain having undergone a greater number of CT scans for diagnosis. With increasing concern of radiation exposure in pediatric patients, this may be an area of focus for quality improvement across referring networks.
References [1] Rothrock SG, Pagane J. Acute appendicitis in children: emergency department diagnosis and management. Ann Emerg Med 2000;36(1):39–51. [2] Ingraham AM, Cohen ME, Bilimoria KY, et al. Effect of delay to operation on outcomes in adults with acute appendicitis. Arch Surg 2010;145(9):886–92. [3] Ditillo MF, Dziura JD, Rabinovici R. Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg 2006;244(5):656–60. [4] Newman K, Ponsky T, Kittle K, et al. Appendicitis 2000: variability in practice, outcomes, and resource utilization at thirty pediatric hospitals. J Pediatr Surg 2003; 38(3):372–9. [5] Narsule CK, Kahle EJ, Kim DS, et al. Effect of delay in presentation on rate of perforation in children with appendicitis. Am J Emerg Med 2011;29:890–3. [6] Busch M, Gutzwiller FS, Aellig S, et al. In-hospital delay increases the risk of perforation in adults with appendicitis. World J Surg 2011;35(7):1626–33. [7] Yardeni D, Hirschl RB, Drongowski RA, et al. Delayed versus immediate surgery in acute appendicitis: do we need to operate during the night. J Pediatr Surg 2004; 39:464–9. [8] Chiu CJ, Bratu I. The process of treating pediatric appendicitis. Clin Pediatr 2011; 50(9):803–6. [9] Schnüriger B, Laue J, Kröll D, et al. Introduction of a new policy of no nighttime appendectomies: impact on appendiceal perforation rates and postoperative morbidity. World J Surg 2014;38:18–24. [10] Norton VC, Schriger DL. Effect of transfer on outcome in patients with appendicitis. Ann Emerg Med 1997;29:467–73. [11] Hornby ST, Shahtahmassebi G, Lynch S, et al. Delay to surgery does not influence the pathological outcome of acute appendicitis. Scand J Surg 2013;103:5–11. [12] The United Kingdom National Surgical Research Collaborative. Safety of short, inhospital delays before surgery for acute appendicitis: Multicentre cohort study, systematic review, and meta-analysis. Ann Surg 2014;259(5):894–903. [13] Teixeira PG, Sivrikoz E, Inaba K, et al. Appendectomy timing: waiting until the next morning increases the risk of surgical site infections. Ann Surg 2012; 256(3):538–43. [14] Dunlop JC, Meltzer JA, Silver EJ, et al. Is nonperforated pediatric appendicitis still considered a surgical emergency? A survel of pediatric surgeons. Acad Pediatr 2012; 12(6):567–71. [15] Pittman-Waller VA, Myers JG, Stewart RM, et al. Appendicitis: why so complicated? Analysis of 5755 consecutive appendectomies. Am Surg 2000;66(6): 548–54. [16] Abou-Nukta F, Bakhos C, Arroyo K, et al. Effects of delaying appendectomy for acute appendicitis for 12 to 24 hours. Arch Surg 2006;141:504–7. [17] Kearney D, Cahill RA, O'Brien E, et al. Influence of delays on perforation risk in adults with acute appendicitis. Dis Colon Rectum 2008;51:1823–7. [18] Papandria D, Goldstein SD, Rhee D, et al. Risk of perforation increases with delay in recognition and surgery for acute appendicitis. J Surg Res 2013;184:723–9. [19] Omundsen M, Dennett E. Delay to appendicectomy and associated morbidity: a retrospective review. ANZ J Surg 2006;76:153–5. [20] Boomer LA, Cooper JN, Deans KJ, et al. Does delay in appendectomy affect surgical site infection in children with appendicitis? J Pediatr Surg 2014;49:1026–9. [21] Rice HE, Frush DP, Farmer D, et al. Review of radiation risks from computed tomography: essentials for the pediatric surgeon. J Pediatr Surg 2007;42: 603–7. [22] Brenner D, Elliston C, Hall E, et al. Estimated risks of radiation induced fatal cancer from pediatric CT. Am J Roentgenol 2001;176:289–96. [23] Nosek AE, Hartin CW, Bass KD, et al. Are facilities following best practices of pediatric abdominal CT scans? J Surg Res 2013;181:11–5.
Please cite this article as: Farach SM, et al, Pediatric patients transferred for operative management of appendicitis: are they at a disadvantage?, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.03.041
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Pediatric patients transferred for operative management of appendicitis: are they at a disadvantage? Sandra M. Farach ⁎, Paul D. Danielson 1, N. Elizabeth Walford 1, Richard P. Harmel Jr. 1, Nicole M. Chandler 1 Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Saint Petersburg, FL, USA
a r t i c l e
i n f o
Article history: Received 6 November 2014 Received in revised form 8 March 2015 Accepted 10 March 2015 Available online xxxx Key words: Pediatric Appendicitis Appendectomy Transfer
a b s t r a c t Purpose: Many pediatric patients are initially diagnosed with appendicitis at referring hospitals and are subsequently transferred to pediatric facilities. We aimed to compare outcomes of patients transferred to a pediatric referral center to those who present primarily for operative management of appendicitis. Methods: A retrospective review of 326 patients with operative appendicitis from July 2012 to July 2013 was performed. Demographic data, clinical parameters, and outcomes were analyzed. Results: Transferred (n = 222, 68%) and primary patients (n = 104, 32%) were similar except for mean age (primary 12.4 vs. transferred 11.2 years, p b 0.01). Computed tomography scans were performed in 80% of transferred compared to 40% of primary patients. Primary patients were more likely to present between the hours of 09:00 and 17:59 (52%), while transferred arrived equally across all hours. Both groups were more likely to present with acute appendicitis (primary 56% vs. transfer 61%, p = NS). There was no difference in time of diagnosis to time of appendectomy, length of hospital stay, or 30 day complications (primary 8.6% vs. transfer 5.8%, p = NS). Conclusions: Patients transferred for definitive care of appendicitis are not found to have more advanced disease or have increased complications; however, they are exposed to significantly more ionizing radiation during evaluation for appendicitis. © 2015 Elsevier Inc. All rights reserved.
Appendicitis has been described as a progressive inflammatory process induced by luminal obstruction that ultimately leads to infection, ischemic necrosis, and perforation [1–3]. Given this progression, appendicitis is usually considered a disease requiring timely surgical management. It is believed that a delay in diagnosis contributes to a higher perforation rate and in turn increased morbidity, hospital length of stay, and health care costs [4]. One report found a linear relationship between duration of symptoms of appendicitis and risk of perforation in children, rising from 10% at 18 hours to greater than 40% at 48 hours [5]. A second study found that an in-hospital delay greater than 12 hours was associated with a significantly higher perforation rate and longer hospital stay [6]. Many pediatric patients are initially evaluated at non-pediatric hospitals and subsequently transferred to pediatric tertiary referral hospitals. This may be for further work up if there is a concern for appendicitis or further management if there is a confirmed diagnosis of appendicitis. This process may lead to a delay in either diagnosis or treatment in this patient population. While recent studies have demonstrated that a short delay to appendectomy yield the same result as immediate ⁎ Corresponding author at: All Children's Hospital, Outpatient Care Center, 601 5th Street South, Dept 70-6600, 3rd Floor, St. Petersburg, FL 33701. Tel.: +1 727 767 2205; fax: +1 727 767 4346. E-mail addresses: [email protected] (S.M. Farach), [email protected] (P.D. Danielson), [email protected] (N.E. Walford), [email protected] (R.P. Harmel), [email protected] (N.M. Chandler). 1 All Children’s Hospital, Outpatient Care Center, 601 5th Street South, Dept 70-6600, 3rd Floor, St. Petersburg, FL 33701. Tel.: +1 727 767 4170; fax: +1 727 767 4346.
appendectomy, it is believed that this is dependent on timely, correct diagnosis with the initiation of appropriate antibiotic coverage [7,8]. The purpose of this study is to compare outcomes of patients transferred to a pediatric tertiary referral center to those who present primarily to the pediatric hospital for operative management of appendicitis. 1. Material and methods After Institutional Review Board approval (IRB # 13-0601), a retrospective analysis of 326 patients who underwent appendectomy at a free-standing, tertiary children's hospital from July 2012 to July 2013 was performed. Patients who presented primarily for initial evaluation and patients who were transferred from referring hospitals were included. As a tertiary children's hospital, our institution has a large geographic catchment area. While many patients are transferred for definitive care after a diagnosis of appendicitis, other patients are transferred for further workup to rule out possible appendicitis. Our institution has 24 hour ultrasound capability performed by technicians who are specialized in pediatric ultrasonography. One of four attending pediatric surgeons performed all appendectomies on a rotating basis determined by call schedule with the aid of a pediatric surgery fellow or mid-level provider. Our operating suite has an add-on room that is available for cases that are booked overnight or on an ongoing basis during the day. All patients received preoperative antibiotics prior to appendectomy. Antibiotics are started once the diagnosis of appendicitis is made, and they are continued at the appropriate dosing and timing based on patient age and type of antibiotic
http://dx.doi.org/10.1016/j.jpedsurg.2015.03.041 0022-3468/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Farach SM, et al, Pediatric patients transferred for operative management of appendicitis: are they at a disadvantage?, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.03.041
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S.M. Farach et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
administered. Appendectomy was performed by an open, multi-port laparoscopic, or single incision laparoscopic technique based on surgeon preference. Pre-operative, peri-operative, and post-operative care is standardized at our institution regardless of the operative technique utilized for appendectomy. During the study period, patients with intraoperative findings of acute appendicitis were admitted following appendectomy, without further antibiotic treatment and discharged once discharge criteria were met. Patients with intraoperative findings of suppurative, gangrenous, or perforated appendicitis were also admitted following appendectomy, however they were continued on intravenous antibiotic treatment until discharge criteria were met. Discharge criteria included temperature b 38.5 °C, tolerating an adequate liquid diet, and pain control with oral pain medication. Patients were grouped into “primary” (those who presented to our institution for initial evaluation) and “transferred” (those who were transferred from referring hospitals). Demographic data were obtained on age, weight, gender, category of appendicitis, surgical procedure utilized, and time of arrival to our emergency center (EC). Quality and outcome measures including time from EC diagnosis at our institution to operating room arrival, modality for diagnosis, post-operative length of stay, and 30-day complications were analyzed. Complications were defined as any event or occurrence that is a departure from the standard course of events following appendectomy. This included events occurring pre-operatively, intraoperatively, post-operatively, and/or within 30 days of surgery. The patient medical records were reviewed by one of two reviewers thoroughly to ensure the same definitions for complications were applied. Surgical site infection was defined as the presence of any localized swelling, erythema, calor, or wound drainage requiring treatment with antibiotics or open drainage by the surgeon. Intraabdominal abscess was defined as the presence of an intraabdominal collection following appendectomy diagnosed by ultrasound or computed tomography scan. Post-operative ileus was defined as a delay in return of bowel function prolonging a patient's hospital course or requiring re-admission. Descriptive data are reported as mean ± standard deviation and range where appropriate. Statistical analysis was performed using Student's t-test for continuous variables and Fisher's exact test for categorical variables. Significance was set at p b 0.05. 2. Results During the study period, a total of 326 patients underwent appendectomy. Two hundred twenty-two (67.7%) patients presented as transfers from referring hospitals, while 104 (31.9%) presented as primary patients for initial evaluation at our institution. Demographic, quality, and outcome measures are described in detail in Table 1. Primary patients were found to be significantly older compared to transferred patients (12.4 vs. 11.2 years, p b 0.05). Gender, weight, white blood cell count, and C-reactive protein were similar for both groups and found to be non-significant. The duration of abdominal pain was not significantly different between the two groups (1.39 vs. 1.42 days, p = NS). There were significantly more patients with private insurance and significantly less patients with Medicaid presenting to our institution primarily compared to those transferred. Of the 222 patients who were transferred, 131 (59%) received intravenous antibiotic treatment prior to their transfer. The most commonly administered antibiotics included cephalosporins (35.9%) and broad spectrum, beta-lactamase inhibiting penicillins (62.6%). The remaining 91 patients who were not treated with antibiotics did not have a definitive diagnosis of appendicitis prior to their transfer. For patients who presented for initial evaluation at out institution, 77.9% received Cefoxitin, 12.5% received Zosyn, 5.8% received Ciprofloxacin and Flagyl, and 3.8% received other antibiotics. The time of arrival to our institution's emergency center was evaluated for all patients. These were divided into three separate time frames: 01:00–08:59, 09:00–17:59, and 18:00–00:59 hours. It was noted that primary patients were more likely to arrive between the hours of 09:00 and 17:59 (51.9%), while those transferred arrived between all
Table 1 Demographics and outcomes of primary and transferred patient groups. Demographics and outcomes
Number of patients Age (years)a Males (%) Weight (kg)a Insurance status Private insurance Medicaid Self-pay Race Asian Black Caucasian Hispanic Other White blood cell counta C-reactive proteina Abdominal pain duration (days)a Modality for diagnosis Ultrasound (US) Computed tomography (CT) US + CT OR findings Acute (%) Complex (%) Time of diagnosis to OR (hours)a Hospital length of stay (hours)a Complications a
Primary
Transferred
p-Value
104 (31.9%) 12.5 ± 3.9 (2.7–20.6) 60 (57.7%) 48.8 ± 21.2 (13–109)
222 (67.7%) 11.2 ± 3.7 (1.5–20.5) 137 (61.7%) 45.2 ± 20.8 (11.7–124)
0.004 0.543 0.15
52 (50%) 47 (45.2%) 5 (4.8%)
81 (36.5%) 134 (60.4%) 7 (3.2%)
0.022 0.012 0.53
3 (2.9%) 12 (11.5%) 74 (71.2%) 13 (12.5%) 2 (1.9%) 14.9 ± 5.2 (2.4–30.7) 5.8 ± 7.1 (0.5–30.2) 1.39 ± 1.1 (0.5–7)
2 (0.9%) 10 (4.5%) 137 (61.7%) 62 (28%) 11 (4.9%) 14.9 ± 4.9 (3.8–28.3) 4.5 ± 5.7 (0.05–33.7) 1.42 ± 1.1 (0.5–7)
0.332 0.163 0.107 0.002 0.239 0.981 0.131 0.525
63 (60.6%) 22 (21.2%)
47 (21.2%) 143 (64.4%)
0.0001 0.0001
19 (18.2%)
32 (14.4%)
0.414 0.397
58 (55.8%) 46 (44.2%) 5.9 ± 5.2 (0.6–26)
136 (61.3%) 86 (38.7%) 5.5 ± 4.3 (0.4–31.1)
0.515
46.4 ± 63.7 (3.4–341)
38.8 ± 70.1 (2.6–760)
0.353
9 (8.6%)
13 (5.8%)
0.352
Values are reported at mean ± standard deviation and (range).
hours equally (Fig. 1). When comparing the two groups, primary patients were significantly more likely to arrive between the hours of 09:00 and 17:59 when compared to the transferred patients (51.9 vs. 30.7%, p b 0.05); while transferred patients were significantly more likely more likely to arrive between the hours of 01:00 and 08:59 when compared to the primary patients (32.4 vs. 13.5%, p b 0.05). When evaluating the modality for diagnosis of appendicitis, transferred patients were more likely to have undergone computed tomography (CT) scans compared to patients who presented primarily (78.8 vs. 39.4%, p b 0.05) (Fig. 2). Patients who presented primarily were significantly more likely to undergo ultrasound alone for diagnosis of appendicitis compared to transferred patients (60.6 vs. 21.2%, p b 0.05).
Fig. 1. Number of patients presenting to the emergency department in each group over three time periods. Percentages are listed within the bars.
Please cite this article as: Farach SM, et al, Pediatric patients transferred for operative management of appendicitis: are they at a disadvantage?, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.03.041
S.M. Farach et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
Fig. 2. A comparison of the total number of computed tomography scans performed in the primary group versus the transferred group.
Operative findings at the time of appendectomy were grouped into acute appendicitis and complex appendicitis. Complex appendicitis included suppurative, gangrenous, and perforated appendicitis. When comparing operative findings between the primary and transferred groups, it was noted that patients in both groups more likely to present with acute appendicitis overall. Transferred patients were not found to have a significantly higher incidence of complex appendicitis when compared to the primary group (44.2 vs. 38.7%, p = NS) (Table 1). When comparing the time of EC diagnosis to time of arrival to the operating room between the two groups, there was no significant difference appreciated (primary 5.9 hours vs. transferred 5.5 hours, p = NS). Total hospital length of stay was also similar between the two groups and found to be non-significant (primary 46.4 hours vs. transferred 38.8 hours, p = NS). Complications and re-admissions for primary and transferred groups are listed in Table 2. There was no significant difference in the 30-day complication or re-admission rates between primary or transferred patients.
3. Discussion While it is generally accepted that appendicitis is a progressive disease requiring timely surgical management to avoid increased morbidity associated with perforated appendicitis, this historical concept has been challenged. Many reports have demonstrated no difference in outcomes with a short delay in operative intervention [5,9–12], suggesting that after initiation of antibiotic therapy, appendicitis can be managed in a more urgent or semi-elective manner [7,12–14]. This has led to a significant shift in surgical practice for appendicitis. A recent survey of 484 pediatric surgeons revealed that only 3.8% believed non-perforated appendicitis to be a surgical emergency, with the majority (92%) preferring to postpone overnight appendectomy [14].
Table 2 Comparison of complications and re-admission between the primary and transferred groups. Complications
Surgical site infection Intra-abdominal abscess Ileus/bowel obstruction Other Total Re-admissions
Primary
Transferred
p-Value
3 3 2 1 9 (8.6%) 3 (2.9%)
5 3 3 2 13 (5.8%) 5 (2.3%)
0.713 0.388 0.656 1.000 0.352 0.713
3
There remains large variability in the literature with regards to the outcomes resulting from delay to appendectomy. A number of reports have shown that a short delay to appendectomy, ranging from 6 to 24 hours, does not result in increased perforation rates or worse outcomes [2,5,7,9–12,15–17]. Other reports, however, have attributed delays in operative intervention for appendicitis to increased rates of perforation [3,6,18]. In a retrospective review of 1081 patients who underwent appendectomy, Ditillo et al. noted that the prevalence of advanced appendiceal pathology correlated positively with prolonged total interval to surgical intervention. They did, however, note that pre-hospital delays were more profoundly related to worsening pathology when compared to in-hospital delays [3]. Pittman-Waller et al. examined 5755 consecutive appendectomies and found an overall rate of complicated appendicitis of 32% and concluded that patient delay in presentation was the only significant factor determining the incidence of complicated appendicitis [15]. Over a 1 year period, 67.7% of patients presenting to our pediatric tertiary referral center with appendicitis were transferred from a referring facility. We sought to determine if this patient population had increased rates of appendiceal perforation or worse outcomes when compared to those who presented to our institution primarily given the potential for delay in treatment. We found that the majority of patients in both groups presented with acute appendicitis, 55.8 and 61.3% respectively, and there was no significant increase in the rates of complicated appendicitis in transferred patients. A study of 223 patients aged 15 to 50 evaluating the effect of transfer on outcomes in patient with appendicitis found that transferred patients were less likely to be ruptured at the time of operation [10]. In our analysis, we found that the duration of abdominal pain was not significantly different between the two groups (1.39 vs. 1.42 days, p = NS). It was also noted that the time of EC diagnosis to time of appendectomy was similar between the two groups, with mean time of less than 6 hours for both primary and transferred patients. Prior studies have shown no increase in perforation rates with in-hospital delay to appendectomy of less than 6 hours [2,6,7,12,16,19]. Transferred patients in our study were not found to have an increased incidence of perforation and this may be attributed to the fact that the mean time to appendectomy from EC diagnosis was less than 6 hours. We found no increase in the incidence of complications or readmission rates between the two groups. Studies on the topic of surgical site infection (SSI) rates with delayed appendectomy remain variable. Teixeira et al. demonstrated an increase in SSI when surgery was delayed longer than 6 hours from the time of admission to appendectomy [13]. Boomer et al. found no significant increase in the risk of SSI related to delay in appendectomy when evaluating emergency department triage to appendectomy and admission to appendectomy time in their analysis of 1388 pediatric patients [20]. They did, however, note an increase in SSI as the length of time between the start of symptoms and appendectomy increased [20]. A recent systematic review and metaanalysis demonstrated delays beyond 48 hours to be associated with an increase rate of wound infection [12]. We found no significant difference between primary and transferred patients with regards to SSI. Again, this may be attributed to the fact that the mean time to appendectomy from emergency department arrival was less than 6 hours for both groups. Another important finding in our results was the significantly higher number of computed tomography scans noted in transferred patients when compared to primary patients. Recent literature has expressed concerns regarding the increasing number of CT scans performed and subsequent increase in radiation exposure to patients in this population. The radiation exposure from an abdominopelvic CT scan is equivalent to approximately 100 to 250 chest radiographs [21]. One report estimated the development of approximately one fatal cancer for every 1000 CT scans performed in children [22]. A study evaluating whether established guidelines for CT scanning are being utilized at non-pediatric facilities prior to transfer of children with suspected appendicitis to tertiary
Please cite this article as: Farach SM, et al, Pediatric patients transferred for operative management of appendicitis: are they at a disadvantage?, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.03.041
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pediatric centers found that only 17% were performed according to published best-practice guidelines [23]. We therefore encourage other institutions to investigate their own CT imaging practices and to take a proactive approach in minimizing radiation exposure in the children. There may be a benefit to transferring patients with suspected appendicitis to institutions that specialize in pediatric ultrasound. The major limitations of this study include its retrospective design, single institutional data, and relatively small number of patients. This limits the ability to access more specific demographic, qualitative, and quantitative data. While we are able to assess the length of time of patient symptoms prior to presentation, this is very difficult to measure and subject to bias with regards to patient recall. We are unable to determine if there was a specific reason for a patient's delay in presentation, which again will have an impact on the disease severity. We are unable to determine the time of arrival to the referring facility, the amount of time at the referring facility, or the time to transfer as these data were not available for analysis. This again is another area of potential delay to definitive care for the patient and, thus, may affect severity and outcome. The amount of time at the referring facility and time to transfer would be a useful area for future investigation that may be best studied prospectively. While most patients younger than 18 are referred to our pediatric hospital for surgical care, there may be a subset of patients that undergo appendectomy at non-pediatric hospitals.
4. Conclusion Patients who are evaluated and diagnosed with appendicitis at a referring facility and transferred to a pediatric hospital for definitive care are not found to have more advanced disease or have increased complications compared to patient who initially present to a pediatric hospital. This may be attributed to the administration of antibiotics once the diagnosis of appendicitis is made as well as a semi-elective approach with a mean time of less than 6 hours to appendectomy for both groups. Given the majority of studies reporting no increased risk of complications with a short delay in appendectomy, this allows for pediatric patients to be transferred to specialized pediatric centers for definitive treatment without concerns for more advanced disease or worse outcomes. Patients transferred from referring hospitals were found to be exposed to significantly more ionizing radiation during evaluation for abdominal pain having undergone a greater number of CT scans for diagnosis. With increasing concern of radiation exposure in pediatric patients, this may be an area of focus for quality improvement across referring networks.
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Please cite this article as: Farach SM, et al, Pediatric patients transferred for operative management of appendicitis: are they at a disadvantage?, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.03.041
