The varied complications associated with complicated appendicitis in pediatric patients may influence disease severity and adverse events, and be associated with greater health care resource use, according to a study published in JAMA Surgery.

A research team from various hospitals in the United States conducted a multicenter cohort study of 1333 patients aged 3 to 18 years who underwent appendectomy between January 1, 2013, and December 31, 2014. Intraoperative findings included a visible hole, diffuse fibrinopurulent exudate (exudate found in more than 2 quadrants of the abdomen and pelvis), intra-abdominal abscess, or an extraluminal fecalith.

Outcomes included 30-day postoperative adverse events including morbidity, overall rate of surgical site infections (SSIs), hospital revisits, length of stay, and cumulative cost from all hospital revisit encounters. All clinical data were obtained from the American College of Surgeons National Surgical Quality Improvement Program pediatric (NSQIP-P) appendectomy pilot database.

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Of the patients included in the study, 783 (58.7%) were male, 538 (40.4%) were white, 496 (37.2%) were publicly insured, and median age was 10 years. Multiple intraoperative findings of complicated appendicitis were reported in 589 cases (44.2%); the most frequently reported included a visible hole with diffuse fibrinopurulent exudate (231 [39.2%]), a visible hole with exudate and abscess (86 [14.6%]), and a visible hole with abscess (80 [13.6%]).

A total of 290 adverse events occurred in 181 (13.6%) patents, with the most common being organ space SSIs (133 patients [73.5%]), incisional SSIs (17 [9.4%]), other occurrences (14 [7.7%]), pneumonia (8 [4.4%]), and sepsis (8 [4.4%]). Multiple findings were linked with higher rates of overall adverse events and SSI rates (OR, 1.66 and OR 1.40, respectively), overall hospital revisits (OR, 1.60), inpatient readmissions (OR, 2.04), emergency department revisits without readmission (OR, 1.52), cumulate length of stay (RR, 1.45), and cumulative cost (RR, 1.35) compared with single intraoperative findings.

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“The results of this study add to the growing body of evidence that not all cases of complicated appendicitis are created equally with respect to clinical course and resource use,” the researchers concluded.


Anandalwar SP, Cameron DB, Graham DA, et al. Association of intraoperative findings with outcomes and resource use in children with complicated appendicitis [published online July 25, 2018]. JAMA Surg. doi: 10.1001/jamasurg.2018.2085