W. Svetanoff1, N. Talukdar1, C. Dekonenko1, R. M. Dorman1, O. Osuchukwu1, J. Fraser1, T. Oyetunji1, S. St. Peter1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA
Introduction: Previous research has shown that patients who develop an intra-abdominal abscess (IAA) after appendectomy have a greater number of healthcare visits if a drain is placed. Our institution developed an algorithm to limit drain placement to patients who develop an IAA >20cm2 (large) compared to <20cm2 (small). We sought to determine the adherence to and the effectiveness of the algorithm by comparing the outcomes of patients who develop small versus large abscesses.
Methods: This was a prospective observational study of patients 2-18 years old who develop an IAA following perforated appendicitis from September 2017 to June 2019. Demographics, information on the initial hospital stay, and abscess characteristics were recorded. Outcomes including drain placement, length of stay (LOS), readmission rates, and length of antibiotic course were compared between patients with a small or large abscess. Continuous data are reported in medians with intra-quartile ranges and categorical data in proportions. Analysis was performed in STATA®; p <0.05 was significant.
Results: Thirty patients were included. The median age was 10.6 years (7, 11.7), with 60% of the population male and 60% white. The median duration of symptoms prior to diagnosis of appendicitis was 3 days (2, 6). The median time to full oral intake post-operatively was 3 days (2, 4), with an initial LOS of 4.6 days (3.2, 8.2). Thirteen patients (43%) were diagnosed with an intra-abdominal abscess while still inpatient, and 17 (57%) were readmitted for an abscess diagnosed at a later date. The median abscess size was 28.4cm2 (12, 55). For patients diagnosed with abscess after discharge, the median time to readmission was 6.4 days (4, 9.4). Computed tomography (CT) alone was used for diagnosis in 16 patients (53%), ultrasound (US) in 3 (10%) and both US and CT in 10 (33%). Of the entire study cohort, twenty patients (67%) had a drain placed for abscess management.
After algorithm implementation, 95% (n=19) of patients with a large abscess had aspiration (16 also had a drain placed) at time of diagnosis compared to 30% (n=3) of patients with a small abscess (p<0.001). LOS following abscess diagnosis (4.5 vs 5, p=0.76), total days of antibiotics (21 vs 19, p=0.54), readmission rate after the initial hospitalization (60% vs 55%, p=0.79), and number of healthcare visits (2.6 vs 2.4, p=0.58) were the same between groups, respectively. One patient with a small abscess (not drained) required a re-operation for a small bowel obstruction from adhesions; one patient with a large abscess treated with drainage was readmitted a second time for abscess recurrence and was treated with antibiotics alone.
Conclusion: Patients who develop a small abscess after perforated appendicitis do not routinely need intervention. They have a similar LOS, antibiotic course, and number of healthcare visits as those with a large abscess, validating our algorithm to avoid drain placement in these patients.