C. Feng1, S. Anandalwar1, F. Sidhwa1, C. Glass1, M. Karki1, D. Zurakowski1, S. Rangel1 1Children’s Hospital Boston,Surgery,Boston, MA, USA
Introduction: The degree of peritoneal contamination can be widely variable in children with perforated appendicitis and its effects on disease severity has not been characterized. The purpose of the study was to explore this relationship in the post-operative setting using measures of resource utilization as surrogate markers for disease severity.
Methods: Intraoperative findings were collected prospectively from attending surgeons using a standardized survey at a single children’s hospital from 2011 to 2014. Peritoneal contamination (defined as the presence of purulent fluid or fibrinous exudate) was categorized as ‘localized’ (confined to the right lower quadrant and pelvis) or ‘extensive’ (extending to the liver as a marker for uncontained perforation) in patients with perforated disease. Imaging utilization, postoperative length of stay (PLOS), hospital cost, and readmission rates were compared using chi-square statistics for proportions and the Mann-Whitney U-test for continuous data.
Results: Eighty-eight patients were identified with perforated disease, of which 38% (34/88) were found to have extensive peritoneal contamination. Groups were similar on the basis of age, weight, gender, race, insurance status, preoperative WBC count and maximum temperature. Patients with extensive peritoneal contamination had significantly higher rates of postoperative abdominal imaging (58.8% vs 27.7%, p<0.01) and a 30% higher median hospital cost ($17,663[IQR $12,564-$23,697] vs $13,516[IQR $10,546-$16,686], p<0.01, figure) compared to patients with localized contamination. Median PLOS was 50% longer for patients with extensive contamination (6 days [IQR 4-9] vs 4 days [IQR 2-5], p<0.01, figure), and the readmission rate was nearly four-fold higher compared to children with localized contamination (20.6% vs 5.6%, p=0.04).
Conclusion: In children with complicated appendicitis, extensive peritoneal contamination is associated with greater postoperative imaging, length of stay, cost, and readmission rates. These findings may have important severity-adjustment implications for reimbursement and comparative performance reporting for hospitals that serve populations where late presentation and more severe disease are common.
