14.05 Abscess on Admission is a Predictor of Outcomes for Childrens with Complicated Appendicitis

A. Munoz Abraham1,2, H. Osei1,2, P. Sutthatarn1,2, S. Kazmi1,2, M. Winkelmann1,2, M. Gibbons1,2, K. Chatoorgoon1,2, J. Greenspon1,2, C. M. Fitzpatrick1,2, G. A. Villalona1,2  1Saint Louis University,Pediatric Surgery,St. Louis, MO, USA 2Cardinal Glennon Children’s Hospital,Pediatric Surgery,St. Louis, MO, USA

Introduction:

A complicated appendicitis clinical practice guideline was established in July 2016. Early appendectomy (EA) was offered to patients presenting with no abscess or abscess ≤ 3 cm, whereas, interval appendectomy (IA) was offered to patients with presenting with an abscess > 3 cm. We hypothesized that patients presenting with abscess ≤ 3 cm would least likely benefit from interval appendectomy. We tracked the overall and subgroup effectiveness of the new appendicitis management protocol for outcomes and complications.

Methods:

An appendicitis protocol establishing criteria for management of complicated appendicitis patients was instituted in July 2016 (Figure 1). Pre-protocol (G1, 2014-2016) records were compared to post-protocol (G2, 2016-2018) records. Differences in early (EA) versus interval appendectomy (IA), demographics, baseline clinical characteristics, short-term outcomes, antibiotic and imaging utilization were assessed with chi-squared test and analysis of variance.  Subgroup analysis was performed to compare patients with abscess ≤3 cm treated with IA pre-protocol versus same patients treated by EA post-protocol.

Results:

A total of 246 patients were reviewed (G1=152, G2=94). Half of patients pre-protocol were treated with early appendectomy (51%). Whereas, 82% of post-protocol patients were treated with EA. There were no differences in demographics. Post-protocol patients had less total CT scans performed (40% vs 28%, p 0.03), lower number of admissions (2 days  vs 1 day, p=0.000, median) and decreased total (LOS) length of stay (7.7 days vs 6.5 days, p=0.049).

On subgroup analysis, we matched pre-protocol IA patients to post-protocol EA patients presenting with no abscess or abscess ≤3 cm. For this cohort, post-protocol EA patients had lower total number of admissions (EA 1 vs IA 2, p=0.000, median), decreased total LOS (EA 5 days vs IA 7 days, p= 0.000), less total CT scans performed (EA 23% vs IA 58%, p=0.000) and less complications (EA 22% vs IA 42%, p 0.022).

Conclusion:

Establishment of a new management protocol for complicated appendicitis improves resource utilization and decreased complications. Patients presenting with no abscess or ≤3 cm abscess have higher complications and longer hospital stay if treated with interval appendectomy.