Justin B. Mahida

Feasibility of a Nonoperative Management Strategy for Uncomplicated Acute Appendicitis in Children

BACKGROUND For decades, urgent operation has been considered the only appropriate management of acute appendicitis in children. The purpose of this study was to investigate the feasibility of nonoperative management of uncomplicated acute appendicitis in children. STUDY DESIGN A prospective nonrandomized clinical trial of children with uncomplicated acute appendicitis comparing nonoperative management with urgent appendectomy was performed. The primary result was 30-day success rate of nonoperative management. Secondary outcomes included comparisons of disability days, missed school days, hospital length of stay, and measures of quality of life and health care satisfaction. RESULTS Seventy-seven patients were enrolled during October 2012 to October 2013; 30 chose nonoperative management and 47 chose surgery. There were no significant differences in demographic or clinical characteristics. The immediate and 30-day success rates of nonoperative management were 93% (28 of 30) and 90% (27 of 30). There was no evidence of progression of appendicitis to rupture at the time of surgery in the 3 patients for whom nonoperative management failed. Compared with the surgery group, the nonoperative group had fewer disability days (3 vs 17 days; p < 0.0001), returned to school more quickly (3 vs 5 days; p = 0.008), and exhibited higher quality of life scores in both the child (93 vs 88; p = 0.01) and the parent (96 vs 90; p = 0.03), but incurred a longer length of stay (38 vs 20 hours; p < 0.0001). CONCLUSIONS Nonoperative management of uncomplicated acute appendicitis in children is feasible, with a high 30-day success rate and short-term benefits that include quicker recovery and improved quality of life scores. Additional follow-up will allow for determination of longer-term success rate, safety, and cost effectiveness.

Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis

IMPORTANCE Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe, but overall effectiveness is determined by combining medical outcomes with the patients and familys perspective, goals, and expectations. OBJECTIVE To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children. DESIGN, SETTING, AND PARTICIPANTS Prospective patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1, 2012, through March 6, 2013. Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy. INTERVENTIONS Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and, on demonstrating improvement of symptoms, completion of 10 days of treatment with oral antibiotics. MAIN OUTCOMES AND MEASURES The primary outcome was the 1-year success rate of nonoperative management. Successful nonoperative management was defined as not undergoing an appendectomy. Secondary outcomes included comparisons of the rates of complicated appendicitis, disability days, and health care costs between nonoperative management and surgery. RESULTS A total of 102 patients were enrolled; 65 patients/families chose appendectomy (median age, 12 years; interquartile range [IQR], 9-13 years; 45 male [69.2%]) and 37 patients/families chose nonoperative management (median age, 11 years; IQR, 10-14 years; 24 male [64.9%]). Baseline characteristics were similar between the groups. The success rate of nonoperative management was 89.2% (95% CI, 74.6%-97.0%) at 30 days (33 of 37 children) and 75.7% (95% CI, 58.9%-88.2%) at 1 year (28 of 37 children). The incidence of complicated appendicitis was 2.7% in the nonoperative group (1 of 37 children) and 12.3% in the surgery group (8 of 65 children) (P = .15). After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days (median [IQR], 8 [5-18] vs 21 [15-25] days, respectively; P < .001) and lower appendicitis-related health care costs (median [IQR],

High failure rate of nonoperative management of acute appendicitis with an appendicolith in children

4219 [

Tracheostomy Placement in Children Younger Than 2 Years: 30-Day Outcomes Using the National Surgical Quality Improvement Program Pediatric.

2514-

Laparoscopic pyloromyotomy decreases postoperative length of stay in children with hypertrophic pyloric stenosis

7795] vs

Prediction of symptom improvement in children with biliary dyskinesia

5029 [

Laparoscopic bowel resection for pediatric inflammatory bowel disease.

4596-

Comparison of 30-day outcomes between thoracoscopic and open lobectomy for congenital pulmonary lesions.

5482], respectively; P = .01). CONCLUSIONS AND RELEVANCE When chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, incurring less morbidity and lower costs than surgery. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01718275.

Using the Maxillary-Nasal Angle to Evaluate Congenital Nasal Pyriform Aperture Stenosis

BACKGROUND The purpose of this study was to investigate the feasibility of nonoperative management of acute appendicitis in children with an appendicolith identified on preoperative imaging. STUDY DESIGN We performed a prospective nonrandomized trial of nonoperative management of uncomplicated acute appendicitis with an appendicolith in children aged 7 to 17years. The primary outcome was the failure rate of nonoperative management, defined as having undergone an appendectomy. Early termination was set to occur if the lower limit of the 95% confidence interval of the failure rate was greater than 20% at 30days or 30% at 1year. RESULTS Recruitment for this study was halted after enrollment of 14 patients (N=5 nonoperative; N=9 surgery). The failure rate of nonoperative management was 60% (3/5) at a median follow-up of 4.7months (IQR 1.0-7.6) with a 95% CI of 23%-88%. None of the three patients that failed nonoperative management had complicated appendicitis at the time of appendectomy, while six out of nine patients who chose surgery had complicated appendicitis (0/3 vs. 6/9, p=0.18). The trial was stopped for concerns over patient safety. CONCLUSIONS Nonoperative management of acute appendicitis with an appendicolith in children resulted in an unacceptably high failure rate.

Comparing laparoscopic versus open Ladd's procedure in pediatric patients

IMPORTANCE Analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric demonstrated that the highest contribution to composite morbidity in otolaryngology is seen in children younger than 2 years undergoing tracheostomy. OBJECTIVE To determine predictive factors for complications following tracheostomy placement in patients younger than 2 years that, if targeted for reduction in quality initiatives, might result in improved surgical outcomes. DESIGN, SETTING, AND PARTICIPANTS The NSQIP Pediatric reports predefined 30-day postoperative outcomes for surgical cases from participating institutions for quality improvement. All 206 cases of elective tracheostomy performed in children younger than 2 years from 2012 to 2013 among 61 participating institutions and documented in the NSQIP Pediatric public use file were included. Data analysis was conducted from December 1, 2014, to June 30, 2015. INTERVENTIONS Surgical placement of tracheostomy in children younger than 2 years. MAIN OUTCOMES AND MEASURES Demographics and clinical and perioperative characteristics for children who did and did not experience a major complication from elective tracheostomy were compared. Continuous variables were compared using Wilcoxon rank sum tests and categorical variables were compared using Pearson χ2 tests or Fisher exact tests where appropriate. A logistic regression model was fit to identify adjusted odds ratios (aORs) with 95% CIs of preoperative factors predictive of occurrence of a major complication. RESULTS Of the 206 children younger than 2 years who underwent tracheostomy, 50 (24.3%) experienced a major complication within 30 days. The most common complications were pneumonia (16 [7.8%]), postoperative sepsis (12 [5.8%]), death (12 [5.8%]), and deep or organ space surgical site infections (8 [3.9%]). Neonatal age (aOR, 2.38; 95% CI, 1.06-5.37; P = .04), intraventricular hemorrhage (aOR, 2.72; 95% CI, 1.01-7.32; P = .048), and comorbid cardiac risk factors (relative to none: minor risk factors, aOR, 2.94; 95% CI, 1.19-7.24; major or severe risk factors, aOR, 1.31; 95% CI, 0.44-3.84; P = .04 for all cardiac risk factors) were independently predictive of major complications. CONCLUSIONS AND RELEVANCE Young children undergoing tracheostomy tube placement have high rates of morbidity. This analysis identifies the need for additional procedure-specific outcome variables and improved variable definitions to incorporate into a detailed module for NSQIP Pediatric that will more effectively promote national, specialty-specific targeted quality improvement efforts.