| Objectives:Appendicitis remains the most common indication for abdominal surgery in pediatric population. Rate of perforated appendicitis vary widely (15-35%). The diagnosis of appendicitis continues to be problematic in young children because of overlapping signs and symptoms with other common childhood illnesses. Furthermore, clinical manifestations differ considerably in different age groups of children, requiring different diagnostic approaches. Clinical management of children with perforated appendicitis remains controversial. Management options include antibiotics, appendectomy and drainage. The aim of this thesis is to investigate1) The clinical characteristics of appendicitis in different age groups within the last20years;2) The different preoperative diagnostic methods;3) Operative procedures and complications in different age groups.4) Changes in spectrum of bacteria and antibiotics in different age groups in the last20years.5) Expenses (medical, surgical and total cost) in20years of time period.MethodsWe conducted a retrospective descriptive analysis in the patients diagnosed of perforated appendicitis in Children’s Hospital of Fudan University from January1991to December2010. All children with perforated appendicitis under16years were enrolled in this study including all were inpatient. Diagnosis of perforated appendicitis was confirmed by histopathology. Data was collected from electronic database and patient charts. All patients were divided into groups based on the year they were diagnosed (group A:1991—1995; group B:1996—2000:Group C:2001—2005; Group D:2006—2010) and their age at disease onset (infant group, I:day1to3yrs; pre-school group, P:4years to7years; primary school group, S:8years to12years and adolescent group, A:12to16years). Clinical manifestations (signs and symptoms), diagnostic methods (laboratory and imaging study), operative procedure, complications, intra-abdominal bacterial cultures and medical costs were reviewed. The rates of perforated appendicitis were analyzed in different age group during different time periods. The time from onset of symptoms to hospital arrival and the time from hospital arrival to surgery were studied. Information about WBC count, neutrophil and CRP were also collected for different age groups. Mean duration between hospital arrivals to surgery was calculated respectively for patients with or without USG and CT scan. Rate of drainage in different age groups and its postoperative effects were analyzed. Information about spectrum of bacteria and antibiotic treatment were also collected. Information about postoperative complications was collected for different age groups and different time periods. The duration from onset of symptoms to hospital arrival, hospital arrival to surgery, drainage use, total length of hospital stay, total antibiotic use and total costs were analyzed, along with complications. Finally, total length of hospital stay and costs incurred were studied for different age groups in different time periods.All data were collected and expressed in percentage. The data was analyzed with a statistical software package (SPSS17for window). The results were expressed as percentage and mean with standard deviation. Chi-square tests were performed for frequency distribution. Mean values were compared by t-tests and/or ANOVO tests (when more than two mean values were compared). Different subgroups were compared and P values were adjusted by Bonferroni method. P value <0.05was considered statistically significant.Results:1. The rate of appendicitis perforation in Children’s Hospital of Fudan University between January1st1996and December31st-2010was24.71%(1448) out of a total5859cases. Percentage of perforation was highest in Group A (1991-1995,31.55%;1996-2000,22.92%:2001-2005,22.28%;2006-2010,24.36%; A vs. B p=0.000; A vs. C p=0.000). Rate of perforation was highest in infants (group I,29.18%) and slowly decreased with age (P group.23.47%:S group.22.56%I vs. S p=0.000:A group,13.51%; I vs. A p=0.000).2. Abdominal pain was the most common clinical symptom in all groups. Vomiting, fever and diarrhea were more common in infant age group compared to other age groups, whereas tenderness and guarding were less common. The duration between onsets of symptoms to hospital arrival was different in different age groups. Infants (group I) had longest mean time (55.82±36.88h, p=0.000<0.05) among all age groups, and adolescents (group A) had the shortest mean duration (38.88±24.02h, p=0.000<0.05). Mean time from hospital arrival to surgery was significantly higher in infant age group (8.43±9.05h, p=0.001) compared with other age groups. P group has the shortest mean time duration (6.76±6.35h, p=0.001).3. Mean WBC count of S group was the highest among all age groups, while I age group had the lowest count. But statistically they were not significant (p=0.097>0.05). I age group had a significantly low mean neutrophil count. Mean value of CRP was higher in I age group and decreased with age, but without statistical significance. There were delays of more than two hours for surgery in patients undergoing USG (with USG=8.16; no USG=6.26, p=0.000) or CT scan (with CT=9.60; no CT=6.87, p=0.000). There average costs were higher when either USG and/or CT scan were performed.4. There were a total of272(18.78%) cases in which peritoneal drains were placed. The drainage rate was highest in Group A. Use of drainage significantly increased the rate of complication (p=0.000). Drainage was used in children with longer duration between first symptoms to hospital arrival (56.49h vs.43.05h; p=0.000<0.05), drainage was also placed in children with longer duration between hospital arrival to surgery (7.73h vs.6.67h; p=0.004<0.05). Placement of drains was found to be associated with increased duration of antibiotics (9.16days vs.7.75days, p=0.000<0.05), increased length of hospital stay (13.8days vs.9.69days, p=0.000<0.05), and increased total costs (6010.75RMB vs.5774.82RMB, p=0.404>0.05.5. E. coli was the most common bacteria (70%) in abdominal bacterial culture, and the second was Pseudomonas (17.30%). Mean duration of antibiotic usage in all age groups was about8days. Between1991and1995(time period A), Triple therapy was used both pre-and post-operatively (Cephalosporin Ⅱ gen., Ampicilin Sulphate, Metronidazole), whereas in time periods B, C and D, dual-drug therapy(Metronidazole and3rd gen. cephalosporin) was used as empirical therapy. Second line of drugs was mainly decided based on culture and sensitivity reports.6. There were a total of217(14.98%) cases that had complications. The complications, in decreasing order of incidence, were pelvic abscess, intra-abdominal infection, pelvic mass, intra-abscess, post-operation diarrhea, adhesion, and bowel obstruction. Complications were most common in A period and in I age group. Increased duration between first symptoms and hospital arrival was associated with more complications (53.77±35.63h vs.45.18±29.65h; p=0.007<0.05), while duration between hospital arrival to surgery, and duration of drainage placement had no effect on complications (7.48±7.60h vs.6.77±6.11h; p=0.134>0.05). Complications increased the total length of hospital stay (13.82±5.42days vs.9.72±3.52days; p=0.000<0.05), the length of antibiotic use (10.83±4.91days vs.7.23±2.95days; p=0.000<0.05) and total costs (7785.85±4199.55RMB vs.5563.66±2839.32RMB:p=0.000<0.05).7. Average length of hospital stay was about10days, and decreased with time period (longest duration in A-period,12.98days and shortest in D-period,8.9days, p=0.000<0.05). Medical expenses, operation cost and total cost increased with time period. Adolescent age group had a higher total cost compared to other age groups.Conclusions:Our observation demonstrates that the rates of perforated appendicitis have decreased over time, but still remains the highest in infants. Clinical manifestation of perforated appendicitis in children was different in different age groups. Vomiting, fever, tenderness and guarding were less common in infants. Infants had the longest mean time in first symptom to hospital and hospital to operation room. Performing USG and CT scan in children delayed the operation and significantly increased the average costs. Usage of peritoneal drainage increased the rate of complications, and the duration of hospital stay and antibiotics. E.coli was the most common organism isolated from cultures and Pseudomonas was the second most common. Dual therapy has been gaining in popularity in recent years. Complications have decreased over time. Expenses on medical, surgical and total cost have increased over time. These findings may provide supplementary information for the management of perforated appendicitis in children. |
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