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. 2017 Jan;52(1):89-92.
doi: 10.1016/j.jpedsurg.2016.10.026. Epub 2016 Oct 27.

A call for a standardized definition of perforated appendicitis

Andrew P Rogers  1 , Tiffany J Zens  2 , Charles M Leys  2 , Peter F Nichol  2 , Daniel J Ostlie  2
Affiliations

A call for a standardized definition of perforated appendicitis

Andrew P Rogers et al. J Pediatr Surg. 2017 Jan.

Abstract

Background: Abscess rates have been reported to be as low as 1% and as high as 50% following perforated appendicitis (PA). This range may be because of lack of universal definition for PA. An evidence-based definition (EBD) is crucial for accurate wound classification, risk-stratification, and subsequent process optimization. ACS NSQIP-Pediatric guidelines do not specify a definition of PA. We hypothesize that reported postoperative abscess rates underrepresent true incidence, as they may include low-risk cases in final calculations.

Methods: Local institutional records of PA patients were reviewed to calculate the postoperative abscess rate. The ACS NSQIP-Pediatric participant use file (PUF) was used to determine cross-institutional postoperative abscess rates. A PubMed literature review was performed to identify trials reporting PA abscess rates, and definitions and rates were recorded.

Results: 20.9% of our patients with PA developed a postoperative abscess. The ACS NSQIP-Pediatric abscess rate was significantly lower (7.61%, p<0.001). In the eighteen published studies analyzed, average abscess rate (14.49%) was significantly higher than ACS NSQIP-Pediatric (p<0.001). There was significantly more variation in trials that do not employ an EBD of perforation (Levene's test F-value =6.980, p=0.018).

Conclusions: A standard EBD of perforation leads to lower variability in reported postoperative abscess rates following PA. Nonstandard definitions may be significantly altering the aggregate rate of postoperative abscess formation. We advocate for adoption of a standard definition by all institutions participating in ACS NSQIP-Pediatric data submission.

Level of evidence: III.

Keywords: Abscess; Evidence-based; NSQIP; Perforated appendicitis; Wound classification.

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Conflict of interest statement

Conflicts of Interest: Dr. Nichol is a member of the scientific advisory board for MedAware Systems Inc. Dr. Ostlie is a consultant for JustRight Inc. Neither of these conflicts relates to the subject material of this manuscript.

Figures

Figure 1
Figure 1. Post-operative abscess rates by definition of perforated appendicitis
Each mark represents an individual published study reporting post-operative abscess rates following perforated appendicitis. The non-evidence based trials have a significantly higher amount of variation than the evidence-based trials.
See this image and copyright information in PMC

References

    1. Ashcraft KW, Holcomb GW, Murphy JP, Ostlie DJ, editors. Ashcraft’s pediatric surgery. 6. London; New York: Saunders/Elsevier; 2014.
    1. PEDIATRIC ACS NSQIP OPERATIONS MANUAL. n.d
    1. ACS NSQIP Pediatric. American College of Surgeons National Surgical Quality Improvement Project - Pediatric Participant Use File 2013–2015. n.d
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    1. Zens TJ, Rusy DA, Gosain A. Pediatric surgeon-directed wound classification improves accuracy. J Surg Res. 2016;201:432–9. doi: 10.1016/j.jss.2015.11.051. - DOI - PMC - PubMed