Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York.
JAMA Surg. 2022 Aug 1;157(8):685-692. doi: 10.1001/jamasurg.2022.1928.
The clinical significance of gangrenous, suppurative, or exudative (GSE) findings is poorly characterized in children with nonperforated appendicitis.
To evaluate whether GSE findings in children with nonperforated appendicitis are associated with increased risk of surgical site infections and resource utilization.
DESIGN, SETTING, AND PARTICIPANTS: This multicenter cohort study used data from the Appendectomy Targeted Database of the American College of Surgeons Pediatric National Surgical Quality Improvement Program, which were augmented with operative report data obtained by supplemental medical record review. Data were obtained from 15 hospitals participating in the Eastern Pediatric Surgery Network (EPSN) research consortium. The study cohort comprised children (aged ≤18 years) with nonperforated appendicitis who underwent appendectomy from July 1, 2015, to June 30, 2020.
The presence of GSE findings was established through standardized, keyword-based audits of operative reports by EPSN surgeons. Interrater agreement for the presence or absence of GSE findings was evaluated in a random sample of 900 operative reports.
The primary outcome was 30-day postoperative surgical site infections (incisional and organ space infections). Secondary outcomes included rates of hospital revisits, postoperative abdominal imaging, and postoperative length of stay. Multivariable mixed-effects regression was used to adjust measures of association for patient characteristics and clustering within hospitals.
Among 6133 children with nonperforated appendicitis, 867 (14.1%) had GSE findings identified from operative report review (hospital range, 4.2%-30.2%; P < .001). Reviewers agreed on presence or absence of GSE findings in 93.3% of cases (weighted κ, 0.89; 95% CI, 0.86-0.92). In multivariable analysis, GSE findings were associated with increased odds of any surgical site infection (4.3% vs 2.2%; odds ratio [OR], 1.91; 95% CI, 1.35-2.71; P < .001), organ space infection (2.8% vs 1.1%; OR, 2.18; 95% CI, 1.30-3.67; P = .003), postoperative imaging (5.8% vs 3.7%; OR, 1.70; 95% CI, 1.23-2.36; P = .002), and prolonged mean postoperative length of stay (1.6 vs 0.9 days; rate ratio, 1.43; 95% CI, 1.32-1.54; P < .001).
In children with nonperforated appendicitis, findings of gangrene, suppuration, or exudate are associated with increased surgical site infections and resource utilization. Further investigation is needed to establish the role and duration of postoperative antibiotics and inpatient management to optimize outcomes in this cohort of children.
背景：在非穿孔性阑尾炎患儿中，坏疽性、化脓性或渗出性（GSE）表现的临床意义尚未得到充分描述。
目的：评估非穿孔性阑尾炎患儿中 GSE 表现是否与手术部位感染风险增加和资源利用增加相关。
设计、地点和参与者：这是一项多中心队列研究，使用了美国外科医师学院儿科国家手术质量改进计划的阑尾靶向数据库中的数据，并通过补充病历审查获得的手术报告数据进行了扩充。数据来自于参加东儿科外科学术网络（EPSN）研究联盟的 15 家医院。研究队列包括接受阑尾切除术的年龄≤18 岁的非穿孔性阑尾炎患儿（2015 年 7 月 1 日至 2020 年 6 月 30 日）。
暴露：通过 EPSN 外科医生对手术报告进行基于关键词的标准化审核，确定 GSE 表现的存在。在 900 份手术报告的随机样本中评估了 GSE 表现存在或不存在的观察者间一致性。
主要结局和措施：主要结局为 30 天术后手术部位感染（切口和器官间隙感染）。次要结局包括医院复诊率、术后腹部影像学检查和术后住院时间。使用多变量混合效应回归来调整与患者特征和医院内聚类相关的措施关联。
结果：在 6133 名非穿孔性阑尾炎患儿中，867 名（14.1%）从手术报告审查中发现 GSE 表现（医院范围，4.2%-30.2%；P<0.001）。审查员在 93.3%的病例中对 GSE 表现的存在或不存在达成一致意见（加权 κ，0.89；95%CI，0.86-0.92）。在多变量分析中，GSE 表现与任何手术部位感染（4.3%比 2.2%；优势比[OR]，1.91；95%CI，1.35-2.71；P<0.001）、器官间隙感染（2.8%比 1.1%；OR，2.18；95%CI，1.30-3.67；P=0.003）、术后影像学检查（5.8%比 3.7%；OR，1.70；95%CI，1.23-2.36；P=0.002）和平均术后住院时间延长（1.6 天比 0.9 天；率比，1.43；95%CI，1.32-1.54；P<0.001）相关。
结论和相关性：在非穿孔性阑尾炎患儿中，坏疽、化脓或渗出的表现与手术部位感染和资源利用增加相关。需要进一步研究以确定术后抗生素和住院管理的作用和持续时间，以优化这组患儿的结局。
