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Disease Severity, Not Operative Approach, Drives Organ Space Infection After Pediatric Appendectomy

Kelly, Kristin N. MD*; Fleming, Fergal J. MD, FRCS*; Aquina, Christopher T. MD*; Probst, Christian P. MD*; Noyes, Katia PhD*; Pegoli, Walter MD; Monson, John R. T. MD, FRCS, FACS*

doi: 10.1097/SLA.0000000000000874
Papers of the 134th ASA Annual Meeting

Objective: This study examines patient and operative factors associated with organ space infection (OSI) in children after appendectomy, specifically focusing on the role of operative approach.

Background: Although controversy exists regarding the risk of increased postoperative intra-abdominal infections after laparoscopic appendectomy, this approach has been largely adopted in the treatment of pediatric acute appendicitis.

Methods: Children aged 2 to 18 years undergoing open or laparoscopic appendectomy for acute appendicitis were selected from the 2012 American College of Surgeons Pediatric National Surgical Quality Improvement Program database. Univariate analysis compared patient and operative characteristics with 30-day OSI and incisional complication rates. Factors with a P value of less than 0.1 and clinical importance were included in the multivariable logistic regression models. A P value less than 0.05 was considered significant.

Results: For 5097 children undergoing appendectomy, 4514 surgical procedures (88.6%) were performed laparoscopically. OSI occurred in 155 children (3%), with half of these infections developing postdischarge. Significant predictors for OSI included complicated appendicitis, preoperative sepsis, wound class III/IV, and longer operative time. Although 5.2% of patients undergoing open surgery developed OSI (odds ratio = 1.82; 95% confidence interval, 1.21–2.76; P = 0.004), operative approach was not associated with increased relative odds of OSI (odds ratio = 0.99; confidence interval, 0.64–1.55; P = 0.970) after adjustment for other risk factors. Overall, the model had excellent predictive ability (c-statistic = 0.837).

Conclusions: This model suggests that disease severity, not operative approach, as previously suggested, drives OSI development in children. Although 88% of appendectomies in this population were performed laparoscopically, these findings support utilization of the surgeon's preferred surgical technique and may help guide postoperative counsel in high-risk children.

For children undergoing appendectomy for acute appendicitis in the pediatric NSQIP database, operative approach is not associated with higher rates of organ space infection and incisional complication after adjusting for selection bias via propensity score analysis.

*Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY; and

Department of Pediatric Surgery, University of Rochester Medical Center, Rochester, NY.

Reprints: Fergal J. Fleming, MD, FRCS, Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave, Box SURG, Rochester, NY 14642. E-mail:

The manuscript was presented at the 134th Annual Meeting of the American Surgical Association in Boston, MA, on April 11, 2014.

Disclosure: The authors declare no conflicts of interest.

© 2014 by Lippincott Williams & Wilkins.