Journal of Pediatric Surgery (2005) 40, 1908–1911

www.elsevier.com/locate/jpedsurg

The influence of advanced radiographic imaging on the

treatment of pediatric appendicitis

Douglas Yorka,b, Angela Smitha, J. Duncan Phillipsa,b,*, Daniel von Allmena,b

aDivision of Pediatric Surgery, Department of Surgery, University of North Carolina School of Medicine,

Chapel Hill, NC 27599, USAbDepartment of Surgery, WakeMed Hospital, Raleigh, NC 27610, USA

0022-3468/$ – see front matter D 2005

doi:10.1016/j.jpedsurg.2005.08.004

Presented at the 38th Annual Meet

Pediatric Surgeons, May 22-26, 2005, V

T Corresponding author. Tel.: +1 919

E-mail address: duncan_phillips@m

Index words:Appendicitis;

Computed tomography

Abstract

Purpose: Since 1998, the use of advanced radiographic imaging with computed tomography (CT) and/

or diagnostic ultrasound (US) has increased dramatically for the diagnosis of acute appendicitis in

children. This study investigates the impact of this imaging on the evaluation, management, and

outcome of pediatric patients who underwent appendectomy for suspected appendicitis.

Methods: Retrospective review of 197 consecutive children with a preoperative diagnosis of acute

appendicitis, from January 2002 through May 2004, undergoing appendectomy at a university-affiliated

community hospital by pediatric and general surgeons.

Results: Patients were divided into two groups: imaged (n = 106; 54%) and nonimaged (n = 91; 46%).

Groups were similar with respect to age, sex, temperature, white blood count, and insurance status.

Ninety-seven imaged patients had CT, 6 had US, and 3 had both CT and US. Seventy-one percent of

imaging studies were ordered by emergency department physicians and 24% by treating surgeons.

Average wait from emergency department triage to operative incision for the imaged and nonimaged

groups was 12.1 and 5.4 hours, respectively (P b .0001). Both groups had similar perforation rates

(imaged: 15.1%, nonimaged: 14.6%). Negative appendectomy rates were 10.4% (imaged) and 4.4%

(nonimaged). Average hospital charges were $11,791 (imaged) and $9360 (nonimaged) (P = .001).

Time on antibiotics, complication rates, and length of stay were similar for both groups.

Conclusions: More than half of pediatric patients with suspected appendicitis now undergo advanced

imaging and experience a significant delay in surgical treatment with a 26% increase in hospital charges

and no clear-cut improvement in diagnostic accuracy nor outcome, when compared with evaluation by

the treating surgeons.

D 2005 Published by Elsevier Inc.

Despite the high incidence of acute appendicitis in chil-

dren, its clinical presentation can be varied at times, mak-

ing the diagnosis challenging. Because of this and perhaps

Published by Elsevier Inc.

ing of the Pacific Association of

ancouver, Canada.

966 4643; fax: +1 919 843 2497.

ed.unc.edu (J.D. Phillips).

other factors, appendicitis in younger children (b8 years) has

been associated with an increased perforation rate of up to

33% [1]. The diagnostic challenge of pediatric appendicitis

has continued to expand the role of radiographic imaging in

assessing children with suspected appendicitis [2].

First described for appendicitis in 1981, ultrasound (US)

remained the diagnostic imaging procedure of choice in

many centers for the next 17 years [2,3]. In 1998, Rao et al

Table 1 Demographics and preoperative variables for imaged

and nonimaged patients

Variable Imaged

(group A)

Nonimaged

(group B)

P

No. of patients (%) 106 (54) 91 (46)

Males/females 61/45 61/30 .188

Age (y) 10.3 10.8 .350

Temperature (8C) 37.8 37.8 .681

WBC count (�109/L) 15.558 16.994 .048T

Insurance status

Private 60 61

Medicaid 28 11

None 17 18

Wait till OR (h) 12.1 5.4 b.0001T

OR indicates operating room.

T Statistical significance was established at a level of P b .05.

The influence of advanced radiographic imaging on the treatment of pediatric appendicitis 1909

[4] advocated that the routine use of computed tomography

(CT) scans improved patient care for patients presenting

with suspected appendicitis. Since the publication of this

report and others, there has been a dramatic increase in the

use of CT in both adult and pediatric patients with suspected

appendicitis [5,6]. Two recent reports have documented

dramatic increases in the preoperative use of CT scans from

1% to 5% in 1997 to nearly 60% in 2001 [6,7]. Selective

radiological imaging studies (CT or US) have now become

standard at certain institutions for the evaluation of pediatric

patients suspected of appendicitis [6,8]. Advocates for

imaging for appendicitis report a decreased negative

appendectomy rate [2,4,6,8,9], decreased perforation rate

[2,8], and decreased cost [4,10,11].

We have also noted an increase in the utilization of

advanced imaging for pediatric appendicitis, especially with

CT scanning. This study was designed to investigate the

impact of this on the evaluation, management, and outcome

of patients who underwent appendectomy for suspected

acute appendicitis.

Fig. 1 Physicians ordering the advanced imaging studies.

1. Materials and methods

A retrospective review of medical records of 197 consec-

utive children with a preoperative diagnosis of acute

appendicitis from January 2002 through May 2004 was

completed following institutional review board approval.

Demographic data including sex, age, and insurance status

were collected as well as variables corresponding to preoper-

ative evaluation, management, and postoperative outcomes.

Variables included white blood cell (WBC) count, highest

preoperative temperature, preoperative imaging studies

(US, CT), total wait from the initial evaluation in the emer-

gency department (ED) until incision time, appendectomy

technique (open appendectomy or laparoscopic appendecto-

my), and operation time.

Both the decision to image and the imaging study of

choice (CT, US) was based on the discretion of the attending

physician. Only oral barium contrast was given for all CT

scans with a weight-adjusted radiation dose. All imaging

studies were interpreted by attending radiologists at the time

of completion and the final written report was reviewed. The

results (positive, negative, indeterminate) and status of the

physician who ordered the study (ED physician, surgeon,

primary care physician) were recorded. All pathology

specimens were interpreted by attending pathologists and

the report was reviewed to document the gross and

histological types of appendicitis. The appendix types were

classified as normal, simple, gangrenous, or perforated.

Postoperative variables collected include time on intra-

venous (IV) antibiotics and IV opiates and whether the

patient was sent home with oral (PO) antibiotics or opiates.

Postoperative complications, length of stay, and hospital

charges were also recorded.

Results were evaluated using general linear models for

continuous variables. v2 P values were used for unordered

discrete or dichotomous variables, whereas Mantel-Haenszel

v2 P values were used for ordered discrete variables. Stat-

istical significance was established at P b .05.

2. Results

From January 2002 through May 2004, there were

197 pediatric appendectomies performed for a preoperative

diagnosis of acute appendicitis. The mean age for the group

was 10.5 years (range, 2-17 years). There were 75 females

(38%) and 122 males (62%).

D. York et al.1910

Imaging studies were performed in 106 (54%) patients

(group A) (Table 1). Ninety-one (46%) patients did not

receive an imaging study (group B). There was no

significant difference in the sex of the patient with regard

to who received an imaging study. Both group A and B

patients presented with an average temperature of 37.88C.

Average WBC counts were slightly lower in imaged

patients (15.6 � 109/L vs 17.0 � 109/L for groups A and

B, respectively; P = .04). Insurance status between the two

groups did not appear to affect whether a patient received

an imaging study.

Of the patients in group A, a CT scan alone was the most

popular imaging study. Ninety-seven (91.5%) patients had

CT scans only, 6 patients had US, and 3 patients had both US

and CT. Of the patients who were imaged, 75 (70%) studies

were ordered by the ED physicians, 25 (24%) were ordered

by the attending surgeon or surgical team, and 4 (4%) by the

primary care physician (Fig. 1). Positive or highly probable

appendicitis results were reported in 96 (90%) of the imaged

cases, whereas 9 cases were indeterminate and 1 case was

reported as negative. Group A patients had an average delay

until surgery of 6.7 hours greater than their nonimaged

counterparts. Themean time from the initial consultation with

the ED physician to incision time in the operating room was

12.1 hours for group A and 5.4 hours for group B (P b .0001).

A preoperative imaging study did not appear to affect

operative and postoperative management of the two groups of

patients. There were no significant differences among the

proportion of patients who underwent a laparoscopic

appendectomy vs open appendectomy or among the perfo-

ration rates among the two groups (Table 2). The negative

appendectomy rates were 10.4% (n = 11) and 4.4% (n = 4) for

groups A and B, respectively. Seven of the 11 negative

appendectomies of group A and 3 of the 4 in group B were

associated with either another pathological or operative

diagnosis. Group A also incurred greater total charges during

their hospital stay. The mean charges for group A was

$11,791 as compared with those of group B, totaling $9360

Table 2 Outcomes for imaged and nonimaged patients

Variable Imaged

(group A)

Nonimaged

(group B)

Appendix type (%)

Simple 67 (63.2) 55 (60.4)

Gangrenous 12 (11.3) 17 (18.7)

Perforated 16 (15.1) 14 (15.4)

Normal 11 (10.4) 4 (4.4)

Mean charge ($)T 11,791 9360

Time on IV

antibiotics (d)

1.62 1.79

Postoperative

complications (%)

11.3 12.1

Postoperative LOS (d) 2.2 2.3

LOS indicates length of stay.

T Statistical significance was established at a level of P b .05.

(P = .001). Outcomes were similar among the two groups

with respect to the complication rate and postoperative length

of stay.

3. Discussion

The use of advanced imaging studies for the diagnosis of

suspected acute appendicitis in children appears to be routine

in some institutions, although others argue for its use only in

selective cases, mostly using it in females and equivocal cases

[6-8,12,13]. In a recent survey of 344 members of the

American Pediatric Surgical Association, 19.8% of respond-

ents report the frequent use of imaging (N67% of cases) for

the preoperative evaluation of appendicitis [14]. Although

US was considered the imaging test of choice before 1997,

CTappears to have replaced US for the preoperative manage-

ment of appendicitis, with greater than 94% of the imaged

patients in this study receiving a CT scan. This is likely

because of the decreased operator dependence and thus

increased diagnostic accuracy of CT [2].

The use of advanced radiographic imaging in greater than

50% of children with suspected appendicitis was an

unexpected finding in this study. Most preoperative imaging

studies in this series were ordered by ED physicians, with

only 24% of the imaging studies being ordered by the

surgeon. Some authors have suggested that earlier surgical

consultation may decrease the number of CT scans ordered

[15]. Kosloske et al [13] have shown that a protocol based on

clinical evaluation by pediatric surgeons with selective

imaging use achieves very low negative appendectomy

(5%) and perforation (17%) rates.

It appears that the diagnostic accuracy of the imaging

studies offered no advantage over those patients who were

diagnosed by physical examinations and laboratory values

alone. Although there was a higher rate of negative

appendectomies in imaged patients (10.4% vs 4.4%), this

result was not statistically significant. We believe, however,

that the detailed pediatric surgical examination is still the

most useful tool for diagnosis in pediatric appendicitis. If this

current trend of increased utilization of advanced imaging

continues, one cannot help to be concerned about the waning

of bclinical skillsQ to diagnose appendicitis.

The increased delay of 6.7 hours until surgery for those

patients who underwent imaging studies is consistent with

previous studies [15-17]. In patients who undergo an imaging

study, a variety of bpatientQ factors may play a role in the

increased delay. Pediatric cooperation in receiving the oral

contrast material, the ability to convey the history, nausea,

vomiting, and the possible need to place a nasogastric tube for

contrast delivery are all patient factors that may decrease the

efficiency of obtaining an imaging study. Furthermore,

competing interests within the institution such as urgent

trauma studies requiring the use of the CT scanner and the

attention of the on-call radiologist for study interpretation

may have contributed to the delay.

The influence of advanced radiographic imaging on the treatment of pediatric appendicitis 1911

Limitations of this study, with regard to this increased

delay and charges, are that we do not know the detailed

initial presentation of these patients. Surgical treatment of

patients with unclear diagnoses may be prolonged because

of the increased need for laboratory testing or observation

periods for those patients with different or difficult clinical

presentations. Furthermore, this study does not identify

those patients whose management may have been changed

based on the result of an imaging study because only

patients who subsequently underwent appendectomies were

included in the study. It seems unlikely, however, that more

than half of patients with appendicitis present as equivocal

or difficult cases.

In addition, the finding that most studies were ordered by

ED physicians may also contribute to a discrepancy of the

clinical diagnosis of appendicitis with that of surgeons. One

recent study has shown a difference between ED physicians

and pediatric surgeons for specific components of the abdo-

minal examination in patients presenting with abdominal

pain [18]. Any susceptibility to come to a different clinical

diagnosis may inherently lead to one physician type to further

pursue other methods, such as radiographic imaging, to be

comfortable to move to the next step of treatment.

In summary, in this study, advanced radiographic imaging

was used in more than half of pediatric patients undergoing

appendectomy for suspected appendicitis. Not only did those

imaged patients experience a significant delay in definitive

surgical treatment, but they also incurred an average of $2431

increase in hospital charges. Furthermore, this study con-

cluded that preoperative advanced radiographic imaging was

no more accurate in ruling in appendicitis than clinical

evaluation by an experienced surgeon. Mandatory surgical

consultation before an image study, as suggested by Perez et

al [15], may help reduce this surgical delay and the increased

charges associated with pediatric appendicitis, with no effects

on surgical outcomes.

Acknowledgments

The authors thank Gary Koch, PhD, for statistical

analysis assistance. DY thanks the National Institute of

Diabetes and Digestive and Kidney Diseases of the National

Institutes of Health for a short-term research training grant.

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