ASA - Disease Severity Not Operative Approach Drives Organ Space Infection Following Pediatric Appendectomy

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Disease Severity Not Operative Approach Drives Organ Space Infection Following Pediatric Appendectomy
Fergal J Fleming*^¹, Kristin N Kelly*^¹, Christopher T Aquina*^¹, Christian P Probst*^¹, Katia Noyes*^¹, Walter Pegoli*^², John RT Monson^¹
^¹University of Rochester Medical Center, Surgical Health Outcomes and Research Enterprise, Rochester, NY;^²University of Rochester Medical Center, Deptartment of Pediatric Surgery, Rochester, NY

OBJECTIVE(S):
While controversy exists regarding the risk of increased postoperative intra-abdominal infections following laparoscopic appendectomy, this approach has been largely adopted in the treatment of pediatric acute appendicitis. This study examines patient and operative factors associated with organ space infection (OSI) in children following appendectomy.
METHODS:
Children ages 2-18 years undergoing open or laparoscopic appendectomy for acute appendicitis were selected from the 2012 ACS Pediatric NSQIP database. Univariate analysis compared patient and operative characteristics with 30-day OSI rates. Factors with a p<0.1 and clinical importance were included in the multivariable logistic regression. A p-value <0.05 was considered significant.
RESULTS:
For 5,097 children undergoing appendectomy 4,481(87.9%) cases were performed laparoscopically. OSI occurred in 155(3%) children with half of these infections developing post-discharge. Significant predictors for OSI included complicated appendicitis, wound class III/IV, preoperative sepsis, and longer operative time(Table 1). Although 5.2% of patients undergoing open surgery developed OSI(OR=1.94; CI: 1.30,1.89, p=0.001), after adjustment for other risk factors operative approach was not associated with increased relative odds of OSI(OR=0.99; CI: 0.64,1.53, p=0.948). Overall, the model had excellent predictive ability(c-statistic=0.836).
CONCLUSIONS:
This model demonstrates that disease severity, not operative approach as previously suggested, drives OSI development in children. While 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.
Table 1: Multivariate Analysis of Factors Associated with Organ Space Infection
Variable Adjusted Odds Ratio 95% Confidence Interval p-value
Complicated appendicitis (peritonitis or perforation/abscess during operation) 5.39 3.42, 8.50 <0.0001
Wound class III/IV (vs. I/II) 4.35 1.97, 9.62 <0.0001
Preoperative sepsis/septic shock 2.52 1.73, 3.65 <0.0001
Operative Time (per 10 minute increase) 1.06 1.04, 1.10 <0.0001
Age (per one year increase) 1.05 1.00, 1.09 0.047
Open surgery* 0.99 0.64, 1.53 0.948
Model also controlled for sex, pulmonary comorbidity, obesity, and emergency operations.
* Patients were classified by the intent to treat; cases that were converted from laparoscopic to open were considered in the laparoscopic group.

Table 1: Multivariate Analysis of Factors Associated with Organ Space Infection
Variable	Adjusted Odds Ratio	95% Confidence Interval	p-value
Complicated appendicitis (peritonitis or perforation/abscess during operation)	5.39	3.42, 8.50	<0.0001
Wound class III/IV (vs. I/II)	4.35	1.97, 9.62	<0.0001
Preoperative sepsis/septic shock	2.52	1.73, 3.65	<0.0001
Operative Time (per 10 minute increase)	1.06	1.04, 1.10	<0.0001
Age (per one year increase)	1.05	1.00, 1.09	0.047
Open surgery*	0.99	0.64, 1.53	0.948
Model also controlled for sex, pulmonary comorbidity, obesity, and emergency operations. * Patients were classified by the intent to treat; cases that were converted from laparoscopic to open were considered in the laparoscopic group.

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