Is there a need for revised guidelines in the treatment of perforated appendicitis in children? A study of risk factors for prolonged hospital stay and postoperative complications

Purpose To study the need for revised guidelines in the treatment of children with acute perforated appendicitis (APA) by describing the clinical course of children surgically treated for APA in one county in Sweden, with focus on length of hospital stay (LOS) and risk of postoperative complications. The study also aimed to identify variation in practice, comparing a university children's hospital (UCH) to county hospitals (CH). Methods Two thousand children, <16 years, who had surgery for acute appendicitis 2014-2018 in four public hospitals (1 UCH and 3 CH), were identified. Patients with perforation of the appendix, n = 383(19 %) were selected for study and retrospective assessment of patient records. Uni and multivariable logistic regression analyses were done to identify risk factors for prolonged length of stay (PLOS) and complications. Results The median LOS was 5.05 days (0.5-61.9), 6.79 (1.81-61.91) for the UCH (n = 186) and 3.65 (0.54-35.65) for CH's (n = 197)(p < 0.0001). PLOS (=>5 days in hospital) was seen in 147 (79 %) at UCH and 53(26.9 %) at CH's(p < 0.0001). Intra-abdominal abscess within 30 days was identified in 36 (9.4 %) and surgical re-intervention was needed in 19 (5 %) with no differences between hospitals. The need for readmission within 30 days was higher at CH n = 22(11.4 %) than at UCH n = 4(2.2 %), (p = 0.0006). Multivariable analyses showed independent predictors of PLOS to be: male gender(OR 2.97 (1.68-5.23)), treatment at UCH (OR 10.24 (6.38-16.44)), CRP >135 mg/l(OR per 50 units 1.42 (1.16-1.73)), prehospital delay>2.5 days(OR 1.22 (1.01-1.47)), delayed time to surgery(OR per 10 h 1.74 (1.26-2.41)) extended surgery time(OR per 2 h 4.59 (1.43-14.76)) and use of urinary catheter(OR 2.99 (1.42-6.29)). Conclusion Guidelines for treatment of childhood APA, focusing on minimizing antibiotics and facilitating early discharge, would optimize care of the patients but also the economical use of resources. Most children with APA have an uncomplicated course, but factors predicting PLOS have been identified. We found a pronounced variation in practice between the UCH and CH's, without increasing the risk of postoperative complications.