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Fast-track surgery for acute appendicitis in children: a systematic review of protocol-based care
Montgommery Do-Wyeld1, Thomas Rogerson1, Stefan Court-Kowalski1,2
1Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.
Insights
Fast-track surgery for childhood appendicitis is safe and effective, reducing hospital stays. Further research is needed to standardize protocols for complicated cases, including pain management and disease classification.
Area of Science:
- Pediatric Surgery
- Evidence-Based Medicine
- Healthcare Protocol Optimization
Background:
- Fast-track surgery protocols standardize post-operative care for childhood appendicitis.
- Evidence supports their safety and efficacy in both uncomplicated and complicated cases.
- Variations in protocol design hinder broader adoption.
Purpose of the Study:
- To systematically review evidence on fast-track protocols for childhood appendicitis.
- To identify areas of consensus and controversy in current protocols.
Main Methods:
- Systematic literature review of 33 studies (observational, case-control, cohort, RCTs).
- Studies included uncomplicated, complicated, and mixed appendicitis cohorts.
- Analysis focused on protocol elements like antibiotics, discharge criteria, and monitoring.
Main Results:
- Fast-track protocols consistently reduce hospital length of stay.
- Complication rates were equivalent or improved compared to standard care.
- Key protocol themes include antibiotic management and discharge criteria; rationalized analgesia and a standardized definition for complicated appendicitis require further investigation.
Conclusions:
- Standardized fast-track care for childhood appendicitis is safe and effective.
- Future research should focus on protocols for complicated appendicitis, incorporating analgesia and a consistent classification scheme.
Background:
'Fast-track' surgery protocols aim to standardize and rationalize post-operative care, with evidence of safety and efficacy in both uncomplicated and complicated childhood appendicitis. Generalization for broader adoption has been limited by variation in protocol design, including specific antibiotic choice, discharge criteria, post-operative monitoring and patient selection.
Methods:
A systematic review of the literature was performed to evaluate the current evidence underpinning fast-track protocols for childhood appendicitis and identify areas of consensus and controversy.
Results:
About 33 studies met the inclusion criteria, including four prospective observational studies, 20 case-control studies, seven cohort studies and two randomized controlled trials studying uncomplicated (n = 9), complicated (n = 18) and mixed cohorts (n = 6). Reduction in length of hospital stay was almost universally reported, with equivalent or improved complication rates. Key themes of protocols included antibiotic choice and duration, discharge criteria and post-operative laboratory and radiographic testing. Rationalized analgesia is an underexplored aspect of protocol design, and a standardized definition of complicated appendicitis remains elusive.
Conclusion:
Standardized care of childhood appendicitis has been shown to be safe and effective in several local and international centres. Next steps include investigation of a complicated appendicitis protocol that integrates rationalized analgesia in appendicectomy recovery, and development of a consistent classification scheme for complicated disease to aid in identification of amenable cohorts.
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