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PEDIATRICS Vol. 113 No. 3 March 2004, pp. 626

Effect of an Imaging Protocol on Clinical Outcomes Among Pediatric Patients With Appendicitis

Hugo A. Heij, MD, PhD^a
Martin Offringa, MD, PhD^b
a Pediatric Surgical Center of Amsterdam
Academic Medical Center and VU University Medical Center
1100 DD Amsterdam, The Netherlands
^b Academic Medical Center
1100 DD Amsterdam, The Netherlands

To the Editor.—

The article by Garcia Pena et al¹ involving a combined retrospective and prospective cohort, that evaluated the effect of the introduction of ultrasound and computed tomographic scanning for children with suspected appendicitis on the rate of negative appendectomies and perforations. Apparent dramatic reductions were achieved in both parameters by performing imaging studies in all patients with equivocal clinical findings. We question whether these reductions were caused by the imaging procedures or the introduction of a protocol.

A total of 1338 children were evaluated: 920 before introduction of the imaging protocol and 418 after introduction. Children with unequivocal appendicitis were operated on without imaging. The number of children with equivocal signs was 810, and 528 went to the operating theater without imaging. The articles presents the overall data and the outcome for the equivocal patients, allowing calculation of the figures for the patients with unequivocal findings.

Table 2 shows the rates of perforations and negative appendectomies in patients with equivocal findings. Interestingly, similar reductions are found in all patients. Subtraction of the equivocal group from the total provides the data for the patients with unequivocal findings.

Before protocol, there were 404 patients, of whom 352 (87%) had appendicitis, 126 with perforations (35.7%), and 51 underwent negative appendectomy (12.6%). After introduction of the protocol, 124 were operated on without imaging: 116 had appendicitis (93%), 14 with perforations (12.0%), and 7 had a negative appendectomy (5.7%). These improvements seem as impressive as those in the imaged groups (33.7%–72.1%, 34.5%–17.5%, and 18.7%–3.2%, respectively).

The conclusion of the authors, that dramatic reductions in the perforation and negative appendectomy rates were due to the introduction of an imaging protocol, may be true. However, there is apparently no direct causal relation with the imaging itself, because a parallel reduction occurs in the patients who were evaluated in the same period without imaging. The explanation may be found in the fact that clinicians perform better when involved in a research protocol. The value of clinical assessment of children with suspected appendicitis without imaging but with active observation has been stressed by several authors.^2–4

The study by Garcia Pena et al may very well be interpreted as support for this viewpoint.

REFERENCES

1. Garcia Pena BM, Taylor GA, Fishman SJ, Mandl KD. Effect of an imaging protocol on clinical outcomes among pediatric patients with appendicitis. Pediatrics.2002; 110 :1088 –1093[Abstract/Free Full Text]
2. Bachoo P, Mahomed AA, Ninan GK, Youngson GG. Acute appendicitis: the continuing role for active observation. Pediatr Surg Int.2001; 17 :125 –128[Medline]
3. Jones PF. Suspected acute appendicitis: trends in management over 30 years. Br J Surg.2001; 88 :1570 –1577[CrossRef][Web of Science][Medline]
4. Kirby CP, Sparnon AL. Active observation of children with possible appendicitis does not increase morbidity. ANZ J Surg.2001; 71 :412 –413[Medline]

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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Heij, H. A. Articles by Offringa, M. Search for Related Content PubMed PubMed Citation Articles by Heij, H. A. Articles by Offringa, M. Social Bookmarking                         What's this?