title: Early discharge following laparoscopic appendectomy in children utilizing an evidence-based clinical pathway.
abstract: BACKGROUND
  The utility of laparoscopic appendectomy (LA) in children remains controversial. The determination of the efficacy of LA in children is complicated by variable postoperative management, duration of antibiotics,and criteria for discharge. The aim of this study was to examine the results of a commitment to LA and the concurrent implementation of an evidence-based clinical pathway (CP) for management appendicitis in a children's hospital.
  
  
  METHODS
  With institutional review board approval, all children presenting with appendicitis (n = 72; age =10.6 +/- 0.1 years) were offered LA and management directed by CP. Data were accrued prospectively for 12 consecutive months (May 2006 to April 2007) and analysis performed at 15 months. Data are reported as the mean +/- standard error of the mean.
  
  
  RESULTS
  Children were stratified based on the operative findings: group one - acute 41; group two-suppurative=11; and group 3-gangrenous or perforated 20. Duration of hospital stay differed between the groups:group one= 26 +/- 0.3 hours; group 2 =48 +/- 3 hours; group 3= 127 +/- 6 hours (P <0.05). No patients in groups one or two suffered a complication or were readmitted following discharge. Two patients in group 3 (10%)were readmitted and treated with antibiotic therapy alone. Overall, 66% of the children with acute appendicitis(27/41) and 27% with suppurative appendicitis (3/11) were discharged within 24 hours of admission. Discharge by 24 hours in groups 1 and 2 was not influenced by age, gender, or time of operation (before or after 7 PM).
  
  
  CONCLUSIONS
  The commitment to LA and use of CP resulted in discharge within 24 hours in 2 of 3 of children with acute appendicitis without readmission or complications being observed. Early discharge was not influenced by age, gender, or time of admission. For advanced appendicitis, length of hospital stay, determined by clinical parameters, resulted in a low rate of complication or readmission.
authors.affiliation: Department of Pediatric Surgery, The Peyton Manning Children's Hospital at St. Vincent, Indianapolis, Indiana, USA. dxbensar@stvincent.org
authors.forename: Denis D
authors.initials: DD
authors.lastname: Bensard
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Hendrickson
authors.forename: Carla J
authors.initials: CJ
authors.lastname: Fyffe
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Careskey
authors.forename: Richard G
authors.initials: RG
authors.lastname: Azizkhan
mesh_terms: D001062:Appendectomy / Q000379:methods* / Q000534:rehabilitation*; D001064:Appendicitis / Q000601:surgery; D002648:Child; D019091:Critical Pathways; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D010535:Laparoscopy; D007902:Length of Stay; D008297:Male; D010351:Patient Discharge; D013492:Suppuration