title: Disease severity, not operative approach, drives organ space infection after pediatric appendectomy.
abstract: OBJECTIVE
  This study examines patient and operative factors associated with organ space infection (OSI) in children after appendectomy, specifically focusing on the role of operative approach.
  
  
  BACKGROUND
  Although controversy exists regarding the risk of increased postoperative intra-abdominal infections after laparoscopic appendectomy, this approach has been largely adopted in the treatment of pediatric acute appendicitis.
  
  
  METHODS
  Children aged 2 to 18 years undergoing open or laparoscopic appendectomy for acute appendicitis were selected from the 2012 American College of Surgeons Pediatric National Surgical Quality Improvement Program database. Univariate analysis compared patient and operative characteristics with 30-day OSI and incisional complication rates. Factors with a P value of less than 0.1 and clinical importance were included in the multivariable logistic regression models. A P value less than 0.05 was considered significant.
  
  
  RESULTS
  For 5097 children undergoing appendectomy, 4514 surgical procedures (88.6%) were performed laparoscopically. OSI occurred in 155 children (3%), with half of these infections developing postdischarge. Significant predictors for OSI included complicated appendicitis, preoperative sepsis, wound class III/IV, and longer operative time. Although 5.2% of patients undergoing open surgery developed OSI (odds ratio = 1.82; 95% confidence interval, 1.21-2.76; P = 0.004), operative approach was not associated with increased relative odds of OSI (odds ratio = 0.99; confidence interval, 0.64-1.55; P = 0.970) after adjustment for other risk factors. Overall, the model had excellent predictive ability (c-statistic = 0.837).
  
  
  CONCLUSIONS
  This model suggests that disease severity, not operative approach, as previously suggested, drives OSI development in children. Although 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.
authors.affiliation: *Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY; and †Department of Pediatric Surgery, University of Rochester Medical Center, Rochester, NY.
authors.forename: Kristin N
authors.initials: KN
authors.lastname: Kelly
authors.forename: Fergal J
authors.initials: FJ
authors.lastname: Fleming
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Aquina
authors.forename: Christian P
authors.initials: CP
authors.lastname: Probst
authors.forename: Katia
authors.initials: K
authors.lastname: Noyes
authors.forename: Walter
authors.initials: W
authors.lastname: Pegoli
authors.forename: John R T
authors.initials: JR
authors.lastname: Monson
mesh_terms: D000293:Adolescent; D001062:Appendectomy / Q000379:methods; D001064:Appendicitis / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D059413:Intraabdominal Infections / Q000453:epidemiology*; D010535:Laparoscopy; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D057216:Propensity Score; D012086:Reoperation / Q000706:statistics & numerical data; D012307:Risk Factors; D012720:Severity of Illness Index