Journal of Pediatric Surgery (2010) 45, 890–893

www.elsevier.com/locate/jpedsurg

Appendicitis in northern aboriginal children: does delay

in definitive treatment affect outcome?
Alana Beres, Saleh Al-Abbad, Pramod S. Puligandla ⁎
Division of Pediatric General Surgery, The Montreal Children's Hospital of the McGill University Health Centre,
Montreal, Quebec, Canada H3H1P3

Received 23 January 2010; accepted 2 February 2010

Key words:
Abstract
Appendicitis;
Background: The treatment of northern aboriginal children (NAC) is often complicated by distance
Outcome;
from a treating facility. We sought to compare outcomes of NAC requiring transfer with appendicitis to
Aboriginal populations;
those who presented locally. We hypothesized that NAC with appendicitis experienced higher rates of
Appendiceal perforation
perforation and increased length of stay (LOS).
Methods: A retrospective chart review of 210 appendectomies was performed. Charts were reviewed for
age, sex, weight, days of symptoms before presentation, time of transfer, leukocyte count (white blood
cell count), usage of antibiotics prior to transfer, time to operation, type of procedure and findings,
pathology, postoperative outcomes, and LOS.
Results: Sixty-eight children were NAC, whereas 142 were local. The average transfer times for NAC
was 10 hours (range, 4-20 hours). The two groups had similar ages (11.1 vs 10.7 years), time to
presentation (1.64 vs 1.85 days), and LOS (2.91 vs 2.90 days). Significantly higher perforation rates (44
vs 28%; P = .02), higher white blood cell count (17.9 vs 16.0; P = .02), and longer times to operation
after arrival (10.3 vs 7.0 hours; P = .0002) were noted in NAC. Postoperative complications were
similar between groups. Forty-seven (69%) NAC received antibiotics prior to transfer, which did not
affect rate of rupture.
Conclusion: NAC with appendicitis experience longer transfer times and higher perforation rates than
local children without a difference in length of stay or complications. Pretransfer antibiotics do not
reduce perforation rates but may impact complications. We endorse their use if a delay in transfer
is anticipated.
© 2010 Elsevier Inc. All rights reserved.

Appendicitis remains the most common surgical emer-
gency in children [1-3]. Although the reported rates of
perforation for appendicitis vary widely, ranging from 20%
to 76% [2,4,5], it is generally accepted that delays in
Presented at the 41st Annual Meeting of the Canadian Association of
Paediatric Surgeons, Halifax, Nova Scotia, Canada, October 1-3, 2009.
⁎ Corresponding author. Tel.: +1 514 412 4438; fax: +1 514 412 4289.
E-mail address: pramod.puligandla@mcgill.ca (P.S. Puligandla).
diagnosis and treatment lead to higher rates of perforation
and postoperative complications. This may be a particularly
pertinent problem affecting northern aboriginal children
(NAC) who often suffer long delays in the comprehensive
management of appendicitis because of their remote
location, long transport times, and lack of physician
coverage. The goal of this study was to compare the
outcomes of NAC with a diagnosis of appendicitis to
children presenting from local populations.

0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpedsurg.2010.02.008
Appendicitis in northern aboriginal children 891

1. Methods Table 1 Type of appendectomy and rates of perforation

NAC (n = 68) Local (n = 142) P
After obtaining research ethics board approval, a Laparoscopic 39 (57) 104 (73) .02
retrospective chart review of 210 appendectomies at a Open 29 (43) 38 (27) .02
tertiary care institution was performed. Data for the NAC Perforation rate 30 (44) 40 (28) .02
group were reviewed from January 2006 to December 2008, P values less than .05 was considered significant. Data are presented as
whereas data for the local group was reviewed over a number (percentage).
consecutive 9-month period during the same time frame.
Data collected included age, sex, length of symptoms prior to
presentation, white blood cell count (WBC), time to transfer
to our institution, antibiotic use pre-transfer, time from However, there was no significant difference in the
arrival to the operating room (OR), rate of appendiceal perforation rate for NAC who did (22/47; 47%) or did not
rupture (operative findings correlated with pathological (8/21; 38%) receive antibiotics before transfer (P = .5). The
examination), operative method (laparoscopic, open or postoperative complications for the NAC and local groups
converted), length of procedure, intraoperative findings, were also similar and are presented in Table 2. Three patients
postoperative complications (ileus, postoperative abscess in the NAC group required readmission for their complica-
and wound infections), and length of stay. The study group tions compared to only 1 in the local group.
consisted of all NAC who were transferred by airplane from
Northern Quebec, whereas the control group consisted of
children who presented directly to our institution from local 3. Discussion
populations. All children in this study had a diagnosis of
appendicitis and underwent appendectomy. Patients man- Appendicitis remains the most frequent diagnosis requir-
aged nonoperatively, by interval appendectomy or who had ing emergency surgical intervention in children [1-3] and
an appendectomy as part of an unrelated procedure were occurs with an estimated lifetime risk of 7%. Overall, the
excluded. Statistical analysis was completed using StatPac outcome for children with appendicitis is extremely good.
(version 3.0, Bloomington MN). Student's t test or χ2 test Indeed, complication rates for appendicitis are reported to be
was used to analyze continuous and categorical variables, less than 5%, even for complicated cases involving
respectively. A P value of b.05 was considered significant. perforation [6]. Although the reported rates of appendiceal
perforation vary, one of the most common causes for
perforation is the delay to diagnosis and management [2,7].
2. Results We hypothesized that NAC may be at particular risk of
developing complicated appendicitis (perforation) and
Of the 210 medical records that were reviewed, 68 were postoperative complications resulting from longer transfer
NAC, whereas the remaining 142 children presented from times to hospital and delays in definitive management. Our
local populations. These two groups were similar with respect results demonstrate that despite higher rates of perforation in
to age (11.1 vs 10.7 years), time to initial presentation (1.6 vs NAC compared to local populations, NAC did not
1.9 days), and overall length of stay (NAC: 2.9 ± 2.0 vs local: experience significantly elevated rates of postoperative
2.9 ± 3.0 days). The average transfer time for NAC, defined as complication, including wound infection, abscess, and ileus.
the time elapsed from the moment a transfer was accepted, The remote location of our aboriginal populations in
was 10 hours (range, 4-20 hours). Of the 68 patients in the Canada makes the management of common medical
NAC group, 47 (69%) received antibiotics before transfer problems such as appendicitis more difficult [8]. Despite
while antibiotics for the local group were generally provided the introduction of telemedicine and broader physician
only “on call to the OR”, unless we anticipated a time delay, coverage to many northern communities that were previously
the child had a high fever, or the patient was thought to be inaccessible, distance still plays a major role in the provision
perforated on clinical examination. NAC were noted to have a
higher WBC on presentation (17.9 vs 16.0; P = .02). Table 2 Complications
Interestingly, NAC experienced longer intervals to the OR
Complication NAC (n = 68) Local (n = 142) P
after arrival at our institution (10.3 vs 7.0 hours; P = .0002).
The operative approach was left to surgeon preference and is Ileus 5 (7) 6 (4) 0.3 (NS)
presented in Table 1. The mean operative time was 49.0 ± Wound infection 1 (1.5) 2 (1.4) 0.97 (NS)
20.2 (mean ± SD) minutes in the NAC group and 54.5 ± 17.6 Abscess 1 (1.5) 2 (1.4) 0.97 (NS)
Readmission 3 (4.4) 1 (1) 0.07 (NS)
minutes in the local group (P b .05).
LOS mean (SD) 2.9 (2.0) 2.9(3.0) 0.98 (NS)
Higher rates of appendiceal perforation were noted in the
NAC group when compared to locally presenting popula- P value less than .05 was considered significant. Data presented are
number (percentage) or mean (SD). LOS indicates length of stay.
tions (30/68; 44% vs 40/142; 28%; P = .02) (Table 1).
892
of timely surgical care. At our institution, it is common for a
“northern transfer” to take several hours. Moreover, the
patient transfer may be further delayed by unpredictable
weather and the availability of medical transport.
The diagnosis of appendicitis is not always straightfor-
ward. Atypical presentations and the experience of the health
care professional evaluating the patient may confound the
ability to make a diagnosis. In many northern communities,
children are evaluated at nursing stations with limited
physician coverage. In these situations, patients with right
lower quadrant pain are evaluated with a history and physical
examination, and triaged to our institution as needed. Many
aspects of a patient's “routine evaluation” that we take for
granted such as laboratory (WBC) and radiologic (ultrasound
or computed tomography) investigations are scarce [9].
Our current approach for NAC referred for abdominal
pain is to expedite transfer to our center as quickly as
possible to make a timely diagnosis and institute care. If the
information provided to us by the referring center is
suggestive of appendicitis, we often request the referring
physician to provide a dose of antibiotics before transfer. Our
current regimen includes clindamycin (10 mg/kg to maxi-
mum 900 mg) and gentamicin (2 mg/kg to maximum 100
mg). Upon arrival, the patient is evaluated and booked for
surgery, if indicated. Our postoperative care is based on
operative findings. Patients with simple appendicitis receive
no further antibiotics and are routinely discharged in 24
hours, whereas those with complicated appendicitis (gan-
grenous or perforated) receive postoperative intravenous
antibiotics (ampicillin, gentamicin, and metronidazole).
These patients are discharged only after they have been
afebrile for a continuous 24 hours and if a subsequent WBC
and differential cell count is normal. This protocol has been
previously published and has demonstrated excellent out-
comes with low rates of complication and readmission [10].
All patients in the current study were treated according to the
same protocol with no appreciable difference in postopera-
tive complications (Table 2). These results are similar to
results previously published by our center evaluating the
outcome of laparoscopic and open appendectomy for
perforated appendicitis in children [11].
Although NAC patients experienced higher perforation
rates overall, the use of pretransfer antibiotics did not affect
the rate of perforation despite equivalent times to initial
presentation when compared to the local group. This is not
unexpected as antibiotics are not likely to change the
pathophysiologic process leading to perforation. These
perforations likely occurred because of delays in definitive
management as a result of longer transport times. Despite
these higher rates of perforation, however, the NAC group
did not experience a higher rate of postoperative complica-
tions. There may be a few reasons for this. The nonoperative
management of perforated appendicitis using broad-spec-
trum antibiotics has gained increasing favor in recent years,
and studies have demonstrated good outcomes and low rates
of complication. Some have surmised that the efficacy of
A. Beres et al.
current broad-spectrum antibiotics may be partially respon-
sible for these encouraging results [12]. More importantly, it
is also possible that our protocolized approach to the
management of perforated appendicitis has led to better
outcomes and minimal postoperative complications.
Our study has several limitations. The retrospective
nature of this study could not control for treatment bias,
including the use of pretransfer antibiotics. Sixty-nine
percent of patients received pretransfer antibiotics and the
relatively small number of NAC patients in this study
makes it difficult to interpret the importance of early
antibiotics for these patients. Furthermore, some of the
delay to treatment occurred within our own institution as
NAC patients had a significantly longer interval to operative
management after their arrival. We have interpreted this to
be the result of late night arrivals to our emergency
department. Appendicitis referrals arriving late at night are
often processed the following morning unless the patient
exhibits systemic signs of sepsis or hemodynamic instabil-
ity. Some of these patients may also have undergone further
radiologic investigation that would also have been delayed
until the following morning. Nonetheless, this is one of the
first reports in the literature to specifically evaluate transfer
times as an important factor affecting the outcome of
appendicitis in NAC.
Appendicitis is a common surgical diagnosis in children.
Northern aboriginal children represent a specific manage-
ment problem because of their remote location and
subsequent longer transfer times for definitive care. Despite
a higher rate of perforation, NAC children in this study
experienced equivalent rates of postoperative complications
when compared to a similar group of children presenting
from local populations. A larger, prospective study would be
needed to corroborate our findings and further examine the
role of pretransfer antibiotics in preventing postoperative
complications in this special cohort of patients.
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