j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 4 ( 2 9 3 ) 5 8 7 e5 9 5

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.JournalofSurgicalResearch.com

A Magnetic Resonance Imaging Protocol for the

Evaluation of Pediatric Postappendectomy
Abscess: A Quality Improvement Project

Alicia C. Greene, DO,a Marc M. Mankarious, MD,a

Madeline Matzelle-Zywicki, BS,b Akshilkumar Patel, MD,a
Lilia Reyes, MD,c Anthony Y. Tsai, MD,d Mary C. Santos, MD, MEd,d
Michael M. Moore, MD,e and Afif N. Kulaylat, MD, MScd,*
a
Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
b
The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
c
Division of Pediatric Emergency Medicine, Penn State Children’s Hospital, Hershey, Pennsylvania
d
Division of Pediatric Surgery, Penn State Children’s Hospital, Hershey, Pennsylvania
e
Department of Radiology, Nemours Children’s Hospital, Wilmington, Delaware

article info abstract

Article history: Introduction: Computed tomography (CT) scans are often used when cross-sectional imag-
Received 1 June 2023 ing is required for evaluation of postappendectomy abscess, exposing children to a source
Received in revised form of ionizing radiation. Our aim was to decrease the use of CT scans in pediatric post-
7 September 2023 appendectomy patients by 50% in 12 mo and to sustain those results for 1 y.
Accepted 12 September 2023 Methods: A comprehensive magnetic resonance imaging protocol was introduced in 2018 at
Available online 12 October 2023 a tertiary children’s hospital within a general health system to replace CT scans in sus-
pected pediatric postappendectomy abscess. Diagnostic and clinical outcomes were
Keywords: compared preprotocol (2015-2017) and postprotocol (2018-2022) implementation using
Appendicitis standard univariate statistics. P < 0.05 was considered significant. Quality improvement
Magnetic resonance imaging methodology was used to design and implement the protocol.
Pediatric Results: Sixty eight pediatric postappendectomy patients received cross-sectional imaging
Postappendectomy abscess during the study period. Overall, CT scans were used exclusively (100%, n ¼ 27) in the
Quality improvement preimplementation period compared to 31.7% (n ¼ 13) of cross-sectional imaging in the
Radiation stewardship postimplementation period. However, in the first year of protocol implementation, CT scan
use only decreased to 78% of cross-sectional studies performed. The majority of protocol
deviations (54%) also occurred in this time period. With improved education and rein-
forcement, CT scan utilization decreased to approximately 24% of cross-sectional studies
annually. Missed abscess rate, time to diagnosis, drainage procedure type, readmission,
and reoperation were similar between preimplementation and postimplementation
periods.

* Corresponding author. Assistant Professor of Surgery and Pediatrics, Division of Pediatric Surgery, Penn State Children’s Hospital, 500
University Drive, Hershey, PA 17033.
E-mail address: akulaylat@pennstatehealth.psu.edu (A.N. Kulaylat).
0022-4804/$ e see front matter ª 2023 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jss.2023.09.029
588 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 4 ( 2 9 3 ) 5 8 7 e5 9 5

Conclusions: Implementation of a postappendectomy abscess magnetic resonance imaging

protocol was associated with decreased CT utilization in the pediatric population, while
maintaining comparable diagnostic evaluation and clinical outcomes. Adherence to quality
improvement principles facilitated achieving goals and sustaining gains.
ª 2023 Elsevier Inc. All rights reserved.

Introduction Materials and Methods

Intra-abdominal abscess following appendectomy has been
reported in 3%-6% of pediatric cases of uncomplicated
appendicitis, and 10-16% of cases of perforated appendicitis.1-
8
While the reduction of computed tomography (CT) scan
utilization in the initial diagnosis of appendicitis has been a
focus of many institutional efforts, less attention has been
directed to the role of CT scan in the evaluation of post-
appendectomy abscess.9-16 To this end, CT scan use remains
prevalent when cross-sectional imaging is needed in the
diagnosis and management of intra-abdominal abscess
following pediatric appendectomy.3,17-20
Increasing awareness of the potential long-term risks of
ionizing radiation exposure in children has driven the
increasing focus on CT scan reduction.21-24 Alternative stra-
tegies to reduce reliance on CT scans have emphasized the use
of clinical pathways and ultrasound imaging.14,25,26 Only a
limited number of studies have investigated the use of mag-
netic resonance imaging (MRI) for postappendectomy abscess,
though its utility in the initial diagnosis of appendicitis has
been well demonstrated.9,10,13,17-19,27,28
Given our previous institutional success with utilizing MRI
for the diagnosis of pediatric appendicitis, our aim was to see
if this experience could be translated to the post-
appendectomy setting with the global aim of continuing to
reduce our reliance on CT scans and subsequent ionizing ra-
diation exposure. We designed and executed a quality
improvement (QI) project at a tertiary children’s hospital in
2018 where a comprehensive MRI protocol was implemented
to replace CT scans in children with suspected post-
appendectomy abscesses. Our specific aim was to decrease
the use of CT scans in pediatric postappendectomy patients by
50% in 12 mo and to sustain those results for 1 y.
QI project design, key driver diagram, and
postappendectomy pathway
A QI project was designed to reduce the utilization of CT scans
in the evaluation of pediatric postappendectomy patients
with concern for an intra-abdominal abscess. Stakeholders
including pediatric surgery, pediatric radiology, emergency
department (ED) physicians, and MRI technologists were
convened. A key driver diagram was constructed and a
comprehensive postappendectomy MRI protocol for abscess
identification was developed (Fig. 1). A clinical pathway was
then developed for postappendectomy children with concern
for intra-abdominal abscess (Fig. 2). The pathway and details
of the MRI postappendectomy protocol were distributed to
pediatric surgical, radiology, and ED faculty and correspond-
ing trainees in the beginning of 2018. The initial aim was to
decrease the use of CT scans in postappendectomy pediatric
patients by 50% in the first 12 mo and sustain those results for
1 y. The global aim of the study was to reduce radiation
exposure to pediatric patients.
MRI protocol
In contradistinction to our institution’s four-sequence MRI
protocol that is used for diagnostic appendicitis evaluation,
the MRI postappendectomy intra-abdominal abscess protocol
is more comprehensive to allow for both abscess character-
ization and potential drainage planning.9 The comprehensive
postappendectomy abscess protocol includes initial fluid
weighted T2 HASTE (SS-TSE), diffusion weighted imaging, and
postgadolinium T1 weighted rapid volumetric gradient se-
quences (VIBE, axial, and coronal). Diffusion weighted

Fig. 1 e Key driver diagram.

 greene et al  mri quality improvement project 589

Fig. 2 e Protocol for the work-up and management of postappendectomy patients.

imaging diffusion at b values 0 s/mm2 and 500s/mm2 with Data collection

apparent diffusion coefficient allows for assessment of
restricted diffusion in the setting of an abscess. Imaging was
performed on ED and hospitalized patients. Post-
appendectomy patients could also be referred for imaging
from an outpatient clinic. MRI examinations were completed
24 h per day, 7 d per week. All patients in our cohort were
imaged awake without sedation. Parents were allowed to
accompany small children in the scanner to decrease patient
anxiety. In general, our typical MRI pathway is reserved for
children 5 y or older, or if it seems they would be able to
tolerate MRI imaging if younger than 5 y. While moderate
sedation could be considered for younger children, it was not
utilized in the presented cohort of patients.
Baseline data were obtained for all patients less than 18 y of age
who received imaging at our tertiary children’s hospital from
January 1, 2015 to December 31, 2017. In order to assemble a
comprehensive cohort of patients evaluated with imaging
postappendectomy at our institution, a radiology database
(Primordial Design, Inc., San Mateo, CA) was queried for the
word “appendicitis” and “abscess” in any imaging request,
indication, or interpretation report for diagnostic MRI, CT, or
ultrasound (US) studies. For the patients identified, imaging
reports were reviewed to confirm postappendectomy evalua-
tion. Corresponding data for the patients in the baseline cohort
were compared to those in the postprotocol cohort (January 1,
590 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 4 ( 2 9 3 ) 5 8 7 e5 9 5
2018 to September 30, 2022). Patients were excluded if they
received only an US (n ¼ 5) in their postappendectomy evalu-
ation since our focus was on institutional changes in cross-
sectional imaging selection. Patients that only had imaging
performed at referring institutions were excluded since they
did not participate in our pathway (n ¼ 4). In accordance with
the institutional review board-approved waiver for this QI
study, informed consent was not required from participants.
Data extracted from patient records included patient de-
mographics (age, sex, and body mass index) and the type of
appendicitis (simple, perforated). Age was categorized by less
than 5 y of age, 5-12 y of age, and 12 y of age and greater.
Additionally, we characterized timing to abscess identifica-
tion and associated intervention, as well as 30-day post-
appendectomy outcomes such as return to the operating
room, return to the ED, or readmissions. The days between
appendectomy and abscess identification is defined as time to
diagnosis. To assess diagnostic accuracy, if a specific imaging
modality did not visualize an abscess that was identified
within 24 h via a different imaging modality, the patient was
considered to have a missed abscess.
We also evaluated and categorized protocol deviations.
These included: CT requests prior to pediatric surgery consult,
pediatric surgery ordered a CT scan instead of an MRI, pedi-
atric surgery ordered a CT scan at the request of radiology for
drainage planning, MRI not available, patient was not able to
tolerate an MRI, or other.
Data analysis
Patient characteristics and clinical outcomes were stratified by
preprotocol (2015-2017) and postprotocol (2018-2022) and
compared using Pearson’s Chi-Square Tests and Fisher’s Exact
Tests, as appropriate. Continuous data were assessed for distri-
bution normality through the examination of histograms and the
application of the ShapiroeWilk Test. Nonparametric contin-
uous data were analyzed using the Wilcoxon Rank Sum Test. All
analyses were performed using STATA software (version 16/MP;
Stata Corp., College Station, TX). P values less than 0.05 were
considered statistically significant. The proportion of CT scans to
cross-sectional imaging studies performed was analyzed using a
Shewhart control P-chart. The P-chart was created using the
Anhoj rules and Qicharts 2 Package in R software (version 4.2.2, R
Foundation for Statistical Computing, Vienna, Austria).29-31
Results
There were 68 pediatric patients who were evaluated by cross-
sectional imaging for a postappendectomy intra-abdominal ab-
scess (preprotocol: n ¼ 27, postprotocol: n ¼ 41). Patient charac-
teristics and clinical outcomes are summarized in Table 1. There
was no difference in mean patient age between patients evalu-
ated preprotocol versus postprotocol (10.4  4.1 y versus
11.5  4.1 y). Likewise, average body mass index was comparable
between protocol implementation periods (preprotocol:
18.9  4.0 versus postprotocol: 19.7  5.4). There was no differ-
ence in the proportion of patients that had perforated appendi-
citis at their index procedure (preprotocol: 85.2% versus
postprotocol: 82.9%).
Prior to the initiation of the protocol, CT scans comprised
100% (n ¼ 27/27) of the cross-sectional imaging completed for
postappendectomy patients. In the postprotocol period, 69.8%
(n ¼ 30/43) of cross-sectional imaging was MRI, with an overall
decrease in utilization of CT scans to 30.2% (n ¼ 13/43) of cross-
sectional imaging. Thirteen patients had an US performed
prior to CT scan or MRI (19.1%). Of these 13 patients, 6 had an
US that identified an abscess and had further cross-sectional
imaging completed to plan for a potential drainage proced-
ure, 5 patients had an US that was later followed by a cross-
sectional study to evaluate for abscess evolution, and 2 pa-
tients had an US that missed an abscess that was identified
within 24 h with a cross-sectional imaging study. The subse-
quent CT or MRI was performed due to the patient remaining
febrile with a leukocytosis and persistent abdominal pain,
highly concerning for a missed intra-abdominal abscess. Four
patients underwent multiple cross-sectional studies, 3 pa-
tients with CT prior to MRI (4.4%), and 1 patient with MRI prior
to CT scan (1.5%). The reasoning for multiple cross-sectional
studies was to evaluate for further abscess evolution in 2 pa-
tients with CT scans from a referring facility prior to MRI at our
institution and to evaluate for a missed abscess in the other 2
patients where an abscess was highly suspected given
persistent fevers with leukocytosis but not initially identified
via the initial modality. There were no missed abscesses by
cross-sectional modalities in the preimplementation period.
There were two missed abscesses by cross-sectional modal-
ities in the postimplementation period, one by MRI (3.7% of
MRIs) and one by CT (7.7% of CTs), both identified subse-
quently with the alternative imaging modality within 24 h.
There was no significant difference in the average time
between appendectomy and abscess identification (pre-
protocol: 9.3  7.3 d versus postprotocol: 8.6  5.1 d) and which
admission the abscess was identified (index versus re-
presentation). Thirty-day outcomes between protocol imple-
mentation periods, including return to the operating room
(preprotocol: 7.4% versus postprotocol: 7.3%), return to the ED
(preprotocol: 25.9% versus postprotocol: 7.3%) and readmission
(preprotocol: 18.5% versus postprotocol: 4.9%), were not sta-
tistically different between modalities.
Deviations from the protocol after implementation are
described in Table 2. The majority of protocol deviations
(53.8%, n ¼ 7) occurred in the first year of protocol imple-
mentation. In the first year of protocol implementation, CT
use decreased to 78% of cross-sectional studies performed.
After the first year, the utilization of CT scans decreased to an
average of 24% of cross-sectional imaging completed each
year with only one to two deviations recorded per year. A
control chart is presented in Figure 3 of the proportion of CT
scans used across the tracked time interval. After imple-
mentation of the protocol, there was a shift in the process
mean of proportion of cross-sectional studies utilizing CT
scans to approximately 30%.
Discussion
The use of CT scans in pediatric patients in the evaluation of a
postappendectomy abscess remains prevalent.17 Using QI
methodology, we designed a contrast-enhanced MRI protocol
 greene et al  mri quality improvement project 591

Table 1 e Patient characteristics and clinical outcomes preprotocol and postprotocol.

Variable Total n ¼ 68 Preprotocol n ¼ 27 Postprotocol n ¼ 41 P value
Age, mean (SD) 11.1 (4.1) 10.4 (4.1) 11.5 (4.1) 0.45
<5 y 7 (10.3%) 3 (11.1%) 4 (9.8%)
5-12 y 27 (39.7%) 13 (48.1%) 14 (34.1%)
>12 y 34 (50.0%) 11 (40.7%) 23 (56.1%)
Sex 0.96
Male 38 (55.9%) 15 (55.6%) 23 (56.1%)
Female 30 (44.1%) 12 (44.4%) 18 (43.9%)
BMI, mean (SD) 19.4 (4.9) 18.9 (4.0) 19.7 (5.4) 0.53
Proportion of perforated appendicitis 57 (83.8%) 23 (85.2%) 34 (82.9%) 0.80
Imaging*
CT scans 40 (58.8%) 27 (100.0%) 13 (31.7%) <0.001
MRI scans 30 (44.1%) 0 (0.0%) 30 (73.2%) <0.001
Prior imaging performed postappendectomy 0.16
No prior imaging 51 (75.0%) 19 (70.4%) 32 (78.0%)
CT prior to MRIy 3 (4.4%) 0 (0.0%) 3 (7.3%)
MRI prior to CT scan 1 (1.5%) 0 (0.0%) 1 (2.4%)
US prior to CT/MRI 13 (19.1%) 8 (29.6%) 5 (12.2%)
Abscesses identified 55 (80.9%) 25 (92.6%) 30 (73.2%) 0.05
Missed abscess by CT 1 (1.5%) 0 (0.0%) 1 (2.4%) 0.41
Missed abscess by MRI 1 (1.5%) 0 (0.0%) 1 (2.4%) 0.41
Missed abscess by US 2 (2.9%) 2 (7.4%) 0 (0.0%) 0.08
Time to diagnosis, days, median (IQR)z 9.0 (4.0-13.0) 8.0 (4.0-13.0) 9.0 (5.0-11.5) 0.99
During index admission 33 (60.0%) 14 (56.0%) 19 (63.3%) 0.66
On re-presentation 22 (40.0%) 11 (44.0%) 11 (36.7%) 0.23
Drainage or aspiration attemptedz 37 (67.3%) 18 (72.0%) 19 (63.3%) 0.10
Drainage procedure typex 1.00
CT-guided 31 (83.8%) 15 (83.3%) 16 (84.2%)
US-guided 6 (16.2%) 3 (16.7%) 3 (15.8%)
Within 30 days of postappendectomy imaging
Return to ED 10 (14.7%) 7 (25.9%) 3 (7.3%) 0.08
Readmission 7 (10.3%) 5 (18.5%) 2 (4.9%) 0.10
Return to OR 5 (7.4%) 2 (7.4%) 3 (7.3%) 1.00

SD ¼ standard deviation; BMI ¼ body mass index; CT ¼ computed tomography; MRI ¼ magnetic resonance imaging; US ¼ ultrasound; IQR ¼
interquartile range; OR ¼ operating room; ED ¼ emergency department.
*
Four patients had multiple imaging studies completed.
y
Two prior CT scans were performed at a referring facility.
z
n ¼ 55 (all), 25 (preprotocol), 30 (postprotocol).
x
n ¼ 37 (all), 18 (preprotocol), 19 (postprotocol).

and implementation strategy that was associated with an
institutional reduction in CT scan utilization while main-
taining comparable clinical outcomes. While we did not ach-
ieve our initial aim of a 50% reduction in CT scan use in 1 y
postimplementation, tracking of protocol compliance and
targeted re-education efforts facilitated achieving our aim in
year 2 postimplementation, and sustaining that success.
While extensive efforts have been directed toward
reducing radiation exposure in the initial diagnosis of pedi-
atric appendicitis, few studies have focused on post-
appendectomy imaging strategies. Some institutions have
established standardized clinical pathways and guidelines for
postappendectomy patients with perforated acute
appendicitis.25,32-34 Munoz-Abraham et al. demonstrated that
their pathway, which established clear guidelines for antibi-
otics and timing of abdominal CT scans, successfully
decreased the overall utilization of CT imaging, total mean
length of stay, and the amount of postoperative antibiotics
prescribed at discharge.25 Nielsen et al. also completed a study
comparing the outcomes in the evaluation of a post-
appendectomy abscess when a CT scan was performed on
postoperative day 5 compared to postoperative day 7.34 They
found that later use of CT scans resulted in less recurrent CT
scan rates and fewer drainage procedures. US provides an
alternative imaging modality to identify intra-abdominal ab-
scesses, although it can be challenging due to operator
592 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 4 ( 2 9 3 ) 5 8 7 e5 9 5
Table 2 e Deviations from protocol.
Variable Total n ¼ 13
CT scans performed postprotocol 13 (100%)
ED or other service ordered CT scan prior to 3 (23.1%)
pediatric surgery consult
Pediatric surgery ordered CT scan instead of MRI 6 (46.1%)
Pediatric surgery ordered CT scan at request of 1 (7.7%)
radiology for drainage planning
MRI not available 0 (0%)
Patient was unable to tolerate MRI 2 (15.4%)
Other 1 (7.7%)
Proportion of CT scans performed by total cross-
sectional imaging (percent of noncompliant scans)
ED ¼ emergency department; CT ¼ computed tomography; MRI ¼ magnetic resonance imaging.
dependence, overlying surgical dressings, abdominal pain,
ileus, or larger body habitus.17,19 There are few formal studies
critically analyzing the use and comparative outcomes of US
in the postappendectomy setting.18,26,35-39
Abdeen et al. conducted a study that analyzed 20 pediatric
postappendectomy patients with an intra-abdominal abscess
who had US and noncontrast MRI performed in their evalua-
tion.18 When the studies were reviewed retrospectively by
three radiologists, they determined that US detected fewer
abscesses compared to MRI in all patients, US frequently
missed pelvic abscesses that were detected on MRI, US was
read as an abscess in multiple patients that MRI determined
was bowel or a phlegmon instead of an abscess, and all radi-
ologists determined MRI had a higher proportion of safe
drainage routes compared with US which was most staggering
in the pelvic abscesses with US only showing a safe drainage
pathway in 7-10% of patients compared to 93-97% for MRI in
those same patients.18 Zens et al. performed a study
comparing the utilization of contrast-enhanced CT scan to
noncontrast MRI (n ¼ 16) in the evaluation of pediatric post-
appendectomy abscesses.19 This has been the only other
study, in addition to ours, that compared the use of MRI to CT
scans with IV contrast in this population. Similar to our study,
the referenced study had a postappendectomy MRI protocol
that showed equivalent outcomes to CT in terms of diagnostic
accuracy, abscess volume, drain placement, and read-
missions. The third study utilizing an MRI protocol to evaluate
postappendectomy abscesses was performed by Lee et al.17
They concluded that their rapid noncontrast MRI protocol
was accurate and efficient for evaluating abscesses but the
sample size was small without a control group, including only
fifteen patients. Our study is the largest to date utilizing MRI
for the evaluation of postappendectomy abscesses with
comparable outcomes to CT scan.
Our QI study highlighted the importance of clinician edu-
cation when implementing new protocols across an institu-
tion. Deviations from the protocol after initiation were
investigated and were highest during the first year, primarily
due to provider unfamiliarity with the new protocol. After the
first year of protocol initiation, there was a significant
decrease in deviations, with only one to two CT scans ordered
Year (post-protocol)
2018 2019 2020 2021 2022
7 1 1 2 2
0 0 0 1 2
4 1 0 1 0
0 0 1 0 0
0 0 0 0 0
2 0 0 0 0
1 0 0 0 0
78% (7/9) 8% (1/12) 13% (1/8) 50% (2/4) 25% (2/8)
each year to evaluate for postappendectomy abscess. Our
team learned the importance of widely disseminating pre-
training materials and protocol details to all involved staff
members prior to protocol implementation. Other important
strategies to consider when implementing a new QI protocol is
to set clear objectives, demonstrate real-life scenarios, pro-
vide visual aids, and encourage questions and discussion.40
Following models such as the Plan-Do-Study-Act cycle can
also guide teams when implementing QI initiatives in their
health-care systems.40 In our study, we also observed that in
the last 2 y of the study period there was an increase in pro-
tocol deviations from the ED. Since 2020, due to the COVID-19
pandemic, like many institutions, we experienced turnover,
staffing issues, and new providers particularly in the ED,
reinforcing the importance of tracking and reviewing out-
comes and providing targeted and cyclical education.41-43
This study is limited as it evaluates an implemented QI
protocol at a single institution and contains a small sample
size. As a tertiary children’s hospital, many of our patients
arrive with imaging already performed at the referring insti-
tution. In the setting of evaluating a postappendectomy pe-
diatric patient, this is typically a CT scan. Therefore, the
cohort of patients that are evaluated primarily at our institu-
tion to assess the implementation of a protocol is much
smaller. Our institution represents a children’s hospital
within a general health system. As such, we share MRI re-
sources with our adjoining adult hospital and therefore have
ready access to this resource 24 h a day and 7 d a week. While
numerous strategies exist to reduce CT radiation, given that
our institution already uses MRI commonly for the preopera-
tive diagnosis of appendicitis, the strategy of adopting MRI for
postappendectomy abscess was an organic next step.
Despite our ability to use MRI to reduce CT scan use in the
diagnosis of postappendectomy abscess, if an abscess is pre-
sent, many of our patients will still receive a focused CT as
part of the CT-guided drainage placement procedure. Our
institutional structure relies on adult trained interventional
radiologists for drainage procedures. There is a preference for
cross-sectional imaging to help assess the accessibility and
extent of the collections. There is concern that ultrasound will
miss small or additional fluid collections.18,19,44 Additionally,
 greene et al  mri quality improvement project 593

Fig. 3 e P-chart demonstrating the proportion of cross-sectional imaging performed by CT scans quarterly from 2015
to 2022.

some providers are not as comfortable using the US during

drainage procedures, particular in children. US-guided pro- Author Contributions
cedures are more commonly practiced by pediatric trained
interventional radiologists in entirely freestanding children’s Study conception and design: AG, LR, AT, MS, MMo, AK. Data
hospitals; however, although pediatric interventional radi- acquisition: AG, MMa, MMo, AK. Analysis and data interpre-
ology has grown, there remain many gaps in pediatric inter- tation: AG, MMa, MMZ, AP, MMo, AK. Drafting of the manu-
ventional radiology availability.45,46 Collectively, these factors script: AG, MMa, MMZ, AP, MMo, AK. Finally, critical revision
limited the integration of US into our postappendectomy im- and editing: AG, MMa, MMZ, AP, LR, AT, MS, MMo, AK.
aging pathway. However, the use of US remains an important
tool and potential area of future refinement of our clinical
pathway. Acknowledgments
Our abscess identification rate with MRI was 79.3% which is
similar to Zens et al. (87.5%) and Lee et al. (66.7%).17,19 Our The authors would like to recognize Lisa McCully for manu-
pathway involves waiting until at least postoperative day 7 script and figure formatting.
prior to any imaging, which likely helped improve the yield of
imaging.34 It is likely that with additional US resources,
Disclosure
screening with US could be considered. However, for this to be
resource effective, it would be important to have interven-
None declared.
tional radiology support comfortable with pursuing drainage
based on this imaging alone. In our study 13 patients received
an US prior to CT or MRI. Almost half of these cases identified
Funding
an abscess, but additional cross-sectional imaging was
requested for comprehensive planning of the drainage
This research did not receive any specific grant from funding
procedure.
agencies in the public, commercial, or not-for-profit sectors.

references
Conclusions

Implementation of a postappendectomy abscess MRI protocol
was associated with decreased CT utilization in the pediatric
population at our institution, while maintaining comparable
diagnostic and clinical outcomes. Working collaboratively
with referring hospitals and community partners, as well as
national consortiums will be important to magnify these ef-
fects. A formal cost-effectiveness evaluation will be required
to better understand the value proposition of different imag-
ing and intervention strategies based on differing institutional
resources.
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