Risk stratification in pediatric perforated appendicitis: Prospective correlation with outcomes and resource utilization Yasmine Yousef, Fouad Youssef, Trish Dinh, Kartikey Pandya, Hayden Stagg, Michael Homsy, Robert Baird, Jean-Martin Laberge, Dan Poenaru, Pramod Puligandla, Kenneth Shaw, Sherif Emil ⁎ Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada abstract article info Article history: Received 2 November 2017 Accepted 8 November 2017 Available online xxxx Key words: Appendicitis Perforation Grade Outcomes Resource utilization Purpose: Despite a wide spectrum of severity, perforated appendicitis in children is typically considered a single entity in outcomes studies. We performed a prospective cohort study to define a risk stratification system that correlates with outcomes and resource utilization. Methods: A prospective study was conducted of all children operated for perforated appendicitis between May 2015 and December 2016 at a tertiary free-standing university children's hospital. Surgical findings were classi- fied into one of four grades of perforation: I. localized or contained perforation, II. Contained abscess with no gen- eralized peritonitis, III. Generalized peritonitis with no dominant abscess, IV. Generalized peritonitis with one or more dominant abscesses. All patients were treated on a clinical pathway that involved all points of care from ad- mission to final follow-up. Outcomes and resource utilization measures were analyzed using Fisher's exact test, Kruskal–Wallis test, One-way ANOVA, and logistic regression. Results: During the study period, 122 patients completed treatment, and 100% had documented follow-up at a median of 25 days after operation. Grades of perforation were: I, 20.5%; II, 37.7%; III, 10.7%; IV, 31.1%. Postopera- tive abscesses occurred in 12 (9.8%) of patients, almost exclusively in Grade IV perforations. Hospital stay, dura- tion of antibiotics, TPN utilization, and the incidence of postoperative imaging significantly increased with increasing grade of perforation. Conclusion: Outcomes and resource utilization strongly correlate with increasing grade of perforated appendici- tis. Postoperative abscesses, additional imaging, and additional invasive procedures occur disproportionately in patients who present with diffuse peritonitis and abscess formation. The current stratification allows risk- adjusted outcome reporting and appropriate assignment of resource burden. Level of evidence: I (Prognosis Study). © 2017 Elsevier Inc. All rights reserved. Appendicitis is the most common acute surgical disease encoun- tered by pediatric surgeons [1]. Perforated appendicitis (PA) comprises approximately 25%–30% of appendicitis cases and has historically been considered a single disease entity despite important disparities in out- comes and resource utilization [1,2]. Current clinical scoring systems for appendicitis, such as the Pediat- ric Appendicitis Score and the Alvarado score, focus on diagnosis of the disease, rather than its severity [3,4]. Attempts have also been made to achieve a standard definition for perforated appendicitis [5]. However, a recent review of the outcomes of perforated appendicitis in the NSQIP pediatric database revealed persistent significant variability in the outcomes of perforated appendicitis owing to lack of utilization of an evidence-based definition [6]. Every surgeon who treats appendicitis knows that perforated appendicitis represents a wide spectrum of dis- ease, from early perforations with minimal peritoneal contamination to late perforations with abscess formation and diffuse fibrinopurulent peritonitis. Yet, this spectrum is not objectively defined or widely used in outcomes reporting or assessment of treatment protocols. Our group has been interested in decreasing variability of care in pe- diatric perforated appendicitis for the last three decades [7–10]. During the last several years, we have focused our work on evidence-based def- initions of disease severity and analysis of outcome determinants [10–12]. In the current study, we prospectively validated the ability of a grading system for perforated appendicitis to predict outcomes and resource utilization associated with treatment of the disease. We Journal of Pediatric Surgery xxx (2017) xxx–xxx ⁎ Corresponding author at: Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, 1001 Decarie Blvd, Room B04.2028, Montreal, Quebec H4A 3J1, Canada. Tel.: +1 514 412 4497; fax: +1 514 412 4289. E-mail address: sherif.emil@mcgill.ca (S. Emil). https://doi.org/10.1016/j.jpedsurg.2017.11.023 0022-3468/© 2017 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg Please cite this article as: Yousef Y, et al, Risk stratification in pediatric perforated appendicitis: Prospective correlation with outcomes and resource utilization, J Pediatr Surg (2017), https://doi.org/10.1016/j.jpedsurg.2017.11.023