Fast-track surgery for acute appendicitis in children: a systematic review of protocol-based care.

Background: 'Fast-track' surgery protocols aim to standardize and rationalize post-operative care, with evidence of safety and efficacy in both uncomplicated and complicated childhood appendicitis. Generalization for broader adoption has been limited by variation in protocol design, including specific antibiotic choice, discharge criteria, post-operative monitoring and patient selection.

Methods: A systematic review of the literature was performed to evaluate the current evidence underpinning fast-track protocols for childhood appendicitis and identify areas of consensus and controversy.

Results: About 33 studies met the inclusion criteria, including four prospective observational studies, 20 case-control studies, seven cohort studies and two randomized controlled trials studying uncomplicated (n = 9), complicated (n = 18) and mixed cohorts (n = 6). Reduction in length of hospital stay was almost universally reported, with equivalent or improved complication rates. Key themes of protocols included antibiotic choice and duration, discharge criteria and post-operative laboratory and radiographic testing. Rationalized analgesia is an underexplored aspect of protocol design, and a standardized definition of complicated appendicitis remains elusive.

Conclusion: Standardized care of childhood appendicitis has been shown to be safe and effective in several local and international centres. Next steps include investigation of a complicated appendicitis protocol that integrates rationalized analgesia in appendicectomy recovery, and development of a consistent classification scheme for complicated disease to aid in identification of amenable cohorts.