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Acute appendicitis in children: the goal posts have moved

Wilson et al.’s paper and the editorial (also by a paediatric surgeon) ask what has changed in the last decade when it comes to children with acute appendicitis, but fail to deal with the elephant in the room. General surgeons are comfortable diagnosing and managing adults with suspected acute appendicitis. We keep up to date. We are only too well aware of the potential difficulties of diagnosis of the acute abdomen in a child and a recent coronial report lays bare the tragedy that may occur. Medical students are taught that children are not little adults. The diagnosis is the challenge. Wilson et al.’s paper deals exclusively with patients who underwent appendicectomy, but does not quantify the group of children who did not undergo surgery. Even at the Westmead Hospital for Children, one in seven children underwent a non-therapeutic appendicectomy in 2009. This rate is higher in non-specialist centres. When complications occur, it is our legal system that opines whether the decision to operate was correct. The legal system also dictates the consent process. A recent coronial judgement may impact on how we investigate patients. The 12-point plan for emergency surgery by General Surgeons Australia makes no mention of paediatric emergency surgery, despite the fact that in many hospitals (regional and outer metropolitan), general surgeons are required to perform emergency paediatric surgery, have substantial experience and do it well. Our actions as general surgeons are judged with the benefit of hindsight by the legal system. Until such time as The College provides concrete guidelines, children will continue to be transferred because the goal posts have moved and surgeons have changed their game to match.