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Hori T, Machimoto T, Kadokawa Y, Hata T, Ito T, Kato S, Yasukawa D, Aisu Y, Kimura Y, Sasaki M, Takamatsu Y, Kitano T, Hisamori S, Yoshimura T. Laparoscopic appendectomy for acute appendicitis: How to discourage surgeons using inadequate therapy. World J Gastroenterol 2017; 23:5849-5859. [PMID: 28932077 PMCID: PMC5583570 DOI: 10.3748/wjg.v23.i32.5849] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/25/2017] [Accepted: 08/02/2017] [Indexed: 02/06/2023] Open
Abstract
Acute appendicitis (AA) develops in a progressive and irreversible manner, even if the clinical course of AA can be temporarily modified by intentional medications. Reliable and real-time diagnosis of AA can be made based on findings of the white blood cell count and enhanced computed tomography. Emergent laparoscopic appendectomy (LA) is considered as the first therapeutic choice for AA. Interval/delayed appendectomy at 6-12 wk after disease onset is considered as unsafe with a high recurrent rate during the waiting time. However, this technique may have some advantages for avoiding unnecessary extended resection in patients with an appendiceal mass. Non-operative management of AA may be tolerated only in children. Postoperative complications increase according to the patient’s factors, and temporal avoidance of emergent general anesthesia may be beneficial for high-risk patients. The surgeon’s skill and cooperation of the hospital are important for successful LA. Delaying appendectomy for less than 24 h from diagnosis is safe. Additionally, a semi-elective manner (i.e., LA within 24 h after onset of symptoms) may be paradoxically acceptable, according to the factors of the patient, physician, and institution. Prompt LA is mandatory for AA. Fortunately, the Japanese government uses a universal health insurance system, which covers LA.
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Affiliation(s)
- Tomohide Hori
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
| | - Takafumi Machimoto
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
| | - Yoshio Kadokawa
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
| | - Toshiyuki Hata
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
| | - Tatsuo Ito
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
| | - Shigeru Kato
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
| | - Daiki Yasukawa
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
| | - Yuki Aisu
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
| | - Yusuke Kimura
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
| | - Maho Sasaki
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
| | - Yuichi Takamatsu
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
| | - Taku Kitano
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
| | - Shigeo Hisamori
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
| | - Tsunehiro Yoshimura
- Department of Gastrointestinal Surgery, Tenriyorodusoudanjyo Hospital, Tenri, Nara 632-8552, Japan
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102
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Affiliation(s)
- Sandra Werner
- Case Western Reserve University School of Medicine, Cleveland, OH; Department of Emergency Medicine, MetroHealth Medical Center, Cleveland, OH.
| | - Andy Grock
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine, LAC + USC, Los Angeles, CA
| | - Jessica Mason
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, CA
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Hall NJ, Eaton S, Abbo O, Arnaud AP, Beaudin M, Brindle M, Bütter A, Davies D, Jancelewicz T, Johnson K, Keijzer R, Lapidus-Krol E, Offringa M, Piché N, Rintala R, Skarsgard E, Svensson JF, Ungar WJ, Wester T, Willan AR, Zani A, St Peter SD, Pierro A. Appendectomy versus non-operative treatment for acute uncomplicated appendicitis in children: study protocol for a multicentre, open-label, non-inferiority, randomised controlled trial. BMJ Paediatr Open 2017; 1:bmjpo-2017-000028. [PMID: 29637088 PMCID: PMC5843002 DOI: 10.1136/bmjpo-2017-000028] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 04/26/2017] [Accepted: 04/27/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Appendectomy is considered the gold standard treatment for acute appendicitis. Recently the need for surgery has been challenged in both adults and children. In children there is growing clinician, patient and parental interest in non-operative treatment of acute appendicitis with antibiotics as opposed to surgery. To date no multicentre randomised controlled trials that are appropriately powered to determine efficacy of non-operative treatment (antibiotics) for acute appendicitis in children compared with surgery (appendectomy) have been performed. METHODS Multicentre, international, randomised controlled trial with a non-inferiority design. Children (age 5-16 years) with a clinical and/or radiological diagnosis of acute uncomplicated appendicitis will be randomised (1:1 ratio) to receive either laparoscopic appendectomy or treatment with intravenous (minimum 12 hours) followed by oral antibiotics (total course 10 days). Allocation to groups will be stratified by gender, duration of symptoms (> or <48 hours) and centre. Children in both treatment groups will follow a standardised treatment pathway. Primary outcome is treatment failure defined as additional intervention related to appendicitis requiring general anaesthesia within 1 year of randomisation (including recurrent appendicitis) or negative appendectomy. Important secondary outcomes will be reported and a cost-effectiveness analysis will be performed. The primary outcome will be analysed on a non-inferiority basis using a 20% non-inferiority margin. Planned sample size is 978 children. DISCUSSION The APPY trial will be the first multicentre randomised trial comparing non-operative treatment with appendectomy for acute uncomplicated appendicitis in children. The results of this trial have the potential to revolutionise the treatment of this common gastrointestinal emergency. The randomised design will limit the effect of bias on outcomes seen in other studies. TRIAL REGISTRATION NUMBER clinicaltrials.gov: NCT02687464. Registered on Jan 13th 2016.
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Affiliation(s)
- Nigel J Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, Hampshire, UK
| | - Simon Eaton
- Developmental Biology & Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Olivier Abbo
- Pediatric Surgery Department, Hôpital des Enfants, Centre Hospitalier Universitaire Toulouse, Toulouse, France
| | - Alexis P Arnaud
- Paediatric Surgery Department, Hôpital Sud, Centre Hospitalier Universitaire, Rennes, France
| | - Marianne Beaudin
- Division of PediatricSurgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Mary Brindle
- Departments of Surgery and Community Health Sciences, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Andreana Bütter
- Division of Pediatric Surgery, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Dafydd Davies
- Department of General and Thoracic Surgery, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kathy Johnson
- Department of Surgery, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Richard Keijzer
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eveline Lapidus-Krol
- Division of Thoracic and General Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Nelson Piché
- Division of PediatricSurgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Risto Rintala
- Department of Pediatric Surgery, Children's Hospital, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Erik Skarsgard
- Department of Surgery, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Jan F Svensson
- Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Wendy J Ungar
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Tomas Wester
- Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Andrew R Willan
- Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada
| | - Augusto Zani
- Division of Thoracic and General Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Agostino Pierro
- Division of Thoracic and General Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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Sherratt FC, Eaton S, Walker E, Beasant L, Blazeby JM, Young B, Crawley E, Wood WW, Hall NJ. Development of a core outcome set to determine the overall treatment success of acute uncomplicated appendicitis in children: a study protocol. BMJ Paediatr Open 2017; 1:e000151. [PMID: 29637158 PMCID: PMC5862231 DOI: 10.1136/bmjpo-2017-000151] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/20/2017] [Accepted: 07/24/2017] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION In recent years, there has been growing interest in alternatives to appendicectomy. In particular, non-operative treatment of appendicitis, with antibiotics alone, has been proposed as a potential treatment. A small number of randomised controlled trials (RCTs) in adults and, more recently, children suggest that antibiotic treatment may be a valid alternative to appendicectomy. However, there is currently insufficient data to justify its widespread use. Prior to performing further efficacy studies of the treatment of appendicitis in children, it is imperative to identify the most relevant outcome measures for inclusion in the design of comparative studies. This is of particular importance when evaluating a novel treatment approach since the outcomes of importance may differ from those commonly reported with traditional therapies.A review of the relevant literature and electronic resources failed to identify a core outcome set (COS) for children with appendicitis. We aim to define a COS for the measurement of treatment interventions in children (<18 years) with acute appendicitis. METHODS AND ANALYSIS This project will entail: (1) a systematic review to identify previously reported acute uncomplicated appendicitis treatment outcomes; (2) assembly of stakeholder panels (paediatric and adult surgeons, patients and parents); (3) a three-stage Delphi process; and (4) a final consensus meeting to complete the COS. ETHICS AND REGISTRATION COS development is part of CONservative TReatment of Appendicitis in Children - a randomised controlled Trial (Feasibility) (CONTRACT) study, for which full ethical approval for CONTRACT has been granted. The COS development study is registered with the COMET Initiative in May 2017 (http://www.comet-initiative.org/studies/details/987).
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Affiliation(s)
- Frances C Sherratt
- Department of Psychological Sciences, Institute of Psychology, Health & Society, University of Liverpool, Liverpool, UK
| | - Simon Eaton
- Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Erin Walker
- Great Ormond Street Hospital NHS Foundation Trust, London, London, UK
| | - Lucy Beasant
- Centre for Child and Adolescent Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- Centre for Surgical Research, School of Social & Community Medicine, University of Bristol, Bristol, UK
| | - Bridget Young
- Department of Psychological Sciences, Institute of Psychology, Health & Society, University of Liverpool, Liverpool, UK
| | - Esther Crawley
- Centre for Child and Adolescent Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Wendy W Wood
- Research Design Services South Central, University of Southampton, Southampton, UK
| | - Nigel J Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
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