Nationwide study of appendicitis in children

Management and outcomes of acute appendicitis in children with congenital heart disease

BACKGROUND

Congenital heart disease (CHD) care has evolved during the past decades. Advances in care have contributed to improved survival among CHD patients. Children with CHD are requiring interventions for non-CHD related medical issues that occur in the general pediatric population.

METHODS

A retrospective review of the Pediatric Health Information System (PHIS) database from January 1, 2004, to July 31, 2023. Discharges of patients with an admitting/principal diagnosis of appendicitis were evaluated and categorized as CHD or non-CHD.

RESULTS

A total of 319,228 patients were identified with 1,25,858(39.4%) female, 1,38,966(43.5%) white, and median age of 11[IQR:8-14] years. 708(0.2%) had CHD with 85(12%) of them having a diagnosis consistent with single-ventricle CHD (SV-CHD). In univariate analysis, CHD patients were more likely to undergo conservative treatment (n = 172(24.2%)vs n = 59,358(18.6%)) and less likely to undergo laparoscopic appendectomy (n = 483(68.2%) vs n = 2,35,324(73.8%))(p < 0.001) compared to non-CHD. After adjustment, CHD patients had increased odds of undergoing open appendectomy compared to non-CHD. CHD patients were more likely to have an ICU admission (OR:8.36(95%CI 6.35-10.00),p < 0.001) and had a 77.6%(95%CI 40.89-123.93) increase in length of stay (LOS) (p < 0.001).

CONCLUSION

CHD patients are more likely to have an open appendectomy than non-CHD patients. These findings suggest a distinctive pattern in the care of CHD patients compared to non-CHD. Overall, CHD patients had a more intense level of care with longer LOS and increased ICU admissions. Further work is needed to evaluate drivers of management decisions, the role of conservative treatment with antibiotics alone in the CHD population, and the potential impacts and safety of a laparoscopic approach.

SAME day amBulatory c (SAMBA): a multicenter, prospective, randomized clinical trial protocol

BACKGROUND

A recent meta-analysis concluded that outpatient appendectomy appears feasible and safe, but there is a lack of high-quality evidence and a randomized trial is needed. The aim of this trial is to demonstrate that outpatient appendectomy is non-inferior to conventional inpatient appendectomy in terms of overall morbi-mortality on the 30th postoperative day (D30).

METHODS

SAMBA is a prospective, randomized, controlled, multicenter non-inferiority trial. We will include 1400 patients admitted to 15 French hospitals between January 2023 and June 2025. Inclusion criteria are patients aged between 15 and 74 years presenting acute uncomplicated appendicitis suitable to be operated by laparoscopy. Patients will be randomized to receive outpatient care (day-surgery) or conventional inpatient care with overnight hospitalization in the surgery department. The primary outcome is postoperative morbi-mortality at D30. Secondary outcomes include time from diagnosis to appendectomy, length of total hospital stay, re-hospitalization, interventional radiology, re-interventions until D30, conversion from outpatient to inpatient, and quality of life and patient satisfaction using validated questionnaires.

DISCUSSION

The SAMBA trial tests the hypothesis that outpatient surgery (i.e., without an overnight hospital stay) of uncomplicated acute appendicitis is a feasible and reliable procedure in establishments with a technical platform able to support this management strategy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05691348. Registered on 20 January 2023.

Non-operative management of uncomplicated appendicitis in children: a randomized, controlled, non-inferiority study evaluating safety and efficacy

BACKGROUND

Appendicitis is the commonest paediatric surgical emergency. Adult studies suggest non-operative management (NOM) may have a place in care. There have been no adequately powered randomized controlled trials in children.

OBJECTIVE

to determine the safety and efficacy of NOM for paediatric simple appendicitis.

METHODS

A non-inferiority randomized controlled trial was conducted comparing operative (OM) to NOM of SA in children aged five-15 years. Primary outcome was treatment success (no unplanned or unnecessary operation, or complication) at 30 days and 12 months, with a non-inferiority margin of 15%. (anzctr.org.au: ACTRN12616000788471).

RESULTS

From 11 June 2016 to 30 November 2020, 222 children were randomized: 94 (42.34%) to OM and 128 (57.66%) to NOM. Non-inferiority of NOM was not demonstrated at either time point, with 45.67% of NOM patients subsequently undergoing operation. There was no significant difference in complications.

CONCLUSIONS

While noninferiority was not shown, NOM was safe, with no difference in adverse outcomes between the two groups. Further research to refine the place of NOM of simple appendicitis in children is required, including nuanced patient selection, longer term evaluation, the place of choice, and the acceptability of the treatment for children and their carers.

The Risk of Adhesive Bowel Obstruction in Children With Appendicitis: A Systematic Review

OBJECTIVE

Complicated appendicitis is associated with a higher risk of postoperative complications, including adhesive bowel obstruction. The aim of this meta-analysis is to investigate the difference in rates of postoperative bowel obstruction in paediatric patients with complicated versus simple appendicitis and whether this is influenced by the surgical approach.

METHODS

A systematic literature search following PRISMA guidelines was conducted using MEDLINE, Embase and Cochrane Library for studies that analysed incidence of adhesive bowel obstruction in paediatric patients after appendicectomy. Studies from 1998 to 2022 were included in analysis. The study protocol was registered on PROSPERO (ID CRD42022309769).

RESULTS

Pooled analysis of 6 studies with low risk of bias and adequate follow up periods, considering 58,962 cases of appendicectomy, revealed complex appendicitis was associated with a near two-fold increase in incidence of SBO (pooled odds ratio 2.02 (95% CI 1.35-2.69)). Interestingly, a similar pooled analysis of 10 studies, considering 62,433 cases of appendicectomy, revealed no significant difference between open and laparoscopic management of complex appendicitis (pooled odds ratio 0.93 (95% CI 0.24 to 1.62)).

CONCLUSION

Complex appendicitis is associated with a two-fold increase in the rates of adhesive bowel obstruction. Whilst there are cosmetic advantages of a laparoscopic approach, surgical expertise should be favoured in decision making relating to surgical approach (laparoscopic versus open) as the evidence for a laparoscopic approach reducing risks of adhesive bowel obstruction is not convincing.

LEVEL OF EVIDENCE

Level II.

Evaluation of the clinical effects of atropine in combination with remifentanil in children undergoing surgery for acute appendicitis

BACKGROUND

Acute appendicitis (AA) is the most common cause of acute abdomen in children. Anesthesia significantly influences the surgical treatment of AA in children, making the scientific and effective selection of anesthetics crucial.

AIM

To assess the clinical effect of atropine (ATR) in combination with remifentanil (REMI) in children undergoing surgery for AA.

METHODS

In total, 108 cases of pediatric AA treated between May 2020 and May 2023 were selected, 58 of which received ATR + REMI [research group (RG)] and 50 who received REMI [control group (CG)]. Comparative analyses were conducted on the time to loss of eyelash reflex, pain resolution time, recovery time from anesthesia, incidence of adverse events (AEs; respiratory depression, hypoxemia, bradycardia, nausea and vomiting, and hypotension), intraoperative responses (head shaking, limb activity, orientation recovery, safe departure time from the operating room), hemodynamic parameters [oxygen saturation (SPO2), mean arterial pressure, heart rate, and respiratory rate], postoperative sedation score (Ramsay score), and pain level [the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale].

RESULTS

Compared with the CG, the RG showed significantly shorter time to loss of eyelash reflex, pain resolution, recovery from anesthesia, and safe departure from the operating room. Furthermore, the incidence rates of overall AEs (head shaking, limb activity, etc.) were lower, and influences on intraoperative hemodynamic parameters and stress response indexes were fewer. The Ramsay score at 30 min after extubation and the FLACC score at 60 min after extubation were significantly lower in the RG than in the CG.

CONCLUSION

ATR + REMI is superior to REMI alone in children undergoing AA surgery, with a lower incidence of AEs, fewer influences on hemodynamics and stress responses, and better post-anesthesia recovery.

Risk factors for complications after emergency surgery for paediatric appendicitis: a national prospective observational cohort study

Appendicectomy is a common procedure in children with a low risk of mortality, however, complication rates and risk factors are largely unknown. This study aimed to characterise the incidence and epidemiology of postoperative complications in children undergoing appendicectomy in the UK. This multicentre prospective observational cohort study, which included children aged 1-16 y who underwent surgery for suspected appendicitis, was conducted between November 2019 and January 2022. The primary outcome was 30-day postoperative morbidity. Data collected included: patient characteristics; comorbidities; and physiological status. Multivariable regression analysis was used to identify independent risk factors for poor outcomes. Data from 2799 children recruited from 80 hospitals were analysed, of which 185 (7%) developed postoperative complications. Children from black and 'other' minority ethnic groups were at significantly higher risk of poor outcomes: OR (95%CI) 4.13 (1.87-9.08), p < 0.001 and 2.08 (1.12-3.87), p = 0.021, respectively. This finding was independent of socio-economic status and type of appendicitis found on histology. Other risk factors for complications included: ASA physical status ≥ 3 (OR (95%CI) 4.05 (1.70-9.67), p = 0.002); raised C-reactive protein (OR 95%CI 1.01 (1.00-1.01), p < 0.001); pyrexia (OR (95%CI) 1.77(1.20-2.63), p = 0.004); and peri-operative oxygen supplementation (OR (95%CI) 4.20 (1.44-12.24), p = 0.009). In the UK NHS, which is a universally accessible healthcare system, ethnicity, but not socio-economic status, was associated with an increased risk of postoperative complications in children having surgery for acute appendicitis. Further evaluations and interventions are required to address this health inequality in keeping with NHS and international priorities.

Perforated Appendicitis in Children: Management, Microbiology, and Antibiotic Stewardship

Although appendicitis has been described for more than 300 years, its optimal management remains a topic of active investigation. Acute appendicitis is the most common cause of peritonitis in children, and rates of perforated appendicitis are much higher in children than in adults. Increased risk for perforated appendicitis in children is related to a delay in diagnosis due to age, size, access to care, and more. Surgical options include immediate appendectomy versus nonoperative management with intravenous antibiotics ± a drainage procedure, with a subsequent interval appendectomy. Microbiota of perforated appendicitis in children most often includes Escherichia coli, Bacteroides fragilis, Streptococcus, and more. Even though the most common organisms are known, there is a large variety of practice when it comes to postoperative antibiotic management in these patients. Studies discuss the benefits of mono- versus dual or triple therapy without a particular consensus regarding what to use. This is reflected across differing practices at various institutions. In this review, we aim to explore the implications of perforated appendicitis in pediatrics, common organisms seen, antibiotic regimen coverage, and the implications of variations of practice. Resistance to commonly used broad-spectrum antibiotics is evolving, therefore minimization of care variability is needed for improved patient outcomes and proper antibiotic stewardship.

A rare case of cecal foreign body leading to cecal perforation in 12-year-old child: a clinical case report and review of literature

Introduction and importance

Cecal foreign bodies are uncommon causes of acute abdomen, and their presentation can often mimic acute appendicitis (AA), making it challenging to diagnose. The authors present the case of a 12-year-old male from Ethiopia who initially presented with symptoms suggestive of AA. However, during surgery, the authors found a multiple magnetic fields result in perforation. This case highlights the importance of considering unusual etiologies.

Case presentation

A 12-year-old boy with AA associated with anorexia, nausea, and low-grade fever was referred from a private clinic. Otherwise, no history of recent respiratory infection and diarrhea, and was previously in good health. The patient did not report any history of a foreign body (FB), even to his own family, and, except for himself, no one was aware of the ingested FB. The work has been reported in line with the Surgical CAse REport (SCARE) 2023 criteria.

Discussion

In this case, the authors experienced multiple magnetic FB in the cecum, which were not observed on ultrasound (U/S). However, this case closely resembled appendicitis. U/S can aid in differentiation. However, it may not always identify the underlying etiology, specifically in a resource-limited setting.

Conclusion

Based on the patient's presentation, AA was diagnosed and emergency surgery was presumed to be inflamed. However, three magnetic FB were the underlying cause of the presentation, which created pressure on the cecal wall, and the authors successfully performed surgical management. This case reminds us of uncommon etiologies, such as magnets in patients with symptoms of appendicitis. This underscores the importance of an open-minded approach to unexpected findings during surgery.

Trends in Simple and Complex Appendicitis in Children and the Potential Correlation to Common Viral Pathogens-A Retrospective Cohort Study between 2010 and 2019 in The Netherlands

The aim of this study was to evaluate the annual, seasonal and monthly trends in children with simple and complex appendicitis and their correlation to common viral pathogens in the Netherlands. A consecutive multicenter retrospective cohort study was performed between 2010 and 2019 including children (<18 years) surgically treated for appendicitis. The primary outcome was the distribution of children with simple and complex appendicitis per year, season and month. Relevant seasonal variation was defined as ≥5%. The secondary outcome was a positive correlation of the number of patients with simple and complex appendicitis to common viral pathogens (data anonymously provided by the Dutch Working Group on Clinical Virology from the Dutch Society for Clinical Microbiology (NVMM)). In total, 896 patients were included: N = 524 (58%) patients with simple and N = 372 (42%) with complex appendicitis. Of the children aged 0-5 years, 81% had complex appendicitis, versus 38% in 6-18 years (p < 0.001). An overall decline was demonstrated for both simple and complex appendicitis between 2010 and 2019. No seasonal variation was found for simple appendicitis. For complex appendicitis, the highest number of patients was found in spring, and lowest in summer (N = 372, spring 28.2 ± 5.1% versus summer 21.0 ± 5.8%, p = 0.011), but the variance was regarded as not relevant (<5% from baseline). A positive correlation was found between complex appendicitis with Adenovirus 40.41 (R = 0.356, 95%CI 0.045-0.604, p = 0.026) and simple appendicitis with Adenovirus NON 40.41 (R = 0.332, 95%CI 0.019-0.586, p = 0.039), but these correlations did not remain significant after a Bonferroni correction (p < 0.003). In conclusion, we found no relevant seasonal variation for simple or complex appendicitis, nor positive correlation with common viral pathogens.

Reasons for Delayed Diagnosis of Pediatric Acute Appendicitis during the COVID-19 Era: A Narrative Review

Global pandemics cause health system disruptions. The inadvertent disruption in surgical emergency care during the Coronavirus Disease 2019 (COVID-19) pandemic has been the topic of several published studies. Our aim was to summarize the reasons that led to the delayed diagnosis of pediatric appendicitis during the COVID-19 era. This systematic literature search evaluated studies containing pediatric appendicitis patient data regarding outcomes, times to hospital admission or times from symptom onset to emergency department visit. Studies elucidating reasons for delays in the management of pediatric appendicitis were also reviewed. Ultimately, 42 studies were included. Several reasons for delayed diagnosis are analyzed such as changes to public health measures, fear of exposure to COVID-19, increased use of telemedicine, COVID-19 infection with concurrent acute appendicitis, recurrence of appendicitis after non-operative management and increased time to intraoperative diagnosis. Time to hospital admission in conjunction with patient outcomes was extracted and analyzed as an indicative measure of delayed management. Delayed diagnosis of acute appendicitis has been documented in many studies with various effects on outcomes. Suspicion of pediatric acute appendicitis must always lead to prompt medical examination, regardless of pandemic status. Telemedicine can be valuable if properly applied. Data from this era can guide future health system policies.

The impact of delay and prehospital factors on acute appendicitis severity in New Zealand children: a national prospective cohort study

BACKGROUND

Appendicitis is the most common reason children undergo acute general surgery but international, population-level disparities exist. This is hypothesised to be caused by preoperative delay and differential access to surgical care. The impact of prehospital factors on paediatric appendicitis severity in New Zealand is unknown.

METHODS

A prospective, multicentre cohort study with nested parental questionnaire was conducted by a national trainee-led collaborative group. Across 14 participating hospitals, 264 patients aged ≤16 years admitted between January and June 2020 with suspected appendicitis were screened. The primary outcome was the effect of prehospital factors on the American Association for the Surgery of Trauma (AAST) anatomical severity grade.

RESULTS

Overall, 182 children had confirmed appendicitis with a median age of 11.6. The rate of complicated appendicitis rate was 38.5% but was significantly higher in rural (44.1%) and Māori children (54.8%). Complicated appendicitis was associated with increased prehospital delay (47.8 h versus 20.1 h; P < 0.001), but not in-hospital delay (11.3 h versus 13.3 h; P = 0.96). Multivariate analysis revealed increased anatomical severity in rural (OR 4.33, 95% CI 1.78-7.25; P < 0.001), and Māori children (OR 2.39, 95% CI 1.24-5.75; P = 0.019), as well as in families relying on external travel sources or reporting unfamiliarity with appendicitis symptomology.

CONCLUSION

Prehospital delay and differential access to prehospital determinants of health are associated with increased severity of paediatric appendicitis. This manifested as increased severity of appendicitis in rural and Māori children. Understanding the pre-hospital factors that influence the timing of presentation can better inform health-system improvements.

Evaluation of the outcome of right subumbilical transverse incision approach for the management of complicated appendicitis in paediatric age group - A multi-institutional retrospective study

Aim

The aim is to evaluate the outcome of right subumbilical transverse incision approach for the management of complicated appendicitis in paediatric age group.

Materials and Methods

This is a retrospective multi-institutional study which was conducted in the Department of Paediatric Surgery, I Q City Medical College and Hospital, Durgapur, West Bengal, India and the Department of Paediatric Surgery, Rajiv Gandhi Super Speciality Hospital/Raichur Institute of Medical Sciences, Raichur, Karnataka, India. In this study, a review of 77 paediatric patients operated for complicated appendicitis using a right subumbilical transverse incision approach was done for a period of 3 years (from December 2017 to December 2020). All patients had proven complicated appendicular pathology like appendicular perforation, appendicular abscess or complicated appendicular lumps on ultrasonography or computed tomography scan, which mandated exploration.

Results

There was no mortality. Average operative time was 1 h 48 min (ranging from 58 min to 3 h 12 min). Average length of hospital stay was 9 days (ranging from 5 days to 13 days). There was no incidence of fecal fistula. Seventeen (22%) patients developed superficial surgical site infection which subsided with regular dressings. There was no incidence of wound dehiscence or burst abdomen. Five (6.5%) patients required the incision to be extended beyond the midline to the left side to deal with the pathology and to access the entire peritoneal cavity. Nine (11.6%) patients required loop ileostomies, which was fashioned on the lateral aspect of the transverse incision. Only one patient had a doubtful caecal injury which was repaired and loop ileostomy was done. Six patients (7.7%) had adhesive intestinal obstruction postoperatively, of which three required re-exploration. There was no incidence of incisional hernia or any stoma-related complications.

Conclusion

Complicated appendicitis is a condition which lacks standardisation of approach for management, and is inherently associated with complications. However, with a more logical incision and intra-operative approach we can keep the complications to minimum and improve outcomes to great extent in those patients requiring surgical intervention. We have been using the subumbilical transverse incision in all sizes of patients ranging from small children to adolescents with excellent results, and we believe that the same approach can be applied even in adult patients in similar clinical scenarios.

Bacterial pathogens in pediatric appendicitis: a comprehensive retrospective study

Background

Appendicitis is a frequent condition, with peak incidences in the second decade of life. Its pathogenesis is under debate, but bacterial infections are crucial, and antibiotic treatment remains essential. Rare bacteria are accused of causing complications, and various calculated antibiotics are propagated, yet there is no comprehensive microbiological analysis of pediatric appendicitis. Here we review different pre-analytic pathways, identify rare and common bacterial pathogens and their antibiotic resistances, correlate clinical courses, and evaluate standard calculated antibiotics in a large pediatric cohort.

Method

We reviewed 579 patient records and microbiological results of intraoperative swabs in standard Amies agar media or fluid samples after appendectomies for appendicitis between May 2011 and April 2019. Bacteria were cultured and identified via VITEK 2 or MALDI-TOF MS. Minimal inhibitory concentrations were reevaluated according to EUCAST 2022. Results were correlated to clinical courses.

Results

Of 579 analyzed patients, in 372 patients we got 1330 bacterial growths with resistograms. 1259 times, bacteria could be identified to species level. 102 different bacteria could be cultivated. 49% of catarrhal and 52% of phlegmonous appendices resulted in bacterial growth. In gangrenous appendicitis, only 38% remained sterile, while this number reduced to 4% after perforation. Many fluid samples remained sterile even when unsterile swabs had been taken simultaneously. 40 common enteral genera were responsible for 76.5% of bacterial identifications in 96.8% of patients. However, 69 rare bacteria were found in 187 patients without specifically elevated risk for complications.

Conclusion

Amies agar gel swabs performed superior to fluid samples and should be a standard in appendectomies. Even catarrhal appendices were only sterile in 51%, which is interesting in view of a possible viral cause. According to our resistograms, the best in vitro antibiotic was imipenem with 88.4% susceptible strains, followed by piperacillin-tazobactam, cefuroxime with metronidazole, and ampicillin-sulbactam to which only 21.6% of bacteria were susceptible. Bacterial growths and higher resistances correlate to an elevated risk of complications. Rare bacteria are found in many patients, but there is no specific consequence regarding antibiotic susceptibility, clinical course, or complications. Prospective, comprehensive studies are needed to further elicit pediatric appendicitis microbiology and antibiotic treatment.

The global, regional, and national burden of appendicitis in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Appendicitis is the most common abdominal surgical emergency worldwide, and its burden has been changing. We report the level and trends of appendicitis prevalence, and incidence; and years lived with disability (YLD) in 204 countries and territories from 1990 to 2019, based on data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

The numbers and age-standardized prevalence, incidence, and YLD rates per 100,000 population of appendicitis were estimated across regions and countries by age, sex, and sociodemographic index (SDI). All the estimates were reported with 95% uncertainty intervals (UIs).

RESULTS

Globally, the age-standardized prevalence and incidence rates of appendicitis in 2019 were 8.7 (95% UI 6.9 to 11.0) and 229.9 (95% UI 180.9 to 291.0) per 100,000 population, with increases of 20.8% (95% UI 18.9 to 23.0%) and 20.5% (95% UI 18.7 to 22.8%) from 1990 to 2019, respectively. Additionally, the age-standardized YLDs rate was 2.7 (95% UI 1.8 to 3.9) in 2019, with an increase of 20.4% (95% UI 16.2 to 25.1%) from 1990 to 2019. In 2019, the age-standardized prevalence, incidence, and YLD rates peaked in the 15-to-19-year age groups in both male and female individuals. However, no statistically significant differences were observed between the male and female individuals in all groups. Ethiopia, India, and Nigeria showed the largest increases in the age-standardized prevalence rate between 1990 and 2019. Generally, positive associations were found between the age-standardized YLD rates and SDI at the regional and national levels.

CONCLUSIONS

Appendicitis remains a major public health challenge globally. Increasing awareness of appendicitis and its risk factors and the importance of early diagnosis and treatment is warranted to reduce its the burden.

A Bizarre Cause of Acute Appendicitis in a Pediatric Patient: An Ingested Tooth

(1) Background: Among all possible causes, foreign bodies are the rarest cause of appendicitis in the pediatric population. In the majority of cases, ingested foreign bodies pass through the gastrointestinal tract without causing symptoms. However, those foreign bodies that pass through the lumen of the vermiform appendix cannot re-enter the colon and may cause acute appendicitis. So far, various foreign bodies have been described to enter the appendix and cause acute appendicitis, such as seeds, needles, toothpicks, plant material, or even hair. Tooth or dental implants as a cause of acute appendicitis have been described in only a few cases. To our knowledge, this is the first described case of the tooth causing acute appendicitis in the pediatric population. (2) Case presentation: A 14-year-old male patient presented to the emergency department complaining of pain in the right lower quadrant of the abdomen and vomiting that persisted for approximately 24 h. Until then, the patient was healthy and had no concomitant diseases. Physical examination revealed guarding and tenderness in the right lower abdominal quadrant. The white blood cell count was 17.1 × 109/L with a neutrophil count of 91.1% and a C-reactive protein of 39.3 mg/dL. Ultrasonography of the abdomen revealed a thickened, inflamed appendix with a diameter of 11 mm and free periappendicular fluid. A 9 × 6 mm foreign body at the base of the appendix was visualized. The patient was diagnosed with acute appendicitis, and an emergency laparoscopic appendectomy was performed on the same day. Intraoperatively, gangrenous appendicitis was noted and removed without complications. Upon examination of the removed specimen, it was determined that the patient's appendicitis had been caused by an ingested tooth. As it later turned out, the patient had broken a lateral incisor while playing sports the day before admission without knowing that he had swallowed it. The patient recovered well and was discharged the day after surgery. (3) Conclusion: Although an extremely rare event, acute appendicitis can be caused by a swallowed tooth. This case highlights the importance of a thorough history in pediatric patients who present to the emergency department with suspected acute appendicitis to determine if there is a precipitating event that may have caused acute appendicitis.

Use of a bipolar device (LigaSure) to seal the appendiceal stump in pediatric laparoscopic appendectomy: 10-year Latin-American experience

BACKGROUND

Closure of the appendiceal stump is a critical step during an appendectomy. There is a lack of knowledge about the feasibility of using electrosurgical devices for the occlusion of the appendix. This study aims to determine the safety of this technique in pediatric patients.

METHODS

We performed a cross-sectional analytical study in patients less than 18 years of age treated at Hospital Militar Central Colombia between 2012 and 2021. Our institution's ethics committee approved the study. We analyzed the data using SPSS 22 statistical program. We present frequencies for qualitative variables and measures of central tendency or dispersion for quantitative variables depending on the distribution measured by the Kolmogorov-Smirnov test. In addition, we measured the association of nominal variables with the Chi-square test or Fisher's exact test. For numerical variables, the difference of means with the Student's t-test or the difference of medians with the Mann-Whitney U test.

RESULTS

We treated 209 patients. One hundred sixteen (55.5%) were boys, and the mean age was 9.7 years (SD 3.2). The median intraoperative time was 60 min, and the hospital stay was 2.8 days on average. There were no cases of stump leakage, and only two patients (1%) had an organ-space surgical site infection, which was unrelated to the closure technique. We found no association between procedural complications and appendicular status (p = 0.450).

CONCLUSIONS

Our research suggests that using a bipolar sealing device (Ligasure, Medtronic, USA) for appendiceal stump closure in pediatric patients undergoing laparoscopic appendectomy is feasible and should be further studied.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Parasites in surgically removed appendices as a neglected public health concern: a systematic review and meta-analysis

The role of various parasitic infections in the occurrence of appendicitis is illustrated through cases recorded all over the world. The purpose of the current study was to estimate the global prevalence of parasite infestation (other than E. vermicularis) in appendectomy specimens.In the setting of the PRISMA guidelines, multiple databases (Science Direct, Scopus, Web of Science, PubMed, and Google Scholar) were explored in articles published until 28 September 2020. Totally, 62 studies (106 datasets) with 77, 619 participants were included in the analysis.The pooled prevalence of parasites in appendectomy samples was as follows; 0.012% (95% CI; 0.004-0.025) for Ascaris lumbricoides, 0.004% (95% CI; 0.001-0.009) for Trichuris trichiura, 0.025% (95% CI; 0.007-0.052) for Schistosoma mansoni, 0.002% (95% CI; 0.001-0.005) for Taenia spp., 0.061% (95% CI; 0.020-0.122) for Entamoeba histolytica and 0.034% (95% CI; 0.018-0.056) for Giardia lamblia.Our results demonstrated that the risk of appendicitis may increase in the presence of helminth and protozoan infections. As such, the most cases of parasites in appendectomy specimens were reported in developing countries. Regular screening plans for diagnosis, treatment and prevention are needed for prevention of parasitic infection as well as parasitic associated appendicitis, especially in endemic regions of the world.

Presurgical time and associated factors as predictors of acute perforated appendicitis: a prospective cohort study in a teaching pediatric hospital in Colombia

Background

We aim to determine the association between out and in-hospital factors with time, from the beginning of the symptoms to the surgery, in patients with acute appendicitis treated at Fundación Hospital Pediatrico La Misericordia (HOMI) in Colombia.

Methods

Eleven month prospective cohort study of pediatric patients at HOMI with acute appendicitis diagnosis taken to surgery. Data from the out-of-hospital phase was collected by surveying parents, and the data regarding the in-hospital phase was completed with medical records. We analyzed the association between the time from the beginning of the symptoms to the surgery, and out and in-hospital factors associated with this time using generalized linear models.

Results

Eight hundred three patients were included in the study. Total pre-surgical time was longer in perforated appendicitis (PA) group (2.65 days, standard deviation (SD) 1.88 vs. 2.04 days, SD 1.45) (p < 0.01). Factors associated with longer total and out-of-hospital presurgical times were age under 4 years old, lower socioeconomic status, father as a caregiver, self-medication, and underestimating disease severity.

Conclusions

Out-of-hospital timing determines the longer pre-surgical time in complicated appendicitis. Younger age and lower socioeconomic status affect time significantly. We suggest the implementation of strategies in order to lower prehospital time, rates, and costs of complicated appendicitis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03121-8.

Nationwide paediatric cohort study of a protective association between allergy and complicated appendicitis

BACKGROUND

In a nationwide cohort the potentially protective association between allergy and complicated appendicitis was analysed, and the influence of seasonal antigens, antihistamine treatment, and timing of allergy onset assessed.

METHODS

Some 1 112 571 children born between 2000 and 2010 were followed from birth until the end of 2014. A cross-sectional analysis of appendicitis cases, with comparison of allergic versus non-allergic children for absolute risk and odds of complicated appendicitis was first undertaken. This was followed by a longitudinal analysis of children with allergy and matched controls who had never had an allergy, for incidence rate and hazard of subsequent complicated or simple appendicitis.

RESULTS

Of all children, 20.4 per cent developed allergy and 0.6 per cent had appendicitis during follow-up. Among children with appendicitis, complicated appendicitis was more common among non-allergic children (18.9 per cent, 948 of 5016) than allergic children (12.8 per cent, 173 of 1351) (P < 0.001), and allergic children had a lower adjusted odds of complicated appendicitis (adjusted odds ratio (OR) 0.80, 95 per cent c.i. 0.67 to 0.96; P = 0.021). The risk of complicated appendicitis among children with manifest allergy was reduced by one-third in the longitudinal analysis (incidence rate 0.13 versus 0.20 per 1000 person-years; hazard ratio (HR) 0.68, 95 per cent c.i. 0.58 to 0.81; P < 0.001), whereas the risk of simple appendicitis remained unchanged (incidence rate 0.91 versus 0.91; HR 1.00, 0.94 to 1.07; P = 0.932). Seasonal antigen exposure was a protective factor (adjusted OR 0.82, 0.71 to 0.94; P = 0.004) and ongoing antihistamine medication a risk factor (adjusted OR 2.28, 1.21 to 4.28; P = 0.012).

CONCLUSION

Children with allergy have a lower risk of complicated appendicitis, but the same overall risk of simple appendicitis. Seasonal antigen exposure reduced, and antihistamine treatment increased, the risk of complicated disease.

A Nationwide Cohort Study of Outcome after Pediatric Appendicitis

INTRODUCTION

 Children with appendicitis often present with complicated disease. The aim of this study was to describe the clinical management of pediatric appendicitis, and to report how disease severity and operative modality are associated with short- and long-term risks of adverse outcome.

MATERIALS AND METHODS

 A nationwide retrospective cohort study of all Swedish children (<18 years) diagnosed with appendicitis, 2001 to 2014 (n = 38,939). Primary and secondary outcomes were length of stay, surgical site infections, readmissions, 30-day mortality, and long-term risk of surgery for small bowel obstruction (SBO). Implications of complicated disease and operative modality were assessed with adjustment for age, gender, and trends over time.

RESULTS

 Complicated appendicitis was associated with longer hospital stay (4 vs. 2 days, p < 0.001), increased risk of surgical site infection (5.9 vs. 2.3%, adjusted odds ratio [aOR]: 2.64 [95% confidence interval, CI: 2.18-3.18], p < 0.001), readmission (5.5 vs. 1.2, aOR: 4.74 [95% CI: 4.08-5.53], p < 0.001), as well as long-term risk of surgery for SBO (0.7 vs. 0.2%, adjusted hazard ratio [aHR]: 3.89 [95% CI: 2.61-5.78], p < 0.001). Intended laparoscopic approach was associated with reduced risk of surgical site infections (2.3 vs. 3.1%, aOR: 0.74 [95% CI: 0.62-0.89], p = 0.001), but no overall reduction in risk for SBO; however, successful laparoscopic appendectomy was associated with less SBO during follow-up compared with open appendectomy (aHR: 0.27 [95% CI: 0.11-0.63], p = 0.002).

CONCLUSION

 Children treated for complicated appendicitis are at risk of substantial short- and long-term morbidities. Fewer surgical site infections were seen after intended laparoscopic appendectomy, compared with open appendectomy, also when converted procedures were accounted for.

Rates of Complications After Appendectomy in Children and Adolescents: Pediatric Surgical Compared to General Surgical Hospitals

BACKGROUND

Appendectomies in children and adolescents are performed in Germany in pediatric surgical (PS) or general surgical hospitals (GS). The aim of this study is to evaluate whether the surgery in a PS or GS hospital has an influence on the postoperative course after appendectomy in children and adolescents.

MATERIALS AND METHODS

Nationwide routine data from children and adolescents aged 1-17 y insured by the Local Health Insurance Fund who underwent appendectomy between 2014 and 2016 were analyzed (cohort study). Descriptive statistics were calculated both overall and in the two groups (PS and GS). Patients were additionally examined by age (1-5, 6-12, and 13-17 y), treatment (laparoscopic, open surgical, and conversion), and appendicitis type (nonacute: K36/K37/K38/R10, acute simple: K35.30/K35.8, and acute complex: K35.2/K35.31/K35.32). The influence of surgeon specialization on 90-d secondary surgery and 90-d general complications was assessed by multiple logistic regression.

RESULTS

Altogether, 25,065 patients who underwent surgery in 83 PS and 906 GS hospitals were included. Logistic regression analysis revealed that PS was associated with a reduced risk of interventions in the 1-5- and 6-12-y age groups (odds ratio: 0.44, 0.62). Acute complex appendicitis, comorbidities, and open surgery significantly increased the risk for reintervention. PS was associated with an increased risk for complications in the 13-17-y age group (odds ratio: 1.66).

CONCLUSIONS

PS and GS hospitals provided safe appendectomies in children and adolescents with low reintervention and complication rates. PS hospitals demonstrated advantages for patients in the 1-5- and 6-12-y age groups and GS hospitals for patients 13-17 y.

Adhesive small bowel obstruction after appendectomy in children - Laparoscopic versus open approach

BACKGROUND

The aims of this study were to compare the incidence of small bowel obstruction (SBO) requiring laparotomy after laparoscopic appendectomy (LA) and open appendectomy (OA) in children and to identify risk factors for SBO.

METHODS

Medical records of patients who underwent appendectomy from 2000 to 2014 at our department of Pediatric Surgery were reviewed. Risk factors were analyzed using Cox proportional hazard regression.

RESULTS

Totally 619 out of 840 patients were included. OA was performed in 474 (76.6%), LA in 130 patients (21%), and 15 (2.4%) were converted from LA to OA. Age, sex and proportion of perforated appendicitis were comparable in the LA and OA groups. Median follow-up time was 11.4 years (2.6-18.4). The incidence of SBO after LA was 1.5%, after OA 1.9% and in the converted group 6.7% (p = 0.3650). There were no significant differences in the incidence of postoperative intraabdominal abscess, wound infection or length of stay between LA and OA. Perforation and postoperative intra-abdominal abscess were identified as risk factors with 9.03 (p < 0.001) and 6.98 (p = 0.004) times higher risk of SBO, respectively.

CONCLUSIONS

The risk for SBO after appendectomy in children was significantly related to perforated appendicitis and postoperative intra-abdominal abscess and not to the surgical approach.

LEVEL OF EVIDENCE

Level III.

Ultrastructural Changes of Blood Cells in Children with Generalized Purulent Peritonitis: A Cross-Sectional and Prospective Study

In conditions of abdominal sepsis with indications of first- or second-stage shock, blood cells undergo significant ultrastructural changes that cause impaired gas exchange, changes in reactivity, and decompensation of organs and systems functions. This paper presents a cross-sectional prospective study aimed at researching the ultrastructure of blood cells in children experiencing abdominal septic shock against the background of generalized purulent peritonitis of appendicular origin. This study was conducted with 15 children aged 6-12 who were undergoing treatment for generalized appendicular purulent peritonitis, with first- or second-stage abdominal septic shock, in emergency care. The changes in the ultrastructure of erythrocytes did not correspond to changes characteristic of eryptosis, which confirms their occurrence under the influence of such pathogenic factors as intoxication, metabolic, water-electrolyte balance, and acid-base disorders. Ultrastructural changes of granulocytes indicate their hyperactivation, which leads to the exhaustion of membrane synthetic resources, membrane destruction, ineffective expenditure of bactericidal factors on substrates that are not subject to destruction. In lymphocytes, disorganization of the nuclear membrane and intracellular membranes, uneven distribution of chromatin, the hypertrophied Golgi apparatus, and a large number of young mitochondria, lysosomes, ribosomes, vesicles manifesting the disruption of metabolism, stress and decompensation of energy supply and protein synthesis systems, have been demonstrated. In conditions of abdominal sepsis with indications of first- or second-stage shock, blood cells undergo substantial ultrastructural changes causing gas exchange disruption, changes in reactivity, as well as decompensation of organs and system functioning.

How boys and testicles wander to surgery: a nationwide cohort study of surgical delay in Sweden

BACKGROUND

Early orchidopexy is recommended for cryptorchidism and the surgery is increasingly centralised. The objectives were to determine the incidence, risk factors and if distance to treating hospital impacted on timely treatment of cryptorchidism.

METHODS

In this observational study, all boys born in Sweden from 2001 to 2014 were followed in national registers to determine the incidence of cryptorchidism by levels of birth-related risk factors and social determinants. Travel time to hospital was used as the primary exposure in multivariable survival analysis, with age at surgery as main outcome.

RESULTS

Of 748 678 boys at risk for cryptorchidism, 7351 were treated and evaluated for timing of surgery (cumulative childhood incidence 1.4%, 95% CI 1.3% to 1.5%). The incidence was clearly associated with prematurity and overdue pregnancy (HR for <32 weeks 2.77 (95% CI 2.39 to 3.21); 32-36 weeks HR 1.36 (95% CI 1.24 to 1.49); >41 weeks HR 1.19 (95% CI 1.10 to 1.29)), low birth weight (<1000 g HR 3.94 (95% CI 3.15 to 4.92); 1000-1499 g HR 3.70 (95% CI 3.07 to 4.46); 1500-2500 g HR 1.69 (95% CI 1.52 to 1.88)) and intrauterine growth restriction (small for gestational age HR 2.38 (95% CI 2.14 to 2.65); large for gestational age HR 1.26 (95% CI 1.13 to 1.42)), but not with smoking or maternal age. Each 30 min increase in travel time was associated with a reduced probability of timely treatment (HR for being treated by age 3 adjusted for risk factors and socioeconomic determinants: 0.91 (95% CI 0.88 to 0.95)). Lower income and financial support were also associated with treatment delays (adjusted HR for lowest income quintile 0.82 (95% CI 0.72 to 0.93) and for families with financial support 0.85 (95% CI 0.73 to 0.97)).

CONCLUSIONS

Travel distance to treating hospital was associated with delayed treatment. 'Not all those who wander are lost', but these findings suggest a trade-off between centralisation benefits and barriers of geography also in elective paediatric surgery.

Management of complicated acute appendicitis in children: Still an existing controversy

Complicated acute appendicitis (CAA) is a serious condition and carries significant morbidity in children. A strict diagnosis is challenging, as there are many lesions that mimic CAA. The management of CAA is still controversial. There are two options for treatment: Immediate operative management and non-operative management with antibiotics and/or drainage of any abscess or phlegmon. Each method of treatment has advantages and disadvantages. Operative management may be difficult due to the presence of inflamed tissues and may lead to detrimental events. In many cases, non-operative management with or without drainage and interval appendectomy is advised. The reasons for this approach include new medications and policies for the use of antibiotic therapy. Furthermore, advances in radiological interventions may overcome difficulties such as diagnosing and managing the complications of CAA without any surgeries. However, questions have been raised about the risk of recurrence, prolonged use of antibiotics, lengthened hospital stay and delay in returning to daily activities. Moreover, the need for interval appendectomy is currently under debate because of the low risk of recurrence. Due to the paucity of high-quality studies, more randomized controlled trials to determine the precise management strategy are needed. This review aims to study the current data on operative vs non-operative management for CAA in children and to extract any useful information from the literature.

Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines

BACKGROUND AND AIMS

Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.

METHODS

This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.

CONCLUSIONS

The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.