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Jeski MA, Stanger JD, Schafer MS, Osten AW, Conners GP. Reducing Post-Operative Hospital Length of Stay following Uncomplicated Appendectomy in Pediatric Patients: A Prospective Clinical Study. Healthcare (Basel) 2024; 12:474. [PMID: 38391848 PMCID: PMC10888031 DOI: 10.3390/healthcare12040474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/01/2024] [Accepted: 02/12/2024] [Indexed: 02/24/2024] Open
Abstract
An uncomplicated appendectomy in children is common. Safely minimizing the post-operative length of stay is desirable from hospital, patient, and parent perspectives. In response to an overly long mean length of stay following uncomplicated appendectomies in children of 2.5 days, we developed clinical pathways with the goal of safely reducing this time to 2.0 or fewer days. The project was conducted in an urban, academic children's hospital. The pathways emphasized the use of oral, non-narcotic pain medications; the education of parents and caregivers about expectations regarding pain control, oral food intake, and mobility; and the avoidance of routine post-operative antibiotic use. A convenience sample of 46 patients aged 3-16 years old was included to evaluate the safety and efficacy of the intervention. The mean post-operative length of stay was successfully reduced by 80% to 0.5 days without appreciable complications associated with earlier discharge. The hospital length of stay following an uncomplicated appendectomy in children may be successfully and safely reduced through the use of carefully devised, well-defined, well-disseminated clinical pathways.
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Affiliation(s)
- Michelle A Jeski
- Department of Nursing, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
- School of Nursing, Quinnipiac University, Hamden, CT 06518, USA
| | - Jennifer D Stanger
- Department of Surgery, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
| | - Melissa S Schafer
- Department of Pediatrics, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
| | - Andrew W Osten
- Department of Pediatrics, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
- Department of Emergency Medicine, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
| | - Gregory P Conners
- Department of Pediatrics, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
- Department of Emergency Medicine, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
- Department of Public Health and Preventive Medicine, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
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2
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Lipsett SC, Monuteaux MC, Shanahan KH, Bachur RG. Nonoperative Management of Uncomplicated Appendicitis. Pediatrics 2022; 149:186782. [PMID: 35434736 DOI: 10.1542/peds.2021-054693] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Several studies have revealed the success of nonoperative management (NOM) of uncomplicated appendicitis in children. Large studies of current NOM utilization and its outcomes in children are lacking. METHODS We queried the Pediatric Health Information System database to identify children <19 years of age with a diagnosis code for appendicitis. We used linear trend analysis to assess the subsequent utilization and outcomes of NOM in children with nonperforated appendicitis over time. We calculated the proportion of children experiencing treatment failure, defined as either a subsequent appendectomy or hospitalization with a diagnosis code of perforated appendicitis. RESULTS We identified 117 705 children with appendicitis over the 9-year study period. Of the 73 544 children with nonperforated appendicitis, 10 394 (14.1%) underwent NOM. The odds of NOM significantly increased (odds ratio 1.10 per study quarter, 95% confidence interval [CI] 1.05-1.15). The 1-year and 5-year failure rates were 18.6% and 23.3%, respectively. Children who experienced failure of NOM had higher rates of perforation at the time of failure than did the general cohort at the time of initial presentation (45.7% vs 37.5%, P < .001). Patients undergoing NOM had higher rates of subsequent related emergency department visits (8.0% vs 5.1%, P < .001) and hospitalizations (4.2% vs 1.4%, P < .001) over a 12-month follow-up period. CONCLUSIONS NOM of nonperforated appendicitis in children is increasing. Although the majority of children who undergo NOM remain recurrence-free years later, they carry a substantial risk of perforation at the time of recurrence and may experience a higher rate of postoperative complications than children undergoing an immediate appendectomy.
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Affiliation(s)
- Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Pediatrics.,Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kristen H Shanahan
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Pediatrics.,Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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3
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van Amstel P, M L The SM, Bakx R, Bijlsma TS, Noordzij SM, Aajoud O, de Vries R, Derikx JPM, van Heurn LWE, Gorter RR. Predictive scoring systems to differentiate between simple and complex appendicitis in children (PRE-APP study). Surgery 2022; 171:1150-1157. [PMID: 35067338 DOI: 10.1016/j.surg.2021.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/15/2021] [Accepted: 12/19/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Several clinical prediction rules have been developed for preoperative differentiation between simple and complex appendicitis in children, as potential treatment strategies differ. This study aimed to externally validate applicable clinical prediction rules that could be used to differentiate between simple and complex appendicitis in children. METHODS Potential clinical prediction rules were identified by a scoping review of the literature. Clinical prediction rules applicable in our daily practice were subsequently externally validated in a multicenter historical cohort consisting of 1 tertiary center and 1 large teaching hospital. All children (<18 years old) with histopathologically confirmed acute appendicitis between 2013 and 2020 were included. Test results of clinical prediction rules were compared to the gold standard of either simple or complex appendicitis consisting of predefined perioperative and histopathological criteria. Areas under the receiver operating characteristic curves were determined for the selected clinical prediction rules. Areas under the receiver operating characteristic curve >0.7 were considered acceptable and potentially useful. RESULTS In total, 31 clinical prediction rules were identified, of which 12 could be evaluated in our cohort consisting of 550 children. The main reason to exclude clinical prediction rules was the use of variables that were not routinely measured in our cohort. In our cohort, 208/550 (38%) were diagnosed with complex appendicitis according to the gold standard. Clinical prediction rules with areas under the receiver operating characteristic curve >0.7 were: Gorter (0.81), Bogaard (0.79), Bröker (0.79), Graham (0.77), Hansson (0.76), BADCF (0.76), and Eddama (0.75). CONCLUSION In this study, clinical prediction rules consisting of a combination of clinical and objective variables had the highest discriminative ability. External validation showed that 7 clinical prediction rules were potentially useful. Integration of these clinical prediction rules in daily practice is proposed to guide decision making regarding treatment strategies.
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Affiliation(s)
- Paul van Amstel
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands.
| | - Sarah-May M L The
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands; Department of Surgery, Northwest Hospital, Alkmaar, The Netherlands
| | - Roel Bakx
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands
| | - Taco S Bijlsma
- Department of Surgery, Northwest Hospital, Alkmaar, The Netherlands
| | | | - Oumaima Aajoud
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands
| | - Ralph de Vries
- Vrije Universiteit Amsterdam, University Library, The Netherlands
| | - Joep P M Derikx
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands
| | - L W Ernest van Heurn
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands
| | - Ramon R Gorter
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam & Vrije Universiteit Amsterdam, The Netherlands
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Hannan MJ, Parveen MK, Hoque MM, Chowdhury TK, Hasan MS, Nandy A. Management of Acute Appendicitis in Children During COVID-19 and Perspectives of Pediatric Surgeons From South Asia: Survey Study. JMIR Perioper Med 2021; 4:e26613. [PMID: 34818209 PMCID: PMC8691415 DOI: 10.2196/26613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/26/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Nonoperative treatment (NOT) of pediatric appendicitis as opposed to surgery elicits great debate and is potentially influenced by physician preferences. Owing to the effects of the COVID-19 pandemic on health care, the practice of NOT has generally increased by necessity and may, in a post-COVID-19 world, change surgeons' perceptions of NOT. OBJECTIVE The aim of this study was to determine whether the use of NOT has increased in South Asia and whether these levels of practice would be sustained after the pandemic subsides. METHODS A survey was conducted among pediatric surgeons regarding their position, institute, and country; the number of appendicitis cases they managed; and their mode of treatment between identical time periods in 2019 and 2020 (April 1 to August 31). The survey also directly posed the question as to whether they would continue with the COVID-19-imposed level of NOT after the effect of the pandemic diminishes. RESULTS A total of 134 responses were collected out of 200 (67.0%). A significant increase in the practice of NOT was observed for the entire cohort, although no effect was observed when grouped by country or institute. When grouped by position, senior physicians increased the practice of NOT the most, while junior physicians reported the least change. The data suggest that only professors would be inclined to maintain the COVID-19-level of NOT practice after the pandemic. CONCLUSIONS Increased practice of NOT during the COVID-19 pandemic was observed in South Asia, particularly by senior surgeons. Only professors appeared inclined to consider maintaining this increased level of practice in the post-COVID-19 world.
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Affiliation(s)
- Md Jafrul Hannan
- Department of Pediatric Surgery, South Point Hospital, Chittagong, Bangladesh
| | | | - Md Mozammel Hoque
- Department of Pediatric Surgery, Chattagram Maa-O-Shishu Hospital Medical College, Chittagong, Bangladesh
| | | | - Md Samiul Hasan
- Department of Pediatric Surgery, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Alak Nandy
- Department of Anesthesiology, Chattgram Maa-O-Shishu Hospital Medical College, Chittagong, Bangladesh
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5
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Thapa Basnet A, Singh S, Thapa B, Kayastha A. Management of Acute Appendicitis during COVID-19 Pandemic in a Tertiary Care Centre: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc 2021; 59:252-255. [PMID: 34506434 PMCID: PMC8369543 DOI: 10.31729/jnma.6307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Acute appendicitis is the most common reason for abdominal surgery in children. Though appendectomy considered the gold standard there are a lot of complications related to it. Conservative management of acute appendicitis is not new to medical science. In pandemic like COVID-19 when all the health systems were about to shut-down because of lack of manpower and resources, we started a trial of non-operative management. The main aim of this study is to find out the management of acute appendicitis during COVID-19. METHODS This was a descriptive cross-sectional study conducted in a tertiary care centre. Data collection was done from the record section which included the patients diagnosed with acute appendicitis from February 2020 to July 2020 after obtaining ethical clearance from Institutional Review Committee. Cases of appendicular lump, appendicular abscess, appendicular perforations have been excluded. Data was collected and entry was done in Statistical Package for the Social Science software version 20, point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS The conservative management of acute appendicitis was done in 44 cases (55.7%) while 35 cases (44.3%) had to undergo appendectomy. CONCLUSIONS COVID-19 can complicate the perioperative course as a result of direct lung injury and multiple organ dysfunctions and can also bring serious threats to the safety of medical staffs involved in managing the acute appendicitis case operatively, so conservative management can be considered as an alternative way of management of acute appendicitis in the pandemic outbreak.
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Affiliation(s)
- Anupama Thapa Basnet
- Department of Pediatric Surgery, Kanti Children's Hospital, Maharajganj, Kathmandu, Nepal
| | - Suraj Singh
- Department of Pediatric Surgery, Kanti Children's Hospital, Maharajganj, Kathmandu, Nepal
| | - Bijay Thapa
- Department of Pediatric Surgery, Kanti Children's Hospital, Maharajganj, Kathmandu, Nepal
| | - Anuj Kayastha
- Department of Pediatric Surgery, Kanti Children's Hospital, Maharajganj, Kathmandu, Nepal
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Hall NJ, Sherratt FC, Eaton S, Reading I, Walker E, Chorozoglou M, Beasant L, Wood W, Stanton M, Corbett HJ, Rex D, Hutchings N, Dixon E, Grist S, Hoff WV, Crawley E, Blazeby J, Young B. Conservative treatment for uncomplicated appendicitis in children: the CONTRACT feasibility study, including feasibility RCT. Health Technol Assess 2021; 25:1-192. [PMID: 33630732 PMCID: PMC7958256 DOI: 10.3310/hta25100] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Although non-operative treatment is known to be effective for the treatment of uncomplicated acute appendicitis in children, randomised trial data comparing important outcomes of non-operative treatment with those of appendicectomy are lacking. OBJECTIVES The objectives were to ascertain the feasibility of conducting a multicentre randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of a non-operative treatment pathway with appendicectomy for the treatment of uncomplicated acute appendicitis in children. DESIGN This was a mixed-methods study, which included a feasibility randomised controlled trial, embedded and parallel qualitative and survey studies, a parallel health economic feasibility study and the development of a core outcome set. SETTING This study was set in three specialist NHS paediatric surgical units in England. PARTICIPANTS Children (aged 4-15 years) clinically diagnosed with uncomplicated acute appendicitis participated in the feasibility randomised controlled trial. Children, their families, recruiting clinicians and other health-care professionals involved in caring for children with appendicitis took part in the qualitative study. UK specialist paediatric surgeons took part in the survey. Specialist paediatric surgeons, adult general surgeons who treat children, and children and young people who previously had appendicitis, along with their families, took part in the development of the core outcome set. INTERVENTIONS Participants in the feasibility randomised controlled trial were randomised to a non-operative treatment pathway (broad-spectrum antibiotics and active observation) or appendicectomy. MAIN OUTCOME MEASURES The primary outcome measure was the proportion of eligible patients recruited to the feasibility trial. DATA SOURCES Data were sourced from NHS case notes, questionnaire responses, transcribed audio-recordings of recruitment discussions and qualitative interviews. RESULTS Overall, 50% (95% confidence interval 40% to 59%) of 115 eligible patients approached about the trial agreed to participate and were randomised. There was high acceptance of randomisation and good adherence to trial procedures and follow-up (follow-up rates of 89%, 85% and 85% at 6 weeks, 3 months and 6 months, respectively). More participants had perforated appendicitis than had been anticipated. Qualitative work enabled us to communicate about the trial effectively with patients and families, to design and deliver bespoke training to optimise recruitment and to understand how to optimise the design and delivery of a future trial. The health economic study indicated that the main cost drivers are the ward stay cost and the cost of the operation; it has also informed quality-of-life assessment methods for future work. A core outcome set for the treatment of uncomplicated acute appendicitis in children and young people was developed, containing 14 outcomes. There is adequate surgeon interest to justify proceeding to an effectiveness trial, with 51% of those surveyed expressing a willingness to recruit with an unchanged trial protocol. LIMITATIONS Because the feasibility randomised controlled trial was performed in only three centres, successful recruitment across a larger number of sites cannot be guaranteed. However, the qualitative work has informed a bespoke training package to facilitate this. Although survey results suggest adequate clinician interest to make a larger trial possible, actual participation may differ, and equipoise may have changed over time. CONCLUSIONS A future effectiveness trial is feasible, following limited additional preparation, to establish appropriate outcome measures and case identification. It is recommended to include a limited package of qualitative work to optimise recruitment, in particular at new centres. FUTURE WORK Prior to proceeding to an effectiveness trial, there is a need to develop a robust method for distinguishing children with uncomplicated acute appendicitis from those with more advanced appendicitis, and to reach agreement on a primary outcome measure and effect size that is acceptable to all stakeholder groups involved. TRIAL REGISTRATION Current Controlled Trials ISRCTN15830435. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nigel J Hall
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Frances C Sherratt
- Department of Health Services Research, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Simon Eaton
- University College London Great Ormond Street Institute of Child Health, Department of Population Health Sciences, University College London, London, UK
| | - Isabel Reading
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Erin Walker
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Maria Chorozoglou
- Southampton Health Technology Assessment Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Lucy Beasant
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, Bristol, UK
| | - Wendy Wood
- National Institute for Health Research (NIHR), Research Design Service South Central, University of Southampton, Southampton, UK
| | - Michael Stanton
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Harriet J Corbett
- Department of Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Dean Rex
- Department of Paediatric Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Natalie Hutchings
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Elizabeth Dixon
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Simon Grist
- Patient and public involvement representative
| | - William Van't Hoff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Esther Crawley
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Blazeby
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Bridget Young
- Department of Health Services Research, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
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Abstract
BACKGROUND The novel coronavirus and the disease it causes COVID-19, like other viral outbreaks, have an unpredictable timeline. Therefore, a triumph in the battle against COVID-19 could only be achieved if a health care system's capacity to support a potentially overwhelming increase in critical patient care needs is maintained, and the viral curve is flattened. Accordingly, health care bodies around the globe called upon prioritising appropriate resource allocation as it relates to elective invasive procedures and minimising the use of essential items required to care for patients. The unpredictability COVID-19 timeline in the absence of effective drug treatments and vaccination along with the restrictive health care policies implemented suggest that patients may be deprived of access to needed surgical care, likely for many months. However, the potential undue delay in delivering essential elective surgical care may have a more detrimental impact on patients' health compared to that of COVID-19 itself. This particularly applies to the paediatric population in which infection rates have been demonstrated to be considerably lower and mortalities have not been reported yet. Therefore, the need emerges for actions to be taken that allow for the resumption of essential elective surgical procedures in this population of patients. MATERIALS AND METHODS A comprehensive search through surgical guidance and recommendations to develop a set of evidence based recommendations that allow for the safe and timely delivery of essential paediatric surgical care during the time of COVID-19. CONCLUSION No compelling evidence that the paediatric population is at an increased risk of morbidity or mortality exists. Therefore, delaying essential paediatric surgical care cannot be justified as it may have a potentially negative health impact, and continuous refinements of surgical recommendations are encouraged in view of evolving circumstances.
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Affiliation(s)
- Khaled Al-Omar
- Department of Surgery, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Sohail Bakkar
- Department of Surgery, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
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Nonsurgical Management of Acute Appendicitis in Sickle Cell Disease. J Pediatr Hematol Oncol 2021; 43:28-30. [PMID: 32134840 DOI: 10.1097/mph.0000000000001774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 9-year-old child with sickle cell disease (sickle beta zero thalassemia) was diagnosed to have acute appendicitis during a hospitalization for pain, acute chest syndrome, and exacerbation of asthma. Because of his high surgical risk, his appendicitis was treated nonsurgically, successfully deferring his appendectomy. He remains well after 1 year. This approach should be considered at least in other sickle cell patients with appendicitis, and perhaps other high-risk populations, if not all children with appendicitis.
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Hartford EA, Woodward GA. Appendectomy or Not? An Update on the Evidence for Antibiotics Only Versus Surgery for the Treatment of Acute Appendicitis in Children. Pediatr Emerg Care 2020; 36:347-352. [PMID: 32618901 DOI: 10.1097/pec.0000000000002157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Appendicitis is a common diagnosis in children being evaluated in the emergency department. After diagnosis, standard treatment has been surgical appendectomy; however, in recent years there is a growing body of evidence evaluating the possibility of nonoperative management in both children and adults. This review will present the current state of the pediatric literature that suggests patients may be successfully treated with antibiotics alone (ie, without surgery), but that a proportion of these patients will have recurrent appendicitis. Given that the literature regarding the option of antibiotic-only management compared with surgery is not yet definitive, there are many factors for providers to discuss with families and patients when considering treatment for acute appendicitis.
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Affiliation(s)
| | - George A Woodward
- Professor, Division of Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
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10
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Mazingi D, Ihediwa G, Ford K, Ademuyiwa AO, Lakhoo K. Mitigating the impact of COVID-19 on children's surgery in Africa. BMJ Glob Health 2020; 5:e003016. [PMID: 32527851 PMCID: PMC7292041 DOI: 10.1136/bmjgh-2020-003016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 05/29/2020] [Accepted: 06/02/2020] [Indexed: 12/17/2022] Open
Affiliation(s)
- Dennis Mazingi
- Department of Surgery, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - George Ihediwa
- Paediatric Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, Surulere, Lagos, Nigeria
| | - Kathryn Ford
- Department of Specialist Neonatal And Paediatric Surgery, Great Ormond Street Hospital, London, UK
- Department of Population, Policy and Practice, Institute of Child Health, University College London, London, UK
| | - Adesoji O Ademuyiwa
- Department of Surgery, College of Medicine, University of Lagos, Lagos, Lagos, Nigeria
| | - Kokila Lakhoo
- Nuffield Department of Surgical Sciences, Oxford University Hospitals NHS Trust, Oxford, Oxfordshire, UK
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11
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Maita S, Andersson B, Svensson JF, Wester T. Nonoperative treatment for nonperforated appendicitis in children: a systematic review and meta-analysis. Pediatr Surg Int 2020; 36:261-269. [PMID: 31838546 PMCID: PMC7012795 DOI: 10.1007/s00383-019-04610-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2019] [Indexed: 12/18/2022]
Abstract
Acute appendicitis is the most common surgical emergency in children. Nonoperative treatment of nonperforated acute appendicitis in children is an alternative to appendectomy. The purpose of this systematic review and meta-analysis was to determine the outcomes of nonoperative treatment of nonperforated acute appendicitis in children in the literature. Databases were searched to identify abstracts, using predefined search terms. The abstracts were reviewed by two independent reviewers and articles were selected according to inclusion and exclusion criteria. Data were extracted by the two reviewers and analyzed. The literature search yielded 2743 abstracts. Twenty-one articles were selected for analysis. The study design was heterogenous, with only one randomized controlled study. The symptoms resolved in 92% [95% CI (88; 96)] of the nonoperatively treated patients. Meta-analysis showed that an additional 16% (95% CI 10; 22) of patients underwent appendectomy after discharge from initial hospital stay. Complications and length of hospital stay was not different among patients treated with antibiotics compared with those who underwent appendectomy. Nonoperative treatment of nonperforated acute appendicitis children is safe and efficient. There is a lack of large randomized controlled trials to compare outcomes of nonoperative treatment with appendectomy.
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Affiliation(s)
- Sonia Maita
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University of Padua, Padua, Italy
| | - Björn Andersson
- Department of Pediatric Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Jan F. Svensson
- Department of Pediatric Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden ,Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Wester
- Department of Pediatric Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden ,Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
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12
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Rawolle T, Reismann M, Minderjahn MI, Bassir C, Hauptmann K, Rothe K, Reismann J. Sonographic differentiation of complicated from uncomplicated appendicitis. Br J Radiol 2019; 92:20190102. [PMID: 31112397 DOI: 10.1259/bjr.20190102] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE This study aims to differentiate acute uncomplicated and complicated appendicitis, by investigating the correlation between sonographic findings and histological results in different types of paediatric appendicitis. METHODS This is a retrospective study of 1017 paediatric patients (age < 18 years) who underwent ultrasound by paediatric radiologists before appendicectomy at our institution between 2006 and 2016. Histologically, uncomplicated appendicitis was primarily associated with transmural infiltration of neutrophil granulocytes, while complicated appendicitis was characterised by transmural myonecrosis. Logistic regression analyses were used to investigate the association between sonographic and histological findings. RESULTS Out of 566 (56%) male and 451 (44%) female patients with a mean age of 10.7 years, uncomplicated appendicitis was histologically diagnosed in 446 (44%) children and complicated appendicitis was diagnosed in 348 (34%) cases. The following ultrasound findings were significantly associated with complicated appendicitis in multivariate regression: an increased appendiceal diameter (OR = 1.3, p < .001), periappendiceal fat inflammation (OR = 1.5, p = 0.02), the presence of an appendicolith (OR = 1.7, p = 0.01) and a suspected perforation (OR = 6.0, p < .001) by the pediatric radiologist. For complicated appendicitis, an appendiceal diameter of more than 6 mm had the highest sensitivity (98%), while a sonographically suspected perforation showed the highest specificity (94%). CONCLUSION Abdominal sonography by paediatric radiologists can differentiate between uncomplicated and complicated appendicitis in paediatric patients by using an increased appendiceal diameter, periappendiceal fat inflammation, the presence of an appendicolith and a suspected perforation as discriminatory markers. ADVANCES IN KNOWLEDGE This paper demonstrates expanded information on ultrasound, which is not only an essential tool for diagnosing appendicitis, but also a key method for distinguishing between different forms of appendicitis when performed by paediatric radiologists. Compared with previous studies, the crucial distinction features in our analysis are 1) the definition of gangrene and not primarily perforation as an acute complicated appendicitis enabling early decision-making by sonography and 2) a large number of patients in a particularly affected age group.
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Affiliation(s)
- Tanja Rawolle
- 1 Department of Pediatric Surgery, Charité - Universitätsmedizin Berlin, Augustenburger Platz , Berlin , Germany
| | - Marc Reismann
- 1 Department of Pediatric Surgery, Charité - Universitätsmedizin Berlin, Augustenburger Platz , Berlin , Germany
| | - Maximiliane I Minderjahn
- 1 Department of Pediatric Surgery, Charité - Universitätsmedizin Berlin, Augustenburger Platz , Berlin , Germany
| | - Christian Bassir
- 2 Department of Pediatric Radiology, Charité - Universitätsmedizin Berlin, Augustenburger Platz , Berlin , Germany
| | - Kathrin Hauptmann
- 3 Department of Pathology, Charité - Universitätsmedizin Berlin, Augustenburger Platz , Berlin , Germany
| | - Karin Rothe
- 1 Department of Pediatric Surgery, Charité - Universitätsmedizin Berlin, Augustenburger Platz , Berlin , Germany
| | - Josephine Reismann
- 1 Department of Pediatric Surgery, Charité - Universitätsmedizin Berlin, Augustenburger Platz , Berlin , Germany
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