Nonoperative management of pediatric ruptured appendix with inflammatory mass or abscess: presence of an appendicolith predicts recurrent appendicitis

SAGES guideline for the diagnosis and treatment of appendicitis

BACKGROUND

Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis.

METHODS

A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts.

RESULTS

Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty.

CONCLUSIONS

These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.

Investigation of VGLL3 and sub-target genes in the aetiology of paediatric acute appendicitis: a prospective case-control study

PURPOSE

Vestigial like family member 3 (VGLL3) and its sub-target genes show considerable transcriptomic overlap in terms of several autoimmune and inflammatory diseases. Herein, we investigated the role of VGLL3 rs13074432 polymorphism and its sub-target genes in the aetiology of acute appendicitis (AA).

METHODS

In this prospective case-control study, we included 250 patients (age, 0-18 years) who underwent appendectomy with the diagnosis of AA (patient group; blood and appendix tissue samples) and 200 healthy children (control group; only blood samples) without appendectomy. ELISA method was used for protein-level detection of VGLL3 and sub-target genes expression change in obtained tissue samples, and real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR) was used for mRNA level detection. Genotyping analyses were performed on DNA samples isolated from blood using TaqMan SNP genotyping test.

RESULTS

The frequency of TT variant genotype (p < 0.001) and T allele (p = 0.002) showed a significant decrease in the patient group compared with the control group. No significant correlation was observed between the expression of VGLL3 in the appendiceal tissue and patient clinical and demographic data (p > 0.050).

CONCLUSION

This study revealed that the VGLL3 gene and its sub-target genes are associated with AA aetiology.

Covid-19 Pandemic Strategy for Treatment of Acute Uncomplicated Appendicitis with Antibiotics- Risk Categorization and Shared Decision-Making

BACKGROUND

During the Coronavirus disease 2019 (COVID-19) pandemic, a protocol was adopted by our department on antibiotics treatment for Acute Uncomplicated Appendicitis (AUA). Our study aimed to determine the feasibility and safety of non-operative treatment (NOT), compared to upfront laparoscopic appendectomy (LA), for AUA in children during the pandemic.

METHOD

Our prospective comparative study was conducted from May 1, 2020 to January 31, 2021. Patient selection criteria included: age ≥5 years, abdominal pain duration ≤48 h, ultrasound (US)/Computered Tomography scan confirmation of AUA, US appendiceal diameter 6-11 mm with no features of perforation/abscess collection and no faecolith. For NOT patients, intravenous antibiotics were administered for 24-48 h followed by oral for 10-day course. Comparison was performed between patients whose parents preferred NOT to those who opted for up-front appendectomy. Primary outcomes were NOT success at index admission, early and late NOT failure rates till 27 months. Secondary outcomes were differences in complication rate, hospital length of stay (LOS) and cost between groups.

RESULTS

77 patients were recruited: 43 (55.8%) underwent NOT while 34 (44.2%) patients opted for LA. Success of NOT at index admission was 90.7% (39/43). Overall, NOT failure rate at 27 months' follow-up was 37.2% (16/43). Of the NOT failures, 1 appendix was normal on histology while only 1 was perforated. There were no significant differences in secondary outcomes between both groups except for LOS of late NOT failure. Cost for upfront LA was nearly thrice that of NOT.

CONCLUSION

Our stringent COVID protocol together with shared decision-making with parents is a safe and feasible treatment option during a crisis situation.

LEVEL OF EVIDENCE

Treatment study, Level II.

Risk Factors of Recurrent Appendiceal Abscess after Initial Non-Surgical Treatment without Drainage of Children with Appendiceal Abscess: A Single Center Retrospective Review

Background: Exploration of the risk factors of recurrent appendiceal abscess after initial non-surgical treatment without drainage in children with appendiceal abscess. Patients and Methods: The medical records of all children diagnosed with appendiceal abscess and who were treated conservatively in the Children's Hospital of Chongqing Medical University from June 2012 to June 2020 were collected. The collected cases were divided into the recurrent group and the non-recurrent group, and all clinical indicators were compared. Logistic regression analysis was used to determine the risk factors for recurrent appendiceal abscess in children. Results: One hundred twenty-four patients were included and among them, 62 (50.0%) had clinical manifestations of recurrent appendiceal abscess (the recurrent group) and five patients (8%) suffered several instances of recurrence. Duration of intravenous antibiotic agents (odds ratio [OR], 0.905; 95% confidence interval [CI], 0.820-1.000) was independently associated with the recurrence of appendiceal abscess. The risk of recurrence was increased in children with the white blood cell (WBC) count at discharge greater than 8 × 10⁹/L (OR, 2.702; 95% CI,1.172-6.231), the ratio of mass size to body surface area (BSA) at discharge greater than 4.255 (OR, 1.369; 95% CI, 1.104-1.697), and without continuous oral antibiotic agents after discharge (OR, 3.111; 95% CI, 1.240-7. 802). Conclusions: Interval appendectomy is recommended for children with WBC count at discharge greater than 8 × 10⁹/L, and the ratio of mass size to BSA at discharge greater than 4.255, because they are more likely to develop recurrent appendiceal abscess after initial conservative treatment. The duration of intravenous antibiotic agents is an independent factor of the recurrence of appendiceal abscess, and a longer course of intravenous antibiotic agents is strongly associated with a reduced risk of recurrence. Continued oral antibiotic agents after discharge can effectively reduce the risk of recurrence of appendiceal abscesses.

Treatment for Appendicitis With Appendicolith by the Stone Size and Serum C-Reactive Protein Level

INTRODUCTION

Appendicolith causes acute appendicitis. However, surgical indications for appendicolith-related acute appendicitis have not been established. We aimed to clarify the clinical features of appendicolith-associated appendicitis and determine an appropriate treatment strategy based on the initial presentation.

MATERIALS AND METHODS

We retrospectively reviewed the records of 479 consecutive patients with acute appendicitis and verified the therapeutic strategy as per the appendicolith and clinical status.

RESULTS

Appendicoliths were identified in 214 of 479 patients (44.6%) using computed tomography. Surgery was more frequently required in patients with appendicolith than in patients without appendicolith (82.7 versus 64.9%; P < 0.001). The stones were smaller and serum C-reactive protein (CRP) concentration was lower among patients with appendicoliths treated with medication alone than among those surgically treated (both P < 0.001). An appendicolith measuring ≤5 mm in diameter and CRP concentration ≤5.36 mg/dL were predictive of completion of nonsurgical therapy. CRP concentration >10 mg/dL and stone diameter of 10 mm were significantly associated with appendiceal perforation.

CONCLUSIONS

Nonsurgical therapy could be considered for patients with appendicoliths measuring ≤5 mm in diameter and in cases where the serum CRP concentration is ≤5 mg/dL. An appendicolith measuring >10 mm in diameter or CRP concentration >10 mg/dL is an indication for surgery.

Identification of the optimal treatment strategy for complex appendicitis in the paediatric population: a protocol for a multicentre prospective cohort study (CAPP study)

INTRODUCTION

In daily practice large heterogeneity in the treatment of children with complex appendicitis exists. Complex appendicitis can be divided into two subtypes; complex appendicitis with and without appendiceal mass and/or abscess. As complex appendicitis is associated with high morbidity and costs, identification of the optimal treatment strategy is essential. In this article, we present the study protocol for the CAPP (Complex Appendicitis in the Pediatric Population) study.

METHODS AND ANALYSIS

This nation-wide, multi-centre, comparative, non-randomised prospective cohort study includes all children <18 years old with a preoperative suspicion of complex appendicitis, which is based on imaging confirmed acute appendicitis and predefined criteria regarding the severity of appendicitis. Eligible patients are recruited in more than 30 hospitals. Open appendectomy will be compared with laparoscopic appendectomy for children without appendiceal mass and/or abscess and initial non-operative treatment (ie, intravenous antibiotics with or without percutaneous drainage) to direct appendectomy for children with appendiceal mass and/or abscess. Based on historical data supplied by the participating hospitals and an inclusion period of 2 years and 9 months, a sample size of 1308 patients is aimed. Primary outcome is the proportion of patients experiencing any complication at 3 months follow-up. Reported complications will be assessed by an independent adjudication committee. Secondary outcomes include, but are not limited to, quality of life, and (in)direct costs. To adjust for baseline differences and selection bias, outcomes will be compared after propensity score analysis (inverse probability weighting and stratification).

ETHICS AND DISSEMINATION

The Medical Ethics Review Committee of the Amsterdam UMC, location AMC, declared that the Medical Research involving Human Subjects Act (WMO) did not apply to this study. Therefore, no official approval was required by national law. Study results will be presented in peer-reviewed scientific journals and at (inter)national conferences.

TRIAL REGISTRATION NUMBERS

NCT04755179; NL9371.

When to take it out? Optimal timing of interval appendectomy in 500 consecutive children

PURPOSE

While interval appendectomy following nonoperative management of perforated appendicitis is delayed until several weeks after presentation, the optimal time from presentation to interval appendectomy is unknown.

METHODS

The data warehouse of a large children's hospital was queried for interval appendectomies from 2006 to 2019. Data extracted included demographics, initial and operative hospitalization details, and pathology findings. Student's t-test and logistic regression were used where appropriate.

RESULTS

500 patients were identified with a mean age of 10 years, 53% male. Mean time to operation was 12.7 weeks. Operation prior to 12 weeks was associated with increased odds of acute inflammation on pathology (OR = 2, p < 0.01). Acute inflammation was associated with increased mean operative time (101 vs 84 min, p < 0.01). Presence of an appendicolith, initial hospitalization length, drain placement, readmission prior to operation, age and gender were all non-predictive of acute inflammation. Only 11% of appendices had an occluded lumen and 17% an appendicolith. Carcinoid tumors were identified in 6 patients (1.2%).

CONCLUSION

Acute inflammation is found many weeks after perforation and is associated with increased operative time. Acute inflammation is more likely to be present in operations performed prior to 12 weeks.

The Histopathology of the Appendix in Children at Interval Appendectomy

Whilst most surgeons agree that conservative treatment of appendiceal abscess in children is an adequate treatment, the need for subsequent interval appendectomy is still controversial. We analyzed the histopathology in interval appendectomy in search of signs of inflammation. All patients admitted between 2010 and 2017 with appendiceal abscess and scheduled for interval appendectomy were reviewed. The specimens were evaluated for grade of inflammation, type and distribution of cellular infiltrate, presence of necrosis or hemorrhage and infiltrate in the serosa. Forty-two patients had appendiceal abscess and were treated conservatively. Seven underwent emergent appendectomy. Thirty-three out of 35 patients underwent elective interval appendectomy. Thirty-two specimens were revised. Carcinoid tumor or other malignant lesions were not found. All of them presented some amount of inflammation, grade 1 to 2 in 53%, grade 3 to 4 in 47%. Twenty-five percent of the specimens had signs of necrosis accompanied by hemorrhage and in more than the half (53%) the infiltrate extended to the serosa. Conclusions: Although the appendix was mostly found not macroscopically inflamed intraoperatively, histology confirmed a certain grade of inflammation even months after the conservative treatment. No correlation was found between histopathologic findings and lapse of time between abscess treatment and interval appendectomy.

Fecalith in the Proximal Area of the Appendix is a Predictor of Failure of Nonoperative Treatment for Complicated Appendicitis in Adults

BACKGROUND

The management of complicated appendicitis remains controversial, since this disease has various clinical presentations and is associated with high rates of adverse events. Although initial nonoperative treatment is generally employed for complicated appendicitis, its clinical presentation and the predictors of nonoperative treatment failure are unclear.

METHODS

Patients diagnosed with complicated appendicitis in our hospital between April 2015 and March 2020 were enrolled. In total, 113 patients were classified into three categories: emergency appendectomy, failure of nonoperative treatment and successful nonoperative treatment. The primary outcome was the rate of failure of nonoperative treatment, as assessed by logistic regression analysis. The secondary outcomes were the operative procedures and postoperative courses of the three groups.

RESULTS

Of 113 patients, 45 (40%) underwent emergency appendectomy, 25 (22%) failed nonoperative treatment, and 43 (38%) had successful nonoperative treatment. Among these successful cases, 38 patients (88%) underwent interval appendectomy. In multivariate analyses, the presence of a fecalith in the proximal area of the appendix was an independent risk factor for failure of nonoperative treatment (odds ratio, 20.5; 95% confidence interval, 4.37-95.7, P < 0.001). Postoperative outcomes were more unfavorable in cases of failed nonoperative treatment than in cases of emergency and interval appendectomy.

CONCLUSIONS

The presence of a fecalith in the proximal area of the appendix is an independent predictor for failure of nonoperative treatment for complicated appendicitis in adults. Patients with this risk factor should be considered candidates for surgical treatment.

Pathology findings following interval appendectomy: Should it stay or go?

PURPOSE

Interval appendectomy following nonoperative management of complicated appendicitis remains controversial. The aim of this study was to evaluate surgical pathology and clinical outcomes after pediatric interval appendectomy.

METHODS

Pathology results from children with complicated appendicitis who underwent interval appendectomy at a single children's hospital from 2010 to 2017 were reviewed. The primary outcome was pathology results. Secondary outcomes included complications and readmission following initial treatment and after interval appendectomy.

RESULTS

Among 149 patients (median age 11 years; range, 1-18), all had evidence of persistent inflammation on surgical pathology, 25 (17%) had an appendicolith, and no neoplasms were identified. Median duration of the initial admission was 8 days (range, 2-28) and 70% received a percutaneous drain prior to appendectomy. Interval appendectomy was performed at a median of 7.5 weeks (range, 2.9-29.1). Thirty-six (24%) returned to the hospital prior to their scheduled appendectomy and 6 (4%) required appendectomy earlier than planned. Nine patients (6%) experienced a complication following interval appendectomy, of which superficial surgical site infection was the most common (n = 4).

CONCLUSION

All children had evidence of ongoing inflammation on surgical pathology. While the clinical implications of persistent inflammation remain uncertain, these findings suggest that interval appendectomy is an appropriate treatment following medical management of complicated appendicitis in children.

LEVEL OF EVIDENCE SECTION

IV, Case series with no comparison groups.

Multi-institutional trial of non-operative management and surgery for uncomplicated appendicitis in children: Design and rationale

Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children's hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a "successful" treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.

What is the Long-Term Follow-Up of Nonoperatively Treated Patients with Appendicitis?

In this study, we determine outcomes after nonoperative treatment of appendicitis. First, we abstracted data for patients discharged with a diagnosis of appendicitis from a tertiary care facility from August 1, 2007, through June 30, 2017. For patients treated nonoperatively, we collected additional medical treatment for appendicitis, future surgical treatment, and date of last follow-up. In our study, we identified 487 patients treated for appendicitis. From this group, 66 patients were successfully treated nonoperatively. Eight patients (12%) had an interval appendectomy at a mean follow-up time of two months. Of the 58 remaining patients, 20 (34%) did not have any further appendicitis-related issues over a mean follow-up period of 25 months. A total of 38 (66%) had recurring or additional concerns requiring further treatment or emergent surgery within a mean time of four months. A large proportion, 76 per cent (n = 29), required unscheduled or emergent appendectomy. There were more patients diagnosed with an abscess (55%) in the group that had further appendicitis issues. In conclusion, nonoperative treatment of appendicitis is associated with significant likelihood of future appendicitis-related treatment or emergency surgery (66%). In addition, patients diagnosed with an abscess are at particularly high risk of future appendicitis-related issues.

Perforation risk in pediatric appendicitis: assessment and management

Perforated appendicitis, as defined by a visible hole in the appendix or an appendicolith free within the abdomen, carries significant morbidity in the pediatric population. Accurate diagnosis is challenging as there is no single symptom or sign that accurately predicts perforated appendicitis. Younger patients and those with increased duration of symptoms are at higher risk of perforated appendicitis. Elevated leukocytosis, bandemia, high C-reactive protein, hyponatremia, ultrasound, and CT are all useful tools in diagnosis. Distinguishing patients with perforation from those without is important given the influence of a perforation diagnosis on the management of the patient. Treatment for perforated appendicitis remains controversial as several options exist, each with its indications and merits, illustrating the complexity of this disease process. Patients may be managed non-operatively with antibiotics, with or without interval appendectomy. Patients may also undergo appendectomy early in the course of their index hospitalization. Factors known to predict failure of non-operative management include appendicolith, leukocytosis greater than 15,000 white blood cells per microliter, increased bands, and CT evidence of disease beyond the right lower quadrant. In this review, the indications and benefits of each treatment strategy will be discussed and an algorithm to guide treatment decisions will be proposed.

Management of Pediatric Perforated Appendicitis: Comparing Outcomes Using Early Appendectomy Versus Solely Medical Management

BACKGROUND

There is controversy regarding whether children with perforated appendicitis should receive early appendectomy (EA) versus medical management (MM) with antibiotics and delayed interval appendectomy. The objective of this study was to compare outcomes of children with perforated appendicitis who receive EA versus MM.

METHODS

Case review of consecutive children <18 years of age with perforated appendicitis who received either EA or MM during an 8-year period. Criteria for hospital discharge included patient being afebrile for at least 24 hours, pain-free and able to tolerate oral intake.

RESULTS

Of 203 patients diagnosed with perforated appendicitis, 122 received EA and 81 received MM. All received parenteral antibiotic therapy initiated in the emergency department and continued during hospitalization. There were no significant differences between groups in mean patient age, mean complete blood count total white blood cells count, gender distribution, rates of emergency department fever or rates of intra-abdominal infection (abscess or phlegmon) identified on admission. Compared with patients receiving MM, those receiving EA experienced significantly fewer (1) days of hospitalization, parenteral antibiotic therapy and in-hospital fever; (2) radiographic studies, percutaneous drainage procedures and placement of central venous catheters performed; (3) post admission intra-abdominal complications and (4) unscheduled repeat hospitalizations after hospital discharge. Only 1 EA-managed patient developed a postoperative wound infection.

CONCLUSIONS

Children with perforated appendicitis who receive EA experience significantly less morbidity and complications versus those receiving MM. The theoretical concern for enhanced morbidity associated with EA management of perforated appendicitis is not supported by our analysis.

Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis

Background

Uncomplicated appendicitis may resolve spontaneously or require treatment with antibiotics or appendicectomy. The aim of this randomized trial was to compare the outcome of a non-antibiotic management strategy with that of antibiotic therapy in uncomplicated appendicitis.

Methods

Patients presenting to a university teaching hospital with CT-verified uncomplicated simple appendicitis (appendiceal diameter no larger than 11 mm and without any signs of perforation) were randomized to management with a no-antibiotic regimen with supportive care (intravenous fluids, analgesia and antipyretics as necessary) or a 4-day course of antibiotics with supportive care. The primary endpoint was rate of total treatment failure, defined as initial treatment failure within 1 month and recurrence of appendicitis during the follow-up period.

Results

Some 245 patients were randomized within the trial, and followed up for a median of 19 months. The duration of hospital stay was shorter (mean 3·1 versus 3·7 days; P &lt; 0·001) and the medical costs lower (€1181 versus 1348; P &lt; 0·001) among those randomized to therapy without antibiotics. There was no difference in total treatment failure rate between the groups: 29 of 124 (23·4 per cent) in the no-antibiotic group and 25 of 121 (20·7 per cent) in the antibiotic group (P = 0·609). Eighteen patients (9 in each group) had initial treatment failure, 15 of whom underwent appendicectomy and three received additional antibiotics. Thirty-six patients (20 in the no-antibiotic group, 16 in the antibiotic group) experienced recurrence, of whom 30 underwent appendicectomy and six received further antibiotics.

Conclusion

Treatment failure rates in patients presenting with CT-confirmed uncomplicated appendicitis appeared similar among those receiving supportive care with either a no-antibiotic regimen or a 4-day course of antibiotics. Registration number: KCT0000124 (http://cris.nih.go.kr).

C-reactive Protein may Predict the Recurrence of Appendicitis in Children Formerly with Appendiceal Mass after Successful Non-operative Treatment

BACKGROUND

This study identified factors associated with the recurrence of appendicitis in children with appendiceal masses after successful nonsurgical treatment.

METHODS

In this retrospective study, children who were diagnosed as having appendiceal masses after undergoing conservative treatment between 2000 and 2014 were enrolled and the medical records of those who did not undergo an interval appendectomy were reviewed. The clinical features and outcomes of patients with and those without recurrent appendicitis were compared. Regression analysis was used to identify risk factors of appendicitis recurrence.

RESULTS

Seventy patients were included and successfully discharged after receiving nonsurgical treatment for appendiceal masses. Of the patients, 35 (50.0%) developed recurrent appendicitis and 85.7% (30/35) recurrences developed within 3 months. Multivariate analyses showed that patients with a higher serum C-reactive protein (CRP) level and peritonitis more frequently developed recurrence. The appendicitis recurrence rate was significantly higher in the patients with CRP levels of ≥103 mg/L with an odds ratio of 16.9 or in those with peritonitis with an odds ratio of 4.9.

CONCLUSION

Children with appendiceal masses who develop peritonitis or have CRP levels of ≥103 mg/L have a higher recurrence rate of appendicitis and should undergo an interval appendectomy.

Risk Factors for Prolonged Hospitalization in Pediatric Appendicitis Patients with Medical Treatment

BACKGROUND

With effective antibiotics against enteric flora and computed tomography-guided drainage for abscesses, the initial use of nonoperative therapy for children with appendicitis has increased both in recent reports and at our hospital. However, it has been reported that these patients have a relatively longer hospital stay and that their treatment is more expensive than those who undergo aggressive surgical intervention.

METHODS

This was a retrospective cohort study based in a single medical center. A systemic chart review was conducted to identify risk factors for prolonged hospitalization in pediatric appendicitis patients not initially undergoing surgical treatment. Patient demographics, clinical symptoms, duration of symptoms, laboratory findings, imaging findings, complications, and length of hospital stay were analyzed. Logistic regression analysis was used to identify significant predictors of prolonged hospitalization (≥15 days) and readmission.

RESULTS

One hundred and twenty-five patients were recruited in this study, of whom 53 (42.4%) had prolonged hospitalization. The values of serum C-reactive protein (CRP) were significantly higher in patients with prolonged hospitalization compared with those without prolonged hospitalization (203 ± 108.6 mg/L vs. 140 ± 93.0 mg/L, p = 0.001). Risk factors of prolonged hospitalization were serum CRP >150 mg/L (35/53 vs. 28/72, p = 0.001), abscess formation (38/53 vs. 35/72, p = 0.008), and multiple abscesses (10/53 vs. 1/72, p = 0.001). Under multivariate analysis, CRP >150 mg/L (odds ratio=1.004, p = 0.0334) and multiple abscesses (odds ratio = 8.788, p = 0.044) were two independent predictors for prolonged hospitalization.

CONCLUSION

Marked elevation of serum CRP (>150 mg/L) and multiple abscesses are two independent risk factors for prolonged hospitalization in children with appendicitis who are initially treated nonoperatively.

Pediatric appendicitis: state of the art review

Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.

Acute appendicitis in young children less than 5 years: review article

Despite wide spread availability of sophisticated diagnostic imaging, acute appendicitis in pre-school children remains a diagnostic challenge. Most of these children present late, often with complications e.g. appendicular perforation, abscess formation and peritonitis and as result hospital stay is prolonged and is associated with increased morbidity and mortality.The purpose of this article is to review peculiar features of acute appendicitis in preschool children.

Pediatric Appendicitis

Appendicitis is one of the most common surgical pathologies in children. It can present with right lower quadrant pain. Scoring systems in combination with selective imaging and surgical examination will diagnose most children with appendicitis. Clinical pathways should be used. Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated. Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis. This article discusses the workup and management, modes of treatment, and continued areas of controversy in pediatric appendicitis.

More than one-third of successfully nonoperatively treated patients with complicated appendicitis experienced recurrent appendicitis: Is interval appendectomy necessary?

BACKGROUND

Although nonoperative treatment (non-OPT) for complicated appendicitis is performed widely, the long-term outcomes and merits of interval appendectomy (IA) need to be evaluated.

METHODS

Between April 2007 and December 2013, all appendicitis patients with well-circumscribed abscess or phlegmon were required to select either laparoscopic surgery (OPT) or non-OPT with optional IA on admission. Optional IA was planned at ≥3months after non-OPT. For non-OPT, intravenous injection of antibiotics was continued until the serum C-reactive protein concentration decreased to <0.5mg/dL, with occasional drainage of abscesses.

RESULTS

Thirty-three patients chose OPT, and 55 chose non-OPT. Among non-OPT patients, 16 selected IA. The success rate of non-OPT was 98.2%. Recurrence occurred in 13 (34.2%) of the 38 non-IA group patients. Although the non-IA group patients frequently had perforated appendicitis at recurrence, they visited the hospital earlier than at the initial appendicitis and had less inflammation. Readmission rate or complications in patients undergoing IA were not different compared with those of the patients in the non-IA group, who had recurrence at ≥3months, or with those of patients in the OPT group.

CONCLUSION

Although many patients experienced recurrent appendicitis after successful nonoperative treatment, IA may not be necessary after non-OPT.

LEVEL OF EVIDENCE

Prospective comparative study, level II.

Therapeutic effectiveness of percutaneous drainage and factors for performing an interval appendectomy in pediatric appendiceal abscess

Background

In this study, we studied the therapeutic effectiveness of percutaneous drainage with antibiotics and the need for an interval appendectomy for treating appendiceal abscess in children with a research-oriented dataset released by the Bureau of National Health Insurance in Taiwan through the Collaboration Center for Health Information Application (CCHIA).

Methods

We identified 1225 patients under 18 years of age who had non-surgical treatment for an appendiceal abscess between 2007 and 2012 in a Taiwan CCHIA dataset. The treatment included percutaneous drainage with antibiotics or antibiotics alone. We also analyzed data of patient’s baseline characteristics, outcomes of percutaneous drainage, and indicating factors for performing an interval appendectomy.

Results

Totally, 6190 children had an appendiceal abscess, an 1225 patients received non-operative treatment. Of 1225 patients, 150 patients received treatment with percutaneous drainage and antibiotics, 78 had recurrent appendicitis, 185 went on to receive an interval appendectomy, and 10 had postoperative complications after the interval appendectomy. We found that patients treated with percutaneous drainage and antibiotics had a significantly lower rate of recurrent appendicitis (p < 0.05), a significantly smaller chance of receiving an interval appendectomy (p < 0.05), and significantly fewer postoperative complications after the interval appendectomy (p < 0.05) than those without percutaneous drainage treatment. Older children (13 ~ 18 years) patients were found to have a significantly smaller need to receive an interval appendectomy than those who were ≤ 6 years of age (odd ratio (OR) = 2.071, 95 % confidence interval (CI) = 1.34–3.19, p < 0.01), and those who were 7 ~ 12 years old (OR = 1.662, 95 % CI = 1.15–2.41, p < 0.01). In addition, those treated with percutaneous drainage were significantly less indicated to receive an interval appendectomy later (OR = 2.249, 95 % CI = 1.19 ~ 4.26, p < 0.05). In addition, those with recurrent appendicitis had a significantly increased incidence of receiving an interval appendectomy later (OR = 3.231, 95 % CI = 1.95 ~ 5.35, p < 0.001).

Conclusions

In this study, we used nationwide data to demonstrate therapeutic effectiveness of percutaneous drainage and antibiotics was more beneficial than only antibiotics in treating patients with an appendiceal abscess. We also found three factors that were significantly associated with receiving an interval appendectomy: recurrent appendicitis, being aged ≤ 13 years, and treatment with antibiotics only.

Role of non-operative management in pediatric appendicitis

Appendectomy is currently considered the standard of care for children with acute appendicitis. Although commonly performed and considered a safe procedure, appendectomy is not without complications. Non-operative management has a role in the treatment of both uncomplicated and complicated appendicitis. In uncomplicated appendicitis, initial non-operative management appears to be safe, with an approximate 1-year success rate of 75%. Compared to surgery, non-operative management is associated with less disability and lower costs, with no increase in the rate of complicated appendicitis. In patients with complicated appendicitis, initial non-operative management with interval appendectomy has been shown to be safe with reported success rates between 66% and 95%. Several studies suggest that initial non-operative management with interval appendectomy may be beneficial in patients with perforated appendicitis with a well-formed abscess or inflammatory mass. Recent data suggest that interval appendectomy may not be necessary after initial non-operative management of complicated appendicitis.

Acute appendicitis with a neuroendocrine tumor G1 (carcinoid): pitfalls of conservative treatment

A man in his early thirties presented to our clinic with right lower abdominal pain. Computed tomography (CT) and ultrasonography (US) revealed a swollen appendix and an appendicolith. Abscess formation was not observed but ongoing appendiceal rupture was not ruled out. Three months after successful conservative therapy, the lumen of the apical portion was kept dilated and laparoscopic interval appendectomy was performed. No tumorous findings were observed macroscopically. However, histology revealed many tiny nests infiltrating the submucosa, muscular layer, and subserosa at the root of the appendix. An appendiceal neuroendocrine tumor G1 (NET G1; carcinoid) was diagnosed immunohistologically. Neither CT nor US visualized the tumor because of its non-tumor-forming but infiltrative growth. In conclusion, after successful conservative treatment, interval appendectomy should be considered to uncover a possible appendiceal NET G1 (carcinoid), particularly when dilatation of the distal lumen is kept under observation.

Perforated appendix with abscess: Immediate or interval appendectomy? Some examples to explain our choice

•

There are no clear guidelines in the treatment of a perforated appendicitis associated with localized abscess.

•

Our team’s therapeutic choice, also with presence of coprolith, is the initial conservative case management followed by a routine interval appendectomy.

•

Interval appendectomy should be performed not later than 4 months after discharge.

Introduction

There are no clear guidelines in the treatment of a perforated appendicitis associated with periappendiceal abscess without generalized peritonitis.

Presentation of cases

We retrospectively studied six examples of treated children in order to discuss the reasons of our team’s therapeutic approach. Some children were treated with a conservative antibiotic therapy to solve acute abdomen pain, planning a routine interval appendectomy after some months. Others, instead, underwent an immediate appendectomy.

Discussion

By examining these examples we wanted to highlight how the first approach may be associated with shorter surgery time, fewer overall hospital days, faster refeeding and minor complications.

Conclusion

Our team’s therapeutic choice, in the case of a perforated appendicitis with an abscess and coprolith is an initial conservative case management followed by a routine interval appendectomy performed not later than 4 months after discharge.

Is Interval Appendectomy Indicated after Non-Operative Management of Acute Appendicitis in Patients with Cancer? A Retrospective Review from a Single Institution

Interval appendectomy (IA) is a controversial subject, with little consensus on its use in patients undergoing treatment for malignancy. We sought to determine the frequency of recurrent appendicitis in cancer patients managed nonoperatively (NOM) during index hospitalization (IHA) for acute appendicitis (AA). Clinical presentation, cancer treatment, and follow-up were collected from electronic medical records of patients with CT scan-confirmed AA treated at a single institution between August 1999 and August 2009. Seventy-two of 109 AA patients underwent appendectomy during IHA;34ofthese 109 wereNOM during IHA.Medianindex lengthofNOM patients'staywas six days (0–55), median age was 59 (18–80) years. Indications for NOM were presence of abscess or phlegmon (14), mild symptoms (13), high surgical risk (3), end-stage cancer (3), and patient declining surgery (1). Eight NOM patients underwent percutaneous drainage of abdominal abscess (median total duration of intravenous + oral antibiotics = 12 days [0–55]). There were six deaths (1 IHA, 5 NOM): four sepsis and two cancer progression. At a median of 19-month follow-up (range 1–103), four NOM patients surviving IHA had recurrent AA (11.7%) at two (n = 2) and three months (n = 2) after the first episode. Overall, six had IA (17.6%) one to seven months post AA; 25 remained asymptomatic, without IA. In conclusion, among NOM patients at a cancer center at IHA for AA, recurrent AA was early (< 4 months) but uncommon. IA should be offered to those with recurrent symptoms, but appears to have a very limited role after several months of asymptomatic follow-up.

Role of the transumbilical laparoscopic-assisted single-channel, single-port procedure in an interval appendectomy for pediatric mass-forming appendicitis: a preliminary retrospective analysis

INTRODUCTION

A transumbilical laparoscopic-assisted single-channel, single-port procedure was introduced during laparoscopic interval appendectomy for mass-forming appendicitis in children. The aim of this study was to evaluate the results of the original laparoscopic interval appendectomy.

METHODS

This study analyzed 31 children who underwent laparoscopic interval appendectomy using a single-channel, single-port procedure. The appendectomy was usually planned 8-12 weeks following initial conservative treatment. The procedure was a single-channel surgery using a 12-mm single port. Both a 5-mm telescope and grasper were inserted simultaneously into the single channel. The grasper held the appendix, and an extracorporeal appendectomy was performed.

RESULTS

Appendectomy was planned for 29 patients, as 2 patients deviated from the protocol. The procedure was successful in 21 patients (72.4%). An accessory port was necessary in eight patients, two of whom successfully underwent laparoscopic surgery; the remaining six were converted to open appendectomy. The average length of surgery was 43 min in the single-channel, single-port procedure. No postoperative complications occurred in any patient.

CONCLUSION

The single-channel, single-port procedure was successfully performed in over 70% of the patients. This preliminary retrospective analysis indicates that the procedure is safe and potentially beneficial in children with mass-forming appendicitis who require laparoscopic interval appendectomy.

Drainage of periappendiceal abscess and removal of free fecalith--extraperitoneal approach

Treatment of complicated acute appendicitis is controversial. The dilemma is further complicated by presence of free fecalith in a well-circumscribed abscess, which has been repeatedly demonstrated to be a major predicting factor of treatment failure of nonoperative treatment of acute appendicitis complicated with appendiceal abscess. If left behind after drainage of the abscess, further operations for removal of retained fecalith or recurrence of abscess might be required. However, little had been stressed over the significance of removal of the free fecalith when it was first encountered. We report our experience of drainage of appendiceal abscess and removal of free fecalith by taking an extraperitoneal approach. Both of our cases made a smooth recovery without any complication or recurrence after a 2-year follow-up. Treatment with this approach avoids many of the complications associated with formal laparotomy. Unlike image-guided drainage or laparoscopic drainage, this procedure is relatively simple and straightforward and can be performed in any level of hospital, including private practitioners and in less well-developed areas and countries. With proper case selection, we recommend this approach as one of the alternatives in the treatment of late-presenting appendiceal abscess with free fecalith.

Intraluminal appendiceal fluid is a predictive factor for recurrent appendicitis after initial successful non-operative management of uncomplicated appendicitis in pediatric patients

BACKGROUND

The risk factors for recurrent appendicitis in pediatric patients are unclear. This study aimed to identify the predictive factors for recurrent appendicitis in pediatric patients who initially underwent successful non-operative management of uncomplicated appendicitis.

METHODS

Potential predictive factors for recurrent appendicitis in terms of clinical characteristics, laboratory data, and abdominal ultrasonography and computed tomography findings, were evaluated.

RESULTS

This study included 125 patients who underwent initial successful non-operative management of appendicitis. The rate of recurrent appendicitis was 19.2%, and the mean time to recurrence was 12.6 months. Univariate analyses found that rebound tenderness, muscle guarding, appendicoliths, appendiceal diameter >9 mm, and intraluminal appendiceal fluid were associated with recurrent appendicitis. Multivariate analysis identified only intraluminal appendiceal fluid as an independent predictor of recurrent appendicitis.

CONCLUSIONS

Intraluminal appendiceal fluid is a predictive factor for recurrent appendicitis after initial non-operative management. The results of this study provide valuable information that may help to determine the appropriate management during the first episode of appendicitis.

Interval appendectomy in children clinical outcomes, financial costs and patient benefits

BACKGROUND

Elective interval appendectomy (IA) is traditionally advocated for the management of appendiceal mass (AM) in children. Surgeons have debated the evidence and 'risks' vs. 'benefits' to support IA. There are currently no randomised controlled trials and guiding best practice and financial costings for IA are lacking. We herein report clinical outcomes, patient benefits and tariff charges linked with the provision of IA at a regional UK paediatric surgical centre.

METHODS

Hospital case records of patients with AM were identified using pathology records and hospital admission codes during a 15-year period (1997-2011). Tariff costs (£ Sterling) were calculated for all admissions during the era 2007-2011.

RESULTS

69 children were admitted with AM (61% female, median age 10.5 years, range 2.1-16 years). Median initial hospital stay with resolution of symptoms was 8 days (range 3-14 days). 61 children (88%) had elective IA (median interval 76 days, range 29-230 days). Eight (12 %) patients required emergency readmission for early appendectomy (median interval 21 days, range 6-51 days). Hospital stay for emergency readmission appendectomy in these children was significantly longer than IA (median 6 vs. 3 days, p < 0.01). Laparoscopic appendectomy vs. 'open' appendectomy was associated with shorter length of stay in the IA cohort (median 3 vs. 2 days p < 0.01). No intra-operative morbidity was recorded in the study with only a single case developing a post-operative wound infection. Median cost for IA was £1,936. Costings were higher in the emergency appendectomy group-£2,171 vs. 1,936; p = 0.09, NS.

CONCLUSION

Only 12% of children at this centre develop recurrent appendicitis after primary admission with AM. Interval and emergency appendectomy were associated with low morbidity. Parents should be informed that IA may be 'non essential' surgery. Paediatric surgeons not routinely advocating IA can potentially save the NHS £1,936 per patient. Future randomised studies are warranted to confirm or refute these findings.

Histological analysis of appendices removed during interval appendectomy after conservative management of pediatric patients with acute appendicitis with an inflammatory mass or abscess

BACKGROUND/PURPOSE

To clarify the role of interval appendectomy (IA) in pediatric patients with acute appendicitis with an appendiceal inflammatory mass or abscess, we histologically analyzed the appendices removed during IA.

PATIENTS AND METHODS

We treated 355 consecutive pediatric patients with acute appendicitis and reviewed the admission charts of patients who started conservative management (CM). The histology of the appendix removed during IA was also examined. The relationships among the clinical features, appendicolith formation at the time of IA and histological findings were analyzed by stepwise regression analyses.

RESULTS

(1) CM was started in 48 patients (13.5 %). Recurrence or a remaining abscess was observed in nine patients (18.8 %). (2) Histopathological changes, particularly foreign body reaction with fibrosis and infiltration of inflammatory cells, were observed in about half of the specimens. (3) In a stepwise regression analysis, the presence of an appendicolith at IA was correlated with an appendicolith at diagnosis, foreign body reaction in the appendix and a decrease in the inflammatory reaction at diagnosis.

CONCLUSION

More than half the patients had strong histopathological changes in the appendix, suggesting a high possibility of recurrence. The presence of appendicolith formation at IA, which is a risk factor for recurrence, was influenced by the presence of an appendicolith at diagnosis, foreign body reaction in the appendix and the inflammatory status of patients at diagnosis. These clinical findings are indications for IA.

Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children

BACKGROUND

For decades, urgent operation has been considered the only appropriate management of acute appendicitis in children. The purpose of this study was to investigate the feasibility of nonoperative management of uncomplicated acute appendicitis in children.

STUDY DESIGN

A prospective nonrandomized clinical trial of children with uncomplicated acute appendicitis comparing nonoperative management with urgent appendectomy was performed. The primary result was 30-day success rate of nonoperative management. Secondary outcomes included comparisons of disability days, missed school days, hospital length of stay, and measures of quality of life and health care satisfaction.

RESULTS

Seventy-seven patients were enrolled during October 2012 to October 2013; 30 chose nonoperative management and 47 chose surgery. There were no significant differences in demographic or clinical characteristics. The immediate and 30-day success rates of nonoperative management were 93% (28 of 30) and 90% (27 of 30). There was no evidence of progression of appendicitis to rupture at the time of surgery in the 3 patients for whom nonoperative management failed. Compared with the surgery group, the nonoperative group had fewer disability days (3 vs 17 days; p < 0.0001), returned to school more quickly (3 vs 5 days; p = 0.008), and exhibited higher quality of life scores in both the child (93 vs 88; p = 0.01) and the parent (96 vs 90; p = 0.03), but incurred a longer length of stay (38 vs 20 hours; p < 0.0001).

CONCLUSIONS

Nonoperative management of uncomplicated acute appendicitis in children is feasible, with a high 30-day success rate and short-term benefits that include quicker recovery and improved quality of life scores. Additional follow-up will allow for determination of longer-term success rate, safety, and cost effectiveness.

Recurrence of acute appendicitis after non-operative treatment of appendiceal abscess in children: a single-centre experience

BACKGROUND/PURPOSE

The aim of this study was to evaluate the incidence of recurrence of acute appendicitis after initial successful non-operative treatment of appendiceal abscess in children.

METHODS

This study was an observational cohort study of children treated non-operatively for appendiceal abscess at a large tertiary referral centre from 2006 to 2010. The primary outcome was recurrence of acute appendicitis. Secondary outcome variables were re-admission and interval appendectomy.

RESULTS

Eighty-nine patients were discharged after successful non-operative treatment of appendiceal abscess. The median age was 10.1 (1.3-16.3) years. Nine patients underwent surgery during the follow-up period. Five patients were re-admitted with ongoing symptoms leading to an appendectomy. They all returned shortly after discharge and are considered failures of initial treatment. Two of 82 patients returned with a new episode of acute appendicitis during the trial period. Hence, the recurrence rate was 2.4 % during 5.1 years of follow-up.

CONCLUSION

Our data support the strategy of not performing an interval appendectomy after successful non-operative treatment with antibiotics of an appendiceal abscess in children.

Treatment of suspected acute perforated appendicitis with antibiotics and interval appendectomy

BACKGROUND

Initial antibiotics with planned interval appendectomy (interval AP) have been used to treat patients with complicated perforated appendicitis; however, little experience exists with this approach in children with suspected acute perforated appendicitis (SAPA). We sought to determine the outcome of initial antibiotics and interval AP in children with SAPA.

METHODS

Over an 18-month period, 751 consecutive patients underwent appendectomy including 105 patients with SAPA who were treated with initial intravenous antibiotics and planned interval AP ≥ 8 weeks after presentation. All SAPA patients had symptoms for ≤ 96 hours. Primary outcome variables were rates of readmission, abscess formation, and need for interval AP prior to the planned ≥ 8 weeks.

RESULTS

Intraabdominal abscess rate was 27%. Appendectomy prior to planned interval AP was 11% and readmission occurred in 34%. All patients underwent eventual appendectomy with pathologic confirmation confirming the previous appendiceal inflammation. White blood cell (WBC) count >15,000, WBC >15,000 plus fecalith on imaging, and WBC >15,000 plus duration of symptoms >48 hours were all significantly associated with higher rates of readmission (p=0.01, p=0.04, p=0.02) and need for interval AP prior to the planned ≥ 8 weeks (p=0.003, p=0.05, p=0.03).

CONCLUSIONS

Treatment of SAPA with antibiotics and planned interval AP is successful in the majority of patients; however, complications such as abscess formation and/or readmission prior to planned interval AP occur in up to one-third of patients. Certain clinical variables are associated with increased treatment complications.

Predictors of recurrent appendicitis after non-operative management of children with perforated appendicitis presenting with an appendicular inflammatory mass

AIM

To determine clinical and imaging predictors of recurrent appendicitis after non-operative management for children with perforated appendicitis presenting with an appendicular inflammatory mass.

METHODS

A case-control study was carried out of children with clinical and ultrasonographic diagnosis of an appendicular inflammatory mass. Patients were divided into two groups according to the presence or not of recurrent appendicitis (or predisposing pathological findings during interval appendectomy). Several clinical and imaging factors were compared between both groups using an independent and progressive analysis to identify which were the most relevant predictors.

RESULTS

The persistence of symptoms after resolution of the appendicular inflammatory mass, as well as its time of resolution (p<0.001), were the most relevant factors during group classification. The identification of an ultrasonographic image of an appendicolith and the initial size of the mass were also identified as independent predictors (p<0.018 and p<0.01). The presence of the first two factors in a patient was strongly associated with recurrent appendicitis.

CONCLUSIONS

Persistent symptoms after the recovery of the initial episode, associated with a slow resolution of the appendicular inflammatory mass, are indications for an interval appendectomy. A previous history of appendicitis or detection of an ultrasonographic image of an appendicolith is the other indication for an interval appendectomy.

Management of Complicated Appendicitis in the Pediatric Population: When Surgery Doesn't Cut It

The management of complicated appendicitis in children has evolved significantly over the last century. What initially was a surgeon's dilemma is becoming the interventional radiologist's task because image-guided percutaneous drainage of abscesses from a ruptured appendix obviates the need for urgent surgery and allows for selective interval appendectomy at the surgeon's discretion (versus conservative nonoperative management in selected cases). This paradigm shift places the onus on the interventional radiologist to recognize when the procedure is emergently indicated and to be cognizant of the special needs of a pediatric patient.

Laparoscopic interval appendectomy versus open interval appendectomy: a prospective randomized controlled trial

This was a prospective randomized controlled study designed to compare laparoscopic and open interval appendectomy and involved 100 patients of appendicular phlegmon. After initial conservative management, patients were divided into 2 groups of 50 each and interval appendectomy was performed by laparoscopy in one of the groups and by open method in the other. Mean operative time in open surgery was 33.9 minutes and that in laparoscopic surgery was 57.64 minutes (P < 0.05). Concomitant pathology was observed in 16% and 2% of patients in the laparoscopic and open groups, respectively. Mean pain scores on the first postoperative day were 5.14 in the laparoscopic group and 6.01 in the open group (P < 0.05). Patients in the laparoscopic group had a shorter duration of ileus, postoperative stay, and returned to work earlier (P < 0.05). We conclude that laparoscopy offers a number of advantages over open interval appendectomy.

Transumbilical laparo-assisted appendectomy: a safe operation for the whole spectrum of appendicitis in children-a single-centre experience

The paper reports the results of a retrospective review of the medical charts of 203 patients admitted to a pediatric surgical unit with a diagnosis of acute appendicitis between January 2006 and December 2010 when a transumbilical laparoscopic-assisted appendectomy (TULAA) was introduced as a new surgical technique. Among 203 admitted patients, 7 (3.5%) had a localized appendiceal abscess and were treated with antibiotics. All of them responded to antibiotics and underwent TULAA interval appendectomy 8 weeks later. 196 patients (96.5%) underwent immediate surgery. In 12/181 (6.6%) urgent cases, conversion to laparotomy was necessary, in 3 patients because of bowel distension and in 9 for retrocecal position of appendix. In all 181 TULAA completed procedures, one trocar was used in 151 cases (89.4%), two trocars in 16 (9.4%), and three trocars in 2 (1.2%). The mean operative time for single port TULAA was 52′ Complications included 5 wound infections and 5 intra-abdominal abscesses, all managed conservatively. In conclusion, TULAA is a safe, minimally invasive approach with acute appendicitis, regardless of the perforation status, and can be recommended in the pediatric urgical settings.

Nonoperative management of appendiceal phlegmon or abscess with an appendicolith in children

BACKGROUND

The optimal treatment of appendiceal phlegmon or abscess with an appendicolith is controversial. This study aimed to evaluate outcomes and prognosis of nonoperative management of appendiceal phlegmon or abscess with an appendicolith in children.

METHODS

From 2007 to 2011, 105 children with appendiceal phlegmon or abscess who were treated nonoperatively without interval appendectomy were reviewed. Average follow-up of subjects was 2.4 years. Data were compared between subjects with and without an appendicolith or persistent presence and disappearance of an appendicolith.

RESULTS

The success rate for nonoperative therapy for appendiceal phlegmon or abscess with appendicolith was 95.9 %. The risk of recurrent appendicitis in appendiceal phlegmon or abscess with appendicolith (19.1 %) was higher than that without appendicolith (8.9 %, P = 0.132). The rate of appendicolith disappearance during follow-up was 80.9 %. The persistent presence of an appendicolith was associated with a significantly higher recurrence rate (66.7 %) compared with appendicolith disappearance (7.9 %, P < 0.05).

CONCLUSION

Appendiceal phlegmon or abscess with an appendicolith can be managed nonoperatively, and most appendicoliths can be resolved. Persistent presence of an appendicolith is a significant risk factor for recurrent appendicitis. Interval appendectomy is recommended for persistent presence of appendicolith, but is not indicated in cases without appendicolith or appendicolith disappearance.

Appendicolith delays resolution of appendicitis following nonoperative management

INTRODUCTION

Success in nonoperative management is only based on the clinical symptoms of patients with acute appendicitis. However, imaging studies can provide further insight into the status of the appendix to monitor treatment response if immediate appendectomy is not undertaken. This study investigates sonographic resolution following nonoperative management and assesses the feasibility of incorporating ultrasound into patient care.

MATERIALS AND METHODS

Adult patients with acute appendicitis who had been successfully treated with nonoperative management were enrolled and received repeat sonographic examinations using 3-day intervals until sonographic resolution. The relationship between the time to achieve sonographic resolution and clinical parameters was identified using negative binomial regression models.

RESULTS

From January 2003 to December 2009, 128 patients were successfully treated with nonoperative management. Eighty patients completed sonographic examinations until achieving resolution. Sonographic resolution was achieved on 17 ± 12 days (range, 3-69 days). Ninety-five percent of the patients achieved sonographic resolution within 41 days. The appendicolith was positively related to the time to achieve sonographic resolution (rate ratios, 1.63; 95 % confidence intervals, 1.06-2.51).

CONCLUSIONS

Ultrasound can be used to evaluate the condition of the appendix to monitor treatment response following nonoperative management on the sixth week. An appendicolith delays sonographic resolution of appendicitis.

Significance of size and location of appendicoliths as exacerbating factor of acute appendicitis

The aim of the present study was to investigate the significance of appendicoliths as an exacerbating factor of acute appendicitis using multivariate analysis. A total of 254 patients with pathologically proved acute appendicitis were enrolled in this retrospective study (male, 51 %; mean age, 40.1 years; range, 15-91 years). Two radiologists performed a consensus evaluation of preoperative CT images for the presence of appendicoliths in consensus. When there were appendicoliths, they assessed the number and location of appendicoliths, and measured the longest diameter of the largest appendicolith. Pathological diagnosis was used for the reference standard. The relationships of appendicoliths to gangrenous appendicitis and to perforated appendicitis were each assessed with multiple logistic regression models, which were adjusted for demographic and clinical characteristics of patients. Significant relationships were identified between gangrenous appendicitis and the presence of appendicoliths (OR, 2.2; 95 % CI, 1.2-4.0), the largest appendicolith more than 5 mm in the longest (OR, 3.0; 95 % CI, 1.6-5.7), and location of an appendicolith at the root of the appendix (OR, 2.0; 95 % CI, 1.1-3.8). Among the CT characteristics, the location of an appendicolith at the root of the appendix only showed significant relationship with perforated appendicitis (OR, 4.5; 95 % CI, 1.4-15.4). Size of the largest appendicolith and location of appendicoliths at the root of the appendix are exacerbating factors of acute appendicitis.

Diagnosis and management of pediatric appendicitis, intussusception, and Meckel diverticulum

Three of the most common causes of surgical abdominal pain in pediatric patients include appendicitis, Meckel diverticulum, and intussusception. All 3 can present with right lower quadrant pain, and can lead to significant morbidity and even mortality. Although ultrasound is the preferred method of diagnosis with appendicitis and intussusception, considerable variety exists in the modalities needed in the diagnosis of Meckel diverticulum. This article discusses the pathways to diagnosis, the modes of treatment, and the continued areas of controversy.

Efficacy of Short-Term Antibiotic Therapy for Consecutive Patients with Mild Appendicitis

Although antibiotic therapy seemed to be a safe treatment option for acute appendicitis, indications of this treatment have not been fully evaluated. We hypothesized that clinical and radiologic mild appendicitis may be a candidate for short-term antibiotic therapy. The purpose of present study was to examine the efficacy and the recurrence rate of short-term antibiotic therapy for consecutive patients with mild appendicitis. A prospective observational study was conducted over 3 years. The mild appendicitis was defined as the intermediate Alvarado score (4-8) and dilated appendix from 6 mm to 10 mm in radiologic study. All patients received initial antibiotics administration with clinical observation during 48 hours. The failure to respond to therapy and the incidence of recurrence were assessed. There were 107 enrolled patients with the mean Alvarado score of 6 ± 1 and the mean appendiceal diameter of 7.4 ± 1 mm. Of these, 97 (91%) exhibited improved symptoms and were discharged. The remaining 10 patients underwent surgery because of clinical aggravation, and pathology revealed true appendicitis in six of them. Of the 97 patients in whom the initial treatment was successful, five patients (5%) exhibited recurrent symptoms during a median follow-up period of 18 months. Of these five patients, three were treated with surgery (all true appendicitis), and the remaining two were once again treated with antibiotics. Patients with suspected appendicitis, those in whom mild appendicitis was diagnosed after clinical and radiologic evaluations, were found to benefit from short-term antibiotic therapy.

Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review

BACKGROUND/PURPOSE

Interval appendicectomy (IA) is commonly performed after successful nonoperative treatment of appendix mass (AM); although, this approach has recently been challenged. We systematically reviewed the pediatric literature with regard to the justification for this practice.

METHODS

Using a defined search strategy, studies were identified and data were extracted independently by 2 reviewers. Incidences of recurrent appendicitis, complications after IA, and carcinoid tumor were estimated accounting for interstudy heterogeneity. Cost and length of stay of IA were analyzed.

RESULTS

Three studies (127 cases) reporting routine nonsurgical treatment were identified; all were retrospective. There was marked interstudy heterogeneity and variable follow-up. After successful nonoperative treatment of AM, the risk of recurrent appendicitis is 20.5% (95% confidence interval [CI], 14.3%-28.4%). The incidence of complications after IA (23 studies, n = 1247) is 3.4% (95% CI, 2.2-5.1), and the incidence of carcinoid tumor found at IA (15 studies, n = 955) is 0.9% (95% CI, 0.5-1.8). No reports compared costs. Mean length of stay for IA was 3 days (range, 1-30 days).

CONCLUSIONS

Prospective studies comparing routine IA with nonoperative treatment without IA in children are lacking. Available data suggest that 80% of children with AM may not need IA. A prospective study to evaluate the natural history of this condition compared with the morbidity and costs of IA is warranted.