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Elisa Z, Camilla P, Giulia M, Nicola Z, Daniela C, Francesca G, Marco G, Claudio C, Alessandro P, Fabio B, Antoniello LM, Piergiorgio G. Concordance in Intraoperative Surgeons' Opinion in the Diagnosis and Management of Acute Appendicitis: The Role of Training. JOURNAL OF SURGICAL EDUCATION 2024:S1931-7204(24)00232-0. [PMID: 38908992 DOI: 10.1016/j.jsurg.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 04/24/2024] [Accepted: 05/07/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE Acute appendicitis is a wide spectrum disease, from simple inflammation to evident intestinal perforation. The correct interpretation of the degree of inflammation is crucial to guarantee appropriate treatment and adherence to protocols and guidelines. In order to investigate this concordance, the authors compared the definition of appendicitis and the predicted treatment among all surgeons affiliated to a single Pediatric Surgery School (consisting of 8 different centers). DESIGN Twenty-two short recordings of intra-operative manipulation of appendices were shown to 56 surgeons, blindly to clinical information. Four items were collected and analyzed: classification of appendicitis, type and length of predicted antibiotic therapy, day of re-alimentation. Data were analyzed to identify the concordance kappa coefficient, stratified according to expertise of the responding surgeon. RESULTS The 1232 evaluations obtained in all valued items low overall concordance. Subgroup analysis identified a good agreement between younger surgeons only in the choice of antibiotic (k 0.47). However, if the centers were divided between University and non-University Hospitals, a strong agreement was found in the former both for classification (k 0.45 vs 0.32) and type of antibiotic (k 0.42 vs 0.24). CONCLUSIONS The overall concordance between surgeons in different centers in the diagnostic classification and predicted treatment of appendicitis is quite low. University Hospital have a highest concordance in both items at all levels of expertise; it might be postulated that teaching to younger surgeon increase the comparison between experts and finally the concordance and adherence to protocols within the center.
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Affiliation(s)
- Zambaiti Elisa
- Pediatric Surgery Unit, Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Torino, TO, Italy.
| | - Pagliara Camilla
- Pediatric Surgery Unit, Azienda Ospedaliero Universitaria di Padova, Padova, PD, Italy; Department of Pediatric Surgery, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, TS, Italy
| | - Mottadelli Giulia
- Pediatric Surgery Unit, Azienda Ospedaliero Universitaria di Padova, Padova, PD, Italy; Umberto Bosio Center for Digestive Diseases, Pediatric Surgery Unit, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, AL, Italy
| | - Zampieri Nicola
- Department of Surgery, Policlinico G.B.Rossi, University of Verona, Verona, VR, Italy
| | - Codrich Daniela
- Department of Pediatric Surgery, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, TS, Italy
| | - Grandi Francesca
- Complex Operative Unit-Pediatric Surgery, Hospital of Bolzano, Bolzano, BZ, Italy
| | - Gasparella Marco
- Pediatric Surgery Unit, Ca' Foncello Hospital, Treviso, TV, Italy
| | - Carlini Claudio
- Umberto Bosio Center for Digestive Diseases, Pediatric Surgery Unit, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, AL, Italy
| | - Pane Alessandro
- Pediatric Surgery Unit, Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Torino, TO, Italy
| | - Beretta Fabio
- Pediatric Surgery Unit, Presidio Ospedaliero Santa Chiara, Trento, TN, Italy
| | - Luca Maria Antoniello
- Pediatric Surgery Unit, Azienda Ospedaliero Universitaria di Padova, Padova, PD, Italy
| | - Gamba Piergiorgio
- Pediatric Surgery Unit, Azienda Ospedaliero Universitaria di Padova, Padova, PD, Italy
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Guo X, Yang H, Zhao P, Li J, Zeng L, Wang C, Yang Y, Yang R. The application value of high-frequency ultrasound in the feasibility assessment of endoscopic retrograde appendicitis therapy in children with appendicitis. Sci Rep 2023; 13:19291. [PMID: 37935754 PMCID: PMC10630480 DOI: 10.1038/s41598-023-46387-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/31/2023] [Indexed: 11/09/2023] Open
Abstract
Acute appendicitis is one of the common acute abdominal diseases in pediatrics. However, the implementation of radiological examination guided endoscopic retrograde appendicitis therapy (ERAT) in adults is limited in children. Our previous research explored the non-invasive guidance of high-frequency ultrasound (HFUS) for ERAT and achieved good therapeutic effects. This study mainly focuses on exploring the application value of HFUS in the feasibility assessment of ERAT in children with appendicitis. 163 children with appendicitis received ERAT guided by HFUS were analyzed retrospectively. According to the parameters evaluated by HFUS before and during ERAT, the results indicated that the distance between the appendix orifice and the ileocecal valve significantly affected the time required for the guidewire to enter the appendix cavity (P < 0.05). The diameter and the texture of the fecalith, the thickness of the intestinal wall of the appendiceal orifice all had significant effects on the successful removal of the fecalith (P < 0.05). The success rate, treatment time and final flushing effect of the guidewire to reach the blind end of the appendix were significantly affected by the tortuosity of the appendix and whether there was adhesion with surrounding tissues (P < 0.05). HFUS can accurately assess the feasibility of ERAT in children with appendicitis.
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Affiliation(s)
- Xiaoya Guo
- Department of Ultrasound Diagnosis, Tangdu Hospital of Air Force Military Medical University, Xi'an, China
| | - Hengli Yang
- Department of Ultrasound Diagnosis, The Second Affiliated Hospital of Xi'an Medical College, Xi'an, China.
| | - Ping Zhao
- Department of Ultrasound Diagnosis, Tangdu Hospital of Air Force Military Medical University, Xi'an, China
| | - Jinghua Li
- Department of Ultrasound Diagnosis, Tangdu Hospital of Air Force Military Medical University, Xi'an, China
| | - Lingchao Zeng
- Department of Pediatrics, Tangdu Hospital of Air Force Military Medical University, Xi'an, China
| | - Chunhui Wang
- Department of Pediatrics, Tangdu Hospital of Air Force Military Medical University, Xi'an, China
| | - Yilin Yang
- Department of Ultrasound Diagnosis, Tangdu Hospital of Air Force Military Medical University, Xi'an, China.
| | - Ruijing Yang
- Department of Ultrasound Diagnosis, Tangdu Hospital of Air Force Military Medical University, Xi'an, China.
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Gil LA, Deans KJ, Minneci PC. Appendicitis in Children. Adv Pediatr 2023; 70:105-122. [PMID: 37422289 DOI: 10.1016/j.yapd.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
The management of pediatric appendicitis continues to advance with the development of evidence-based treatment algorithms and a recent shift toward patient-centered treatment approaches. Further research should focus on development of standardized institution-specific diagnostic algorithms to minimize rates of missed diagnosis and appendiceal perforation and refinement of evidence-based clinical treatment pathways that reduce complication rates and minimize health care resource utilization.
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Affiliation(s)
- Lindsay A Gil
- Pediatric Surgery Research Fellow, Nationwide Children's Hospital, The Ohio State University Wexner Medical Center, 700 Children's Drive, Columbus, OH 43206, USA
| | - Katherine J Deans
- Department of Surgery, Nemours Children's Health, Delaware Valley, 1600 Rockland Road, Wilmington, DE 19803, USA
| | - Peter C Minneci
- Division of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University Wexner Medical Center, 611 East Livingston Avenue, Columbus, OH 43206, USA.
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Zachos K, Kolonitsiou F, Panagidis A, Gkentzi D, Fouzas S, Alexopoulos V, Kostopoulou E, Roupakias S, Vervenioti A, Dassios T, Georgiou G, Sinopidis X. Association of the Bacteria of the Vermiform Appendix and the Peritoneal Cavity with Complicated Acute Appendicitis in Children. Diagnostics (Basel) 2023; 13:diagnostics13111839. [PMID: 37296691 DOI: 10.3390/diagnostics13111839] [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: 04/24/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Primary infection has been questioned as the pathogenetic cause of acute appendicitis. We attempted to identify the bacteria involved and to investigate if their species, types, or combinations affected the severity of acute appendicitis in children. METHODS Samples from both the appendiceal lumen and the peritoneal cavity of 72 children who underwent appendectomy were collected to perform bacterial culture analysis. The outcomes were studied to identify if and how they were associated with the severity of the disease. Regression analysis was performed to identify any risk factors associated with complicated appendicitis. RESULTS Escherichia coli, Pseudomonas aeruginosa, and Streptococcus species were the most common pathogens found in the study population. The same microorganisms, either combined or separate, were the most common in the appendiceal lumen and the peritoneal cavity of patients with complicated appendicitis. Gram-negative bacteria and polymicrobial cultures in the peritoneal fluid and in the appendiceal lumen were associated with complicated appendicitis. Polymicrobial cultures in the peritoneal cavity presented a four times higher risk of complicated appendicitis. CONCLUSIONS Polymicrobial presentation and Gram-negative bacteria are associated with complicated appendicitis. Antibiotic regimens should target the combinations of the most frequently identified pathogens, speculating the value of early antipseudomonal intervention.
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Affiliation(s)
| | - Fevronia Kolonitsiou
- Department of Microbiology, University of Patras School of Medicine, 26504 Patras, Greece
| | - Antonios Panagidis
- Department of Pediatric Surgery, Children's Hospital, 26331 Patras, Greece
| | - Despoina Gkentzi
- Department of Pediatrics, University of Patras School of Medicine, 26504 Patras, Greece
| | - Sotirios Fouzas
- Department of Pediatrics, University of Patras School of Medicine, 26504 Patras, Greece
| | | | - Eirini Kostopoulou
- Department of Pediatrics, University of Patras School of Medicine, 26504 Patras, Greece
| | - Stylianos Roupakias
- Department of Pediatric Surgery, University of Patras School of Medicine, 26504 Patras, Greece
| | - Aggeliki Vervenioti
- Department of Pediatrics, University of Patras School of Medicine, 26504 Patras, Greece
| | - Theodore Dassios
- Department of Pediatrics, University of Patras School of Medicine, 26504 Patras, Greece
| | - George Georgiou
- Department of Pediatric Surgery, Children's Hospital, 26331 Patras, Greece
| | - Xenophon Sinopidis
- Department of Pediatric Surgery, University of Patras School of Medicine, 26504 Patras, Greece
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Zarog M, O’Leary P, Kiernan M, Bolger J, Tibbitts P, Coffey S, Byrnes G, Peirce C, Dunne C, Coffey C. Circulating fibrocyte percentage and neutrophil-lymphocyte ratio are accurate biomarkers of uncomplicated and complicated appendicitis: a prospective cohort study. Int J Surg 2023; 109:343-351. [PMID: 37093074 PMCID: PMC10389644 DOI: 10.1097/js9.0000000000000234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/09/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND There is increasing evidence that uncomplicated appendicitis (UA) may be treated nonoperatively in cases of UA. This study aimed to evaluate and compare the diagnostic accuracy of circulating fibrocyte percentage (CFP), white blood cell count, C-reactive protein, and neutrophil-lymphocyte ratio (NLR) in diagnosing uncomplicated and complicated appendicitis. MATERIALS AND METHODS Eighty consecutive adult patients presenting with suspected appendicitis were recruited in a cohort-based prospective study between June 2015 and February 2016 at University Hospital Limerick in Ireland. Peripheral venous samples were obtained at the presentation. Clinical, biochemical, radiological, and histopathological parameters were recorded. The CFP was determined by dual-staining for CD45 and collagen-I using flow cytometry analysis and correlated with histopathological diagnoses. RESULTS Of the 46 patients who underwent appendicectomy, 34 (73.9%) had histologically proven acute appendicitis. A comparison of the diagnostic accuracy of biomarkers demonstrated the CFP had the highest diagnostic accuracy for UA (area under the curve=0.83, sensitivity=72.7%, specificity=83.3%, P=0.002). The NLR had the highest diagnostic accuracy in relation to complicated appendicitis (area under the curve=0.84, sensitivity=75.5%, specificity=83.3%, P=0.005). CONCLUSIONS CFP and NLR are accurate biomarkers of UA and complicated appendicitis.
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Lin Z, Zeng H, Cai S, Chen F, Wang X, Wu D, Liu M, Fang Y. Effects of rhubarb peony decoction combined with antibiotics in treating pediatric periappendiceal abscess. Front Pediatr 2023; 11:1112034. [PMID: 37063672 PMCID: PMC10090493 DOI: 10.3389/fped.2023.1112034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/10/2023] [Indexed: 04/18/2023] Open
Abstract
Background/purpose Rhubarb peony decoction (RPD) is a formula of traditional Chinese medicine that has been widely used to treat intra-abdominal inflammatory diseases. To investigate the therapeutic efficacy of RPD in pediatric periappendiceal abscess, patients who received intravenous antibiotics alone were compared with those treated with intravenous antibiotics combined with RPD. Methods A retrospective review of children with periappendiceal abscess who received conservative treatment in our hospital between January 2013 and April 2022 was performed. The patients were divided into an intravenous antibiotic group (the control group) and an intravenous antibiotic combined with RPD group (the intervention group). Interval appendectomy (IA) was generally performed 10-12 weeks after conservative treatment. The primary outcome was the cure rate of conservative treatment, while the secondary outcomes included the recurrence rate, days of total intravenous antibiotic use, length of hospital stay (LOS), postoperative complications, and liver injury caused by RPD. Results A total of 142 patients (77 girls and 65 boys) were included, 52 in the control group and 90 in the intervention group. The two groups were similar in demographic data and clinical characteristics (P > 0.05). The mean total course of RPD in the intervention group was 11.82 days. The intervention group had a significantly higher cure rate than the control group (93.33% vs. 80.77%, P = 0.029), and the length of total intravenous antibiotic use (P = 0.150), LOS (P = 0.077), recurrence rate (9.52% vs. 4.76%, P = 0.439), as well as the operation time (P = 0.101), LOS (P = 0.572), and postoperative complications (P = 0.549) were not significantly different between the two groups when the patients received IA. No patient had a liver injury caused by RPD during the treatment. Conclusion Intravenous antibiotics combined with RPD demonstrated high effectiveness and safety for treating pediatric periappendiceal abscess.
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Affiliation(s)
- Zhixiong Lin
- Department of Pediatric Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Huiping Zeng
- Department of Pediatric Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Shujie Cai
- Department of Pediatric Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Fei Chen
- Department of Pediatric Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Xiang Wang
- Department of Pediatric Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Dianming Wu
- Department of Pediatric Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Mingkun Liu
- Department of Pediatric Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Correspondence: Mingkun Liu Yifan Fang
| | - Yifan Fang
- Department of Pediatric Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Correspondence: Mingkun Liu Yifan Fang
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Abstract
Appendicitis is one of the most common surgical emergencies in children and adults. Appendectomy as the standard care has been challenged in the recent years with growing evidence about non-operative treatment as a potential primary treatment in patients presenting with signs and symptoms suggestive of acute appendicitis. This review aims to establish where the recent research stands regarding conservative treatment of acute appendicitis, especially in children. There are several studies that report the potential safety and efficacy of treating acute appendicitis non-operatively. Several studies have challenged the concept of acute appendicitis being a progressive disease that always ends in perforation, rather than a disease that can present as different forms with only a defined number of cases progressing to perforation. The lack of randomized controlled studies is a limitation and well-designed randomized controlled trials are needed to determine the role of non-operative management of acute appendicitis in children.
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Affiliation(s)
- Soma Jumah
- Unit of Pediatric Surgery, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Tomas Wester
- Unit of Pediatric Surgery, Karolinska University Hospital, 17176 Stockholm, Sweden ,Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
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KASTRITSI O, SINOPIDIS X, BARBAGADAKIS S, SAKELLARIS S, MATZAKANIS G, KASTRITSI ED, SAKELLARIS G. Non-operative management of acute appendicitis in children: single center, cohort study. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.21.05295-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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9
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Common Conditions II. Surg Clin North Am 2022; 102:797-808. [PMID: 36209746 DOI: 10.1016/j.suc.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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10
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Suzuki T, Matsumoto A, Akao T, Kobayashi S, Matsumoto H. Interval laparoscopic appendectomy after laparotomy drainage for acute appendicitis with abscess: A case report. Int J Surg Case Rep 2022; 96:107319. [PMID: 35738141 PMCID: PMC9218826 DOI: 10.1016/j.ijscr.2022.107319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Immediate appendectomy for acute appendicitis with abscess has a high frequency of ileocecal resection and postoperative complications compared with interval appendectomy after conservative treatment. The optimal approach to acute appendicitis with abscess remains controversial. PRESENTATION OF CASE A 69-year-old woman was referred to our hospital for abdominal pain. A computed tomography scan revealed an enlarged abscess around the cecum. The diagnosis was perforated appendicitis with abscess, and conservative treatment was performed. Percutaneous drainage was difficult because the abscess was near the intestinal tract. Because of the persistence of symptoms on the fourth day of hospitalization, laparotomy drainage was performed, and the patient's condition improved afterwards. Colonoscopy was performed on an outpatient follow-up to rule out malignant tumors of the colon. Interval laparoscopic appendectomy was performed 3 months after discharge to prevent appendicitis. The postoperative course was uneventful. DISCUSSION For this case of acute appendicitis with abscess, conservative treatment such as antibiotic therapy and laparotomy drainage was performed. Laparotomy drainage enabled us to approach the abscess directly and minimized the risk of its spread into the abdominal cavity compared to the laparoscopic approach. Interval laparoscopic appendectomy was more effective and easier for this case of appendectomy, wherein adhesions to the abdominal wall were expected compared to laparotomy. CONCLUSION Conservative treatment approaches, such as drainage and antibiotic therapy, can be first-line for appendicitis with abscesses. Interval laparoscopic appendectomy can be useful to resect the appendix and observe the abdominal cavity.
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Munoz-Abraham AS, Osei H, Kazmi S, Damle R, Zemela MS, Badru F, Gibbons M, Winkelmann M, Chatoorgoon K, Fitzpatrick C, Greenspon J, Villalona GA. Protocolized management of pediatric complicated appendicitis leads to improved outcomes. Pediatr Surg Int 2022; 38:891-897. [PMID: 35396951 DOI: 10.1007/s00383-022-05124-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE We aimed to evaluate a complicated appendicitis clinical practice guideline at our institution. METHODS Records were compared before and after protocol implementation. We standardized an ED consult pathway, antibiotic use and need for early appendectomy (EA) versus interval appendectomy (IA). We evaluated demographics, clinical characteristics, and outcomes. Subgroup analysis was performed to compare patients with small abscess treated with IA pre-protocol versus similar patients treated by EA post-protocol. RESULTS In total 246 patients were reviewed (Pre-protocol = 152, Post-protocol = 94). Pre-protocol early appendectomy rate was 51% versus 82% on post-protocol patients. There were no differences in demographics. Post-protocol the use of preoperative imaging significantly decreased (Pre 92% vs. 56%, p = 0.0001), as well as the use of discharge antibiotics (Pre 93% vs. Post 27%, p = 0.0001) with no change in abscess rate. Overall, post-protocol patients had fewer total CT scans performed (Pre 40% vs. Post 28%, p = 0.03) and decreased total length of stay (Pre 7.7 vs. Post 6.5 days, p = 0.049). On subgroup analysis, post-protocol EA with no or small abscess had lower median number of admissions, decreased total LOS (Pre IA 9 days vs. Post EA 5 days, p = 0.00001) and fewer complications (Pre IA 42% vs. EA 22%, p = 0.022). CONCLUSION The establishment of a standardized pediatric complicated appendicitis protocol may lead to improved outcomes and resource utilization. Patients presenting with no or small abscess may be the least likely to benefit from interval appendectomy. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Armando Salim Munoz-Abraham
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO, USA. .,Saint Louis University School of Medicine, 1465 S Grand Blvd, St. Louis, MO, 63104, USA.
| | - Hector Osei
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO, USA
| | - Sakina Kazmi
- Saint Louis University School of Medicine, 1465 S Grand Blvd, St. Louis, MO, 63104, USA
| | - Rachelle Damle
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO, USA
| | - Mark S Zemela
- Saint Louis University School of Medicine, 1465 S Grand Blvd, St. Louis, MO, 63104, USA
| | - Faidah Badru
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO, USA
| | - Mitchell Gibbons
- Saint Louis University School of Medicine, 1465 S Grand Blvd, St. Louis, MO, 63104, USA
| | - Madelynn Winkelmann
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO, USA
| | - Kaveer Chatoorgoon
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO, USA
| | - Colleen Fitzpatrick
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO, USA
| | - Jose Greenspon
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO, USA
| | - Gustavo A Villalona
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO, USA
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Teng TZJ, Thong XR, Lau KY, Balasubramaniam S, Shelat VG. Acute appendicitis–advances and controversies. World J Gastrointest Surg 2021; 13:1293-1314. [PMID: 34950421 PMCID: PMC8649565 DOI: 10.4240/wjgs.v13.i11.1293] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/24/2021] [Accepted: 09/29/2021] [Indexed: 02/06/2023] Open
Abstract
Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon’s practice. With the recent advancements in AA’s management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon’s repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic’s repercussions on patients and how surgeons’ practices have evolved in the context of AA.
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Affiliation(s)
- Thomas Zheng Jie Teng
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | - Xuan Rong Thong
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | - Kai Yuan Lau
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
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Nepomuceno H, Pearson EG. Nonoperative management of appendicitis in children. Transl Gastroenterol Hepatol 2021; 6:47. [PMID: 34423168 DOI: 10.21037/tgh-20-191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/23/2020] [Indexed: 11/06/2022] Open
Abstract
Appendicitis is a common condition in childhood and adolescence that frequently requires urgent surgical intervention. For almost two centuries appendicitis has been recognized as a medical problem with a surgical solution. Currently the appendix can be removed with a minimally invasive approach, low anesthetic and surgical risk, and swift hospital discharge. Despite these advances, surgery and anesthesia have associated risks including postoperative infection, bleeding, hernia and organ injury among others. In addition, surgery requires time off of school and work to recover and associated healthcare costs can be significant. In both adult and pediatric populations, quality data suggesting a nonoperative approach is suggesting a change to the traditional surgical paradigm. Adults studies have demonstrated both safety and efficacy in the nonoperative management of acute appendicitis. In selected children with uncomplicated appendicitis, initial nonoperative management has been shown to be safe with fewer complications, fewer disability days and less healthcare costs while avoiding the risks inherent to surgery. Ongoing randomized controlled clinical trials in both the United States and Europe seek to further demonstrate the safety of nonoperative management and assist physicians with educating patients about the risk profile of their treatment decision. In complicated appendicitis presenting with abscess or acute appendiceal phlegmon, an initial nonoperative strategy with or without abscess drainage followed by interval appendectomy is the current state of the art though the utility of interval appendectomy is questioned.
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Affiliation(s)
- Helene Nepomuceno
- Department of Pediatric Surgery, Sunrise Children's Hospital, Las Vegas, NV, USA
| | - Erik G Pearson
- Department of Pediatric Surgery, Sunrise Children's Hospital, Las Vegas, NV, USA
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Kohga A, Kawabe A, Yajima K, Okumura T, Yamashita K, Isogaki J, Suzuki K, Muramatsu K. Does the presence of an appendicolith or abscess predict failure of nonoperative management of patients with acute appendicitis? Emerg Radiol 2021; 28:977-983. [PMID: 34173083 DOI: 10.1007/s10140-021-01951-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/24/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE Nonoperative management (NOM) has been widely accepted as one of the standard treatments for patients with acute appendicitis. However, predictive factors for the failure of NOM have not been thoroughly investigated. METHODS A total of 196 patients with acute appendicitis underwent NOM between April 2014 and December 2020. Of these 196 patients, 24 patients failed NOM and required emergency surgery (failure group: n = 24), while the other 172 patients were successfully treated with NOM (success group: n = 172). These two groups were compared, and the predictive factors for the failure of NOM were investigated. RESULTS The number of patients who had a previous history of stroke was significantly increased in the failure group (12.5% vs. 2.9%, p = 0.026). Incarceration of an appendicolith on CT images was significantly associated with the failure group (20.8% vs. 1.7%, p < 0.001), while neither the presence of an appendicolith nor abscess was associated. The presence of periappendiceal fluid was significantly associated with the failure group (50.0% vs. 26.7%, p = 0.019). The incarceration of an appendicolith (p < 0.001, odds ratio = 19.85) and periappendiceal fluid (p = 0.009, odds ratio = 3.62) were found to be independent risk factors for failure of NOM. Neither the presence of an appendicolith nor abscess was associated with the recurrence of appendicitis. CONCLUSIONS The presence of an appendicolith or abscess was not a crucial factor for surgery. Incarceration of an appendicolith and periappendiceal fluid on CT images was predictive factors for the failure of NOM.
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Affiliation(s)
- Atsushi Kohga
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan.
| | - Akihiro Kawabe
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Kiyoshige Yajima
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Takuya Okumura
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Kimihiro Yamashita
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Jun Isogaki
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Kenji Suzuki
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Katsuaki Muramatsu
- Division of Radiology, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
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Téoule P, Laffolie JD, Rolle U, Reissfelder C. Acute Appendicitis in Childhood and Adulthood. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 117:764-774. [PMID: 33533331 DOI: 10.3238/arztebl.2020.0764] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 03/05/2020] [Accepted: 07/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute appendicitis is the most common cause of the acute abdomen, with an incidence of 1 per 1000 persons per year. It is one of the main differential diagnoses of unclear abdominal conditions. METHODS This review is based on pertinent publications that were retrieved by a selective search in the PubMed and Cochrane Library databases. RESULTS In addition to the medical history, physical examination and laboratory tests, abdominal ultrasonography should be performed to establish the diagnosis (and sometimes computed tomography [CT] or magnetic resonance imaging [MRI], if ultrasonography is insufficient). Before any treatment is provided, appendicitis is classified as either uncomplicated or complicated. In both types of appendicitis, the decision to treat surgically or conservatively must be based on the overall clinical picture and the patient's risk factors. Appendectomy is the treatment of choice for acute appendicitis in all age groups. In Germany, appendectomy is mainly performed laparoscopically in patients with low morbidity. Uncomplicated appendicitis can, alternatively, be treated conservatively under certain circumstances. A meta-analysis of five randomized, controlled trials has revealed that ca. 37% of adult patients treated conservatively undergo appendectomy within one year. Complicated appendicitis is a serious disease; it can also potentially be treated conservatively (with antibiotics, with or without placement of a drain) as an alternative to surgical treatment. CONCLUSION Conservative treatment is being performed more frequently, but the current state of the evidence does not justify a change of the standard therapy from surgery to conservative treatment.
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Affiliation(s)
- Patrick Téoule
- Department of Surgery, Universitäts -medizin Mannheim, Medical Faculty Mannheim, Heidelberg UniversityDepartment of General Pediatrics and Neonatology, Pediatric Gastroenterology, University of Giessen, GermanyDepartment of Pediatric Surgery, University Hospital Frankfurt, Goethe-University Frankfurt am Main, Frankfurt, Germany
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Rahman MAM, Chowdhury TK, Chowdhury MZ, Farooq MAA. Early appendectomy for appendicular mass: operative findings and outcome in 220 children—a developing country perspective. ANNALS OF PEDIATRIC SURGERY 2020. [DOI: 10.1186/s43159-020-00051-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Abstract
Background
Lump or mass formation due to delayed presentation after appendicitis is common, and it is frequently complicated by perforation, gangrene, pus, or abscess formation. Care of patients and management vary between developed world and developing country. The aim of the study is to analyze outcome of early surgery for appendicular mass from a developing country perspective. 220 patients of appendicular mass who underwent early appendectomy over a period of 5 years in the Department of Pediatric Surgery, at author’s institute were retrospectively reviewed. Early appendectomy was defined as appendectomy done within 24 h of admission. Presentation, examination findings, investigations, type of surgery, operative findings, post-operative complications, and hospital stay were analyzed.
Results
Age of patients ranged from 2 to 12 years (mean 9.04 ± 2.54 years) and male to female ratio was 2:1. Abdominal pain was the most common presentation followed by vomiting and fever. Mean pain duration was 4.35 ± 4.23 days. There was raised temperature in 140 (63.64%) patients, 154 (74.04%) had tachycardia, and 75.86% had raised WBC count. Laparoscopic appendectomy was done in 31 (14.09%) patients, and the rest 189 (85.91%) patients underwent open surgery. Perforated appendix was the most common (171 patients, 77.73%) peri-operative finding followed by formation of pus (135 patients, 61%). Pus was found more in patients less than 5 years old (18 patients out of 23) than patients more than 5 years old (114 patients out of 197) (P = 0.045). Younger patients also had significantly more complications (39.13% vs 17.26%, P = .000) and hospital stays (mean 15.61 days vs 9.87 days, P = 0.014) than older boys. Complications developed in 42 (19.09%) patients, and wound dehiscence (26 patients, 11.82%) was the most common complication.
Conclusion
Early appendectomy for appendicular mass is a feasible option in the developing world, and laparoscopic appendectomy has good prospect.
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Andric M, Kalff JC, Schwenk W, Farkas S, Hartwig W, Türler A, Croner R. [Recommendations on treatment of acute appendicitis : Recommendations of an expert group based on the current literature]. Chirurg 2020; 91:700-711. [PMID: 32747976 DOI: 10.1007/s00104-020-01237-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The paradigm shift in the treatment concept for acute appendicitis is currently the subject of intensive discussions. The diagnosis and differentiation of an uncomplicated from a complicated appendicitis as well as the selection of an adequate treatment is very challenging, especially since nonoperative treatment models have been published. The laparoscopic appendectomy is still the standard for most cases. Guidelines for the treatment of acute appendicitis do not exist in Germany. Therefore, a group of experts elaborated 21 recommendations on the treatment of acute appendicitis after 3 meetings. After initial definition of population, intervention, comparison and outcome (PICO) questions, recommendations have been finalized through the Delphi voting system. The results were evaluated according to the current literature. The aim of this initiative was to define a basic support for decision making in the clinical routine for treatment of acute appendicitis.
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Affiliation(s)
- M Andric
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Deutschland.
| | - J C Kalff
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - W Schwenk
- Allgemein‑, Viszeral- und Gefäßchirurgie, Städtisches Klinikum Solingen, Solingen, Deutschland
| | - S Farkas
- Allgemein- und Viszeralchirurgie, St. Josefs-Hospital Wiesbaden, Wiesbaden, Deutschland
| | - W Hartwig
- Klinik für Allgemein‑, Viszeral- und Onkologische Chirurgie, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Deutschland
| | - A Türler
- Allgemein- und Viszeralchirurgie, Johanniter Kliniken Bonn, Bonn, Deutschland
| | - R Croner
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Deutschland
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Management of appendiceal mass and abscess in children; early appendectomy or initial non-operative treatment? A systematic review and meta-analysis. Surg Endosc 2020; 34:5234-5249. [PMID: 32710216 PMCID: PMC7644542 DOI: 10.1007/s00464-020-07822-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/10/2020] [Indexed: 12/26/2022]
Abstract
Background Appendiceal mass and abscess and its treatment are associated with significant morbidity and high costs. Still, the optimal treatment strategy is the point of debate. Therefore, this systematic review and meta-analysis aimed to compare overall complications between initial non-operative treatment (NOT) and early appendectomy (EA) in children with appendiceal mass and/or abscess. Methods Pubmed and Embase were searched. Only randomized controlled trials and prospective or historical cohort studies that compared NOT with EA in children with appendiceal mass or abscess in terms of complications were eligible for inclusion. Risk of bias was assessed. Primary outcome was the overall complication rate. Secondary, length of stay and readmission rate were investigated. A meta-analysis of overall complications associated with both treatment strategies was performed. Results 14 of 7083 screened studies were selected, including 1022 children in the NOT group and 333 in the EA group. Duration of follow-up ranged between four weeks and 12 years. Risk of bias was moderate in four and serious in 10 studies. NOT was associated with a lower overall complication rate (risk ratio (RR) 0.37 [95% confidence interval (CI) 0.21–0.65]). However, NOT led to increased length of stay (mean difference varied between 0.2 and 8.4 days) and higher readmission rate (RR 1.75 [95%CI 0.79–3.89]), although not significantly. Interval appendectomy after NOT was performed as a routine procedure in all but one study. This study found a recurrence rate of 34% in a group of 38 patients during a follow-up period of 3.4 ± 1.7 years. Conclusion NOT may reduce the overall complication rate compared to EA, but the evidence is very uncertain. As evidence is scarce, and of low level, and heterogeneity between studies is substantial, the results should be interpreted with caution. Large prospective studies are needed to determine the optimal treatment strategy for children with appendiceal mass and/or abscess. Electronic supplementary material The online version of this article (10.1007/s00464-020-07822-y) contains supplementary material, which is available to authorized users.
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Chowdhury MZ, Farooq MAA, Rahman MAM, Chowdhury TK. Management of early appendicular lump in children - laparoscopic technique versus open surgery: a comparative study in low-middle income country perspective. WORLD JOURNAL OF PEDIATRIC SURGERY 2020; 3:e000131. [DOI: 10.1136/wjps-2020-000131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/13/2020] [Accepted: 06/15/2020] [Indexed: 11/04/2022] Open
Abstract
BackgroundIn the pediatric population, appendectomy is one of the most common emergency operations. Laparoscopic appendectomy (LA) is an accepted way of dealing with suspected uncomplicated appendicitis in children. The role of laparoscopy in appendicular lump is more controversial and remains undefined and is not well practiced in low-middle income countries. The aim of this study was to determine a better surgical treatment plan for early appendicular lump in children.MethodsThis prospective observational study was performed in Pediatric Surgery Department of Chittagong Medical College and Hospital for a period of 1 year from April 2018 to March 2019. Sixty children with appendicular lump selected consecutively as per eligibility criteria underwent either LA or open appendectomy (OA), that is, 30 children per group. They were followed up until hospital discharge to observe outcomes.ResultsThere were no differences in terms of patient’s age, sex, clinical presentation and laboratory findings between the two groups. Postoperative pain severity was significantly less in the LA group than that in the OA group (p<0.01). The incidence of wound infection was significantly lower in the LA group than that in the OA group (6.7% in LA and 46.7% in OA; p<0.01). Children in the LA group had a shorter duration of hospital stay in comparison to the OA group [median (IQR) was 8 (5.75–11.25) days and 12 (7.75–18.00) days, respectively, in LA and OA groups; p=0.01].ConclusionThe study findings suggest that LA is feasible and should replace OA in cases of early appendicular lump in children.
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Alsuwailem AB, Turkistani R, Alomari M. Complicated Appendicitis in a Pediatric Patient With COVID-19: A Case Report. Cureus 2020; 12:e8677. [PMID: 32699677 PMCID: PMC7370680 DOI: 10.7759/cureus.8677] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Perforated appendicitis is a well-known complication of acute appendicitis (AA), which increases the morbidity rate in children. This report discusses the case of a pediatric patient with perforated appendicitis with a secondary diagnosis of coronavirus disease 2019 (COVID-19). The clinical presentation of complicated appendicitis (CA) in association with COVID-19 may not be different from that in the general population. Our patient underwent successful management with open appendectomy and subsequent antibiotics. There is no evidence to alter the standard of care for such patients. So further studies are needed to provide more clarity on the appropriate management.
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Affiliation(s)
- Abdulaziz B Alsuwailem
- Emergency Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Reem Turkistani
- Pediatric Emergency Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Mashael Alomari
- Pediatric Emergency Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
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Zavras N, Vaos G. Management of complicated acute appendicitis in children: Still an existing controversy. World J Gastrointest Surg 2020; 12:129-137. [PMID: 32426092 PMCID: PMC7215970 DOI: 10.4240/wjgs.v12.i4.129] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/24/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023] Open
Abstract
Complicated acute appendicitis (CAA) is a serious condition and carries significant morbidity in children. A strict diagnosis is challenging, as there are many lesions that mimic CAA. The management of CAA is still controversial. There are two options for treatment: Immediate operative management and non-operative management with antibiotics and/or drainage of any abscess or phlegmon. Each method of treatment has advantages and disadvantages. Operative management may be difficult due to the presence of inflamed tissues and may lead to detrimental events. In many cases, non-operative management with or without drainage and interval appendectomy is advised. The reasons for this approach include new medications and policies for the use of antibiotic therapy. Furthermore, advances in radiological interventions may overcome difficulties such as diagnosing and managing the complications of CAA without any surgeries. However, questions have been raised about the risk of recurrence, prolonged use of antibiotics, lengthened hospital stay and delay in returning to daily activities. Moreover, the need for interval appendectomy is currently under debate because of the low risk of recurrence. Due to the paucity of high-quality studies, more randomized controlled trials to determine the precise management strategy are needed. This review aims to study the current data on operative vs non-operative management for CAA in children and to extract any useful information from the literature.
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Affiliation(s)
- Nick Zavras
- Department of Paediatric Surgery, “ATTIKON” University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 12462, Greece
| | - George Vaos
- Department of Paediatric Surgery, “ATTIKON” University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 12462, Greece
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Di Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, Boermeester M, Sartelli M, Coccolini F, Tarasconi A, De' Angelis N, Weber DG, Tolonen M, Birindelli A, Biffl W, Moore EE, Kelly M, Soreide K, Kashuk J, Ten Broek R, Gomes CA, Sugrue M, Davies RJ, Damaskos D, Leppäniemi A, Kirkpatrick A, Peitzman AB, Fraga GP, Maier RV, Coimbra R, Chiarugi M, Sganga G, Pisanu A, De' Angelis GL, Tan E, Van Goor H, Pata F, Di Carlo I, Chiara O, Litvin A, Campanile FC, Sakakushev B, Tomadze G, Demetrashvili Z, Latifi R, Abu-Zidan F, Romeo O, Segovia-Lohse H, Baiocchi G, Costa D, Rizoli S, Balogh ZJ, Bendinelli C, Scalea T, Ivatury R, Velmahos G, Andersson R, Kluger Y, Ansaloni L, Catena F. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg 2020; 15:27. [PMID: 32295644 PMCID: PMC7386163 DOI: 10.1186/s13017-020-00306-3] [Citation(s) in RCA: 430] [Impact Index Per Article: 107.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy. METHODS This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients. CONCLUSIONS The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.
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Affiliation(s)
- Salomone Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy.
| | - Mauro Podda
- Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Belinda De Simone
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Marco Ceresoli
- Emergency and General Surgery Department, University of Milan-Bicocca, Milan, Italy
| | - Goran Augustin
- Department of Surgery, University Hospital Centre of Zagreb, Zagreb, Croatia
| | - Alice Gori
- Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Marja Boermeester
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Antonio Tarasconi
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Nicola De' Angelis
- Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, Paris, France
| | - Dieter G Weber
- Trauma and General Surgeon Royal Perth Hospital & The University of Western Australia, Perth, Australia
| | - Matti Tolonen
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Arianna Birindelli
- Department of General Surgery, Azienda Socio Sanitaria Territoriale, di Valle Camonica, Italy
| | - Walter Biffl
- Queen's Medical Center, University of Hawaii, Honolulu, HI, USA
| | - Ernest E Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Michael Kelly
- Acute Surgical Unit, Canberra Hospital, ACT, Canberra, Australia
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Jeffry Kashuk
- Department of Surgery, University of Jerusalem, Jerusalem, Israel
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carlos Augusto Gomes
- Department of Surgery Hospital Universitario, Universidade General de Juiz de Fora, Juiz de Fora, Brazil
| | | | - Richard Justin Davies
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Dimitrios Damaskos
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
| | - Ari Leppäniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas, SP, Brazil
| | - Ronald V Maier
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA, USA
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Gabriele Sganga
- Department of Emergency Surgery, "A. Gemelli Hospital", Catholic University of Rome, Rome, Italy
| | - Adolfo Pisanu
- Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Gian Luigi De' Angelis
- Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Harry Van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Francesco Pata
- Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano, and La Sapienza University of Rome, Rome, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | | | - Andrey Litvin
- Department of Surgery, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Fabio C Campanile
- Department of Surgery, San Giovanni Decollato Andosilla Hospital, Viterbo, Italy
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Gia Tomadze
- Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia
| | - Rifat Latifi
- Section of Acute Care Surgery, Westchester Medical Center, Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Fakri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | | | - Gianluca Baiocchi
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - David Costa
- Hospital universitario de Alicante, departamento de Cirugia General, Alicante, Spain
| | - Sandro Rizoli
- Department of Surgery, St. Michael Hospital, University of Toronto, Toronto, Canada
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Cino Bendinelli
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | | | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
| | - George Velmahos
- Harvard Medical School, Massachusetts General Hospital, Boston, USA
| | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Luca Ansaloni
- Department of General Surgery and Trauma, Bufalini Hospital, Cesena, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
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Abstract
Neonatal appendicitis is a rare disease with a high mortality rate. Appendicitis is difficult to diagnose in neonatal and infant populations because it mimics other more common conditions in these age groups. Furthermore, signs and symptoms of appendicitis are often nonspecific in nonverbal patients and a high index of suspicion is necessary to initiate the appropriate diagnostic work-up. The keys to successful management of appendicitis in infants include keeping the diagnosis on the differential in the setting of unexplained intra-abdominal sepsis, following a diagnostic algorithm in the work-up of infant abdominal pathology, and performing appendectomy once the diagnosis is confirmed.
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Affiliation(s)
- Christina M Bence
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, 999 North 92nd Street, Suite CCC320, Milwaukee, WI 53226, USA.
| | - John C Densmore
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, 999 North 92nd Street, Suite CCC320, Milwaukee, WI 53226, USA
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