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When to take it out? Optimal timing of interval appendectomy in 500 consecutive children. J Pediatr Surg 2021; 56:1822-1825. [PMID: 33256972 DOI: 10.1016/j.jpedsurg.2020.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/31/2020] [Accepted: 11/06/2020] [Indexed: 01/07/2023]
Abstract
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.
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Howell EC, Dubina ED, Lee SL. Perforation risk in pediatric appendicitis: assessment and management. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2018; 9:135-145. [PMID: 30464677 PMCID: PMC6209076 DOI: 10.2147/phmt.s155302] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Erin C Howell
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Emily D Dubina
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA, .,Division of Pediatric Surgery, UCLA Mattel Children's Hospital, Los Angeles, CA, USA,
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Wagner M, Tubre DJ, Asensio JA. Evolution and Current Trends in the Management of Acute Appendicitis. Surg Clin North Am 2018; 98:1005-1023. [DOI: 10.1016/j.suc.2018.05.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Interval Appendectomy: Finding the Breaking Point for Cost-Effectiveness. J Am Coll Surg 2016; 223:632-43. [PMID: 27502367 DOI: 10.1016/j.jamcollsurg.2016.07.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 07/07/2016] [Accepted: 07/08/2016] [Indexed: 12/29/2022]
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Abstract
Appendectomy has been the standard of care for appendicitis since the late 1800s, and remains one of the most common operations performed in children. The advent of data-driven medicine has led to questions about every aspect of the operation-whether appendectomy is even necessary, when it should be performed (timing), how the procedure is done (laparoscopic variants versus open and irrigation versus no irrigation), length of hospital stay, and antibiotic duration. The goal of this analysis is to review the current status of, and available data regarding, the surgical management of appendicitis in children.
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Affiliation(s)
- Shawn D St Peter
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, Missouri 64108.
| | - Charles L Snyder
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, Missouri 64108
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Abstract
Acute appendicitis is the most common cause of emergent surgery in children. Historically, surgical dogma dictated emergent appendectomy due to concern for impending perforation. Recently, however, there has been a paradigm shift in both the understanding of its pathophysiology as well as its treatment to more nonoperative management. No longer is it considered a spectrum from uncomplicated appendicitis inevitably progressing to complicated appendicitis over time. Rather, uncomplicated and complicated appendicitis are now considered two distinct pathophysiologic entities. This change requires not only educating the patients and their families but also the general practitioners who will be managing treatment expectations and caring for patients long term. In this article, we review the pathophysiology of appendicitis, including the differentiation between uncomplicated and complicated appendicitis, as well as the new treatment paradigms. [Pediatr Ann. 2016;45(7):e235-e240.].
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Guida E, Pederiva F, Grazia MD, Codrich D, Lembo MA, Scarpa MG, Rigamonti W. Perforated appendix with abscess: Immediate or interval appendectomy? Some examples to explain our choice. Int J Surg Case Rep 2015; 12:15-8. [PMID: 25985296 PMCID: PMC4485681 DOI: 10.1016/j.ijscr.2015.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 05/04/2015] [Accepted: 05/04/2015] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Edoardo Guida
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy.
| | - Federica Pederiva
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | | | - Daniela Codrich
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | | | - Maria Grazia Scarpa
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Waifro Rigamonti
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy; University of Trieste, Italy
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Liu W, Wei Qiang J, Xun Sun R. Comparison of multislice computed tomography and clinical scores for diagnosing acute appendicitis. J Int Med Res 2015; 43:341-9. [PMID: 25762518 DOI: 10.1177/0300060514564475] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 11/14/2014] [Indexed: 12/11/2022] Open
Abstract
Objective To compare Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Alvarado scores with multislice computed tomography (MSCT) for diagnosing acute appendicitis (AA). Methods This retrospective study included patients with abdominal pain who had undergone MSCT, and whose medical notes included RIPASA and Alvarado score parameters. MSCT was compared with RIPASA and Alvarado scores for diagnosing AA. Results Of 297 patients included, sensitivity, specificity and accuracy for diagnosing AA were 95.2%, 73.6% and 87.2% for RIPASA score (cutoff value 7.5) and 63.1%, 80.9% and 69.7% for Alvarado score (cutoff value 7). Sensitivity, specificity and accuracy of MSCT for diagnosing AA were 98.9%, 96.4% and 98.0%, respectively. In terms of accuracy, statistically significant differences were observed between RIPASA and Alvarado scores, and between MSCT and RIPASA scores. The mean RIPASA score was significantly different in the simple AA group (9.7 ± 2.2) compared with other AA groups (10.5 ± 1.7). No statistically significant difference was observed in RIPASA score between nonperforated and perforated AA. MSCT sensitivity, specificity and accuracy for diagnosing simple AA were 94.1%, 96.4% and 95.8%, respectively; for differentiating perforated and nonperforated AA, scores were 90.2%, 95.2% and 94.1%, respectively. Conclusion MSCT is the optimum diagnostic tool for AA, followed by RIPASA score and Alvarado score, particularly in diagnosing simple and perforated AA.
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Affiliation(s)
- Wen Liu
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Jin Wei Qiang
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Rong Xun Sun
- Department of General Surgery, Jinshan Hospital, Fudan University, Shanghai, China
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Ohno Y. Role of the transumbilical laparoscopic-assisted single-channel, single-port procedure in an interval appendectomy for pediatric mass-forming appendicitis: a preliminary retrospective analysis. Asian J Endosc Surg 2014; 7:232-6. [PMID: 24861142 DOI: 10.1111/ases.12111] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 03/06/2014] [Accepted: 04/06/2014] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Yasuharu Ohno
- Department of Surgery, Oita Children's Hospital, Oita, Japan; Department of Pediatric Surgery, Saitama Medical University, Iruma, Japan
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Abstract
Neoplasms are an uncommon finding after appendectomy, with malignant tumors occurring in less than 1% of the surgical specimens, and carcinoid being the most frequent malignancy. A negative or inconclusive ultrasound is not adequate to rule out appendicitis and should be followed by CT scan. For pregnant patients, MRI is a reasonable alternative to CT scan. Nonoperative treatment with antibiotics is safe as an initial treatment of uncomplicated appendicitis, with a significant decrease in complications but a high failure rate. Open and laparoscopic appendectomies for appendicitis provide similar results overall, although the laparoscopic technique may be advantageous for obese and elderly patients but may be associated with a higher incidence of intraabdominal abscess. Preoperative diagnostic accuracy is of utmost importance during pregnancy because a negative appendectomy is associated with a significant incidence of fetal loss. The increased morbidity associated with appendectomy delay suggests that prompt surgical intervention remains the safest approach. Routine incidental appendectomy should not be performed except in selected cases. Interval appendectomy is not indicated because of considerable risks of complications and lack of any clinical benefit. Patients older than 40 years with an appendiceal mass or abscess treated nonoperatively should routinely have a colonoscopy as part of their follow-up to rule out cancer or alternative diagnosis.
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Affiliation(s)
- Pedro G R Teixeira
- Division of Trauma and Acute Care Surgery, LAC and USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, Room C5L 100, Los Angeles, CA 90033-4525, USA
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