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

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.

An indirect effect of COVID-19 pandemic: Increased pediatric perforated appendicitis rate due to delayed admission

Objectives

Appendicitis is a common surgical emergency among children. The coronavirus pandemic affected the system of hospitals more than any other field, and great amount of people were concerned about visiting the hospitals for any reason. In this study, it was aimed to evaluate the profile of appendicitis by emphasizing perforated and acute appendicitis in the pandemic period and to compare the rates with previous three years.

Material and Methods

Charts of the children who underwent laparoscopic appendectomy due to appendicitis between March 11-September 30 between 2017-2020 were retrospectively analyzed in terms of demographic data, duration of symptoms, duration between hospital admission and surgery, radiologic imaging and perioperative outcomes.

Results

This study includes 467 children who underwent laparoscopic appendectomy. There were 97 procedures in 2020, 111 in 2019, 146 in 2018 and 113 in 2017. Multiple comparison tests revealed that age did not show difference; but onset of symptoms in admission (p= 0.004), hospitalization time before surgery (p <0.001), total hospitalization time (p <0.001) showed statistically significant difference between years. Pairwise comparisons showed that these parameters were increased in 2020 compared to other years. Perforated appendicitis rate was significantly increased in 2020 when compared to previous years.

Conclusion

Although there is no direct relation between appendicitis and COVID-19 infection in the current knowledge, perforated appendicitis was found to be increased in children during the COVID pandemic. Reason of the higher rate of perforated appendicitis may be multifactorial; however, the pandemic appears to have a role in increased morbidity in children with appendicitis indirectly due to delay of hospital admissions.

Predictive Value of Alvarado Score and Pediatric Appendicitis Score in the Success of Nonoperative Management for Simple Acute Appendicitis in Children

INTRODUCTION

 During the past decade, nonoperative management (NOM) for simple acute appendicitis (SAA) in children has been proven safe with noninferior complications rate. The aim of this study was to examine Alvarado score and pediatric appendicitis score (PAS) together with other factors in predicting failure of NOM in children presenting with SAA.

MATERIALS AND METHODS

 Patients aged 5 to 18 years admitted to our department between 2017 and 2019 diagnosed with SAA were given a choice between surgical management and NOM. We divided the NOM patients into two groups: successful treatment and failed NOM, comparing their files for Alvarado score and PAS and other clinical and demographic factors, with a mean follow-up of 7 months. Failure was determined as need for appendectomy following conservative treatment due to any reason.

RESULTS

 A total of 85 patients answered criteria and chose NOM. Overall failure rate was 32.9%. We found no difference in the mean Alvarado score and PAS as well as in each component of both scores between success and failed NOM groups. However, when using the risk classification of the scores, we found a significant correlation between high-risk Alvarado score and failed NOM. After adjusting for age, gender, duration of symptoms, diagnosis of tip appendicitis, and presence of appendicolith, the odds of failure were four times higher among high-risk Alvarado group.

CONCLUSION

 Alvarado score of 7 or higher, older age, and diagnosis of an appendicolith on imaging are possible predictors for failure of NOM for SAA in children.

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.

Five lessons in uncomplicated appendicitis: Can we remove the surgery?

Appendicectomy has remained the treatment of choice for appendicitis for over a century and is the most commonly performed emergency operation in children. However, emerging evidence suggests that appendicectomy may not always be necessary in uncomplicated appendicitis, with early paediatric trials demonstrating that antibiotic-only therapy can be safe and effective. Further rigorously designed and appropriately powered studies are necessarily to establish the place of non-operative management of uncomplicated appendicitis in the future.

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.

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.

Acute appendicitis in children: not only surgical treatment

PURPOSE

An accurate diagnosis of acute appendicitis is important to avoid severe outcome or unnecessary surgery but management is controversial. The aim of study was to evaluate, in younger and older children, the efficacy of conservative management for uncomplicated appendicitis and the outcome of complicated forms underwent early surgery.

METHODS

Children with acute appendicitis were investigated by clinical, laboratory variables and abdominal ultrasound and divided in two groups: complicated and uncomplicated. Complicated appendicitis underwent early surgery; uncomplicated appendicitis started conservative treatment with antibiotic. If in the next 24-48h it was worsening, the conservative approach failed and patients underwent late surgery.

RESULTS

A total of 362 pediatric patients were included. One hundred sixty-five underwent early appendectomy; 197 patients were at first treated conservatively: of these, 82 were operated within 24-48h for failure. The total percentage of operated patients was 68.2%. An elevated association was found between surgery and ultrasound.

CONCLUSIONS

Conservative treatment for uncomplicated appendicitis had high percentage of success (58%). Complications in operated patients were infrequent. Our protocol was effective in order to decide which patients treat early surgically and which conservatively; specific red flags (age and onset) can identified patients at most risk of complications or conservative failure.

TYPE OF STUDY

treatment study.

LEVEL OF EVIDENCE

II.

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.