Paradigm Shifts in the Treatment of Appendicitis

The Role of Vascular Cell Adhesion Molecule-1 (VCAM-1) in Predicting Complicated Appendicitis in Children

BACKGROUND

Acute appendicitis is a common abdominal emergency observed in emergency departments (ED). Distinguishing between uncomplicated and complicated appendicitis is important in determining a treatment strategy. Serum soluble vascular cell adhesion molecule-1 (VCAM-1) is an inflammatory biomarker. We aimed to determine the role of VCAM-1 in predicting complicated appendicitis in children.

METHODS

Pediatric patients with suspected appendicitis admitted to the ED were enrolled in this prospective study. Pre-surgical serum VCAM-1 was tested in children with acute appendicitis within 72 h of symptoms (from day 1 to day 3). Serum VCAM-1 levels were further analyzed and compared between patients with and without complicated appendicitis.

RESULTS

Among the 226 pediatric appendicitis patients, 70 had uncomplicated appendicitis, 138 had complicated appendicitis, and 18 had normal appendices. The mean serum VCAM-1 levels in patients with perforated appendicitis were higher than in those with simple appendicitis (p < 0.001). On day 1 to day 3, the mean VCAM-1 levels in patients with complicated appendicitis were all significantly higher than in those with uncomplicated appendicitis (all p < 0.001).

CONCLUSION

Serum VCAM-1 levels may be helpful in differentiating uncomplicated and complicated appendicitis in children and could predict appendiceal perforation.

Validation and comparison of two new scoring systems for the prediction of complicated versus uncomplicated appendicitis

OBJECTIVES

To validate the Atema and APSI scoring systems in the diagnosis of complicated vs uncomplicated appendicitis. To compare these scoring systems with computed tomography (CT) imaging alone to establish which method provides most accurate prediction of complicated vs uncomplicated appendicitis.

METHODS

This was a retrospective review of a sample of 160 patients that underwent appendicectomy and CT imaging for suspected appendicitis between 2018 and 2021 in a tertiary university teaching hospital. Each scoring system was applied to all patients and results analysed and compared with the effectiveness of CT imaging, RESULTS: 32.5% (n = 52) were found to have complicated appendicitis and 67.5% (n = 108) uncomplicated appendicitis. Application of the Atema score to our cohort of patients resulted in a sensitivity 76.9% [CI (64.2, 87.5), specificity 58.7% [CI (48.9, 68.1)], PPV 47.1% [CI (40.5, 53.8) and NPV 84.2% [CI (76.0, 89.9)]. By comparison, the APSI yielded a sensitivity 50.9% [CI (36.6, 65.4)], specificity 76.1% [CI (67.0, 87.8)], PPV 50% [CI (39.2, 60.6)] and NPV 76% [CI (71.1, 81.7)]. Radiology prediction of complicated vs uncomplicated appendicitis with CT imaging showed sensitivity 46% [CI (32.2, 60.5)], specificity 79%; [CI (69.8, 86)], PPV 51% [CI (39.6, 62.5)] and NPV 75% [CI (69.8, 79.9)].

CONCLUSION

By comparing the APSI and Atema et al. scoring systems with CT reporting in our hospital, it appears that the Atema may confer some benefit in stratifying patient risk of complicated versus uncomplicated appendicitis. Further larger scale prospective studies are required.

Study on the safety of Polygala tenuifolia Willdenow root extract powder (BT-11) in young person aged from 9 to 19 years old

ETHNOPHARMACOLOGICAL RELEVANCE

Polygala tenuifolia Willdenow root extract (BT-11) has beneficial effects on central nervous system disorders in human. The safety of BT-11 should be elucidated in younger person further.

AIM OF THE STUDY

To evaluate the safety of BT-11 in human aged from 9 to 19 years old.

MATERIAL AND METHODS

The safety was evaluated in randomly assigned subjects who received the test products (61 subjects in BT-11 300 mg daily or 60 subjects in matching placebo) for 12 weeks. Adverse reactions were analyzed by the incidence rate, type, and severity. The clinical examination included hematology and blood chemistry tests, urinalysis, vital signs, body weight, and electrocardiogram (ECG).

RESULTS

Eleven adverse reactions were observed in ten subjects receiving BT-11 while seven adverse reactions in six subjects receiving placebo. There were no statistical differences in the incidence of adverse reactions between the two groups. Serious adverse reactions such as acute appendicitis and acute viral gastroenteritis were observed in the BT-11 group4 and the placebo group, respectively. However, it was confirmed that they were not associated with the test product. All other adverse reactions observed during the test period were resolved completely without special treatment. No statistical difference was also observed in safety laboratory tests, vital signs, and ECG between two groups.

CONCLUSIONS

This study demonstrates the safety of BT-11 in the adolescent by showing no apparent adverse reactions related to it.

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.

Nonoperative management in children with early acute appendicitis: A systematic review

PURPOSE

Appendectomy has remained the gold standard treatment of acute appendicitis for more than 100years. Nonoperative management (NOM) has been shown to be a valid treatment alternative for acute uncomplicated appendicitis in adults. A systematic review of available evidence comparing operative management (OM) and NOM in children with acute uncomplicated appendicitis was performed.

METHODS

Systematic searches of MedLine, Embase, and a clinical trial register (https://clinicaltrials.gov/) were performed in March 2016. Only articles that studied NOM for uncomplicated appendicitis in children were included. Data generation was performed independently by two authors, and quality was assessed using the rating schema by the Oxford Centre for Evidence-Based Medicine.

RESULTS

15 articles were selected: four retrospective analyses, four prospective cohort studies, four prospective nonrandomized comparative trials and one randomized controlled trial (RCT). Initial success of the NOM groups (a cure within two weeks of intervention) ranged from 58 to 100%, with 0.1-31.8% recurrence at one year.

CONCLUSION

Although present literature is scarce, publications support the feasibility of further studies investigating NOM of acute uncomplicated appendicitis in children. Higher quality prospective RCTs with larger sample sizes and robust randomization methods, studying the noninferiority of NOM with antibiotics compared with OM are required to establish its utility.

LEVEL OF EVIDENCE

This manuscript is a systematic review and thus assigned the lowest evidence used from the manuscripts analyzed which is a Level IV.