Management of appendiceal mass and abscess in children; early appendectomy or initial non-operative treatment? A systematic review and meta-analysis

Swedish national guidelines for diagnosis and management of acute appendicitis in adults and children

BACKGROUND

Acute appendicitis is one of the most common causes of acute abdominal pain. Differences in the management of this large group of patients has important consequences for the patients and the healthcare system. Controversies regarding the understanding of the natural course of the disease, the utility of new diagnostic methods, and alternative treatments have lead to large variations in practice patterns between centres. These national guidelines present evidence-based recommendations aiming at a uniform, safe and cost-efficient management of this large group of patients.

METHOD

A working group of six experts with broad clinical and research experience was formed. Additional expertise from outside was consulted during the process. A national survey revealed significant variations in the management of patients with suspicion of appendicitis. The evidence provided in published guidelines and reviews were extracted and systematically graded, according to the GRADE methodology. This was supplemented by additional more recent and more directed search of the literature. Patients treated for appendicitis were involved through interviews. The guidelines were reviewed by external experts before the final version was determined.

RESULTS

The guidelines cover an extensive number of issues: pathology, epidemiology, aetiology, natural history, clinical and laboratory diagnosis, diagnostic scoring systems, diagnostic imaging, treatment, nursing care, follow-up, quality registers and quality indicators, among others. Special considerations related to children and pregnant women are covered.

CONCLUSION

These national guidelines present an extensive and thorough review of the current knowledge base related to appendicitis, and provide up-to-date evidence-based recommendations for the management of this large group of patients.

Effects of rhubarb peony decoction combined with antibiotics in treating pediatric periappendiceal abscess

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.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBERS

NCT04755179; NL9371.

Does the presence of an appendicolith or abscess predict failure of nonoperative management of patients with acute appendicitis?

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.

Early versus delayed (interval) appendicectomy for the management of appendicular abscess and phlegmon: a systematic review and meta-analysis

OBJECTIVE

The safety and role of emergency (EA) versus interval appendicectomy (IA) for appendicular abscess and phlegmon remains debatable with no optimal strategy identified. The aim of this systematic review and meta-analysis is to evaluate outcomes of managing appendicular abscesses and phlegmon with emergency or interval appendicectomy.

METHODS

We conducted a systematic search of electronic databases using key terms including 'appendicular abscess', 'appendicular phlegmon' and 'interval appendicectomy'. Randomised controlled trials and observational studies comparing the two management approaches were included. Operative time, post-operation complication, unplanned bowel resection, rate of surgical site infection, post-operative length of stay and overall mortality rate were evaluated.

RESULTS

We identified six studies (2 RCTs and 4 observational studies) with a total of 9264 patients of whom (n = 1352) underwent IA, and (n 7912) underwent EA. The EA group was associated with statistically significant unplanned bowel resection (OR 0.55, 95% CI [0.33-0.90], P = 0.02) and longer total operating time (MD - 14.11, 95% CI [- 18.26-- 9.96] P = 0.00001). However, the following parameters were compared for both EA and IA groups; there were no significant statistical differences: surgical site infection (OR 0.49, 95% CI [0.17-1.38], P = 0.18), post-operative intra-abdominal collection (RD - 0.01, 95% CI [- 0.04-0.01], P = 0.29), total length of hospital stay (MD 1.83, 95% CI [- 0.19-3.85], P = 0.08), post-operative length of hospital stay (MD - 0.27, 95% CI [- 3.66-3.13], P = 0.88) and mortality rate (MD - 0.27, 95% CI [- 3.66-3.13], P = 0.66).

CONCLUSION

Emergency operation for appendicular abscess and phlegmon may lead to a higher rate of reported morbidity when compared with interval appendicectomy. Although emergency appendicectomy performed for appendicular abscess and phlegmon is a feasible and safe operative approach, it is associated with significantly increased operative time and unplanned bowel resection (ileocolic and right hemicolectomies) compared to interval appendicectomy.