Histopathologic analysis of interval appendectomy specimens: support for the role of interval appendectomy

The Histopathology of the Appendix in Children at Interval Appendectomy

Whilst most surgeons agree that conservative treatment of appendiceal abscess in children is an adequate treatment, the need for subsequent interval appendectomy is still controversial. We analyzed the histopathology in interval appendectomy in search of signs of inflammation. All patients admitted between 2010 and 2017 with appendiceal abscess and scheduled for interval appendectomy were reviewed. The specimens were evaluated for grade of inflammation, type and distribution of cellular infiltrate, presence of necrosis or hemorrhage and infiltrate in the serosa. Forty-two patients had appendiceal abscess and were treated conservatively. Seven underwent emergent appendectomy. Thirty-three out of 35 patients underwent elective interval appendectomy. Thirty-two specimens were revised. Carcinoid tumor or other malignant lesions were not found. All of them presented some amount of inflammation, grade 1 to 2 in 53%, grade 3 to 4 in 47%. Twenty-five percent of the specimens had signs of necrosis accompanied by hemorrhage and in more than the half (53%) the infiltrate extended to the serosa. Conclusions: Although the appendix was mostly found not macroscopically inflamed intraoperatively, histology confirmed a certain grade of inflammation even months after the conservative treatment. No correlation was found between histopathologic findings and lapse of time between abscess treatment and interval appendectomy.

Pediatric hematolymphoid pathology in the gastrointestinal tract

Hematolymphoid processes involving the gastrointestinal tract in the pediatric and adolescent young adult (AYA) populations include processes occurring primarily within the gastrointestinal tract as well as systemic diseases with predilection for gastrointestinal involvement. Here, we present a focused review of reactive and neoplastic entities occurring in the pediatric and AYA age groups.

Actinomyces in Crohn's-like appendicitis

AIMS

Appendicitis with a Crohn's-like histological appearance generally raises concern for Crohn's disease, Yersinia infection, and interval appendectomy. Actinomyces infection is a recognised cause of chronic appendicitis that can histologically mimic Crohn's disease.

METHODS AND RESULTS

We report on 20 cases of appendicitis with Crohn's-like histological features that were due to Actinomyces. Most patients presented with acute or chronic abdominal pain. Imaging studies suggested a mass in five cases. Two patients had interval appendectomy. Histological features showed Crohn's-like appendicitis in 16 cases, with moderate to marked fibrosis and granulomas in seven cases. The other four cases had less consistent histological findings. None of the patients developed Crohn's disease during the follow-up interval (median, 37 months).

CONCLUSIONS

Actinomyces can be associated with Crohn's-like appendicitis with marked fibrosis, transmural inflammation, lymphoid hyperplasia, and granulomas.

Perforation risk in pediatric appendicitis: assessment and management

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.

Minimally Invasive Treatment for Appendiceal Mass Formed After Acute Perforated Appendicitis

The optimal treatment for appendiceal mass formed after appendiceal rupture due to acute appendicitis is surrounded with controversy. The treatment strategy ranges from open surgery (emergency or interval appendectomy), laparoscopic appendectomy, and image-guided drainage, to conservative treatment with or without antibiotics. Nonsurgical treatment (including conservative and drainage treatment), followed by interval appendectomy to prevent recurrence, is the traditional management of these patients. The need for interval appendectomy after a successful conservative or/and image-guided drainage treatment, has recently been questioned as the risk of recurrence is relatively small. Several authors consider that even in cases involving only ambulatory follow-up observation, without interval surgery after conservative management, the recurrence rate and risks of missing underlying pathologies were not high. This article evaluates the minimally invasive treatment modalities in the management of appendiceal mass, risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.

Pediatric Appendicitis

Appendicitis is one of the most common surgical pathologies in children. It can present with right lower quadrant pain. Scoring systems in combination with selective imaging and surgical examination will diagnose most children with appendicitis. Clinical pathways should be used. Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated. Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis. This article discusses the workup and management, modes of treatment, and continued areas of controversy in pediatric appendicitis.

Delayed Appendectomy Is Safe in Patients With Acute Nonperforated Appendicitis

The present study examined whether acute, nonperforated appendicitis is a surgical emergency requiring immediate intervention or a disease that can be treated with a semielective operation. Immediate appendectomy has been the gold standard in the treatment of acute appendicitis because of the risk of pathologic progression. However, this time-honored practice has been recently challenged by studies suggesting that appendectomies can be elective in some cases and still result in positive outcomes. This was a retrospective study using the charts of patients who underwent an appendectomy for acute, nonperforated appendicitis between January 2007 and February 2012. Patients were divided into 2 groups for comparison: an immediate group (those who were moved to an operating room within 12 hours after hospital arrival) and a delayed group (those within 12 to 24 hours after hospital arrival). The end points were conversion rate, operative time, perforation rate, complication rate, readmission rate, length of hospital stay, and medical costs. Of 1805 patients, 1342 (74.3%) underwent immediate operation within 12 hours after hospital arrival, whereas 463 (25.7%) underwent delayed operation within 12 to 24 hours. There were no significant differences in open conversion, operative time, perforation, postoperative complications, and readmission between the 2 groups. Length of hospital stay was significantly greater (3.7 ± 1.7 days) and medical costs were also greater [$2346.30 ± $735.30 (US dollars)] in the delayed group than in the immediate group [3.1 ± 1.9 days; P = 0.000 and $2257.80 ± $723.80 (US dollars); P = 0.026]. Delayed appendectomy is safe for patients with acute nonperforated appendicitis.

Operative management of appendicitis

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.

Interval appendectomy in children clinical outcomes, financial costs and patient benefits

BACKGROUND

Elective interval appendectomy (IA) is traditionally advocated for the management of appendiceal mass (AM) in children. Surgeons have debated the evidence and 'risks' vs. 'benefits' to support IA. There are currently no randomised controlled trials and guiding best practice and financial costings for IA are lacking. We herein report clinical outcomes, patient benefits and tariff charges linked with the provision of IA at a regional UK paediatric surgical centre.

METHODS

Hospital case records of patients with AM were identified using pathology records and hospital admission codes during a 15-year period (1997-2011). Tariff costs (£ Sterling) were calculated for all admissions during the era 2007-2011.

RESULTS

69 children were admitted with AM (61% female, median age 10.5 years, range 2.1-16 years). Median initial hospital stay with resolution of symptoms was 8 days (range 3-14 days). 61 children (88%) had elective IA (median interval 76 days, range 29-230 days). Eight (12 %) patients required emergency readmission for early appendectomy (median interval 21 days, range 6-51 days). Hospital stay for emergency readmission appendectomy in these children was significantly longer than IA (median 6 vs. 3 days, p < 0.01). Laparoscopic appendectomy vs. 'open' appendectomy was associated with shorter length of stay in the IA cohort (median 3 vs. 2 days p < 0.01). No intra-operative morbidity was recorded in the study with only a single case developing a post-operative wound infection. Median cost for IA was £1,936. Costings were higher in the emergency appendectomy group-£2,171 vs. 1,936; p = 0.09, NS.

CONCLUSION

Only 12% of children at this centre develop recurrent appendicitis after primary admission with AM. Interval and emergency appendectomy were associated with low morbidity. Parents should be informed that IA may be 'non essential' surgery. Paediatric surgeons not routinely advocating IA can potentially save the NHS £1,936 per patient. Future randomised studies are warranted to confirm or refute these findings.

Histological analysis of appendices removed during interval appendectomy after conservative management of pediatric patients with acute appendicitis with an inflammatory mass or abscess

BACKGROUND/PURPOSE

To clarify the role of interval appendectomy (IA) in pediatric patients with acute appendicitis with an appendiceal inflammatory mass or abscess, we histologically analyzed the appendices removed during IA.

PATIENTS AND METHODS

We treated 355 consecutive pediatric patients with acute appendicitis and reviewed the admission charts of patients who started conservative management (CM). The histology of the appendix removed during IA was also examined. The relationships among the clinical features, appendicolith formation at the time of IA and histological findings were analyzed by stepwise regression analyses.

RESULTS

(1) CM was started in 48 patients (13.5 %). Recurrence or a remaining abscess was observed in nine patients (18.8 %). (2) Histopathological changes, particularly foreign body reaction with fibrosis and infiltration of inflammatory cells, were observed in about half of the specimens. (3) In a stepwise regression analysis, the presence of an appendicolith at IA was correlated with an appendicolith at diagnosis, foreign body reaction in the appendix and a decrease in the inflammatory reaction at diagnosis.

CONCLUSION

More than half the patients had strong histopathological changes in the appendix, suggesting a high possibility of recurrence. The presence of appendicolith formation at IA, which is a risk factor for recurrence, was influenced by the presence of an appendicolith at diagnosis, foreign body reaction in the appendix and the inflammatory status of patients at diagnosis. These clinical findings are indications for IA.

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

AIM

To determine clinical and imaging predictors of recurrent appendicitis after non-operative management for children with perforated appendicitis presenting with an appendicular inflammatory mass.

METHODS

A case-control study was carried out of children with clinical and ultrasonographic diagnosis of an appendicular inflammatory mass. Patients were divided into two groups according to the presence or not of recurrent appendicitis (or predisposing pathological findings during interval appendectomy). Several clinical and imaging factors were compared between both groups using an independent and progressive analysis to identify which were the most relevant predictors.

RESULTS

The persistence of symptoms after resolution of the appendicular inflammatory mass, as well as its time of resolution (p<0.001), were the most relevant factors during group classification. The identification of an ultrasonographic image of an appendicolith and the initial size of the mass were also identified as independent predictors (p<0.018 and p<0.01). The presence of the first two factors in a patient was strongly associated with recurrent appendicitis.

CONCLUSIONS

Persistent symptoms after the recovery of the initial episode, associated with a slow resolution of the appendicular inflammatory mass, are indications for an interval appendectomy. A previous history of appendicitis or detection of an ultrasonographic image of an appendicolith is the other indication for an interval appendectomy.

Appendicolith delays resolution of appendicitis following nonoperative management

INTRODUCTION

Success in nonoperative management is only based on the clinical symptoms of patients with acute appendicitis. However, imaging studies can provide further insight into the status of the appendix to monitor treatment response if immediate appendectomy is not undertaken. This study investigates sonographic resolution following nonoperative management and assesses the feasibility of incorporating ultrasound into patient care.

MATERIALS AND METHODS

Adult patients with acute appendicitis who had been successfully treated with nonoperative management were enrolled and received repeat sonographic examinations using 3-day intervals until sonographic resolution. The relationship between the time to achieve sonographic resolution and clinical parameters was identified using negative binomial regression models.

RESULTS

From January 2003 to December 2009, 128 patients were successfully treated with nonoperative management. Eighty patients completed sonographic examinations until achieving resolution. Sonographic resolution was achieved on 17 ± 12 days (range, 3-69 days). Ninety-five percent of the patients achieved sonographic resolution within 41 days. The appendicolith was positively related to the time to achieve sonographic resolution (rate ratios, 1.63; 95 % confidence intervals, 1.06-2.51).

CONCLUSIONS

Ultrasound can be used to evaluate the condition of the appendix to monitor treatment response following nonoperative management on the sixth week. An appendicolith delays sonographic resolution of appendicitis.

Prompt or delayed appendectomy? Influence of timing of surgery for acute appendicitis

PURPOSE

The aim of the study was to compare the clinical outcomes and histological findings in prompt and delayed appendectomy for acute appendicitis.

METHODS

All patients who underwent appendectomy for histologically confirmed acute appendicitis from 2003 to 2009 were included in this study. Patients were divided into three groups according to the time of surgery after hospital admission: The early appendectomy (EA) group underwent surgery within 12 h, the early-delayed appendectomy (EDA) group between 12 and 24 h and the delayed appendectomy (DA) group more than 24 h. The perioperative data and pathological state of the appendix were evaluated and compared.

RESULTS

A total of 723 patients, with histologically confirmed acute appendicitis, were included in the study: There were 518 patients in the EA group, 140 patients in the EDA group and 65 patients in the DA group. The operative times were similar in each group. Postoperative complications occurred in 49 patients (6.8 %) and were significantly higher in the DA group in comparison to the EA group (p = 0.0012) and EDA group (p = 0.003). Two patients (3 %) in the DA group died. There were no differences in the length of the hospital stay. The gangrenous appendicitis rate was significantly higher in the DA group (p < 0.05) in comparison to the EA and EDA groups.

CONCLUSIONS

Performing appendectomy within 24 h from presentation does not increase the length of hospital stay or rate of complications. However, delayed appendectomy after 24 h from onset increases the rate of complications.

Interval routine appendectomy following conservative treatment of acute appendicitis: Is it really needed

Conservative management of acute appendicitis (AA) is gradually being adopted as a valuable therapeutic choice in the treatment of selected patients with AA. This approach is based on the results of many recent studies indicating that it is a valuable and effective alternative to routine emergency appendectomy. Existing data do not support routine interval appendectomy following successful conservative management of AA; indeed, the risk of recurrence is low. Moreover, recurrences usually exhibit a milder clinical course compared to the first episode of AA. The role of routine interval appendectomy is also questioned recently, even in patients with AA complicated by plastron or localized abscess formation. Surgical judgment is required to avoid misdiagnosis when selecting a conservative approach in patients with a presumed “appendiceal” mass.

Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review

BACKGROUND/PURPOSE

Interval appendicectomy (IA) is commonly performed after successful nonoperative treatment of appendix mass (AM); although, this approach has recently been challenged. We systematically reviewed the pediatric literature with regard to the justification for this practice.

METHODS

Using a defined search strategy, studies were identified and data were extracted independently by 2 reviewers. Incidences of recurrent appendicitis, complications after IA, and carcinoid tumor were estimated accounting for interstudy heterogeneity. Cost and length of stay of IA were analyzed.

RESULTS

Three studies (127 cases) reporting routine nonsurgical treatment were identified; all were retrospective. There was marked interstudy heterogeneity and variable follow-up. After successful nonoperative treatment of AM, the risk of recurrent appendicitis is 20.5% (95% confidence interval [CI], 14.3%-28.4%). The incidence of complications after IA (23 studies, n = 1247) is 3.4% (95% CI, 2.2-5.1), and the incidence of carcinoid tumor found at IA (15 studies, n = 955) is 0.9% (95% CI, 0.5-1.8). No reports compared costs. Mean length of stay for IA was 3 days (range, 1-30 days).

CONCLUSIONS

Prospective studies comparing routine IA with nonoperative treatment without IA in children are lacking. Available data suggest that 80% of children with AM may not need IA. A prospective study to evaluate the natural history of this condition compared with the morbidity and costs of IA is warranted.

Dollars and sense of interval appendectomy in children: a cost analysis

PURPOSE

Although initial nonoperative management of focal, perforated appendicitis in children is increasingly practiced, the need for subsequent interval appendectomy remains debated. We hypothesized that cost comparison would favor continued nonoperative management over routine interval appendectomy.

METHODS

Decision tree analysis was used to compare continued nonoperative management with routine interval appendectomy after initial success with nonoperative management of perforated appendicitis. Outcome probabilities were obtained from literature review and cost estimates from the Kid's Inpatient Database. Sensitivity analyses were performed on the 2 most influential variables in the model, the probability of successful nonoperative management and the costs associated with successful observation. Monte Carlo simulation was performed using the range of cost estimates.

RESULTS

Costs for continued nonoperative observation were estimated at $3080.78 as compared to $5034.58 for the interval appendectomy. Sensitivity analysis confirms a cost savings for nonoperative management as long as the likelihood of successful observation exceeds 60%. As the cost of nonoperative management increased, the required probability for its success also increased. Using wide distributions for both probability estimates as well as costs, Monte Carlo simulation favored continued observation in 75% of scenarios.

CONCLUSION

Continued nonoperative management has a cost advantage over routine interval appendectomy after initial success with conservative management in children with focal, perforated appendicitis.

Granulomatous appendicitis in a 12-year-old boy

Isolated granulomatous inflammation of the appendix is extremely rare, and its etiology is still unknown. We describe a 12-year-old boy with isolated granulomatous appendicitis where the etiology could not be clarified despite infectious criteria such as high fever and gastroenteritis. Children with epithelioid granulomatous appendicitis have a good prognosis following appendectomy.

A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon)

BACKGROUND

No standardized approach is available for the management of complicated appendicitis defined as appendiceal abscess and phlegmon. This study used meta-analytic techniques to compare conservative treatment versus acute appendectomy.

METHODS

Comparative studies were identified by a literature search. The end points evaluated were overall complications, need for reoperation, duration of hospital stay, and duration of intravenous antibiotics. Heterogeneity was assessed and a sensitivity analysis was performed to account for bias in patient selection.

RESULTS

Seventeen studies (16 nonrandomized retrospective and 1 nonrandomized prospective) reported on 1,572 patients: 847 patients received conservative treatment and 725 had acute appendectomy. Conservative treatment was associated with significantly less overall complications, wound infections, abdominal/pelvic abscesses, ileus/bowel obstructions, and reoperations. No significant difference was found in the duration of first hospitalization, the overall duration of hospital stay, and the duration of intravenous antibiotics. Overall complications remained significantly less in the conservative treatment group during sensitivity analysis of studies including only pediatric patients, high-quality studies, more recent studies, and studies with a larger group of patients.

CONCLUSION

The conservative management of complicated appendicitis is associated with a decrease in complication and reoperation rate compared with acute appendectomy, and it has a similar duration of hospital stay. Because of significant heterogeneity between studies, additional studies should be undertaken to confirm these findings.

Granulomatous diseases and granulomas of the appendix

Granulomatous appendicitis is a rare phenomenon. Idiopathic (primary) granulomatous appendicitis is very rare. It is a diagnosis by exclusion. There are many etiologies, both infectious and noninfectious, for secondary granulomatous appendicitis. Isolated appendiceal Crohn's disease (CD) is no longer an accepted explanation of idiopathic granulomatous appendicitis, but rather, it is thought to be part of more generalized gastrointestinal CD. Yersinia infection and CD constitute the main etiology of granulomatous appendicitis in the West. Infectious causes, mainly tuberculosis and parasitic infestations, are the main culprits in tropical and subtropical countries. This variation is probably a result of differences in the geographical distribution of these diseases. Recently, interval appendectomy has been suggested as an important cause of granulomatous appendicitis. The importance of interval appendectomy may vary according to the local practice of this procedure in each region. Other unusual causes may include sarcoidosis and foreign body reaction, mainly as a result of vegetable matter from feces. A review study of 3381 appendectomy specimens over a 4-year period showed only 13 cases (0.38%) of granulomatous appendicitis. Infectious and noninfectious causes were responsible for 62% and 38% of granulomatous appendicitis, respectively. Parasites alone were responsible for 38.5% of the cases. Interval appendectomy and CD each contributed 15% and 8%, respectively, of the total etiology. Granulomatous appendicitis was more common in young adult males.

Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial

INTRODUCTION

Perforated appendicitis is a common condition in children, which, in a small number of patients, may be complicated by a well-formed abscess. Initial nonoperative management with percutaneous drainage/aspiration of the abscess followed by intravenous antibiotics usually allows for an uneventful interval appendectomy. Although this strategy has become well accepted, there are no published data comparing initial nonoperative management (drainage/interval appendectomy) to appendectomy upon presentation with an abscess. Therefore, we conducted a randomized trial comparing these 2 management strategies.

METHODS

After internal review board approval (#06 11-164), children who presented with a well-defined abdominal abscess by computed tomographic imaging were randomized on admission to laparoscopic appendectomy or intravenous antibiotics with percutaneous drainage of the abscess (when possible), followed by interval laparoscopic appendectomy approximately 10 weeks later. This was a pilot study with a sample size of 40, which was based on our recent volume of patients presenting with appendicitis and abscess.

RESULTS

On presentation, there were no differences between the 2 groups regarding age, weight, body mass index, sex distribution, temperature, leukocyte count, number of abscesses, or greatest 2-dimensional area of abscess in the axial view. Regarding outcomes, there were no differences in length of total hospitalization, recurrent abscess rates, or overall charges. There was a trend toward a longer operating time in patients undergoing initial appendectomy (61 minutes versus 42 minutes mean, P = .06).

CONCLUSIONS

Although initial laparoscopic appendectomy trends toward a requiring longer operative time, there seems to be no advantages between these strategies in terms of total hospitalization, recurrent abscess rate, or total charges.

Surgery for appendicitis: is it necessary?

BACKGROUND

Appendectomy for acute appendicitis is an effective, universally accepted procedure performed more than 300,000 times annually in the United States. It is generally believed that appendicitis progresses invariably from early inflammation to later gangrene and perforation, and that appendectomy is required for surgical source control. Although non-operative management with antibiotics of uncomplicated diverticulitis, salpingitis, and neonatal enterocolitis is now established, the non-operative management of appendicitis remains largely unexplored.

METHODS

Systematic review of published literature and derived expert opinion.

RESULTS

Clinical, epidemiologic, radiologic, and pathologic evidence is presented for spontaneous resolution of uncomplicated acute appendicitis. The pathogenesis of appendicitis is reviewed with specific consideration of the role of bacterial infection in the pathogenesis. Evidence is also provided documenting the clinical success of non-operative management.

CONCLUSIONS

Appendectomy may not be necessary for the majority of patients with acute uncomplicated appendicitis, as many patients resolve spontaneously and others may be treatable with antibiotics alone. However, the supporting documentation is scant and of poor quality. A randomized, prospective trial of non-operative management versus early appendectomy of acute uncomplicated appendicitis corroborated by radiologic imaging is called for.

Antibiotic Therapy and Interval Appendectomy for Perforated Appendicitis in Children: A Selective Approach

The role of initial nonoperative treatment in pediatric perforated appendicitis remains controversial. We examined our outcomes after using this approach in a selective manner. Children with perforated appendicitis treated during a 28-month period were retrospectively reviewed. Antibiotics and delayed appendectomy were used if there were more than 3 days of symptoms, absence of bowel obstruction, absence of diffuse peritonitis, and an appendiceal mass. Of 221 patients with perforated appendicitis, 32 (14%) were treated with this approach. Average age was 7.4 ± 4.2 years. Twenty-eight patients (88%) were successfully managed and 26 (81%) underwent appendectomy 8.6 ± 4.2 weeks after first presentation. Two patients did not respond completely, and underwent appendectomy during the same admission. Two patients initially responded, but had recurrent symptoms necessitating earlier appendectomy. There were no complications. Average total hospital stay was 7.2 ± 3.0 days. Initial nonoperative treatment is highly successful in selected children who meet specific criteria. Failure is not associated with increased morbidity.

New primary management for appendiceal masses in children: laparoscopic drainage

PURPOSE

The management of appendiceal masses (AM) in children remains controversial. In this study, we evaluated primary laparoscopic drainage (PLD) for efficacy.

METHODS

Eleven (11) consecutive cases of AM (mean age, 8.1 +/- 2.8 years) treated between 2000 and 2004 were the subjects for this study. All had PLD on presentation. If the appendix was seen easily seen after PLD, a laparoscopic appendectomy (LA) was also performed.

RESULTS

Eight (8) patients underwent PLD alone (LD group) and 3 underwent PLD and LA (LDLA group). In the LD group, the mean operating time was 87.9 +/- 23.2 minutes, oral feeding was commenced after a mean of 2.3 +/- 0.8 days, patients became afebrile within 4.3 +/- 3.1 days, intravenous antibiotics were ceased after 5.3 +/- 3.1 days, C-reactive protein normalized within 13.6 +/- 4.2 days, drains were removed within 4.0 +/- 1.3 days, and hospital stay ranged from 7 to 15 days. There were no intra- or postoperative complications related to the PLD procedure. Interval LA was performed 6.8 +/- 5.8 months after PLD in 6 of 8 LD group patients and was not performed in the remaining 2 owing to parental refusal. In the LDLA group, operating time ranged from 125 to 150 minutes, and oral feeding commenced 4, 5, and 5 days after LA, respectively. One (1) patient developed an adhesive bowel obstruction after LA, which resolved with conservative therapy; in the remaining 2, there were no complications. All 11 patients are well after a mean follow-up period of 3.7 +/- 1.0 years. A histologic examination of the excised appendices showed mild to severe inflammation.

CONCLUSIONS

We recommend that PLD be adopted for the primary management of appendiceal masses, as it would appear to be simple, safe, and effective.

Current management of appendicitis

Appendicitis is the most common surgical disease of the abdomen in children. Pediatric appendicitis varies considerably in its clinical presentation, contributing to delay in diagnosis and increased morbidity. The methods of diagnosis and treatment of appendicitis also vary significantly among clinicians and medical centers according to the patient's clinical status, the medical center's capabilities, and the physician's experience and technical expertise. Recent trends include the increased use of radiologic imaging, minimally invasive and nonoperative treatments, shorter hospital stays, and home antibiotic therapy. Little consensus exists regarding many aspects of the care of the child with complicated appendicitis. This article examines the most debated aspects of the diagnosis and management of the diseased pediatric appendix.

Comparison of therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of periappendiceal abscess: is appendectomy always necessary after perforation of appendix?

BACKGROUND

The present study was designed to compare the therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of appendicitis complicated by periappendiceal abscess.

METHODS

In a prospective study, 50 patients with acute appendicitis complicated by periappendiceal abscess > or = 3 cm in size were randomly assigned to two groups. The first group received treatment with ultrasound guided-percutaneous drainage and i.v. antibiotics (ampicillin, cefuroxime, and metronidazole), and the other group received antibiotics only. Patient's baseline characteristics, duration of hospital stay, and treatment outcome and complications were analyzed.

RESULTS

Appendectomy was avoided in 16/25 patients in the drainage group and 2/25 patients in the non-drainage group during follow-up with RR of 0.39 (95% CI = 0.22-0.62; p < 0.05). One patient in the drainage group and 8 patients in the non-drainage group underwent surgery in the first month after the beginning of treatment. Eight patients in the drainage group and 15 in the non-drainage group underwent interval appendectomy. There was no statistically significant difference between the two groups regarding patient demographics, abscess size, and pretreatment clinical symptoms. Hospital stay up to the subsidence of clinical and sonographic signs was significantly shorter (p < 0.001) in the drainage group, with a mean difference of 6.4 days (95% CI = 5.0-7.9; p < 0.05).

CONCLUSIONS

Percutaneous drainage with antibiotics is a safe and effective way of treating acute perforated appendicitis. The recurrence rate for these patients is relatively low, and very often interval appendectomy is not required. For patients with periappendiceal abscess > or = 3 cm in diameter, antibiotic therapy alone is insufficient and the recurrence rate is high.

Comparison of therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of periappendiceal abscess: is appendectomy always necessary after perforation of appendix?

BACKGROUND

The present study was designed to compare the therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of appendicitis complicated by periappendiceal abscess.

METHODS

In a prospective study, 50 patients with acute appendicitis complicated by periappendiceal abscess > or = 3 cm in size were randomly assigned to two groups. The first group received treatment with ultrasound guided-percutaneous drainage and i.v. antibiotics (ampicillin, cefuroxime, and metronidazole), and the other group received antibiotics only. Patient's baseline characteristics, duration of hospital stay, and treatment outcome and complications were analyzed.

RESULTS

Appendectomy was avoided in 16/25 patients in the drainage group and 2/25 patients in the non-drainage group during follow-up with RR of 0.39 (95% CI = 0.22-0.62; p < 0.05). One patient in the drainage group and 8 patients in the non-drainage group underwent surgery in the first month after the beginning of treatment. Eight patients in the drainage group and 15 in the non-drainage group underwent interval appendectomy. There was no statistically significant difference between the two groups regarding patient demographics, abscess size, and pretreatment clinical symptoms. Hospital stay up to the subsidence of clinical and sonographic signs was significantly shorter (p < 0.001) in the drainage group, with a mean difference of 6.4 days (95% CI = 5.0-7.9; p < 0.05).

CONCLUSIONS

Percutaneous drainage with antibiotics is a safe and effective way of treating acute perforated appendicitis. The recurrence rate for these patients is relatively low, and very often interval appendectomy is not required. For patients with periappendiceal abscess > or = 3 cm in diameter, antibiotic therapy alone is insufficient and the recurrence rate is high.

Role of interval appendectomy in the management of complicated appendicitis in children

INTRODUCTION

The aim of this study was to ascertain the optimal treatment for children with complicated appendicitis. We reviewed an inception cohort of children with documented complicated appendicitis to develop criteria for interval appendectomy. We compared the outcomes of two treatments: immediate operation and interval appendectomy.

METHODS

Children with complicated appendicitis were separated into two groups. Group 1 patients had had symptoms of complicated appendicitis for less than 72 hours or appeared toxic. Group 2 patients had had symptoms of complicated appendicitis for longer than 72 hours and did not appear toxic. Group 1 underwent immediate operation treated by criteria previously published. Group 2 patients were treated in hospital with triple antibiotics until they were afebrile, had normal white blood cell counts, tolerated an oral diet, and had adequate pain control. They were discharged on oral metronidazole or metronidazole plus Bactrim for 6 weeks and then underwent interval appendectomy.

RESULTS

A total of 86 children had complicated appendicitis; 59 were operated on immediately, and 27 underwent an interval appendectomy. Complications included one wound infection and two intraabdominal abscesses (all in group 1). There was one death (group 1). The length of stay for the immediate operation group was 4.9 +/- 1.7 days; the initial-admission length of stay for the interval appendectomy group was 4.1 +/- 1.0 days with a subsequent postoperative stay of 0.9 +/- 0.8 days. One patient in the interval appendectomy group was treated off protocol.

CONCLUSIONS

Treating selected children with interval appendectomy led to a decrease in complications and a shorter length of stay in this limited population. Interval appendectomy is a safe, cost-effective, useful adjunct treatment for children with complicated appendicitis.

Interval appendectomy after conservative treatment of an appendiceal mass

INTRODUCTION

The purpose of this study was to clarify the role of interval appendectomy after conservative treatment of an appendiceal mass.

METHODS

From January 1998 to December 2003, patients with an appendiceal mass who received conservative treatment at the Taipei Veterans General Hospital were studied retrospectively. Data on demographics, rate of appendicitis recurrence, duration of hospital stay, and complication rate were collected and analyzed.

RESULTS

A total of 165 patients were included (89 males, 76 females). The mean age was 53.6 years (range 7-89 years). The rate of appendicitis recurrence after conservative treatment was 25.5%; most recurred within 6 months after discharge (83.3%). The benefit of preventing recurrence is less than 16% if interval appendectomy is performed 6 weeks after discharge and less than 10% if it is done 12 weeks later. The complication rate of appendectomy performed before or after recurrence was 10% in both groups. The duration of the second hospital stay for patients who underwent interval appendectomy before or after recurrence was 4.43 +/- 3.32 vs. 6.75 +/- 5.73 days (P = 0.023). Of the 165 patients, 17 (10.3%) had their diagnosis changed after survey or surgery, and 5 (3.03%) were found to have colon cancer upon follow-up.

CONCLUSIONS

Patients who recovered from conservative treatment of an appendiceal mass should undergo colonoscopy or barium enema to detect any underlying diseases and to rule out coexistent colorectal cancer. Routine interval appendectomy benefits less than 20% of patients.

Interval Appendectomy: An Old New Operation

A retrospective chart review of 32 patients who underwent laparoscopic interval appendectomy at the Children's Hospital of Eastern Ontario between May 1999 and December 2003 was performed. The age range was 0.5 to 18 years (mean, 11.8 years; median, 11.5 years). The interval time from the acute episode to the laparoscopic interval appendectomy ranged from 1 to 16 weeks (median, 6 weeks). The initial presentations were 11 patients with appendiceal abscess, 9 with appendiceal masses/phlegmons, and 12 patients with an acute but resolving clinical picture with ultrasonographic evidence of appendicitis. There were no wound infections or recurrent intra-abdominal abscesses. The average length of stay was 1.38 days, ranging from same-day discharge (1 patient) to a three-night stay (2 patients). There were no complications related to the laparoscopic technique, confirming reports that laparoscopic interval appendectomy is a technically safe procedure. Pathologic analysis of the appendices demonstrated acute or subacute changes in 14 patients (interval time = 7.9 weeks), chronic changes in 8 (interval time = 8.1 weeks), both acute and chronic changes in 5 (interval time = 8.2 weeks), and no pathologic diagnosis in 6 (interval time = 4.28 weeks). These findings support the need for interval appendectomy, and suggest that laparoscopy is a safe alternative to open appendectomy.

Nonoperative management of pediatric ruptured appendix with inflammatory mass or abscess: presence of an appendicolith predicts recurrent appendicitis

AIM OF STUDY

The aim of this study was to determine if the presence of an appendicolith is associated with an increased risk for recurrent appendicitis after nonoperative treatment of pediatric ruptured appendix with inflammatory mass or abscess.

METHODS

Ninety-six pediatric patients (52 girls, 44 boys), aged 16 months to 17 years (average, 7 years), were managed between 1980 and 2003. All were treated nonoperatively with intravenous triple antibiotics for 5 to 21 days. All children had at least a 2-year follow-up. This study was approved by the hospital research ethics board.

MAIN RESULTS

Six children (6%) who became worse and 41 (46%) who had an interval appendectomy were eliminated from the study. The other 49 patients comprised the study group and received no further treatment. Twenty-eight (57%) had no recurrence, and 21 (43%) had a recurrence within 1 month to 2 years (average, 3 months). In the study group, 31 (63%) children had no appendicolith on radiological imaging and 18 (37%) had. Presence of an appendicolith was associated with a 72% rate of recurrent appendicitis compared with a recurrence rate of 26% in those with no appendicolith (chi2 test, P < .004).

CONCLUSION

We conclude that the patients with appendicolith should have an interval appendectomy.

Is early laparoscopic appendectomy feasible in children with acute appendicitis presenting with an appendiceal mass? A prospective study

BACKGROUND

The management of an appendiceal mass remains controversial with 2 schools of thought; early surgical intervention vs nonoperative management with or without interval appendectomy. The aim is to determine the role and safety of early laparoscopic appendectomy (LA) in children with acute appendicitis presenting with an appendiceal mass.

METHODS

This is a prospective study of 88 consecutive pediatric patients who underwent attempted LA for suspected acute appendicitis at KK Women's and Children's Hospital, Singapore, between May and October 2003.

RESULTS

A total of 88 patients with a mean age of 10 +/- 3 years (range, 3-16 years) underwent LA for an appendiceal mass (n = 22), simple appendicitis (n = 36), other complicated (gangrenous or perforated) appendicitis (n = 23), and a normal appendix (n = 7). There were 7 conversions to open appendicectomy, 3 of which occurred in patients with an appendiceal mass. There were no perioperative or postoperative mortalities. Morbidity occurred in only one patient who underwent LA for perforated appendicitis. He had prolonged sepsis that resolved after 2 weeks of intravenous antibiotics. None of the patients with an appendiceal mass developed complications. Patients who underwent early LA for an appendiceal mass had a statistically significant (P < .05) longer operating time (median, 103 minutes; interquartile range, 90-151 minutes, vs median, 87 minutes; interquartile range, 71-112 minutes), prolonged time to ambulation (median, 2.0 days; interquartile range, 2-2.5 days, vs median, 1.0 days; interquartile, 1-2 days), increased time to resumption of diet (median, 4 days; interquartile, 3-5 days, vs median, 2 days; interquartile, 2-3 days), and longer postoperative stay (median, 6.0 days; interquartile, 5.5-6.5 days, vs median, 4.0 days; interquartile, 3-5.5 days) compared with patients presenting with appendicitis without mass formation. However, there was no statistical difference in these parameters when LA for an appendiceal mass was compared with LA for other complicated appendicitis (perforated and gangrenous).

CONCLUSION

Although early LA for an appendiceal mass is a technically demanding procedure, it can be performed safely in children with minimal morbidity and mortality. In an era where patients' demand for "key-hole" surgery is rising, early LA is a safe and viable option in the management of children with an appendiceal mass. It also offers the advantage of avoiding misdiagnoses and the need for a second hospitalization.

Granulomatous appendicitis and the appendix in idiopathic inflammatory bowel disease

Granulomatous appendicitis is a rare condition, accounting for less than 2% of all cases of appendicitis. The initial belief that it represented a manifestation of Crohn's disease is incorrect in the great majority of cases, as only 5-10% of patients with granulomatous appendicitis develop Crohn's disease elsewhere in their gastrointestinal tract. The remaining etiologies are diverse. Unusual causes include sarcoidosis, foreign body reaction, and infection by mycobacteria, fungi, or parasites. These conditions combined explain less than 10% of cases. More recently, two etiologies have been recognized that potentially account for most of the previous "idiopathic" cases of granulomatous appendicitis. The first is infection by pathogenic Yersinia species, now demonstrated in approximately 25% of cases. The second cause may be the most common of all, namely subacute/recurrent appendicitis with interval appendectomy. This condition likely produces a granulomatous reaction in relation to a protracted secondary inflammatory response to appendicitis and temporizing measures to delay appendectomy, such as antibiotic therapy. Thus, granulomatous appendicitis only rarely represents a manifestation of Crohn's disease. Rather, the overwhelming majority of patients with this condition are cured by appendectomy alone. The appendix, however, can be involved by idiopathic inflammatory bowel disease, both Crohn's disease and ulcerative colitis. It can be involved by ulcerative colitis in patients with distal colonic involvement and sparing of the intervening colonic segment, a phenomenon known as the appendiceal "skip lesion" or "cecal patch" and this pattern of involvement does not necessarily indicate Crohn's disease. Interestingly, appendectomy has been shown to provide some protection against developing inflammatory bowel disease and in reducing its severity if performed before the onset of disease.

Beta hemolytic streptococcus group f causing pelvic inflammatory disease in a 14-year-old girl

BACKGROUND

Pelvic inflammatory disease in prepubertal and non-sexually active adolescents is rare and poorly understood. Various organisms have been named as causative agents in adolescent pelvic infections. Early diagnosis and treatment of pelvic inflammatory disease in young girls is imperative to future fertility and long term sequela.

CASE

We present a 14-year-old, menarchal, non-sexually active female with a 3-week history of abdominal pain and fever. Surgical exploration and cultures revealed Stage IV pelvic inflammatory disease caused by Beta Streptococcus Group F.

CONCLUSION

Various organisms including Streptococcal infections should be considered in the differential diagnosis of pelvic inflammatory disease in young girls without risk factors.

Predictors of Outcome for Children with Perforated Appendicitis Initially Treated with Non-Operative Management

BACKGROUND

Initial non-operative therapy for children with perforated appendicitis has become increasingly popular with the advent of powerful broad-spectrum antibiotics. However, there is no consensus regarding which patients may be managed effectively with this strategy. We reviewed all children with perforated appendicitis who were treated initially with non-operative therapy to determine those characteristics that may predict a successful outcome.

METHODS

We reviewed the medical records of children admitted to our hospital between January 1, 2000 and May 1, 2003 with the diagnosis of perforated appendicitis. Only those who were treated initially with a single broad-spectrum antibiotic (piperacillin-tazobactam), with the intention of performing an interval appendectomy, were included in this study. Patients were divided into two groups based on whether they were managed successfully with non-operative therapy: Responders and non-responders. Non-responders were defined as patients who either did not improve with antibiotic therapy or who required appendectomy prior to their electively scheduled time (six weeks). Demographic data, duration and type of presenting symptoms, initial white blood cell count (WBC), percent bands, percent neutrophils (PMNs), computed tomography (CT) interpretation, and interventions/operations were abstracted. Categorical data were compared using Chi-square analysis or the Fisher exact test; continuous variables were compared using the Student t-test and the Mann-Whitney U-test.

RESULTS

Overall, 26% (19/73) of patients treated initially non-operatively required appendectomy prior to the electively scheduled date. There was no difference between responders (n = 54) and non-responders (n = 19) with respect to age, gender, initial WBC, percent bands, percent PMNs, or duration and type of presenting symptoms. However, responders were more likely to have a phlegmon on CT scan compared to non-responders (11/54 vs. 0/19, p = 0.03). Non-responders were twice as likely to undergo drainage of an abscess by interventional radiology (10/19 vs. 13/54, p = 0.02) compared to responders. Among all patients who required percutaneous drainage, the failure rate of non-operative management was 43% (10/23).

CONCLUSIONS

Children with perforated appendicitis can be managed effectively with nonoperative therapy, even in the presence of intra-abdominal abscesses. However, the need for abscess drainage increases the failure rate, perhaps due to inadequate source control. Those patients with a phlegmon on CT scan as opposed to an abscess, are most likely to respond to non-operative management. Initial non-operative therapy of perforated appendicitis in children is appropriate under certain clinical circumstances, especially when the body itself or interventional radiology can achieve adequate source control.

Delayed versus immediate surgery in acute appendicitis: do we need to operate during the night?

BACKGROUND/PURPOSE

Over the last 4 years, the authors changed their management of acute nonperforated appendicitis from emergent surgery within the first 2 to 6 hours of admission to initiation of antibiotic therapy with operation within 24 hours of admission in those seen in the late evening or early morning. They examined, therefore, whether a delay in operation for acute appendicitis would affect outcome measures of patient morbidity and resource use.

METHODS

The medical records of 126 patients with acute appendicitis occurring between 1998 and 2001 were retrospectively reviewed. Incidence of perforation at surgery, length of stay (LOS), hospital charges, operating time, and complications as a function of duration between emergency room (ER) triage and operation (ER-OR) or admission and operation (Admit-OR) were analyzed by Student's t test, and regression analysis with P less than.05 considered significant.

RESULTS

Thirty-eight children (26%) were operated on within 6 hours of ER triage, whereas the remaining 88 children (74%) were operated on between 6 and 24 hours from ER triage. No significant difference was noted in perforation rate, LOS, costs, or operative time, nor were substantial changes in complications noted between those with an ER-OR < or =6 hours and greater than 6 hours. Likewise, no significant differences in these outcome measures were noted for Admit-OR greater than 6 when compared with < or =6 hours. Only costs with ER-OR greater than 12 hours and LOS with Admit-OR greater than 6 hours were significantly (without Bonferroni correction) different than < or = 6 hours. Multivariable linear regression analysis identified only LOS as a significant predictor of time to OR.

CONCLUSIONS

In children with acute appendicitis, delaying surgery until the daytime hours did not significantly affect operating time, perforation rate, or complications. Delayed management allows greater efficiency and effective use of physician and hospital resources, including decreased resident involvement in operations during the night.

Is delayed operative treatment worth the trouble with perforated appendicitis is children?

BACKGROUND

Approximately 30% to 50% of appendicitis in children is already perforated at presentation. The optimal management of these children remains controversial.

METHODS

Ninety-six children (aged 2 to 16 years) were treated for perforated appendicitis. Seventy-one underwent immediate appendectomy and drainage of abscess, if present (group I). In the other 25 an attempt was made to treat with intravenous antibiotics, combined with transrectal (4) or percutaneous (2) drainage of abscess. This treatment was successful in 16 patients (group II), who underwent appendectomy 6 to 8 weeks later, and unsuccessful in 9 patients (group III), who underwent appendectomy 3 to 12 days later.

RESULTS

The mean length of stay was as follows: group I, 6.7 days; group II, 8.9 days; and group III, 10.9 days (not significant). The white blood cell count (WBC) at presentation was group I, 18.6 K; group II, 17.9 K; group III, 18.8 K. The percent fall of WBC on day 4 was group I, 55%; group II, 25.5%; group III, 17% (P >0.05 versus groups I and II). Twenty of 71 patients in group I (28%) developed wound infection (5), pelvic abscess (14), and pancreatitis (1), while 2 of 16 (12.5%) of group II and 1 of 9 (11%) of group III patients required readmission (both P <0.05 versus group I).

CONCLUSIONS

These data show that initial antibiotic treatment of perforated appendicitis in children, followed by interval appendectomy, is useful for a select group who present with little or no peritonitis, slightly elevated temperature, and WBC that falls at least 25% within 3 to 4 days.

Histopathology of interval (delayed) appendectomy specimens: strong association with granulomatous and xanthogranulomatous appendicitis

Patients who present with a ruptured acute appendicitis are often treated with antibiotic therapy and drainage followed by a delayed or interval appendectomy. We noticed interval appendectomy specimens with granulomatous inflammation and postulated that interval appendectomy may lead to granulomatous appendicitis. To test this hypothesis, we reviewed the histopathology of all interval appendectomy specimens within a 4-year period and compared them with a control group of patients who had acute appendicitis and underwent routine acute appendectomy. All slides were randomized and reviewed blindly to assess the inflammatory patterns, with special attention given to the presence of granulomas and other Crohn-like features. Twenty-two cases of interval appendectomy were found. The interval between symptom onset and appendectomy ranged from 30 to 95 days with a mean of 58 days, whereas all 44 control patients had surgery within 72 hours of symptoms onset. Thirteen (59.1%) of the 22 interval appendectomy cases contained granulomas compared with only 3 of 44 controls (P < 0.0001). Eight (36.4%) of the interval appendectomy cases had xanthogranulomatous inflammation compared with none in the acute appendicitis group (P < 0.0001). A Crohn-like appearance was seen in 11 (50.0%) of the interval appendectomy cases and 1 of the controls (P < 0.0001). Follow-up data were available in 8 of 11 cases with Crohn-like features; none developed Crohn disease during an average follow-up period of 23 months. Delayed or interval appendectomy specimens often have a characteristic inflammatory pattern that includes granulomas, xanthogranulomatous inflammation, mural fibrosis/thickening, and transmural chronic inflammation. Without the appropriate clinical history, these changes may be misinterpreted as Crohn disease.

Prospective evaluation of nonsurgical versus surgical management of appendiceal mass

PURPOSE

Prospective evaluation was undertaken of surgical findings, complications, morbidity, and hospital stay between initial nonsurgical management versus early surgical intervention of an appendicular mass.

METHODS

A prospective, nonrandomized study was conducted of 82 consecutive patients (mean age, 6.9 +/- 3.3 years) presenting with an appendicular mass over a 5-year period. They were categorized as group 1, 58.5% (48 of 82) nonsurgically managed and an interval appendectomy performed at a mean period of 8.6 +/- 4.6 weeks and group 2, 41.5% (34 of 82) appendectomy at presentation.

RESULTS

An appendix was identified in all 82 patients in both groups at operation. In-group 1, recurrent episodes of abdominal pain necessitated interval appendectomy in 39.6% (19 of 48) patients at a mean 4.3 +/- 0.8 versus 11.5 +/- 3.7 weeks in 60.4% (29 of 48) who underwent scheduled interval appendectomy. Periappendiceal abscesses present at interval appendectomy in group 1 was (38 of 48) 79.2% versus 100% (34 of 34) at appendectomy in group 2. Adhesions at interval appendectomy in group 1 was 81.3% (39 of 48) versus 100% (34 of 34) at appendectomy in group 2. In-group 1, superficial wound infection was observed in 0 versus 4 wound infections in group 2. Overall morbidity rate between group 1 and group 2 was statistically significant (P <.05). Total mean hospital stay in group 1 was 13.2 +/- 1.5 versus 4.8 +/- 0.4 days in group 2. Of the 48-interval appendectomy specimens, 37 of 48 (77%) appendices had a patent lumen, and 11 of 48 (23%) showed fibrosis and obliteration of appendicular lumen. There was no correlation (r = 0.22) between the histopathologic findings and the interval between abscess treatment and interval appendectomy.

CONCLUSIONS

Early surgical intervention was beneficial over nonoperative management in this cohort of patients. Interval appendectomy is recommended after nonsurgical management of an appendicular mass.

Conservative management of appendix mass in children

BACKGROUND

The management of an appendix mass in children is controversial. An experience of conservative management of appendix masses in a paediatric population over the last 19 years is reviewed.

METHODS

The medical records of all children who presented with an appendix mass to one of three children's hospitals between 1982 and 2000 were reviewed. In that interval 427 children with a mean age of 7.3 years (range from 2 months to 18 years) presented with an appendix mass. Sixteen children had an immediate appendicectomy. The remaining 411 children were treated conservatively by close observation and antibiotics, with intravenous fluids and nasogastric suction if required. Once the child was well enough for discharge home, elective appendicectomy was booked for 4-6 weeks later.

RESULTS

Three hundred and forty-six (84.2 per cent) of the children responded to initial conservative management and were discharged after a median stay of 6 (range 3-24) days. The children returned 4-6 weeks later for elective appendicectomy. The complication rate for elective appendicectomy was 2.3 per cent (eight patients). Those who had an uncomplicated elective appendicectomy had a median hospital stay of 3 (range 1-6) days. Histological examination demonstrated acute or subacute inflammation in 50.8 per cent of appendices removed at elective appendicectomy.

CONCLUSION

Non-operative management of an appendix mass followed by elective appendicectomy is a safe and effective method of management.

Laparoscopic interval appendectomy for periappendicular abscess

BACKGROUND

Laparoscopic appendectomy was first described in the early 1980s and is currently widely used for the treatment of acute appendicitis. The application of laparoscopic techniques to interval appendectomy and the value of this procedure as compared to open elective interval appendectomy remains uncertain. Therefore, we set out to assess the usefulness of interval laparoscopic appendectomy following periappendicular abscess.

METHODS

This study analyzes the data for 10 patients who underwent interval laparoscopic appendectomy 8-10 weeks following documented periappendicular abscess in the period between January 1996 and June 1998.

RESULTS

Laparoscopic appendectomy was completed successfully in all 10 patients. Nine patients were discharged 1 day after the operation; one patient was discharged on the evening of the operative day. There were no complications and no wound infections.

CONCLUSION

We conclude that the laparoscopic approach is the preferable treatment for interval appendectomy. It is associated with minimal or no morbidity and a very short hospital stay.