Interval appendectomy for perforated appendicitis in children

Effect of instant surgery compared with traditional management on paediatric complicated acute appendicitis post-surgery wound: A meta-analysis

A meta-analysis study to assess the influence of instant surgery (IS) compared with conservative therapy (CT) on paediatric complicated acute appendicitis (CAA) post-surgery wounds. A comprehensive literature examination until January 2023 was implemented, and 2098 linked studies were appraised. The picked studies contained 66 674 subjects with paediatric CAA post-surgery wounds in the picked studies' baseline; 64 643 of them were using IS, and 2031 were using CT. The odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of the IS compared with the CT on paediatric CAA post-surgery wounds using the dichotomous and continuous styles and a fixed or random model. The IS had a significantly higher wound infection (OR, 4.97; 95% CI, 2.35-10.54, P < .001) with moderate heterogeneity (I2  = 57%) compared with the CT in a paediatric CAA post-surgery wound. However, no significant difference was found between IS and CT in total antibiotic duration (MD, -5.34; 95% CI,-12.67 to -1.98, P = .15) with high heterogeneity (I2  = 95%) in paediatric CAA post-surgery wounds. The IS had a significantly higher wound infection; however, no significant difference was found in total antibiotic duration compared with the CT in paediatric CAA post-surgery wounds. Although precautions should be taken when commerce with the consequences because most of the studies picked for this meta-analysis had low sample sizes.

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.

Early versus interval appendicectomy for localised perforated appendicitis in children: A best evidence review

A best evidence topic in general surgery was written according to a structured protocol. The question addressed was whether early or interval appendicectomy provides a superior clinical outcome for children presenting with localised perforated appendix. Altogether 204 papers were found using the search strategy reported below; of which 5 were identified to provide the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We concluded that for children presenting with localised perforated appendix without abscess formation, early appendicectomy provides better clinical outcome in terms of lower complication and re-admission rate and shorter length of hospital stay.

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There is controversy in the management of perforated appendicitis in children.

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Limited studies focus on analysing free perforated appendicitis separately from appendicular abscess, mass and phlegmon.

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Localised perforated appendicitis treated with early appendectomy have lower complication and re-admission rate.

Management of complicated acute appendicitis in children: Still an existing controversy

Complicated acute appendicitis (CAA) is a serious condition and carries significant morbidity in children. A strict diagnosis is challenging, as there are many lesions that mimic CAA. The management of CAA is still controversial. There are two options for treatment: Immediate operative management and non-operative management with antibiotics and/or drainage of any abscess or phlegmon. Each method of treatment has advantages and disadvantages. Operative management may be difficult due to the presence of inflamed tissues and may lead to detrimental events. In many cases, non-operative management with or without drainage and interval appendectomy is advised. The reasons for this approach include new medications and policies for the use of antibiotic therapy. Furthermore, advances in radiological interventions may overcome difficulties such as diagnosing and managing the complications of CAA without any surgeries. However, questions have been raised about the risk of recurrence, prolonged use of antibiotics, lengthened hospital stay and delay in returning to daily activities. Moreover, the need for interval appendectomy is currently under debate because of the low risk of recurrence. Due to the paucity of high-quality studies, more randomized controlled trials to determine the precise management strategy are needed. This review aims to study the current data on operative vs non-operative management for CAA in children and to extract any useful information from the literature.

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.

Early appendectomy vs. conservative management in complicated acute appendicitis in children: A meta-analysis

BACKGROUND

No consensus exists among surgeons regarding the optimal treatment of complicated acute appendicitis in children (CAA). Existing studies present heterogeneity of data and only few studies analyzed free perforated appendicitis (FPA) separately from appendicular abscess (AAb) and appendicular phlegmon (AP).

METHOD

Studies which have been judged eligible for this systematic review and consequent meta-analysis are those comparing non-operative management (NOM) with operative management (OM) in children with CAA. Studies were subgrouped between those analyzing mixed patients with CAA, those focusing on patients with AAb/AP and those focusing on patients with FPA.

RESULTS

Fourteen studies fulfilled the inclusion criteria and were included in the meta-analysis with a total of 1288 patients. In the fixed-effects model the complication rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.07, 95%CI = 0.02-0.27) and to the OM arm for the FPA subgroup (RR = 1.86, 95%CI = 1.20-2.87); the re-admission rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.35, 95%CI = 0.13-0.93) and to the OM arm for the FPA subgroup (RR = 1.49, 95%CI = 1.49-7.44). There was no statistical heterogeneity for the two subgroups of patients. The costs weren't significantly different between NOM and OM. The length of stay was favorable to OM. The pooled proportion rate of NOM success was 90%, the pooled relapse rate of appendicitis was 15.4%.

CONCLUSIONS

Children with AAb/AP reported better results in terms of complication rate and re-admission rate if treated with NOM. Conversely children with FPA showed lower complication rate and re-admission rate if treated with OM.

LEVEL OF EVIDENCE

II.

Early versus late surgical management for complicated appendicitis in adults: a multicenter propensity score matching study

Purpose

Surgeons may be uncertain about the optimal timing of appendectomy to decrease complications, especially for complicated appendicitis. The aim of the study was to compare clinical outcomes between early and late surgery for complicated appendicitis.

Methods

A prospectively maintained database of complicated appendicitis was queried. Elective interval surgery (EIS) group and early surgery (ES) were matched with propensity score and marked with a prefix ‘p.’ Patient characteristics and surgical outcomes were compared.

Results

The propensity score-matched EIS group had a lower chance to underwent ileo-cecectomy or right hemicolectomy (1.5% vs. 6.9%, P = 0.031), a tendency of lower rate of postoperative complication (6.9% vs. 13.7%, P = 0.067), a lower rate of wound infection (1.5% vs. 8.4%, P = 0.010), and shorter postoperative hospital stay (3.72 days vs. 5.82 days, P < 0.001) than the propensity score-matched ES group. Multivariate analysis showed that delayed surgery for more than 48 hours or urgent surgery due to failure of EIS and open conversion were independent risk factors for postoperative complications (P = 0.001 and P = 0.025, respectively). In subgroup analysis, high American Society of Anesthesiologists physical status classification and distant abscess or generalized ascites in initial CT increased the risk of failure of EIS.

Conclusion

EIS can be a useful option for selected adult patients with complicated appendicitis.

Immediate surgery or conservative treatment for complicated acute appendicitis in children? A meta-analysis

PURPOSE

This study carried out a meta-analysis to compare immediate surgery (IS) with conservative treatment (CT) of complicated acute appendicitis (CAA) in children.

METHODS

Systematic literature research was performed for relevant studies published from 1969 to date. Trials of IS compared with CT were included. Outcomes of interest were postoperative morbidity and length of hospital stay (LOS).

RESULTS

Fifteen trials were studied (1.243 patients). CT achieved better rates of any complication type (odds ratio [OR] 0.22, [95% confidence interval (CI): 0.14, 0.38], p = 0.001) and wound infection (OR: 0.40 [95% CI: 0.17, 0.96], p = 0.041). Neither intraabdominal abscess (OR: 1.03 [95% CI: 0.31, 3.37], p = 0.958) nor postoperative ileus (OR: 0.29 [95% CI: 0.06, 1.44], p = 0.130) was affected by the treatment option. The polled difference in LOS showed a trend for shorter LOS in the IS group (standard mean difference [SMD]: 0.25 [95% CI: 0.07, -0.43], p = 0.007).

CONCLUSIONS

IS was associated with shorter LOS, while overall complication rates and wound infection declined significantly with CT. The development of intraabdominal abscess and postoperative ileus was not affected by the treatment of choice. The heterogeneity of most studies depicts the need for randomized controlled trials (RCTs) to discover safe management of CAA in children.

LEVEL OF EVIDENCE

III: Type of study: Meta-analysis.

Non-Operative Management is More Cost-Effective than Immediate Operation in Perforated Appendicitis Patients with Seven or More Days of Symptoms

BACKGROUND

Management of perforated appendicitis in children remains controversial. Nonoperative (NO) and immediate operative (IO) strategies are used with varying outcomes. We hypothesized that IO intervention for patients with perforated appendicitis would be more cost-effective than NO management.

METHODS

A retrospective chart review of all patients with appendicitis from 2012 to 2015 was performed. Patients with perforated appendicitis were defined by evidence of perforation on imaging. We excluded patients who presented with sepsis, organ failure, and ventriculoperitoneal shunts. NO management was determined by surgeon preference. Univariate and multivariate analyses were performed.

RESULTS

IO was performed on 145 patients with perforated appendicitis, whereas 83 were treated with NO management. Compared to IO patients, NO patients incurred higher overall costs, greater length of stay, more readmissions, complications, peripherally inserted central venous catheter lines, interventional radiology drains, and unplanned clinic and emergency department visits (P < 0.0001 for all). Multivariate analysis adjusting for age, days of symptoms, admission C-reactive protein and white blood cell count revealed that NO management was independently associated with increased costs (OR 1.35, 1.12-1.62, 95% CI). Cost curves demonstrated that total cost for IO surpasses that of NO management when patients present with greater than 6.3 d of symptoms (P = 0.01).

CONCLUSIONS

Our data suggest that IO is more cost-effective than NO management for patients with perforated appendicitis who present with less than 6.3 d of symptoms, after which point, NO management is more cost-effective.

LEVEL OF EVIDENCE

IV.

Conservative treatment of acute appendicitis

Acute appendicitis has been considered by surgeons a progressive disease leading to perforation for more than 100 years. In the last decades the theories about this concept gained attention, especially in adults. However, appendectomy for acute appendicitis remains the most common urgent/emergent surgical procedure. At present, accumulating evidences are showing the changing in clinical practice towards the non-operative management of several cases of acute appendicitis either non-complicated or complicated. The present review aims to show the literature results regarding the non-operative management of acute appendicitis in non-complicated and in complicated cases.

Acute Appendicectomy or Conservative Treatment for Complicated Appendicitis (Phlegmon or Abscess)? A Systematic Review by Updated Traditional and Cumulative Meta-Analysis

Background

The existing evidence on the treatment of complicated appendicitis favors conservative treatment rather than acute appendicectomy. Update traditional meta-analysis and consequently cumulative meta-analysis was performed to track the accumulation of evidence over time.

Methods

Studies were identified by a systematic literature search of the EMBASE, PubMed, Cochrane Library and Google Scholar databases. The main outcome measures were duration of the first hospitalization, overall duration of hospitalization, duration of intravenous (IV) antibiotic treatment, overall complications, abdominal/pelvic abscesses, wound infections, re-admissions and unplanned re-operations.

Results

Overall complications, abdominal/pelvic abscesses, wound infections and unplanned procedures were significantly lower in the conservative treatment cohort. In contrast, subgroup analysis of three randomized controlled trials (RCTs) revealed no significant difference in abdominal/pelvic abscesses (odds ratio (OR): 0.46, 95% confidence interval (CI): 0.17 - 1.29, P = 0.14). No significant differences were found in the duration of the first and overall hospitalizations. Of the note, high-quality RCTs demonstrated a shorter hospital stay by 1 day for the laparoscopic appendicectomy cohort compared to conservative treatment (mean difference (MD): -0.99, 95% CI: -1.31 to -0.67, P < 0.0001).

Conclusion

The present meta-analysis demonstrates that a shift in paradigm has begun, with a more widespread use of the laparoscopic approach for the management of complicated appendicitis.

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.

Effects of Timing of Appendectomy on the Risks of Perforation and Postoperative Complications of Acute Appendicitis

BACKGROUND

It is generally believed that appendectomy should be performed immediately to prevent perforation and complications. Therefore, our objectives were to investigate the effect of timing of appendectomy on the incidence of perforation and complications.

METHODS

We retrospectively reviewed the medical records of patients who underwent laparoscopic appendectomy between January 2014 and June 2015. The time from symptom onset to appendectomy was categorized into three periods: time from symptom onset to hospital admission (symptomatic time), time from admission to appendectomy (hospitalization time), and time from symptom onset to appendectomy [symptomatic period + hospitalization period (overall time)]. Multivariable analyses were performed to identify independent factors associated with perforation and complications.

RESULTS

A total of 1753 patients were included in the present study. Perforation occurred in 28.2% of patients, and postoperative complications occurred in 10.0% of patients. Multivariable analysis showed that BT > 38 °C (P = 0.006), WBC count >13,000 cells/µl (P = 0.02), neutrophil ratio >80% (P < 0.001), and symptomatic time >24 h (P < 0.001) were independent factors of appendiceal perforation, while the neutrophil ratio >80% (P < 0.001) and symptomatic time >48 h (P = 0.003) were independently associated with complications.

CONCLUSIONS

The present study showed that the symptomatic time and overall time were significantly associated with perforation and complications, whereas hospitalization time was not associated with either perforation or complications.

Acute appendicitis in children: can surgery be postponed? Short-term results in a cohort of 225 children

PURPOSE

To our knowledge, there is no German study, which has examined the relationship between a postponement of surgery (from emergency service to standard working time) and the corresponding risk of postoperative complications in children and adolescents with acute appendicitis. The aim of this study is to examine if surgery of acute appendicitis in childhood can be postponed from night shift to the next working day without negative effects for the patient.

METHODS

In a retrospective analysis (September 2001 to June 2007), the files of 225 paediatric surgical patients with acute appendicitis have been analysed concerning history, histology, course of treatment and development of complications. The cohort was divided into groups by their histology (common, "A", complicated appendicitis, "B") and by the median time (10 h) from admission to surgery (immediate, "C", delayed surgery, "D"). These groups have been analysed and compared.

RESULTS

Groups A and B did not differ concerning time to admittance (p = 0.922). Seven patients developed complications (n = 7/225, 3.1%). Six complications were seen in group C (n = 6/113, 5.3%) compared to 1 in group D (n = 1/112, 0.9%), the difference was not significant (p = 0.119). None of the patients of group B developed complications after delayed surgery. Median follow-up was 10 days (IQR 7-15).

CONCLUSIONS

In view of the development of complications, there was no evidence that the time between inpatient admission and surgery had any impact on the postoperative result. Thus, there is usually no need to perform surgery in common appendicitis during night shift.

Impact of high-grade obstruction on outcomes in patients with appendiceal inflammatory masses managed by nonoperative treatment

Purpose

To retrospectively assess the impact of high-grade obstructions identified on initial CT on outcomes of patients with appendiceal inflammatory masses managed by nonoperative treatment.

Methods

Institutional Review Boards approved this retrospective study and informed consent was waived. Included were 52 consecutive patients diagnosed with appendiceal inflammatory masses by CT scan and managed by nonoperative treatment. The main outcome measure was treatment failure and secondary outcomes were complications and initial and total hospital stay. Patient demographics, inflammatory markers, and CT findings for presence of an appendiceal inflammatory mass and high-grade obstruction were assessed. Patients with and without high-grade obstruction were compared for patient characteristics and outcomes using Fisher exact test and Student t-test.

Results

Among 52 patients, 14 (27%) had high-grade obstruction on CT examination at presentation. No significant differences were observed in patient characteristics (P > 0.05), treatment failure (P = 0.33), complications (P = 0.29), or initial (P = 0.73) or total (P = 0.72) hospitalization between patients with and without high-grade obstruction.

Conclusion

For patients who were managed by nonoperative treatment for appendiceal inflammatory masses, the presence of high-grade obstruction identified on initial CT scan did not significantly affect outcomes of treatment failure, complications, and initial and total hospitalization.

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.

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.

A history of the treatment of appendicitis in children: lessons learned

During the latter half of the 19th century, surgeons increasingly reported performing appendicectomies. Fitz from Harvard, Groves from Canada and Tait from Britain all recorded successful removal of the appendix. McBurney described the point of maximal tenderness in classic appendicitis and also the muscle-splitting incision centred on this point. Priority is given to McArthur in describing the lateral muscle-splitting incision. The direction of the cutaneous incision was later modified by Elliott and Lanz. Incisions that healed well were essential to recovery. Appendicectomy became a 'fashionable' operation after the London surgeon, Treves, removed the appendix of King Edward VII. Through the 20th century, the mortality from appendicitis fell notably with the advent of sulphonamide and penicillin, improvements in fluid therapy and safer anaesthesia. By 1990, diagnostic delay was the main cause of death. Semm performed the first laparoscopic appendicectomy in 1990, roundly criticized at the time for what is now a routine procedure. We view contemporary debates on the indications for appendicectomy, the best approach and how to optimize recovery in the light of the history of this intriguing disease.

Utility of immature granulocyte percentage in pediatric appendicitis

BACKGROUND

Acute appendicitis is the most common cause of abdominal surgery in children. Adjuncts are used to help clinicians predict acute or perforated appendicitis, which may affect treatment decisions. Automated hematologic analyzers can perform more accurate automated differentials including immature granulocyte percentages (IG%). Elevated IG% has demonstrated improved accuracy for predicting sepsis in the neonatal population than traditional immature-to-total neutrophil count ratios. We intended to assess the additional discriminatory ability of IG% to traditionally assessed parameters in the differentiation between acute and perforated appendicitis.

MATERIALS AND METHODS

We identified all patients with appendicitis from July 2012-June 2013 by International Classification of Diseases-9 code. Charts were reviewed for relevant demographic, clinical, and outcome data, which were compared between acute and perforated appendicitis groups using Fisher exact and t-tests for categorical and continuous variables, respectively. We used an adjusted logistic regression model using clinical laboratory values to predict the odds of perforated appendicitis.

RESULTS

A total of 251 patients were included in the analysis. Those with perforated appendicitis had a higher white blood cell count (P=0.0063), C-reactive protein (CRP) (P<0.0001), and IG% (P=0.0299). In the adjusted model, only elevated CRP (odds ratio 3.46, 95% confidence interval 1.40-8.54) and presence of left shift (odds ratio 2.66, 95% confidence interval 1.09-6.46) were significant predictors of perforated appendicitis. The c-statistic of the final model was 0.70, suggesting fair discriminatory ability in predicting perforated appendicitis.

CONCLUSIONS

IG% did not provide any additional benefit to elevated CRP and presence of left shift in the differentiation between acute and perforated appendicitis.

Treatment of suspected acute perforated appendicitis with antibiotics and interval appendectomy

BACKGROUND

Initial antibiotics with planned interval appendectomy (interval AP) have been used to treat patients with complicated perforated appendicitis; however, little experience exists with this approach in children with suspected acute perforated appendicitis (SAPA). We sought to determine the outcome of initial antibiotics and interval AP in children with SAPA.

METHODS

Over an 18-month period, 751 consecutive patients underwent appendectomy including 105 patients with SAPA who were treated with initial intravenous antibiotics and planned interval AP ≥ 8 weeks after presentation. All SAPA patients had symptoms for ≤ 96 hours. Primary outcome variables were rates of readmission, abscess formation, and need for interval AP prior to the planned ≥ 8 weeks.

RESULTS

Intraabdominal abscess rate was 27%. Appendectomy prior to planned interval AP was 11% and readmission occurred in 34%. All patients underwent eventual appendectomy with pathologic confirmation confirming the previous appendiceal inflammation. White blood cell (WBC) count >15,000, WBC >15,000 plus fecalith on imaging, and WBC >15,000 plus duration of symptoms >48 hours were all significantly associated with higher rates of readmission (p=0.01, p=0.04, p=0.02) and need for interval AP prior to the planned ≥ 8 weeks (p=0.003, p=0.05, p=0.03).

CONCLUSIONS

Treatment of SAPA with antibiotics and planned interval AP is successful in the majority of patients; however, complications such as abscess formation and/or readmission prior to planned interval AP occur in up to one-third of patients. Certain clinical variables are associated with increased treatment complications.

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.

Management of appendicitis presenting with abscess or mass

Purpose

Management strategy in acute appendicitis patients initially presenting with abscess or mass is surrounded with controversy. This study was performed to identify the outcomes of management for this condition.

Methods

We retrospectively analyzed prospectively registered 76 patients (male:female = 39:37; mean age, 50.8 years) with appendicitis presenting with abscess or mass over a 9-year period at the Seoul National University Hospital. Patients were divided into three groups (emergency operation group, delayed operation group, and follow-up group), and clinical characteristics and outcomes of treatment were investigated.

Results

Twenty-eight patients (36.8%) underwent an emergency operation. Of the remaining 48 patients, 20 (41.7%) were initially treated with conservative management through the use of antibiotics only; the other 28 (58.3%) with and additional ultrasound-guided percutaneous drainage of the abscess. Twenty-six (54.2%) patients underwent planned operations after conservative management, and 22 (45.8%) were followed without surgery (median duration, 37.8 month), of which 3 (13%) underwent an appendectomy due to recurrent appendicitis (mean of 56.7 days after initial attack). There were no statistical differences in types of operation performed (appendectomy or ileocecectomy), postoperative complications, and postoperative hospital stay among the patients who underwent emergency operations, delayed operations and operations for recurrence during follow-up.

Conclusion

Although the recurrence rate was relatively low after conservative management for appendicitis patients presenting with abscess or mass, there was no difference in surgical outcome between the emergent, elective, or recurrent groups. Our results indicate that proper management of appendicitis with abscess or mass can be selected according to surgeon's preference.

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.

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.

Spontaneous vaginal drainage of a pelvic abscess: an unusual presentation of perforated appendicitis

We report a child with the unusual presentation of spontaneous vaginal drainage of a pelvic abscess after nonoperative management of perforated appendicitis. Although drainage through the rectum has been previously described, this is the first report of spontaneous transvaginal drainage of a pelvic abscess from appendicitis in a child.

Early decisions in perforated appendicitis in children: lessons from a study of nonoperative management

BACKGROUND

In nonoperative management of perforated appendicitis, some children do not respond to treatment. This study sought early identifiers of failure to help in surgical decision making.

METHODS

Fifty-eight patients with computed tomographic (CT)-proven perforated appendicitis were treated according to a nonoperative protocol. Patients who recovered were considered "successes;" those who did not improve underwent appendectomy and were scored as "failures" of nonoperative treatment.

RESULTS

Thirty-six (62%) of 58 patients responded to treatment and 22 (38%) failed. Three parameters distinguished the 2 groups: the number of band forms on the admission white blood cell count, the body temperature response after 24 hours of treatment, and the areas of the abdomen involved in the CT scan. Patients in whom nonoperative treatment failed stayed in the hospital longer (17 vs 9 days) and had more complications (46% vs 0%).

CONCLUSIONS

Because failure of nonoperative management is associated with a high complication rate, it is important to make an early decision about appendectomy. Persistence of fever after 24 hours of treatment, bandemia on admission, and multisector involvement on CT scan identify most patients who fail nonoperative management. When combined with clinical judgment, these are useful indicators to guide early decisions.

Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis

OBJECTIVE

A systematic review of the nonsurgical treatment of patients with appendiceal abscess or phlegmon, with emphasis on the success rate, need for drainage of abscesses, risk of undetected serious disease, and need for interval appendectomy to prevent recurrence.

SUMMARY BACKGROUND DATA

Patients with appendiceal abscess or phlegmon are traditionally managed by nonsurgical treatment and interval appendectomy. This practice is controversial with proponents of immediate surgery and others questioning the need for interval appendectomy.

METHODS

A Medline search identified 61 studies published between January 1964 and December 2005 reporting on the results of nonsurgical treatment of appendiceal abscess or phlegmon. The results were pooled taking the potential clustering on the study-level into account. A meta-analysis of the morbidity after immediate surgery compared with that after nonsurgical treatment was performed.

RESULTS

Appendiceal abscess or phlegmon is found in 3.8% (95% confidence interval (CI), 2.6-4.9) of patients with appendicitis. Nonsurgical treatment fails in 7.2% (CI: 4.0-10.5). The need for drainage of an abscess is 19.7% (CI: 11.0-28.3). Immediate surgery is associated with a higher morbidity compared with nonsurgical treatment (odds ratio, 3.3; CI: 1.9-5.6; P < 0.001). After successful nonsurgical treatment, a malignant disease is detected in 1.2% (CI: 0.6-1.7) and an important benign disease in 0.7% (CI: 0.2-11.9) during follow-up. The risk of recurrence is 7.4% (CI: 3.7-11.1).

CONCLUSIONS

The results of this review of mainly retrospective studies support the practice of nonsurgical treatment without interval appendectomy in patients with appendiceal abscess or phlegmon.

Routine interval appendectomy in children is not indicated

BACKGROUND

This study evaluates outcomes for children treated without interval appendectomy (IA) after successful nonoperative management of perforated appendicitis.

METHODS

A retrospective study of pediatric patients with appendicitis was performed from 12 regional acute-care hospitals from 1992 to 2004 with mean length of follow-up of 7.5 years. Main outcomes were recurrent appendicitis and cumulative length of hospital stay.

RESULTS

The study included 6439 patients, of which 6367 (99%) underwent initial appendectomy. Seventy-two (1%) patients were initially managed nonoperatively and 11 patients had IA. Of the remaining 61 patients without IA, 5 (8%) developed recurrent appendicitis. Age, sex, type of appendicitis, and abscess drainage had no influence on recurrent appendicitis. Cumulative length of hospital stay was 6.6 days in patients without IA, 8.5 days in patients with IA, and 9.6 days in patients with recurrent appendicitis.

CONCLUSION

Recurrent appendicitis is rare in pediatric patients after successful nonoperative management of perforated appendicitis. Routine IA is not necessarily indicated for these children.

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.

Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences

INTRODUCTION

The initial nonoperative management of perforated appendicitis fails in 15% to 25% of children. These children have complications and increased hospitalization. The purpose of this study was to identify predictors of failure.

METHODS

Children with perforated appendicitis treated with antibiotics and intent for nonoperative management over a 4-year period were reviewed. Seventy-five children were identified and included in the study. Failure was defined as undergoing appendectomy before the initially planned interval.

RESULTS

Nine (12%) of the patients required appendectomy sooner than initially planned. Age, presenting symptoms, physical examination findings, and white blood cell (WBC) count were similar in both success and failure groups. Absence of abscess and presence of appendicolith were both predictors of failure in a multivariate analysis, which included the presence of small bowel obstruction. The failed group had a longer median total length of stay (18 days [range, 4-67] vs 8 days [range, 4-31]; P = .002) and underwent 3 times as many computed tomography scans as successes (3 [range, 2-7] vs 1 [range, 0-5]; P < .001).

CONCLUSION

Lack of abscess and presence of an appendicolith predict failure of nonoperative management of perforated appendicitis in children even when the effect of small bowel obstruction is accounted for. Children with these characteristics may benefit from alternative management strategies.

Nonoperative management of perforated appendicitis in children: can CT predict outcome?

BACKGROUND

The optimal treatment of perforated appendicitis remains controversial, but there is a trend toward nonoperative management. CT scanning might be helpful in determining which patients could benefit from this treatment option.

OBJECTIVE

To determine the value of CT imaging in predicting clinical success or failure in children with nonoperative management of perforated appendicitis.

MATERIALS AND METHODS

Admission CT scans of 34 children with perforated appendicitis treated nonoperatively between January 2003 and June 2006 were retrospectively reviewed. All children were given intravenous antibiotics. Clinical outcome was correlated with imaging findings including the maximal area, number and complexity of collections, presence of an appendicolith or extraluminal air, and extent of intra-abdominal disease outside the right lower quadrant. Patients with an accessible simple collection were drained if their clinical condition did not improve.

RESULTS

Successful nonoperative management was achieved in 20 patients; 14 patients failed nonoperative therapy. The presence of collections in three or more sectors (defined as the pelvis and four abdominal quadrants) correlated strongly with clinical failure (P < 0.05), while there was no correlation found between clinical outcome and the presence of an appendicolith, extraluminal air, distant ascites, and collection size or complexity.

CONCLUSION

In the nonoperative management of children with perforated appendicitis, admission CT findings demonstrating disease beyond the right lower quadrant correlate with treatment failure.

Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis

BACKGROUND

The role of nonoperative therapy vs immediate appendectomy in the management of children with perforated appendicitis remains undefined. The objective of this study was to rigorously compare these management options in groups of patients with matched clinical characteristics.

METHODS

Multicenter case-control study was conducted from 1998 to 2003. We compared patients treated nonoperatively vs those undergoing appendectomy to identify differences in 12 clinical parameters. We then generated a second control group of patients matched for these variables and compared the following outcomes in these clinically similar groups: complication rate, abscess rate, and length of stay (LOS). Analysis was performed according to intention-to-treat principles, using chi2, Fisher exact, and Student t tests.

RESULTS

The only significant difference between patients treated nonoperatively and those treated by appendectomy was the duration of pain on presentation (6.8 vs 3.1 days of pain). We created a second control group of patients undergoing immediate appendectomy matched on duration of pain on presentation to patients treated nonoperatively. These groups continued to be clinically comparable for the other 11 parameters. Compared to this matched control group, the nonoperative group had fewer complications (19% vs 43%, P < .01), fewer abscesses (4% vs 24%, P < .01), and a trend for shorter LOS (6.5 +/- 5.7 vs 8.8 +/- 6.7 days, P = .08).

CONCLUSIONS

When nonoperative management for perforated appendicitis was studied using appropriately matched clinical controls, we found that it resulted in a lower complication rate and shorter LOS in the subset of patients presenting with a long duration of pain. Our data suggest that nonoperative management should be prospectively evaluated in children with perforated appendicitis presenting with a history of pain exceeding 5 days.

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.

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.