Moving to Medical Treatment for COVID-19 Influence on Pediatric Appendicitis: A Meta-Analysis

Appendectomy by Pediatric Surgeons in North Carolina is Associated With Higher Charge Than General Surgeons

See Article on Page 192-197 Acute appendicitis is the most common indication for surgery in patients admitted to hospital due to an acute abdomen. Although most are uncomplicated, about 20% of all acute appendicitis cases are complicated, leading to local or diffuse peritonitis. An urgent appendectomy is the recommended treatment for both complicated and uncomplicated appendicitis. The appendectomy, which has been the first choice for the treatment of acute appendicitis for over 120 years, is a classic surgical procedure [1]. Nowadays, a laparoscopic appendectomy is widely practiced for its benefits, such as significantly shorter operative time, lower incidence of wound infection, and reduced length of hospital stay [2]. Although an appendectomy is generally well tolerated, it is still considered a major surgical intervention and can be associated with postoperative morbidity in about 2%-23% of patients [3]. According to a study that followed patients for over a decade, 3% of the patients undergoing appendectomy were readmitted for intestinal obstruction related to postoperative adhesion [4,5]. Therefore, physicians are taking higher interest in noninvasive interventions, such as antibiotic therapy, as a primary treatment. Although the appendectomy remains the standard approach for treating appendicitis [6], several studies have already suggested that appendicitis can be treated with antibiotics [5]. Two well-studied appendicitis scoring systems based on clinical symptoms were used to diagnose appendicitis: the Alfredo Alvarado system for adults and the Madan Samuel system for children. The Alvarado score was developed in Philadelphia in the mid-1980s and has a sensitivity of 81% and a specificity of 74% [7]. The Pediatric Appendicitis Score was developed to diagnose appendicitis in children and has a high sensitivity of 100% and specificity of 92% [8]. Although these scoring systems were widely used to diagnose appendicitis in the past, they are no longer practically implicated. Recently, various diagnostic tools, such as computed tomography (CT) and ultrasound, have been developed to diagnose appendicitis. With the improvement of such radiologic tools, determining the severity of and diagnosing appendicitis have become more accurate. The development of radiologic tools has provided many advantages for diagnosing appendicitis and determining its severity. The increased use of CT has reduced the rate of negative (unnecessary) appendectomies [9]. A meta-analysis consisting of data from 31 studies revealed that both the sensitivity and the specificity of CT for appendicitis were as high as 94% [10]. The development of a precise scoring system based on CT to distinguish between complicated and uncomplicated appendicitis has led to an improvement in diagnostic accuracy [11]. This system provides the physician with the evidence needed to decide on a treatment strategy for appendicitis patients. A meta-analysis [12] of randomized controlled trials comparing antibiotics with appendectomies has shown that although antibiotic treatment alone can be successful in 77%-95% of the cases, patients should be made aware of the fact that the failure rate during the first year, with a need for readmission or surgery, is around 25%-30%. However, recently conducted research proposed the use of antibiotics as the single treatment for uncomplicated appendicitis. However, one should note that more accurate selection criteria, based on combinations of clinical risk scores and imaging, are required for patients or subgroups of patients in whom primary antibiotic treatment is more likely to succeed in the long-term, and CT could be of assistance in the process of selecting patients suitable for antibiotics therapy. Although the appendectomy is the best treatment for the appendicitis, studies on the use of antibiotics therapy to treat patients with uncomplicated appendicitis are still meaningful; thus, efforts for such research should be supported.

Acute Appendicitis in Infants: Still a Diagnostic Dilemma

<p dir="ltr">Acute appendicitis is a clinical term for inflammation of the vermiform appendix with a sudden onset. Symptoms depend both on the age of a patient and on the position of appendix intraabdominally. The aetiology remains unknown, although, there are multiple theories. The lifetime risk of acute appendicitis in Western countries has been established as 7-8%, with 8.6% for males and 6.7% for females. The standard treatment has been surgery for many decades, but non-operative treatment, in the form of antibiotics, has more recently come to light as a feasible alternative to appendectomies.</p><p dir="ltr">Aims: The aim of this thesis was to assess intermediate and long-term outcomes of non- operative treatment in both children and adults. This included assessing safety and feasibility of non-operative treatment and its complications. An additional aim was to ascertain the failure rate of non-operative treatment and recurrence of acute uncomplicated appendicitis in children and try to establish the reasons for the treatment failure.</p><p dir="ltr">Methods: Study I was a 5-year follow-up of all participants who underwent surgery or non- operative treatment with antibiotics in a previous randomised controlled pilot trial. Data was extracted from the hospital notes and telephone interviews.</p><p dir="ltr">Study II was a long-term follow-up of adults with acute appendicitis who were involved in two randomised controlled trials, which compared non-operative treatment with appendectomy. The first trial consisted of 40 patients (13 female) and second trial was a multicentre study with 252 male patients. National registers were used to retrieve data at follow up, including the Swedish National Patient Register, the Cancer Register, the Cause of Death Register and Statistics Sweden.</p><p dir="ltr">Study III was a systematic review that was registered in PROSPERO (CRD42024592607) and done according to PRISMA statement. We searched three databases (PubMed, Medline, Web of Science). Eligible studies were randomised controlled trials or prospective cohort studies with children aged <18 years that received non-operative treatment for uncomplicated appendicitis and reporting at least 30 days follow-up. We carried out a meta- analysis.</p><p dir="ltr">Results: In Study I, we followed up all 50 children (26 children in the appendectomy group, 24 children in the nonoperative group) for at least 5 years. The surgical group was without failures and in the nonoperative group there were 11 failures and recurrences. In the first year there were nine failures, two of them had an appendicitis on the histopathology. Another two recurrences, that were histopathologically confirmed appendicitis occurred one to five years after the initial trial. At the 5-year follow-up, 54% of children had been successfully treated nonoperatively with antibiotics alone.</p><p dir="ltr">In Study II, in total, we were able to trace down 259 patients in the Patient Register, 137 patients in the non-operative group and 122 in the surgical group. At the end of follow-up, 82 (60%) patients had had successful non-operative treatment without an appendectomy. In the non-operative group there were 21 (15%) failures during the first admission. Thirty-four recurrences happened after discharge, all with a diagnostic code of acute appendicitis. After successful initial treatment, 82/116 (71%) remained without appendectomy.</p><p dir="ltr">In Study III, through a systematic search we were able to identify 2343 abstracts. Thirty studies were eligible, 8 randomised controlled trials and 22 prospective cohort studies reporting 27 different patient cohorts. An early failure rate occurred in 10% (95% CI 7-14%) and the recurrence rate was 29% (95% CI 24-34%) at the end of follow-up. When analysing studies with faecalith, a failure rate was higher (17% versus 6.4%) with P-value <0.0001.</p><p dir="ltr">Conclusions: Studies I and II demonstrated intermediate- and long-term safety of non- operative treatment alone in children and adults. This treatment does not increase the risk of malignancy and other complications and patients avoid surgery. Study III demonstrated a low initial failure rate and the recurrence rate was 29%. Non-operative treatment was less successful in children with a faecalith, particularly during first admission. These results can be used for discussion about treatment options of uncomplicated appendicitis with child patients and their caregivers.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Patkova B</b>, Svenningsson A, Almström M, Eaton S, Wester T, Svensson JF. Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial. Ann Surg. 2020 Jun;271(6):1030-1035. <a href="https://doi.org/10.1097/SLA.0000000000003646">https://doi.org/10.1097/SLA.0000000000003646</a></p><p dir="ltr">II. <b>Pátková B,</b> Svenningsson A, Almström M, Svensson JF, Eriksson S, Wester T, Eaton S. Long-Term Outcome of Nonoperative Treatment of Appendicitis. JAMA Surg. 2023 Oct 1;158(10):1105-1106. <a href="https://doi.org/10.1001/jamasurg.2023.2756">https://doi.org/10.1001/jamasurg.2023.2756</a></p><p dir="ltr">III. <b>Patková B</b>, Svenningsson A, Jumah S, Wester T, Eaton S. Failure and recurrence of non-operative treatment of uncomplicated appendicitis in children; a systematic review and meta-analysis. [Manuscript]</p>

<p dir="ltr">Acute appendicitis is a clinical term for inflammation of the vermiform appendix with a sudden onset. Symptoms depend both on the age of a patient and on the position of appendix intraabdominally. The aetiology remains unknown, although, there are multiple theories. The lifetime risk of acute appendicitis in Western countries has been established as 7-8%, with 8.6% for males and 6.7% for females. The standard treatment has been surgery for many decades, but non-operative treatment, in the form of antibiotics, has more recently come to light as a feasible alternative to appendectomies.</p><p dir="ltr">Aims: The aim of this thesis was to assess intermediate and long-term outcomes of non- operative treatment in both children and adults. This included assessing safety and feasibility of non-operative treatment and its complications. An additional aim was to ascertain the failure rate of non-operative treatment and recurrence of acute uncomplicated appendicitis in children and try to establish the reasons for the treatment failure.</p><p dir="ltr">Methods: Study I was a 5-year follow-up of all participants who underwent surgery or non- operative treatment with antibiotics in a previous randomised controlled pilot trial. Data was extracted from the hospital notes and telephone interviews.</p><p dir="ltr">Study II was a long-term follow-up of adults with acute appendicitis who were involved in two randomised controlled trials, which compared non-operative treatment with appendectomy. The first trial consisted of 40 patients (13 female) and second trial was a multicentre study with 252 male patients. National registers were used to retrieve data at follow up, including the Swedish National Patient Register, the Cancer Register, the Cause of Death Register and Statistics Sweden.</p><p dir="ltr">Study III was a systematic review that was registered in PROSPERO (CRD42024592607) and done according to PRISMA statement. We searched three databases (PubMed, Medline, Web of Science). Eligible studies were randomised controlled trials or prospective cohort studies with children aged <18 years that received non-operative treatment for uncomplicated appendicitis and reporting at least 30 days follow-up. We carried out a meta- analysis.</p><p dir="ltr">Results: In Study I, we followed up all 50 children (26 children in the appendectomy group, 24 children in the nonoperative group) for at least 5 years. The surgical group was without failures and in the nonoperative group there were 11 failures and recurrences. In the first year there were nine failures, two of them had an appendicitis on the histopathology. Another two recurrences, that were histopathologically confirmed appendicitis occurred one to five years after the initial trial. At the 5-year follow-up, 54% of children had been successfully treated nonoperatively with antibiotics alone.</p><p dir="ltr">In Study II, in total, we were able to trace down 259 patients in the Patient Register, 137 patients in the non-operative group and 122 in the surgical group. At the end of follow-up, 82 (60%) patients had had successful non-operative treatment without an appendectomy. In the non-operative group there were 21 (15%) failures during the first admission. Thirty-four recurrences happened after discharge, all with a diagnostic code of acute appendicitis. After successful initial treatment, 82/116 (71%) remained without appendectomy.</p><p dir="ltr">In Study III, through a systematic search we were able to identify 2343 abstracts. Thirty studies were eligible, 8 randomised controlled trials and 22 prospective cohort studies reporting 27 different patient cohorts. An early failure rate occurred in 10% (95% CI 7-14%) and the recurrence rate was 29% (95% CI 24-34%) at the end of follow-up. When analysing studies with faecalith, a failure rate was higher (17% versus 6.4%) with P-value <0.0001.</p><p dir="ltr">Conclusions: Studies I and II demonstrated intermediate- and long-term safety of non- operative treatment alone in children and adults. This treatment does not increase the risk of malignancy and other complications and patients avoid surgery. Study III demonstrated a low initial failure rate and the recurrence rate was 29%. Non-operative treatment was less successful in children with a faecalith, particularly during first admission. These results can be used for discussion about treatment options of uncomplicated appendicitis with child patients and their caregivers.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Patkova B</b>, Svenningsson A, Almström M, Eaton S, Wester T, Svensson JF. Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial. Ann Surg. 2020 Jun;271(6):1030-1035. <a href="https://doi.org/10.1097/SLA.0000000000003646">https://doi.org/10.1097/SLA.0000000000003646</a></p><p dir="ltr">II. <b>Pátková B,</b> Svenningsson A, Almström M, Svensson JF, Eriksson S, Wester T, Eaton S. Long-Term Outcome of Nonoperative Treatment of Appendicitis. JAMA Surg. 2023 Oct 1;158(10):1105-1106. <a href="https://doi.org/10.1001/jamasurg.2023.2756">https://doi.org/10.1001/jamasurg.2023.2756</a></p><p dir="ltr">III. <b>Patková B</b>, Svenningsson A, Jumah S, Wester T, Eaton S. Failure and recurrence of non-operative treatment of uncomplicated appendicitis in children; a systematic review and meta-analysis. [Manuscript]</p>

Acute appendicitis is one of the most common urgent abdominal interventions.Open appendectomy has been a standard procedure for acute appendicitis for more than 100 years.However, in the last 20 years, after many studies, laparoscopic appendectomy has become a gold standard in solving acute appendicitis.The main goal of our study was to compare results of open and laparoscopic appendectomies with regard to in-hospital stay, time of operation, postoperative complications and postoperative pain.All patients underwent open or laparoscopic appendectomy in the Center of Minimally Invasive Surgery and Emergency Center of the University Clinical Center Ni, Serbia in the period of one year.A total of 126 patients were enrolled and submitted to retrospective analysis.One hundred and twenty-six patients who underwent laparoscopic or open appendectomy surgery were retrospectively analysed.A laparoscopic appendectomy was performed in 58 patients, while 68 patients underwent an open appendectomy.Groups were demographically similar and there was no significant difference between the age structure and gender distribution (t = 0.927; p = 0.057).Average height (p = 0.123), weight (p = 0.200) and BMI (p = 0.425) were mostly similar.Previous surgical operations were more common in patients with open appendectomy, but with no statistical significance (p = 0.141).Percentage of patients with WBC > 10 were the same in both groups (p = 0.927).Diabetes mellitus was more common in patients with open appendectomy, but with no statistical significance (p = 0.563).Acute and perforated appendicitis were similar in both groups (p = 0.490).Average time of operation was the same in both groups (p = 0.751).Number of days of in-hospital stay was shorter in patients who underwent laparoscopic appendectomy (p < 0.001).The analysis of administration of parenteral and oral analgesics showed that postoperative pain was less in the group of patients who underwent laparoscopic appendectomy than in the group of patients with open appendectomy.There was no statistically significant difference with respect to postoperative complications between two groups (p < 0.001).The treatment of appendicitis by using laparoscopic surgery in comparison to open approach provides a better result in terms of duration of hospital stay, recovering time, postoperative complications and postoperative pain.

Background: Acute appendicitis is the most common pediatric surgical emergency. Its diagnosis and management are challenging due to atypical presentations in children, which can lead to delays and a high risk of perforation, underscoring the need for an integrated, evidence-based clinical approach. Aim: This article provides a comprehensive review of pediatric appendicitis, focusing on the integrated roles of laboratory evaluation, diagnostic imaging, and nursing management to optimize timely diagnosis, guide treatment, and improve patient outcomes. Methods: A detailed analysis of the pathophysiology, clinical presentation, and diagnostic pathways for pediatric appendicitis is presented. The evaluation of laboratory markers (e.g., leukocytosis), the application of clinical scoring systems (e.g., Pediatric Appendicitis Score), and the strategic use of imaging modalities (Ultrasound-first, then MRI or CT) are examined. Management strategies, including laparoscopic appendectomy and non-operative antibiotic therapy, are reviewed. Results: No single test is diagnostic; a combination of serial clinical exams, laboratory trends, and selective imaging is most effective. Ultrasound is the preferred initial imaging modality. Treatment for uncomplicated appendicitis is typically laparoscopic appendectomy, though non-operative management with antibiotics is a safe option for select patients. Complicated appendicitis (e.g., with perforation) requires a tailored approach, often involving antibiotics with or without percutaneous drainage. Nursing care is critical for pain management, fluid balance, and patient/family education throughout the perioperative and recovery phases. Conclusion: Optimal outcomes in pediatric appendicitis are achieved through a multidisciplinary, protocol-driven approach that emphasizes early surgical consultation, judicious diagnostic testing, and individualized treatment plans to reduce complications and ensure a swift recovery.

Antibiotic therapy may be an alternative in the treatment of uncomplicated appendicitis. The primary concern about antibiotic therapy is the need for appendectomy due to recurrent acute appendicitis after treatment. The optimal antibiotic choice, route of administration, and duration of treatment remain controversial. We aimed to demonstrate the long-term success of oral antibiotic therapy in uncomplicated appendicitis. This was a single-center retrospective study including all patients diagnosed with uncomplicated acute appendicitis between January 2020 and December 2022, who were discharged from the emergency department on oral antibiotics without hospitalization. Treatment success was defined as the absence of appendectomy during follow-up. We reported long-term treatment success rates of oral antibiotic therapy. In addition, factors that may affect treatment success were evaluated. A total of 99 patients were included in the study. At 1 year, the treatment success rate was 76% (95% CI = 66-83%). At a median follow-up of 34months, 70% (95% CI = 60-78%) remained free of surgery. The Kaplan-Meier analysis revealed that 80% of appendectomies due to recurrent acute appendicitis occurred within the first 10months. There were no significant differences between patients who required appendectomy and those who did not regarding age, sex, WBC count, neutrophil-to-lymphocyte ratio, appendix diameter, or previous intravenous antibiotic use. With a median follow-up of 34months, oral antibiotic-only treatment prevented appendectomy in 70% of patients. Larger, prospective randomized studies are needed to identify factors influencing treatment success.

2412 Cost effectiveness analysis of operative Versus antibiotic management for uncomplicated appendicitis

Use of antibiotics alone for treatment of uncomplicated acute appendicitis: A systematic review and meta-analysis

This Living FRISBEE (Living FRIendly Summary of the Body of Evidence using Epistemonikos) is an update of the summary published in January 2016. Appendicitis is a typical cause of acute abdominal pain and the most frequent cause of emergency abdominal surgery. In the last two decades, increasing evidence has been published about the use of antibiotics as an exclusive treatment for acute appendicitis. To answer this question, we used Epistemonikos, the largest database of systematic reviews in health, which is maintained through searches from multiple sources of information, including MEDLINE, EMBASE, Cochrane, among others. We extracted the data from the identified reviews, reanalyzed the data from the primary studies, performed a meta-analysis and prepared a summary of findings table using the GRADE approach. We identified 23 systematic reviews including 28 primary studies, of which eight were randomized trials. We concluded the exclusive use of antibiotics for the treatment of uncomplicated acute appendicitis could be less effective than appendectomy, but it might be associated with a lower rate of complications.

Demographic changes associated with the aging population mean that surgeons increasingly have contact and make decisions about treating patients from the oldest age groups. The aim of the study was to review the literature concerning the treatment of acute appendicitis in patients over the age of 60 years old. A review of the literature published in the years 2000-2015 has been carried out using the PubMed database. The initial number of results corresponding to the query in English, "appendicitis (MeSH) AND elderly (MeSH)" was 260. Selection based on the titles, abstracts, and eventually whole articles, ultimately resulted in 11 papers concerning the treatment of appendicitis in patients above 60 years of age. Nine papers were retrospective and 2 were prospective. In total, the studies included 82,852 patients. Laparoscopic appendectomy was associated with a lower mortality rate, a smaller number of postoperative complications and a shorter length of hospital stay, which led to it being recommended by most authors. Four of the ten papers demonstrated that the patients who were qualified for laparoscopic surgery had less comorbidity and were in a lower ASA (American Society of Anaesthesiology) category. Antibiotic therapy as an independent method was assessed in one study in a group of elderly people, on a selected group of 26 patients, and its effectiveness was shown to be 70%. Most studies, however, are highly heterogeneous which significantly hindered comparisons. Currently, laparoscopic appendectomy seems to be the treatment of choice in the elderly with acute appendicitis. Antibiotic therapy, as an independent method of treatment of acute appendicitis, cannot currently be recommended. However, further, prospective, and better-designed studies are needed, involving a larger number of patients, and primarily dedicated to the elderly.

Essential treatment of acute appendicitis is surgical resection with the use of appropriate antibiotics. In order to effectively treat acute appendicitis, it is important to identify the microorganism of acute appendicitis and evaluate the effective antibiotics. A total of 694 patients who underwent appendectomy for acute appendicitis and had positive microbial result between 2006 and 2015 were recruited. For microbial assessment, luminal contents of the appendix were swabbed after appendectomy. In patients with periappendiceal abscess, the specimens were obtained from abscess fluid. The patient characteristics, operative data, use of antibiotics, the results of microbiology, and postoperative morbidities including surgical site infection (SSI) were retrospectively reviewed. The mean age was 38.2 (± 19.8)years, and 422 patients (60.8%) were male. Most of the operations were performed by conventional laparoscopy (83.1%), followed by single-port laparoscopy (11.8%). The most common microorganism was Escherichia coli (64.6%), which was susceptible to amoxicillin/clavulanate, ciprofloxacin, most cephalosporins, piperacillin/tazobactam, and imipenem. The second most common microorganism was Pseudomonas aeruginosa (16.4%), which was resistant to amoxicillin/clavulanate and cefotaxime. The rate of postoperative morbidity was 8.6%, and the most common type was superficial SSI (6.2%), followed by ileus (1.2%), gastroenteritis (0.7%), and organ/space SSI (0.3%). P. aeruginosa (odds ratio = 2.128, 95% confidence interval 1.077-4.206, P = 0.030) was the only significant microorganism associated with SSI according to multivariate analysis adjusting for other clinical factors. In perforated appendicitis, the use of empirical antibiotics seems to be safe. In some cases of Pseudomonas infection, adequate antibiotics should be considered.

Comparatively study of laparoscopic and open surgery for postoperative complications of acute gangrenous appendicitis

Objective To evaluate the efficacy of single or double-antibiotic regimen for the treatment of complicated appendicitis in children, with the purpose to guide the rational use of antibiotics in clinic. Methods Six hundred and sixty-three patients with acute appendicitis admitted to the department of pediatric surgery in Jinhua Municipal Central Hospital between March 2011 and February 2015.One hundred and seventy-two of 663 patients with complicated appendicitis which confirmed by intra-operative macroscopic or post-operative pathological examination were eligible for the study.These patients were divided into two groups based on the regimen of their postoperative antibiotics: single or double-antibiotic regimen(treatment group, n=66); triple antibiotics regimen(control group, n=106). Demographic data, blood routine test and C-response protein(CRP), length of hospital stay, postoperative complications and duration of antibiotic treatment were recorded and statistically analyzed. Results There was no difference between the treatment group and control group with respect to age distribution, blood routine examination and CRP, length of hospital stay, duration of antibiotic treatment or postoperative complications.Although the number of patients changed of antibiotics on the basis of bacterial culture of pyogenic fluids in treatment group were more frequently than those in the control group(7/66 vs.1/106), the therapeutic effective rate of changed of antibiotics was 100% in both two groups.The culture positive rate of peritoneal fluids was 72.09% (124/172), the most common pathogens were escherichia coli(80.15%, 105/131), pseudomonas aeruginosa(5.34%, 7/131)and klebsiella pneumonia (3.05%, 4/131). The results of bacterial culture of peogenic fluids showed no difference in both two groups. Conclusion Children with complicated appendicitis can be managed effectively with single or double broad-spectrum antibiotics after appendectomy, and it may be beneficial to guide the rational use of antibiotics and decrease the irrational use of multi-antibiotics combination in clinic. Key words: Children; Appendicitis; Complicated; Antibiotic drug; Therapy