Complicated Appendicitis In Children Research Articles

Complicated Appendicitis in Children: Current Management. Review Article

Complicated appendicitis in children is a challenging condition to treat and the treatment options that are available include conservative treatment followed by interval appendectomy and immediate appendectomy. Both these treatment options are effective but as there is no consensus on the management of complicated appendicitis, the treatment option is often decided by the treating surgeon. We have conducted this review article to look at the treatment options that are available, from conservative treatment to immediate appendectomy. We have also looked at the role of percutaneous drainage of appendicular abscess and the role of interval appendectomy.

Associations between Th1-related cytokines and complicated pediatric appendicitis

The pathogenesis of appendicitis is not understood fully, and the diagnosis can be challenging. Previous research has suggested an association between a T helper (Th) 1-dependent immune response and complicated appendicitis. This prospective cohort study aimed to evaluate the association between serum concentrations of the Th1-associated cytokines interleukin (IL)-1α, IL-1β, IL-2, IL-6, IL-10, IL-17A and tumor necrosis factor beta (TNF-β) and the risk of complicated appendicitis in children. Appendicitis severity was determined through histopathological examination. A total of 137 children < 15 years with appendicitis were included with a median age of 10 years (IQR 8–12); 86 (63%) were boys, and 58 (42%) had complicated appendicitis. Children with complicated appendicitis had significantly higher concentrations of serum IL-6 and IL-10, and lower of TNF-β. After adjustment for age, symptom duration, and presence of appendicolith in a multivariable logistic regression, a higher concentration of IL-6 remained associated with an increased risk of complicated appendicitis (aOR 1.001 [95% CI 1.000–1.002], p = 0.02). Serum concentrations of IL-1α, IL-1β, IL-2, IL-10, IL-17A and TNF-β were not significantly associated with the risk of complicated appendicitis. In conclusion, our results suggests that the systemic inflammatory response in complicated appendicitis is complex and not solely Th1-dependent.

Ultrasound and laboratory parameters in distinguishing complicated from uncomplicated appendicitis in children

Introduction/Objective. To evaluate sonographic and laboratory findings as predictors of complicated and uncomplicated appendicitis in order to decide on further treatment options. Methods. This is a retrospective cohort study of 174 pediatric patients who had laboratory tests and ultrasound done before appendectomy in one year period. Results were compared with the intraoperative and histopathological findings of complicated (gangrenous or perforated) or uncomplicated (phlegmonous) appendicitis and assessed by binary logistic regression with backward elimination. The initial model included eight predictors. After backward elimination four remained: periappendiceal fluid, hyperechoic periappendiceal fat, white blood cell (WBC) count and C-reactive protein (CRP). The final model included the interaction between periappendiceal fluid and hyperechoic periappendiceal fat. Diagnostic performance of each parameter was presented with sensitivity and specificity. Results. Out of all patients, 86 had uncomplicated and 88 had complicated appendicitis (37 gangrenous and 51 perforated). In the final model three predictors were significantly associated with complicated appendicitis: interaction between periappendiceal fluid and hyperechoic periappendiceal fat, WBC count &gt; 11 ? 109 / l, and CRP &gt; 100 mg/l. Inclusion of interaction between periappendiceal fluid and hyperechoic periappendiceal fat excluded them as individual predictors. The maximum outside appendiceal diameter of more than 6mm had the highest sensitivity (93.2%), while wall thickness &gt; 3 mm was the most specific (95.2%). Conclusion. Using periapendiceal fluid and hyperechoic periappendiceal fat as sonographic predictors and WBC and CRP as laboratory predictors can differentiate uncomplicated from complicated appendicitis in children and help a physician decide on antibiotic or surgical treatment.

The development and application of pediatric complicated appendicitis prediction model.

Acute appendicitis in children refers to the acute inflammation of the appendix, which accounts for 20% ∼ 30% of cases of acute abdomen in pediatric surgery. This study aimed to establish a decision tree model of complicated appendicitis in children using appendiceal ultrasound combined with an inflammatory index and evaluated its clinical efficacy in pediatric patients. A total of 395 children admitted to the Emergency Department of the Shanghai Children's Hospital from January 2018 to December 2021 and diagnosed with appendicitis by postoperative pathology were retrospectively analyzed. According to the postoperative pathology, the children were divided into a complicated and non-complicated appendicitis group, respectively. Routine laboratory inflammatory indicators, including white blood cell count, N(%), neutrophil (Neu) count, Neu/lymphocyte ratio (NLR), C-reactive protein (CRP), and procalcitonin were collected from the two groups. Collecting data on ultrasound examination of the appendix includes whether the appendix diameter is thickened, whether the echogenicity of the mesenteric rim surrounding the appendix is enhanced, whether there is rich blood supply in the appendix, and whether there are fecaliths in the appendix lumen. The risk factors for complicated appendicitis were screened out by univariate and multivariate logistic regression analyses, the binary logistic regression prediction and decision tree models were established, respectively, and the receiver operating characteristic (ROC) curve was used to verify the accuracy of the two prediction models. Binary logistic regression analysis showed that CRP, NLR, the presence of an appendicolith, and peripheral retina echo enhancement were independent risk factors for complicated appendicitis in children (P< 0.05). The decision tree model had an overall accuracy of 79%, an area under the ROC curve (AUC) of 0.809 (95% confidence interval [CI] 0.780-0.865), and sensitivity and specificity of 71.3% and 77.7%, respectively. The logistic regression model had an overall accuracy of 74.9%, an AUC value of 0.823 (95% CI, 0.765-0.853), a sensitivity value of 80.3%, and a specificity of 71.8%. This predictive model, based on ultrasound of the appendix combined with inflammatory markers, provides a useful method to assist pediatric emergency physicians in diagnosing childhood appendicitis. The decision tree model reflected the interaction of various indexes, and the model was simple, intuitive, and effective.

Blood cell indices as predictors of complicated appendicitis: A diagnostic study

BackgroundAppendicitis in children is associated with diagnostic complexity leading to delayed diagnosis. Such delays risk progression to complicated appendicitis. This study investigates the potential of cellular indices, including neutrophil-to-lymphocyte ratio (NLR), derived neutrophil-to-lymphocyte ratio (dNLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR), to differentiate uncomplicated (UA) from complicated appendicitis (CA). MethodsDiagnostic study of pediatric patients with acute appendicitis admitted to our hospital from 2021 to 2022. NLR, dNLR, PLR and MLR were compared between groups. ResultsA total of 182 patients were enrolled: 116 cases with CA (63 % male, age 9.6 ± 5.5 years) and 66 patients with UA (67 % male, age 10.6 ± 2.7 years). All blood cell indices were significantly higher in the CA group than in the UA group (p= <0.0001). NLR, dNLR and PLR have a good area under the receiver operating characteristic (ROC) curve, whereas MLR has a regular curve (0.735). PLR was the most accurate predictor of CA with a sensitivity of 60 %, specificity of 85 %, positive predictive value of 88 %, area under the ROC curve of 0.802 (95 % CI 0.737–0.866) and a cut-off point for the diagnosis of CA of 213.3. The post-test probability of CA for a positive result on PLR was 80 % (95 % CI 69–88). ConclusionsPLR seems to be the most accurate cellular index to differentiate uncomplicated from complicated appendicitis in children. It may be useful for prioritizing cases for surgery as a predictor of intraoperative findings and early postoperative courses.

Safety of Laparoscopic Appendectomy in Complicated Appendicitis in children

ABSTRACT&#x0D; INTRODUCTION: Acute appendicitis is one of the most common surgical emergency in pediatric age group. Laparoscopic Appendectomy (LA) is no more a new procedure in pediatric surgery. The idea behind laparoscopy is short hospital stay, minimal complications and better cosmesis especially in overweight and obese patients. Laparoscopy offers detailed and magnified visualization and better access into the whole abdominal cavity. In many pediatric surgery centers, laparoscopic management of acute appendicitis is practiced but we have observed that most of them performed laparoscopic appendectomy for simple straight forward appendicitis. It is generally considered that complicated appendicitis is better managed by open procedure. We have performed laparoscopy in 42 patients of Complicated Appendicitis (CA) and observed that the rate of complication is comparable to the known reported studies.&#x0D; OBJECTIVE: The objective of this study was to establish safety of laparoscopic appendectomy in complicated appendicitis in children&#x0D; STUDY DESIGN: It was a retrospective study.&#x0D; SETTING: Research was conducted at Department of Pediatric Surgery, Shifa International Hospital Islamabad.&#x0D; DURATION: Duration of study was 3 years after due approval from ethical and research review board.&#x0D; MATERIAL AND METHODS: The present study is a retrospective analytical review of 42 patients who were operated for complicated appendicitis laparoscopically at Shifa International Hospital, Islamabad from January 2018 to December 2020.&#x0D; All patients were enrolled from emergency department. Clinical assessment of the patients were done in the routine way by history and physical examination. Investigations included complete blood count, C reactive protein and ultrasound abdomen and pelvis. Those patients were excluded from the study who had simple non-complicated appendicitis, open appendectomy, those who had laparotomy for other reasons and interval appendectomy. Similarly those patients who were COVID positive were excluded from the study.&#x0D; All those patients who had complicated appendix like perforation, abscess, mass or gangrene were included in the study.&#x0D; Variables observed in this study were age, sex, operative findings, operative time, hospital stay and post op complications.&#x0D; RESULTS: From January 2018 to December 2020, total 42 patients were included in this study who underwent laparoscopic appendectomy for complicated appendicitis. Complicated appendicitis includes perforated appendicitis, abscess, mass or gangrene. Mean age of the patients was 9.95 with standard deviation of 3.22. Of 42 patients in total, 32 (76%) patients were male and 10 (24%) were female. Mean operative time was 42.5min with standard deviation of 20.03. Mean hospital stay time was 2.23 days with standard deviation of 1.55 (table 1).&#x0D; Out of total 42 patients, 20 (48%) had perforated appendicitis, 9 (21%) patients had appendicular mass, 12 (29%) patients had appendicular abscess and 1 (2%) patient had gangrenous appendicitis. Postoperatively, one patient of perforated appendicitis had trocar site infection. One patient had mass formation with partial obstruction and post-operatively developed urinary retention with peri-orbital puffiness. Two patients of appendicular mass had transaction of appendicular base due to perforated and sloughed appendicular base. One patient of appendicular abscess had large collection in right paracolic gutter. One patient of appendicular abscess developed peritonitis with abscess formation secondary to cecal perforation.&#x0D; CONCLUSION: Our experience with laparoscopy in appendicitis revealed that for complicated appendix laparoscopy is very safe in children with only fewer complications. Although our sample size is small but in our 3 last year experience we learned that laparoscopy may safely be done as a first choice in all patients with appendicitis, whether simple or complicated. Our experience indicates that the apprehension amongst the treating surgeons is not very justified as we routinely do laparoscopy in all appendicitis.&#x0D; KEY WORDS: Laparoscopic appendectomy, complicated appendicitis.

Predicting Complicated Appendicitis in Children: Pros and Cons of a New Score Combining Clinical Signs, Laboratory Values, and Ultrasound Images (CLU Score).

This retrospective study aimed to combine the clinical signs, laboratory values, and ultrasound images of 199 children with acute appendicitis in order to create a new predictive score for complicated appendicitis in children. The study included children who had clinical examination of abdominal pain (description of pain, anorexia, body temperature, nausea or vomiting, duration of symptoms), laboratory findings on admission (white blood cell, platelets, neutrophils, C-reactive protein), preoperative abdominal ultrasound, and histopathological report after an operation for appendicitis in their records during the period from January 2016 to February 2022. According to the statistical analysis of the values using multivariate logistic regression models, the patients with appendiceal diameter ≥ 8.45 mm, no target sign appearance, appendicolith, abscess, peritonitis, neutrophils ≥ 78.95%, C-reactive protein ≥ 1.99 mg/dL, body temperature ≥ 38 °C, pain migration to right lower quadrant, and duration of symptoms < 24 h were more likely to suffer from complicated appendicitis. The new score was comprised of the 10 variables that were found statistically significant in the multivariate logistic model. Each of these variables was assigned a score of 1 due to the values that were associated with complicated appendicitis. A cutoff value of ≥4 has been a good indicator of the final score. The sensitivity with the usage of this score is 81.1%, the specificity 82.4%, the PPV 73.2%, the NPV approaches 88% and finally the accuracy is 81.9%. Also, the pros and cons of this score are discussed in this study.

Relationship between IgE-mediated allergy and complicated appendicitis in children.

To investigate the relationship of IgE-mediated allergy and complicated appendicitis (CA) and overall prognosis. We retrospectively analyzed a consecutive series of patients with acute appendicitis (AA) who received appendectomy at Beijing Children's Hospital between July 1, 2018 and June 30, 2020. Patients were classified into two groups, with or without IgE-mediated allergies. Logistic regression adjusting for age, duration of symptoms, WBC count, neutrophil count, C-reactive protein (CRP), Appendicolith and presence of allergy was used to evaluate the association between CA and IgE-mediated allergy. In total, 1156 patients were included. 162 (14.0%) of the patients had IgE-mediated allergy while 994 (86.0%) did not. Children with allergies had a decreased chance of developing CA after adjustment for age, duration of symptoms, WBC count, Neutrophil count, CRP, and appendicolith present rate (adjusted OR = 0.582, 0.364-0.929, P = 0.023). There were no significant differences in operative time, length of hospital stay (LOS), readmission, or adhesive intestinal obstruction rate between allergy and non-allergy patients. IgE-mediated allergy is related to a reduction risk of CA in the pediatric population and may not affect the prognosis of patients received appendectomy.

Diagnostic Algorithm Based on Machine Learning to Predict Complicated Appendicitis in Children Using CT, Laboratory, and Clinical Features

This retrospective study included 315 children (<18 years old) who were diagnosed with acute appendicitis and underwent appendectomy between January 2014 and December 2018. A decision tree algorithm was used to identify important features associated with the condition and to develop a diagnostic algorithm for predicting complicated appendicitis, including CT and clinical findings in the development cohort (n = 198). Complicated appendicitis was defined as gangrenous or perforated appendicitis. The diagnostic algorithm was validated using a temporal cohort (n = 117). The sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) from the receiver operating characteristic curve analysis were calculated to evaluate the diagnostic performance of the algorithm. All patients with periappendiceal abscesses, periappendiceal inflammatory masses, and free air on CT were diagnosed with complicated appendicitis. In addition, intraluminal air, transverse diameter of the appendix, and ascites were identified as important CT findings for predicting complicated appendicitis. C-reactive protein (CRP) level, white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and body temperature also showed important associations with complicated appendicitis. The AUC, sensitivity, and specificity of the diagnostic algorithm comprising features were 0.91 (95% CI, 0.86-0.95), 91.8% (84.5-96.4), and 90.0% (82.4-95.1) in the development cohort, and 0.7 (0.63-0.84), 85.9% (75.0-93.4), and 58.5% (44.1-71.9) in test cohort, respectively. We propose a diagnostic algorithm based on a decision tree model using CT and clinical findings. This algorithm can be used to differentiate between complicated and noncomplicated appendicitis and to provide an appropriate treatment plan for children with acute appendicitis.

The utility of sonographic signs to diagnose simple and complicated appendicitis in children

BackgroundAcute appendicitis is classified into simple (SA) and complicated (CA). Ultrasound scans (USS) can be useful in clinically equivocal cases, by visualising primary and secondary signs. This study explores the utility of sonographic signs to diagnose and differentiate appendicitis in children.MethodsSingle-centre retrospective cohort study over a 2-year period. Consecutive USS for suspected appendicitis were included; sonographic signs were extracted from standardised institutional worksheets. USS results were compared with pre-defined intraoperative criteria for SA and CA, confirmed with histological analysis. Data are reported as median [interquartile range], percentages (number), area under the curve (AUC), conventional diagnostic formulae and adjusted odds ratios following multiple logistic regression (p < 0.05 considered significant).ResultsA total of 934 USS were included, with median age 10.7 [8.0–13.4] years, majority were female (54%). One quarter (n = 226) had SA, 12% (n = 113) had CA, 61% (n = 571) had no appendectomy and 3% (n = 24) had negative appendicectomy. Appendix visualisation rate on USS was 61% (n = 569), with 62% (n = 580) having a conclusive report. Sonographic signs suggesting appendicitis included an appendiceal diameter > 7 mm (AUC 0.92, [95% CI: 0.90–0.94]), an appendicolith (p = 0.003), hyperaemia (p = 0.001), non-compressibility (p = 0.029) and no luminal gas (p = 0.004). Secondary sonographic signs included probe tenderness (p < 0.001) and peri-appendiceal echogenic fat (p < 0.001). Sonographic signs suggesting CA over SA comprised a diameter > 10.1 mm (AUC 0.63, [95% CI: 0.57–0.69]), an appendicolith (p = 0.003) and peri-appendiceal fluid (p = 0.004).ConclusionPresence of specific sonographic signs can aid diagnosis and differentiation of simple and complicated appendicitis in children.

Can C-Reactive Protein and White Blood Cell Count Predict Complicated Appendicitis in Children?

Objective and summary of background data Acute appendicitis remains a challenging diagnosis in pediatrics, and inflammatory markers are helpful in the management of these patients. Our purpose is to evaluate the prediction potential of specific laboratory parameters (total white blood cell count and C-reactive protein) regarding complicated appendicitis and to highlight the need for a careful interpretation of their levels. Methods A retrospective study was performed on a population of children who underwent appendectomy between January and December 2014. Patients were clustered in 2 groups according to severity of disease: group I, uncomplicated appendicitis; and group II, complicated appendicitis. Data regarding total white blood cell count and C-reactive protein levels were obtained. Variables were compared using χ2, Student t-tests, and Pearson correlation. Results A total of 128 pediatric patients (age &amp;lt;18 years) with a mean age of 10.2 ± 3.9 years were included (76 males). Complicated appendicitis occurred in 27 patients. Age of patient was statistically different in groups I (10.6 ± 3.8 years) and II (8.5 ± 3.7 years; P = 0.011). CRP is a parameter statistically correlated to severity of appendicitis (P &amp;lt; 0.001), but white blood cell count is not (P = 0.295). A CRP level (above 4.3 mg/dL) was 74% sensitive and 77% specific for complicated appendicitis. Conclusions The authors emphasize the role of CRP value in the prediction of the severity of appendicitis in children and present a potential usable cutoff value of 4.3 mg/dL, as a marker of complicated appendicitis.

Effects of COVID-19 Pandemic on the Frequency of Complicated Appendicitis in Pediatric Populations

Background: The clinical course of acute appendicitis, one of the most common diseases needing surgical intervention in children, was affected by the coronavirus disease 2019 (COVID-19) pandemic. The global fear and panic about the outbreak and governmental decisions on lockdowns and restrictions led to an increasing number of complicated forms of appendicitis. Objectives: This study aimed to compare different aspects of appendicitis and its complications between the pre-pandemic and pandemic periods. Methods: In a retrospective cross-sectional analytical study, we enrolled all patients with a diagnosis of acute appendicitis for two consecutive years. Only children under 14 years of age were included in the study. The patients were divided into two groups based on the time of disease presentation, the pre-pandemic and pandemic periods. Demographic features, as well as clinical, laboratory, and imaging findings, were compared between the two groups. Results: Out of 369 patients included in the study, 173 were placed in the pre-pandemic group. There was no significant change in the incidence of appendicitis between the two periods (P = 0.232). However, the incidence of complicated appendicitis increased remarkably during the pandemic (27% vs. 11%, P &lt; 0.001). No substantial differences were found in parameters like age, sex, laboratory findings, and the length of hospital stay between the two groups (P &gt; 0.005). The patients who tested positive for COVID-19 had a significantly higher hospitalization duration (P &lt; 0.001). Conclusions: Our results suggested that the rate of complicated appendicitis was substantially higher during the pandemic compared to the pre-pandemic time. Also, the proportion of midline laparotomy was significantly higher after the outbreak. These findings suggested that delays in care provision during the COVID-19 outbreak could have probably contributed to the rise in the incidence of complicated appendicitis in children.

Oral antibiotics and organ space infection after appendectomy and intravenous antibiotics therapy for complicated appendicitis in children.

There is little consensus regarding management after appendectomy for complicated appendicitis in children. Recent literature suggests that patients may be safely discharged without oral antibiotics after adequate intravenous antibiotics therapy. We conducted a nationwide retrospective cohort study comparing the proportion of postoperative organ space infection between patients discharged with and without oral antibiotics after appendectomy followed by intravenous antibiotics therapy for complicated appendicitis. Using the Diagnosis Procedure Combination database, we identified patients between 3 and 18 years of age who had undergone appendectomy for complicated appendicitis between July 2010 and March 2018. Propensity score matched analyses were performed to compare outcomes between the groups with and without oral antibiotics. The primary outcome was readmission due to organ space infection within 60 days of discharge and the secondary outcome was 60-day readmission due to any reason. Additionally, we conducted a stabilized inversed probability of treatment weighting analysis as a sensitivity analysis. We identified 13,100 eligible patients who had received oral antibiotics (n=3,501) and who had not (n=9,599). Propensity score matching created 2,769 pairs. Readmissions due to organ space infection were 3.4% and 5.2% in the non-users and users of oral antibiotics, respectively (P=0.007). The oral antibiotics users also had a significantly higher proportion of readmission due to any reason than the non-users (5.5% vs 7.4%, P=0.004). The sensitivity analyses demonstrated consistent results. Among children who had undergone appendectomy for complicated appendicitis, oral antibiotics following discharge after adequate intravenous antibiotics therapy may increase organ space infection.

Hyponatremia As A Marker Of Complicated Appendicitis.

The most frequent cause of paediatric acute abdomen is acute appendicitis. If acute appendicitis is not treated promptly, one third of cases progress to complicated appendicitis. Complicated appendicitis is associated with significant morbidity and its management protocol differs significantly from that of uncomplicated appendicitis. In this study, we assessed the relationship between serum sodium levels and complicated appendicitis. We conducted a prospective observational study from July to December 2020 at the Department of Neonatal and Paediatric Surgery, The Children Hospital, Pakistan Institute of Medical Sciences, Islamabad, on a sample size of 140 patients who met inclusion and exclusion criteria. For this study, we divided the patients into two groups. Group 1 had uncomplicated appendicitis and Group 2 had complicated appendicitis. These findings were then compared to preoperative serum sodium (Na) levels. The median serum sodium level in group 1 (uncomplicated appendicitis) was 137.81 mg/dl, while in group 2 it was 131.35 mg/dl (Complicated Appendicitis). The sensitivity and specificity of serum sodium levels at a cut-off point of less than 135 mg/dl were 84.80% and 89.40%, respectively. Hyponatremia is currently thought to be a new marker for differentiating between complicated and uncomplicated appendicitis. It is a low-cost, high efficiency predictive marker for diagnosing and differentiating complicated appendicitis in children.

Laparoscopic appendectomy for complicated appendicitis in children: does the post-operative peritoneal drain make any difference? A pilot prospective randomised controlled trial

PurposeThis was a pilot randomised, prospective study, which aimed to determine and compare the post-operative complications of paediatric patients undergoing laparoscopic appendectomy (LA) for complicated appendicitis, with and without a peritoneal drain.MethodsPatients younger than 13 years, undergoing LA for complicated appendicitis at the Dr George Mukhari Academic Hospital (DGMAH), over a 15-month period during 2019–2020 were enrolled. Randomisation was achieved by a blocked randomisation plan. Patients were randomised in a 1:1 ratio into the “drain” (D) and “no drain” (ND) groups.ResultsThirty-four patients were included in this study; seventeen in each group. The complication rate was 26%. Intra-abdominal collection accounted for 89% of the complications. The complication rate in the “D” group was 18% and 35% in the “ND” group, with no statistically significant difference. Complication rates were higher (38%) in patients with generalised pus when compared to localised pus (7%), although not statistically significant. The mean theatre time, hospital stay, and duration of antibiotic use did not differ significantly between the groups.ConclusionFrom our study, the post-operative peritoneal drain did not make any statistically significant difference in patient outcome. The amount of intra-abdominal contamination is more likely to contribute in the development of complications.Trial registration numberSMUREC/M/15/2019: PG.

Appendicolith on Ultrasound Is Predictive of Complicated Appendicitis in Children.

Appendicolith on Ultrasound Is Predictive of Complicated Appendicitis in Children.

The use of the ratio of C-reactive protein to albumin for the diagnosis of complicated appendicitis in children

No reliably specific marker for complicated appendicitis has been identified. The ratio of serum C-reactive protein (CRP) to albumin (ALB) (CRP/ALB ratio) is a new inflammation-based prognostic score that is associated with the severity of inflammation. The aim of this study was to evaluate the predictive value of CRP/ALB ratio for the diagnosis of complicated appendicitis in children. A retrospective study of 296 children with acute appendicitis was conducted with assessments of demographic data, clinical symptoms, pre-operative laboratory results, abdominal ultrasound examinations and clinical outcomes. According to the postoperative pathological results, patients were divided into a simple appendicitis group (169 patients) and a complicated appendicitis group (127 patients). SPSS version 22.0 was used to analyse the data. Of the 296 patients, CRP/ALB ratio was higher in complicated appendicitis than in simple appendicitis (P<0.05). Logistic regression analysis showed that higher levels of white blood cell count (WBC), CRP, CRP/ALB ratio, and increased incidence in submucosal layer loss and appendicolith were independent risk factors for complicated appendicitis in children. Receiver operating characteristic curve analysis showed that the area under the curve of the CRP/ALB ratio (0.883) was larger than that of WBC (0.702), CRP (0.802), ALB (0.835), submucosal layer loss (0.633) and appendicolith (0.673). A CRP/ALB ratio≥1.39 was found to be a significant marker in the prediction of complicated appendicitis, with 86.61% sensitivity and 84.62% specificity. Patients with a CRP/ALB ratio≥1.39 had a 31.263 times higher chance of having complicated appendicitis (95% CI: 16.449-59.418) than those with a CRP/ALB ratio<1.39. The admission CRP/ALB ratio was significantly higher in children with complicated appendicitis. The CRP/ALB ratio is a novel but promising haematological marker that aids in the differentiation of acute complicated and simple appendicitis.

Incidence of Complicated Appendicitis during the COVID-19 Pandemic versus the Pre-Pandemic Period: A Systematic Review and Meta-Analysis of 2782 Pediatric Appendectomies.

Background: The Coronavirus Disease 2019 (COVID-19) pandemic has impacted volume, management strategies and patient outcomes of acute appendicitis. The aim of this systematic review and meta-analysis was to evaluate whether the COVID-19 pandemic resulted in higher incidence of complicated appendicitis in children presenting with acute appendicitis compared to the pre-COVID-19 period. The secondary aim was to investigate the proportion of the patients treated by non-operative management (NOM). Methods: A systematic search of four scientific databases was performed. The search terms used were (coronavirus OR SARS-CoV-2 OR COVID-19 OR novel coronavirus) AND (appendicitis). The inclusion criteria were all patients aged <18 years and diagnosed with acute appendicitis during the COVID-19 and pre-COVID-19 periods. The proportion of children presenting with complicated appendicitis and the proportion of children managed by NOM was compared between the two groups. The Downs and Black scale was used for methodological quality assessment. Results: The present meta-analysis included thirteen studies (twelve retrospective studies and one cross-sectional study). A total of 2782 patients (1239 during the COVID-19 period) were included. A significantly higher incidence of complicated appendicitis (RR = 1.63, 95% CI 1.33–2.01, p < 0.00001) and a significantly higher proportion of children managed via the NOM (RR = 1.95, 95% CI 1.45–2.61, p < 0.00001) was observed in patients during the COVID-19 pandemic when compared to the pre-COVID-19 period. Conclusion: There is a significantly higher incidence of complicated appendicitis in children during the COVID-19 pandemic than in the pre-COVID-19 period. Additionally, a significantly higher proportion of children was managed via the NOM during the pandemic in comparison to the pre-pandemic period.

Applying the Pediatric Appendicitis Score to predict complicated appendicitis in children.

This study aimed to investigate the efficacy of the Pediatric Appendicitis Score (PAS) and other indicators to enable the prediction of complicated appendicitis (CA) in children. This retrospective cohort study evaluated children (n = 161) aged ≤16 years with acute appendicitis between 2008 and 2020. Demographic data, symptoms, physical findings, laboratory data, and PASs were collected. Multivariate analysis was performed to identify predictors for CA. Receiver operating characteristic (ROC) curves were constructed. The diagnostic performance of each predictor was evaluated. Multivariate analysis identified three predictors for CA: duration of symptoms >1 day, C-reactive protein (CRP) level > 4 mg/dL, and PAS ≥ 8. The ROC curve of the combined three predictors showed an area under the curve of 0.91. The multivariate ROC curve revealed that the presence of a PAS contributed to a significant improvement in the diagnosis of CA compared to the absence of PAS. When combined, the three predictors had a high specificity of 99% and positive predictive value of 98%. A symptom duration >1 day, CRP > 4 mg/dL, and PAS ≥ 8 were predictors for CA. The PAS can be useful for prediction of CA when combined with the duration of symptoms, CRP, or both.

A new score for the diagnosis of complicated appendicitis in children - Complicated appendicitis pediatric score

Aim:This study aims to construct and validate a new score for diagnosis of complicated appendicitis in children, complicated appendicitis pediatric score (CoAPS), to guide residents’ clinical decision-making on choosing the correct patients for immediate surgery, reducing the emergency negative surgeries.Methods:This prospective observational study enrolled two cohorts of patients 5–15 years old. Four hundred and seven consecutive patients were enrolled for the derivation cohort. Demographic data, clinical features, and histopathology data were collected. The outcome measure was the histological diagnosis of gangrenous appendicitis with or without perforation. The score was next validated in a separate cohort of 312 consecutive patients who were classified according to their risk of complicated appendicitis. The diagnostic performance of the score and the potential for the risk stratification to select patients for diagnostic imaging, emergency operative management, and reduce emergency negative operation rates were quantified.Results:A positive “jumping up” test, vomiting, white blood cell >13.5 × 10^3/ml, lymphocytes <18%, and C-reactive protein >50 mg/dl were independent predictors for complicated appendicitis. The final prediction model exhibited an area under the curve of 0.890 (95% confidence interval: 0.859–0.922). The low-risk group demonstrated high sensitivity (90.4%) for complicated appendicitis, while scores 6 or more were very specific (95%) for the disorder. Describing the potential utility of the score, emergency ultrasound imaging would have been postponed in 14.5% of patients (P = 0.0016), and emergency negative explorations would have been cut by 87%.Conclusion:The CoAPS score could guide residents in emergency management of children with complicated appendicitis reducing hospitalizations and urgent surgeries.